Technical challenges during emergent endovascular aneurysm repair with the ALTO system.

INTRODUCTION: Ruptured abdominal aortic aneurysms (AAAs) pose an immediate threat for patient's life and endovascular repair (EVAR) is currently the preferred treatment modality in the presence of suitable anatomy. This is determined based on the requirements of each endograft as described in the instructions for use (IFU). The new ALTO system (Endologix, Irvin, CA, U.S.A.), can accommodate a great range of anatomies such as short necks and/or narrow access, but its unique design requires specific technical modifications during treatment of ruptured AAAs. AREAS COVERED: The standard double balloon technique has long been described and it is used to provide circulatory support during EVAR for ruptured AAA. While this technique is straightforward with the use of endografts with a traditional design, this would not be the case if one uses the ALTO system. In that case specific maneuvers would be required to treat AAA patients in an acute setting. EXPERT OPINION: The ALTO system although being able to treat AAAs with adverse anatomy, it may not be appropriate during treatment of ruptured AAA patients with profound hemodynamic instability. A careful evaluation of the individual's patient anatomy and hemodynamic condition is mandatory in order to decide the best endograft for each case.

Educational video demonstrating collapsibility of the upper airway during sleep improves initial acceptance of CPAP in patients with severe obstructive sleep apnea: a retrospective study.

STUDY OBJECTIVES: To investigate if an audio-visual educational video demonstrating collapsibility of the upper airway during sleep influences initial CPAP acceptance among patients with severe obstructive sleep apnea (OSA). METHODS: Between January 2017 and December 2018, a single-center retrospective study was conducted. We implemented an educational video demonstrating upper airway collapsibility during sleep in February 2018. We analyzed the medical records from 145 consecutive patients diagnosed with severe OSA who underwent in-lab polysomnography (PSG) both before and after implementing the educational video. Among them, 76 patients received standard care before the video's introduction (standard care group), and another 69 patients were managed after its implementation (video group). RESULTS: Baseline characteristics including age, BMI, educational level, occupation category, comorbidities, Mallampati score, Epworth Sleepiness Scale (ESS) score, apnea hypopnea index (AHI) and sleep time with SpO2 below 90% (T90%) were not significantly different between the two groups. Acceptance of CPAP following in-lab overnight titration study was significantly higher in the video group (80%) compared to the standard care group (57%), P= .004.Multivariate regression analyses revealed that watching the video was a strong predictor of initial CPAP acceptance (OR 4.162, 95%, CI 1.627-10.646; P= .004). Both T90% (OR 1.020 95% CI 1.002 to 1.038; P= .029) and sleep efficiency (OR 1.052 95% CI 1.023 to 1.083; P< .001) were weak predictors for initial CPAP acceptance. At 12 months, adherence among those who accepted the CPAP treatment was similar between the two groups (78% vs 74%, P= .662). However, within the initial cohorts, a significantly higher proportion of patients in the video group (62%) were using CPAP at 12 months compared to the standard care group (42%), P= .015. CONCLUSIONS: Among patients with severe OSA, an educational video demonstrating upper airway collapsibility during sleep improved initial CPAP acceptance rates when compared to standard care.

Patients Hospitalized for COVID-19 in the Periods of Delta and Omicron Variant Dominance in Greece: Determinants of Severity and Mortality.

BACKGROUND: Coronavirus disease 2019 (COVID-19) has been a pandemic since 2020, and depending on the SARS-CoV-2 mutation, different pandemic waves have been observed. The aim of this study was to compare the baseline characteristics of patients in two phases of the pandemic and evaluate possible predictors of mortality. METHODS: This is a retrospective multicenter observational study that included patients with COVID-19 in 4 different centers in Greece. Patients were divided into two groups depending on the period during which they were infected during the Delta and Omicron variant predominance. RESULTS: A total of 979 patients (433 Delta, 546 Omicron) were included in the study (median age 67 years (54, 81); 452 [46.2%] female). Compared to the Omicron period, the patients during the Delta period were younger (median age [IQR] 65 [51, 77] vs. 70 [55, 83] years, p < 0.001) and required a longer duration of hospitalization (8 [6, 13] vs. 7 [5, 12] days, p = 0.001), had higher procalcitonin levels (ng/mL): 0.08 [0.05, 0.17] vs. 0.06 [0.02, 0.16], p = 0.005, ferritin levels (ng/mL): 301 [159, 644] vs. 239 [128, 473], p = 0.002, C- reactive protein levels (mg/L): 40.4 [16.7, 98.5] vs. 31.8 [11.9, 81.7], p = 0.003, and lactate dehydrogenase levels (U/L): 277 [221, 375] vs. 255 [205, 329], p < 0.001. The Charlson Comorbidity Index was lower (3 [0, 5] vs. 4 [1, 6], p < 0.001), and the extent of disease on computed tomography (CT) was greater during the Delta wave (p < 0.001). No evidence of a difference in risk of death or admission to the intensive care unit was found between the two groups. Age, cardiovascular events, acute kidney injury during hospitalization, extent of disease on chest CT, D-dimer, and neutrophil/lymphocyte ratio values were identified as independent predictors of mortality for patients in the Delta period. Cardiovascular events and acute liver injury during hospitalization and the PaO2/FiO2 ratio on admission were identified as independent predictors of mortality for patients in the Omicron period. CONCLUSIONS: In the Omicron wave, patients were older with a higher number of comorbidities, but patients with the Delta variant had more severe disease and a longer duration of hospitalization.

