Atrial Flutter After Radiofrequency Ablation for Barrett's Esophagus: A Case Report.

BACKGROUND Barrett's esophagus (BE) is a metaplastic change in the normal esophageal squamous epithelium and is a well-recognized precursor of esophageal adenocarcinoma (EAC). Nowadays, focal radiofrequency ablation is a valid technique for BE treatment by inducing a superficial and focal thermic destruction of metaplastic tissues. According to the literature, the most frequent patient-related adverse events of this procedure are esophageal iatrogenic stenosis, mucosal laceration or perforation of the esophagus, chest pain, and odynophagia/dysphagia. Postoperative heart rhythm abnormalities have been reported very rarely. CASE REPORT A 74-year-old patient with HE was treated by radiofrequency ablation (RFA) with the Barrx™ catheter system. He had 2 symptomatic episodes of atrial flutter in the immediate postoperative period requiring an external electrical cardioversion to induce a return to sinus cardiac rhythm. After atrial flutter ablation, 2 more radiofrequency procedures were performed, without adverse events. A laparoscopic Nissen fundoplication was carried out with complete endoscopic and histologic eradication of BE after 12-month follow-up. To the best of our knowledge, this is the first reported case of atrial flutter after esophageal RFA. Different mechanisms acting on an anatomic predisposing substrate can potentially play a role in starting atrial flutter, and include inflammation, autonomic activation, and myocardial injury. CONCLUSIONS The occurrence of this new type of adverse effect could potentially modify indications and postoperative monitoring of RFA treatment for BE. Endoscopists should know the possibility of this procedural complication in high-risk patients and they should propose alternative techniques or implement close cardiac monitoring in the postoperative period.

Creatinine Clearance Measurement with Bioelectrical Impedance Analysis in Heart Failure Patients: Comparison with Estimated-Creatinine Clearance Formulas.

BACKGROUND: Kidney disease is common in patients with heart failure (HF). The Donadio equation combines plasma creatinine and bioimpedance vector analysis (BIVA) to estimate creatinine clearance. This study aimed to compare the Donadio formula to the Cockcroft-Gault (CG), Modification of Diet in Renal Disease Study (MDRD-4), and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations in patients with HF. METHODS: We analysed data from 900 patients (mean age: 76 ± 10 years) with HF. All of them underwent clinical, laboratory, BIVA, and echocardiographic evaluations. RESULTS: Donadio equation overestimated eGFR as compared to CG and CKD-EPI formulas (+6.8 and +12 mL/min/1.73 m2, respectively) while computing similar results to MDRD-4 (overestimation: +0.1 mL/min/1.73 m2). According to the different formulas, the prevalence of renal insufficiency (eGFR< 30 ml/min/1.73 m2) in relation to the different formulas was as follows: 24% with Donadio, 21% with CG, 13% with MDRD-4, and 23% with CKD-EPI formulas. All the equations demonstrated a high precision rate (r>0.8 for all). There was a "good" agreement between the Donadio and CG/MDRD-4 formulas and "fair" with the CDK-EPI formula. The Donadio equation showed a high accuracy in predicting severe renal dysfunction (eGFR< 30 mL/min/1.73 m2) in patients with HF (AUC > 0.9), showing comparable performances to CG. CONCLUSION: The Donadio formula provided an estimation of GFR comparable to MDRD-4 in HF patients, independently from acute or chronic HF conditions. The use of BIVA in HF patients may be adopted both for HF management and for evaluating kidney function.

Plasma Levels of Intact Parathyroid Hormone and Congestion Burden in Heart Failure: Clinical Correlations and Prognostic Role.

