Features of infective endocarditis in a contemporary cohort of persons who inject drugs: a matched comparison analysis of long-term prognostic factors.

The objective of the study was to assess the short- and long-term mortality of infective endocarditis (IE) among people who inject drugs (PWID). Using prospectively collected data on hospitalized patients (years 2000 through 2021) with IE, PWID were identified and included in this study. Survival analysis was performed to analyze short- and long-term mortality and study their risk factors among PWID and a matched group of non-intravenous drug users (N-IDU). In a study of 485 patients admitted for IE, 55 (11%) of them were PWID. These PWID patients were 1:1 age- and sex- matched to an N-IDU group (N = 55 per group). Both groups had similar baseline comorbid conditions, including congestive heart failure, type 2 diabetes, and neoplastic diseases. However, PWID were more likely to have HCV co-infection (62% vs 16%, respectively, p < 0.001) and advanced liver disease/cirrhosis (52% vs 7.9%, respectively, p < 0.001). IE in PWID more often affected the tricuspid valve (42% vs 22%, respectively, p = 0.024) and presented with more embolic events (66% vs 35%, respectively, p < 0.01). S. aureus was the primary cause of IE in PWID (44% vs 21%, respectively, p = 0.01). After adjusting for other variables, PWID (HR = 2.99, 95% CI [1.06, 8.43], p = 0.038) and valve bioprosthetic replacement (HR = 5.37, 95% CI [1.3, 22.1], p = 0.02) were independently associated with increased mortality risk, whereas IE caused by tricuspid valve infection was associated with reduced mortality risk (HR = 0.25, 95% CI [0.06, 0.97], p = 0.046). In this cohort, PWID had increased risk of long-term mortality after hospital discharge for IE, when compared to matched N-IDU with similar baseline characteristics. The reasons behind the significant increase in mortality warrant further investigation.

Personalized Respiratory Support in ARDS: A Physiology-to-Bedside Review.

Acute respiratory distress syndrome (ARDS) is a leading cause of disability and mortality worldwide, and while no specific etiologic interventions have been shown to improve outcomes, noninvasive and invasive respiratory support strategies are life-saving interventions that allow time for lung recovery. However, the inappropriate management of these strategies, which neglects the unique features of respiratory, lung, and chest wall mechanics may result in disease progression, such as patient self-inflicted lung injury during spontaneous breathing or by ventilator-induced lung injury during invasive mechanical ventilation. ARDS characteristics are highly heterogeneous; therefore, a physiology-based approach is strongly advocated to titrate the delivery and management of respiratory support strategies to match patient characteristics and needs to limit ARDS progression. Several tools have been implemented in clinical practice to aid the clinician in identifying the ARDS sub-phenotypes based on physiological peculiarities (inspiratory effort, respiratory mechanics, and recruitability), thus allowing for the appropriate application of personalized supportive care. In this narrative review, we provide an overview of noninvasive and invasive respiratory support strategies, as well as discuss how identifying ARDS sub-phenotypes in daily practice can help clinicians to deliver personalized respiratory support and potentially improve patient outcomes.

Malaria as a Papal Disease.

OBJECTIVES: In this study, we aimed to investigate the effects of malaria on the lives of Roman pontiffs. MATERIALS AND METHODS: The histories of all 264 popes from Saint Peter to John Paul II were extensively studied. RESULTS: Malaria affected the lives of Roman pontiffs. Between 999 AD and 1644 AD, 21 of 99 popes were affected by malaria (21.4%). The first affected was Gregory V and the last was Urban VII, the 138th and the 235th pope, respectively. There were 15 deaths (15.2%). Six pontiffs (6.1%) were infected but survived. Many cardinals and their assistants, especially those coming from northern countries, contracted malaria during conclaves, and many died. CONCLUSIONS: By about 450 BC, malaria had arrived in Rome. By the second century BC, malaria was endemic. It affected the lives of Roman people. To prevent infection, the popes adopted the custom of ancient affluent Romans who used to spend summer months in high plains far from Rome. The first to adopt the custom was Paul I in 767, who just moved his residence to Saint Paul, out of the walls. Sixtus V started the Congregation of Waters and Streets, which was routinely reinforced by his successors until 1860, when the Kingdom of Italy was born.

Acute Kidney Injury as a Leading Cause of Papal Deaths in the Years 1277 to 2005: A Review of 21 Cases.

