Investigation of the Association between Bilateral Selective Anterograde Cerebral Perfusion and Postoperative Ischemic Stroke in Obese Patients with Emergency Surgery for Acute Type A Aortic Dissection.

Background and objectives: The relationship between cerebral perfusion and new postoperative ischemic stroke in obese patients is not well defined. The aim of this study was to investigate the association between selective bilateral anterograde cerebral perfusion and new postoperative ischemic stroke in obese patients with emergency surgery for acute type A aortic dissection. Materials and methods: A total of 292 patients with emergency surgery for acute type A aortic dissection were included in this study. Patients with hemorrhagic stroke or ischemic stroke with severe neurological dysfunction at admission that were not candidates for surgery; patients who died in the first 48 h after intensive care admission and patients with incomplete medical records were excluded. Results: The mean age was 59.42 ± 10.68 years and the mean Euroscore was 9.12 ± 1.63. Obesity was present in 76.4%, the incidence of new postoperative ischemic stroke was 27.5%, and the postoperative mortality rate was 26.7%. The mean cardiopulmonary bypass time was 206.81 ± 75.48 min, the aortic cross-clamp time was 118.2 ± 46.42 min, and 90% of cases required cerebral perfusion. The mean cerebral perfusion time was 30.8 ± 24.41 min. Obese patients had a higher frequency of in-hospital death (p = 0.009), smoking (p = 0.036), hypertension (p = 0.023), left common carotid artery dissection (p < 0.001), right common carotid artery dissection (p = 0.029), femoral artery cannulation (p = 0.026), aortic root replacement (p = 0.009), aortic valve replacement (p = 0.005) and early reintervention for bleeding (p = 0.004). Using logistic regression, selective bilateral anterograde cerebral perfusion over 40 min in obese patients was independently associated with new postoperative ischemic stroke (OR = 2.35; 95%CI = 1.36-4.86; p = 0.021). Conclusions: A patient-tailored strategy for cerebral perfusion should be considered in obese patients, considering the high atheromatous burden of the supra-aortic vessels in these patients and the potential risk of atheromatous embolization associated with this technique.

Clinical characteristics and factors associated with ICU mortality during the first year of the SARS-Cov-2 pandemic in Romania: A prospective, cohort, multicentre study of 9000 patients.

BACKGROUND: The epidemiology of critically ill patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may be different worldwide. Despite similarities in medicine quality and formation, there are also significant differences concerning healthcare and ICU organisation, staffing, financial resources and population compliance and adherence. Large cohort data of critically ill patients from Central and Eastern Europe are also lacking. OBJECTIVES: The study objectives were to describe the clinical characteristics of patients admitted to Romanian ICUs with SARS-CoV-2 infection and to identify the factors associated with ICU mortality. DESIGN: Prospective, cohort, observational study. SETTING: National recruitment, multicentre study, between March 2020 to March 2021. PATIENTS: All patients with SARS-CoV-2 infection admitted to Romanian ICUs were eligible. There were no exclusion criteria. INTERVENTION: None. MAIN OUTCOME MEASURE: ICU mortality. RESULTS: The statistical analysis included 9058 patients with definitive ICU outcome. The multivariable mixed effects logistic regression model found that age [odds ratio (OR) 1.27; 95% confidence interval (CI), 1.23 to 1.31], male gender (OR 1.21; 95% CI 1.05 to 1.4), medical history of neoplasia (OR 1.74; 95% CI, 1.36 to 2.22), chronic kidney disease (OR 1.54; 95% CI, 1.27 to 1.88), type II diabetes (OR 1.23; 95% CI, 1.06 to 1.43), chronic heart failure (OR 1.24; 95% CI, 1.03 to 1.49), dyspnoea (OR 1.3; 95% CI, 1.1 to 1.5), SpO2 less than 90% (OR 3; 95% CI, 2.5 to 3.5), admission SOFA score (OR 1.07; 95% CI, 1.05 to 1.09), acute respiratory distress syndrome (ARDS) on ICU admission (OR 1.35; 95% CI, 1.1 to 1.63) and the need for noninvasive (OR 1.8, 95% CI, 1.5 to 1.22) or invasive ventilation (OR 28; 95% CI, 22 to 35) and neuromuscular blockade (OR 3.5; 95% CI, 2.6 to 4.8), were associated with larger ICU mortality.Higher GCS on admission (OR 0.81; 95% CI, 0.79 to 0.83), treatment with hydroxychloroquine (OR 0.78; 95% CI, 0.64 to 0.95) and tocilizumab (OR 0.58; 95% CI, 0.48 to 0.71) were inversely associated with ICU mortality. CONCLUSION: The SARS-CoV-2 critically ill Romanian patients share common personal and clinical characteristics with published European cohorts. Public health measures and vaccination campaign should focus on patients at risk.