Circulating parathyroid hormone (PTH) concentrations increase in heart failure (HF) and are related to disease severity. The relationship between PTH and congestion is still a matter of debate. The objective of this analysis was to evaluate the role of PTH as a marker of congestion and prognosis in HF. We enrolled 228 patients with HF. Intact PTH concentrations and HYDRA score (constituted by: B-type natriuretic peptide, blood urea nitrogen−creatinine ratio, estimated plasma volume status, and hydration status) were evaluated. The study endpoint was all-cause mortality. PTH levels were higher in acute compared with chronic HF and in patients with clinical signs of congestion (i.e., peripheral oedema and orthopnea). PTH concentrations significantly correlated with NYHA class and HYDRA score. At multivariate analysis of HYDRA score, estimated glomerular filtration rate (eGFR), and corrected serum calcium were independently determinants of PTH variability. Fifty patients (22%) died after a median follow-up of 408 days (interquartile range: 283−573). Using univariate Cox regression analysis, PTH concentrations were associated with mortality (hazard ratio [HR]: 1.003, optimal cut-off: >249 pg/mL­area under-the-curve = 0.64). Using multivariate Cox regression analysis, PTH was no longer associated with death, whereas HYDRA score, left ventricular ejection fraction, and eGFR acted as independent predictors for mortality (HR: 1.96, 0.97, and 0.98, respectively). Our study demonstrated that intact PTH was related to clinical and subclinical markers of congestion. However, intact PTH did not act as an independent determinant of all-cause death in HF patients.

Rare species disproportionally contribute to functional diversity in managed forests.

Functional diversity is linked with critical ecosystem functions, yet its relationship with numerical diversity, e.g. species richness, is not fully understood. The mechanisms linking changes of species richness, e.g. random and non-random species losses and gains, with changes of functional diversity become more relevant in the face of rapid environmental changes. In particular, non-random species changes including rare species may affect functional diversity, and the overall ecosystem function, disproportionately compared to random species changes including common species. In this study, I investigated how changes in numerical diversity of bird assemblages are related to functional diversity, and how the environment, and in particular forest management, influences such a relationship. I collected bird count data in the extensively-managed forest landscape of the Black Forest (Germany), at 82 sampling sites over three years. Data included species richness and abundance per site, and functional traits related to diet and habitat type for each species to compute functional diversity. By partitioning numerical diversity changes into five components using Price Equations, I calculated the contribution of random and non-random species losses and gains, and the abundance of common species, to functional diversity. Then I modelled these contributions as a function of several environmental variables describing broad forest conditions, and including forest management intensity. I found that, beside the major contribution of random species losses to functional diversity, non-random species losses also play a role, indicating that rare species that contribute more to functional diversity are often lost earlier than common species. The overall contribution to functional diversity of species losses is larger than that of species gains, pointing toward an ongoing simplification of the forest bird assemblage. Among all Price components, random species gains were influenced by management intensity, while other components were not influenced by any management variable. This highlight that potential conservation actions may not be effective in halting ecosystem functioning decline, as species gains do not result in increased functional diversity.

Respiratory failure and bioelectrical phase angle are independent predictors for long-term survival in acute heart failure.

Background. The assessment of long-term mortality in acute decompensated heart failure (ADHF) is challenging. Respiratory failure and congestion play a fundamental role in risk stratification of ADHF patients. The aim of this study was to investigate the impact of arterial blood gases (ABG) and congestion on long-term mortality in patients with ADHF. Methods and results. We enrolled 252 patients with ADHF. Brain natriuretic peptide (BNP), blood urea nitrogen (BUN), phase angle as assessed by means of bioimpedance vector analysis, and ABG analysis were collected at admission. The endpoint was all-cause mortality. At a median follow-up of 447 d (interquartile range [IQR]: 248-667), 72 patients died 1-840 d (median 106, IQR: 29-233) after discharge. Respiratory failure types I and II were observed in 78 (19%) and 53 (20%) patients, respectively. The ROC analyses revealed that the cut-off points for predicting death were: BNP > 441 pg/mL, BUN > 1.67 mmol/L, partial pressure in oxygen (PaO2) ≤69.7 mmHg, and phase angle ≤4.9°. Taken together, these four variables proved to be good predictors for long-term mortality in ADHF (area under the curve [AUC] 0.78, 95% CI 0.72-0.78), thus explaining 60% of all deaths. A multiparametric score based on these variables was determined: each single-unit increase promoted a 2.2-fold augmentation of the risk for death (hazard ratio [HR] 2.2, 95% CI 1.8-2.8, p< .0001). Conclusions. A multiparametric approach based on measurements of BNP, BUN, PaO2, and phase angle is a reliable approach for long-term prediction of mortality risk in patients with ADHF.

Sex Differences in the Evaluation of Congestion Markers in Patients with Acute Heart Failure.

