Cardiopulmonary Comorbidities Research Articles

Relevance of medical comorbidities for functional mobility in people with limb loss: retrospective explanatory models for a clinical walking measure and a patient-reported functional outcome

ObjectivesVarious modifiable and non-modifiable factors affect functional mobility, but subjective patient-reported and objective performance-based measures are rarely combined in explanatory analyses of functional mobility in people with limb loss. This study determined separate explanatory models for patient-reported function using the Prosthetic Evaluation Questionnaire Mobility Subscale (PEQ-MS), and performance-based 2-Minute Walk Test (2MWT). DesignRetrospective cross-sectional observational analysis. SettingWellness-walking program. ParticipantsThree hundred five volunteers with lower limb loss participated. Sixty nine percent were men, mean age 56 (15) years. Fifty two percent had vascular amputation causes, 42% had surgical levels above the knee, and 82% had medical comorbidities. Walking levels included limited-household (21%), limited-community (30%), and independent-community (49%). Outcome measures included patient-reported PEQ-MS, Activities-specific Balance Confidence (ABC) and Houghton scales; and performance-based balance and walking. Main outcomesSeparate PEQ-MS and 2MWT multiple regression models fit using backward deletion. ResultsModifiable (balance ability, ABC, Houghton score; P<0.05) and non-modifiable factors (sex, amputation cause, surgical level; P<0.05) explained the variance in 2MWT (adjusted R2=0.685). Patient-reported and performance-based modifiable factors (Houghton score, 2MWT; P<0.001) explained PEQ-MS variance (adjusted R2=0.660). Integumentary (P=0.022) and cardiopulmonary (P<0.001) comorbidities explained an additional 4% of PEQ-MS variance, while surgical level was insignificant. ConclusionsBoth modifiable and non-modifiable factors explained prosthetic functional mobility. Performance-based walking was explained by modifiable factors including balance ability and confidence, prosthesis and walking aid use. Patient-reported function was also explained by prosthesis and walking aid use, walking speed and medical comorbidities. Modifiable factors for objective and subjective prosthetic mobility may provide a clinical roadmap for rehabilitation.

COVID-19: the older adult and the importance of vitamin D sufficiency

Abstract In December 2019, in Wuhan, China, the novel coronavirus ‘severe acute respiratory syndrome 2’ (SARS-CoV-2) was discovered as the cause of a pneumonia-like illness and subsequently named coronavirus disease 2019 (COVID-19). COVID-19 spread and is now a global pandemic. With few exceptions, countries in the Northern hemisphere have higher mortality rates from COVID-19. This may be due to an increased prevalence of older people in Northern Europe at higher risk of having cardio-pulmonary and metabolic comorbidities as well as hypovitaminosis D. With increasing age, immunosenescence and ‘inflammaging’ lead to impaired and maladaptive immune responses to SARS-CoV-2 infections, contributing to the enhanced prevalence of severe COVID-19 in older patients. The association of ageing with increased vitamin D deficiency, which is associated with cardiovascular risk factors and disease and worse prognosis in COVID-19 infection, is discussed. Considerable experimental evidence demonstrates the immuno-modulatory properties of vitamin D, in particular, its role in regulating and suppressing the inflammatory cytokine response to viral respiratory infections links the importance of vitamin D sufficiency as a potential protective factor in COVID-19. There is an urgent need for prospective randomised studies to examine whether hypovitaminosis D correlates with severity of COVID-19 disease and the actual benefit of repletion. Moreover, given what has been described as a ‘pandemic of vitamin D deficiency’, especially in Europe, and in the context of the SARS-CoV-2 contagion, the authors support the call for public health doctors and physicians, with support from Governments, to prioritise and strengthen recommendations on vitamin D intake and supplementation.

