Exploring the Environmental Impact of Telemedicine: A Life Cycle Assessment.

BACKGROUND: Telemedicine has emerged as a potential solution to mitigate the significant greenhouse gas emissions of the healthcare sector. A comprehensive evaluation is required to quantify the environmental benefits of its implementation. OBJECTIVES: The study aims to compare the environmental sustainability of in-person and virtual examinations for heart failure patients. METHODS: A standard life cycle assessment has been applied to quantify the equivalent CO2 of direct and indirect activities required to release a medical examination (virtual or physical) for a patient in an Italian hospital. Inputs of the analysis include electronic devices of hospital and patients, energy consumption, wastes, internet usage and patient travel. Depending on the type of visit (virtual or physical), inputs have been processed differently, considering actual consumption and utilization. RESULTS: Televisit reduces emissions from 9.77 kgCO2e to 0.41 kgCO2e. Transport and internet data use are key inputs for in-person (i.e., 98%) and telemedicine visits (i.e., 72%), respectively. DISCUSSION: Given the frequent car travels, telemedicine emerges as a tool to improve environmental benefits and reduce time for patients and caregivers.

Sustainability in Healthcare: Methods and Tools for the Assessment.

BACKGROUND: Healthcare sector has a significant impact on the environment and people well-being. Therefore, it is interesting to understand how healthcare contributes to sustainable development. OBJECTIVE: The study aims to perform a literature review on the methodologies applied to quantify environmental impact in healthcare with an attention to telemedicine activities. METHODS: Scopus and PubMed databases were investigated between 2018 and 2022. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) frameworks was followed for article selection. RESULTS: From initial 183 articles, 50 full-studies were included. Life-cycle assessment method proved to be a standard for assessing the impact of devices used in clinical practice. Indeed, for the investigation of care activities a unique methodology was not defined. The assessment of telemedicine is mainly based on avoided travels, and a standard methodology is still missing. CONCLUSIONS: To move toward a sustainable development other aspects of sustainability should be investigated.

Reuse of end-of-life personal protective equipment in hot asphalt mixtures: an environmental evaluation.

In the present global health emergency, face masks, gowns, caps, gloves play a key role in limiting the diffusion of the COVID-19 pandemic, by acting as physical barriers to avoid droplets and filtrate exhalations coming from infected subjects. Since the most widespread devices are disposable products made of plastic or rubber materials, this means that relevant quantities of fossil resources are consumed, and huge amounts of wastes are generated. Currently the end of life of personal protective equipment (PPE) represents a problem in environmental, economic, and social terms. The market considers two possible disposal scenarios: incineration with energy recovery or landfill. In both cases, significant impacts are achieved both on the environment and on human health. This study aims to propose and validate a new scenario for PPE based on material reuse for bituminous conglomerates. The Life Cycle Assessment methodology and the experimental tests has been used to assess the environmental impacts in terms of both ReCiPe midpoints and endpoints and for demonstrate the technical feasibility of this new scenario. From an environmental point of view, relevant benefits were observed in comparison with the standard incineration for energy recovery or disposal in landfill.

Single Use Personal Protective Equipment Reinforced Asphalt.

Due to the COVID-19 pandemic, global personal protective equipment (PPE) volume production and demand increased by 300-400% between 2019 and 2021. In this scenario, the present study aims to propose and validate an innovative circular economy scenario for end of life (EoL) PPEs, reusing them to produce reinforced bituminous mixtures. Despite that several studies confirmed the possibility of reusing plastic in the asphalt mixtures, none of them investigated the potential of PPEs, highlighting the innovativeness in the scientific panorama. Five different alternatives of EoL PPE mixtures (different products, materials, dosages, etc.) were tested at laboratory scale to verify the technical feasibility of the proposed scenario. The most promising solution resulted to be the mix of gloves and face masks composed by polypropylene, polyethylene, nitrile and lattice at a dosage of 0,5% weight/weight that allowed to produce bituminous mixtures with acceptable performances in terms of relevant mechanical parameters while recycling waste PPEs. This leads to environmental benefits, since more than 3kg of EoL PPEs per square meter of road pavement can be reused instead of disposed (about 1,5 million tons/year considering the bituminous mixtures produced at European level), as well as economic benefits for public administrations and the collectivity, due to the reduced landfilling of solid wastes.