The impact of sex on the assessment of congestion in acute heart failure (AHF) is still a matter of debate. The objective of this analysis was to evaluate sex differences in the evaluation of congestion at admission in patients hospitalized for AHF. We consecutively enrolled 494 AHF patients (252 female). Clinical congestion assessment, B-type natriuretic peptide levels analysis, blood urea nitrogen to creatinine ratio (BUN/Cr), plasma volume status estimate (by means of Duarte or Kaplam-Hakim PVS), and hydration status evaluation through bioimpedance analysis were performed. There was no difference in medications between men and women. Women were older (79 ± 9 yrs vs. 77 ± 10 yrs, p = 0.005), and had higher left ventricular ejection fraction (45 ± 11% vs. 38 ± 11%, p < 0.001), and lower creatinine clearance (42 ± 25 mL/min vs. 47 ± 26 mL/min, p = 0.04). The prevalence of peripheral oedema, orthopnoea, and jugular venous distention were not significantly different between women and men. BUN/Cr (27 ± 9 vs. 23 ± 13, p = 0.04) and plasma volume were higher in women than men (Duarte PVS: 6.0 ± 1.5 dL/g vs. 5.1 ± 1.5 dL/g, p < 0.001; Kaplam−Hakim PVS: 7.9 ± 13% vs. −7.3 ± 12%, p < 0.001). At multivariate logistic regression analysis, female sex was independently associated with BUN/Cr and PVS. Female sex was independently associated with subclinical biomarkers of congestion such as BUN/Cr and PVS in patients with AHF. A sex-guided approach to the correct evaluation of patients with AHF might become the cornerstone for the correct management of these patients.

Species co-occurrence and management intensity modulate habitat preferences of forest birds.

BACKGROUND: Species co-occurrences can have profound effects on the habitat use of species, and therefore habitat structure alone cannot fully explain observed abundances. To account for this aspect of community organization, we developed multi-species abundance models, incorporating the local effect of co-occurring and potentially associated species, alongside with environmental predictors, linked mainly to forest management intensity. We coupled it with a landscape-scale analysis to further examine the role of management intensity in modifying the habitat preferences in connection with the landscape context. Using empirical data from the Black Forest in southern Germany, we focused on the forest bird assemblage and in particular on the cavity-nesting and canopy-foraging guilds. We included in the analysis species that co-occur and for which evidence suggests association is likely. RESULTS: Our findings show that the local effect of species associations can mitigate the effects of management intensity on forest birds. We also found that bird species express wider habitat preferences in forests under higher management intensity, depending on the landscape context. CONCLUSIONS: We suspect that species associations may facilitate the utilization of a broader range of environmental conditions under intensive forest management, which benefits some species over others. Networks of associations may be a relevant factor in the effectiveness of conservation-oriented forest management.

Birds seen and not seen during the COVID-19 pandemic: The impact of lockdown measures on citizen science bird observations.

In early 2020, the rapid spread of the novel coronavirus disease 2019 (COVID-19) led multiple countries to introduce strict lockdown measures to contain the pandemic. Movement restrictions may have influenced the ability of the public to contribute to citizen science projects. We investigated how stay-at-home orders affected data submitted by birdwatchers in Italy, Spain and the United Kingdom (UK) to a widely-used citizen science platform, iNaturalist, depending on whether observations were collected in urban or non-urban areas. We found significant trends in the daily number of observations in all three countries, indicating a surge in urban observation during lockdowns. We found an increase in the mean daily number of urban observations during the lockdown in Italy and Spain, compared to previous years. The mean daily number of non-urban observations decreased in Italy and Spain, while remained similar to previous years in the UK. We found a general decrease of new records during the lockdowns both in urban and non-urban areas in all countries. Our results suggest that the citizen science community remained active during the lockdowns and kept reporting birds from home. However, limitations to movements may have hampered the possibility of birdwatchers to explore natural areas and collect new records. Our findings suggest that future research and conservation applications of citizen science data should carefully consider the bias and gaps in data series caused by the pandemic. Furthermore, our study highlights the potential of urban areas for nature activities, such as birdwatching, and its relevance for sustainable urban planning.

Time-for-space substitution in N-mixture models for estimating population trends: a simulation-based evaluation.

