New techniques and principles in acute aortic pathologies requiring emergency surgical interventions

Aortic surgery, especially for pathologies requiring urgent surgical intervention has undergone significant changes in the past twenty years, leading to major improvement in short- and long-term outcomes. This thesis aims to provide a comprehensive, up-to-date overview on clinical characteristics of acute aortic syndrome, with special emphasis on current operative treatment possibilities, including well-established and novel, innovative surgical approaches. Within this scheme, further specific goals are to analyse different cannulation and perfusion options, the role of core temperature management during hypothermic circulatory arrest and impact of age-related differences in surgical approach of AAS. Ultrasound-guided direct cannulation on the concavity of aortic arch applying Seldinger technique is a reliable method in dissection repairs. Prompt antegrade perfusion provides not only cerebral, but also peripheral organ and tissue protection, which is an advantage in this high-risk group of patients. This alternative arterial inflow technique can be applied for prompt establishment of cardiopulmonary bypass in type A dissections or other aortic emergencies, especially during haemodynamic instability. We have proven that tympanic temperature measurements correlate with arterial blood temperature monitoring during aortic surgery applying hypothermic circulatory arrest, therefore, should replace bladder and rectal measurements. Early diagnosis and aggressive surgical approach without delay is a key factor in effective treatment for aortooesophageal fitulas. Endovascular treatment is essential to save the patient, but as a standalone procedure often ends-up with life threatening mid-term graft infection. Eliminating the source of bleeding as an emergency, resecting the oesophagus urgently to prevent sepsis and reconstructing the gastrointestinal continuity as an elective case after having the inflammatory processes settled seems to justify the sequence of endovascular aortic repair and subtotal oesophageal resection, followed by a gastro-oesophageal reconstruction, as an effective surgical approach. More frequent proximal and distal progression of the dissection flap occurs in younger patients with acute type A aortic dissection. Older age is associated with a lower probability of an intimal tear at the level of sinus of Valsalva. These findings, associated with prognostic implications, account for the choice of more radical proximal procedures for repair of aortic dissection in younger patients

OWLAP - using OLAP approach in anomaly detection

OWLAP (Operative Workbench for Large-scale Analytics and Presentation) is a visual analytics tool that allows the user to browse and drill down the multidimensional data on-line with the possibility to export result into a zooming presentation framework. We address the challenges of multidimensional visualization by aiding the cognitively hard task of understanding attributes, finding patterns and outliers. We successfully solved the challenge of real time Big Data OLAP reporting by a home developed multithreaded inmemory database manager. Our additional focus is the automatic management of summary preparation that we aid by scripting the presentation framework of Prezi Inc

Minimal invasive coronary bypass surgery the robotic total endoscopic approach

The aim of this paper is to present the latest recommendations for practitioners for preoperative preparation, surgical procedures and postoperative treatment in patients with myocardial revascularization using robotic total endoscopic coronary artery bypass grafting (CARG), which is applied as daily clinical routine practice at the Heart and Vascular Institute, Cleveland Clinic Abu Dhabi. Many patients indicated for coronary bypass surgery may be candidates for robotic total endoscopic CARG. The paper illustrates eligibility criteria of this procedure, preoperative assessment and preparation principles, peripheral access for cardiopulmonary bypass and port insertion, then graft harvesting procedure, initiation of cardiopulmonary bypass and application of endoaortic clamping, identification and exposure of the target vessels, anastomosis procedure and postoperative care in this group of patients

A minimalizált extracorporalis keringés és alkalmazási területei = The principals of minimal extracorporeal circulation

Az újdonságnak számító minimalizált extracorporalis keringés a hagyományos szívmotor említésre méltó alternatívája. Felépítése egyszerű: egy centrifugális pumpából, oxigenátorból, teljes hosszában heparinizált csőrendszerből és egy módosított cell saverből áll. Zárt rendszerének és a redukált mennyiségű feltöltőfolyadéknak köszönhetően a hagyományos perfúzió előnytelen következményei, mint a hemodilúció, a gyulladásos válasz, a lokoregionális malperfúzió, a transzfúziós igény, jelentősen csökkenthetők. Rövid összefoglalónk a rendszer több mint 2000 betegen tapasztalt előnyeit és biztonságosságát mutatja be. A minimalizált perfúzió szerteágazó alkalmazási területei a bypassműtét dobogó vagy megállított szíven, a balszívfél-bypass mellkasi aortaaneurizmáknál, szívelégtelenségben vagy reanimáció után „áthidalás a felépüléshez” (bridge to recovery), extracorporalis membránoxigenizáció, de lehetőségeink tárháza ezen eljárásokkal még korántsem merül ki. | The recently introduced minimal extracorporeal circulation system is a remarkable alternative to the conventional heart-lung machine in several cardiosurgical indications. It consists of a centrifugal pump, an oxygenator, a tip-to-tip heparin coated line set and a modified cell saver application. Due to its closed blood-air interaction-free construction and reduced priming volume, the unfavourable effects of perfusion as haemodilution, inflammatory response, locoregional malperfusion, transfusion needs, can be effectively reduced. Our short summary demonstrates the advantages and safety of the system proven over 2000 cases. The potential applications are aortocoronary bypass operations with or without arrest, left heart bypass at thoracal aneurysms, „bridge to recovery” in heart failure or subsequent to reanimation, extracorporeal membrane oxygenation and many more

