Optimizing the Live Attenuated Influenza A Vaccine Backbone for High-Risk Patient Groups.

Together with inactivated influenza vaccines (IIV), live attenuated influenza vaccines (LAIV) are an important tool to prevent influenza A virus (IAV) illnesses in patients. LAIVs present the advantages to have a needle-free administration and to trigger a mucosal immune response. LAIV is approved for healthy 2- to 49-year old individuals. However, due to its replicative nature and higher rate of adverse events at-risk populations are excluded from the benefits of this vaccine. Using targeted mutagenesis, we modified the nonstructural protein 1 of the currently licensed LAIV in order to impair its ability to bind the host cellular protein CPSF30 and thus its ability to inhibit host mRNA poly-adenylation. We characterized our optimized LAIV (optiLAIV) in three different mouse models mimicking healthy and high-risk patients. Using a neonatal mouse model, we show faster clearance of our optimized vaccine compared to the licensed LAIV. Despite lower replication, optiLAIV equally protected mice against homosubtypic and hetesubtypic influenza strain challenges. We confirmed the safer profile of optiLAIV in Stat1-/- mice (highly susceptible to viral infections) by showing no signs of morbidity compared to a 50% mortality rate observed following LAIV inoculation. Using a human nasal 3D tissue model, we showed an increased induction of ER stress-related genes following immunization with optiLAIV. Induction of ER stress was previously shown to improve antigen-specific immune responses and is proposed as the mechanism of action of the licensed adjuvant AS03. This study characterizes a safer LAIV candidate in two mouse models mimicking infants and severely immunocompromised patients and proposes a simple attenuation strategy that could broaden LAIV application and reduce influenza burden in high-risk populations. IMPORTANCE Live attenuated influenza vaccine (LAIV) is a needle-free, mucosal vaccine approved for healthy 2- to 49-year old individuals. Its replicative nature and higher rate of adverse events excludes at-risk populations. We propose a strategy to improve LAIV safety and explore the possibility to expand its applications in children under 2-year old and immunocompromised patients. Using a neonatal mouse model, we show faster clearance of our optimized vaccine (optiLAIV) compared to the licensed LAIV. Despite lower replication, optiLAIV equally protected mice against influenza virus challenges. We confirmed the safer profile of optiLAIV in Stat1-/- mice (highly susceptible to viral infections) by showing no signs of morbidity compared to a 50% mortality rate from LAIV. OptiLAIV could expand the applications of the current LAIV and help mitigate the burden of IAV in susceptible populations.

[Update of the S3-guideline on diagnostics, prophylaxis and treatment of osteoporosis]. / Update der S3-Leitlinie Diagnostik, Prophylaxe und Therapie der Osteoporose.

With the aid of a new fracture risk model, the great treatment gap for osteoporosis should be closed. All patients older than 70 years should undergo a diagnostic procedure for osteoporosis. An additional risk threshold (≥ 10% per 3 years for femoral and vertebral fractures) should enable patients with a high risk of fracture to be treated with osteoanabolic agents. The use of osteoanabolic agents makes it necessary to administer antiresorptive drugs afterwards. Due to the low event rate of osteonecrosis of the jaw, the initiation of a specific osteoporosis treatment should not be delayed by prophylactic dental treatment. The adherence to the drug treatment should be improved by an individualized approach on the basis of a cooperation between patients, caregivers, and physicians. A regular assessment of falls, including the timed up and go test should be carried out in patients older than 70 years.

[Anatomical resection for non-small cell lung cancer: cardiopulmonary exercise testing in assessing the risk of respiratory complications]. / Anatomicheskie rezektsii po povodu nemelkokletochnogo raka legkogo: kardiorespiratornoe nagruzochnoe testirovanie v otsenke riska respiratornykh oslozhnenii.

