Objective: Valve-sparing root replacement is commonly used for management of aortic root aneurysms in elective setting, but its technical complexity hinders its broader adoption for acute Type-A Aortic Dissection (ATAAD). The Florida Sleeve (FS) procedure is a simplified form of valve sparing aortic root reconstruction that does not require coronary reimplantation. Here, we present our outcomes of the Florida Sleeve (FS) repair in patients with dilated roots in the setting of an ATAAD. Methods: We retrospectively reviewed 24 consecutive patients (2002-2018) treated with FS procedure for ATAAD. Demographic, operative, and postoperative outcomes were queried from our institutional database. Long term follow-up was obtained from clinic visits for local patients, and with telephone and telehealth measures otherwise. Results: Mean age was 49 ± 14 years with 19 (79%) males. Marfan syndrome was present in 4 (16.7%) patients and 14 (58.3) had ≥2+ aortic insufficiency (AI). Nine (37.2%) had preoperative mal-perfusion or shock. The FS was combined with hemi-arch replacement in 15 (62.5%) patients and a zone-2 arch replacement in 9 (37.5%) patients. There were 2 (8.3%) early postoperative mortalities. Median follow-up period was 46 months (range; 0.3-146). The median survival of the entire cohort was 143.4 months. One patient (4.2%) required redo aortic valve replacement for unrelated aortic valve endocarditis at 30 months postoperatively. Conclusion: FS is simplified and reproducible valve-sparing root repair. In appropriate patients, it can be applied safely in acute Stanford type-A aortic dissection with excellent early and long-term results.
Atrial Fibrillation (AF) is the most common arrhythmia affecting the general population, with the prevalence projected to reach 12.1 million cases in 2030. Recently, attention has focused on the role of the Left Atrial Appendage (LAA) and its association with the most feared complication of AF: thromboembolism. Common sense indicates that the LAA should be excluded in all patients with AF; however, procedures to exclude the LAA have yet to become the standard of care. Recent studies in the cardiac surgery literature , , indicate a clear benefit of LAA exclusion amongst patients with AF undergoing cardiac surgery. Interestingly, this benefit was found to extend well beyond the postoperative period, in cohorts that were equally anticoagulated and had similar CHA2DS2-VASC scores. It appears reasonable that our medical community should strongly consider initiating a prospective randomized trial in an effort to fully elucidate the need for routine LAA exclusion in this patient population.
In patients with midventricular obstructive hypertrophic cardiomyopathy (HCM), a transapical approach allows excellent exposure for midventricular myectomy. Although the ventriculotomy is required on the antero-lateral left ventricular wall, the minimal ventriculotomy would be ideal, especially for cases with concomitant apical aneurysm. We report a case of midventricular obstructive HCM with concomitant apical aneurysm. Through the minimal ventriculotomy within the aneurysm, the hypertrophic septum was successfully hollowed out under repeated ultrasound guidance. Intraoperative ultrasound guidance is useful for transapical septal myectomy in midventricular obstructive HCM.
Background: Atrial fibrillation (AF) following cardiac surgery is common and has clinical impact on morbidity. The preoperative and intraoperative risk factors are still not well defined. The objective of the study was to examine preoperative and intraoperative risk factors for AF following cardiac surgery. Methods: A retrospective analysis of a database of cardiac surgeries was performed during 2017-2019 at Poriya Medical Center. Preoperative factors and intraoperative were recorded. Results: 208 patients were included in this analysis. Overall AF following cardiac surgery was detected in 50 (24%) patients. Of 175 patients who did not have history of AF prior to surgery, 27 (15.5%) had post-operative AF. In the 33 patients with previous AF, AF following surgery was detected in 23 (70%). Patients with AF following surgery who were older (66.2±8.0 vs. 60.7± 11.4 years, p=0.002), were treated more with anti-arrhythmic drugs (18.9% vs 4.5, p<0.001), and had higher rates of pre-operative AF (46% vs 6.3%, p=0.0001), prior cerebral vascular accidents (14% vs 4.4%, p=0.019), and prior valve replacement (10% vs 1.9%, p=0.009) compared to patients without AF following surgery. In multivariate Cox regression analysis, age (HR 1.04, CI 1.01-1.07, P=0.006) and history of preoperative AF (HR 6.01, CI 3.42-10.57, P<0.001) were predictors of AF following cardiac surgery. The probability of being free of postsurgical AF was 80% among patients without history of AF compared to 30% in patients with previous AF history (p<0.001). Conclusion: Preoperative AF and age were predictors of AF following cardiac surgery
A novel over-the-peritoneum aorta clamp enabled a senior obstetrician, backed by a urologist, to manage 33 women with histopathology-confirmed Placenta Accreta spectrum, with no maternal mortality, relatively low incidence of blood transfusion and urological injuries in a limited resource setting. Easily applied by the obstetricians themselves, this clamp can be an effective and relatively safer alternative to intra-aortic balloon occlusion and aortic-cross clamping. We anticipate, obstetricians in low-resource settings can easily adapt our methods and contribute further prospective evidence.
