Idiopathic Right Ventricular Arrhythmias With Changes in the QRS Morphology After AblationMohamad N. El Moheb MD1, Marwan M. Refaat MD21Division of Trauma Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA2Division of Cardiology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon.Running Title: Idiopathic RV Arrhythmias With QRS Morphology Changes After AblationWords (excluding references): 694Disclosures: NoneFunding: NoneKeywords: Heart Diseases, Outflow Tract, Catheter Ablation, Cardiac Arrhythmias, Cardiovascular DiseasesCorrespondence:Marwan M. Refaat, MD, FACC, FAHA, FHRS, FASE, FESC, FACP, FRCPAssociate Professor of MedicineDirector, Cardiovascular Fellowship ProgramDepartment of Internal Medicine, Cardiovascular Medicine/Cardiac ElectrophysiologyDepartment of Biochemistry and Molecular GeneticsAmerican University of Beirut Faculty of Medicine and Medical CenterPO Box 11-0236, Riad El-Solh 1107 2020- Beirut, LebanonClinic: +961-1-350000/+961-1-374374 Extension 5800Office: +961-1-350000/+961-1-374374 Extension 5353 or Extension 5366 (Direct)Email: firstname.lastname@example.org
Non-invasive assessment of Durability of Ablation Lesions with Magnetic Resonance Imaging: are we there yet?Dhiraj Gupta, MDInstitute of Cardiovascular Medicine and Science, Department of Cardiology, Liverpool Heart and Chest Hospital, UKCorrespondence:Professor Dhiraj GuptaProfessor of Cardiac Electrophysiology / Consultant Cardiologist & ElectrophysiologistDepartment of Cardiology,Liverpool Heart and Chest Hospital,Liverpool, L14 3PE, U.K.Tel: +44(0)1516001616Fax: +44(0)151Email: email@example.comWord Count: 951Conflicts of Interest: DG has received research funding from Biosense Webster, Boston Scientific and Medtronic.Pulmonary Vein Isolation (PVI) remains the cornerstone for catheter ablation for atrial fibrillation (AF). Achieving durable PVI safely with Radiofrequency Catheter Ablation (RFCA) has proven challenging until recently, even with the use of Contact Force (CF) sensing catheters and electroanatomical mapping1. Ablation success rates improve markedly, including in persistent AF, when permanent PVI can be achieved1,2, which only underscores the critical role of the Pulmonary Veins (PV) in AF arrhythmogenesis.Historically, the only way to assess PVI durability has been through invasive electrophysiology study, with all its associated risk, inconvenience, and costs. This price appears particularly galling to pay if the PVs are found to be isolated at repeat study, as is now becoming increasingly common3. Multiple randomised studies have failed to show additional benefit from ablating extra-PV structures4,5, and the best outcomes following repeat AF ablation procedures are restricted to those where PV reconnection is identified and treated6. As such, there remains a pressing need for a non-invasive tool that can accurately assess PVI durability, and ideally, the size and location of residual gaps. As Magnetic Resonance Imaging (MRI) has increasingly been shown capable of delineating atrial scar, there is much anticipation that it may serve this important purpose7.RFCA and Cryoballoon ablation (CBA) are by far the most common modalities used for PVI, and there is remarkable equivalence in their clinical results8. However, the handling of the two technologies in the catheter laboratory is very different, and ultrahigh density mapping has shown important differences in the number and location of chronic gaps between the two9. The use of MRI in characterizing these differences has not been well described so far.In this issue of the journal, Kurose and colleagues present a small but elegant study10, in which 30 consecutive patients who underwent PVI (18 with CBA, 12 with RFCA) were assessed by LGE-MRI two months later, where lesion width and visual gap(s) around each vein were assessed. The RF applications were delivered using a CF sensing catheter, with a target lesion size index (LSI) of 5, and an inter-lesion distance of <6mm. They found that the mean lesion width on MRI was significantly wider in the CBA group (8.1±2.2 mm) as compared to the RFCA group (6.3±2.2 mm), p=0.032. However, there were more