OBJECTIVES: This study was devised to investigate papal deaths due to acute kidney injury, a topic for which scarce data exist. MATERIALS AND METHODS: We studied all popes between John XXI, who died in 1277 of crush syndrome, and John Paul II, who died of anuria and urinary sepsis in 2005. RESULTS: Between pontification years from 1277 to 2005, 21 of 78 popes (26.9%) died of acute kidney injury. Sepsis was identified as the leading cause of acute kidney injury and death in 20 of 21 popes (95.2%). Mean ± SE age at death of the 21 popes was 69.4 ± 2.26 years. Six popes (28.6%) died of stroke. CONCLUSIONS: Sepsis-associated acute kidney injury, a syndrome with a complex pathogenesis and poor prognosis, which is far from being fully understood, contributed to a high number of papal deaths.

High Prevalence of Kidney Stone Disease of Gouty Origin in Roman Pontiffs Reigning in the Years 537-2005.

OBJECTIVES: Many Roman pontiffs are known to have had kidney stone disease. However, no specific report has explored the prevalence of the various stones in popes, which is the purpose of this study. MATERIALS AND METHODS: We extensively studied the histories of all popes (n = 264) from Saint Peter to John Paul II (34-2005). RESULTS: Among 206 popes reigning from 537 to 2005, 26 popes (12.6%) had uric acid stones. In the same period, 11 of 206 popes (5.3%) had nongouty stones (mainly calcium stones). In total, 37 of 208 (17.8%) popes complained of kidney stone disease. The ratio of calcium stone formers to other stone formers (including uric acid) was 0.42. CONCLUSIONS: The data suggest a higher prevalence of uric acid stones, which is linked to higher consumption of meat and sodium chloride. However, the last pope with kidney stone disease died in 1914. Although renal stone disease disappeared from papal palaces, population studies now indicate an increase in uric acid levels in the general population. The data can be explained based on the "Theory of Epidemiological Transition," pointing to the importance of education in eradicating poor lifestyles.

Recruitment-to-inflation Ratio Assessed through Sequential End-expiratory Lung Volume Measurement in Acute Respiratory Distress Syndrome.

BACKGROUND: Positive end-expiratory pressure (PEEP) benefits in acute respiratory distress syndrome are driven by lung dynamic strain reduction. This depends on the variable extent of alveolar recruitment. The recruitment-to-inflation ratio estimates recruitability across a 10-cm H2O PEEP range through a simplified maneuver. Whether recruitability is uniform or not across this range is unknown. The hypotheses of this study are that the recruitment-to-inflation ratio represents an accurate estimate of PEEP-induced changes in dynamic strain, but may show nonuniform behavior across the conventionally tested PEEP range (15 to 5 cm H2O). METHODS: Twenty patients with moderate-to-severe COVID-19 acute respiratory distress syndrome underwent a decremental PEEP trial (PEEP 15 to 13 to 10 to 8 to 5 cm H2O). Respiratory mechanics and end-expiratory lung volume by nitrogen dilution were measured the end of each step. Gas exchange, recruited volume, recruitment-to-inflation ratio, and changes in dynamic, static, and total strain were computed between 15 and 5 cm H2O (global recruitment-to-inflation ratio) and within narrower PEEP ranges (granular recruitment-to-inflation ratio). RESULTS: Between 15 and 5 cm H2O, median [interquartile range] global recruitment-to-inflation ratio was 1.27 [0.40 to 1.69] and displayed a linear correlation with PEEP-induced dynamic strain reduction (r = -0.94; P < 0.001). Intraindividual recruitment-to-inflation ratio variability within the narrower ranges was high (85% [70 to 109]). The relationship between granular recruitment-to-inflation ratio and PEEP was mathematically described by a nonlinear, quadratic equation (R2 = 0.96). Granular recruitment-to-inflation ratio across the narrower PEEP ranges itself had a linear correlation with PEEP-induced reduction in dynamic strain (r = -0.89; P < 0.001). CONCLUSIONS: Both global and granular recruitment-to-inflation ratio accurately estimate PEEP-induced changes in lung dynamic strain. However, the effect of 10 cm H2O of PEEP on lung strain may be nonuniform. Granular recruitment-to-inflation ratio assessment within narrower PEEP ranges guided by end-expiratory lung volume measurement may aid more precise PEEP selection, especially when the recruitment-to-inflation ratio obtained with the simplified maneuver between PEEP 15 and 5 cm H2O yields intermediate values that are difficult to interpret for a proper choice between a high and low PEEP strategy.