Objectives. To investigate the obstetrical management of cancer in pregnancy and to determine adverse pregnancy and neonatal outcomes. Design. A register-based nationwide historical prospective cohort study. Setting and population. We assessed all pregnancies (N = 4,071,848) in Denmark from 1 January 1973 to 31 December 2018. Methods. We linked data on maternal cancer, obstetrical, and neonatal outcomes. Exposure was defined as pregnancies exposed to maternal cancer (n = 1,068). The control group comprised pregnancies without cancer. The groups were compared using logistic regression analysis and adjusted for potential confounders. Main outcome Measures. The primary outcome was the iatrogenic termination of the pregnancy (induced abortions/labor induction or elective caesarean section). Secondary outcomes were adverse neonatal outcomes. Results. More women with cancer in pregnancy, as compared to the control group, experienced first-trimester induced abortion; adjusted odds ratio (aOR) 3.7 (95% CI 2.8─4.7), second-trimester abortion; aOR 9.0 (6.4─12.6), iatrogenic preterm delivery; aOR 10.9 (8.1─14.7), and iatrogenic delivery below 32 gestational weeks; aOR 16.5 (8.5─32.2). Neonates born to mothers with cancer in pregnancy had a higher risk of respiratory distress syndrome; aOR 1.5 (1.2─2.0), but not of low birth weight; aOR 0.6 (0.4─0.8), admission to neonatal intensive care unit more than seven days; aOR 1.4 (1.1─1.9), neonatal infection; aOR 0.9 (0.5─1.5) nor neonatal mortality; aOR1.3 (0.6─2.6). Conclusion. Cancer in pregnancy implies an increased risk of iatrogenic termination of pregnancy and iatrogenic premature birth. Neonates born to mothers with cancer in pregnancy had no increased risk of severe adverse neonatal outcomes.
Background: Polycystic ovary syndrome (PCOS) is an endocrine condition associated with sub-fertility, infertility and poor reproductive outcomes. Objectives: To review the effectiveness of different pharmacological interventions on fertility outcomes in women with PCOS. Search Strategy: We searched PubMed, MEDLINE, Scopus, Embase, Cochrane Library, Web of Science in April 2020 and updated the search in PubMed March 2021. Selection Criteria: Two independent reviewers selected studies, and only randomised controlled trials (RCTs) were included. Data Collection and Analysis: Thirty-four RCTs that met the eligibility criteria were used to calculate odds ratios (OR) and the 95% confidence interval (95% CI) using the random effect model. Main Results: There was a significant increase in pregnancy rate with follicular stimulating hormone (FSH) vs clomiphene citrate (CC)+ metformin (Odd Ratio(OR):4.08; 95%CI:1.12-14.83,I²=79%), Letrozole vs CC (OR: 1.58; 95%CI: 1.34-1.86, I²= 0%), metformin vs placebo(OR: 3.00; 95%CI: 1.95-4.59, I²= 0%) and with CC+ metformin vs CC (OR: 1.48; 95%CI: 1.02-2.16, I²= 39%). There were significant increases in ovulation rate with CC+ metformin vs FSH (OR: 0.09; 95%CI: 0.02-0.37, I² = 75%), CC+ metformin vs CC (OR: 2.04; 95%CI: 1.35-3.08, I² = 63%) and with Letrozole vs CC (OR: 1.60; 95%CI: 1.02-2.52, I²= 88%). A significant increase in live birth with Letrozole vs CC (OR: 1.63; 95%CI: 1.21-2.21, I² = 0%) was observed. Conclusions: CC, letrozole alone or either added to metformin, were associated with a significant increase in the pregnancy rate, ovulation rate, and live birth rate in women with PCOS. Funding: No fund for the review.