visual gaps seen in the CBA group, especially in the bottom segments of the two inferior veins. In the RFCA group, gaps were seen most often seen in the left posterior segments where the target LSI value could not be achieved because of esopheageal temperature rise. Furthermore, the number of gaps visualised on MRI was linked to freedom from AF at 12 months; receiver operating characteristic curve analysis suggested a cut off value of less than 5 visual gaps per patient as being predictive of a good outcome.The authors deserve to be congratulated for their study, which builds on their previous work where LGE-MRI was used to compare chronic lesions between CBA and RFCA with non-CF sensing catheters11. It is notable that whilst the lesion width in their previous study was also significantly greater in the CBA group than the RFCA group, the mean number of gaps in the RFCA group was higher. This suggests that the modern technique of delivering LSI-guided contiguous RFCA lesions has resulted in a material improvement in PVI durability, something that is borne out in clinical studies too3.Some limitations of the work should be mentioned. Patients were not randomised to RFCA or CBA; rather, patients undergoing CBA were pre-selected with those with left common PV or large PVs excluded. The ablation technique used for CBA was unusual in that the use of RFCA was allowed if PVI could not be achieved after a single 3-minute freeze. This low bar for defining CBA failure led to as many as 3 patients out of 25 being excluded from the study. Many readers will feel that the mean procedural times of 129 minutes and fluoroscopy times of 39 minutes for CBA are much longer than what is the norm today. They may also find the RF powers used in this study unusual; only 30W was used on the anterior wall, and 20-25W on the posterior wall, which was reduced even further if esophageal temperature rise was observed. The field is moving towards using higher power short duration (HPSD) RF applications, and as HPSD lesions have been shown to be wider12, it is possible that the gaps on the posterior wall identified in this study may not have been present had HPSD applications been used. Finally, the definition of visual gap on MRI used in this study, a non-LGE site larger than 4 mm, almost certainly overestimated the number of true gaps. For instance, the authors observed at least one visual gap in each of the 16 segments around the PVs in more than 10% CB patients; this is at odds with data obtained with ultrahigh density mapping9, and also with the good clinical outcomes reported here. Future research should look at correlating these MRI-visualised gaps with actual gaps seen on repeat electrophysiological study, so that the clinical significance of these can be better defined.What can we take away from this study? Firstly, the use of MRI to assess post-ablation scar is now a reality in many labs, allowing assessment of PVI durability to help decide whether or not to offer a repeat procedure to a patient with AF recurrence. Secondly, the evolution of the RFCA technique to include target lesion indices and inter-lesion distance has made RFCA at least as effective as CBA in achieving durable PVI. Finally, this is an area ripe for further research, and we look forward to similarly valuable contributions from Kurose and colleagues in the future.
The prevalence, heterogeneity and severity of type 2 inflammatory diseases, including asthma and atopic dermatitis, continue to rise, especially in children and adolescents. Type 2 inflammation is mediated by both the innate and adaptive immune cells and sustained by a specific subset of cytokines, such as interleukin(IL)‐4, IL‐5,IL‐13, and IgE. IL-4 and IL-13 are considered signature type 2 cytokines, as they both have a pivotal role in many of the pathobiological changes featured in asthma and atopic dermatitis. Several biologics targeting IL-4, IL-5, and IL-13, as well as IgE, have been proposed to treat severe allergic disease in the pediatric population with promising results. A better definition of type 2 inflammatory pathways is essential to implement targeted therapeutic strategies.
