European Association of Cardiothoracic Anesthesiology and Intensive Care Pediatric Cardiac Anesthesia Fellowship Curriculum: First Edition.

Pediatric cardiac anesthesia is a subspecialty of cardiac and pediatric anesthesiology dedicated to the perioperative care of patients with congenital heart disease. Members of the Congenital and Education Subcommittees of the European Association of Cardiothoracic Anaesthesiology and Intensive Care (EACTAIC) agreed on the necessity to develop an EACTAIC pediatric cardiac anesthesia fellowship curriculum. This manuscript represents a consensus on the composition and the design of the EACTAIC Pediatric Cardiac Anesthesia Fellowship program. This curriculum provides a basis for the training of future pediatric cardiac anesthesiologists by clearly defining the theoretical and practical requirements for fellows and host centers.

Thoracic Anesthesia during the COVID-19 Pandemic: 2021 Updated Recommendations by the European Association of Cardiothoracic Anaesthesiology and Intensive Care (EACTAIC) Thoracic Subspecialty Committee.

The novel coronavirus pandemic has radically changed the landscape of normal surgical practice. Lifesaving cancer surgery, however, remains a clinical priority, and there is an increasing need to fully define the optimal oncologic management of patients with varying stages of lung cancer, allowing prioritization of which thoracic procedures should be performed in the current era. Healthcare providers and managers should not ignore the risk of a bimodal peak of mortality in patients with lung cancer; an imminent spike due to mortality from acute coronavirus disease 2019 (COVID-19) infection, and a secondary peak reflecting an excess of cancer-related mortality among patients whose treatments were deemed less urgent, delayed, or cancelled. The European Association of Cardiothoracic Anaesthesiology and Intensive Care Thoracic Anesthesia Subspecialty group has considered these challenges and developed an updated set of expert recommendations concerning the infectious period, timing of surgery, vaccination, preoperative screening and evaluation, airway management, and ventilation of thoracic surgical patients during the COVID-19 pandemic.

European Association of Cardiothoracic Anesthesiology (EACTA) Cardiothoracic and Vascular Anesthesia Fellowship Curriculum: First Edition.

This special article summarizes the design and certification process of the European Association of Cardiothoracic Anesthesiology (EACTA) Cardiothoracic and Vascular Anesthesia (CTVA) Fellowship Program. The CTVA fellowship training includes a two-year curriculum at an EACTA-accredited educational facility. Before fellows are accepted into the program, they must meet a number of requirements, including evidence of a valid license to practice medicine, a specialist degree examination in anesthesiology, and appropriate language skills as required in the host centers. The CVTA Fellowship Program has 2 sequential and complementary levels of training-both with a modular structure that allows for individual planning and also takes into account the differing national healthcare needs and requirements of the 36 countries represented in EACTA. The basic training period focuses on the anesthetic management of patients undergoing cardiac, thoracic, and vascular surgery and related procedures. The advanced training period is intended to deepen and to extend the clinical and nontechnical skills that fellows have acquired during the basic training. The goal of the EACTA fellowship is to produce highly trained and competent perioperative physicians who are able to care for patients undergoing cardiac, thoracic, and vascular anesthesia.

Thoracic Anesthesia of Patients With Suspected or Confirmed 2019 Novel Coronavirus Infection: Preliminary Recommendations for Airway Management by the European Association of Cardiothoracic Anaesthesiology Thoracic Subspecialty Committee.

The novel coronavirus has caused a pandemic around the world. Management of patients with suspected or confirmed coronavirus infection who have to undergo thoracic surgery will be a challenge for the anesthesiologists. The thoracic subspecialty committee of European Association of Cardiothoracic Anaesthesiology (EACTA) has conducted a survey of opinion in order to create recommendations for the anesthetic approach to these challenging patients. It should be emphasized that both the management of the infected patient with COVID-19 and the self-protection of the anesthesia team constitute a complicated challenge. The text focuses therefore on both important topics.

[Palliative endoscopic treatment of malignant gastroduodenal obstructions with uncovered enteral stents]. / Malignus gastroduodenalis obstrukció endoszkópos palliációja fedetlen enteralis stenttel.