Prognostic Implication of Preoperative Anemia in Redo Cardiac Surgery: A Single-Center Propensity-Matched Analysis.

Preoperative anemia has been associated with increased morbidity and mortality after cardiac surgery, but little is known about its prognostic value in the setting of redo procedure. A retrospective, observational cohort study of prospectively collected data was undertaken on 409 consecutive patients referred for redo cardiac procedures between January 2011 and December 2020. The EuroSCORE II calculated an average mortality risk of 25.7 ± 15.4%. Selection bias was assessed with the propensity-adjustment method. The prevalence of preoperative anemia was 41%. In unmatched analysis, significant differences between the anemic and nonanemic groups emerged in the risk for postoperative stroke (0.6% vs. 4.4%, p = 0.023), postoperative renal dysfunction (29.7% vs. 15.6%, p = 0.001), a need for prolonged ventilation (18.1% vs. 7.2%, p = 0.002), and high-dosage inotropes (53.1% vs. 32.9%, p < 0.001) along with both length of ICU and hospital stay (8.2 ± 15.9 vs. 4.3 ± 5.4 days, p = 0.003 and 18.8 ± 17.4 vs. 14.9 ± 11.1, p = 0.012). After propensity matching (145 pairs), preoperative anemia was still significantly associated with postoperative renal dysfunction, stroke, and the need for high-dosage inotrope cardiac morbidity. Preoperative anemia is significantly associated with acute kidney injury, stroke, and the need for high-dosage inotropes in patients referred for redo procedures.

Non-invasive ventilation for acute hypoxemic respiratory failure, including COVID-19.

Optimal initial non-invasive management of acute hypoxemic respiratory failure (AHRF), of both coronavirus disease 2019 (COVID-19) and non-COVID-19 etiologies, has been the subject of significant discussion. Avoidance of endotracheal intubation reduces related complications, but maintenance of spontaneous breathing with intense respiratory effort may increase risks of patients' self-inflicted lung injury, leading to delayed intubation and worse clinical outcomes. High-flow nasal oxygen is currently recommended as the optimal strategy for AHRF management for its simplicity and beneficial physiological effects. Non-invasive ventilation (NIV), delivered as either pressure support or continuous positive airway pressure via interfaces like face masks and helmets, can improve oxygenation and may be associated with reduced endotracheal intubation rates. However, treatment failure is common and associated with poor outcomes. Expertise and knowledge of the specific features of each interface are necessary to fully exploit their potential benefits and minimize risks. Strict clinical and physiological monitoring is necessary during any treatment to avoid delays in endotracheal intubation and protective ventilation. In this narrative review, we analyze the physiological benefits and risks of spontaneous breathing in AHRF, and the characteristics of tools for delivering NIV. The goal herein is to provide a contemporary, evidence-based overview of this highly relevant topic.

Are there difficulty variables in maxillary third molar surgery? A prospective observational cohort study.

BACKGROUND: The main aim of the present study was to assess which factors were related to surgical difficulty in maxillary third molar extraction. Intra- and postoperative complications were also evaluated. METHODS: A prospective observational cohort study was performed on out-patients who underwent impacted maxillary third molar extraction. Principal component analysis and multiple linear regression were used to assess the correlation among variables as well as the influence of different preoperative variables on surgical difficulty, suture duration and risk of intraoperative complications. RESULTS: Eighty-six teeth were extracted. There was a positive correlation between pre- and postoperative evaluations and surgery duration. Available space for surgical access in the upper fornix, second molar contact, crown palatal position, depth of the elevation point and surgeon's seniority had a significant effect on the overall difficulty index. Risk of intraoperative complications increased considerably as the percentage of reduction of maximum mouth opening increased (2.03±0.98) as well as in cases in which ostectomy and tooth sectioning were performed (7.02±2.68). The surgeon's seniority was associated with a decreased risk of intraoperative complications (-1.52±0.72). Surgeons were able to predict the difficulty of surgery only to a limited extent. CONCLUSIONS: The percentage of maximum mouth opening reduction with an object in the fornix, crown palatal position, and contact with the second molar were found to be related to surgical difficulty.

The Dropsy of Popes (1555-1978): A Bad Prognostic Sign Foreboding of Death.