Dear Dr Harky et. al,We appreciate your inquiry regarding our case report. Dr Harky et. al suggested that TEVAR for a Marfan patient could be an unnecessary approach even during the COVID-19 pandemic.We believe in this particular case, the endovascular approach was fully justified as the patient had clear signs of end organ ischemia at presentation. He presented with extreme right leg ischemia with diffuse numbness. There was no detectable distal arterial flow of the right extremity by a Doppler and physical evaluation. Contrast computed tomography scan showed a completely occluded right common iliac artery and diminished flow to the right renal and celiac arteries due to the compression of the true lumen from the false lumen. Preoperative creatinine was elevated to 1.2 mg/dl. She was also suffering ongoing right kidney malperfusion.It was during the time when COVID-19 epidemic started spreading rapidly in New York City. Our hospital beds were filled with COVID-19 patients and there was a shortage of medical supplies with no ventilators immediately available. It was important to reduce exposure of the individual to the hospital environment and minimize length of stay and ventilator needs. As such, we chose to proceed with TEVAR to minimize the risk of lung injury which can occur in open repair. Postoperative respiratory failure is a major issue in open thoracic aortic repair . The patient did not have a risk of respiratory comorbidities but we believed that this pandemic placed all patients at risk for contracting COVID-19 and subsequent acute respiratory distress .Due to the high risk of spinal cord ischemia in this particular patient, we performed TEVAR with a distal bare metal component to preserve the blood flow into spinal cord arteries . The initial clinical treatment plan was to perform the TEVAR as a bridge to open repair. We obviously will need to follow-up with her carefully and if any signs of failure of TEVAR is detected, open repair will ultimately be required.Dr Harky et. al suggested axillary femoral artery bypass to rescue the ischemic leg, however, this patient also suffered malperfsuion of the renal and celiac arteries, so further intervention was required.Thank you for your insightful suggestions.References1) Khan FM, Naik A, Hameed I, et al. Open repair of descending thoracic and thoracoabdominal aortic aneurysms: a meta-analysis. Ann Thorac Surg . 2020;S0003-4975(20)30865-1.2) Bai Y, Yao L, Wei T, et al. Presumed Asymptomatic Carrier Transmission of COVID-19. JAMA. 2020;323:1406–7.3) Lombardi JV, Cambria RP, Nienaber CA, et al. Five-year results from the study of Thoracic Aortic Type B Dissection Using Endoluminal Repair (STABLE I) study of endovascular treatment of complicated type B aortic dissection using a composite device design. J Vasc Surg. 2019; 70:1072-81.
Sir, We read with interests the article by Kate F Walker and colleagues, entitled ”Maternal transmission of SARS-COV-2 to the neonate, and possible routes for such transmission: A systematic review and critical analysis”. In the article, the authors systematically analyzed the mode of delivery on the infection rates of COVID-19 in the newborn. Despite the limitations, especially the retrospective nature of studies examined, this study provided important information about the selection of mode of delivery of women with COVID-19. It suggests that neonatal infection rates are not different after Caesarean birth or vaginal delivery. However, the severity of the COVID-19 infection of the mothers was not considered. Clinically, pregnant women with the more severe COVID-19 infection appear to prefer delivery by Caesarean delivery rather than vaginal birth. Therefore, it is possible that any beneficial effects of Caesarean birth in reducing transmission of COVID-19 might not be apparent because the severity of COVID-19 infection was greater in these women. This selective bias would weaken the conclusions of current studies. We feel that prospective evaluation the safety of mode of delivery with COVID-19 is required.Rui-hong Xue11Department of Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
Background The International Soft Tissue Sarcoma Consortium (INSTRuCT) was founded as an international collaboration between different pediatric soft tissue sarcoma cooperative groups (COG, EpSSG, CWS). Besides other tasks, a major goal of the INSTRuCT is to develop consensus expert opinions for best clinical treatment. This consensus paper for patients with rhabdomyosarcoma of the female genital tract (FGU-RMS) provides treatment recommendations for local treatment, long term follow up and fertility preservation. Methods Review of the current literature was combined with recommendations of the treatment protocols of the appropriate clinical trials. Additionally, opinions of international FGU-RMS experts were incorporated into recommendations. Results The prognosis of FGU-RMS is favorable with an excellent response to chemotherapy. Initial complete surgical resection is not indicated, but diagnosis should be established properly. In patients with tumors localized at the vagina or cervix demonstrating incomplete response after induction chemotherapy, local radiotherapy (brachytherapy) should be carried out. In patients with persistent tumors at the corpus uteri, hysterectomy should be performed. Fertility preservation should be considered in all patients. Conclusion For the first time, an international consensus for the treatment of FGU-RMS patients could be achieved, which will help to harmonize the treatment in different study groups.