Identification of Risk Genes Associated with Myocardial Infarction-Big Data Analysis and Literature Review.

Acute myocardial infarction occurs when blood supply to a particular coronary artery is cut off, causing ischemia or hypoxia and subsequent heart muscle destruction in the vascularized area. With a mortality rate of 17% per year, myocardial infarction (MI) is still one of the top causes of death globally. Numerous studies have been done to identify the genetic risk factors for myocardial infarction, as a positive family history of heart disease is one of the most potent cardiovascular risk factors. The goal of this review is to compile all the information currently accessible in the literature on the genes associated with AMI. We performed a big data analysis of genes associated with acute myocardial infarction, using the following keywords: "myocardial infarction", "genes", "involvement", "association", and "risk". The analysis was done using PubMed, Scopus, and Web of Science. Data from the title, abstract, and keywords were exported as text files and imported into an Excel spreadsheet. Its analysis was carried out using the VOSviewer v. 1.6.18 software. Our analysis found 28 genes which are mostly likely associated with an increased risk for AMI, including: PAI-1, CX37, IL18, and others. Also, a correlation was made between the results obtained in the big data analysis and the results of the review. The most important genes increasing the risk for AMI are lymphotoxin-a gene (LTA), LGALS2, LDLR, and APOA5. A deeper understanding of the underlying functional genomic circuits may present new opportunities for research in the future.

Diagnostic and Therapeutic Characteristics in Patients with Pneumotorax Associated with COVID-19 versus Non-COVID-19 Pneumotorax.

Introduction: Pneumothorax is a condition that usually occurs in thin, young people, especially in smokers. It is an unusual complication of COVID-19 disease that can be associated with worse results. This disease can occur without pre-existing lung disease or without mechanical ventilation. Materials and Methods: We present a monocentric comparative retrospective study of diagnostic and treatment analysis of two groups of patients diagnosed with COVID-19 and non-COVID-19 pneumothorax. All patients included in this study underwent surgery in a thoracic surgery department. The study was conducted over a period of 18 months. It included 34 patients with COVID-19 pneumothorax and 42 patients with non-COVID-19 pneumothorax. Results: The clinical symptoms were more intense in patients with COVID-19 pneumothorax. We found that the patients with COVID-19 had significantly more respiratory comorbidities. Diagnostic procedures include chest CT exam for both groups. Laboratory findings showed that increasing values for the analyzed data were consistent with the deterioration of the general condition and the appearance of pneumothorax in the COVID-19 group. The therapeutic attitude regarding the non-COVID-19 group was to eliminate the air from the pleural cavity and surgical approach to the lesion that determined the occurrence of pneumothorax. The group of patients with COVID-19 pneumothorax received systemic treatment, and only minimal pleurotomy was performed. The surgical approach did not alter patients' survival. Conclusions: Careful monitoring of the patient's clinic and laboratory tests evaluating the degradation of the lung parenchyma, correlated with the imaging examination (chest CT) is mandatory and reduces COVID-19 complications. Early imaging examination starts an effective diagnosis and treatment management. In severe COVID-19 pneumothorax cases, the pneumothorax did not influence the evolution of COVID-19 disease. When we found that the general condition worsened with the rapid progression of dyspnea and the deterioration of the general condition, and we found that it represented the progression or recurrence of pneumothorax.

Diastolic versus Systolic Left Ventricular Dysfunction as Independent Predictors for Unfavorable Postoperative Evolution in Patients with Aortic Regurgitation Undergoing Aortic Valve Replacement.