3001 A Rare Location for Signet Ring Cell Carcinoma

INTRODUCTION: Roughly 96% of Signet Ring Cell Carcinoma (SRCC) occurs in the stomach. However, it has also been reported at extra-gastric locations such as the breast, colon, and gallbladder. Although still rare, the incidence of gastric signet ring cell carcinoma has been rising in the past decade and it is now being found in uncommon locations. Only 7 cases have been reported for the presence of a SRCC in pancreas. We report a case of pancreatic signet ring cell carcinoma which was diagnosed with EUS-guided biopsy. CASE DESCRIPTION/METHODS: Case A 71-year-old Caucasian male presented with diarrhea and abdominal pain for 1 month as well as a 10 lb weight loss over a 2-month period. Physical examination was positive for jaundice and initial labs showed a bilirubin of 9.8, AST 229, ALT 240, and alkaline phosphatase 420. MRI of the abdomen showed dilation of both the pancreatic duct and common bile duct (CBD), and a distal CBD stricture. The patient underwent an EUS, which showed a 2.8 cm × 2.5 cm hypoechoic ill-defined mass in the head of the pancreas with poorly defined, irregular borders. A 22-gauge needle was used to perform aspiration with four needle passes. ERCP was then performed to place a 10 Fr plastic stent across the CBD stricture. Pathology of the pancreatic mass aspiration revealed moderately to poorly differentiated adenocarcinoma with signet ring cell features. PET CT and abdominal CT were performed without evidence of distant metastasis. CA 19-9 levels were 352. Based on radiographic imaging and endoscopic ultrasound, the patient was staged IIA (T3N0M0) but was found not to be a surgical candidate due to multiple cardiopulmonary comorbidities and was started on neoadjuvant chemotherapy. DISCUSSION: The histopathology of SRCC in pancreas appears similar to that of the gastric variant in that the tumor is characterized by intra-cytoplasmic mucin vacuoles that expand the nucleus of the cell to the periphery. Little is known about the differences in prognosis and treatment. However, there is an overall poorer prognosis in patients with SRCC regardless of location. EUS guided biopsy provides a safe technique in the setting of co-morbidities which preclude surgery. Our case demonstrates the need for more research in SRCC on any location as well as targeted modalities for extra-gastric locations while also highlighting the usefulness of EUS as a tool for diagnosis.

The association between sarcopenia and osteoporotic vertebral compression refractures.

The purpose of this study was to investigate the association between osteoporotic vertebral compression refractures (OVCRFs) and sarcopenia, and to identify other risk factors of OVCRFs. We evaluated 237 patients with osteoporotic vertebral compression fracture who underwent percutaneous kyphoplasty (PKP) in our hospital from August 2016 to December 2017. To diagnose sarcopenia, a cross-sectional computed tomography (CT) image at the inferior aspect of the third lumbar vertebra (L3) was selected for estimating muscle mass. Grip strength was used to assess muscle strength. Possible risk factors, such as age, sex, body mass index (BMI), bone mineral density (BMD), location of the treated vertebra, anterior-posterior ratio (AP ratio) of the fractured vertebra, cement leakage, and vacuum clefts, were assessed. The multivariable analysis was used to determine the risk factors of OVCRFs. During the follow-up period, OVCRFs occurred in 64 (27.0%) patients. Sarcopenia was present in 48 patients (20.3%), including 21 OVCRFs and 27 non-OVCRFs patients. Sarcopenia was significantly correlated with advanced age, lower BMI, lower BMD, and hypoalbuminemia. Compared with non-sarcopenic patients, sarcopenic patients had higher OVCRFs risk. In univariate analysis, sarcopenia (p = 0.003), female (p = 0.024), advanced age (≥ 75years; p < 0.001), lower BMD (p < 0.001), lower BMI (p = 0.01), TL junction (vertebral levels at the thoracolumbar junction) (p = 0.01), cardiopulmonary comorbidity (p = 0.042), and hypoalbuminemia (p = 0.003) were associated with OVCRFs. Multivariable analysis revealed that sarcopenia (OR 2.271; 95% CI 1.069-4.824, p = 0.033), lower BMD (OR 1.968; 95% CI 1.350-2.868, p < 0.001), advanced age (≥ 75years; OR 2.431; 95% CI 1.246-4.744, p = 0.009), and female sex (OR 4.666; 95% CI 1.400-15.552, p = 0.012) were independent risk predictors of OVCRFs. Sarcopenia is an independent risk predictor of osteoporotic vertebral compression refractures. Other factors affecting OVCRFs are low BMD T-scores, female sex, and advanced age.

Prune belly syndrome: current perspectives.

