Background
in COVID-19 acute respiratory failure, the effects of CPAP and FiO
2
on respiratory effort and lung stress are unclear. We hypothesize that, in the compliant lungs of early Sars-CoV-2 ...pneumonia, the application of positive pressure through Helmet-CPAP may not decrease respiratory effort, and rather worsen lung stress and oxygenation when compared to higher FiO
2
delivered via oxygen masks.
Methods
In this single-center (S.Luigi Gonzaga University-Hospital, Turin, Italy), randomized, crossover study, we included patients receiving Helmet-CPAP for early (< 48 h) COVID-19 pneumonia without additional cardiac or respiratory disease. Healthy subjects were included as controls. Participants were equipped with an esophageal catheter, a non-invasive cardiac output monitor, and an arterial catheter. The protocol consisted of a random sequence of non-rebreather mask (NRB), Helmet-CPAP (with variable positive pressure and FiO
2
) and Venturi mask (FiO
2
0.5), each delivered for 20 min. Study outcomes were changes in respiratory effort (esophageal swing), total lung stress (dynamic + static transpulmonary pressure), gas-exchange and hemodynamics.
Results
We enrolled 28 COVID-19 patients and 7 healthy controls. In all patients, respiratory effort increased from NRB to Helmet-CPAP (5.0 ± 3.7 vs 8.3 ± 3.9 cmH
2
O, p < 0.01). However, Helmet’s pressure decreased by a comparable amount during inspiration (− 3.1 ± 1.0 cmH
2
O, p = 0.16), therefore dynamic stress remained stable (p = 0.97). Changes in static and total lung stress from NRB to Helmet-CPAP were overall not significant (p = 0.07 and p = 0.09, respectively), but showed high interpatient variability, ranging from − 4.5 to + 6.1 cmH
2
O, and from − 5.8 to + 5.7 cmH
2
O, respectively. All findings were confirmed in healthy subjects, except for an increase in dynamic stress (p < 0.01). PaO
2
decreased from NRB to Helmet-CPAP with FiO
2
0.5 (107 ± 55 vs 86 ± 30 mmHg, p < 0.01), irrespective of positive pressure levels (p = 0.64). Conversely, with Helmet’s FiO
2
0.9, PaO
2
increased (p < 0.01), but oxygen delivery remained stable (p = 0.48) as cardiac output decreased (p = 0.02). When PaO
2
fell below 60 mmHg with VM, respiratory effort increased proportionally (p < 0.01, r = 0.81).
Conclusions
In early COVID-19 pneumonia, Helmet-CPAP increases respiratory effort without altering dynamic stress, while the effects upon static and total stress are variable, requiring individual assessment. Oxygen masks with higher FiO
2
provide better oxygenation with lower respiratory effort.
Trial registration
Retrospectively registered (13-May-2021): clinicaltrials.gov (NCT04885517),
https://clinicaltrials.gov/ct2/show/NCT04885517
.
Abstract
Ischaemic heart disease (IHD) is one of the world’s leading causes of morbidity and mortality. Likewise, the diagnosis and risk stratification of patients with coronary artery disease (CAD) ...have always been based on the detection of the presence and extent of ischaemia by physical or pharmacological stress tests with or without the aid of imaging methods (e.g. exercise stress, test, stress echocardiography, single-photon emission computed tomography, or stress cardiac magnetic resonance). These methods show high performance to assess obstructive CAD, whilst they do not show accurate power to detect non-obstructive CAD. The introduction into clinical practice of coronary computed tomography angiography, the only non-invasive method capable of analyzing the coronary anatomy, allowed to add a crucial piece in the puzzle of the assessment of patients with suspected or chronic IHD. The current review evaluates the technical aspects and clinical experience of coronary computed tomography in the evaluation of atherosclerotic burden with a special focus about the new emerging application such as functional relevance of CAD with fractional flow reserve computed tomography (CT)-derived (FFRct), stress CT perfusion, and imaging inflammatory makers discussing the strength and weakness of each approach.