Background and Objectives: Chronic severe aortic valve disease is associated with important changes in left ventricle (LV) performance associated with eccentric or concentric LV hypertrophy. We aimed to assess the immediate prognostic implications of the type of the LV diastolic filling pattern (LVDFP) compared with LV systolic performance in patients with severe aortic regurgitation (AR) undergoing aortic valve replacement (AVR) and to define the independent echographic predictors for the immediate and long-term prognoses. Materials and Methods: We performed a prospective study enrolling 332 AR patients undergoing AVR, divided into two groups: Group A­201 pts with normal LV systolic function, divided into two subgroups (A1: 129 pts with a nonrestrictive LVDFP and A2: 72 pts with restrictive LVDFP), and Group B­131 pts with LV systolic dysfunction (LV ejection fraction LVEF < 50%), divided into two subgroups (B1: 83 pts with a nonrestrictive LVDFP and B2: 48 pts with restrictive LVDFP). Results: The early postoperative mortality rate was higher in patients with a restrictive LVDFP (11.12% in A2 and 12.5% in B2) compared with normal LV filling (2.32% in A1 and 7.63% in B1, p < 0.0001), regardless of the LVEF. The restrictive LVDFP­defined by at least one of the following echographic parameters: an E/A > 2 with an E wave deceleration time (EDt) < 100 ms; an isovolumetric relaxation time (IVRT) < 60 ms; or an S/D ratio < 1 in the pulmonary vein flow­was an independent predictor for early postoperative mortality, increasing the relative risk by 8.2-fold. Other independent factors associated with early poor prognosis were an LV end-systolic diameter (LVESD) > 58 mm, an age > 75 years, and the presence of comorbidities (chronic obstructive pulmonary disease-COPD or diabetes mellitus). On a medium-term, an unfavorable evolution was associated with: an age > 75 years (RR = 8.1), an LV end-systolic volume (LVESV) > 95 cm3 (RR = 6.7), a restrictive LVDFP (RR = 9.8, p < 0.0002), and pulmonary hypertension (RR = 8.2). Conclusions: The presence of a restrictive LVDFP in patients with AR undergoing AVR is associated with both increased early and medium-term mortality rates. The LV diastolic function is a more reliable parameter for prognosis than LV systolic performance (RR 9.2 versus 2.1). Other independent predictors for increased early postoperative mortality rate were: an age > 75 years, an LVESD > 58 mm, and comorbidities (diabetes mellitus, COPD), and for unfavorable evolution at 2 years postoperatively: an age > 75 years, an LVESV > 95 cm3, and severe pulmonary hypertension.

Hemorrhagic Cardiac Tamponade-An Unusual Threat in the COVID-19 Recovery Phase.

Cardiac tamponade is a rare presentation in patients with COVID-19, which may be induced by the associated exacerbated inflammatory response. The onset of cardiac tamponade may be concomitant with the acute phase of the disease or may develop subsequently as a new health condition secondary to the disease. We report four cases of cardiac tamponade that occurred late after the acute phase of the disease. One of them may be considered a post-acute complication of the disease, and three of them may be classified as a new health condition induced by COVID-19. Only two cases had a history of severe respiratory distress due to COVID-19. In all four cases, pericardiocentesis was imposed, and surprisingly, in every case, hemorrhagic fluid was evacuated. In this case, series, immune-mediated etiology is supported by histopathological results, where the main identified feature was fibrous pericarditis with inflammatory infiltrate. Only one patient included in this report died, and three of them were discharged after anti-inflammatory treatment was initiated.

The Effectiveness of Antiplatelet Therapy and the Factors Influencing It in Patients with Acute Coronary Syndrome before and during the COVID-19 Pandemic.