DNA barcoding based on mitochondrial (mt) nucleotide sequences is an enigma. Neutral models of mt evolution predict DNA barcoding cannot work for recently diverged taxa, and yet, mt DNA barcoding accurately delimits species for many bilaterian animals. Meanwhile, mt DNA barcoding often fails for plants and fungi. I propose that because mt gene products must cofunction with nuclear gene products, the evolution of mt genomes is best understood with full consideration of the two environments that impose selective pressure on mt genes: the external environment and the internal genomic environment. Moreover, it is critical to fully consider the potential for adaptive evolution of not just protein products of mt genes but also of mt transfer RNAs and mt ribosomal RNAs. The tight linkage of genes on mt genomes that do not engage in recombination could facilitate selective sweeps whenever there is positive selection on any element in the mt genome, leading to the purging of mt genetic diversity within a population and to the rapid fixation of novel mt DNA sequences. Accordingly, the most important factor determining whether or not mt DNA sequences diagnose species boundaries may be the extent to which the mt chromosomes engage in recombination.
1 Division of Pediatric Hematology and Oncology, Department of Pediatrics, Rainbow Babies and Children’s Hospital, Case Western Reserve University, Cleveland, OH.* CorrespondenceJignesh Dalal, Pediatric Hematology Oncology, Rainbow Babies and Children’s Hospital, Case Western Reserve University, 11100 Euclid Avenue, Cleveland OH 44106, Tel: 216 844 3345, Email: Jignesh.firstname.lastname@example.orgText word count: 951Brief running title: Challenges in HLH transplantKey words: primary hemophagocytic lymphohistiocytosis, hematopoietic stem cell transplant, mixed chimerismTables: 1
Anaphylaxis in children is a potential acute life-threatening systemic hypersensitivity reaction. Anaphylaxis fatality rate is estimated to be 0.65% to 2%. Food is the main anaphylaxis trigger in children, notably cow’s milk, peanuts and tree nuts. Mucocutaneous manifestations are observed in more than 90% of cases, but it is not essential for diagnosis. Deaths are rather secondary to the laryngeal edema, observed in 40-50% of cases. Personal history of asthma, allergy to particular foods such as peanuts and tree nuts, and adolescence are known risk factors for anaphylaxis and more severe reactions. Epinephrine (adrenaline) is the medication of choice for the first-aid treatment of anaphylaxis. However, adrenaline auto-injectors (AAIs) are commercially available in only 32% of world countries. There are still considerable unmet needs in the field of anaphylaxis in children. Therefore, the Montpellier WHO Collaborating Centre aims to start the global actions plan applied to anaphylaxis.
The authors of “Outcomes of truncus arteriosus repair and predictors of mortality” carried out a retrospective analysis of more than 3000 infants with truncus arteriosus using the National Inpatient Sample dataset of the Healthcare Cost and Utilization Project database. Logistic regression was used to identify factors associated with in-hospital mortality. The authors also identified a seemingly protective effect of 22q11.2 deletion. But do these findings offer a complete understanding of surgical risk factors for patients with truncus arteriosus?
We are all likely to need a blood test, a biopsy or wind up on the wrong end of an endoscope. We know that the experience is not going to be pleasant. Many of us will revert to techniques to divert attention away from painful stimuli, such as counting forwards or backwards in our heads, deep breathing, imagining tranquil places or listening to music. But the paper published in this issue of BJOG by (Neo D et al, BJOG 2020; xxxx) shows us how we can distract patients in a more sophisticated way, using virtual reality (VR) technology. The procedure the research groups chose to investigate was outpatient hysteroscopy.Outpatient hysteroscopy is a key part of contemporary gynaecological practice. The procedure is acceptable to the vast majority of women, but most will experience some pain and, in a small proportion of women, this can be severe (Smith P, et al, BJOG 2019;126:891-899). Thus, outpatient hysteroscopy, being common and potentially painful, is a good health technology to evaluate the impact of VR technology on patient experienceDeo N et al, conducted a randomised trial of 40 women undergoing outpatient hysteroscopy for a variety of indications and simple therapeutic procedures were allowed such as biopsy, polypectomy and insertion of a Mirena® device. Women were allocated to standard care or “immersive and interactive video content using a portable, standalone VR headset”. The latter delivered a “guided relaxation experience” which included viewing an 8-minute, narrated video depicting “a calming rainforest and lake setting with animated wildlife, which could be explored by using the “head-tracker”.The preliminary results are impressive. Reduction in