The use of extracorporeal circulation (ECC) for intraoperative cardiopulmonary support during lung transplantation has been increasing in the recent years. Our group previously described a novel hybrid extracorporeal membrane oxygenation (ECMO) circuit for use in lung transplantation. Our novel technique for intraoperative management of this circuit during lung transplantation is described.
Background: Radiofrequency ablation in patients with atrial fibrillation (AF) is effective but hampered by pulmonary veins reconnection due to insufficient lesions. High power shorter duration ablation (HPSD) seen to increase efficacy and safety. This analysis aimed to evaluate the clinical benefits of HPSD in patients with AF. Methods: The Medline, PubMed, Embase, and the Cochrane Library databases were searched for studies comparing HPSD and Low power longer duration (LPLD) ablation. Results: A total of seven trials with 2023 patients were included in the analysis. Pooled analyses demonstrated that HPSD showed a benefit of first-pass pulmonary vein isolation (PVI) [risk ratio (RR): 1.27; 95% confidence interval (CI): 1.18–1.37, P < 0.001]. HPSD could reduce recurrence of atrial arrhythmias (RR: 0.70; 95% CI: 0.50–0.98, P = 0.04). Additionally, HPSD was more beneficial in terms of procedural time [Weighted Mean Difference, (WMD): −44.62; 95% CI, −63.00 to −26.23, P < 0.001], ablation time (WMD: −21.25; 95% CI: −25.36 to −17.13, P < 0.001), and fluoroscopy time (WMD: −4.13; 95% CI: −7.52 to −0.74, P < 0.001). Moreover, major complications and esophageal thermal injury (ETI) were similar between two groups (RR: 0.75; 95% CI: 0.44–1.30, P = 0.31) and (RR: 0.64; 95% CI: 0.17–2.39, P = 0.51). Conclusion: HPSD was safe and efficient for treating AF with clear advantages of procedural features, it also showed benefits of higher first-pass PVI and reducing recurrence of atrial arrhythmias compared with the LPLA. Moreover, major complications and ETI were similar between two groups.
Type A acute aortic dissection (TAAD) during pregnancy is a life-threatening event for both the mother and unborn baby. Pregnancy has been recognised as an independent risk factor for TAAD, postulated to be due to physiological changes that cause hyperdynamic circulation. Presentation can be atypical in many cases and further concern from clinicians of fetal radiation exposure can result in missed or delayed diagnoses. Investigation via quickest form of imaging, whether CT, MRI or transoesophageal echocardiography, should be carried out promptly due to the high risk of mortality. Surgical management of TAAD in pregnancy revolves primarily around the decision to deliver the foetus concomitantly or to perform aortic repair with the foetus in utero. This review will summarise the difficulties faced when managing TAAD in pregnancy, and important questions for future research.
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), also known as COVID-19, is a new strain of coronavirus that has not been previously identified in humans. SARS-CoV-2 is recognized as a highly contagious respiratory virus with severe morbidity and mortality, especially in vulnerable populations. Being a novel disease, everyone is susceptible, there are no vaccine and no treatment. To contain the spread of the disease, health authorities throughout the world have restricted the social interactions of individuals in various degrees. Allergists like other physicians are faced with the challenge of providing care for their patients, while protecting themselves and patients from getting infected, with strategies that are in continuous evolution as States work through the different stages of social distance. Allergist provides care for patients with the most common noncommunicable disease in the world: asthma, allergic rhinitis, food allergy, venom allergy, drug allergy atopic dermatitis, and urticarial. Some of these diseases are not only considered risk factors for severe reactions but also have symptoms like cough and sneezing that are in differential diagnosis with COVID-19, and as we move forward may prevent allergy patient from working, go to school or access medical services that increasingly are allowing only asymptomatic patients. In this review, we will outline how to take care safety of different allergic patients during the pandemic.