Prune belly syndrome (PBS) is a rare but morbid congenital disease, classically defined by a triad of cardinal features that includes cryptorchidism, urinary tract dilation and laxity of the abdominal wall musculature. Children often require numerous surgical interventions including bilateral orchidopexy as well as individually tailored urinary tract and abdominal wall reconstruction. Along with the classic features, patients with PBS often experience gastrointestinal, orthopedic, and cardiopulmonary comorbidities.

Screening and systematic follow-up for cardiopulmonary comorbidity in elective surgery for colorectal cancer: a randomised feasibility study

BackgroundOne third of patients with colorectal cancer (CRC) have comorbidity, which impairs their postoperative outcomes. Scoring systems may predict mortality, but there is limited evidence of effective interventions in high-risk patients. Our aim was to test a trial setup to assess the effect of extra postoperative medical visits and follow-up on 1-year mortality and other outcomes in patients with cardiopulmonary risk factors undergoing elective surgery for colorectal tumours.MethodsPatients preoperatively screened positive for cardiopulmonary comorbidity were eligible. On postoperative day 4, they were randomised to either routine follow-up (RFU) or RFU with one extra medical visit and additional visits to the Cardiology and Respiratory Medicine Clinics 1 and 3 months postoperatively. The primary outcome measure was 1-year mortality; secondary outcome measures were length of stay (LOS), complications, and readmissions.ResultsOf 673 screened patients 326 (48%) were found eligible, 108 declined participation, and 198 were randomised. Postoperative medical problems and/or need for intervention were found in 15–23% of the patients at the extra medical visits. The 90-day mortality was 0 and the 1-year mortality only 2.6% with no differences between the two groups. LOS and complication rates did not differ, but there were significantly fewer readmissions in the intervention group.ConclusionsThe 1-year mortality after elective CRC surgery was low, even in the presence of cardiopulmonary risk factors. There was no evidence of reduced mortality with additional medical follow-up in these patients.Trial registrationClinicalTrials.gov NCT02328365 registered 31 December 2014 (retrospectively registered)

Cardiopulmonary Comorbidity, Radiomics and Machine Learning, and Therapeutic Regimens for a Cerebral fMRI Predictor Study in Psychotic Disorders.

Cardiopulmonary Comorbidity, Radiomics and Machine Learning, and Therapeutic Regimens for a Cerebral fMRI Predictor Study in Psychotic Disorders.

Early cardiac complications after bariatric surgery: does the type of procedure matter?

BackgroundMajor adverse cardiac events (MACE) can be a cause of postoperative mortality. This is specifically important in bariatric surgery due to obesity-related cardiovascular risk factors. ObjectiveTo assess postoperative cardiac adverse events after bariatric surgery and its independent predictors. SettingA retrospective analysis of 2011–2015 Healthcare Cost and Utilization Project-National Inpatient Sample. MethodsData on patients who underwent laparoscopic sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) were retrieved. MACE was identified as a composite variable including myocardial infarction, acute ischemic heart disease without myocardial infarction, and acute heart failure. Dysrhythmia (excluding premature beats) was identified as a separate outcome. Multivariate regression analysis for MACE was performed using demographic factors, co-morbidities, and type of surgery. ResultsThe analysis included 108,432 patients (SG: 54.6%, RYGB: 45.4%). MACE was found in 116 patients (.1%), and dysrhythmia occurred in 3670 patients (3.4%). Median length of stay in patients with MACE was 4.5 versus 2 days in others (P < .001). There were 43 deaths overall, and 31 were in patients with MACE or dysrhythmia (P < .001). Age ≥ 50 years, male sex, congestive heart failure, chronic pulmonary disease, ischemic heart disease, history of pulmonary emboli, and fluid or electrolyte disorders were independent predictors of MACE based on multivariate analysis. Type of surgery (SG versus RYGB) was not an independent predictor for MACE (odds ratio 1.41, 95% confidence interval: .77–2.55). ConclusionsWhile cardiac complications are rare after bariatric surgery, their occurrence is associated with increased length of stay, hospital charges, and mortality. Older age, male sex, cardiopulmonary co-morbidities, and fluid or electrolyte disorders are predictive of MACE. RYGB does not increase the risk of MACE compared with SG.