N-mixture models usually rely on a meta-population design, in which repeated counts of individuals in multiple sampling locations are obtained over time. The time-for-space substitution (TSS) in N-mixture models allows to estimate population abundance and trend of a single population, without spatial replication. This application could be of great interest in ecological studies and conservation programs; however, its reliability has only been evaluated on a single case study. Here we perform a simulation-based evaluation of this particular application of N-mixture modelling. We generated count data, under 144 simulated scenarios, from a single population surveyed several times per year and subject to different dynamics. We compared simulated abundance and trend values with TSS estimates. TSS estimates are overall in good agreement with real abundance. Trend and abundance estimation is mainly affected by detection probability and population size. After evaluating the reliability of TSS, both against real world data, and simulations, we suggest that this particular application of N-mixture model could be reliable for monitoring abundance in single populations of rare or difficult to study species, in particular in cases of species with very narrow geographic ranges, or known only for few localities.

Biodiversity response to forest management intensity, carbon stocks and net primary production in temperate montane forests.

Managed forests are a key component of strategies aimed at tackling the climate and biodiversity crises. Tapping this potential requires a better understanding of the complex, simultaneous effects of forest management on biodiversity, carbon stocks and productivity. Here, we used data of 135 one-hectare plots from southwestern Germany to disentangle the relative influence of gradients of management intensity, carbon stocks and forest productivity on different components of forest biodiversity (birds, bats, insects, plants) and tree-related microhabitats. We tested whether the composition of taxonomic groups varies gradually or abruptly along these gradients. The richness of taxonomic groups was rather insensitive to management intensity, carbon stocks and forest productivity. Despite the low explanatory power of the main predictor variables, forest management had the greatest relative influence on richness of insects and tree-related microhabitats, while carbon stocks influenced richness of bats, birds, vascular plants and pooled taxa. Species composition changed relatively abruptly along the management intensity gradient, while changes along carbon and productivity gradients were more gradual. We conclude that moderate increases in forest management intensity and carbon stocks, within the range of variation observed in our study system, might be compatible with biodiversity and climate mitigation objectives in managed forests.

What do tree-related microhabitats tell us about the abundance of forest-dwelling bats, birds, and insects?

Retaining trees during harvesting to conserve biodiversity is becoming increasingly common in forestry. To assess, select and monitor these habitat trees, ecologists and practitioners often use Tree-related Microhabitats (TreMs), which are assumed to represent the abundance and diversity of environmental resources for a wide range of forest-dwelling taxa. However, the relationship between TreMs and forest organisms is not fully understood. In this context, we attempted to identify and quantify the links between TreMs and three groups of forest organisms: insects, bats, and birds. Specifically, we tested whether species abundance is influenced by TreM abundance, either as direct predictor or as mediator of environmental predictors. We collected data in 86 temperate, 1-ha mixed forest plots and employed a hierarchical generalized mixed model to assess the influence of seven environmental predictors (aspect, number and height of standing dead trees, cover of herb and shrub layer, volume of lying deadwood, and terrain ruggedness index (TRI)) on the abundance of TreMs (15 groups) on potential habitat trees, insects (10 orders), bats (5 acoustic groups) and birds (29 species) as a function of seven environmental predictors: aspect, number and height of standing dead trees, cover of herb and shrub layer, volume of lying deadwood, and terrain ruggedness index (TRI). This allowed us to generate a correlation matrix with potential links between abundances of TreMs and co-occurring forest organisms. These correlations and the environmental predictors were tested in a structural equation model (SEM) to disentangle and quantify the effects of the environment from direct effects of TreMs on forest organisms. Four TreM groups showed correlations > |0.30| with forest organisms, in particular with insects and bats. Rot holes and concavities were directly linked with three insect groups and two bat groups. Their effect was smaller than effects of environmental predictors, except for the pairs "rot holes - Sternorrhyncha" and "rot holes - bats" of the Pipistrellus group. In addition, TreMs had indirect effects on forest organisms through mediating the effects of environmental predictors. We found significant associations between two out of fifteen TreM groups and five out of 44 forest organism groups. These results indicate that TreM abundance on potential habitat trees is not suited as a general indicator of the species abundance across broad taxonomic groups but possibly for specific target groups with proven links.

Evaluating the effectiveness of retention forestry to enhance biodiversity in production forests of Central Europe using an interdisciplinary, multi-scale approach.