Coronavirus disease 2019 (COVID-19)diagnosis is based on molecular detection of SARS-CoV-2 in respiratory samples such as nasal swab (NS). However, the evidence that NS in patients with pneumonia were sometimes negative raise the attention to collect other clinical specimens. SARS-CoV-2 was shown in 10.3%rectal swabs (RS), 7.7% plasma,1% urine, 0% feces from 143NS positive patients. Potential infection by fluids different from respiratory secretion is possible but unlikely.
Mini-commentary on BJOG-20-0320.R1: Cesarean section in the second delivery to prevent anal incontinence after asymptomatic obstetrical anal sphincter injury: the EPIC multicenter randomized trialAn obstetric anal sphincter injury poses an important clinical dilemma for subsequent vaginal deliveries, which may be complicated by recurrent obstetric anal sphincter injury and / or worsening or de novo anal incontinence.Recurrent obstetric anal sphincter injury has a similar incidence to primary obstetric anal sphincter injury (6.3% vs 5.7%), and similar associated risk factors including instrumental delivery with either forceps [OR 3.12, 95% confidence interval (CI) 2.42-4.01) or ventouse (OR 2.44, 95%CI 1.83-3.25), birth weight ≥4 kg (OR 2.29, 95%CI 2.06-2.54) and previous fourth-degree tear (OR 1.7, 95%CI 1.24-2.36) (Jha S, Parker V: Int Urogynecol J. 2016 Jun;27(6):849-57).The risk of long-term anal incontinence is also related to the degree of sphincter tear. Women with a fourth-degree sphincter injury in the first delivery are at higher risk for anal incontinence compared to women with a third-degree injury (58.8% vs. 41.0%). (Jangö H et al. 2018 Feb;218(2):232.e1-232.e10. Am J Obstet Gynecol). Although primary caesarean may be protective against anal incontinence, the previous observational evidence is consistent in finding that adjusted odds of long-term anal incontinence do not differ significantly by mode of second delivery after obstetric anal sphincter injury, and specifically that subsequent elective cesarean delivery is not protective (Jangö H et al, Am J Obstet Gynecol. 2016;214(6):733.e1-733.e13.) However, previous observational studies may suffer from confounding by indication, due to widespread adoption of planned caesarean for subsequent deliveries in women with incontinence symptoms or persistent sphincter defectsThere have been no previous randomised trials to test whether anal incontinence could be prevented by planned cesarean section for the second delivery. Abramowitz and colleagues’ (Abramowitz L et al. BJOG 2020) RCT provides us with a better understanding of the role of caesarean in women with asymptomatic third degree anal sphincter injury. There was limited cross-over between groups: of the 112 women randomized to the vaginal delivery group, 17 (15.6%) had a caesarean section for obstetric indications. For those randomized to the planned cesarean section, 18 (16.58%) delivered vaginally. One fifth of the randomized women did not complete the post-partum follow-up, but their characteristics did not differ between the two study groups. In this RCT, planned cesarean section in the second delivery was unequivocally not protective against anal incontinence at 8 months post-partum, with low rates of symptoms in both groups (Vaizey score 1/24 vs. 1/24 p=0.34). As rates of incontinence were lower than expected, the trial may have been underpowered for a clinically relevant difference between groups. In an unplanned analysis, there was however, an interaction between baseline Vaizey score, and worsening symptoms after vaginal delivery, with significantly worse symptoms after vaginal delivery for women with pre-existing mild symptoms.The authors rightly suggest that the findings are useful when counseling women about risks and benefits of caesarean at their second delivery. These results do not support advising systematic cesarean after asymptomatic third degree obstetric anal sphincter injury. The medicalization of pregnancy associated with planned caesarean is undesirable from both individual and societal perspectives, and cesarean delivery is associated with a number of health risks when compared to vaginal delivery (NICE Clinical Guideline CG132, https://www.nice.org.uk/guidance/cg132/). Important questions remain for future work whether subsequent cesarean section may be useful in the long term, among women with mildly symptomatic anal incontinence, or for women with asymptomatic fourth degree obstetric anal sphincter injury.Disclosure of interests: Tähtinen declares honoraria from Olympus. Cartwright declares no conflicts of interest. Completed disclosure of interest forms are available to view online as supporting information.
