Closure of muscular ventricular septal defects remains a challenge for cardiac surgeons and interventional cardiologists. Different techniques, approaches, and devices are available to increase the success of these procedures. Changwe et al, in this issue of the Journal, describe a novel approach with the usage of a probe-guided system, with encouraging results.
Background: Although the burden of influenza is well characterized, the burden of community-onset non-influenza respiratory viruses has not been systematically assessed. Understanding the severity and seasonality of non-influenza viruses, including human coronaviruses, will provide a better understanding of the overall disease burden from respiratory viruses that could better inform resource utilization for hospitals and highlight the value of preventative strategies, including vaccines. Methods: From October 2017 to September 2019, a retrospective study was performed in a pre-defined catchment area to estimate the population-based incidence of community-onset respiratory viruses associated with hospitalization. Included patients were >18 years old, resided in New York City, were hospitalized for >24 hours, and had a respiratory virus detected within 3 calendar-days of admission. Disease burden was measured by hospital length of stay (LOS), intensive care unit (ICU) admissions, and in-hospital mortality and compared among those with laboratory-confirmed influenza versus those with laboratory-confirmed non-influenza viruses (human coronaviruses, parainfluenza viruses, respiratory syncytial virus, human metapneumovirus, and adenovirus). Results: During the study period, 4,232 eligible patients were identified of whom 50.9% were >65 years of age. For each virus, the population-based incidence was highest for those >80 years of age. When compared to those with influenza viruses detected, those with non-influenza respiratory viruses detected (combined) had higher population-based incidence, significantly more ICU admissions, and higher in-house mortality. Conclusions: The burden of non-influenza respiratory viruses for hospitalized adults is substantial. Prevention and treatment strategies are needed for non-influenza respiratory viruses, particularly for older adults.
Background Ebstein’s anomaly (EA) is a kind of congenital heart disease, which is currently widely treated by cone reconstruction. However, prediction of postoperative recovery is still challenging. Methods A retrospective analysis was performed on EA cases undergoing cone reconstruction from January 2010 to January 2016. Univariate and multivariate logistic regression analyses were performed, with postoperative adverse events defined as dependent variable and pre- and intra-operative parameters defined as independent variables. Predictive capacity of preoperative SPO2 and Great Ormond Street (GOS) score was evaluated using areas under the curve of receiver operating characteristic (ROC). Results Preoperative SPO2 was 95.7 ± 5.20%. Cardiopulmonary bypass, aortic cross-clamp, postoperative mechanical ventilation, and hospitalization time were 101.7 ± 28.26 min, 60.9 ± 18.04 min, 16 hours (8, 22), and 8 days (7, 11), respectively. The incidence of total postoperative adverse events including low cardiac output syndrome, mechanical ventilation more than 3 days, postoperative hospitalization more than 2 weeks, postoperative re-intubation, extracorporeal membrane oxygenation assistance, and death was 13.1% (n=13). Low pre-operative SPO2 (P=0.001, OR=0.834), GOS score (P=0.021, OR=0.368), and cardiopulmonary bypass time (P=0.034, OR=1.021) were risk factors for adverse events. Multivariate logistic regression analysis showed that low preoperative SPO2 (P=0.002, OR=0.846) and GOS score (P=0.043, OR=0.577) were independent risk factors for adverse events. The areas of SPO2 and GOS score under the ROC curve were 0.764 and 0.740, respectively. Conclusions Low pre-operative SPO2 and GOS score were predictors of adverse events after cone reconstruction, and SPO2 was more convenient and objective than GOS score.
In the last decades, the overlapping areas of intervention between cardiac surgeons and interventional cardiologists are rocketing, especially in the field of treatment of heart valve disease. But, while for the aortic valve the competition, even for non-high risk patients, has become tightened, in the context of mitral regurgitation, the surgery seems to not have competitors .In fact looking the results of studies published so far, a question arises: Is surgery the fair competitor for the Mitraclip? The meta-analysis by Abdul Khader et al summarized few evidences present in this field, only 11 observational studies and 1 randomized trial, providing an awesome response: “NO”. Is therefore not a case if recently two trials, MITRA-FR and COAPT, chose to use as competitor for MitraClip, more rightly, medical therapy instead of surgery. In conclusions, in case of mitral regurgitation, surgery is still largely the gold standard treatment and so MitraClip cannot be mention at all as competitor of surgery. It can be the right choice of case of primary MR where patients showed high risk for surgery. In case of secondary MR, especially with large and poor left ventricle we should wait for a clear answer on its role, yet.