Prothrombotic state in patients with stable COPD: an observational study.

BACKGROUND: COPD patients have an increased risk of cardiovascular disease and venous thromboembolism. METHODS: This study aimed to investigate whether patients with stable COPD have a prothrombotic state compared to COPD-free smokers. We conducted an observational study comparing levels of: D-dimers, INR, aPTT, coagulation factors; fibrinogen, FII, FV, FVII, FVIII, FIX, FX and coagulation inhibitors; protein S, proteins C and antithrombin between stable COPD patients and control subjects. RESULTS: A total of 103 COPD patients and 42 controls with similar age, sex, current smoking status, comorbidity burden and cardiovascular risk met the inclusion criteria. Compared to controls, COPD patients had higher levels of D-dimers (median (interquartile range): 360 (230-600) ng·mL-1 versus 240 (180-400) ng·mL-1, p=0.001), fibrinogen (mean±sd: 399±82 mg·dL-1 versus 346±65 mg·dL-1, p<0.001), FII (122±22% versus 109±19%, p=0.004), FV (131±25% versus 121±19%, p=0.015), FVIII (143±32% versus 122±20%, p<0.001) and FX (111 (94-134)% versus 98 (88-107)%, p=0.002), and lower levels of protein S (95 (85-105)% versus 116 (98-121)%, p<0.001) and antithrombin (94.4±11.5% versus 102.3±13.2%, p=0.001). In the COPD group, patients with more severe airflow limitation and frequent exacerbations had significantly higher levels of FII, FV and FX, whereas patients with higher COPD assessment test score had significantly higher levels of FX and lower levels of protein S. CONCLUSION: Patients with stable COPD exhibited increased levels of key coagulation factors and decreased levels of coagulation inhibitors, namely protein S and antithrombin, compared to COPD-free smokers. Among COPD patients, increased levels of FII, FV and FX and decreased levels of protein S were found in patients with more severe disease.

A direct adverse effect of smoking.

Smoking has been accounted for numerous adverse effects. We report a direct effect of smoking in a 73-year-old patient, a heavy smoker who presented to the emergency department with a 48-h history of productive cough and fever. Chest x-ray and chest CT revealed right lung infiltrates; however, they were not suggestive of the diagnosis, which was established through flexible bronchoscopy. The specific procedure concurrently contributed to the treatment of the patient.

Validation of the portable Bluetooth® Air Next spirometer in patients with different respiratory diseases.

BACKGROUND: Chronic respiratory diseases constitute a considerable part in the practice of pulmonologists and primary care physicians; spirometry is integral for the diagnosis and monitoring of these diseases, yet remains underutilized. The Air Next spirometer (NuvoAir, Sweden) is a novel ultra-portable device that performs spirometric measurements connected to a smartphone or tablet via Bluetooth®. METHODS: The objective of this study was to assess the accuracy and validity of these measurements by comparing them with the ones obtained with a conventional desktop spirometer. Two hundred subjects were enrolled in the study with various spirometric patterns (50 patients with asthma, 50 with chronic obstructive pulmonary disease and 50 with interstitial lung disease) as well as 50 healthy individuals. RESULTS: For the key spirometric parameters in the interpretation of spirometry, i.e. FEV1, FVC, FEV1/FVC and FEF25-75%, Pearson correlation and Interclass Correlation Coefficient were greater than 0.94, exhibiting perfect concordance between the two spirometers. Similar results were observed in an exploratory analysis of the subgroups of patients. Using Bland-Altman plots we have shown good reproducibility in the measurements between the two devices, with small mean differences for the evaluated spirometric parameters and the majority of measurements being well within the limits of agreement. CONCLUSIONS: Our results support the use of Air Next as a reliable spirometer for the screening and diagnosis of various spirometric patterns in clinical practice.