INTRODUCTION: Palliative treatment of malignant gastroduodenal obstructions with enteral stents is an effective and safe method, and a viable alternative to gastroenterostomy. AIM: The authors present the most common malignancies behind gastroduodenal obstructions, the aspects of stent selections, insertion techniques, technical and clinical success rates, and possible procedure-related complications. METHOD: Between 1 March, 2013 and 9 April, 2015 nineteen patients were treated with uncovered, self-expandable enteral stents. Out of the 19 patients, 6 were females and 13 males, with an average age of 67 years. Indications of stenting were peripyloric ventricular tumour in five cases, malignancies of the duodenum, gastroenteralis anastomosis, Vater papilla and gallbladder in one case respectively, pancreatic tumor in seven cases and bile duct malignancies in three cases. RESULTS: The technical success rate of stent placement was 100%. The evaluation of clinical success was analised on the basis of the Gastric Outlet Obstruction Scoring System. CONCLUSIONS: The use of enteral stents in malignant gastroduodenal obstructions is a reliable and safe method, which promptly decreases symptoms of the patients and improves their quality of life.

A Multi-Country Survey on the Availability of Intraoperative Use of Echocardiography for Noncardiac Surgery.

BACKGROUND: This survey aimed to explore the availability and accessibility of echocardiography during noncardiac surgery worldwide. METHODS: An internet-based 45-item survey was sent, followed by reminders from August 30, 2021, to August 20, 2022. RESULTS: 1189 responses were received from 62 countries. Nearly seventy-one percent of respondents had intraoperatively used transesophageal or transthoracic echocardiography (TEE and TTE, respectively) for monitoring or examination. The unavailability of echocardiography machines (30.3%), lack of trained personnel (30.2%), and absence of clinical indications (22.6%) were the top 3 reasons for not using intraoperative echocardiography in noncardiac surgery. About 61.5% of participants had access to at least one echocardiography machine. About 41% had access to at least 1 TEE probe, and 62.2% had access to at least 1 TTE probe. Seventy-four percent of centers had a procedure to request intraoperative echocardiography if needed for noncardiac cases. Intraoperative echocardiography service was immediately available in 58% of centers. CONCLUSIONS: Echocardiography machines and skilled echocardiographers are still unavailable at many centers worldwide. National societies should aim to train a critical mass of certified TEE/TTE anesthesiologists and provide all anesthesiologists access to perioperative TEE/TTE machines in anesthesiology departments, considering the increasing number of older and sicker surgical patients scheduled for noncardiac surgery.

Sampling Strategies in PRRS Elimination in Hungary: An Observational Study Involving Four Farrow-to-Finish Swine Herds.

PRRS elimination strategies often rely on depopulation-repopulation. However, this approach is accompanied by a long-term loss of production. With adequate control measures, such as well-designed immunization programs and technological changes along with prevalence-based laboratory testing, the virus-free status of the most vulnerable age groups in swine herds can be achieved. The most common reason for acquiring PRRSV at large farrow-to-finish swine farm units is that the previously settled fattening pigs serve as a source of infection for the newly reared PRRS-free animals. Following such unwanted events, PRRSV may persist in an affected establishment for several years. In this observational study, we selected four farrow-to-finish type swine herds. We implemented different laboratory testing protocols to find the most optimal solution for a successful PRRS elimination program. To aid our objectives, we used a DIVA PCR technique. The PRRS DIVA PCR assay is a fast, reliable method to identify sows shedding farm-specific PRRSV strain(s). As a result of elimination efforts at the sentinel pig herds, we found that reliable detection of wild-type PRRSV shedding among sows requires sampling at least three weaned piglets per litter. The strict adherence to this sampling protocol, the systematic use of laboratory methods that quickly detect the presence of wild virulent virus in the herd during the rearing period and the culling of DIVA PCR positive litters and their sows decreased the presence of the resident virus markedly. These procedures at Hungarian farrow-to-finish type farms successfully inhibited the wild-type PRRSV infection of different age groups. The results of this study demonstrate that applying this methodology together with strict biosecurity measures enabled us to reach PRRS-vaccinated-free status in large, farrow-to-finish herds within two years.