A finite element analysis for evaluating mandibular advancement devices.

Obstructive sleep apnoea (OSA) is a disorder characterised by complete or partial occlusion of the upper airway during sleep. Muscles relax during sleeping and collapse into the airway, closing the throat and prohibiting air flowing into the lungs. Different solutions have been adopted to manage the pathology to improve the life quality of affected patients. Mandibular advancement devices (MADs) are proven to be a compliant and successful therapy in the forward repositioning of the mandible to increase the upper airway volume. However, this method has some long-term adverse events that may affect the teeth and periodontal ligaments. This paper presents a finite element model to evaluate the MADs effects (displacement and stress) on teeth and periodontal ligaments, by varying the design, the point of application of the force and the material. The modelled bodies have been reconstructed through a Reverse Engineering approach and computer-aided design tools starting from tomographic images of anatomic bodies and from laser scans of a physical MAD. The results suggest that a central connection mechanism could affect mostly the anterior teeth. In contrast, a lateral connection mechanism provides a more uniform distribution of the load on teeth.

A Procedure for Analyzing Mandible Roto-Translation Induced by Mandibular Advancement Devices.

BACKGROUND: Sleep-Related Breathing Disorders are characterized by repeated episodes of complete or partial obstruction of the upper airway during sleep. Mandibular advancement devices represent a non-invasive treatment in reducing the number of respiratory events and in decreasing symptoms. The advancement extent of these devices is responsible for the mandibular roto-translation and its effects on the temporomandibular joint. METHODS: This study defined a systematic method to assess the mandible roto translation that is caused by MADs according to a scan-to-CAD approach. Starting from a closed mouth position and simulating the oral appliance at different settings it was possible to define a local reference system that is useful for the evaluation of the mandibular roto-translation. This latter was then applied to evaluate the movements of the condyle and the mandibular dental arch. RESULTS: MAD1 resulted in a reduced mouth opening and protrusion, while MAD2 enabled a higher degree of motion of the mandible useful for patients who need an important protrusion. CONCLUSIONS: The two devices present different dynamics. Results that are achievable employing this method can be directly used by practitioners in comparing MADs, as well as by researchers in evaluating MADs effects.

Vulnerable struts with CRE8, Biomatrix and Xience stents assessed with OCT and their correlation with clinical variables at 6-month follow-up: the CREBX-OCT study.

First-generation drug eluting stents (DES) reduced the incidence of restenosis and need for repeated target lesion revascularization but, in autoptic studies, frequently resulted in incomplete endothelial coverage, which is an important predictor of late adverse events and increased mortality after stent implantation. More recently, not only uncovered, but also malapposed or protruding struts have been considered vulnerable structures, as they are deemed to perturb blood flow, whereas only struts well embedded into the vessel wall are considered stable. We compared the number of uncovered and of other vulnerable (protruding or malapposed) struts among three different second-generation drug-eluting stents (DES) (Cre8, Biomatrix, Xience), using optical coherence tomography (OCT) 6 months after implantation. Moreover, we analyzed the relationship between the percentage of vulnerable struts and the clinical characteristics of patients. 60 patients with stable angina or non-ST-Elevation acute coronary syndrome and indication to percutaneous angioplasty were randomly assigned to receive one of the three DES. After 6 months, OCT images were obtained. After 6 months, OCT images were obtained (1289 cross sections; 10,728 struts). None of the three DES showed non-coated struts or areas of stent thrombosis. Significant differences in the average number of protruding struts (Cre8: 33.9 ± 12.6; Biomatrix: 26.2 ± 18.1; Xience: 13.2 ± 8.5; p < 0.001) and in the proportion of malapposed struts (Cre8: 0.7%; Biomatrix: 0.9%; Xience: 0.0%; p = 0.040) and of incomplete stent apposition area (Cre8: 10.4%; Biomatrix: 4.7%; Xience: 0.7%; p < 0.001) were observed. No significant difference was found in neointimal hyperplasia area with a not significant tendency toward greater minimal and maximal struts thickness for Biomatrix. In comparison with Cre8 and Biomatrix, Xience showed a significantly lower proportion of vulnerable struts in all clinical sub-groups considered. In the group of 60 patients a significant relation was found between age and number of vulnerable struts (p = 0.014). The three second-generation DES were similarly effective in permitting neo-intimal formation and complete struts coating 6 months after implantation, but Cre8 and Biomatrix showed a greater proportion of protruding and malapposed struts.Trail Registry: Clinical Trials.gov Identifier: NCT02850497.