Long-term durability of multibranched endovascular repair of thoracoabdominal and pararenal aortic aneurysms

ObjectiveThe objective of this study was to assess the durability of multibranched endovascular repair of thoracoabdominal aortic aneurysms (TAAAs) and pararenal aortic aneurysms by examining the rates of late-occurring (beyond 30 days) complications. MethodsThere were 146 patients who underwent endovascular TAAA repair using a stent graft, with a total of 538 caudally oriented self-expanding branches. Four patients died in the perioperative period and were excluded, leaving 142 patients (mean age, 73 ± 8 years; 35 [24.7%] women). Follow-up included clinical examination and computed tomography angiography at 1 month, 6 months, and 12 months and yearly thereafter. ResultsMean aneurysm diameter was 67 ± 9 mm. Sixty-seven TAAAs (47.2%) were Crawford type I, II, III, or V; 75 (52.8%) were type IV or pararenal. Three patients (2.1%) died >30 days after operation from perioperative complications. During a mean follow-up of 36 months (±28 months), there were four additional aneurysm-related deaths: one (0.7%) as a result of aneurysm rupture in the presence of untreatable type I endoleak, one (0.7%) after conversion to open repair for stent graft infection, one (0.7%) after occlusion of superior mesenteric artery and celiac branches, and one (0.7%) due to bilateral renal branch occlusion. There was one additional open conversion for stent graft infection (0.7%). Nineteen patients (13.3%) underwent 20 reinterventions for late-occurring complications, including 11 (7.7%) for renal branch occlusion or stenosis, 1 (0.7%) for mesenteric branch stenosis, 4 (2.8%) for graft limb occlusion, 1 (0.7%) for type IB endoleak (distal stent graft migration), and 1 (0.7%) for type III endoleak (fabric erosion); 2 (1.4%) open conversions were performed for stent graft infection. There were no late type IA endoleaks. By Kaplan-Meier analysis, freedom from aneurysm-related death was 91.1% and freedom from aneurysm-related death or reintervention was 76.8% at 5 years. The 5-year overall survival rate of 49.1% reflects the high rate of cardiopulmonary comorbidity. Although renal branch occlusion (23 occlusions of 256 renal branches [8.9%]) was the most common late complication, only five patients required permanent dialysis. ConclusionsTotal endovascular repair of TAAAs and pararenal aortic aneurysms using axially oriented cuffs is safe, effective, and durable in the long term.

Clinical and Laboratory Predictors of 30-Day Hospital Readmission Risk in Adult Patients with Sickle Cell Disease

Introduction: Thirty-day readmission risk is widely accepted as an indicator of quality of care. Sickle cell disease (SCD) has one the highest hospital readmission risk with a wide variation between different studies. In recent studies, older age, insurance status, and systemic complications including sepsis, renal and liver disease increased the risk of readmission whereas blood transfusion reduced the risk. During hospital stay, patients experience a variety of changes in their symptoms and laboratory measures. Evidence on the role of these changes on readmission risk is limited. In the current study, we aimed to assess the clinical and laboratory predictors of 30-day readmission risk in SCD adult patients in a tertiary health care system.Methods: Medical record discharge abstract files which cover visits for the SCD patients at the University of Pittsburgh Medical Center (UPMC) were extracted from electronic health records. Laboratory test results were obtained for each admission and were linked to discharge data. For each admission ICD 9/10 codes were used to identify the comorbidities. Blood transfusion information was recorded during each the admission. Natural language processing was used to extract medical concepts from chest X-ray and CT scan reports during patient's admission. Acute chest syndrome/pneumonia were identified from a combination of ICD codes and radiologic reports. For each laboratory value, a single rate of change (trajectory) was calculated with a random coefficient model from any measures during the hospital stay. Rate of changes were categorized to negative and positive trajectory. We used Generalized Estimating Equations models to assess predictors of 30-day readmission risk including the relationship between negative trajectory of any laboratory values duration the admission.Results: During January 2010 to May 2016, data for 2,108 hospital admissions in 173 SCD unique adult patients (median age of 32, 57% female and 59% SS genotype) were extracted. Risk of 30-day readmission was 41.2%. Older age (P <0.001) but not genotype (P = 0.8) predicted a lower readmission risk. Blood transfusion reduced readmission risk by 15% (Figure a). This effect was more significant in younger age (P for interaction with age = 0.045, Figure b). The most common discharge diagnoses were chronic pulmonary heart disease (23%), acute chest/pneumonia (22%), chronic renal disease (12%) and chronic liver disease (7%). Trajectory of neutrophil and WBC count changes were negative in 85% and 78% of admissions, respectively. These values were 67% for hemoglobin, 71% for creatinine and 46% for platelet count. During the period of hospital stay, decline in WBC (OR = 0.47, P = 0.030), neutrophil count (OR = 0.37, P = 0.023) or creatinine (OR = 0.40, P = 0.004) was associated with lower readmission risk.Conclusions: These results support that cardiopulmonary comorbidities are unexpectedly common in adult SCD patients. Blood transfusion in younger SCD patient reduced the readmission risk. Renal complications and leukocytosis in these patients contributed to health care utilization. Using advanced predictive models can help us to define patients who are at higher risk of readmission and generate strategies to reduce hospital readmission. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Stereotactic body radiation therapy for stage I non-small cell lung carcinomas: Moderate hypofractionation optimizes outcome

