How future surgery will benefit from SARS-COV-2-related measures: a SPIGC survey conveying the perspective of Italian surgeons

COVID-19 negatively affected surgical activity, but the potential benefits resulting from adopted measures remain unclear. The aim of this study was to evaluate the change in surgical activity and potential benefit from COVID-19 measures in perspective of Italian surgeons on behalf of SPIGC. A nationwide online survey on surgical practice before, during, and after COVID-19 pandemic was conducted in March-April 2022 (NCT:05323851). Effects of COVID-19 hospital-related measures on surgical patients' management and personal professional development across surgical specialties were explored. Data on demographics, pre-operative/peri-operative/post-operative management, and professional development were collected. Outcomes were matched with the corresponding volume. Four hundred and seventy-three respondents were included in final analysis across 14 surgical specialties. Since SARS-CoV-2 pandemic, application of telematic consultations (4.1% vs. 21.6%; p < 0.0001) and diagnostic evaluations (16.4% vs. 42.2%; p < 0.0001) increased. Elective surgical activities significantly reduced and surgeons opted more frequently for conservative management with a possible indication for elective (26.3% vs. 35.7%; p < 0.0001) or urgent (20.4% vs. 38.5%; p < 0.0001) surgery. All new COVID-related measures are perceived to be maintained in the future. Surgeons' personal education online increased from 12.6% (pre-COVID) to 86.6% (post-COVID; p < 0.0001). Online educational activities are considered a beneficial effect from COVID pandemic (56.4%). COVID-19 had a great impact on surgical specialties, with significant reduction of operation volume. However, some forced changes turned out to be benefits. Isolation measures pushed the use of telemedicine and telemetric devices for outpatient practice and favored communication for educational purposes and surgeon-patient/family communication. From the Italian surgeons' perspective, COVID-related measures will continue to influence future surgical clinical practice

Debridement, antibiotics, and implant retention (DAIR) for the early prosthetic joint infection of total knee and hip arthroplasties: a systematic review

International audienceEarly periprosthetic joint infection (PJI) represents one of the most fearsome complications of joint replacement. No international consensus has been reached regarding the best approach for early prosthetic knee and hip infections. The aim of this updated systematic review is to assess whether debridement, antibiotics, and implant retention (DAIR) is an effective choice of treatment in early postoperative and acute hematogenous PJI. Methods: This systematic review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The diagnostic criteria defining a PJI, the most present pathogen, and the days between the index procedure and the onset of the PJI were extracted from the selected articles. Additionally, the mean follow-up, antibiotic regimen, and success rate of the treatment were also reported. Results: The articles included provided a cohort of 970 patients. Ten studies specified the joint of their cohort in PJIs regarding either hip prostheses or knee prostheses, resulting in 454 total knees and 460 total hips. The age of the patients ranged from 18 to 92 years old. Success rates for the DAIR treatments in the following cohort ranged from 55.5% up to a maximum of 90% (mean value of 71%). Conclusion: Even though the DAIR procedure is quite limited, it is still considered an effective option for patients developing an early post-operative or acute hematogenous PJI. However, there is a lack of studies, in particular randomized control trials (RCTs), comparing DAIR with one-stage and two-stage revision protocols in the setting of early PJIs, reflecting the necessity to conduct further high-quality studies to face the burden of early PJI

Three-dimensional STI assessment of right ventricular function in acute cor pulmonale