Background and Objectives: Dual antiplatelet therapy (DAPT) is essential in the treatment of patients with acute coronary syndrome (ACS). The objective of this study was to evaluate the effectiveness of antiplatelet medication in our practice and to investigate the factors that influence it. Materials and Methods: A prospective cohort observational study was conducted, in which 193 patients with ACS were enrolled. The patients were stented in the catheterization laboratory between May 2019 and October 2020, before and during the COVID-19 pandemic, and were receiving DAPT. Their platelet functions were tested using a Multiplate Analyzer. In addition to this, clinical data, demographics, laboratory tests, and cardiovascular risk factors were also analyzed. Results: 43.46% of the patients treated with aspirin were found to be resistant to it. This phenomenon was more common in men (48.17% vs. 31.48%, p = 0.036), and it was associated with being under the age of 50 (OR: 2.08; 95% CI: 1.11-3.90) and weighing over 70 kg (OR: 3.00; 95% CI: 1.21-7.40). Most of the patients treated with clopidogrel were in the optimal treatment window, while about half of the patients treated with ticagrelor had an exaggerated pharmacological response. Among the laboratory parameters, leukocytosis and platelet count were found to be determinants of platelet reactivity for both the aspirin and ticagrelor treatments. Conclusions: Many patients treated with antiplatelet agents are outside of the treatment window. The results obtained showed that low doses of gastro-resistant aspirin tablets are ineffective, and their efficacy can be influenced by various clinical and laboratory factors. Patients receiving ticagrelor have significantly reduced platelet reactivity, influenced only by certain laboratory indicators. The pandemic significantly influenced the results of the platelet aggregation tests only in patients treated with clopidogrel.

Delayed Surgical Management of Acute Type A Aortic Dissection in a Patient with Recent COVID-19 Infection and Post-COVID-19 Bronchopneumonia-Case Report and Review of Literature.

Ever since it was first described in 1760, acute type A aortic dissection has created difficulties in its management. The recent COVID-19 pandemic revealed that extrapulmonary manifestations of this condition may occur, and recent reports suggested that aortic dissection may be amongst them since it shares a common physiopathology, that is, hyper-inflammatory syndrome. Cardiac surgery with cardiopulmonary bypass in the setting of COVID-19-positive patients carries a high risk of postoperative respiratory failure. While the vast majority accept that management of type A aortic dissection requires urgent surgery and central aortic therapy, there are some reports that advocate for delaying surgery. In this situation, the risk of aortic rupture must be balanced with the possible benefits of delaying urgent surgery. We present a case of acute type A dissection with COVID-19-associated bronchopneumonia successfully managed after delaying surgery for 6 days.

Surgical Treatment in a High-Risk Pulmonary Embolism: Case Report.

We present the case of a 35-year-old woman who had a high-risk pulmonary embolism (according to ESC risk stratification for pulmonary embolism) after she had undergone a Caesarion section. Postoperatively, she presented with acute left lower limb pain, swelling and erythema. A diagnosis was made of deep vein thrombosis (DVT) of the ilio-femoral and popliteal veins. She was started on anticoagulant therapy, which proved to be inefficient, the patient developing a left calf and thigh oedema and shortness of breath. A CT scan revealed high-risk embolus located in the right atrium and through the tricuspid valve. The decision was made to refer her to a cardiovascular surgeon. During her preoperative evaluation, the patient became hemodynamically unstable and was rushed into the operating room, severely desaturated, bradycardic, without consciousness, with severe hypotension. On the basis of the severe state of the patient and the CT scan findings we performed an emergency pulmonary embolectomy, with the patient on cardio-pulmonary by-pass, without cross-clamping the aorta, using a modified Trendelenburg procedure. This case supports using open pulmonary embolectomy for patients with hemodynamic instability on the basis of clinical diagnosis.

Native Valve Infective Endocarditis - the Postoperative Results and Role of the Endocarditis Team. A Single Center Experience.

Background: Infective endocarditis (IE) may present with quite different aspects. Consequently, it's management involves a collaborative approach between several specialties. We analyzed the timing of surgery and the role of the "Endocarditis Team" in patients with IE. Methods: The medical records of patients operated for IE in our center during an 18-year period were retrospectively analyzed for the demographic data, causative agent, imagistic features of the affected valve and systemic lesion extension and postoperative results. Results: Patients age ranged between 7 and 84 years, and in many cases (55.88%) the etiology remained unidentified. The early postoperative complications were not significantly higher in patients operated in emergency compared to those with elective surgery. The overall early postoperative mortality rate was 14.05%, significantly lower in the elective surgery cases (p = 0.001). The long-term follow-up for patients operated between 2008 and 2017 showed a late postoperative death rate of 17.8% (34 patients). Conclusions: Emergency surgery for patients with native valve IE provides in most cases a good chance for a cure, despite the relatively high frequency of postoperative complications and rate of postoperative death. The advances in pre- and post-operative management of IE patients, as well as in surgical techniques and prosthetic valves seem to further improve the outcome.