Background. The use of transcutaneous near-infrared spectroscopy (NIRS) for the monitoring of the perfusion of renal allografts in paediatric population has been proposed in the last years. This device might detect early decrease in allograft oxygenation allowing prompt detection of vascular complications. Methods. A systematic review of literature about the use of transcutaneous NIRS in monitoring allograft perfusion was performed according to the PRISMA guidelines. Results. The authors screened 1313 papers. The search yielded five pertinent articles. Three of them reported the experience of NIRS in kidney transplantation, for a total of 53 paediatric patients and 50 adults. In these studies, NIRS measurements was significantly related to serum creatinine, estimated glomerular filtration rate (eGFR), urinary neutrophil gelatinase-associated lipocalin (u-NGAL), serum lactate, resistive index assessed by doppler-ultrasonography and systolic blood pressure. In the paediatric studies no vascular complications were encountered. Conclusions. Preliminary studies have related NIRS monitoring to renal allograft perfusion and function. Further investigation is needed to establish the normal range of NIRS values for renal allografts and the factors influencing NIRS monitoring.
Pediatric histiocytic neoplasms are hematopoietic disorders frequently driven by the BRAF-V600E mutation. Here we identified two BRAF gene fusions (novel MTAP-BRAF and MS4A6A-BRAF) in two aggressive histiocytic neoplasms. In contrast to previously described BRAF fusions, MTAP-BRAF and MS4A6A-BRAF do not respond to the paradox breaker RAF inhibitor (RAFi) PLX8394 due to stable fusion dimerization mediated by the N-terminal fusion partners. This highlights a significant and clinically relevant shift from the current dogma that BRAF-fusions respond similarly to BRAF-inhibitors. As an alternative, we show suppression of fusion-driven oncogenic growth with the pan-RAFi LY3009120 and MEK inhibition.
Decomposition of forest litter plays a major role in nitrogen (N) dynamics in soil. But to which extent that forest litter affects soil N and how much soil N is derived from the new litter remains unknown. An in-situ soil column experiment with 14-month litter decomposition was conducted to examine the effect of litter retention on soil N dynamics in a typical forest of subtropical China in 2018. Litter removal in the soil column was used as a control treatment, while natural litter or identical amount of 15N labeled litter was added to soil columns as litter retention treatment. The results showed that litter removal caused a continuous decrease in concentration of soil soluble organic nitrogen (SON) in the first 5 months, and then SON began to accumulate and its concentration went up in spring showing obvious seasonal change. Litter retention accelerated the reduction of soil SON concentration in the first 2 months, while maintained a high concentration after that period. Soil NH4+-N derived from litter was nitrified rapidly, and newly formed NO3–N was quickly immobilized or lost. Only 1.8% of soil SON came from litter N and 98.2% from indigenous soil N under the decomposition of labeled litter. Litter provided supplementation N to form new soil SON continuously, however, only a small part of SON was relatively stable, and SON played the role of reserve and regulatory pool. Soil SON and TN were formed after long-term litter accumulation and decomposition.
This paper aims to solve the celebrated Fuzzy Fractional Differential Equations (FFDE) using an Artificial Neural Network (ANN) technique. Compared to the integer order differential equation, the proposed FFDE can better describe several real application problems of various physical systems. To accomplish the aforementioned aim, the error back propagation algorithm and a multi-layer feed forward neural architecture are utilized using the unsupervised learning in order to minimize the error function as well as the modification of the parameters such as weights and biases. By combining the initial conditions with the ANN, output provides an appropriate approximate solution of the proposed FFDE. Then, two illustrative examples are solved to confirm the applicability of the concept as well as to demonstrate both the precision and effectiveness of the developed method. By comparing with some traditional methods, the obtained results reveals a close match that confirms both accuracy and correctness of the proposed method.
