Federico Lombardi

Objectives The avaliability of new devices aimed at improving fluid distribution with a CO2 Peritoneal Recirculation System (PRS-1.0 Combat) may be useful to further improve the clinical benefit recently showed by hypertermic intraperitoneal chemotherapy (HIPEC) after interval debulking surgery (IDS) in advanced ovarian cancer (AOC) patients. This study aimed at assessing the feasibility and perioperative outcomes of the CO2 PRS HIPEC after IDS. Methods Over the study period 24 patients were prospectively enrolled. Patients underwent 3 neoadjuvant cycles of carboplatin AUC5 + paclitaxel 175 mg/m2 and IDS with absent residual disease. Sodium thiosulfate (9 g/m2) was administered before CO2 PRS HIPEC with cisplatin (75 mg/m2, temperature 42°C, for 60 minutes). Results Almost one third of patients (37,5%) underwent ultraradical surgery with 12.5% bowel resections. Median blood loss was 500 (100–1200) mL and mean operative time 407.5 minutes. Median (range) intensive care unit stay and time-to-discharge were 0 (0–10) and 6 (4–17) days, respectively. We registered 3/24 (12.5%) early serious adverse events including one acute respiratory failure and two acute kidney injuries (only one of these retained a mild chronic renal failure); one patient was readmitted within 30 days after discharge because of a dehiscence of the vaginal vault. No late adverse events were reported. Median time-to-chemotherapy was 33 days (range 22- 51). Conclusions The CO2 PRS may improve the safety profile of HIPEC in the setting of IDS for AOC patients probably because of the more tailored drug distribution.

Atrial flutter (AFL) is a common atrial arrhythmia typically characterized by electrical activity propagating around specific anatomical regions. It is usually treated with catheter ablation. However, the identification of rotational activities is not straightforward, and requires an intense effort during the first phase of the electrophysiological (EP) study, i.e., the mapping phase, in which an anatomical 3D model is built and electrograms (EGMs) are recorded. In this study, we modeled the electrical propagation pattern of AFL (measured during mapping) using network theory (NT), a well-known field of research from the computer science domain. The main advantage of NT is the large number of available algorithms that can efficiently analyze the network. Using directed network mapping, we employed a cycle-finding algorithm to detect all cycles in the network, resembling the main propagation pattern of AFL. The method was tested on two subjects in sinus rhythm, six in an experimental model ofin-silicosimulations, and 10 subjects diagnosed with AFL who underwent a catheter ablation. The algorithm correctly detected the electrical propagation of both sinus rhythm cases andin-silicosimulations. Regarding the AFL cases, arrhythmia mechanisms were either totally or partially identified in most of the cases (8 out of 10), i.e., cycles around the mitral valve, tricuspid valve and figure-of-eight reentries. The other two cases presented a poor mapping quality or a major complexity related to previous ablations, large areas of fibrotic tissue, etc. Directed network mapping represents an innovative tool that showed promising results in identifying AFL mechanisms in an automatic fashion. Further investigations are needed to assess the reliability of the method in different clinical scenarios.

Objectives: The DETECT algorithm has been developed to identify SSc patients at risk for pulmonary arterial hypertension (PAH) yielding high sensitivity but low specificity, and positive predictive value. We tested whether cardiopulmonary exercise testing (CPET) could improve the performance of the DETECT screening strategy. Methods: Consecutive SSc patients over a 30-month period were screened with the DETECT algorithm and positive subjects were referred for CPET before the execution of right-heart catheterization. The predictive performance of CPET on top of DETECT was evaluated and internally validated via bootstrap replicates. Results: Out of 314 patients, 96 satisfied the DETECT application criteria and 54 were positive. PAH was ascertained in 17 (31.5%) and pre-capillary pulmonary hypertension in 23 (42.6%) patients. Within CPET variables, the slope of the minute ventilation to carbon dioxide production relationship (VE/VCO2 slope) had the best performance to predict PAH at right-heart catheterization [median (interquartile range) of specificity 0.778 (0.714–0.846), positive predictive value 0.636 (0.556–0.750)]; exploratory analysis on pre-capillary yielded a specificity of 0.714 (0.636–0.8) and positive predictive value of 0.714 (0.636–0.8). Conclusion: In association with the DETECT algorithm, CPET may be considered as a useful tool in the workup of SSc-related pulmonary hypertension. The sequential determination of the VE/VCO2 slope in DETECT-positive subjects may reduce the number of unnecessary invasive procedures without any loss in the capability to capture PAH. This strategy had also a remarkable performance in highlighting the presence of pre-capillary pulmonary hypertension.

Aims: An increased mortality risk during weekend hospital admission has been consistently observed. In the present study, we evaluated whether the current improvement in management of acute coronary syndromes (ACS) has reduced this phenomenon. Methods and results: We extracted data from the Italian National Healthcare System Databank of 80 391 ACS admissions in the region of Lombardia between 2010 and 2014. ICD-9 codes were used to assess the diagnosis. We performed a multiple logistic regression analysis to compare the mortality rates between weekend and weekday admissions. Mean age of the study population was 67.6 years; 30.1% of patients were women. ST segment elevation myocardial infarction (STEMI) accounts for 42.2% of admissions. The total in-hospital mortality was 3.05% and was positively predicted by weekend admission [odds ratio (OR) 1.13, P = 0.006], age and female sex. The weekend effect on mortality was only significant for STEMI (OR 1.11, P = 0.04) in comparison to non-STEMI (NSTEMI) or unstable angina. The trend of the risk of death was found to be negatively correlated with age: the risk of death was significantly higher in all age clusters younger than 75 (OR 1.22, P < 0.01) and even greater in the very young subgroup under 45 years of age (OR 2.09, P = 0.03). Conclusion: Our data indicate that increased mortality risk is still present during weekend admissions. This phenomenon is particularly evident in younger patients and in individuals admitted for STEMI.