Background and aim of the study: Blood cysts of cardiac valves are generally seen in newborns and infants and very rarely in adults. Although in most cases they are incidental findings they may be associated to severe cardiac or systemic complications. This study analyzes incidence, presentation and treatment of valvular blood cysts in adults. Methods: A review of the pertinent literature through a search mainly on PubMed and Medline was performed. Results: In patients ≥ 18 years of age, our search disclosed 54 patients with mitral blood cysts (mean age, 48±18 years), 9 with a tricuspid valve cyst (mean age, 67±15 years), 3 with a blood cyst on the pulmonary valve (age 31, 43 and 44 years) and 1 aortic valve cyst in a 22-year-old man. Most patients were asymptomatic while stroke, syncope or myocardial infarction occurred in 6 patients with a mitral valve cyst. Blood cysts were removed surgically in 70% of patients with a mitral cyst, in 55% with a tricuspid cyst and in all those with a pulmonary or aortic cyst. At histology the cyst wall was composed mainly by fibrous tissue and with the inner surface lined with typical endothelium. Conclusions: Blood cysts of cardiac valves are rare in adults but may cause life-threatening complications particularly when located on the mitral valve. For such reason surgical removal appears advisable, with low-risk procedures. Widespread use of multimodality imaging techniques will most likely increase the number of valvular blood cysts diagnosed also in adults.
Cutaneous Leishmaniasis (CL) is the most prevalent clinical form of leishmaniasis. CL is difficult for the clinicians to diagnose because of the rarity of the disease and non-specific presentation. As CL is rare and given the limitation of available diagnostic modalities in a resource poor setting, diagnosis can be confusing.
Title: Learning the Learning Curve of Robotic Coronary Artery BypassAuthors : Saqib Masroor, MD, MBA1, Abdullah Nasif, MD1 1Division of Cardiothoracic Surgery, Department of Surgery, University of Toledo Medical Center Toledo, OH USAManuscript: The Learning Curve of Robotic Coronary Arterial Bypass Surgery: A Report from The STS DatabaseDisclosure : NoneWord Count : 1229Learning the learning curve of robotically assisted coronary artery bypass grafting is important for the advancement of this technique and the improvement in patient outcomes. There have been many reports of single surgeon learning curves.1, 2 But one can argue that they depict one surgeon’s journey, depicting his or her dedication to the field and making generalization to other surgeons difficult, if not impossible.In this issue of the Journal of Cardiac Surgery, Patrick et al, report on their investigation of the Society of Thoracic Surgeons (STS) database for Robotically Assisted Coronary Artery Bypass (RA-CABG) procedures and the beginner surgeon’s learning curve.3Between 2014 and 2018, a total of 1195 RA-CABGs were performed by 114 surgeons, with 74 surgeons performing <5 procedures and only 9 surgeons performing >25 procedures. The median number of cases performed was 2. The patient population was younger and relatively lower risk. The cases included single-vessel as well as multi-vessel Minimally Invasive Direct Coronary Artery Bypass (MIDCAB) in addition to Totally Endoscopic Coronary Artery Bypass (TECAB) and there is no subgroup analysis reported for the different procedures. The authors conclude that the learning curve for procedural success is overcome by the 10th case, even though the curve for reoperation is still steep by the 25th case. Operative mortality however was similar in the two groups. The authors conclude that surgeon experience is an independent predictor of RA-CABG procedural success and that the learning curve consistently flattens after the surgeon’s 10th case. We agree with the first but not the second conclusion. Here is why!In 2013, Prof Mohr’s group in Leipzig reported on the learning curve of minimally invasive mitral valve surgery at their institution over a 17-year period involving 3895 operations performed by 17 surgeons performing their first minimally invasive procedure, using the sequential probability cumulative sum (CUSUM) statistical technique.4 Learning curves were then determined for total operation times, aortic cross-clamp times, and primary outcomes. The mean number of operations per surgeon was 189. The authors reported a learning curve of between 75-125 procedures, with evidence that surgeons needed to perform more than 1 cases per week to maintain good results. Importantly however, patient mortality was not compromised because of the learning curve.To assess the learning curve involved in performing a task, it is important that both the task and the tools needed for the task remain constant. The above publication fulfills both of these criteria. 