Protocol for a systematic review and meta-analysis of human exposure to pesticide residues in honey and other bees' products.

BACKGROUND: The presence of pesticides in honey and related products is an increasing concern for consumers and producers, although there is lack of data on the current burden of exposure of the general human population through these products. We present a protocol for a systematic review and meta-analysis of contamination to insecticides, herbicides and fungicides of products from honeybees, and an estimation of how much the consumption of these products contributes to the ADI (Acceptable Daily Intake) of selected substances. OBJECTIVES: We aim to systematically review and meta-analyse studies on the contamination to plant protection products in honey, royal jelly, beeswax and propolis, applying the Navigation Guide and WHO-ILO systematic review methodology as an organizing framework. DATA SOURCES: We will search electronic academic databases for potentially relevant records from PubMed, TOXNET and EMBASE. We will include quantitative studies analysing the contamination from insecticides, herbicides and fungicides in honey, propolis, royal jelly and beeswax. In particular, we will evaluate the presence of the following substances and classes of pesticides: Glyphosate, Chlorpyrifos, pyrethroid and neonicotinoid pesticides, fungicides and acaricides. STUDY APPRAISAL AND SYNTHESIS METHODS: At least two authors will independently screen titles and abstracts at a first stage of review, and full texts at a second stage, of potentially eligible records against the eligibility criteria; data extraction of included studies will then be performed by at least two authors, in blind. At least two authors will assess risk of bias and the quality of evidence, using the most suited tools currently available. The data on prevalence of contaminated samples and concentration of pesticides in the products will be combined using meta-analysis: when more than three studies reporting the necessary measures to fit the models are available, meta-analysis will be performed separately by product and by exposure; otherwise, weighted descriptive analysis will be performed. We will report the results using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRISMA).

Exposure to solar UV radiation in outdoor construction workers using personal dosimetry.

Occupational exposure to solar UV radiation (SUVR), a Group 1 carcinogen according to the IARC classification is at high exposure levels in outdoor construction workers, usually above the suggested occupational limits. Furthermore, there are no regulations related to this exposure in the EU, except for the artificial UVR. Also, the use of the ICNIRP exposure guideline in an outdoor setting poses problems of adequate dose assessment. In this context, the main purpose of the study was to perform direct measurements of the SUVR dose in outdoor workers from the construction sector, using individual SUVR dosimeters (GENESIS-UV system), for a period of 7 months, from April to October, in a prospective, observational study in two groups of 10 outdoor workers in Romania, located at two different geographic sites. In term of cumulative standard erythema dose (SED), our study population of outdoor construction workers received high levels of solar UV radiation, ranging from 165 SED to 453 SED during 7 months of occupational activity, from April to October. Our results, ranging from 1.28 SED (standard erythema dose) per day to 6.4 SED per day pose an alarm signal to the national and European health authorities to take preventive action for outdoor workers, as the ICNIRP suggested limit value of 1.33 SED for mean daily erythemal UV exposure is vastly exceeded. We suggest that personal dosimetry for SUVR, from simple devices to complex systems as GENESIS-UV should be regularly and mandatory used in outdoor workers, similarly to the usage of personal dosimetry in occupational exposure to ionizing radiations, which could be included in European and national legislation to reduce both, the level of exposure and the detrimental effects on outdoor workers' health.

Giant Cavernous Hemangioma of the Right Atrium - A Rare Case and Literature Review.

A 52 years old woman, asymptomatic, with no significant medical history, presented to a thoracic surgery department for excision of a giant mediastinal mass that was incidentally detected during a routine abdominal ultrasound. Various imaging methods (echocardiography, chest X-ray, CT-scan, MRI) located the mediastinal mass as paracardiac and the excision using video-assisted thoracoscopic surgery (VATS) was proposed, in general thoracic surgery department. Although initially considered a paracardiac mass, intraoperatively the tumor location proved to be intrapericardial. Reaching the limits of VATS, a median sternotomy and longitudinal pericardiotomy were performed, demonstration a right atrium tumor with intrapericardial extension. At this stage, the excision was considered impossible without cardiopulmonary bypass and cardiac arrest. Having this information, the case was deferred to cardiovascular surgery, one week after and, a complete resection of the tumor was performed without incidents. Both atria were reconstructed with patches of autologous and bovine pericardium. The postoperative outcome of the patient was very good and the histopathology report showed that the tumor was a cavernous hemangioma. The literature was reviewed for this pathology. a rare case of a giant cavernous hemangioma of the heart, with diagnostic pitfalls had a successful multidisciplinary staged approach.