A minimalizált extracorporalis tüdőtámogatás = The principals of pumpless extracorporeal lung assist

A minimalizált extracorporalis tüdőtámogatás az elmúlt évek szervpótló fejlesztéseinek jelentős lépése, amely lehetővé teszi az egyébként terápiarezisztens ARDS hatékony kezelését. Az arteria és a vena femoralis között létesített arteriovenosus söntön keresztül oxigenizáljuk a beteget, így kielégítő pumpafunkció mellett szükségtelen a mesterséges keringés kialakítása. Zárt rendszerének, a redukált mennyiségű feltöltő folyadéknak és csekély heparinizációs igényének köszönhetően a hagyományos extracorporalis membránoxigenizáció előnytelen következményei jelentősen csökkenthetők. Alacsony eszköz- és személyzetigénye megteremti kis kórházakban vagy akár betegszállítás során történő használatának lehetőségét, üzemeltetési költsége is csekélyebb az ECMO-nál. Összefoglalónk a rendszer 123 betegen tapasztalt előnyeit és biztonságosságát mutatja be. | The recently introduced pumpless extracorporeal lung assist (PECLA) is a remarkable alternative to the conventional extracorporeal membrane oxygenation in case of severe lung failure. By establishing a shunt between femoral artery and vein using the arterio-venous pressure gradient as a driving force through a low-resistance membrane oxygenator, PECLA provides highly effective gas-exchange by preserved cardiac function. Due to its closed system, reduced priming volume and low heparin demand, the unfavourable effects of extracorporeal membrane oxygenation can be effectively diminished. Hence the small technical, financial and personal input, the PECLA can be ideally used in district hospitals and during transport as well. Our short summary demonstrates the advantages and safety of the system proven over 123 cases

Global fertility in 204 countries and territories, 1950–2021, with forecasts to 2100: a comprehensive demographic analysis for the Global Burden of Disease Study 2021