Unexpected delayed complete atrioventricular block after Cardioband implantation.

The Cardioband system is a transcatheter direct annuloplasty device that is implanted in patients with severe symptomatic functional mitral regurgitation (MR) due to annulus dilatation and high surgical risk. This device covers the posterior two-thirds of the annulus, from the anterolateral to the posteromedial commissure, implanted in close proximity of the left circumflex artery, atrioventricular (AV) conduction system, and coronary sinus. We present the case of an 80-year-old-gentleman with prohibitive surgical risk, treated with Cardioband implantation for functional MR with an evident P1-P2 cleft and P2-P3 indentation, a relative contraindication to MitraClip implantation. We achieved procedural success with significative mitral annulus reduction (30% anteroposterior reduction from 37 to 26 mm) and MR reduction (from grade 4 to grade 1-2). A late onset Mobitz 2 AV block developed after 26 hr and evolved to complete AV block in the following day, requiring definitive biventricular pacemaker (PM). Less than 200 Cardioband implantations have been performed but, to our knowledge, this is the first reported AV block, possibly facilitated by the pre-existing bifascicular block, suggesting the opportunity of prolonged ECG monitoring after Cardioband like any other mechanical transcatheter structural intervention possibly affecting the AV conduction system.

Investigating the feasibility of a reuse scenario for textile fibres recovered from end-of-life tyres.

The management of end-of-life tyres (ELTs) is regulated by several national and international legislations aiming to promote the recovery of materials and energy from this waste. The three main materials used in tyres are considered: rubber (main product), which is currently reused in other closed-loop applications; steel, which is used for the production of virgin materials; and textile fibres (approximately 10% by weight of ELTs), which are mainly incinerated for energy recovery (open-loop scenario). This study aims to propose and validate a new closed-loop scenario for textile fibres based on material reuse for bituminous conglomerates. The final objective is to verify the technical, environmental, financial, and economic feasibility of the proposed treatment process and reuse scenario. After characterization of the textile material, which is required to determine the technological feasibility, a specific process has been developed to clean, compact, and prepare the fibres for subsequent reuse. A life cycle assessment (LCA) has been carried out to quantify the environmental benefits of reusing the fibres. Finally, a cost benefit analysis based on the LCA results was conducted to establish the long-term financial and economic sustainability. From a technological point of view, the tyre textile fibres could be a promising substitute to the reinforcement cellulose commonly used in asphalts as long as the fibres are properly prepared (compaction and pellet production) for application in the standard bituminous conglomerate production process. From an environmental point of view, relevant benefits in terms of global warming potential and acidification potential reduction were observed in comparison with the standard incineration for energy recovery (respectively -86% and -45%). Moreover, the proposed scenario can be considered as financially viable in the medium to long term (cumulative generated cash flow is positive after the 5th year) and economically sustainable (expected net present value of more than €3,000,000 and economic rate of return of approximately 30%). Finally, the sensitivity and risk analyses show that no specific issues are foreseen for the future implementation in real industrial applications.

COmparison between COronary THrombus aspiration with Angiojet® or Export® catheter in patients with ST-elevation myocardial infarction submitted to primary angioplasty: The COCOTH Study.

AIMS: To compare the effects of two thrombus aspiration devices, the manual catheter Export® and the more complex and expensive mechanical Angiojet®, on several indices of reperfusion in acute ST-elevation myocardial infarction (STEMI). METHODS AND RESULTS: Clinical, hemodynamic and procedural characteristics of 185 STEMI patients, randomized to treatment with Export (n=95) or Angiojet (n=90) during primary percutaneous coronary intervention (PPCI) were analyzed. The primary endpoint was ST-segment elevation reduction 90 min after culprit vessel re-opening. Secondary endpoints included variations in some angiographic parameters (TIMI Flow, TIMI Frame Count and Myocardial Blush Grade) and Infarct Size and Severity at myocardial scintigraphy. A significant reduction in ST-elevation was observed in both groups after PPCI without significant differences between the two groups. No significant difference between Angiojet vs. Export was observed in ST-segment resolution >50% and ≥ 70%, in TIMI Flow, TIMI Frame Count and Myocardial Blush Grade before vs. after PPCI and in Infarct Size and Severity. CONCLUSIONS: PPCI with thrombus aspiration was effective in both groups of patients, without differences in myocardial reperfusion and necrosis indices. These results could support the routine use of manual devices during PPCI, reserving the more expensive Angiojet in case of manual device failure and persistent or massive intracoronary thrombosis, with favorable implications in terms of cost containment.