The Best Approach for Patients with Stable Coronary Disease: The Importance of a Multidisciplinary Heart Team.

Background: A multidisciplinary Heart Team (HT) is nowadays considered to be of great importance for a complete and accurate assessment of patients with stable coronary disease (CAD). This study evaluates the role of the HT approach in the selection of best therapeutic strategies for patients with stable CAD. Methods: The study included 200 patients with stable coronary artery disease. The weekly HT meetings consisted of open discussion taking into consideration the latest recommended therapies. HT outcome options included medical therapy (MT), percutaneous coronary intervention (PCI), or surgical intervention (CABG). Following HT implementation, the 1-, 3-, and 6-month outcomes in addition to the distribution of baseline characteristics were assessed. Results: The following HT strategies were implemented: PCI - 46%, CABG - 10% and MT - 44% of patients. Patients selected for surgical treatment were more likely to have multi-vessel coronary disease (p=0.011). The survival rates at 6 months according to HT strategy were 96.8% for PCI, 95% for CABG, and 94.2% for MT. Conclusions: The HT multidisciplinary decision is mandatory for optimal patient care and can prevent specialty biases. Tertiary care institutions should develop and implement interdisciplinary protocols for common CAD cases.

Gastric Adenocarcinoma Associated with Acute Endocarditis of the Aortic Valve and Coronary Artery Disease in a 61-Year-Old Male with Multiple Comorbidities-Combined Surgical Management-Case Report.

The case of a 61-year-old male with a recent total gastrectomy for a hemorrhagic gastric tumor is presented, with the important co-morbidities of type II diabetes mellitus requiring insulin, chronic hepatitis C with liver dysfunction, stage II essential hypertension, chronic stage III renal disease peripheral type II aorto-iliac disease with stage II ischemia of both legs, and chronic anemia. About one month following the gastrectomy, the patient presented with fever and acute inflammatory syndrome. Severe aortic insufficiency, aortic valvular vegetations, and positive blood cultures with Staphylococcus saprophytic were found. The diagnosis of infectious endocarditis on the aortic valve was established (positive blood cultures with echocardiographic features of vegetations, fever), and antibiotic treatment with Levofloxacin and Vancomycin was initiated. The evolution was favorable with the remission of the inflammatory syndrome and quick cessation of fever. However, the hemodynamic aspect showed progressive heart failure with acute pulmonary edema. The transesophageal echocardiographic examination confirmed the existence of severe aortic insufficiency and valvular vegetations with a left ventricular ejection fraction of 38%. The coronary angiography revealed double vessel disease. The calculated Euroscore II was 33.4%. Aortic valve replacement with porcine xenograft and double coronary artery bypass graft surgery was performed. The patient had a favorable postoperative course remaining afebrile and out of heart failure, with the markers of inflammation largely within normal limits. The left ventricular ejection fraction increased to 50%. The successful outcome of this case, represented by a rare association of cancer, endocarditis, and coronary disease, reveals the importance of the multidisciplinary teams involved in this case: gastroenterology, general surgery, cardiology, infectious diseases, cardiac surgery, and intensive care. Therefore, in such cases with high risk, complex patients, a strong collaboration between all specialties is needed to overcome all of the limitations of the patient's co-morbidities.

LOW-BACK PAIN DISORDERS AS OCCUPATIONAL DISEASES IN THE CZECH REPUBLIC AND 22 EUROPEAN COUNTRIES: COMPARISON OF NATIONAL SYSTEMS, RELATED DIAGNOSES AND EVALUATION CRITERIA.