Purpose: Degenerative mitral stenosis (DMS) is an increasingly recognized cause of mitral stenosis. The goal of this study was to compare echocardiographic differences between DMS and rheumatic mitral stenosis (RMS), identify echocardiographic variables reflective of DMS severity, and propose a dimensionless mitral stenosis index (DMSI) for assessment of DMS severity. Methods: This is a single-center, retrospective cohort study. We included patients with at least mild MS and a mean transmitral pressure gradient (TMPG) ≥ 4 mmHg. Mitral valve area by the continuity equation (MVACEQ) was used as an independent reference. The DMSI was calculated as follows: DMSI = VTILVOT / VTIMV. All-cause mortality data were collected retrospectively. Results: A total of 64 patients with DMS and 24 patients with RMS were identified. MVACEQ was larger in patients with DMS (1.43 0.4 cm2) than RMS (0.9 0.3 cm2) by ~0.5 cm2 (p = <0.001) and mean TMPG was lower in the DMS group (6.0 2 vs. 7.93 mmHg, p=0.003). A DMSI of 0.50 and ≤ 0.351 were associated with MVACEQ ≤ 1.5 and MVACEQ ≤ 1.0 cm2 (p<0.001), respectively. With the progression of DMS from severe to very severe, there was a significant drop in DMSI. There was a non-significant trend towards worse survival in patients with MVACEQ ≤ 1.0 cm2 and DMSI ≤ 0.35, suggesting severe stenosis severity. Conclusion: Our results show that TMPG correlates poorly with MVA in patients with DMS. Proposed DMSI may serve as a simple echocardiographic indicator of hemodynamically significant DMS.
Density functional theory (DFT) calculations were conducted to investigate mechanistic details of ethanol-to-butadiene conversion reaction over MgO or ZnO catalyst. We evaluated the Lewis acidity and basicity of MgO and ZnO and found that ZnO had the stronger Lewis acidity and basicity compared with those of MgO. Potential energy surfaces (PESs) of ethanol-to-butadiene conversion, which included relevant transition states (TSs) and intermediates, were computed in detail following the generally accepted mechanism reported in the literature, where such mechanism included ethanol dehydrogenation, aldol condensation, Meerwein-Pondorf-Verley (MPV) reduction and crotyl alcohol dehydration. DFT results showed that ethanol dehydrogenation was the rate limiting step of overall reaction when the reaction was catalyzed by MgO. Also, DFT results showed that ethanol dehydrogenation occurred more easily on ZnO compared with MgO where such a result correlated with the stronger Lewis acidity of ZnO. In addition, we computed ethanol dehydration which generates ethylene, one of the major undesired side reaction products for butadiene formation. DFT results showed that ZnO favored dehydrogenation over dehydration while MgO favored dehydration.
The raw case fatality rate (CFR, reported number of COVID-19 deaths divided by the number of cases) is a useful indicator to quantify the severity or treatment efficacy in a locality. In many countries, the pandemic showed a two-wave pattern now, namely the daily reported cases once reached a low level and now went up. To our knowledge, no study has compared the CFR for the two waves. In this work, we report that in 53 countries or regions with the highest deaths, the CFR is reduced in 43 countries or regions in the on-going second wave. We discussed the possible reasons. Also, we compare the two-wave pattern of COVID-19 with the weekly influenza positive tests. The influenza activity in pre-pandemic era provided an indicator for climate in a country, since it is well-known that influenza is driven by weather. The sharp drop in 2020 influenza activity is an indicator of the effects of social distancing.
Allergic bronchopulmonary aspergillosis (ABPA) is a pulmonary disease caused by Aspergillus induced hypersensitivity that occurs in immunocompetent but susceptible patients with asthma and/or cystic fibrosis (CF). In children, ABPA remains mostly undiagnosed, resulting in one of the most common causes of poorly controlled asthma and highly significant morbidity in children with CF. Currently, no specific diagnostic criteria of ABPA for children are available. Corticosteroids and itraconazole are the mainstays of therapy, althoughthere is a lack of randomized clinical trials regarding their usefulness for ABPA in children. Several monoclonal antibodies, such asomalizumab and mepolizumab, may be potential therapies for refractory ABPA in pediatric patients; however, further data are required to clarify the optimal dose and duration of therapy as a routine treatment approach.