The purpose of this study is to explore the historical background of edema as a prognostic sign in popes, a special category of medical subjects whose health status was closely monitored and chronicled because of their unique important status in the events of their times. Nine out of 51 popes, who reigned in the years 1555-1978, died edematous at a mean age of 75.5 years of age. The cause of edema was: heart failure for John Paul I, liver disease, obstructive nephropathy associated with anemia for Paul IV, who also suffered from deep vein thrombosis, and malnutrition for Innocent XIII. Chronic kidney disease due to renal stones of gouty origin caused edema in Clement VIII, Clement X, Clement XI, and Benedict XIV. Obstructive nephropathy due to renal stones of non-gouty origin caused edema in Clement XIII, whereas toxic nephropathy due to the use of mercurials caused edema in Clement XIV. Innocent XI, Benedict XIV, and Clement XIV were bled before death because of impending pulmonary edema. It is not surprising that chronic kidney disease was a significant cause of edema in popes with chronic kidney disease which is associated with impaired sodium excretion. The edema was likely aggravated by the excessive dietary salt intake of the period when the importance of sodium chloride restriction was still not discovered and effective diuretic agents were not available.

High-Flow Nasal Oxygen for Severe Hypoxemia: Oxygenation Response and Outcome in Patients with COVID-19.

Rationale: The "Berlin definition" of acute respiratory distress syndrome (ARDS) does not allow inclusion of patients receiving high-flow nasal oxygen (HFNO). However, several articles have proposed that criteria for defining ARDS should be broadened to allow inclusion of patients receiving HFNO. Objectives: To compare the proportion of patients fulfilling ARDS criteria during HFNO and soon after intubation, and 28-day mortality between patients treated exclusively with HFNO and patients transitioned from HFNO to invasive mechanical ventilation (IMV). Methods: From previously published studies, we analyzed patients with coronavirus disease (COVID-19) who had PaO2/FiO2 of ⩽300 while treated with ⩾40 L/min HFNO, or noninvasive ventilation (NIV) with positive end-expiratory pressure of ⩾5 cm H2O (comparator). In patients transitioned from HFNO/NIV to invasive mechanical ventilation (IMV), we compared ARDS severity during HFNO/NIV and soon after IMV. We compared 28-day mortality in patients treated exclusively with HFNO/NIV versus patients transitioned to IMV. Measurements and Main Results: We analyzed 184 and 131 patients receiving HFNO or NIV, respectively. A total of 112 HFNO and 69 NIV patients transitioned to IMV. Of those, 104 (92.9%) patients on HFNO and 66 (95.7%) on NIV continued to have PaO2/FiO2 ⩽300 under IMV. Twenty-eight-day mortality in patients who remained on HFNO was 4.2% (3/72), whereas in patients transitioned from HFNO to IMV, it was 28.6% (32/112) (P < 0.001). Twenty-eight-day mortality in patients who remained on NIV was 1.6% (1/62), whereas in patients who transitioned from NIV to IMV, it was 44.9% (31/69) (P < 0.001). Overall mortality was 19.0% (35/184) and 24.4% (32/131) for HFNO and NIV, respectively (P = 0.2479). Conclusions: Broadening the ARDS definition to include patients on HFNO with PaO2/FiO2 ⩽300 may identify patients at earlier stages of disease but with lower mortality.

A Prospective Observational Study on the Variables Affecting the Risk of Inferior Alveolar Nerve Damage During Lower Third Molar Surgery With Nerve/Root Proximity.

PURPOSE: The present study aimed to evaluate which factors were statistically associated with a greater probability of inferior alveolar nerve (IAN) damage during lower third molar surgery. METHODS: A prospective observational study was performed at the Oral Surgery Unit of the Umberto I Hospital on 92 patients who underwent surgical extraction of a lower third molar that was radiographically overlapped with the mandibular canal. All surgeries were performed by the same expert surgeon. A principal component analysis and the exact 2-tailed Fisher exact test were used. RESULTS: Temporary IAN damage occurred in 10 cases (10.9%). Symptoms lasted from 18 to 180 days (73 ± 49.15). IAN damage was more frequent in difficult and long-lasting surgeries, in the presence of many risk factors and in patients with a reduced maximum mouth opening. CONCLUSION: Such factors should be accurately evaluated before surgery to assess and discuss the overall surgical risk of IAN damage with the patient especially when they are over the maximum limit of their significant variability range found in the present study, that is, >12 for difficulty index, >2 for number of orthopantomography risk markers and <3.7 cm for maximum mouth opening.