OBJECTIVE: To assess the role of cardiopulmonary exercise testing in examination of patients with high risk of respiratory complications in anatomical resections for non-small cell lung cancer. MATERIAL AND METHODS: A non-randomized retrospective single-center study was devoted to immediate results of surgical treatment of patients with NSCLC between December 2020 and April 2021. Median age of patients was 65 (84; 30) years, male-to-female ratio - 129 (57%)/98 (43%). All patients were examined according to a unified algorithm recommended by the American (ATS) and European (ESTS) societies of thoracic surgeons. At the first stage, we analyzed airflow rate and performed non-invasive exercise tests (6-minute walk and/or stair test). Resections of lungs were performed in 231 patients, anatomic lung resections - in 227 patients (lobectomy - 199, bilobectomy - 4, segmentectomy - 17, pneumonectomy - 7). We excluded 4 patients who underwent non-anatomic lung resections (marginal resections). RESULTS: Among 236 patients referred for anatomical lung resections, 34 (14.4%) ones were selected for cardiopulmonary testing. Selection was based on low exercise tolerance and/or severe decrease in predictive respiratory parameters (FEV<50%). Patients were divided into 4 groups depending on peak oxygen consumption. There were 5 (2%), 10 (29.4%), 11 (32.3%) and 8 (23.5%) patients with extremely high, high, moderate and low risk of respiratory complications, respectively. Surgeries were performed for IA1 (n=6), IA2 (n=50), IA3 (n=37), IB (n=31), IIA (n=19), IIB (n=37), IIIA (n=25) and IIIB (n=4) stages. The overall incidence of postoperative complications was 23% (95% CI: 18-28.8). Complications Clavien-Dindo grade I, IIIA, IIIB, IVA, IVB and V prevailed in both groups. Median postoperative hospital-stay (6 (6; 8) vs. 7 (6; 8) days) and time of pleural drainage (4 (2; 5) vs. 3 (3; 4) days) were similar. Organ-sparing procedures prevailed in the main group (5 (26%) out of 19 (95% CI: 11.81-48.8) vs. 12 (6.7%) out of 180 (95% CI: 3.8-11.3)). Overall mortality (n=231) was 1.7% (95% CI: 0.7-4.4). Mortality throughout the first postoperative year was 24% (95% CI: 12.2-42.1) and 7.4% (95% CI: 4.2-11.3), respectively. CONCLUSION: Cardiopulmonary exercise testing makes it possible to objectively assess exercise tolerance and identify high-risk patients for respiratory complications. These data are valuable when planning the treatment of patients with non-small cell lung cancer.

[Prostatic artery embolization for high-risk patients with benign prostatic hyperplasia: A clinical effect observation].

OBJECTIVE: To observe the clinical effect of prostatic artery embolization (PAE) in the treatment of high-risk patients with BPH. METHODS: Nine high-risk patients with BPH underwent PAE in the Third Affiliated Hospital of Anhui Medical University from January 2016 to June 2018. We followed up the patients and obtained their IPSS, quality of life score (QOL), postvoid residual urine volume (PVR), maximum urinary flow rate (Qmax), prostate volume (PV), hours of undisturbed sleep (HUS), Self-Rating Anxiety Scale score (SAS) and incidence of postoperative complications before and at 6, 12 and 24 months or longer after surgery, followed by comparative analysis of the parameters. RESULTS: Compared with baseline, IPSS, QOL, PVR, Qmax, PV, HUS and SAS were all significantly improved in the patients at 6, 12 and ≥24 months after PAE (P < 0.05). Only 1 case complained of mild numbness in the buttocks, which was gradually relieved after acupuncture therapy. CONCLUSIONS: Prostatic artery embolization is definitely effective for the treatment of high-risk patients with BPH with the bladder volume ≥200 ml, with few postoperative complications, and can be used as an effective therapeutic supplementary for improving the urination symptoms of the patients.

The Assessment of Complications After Major Abdominal Surgery: A Comparison of Two Scales.