ObjectivesIn case of inoperability or refusal of surgery, stereotactic body radiation therapy (SBRT) is the most effective treatment for a stage I non-small cell lung carcinoma (NSCLC). The results obtained by this irradiation technique are considerably superior to those observed in the time of conventional 3D irradiation and its toxicities are much less important, which makes it possible in elderly patients, or those presenting cardio-pulmonary comorbidities and a poor perfomance status. Materials and methodsThis study is a retrospective analysis of 90 patients who underwent SBRT for a stage I NSCLC between 2010 and 2015. Its purpose is to describe its effectiveness in term of overall survival (OS), specific survival (SS), local control (LC), regional control (RC) and metastatic control (MC) as well as their prognostic factors, and its tolerance. ResultsLC, RC, MC as well as OS and SS rate at 4 years were comparable to the main prospective studies, respectively 89%, 92%, 70%, 33% and 66%. No LC prognostic factor could be identified. Radiation pneumonitis was observed with a rate of 61.5%, of which 56% were asymptomatic, and 4% of the patients had a rib fracture. ConclusionsSBRT is an efficient and well-tolerated treatment for stage I non-small cell lung carcinomas

Healthcare utilization in chronic thromboembolic pulmonary hypertension after acute pulmonary embolism

Essentials Diagnostic delay of chronic thromboembolic pulmonary hypertension (CTEPH) is long. We explored healthcare utilisation of patients diagnosed with CTEPH after pulmonary embolism. A large number of physicians were consulted and test results were not always interpreted correctly. Better education and higher awareness of CTEPH may lead to faster diagnosis. SUMMARY: Background The median diagnostic delay of chronic thromboembolic pulmonary hypertension (CTEPH) is 14months, which may affect prognosis. We aimed to explore the healthcare utilization of patients diagnosed with CTEPH after acute pulmonary embolism (PE), and to identify the causes of diagnostic delay. Methods We collected all data on patient symptoms, medical specialist referrals and ordered diagnostic tests to reconstruct the clinical pathways of 40 patients referred to the VU University Medical Center Amsterdam (VUMC, the Netherlands) for CTEPH treatment. Diagnostic delay was defined as the time between first symptom onset and referral to the VUMC. Correlations of patient-specific characteristics and diagnostic delay were evaluated. Results Patients consulted four (median) different physicians for a median of 13 (interquartile range [IQR]10-18) consultations before the correct diagnosis was made. The median diagnostic delay was 21months (IQR12-49months). Echocardiographic results suggestive of CTEPH were not always followed by an adequate work-up; most patients were not subjected to ventilation/perfusion scanning. Prior cardiopulmonary comorbidity and recurrent venous thromboembolism were predictors of a longer delay. Conclusion Healthcare utilization in patients before their final CTEPH diagnosis was far from optimal, contributing to a considerable diagnostic delay. Better education and higher awareness of CTEPH among PE caretakers may lead to faster diagnosis.