Objective: To study the impact of absolute uterine factor infertility (AUFI) and uterus transplantation (UTx) on women, and UTx recipients’ perceptions of Utx and reproductive autonomy Design: Convergent mixed-methods study. Setting: UTx program in a large academic medical centre in the United States. Population/Sample: 20 Utx recipients Methods: A medical chart review was conducted to collect patient demographic information, and clinical outcomes. Semi-structured interviews collected information regarding participants’ experience. Main Outcome Measure(s): The outcomes of interest were participants’ experience of infertility, experience with UTx, and general perceptions of UTx. Results: 7 participants were pregnant (one with a second child), 6 had experienced early graft failure and removal, 5 had delivered a healthy baby, and 4 had a viable graft and were awaiting embryo transfer. The primary themes identified were: the negative impact of AUFI diagnosis on psychological wellbeing, relationships, and female identity; the positive impact of UTx on healing the emotional scars of AUFI, female identity, and value of research trial participation; and the perception of UTx as an expansion of reproductive autonomy. All participants reported Utx was worthwhile, regardless of individual outcome. On bivariate analysis, disease aetiology, having a child after uterus transplantation, experiencing graft failure and current pregnancy were not significantly associated with the impact of AUFI or of UTx on participants’ identities. Conclusion: AUFI has a negative impact on women from a young age, affects multiple relationships, and challenges female identity. UTx helps reverse this impact, transforming women’s life narrative of infertility and enhancing female identity.
Objective: To determine the impact of the COVID-19 pandemic on surgery for severe endometriosis in the UK at a national, regional and centre-level. Design: Population-based national cohort study. Population: All women undergoing endometriosis surgery requiring dissection of the pararectal space in the UK from 2017 to 2020 inclusive. Methods: The British Society for Gynaecological Endoscopy (BSGE) collects data nationally on all operations for severe endometriosis which involve dissection of the pararectal space. Annual audits of this database were obtained from the BSGE. Publicly available data on COVID-19 deaths and population were obtained from the UK Office for National Statistics. Main outcome measures: Numbers of annual BSGE-registered endometriosis operations. Results: A total of 5916 operations were performed. The number of operations decreased by 49.4% overall between 2019 and 2020. The number of endometriosis centres remained the same, however the median number of operations per centre decreased from 21 to 12.5, with a median percentage decrease at each centre of 51.0% (IQR 29.4% – 75.0%). There was no significant change in the type of surgery performed. All 11 administrative regions of Great Britain had reduced numbers of BSGE-registered operations in 2020 compared with the average for 2017-2019, with a median 56.6% decrease (range 6.13% - 68.62%). Regional reduction in operations was significantly correlated with COVID-19 death rates (r=0.557, 95% CI of r 0.048 – 1.00, p=0.037). Conclusions: There has been a dramatic fall in the number of operations for severe endometriosis in Britain during the COVID-19 pandemic.
Objective To investigate the association between the maternal lipid profile in early pregnancy and embryonic growth. Design Prospective population-based cohort study. Setting Rotterdam, the Netherlands. Population We included 1474 women from the Generation R(otterdam) Study. Methods The maternal lipid profile was defined as total cholesterol, triglycerides (TG), high-density lipoprotein cholesterol (HDL-c), low-density lipoprotein cholesterol (LDL-c), remnant cholesterol, non-high-density (non-HDL-c) lipoprotein cholesterol concentrations and the triglycerides/high-density lipoprotein (TG/HDL-c) ratio. Additionally, maternal glucose concentrations were assessed. Associations were studied with linear regression models, adjusted for confounding factors: maternal age, pre-pregnancy BMI, parity, educational level, ethnicity, smoking and folic acid supplement use Main Outcome Measures Crown-rump length (CRL). Results Triglycerides and remnant cholesterol concentrations are positively associated with embryonic growth (fully adjusted models, 0.17 SDS: 95% CI 0.03 ; 0.30, and 0.17 SDS: 95% CI 0.04 ; 0.31, respectively). These associations were not present in women with normal weight (triglycerides and remnant cholesterol: fully adjusted model, 0.44 SDS: 95% CI 0.15 ; 0.72). Associations between maternal lipid concentrations and embryonic growth were not attenuated after adjustment for glucose concentrations. Total cholesterol, HDL-c, LDL-c, non-HDL-c concentrations and the TG/HDL-c ratio were not associated with embryonic growth. Conclusions Higher triglycerides and remnant cholesterol concentrations in early pregnancy are associated with increased embryonic growth, most notably in overweight women. Keywords Pregnancy, Cholesterol, Low-density lipoprotein (LDL-c), High-density lipoprotein (HDL-c), Triglycerides, Intrauterine development, Fetal growth, Early pregnancy Tweetable abstract The maternal lipid profile in pregnancy is associated with embryonic growth.