Prognostic impact of atrial fibrillation occurrence in patients with non-ST-elevation acute coronary syndromes: is dysrhythmia duration a parameter to focus on?

Several studies have evaluated the prognostic impact of atrial fibrillation (AF) in ST-elevation myocardial infarction (STEMI) patients, but scarce data are available on the role of AF in non-ST-elevation acute coronary syndromes (NSTE-ACS). The aim of this study was to investigate long-term outcome of NSTE-ACS patients experiencing an episode of AF during in-hospital course. Of 1,147 NSTE-ACS patients, 54.4% for non-STEMI (NSTEMI) and 45.6% for unstable angina, 65 (5.7%) had an episode of AF. Long-term survival was compared with that of 1,082 NSTE-ACS patients who did not develop AF. Patients who developed AF, with respect to those who did not, were older and more frequently with NSTEMI at admission (69.2 vs. 53.5%, p = 0.013), diabetes, dyslipidemia and history of heart failure. Moreover, patients who developed AF had a significantly higher New York Heart Association class and lower values of glomerular filtration rate. During a median follow-up of 40.7 months, we observed a significantly higher mortality in NSTE-ACS patients who developed AF versus those who did not (42.2 vs. 19.8%, p < 0.001). AF occurrence in NSTE-ACS was a significant predictor of mortality at Cox regression (adjusted HR: 1.85; p = 0.03). After propensity score analysis, only patients with AF duration >6 h showed a significantly higher mortality at Cox regression (p = 0.021). Our results suggest that NSTE-ACS patients who develop AF are characterized by a higher clinical complexity. The occurrence of AF, when longer than 6 h, represents an important negative prognostic factor for long-term survival.

Impact of hypertension history on short and long-term prognosis in patients with acute myocardial infarction treated with percutaneous angioplasty: comparison between STEMI and NSTEMI.

Previous studies analyzing the impact of hypertension (HTN) on myocardial infarction (MI) outcome reached conflicting results and scarce data are available in patients treated with percutaneous coronary intervention (PCI). In this study the prognostic impact of HTN history in ST-elevation MI (STEMI) and Non-STEMI (NSTEMI) patients treated with PCI was analyzed. We compared characteristics of 1,031 STEMI and 437 NSTEMI patients, in relation to the presence of HTN. Median follow-up duration was 40.2 months. HTN was significantly higher in NSTEMI vs. STEMI patients (p < 0.001). NSTEMI patients were older, with higher values of left ventricular ejection fraction (LVEF) and more frequently with previous myocardial revascularization than STEMI patients either among hypertensives and non-hypertensives. At univariate analysis HTN resulted associated with long-term mortality in STEMI but not in NSTEMI patients. At multivariate analysis HTN was not associated with either in-hospital and long-term mortality in both NSTEMI and STEMI group. In conclusion, in the PCI era HTN does not influence MI patients prognosis; other factors, such as age, admission LVEF, coronary disease extension, previous MI and creatinine levels are independently associated with MI patients outcome even though this should not discourage from a strict control of HTN after the acute event.

Congestive heart failure and decongestion ability of two different treatments: continuous renal replacement and diuretic therapy: experience of a cardiac step down unit.