Fetal lung fluid: Not the same as amniotic fluidAuthor: Hemananda Muniraman MBBS, FAAP, FRCPCHAffiliations:Creighton University School of Medicine, Phoenix Campus, Arizona, USCorresponding Author: Hemananda Muniraman, MBBS, FAAP, FRCPCHAssistant Professor of Pediatrics Affiliate, Creighton University School of MedicinePhoenix Campus, 350 W Thomas Rd, Phoenix, AZ, US 85013Email; Hemu_Muniraman@mednax.com, Phone: +16022564628 Fax: +16026276325Conflict of Interest Disclosure: I have no conflicts of interest relevant to this article to disclose. Funding/Support.No funding to be reportedKey words: Extreme preterm, neonates, pneumatocele, fetal lung fluidDear Dr MurphyEditor in chief, Pediatric PulmonologyI read with interest the recently published article “Pulmonary pneumatoceles in neonates” by Dr Rocha.  It is a well written comprehensive review of pulmonary pneumatoceles in neonates and an important resource for the clinicians in decision making, that I found to be very insightful whilst recently managing an extreme preterm with a large pneumatocele.However, I wanted to bring attention to a statement in the introduction where the author states that the “preterm infants’ lungs are filled with amniotic fluid”. This is not accurate and appears to be a common misconception, particularly among medical students and junior residents despite recognition of fetal lung fluid as being a separate entity from the amniotic fluid as originally described in 1948 by Jost and Policard.  I believe this is an important knowledge gap that needs to be addressed. Understanding of metabolism and role of fetal lung fluid in lung development and postnatal transition is essential to clinicians involved in the care of newborns and infants.Though a comprehensive review of fetal lung fluid is beyond the scope of this letter, I provide a brief basic overview of fetal lung fluid with references for more comprehensive reading.Fetal lung fluid is a chloride rich acidic fluid produced with in the fetal lungs by secretion of chloride across the distal lung epithelial cells and is a major determinant for fetal lung growth and development. The fluid lung volume is maintained by transglottic pressure gradient with periodic egress of excess fluid during fetal breathing. Decreased lung fluid volume is associated with pulmonary hypoplasia and conversely, upper airway lesions obstructing the egress of lung fluid leads to increase in fetal lung fluid and volume, a principle used in fetal interventions such as endoluminal tracheal occlusion to enhance pulmonary growth in conditions namely congenital diaphragmatic hernia. [2,3,4]As important the fetal lung fluid is for lung development, clearance of lung fluid is crucial for normal postnatal transition and establishment of air filled lungs for effective gas exchange. Clearance of lung fluid is a complex and coordinated process that starts before the process of birth itself. The rate of lung fluid secretion diminishes before labor at term gestation. Catecholamines namely epinephrine released during labor upregulates the epithelial sodium channels (ENaC) promoting influx of sodium and fluid from lumen into pulmonary interstitial space thereby reversing the direction of fluid movement in the perinatal period. Lung fluid is decreased to about 35% following active labor and birth which are further cleared with neonatal cry and breathing and inflow of air after birth. The fluid from the interstitial space is cleared over the next few hours via pulmonary circulation and lymphatic drainage. However this process is impaired in infants delivered by elective cesarean sections leading to increased retained lung fluid after birth and resulting in transient respiratory distress and tachypnea of newborn (TTN). In preterm infants, catecholamine induced fluid reabsorption via ENaC is limited and may contribute to respiratory distress after birth. Prenatal maternal steroids and triiodothyronine administration is known to induce expression of messenger RNA for ENaC subunits in the fetal lungs and may facilitate lung fluid clearance. [2,4]Lastly, amniotic fluid aspiration into fetal lungs, with and without meconium contamination, has been reported to be the cause of respiratory distress with case reports of massive amniotic fluid aspiration noted on postmortem histological examination of newborn lungs. References:Rocha G. Pulmonary pneumatoceles in neonates. Pediatr Pulmonol. 2020 Jul 21. doi: 10.1002/ppul.24969. Epub ahead of print. PMID: 32691976.Katz C, Bentur L, Elias N. Clinical implication of lung fluid balance in the perinatal period. J Perinatol. 2011 Apr;31(4):230-5. doi: 10.1038/jp.2010.134. PMID: 21448181.Hooper SB, Harding R. Fetal lung liquid: a major determinant of the growth and functional development of the fetal lung. Clin Exp Pharmacol Physiol. 1995 Apr;22(4):235-47. doi: 10.1111/j.1440-1681.1995.tb01988.x. PMID: 7671435Kallapur S, Jobe A; Fetal Lung fluid. Richard J. Martin, Avroy A. Fanaroff, Michele C. Walsh. Fanaroff And Martin’s Neonatal-Perinatal Medicine : Diseases of the Fetus and Infant, 10th edition. Philadelphia, PA :Elsevier/Saunders, 2015Lavezzi AM, Poloniato A, Rovelli R, Lorioli L, Iasi GA, Pusiol T et al. Massive Amniotic Fluid Aspiration in a Case of Sudden Neonatal Death With Severe Hypoplasia of the Retrotrapezoid/Parafacial Respiratory Group. Front Pediatr. 2019 Apr 4;7:116. doi: 10.3389/fped.2019.00116. PMID: 31019904
Pulmonary hypertension represents an increasingly important group of pediatric patients which commonly come to the attention, if not the primary care of pediatric pulmonologists around the world. There have been major advances in diagnosis and therapy over the past 25 years. To address potential gaps in knowledge, the authors were invited by the Editor of Pediatric Pulmonology to organize a series of manuscripts in a special supplement of the journal. Our authors include pulmonologists, pharmacists, intensivists, mid-level practitioners, neonatologists and cardiologists. We believe that this issue will be of great interest to most of the readership community that the Journal addresses.