Background: Recent works imply that immune memory might be expanded to group 2 innate lymphoid cells (ILC2s), but the cellular and molecular bases are largely unknown. Here, we investigated the memory and migrating properties of Lin -KLRG1 +IL-17RB + ILC2s (herein referred as mILC2s) and their contribution to asthma relapse. Methods: Clinical asthmatic subjects and HDM-induced mice asthma models were applied to investigate the memory-like characteristics of mILC2s including greater effector cytokine-producing potential and in vivo persistence. Parabiosis pairs of CD45.1 + and CD45.2 + mice were employed to determine whether mILC2s were circulating cells. Adoptive transplantation was performed to analyze the origin of the mILC2s accumulated in airway upon asthma relapse. CCR9 and S1P signaling blockade were used to confirm the migration of mILC2s during different asthma phases by In vivo imaging. KLRG1 neutralization was utilized to analyze the role of mILC2s in asthma relapse on Rag1 -/- mice. Results: mILC2s persisted in vivo and retained the potency of producing IL-13 and re-inducing allergic responses. Critically, parabiosis study and in vivo imaging showed that the vast majority of mILC2s migrated to and resided in small intestine during asthma remission, and subsequently moved to airway upon re-encountering antigens, regulated by CCR9 and S1P signaling. Blockade of S1P signaling markedly limited secondary exposure-induced airway inflammation. Furthermore, KLRG1 neutralization attenuated asthmatic responses of Rag1 -/- mice, supporting a pivotal role for mILC2s in mediating asthma relapse independent of adaptive immune cells. Conclusion: mILC2s exhibit memory-like and lung-small intestine migratory properties, which empowers them to drive asthma relapse.
A 25-year-old male with Marfan Syndrome and previous aortic root surgery presented with severe chest and upper back pain. Initial CT angiogram showed mild aortic dilatation but no acute dissection. Anti-impulse therapy was initiated. Five days after presentation, follow-up CT angiography revealed a new pseudoaneurysm of the descending thoracic aorta. The patient underwent replacement of the mid-descending thoracic aorta with a collagen-impregnated woven polyester tube graft without complication. Despite negative initial imaging and relatively small aortic size, patients with Marfan Syndrome with acute chest pain should be treated with high suspicion and may benefit from admission and serial imaging.
A 56-year-old female with a history of rheumatic mitral stenosis presented with severe pulmonary edema. Transthoracic echocardiogram demonstrated severe MS (mean valve area .5 cm2, mean gradient of 16 mmHg) with preserved left ventricular ejection fraction. Right heart catheterization demonstrated elevated pulmonary artery (PA) pressures of 110/80 mmHg and a wedge pressure of 40 mmHg. Mechanical circulatory support (MCS) was initiated with extracorporeal left atrial to femoral artery bypass. MCS allowed preoperative unloading of the left atrium. The volume status and lung congestion were optimized before surgery. In addition, pulmonary hypertension reversibility was demonstrated with significantly lower PA pressures after initiation of MCS. Intraoperatively, the MCS left atrial inflow cannula was pulled back into the right heart and used as a venous cannula for cardiopulmonary bypass. Successful mitral valve replacement was performed. Postoperatively, the mitral valve mean gradient was 3 mmHg.