BackgroundAccurate assessments of current and future fertility—including overall trends and changing population age structures across countries and regions—are essential to help plan for the profound social, economic, environmental, and geopolitical challenges that these changes will bring. Estimates and projections of fertility are necessary to inform policies involving resource and health-care needs, labour supply, education, gender equality, and family planning and support. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 produced up-to-date and comprehensive demographic assessments of key fertility indicators at global, regional, and national levels from 1950 to 2021 and forecast fertility metrics to 2100 based on a reference scenario and key policy-dependent alternative scenarios. MethodsTo estimate fertility indicators from 1950 to 2021, mixed-effects regression models and spatiotemporal Gaussian process regression were used to synthesise data from 8709 country-years of vital and sample registrations, 1455 surveys and censuses, and 150 other sources, and to generate age-specific fertility rates (ASFRs) for 5-year age groups from age 10 years to 54 years. ASFRs were summed across age groups to produce estimates of total fertility rate (TFR). Livebirths were calculated by multiplying ASFR and age-specific female population, then summing across ages 10–54 years. To forecast future fertility up to 2100, our Institute for Health Metrics and Evaluation (IHME) forecasting model was based on projections of completed cohort fertility at age 50 years (CCF50; the average number of children born over time to females from a specified birth cohort), which yields more stable and accurate measures of fertility than directly modelling TFR. CCF50 was modelled using an ensemble approach in which three sub-models (with two, three, and four covariates variously consisting of female educational attainment, contraceptive met need, population density in habitable areas, and under-5 mortality) were given equal weights, and analyses were conducted utilising the MR-BRT (meta-regression—Bayesian, regularised, trimmed) tool. To capture time-series trends in CCF50 not explained by these covariates, we used a first-order autoregressive model on the residual term. CCF50 as a proportion of each 5-year ASFR was predicted using a linear mixed-effects model with fixed-effects covariates (female educational attainment and contraceptive met need) and random intercepts for geographical regions. Projected TFRs were then computed for each calendar year as the sum of single-year ASFRs across age groups. The reference forecast is our estimate of the most likely fertility future given the model, past fertility, forecasts of covariates, and historical relationships between covariates and fertility. We additionally produced forecasts for multiple alternative scenarios in each location: the UN Sustainable Development Goal (SDG) for education is achieved by 2030; the contraceptive met need SDG is achieved by 2030; pro-natal policies are enacted to create supportive environments for those who give birth; and the previous three scenarios combined. Uncertainty from past data inputs and model estimation was propagated throughout analyses by taking 1000 draws for past and present fertility estimates and 500 draws for future forecasts from the estimated distribution for each metric, with 95% uncertainty intervals (UIs) given as the 2·5 and 97·5 percentiles of the draws. To evaluate the forecasting performance of our model and others, we computed skill values—a metric assessing gain in forecasting accuracy—by comparing predicted versus observed ASFRs from the past 15 years (2007–21). A positive skill metric indicates that the model being evaluated performs better than the baseline model (here, a simplified model holding 2007 values constant in the future), and a negative metric indicates that the evaluated model performs worse than baseline. FindingsDuring the period from 1950 to 2021, global TFR more than halved, from 4·84 (95% UI 4·63–5·06) to 2·23 (2·09–2·38). Global annual livebirths peaked in 2016 at 142 million (95% UI 137–147), declining to 129 million (121–138) in 2021. Fertility rates declined in all countries and territories since 1950, with TFR remaining above 2·1—canonically considered replacement-level fertility—in 94 (46·1%) countries and territories in 2021. This included 44 of 46 countries in sub-Saharan Africa, which was the super-region with the largest share of livebirths in 2021 (29·2% [28·7–29·6]). 47 countries and territories in which lowest estimated fertility between 1950 and 2021 was below replacement experienced one or more subsequent years with higher fertility; only three of these locations rebounded above replacement levels. Future fertility rates were projected to continue to decline worldwide, reaching a global TFR of 1·83 (1·59–2·08) in 2050 and 1·59 (1·25–1·96) in 2100 under the reference scenario. The number of countries and territories with fertility rates remaining above replacement was forecast to be 49 (24·0%) in 2050 and only six (2·9%) in 2100, with three of these six countries included in the 2021 World Bank-defined low-income group, all located in the GBD super-region of sub-Saharan Africa. The proportion of livebirths occurring in sub-Saharan Africa was forecast to increase to more than half of the world's livebirths in 2100, to 41·3% (39·6–43·1) in 2050 and 54·3% (47·1–59·5) in 2100. The share of livebirths was projected to decline between 2021 and 2100 in most of the six other super-regions—decreasing, for example, in south Asia from 24·8% (23·7–25·8) in 2021 to 16·7% (14·3–19·1) in 2050 and 7·1% (4·4–10·1) in 2100—but was forecast to increase modestly in the north Africa and Middle East and high-income super-regions. Forecast estimates for the alternative combined scenario suggest that meeting SDG targets for education and contraceptive met need, as well as implementing pro-natal policies, would result in global TFRs of 1·65 (1·40–1·92) in 2050 and 1·62 (1·35–1·95) in 2100. The forecasting skill metric values for the IHME model were positive across all age groups, indicating that the model is better than the constant prediction. InterpretationFertility is declining globally, with rates in more than half of all countries and territories in 2021 below replacement level. Trends since 2000 show considerable heterogeneity in the steepness of declines, and only a small number of countries experienced even a slight fertility rebound after their lowest observed rate, with none reaching replacement level. Additionally, the distribution of livebirths across the globe is shifting, with a greater proportion occurring in the lowest-income countries. Future fertility rates will continue to decline worldwide and will remain low even under successful implementation of pro-natal policies. These changes will have far-reaching economic and societal consequences due to ageing populations and declining workforces in higher-income countries, combined with an increasing share of livebirths among the already poorest regions of the world. FundingBill & Melinda Gates Foundation

Global age-sex-specific mortality, life expectancy, and population estimates in 204 countries and territories and 811 subnational locations, 1950–2021, and the impact of the COVID-19 pandemic: a comprehensive demographic analysis for the Global Burden of Disease Study 2021