peri-procedural pain was statistically significant but more importantly the effect size of a 2cm (20%) difference on a 10cm visual analogue scale must be clinically significant. Reduction in anxiety scores were of a similar magnitude. However, the average hysteroscopy procedure duration was less than 4 minutes, which begs the question, is the cost, time and hassle of setting up and using VR technology worth it? Moreover, 16% of eligible women did not want to use the VR technology because of prior adverse experiences, anxiety or state a preference to see the procedure or use their own distraction media.No-one is going to change clinical practice on a sample of 40, but many practitioners will be energised to conduct larger scale trials to confirm these provisional results and to analyse more deeply the impact of immersive VR technology on reducing pain and anxiety associated with outpatient hysteroscopy. Future work should look at the type of VR technology, the context where it is deployed for what kind of procedure. The optimal VR programme may vary according to patient characteristics, the type of surgery and its duration. VR technology should be tested in more painful gynaecological interventions such as endometrial ablation, cervical biopsy and transvaginal egg collection. Moreover, the prospective benefit of VR need not be restricted to gynaecological practice but should be evaluated in a whole host of ambulatory procedures involving conscious patients.No disclosures: A completed disclosure of interest form is available to view online as supporting information.
Global estimates for 2017 indicated that there were 295,000 maternal deaths, 35 per cent lower than in 2000 with a decline in global maternal mortality ratio from 342 to 211 deaths per 100,000 live births (World Health Organization (WHO) 2019). Maternal hemorrhage is the leading direct cause of maternal death worldwide, representing 27% (20-36) of maternal deaths ( Say L, et al. Lancet 2014).Multiple large retrospective population cohorts have identified risk factors invariably associated with maternal hemorrhage including mode of delivery, prolonged labor, chorioamnionitis, and twins among others (Briley A, et al. BJOG 2014). Factors such as maternal BMI, race or ethnicity, pregnancy induced hypertension, and maternal age have not been consistently associated with increased PPH and require more research, especially given the relationship between maternal obesity, gestational diabetes, pregnancy induced hypertension and PPH.Over 80% of cases of primary PPH are preventable and are due to uterine atony. Active management of the third stage is the gold standard for prevention of PPH. Among women at low risk it is not clear whether active management provides benefit, as with women at mixed risk or at high risk for PPH (RR 0.34, 0.14-0.87) (Begley CM, et.al. Cochrane 2019). The WHO has published evidence-based recommendations for management of PPH and have included use of an effective uterotonic with oxytocin being the preferred agent with alternatives used in specific circumstances when oxytocin is not available (Who, 2018). Most recently, use of tranexamic acid has been introduced for prevention and treatment of PPH with a potential to reduce risk of severe PPH by 50% and maternal death by 20%. (Shakir H, et. al. Lancet 2017). These evidence based interventions have been endorsed by professional organizations and the WHO, and have contributed to a progressive decrease in maternal mortality secondary to hemorrhage.Assessment of risk for hemorrhage incorporates risk factors and appropriate protocols according to risk, implementing preventive measures on an individualized basis. It has been demonstrated that successful implementation requires more than identifying risk factors and their interdependence. Attention to organizational context, involvement of entire health care team, and increased recognition of the role of organizational leadership have been identified as basic components (Main EK, et al. AJOG 2017).In this issue of BJOG, Neary et. al. (BJOG 2020 xxxx) address the important aspect of quality and clinical applicability of risk assessment tools using a structured review that included systematic assessment for bias, sample size and both internal and external validation following a standardized methodology established by PRISMA and CHARMS. The authors concluded that current risk assessment protocols have deficiencies related to general obstetrical applicability and lack of external validation. They recommend development of more broadly applicable and appropriately validated risk assessment protocols that would applicable to the general obstetrical population.Evidenced based risk assessment and corresponding protocols during the antepartum, intrapartum and most importantly immediately after delivery, has the potential of contributing to the prevention of over 80% of maternal deaths attributable to maternal hemorrhage.No disclosures: A completed disclosure of interest form is available to view online as supporting information.