Postpneumonectomy-like syndrome due to bronchial carcinoid: a unique case report.

BACKGROUND: Postpneumonectomy-like syndrome is a rare condition resulting from unilateral lung disease with severe lung volume loss leading to excessive mediastinal shift and herniation of the healthy lung into the contralateral hemithorax, mimicking the mediastinal shift observed in postpneumonectomy syndrome after pneumonectomy. We report a unique case of postpneumonectomy-like syndrome caused by an atypical bronchial carcinoid completely occluding the left main bronchus. CASE PRESENTATION: A 25-year-old woman presented with symptoms of chronic exertional dyspnea and productive cough. Imaging studies showed complete left lung atelectasis due to a mass occluding the left main bronchus, as well as extreme mediastinal deviation and substantial herniation of the right lung into the left hemithorax. Bronchoscopic biopsy of the tumor and subsequent left pneumonectomy with concurrent lymph node dissection revealed an atypical carcinoid. Sixteen months after surgery the patient has been asymptomatic with repeat imaging studies showing no change in mediastinal shifting. CONCLUSION: Bronchial carcinoids are notorious for causing bronchial obstruction. The present case represents an extreme complication of centrally located bronchial carcinoid, resulting in postpneumonectomy-like syndrome with severe mediastinal shift and herniation of the healthy lung into the diseased hemithorax.

Spontaneous Type Ia Endoleak Sealing in Patients Undergoing Endovascular Aneurysm Repair With the Ovation Stent Graft.

BACKGROUND: Type Ia endoleak may lead to continuous sac pressurization and late rupture after endovascular aneurysm repair (EVAR). Nevertheless, there have been scarce reports suggesting that these endoleaks may occasionally present spontaneous sealing. Taking into account the original sealing mechanism of the Ovation endograft that exploits 2 polymer-filled O-rings, we hypothesize that spontaneous type Ia endoleak sealing may sometimes incur following implantation of this device. We aim to report our experience with spontaneous type Ia endoleak sealing in patients treated with the Ovation endograft. METHODS: This is a retrospective observational study which included all patients undergoing EVAR with the Ovation endograft in a single institution during a 6-year period. Patients with an intraoperative type Ia endoleak were identified. The primary endpoint was rate of spontaneous sealing. Secondary endpoints were migration, sac expansion, need for reinterventions, secondary type Ia endoleaks, and aneurysm-related and overall mortality. Adherence to the instructions for use (IFU) was evaluated to examine relation with occurrence of endoleak and rates of spontaneous sealing. RESULTS: Among 147 patients treated, 8 (5%) left the operation theater with a type Ia endoleak. In 6 patients, the endoleak spontaneously resolved during a maximum of 3 months of follow-up. Among those, 5 cases were treated outside the IFU (2 short necks and 3 with severe angulation), while the sixth was a patient treated inside the IFU but was anticoagulated. In 2 patients, the endoleak did not spontaneously resolve. One presented a conical neck of marginal length and the other circumferential calcifications. Type Ia endoleak was significantly more common among patients treated in an off-label fashion. CONCLUSIONS: Spontaneous sealing of type Ia endoleak is common after EVAR with the Ovation endograft. Nonadherence to the IFU results in more endoleaks, but it does not seem to reduce possibilities for spontaneous sealing.

Has Anatomic Complexity of Abdominal Aortic Aneurysms Undergoing Open Surgical Repair Changed after the Introduction of Endovascular Treatment? Systematic Review and Meta-analysis of Comparative Studies.