82 percent of cases were mitral valve repair and 18 percent were mitral valve replacement. The surgical technique and technology used was nearly identical and robotic mitral valve procedures were excluded. The institution had the same leadership over the period, allowing for a very stable work environment as well as a consistent approach including case selection, operative technique etc. As much as possible, every variable was the same, except the variable under investigation-‘the beginner surgeon’. The same group had reported the learning curve for MIDCAB to be between 50-100 cases for 8 surgeons at their institution.5Now let us analyze the report from Patrick et al.3 In this report, the task is not the same and neither are the tools. Single vessel RA-MIDCAB is a less challenging procedure than multi-vessel RA-MIDCAB, with its associated variety of conduit procedures (such as bilateral Internal Mammary Artery (IMA) grafting, Radial Artery T-grafting from Left Internal Mammary Artery (LIMA) to the lateral wall, or aortocoronary Saphenous Vein bypass procedures). TECAB is a totally different beast altogether. Grouping all of them in one learning curve is not a valid assumption. As far as the tools/technique is concerned, some patients had beating heart surgery while others had arrested heart procedures, exposing the Left Anterior Descending Artery (LAD) in MIDCAB is a different task than exposing the lateral wall targets or the stabilizing the LAD endoscopically. Each one of those steps/techniques have their own learning curves.Another shortcoming of this study is the relatively small experience of most of the surgeons in the study. 74 out of the 114 surgeons in the study had < 5-case experience. Moreover, it is not clear what the experience of the surgeons was before embarking on this technique. In the Leipzig study, surgeons with less than 5 cases were excluded from analysis and the 17 surgeons had an experience of at least 40 mitral valve procedures via sternotomy before using the minimally invasive approach.1Finally, the definition of procedural success can be debated. It was defined as an inverse composite of the three primary outcomes - conversion, re-operation, and major morbidity/mortality. While this “procedural success” composite showed a flattening of the learning curve at 10 cases, the reoperation rate was still improving even after 25 cases. A chain is only as strong as the weakest link. If the reoperation rate is still improving after 25 cases, procedural success cannot be declared to have been mastered at 10 cases. Further analysis of the groups of surgeons with < 10 or > 10 cases reveals the procedural success to be 72.9% and 85.3% respectively. 15% failure of procedural success would not be consistent with overcoming the learning curve. We assume that surgeons must strive to continue improving the procedural success until it reaches well into the 90’s percent rate, which would be required for a successful RA-CABG program.The major advantage of a large clinical database such as the Adult Cardiac Surgery Database (ACSD) is the minimization of bias due to its large number of observations. However, for rare procedures such as RA-CABG, that advantage is lost. In fact, with such a small number of observations over such a diverse set of procedures and institutions, ACSD data is not granular enough to explore an individual surgeon’s learning curve because there is no control for numerous other variables at the departmental and institutional level that are not tracked by ACSD. A high-volume center in a steady-state clinical work environment controls for most variables that influence clinical outcomes. The only variable that changes, is the beginner surgeon, and the data thus obtained is more likely to represent the true “learning curve” of the procedure.It is important to have realistic expectations from new technology. Many beginners would embark on this journey, hoping to master the learning curve in 10 cases. And when that expectation is not fulfilled in real life, they might give up altogether on this very useful approach. The number and frequency of operations are important, not just for the surgeons, but even more so, for the rest of the operating room team including anesthesiologists and patient-side assistants. The whole team can be feel discouraged if they continue to have a learning curve beyond 10 or even 20 cases.In conclusion, querying the Adult Cardiac Surgery Database of STS may not be the best way of learning the learning curve of a rare procedure(s). There is a concern that setting an unrealistically optimistic expectation of 10 operative cases to master the learning curve of RA-CABG may be detrimental to the progress of this approach. A high-volume centers’ experience with multiple beginner surgeons may be a better representative of the learning curve of RA-CABG and that study has not yet been done. But based on the learning curves of other similar procedures and our own experience, it is our opinion that the learning curve of RA-CABG would be somewhere between 50 and 100 cases for MIDCAB and another 50-100 for TECAB.