The challenge of multiple paediatric febrile neutropenia clinical decision rules has been well described, and the difficulties with ever-expanding variants based on individual datasets discussed extensively.1 The re-calibration of the SPOG rule undertaken by Haeusler and colleagues2 (creating the ‘AUS’ rule) for a practical, bedside tool which would be able to risk stratify episodes of FN. This letter reports a further validation in a meta-analytic dataset from the ‘Predicting Infectious Complications in Children with Cancer’ (PICNICC) collaboration.Briefly, the PICNICC collaboration was formed to develop a robust prediction rule for febrile neutropenia, with methods and materials detailed in previous publications.1,3 Over 8000 episodes of 33 different candidate predictor variables and seven clinically relevant outcomes have been collated from 26 study groups, with varied completeness. The ‘AUS’ rule uses three equally weighted factors to scale the risk of complications in an episode of FN, summed between 0 and 3.These factors are: preceding chemotherapy more intensive than acute lymphoblastic leukaemia maintenance, platelet count less than 50 g/L, total white cell count lower than 300 cells/mm3. The clinical response can be scaled according to this score, with values of 0 and 1 considered as ‘lower risk’.We evaluated the association between the AUS rule and bacterial infection using these data, reporting the discrimination (Area Under the receiver-operator Curve, AUC) and proportion of episodes classed as lower risk (scoring 0 or 1). Analyses were undertaken using R (v3.2.0).1520 episodes contributed to the analysis, with 301 episodes of documented bacterial infection. The discriminatory ability appeared very similar to Haeusler’s values; AUC 0.64 (95% CI 0.61 to 0.68) compared with the original AUC 0.67 (95% CI 0.63 to 0.71). Using the AUS rule on the PICNICC dataset would have identified 44% (668/1520) of the population as a lower risk group (score 1 or 0).This reassuring data has led to the introduction of an AUS rule based system to shorten the duration of antibiotic therapy, in concordance with UK National and International guidelines[3,4]. This now-validated rule will reduce hospitalisation for febrile neutropenic episodes in the UK, which was of particular importance during the 2020 SARS-CoV-2 coronavirus pandemic.
Phenotypic variation among individuals and species is a fundamental principle of natural selection. In this review, we focus on numerous experiments involving the model species Daphnia (Crustacea) and categorize the factors, especially secondary ones, affecting intraspecific variations in inducible defense. Primary factors, such as predator type and density, determine the degree to which inducible defense expresses and increases or decreases. Secondary factors, on the other hand, act together with primary factors to inducible defense, or without primary factors on inducible defense. The secondary factors increase intra-species variation in inducible defense, and thus the level of adaptation of organisms varies within species. Future research will explore the potential for new secondary factors, as well as the relative importance between factors needs to be clarified.
It is known that LIMA-to-LAD is the major determinant of the patient’s prognosis and long term survival for a large percentage of the population with coronary artery disease Off pump, minimally invasive LIMA-to-LAD provides excellent long-term results ). As Awad et al state, this pandemic has disrupted and challenged delivery of health care services worldwide ). LIMA-to-LAD can be performed with minimal resources in an isolated area from COVID-19 facilities within the hospital.Hybrid treatment of coronary heart disease is another option for patients under these circumstances . Surgeons must take the lead and play an active role in the decision process. . As the authors conclude, given fluidity of the current situation, there is need for new processes and clinical decision – making that will allow patients to receive appropriate treatment,
The COVID-19 has posed a wide range of urgent questions: about the disease, testing, immunity, treatments, and outcomes. Extreme situations, such as pandemics, call for exceptional measures. However, this threatens the production and application of evidence. This paper directs evidence production towards four types of uncertainty in order to address the challenges of the pandemic: Risk, Fundamental uncertainty, Ignorance, and Ambiguity. Eliminating ambiguity, being alert to the unknown, and gathering data to estimate risks are crucial to preserve evidence and save lives. Hence, in order to avoid fake facts and to provide sustainable solutions we need to pay attention to the various kinds of uncertainty. Producing high quality evidence is the solution, not the problem.