The interesting report by Karagianni P et al on the finding of increased DNA methylation of H19 locus imprinting control region in saliva samples of Sjögren’s syndrome patients correlating with low complement C4 levels, may offer insights into how C4 level may be regulated in serpinopathies such as C1-inhibitor deficiency. An undetectable or low C4 level in patients with severe angioedema is a feature of C1-inhibitor deficiency (hereditary angioedema (HAE) type I with low to absent function and antigenic levels; HAE type II with point mutations in SERPING1 gene that affect the reactive centre loop affecting protein function only). However, C4 levels do not always clinically correlate with disease activity, and up to 6% patients do not have known mutations in the SERPING1 gene.
Ambrosia artemisiifolia and Ambrosia trifida are two species of very harmful and invasive plants of the same genus. However, it remains unclear why A. artemisiifolia is more widely distributed than A. trifida worldwide. Distribution and abundance of these two species were surveyed and measured from 2010 to 2017 in the Yili Valley, Xinjiang, China. Soil temperature and humidity, main companion species, the biological characteristics in farmland ecotone, residential area, roadside and grassland, and water demand of the two species were determined and studied from 2017 to 2018. The area occupied by A. artemisiifolia in the Yili Valley was more extensive than that of A. trifida, while the abundance of A. artemisiifolia in grassland was less than that of A. trifida at eight years after invasion. The interspecific competitive ability of two species were stronger than those of companion species in farmland ecotone, residential, and roadside. In addition, A. trifida had greater interspecific competitive ability than other plant species in grassland. The seed size and seed weight of A. trifida were five times or eight times those of A.artemisiifolia. When comparing the changes under simulated annual precipitation of 840 mm versus 280 mm, the seed yield per m2 of A. trifida decreased from 50,185 to 19, while that of A. artemisiifolia decreased from 15,579 to 530. The differences in the distribution of the two species are mainly due to differences in interspecific competitive ability, seed size, and water dependence. The two species have stronger interspecific competitive ability than that of companion species, but A. artemisiifolia has a smaller seed size and stronger drought tolerance, which allows A. artemisiifolia to spread farther than A. trifida. The reason for wider distribution of A. trifida in grassland is that A. trifida has stronger interspecific competitive ability than A. artemisiifolia under sufficient water.
Epidemiologic studies performed in the Melbourne Sexual Health Center over several years have explored and emphasized the role of sexual transmission in the pathogenesis of sporadic bacterial vaginosis (BV) as well as recurrent BV (Fethers KA., et al. Infect. Dis. 2008; 47: 1426-1435). Some of the most definitive studies documenting details of heterosexual sexual transmission followed. There can be little doubt as to the causal role of sexual transmission in BV particularly with regard to the initial episode (Cherpes, TL., et al. Sex. Transm. Dis 2008; 35: 78-83). The present study adds solid molecular data to their previous epidemiologic data that recurrent BV is more likely to occur in a heterosexual woman with a single regular male partner (Ratten L., et al BJOG 2020 xxxx): Moreover, the risk is mitigated by use of an oral contraceptive and barrier contraceptives. Specifically, Ratten et al conclude that sex is associated with persistence of non-optimal, BV-associated vaginal dysbiosis following appropriate antimicrobial treatment for BV in a cohort followed prospectively, likely the result of sexual transmission from a regular partner. The key term used in the title of the study is persistence, which implies that the non-optimal vaginal microbiota fails to resolve, as opposed to future reintroduction from the same guilty partner. Persistence in this context, unfortunately, also indirectly suggests that inadequate antimicrobial treatment is currently prescribed to women, perhaps sufficient to relieve symptoms and meet diagnostic criteria of satisfactory response, but insufficient to eradicate BV pathogens. The author emphasizes needed improvement in the, so far, futile male partner therapy to prevent female reinfection, a goal that has repeatedly eluded experts to date.The unanswered question facing patients and clinicians