BACKGROUND: An accurate and reproducible method for the evaluation of postoperative morbidity is essential for a valid assessment of the outcomes of surgery. However, there is still no consensus on reporting of complications. The Clavien-Dindo classification (CDC) of complications is a validated system which reports only the most severe complication. The Comprehensive Complication Index (CCI) is a novel scale designed to capture the overall burden of complications. The aim of our study is to validate and compare the CDC and the CCI in the setting of high-risk surgical patients in whom multiple complications are common. METHODS: A prospective, observational study analyzed 206 high-risk adult patients undergoing major abdominal surgery. Each postoperative complication was recorded until discharge or readmission within 30 days. The severity of complications was graded with the CDC, and the CCI was calculated subsequently. Correlations of the CDC and the CCI with hospitalization indicators and functional activity on discharge were assessed and compared. RESULTS: A total of 424 complications occurred in 125 (60.7%) patients. The median CCI for the cohort was 20.9 (0-44.9). CD grade II was the most frequent among patients with complications (62/125; 49.6%). The CCI and the CDC have shown a strong correlation (r = 0.969, P < 0.01). Both scales strongly correlated with the parameters of hospitalization, but the CCI showed a stronger correlation to the intensive care unit length of stay (LOS; 0.670 versus 0.628, P < 0.001), postoperative LOS (0.652 versus 0.630, P = 0.041), and prolonged intensive care unit LOS (0.604 versus 0.555, P < 0.001). The median CCI and the highest CD grade were significantly different respective to the functional activity on discharge (P < 0.001). CONCLUSIONS: The CDC and the CCI are the effective methods for reporting of complications after major abdominal surgery. The CCI is a more accurate scale for use in high-risk patients and correlates better with the postoperative LOS.

Functional outcomes and safety of GreenLight photovaporization of the prostate in the high-risk patient with lower urinary tract symptoms due to benign prostatic enlargement.

AIMS: Photovaporization of the prostate (PVP) with GreenLight Laser is a surgical treatment for lower urinary tract symptoms. It is considered safe in elderly patients with comorbidities, however, the evidence is inconclusive. The objective of this study is to evaluate the efficacy and safety outcomes of PVP according to the American Society of Anesthesiologists Physical Status (ASAPS). METHODS: A cohort of 675 patients who underwent PVP between 2012 and 2018 was evaluated. Patients were classified according to their ASAPS as low (I and II) and high risk (III and IV). Surgical characteristics and improvement of symptoms and Quality of Life (QoL) were evaluated. RESULTS: The median age of high-risk group was higher than low-risk group. The high-risk group had more history of anticoagulation, antiaggregation, urinary catheterization, urinary retention and urethral stricture. Longer times of hospitalization (23.7 [interquartile range {IQR} = 18.9-41.35] vs 21.8 hours [IQR = 18.7-26.6], P = .008) and catheterization (19.55 [IQR = 15.6-35.57] vs 17.67 hours [IQR = 14.76-22.5], P = .004) were found in the high-risk group. Conversion and bleeding control were not different between groups. In the follow-up, improvement of International Prostate Symptoms Score (IPSS) and QoL was significant in all patients when compared before and after surgery scores (P < .001). There were no difference between groups for QoL, however, IPSS was lower for the low-risk group (8 [IQR = 4-14.5] vs 5 [2-12], P = .001). CONCLUSION: PVP with GreenLight Laser is a safe and efficient procedure for all patients despite their comorbidities, with comparable middle-term outcomes which makes it a standard treatment for the entire aging population, improving their QoL.

Outcome of Radiation Monotherapy for High-risk Patients with Stage I Esophageal Cancer.

Currently, chemoradiation is the most widely used nonsurgical treatment for esophageal cancer. However, some patients, particularly the very elderly or those with severe vital organ dysfunction, face difficulty with the chemotherapy component. We therefore examined the outcome of radiation therapy (RT) alone for patients with esophageal cancer at our facility. Between January 2005 and December 2014, 84 patients underwent RT at our hospital, and 78 of these patients received concomitant chemotherapy. The remaining 6 patients underwent RT alone; these patients were considered to be high-risk and to have no lymph node metastasis (stage I). Five of them received irradiation up to a curative dose: 4 showed a complete response (CR) and 1 showed a partial response (PR). Of the patients exhibiting CR, 3 are currently living recurrence-free, whereas 1 patient underwent endoscopic submucosal dissection (ESD) as salvage therapy for local recurrence, with no subsequent recurrence. High-risk stage I esophageal cancer patients can be treated radically with RT alone under certain conditions. In the future, to broaden the indications for RT monotherapy to include some degree of advanced cancers, a novel concurrent therapy should be identified.