Sir ,We read with great interest the study by Zhou et al.1, where the authors demonstrated a significant association between preconception paternal smoking and birth defects in the offspring. The study is timely given the increasing recognition of the role that paternal factors play in pregnancy outcomes. The authors must be congratulated on performing a large scale, nationwide study, in which a potential link between preconception paternal smoking and birth defects in offspring was made.A salient point discussed by Zhou and colleagues is the difficulty in estimating the effect of paternal smoking as an independent variable on the risk of birth defects due to a myriad of confounding factors. Although the authors had adequately adjusted for maternal biological, environmental and behavioural factors, as well as paternal alcohol consumption, it may be prudent to note that paternal age could be a potentially significant confounder in this relationship.Advanced paternal age has shown robust links with increases in sperm DNA fragmentation.2 DNA damage is attributed to environmental, hormonal and degenerative changes.2Over time, multiple cycles of mitotic replications generate greater stress on the DNA repair mechanisms.2 The failure to control the DNA repair mechanisms invariably amounts to ejaculated spermatozoa containing a higher proportion of abnormal paternal DNA.2 In the same vein, children born to fathers of advanced age are at a slightly increased risk of birth defects including cardiac, respiratory, gastrointestinal tract and musculoskeletal abnormalities.3 It has been speculated that mutations accumulate over repeated spermatogenesis, subsequently increasing the number of birth defects in the offspring.3 At the opposite end of the age spectrum, young paternal age has also been associated with a slight increased risk of selected birth defects.3At large, prenatal smoke exposure has unfavourable effects on pregnancies. Effects of maternal smoking has been comprehensively studied and is associated with fetal and developmental conditions. Harmful substances in tobacco smoke such as nicotine, carbon monoxide and polycyclic aromatic hydrocarbons are able to cross the placenta and negatively affect the fetal development.4 On the other hand, the extent of paternal smoking has not been well-established. Exposure to cigarette smoke has been found to affect sperm parameters, as well as increase sperm chromatin structural abnormalities and DNA damage.5 Infant low birth weight, increased obesity risk in childhood and high blood pressure have been identified as potential complications of paternal smoking.4 This study provides new evidence that birth defects are also complications of paternal smoking.In conclusion, Zhou et al. have accomplished a tremendous job of investigating the effects of paternal smoking on birth defects. The current study has laid the groundwork for future research to be built upon and to elucidate the true effects of paternal smoking during pregnancy. As exposure to first or second-hand smoke poses a major risk to pregnancies, it might be worthwhile to recommend smoking cessation in both parents during preconception counselling.Jania J. Y. Wu1, Kyla Ng Yin2, Keng Siang Lee3, John J. Y. Zhang11Yong Loo Lin School of Medicine, National University of Singapore, Singapore2Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK3Bristol Medical School, Faculty of Health Sciences, University of Bristol, Bristol, UK
ABSTRACT Background: COVID-19 was declared a pandemic by the World Health Organization (WHO) on March 11st, 2020. Responses to this crisis integrated resource allocation for the increased amount of infected patients, while maintaining an adequate response to other severe and life-threatening diseases. Though cardiothoracic patients are at high risk for Covid-19 severe illness, postponing surgeries would translate in increased mortality and morbidity. We reviewed our practice during the initial time of pandemic, with emphasis on safety protocols. Methods: From March 11st to May 15th 2020, 148 patients underwent surgery at the Department of Cardiothoracic Surgery of CHUSJ. The clinical characteristics of the patients were retrospectively registered, along with novel containment and infection prevention measures targeting the new Corona Virus. Results: The majority of adult cardiac patients were operated on an urgent basis. Hospital mortality was 1.9% (n = 2 patients). Most of adult thoracic patients were admitted from home, with a diagnosis of neoplasic disease in 60% patients. Hospital mortality was 3.3% (1). Fifteen children underwent cardiothoracic surgery. There was no mortality. The infection prevention procedures applied, totally excluded the transmission of Covid-19 in the Department. Conclusion: While guaranteeing a prompt response to emergent, urgent and high priority cases, novel safety measures in individual protection, patients circuits and pre-operative diagnose of symptomatic and asymptomatic infection were adopted. The surgical results corroborate that it was safe to undergo cardiothoracic surgery during the initial time of Covid-19 pandemic. The new policies will be maintained while the virus stays in the community.