INTRODUCTION: The rehospitalization rate for decompensated heart failure (HF) is high and can be ascribed also to a suboptimal decongestion before discharge. Congestion can be treated with diuretics or continuous renal replacement therapy (CRRT). Aim of this study was to evaluate if diuretics and CRRT, used in agreement to international guidelines, may have a dissimilar decongestion ability in patients with decompensated HF with different baseline characteristics. METHODS: In 88 patients with HF (NYHA class Ill-IV) we evaluated the effect of CRRT (n = 46) and intravenous diuretics (n = 42) on clinical and instrumental signs of congestion. A clinical score was obtained as the sum of signs and symptoms of HF to estimate the severity of each patient's clinical condition.The choice of diuretics or CRRT was guided by renal impairment or diuretics' resistance. RESULTS: A significant reduction in clinical HF score was observed in the CRRT group at discharge vs admission (1.3 +/- 1.9 vs 5.7 +/- 2.3, P < 0.001) and in the diuretic group (1.8 +/- 1.4 vs 3.7 +/- 1.6, P < 0.001), while a significant reduction in radiographic signs of pulmonary congestion, pleural effusion, echocardiographic systolic arterial pulmonary pressure (43.41 +/- 13.6 vs 50.5 +/- 20.2 mmHg, P < 0.005) and NT-proBNP (6,676 vs 15,492 pg/ml, P < 0.05) were observed only in CRRT patients. Moreover, also urine output significantly increased only in CRRT patients (1.8 +/- 0.8 vs 0.9 +/- 0.6 ml/h/kg, P < 0.001). CONCLUSIONS: CRRT and diuretics showed an equivalent ability in relieving clinical signs and symptoms of HF but only CRRT was able to significantly improve several instrumental and biohumoral indicators of congestion.

Effects of two different treatments with continuous renal replacement therapy in patients with chronic renal dysfunction submitted to coronary invasive procedures.

BACKGROUND: Percutaneous coronary intervention (PCI) requires the use of iodinated contrast medium and consequently poses the risk of contrast-induced nephropathy (CIN), which can negatively impact on outcome. Patients with chronic kidney disease (CKD) are at particularly high risk of CIN. In this study, we investigated the role of continuous renal replacement therapy (CRRT) performed before and after versus only after PCI in patients with CKD. METHODS: We studied 46 consecutive patients with CKD (mean creatinine >2 mg/dL) submitted to PCI: 21 (mean creatinine 2.7 ± 1.6 mg/dL) treated with CRRT only after PCI (CRRTpost) and 25 (mean creatinine 3.0 ± 1.3 mg/dL) with CRRT before and after PCI (CRRTpre-post). CRRT was performed with hemofiltration (creatinine <3 mg/dL) or hemodiafiltration (creatinine >3 mg/dL), initiated 6-8 hours before PCI and re-started immediately post PCI for 18-24 hours. RESULTS: Creatinine showed a greater reduction in CRRTpre-post (2.4 ± 1.0 vs. 3.0 ± 1.3 mg/dL; P=.002) with respect to CRRTpost (2.6 ± 1.3 vs 2.7 ± 1.6 mg/dL; P=.667). At median 14.7-month follow-up, CKD worsened in 3 patients (12%) of CRRTpre-post and in 9 (43%) of CRRTpost (P=.042). Kaplan-Meier analysis at 18 months showed a significantly higher overall mortality in patients treated with CRRTpre-post vs. CRRTpost (P=.041), which became even more significant during the entire follow-up period (P=.026) and an increase in cardiovascular deaths (5 vs. 0, respectively). CONCLUSIONS: Our results suggest that in CKD patients undergoing PCI, CRRT performed before and after is more effective in preventing a further deterioration of renal function and is associated with an improved long-term outcome when compared to CRRT performed only after.

Early invasive strategy and outcomes of non-ST-elevation acute coronary syndrome patients: is time really the major determinant?

In non-ST-elevation acute coronary syndromes (ACS), an early invasive strategy is recommended for middle/high-risk patients; however, the optimal timing for coronary angiography is still debated. The aim of this study was to evaluate the prognostic implications of the time of angiography in ACS patients treated in accord with an early invasive strategy. We analyzed the relationship between the time of angiography and outcomes at follow-up in 517 ACS patients, of whom 482 were revascularized with percutaneous coronary intervention (PCI) (86.9%) or coronary artery by-pass graft (13.1%). We also evaluated the influence of clinical, biohumoral and angiographic variables on the patients' outcomes at follow-up. Among patients submitted to angiography at different time intervals from both hospital admission and symptom onset, significant differences neither in mortality nor in cardiac ischemic events at follow-up were observed. At univariate analysis, complete versus partial revascularization, longer hospital stay, higher TIMI risk score, diabetes mellitus, higher discharge creatinine and admission anemia were associated with mortality and cardiac ischemic events at follow-up; a lower left ventricular ejection fraction was associated with mortality; higher peak troponin I and previous PCI were associated with cardiac ischemic events at follow-up. At multivariate analysis longer hospital stay, higher discharge creatinine levels, and previous PCI were independent predictors of cardiac ischemic events at follow-up. Our evaluation in ACS patients treated with an early invasive strategy does not support the concept that angiography should be performed as soon as possible after symptom onset or hospital admission. Rather, an unfavorable long-term outcome is influenced principally by the clinical complexity of patients.