Acute hydrocephalus caused by a colloid cyst - a case report.

BACKGROUND: Colloid cysts are rare benign, slowly growing intracranial tumors of endodermal origin. Most colloid cysts are found incidentally and are asymptomatic, but rarely, they can lead to sudden death. CASE PRESENTATION: A 73-year-old female patient was admitted to our emergency department with complaints of dizziness, nausea, vomiting, fatigue, walking difficulties, and behavioral changes. CT imaging revealed acute obstructive hydrocephalus attributable to a third ventricular colloid cyst. The patient was immediately transferred to a tertiary center where she underwent successful neurosurgical resection of the mass. Pathology results of the lesion confirmed the diagnosis of colloid cyst. CONCLUSION: The case we present emphasizes the critical importance of prompt identification of warning signs, complex thinking, and evaluation. Establishing the right diagnostic approach early on can facilitate accurate diagnosis.

Lung separation in adult thoracic anesthesia.

Thoracic anesthesia is mainly the world of OLV during anesthesia. The indications for OLV, classified as absolute or relative are more representative of the new concepts in OLV: It includes either the separation or the isolation of the lungs. Modern DLTs are most widely employed worldwide to perform OLV including the concept of one lung separation. Endobronchial blockers are a valid alternative to DLTs, and they are mandatory in the education of lung separation and in case of predicted difficult airways as they are the safest approach (with an awake intubation with an SLT through a FOB). Every general anesthesiologist should know how to insert a left-sided DLT, but he/she should also have in his technical luggage and toolbox, basic knowledge and minimal expertise with BBs, this option being considered a suitable alternative, particularly in emergency situation where the patient is already intubated and/or in case of difficult airways. One should keep in mind that extubation or re-intubation after DLT might be difficult too, and additional intubation tools are necessary for the safety conditions.

Anesthesia for robotic thoracic surgery.

The management of the robotic thoracic surgical patient requires the knowledge of minimally invasive surgery techniques involving the chest. Over the past decade, robotic-assisted thoracic surgery has grown, and, in the future, it will take an important place in the treatment of complex thoracic pathologies. The enhanced dexterity and three-dimensional visualization make it possible to do this in the small space of the thoracic cavity. Familiarity with the robotic surgical system by the anesthesiologists is mandatory. Management of a long period of one-lung ventilation with a left-sided double-lumen endotracheal tube or an independent bronchial blocker is required, along with flexible fiberoptic bronchoscopy techniques (best continuous monitoring). Correct patient positioning and prevention of complications such as eye or nerve or crashing injuries while the robotic system is used is mandatory. Recognition of the hemodynamic effects of carbon dioxide during insufflation in the chest is required. Cost is higher and outcome is not yet demonstrated to be better as compared to video-assisted thoracic surgery. The possibility for conversion to open thoracotomy should also be kept in mind. Teamwork is mandatory, as well as good communication between all the actors of the operating theatre.

Palliative treatment of esophageal carcinoma with self-expanding plastic stents: a report on 69 cases.

OBJECTIVES: The use of self-expandable plastic stents has offered a reasonable alternative of self-expandable metal stents in palliative treatment of esophageal malignancies, in the recent years. Studies and clinical data on the use of self-expandable plastic stents in esophageal cancer are, however, available in a very limited number. Here, we present the results of our 3-year study designed to evaluate the efficacy of self-expandable plastic stents in palliation of advanced esophageal carcinoma. PATIENTS AND METHODS: Between January 2001 and February 2004, 69 patients with advanced nonoperable esophageal cancer were enrolled in the study and followed up until their death, after insertion of Polyflex self-expandable plastic stents. Dysphagia scores, Karnofsky indices and body weights were determined and compared in order to evaluate the effect of the stent insertion on general status and well-being of the patients. RESULTS: Insertion of Polyflex self-expandable plastic stents and covered self-expandable metal stents was performed in 66 cases and in eight cases, respectively; in certain patients, owing to complications, more than one stent had to be inserted. In all cases, the insertion of stents has been performed without major complication and it has led to an instant improvement in swallowing and dysphagia scores. The rates of tumoral overgrowth and of stent migration were low. The mean follow-up time of our patients was 129 days (10-312 days). CONCLUSION: In concordance with previous studies, according to our results, the use of self-expandable plastic stents in palliation of esophageal cancer seems to be safe and effective in improving the quality of life of these patients.