Special situations of preconditioning and prehabilitation in oncological visceral surgery

Prehabilitation prior to complex visceral oncological surgery is playing an increasingly important role. The aim of this review article is to present special situations of preconditioning in visceral oncological patient cohorts. The following conditions were defined as special situations with subsequently increased risk profile: cardiopulmonary comorbidities, geriatric patients, neoadjuvant therapy and simultaneous fatigue. Aselective literature review based on asearch in the electronic databases MEDLINE, PubMed, Cochrane Library and the International Standard Randomization Controlled Trial Number (ISRCTN) was performed. The identification of high-risk patients is an essential part of the preoperative evaluation conducted by the anesthesiologist prior to surgery. The cardiovascular and the pulmonary risk profile are determined by means of prediction indices evaluating patient-specific and surgery-related risk factors. The increased use of new oral anticoagulants and dual platelet aggregation inhibition requires individualized treatment strategies. Numerous studies have shown clinically relevant effects of exercise therapy interventions throughout all phases of oncological treatment. In addition to positive effects on therapy-associated side effects, sport can also counteract the effects of sedentary behavior in cancer patients and improve the health-related quality of life. The effectiveness of sport and exercise therapies as well as psychological interventions in oncological patients with fatigue (CRF) is broad, with important components being motivation and compliance. In high-risk patients an interdisciplinary approach to planning and conduction of prehabilitation is essential for the early detection and optimization of perioperative risk factors and potential complications. The aim is faster recovery, reduced morbidity and mortality and the possibility to improve long-term survival and quality of life.

Acute complications in the post-anaesthesia care unit after infrainguinal surgery for lower limb ischaemia - a prospective observational cohort study.

Arterial surgery for lower limb ischaemia is a frequently performed procedure in patients with severe cardio-pulmonary comorbidities, making them high-risk patients for acute postoperative complications with a need for prolonged stay in the post-anaesthesia care unit (PACU). However, detailed information on complications during the PACU stay is limited, hindering mechanism-based interventions for early enhanced recovery. Thus, we aimed to systematically describe acute complications and related risk factors in the immediate postoperative phase after infrainguinal arterial surgery. Patients transferred to the PACU after infrainguinal arterial surgery due to chronic or acute lower limb ischaemia were consecutively included in a six-month observational cohort study. Pre- and intraoperative data included comorbidities as well as surgical and anaesthetic technique. Data on complications and treatments in the PACU were collected every 15 minutes using a standardised assessment tool. The primary endpoint was occurrence of predefined moderate or severe complications occurring during PACU stay. In total, 155 patients were included for analysis. Eighty (52 %) patients experienced episodes with oxygen desaturation (< 85 %) and moderate or severe pain occurred in 72 patients (47 %); however, circulatory complications (hypotension, tachycardia) were rare. Preoperative opioid use was a significant risk factor for moderate or severe pain in PACU (59 vs. 38 % chronic vs. opioid naïve patients (P = 0.01). Complications in the PACU after infrainguinal arterial surgery relates to saturation and pain, suggesting that future efforts should focus on anaesthesia and analgesic techniques including opioid sparing regimes to enhance early postoperative recovery.

Incidences and factors associated with perioperative cardiac arrest in trauma patients receiving anesthesia.

PurposeThe aim of this study was to determine the incidences and factors associated with perioperative cardiac arrest in trauma patients who received anesthesia for emergency surgery.Patients and methodsThis retrospective cohort study was approved by the medical ethical committee, Faculty of Medicine, Maharaj Nakorn Chiang Mai Hospital, Thailand. Data of 19,683 trauma patients who received anesthesia between January 2007 and December 2016, such as patient characteristics, surgery procedures, anesthesia information, anesthetic drugs, and cardiac arrest outcomes, were analyzed. Data of patients receiving local anesthesia by surgeons or monitoring anesthesia care (MAC) and those with much information missing were excluded. Factors associated with perioperative cardiac arrest were identified using univariate analysis and the multiple regression model. A stepwise algorithm was chosen at a P-value of <0.20 which was selected for multivariate analysis. A P-value of <0.05 was concluded as statistically significant.ResultsThe perioperative cardiac arrest in trauma patients receiving anesthesia for emergency surgery was 170.04 per 10,000 cases. Factors associated with perioperative cardiac arrest in trauma patients were as follows: age >65 years (risk ratio [RR] =1.41, CI =1.02–1.96, P=0.039), American Society of Anesthesiologist (ASA) physical status 3 or higher (ASA physical status 3–4, RR =4.19, CI =2.09–8.38, P<0.001; ASA physical status 5–6, RR =21.58, CI =10.36–44.94, P<0.001), sites of surgery (intracranial, intrathoracic, upper intra-abdominal, and major vascular, each P<0.001), cardiopulmonary comorbidities (RR =1.55, CI =1.10–2.17, P=0.012), hemodynamic instability with shock prior to receiving anesthesia (RR =1.60, CI =1.21–2.11, P<0.001), and having a history of alcoholism (RR =5.27, CI =4.09–6.79, P<0.001).ConclusionThe incidence of perioperative cardiac arrest in trauma patients receiving anesthesia for emergency surgery was very high and correlated with patient’s factors, especially old age and cardiopulmonary comorbidities, a history of drinking alcohol, increased ASA physical status, hemodynamic instability with shock prior to surgery, and sites of surgery such as brain, thorax, abdomen, and the major vascular region. Anesthesiologists and surgeons should be aware of a warning system and a well-equipped track to manage the surgical trauma patients.