Retention forestry, which retains a portion of the original stand at the time of harvesting to maintain continuity of structural and compositional diversity, has been originally developed to mitigate the impacts of clear-cutting. Retention of habitat trees and deadwood has since become common practice also in continuous-cover forests of Central Europe. While the use of retention in these forests is plausible, the evidence base for its application is lacking, trade-offs have not been quantified, it is not clear what support it receives from forest owners and other stakeholders and how it is best integrated into forest management practices. The Research Training Group ConFoBi (Conservation of Forest Biodiversity in Multiple-use Landscapes of Central Europe) focusses on the effectiveness of retention forestry, combining ecological studies on forest biodiversity with social and economic studies of biodiversity conservation across multiple spatial scales. The aim of ConFoBi is to assess whether and how structural retention measures are appropriate for the conservation of forest biodiversity in uneven-aged and selectively harvested continuous-cover forests of temperate Europe. The study design is based on a pool of 135 plots (1 ha) distributed along gradients of forest connectivity and structure. The main objectives are (a) to investigate the effects of structural elements and landscape context on multiple taxa, including different trophic and functional groups, to evaluate the effectiveness of retention practices for biodiversity conservation; (b) to analyze how forest biodiversity conservation is perceived and practiced, and what costs and benefits it creates; and (c) to identify how biodiversity conservation can be effectively integrated in multi-functional forest management. ConFoBi will quantify retention levels required across the landscape, as well as the socio-economic prerequisites for their implementation by forest owners and managers. ConFoBi's research results will provide an evidence base for integrating biodiversity conservation into forest management in temperate forests.

Retention as an integrated biodiversity conservation approach for continuous-cover forestry in Europe.

Retention forestry implies that biological legacies like dead and living trees are deliberately selected and retained beyond harvesting cycles to benefit biodiversity and ecosystem functioning. This model has been applied for several decades in even-aged, clearcutting (CC) systems but less so in uneven-aged, continuous-cover forestry (CCF). We provide an overview of retention in CCF in temperate regions of Europe, currently largely focused on habitat trees and dead wood. The relevance of current meta-analyses and many other studies on retention in CC is limited since they emphasize larger patches in open surroundings. Therefore, we reflect here on the ecological foundations and socio-economic frameworks of retention approaches in CCF, and highlight several areas with development potential for the future. Conclusions from this perspective paper, based on both research and current practice on several continents, although highlighting Europe, are also relevant to other temperate regions of the world using continuous-cover forest management approaches.

Diversification of forest management regimes secures tree microhabitats and bird abundance under climate change.

The loss of biodiversity in temperate forests due to combined effect of climate change and forest management poses a major threat to the functioning of these ecosystems in the future. Climate change is expected to modify ecological processes and amplify disturbances, compromising the provisioning of multiple ecosystem services. Here we investigate the impacts of climate change and forest management on the abundance of tree microhabitats and forest birds as biodiversity proxies, using an integrated modelling approach. To perform our analysis, we calibrated tree microhabitat and bird abundance in a forest landscape in Southwestern Germany, and coupled them with a climate sensitive forest growth model. Our results show generally positive impacts of climate warming and higher harvesting intensity on bird abundance, with up to 30% increase. Conversely, climate change and wood removals above 5% of the standing volume led to a loss of tree microhabitats. A diversified set of management regimes with different harvesting intensities applied in a landscape scale was required to balance this trade-off. For example, to maximize the expected bird abundance (up to 11%) and to avoid tree microhabitat abundance loss of >20% necessitates setting aside 10.2% of the forest area aside and application of harvesting intensities < 10.4% of the standing volume. We conclude that promoting forest structural complexity by diversifying management regimes across the landscape will be key to maintain forest biodiversity in temperate forests under climate change.

Complications related to endoscopic lung volume reduction for emphysema with endobronchial valves: results of a multicenter study.