Changing landscape of complex lead extractions: need for patient tailored use of armamentarium for very old leads Arif Elvan, MD, PhD, FESC, FEHRAIsala Heart Centre, Diagram Research, Zwolle, The NetherlandsFunding: NoneConflict of interest: NoneThe numbers of implanted cardiovascular implantable electronic devices (CIED) and leads increased tremendously in the past decades due to an expansion of indications and progressive ageing of the population. The increased demand for complex transvenous lead extractions (TLE) is mainly related to a higher relative incidence of CIED infections, malfunction of leads and the increased need for upgrading or revision of devices. Moreover, the landscape of lead extraction is changing in time with a relative increase in the proportion of old leads with a dwell time of ≥10 years (1, 2). The growing impact of these complex TLEs on the utilization of the health care system has driven dedicated invasive cardiac electrophysiologists and engineers to improve strategies and tools to enable operators to perform lead extractions in a safe, effective and patient-centered way, minimizing risks of morbidity and mortality. We all know that chronically implanted leads may develop extensive fibrous or calcified adhesions around the surrounding structures and require more complex extraction techniques. Of note, the ageing of leads is associated with decreased procedural and clinical success rates and increased risk of lead extraction related complications (1, 2, 3). Currently, the techniques and armamentarium used in the extraction of leads include traction, counter traction, locking stylets, telescoping sheaths, and powered rotational mechanical and laser sheaths.In this issue of the Journal of Cardiovascular Electrophysiology, Issa (4) investigated success and complication rates of complex TLE of very old leads, defined as leads with a dwelling time of ≥20 years compared with younger leads. The indications for TLE were mainly related to pocket (58.9%) and systemic infections (33.9%), and in a minority of patients TLE was performed for other non-infectious indications. Although clinical success was very high in the current study (97.1%), this high clinical success implicates that small residual parts were regarded as a satisfactory result, while non-extracted remnants can be of clinical importance, especially in patients with lead endocarditis. Therefore, the complete procedural success constitutes an important metric rather than clinical success, particularly in patients with infectious TLE indications, in whom extraction of the whole system without any remnants should be the ultimate procedural endpoint.Furthermore, in the study by Issa (4), patients were treated by a single experienced lead extraction specialist in a high-volume center. The results of this study cannot be extrapolated to less experienced operators or low volume centers. This study underlines the necessity of concentrating lead extractions to high-volume centers to provide the best care for these patients. Some single center series reported very low complication rates, which does not reflect potential complications that might be encountered during a complex lead extraction procedure, especially when performing extraction of very old leads with a dwelling time of ≥20 years. It seems reasonable to advocate that all lead extractions should be reserved to experienced centers with a thoracic surgeon standby during complex lead extraction procedures. It is, to my personal opinion, important to emphasize this issue instead of giving space for low volume centers to perform some of the expected “easy” lead extractions.Moreover, in the study by Issa (4), the laser sheath was the primary extraction tool used in the majority of the ≥20 years old leads and mechanical sheaths or femoral snares were only used after failure of laser sheaths. Complete procedural success was lower in the group of patients with very old leads compared with leads with a dwelling time of less than 20 years (90.7% versus 98.5%). However, angiography of the subclavian vein was not a standard routine procedure in all patients. It seems reasonable to incorporate venous angiography as a standard procedure in the workup for TLE (5). Of note, the complexity of the TLE in the group with leads less than 20 years old was very heterogeneous. It is remarkable that 55% of the leads required complex extraction techniques, whereas 45% of these leads could be extracted with manual traction only in this group of patients with less than 20 years old leads, highlighting the nonbinary nature of the extent of adhesions of aging leads to surrounding structures. Despite advances in lead extraction techniques, extraction of older leads in a safe and effective way remains challenging. Issa (4) demonstrated that complex TLE can be