One-Year Outcomes of Endovascular Aneurysm Repair in High-Risk Patients Using the Endurant Stent-Graft: Comparison of the ASA Classification and SVS/AAVS Medical Comorbidity Grading System for the Prediction of Mortality and Adverse Events.

PURPOSE: To evaluate the outcome and survival of patients with extensive comorbid conditions after endovascular aneurysm repair (EVAR) and objectify which of 2 medical comorbidity classifications is more accurate in predicting adverse outcomes. METHODS: All 1263 patients (mean age 73.1 years; 1129 men) treated using the Endurant Stent Graft system and entered in the prospective global postmarketing ENGAGE registry (ClinicalTrials.gov identifier NCT00870051) were grouped using the American Society of Anesthesiologists (ASA) classification and the Society for Vascular Surgery/American Association for Vascular Surgery (SVS/AAVS) medical comorbidity grading system. Patients assigned to ASA III and IV and SVS/AAVS 2 and 3 categories were considered high risk. Primary outcome was 1-year all-cause mortality. Secondary outcomes included technical and clinical success, major adverse events (MAE), aneurysm rupture, endoleaks, and secondary endovascular procedures. One-year follow-up of the entire ENGAGE cohort was the endpoint of the study. RESULTS: A total of 1263 patients were included. The overall technical success rate was high, the lowest being 97.4% in the ASA I group. The overall 30-day and 1-year Kaplan-Meier survival estimates were 98.7% and 92.5%, respectively. All cause 1-year mortality was higher in the ASA III and IV groups, but this did not reach statistical significance (5.2% and 5.7% for ASA I and II vs 9.0% and 9.9% for ASA III and IV, p=0.12). In the SVS/AAVS groups, 1-year all-cause mortality significantly increased with the SVS/AAVS score to 11.3% in the SVS/AAVS 3 group (p=0.002). There were significantly more MAEs in the SVS/AAVS 3 group at 1 year (p<0.001 for group 1 vs 3 and group 2 vs 3). CONCLUSION: Endovascular aneurysm repair has evolved, and high technical success and low mortality and morbidity can be achieved in high-risk patients. When treating high-risk patients, the perioperative risks should always be weighed against the expected gains. In contrast to the ASA classification, the SVS/AAVS medical comorbidity grading system is a useful tool to predict occurrence of MAEs and 1-year survival in patients undergoing EVAR.

A high-risk patient with long-QT syndrome with no response to cardioselective beta-blockers.

We present a case of a high-risk 19-year-old female with long-QT syndrome (LQTS) with compound mutations. She had a history of aborted cardiac arrest and syncope and had received treatment with propranolol for 15 years. However, because she developed adult-onset asthma we tried to switch propranolol, a nonselective beta-blocker, to beta-1-cardioselective agents, bisoprolol and metoprolol. These resulted in both a markedly prolonged corrected QT interval and the development of LQTS-associated arrhythmias. Eventually, propranolol was reinitiated at a higher dose with the addition of verapamil, and she has had no further cardiac or asthmatic events for 5 years.

Successful transcatheter aortic valve implantation for pure aortic regurgitation using a new second generation self-expanding J-Valve(TM) system - the first in-man implantation.