Background: The purpose of this study was to investigate the incidence, predictors, and long-term impact of gastrointestinal (GI) complications following adult cardiac surgery. Methods: Index Society of Thoracic Surgeons (STS) adult cardiac operations performed between January 2010 and February 2018 at a single institution were included. Patients were stratified by the occurrence of postoperative GI complications. Outcomes included early and late survival as well as other associated major postoperative complications. A sub-analysis of propensity score matched patients was also performed. Results: 10,285 patients were included, and the overall rate of GI complications was 2.4% (n=246). Predictors of GI complications included dialysis dependency, intra-aortic balloon pump, congestive heart failure, chronic obstructive pulmonary disease, and longer aortic cross-clamp times. Thirty-day (2.6% vs 24.8%), one- (6.3% vs 41.9%), and three-year (11.1% vs 48.4%) mortality were substantially higher in patients who experienced GI complications (all P<0.001). GI complication was associated with a three-fold increased hazard for mortality (HR 3.1, 95% CI 2.6-3.7) after risk adjustment, and there was an association between the occurrence of GI complications and increased rates of renal failure (39.4% vs 2.5%), new dialysis dependency (31.3% vs 1.5%), multisystem organ failure (21.5% vs 1.0%), and deep sternal wound infections (2.6% vs 0.2%)(all P<0.001). These results persisted in propensity-matched analysis. Conclusions: GI complications are infrequent but have a profound impact on early and late survival, and often occur in association with other major complications. Risk factor modification, heightened awareness, and early detection and management of GI complications appears warranted.
Eltrombopag is a highly effective treatment for immune thrombocytopenia (ITP). Cases of durable remission after the discontinuation of eltrombopag in adult ITP have recently been reported; however, the frequency and mechanisms responsible for this phenomenon remain unknown. In the present study, we examined the phenotypes of lymphocytes in ITP to clarify whether they predict outcomes after the discontinuation of eltrombopag. We examined 56 adult newly diagnosed ITP patients treated with eltrombopag after a median time from diagnosis of 48 months. Among the 38 patients who achieved complete remission, eltrombopag was discontinued in 26. Among the 26 patients, 12 (46.2%) had an immediate relapse after discontinuing eltrombopag and 16 (53.8%) showed sustained response without additional ITP therapy, despite discontinuing eltrombopag, with a median follow-up of 52 months. No significant differences were observed in platelets, the median duration of eltrombopag, the absolute number of T, B, and NK cells at the initiation of eltrombopag between patients who sustained response and those who relapsed after discontinuing eltrombopag. However, the number of B and NK cells at the discontinuation of eltrombopag was higher in patients who sustained response than in those who relapsed (p=0.022 and p=0.012, respectively). The present results indicate that the absolute number of B (≥ 0.20 x 109/L) and NK (≥ 0.36 x 109/L) cells at the discontinuation of eltrombopag contributes to the prediction of outcomes.
Our findings illustrate the widespread collateral impact of implementing measures to mitigate the impact of COVID-19 in people with, or being investigated for diabetes mellitus (DM). Ironically, failure to focus of the wider implications for people with DM and other groups with long-term conditions, may place them at increased risk of poor outcomes from SARS-CoV-2 infection itself, irrespective of the implications for their longer-term health prospects.
