Sinus of Valsalva aneurysm is a rare disease characterized by the partial elevation of the aortic root. Few reports are available on the surgical treatment for infants. We report the repair of an extremely rare case of a sinus of Valsalva defect with a ventricular septal defect and right ventricular outflow tract stenosis in an infant. It was not a sinus of Valsalva aneurysm, but it exhibited abnormal partial bulging of the aortic root and forming an aneurysm-like cavity within the right ventricular myocardium. We performed direct closure of the sinus of Valsalva aneurysm-like cavities and intracardiac repair in two stages. Three years after total repair, the patient remained healthy and asymptomatic.
1. Almost all organisms grow in size during their lifetime and switch diets, trophic positions, and interacting partners as they grow. Such ontogenetic development introduces life-history stages and flows of biomass between the stages through growth and reproduction. However, current research on complex food webs rarely considers life-history stages. The few previously proposed methods do not take full advantage of the existing food web structural models that can produce realistic food web topologies. 2. We extended the niche model by Williams & Martinez (2000) to generate food webs that included trophic species with a life-history stage structure. Our method aggregated trophic species based on niche overlap to form a life-history structured population; therefore, it largely preserved the topological structure of food webs generated by the niche model. We applied the theory of allometric predator-prey body mass ratio and parameterized an allometric bioenergetic model augmented with biomass flow between stages via growth and reproduction to study the effects of a stage structure on the stability of food webs. 3. When life-history stages were linked via growth and reproduction, fewer food webs persisted while persisting food webs tended to retain more trophic species. Topological differences between persisting linked and unlinked food webs were small to modest. Temporal variability of biomass dynamics and slopes of biomass spectra were lower in the linked food webs than the unlinked ones, suggesting that a life-history stage structure enhanced stability of complex food webs. 4. Our results suggest a positive relationship between the complexity and stability of complex food webs. A life-history stage structure in food webs may play important roles in dynamics of and diversity in food webs.
We report mild COVID-19 manifestation in high-risk patient with sufficient plasma 25-OH-Vitamin D3 level. Given the global pandemic of vitamin D deficiency, as well as its likely beneficial effects during SARS-CoV-2 infection, report highlights importance of routine 25-OH-Vitamin D3 measurement, either for clinical course prediction or deciding on supplementation.
We carefully read the recent paper by Hammond et al. (1) on the use of sutureless bioprosthetic valve for homograft failure in the setting of infective endocarditis (IE). This article is the latest demonstration that new sutureless and rapid deployment (RD) valve prostheses are safe and easy-to-use devices for surgical aortic valve replacement, and indicates their suitability for different scenarios and peculiar surgical situations as infective endocarditis (IE).
A 14-year-old boy presented to our Emergency Department complaining of fever, and abdominal pain. An abdominal computed tomography showed a large abscess of the spleen. Percutaneous aspiration of the lesion was performed. Splenectomy was performed 38 days after percutaneous aspiration because of the abscess's considerable size.
Respiratory syncytial virus (RSV) infection is the leading cause of bronchiolitis among infants <12 months old. It is widely known that coinfections between RSV and other viruses can worsen the clinical picture of affected patients. To evaluate the severity of clinical pictures of bronchiolitis in the 2019-2020 winter season, we performed a retrospective study of our third-level Pediatric Emergency Department (ED) admission charts. From February 2 to March 9, 2020 (start date of the Italian lockdown), we observed a peak of patients with a clinical picture of bronchiolitis requiring oxygen therapy of 55.1%, compared with 18% and 14.5% during the same period in 2017-2018 and 2018-2019, respectively (p<0.0001), without other clinically significant differences between the groups. Several authors hypothesized that SARS-CoV2 was present in northern Italy some weeks be-fore the first confirmed case. We suggest that one of the causes of this unexpected severe bronchiolitis peak may be a SARS-CoV2 - RSV coinfection in a period when SARS-CoV2 was already circulating in north-ern Italy. Given the lack of real-time polymerase chain reaction (RT-PCR) tests for SARS-CoV2 at that time, our suggestion remains a hypothesis.
Objective: To study the profile of patients with obstructive sleep apnea syndrome (OSAS) and laryngopharyngeal reflux (LPR) at the hypopharyngeal-esophageal multichannel intraluminal impedance-pH monitoring (HEMII-pH) and to compare their reflux findings with LPR patients without OSAS. Design: Prospective controlled study. Methods: Patients with LPR and OSAS were prospectively recruited from Augustus 2019 to June 2020. The profile of hypopharyngeal reflux events (HRE) of patients was studied through a breakdown of the HEMII-pH findings over the 24-hour of testing. Reflux symptom score (RSS), gastrointestinal and HEMII-pH outcomes were compared between LPR patients and patients with LPR and OSAS. Multivariate analysis was used to study the relationship between reflux data and the following sleep outcomes: Apnea-Hypopnea Index, Epworth Slippiness Scale (ESS) and paradoxical sleep data. Results: A total of 89 patients completed the study. There were 45 patients with LPR and 44 subjects with both OSAS and LPR. The numbers of upright and daytime HREs and the otolaryngological RSS were significantly higher in patients with LPR compared with those with OSAS and LPR. There was a significant positive association between RSS quality of life score and ESS (p=0.001). The occurrence of HREs in the evening was associated with higher ESS (p=0.015). Patients with OSAS, LPR and GERD had higher number of nocturnal HREs compared with those without GERD (p=0.001). Conclusion: The presence of OSAS in LPR patients is associated with less severe HEMII-pH and ear, nose and throat symptoms. There may have different OSAS patient profiles according to the occurrence of GERD.