Transcatheter aortic valve implantation (TAVI) has been recognised as an effective treatment option for high-risk or inoperable patients with aortic stenosis. However, experience with TAVI for non-calcified aortic regurgitation is still limited. The new J-Valve(TM) prosthesis is designed for antegrade transapical implantation which is characterised by three U-shape graspers that could facilitate intuitive 'self-positioning' valve implantation and provide axial as well as radial fixation by embracing the native valve leaflets. Here we report the first in-man TAVI procedure of J-Valve(TM) prosthesis in a high risk patient with pure aortic regurgitation.

Introduction of an interdisciplinary heart team-based transcatheter aortic valve implantation programme: short and mid-term outcomes.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) has been developed to treat symptomatic aortic stenosis in patients deemed too high risk for open-heart surgery. To address this complex population, an interdisciplinary heart team approach was proposed. AIM: Present the short- and mid-term outcomes of the first 100 patients in the Royal Prince Alfred Hospital multidisciplinary TAVI programme. METHODS: Single-centre registry. Baseline and procedural data were prospectively recorded. Outcomes were recorded according to Valve Academic Research Consortium - version 2 guidelines. RESULTS: All patients underwent a comprehensive interdisciplinary pre-procedural evaluation. Sixty-eight transfemoral and 32 transapical implantations were performed. Mean age was 82 (±8.9) years old with an average logistic EuroSCORE of 33. Although 13 procedures had major complications, there was no intraprocedural mortality. During the first month, 9% of patients were re-admitted due to heart failure and 13% had a permanent pacemaker implanted. A 3% 30-day and 8% follow-up (mean 17 months) mortalities were recorded. While no significant differences in the rate of complications were found between the first and second half of the experience, all cases of mortality within 30 days (n = 3) occurred in the initial half. Sustained haemodynamic results were obtained with TAVI (immediate mean aortic valve gradient reduction from 47 to 9 mmHg; 1-year echocardiographic gradient 9.9 mmHg, with no moderate or severe aortic regurgitation). CONCLUSION: Excellent results can be achieved with TAVI in very high-risk patients at an Australian institution. A comprehensive evaluation based on a heart team can overcome most of the difficulties imposed by this challenging population.

Continuous spinal anaesthesia versus ultrasound-guided combined psoas compartment-sciatic nerve block for hip replacement surgery in elderly high-risk patients: a prospective randomised study.

BACKGROUND: Our aim is to compare the hemodynamic effects of combined psoas compartment-sciatic nerve block (PCSNB) with continuous spinal anaesthesia (CSA) in elderly high-risk patients undergoing hip replacement surgery. METHODS: Seventy patients over the age of 60 with ASA III or IV physical status were randomly allocated to two groups: In the PCSNB group, ultrasound-guided psoas compartment block was performed with modified Winnie technique using 30 mL of 0.25% bupivacaine with 1:200.000 epinephrine (5 µgr/mL) and iliac crest block was performed using the same local anaesthetic solution (5 mL). All patients in the PCSNB group needed continuing infusion of propofol (2 mg/kg/h) during operation. In the CSA group, CSA was performed in the L3-L4 interspaced with the patient in lateral decubitus position using 2.5 mg of isobaric bupivacaine 0.5%. When sensory block was not reached to the level of T12 within 10 minutes in the CSA group, additional 2.5 mg of isobaric bupivacaine 0.5% was administered through the catheter at 5-min intervals by limiting the total dose of 15 mg until a T12 level of the sensory block was achieved. RESULTS: The PCSNB group had significantly higher mean arterial blood pressure values at the beginning of surgery and at 5(th), 10(th) and 20(th) minutes of surgery compared to the CSA group (P = 0.038, P = 0.029, P = 0.012, P = 0.009 respectively). There were no significant differences between groups in terms of heart rate and peripheral oxygen saturation values during surgery and the postoperative period (P >0.05). Arterial hypotension required ephedrine was observed in 13 patients in the CSA and 4 patients in the PCSNB group (P =0.012). CONCLUSIONS: CSA and PCSNB produce satisfactory quality of anaesthesia in elderly high-risk patients with fewer hemodynamic changes in PCSNB cases compared with CSA cases. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry: ACTRN12614000658617, Registered 24 June 2014.