Abstract Aim To identify factors underlying attitudes towards the medical emergency team (MET) and barriers to its utilisation among ward nurses and physicians. Methods Multicentre survey using an ...anonymous questionnaire in hospitals with a fully operational MET system in the Piedmont Region, Italy. Response to questions was scored on a 5-point Likert-type agreement scale. Dichotomised results were included in a logistic regression model. Results Among 2279 staff members who were contacted, 1812 (79.6%) completed the survey. The vast majority of respondents valued the MET. Working in a surgical vs. medical ward and having participated in either the MET educational programme (MET al course) or MET interventions were associated with better acceptance of the MET system. Reluctance by nurses to call the covering doctor first instead of the MET for deteriorating patients (62%) was significantly less likely in those working in surgical vs. medical wards or having a higher seniority or a MET al certification (OR 0.51 0.4–0.65, 0.69 0.47–0.99, and 0.6 0.46–0.79, respectively). Reluctance to call the MET in a patient fulfilling calling criteria (21%), was less likely to occur in medical doctors vs. nurses and in surgical vs. medical ward staff, and it was unaffected by the MET al certification. Conclusions The MET was well accepted in participating hospitals. Nurse referral to the covering physician was the major barrier to MET activation. Medical status, working in surgical vs. medical wards, seniority and participation in the MET al educational programme were associated with lower likelihood of showing barriers to MET activation.
In patients with secondary tricuspid regurgitation (STR), right atrial remodeling (RAR) is a proven marker of disease progression. However, the prognostic value of RAR, assessed by indexed right ...atrial volume (RAVi) and reservoir strain (RAS), remains to be clarified. Accordingly, the aim of our study is to investigate the association with outcome of RAR in patients with STR.
We enrolled 397 patients (44% men, 72.7 ± 13 years old) with mild to severe STR. Complete two-dimensional and speckle-tracking echocardiography analysis of right atrial and right ventricular (RV) size and function were obtained in all patients. The primary end point was the composite of death from any cause and heart failure hospitalization.
After a median follow-up of 15 months (interquartile range, 6-23), the end point was reached by 158 patients (39%). Patients with RAS <13% and RAVi >48 mL/m
had significantly lower survival rates compared to patients with RAS ≥13% and RAVi ≤48 mL/m
(log-rank P < .001). On multivariable analysis, RAS <13% (hazard ratio, 2.11; 95% CI, 1.43-3.11; P < .001) and RAVi > 48 mL/m
(hazard ratio, 1.49; 95% CI, 1.01-2.18; P = .04) remained associated with the combined end point, even after adjusting for RV free-wall longitudinal strain, significant chronic kidney disease, and New York Heart Association class. Secondary tricuspid regurgitation excess mortality increased exponentially with values of 18.2% and 51.3 mL/m
for RAS and RAVi, respectively. In nested models, the addition of RAS and RAVi provided incremental prognostic value over clinical, conventional echocardiographic parameters of RV size and function and RV free-wall longitudinal strain.
In patients with STR, RAR was independently associated with mortality and heart failure hospitalization. Assessment of RAR could improve risk stratification of patients with STR, potentially identifying those who may benefit from optimization of medical therapy and a closer follow-up.
To evaluate neonatal autopsy rates at a tertiary hospital in southern Brazil ascertain the level of agreement between premortem and postmortem diagnosis.
The authors reviewed all neonatal autopsies ...performed over a 10-year period and described the percentage of neonates who died and underwent autopsy. The authors tested for agreement between autopsy findings and the cause of death as defined by the neonatologist. Agreement between clinical diagnosis and autopsy findings was classified using the modified Goldman criteria. Additional findings at autopsy were grouped by organ system. Linear regression and multiple comparisons were used for statistical analyses.
During the study period, 382 neonates died at the Neonatal Intensive Care Unit (NICU). Consent to perform an autopsy was obtained for 73 (19.1%). The complete agreement between autopsy findings and the neonatologist's premortem diagnosis was found in 48 patients (65.8%). Additional findings were obtained at autopsy in 25 cases (34.2%). In 5 cases (6.9%), the autopsy findings contributed to subsequent genetic counseling. Seven autopsies (9.6%) revealed a diagnosis that would have changed patient management if established premortem. The autopsy rate increased by an average of 1.87% each year.
Despite a high level of agreement between clinical diagnosis and pathological findings, autopsies provided relevant data regarding the cause of death, providing additional clinical information to neonatologists and allowing genetic counseling of family members.
Cardiac computed tomography (CCT) was recently validated to measure extracellular volume (ECV) in the setting of cardiac amyloidosis, showing good agreement with cardiovascular magnetic resonance ...(CMR). However, no evidence is available with a whole-heart single source, single energy CT scanner in the clinical context of newly diagnosed left ventricular dysfunction. Therefore, the aim of this study was to test the diagnostic accuracy of ECVCCT in patients with a recent diagnosis of dilated cardiomyopathy, having ECVCMR as the reference technique.