BACKGROUND: Despite bronchoscopic lung volume reduction (BLVR) with valves is a minimally invasive treatment for emphysema, it can associate with some complications. We aimed at evaluating the rate and type of complications related to valve treatment and their impact on clinical outcomes. METHODS: It is a retrospective multicenter study including all consecutive patients with severe heterogeneous emphysema undergoing BLVR with endobronchial valve treatment and developed any complications related to this procedure. The type of complication, the time of onset, the treatment required and the out-come were evaluated. Response to treatment was assessed according to the minimal clinically important difference (MCID) as follows: an improvement of ≥15% in forced expiratory volume in one second (FEV1); of -8% in residual volume (RV); of ≥26 m in 6-minnute walking distance (6MWD); and of ≥4 points on the St. George's Respiratory Questionnaire (SGRQ). Target lobe volume reduction (TLVR) ≥350 mL was considered significant. RESULTS: One hundred and seven out of 423 (25.3%) treated patients had complications related to valve treatment including pneumothorax (17.3%); pneumonia (1.7%), chronic obstructive pulmonary disease (COPD) exacerbation (0.9%), respiratory failure (1.4%), valve migration (2.1%), and hemoptysis (1.9%). In all cases complications resolved with appropriate treatment including removal of valves in 21/107 cases (19.6%). Patients with TLVR ≥350 mL (n=64) vs. those <350 mL (n=43) had a statistically significant higher improvement in FEV1 (19.0%±3.9% vs. 3.0%±0.9%; P=0.0003); in RV (-10.0%±4.8% vs. -4.0%±2.9%; P=0.002); in 6MWD (33.0±19.0 vs. 12.0±6.3 metres; P=0.001); and in SGRQ (-15.0±2.9 vs. -8.0±3.5 points; P=0.01). Only patients with TLVR ≥350 mL met or exceeded the MCID cut-off criteria for FEV1 (19.0%±3.9%), RV (-10.0%±4.8%), 6MWT (33.0±19.0 metres), and SGQR (-15.0±2.9 points). Five patients (1.2%) died during follow-up for causes not related to valves treatment neither to any of the complications described. CONCLUSIONS: Valve treatment is a safe and reversible procedure. The presence of complications seems not to have a significant impact on clinical outcome in patients with lobar atelectasis. Due to poor clinical conditions and possible complications, BLVR should be performed in high volume centers with a multidisciplinary approach.

Advances in Methanol Production and Utilization, with Particular Emphasis toward Hydrogen Generation via Membrane Reactor Technology.

Methanol is currently considered one of the most useful chemical products and is a promising building block for obtaining more complex chemical compounds, such as acetic acid, methyl tertiary butyl ether, dimethyl ether, methylamine, etc. Methanol is the simplest alcohol, appearing as a colorless liquid and with a distinctive smell, and can be produced by converting CO2 and H2, with the further benefit of significantly reducing CO2 emissions in the atmosphere. Indeed, methanol synthesis currently represents the second largest source of hydrogen consumption after ammonia production. Furthermore, a wide range of literature is focused on methanol utilization as a convenient energy carrier for hydrogen production via steam and autothermal reforming, partial oxidation, methanol decomposition, or methanol⁻water electrolysis reactions. Last but not least, methanol supply for direct methanol fuel cells is a well-established technology for power production. The aim of this work is to propose an overview on the commonly used feedstocks (natural gas, CO2, or char/biomass) and methanol production processes (from BASF-Badische Anilin und Soda Fabrik, to ICI-Imperial Chemical Industries process), as well as on membrane reactor technology utilization for generating high grade hydrogen from the catalytic conversion of methanol, reviewing the most updated state of the art in this field.

Sleep Disturbances in COPD are Associated with Heterogeneity of Airway Obstruction.

Individuals with Chronic Obstructive Pulmonary Disease (COPD) experience sleep disturbances due to the impact of respiratory symptoms on sleep quality. We explored whether sleep disturbances in COPD are linked to heterogeneity of airway constriction. The impact of breathing problems on sleep quality was measured in consecutive COPD outpatients with the COPD and Asthma Sleep Impact Scale (CASIS) questionnaire. Impulse oscillometry technique (IOS) was employed to assess heterogeneity of airway constriction. Subjects with a previous or concomitant diagnosis of asthma or obstructive sleep apnea (OSA) were excluded. Fifty COPD subjects (M/F 40/10; age: 71 ± 8 yrs, Body Mass Index (BMI): 26.2 ± 4.7 kg/m2, Forced Expiratory Volume in the first second (FEV1): 65 ± 25% predicted; mean ± SD) were enrolled. The mean CASIS score was 36 ± 3.3, and the R5-R20 value was 0.2 ± 0.15 kPa s L-1. The CASIS score was significantly higher in subjects with increased R5-R20 (>0.07 kPa s L-1) (39 ± 24; p = 0.02) compared to normal R5-R20 (21 ± 17). When subjects were categorized on the basis of lung function in severely versus non severely obstructed (FEV1 ≤ or >50% predicted) or air trappers versus non air trappers (Residual Volume, RV ≥ or <120% predicted) the CASIS score remained unchanged (for FEV1: 37 ± 23 versus 33 ± 25, respectively, p = 0.61; for RV: 30 ± 20 versus 40 ± 23, p = 0.16). Sleep disturbances due to COPD symptoms are associated with heterogeneity of airway constriction, possibly reflecting peripheral airway dysfunction.