AIM: Low-back pain diseases (LBPD) belong to the most frequent diagnoses determined by general practitioners, and constitute one of the most common reasons for sick leave and permanent disability pension in the Czech Republic and other European countries. Epidemiological studies have shown a statistically significant association between LBPD and certain types of occupational burden. However, in the Czech Republic, LBPD caused by overload and/or whole-body vibrations have not yet been included in the list of occupational diseases. The aim of this study was to collect and compare the systems, criteria and diagnoses used to recognize LBPD as occupational diseases in other European countries. METHODS: A questionnaire focused on LBPD was distributed and answered by specialists in occupational diseases in European countries. It included items concerning LBPD in the national list of occupational diseases, and work-related and diagnostic criteria that need to be fulfilled for recognizing LBPD as occupational diseases and possible awarding compensations to the patients. RESULTS: In 13 countries out of the 23 countries studied, LBPD caused by overload can be recognized as occupational, providing that the diagnosis is sufficiently proven and exposure criteria and/or listed occupation are met and duration of exposure is confirmed (Belgium, Denmark, France, Germany, Hungary, Italy, Lithuania, Macedonia, Netherlands, Romania, Slovakia, Sweden, and Switzerland). LBPD due to vibrations can be also recognized as occupational in 14 countries. In 8 countries LBPD are not accepted as occupational unless they are caused by an injury at work. Specific criteria to evaluate occupational exposure of patients with LBPD were set in Belgium, Denmark, France, Germany, Lithuania, Macedonia, Netherlands, and Slovakia. In other countries, the evaluation is done at an individual basis. CONCLUSIONS: In practice, the assessment of occupational overload and its contribution to the development of LBPD as well as its inclusion in the compensation system are important for several reasons. Firstly, it may be considered essentially preventable. Secondly, cases with a significant contribution of occupational aetiology may be viewed as occupational diseases for which compensation may be claimed, as it is the case in many European countries. Importantly, inclusion of LBPD in the list of occupational diseases or another system of compensation may be viewed as a preventive measure as it increases the visibility of this problem not only for the workers, but especially for the employers.

Aortic prosthesis-patient mismatch strongly affects early results of double valve replacement.

BACKGROUND AND AIM OF THE STUDY: The aim of this retrospective single-center study was to assess the authors' results in mitral-aortic double valve replacement (DVR), with attention focused on the risk factors of in-hospital mortality (HM). As the initial results showed a strong relationship between HM and aortic prosthesis-patient mismatch (PPM), this led to an assessment of the impact of PPM on the early results of DVR. METHODS: Data from 196 consecutive patients (mean age 60 +/- 10 years) who had undergone DVR between January 1996 and December 2011 at the authors' institution were analyzed. A statistical comparison was made of groups defined by the presence/absence of in-hospital death, postoperative complications, and aortic PPM. A logistic regression analysis of the factors associated with HM and their postoperative evolution was also conducted. RESULTS: Surgery was mostly performed on an elective basis (89.3%), using mainly bileaflet mechanical valves (93.9%). The rate of associated coronary bypass (CABG) was 11.2%. Aortic PPM (i.e., an effective orifice area index (EOAI) < or = 0.85 cm2/m2) was noted in 28.1% of patients. HM (6.63%) was significantly related to PPM (p < 0.002), greater age (p < 0.003), a smaller EOAI (p = 0.005), associated CABG (p < 0.008), and a longer aortic cross-clamp time (p < 0.03). Patients with aortic PPM had a significantly worse early outcome, with higher overall (p < 0.0007) and cardiac (p < 0.05) complication rates, a longer intensive care unit stay (p < 0.03), and an almost six-fold higher rate of HM (16.4% versus 2.8%; p < 0.002). PPM and age as risk factors were included in a predictive model of HM based on logistic regression; a similar model for postoperative complications highlighted PPM, age and cardiopulmonary bypass time as significant risk factors. CONCLUSION: Aortic PPM greatly affects the postoperative outcome of DVR, as it is related to an increased complication rate and a higher in-hospital mortality. A strategy of avoiding PPM but without taking additional risks might improve the early results of DVR.

Management of a Rare Case of Multiple Coronary Artery Fistulas Associated with Ascending Aortic and Root Aneurysm: Case Report and Review of Literature.