Title PageManuscript TitleComment on: “A newborn with a large NTRK fusion positive infantile fibrosarcoma successfully treated with larotrectinib”Authors:Alana Slomovic, M.D., Pediatric Resident, Department of Pediatrics, Cohen Children’s Medical CenterTerry Amaral, M.D., Associate Chief - Division of Orthopedic Surgery, Long Island Jewish Medical Center, Assistant Professor, Zucker School of Medicine at Hofstra/NorthwellIgor Lobko, M.D., Chief – Division of Vascular/ Interventional Radiology, Long Island Jewish Medical Center, Assistant Professor, Zucker School of Medicine at Hofstra/NorthwellDavid Siegel, M.D., Executive Vice Chairman – Department of Radiology, Long Island Jewish Medical Center, Associate Professor, Zucker School of Medicine at Hofstra/ NorthwellRachelle Goldfisher, M.D., Division of Pediatric Radiology, Department of Pediatrics, Cohen Children’s Medical Center, Assistant Professor, Zucker School of Medicine at Hofstra/NorthwellRachel Kessel, M.D., Division of Pediatric Hematology/Oncology, Department of Pediatrics, Cohen Children’s Medical Center, Assistant Professor, Zucker School of Medicine at Hofstra/NorthwellCarolyn Fein Levy, M.D., Division of Pediatric Hematology/Oncology, Department of Pediatrics, Cohen Children’s Medical Center, Assistant Professor, Zucker School of Medicine at Hofstra/NorthwellCorresponding Author: Carolyn Fein Levy, M.D.269-01 76th Avenue, Suite 255New Hyde Park, NY 11040Phone: (718) 470 3460Fax: (718) 343 4642 email: firstname.lastname@example.orgMain text word count: 564 wordsNumber of figures: 1Short running title: Infantile fibrosarcoma treated with larotrectinibKey Words: Infantile fibrosarcoma, Larotrectinib, NTRK fusionAbbreviations Key:
Reflections from the Book of the Dead: Weighing the Impact of Epicardial Fat on Atrial Fibrillation Vulnerability T. Jared Bunch MDDepartment of Medicine, School of Medicine, University of Utah, Salt Lake City, UtahAddress for correspondence: T. Jared Bunch, M.D.University of Utah School of Medicine Department of Internal Medicine Division of Cardiovascular Medicine 30 North 1900 East, Room 4A100 Salt Lake City, UT 84132 Phone: 801-213-2387 E-mail: email@example.com
Title: Making the Cut for Generator ReplacementsAuthors: Venkatesh Ravi, MD1; Jeremiah Wasserlauf, MD, MS1;1: Section of electrophysiology, Division of Cardiology, Department of Medicine, Rush University Medical Center, Chicago, USACorresponding author:Jeremiah Wasserlauf, MD, MSAssistant Professor of Medicine,Cardiac Electrophysiology, Department of Internal Medicine/Division of Cardiology,Rush University Medical Center.1717 W. Congress Parkway, Suite 345, Chicago, IL 60612Email: Jeremiah_wasserlauf@rush.eduFunding: NoneDisclosure: Dr. Jeremiah Wasserlauf has received consulting fees from Stryker. No other conflicts of interest to disclose.EditorialCardiac implantable electronic devices (CIED) have become a common treatment modality for cardiac arrhythmia with over 300,000 new implants every year in the United States. A growing number of patients will require device replacement procedures throughout their lifetime.1 In a registry of 1744 patients undergoing CIED replacement procedures, lead damage or dislodgement requiring revision was found to occur in 1% of patients without previously planned addition of leads.2 The resulting lead addition and extraction procedures give rise to added procedural time, risk of complications, prolonged hospitalization, and increased health care costs.2 Polyurethane and copolymer insulation materials are more susceptible to thermal damage when compared to silicone.3,4 Avoidance of lead damage during CIED replacement procedures has been a topic of increasing investigation, with studies evaluating differences between electrosurgical modes, power settings, blade orientation, and equipment manufacturers. Operators have the option to choose between standard electrocautery with non-insulated blades, and cautery with insulated blades (PEAK PlasmaBlade, Medtronic Inc., Minneapolis, MN, or Photonblade, Stryker, Kalamazoo, MI).Electrocautery operates by generating a high current density which results in resistive heating and thereby cuts or coagulates tissue. PlasmaBlade uses a proprietary power output waveform to deliver energy along the exposed edge of a thin, insulated electrode powered by a proprietary electrosurgical generator. Photonblade is an alternative insulated electrocautery blade that is compatible with a standard electrosurgical generator. In a retrospective study by Kypta et al, PlasmaBlade was associated with a lesser risk of lead damage and shorter procedure duration and hospital stay when compared with electrocautery and scissors.3 In an ex vivo animal tissue model using Photonblade, coagulation mode during cautery was associated with more damage than cut, and this effect was greatest when contact occurred using the active edge as opposed to the insulated flat side of the cautery blade, and when the lead insulation consisted of polyurethane or copolymer. Visible lead damage was found to be more common with PlasmaBlade when compared to Photonblade. 