performed successfully and safely by a skilled and experienced operator in a specialized center. The rate of major complications was 5.6% including 1 death. These results are in line with previous publications (5, 6, 7).This latter study (4) underlines the importance of the use of combination of multiple extraction tools in enhancing procedural success rates. Especially in leads with a dwelling time of ≥20 years, there is an increased risk of extraction failure or incomplete success. Issa (4) primarily used laser sheaths while others used the powered mechanical sheath as the primary extraction tool. Several reports describing the results of case series were published on the success and complication rates of lead extractions with the use of mechanical sheaths (5, 6. 7). These studies described the results of case series. Moreover, Migliore et al (7) reported that complex lead extractions using the Evolution RL bidirectional rotational mechanical sheaths and ancillary tools in a systematic stepwise approach were effective and safe.The use of dedicated extraction tools and techniques yielded reported major adverse event rates of 2-3% with a mortality of 1% in previous studies (3, 5, 6, 7). In some previous reports, only powered mechanical sheaths were used with comparable results (5, 6, 7). The currently available armamentarium for complex lead extractions including laser sheaths, powered mechanical rotational sheaths and femoral snares enables operators to tailor the procedure in order to enhance procedural and clinical success rates. However, there is a lack of direct comparative data regarding risks and benefits of laser sheath compared with powered mechanical sheaths and femoral snares.Issa (4) performed analyses of retrospective data which should be regarded as exploratory and hypothesis generating. Nevertheless, this study provides data and conveys messages that are important to the clinical practice. The main finding is that transvenous extraction of leads with a dwelling time ≥20 years is associated with a considerable risk of major complications, even in the hands of an experienced operator and in the setting of a high-volume center. This study highlights the need for concentration of complex lead extractions to a selected number of highly specialized centers.Although, direct comparison of the available strategies and techniques has not been performed yet, these studies need to be performed in the near future. Clinicians need guidance based on firm evidence regarding comparative efficacy or safety of bidirectional powered mechanical sheaths and laser sheaths and femoral snares.There are no randomized trials comparing different extraction strategies. The current recommendations are based on outcome data derived from various case series.Therefore, international collaboration, merging of databases and ultimately randomized trials are crucial to gain more insight and to better delineate the incremental values of the available lead extraction tools and techniques.The innovations in the field of complex TLE techniques and tools will continue. In the meantime, the extraction of chronically implanted leads remains a complex procedure associated with major complications including mortality, mandating concentration to specialized centers and standardized metrics for monitoring procedural and clinical outcomes.
Cow's milk allergy non-responsive to amino acid-based formula must raise suspicion of Immune dysregulation, polyendocrinopathy, enteropathy, X-linked syndrome. This is a potentially fatal disease associated with food allergy, sometimes leading to diagnostic delay. In our case, early diagnosis and management provided life-saving therapy.
An 86-year-old man with end-stage renal disease on hemodialysis with an arteriovenous fistula in his left upper extremity presented to his hemodialysis session with thrombosis of his arteriovenous fistula. The patient underwent surgical thrombectomy. The patient later showed evidence of peripheral embolization and livedo reticularis. Transthoracic and transesophageal echocardiograms revealed a large thrombus (5x2 cm) in the left atrium prolapsing to the right atrium via a patent foramen ovale and another thrombus (white arrow) adherent to the apical wall of the right ventricle. The thrombus in the left atrium was intermittently crossing the mitral valve and entering the left ventricle.
We have read with great interest the article by Papakonstantinou et al. providing a single-center analysis of the contemporary approach to tricuspid aortic valve (TAV) insufficiency with the use of HAART 300 annuloplasty ring .We believe that the presented concept of a robust circumferential aortic annuloplasty with separate sinus replacement, avoiding coronary re-implantations when allowed, can be successfully applied to many cases, including BAV.