alike is the role of sexual reinfection as opposed to vaginal relapse in the causation and likelihood of BV recurrence. The tone of the article would indicate that reinfection is the more likely causal mechanism of BV recurrence, by emphasizing “persistence” and outweighing the role of unexplained relapse. In dealing with a symptomatic patient suffering from an episode of recurrent BV, it is currently not possible to differentiate relapse from reinfection unless the patient declares herself to be celibate, ergo relapse is the cause of recurrence. The clinical picture is identical as are Amsel or Nugent criteria. Unfortunately, molecular microbiome studies have not revealed significant differences between sequential episodes regardless of causation. We lack a “unique fingerprint” to differentiate cause or nature of the recurrent episode. Even with reinfection, sexual or otherwise, details of pathogenesis are still lacking. We know too that coitus can elicit symptoms of BV (post coital malodor) even with use of a condom. The role of receptive oral-vulvovaginal sex is also undetermined, as is the role of penile – anorectal penetration although the latter was found to be minimal in the latest study by Ratten L., et al. (BJOG 2020 xxxx): Moreover, not all longitudinal studies have revealed that heterosexual sex is a major factor in recurrence (Sobel J.D., et al. Infect. Drug Resist. 2019: 12; 2297-2307).The role of sex and reinfection in causation of RBV will depend significantly upon the population studied, including biologic and behavioral differences. Determination of causation of BV recurrence in different patient populations should be personalized and acknowledged as we admit our current limitations. Will more effective male treatment help reduce BV recurrence? Hopefully but still unknown. Determining all the causes of vaginal microbiota persistence, including the role of biofilm, remains a challenge.No disclosures: A completed disclosure of interest form is available to view online as supporting information.
Trained immunity refers to the fact that the innate immune system also demonstrates memory, resulting in a faster and more profound second innate reaction, days to weeks after a first reaction to another pathogen or vaccine. Thus, trained immunity is heterologous, non-specific. We applied this principle with MMR vaccination during the COVID-19 pandemic.In a prospective, observational, single-center study 255 subjects, most at high risk for infection with COVID-19, received preventive MMR vaccination; 36 got infected with COVID-19; all had a mild course, even though 40% had risk factors. This might in part be due to trained immunity, conveying innate immune memory secondary to MMR vaccination, enhancing the innate immune response once the subject gets infected with SARS-CoV-2.As a result the well-known immune suppression brought about by coronavirus might not work so well, as the innate immune system is primed, allowing the body to finally eliminate the virus more efficiently.
We describe the anaesthetic management of a 4-day-old premature infant presenting for urgent resection of a massive posterior intrapericardial teratoma. Anaesthetic challenges include anticipating cardiopulmonary collapse upon induction and hemodynamic instability associated with blood loss or tumor manipulation. Premature infants present unique challenges due to patient-to-tumor size discrepancy.
The coronavirus disease 2019 (COVID-19) pandemic has presented unique challenges to international health care systems. Management of the current pandemic puts a huge strain on health care sectors and leads to new strategies conducting by health care systems in countries across the world. In the present article, we review the epidemiologic data, Iranian health care system response, as well as the effects of COVID-19 pandemic on cardiac surgery practice in Iran
A patient with heart failure due to dilated ischemic cardiomyopathy presented in cardiogenic shock for institution of veno-arterial extracorporeal membrane oxygenation as a bridge to cardiac transplantation. To provide adequate venous drainage and simultaneous decompression of the left atrium (indirect left ventricular venting) a single venous cannula was placed across the interatrial septum so the distal orifice and side ports were located within the left atrium and the proximal set of side ports at the cavoatrial junction. Three-dimensional transesophageal echocardiography demonstrated utility in guiding cannula placement and appropriate positioning within the left atrium.