[Update of the S3-guideline on diagnostics, prophylaxis and treatment of osteoporosis]. / Update der S3-Leitlinie Diagnostik, Prophylaxe und Therapie der Osteoporose.

With the aid of a new fracture risk model, the great treatment gap for osteoporosis should be closed. All patients older than 70 years should undergo a diagnostic procedure for osteoporosis. An additional risk threshold (≥ 10% per 3 years for femoral and vertebral fractures) should enable patients with a high risk of fracture to be treated with osteoanabolic agents. The use of osteoanabolic agents makes it necessary to administer antiresorptive drugs afterwards. Due to the low event rate of osteonecrosis of the jaw, the initiation of a specific osteoporosis treatment should not be delayed by prophylactic dental treatment. The adherence to the drug treatment should be improved by an individualized approach on the basis of a cooperation between patients, caregivers, and physicians. A regular assessment of falls, including the timed up and go test should be carried out in patients older than 70 years.

Immediate implant placement in a dialysis patient. A case report.

Implant-supported rehabilitation in high-risk patients poses significant challenges for the dental team. The presence of comorbidities and increased infection risk can, for example, lead to a higher risk of implant loss. For the therapy to be completed with as few complications as possible, special anamnesis, detailed diagnostics, and a risk analysis based on those findings are indispensable. The aim of all considerations is to keep the risk of infection for the patient with a disease history to a minimum and to strive for an appropriate functional and esthetic therapeutic success. Particularly in the esthetic zone, in addition to the general health risks of the surgical procedure, esthetic aspects are increasingly taken into account in planning. The present article describes the implant-prosthetic replacement of a single anterior tooth in a dialysis patient. Several aspects (regular dialysis, missing buccal lamella, high smile line, functional risk) increased the risk of complications in this case.

Academic Detailing as a Health Information Technology Implementation Method: Supporting the Design and Implementation of an Emergency Department-Based Clinical Decision Support Tool to Prevent Future Falls.

BACKGROUND: Clinical decision support (CDS) tools that incorporate machine learning-derived content have the potential to transform clinical care by augmenting clinicians' expertise. To realize this potential, such tools must be designed to fit the dynamic work systems of the clinicians who use them. We propose the use of academic detailing-personal visits to clinicians by an expert in a specific health IT tool-as a method for both ensuring the correct understanding of that tool and its evidence base and identifying factors influencing the tool's implementation. OBJECTIVE: This study aimed to assess academic detailing as a method for simultaneously ensuring the correct understanding of an emergency department-based CDS tool to prevent future falls and identifying factors impacting clinicians' use of the tool through an analysis of the resultant qualitative data. METHODS: Previously, our team designed a CDS tool to identify patients aged 65 years and older who are at the highest risk of future falls and prompt an interruptive alert to clinicians, suggesting the patient be referred to a mobility and falls clinic for an evidence-based preventative intervention. We conducted 10-minute academic detailing interviews (n=16) with resident emergency medicine physicians and advanced practice providers who had encountered our CDS tool in practice. We conducted an inductive, team-based content analysis to identify factors that influenced clinicians' use of the CDS tool. RESULTS: The following categories of factors that impacted clinicians' use of the CDS were identified: (1) aspects of the CDS tool's design (2) clinicians' understanding (or misunderstanding) of the CDS or referral process, (3) the busy nature of the emergency department environment, (4) clinicians' perceptions of the patient and their associated fall risk, and (5) the opacity of the referral process. Additionally, clinician education was done to address any misconceptions about the CDS tool or referral process, for example, demonstrating how simple it is to place a referral via the CDS and clarifying which clinic the referral goes to. CONCLUSIONS: Our study demonstrates the use of academic detailing for supporting the implementation of health information technologies, allowing us to identify factors that impacted clinicians' use of the CDS while concurrently educating clinicians to ensure the correct understanding of the CDS tool and intervention. Thus, academic detailing can inform both real-time adjustments of a tool's implementation, for example, refinement of the language used to introduce the tool, and larger scale redesign of the CDS tool to better fit the dynamic work environment of clinicians.