Gas conditioning during helmet noninvasive ventilation: effect on comfort, gas exchange, inspiratory effort, transpulmonary pressure and patient-ventilator interaction.

BACKGROUND: There is growing interest towards the use of helmet noninvasive ventilation (NIV) for the management of acute hypoxemic respiratory failure. Gas conditioning through heat and moisture exchangers (HME) or heated humidifiers (HHs) is needed during facemask NIV to provide a minimum level of humidity in the inspired gas (15 mg H2O/L). The optimal gas conditioning strategy during helmet NIV remains to be established. METHODS: Twenty patients with acute hypoxemic respiratory failure (PaO2/FiO2 < 300 mmHg) underwent consecutive 1-h periods of helmet NIV (PEEP 12 cmH2O, pressure support 12 cmH2O) with four humidification settings, applied in a random order: double-tube circuit with HHs and temperature set at 34 °C (HH34) and 37 °C (HH37); Y-piece circuit with HME; double-tube circuit with no humidification (NoH). Temperature and humidity of inhaled gas were measured through a capacitive hygrometer. Arterial blood gases, discomfort and dyspnea through visual analog scales (VAS), esophageal pressure swings (ΔPES) and simplified pressure-time product (PTPES), dynamic transpulmonary driving pressure (ΔPL) and asynchrony index were measured in each step. RESULTS: Median [IqR] absolute humidity, temperature and VAS discomfort were significantly lower during NoH vs. HME, HH34 and HH37: absolute humidity (mgH2O/L) 16 [12-19] vs. 28 [23-31] vs. 28 [24-31] vs. 33 [29-38], p < 0.001; temperature (°C) 29 [28-30] vs. 30 [29-31] vs. 31 [29-32] vs 32. [31-33], p < 0.001; VAS discomfort 4 [2-6] vs. 6 [2-7] vs. 7 [4-8] vs. 8 [4-10], p = 0.03. VAS discomfort increased with higher absolute humidity (p < 0.01) and temperature (p = 0.007). Higher VAS discomfort was associated with increased VAS dyspnea (p = 0.001). Arterial blood gases, respiratory rate, ΔPES, PTPES and ΔPL were similar in all conditions. Overall asynchrony index was similar in all steps, but autotriggering rate was lower during NoH and HME (p = 0.03). CONCLUSIONS: During 1-h sessions of helmet NIV in patients with hypoxemic respiratory failure, a double-tube circuit with no humidification allowed adequate conditioning of inspired gas, optimized comfort and improved patient-ventilator interaction. Use of HHs or HME in this setting resulted in increased discomfort due to excessive heat and humidity in the interface, which was associated with more intense dyspnea. Trail Registration Registered on clinicaltrials.gov (NCT02875379) on August 23rd, 2016.

Diaphragm thickening fraction predicts noninvasive ventilation outcome: a preliminary physiological study.

BACKGROUND: A correlation between unsuccessful noninvasive ventilation (NIV) and poor outcome has been suggested in de-novo Acute Respiratory Failure (ARF) patients. Consequently, it is of paramount importance to identify accurate predictors of NIV outcome. The aim of our preliminary study is to evaluate the Diaphragmatic Thickening Fraction (DTF) and the respiratory rate/DTF ratio as predictors of NIV outcome in de-novo ARF patients. METHODS: Over 36 months, we studied patients admitted to the emergency department with a diagnosis of de-novo ARF and requiring NIV treatment. DTF and respiratory rate/DTF ratio were measured by 2 trained operators at baseline, at 1, 4, 12, 24, 48, 72 and 96 h of NIV treatment and/or until NIV discontinuation or intubation. Receiver operating characteristic (ROC) curve analysis was performed to evaluate the ability of DTF and respiratory rate/DTF ratio to distinguish between patients who were successfully weaned and those who failed. RESULTS: Eighteen patients were included. We found overall good repeatability of DTF assessment, with Intra-class Correlation Coefficient (ICC) of 0.82 (95% confidence interval 0.72-0.88). The cut-off values of DTF for prediction of NIV failure were < 36.3% and < 37.1% for the operator 1 and 2 (p < 0.0001), respectively. The cut-off value of respiratory rate/DTF ratio for prediction of NIV failure was > 0.6 for both operators (p < 0.0001). CONCLUSION: DTF and respiratory rate/DTF ratio may both represent valid, feasible and noninvasive tools to predict NIV outcome in patients with de-novo ARF. Trial registration ClinicalTrials.gov Identifier: NCT02976233, registered 26 November 2016.