Risk stratification strategy and assessment of disease progression in patients with pulmonary arterial hypertension: Updated Recommendations from the Cologne Consensus Conference 2018

In the summer of 2016, delegates from the German Respiratory Society, the German Society of Cardiology and the German Society of Pediatric Cardiology met in Cologne, Germany, to define consensus-based practice recommendations for the management of patients with pulmonary arterial hypertension (PAH). These recommendations were built on the 2015 European Pulmonary Hypertension guidelines and included new evidence, where available, and were last updated in the spring of 2018. This article focusses on the proposed risk stratification and assessment of disease progression in patients with pulmonary arterial hypertension (PAH), covering 3 parts: In part 1, methods and markers that are recommended to assess severity and progression of PAH are discussed and commented. These updated comments incorporate most recent data as well as challenges arising from the variability of phenotypes of PAH patients with increasing cardiopulmonary comorbidities. In part 2, the proposed ESC/ERS risk stratification strategy is discussed, together with a review of the recent validation studies from different European registries. Finally, in part 3, the working group of the Cologne Consensus Conference provides recommendations on how risk assessment may be implemented in routine clinical practice and may serve clinical decision making.

Comparison between computed tomography-guided percutaneous microwave ablation and thoracoscopic lobectomy for stage I non-small cell lung cancer.

BackgroundThe study was conducted to investigate the effectiveness and cost of computed tomography (CT)‐guided percutaneous microwave ablation (MWA) and thoracoscopic lobectomy for stage I non‐small cell lung cancer (NSCLC).MethodsWe retrospectively analyzed the data of 46 and 85 patients with stage I NSCLC treated with CT‐guided percutaneous MWA or thoracoscopic lobectomy, respectively, at our center from July 2013 to June 2015. Overall survival (OS), disease‐free survival (DFS), local control rate, hospital stay, and cost were evaluated. Survival curves were constructed using the Kaplan–Meier method and compared using the log‐rank test.ResultsThe one and two‐year OS rates were 97.82% and 91.30% and 97.65% and 90.59% in the MWA and lobectomy groups, respectively. The one and two‐year DFS rates were 95.65% and 76.09% and 95.29% and 75.29%, respectively. No significant differences were observed in log‐rank analysis between the groups (P = 0.169). The hospital stays in the MWA and lobectomy groups were 6.62 ± 2.31 and 9.57 ± 3.19 days, respectively. The costs of MWA and lobectomy were US$3274.50 ± US$233.91 and US$4678.87 ± US$155.96, respectively. The differences were all significant (P = 0.003).ConclusionMWA and thoracoscopic lobectomy for stage I NSCLC demonstrate similar one and two‐year OS and DFS, with no significant differences between the two groups. MWA involved a shorter hospital stay and lower cost, thus should be considered a better option for patients with severe cardiopulmonary comorbidity and patients unwilling to undergo surgery.