Objective To compare the effectiveness, safety and acceptability of medical abortion before and after the introduction of no-test telemedicine Design Cohort study Setting The three main abortion providers in England Population All patients having an early medical abortion (comprising 85% of all medical abortions performed nationally) Methods Comparison of no-test telemedicine hybrid model vs. traditional model (blanket in-person provision including ultrasound), adjusted for baseline differences Main outcome measures Access: waiting time, gestation Effectiveness: successful medical abortion Safety: significant adverse events; ectopic pregnancy and late gestation Acceptability: Patient-reported outcomes Results 52,142 medical abortions were conducted, 29,984 in the telemedicine-hybrid cohort and 22,158 in the traditional cohort. Mean waiting times were 4.2 days shorter in the telemedicine-hybrid cohort and 40% were ≤6 weeks’ gestation vs. 25% in the traditional cohort (p<0.001). There was no difference in success rates (98.8% vs. 98.2%, p=1.0), nor in prevalence of serious adverse events (0.02% vs. 0.04%, p=0.557). Incidence of ectopic pregnancy was equivalent in both cohorts (0.2%, p=0.796); 0.04% of abortions appeared to have been provided after 10 weeks’ gestation with all completed safely at home. In the telemedicine-hybrid cohort, effectiveness was higher in the telemedicine group vs. the in-person group (99.2% vs. 98.1%, p<0.001). Acceptability was high (96% satisfied), 80% reported a future preference for telemedicine, and none reported that they were unable to consult in private using teleconsultation. Conclusions Medical abortion provided through a hybrid model that includes no-test telemedicine without ultrasound is effective, safe, acceptable, and improves access to care. Funding None
Kauri dieback, caused by Phytophthora agathidicida, is an ecosystem disturbance that poses a recent threat to the survival of kauri (Agathis australis) forests in New Zealand. Throughfall and stemflow play an important role in meeting the nutrient requirements of kauri forests. However, the effects of kauri dieback on canopy nutrient deposition remain unknown. Here we measured throughfall, stemflow and forest floor water yield and nutrient concentrations and fluxes (potassium, calcium, magnesium, manganese, silicon, sulphur, sodium, iron) of ten kauri trees differing in soil P. agathidicida DNA concentration and health status. We did not observe an effect of soil P. agathidicida DNA concentration on throughfall and stemflow water yield. Throughfall and forest floor nutrient concentrations and fluxes tended to decrease (up to 50%) with increasing soil P. agathidicida DNA concentration. Significant effects were found for potassium and manganese fluxes in throughfall, and calcium and silicon fluxes in forest floor leachate. The decline in nutrient input will have implications on plant nutrition, tree health and susceptibility to future pathogen infection in these ecologically unique kauri forests. Given our findings and the increasing spread of Phytophthora species worldwide, research on the underlying physiological mechanisms linking dieback and plant-soil nutrient fluxes is critical.
ABSTRACT Objective: We aimed to investigate the prognostic significance of intraductal carcinoma in radical prostatectomy (RP) specimens and predictive value of IDC-P for biochemical recurrence and adjuvant therapy decision. Method: Patients who underwent RP between 2000-2014 with final pathological stage pT3a and negative surgical margins (Group 1, n=35) and pT2 with positive surgical margins (Group 2, n=32) were included. RP specimens were re-evaluated for the presence of IDC-P component and other prognostic factors. In both groups, prognostic factors were compared according to the presence of IDC-P and biochemical recurrence status. Results: In group 1, IDC-P was detected in 5 cases and biochemical recurrence was detected in 3 cases. Patients with IDC-P showed significantly higher biochemical recurrence than those without IDC-P (p=0.002). In univariate analysis, IDC-P was found to be significantly associated with worse progression free survival (p<0.001). In group 2, IDC-P was detected in 4 cases and biochemical recurrence was detected in 10 cases. Also, tumor volume was significantly higher in patients with IDC-P than those without IDC-P (p=0.02). IDC-P was also significantly associated with worse progression free survival in group 2 (p=0.033). Conclusions: In both groups, IDC-P is a prognostic factor for progression free survival and / or biochemical recurrence. Especially in these patients, presence of IDC-P might be helpful for postoperative adjuvant therapy management decision. Keywords: radical prostatectomy, intraductal carcinoma of prostate (IDC-P), prostate cancer, biochemical recurrence, progression free survival.