Use of autobilevel ventilation in patients with obstructive sleep apnea: An observational study.

Continuous positive airway pressure (CPAP) is the first-choice treatment for obstructive sleep-disordered breathing. Automatic bilevel ventilation can be used to treat obstructive sleep-disordered breathing when CPAP is ineffective, but clinical experience is still limited. To assess the outcome of titration with CPAP and automatic bilevel ventilation, the charts of 356 outpatients (obstructive sleep apnea, n = 242; chronic obstructive pulmonary disease + obstructive sleep apnea overlap, n = 80; obesity hypoventilation syndrome [OHS], n = 34; 103 females) treated for obstructive sleep-disordered breathing from January 2014 to April 2017 were reviewed. Positive airway pressure titration was considered successful in the case of sleep-disordered breathing resolution (apnea-hypopnea index <10/hr) with cumulative time at SaO2  < 90% (CT90%) <10% and/or improved daytime arterial blood gases at the end of titration. CPAP was effective in 268 patients (75.0%). CPAP treatment failure (n = 88) occurred in 13.6% of obstructive sleep apnea, 32.5% of overlap, and 85.3% of OHS patients. Compared with successful CPAP cases, patients undergoing the automatic bilevel ventilation trial showed higher body mass index (39.3 ± 10.5 kg/m2 versus 34.8 ± 6.9 kg/m2 , p < 0.0001), worse mean nocturnal SaO2 (89.2 ± 4.0% versus 91.3 ± 4.0%, p < 0.003) and CT90% (40.6 ± 28.6% versus 24.0 ± 23.3%), but similar age (62.8 ± 11.9 years versus 60.5 ± 12.0 years, p = 0.11), apnea-hypopnea index (39.4 ± 23.2/hr versus 41.0 ± 21.2/hr, p = 0.55) and oxygen desaturation index (37.8 ± 23.5/hr versus 39.2 ± 21.1/hr, p = 0.61) at diagnosis. Automatic bilevel ventilation was successful in 79.5% of CPAP treatment failures (n = 70). Automatic bilevel ventilation failure was independently associated with baseline body mass index >40 kg/m2 (odds ratio 6.16, confidence interval 1.50-25.17, p = 0.011) and CT90% >42% (odds ratio 5.87, confidence interval 1.39-24.83, p = 0.016). During follow-up, automatic bilevel ventilation treatment failed in seven patients (10%), and compliance was similar in CPAP (4.5 ± 2.2 hr) and automatic bilevel ventilation (5.2 ± 2.3 hr, p = 0.09) groups. Automatic bilevel ventilation was useful to treat sleep-disordered breathing, but failed in patients with severe OHS.

Revascularization strategies in STEMI with multivessel disease: when and how.

Acute ST-segment elevation myocardial infarction (STEMI) typically arises from total occlusion of an epicardial coronary artery, most often due to atherosclerotic plaque rupture/erosion and subsequent thrombus formation. Granted this, important angiographic information for patients presenting with STEMI is not only about the status of infarct-related artery (IRA) but also about the atherosclerotic disease burden and disease severity of non-IRA vessels. Previous studies have reported that multivessel coronary artery disease is found in approximately 50% of patients with STEMI undergoing primary percutaneous coronary intervention (PCI). Primary PCI is now considered the gold standard in the treatment for patients with STEMI; however, the optimal reperfusion strategy in patients with STEMI and multivessel disease (MVD) remains uncertain. In this review, we summarize the available evidence on treatment options for patients with STEMI and MVD and highlight current guideline recommendations on this topic.