BackgroundEstimates of demographic metrics are crucial to assess levels and trends of population health outcomes. The profound impact of the COVID-19 pandemic on populations worldwide has underscored the need for timely estimates to understand this unprecedented event within the context of long-term population health trends. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 provides new demographic estimates for 204 countries and territories and 811 additional subnational locations from 1950 to 2021, with a particular emphasis on changes in mortality and life expectancy that occurred during the 2020–21 COVID-19 pandemic period.Methods22 223 data sources from vital registration, sample registration, surveys, censuses, and other sources were used to estimate mortality, with a subset of these sources used exclusively to estimate excess mortality due to the COVID-19 pandemic. 2026 data sources were used for population estimation. Additional sources were used to estimate migration; the effects of the HIV epidemic; and demographic discontinuities due to conflicts, famines, natural disasters, and pandemics, which are used as inputs for estimating mortality and population. Spatiotemporal Gaussian process regression (ST-GPR) was used to generate under-5 mortality rates, which synthesised 30 763 location-years of vital registration and sample registration data, 1365 surveys and censuses, and 80 other sources. ST-GPR was also used to estimate adult mortality (between ages 15 and 59 years) based on information from 31 642 location-years of vital registration and sample registration data, 355 surveys and censuses, and 24 other sources. Estimates of child and adult mortality rates were then used to generate life tables with a relational model life table system. For countries with large HIV epidemics, life tables were adjusted using independent estimates of HIV-specific mortality generated via an epidemiological analysis of HIV prevalence surveys, antenatal clinic serosurveillance, and other data sources. Excess mortality due to the COVID-19 pandemic in 2020 and 2021 was determined by subtracting observed all-cause mortality (adjusted for late registration and mortality anomalies) from the mortality expected in the absence of the pandemic. Expected mortality was calculated based on historical trends using an ensemble of models. In location-years where all-cause mortality data were unavailable, we estimated excess mortality rates using a regression model with covariates pertaining to the pandemic. Population size was computed using a Bayesian hierarchical cohort component model. Life expectancy was calculated using age-specific mortality rates and standard demographic methods. Uncertainty intervals (UIs) were calculated for every metric using the 25th and 975th ordered values from a 1000-draw posterior distribution.FindingsGlobal all-cause mortality followed two distinct patterns over the study period: age-standardised mortality rates declined between 1950 and 2019 (a 62·8% [95% UI 60·5–65·1] decline), and increased during the COVID-19 pandemic period (2020–21; 5·1% [0·9–9·6] increase). In contrast with the overall reverse in mortality trends during the pandemic period, child mortality continued to decline, with 4·66 million (3·98–5·50) global deaths in children younger than 5 years in 2021 compared with 5·21 million (4·50–6·01) in 2019. An estimated 131 million (126–137) people died globally from all causes in 2020 and 2021 combined, of which 15·9 million (14·7–17·2) were due to the COVID-19 pandemic (measured by excess mortality, which includes deaths directly due to SARS-CoV-2 infection and those indirectly due to other social, economic, or behavioural changes associated with the pandemic). Excess mortality rates exceeded 150 deaths per 100 000 population during at least one year of the pandemic in 80 countries and territories, whereas 20 nations had a negative excess mortality rate in 2020 or 2021, indicating that all-cause mortality in these countries was lower during the pandemic than expected based on historical trends. Between 1950 and 2021, global life expectancy at birth increased by 22·7 years (20·8–24·8), from 49·0 years (46·7–51·3) to 71·7 years (70·9–72·5). Global life expectancy at birth declined by 1·6 years (1·0–2·2) between 2019 and 2021, reversing historical trends. An increase in life expectancy was only observed in 32 (15·7%) of 204 countries and territories between 2019 and 2021. The global population reached 7·89 billion (7·67–8·13) people in 2021, by which time 56 of 204 countries and territories had peaked and subsequently populations have declined. The largest proportion of population growth between 2020 and 2021 was in sub-Saharan Africa (39·5% [28·4–52·7]) and south Asia (26·3% [9·0–44·7]). From 2000 to 2021, the ratio of the population aged 65 years and older to the population aged younger than 15 years increased in 188 (92·2%) of 204 nations.InterpretationGlobal adult mortality rates markedly increased during the COVID-19 pandemic in 2020 and 2021, reversing past decreasing trends, while child mortality rates continued to decline, albeit more slowly than in earlier years. Although COVID-19 had a substantial impact on many demographic indicators during the first 2 years of the pandemic, overall global health progress over the 72 years evaluated has been profound, with considerable improvements in mortality and life expectancy. Additionally, we observed a deceleration of global population growth since 2017, despite steady or increasing growth in lower-income countries, combined with a continued global shift of population age structures towards older ages. These demographic changes will likely present future challenges to health systems, economies, and societies. The comprehensive demographic estimates reported here will enable researchers, policy makers, health practitioners, and other key stakeholders to better understand and address the profound changes that have occurred in the global health landscape following the first 2 years of the COVID-19 pandemic, and longer-term trends beyond the pandemic