[Balloon dilatation of cervical anastomosis stricture after subtotal resection of the esophagus]. / Szubtotális nyelócsó-resectio után kialakult nyaki anastomosisszukület endoszkópos tágítása és annak eredményei.

AIMS: The stricture of the anastomosis is one of the most common complications of the subtotal esophageal resections. The authors present indications, technics and results of the endoscopic dilatation. PATIENTS AND METHODS: In a 10 year period 26 patients (22 male, 4 female, mean age of 53.7 years) with stricture of anastomosis between the esophagus and the neo-esophagus after subtotal esophageal resection were dilated endoscopically 82 times. The indication of the resection was tumour in 23 (88.5%) cases, congenital atresia in 2 (7.7%) cases and corrosive disease in one (3.8%) case. In 7 (31.8%) cases the stricture developed after anastomosis leakage. The mean time between the operation and the dilatation was 7.8 months. The cause of the stricture was cancer recurrency in 4 (15.4%) cases. RESULTS: There were no complications related to the dilatation. The mean number of the dilatation was 3.2 (1-9). There was no significant difference between the number of dilatation in patients with or without previously anastomotic leakage. The success rate of the dilatation for benign strictures was 95.5%. In only one patient (4.5%) was needed operative intervention. In the 4 patients with tumour recurrency a stent was also implanted in the stenosis. CONCLUSIONS: The endoscopic dilatation for the treatment of the cervical anastomosis stricture after subtotal esophageal resection is a successful method with a low rate of complications. In cases of tumour recurrency a stent implantation is suggested.

[Stromal tumor of the stomach causing life-threatening arterial bleeding]. / A gyomor életveszélyes arteriás vérzést okozó stromalis tumora.

Stromal tumors of the gastrointestinal tract are rare mesenchymal neoplasms. The majority of them are appearing in the stomach: their quite common first manifestation is bleeding. The authors report a case of polypoid gastric GIST causing severe bleeding which needed urgent surgical intervention and partial resection of the stomach. Although histological analysis of the tumor revealed low proliferation rate, the urgent operation did not result in a complete eradication of the neoplasm, thereby our patient needs further follow-up and treatment.

[Use of self-expanding stents in benign and malignant esophageal disease]. / Ontáguló stentek alkalmazása benignus es malignus nyelocsobetegségekben.

Of patients with malignant esophageal tumors, more than the half has incurable disease at the time of diagnosis. In such cases, quality of life and ability to swallow should be improved or restored by palliating the process e.g. by inserting esophageal stents. In the recent years, use of covered self-expandable metal stents (SEMS) has led to an increased success rate in the palliative treatment of--mainly malignant--strictures of the esophagus. High occurrence of complications (perforation, bleeding) associated with the use of rigid plastic esophageal stents necessitated the development of flexible stents. First generation self-expandable stents were made of special metal alloys, such as nickel-titanium. In the recent years, self-expandable plastic stents are available, too, offering new alternatives in the palliative treatment of esophageal diseases. In our present review article, we discuss the most important aspects about the use of self-expanding esophageal stents, based on recent clinical observations and data.

[Wireless capsule endoscopy and its role in gastroenterology: our results and a review of the literature]. / Kapszulás endoszkópia helye a gasztroenterológiai diagnosztikában: irodalmi attekintés saját eredményeink tükrében.