Coronary artery fistulas draining into the left ventricle is a rare finding. They can be associated with other congenital cardiac anomalies like ventricular septal defect or tetralogy of Fallot. While most of them are asymptomatic, they can lead to severe cardiac complications like infective endocarditis, heart failure, or myocardial ischemia. Symptomatic coronary artery fistulas can be managed surgically or percutaneously. We present a case of a 61-year-old male patient with both left anterior descending artery and right coronary artery fistulas draining into the left ventricle associated with ascending aorta and root aneurysm. Preoperative assessment for myocardial ischemia and the size and location of the fistulas was performed. The echocardiography stress test was negative. Surgery consisted of replacement of the ascending aorta and reconstruction of the noncoronary sinus with a Dacron patch with aortic valve preservation and no intervention for the coronary artery fistulas. The surgical strategy was adapted for cardioplegia administration to compensate for the volume of coronary blood drained into the left ventricle and for better protection of the distal myocardium.

Challenges Regarding the Value of Routine Perioperative Transesophageal Echocardiography in Mitral Valve Surgery.

BACKGROUND AND OBJECTIVES: Transesophageal echocardiography (TEE) is considered an indispensable tool for perioperative evaluation in mitral valve (MV) surgery. TEE is routinely performed by anesthesiologists competent in TEE; however, in certain situations, the expertise of a senior cardiologist specializing in TEE is required, which incurs additional costs. The purpose of this study is to determine the indications for specialized perioperative TEE based on its utility and the correlation between intraoperative TEE diagnoses and surgical findings, compared with routine TEE performed by an anesthesiologist. MATERIALS AND METHODS: We conducted a three-year prospective study involving 499 patients with MV disease undergoing cardiac surgery. Patients underwent intraoperative and early postoperative TEE and at least one other perioperative echocardiographic evaluation. A computer application was dedicated to calculating the utility of each type of specialized TEE indication depending on the type of MV disease and surgical intervention. RESULTS: The indications for performing specialized perioperative TEE identified in our study can be categorized into three groups: standard, relative, and uncertain. Standard indications for specialized intraoperative TEE included establishing the mechanism and severity of MR (mitral regurgitation), guiding MV valvuloplasty, diagnosing associated valvular lesions post MVR (mitral valve replacement), routine evaluations in triple-valve replacements, and identifying the causes of acute, intraoperative, life-threatening hemodynamic dysfunction. Early postoperative specialized TEE in the intensive care unit (ICU) is indicated for the suspicion of pericardial or pleural effusions, establishing the etiology of acute hemodynamic dysfunction, and assessing the severity of residual MR post valvuloplasty. CONCLUSIONS: Perioperative TEE in MV surgery can generally be performed by a trained anesthesiologist for standard measurements and evaluations. In certain cases, however, a specialized TEE examination by a trained senior cardiologist is necessary, as it is indirectly associated with a decrease in postoperative complications and early postoperative mortality rates, as well as an improvement in immediate and long-term prognoses. Also, for standard indications, the correlation between surgical and TEE diagnoses was superior when specialized TEE was used.

Clinical and Biological Data in Patients with Pancreatic Cancer vs. Chronic Pancreatitis-A Single Center Comparative Analysis.

INTRODUCTION: In some patients with chronic pancreatitis, the diagnosis of pancreatic cancer can be missed. The objective of the study was to identify clinical and paraclinical data with statistical significance in the differential diagnosis between chronic pancreatitis and pancreatic cancer. MATERIALS AND METHODS: We conducted a retrospective, observational study on a cohort of 120 patients hospitalized over 3 years. The patients were equally distributed in two groups: group A, with 60 patients with pancreatic cancer, and group B, with 60 patients with chronic pancreatitis. The statistical analysis was carried out by using the R program. RESULTS: The comparative analysis of pancreatic cancer vs. chronic pancreatitis revealed a stronger link between pancreatic cancer, female gender (p = 0.001) and age over 60 years (p < 0.001). Patients with pancreatic cancer had higher serum values of aspartate aminotransferase (p 0.005), alanine aminotransferase (p 0.006), total bilirubin (p < 0.001), direct bilirubin (p < 0.001), alkaline phosphatase (p 0.030), C-reactive protein (p = 0.049) and uric acid (p 0.001), while patients with chronic pancreatitis presented slightly higher values of amylase (p 0.020) and lipase (p 0.029). CONCLUSIONS: Female gender, advanced age, elevated aminotransferases, cholestasis markers and uric acid were associated with a higher probability of pancreatic cancer.