4In this edition of the Journal of Cardiovascular Electrophysiology , Ananwattanasuk et al performed a retrospective analysis of traditional electrocautery vs PlasmaBlade on lead parameters and complications following CIED generator replacement procedures.5 The study included 410 consecutive patients (840 leads) who underwent CIED replacement using conventional electrocautery (EC group) and 410 patients (824 leads) who underwent CIED replacement using PlasmaBlade (PK group). The power settings for the PK group were 6 in CUT mode and 8 in COAG mode. In the EC group, power output was set to 40 Watts for both CUT and COAG mode. CUT mode was used for tissue dissection and COAG was only used for hemostasis. The two groups had similar device systems and baseline characteristics. In comparison to the PK group, the EC group had a slightly lower proportion of silicone leads (78% vs 83%, p < 0.01) and a slightly higher proportion of polyurethane leads (19% vs 13%, p < 0.01). The study found no statistically significant difference in lead damage requiring lead revision between the EC group and PK group (0.6% vs 0.4%, p=0.5). There was no difference in procedural complications between the two groups (2.2% vs 1.2%, p = 0.28). There was no difference in lead sensing. There was a higher number of patients with a decrease in lead impedance in the PK group compared to the EC group (61.5% vs 52.1%, p < 0.01), and perhaps unexpectedly, more patients with an increase in lead impedance in the EC group compared to the PK group (46.8% vs 34.2%, p<0.01).On average, the change in pacing impedance changed less than 10% in both groups. A majority of leads in both groups were comprised of silicone which may have been a primary contributor to the low rate of lead damage observed. These findings contrast with the older retrospective study that found a lower risk of lead damage with PlasmaBlade compared to a historical control group where titanium scissors were used with conventional electrocautery for hemostasis. The difference observed in the prior study between groups, and the overall higher rates of lead damage in that study may have been related to the use of scissors or perhaps a greater proportion of leads with non-silicone insulation (lead insulation material was not reported). The present study by Ananwattanasuk et al contributes to the literature with a larger cohort of patients and contemporary operative technique.It is never too late to scrutinize the benefit of tools that have added costs as our procedural techniques evolve. The authors should be commended for rigorously collecting not only clinical outcomes but also electrical device parameters to assess for subclinical lead damage. Although generator replacements are short and less complex when compared to other EP procedures, the total cost of generator replacement procedures is estimated at several billion dollars yearly in the US alone.6 Leadless pacemakers and the evolution of modular systems are attractive and may solve some problems related to lead damage during generator replacements, or perhaps one day eliminate generator replacements altogether. However, with the current number of CIEDs in operation and the aging population, a growing number of patients will continue to require generator replacement procedures over the next several decades. The overall safety of generator replacement procedures has improved though advances such as avoidance of routine capsulectomy, antibiotic-impregnated pouches for appropriate candidates, and prolonged replacement intervals due to improved battery longevity. Through an unremitting focus on safety and cost-effectiveness, we will stay on the cutting edge of straightforward and complex procedures in the EP lab.References1. Greenspon AJ, Patel JD, Lau E, et al. 16-year trends in the infection burden for pacemakers and implantable cardioverter-defibrillators in the United States 1993 to 2008. J Am Coll Cardiol. 2011;58:1001-1006.2. Poole JE, Gleva MJ, Mela T, et al. Complication rates associated with pacemaker or implantable cardioverter-defibrillator generator replacements and upgrade procedures: results from the REPLACE registry.Circulation. 2010;122:1553-1561.3. Kypta A, Blessberger H, Saleh K, et al. An electrical plasma surgery tool for device replacement–retrospective evaluation of complications and economic evaluation of costs and resource use. Pacing Clin Electrophysiol. 2015;38:28-34.4. Wasserlauf J, Esheim T, Jarett NM, et al. Avoiding damage to transvenous leads-A comparison of electrocautery techniques and two insulated electrocautery blades. Pacing Clin Electrophysiol.2018;41:1593-1599.5. Ananwattanasuk T, Jame S, Bogun F, et al. Journal of Cardiovascular Electrophysiology. 2021.6. Hauser RG. The growing mismatch between patient longevity and the service life of implantable cardioverter-defibrillators. J Am Coll Cardiol. 2005;45:2022-2025.