[Comparison of SCORE and Reynolds cardiovascular risk assessments in a cohort without cardiovascular disease]. / A SCORE és a Reynolds cardiovascularis kockázatbecslés összehasonlítása cardiovascularis betegségtol mentes populáción.

INTRODUCTION: Cardiovascular risk assessment may help in the identification of symptom-free subjects with high cardiovascular risk. AIM: The author studied the correlation between SCORE and Reynolds risk assessment systems based on data from the cardiovascular risk screening program carried out in subjects without cardiovascular disease. METHOD: Data obtained from 4462 subjects (1977 men and 2485 women; mean age, 47,4 years) were analysed. The comparison was based on risk categories of the SCORE system. RESULTS: There was a strong correlation between the two scoring systems in the low risk population (under <2% SCORE risk the Spearman rho = 1, p < 0.001). A weak correlation was found in the medium risk group (between 3-4% the Spearman rho = 0.59-0.49, p < 0.001 and between 10-14% the Spearman rho = 0.42, ns.) and a stronger correlation in the high risk group (>15% the Spearmen rho = 0.8, p = 0.017). When correlations were analysed in gender and age categories, the weakest correlation was detected in medium risk women over 40 years of age. In cases when the differences between the two scoring systems were significant, the hsCRP levels were significantly higher (4.1 vs. 5.67 mg/L, p < 0.001). CONCLUSIONS: Introduction of hsCRP into cardiovascular risk assessments can refine the risk status of symptom-free subjects, especially among intermediate risk middle-age women (two-step risk assessment).

Nutrition for the high-risk surgical patient, when they need it most: Question and answer session.

Patients requiring complex or extensive surgery are often at high risk for perioperative and postoperative nutrition risk. Despite published guidelines, providing adequate nutrition to these patients continues to remain a clinical challenge. Using the case of a patient with preoperative nutrition risk who will need to undergo timely cancer resectional surgery, speakers presenting at the American Society for Parenteral and Enteral Nutrition 2022 Preconference discussed novel strategies to assess for nutrition risk, enhanced recovery after surgery, and preoperative and postoperative nutrition management in these often complex surgical patients.

The efficacy of high-flow nasal cannula (HFNC) versus non-invasive ventilation (NIV) in patients at high risk of extubation failure: a systematic review and meta-analysis.

BACKGROUND: Studies suggest that high-flow nasal cannula (HFNC) and non-invasive ventilation (NIV) can prevent reintubation in critically ill patients with a low risk of extubation failure. However, the safety and effectiveness in patients at high risk of extubation failure are still debated. Therefore, we conducted a systematic review and meta-analysis to compare the efficacies of HFNC and NIV in high-risk patients. METHODS: We searched eight databases (MEDLINE, Cochrane Library, EMBASE, CINAHL Complete, Web of Science, China National Knowledge Infrastructure, Wan-Fang Database, and Chinese Biological Medical Database) with reintubation as a primary outcome measure. The secondary outcomes included mortality, intensive care unit (ICU) length of stay (LOS), incidence of adverse events, and respiratory function indices. Statistical data analysis was performed using RevMan software. RESULTS: Thirteen randomized clinical trials (RCTs) with 1457 patients were included. The HFNC and NIV groups showed no differences in reintubation (RR 1.10, 95% CI 0.87-1.40, I2 = 0%, P = 0.42), mortality (RR 1.09, 95% CI 0.82-1.46, I2 = 0%, P = 0.54), and respiratory function indices (partial pressure of carbon dioxide [PaCO2]: MD - 1.31, 95% CI - 2.76-0.13, I2 = 81%, P = 0.07; oxygenation index [P/F]: MD - 2.18, 95% CI - 8.49-4.13, I2 = 57%, P = 0.50; respiratory rate [Rr]: MD - 0.50, 95% CI - 1.88-0.88, I2 = 80%, P = 0.47). However, HFNC reduced adverse events (abdominal distension: RR 0.09, 95% CI 0.04-0.24, I2 = 0%, P < 0.01; aspiration: RR 0.30, 95% CI 0.09-1.07, I2 = 0%, P = 0.06; facial injury: RR 0.27, 95% CI 0.09-0.88, I2 = 0%, P = 0.03; delirium: RR 0.30, 95%CI 0.07-1.39, I2 = 0%, P = 0.12; pulmonary complications: RR 0.67, 95% CI 0.46-0.99, I2 = 0%, P = 0.05; intolerance: RR 0.22, 95% CI 0.08-0.57, I2 = 0%, P < 0.01) and may have shortened LOS (MD - 1.03, 95% CI - 1.86-- 0.20, I2 = 93%, P = 0.02). Subgroup analysis by language, extubation method, NIV parameter settings, and HFNC flow rate revealed higher heterogeneity in LOS, PaCO2, and Rr. CONCLUSIONS: In adult patients at a high risk of extubation failure, HFNC reduced the incidence of adverse events but did not affect reintubation and mortality. Consequently, whether or not HFNC can reduce LOS and improve respiratory function remains inconclusive.