BJOG-21-0722 Statistical associations versus causal inference.Øjvind Lidegaard, professor 11Department of Gynaecology, Rigshospitalet, University of Copenhagen, DenmarkMany clinicians are of the opinion that observational studies may provide only “statistical associations”, but not “causal inference”. And further, that only randomized designs ensure causal interpretation. For the same reason, many medical journals have made rules for all observational studies finding significant statistical associations to be presented as just “associations” often emphasizing that a causal inference is not possible.I hereby sign up to the growing group of epidemiologists, who are of the opinion that just well confounder controlled observational studies are the very design most often providing convincing evidence of a causal interference. Prospective cohort studies better than retrospective case-control studies, but even the latter design has given us important knowledge of risk factors of rare clinical outcomes such as thrombotic diseases, a long list of cancers, obstetrical complications, including latest stillbirths.In a new original Swedish study, Heiddis Valgeirsdottir et al. demonstrate in a nationwide historical follow-up study, that women with polycystic ovary syndrome (PCOS) once pregnant have a 50% increased risk of experiencing stillbirth, as compared to women without PCOS (1). Further, that the rate ratio of stillbirth between women with and without PCOS increased by increasing gestational age, peaking at 42 weeks with 4.3 deaths per 1000 ongoing pregnancies in women with PCOS versus 1.0 deaths per 1000 ongoing pregnancies in women without PCOS.Any such association should certainly be controlled for a long list of potential confounders, the most important being maternal age, calendar year, parity, hypertensive disorders, diabetes, and educational length. Adiposity (BMI) was undertaken in an additional adjustment, because this covariate correctly could be considered as both a confounder (adiposity being a risk factor for stillbirth, and PCOS women more often being adipose), but also as a mediator; women with PCOS are more likely to develop adiposity due to their PCOS. The authors chose carefully to present the BMI adjusted results as the main results, thereby if anything underestimating the risk of stillbirths in women with PCOS.This is far from the first contribution from Scandinavian National Health Registers, identifying and quantifying risk factors for different diseases. We should always be aware that some unknown or unmeasured potential confounders not being controlled for, could reduce (or enhance) the results, and that other research groups should confirm the Swedish findings. A causal inference was made more likely with a suggested biomedical mechanism by which PCOS could confer such a risk. But already with this new carefully provided observational evidence, we should reasonably consider pregnant women with PCOS not to go too far beyond term, to prevent stillbirths in this group, which according to the study results accounts about 5% of all stillbirths. A pragmatic first recommendation could be induction of women with PCOS at 41 gestational weeks.Valgeirsdottir H et al. BJOG 2021; 128: xxx-xxx.
Brugada syndrome masked by complete left bundle branch blockAbbas Hoteit MD, Marwan M. Refaat, MDDivision of Cardiology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, LebanonRunning Title: Brugada Syndrome masked by LBBBWords: 741 (excluding the title page and references)Keywords: Brugada syndrome, Left bundle branch block, Cardiovascular Diseases, Heart Diseases, Cardiac ArrhythmiasFunding: NoneDisclosures: NoneCorresponding Author:Marwan M. Refaat, MD, FACC, FAHA, FHRS, FASE, FESC, FACP, FAAMAAssociate 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, LebanonUS Address: 3 Dag Hammarskjold Plaza, 8th Floor, New York, NY 10017, USAOffice: +961-1-350000/+961-1-374374 Extension 5353 or Extension 5366 (Direct)Brugada syndrome is a genetic disorder that affects the electrical activity of the heart. It is characterized by ST-segment elevations in the right precordial leads and right bundle branch morphology on ECG.1 These ECG changes are present in the absence of other causes of ST elevation or right bundle branch block morphology such as structural heart disease, ischemia, pacing or electrolyte disturbances.2 Clinical presentation varies between patients; it can range from asymptomatic changes seen on ECG to syncope, ventricular arrhythmias, and sudden cardiac death. 