Targeted therapy of pulmonary arterial hypertension: Updated recommendations from the Cologne Consensus Conference 2018

In the summer of 2016, delegates from the German Respiratory Society, the German Society of Cardiology and the German Society of Pediatric Cardiology met in Cologne, Germany, to define consensus-based practice recommendations for the management of patients with pulmonary arterial hypertension (PAH). These recommendations were built on the 2015 European Pulmonary Hypertension guidelines and included new evidence, where available. The treatment algorithm for PAH was modified based on the observation that there are now many patients diagnosed with IPAH who are at an advanced age and have significant cardiopulmonary comorbidities. For patients newly diagnosed with classic forms of PAH, i.e. younger patients without significant cardiopulmonary comorbidities, the consensus-based recommendation was to use initial combination therapy as the standard approach. The use of monotherapies was no longer considered appropriate in such patients. The choice of treatment strategies should be based on the risk assessment as proposed in the European guidelines. In patients presenting with a low or intermediate risk, oral combination therapy with endothelin receptor antagonists and phosphodiesterase-5 inhibitors or soluble guanylate cyclase stimulators, respectively, should be used. In high-risk patients, triple combination therapy including a subcutaneous or intravenous prostacyclin analogue should be considered. For patients who suffer from PAH and significant cardiopulmonary comorbidities, initial monotherapy is recommended and the use of combination therapies should be considered on an individual basis. The latter recommendations are based on the scarcity of evidence supporting the use of combination therapy and the higher risk of drug-related adverse events in such patients.

Identifying appropriate candidates for ambulatory outpatient shoulder arthroplasty: validation of a patient selection algorithm

Outpatient total shoulder arthroplasty (TSA) is increasing in frequency, but the selection of patients who are appropriate outpatient joint candidates remains challenging. We propose an algorithm for selecting outpatient TSA candidates, with validation by a cohort of patients from an ambulatory surgery center (ASC). We identified 61 patients who had primary anatomic and reverse TSA. The selection algorithm, which stratifies patients referable to their age and cardiopulmonary comorbidities, was used to choose patients for outpatient surgery. Complications, including cardiopulmonary, thromboembolic, and postoperative wound problems, were recorded. All 61 patients were discharged from the ASC on the day of surgery. There were no cardiopulmonary events requiring intervention or hospital admission. One patient (2%) required a secondary operation, 3 patients (5%) experienced acute surgical complications, 3 patients (5%) had transient postoperative nausea, and 4 patients (7%) had additional complications within the 90-day episode of care. This study is the first to propose a patient selection method for outpatient TSA. Using this algorithm for patient selection produced a low rate of perioperative complications and no hospital admissions. We suggest this algorithm provides an evidence-based method for the standardization of outpatient TSA candidate selection.

Effects of Preparatory Coaching and Home Practice for Deep Inspiration Breath Hold on Cardiac Dose for Left Breast Radiation Therapy

AimsDeep inspiration breath hold (DIBH) reduces cardiac radiation exposure by creating cardiac–chest wall separation in breast cancer radiotherapy. DIBH requires sustaining chest wall expansion for up to 40 s and involves complex co-ordination of thoraco-abdominal muscles, which may not be intuitive to patients. We investigated the effect of in-advance preparatory DIBH coaching and home practice on cardiac doses. Materials and methodsSuccessive patients from 1 February 2015 to 31 December 2016 with left-sided breast cancer who underwent tangential field radiotherapy utilising the DIBH technique were included. The study cohort consisted of patients treated by a physician who routinely provided DIBH coaching and home practice instructions at least 5 days before simulation. The control group included non-coached patients under another physician's care. Minimum, maximum and mean cardiac doses and V5, V10 and V30 from DIBH and free breathing simulation computed tomography scans were obtained from the planning system. DIBH and free breathing cardiac doses and volume exposures were compared between the coached and non-coached groups using the two-sample t-test, Fisher's exact test and the Mann–Whitney U-test. ResultsTwenty-seven coached and 42 non-coached patients were identified. The DIBH maximum cardiac dose was lower in coached patients at 13.1 Gy compared with 19.4 Gy without coaching (P = 0.004). The percentage cardiac volume exposure in DIBH was lower in coached patients; the DIBH V10 was 0.5% without coaching and 0.1% with coaching (P = 0.005). There was also a trend towards lower DIBH V5 in the coached group compared with the non-coached group (1.2% versus 1.9%, P = 0.071). No significant differences in patient cardiopulmonary comorbidity factors that might influence cardiac doses were found between the groups. ConclusionsOur results suggest that cardiac dose sparing can potentially be further improved with a 5 day regimen of preparatory DIBH coaching and in-advance home practice before simulation. These hypothesis-generating findings should be confirmed in a larger study.