Purpose. We aimed to assess changes in right ventricular (RV) parameters determined by three-dimensional speckle tracking imaging (3D-STI) before and after long-term acute pulmonary embolism (PE) treatment. Methods. We enrolled 23 patients with acute PE confirmed by multidetector row chest computed tomography. 23 healthy subjects without signs of cardiopulmonary dysfunction served as a control group. Conventional echo RV parameters included tricuspid annular plane systolic excursion (TAPSE), myocardial performance index (RV-MPI) and RV fractional area change (RV-FAC). Pulmonary arterial systolic pressure was obtained by standard Doppler methods. Pulmonary hypertension was defined as a pulmonary artery systolic pressure of 40 mmHg or greater. RV end-diastolic and end-systolic volumes were measured from three-dimensional echocardiographic datasets and right ventricular ejection fraction (3D-RVEF) was calculated. 3D-STI was used to determine RV peak systolic strain, time to peak-systolic strain from the onset of QRS, standard deviation of the time to peak-systolic strain, and global area strain (RV-GAS). RV dyssynchrony was defined as the standard deviation of the six time to peak systolic strain values. Global longitudinal strain (RV-GLS) was calculated by averaging local strains along the entire right ventricle. Data analysis was performed offline using the original raw data from all 3DE data sets on a software workstation for semiautomated endocardial surface detection (EchoPAC BT11, 4D Auto LVQ, GE Vingmed Ultrasound, Horten, Norway). Results. Mean percentage intraobserver variability was 8% for RV-GLS and 6% for RV-GAS, and mean percentage interobserver variability was 11% for RV-GLS and 8% for RV-GAS. TAPSE, RV-MPI, RV-FAC (p<0.005) and RV-GAS (p<0.0001) were lower in patients with PE and pulmonary hypertension compared to the control group. A significant correlation was found between RV-GAS and pulmonary artery systolic pressure (r = 0.76, p <0.001), between RV-GAS and RV dyssynchrony (r = 0.71, p <0.005), and between RV-GAS and RV-GLS (r = 0.68, p <0.005). Decreased RV-GAS (<25%) and 3D-RVEF (< 45%) persisted in 5/23 pts after one month of medical treatment and in 4/23 pts after one year. By multivariate analysis, 3D-RVEF (p=0.03) and RV-GAS (p=0.008) were predictive of pulmonary arterial hypertension. Conclusions. Our findings show that acute PE has a significant impact on RV function as assessed by 3D-STI. 3D-RVEF and RV-GAS correlate with pulmonary hypertension and abnormal values may persist long-term during the pts follow-up

Clinical significance of H/M and SS Value in Postischemic and Idiopathic Heart Failure

The prognostic value of semiquantitative parameters of myocardial 123 I‐MIBG uptake for identifying higher vs lower risk respectively for adverse cardiac events in pts with LVEF≤35% (late H/M ratio26) have been recently demonstrated, both in ischemic and idiopathic HF. The aim of our study was to confirm their prognostic independent value in ischemic and idiopathic HF pts, both with primary systolic or diastolic dysfunction, and try to find out if there is a relationship between the site of primary acute event ( acute myocardial infarction, AMI) in post‐ischemic HF and the extension of denervation. 29 HF pts were enrolled, 17 with post‐ischemic HF and 12 with idiopathic HF. They were i.v. injected with 185 MBq of 123 I‐MIBG and 15 minute and 4 hours planar and SPET scan were obtained. H/M and SS were calculated for both early and delayed images. 123 I‐MIBG uptake was decreased in 12/29 pts (10 post‐ischemic pts and 2 idiopathic pts) and preserved in 17/29 pts (10 post‐ischemic pts and 7 idiopathic pts); LVEF was 26 in 6/12 pts. The multiparametric analysis of LVEF, late H/M, late SS, and AMI site revealed a statistically significant correlation between late H/M and LVEF (p value = 0.001 at Fisher’s Exact Test); no statistical correlation was found between site of AMI and extension of denervation. Conclusion The sympathetic denervation in ischemic HF seems to be more severe than that in idiopathic HF (both with systolic or diastolic primary damage): this may suggests that ischemia can produce a more sympathetic fibers injury than that in idiopathic HF. The global denervation (H/M) is constantly decreased in HF, but not the extension of denervation (SS): this may suggests that, despite of an increased risk of cardiac events, the risk for arrhythmias is an independent variable among HF pts. The lack of correlation between the AMI site and the extension of denervation confirms the same prognostic value of H/M and SS both in ischemic and idiopathic HF