3So far, three types of ECG repolarization patterns have been identified (type 1, type 2, and type 3).4 Type 1 pattern is diagnostic of Brugada syndrome whereas types 2 and 3 are considered suggestive.5 According to the 2016 consensus conference of J-wave syndromes, the diagnosis of Brugada syndrome can only be made by finding a type 1 repolarization pattern. A type 1 pattern can either be spontaneous or unmasked by fever or medications. If it has been unmasked by either, then further evidence of patient clinical history, family history, or genetic testing should be present to fulfill a score of 3.5 or higher according to the Shanghai Scoring System.6 7 The Shanghai Scoring System does not include imaging; hence, even if changes in the right ventricle are found on cardiac MRI, they play no role in the diagnosis. 7In patients presenting with a non-type 1 pattern, a sodium channel blocker challenge is frequently used to unmask the type 1 pattern. Unmasking this pattern allows for diagnosis of Brugada syndrome which has a big impact on prognosis and management options. In some patients, an initial flecainide challenge test may be negative due to the variable sensitivity of this test. Some studies have shown that repeating the test may increase sensitivity, but, with increased risk of adverse drug effects. Prasad et al. showed that in patients with high clinical suspicion, family history of sudden cardiac death could serve as an indicator to repeat the flecainide test.5 8 9Several possible risk factors, that might predispose individuals to have a more severe presentation, have been identified. These include male gender, history of syncope, spontaneous type 1 pattern, family history of Brugada syndrome, and loss-of-function mutations in the SCN5A gene (which codes the alpha subunit of the cardiac sodium channel).10 Patients with SCN5A mutations tend to have earlier onset of symptoms, more noticeable electrophysiological defects (such as sick sinus syndrome and AV blocks), and increased risk of major arrhythmic events especially in Asian and Caucasian populations.11 High-risk patients are susceptible to sudden cardiac death; therefore, risk stratification helps in patient selection for Implantable Cardioverter Defibrillator placement.12 13In their article, Eduardo et al. presented the case of a 48-year-old lady who was initially diagnosed with Brugada syndrome after having a type 1 pattern on ECG. During follow-up, the patient’s ECG changed and showed a complete left bundle branch block instead of the typical type 1 pattern. Molecular studies showed the novel SCN5A p.1449Y>H variant and subsequent functional analysis showed a nonfunctional mutated membrane channel. SCN5A mutation can cause Brugada syndrome and conduction system abnormality as described in this lady. This variant generated minimal sodium currents. Such major decrease in current magnitude is associated with high penetrance as seen in the cases in this study. Although, during close follow-up, these patients did not have severe symptoms.14 What is most significant is that the authors presented a patient with Brugada syndrome who subsequently developed findings of complete left bundle branch block on ECG, making the diagnosis challenging due to masking of the type 1 pattern. This opens further discussion about diagnosis of the syndrome and potential maneuvers or procedures that would help unmask type 1 pattern under heart block. Since diagnosis can only be made by witnessing this pattern, this presents us a possibility where a diagnosis would be missed in such patients. SCN5A is the most common gene associated with this syndrome, accounting for around 20%. However, patient presentation varies widely with different mutations affecting channel function differently. In this case, the p.1449Y>H variant showed high penetrance and channel dysfunction despite relatively non-severe symptoms in patients affected. However, further observation is warranted to assess progression of the disease and the incidence of major arrhythmogenic events with aging and subsequent fibrosis. Further research is required to investigate the role of genetic studies in risk stratification and projecting patient clinical course depending on the presence of specific gene mutations/variants.References:Refaat MM, Hotait M, Scheinman MM. Brugada Syndrome. Card Electrophysiol Clin Mar 2016; 8(1): 239-45.Refaat M, Mansour M, Singh JP, Ruskin JN, Heist EK. Electrocardiographic Characteristics in Right Ventricular Versus Biventricular Pacing in Patients With Paced Right Bundle Branch Block QRS Pattern. J Electrocardiol Mar-Apr 2011; 44 (2): 289-95.Tse G, Liu T, Li KH, et al. Electrophysiological mechanisms of Brugada syndrome: insights from pre-clinical and clinical studies. Front Physiol 2016; 7: 467.Wilde, A. a. M.; Antzelevitch, C.; Borggrefe, M.; Brugada, J.; Brugada, R.; Brugada, P.; Corrado, D.; Hauer, R. N. W.; Kass, R. S.; Nademanee, K.; Priori, S. G. (November 2002). ”Proposed diagnostic criteria for the Brugada syndrome”. European Heart Journal . 