High Failure Rate of Noninvasive Oxygenation Strategies in Critically Ill Subjects With Acute Hypoxemic Respiratory Failure Due to COVID-19.

BACKGROUND: The efficacy of noninvasive oxygenation strategies (NIOS) in treating COVID-19 disease is unknown. We conducted a prospective observational study to assess the rate of NIOS failure in subjects treated in the ICU for hypoxemic respiratory failure due to COVID-19. METHODS: Patients receiving first-line treatment NIOS for hypoxemic respiratory failure due to COVID-19 in the ICU of a university hospital were included in this study; laboratory data were collected upon arrival, and 28-d outcome was recorded. After propensity score matching based on Simplified Acute Physiology (SAPS) II score, age, [Formula: see text] and [Formula: see text] at arrival, the NIOS failure rate in subjects with COVID-19 was compared to a previously published cohort who received NIOS during hypoxemic respiratory failure due to other causes. RESULTS: A total of 85 subjects received first-line treatment with NIOS. The most frequently used methods were helmet noninvasive ventilation and high-flow nasal cannula; of these, 52 subjects (61%) required endotracheal intubation. Independent factors associated with NIOS failure were SAPS II score (P = .009) and serum lactate dehydrogenase at enrollment (P = .02); the combination of SAPS II score ≥ 33 with serum lactate dehydrogenase ≥ 405 units/L at ICU admission had 91% specificity in predicting the need for endotracheal intubation. In the propensity-matched cohorts (54 pairs), subjects with COVID-19 showed higher risk of NIOS failure than those with other causes of hypoxemic respiratory failure (59% vs 35%, P = .02), with an adjusted hazard ratio of 2 (95% CI 1.1-3.6, P = .01). CONCLUSIONS: As compared to hypoxemic respiratory failure due to other etiologies, subjects with COVID-19 who were treated with NIOS in the ICU were burdened by a 2-fold higher risk of failure. Subjects with a SAPS II score ≥ 33 and serum lactate dehydrogenase ≥ 405 units/L represent the population with the greatest risk.

Cardiac surgery practice during the COVID-19 outbreak: a multicentre national survey.

OBJECTIVES: Healthcare systems worldwide have been overburdened by the coronavirus disease 2019 (COVID-19) outbreak. Accordingly, hospitals had to implement strategies to profoundly reshape both non-COVID-19 medical care and surgical activities. Knowledge about the impact of the COVID-19 pandemic on cardiac surgery practice is pivotal. The goal of the present study was to describe the changes in cardiac surgery practices during the health emergency at the national level. METHODS: A 26-question web-enabled survey including all adult cardiac surgery units in Italy was conducted to assess how their clinical practice changed during the national lockdown. Data were compared to data from the corresponding period in 2019. RESULTS: All but 2 centres (94.9%) adopted specific protocols to screen patients and personnel. A significant reduction in the number of dedicated cardiac intensive care unit beds (-35.4%) and operating rooms (-29.2%), along with healthcare personnel reallocation to COVID departments (nurses -15.4%, anaesthesiologists -7.7%), was noted. Overall adult cardiac surgery volumes were dramatically reduced (1734 procedures vs 3447; P < 0.001), with a significant drop in elective procedures [580 (33.4%) vs 2420 (70.2%)]. CONCLUSIONS: This national survey found major changes in cardiac surgery practice as a response to the COVID-19 pandemic. This experience should lead to the development of permanent systems-based plans to face possible future pandemics. These data may effectively help policy decision-making in prioritizing healthcare resource reallocation during the ongoing pandemic and once the healthcare emergency is over.

Cardiac surgery practice during the COVID-19 outbreak: a regionwide survey.