Age, successive waves, immunization, and mortality in elderly COVID-19 hematological patients: EPICOVIDEHA findings.

OBJECTIVES: Elderly patients with hematologic malignancies face the highest risk of severe COVID-19 outcomes. The infection's impact on different age groups remains unstudied in detail. METHODS: We analyzed elderly patients (age groups: 65-70, 71-75, 76-80, and >80 years old) with hematologic malignancies included in the EPICOVIDEHA registry between January 2020 and July 2022. Univariable and multivariable Cox regression models were conducted to identify factors influencing death in COVID-19 patients with hematological malignancy. RESULTS: The study included data from 3,603 elderly patients (aged 65 or older) with hematological malignancy, with a majority being male (58.1%) and a significant proportion having comorbidities. The patients were divided into four age groups, and the analysis assessed COVID-19 outcomes, vaccination status, and other variables in relation to age and pandemic waves. The 90-day survival rate for patients with COVID-19 was 71.2%, with significant differences between groups. The pandemic waves had varying impacts, with the first wave affecting patients over 80 years old, the second being more severe in 65-70, and the third being the least severe in all age groups. Factors contributing to 90-day mortality included age, comorbidities, lymphopenia, active malignancy, acute leukemia, less than three vaccine doses, severe COVID-19, and using only corticosteroids as treatment. CONCLUSION: These data underscore the heterogeneity of elderly hematological patients, highlight the different impacts of COVID-19 waves and the pivotal importance of vaccination, and may help in planning future healthcare efforts.

Prophylactic Awake Peripheral V-A ECMO during TAVR.

INTRODUCTION: TAVR remains a complex procedure that may result in serious intraprocedural complications. In many of these circumstances, venoarterial extracorporeal membrane oxygenation (V-A ECMO) helps to manage complications, provides a hemodynamic back-up, and bridges to an emergency open heart surgery. The clinical outcomes of 27 patients who underwent prophylactic implantation of peripheral V-A ECMO (pV-A ECMO) during high-risk transcatheter aortic valve replacement (TAVR) cases are described. METHODS: From June 2012 to October 2022, 590 consecutive patients underwent TAVR at our center. Of these, 27 patients (4.5%) underwent TAVR with pV-AECMO because they were deemed very high risk for periprocedural complications and formed the study population. RESULTS: There were no pV-A ECMO, hemodynamic or TAVR implantation complications. Decannulation of the ECMO system was performed in 92.6% of cases at the end of the procedure in the hybrid-operating theatre. The mean duration of pV-A ECMO for procedure support was 51.4 ± 10.3 min. There were no ECMO-related vascular or bleeding complications. CONCLUSION: This study shows that the prophylactic placement of awake peripheral V-A ECMO provides excellent temporary cardio-circulatory and pulmonary support during very high-risk TAVR procedures.