23 (21): 1648–1654.Prasad S, Namboodiri N, Thajudheen A, Singh G, Prabhu MA, Abhilash SP, Mohanan Nair KK, Rashid A, Ajit Kumar VK, Tharakan JA. Flecainide challenge test: Predictors of unmasking of type 1 Brugada ECG pattern among those with non-type 1 Brugada ECG pattern. Indian Pacing Electrophysiol J. 2016 Mar-Apr;16(2):53-58. doi: 10.1016/j.ipej.2016.06.001. Epub 2016 Jun 20. PMID: 27676161; PMCID: PMC5031807.Antzelevitch C, Yan GX, Ackerman MJ, et al. J-wave syndromes expert consensus conference report: emerging concepts and gaps in knowledge.Heart Rhythm 2016;13:e295-324.Vutthikraivit W, Rattanawong P, Putthapiban P, Sukhumthammarat W, Vathesatogkit P, Ngarmukos T, Thakkinstian A. Worldwide Prevalence of Brugada Syndrome: A Systematic Review and Meta-Analysis. Acta Cardiol Sin. 2018 May;34(3):267-277. doi: 10.6515/ACS.201805_34(3).20180302B. Erratum in: Acta Cardiol Sin. 2019 Mar;35(2):192. PMID: 29844648; PMCID: PMC5968343.Gasparini M, Priori SG, Mantica M, Napolitano C, Galimberti P, Ceriotti C, Simonini S. Flecainide test in Brugada syndrome: a reproducible but risky tool. Pacing Clin Electrophysiol. 2003 Jan;26(1P2):338-41. doi: 10.1046/j.1460-9592.2003.00045.x. PMID: 12687841.Dubner S, Azocar D, Gallino S, Cerantonio AR, Muryan S, Medrano J, Bruno C. Single oral flecainide dose to unmask type 1 Brugada syndrome electrocardiographic pattern. Ann Noninvasive Electrocardiol. 2013 May;18(3):256-61. doi: 10.1111/anec.12052. PMID: 23714084; PMCID: PMC6932426.Bayoumy A, Gong MQ, Christien Li KH, Wong SH, Wu WK, Li GP, Bazoukis G, Letsas KP, Wong WT, Xia YL, Liu T, Tse G; International Health Informatics Study (IHIS) Network. Spontaneous type 1 pattern, ventricular arrhythmias and sudden cardiac death in Brugada Syndrome: an updated systematic review and meta-analysis. J Geriatr Cardiol. 2017 Oct;14(10):639-643. doi: 10.11909/j.issn.1671-5411.2017.10.010. PMID: 29238365; PMCID: PMC5721199.Chen C, Tan Z, Zhu W, Fu L, Kong Q, Xiong Q, Yu J, Hong K. Brugada syndrome with SCN5A mutations exhibits more pronounced electrophysiological defects and more severe prognosis: A meta-analysis. Clin Genet. 2020 Jan;97(1):198-208. doi: 10.1111/cge.13552. Epub 2019 May 6. PMID: 30963536.Probst, V., Veltmann, C., Eckardt, L., Meregalli, P. G., Gaita, F., Tan, H. L., Wilde, A. A. (2010). Long‐term prognosis of patients diagnosed with Brugada syndrome: Results from the FINGER Brugada Syndrome Registry. Circulation , 121 (5), 635–643. https://doi.org/10.1161/circulationaha.109.887026.Rattanawong P, Chenbhanich J, Mekraksakit P, Vutthikraivit W, Chongsathidkiet P, Limpruttidham N, Prasitlumkum N, Chung EH. SCN5A mutation status increases the risk of major arrhythmic events in Asian populations with Brugada syndrome: systematic review and meta-analysis. Ann Noninvasive Electrocardiol. 2019 Jan;24(1):e12589. doi: 10.1111/anec.12589. Epub 2018 Aug 20. PMID: 30126015; PMCID: PMC6931443.
Dear editor, we read with great interest the well written article by Dr Kerget et al with the main objective of investigating the role of TREM-1/TREM-2 ratio on patients with COVID-19 pneumonia. The article pointed that TREM-1 and TREM-2 have important role in inflammation and TREM-1/TREM-2 ratio was higher in severe COVID-19 patients compared with moderate COVID-19 patients. We have certain comments to understand the conclusions of this article. Firstly, triggering receptor expressed on myeloid cells-1 (TREM-1) is mainly express on neutrophils and monocytes in a cell membrane-bound form. A soluble form of TREM-1(sTREM-1), which lacks the cytoplasmic tail and transmembrane part, were detected in the blood in recent studies. Since you have mentioned “serum TREM-1”, we were confused whether you detected TREM-1 or sTREM-1. Secondly, we wanted to know more about the treatment and the kidney functions of the patients. Thirdly, We are curious to see if high TREM-1/TREM-2 ratio could predict the distribution of ILD. We would be glad to hear the opinion of the author on the points, to get a more convincing conclusion.