Levosimendan produces an additional clinical and hemodynamic benefit in patients with decompensated heart failure successfully submitted to a fluid removal treatment.

A pivotal role in treating decompensated heart failure (HF) is played by inotropes and calcium sensitizers such as levosimendan. In this study, the authors evaluated whether levosimendan could determine further clinical and hemodynamic benefits in 31 HF patients (New York Heart Association [NYHA] class III or IV), after successful treatment with diuretics (n=15) or ultrafiltration (n=16). Systolic, diastolic, dicrotic, and mean arterial pressures; systemic vascular resistance (SVR); some classic hemodynamic variables (cardiac output [CO], stroke volume [SV], dP/dt(max) ); and indices of cardiovascular system performance (cardiac cycle efficiency [CCE], cardiac power output) have been assessed by the pressure recording analytical method (PRAM), a minimally invasive monitoring system, before levosimendan infusion, at the end of treatment (EoT), and 36 hours after EoT (post-36). A significant increase in CCE, CO, SV, and dP/dt(max) and a significant decrease in diastolic and dicrotic arterial pressures and in SVR have been observed at EoT and at post-36. After the addition of levosimendan, a further reduction in signs and symptoms of HF and NYHA class was observed. Five patients showed an opposite trend of several hemodynamic parameters without any significant clinical improvement (nonresponders). In conclusion, most HF patients treated with diuretics or ultrafiltration receive additional clinical and hemodynamic benefits from levosimendan. The characterization of nonresponders could help in optimizing its use.

Effects of ULTRAfiltration vs. DIureticS on clinical, biohumoral and haemodynamic variables in patients with deCOmpensated heart failure: the ULTRADISCO study.

AIMS: To evaluate the clinical, biohumoral, and haemodynamic effects of ultrafiltration vs. intravenous diuretics in patients with decompensated heart failure (HF). Signs and symptoms of volume overload are often present in these patients and standard therapy consists primarily of intravenous diuretics. Increasing evidence suggests that ultrafiltration can be an effective alternative treatment. METHODS AND RESULTS: Thirty patients with decompensated HF were randomly assigned to diuretics or ultrafiltration. Haemodynamic variables, including several novel parameters indicating the overall performance of the cardiovascular system, were continuously assessed with the Pressure Recording Analytical Method before, during, at the end of treatment (EoT) and 36 h after completing treatment. Aldosterone and N-terminal pro-B-type natriuretic peptide (NT-proBNP) plasma levels were also measured. Patients treated with ultrafiltration had a more pronounced reduction in signs and symptoms of HF at EoT compared with baseline, and a significant decrease in plasma aldosterone (0.24 ± 0.25 vs. 0.86 ± 1.04 nmol/L; P < 0.001) and NT-proBNP levels (2823 ± 2474 vs. 5063 ± 3811 ng/L; P < 0.001) compared with the diuretic group. The ultrafiltration group showed a significant improvement (% of baseline) in a number of haemodynamic parameters, including stroke volume index (114.0 ± 11.7%; P < 0.001), cardiac index (123.0 ± 20.8%; P < 0.001), cardiac power output (114.0 ± 13.8%; P < 0.001), dP/dt(max) (129.5 ± 19.9%; P < 0.001), and cardiac cycle efficiency (0.24 ± 0.54 vs. -0.14 ± 0.50 units; P < 0.05), and a significant reduction in systemic vascular resistance 36 h after the treatment (88.0 ± 10.9%; P < 0.001), which was not observed in the diuretic group. CONCLUSIONS: In patients with advanced HF, ultrafiltration facilitates a greater clinical improvement compared with diuretic infusion by ameliorating haemodynamics (assessed using a minimally invasive methodology) without a marked increase in aldosterone or NT-proBNP levels.