INTRODUCTION: Since its recent introduction, capsule endoscopy has revolutionized the diagnostics of diseases of the small bowel. The number of studies on the use of this method is constantly increasing. Along with this, our knowledge about the usability and diagnostic power of capsule endoscopy is growing and the indications for this technique are getting progressively more accurate. AIMS: To study the usability of capsule endoscopy in suspected Crohn's disease, in gastrointestinal bleeding of small bowel origin, and in undetermined abdominal complains. METHOD: Capsule endoscopy was performed in 20, previously examined, carefully selected patients. RESULTS: Positive findings were recorded in all patients with gastrointestinal bleeding and in 3/4 of patients with suspected Crohn's disease. However, in patients with indeterminate abdominal complains, the capsule endoscopy proved to be inefficient. CONCLUSION: In the study below, based on their own experience, the authors try to provide an overall picture of capsule endoscopy by reviewing contemporary medical literature. The usability of the capsule endoscopy in suspected Crohn's disease and gastrointestinal bleeding of small bowel origin is suggested by the results of the study.

Leukoencephalopathy, cerebral calcifications and cysts: a family study.

We present a clinical, neuro-radiological and genetic study on a family with members suffering from an autosomal dominantly inherited syndrome characterised by epilepsy, cerebral calcifications and cysts, bone abnormalities; progressive neuro-cognitive deterioration and paranasal sinusitis. This syndrome shares several features with leukoencephalopathy with calcifications and cysts also called Labrune syndrome and the condition of cerebroretinal microangiopathy with calcifications and cysts (CRMCC; Coats plus syndrome). Genetic studies in this family did not reveal mutations in the CTC1 gene defected in CRMCC. We interpret our results as those supporting recent findings that despite clinical similarities, late-onset Labrune and Coats plus syndrome might be distinct entities. This family may have Labrune syndrome or a yet unclassified entity; exploration of similar cases could help classifying this one, and related conditions.

Gastric bleeding in a patient with rheumatoid arthritis complicated by immune thrombocytopenic purpura.

Rheumatoid arthritis, in common with other systemic autoimmune diseases, can involve several other organs presenting with complex immunological manifestations. Immune thrombocytopenic purpura caused by an autoimmune reaction against platelets is an infrequent haematological complications. A female patient with rheumatoid arthritis rapidly developed extremely severe immune thrombocytopenic purpura upon suspending oral corticosteroid therapy. Besides the involvement of the mucosa of the coecum, ascending colon and the gastric antrum, the situation was further complicated by bleeding of a gastric polyp, at the nadir of the thrombocytopenic crisis. The bleeding was managed by endoscopic intervention and platelet count recovered upon high dose corticosteroid treatment within a couple of days.

Gluten intake interferes with the humoral immune response to recombinant hepatitis B vaccine in patients with celiac disease.

OBJECTIVE: Patients with celiac disease, who often carry human leukocyte antigen-DR3;DQ2, are prone to inadequate response to hepatitis B immunization. We evaluated vaccine response in relation to disease activity and whether previous treatment with a gluten-free diet influences the achievement of protective antibody titers. PATIENTS AND METHODS: We studied 128 children and adolescents with celiac disease and 113 age-matched control subjects. Twenty-two patients with celiac disease were prospectively immunized after diagnosis during dietary treatment (group 1). A total of 106 (group 2) and the control subjects received vaccination by mass immunization in schools at 14 years of age regardless of diet status and when celiac disease was still undiagnosed in 27 of these children. Diet compliance and celiac disease activity were monitored by measurement of antibodies against transglutaminase and endomysium. Vaccine response was determined by measuring antihepatitis B antibodies from serum. RESULTS: The seroconversion after hepatitis B vaccination was 95.5% in group 1. All of these patients carried human leukocyte antigen DQ2. The response rate in group 2 was 50.9% and correlated with gluten intake (untreated patients: 25.9%, non-strict diet: 44.4%, strict diet: 61.4%). Treated and compliant patients did not significantly differ from control subjects (75.2%). Thirty-seven antihepatitis B-negative patients with celiac disease received a booster during a controlled gluten-free diet, and 36 (97.3%) seroconverted, irrespective of the presence of human leukocyte antigen DQ2. CONCLUSIONS: Nonresponse to recombinant hepatitis B surface antigen may be a sign of undiagnosed celiac disease. However, there is a good vaccine response in adequately treated patients. Human leukocyte antigen DQ alleles do not seem to have a primary role. Revaccination is recommended during a controlled gluten-free diet.