Microinvasive, catheter-based mitral valve repair of severe mitral regurgitation utilizes less invasive approaches with less procedural morbidity and mortality. The procedural steps and clinical benefits of the transcatheter transapical mitral valve annuloplasty (AMEND mitral repair implant) and transcatheter transapical chordal repair systems (Neochord DS 1000 device and Harpoon Mitral Valve Repair System) are reviewed in this manuscript.
We presenting a patient suffering from a multi-focal liver abscess. Due to the corona pandemic the patient was treated conservatively using recurring out-patient visits. Follow-up was carried through dialogue with the GP, as well as daily telemedicine visits. The virtual visits were supplemented by episodical ultrasound scans.
Background. In the United States, infection with SARS-CoV-2 caused 380,000 reported deaths from March to December 2020. Methods. We adapted the Moving Epidemic Method to all-cause mortality data from the United States to assess the severity of the COVID-19 pandemic across age groups and all 50 states. By comparing all-cause mortality during the pandemic with intensity thresholds derived from recent, historical all-cause mortality, we categorized each week from March to December 2020 as either low severity, moderate severity, high severity, or very high severity. Results. Nationally for all ages combined, all-cause mortality was in the very high severity category for 9 weeks. Among people 18 to 49 years of age, there were 29 weeks of consecutive very high severity mortality. Forty-seven states, the District of Columbia, and New York City each experienced at least one week of very high severity mortality for all ages combined. Conclusions. These periods of very high severity of mortality during March through December 2020 are likely directly or indirectly attributable to the COVID-19 pandemic. This method for standardized comparison of severity over time across different geographies and demographic groups provides valuable information to understand the impact of the COVID-19 pandemic and to identify specific locations or subgroups for deeper investigations into differences in severity.
Background: Although well described in adults, there are scarce and heterogeneous data on the diagnosis and management of chronic urticaria (CU) in children (0-18 years) throughout Europe. Our aim was to explore country differences and identify the extent to which the EAACI/GA²LEN/EDF/WAO guideline recommendations for paediatric urticaria are implemented. Methods: The EAACI Taskforce for paediatric CU disseminated an online clinical survey among EAACI paediatric section members. Members were asked to answer 35 multiple choice questions on current practices in their respective centres. Results: The survey was sent to 2,773 physicians of whom 358 (13.8%) responded, mainly paediatric allergists (80%) and paediatricians (49.7%), working in 69 countries. For diagnosis, Southern European countries used significantly more routine tests (e.g., autoimmune testing, allergological tests, and parasitic investigation) than Northern European countries. Most respondents (60.3%) used a 2nd generation antihistamine as first- line treatment of whom 64.8% up dosed as a second- line. Omalizumab, was used as a second line treatment by 1.7% and third-line by 20.7% of respondents. Most clinicians (65%) follow EAACI/WAO/GA2LEN/EDF guidelines when diagnosing CU, and only 7.3% follow no specific guidelines. Some clinicians prefer to follow national guidelines (18.4%, mainly Northern European) or the AAAAI practice parameter (1.7%). Conclusions: Even though most members of the Paediatric Section of EAACI are familiar with the EAACI/WAO/GA2LEN/EDF guidelines, a significant number do not follow them. Also, the large variation in diagnosis and treatment strengthens the need to re-evaluate, update and standardize guidelines on the diagnosis and management of CU in children.
Letter to the Editor RE: Modification of oxytocin use through a coaching-based intervention based on the WHO Safe Childbirth Checklist in Uttar Pradesh, India: a secondary analysis of a cluster randomized controlled trialAvir Sarkar, MD1; Shalini Venkatappa, MD1; Isha Wadhawan, MD, Diplomate to ABOG21 – Department of Obstetrics and Gynecology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India2 – Department of Obstetrics and Gynecology, Fortis Escorts Hospital, Faridabad, Haryana, IndiaCorresponding author: Avir SarkarAddress: House number 12, Block F, NIT-3, Faridabad, Haryana-121001, IndiaE mail: firstname.lastname@example.orgType of article: Letter to the EditorWord count: 464Number of references: 2Conflict of interest between authors: None declared