BACKGROUND: Health systems worldwide have been overburdened by the "COVID-19 surge". Consequently, strategies to remodulate non-COVID medical and surgical care had to be developed. Knowledge of the impact of COVID surge on cardiac surgery practice is mainstem. Present study aims to evaluate the regional practice pattern during lockdown in Campania. METHODS: A multicenter regional observational 26-question survey was conducted, including all adult cardiac surgery units in Campania, Italy, to assess how surgical practice has changed during COVID-19 national lockdown. RESULTS: All centers adopted specific protocols for screening patients and personnel. A significant reduction in the number of dedicated intensive care unit (ICU) beds (-30.0%±38.1%, range: 0-100%) and cardiac operating rooms (-22.2%±26.4%, range: 0-50%) along with personnel relocation to other departments was disclosed (anesthesiologists -5.8%±11.1%, range: 0-33.3%; perfusionists -5.6%±16.7%, range: 0-50%; nurses -4.8%±13.2%, range: 0-40%; cardiologists -3.2%±9.5%, range: 0-28.6%). Cardiac surgeons were never reallocated to other services. Globally, we witnessed dramatically lower adult cardiac surgery case volumes (335 vs. 667 procedures, P<0.001), as institutions and surgeons followed guidelines to curtail non-urgent operations. CONCLUSIONS: This regional survey demonstrates major changes in practice as a response to the COVID-19 pandemic. In this respect, this experience might lead to the development of permanent systems-based plans for future pandemic and may effectively help policy decision making when prioritizing healthcare resource reallocation during and after the pandemic.

Noninvasive ventilation and high-flow oxygen therapy for severe community-acquired pneumonia.

PURPOSE OF REVIEW: We review the evidence on the use of noninvasive respiratory supports (noninvasive ventilation and high-flow nasal cannula oxygen therapy) in patients with acute respiratory failure because of severe community-acquired pneumonia. RECENT FINDINGS: Noninvasive ventilation is strongly advised for the treatment of hypercapnic respiratory failure and recent evidence justifies its use in patients with hypoxemic respiratory failure when delivered by helmet. Indeed, such interface allows alveolar recruitment by providing high level of positive end-expiratory pressure, which improves hypoxemia. On the other hand, high-flow nasal cannula oxygen therapy is effective in patients with hypoxemic respiratory failure and some articles support its use in patients with hypercapnia. However, early identification of noninvasive respiratory supports treatment failure is crucial to prevent delayed orotracheal intubation and protective invasive mechanical ventilation. SUMMARY: Noninvasive ventilation is the first-line therapy in patients with acute hypercapnic respiratory failure because of pneumonia. Although an increasing amount of evidence investigated the application of noninvasive respiratory support to hypoxemic respiratory failure, the optimal ventilatory strategy in this setting is uncertain. Noninvasive mechanical ventilation delivered by helmet and high-flow nasal cannula oxygen therapy appear as promising tools but their role needs to be confirmed by future research.

Platelet­to­lymphocyte ratio, neutrophil­to­lymphocyte ratio and monocyte­to­HDL cholesterol ratio as markers of peripheral artery disease in elderly patients.

Solid evidence underlines the pivotal role played by inflammation regarding atherosclerosis. Peripheral artery disease (PAD) is one of atherosclerotic cardiovascular diseases (CVDs), it is highly frequently diagnosed in older individuals. In the present study we carried out an investigation on the association between platelet­to­lymphocytes ratio (PLR), neutrophil­to­lymphocyte ratio (NLR), monocyte­to­HDL cholesterol ratio (MHR) with PAD as favourable markers. We identified 300 subjects aged over 70 years, without any concomitant CVDs. The PLR, NLR and MHR were assessed from peripheral venous blood routinely drawn in the ward during hospitalization. Patients were divided in groups according to ankle brachial index (ABI) value (>0.9; 0.9­0.99; 1­1.4; >1.4). Higher PLR (P=0.007), NLR (P=0.0001) and MHR (P=0.0001) were associated with <0.9 ABI. Patients with a >1.4 ABI showed NLR values higher compared to >0.9l ABI (P<0.01). Univariate linear regression analysis demonstrated the direct correlation between increase in PLR (P=0.0023)and MHR (P<0.0001) with the decrease in ABI value. In multivariate linear regression analysis including main cardiovascular risk factors we found that PLR, NLR and MHR were independently associated with lower ABI (P=0.0011). Results show and suggest that the elevated PLR, NLR and MHR are related to PAD evaluated with ABI measurement. PLR and MHR seem to be more reliable markers than NLR in PAD. NLR seems to be more related to incompressibility of arterial wall. It is hypothesized that these three indexes may play a role as simple and repetitive markers of PAD.