Rivers can act as mirrors to in-catchment processes, but integrated concentration-discharge dynamics might not be sufficient for constructing a well-posed solute travel time determination problem. One remedy is to look inside the catchment and see if the extra information provided by long-term time series of groundwater solutes constrains the problem or provides us with some additional insight on retrieving the processes which the stream is aggregating. To test this notion, we used data for Kerrien, a well-studied agriculture dominated small headwater catchment of the French Critical Zone Observatory in Brittany. It contains long-term nitrate concentration time-series from a network of piezometers as well as a stream outlet. In this study, a parsimonious, conceptual dual-permeability mixing model already developed for streams was adapted for piezometers along with detailed uncertainty and sensitivity analysis. We found out the nitrate flushing times of mid to upslope piezometers were consistently higher than the stream outlet. We further observed an asynchronicity in seasonal concentration-discharge dynamics between the piezometers and the stream. We hypothesize the reason behind this counterintuitive finding to be extensive riparian denitrification, vertical stratification of groundwater and disconnect between the stream and the deeper flowpaths that carry legacy contamination, evidenced by the non-closure of water budget at the stream outlet. As a consequence, we argue that in headwater catchments the stream signature might not fully reflect internal processes which can be revealed only by using piezometer data. This adapted conceptual framework could be of great interest for semi-arid catchments where groundwater monitoring could be used in combination or as an alternate to ephemeral streams in travel time determination.
A 20-year-old girl referred with vision loss upon closantel use. Plasma exchange and high-dose corticosteroid pulse therapy were administered. A 2.5-year follow-up showed improved vision and increased layer thickness of the peripheral nerve fiber. Early treatment with plasma exchange and high-dose corticosteroid therapy can be beneficial to reverse closantel toxicity.
Background: ABVD, the standard-of-care in adult Hodgkin lymphoma (HL), has not been directly compared to ABVE-PC, a pediatric regimen designed to reduce late-effects. We aimed to compare the effectiveness and associated toxicities of these two regimens used in the same institution. Methods: This retrospective cohort study evaluated a total of 224 patients diagnosed with HL between 1999 and 2018 at Children’s Hospital Los Angeles (CHLA), of which 93 patients were eligible having received ABVD (n=46) or ABVE-PC (n=47) chemotherapy as their initial treatment. Descriptive analyses were performed using the Student’s t-test or Fisher’s exact test. Survival analysis used the Kaplan-Meier method. Events included: death, relapse, secondary malignancy, need for radiation therapy, pulmonary toxicity and cardiomyopathy determined by shortening fraction <29%. Analyses followed an intention-to-treat principle. Results: There was no difference in baseline characteristics between the patients receiving ABVE-PC or ABVD in regard for stage, risk group or prognostic variables, such as the presence or absence of “B” symptoms, bulky disease, and extra-nodal involvement. A greater proportion of patients treated with ABVE-PC received consolidating external beam radiation treatment (XRT) either by randomization or by response compared to ABVD (59.6% vs 32.6% respectively, p=0.01). While not statistically significant, response to therapy, assessed by PET/CT where available, mirrored the need for radiation (rapid response 58.3% vs 90.0%, n=34, p=0.11). There was no difference in event-free survival (p=0.63) or overall survival (p=0.37) with a median follow up length of 3.9 years. Conclusion: ABVD and ABVE-PC achieved similar survival outcomes in our single-institution cohort
Background: While rare in children, chylothorax is a significant cause of respiratory morbidity and can lead to malnutrition and immunodeficiency. Historically, the traditional pharmacological treatment has been octreotide. There are several treatments that have been utilized in the past few years including sirolimus, however data regarding their efficacy and outcomes is limited. Furthermore, sirolimus has proven efficacy in complex vascular malformations, and hence, its utility/efficacy in pediatric chylous effusions warrants further investigation. Methods: In this retrospective study at Texas Children’s Hospital, data were extracted for all patients with chylothorax who were treated with sirolimus between 2009 and 2020. Details regarding underlying diagnosis, co-morbidities and number of days from sirolimus initiation to resolution of effusion were collected. Descriptive statistics were used to analyze the study cohort. Results: Initially a total of twelve infants were identified. Among them, seven patients had complete data and were included in the study. The mean duration of sirolimus treatment needed for chest tube removal was 16 days, with a median of 19 days and range of 7- 22 days. Chest tube output corresponded with sirolimus serum trough levels and trended down prior to chest tube removal. Conclusion: With close monitoring, sirolimus is a safe and effective therapy for pediatric lymphatic effusions even in critically-ill infants. The study also demonstrates shorter duration of chest tube requirement after initiation of sirolimus compared to previous studies. Our conclusion is based on a small case series due to the rare incidence of the condition.