Early and Midterm Results after Endovascular Repair of Non-infected Saccular Lesions of the Infrarenal Aorta

Objective: The aim was to report short and midterm outcomes of a cohort of consecutive patients treated by endovascular aortic repair (EVAR) for saccular lesion of the abdominal aorta (sl-AA). Methods: This was a multicentre, retrospective, financially unsupported physician initiated, observational cohort study that involved tertiary referral from Italian hospitals. For this study, between January 2010 and December 2020, only those patients treated by EVAR for non-infected sl-AA, namely blister/ulcer like projection and/or penetrating aortic ulcer, were analysed. Primary outcomes of interest were overall survival and freedom from aorta related mortality (ARM). Results: The final cohort included 120 of 3 982 eligible aortic lesions. There were 103 (85.8%) males and 17 (14.2%) females. The median age was 76 years (interquartile range [IQR] 69, 80). Rupture on admission was observed in 10 (8.3%) cases. Early (≤ 30 days) death occurred in two (1.7%) patients. There were five (4.2%) complications requiring surgical re-intervention (iliac limb occlusion n = 4; groin haematoma, n = 1). The median duration of follow up was 20 months (IQR 4, 59.5): the estimated overall survival was 85.5% (standard error [SE] 0.035; 95% confidence interval [CI] 77.3 – 91.1) at 12 months, 78.7% (SE 0.044; 95% CI 69.0 – 86.0) at 36 months, and 74% (SE 0.050; 95% CI 63.2 – 82.5) at 60 months. Only one (0.8%) patient required aortic re-intervention during follow up because of a late endograft infection. The estimated freedom from ARM was 96% (SE 0.050; 95% CI 90.3 – 98.2) at 36 and 60 months. Cox's regression analysis identified that death was associated with age &gt; 70 years (hazard ratio [HR] 1.10; 95% CI 1.04 – 1.17, p = .001), and coronary artery disease (HR 1.14; 95% CI 1.04 – 1.26, p = .006). Conclusion: EVAR for sl-AA proved to be safe and effective. The mortality rate was low for a group of patients known to be at high risk from open repair, and EVAR remained stable with no ARM during midterm follow up, and an acceptably low 0.8% endograft related re-intervention rate

Reduction of Hospitalizations for Myocardial Infarction in Italy in the COVID-19 Era

Aims: To evaluate the impact of the COVID-19 pandemic on patient admissions to Italian cardiac care units (CCUs). Methods and results: We conducted a multicentre, observational, nationwide survey to collect data on admissions for acute myocardial infarction (AMI) at Italian CCUs throughout a 1 week period during the COVID-19 outbreak, compared with the equivalent week in 2019. We observed a 48.4% reduction in admissions for AMI compared with the equivalent week in 2019 (P < 0.001). The reduction was significant for both ST-segment elevation myocardial infarction [STEMI; 26.5%, 95% confidence interval (CI) 21.7-32.3; P = 0.009] and non-STEMI (NSTEMI; 65.1%, 95% CI 60.3-70.3; P < 0.001). Among STEMIs, the reduction was higher for women (41.2%; P = 0.011) than men (17.8%; P = 0.191). A similar reduction in AMI admissions was registered in North Italy (52.1%), Central Italy (59.3%), and South Italy (52.1%). The STEMI case fatality rate during the pandemic was substantially increased compared with 2019 [risk ratio (RR) = 3.3, 95% CI 1.7-6.6; P < 0.001]. A parallel increase in complications was also registered (RR = 1.8, 95% CI 1.1-2.8; P = 0.009). Conclusion: Admissions for AMI were significantly reduced during the COVID-19 pandemic across Italy, with a parallel increase in fatality and complication rates. This constitutes a serious social issue, demanding attention by the scientific and healthcare communities and public regulatory agencies