39 consecutive patients with newly diagnosed dilated cardiomyopathy (LVEF <50%) scheduled for clinically indicated CMR were prospectively enrolled. Myocardial segment evaluability assessment with each technique, agreement between ECVCMR and ECVCCT, regression analysis, Bland-Altman analysis and interclass correlation coefficient (ICC) were performed.
Mean age of enrolled patients was 62 ± 11 years, and mean LVEF at CMR was 35.4 ± 10.7%. Overall radiation exposure for ECV estimation was 2.1 ± 1.1 mSv. Out of 624 myocardial segments available for analysis, 624 (100%) segments were assessable by CCT while 608 (97.4%) were evaluable at CMR. ECVCCT demonstrated slightly lower values compared to ECVCMR (all segments, 31.8 ± 6.5% vs 33.9 ± 8.0%, p < 0.001). At regression analysis, strong correlations were described (all segments, r = 0.819, 95% CI: 0.791 to 0.844). On Bland-Altman analysis, bias between ECVCMR and ECVCCT for global analysis was 2.1 (95% CI: −6.8 to 11.1). ICC analysis showed both high intra-observer and inter-observer agreement for ECVCCT calculation (0.986, 95%CI: 0.983 to 0.988 and 0.966, 95%CI: 0.960 to 0.971, respectively).
ECV estimation with a whole-heart single source, single energy CT scanner is feasible and accurate. Integration of ECV measurement in a comprehensive CCT evaluation of patients with newly diagnosed dilated cardiomyopathy can be performed with a small increase in overall radiation exposure.
TOC Summary: Extracellular volume estimation with cardiovascular magnetic resonance (ECVCMR) has been shown to be a reliable estimation of myocardial fibrosis, common endpoint in the majority of pathological mechanisms affecting cardiac muscle. However, cardiac computed tomography (CCT) with the latest generation single source, single energy CT scanner has several potential advantages over CMR for measuring the interstitium. In this study we found that ECVCCT is feasible and accurate compared to ECVCMR in the setting of recently diagnosed dilated cardiomyopathy, with only a small increase in overall radiation exposure. These results strengthen the concept of comprehensive cardiac assessment with CCT beyond coronary anatomy evaluation.
Abstract
Diagnosis of myocardial fibrosis has a relevant prognostic and therapeutic role. Scar-tissue analysis is commonly performed with late gadolinium contrast-enhanced (CE) cardiac magnetic ...resonance (CMR). However, CMR might be contraindicated or unavailable. Coronary computed tomography (CCT), which is the technique of choice for many routine assessments, is emerging as an alternative to CMR.
The objective of this study is to evaluate whether artificial intelligence (AI) could allow identification of myocardial fibrosis from routine early CE-CCT images.
Fifty consecutive patients with left ventricular dysfunction (LVD), who underwent both CE-CMR and (early and late) CE-CCT were retrospectively selected. According to the late enhancement CMR patterns, patients were classified as with ischemic (n=15, 30%) or non-ischemic (n=25, 70%) LVD. Scar regions were manually traced on late CE-CCT using CE-CMR as ground-truth. On early CE-CCT images, the myocardial sectors were extracted according to AHA 16-segment model and labeled as with scar or not based on the late CE-CCT manual tracing. A deep-learning model was developed to classify each sector (Picture).
Of the initial 44187 sectors computed out of the 8285 slices available from the early CE-CCT images, 4594 sectors (10%) presented scar. The CNN approach on the early CE-CCT images yielded a classification accuracy for all sectors of 71% (95% confidence interval (CI): 63%-79%) obtained through 5-fold cross validation. The mean sensitivity, positive predictive value (PPV) and negative predictive value (NPV) for the testing fold resulted in 73% (95% CI: 66%-79%), 56% (95% CI: 48%-65%) and 85% (95% CI: 82%- 88%), respectively. The mean AUC across the five folds was 76% (95% CI: 72%-81%). In a per-segment analysis of the 16-segment AHA model the bull's eye segmental comparison of CE-CMR and respective early CE-CCT findings an 91% agreement was achieved.
Artificial intelligence can detect both ischemic and non-ischemic myocardial fibrosis from routine noninvasive coronary scans, without additional contrast-agent administration or radiational dose, thus assisting diagnosis and management of patients with LV dysfunction and coronary artery disease.
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