BACKGROUND: At a time when endovascular aneurysm repair (EVAR) is increasingly used to treat abdominal aortic aneurysms (AAAs), lesions undergoing open surgical repair (OSR) may present significant differences compared with those treated before wide EVAR availability. We aim to record discrepancies in AAAs surgically treated before and after the introduction of EVAR. METHODS: We conducted a systematic review of the literature and meta-analysis of comparative studies. The MEDLINE, CENTRAL, and OpenGrey databases were searched up to October 2017. Outcome measures were anatomic complexity, procedural details, and postoperative outcomes. The random-effects model was used to calculate combined overall effect sizes. Data are presented as odds ratio (OR) or mean difference (MD) with 95% confidence intervals (CIs). RESULTS: Five observational studies were included. These involved 1,091 patients treated in the pre-EVAR era and 802 in the post-EVAR era. In general, patients undergoing OSR during the first period presented more comorbidities. Increased anatomic complexity was found among patients in the second group as demonstrated by the increased rate of suprarenal clamping (10.5% vs. 22.3%; OR, 0.34; 95% CI, 0.24-0.50), left renal vein division (10.3% vs. 18.8%; OR, 0.46; 95% CI, 0.25-0.88), iliac aneurysm (28.3% vs. 44.9%; OR, 0.48; 95% CI, 0.37-0.64), and iliac occlusive disease (13.1% vs. 20.2%; OR, 0.59; 95% CI, 0.39-0.88). Intraoperative use of blood products was greater during the latter period, but this difference did not reach statistical significance. Procedural duration was slightly increased in the same group. Morbidity and mortality were similar among the groups. CONCLUSIONS: After the wide availability of endoluminal grafting, more compromised patients tend to be managed with EVAR, leaving a fitter patient population to undergo OSR. At the same time, anatomic complexity of AAAs undergoing open surgery has considerably increased, requiring advanced proximal aortic surgical expertise to deal with these complex aortic pathologies Overall, morbidity and mortality remained unchanged, possibly due to the counterbalancing effects of these factors.

The Use of the Profunda Femoral Artery as the Sole Target Vessel to Bypass Aortoiliac Disease in Patients with Critical Limb Ischemia and Concomitant Unreconstructable Infrainguinal Disease.

BACKGROUND: Critical limb ischemia (CLI) often results from multilevel occlusive disease. There are occasions where a patent profunda femoral artery (PFA) is the only target artery that can be used as outflow during reconstruction to bypass aortoiliac disease (AOID), with no further option for infrainguinal revascularization. We aim to report results of the use of PFA as the sole target vessel for the treatment of these patients. METHODS: This is a retrospective, single-center study including CLI patients treated during 36 months. All procedures were included regardless of inflow site. The outcomes examined were hemodynamic improvement, clinical status change, amputation-free and overall survival, and patency of the prosthesis. Univariate analysis was performed to identify possible predictors of adverse outcomes. RESULTS: Twenty-three patients and 27 limbs were included (2 female, mean age 70.6). Sixteen limbs presented rest pain and 11 tissue loss. Inflow was obtained from the axillary (n = 9), contralateral femoral (n = 8), abdominal aorta (n = 2), thoracic aorta (n = 1), ipsilateral external iliac (n = 2), and contralateral external iliac artery (n = 1). Immediately postoperatively ankle-brachial index significantly increased from 0.15 (0-0.5) to 0.50 (0.25-0.9), (P-value < 0.001). Twenty-four limbs presented clinical improvement (3 minimally, 18 moderately, and 3 markedly improved) and 3 presented no change. During a mean follow-up of 15.8 (2-36) months, we recorded 4 deaths and 4 major amputations. Mean predicted overall survival and amputation-free survival were 29.8 (95% confidence interval [CI] 24.5-35.1) and 26.5 months (95% CI 21.1-31.8), respectively. Predicted primary patency was 76% at 3 years. Univariate analysis revealed significant associations only between bypass patency and limp loss (P-value = 0.021). CONCLUSIONS: In the presence of CLI due to AOID and unreconstructable infrainguinal disease, the use of PFA as the sole target vessel during bypass is associated with significant rates of clinical improvement and limb salvage.

Occupational Asthma guidelines: a systematic quality appraisal using the AGREE II instrument.

The quality of guidelines is often modest and highly variable. We searched the Medline database for occupational asthma (OA) guidelines meeting our inclusion criteria and undertook a systematic appraisal of them. Six appraisers independently evaluated these guidelines using the AGREE II (Appraisal of Guidelines, Research and Evaluation II) instrument. Standardised scores for each domain and for overall quality were calculated, as well as intraclass correlation coefficients to assess agreement among appraisers. Seven relevant guidelines were identified. Three were based on a systematic review of the evidence. Most guidelines scored high on the domains 'Scope and purpose' and 'Clarity and presentation', but scores on the other domains were variable. The lowest scores were for 'Applicability', suggesting that guideline developers did not pay sufficient attention to practical problems affecting the implementation of their recommendations. We also observed a trend toward improved scores in guidelines published after 2000. Inter-rater agreement was good for most domains, and particularly for 'Rigour of development'. This domain was most strongly correlated with the overall assessment scores, together with 'Scope and purpose' and 'Editorial independence'. The quality of OA guidelines is variable, both within and across guidelines. There is significant room for improvement, and greater efforts to produce high-quality guidelines are warranted, in order to assist clinical decision-making.