Spinal cord ischemia remains a dreadful complication after thoracoabdominal aortic aneurysm repair. The role of cerebrospinal fluid drain in such patients needs further clarifications. Tam and colleagues carried out an interesting decision analysis study that supports the routine use of the cerebrospinal fluid drain after thoracoabdominal aneurysm repair. They also demonstrated that the use of the cerebrospinal drain was safe. Here, we firstly discuss the paper's finding and methodology and, secondly, we try to simply explain what a decision analysis study is and, broadly, and how to construct a Markov model.
Determining Prosthesis-Patient Mismatch after TAVR: Which is the Best Method?Authors: Cesar E. Mendoza, MD1 and Diego Celli, MD2Affiliations: 1Division of Cardiovascular Disease, Jackson Memorial Hospital, Miami, Florida;2Internal Medicine, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, Florida.Affiliation addresses: 11801 NW 9th Ave, Suite #209 33136 Miami, Florida, United States; 21611 NW 12th Ave 33136, Miami, Florida, United States.Corresponding author: Cesar E. Mendoza, MD; email@example.com; 1611 NW 12th Ave, East Tower 3019, Miami, Florida 33136.Disclosures: Authors have no relationships with the industry. This work is not under consideration in any other journal.Funding: No grants, contracts, and other forms of financial support were used to perform this manuscript.In the last decade, the medical community has witnessed an accelerated development of multiple devices for the transcatheter management of aortic stenosis. Recently, transaortic valve replacement (TAVR) was granted approval for its use in all types of surgical risk patients underscoring its importance in cardiovascular practice. While evidence has shown non-inferiority of TAVR versus surgical aortic valve replacement (SAVR) , it still has inherent intra- and post-procedural complications, prosthesis-patient mismatch (PPM) is one of them.Since the seminal work published by Rahimtoola in 1978 , several studies have investigated PPM. The incidence of PPM after SAVR ranges from 20% to 50% with severe cases having an occurrence rate from 5% to 25%. [3-5]. Severe PPM has been associated with significantly abnormal prosthetic valve echocardiographic parameters and adverse clinical outcomes including a higher risk of mortality [3,5-7]. Although initial studies showed a lower incidence of PPM after TAVR [8, 9], most recent data surprisingly depict an uptrend incidence of PPM with later-generation TAVR prostheses . Regardless of the true global PPM incidence, the number of cases in the severe category remain within robust margins (5% - 36%). Perhaps, more interestingly, the association of TAVR with adverse outcomes is not firm. Indeed, there are conflicting reports, with some studies showing a weak association [11,12], no association [13, 14, 15], or association in particular group of patients .PPM occurs when the effective orifice area (EOA) of a normally functioning prosthesis is too small in relation to the patient’s body size and cardiac output requirements, and this diagnosis must be done after ruling out dysfunction of the prosthesis heart valve. Historically, surgical aortic valve replacement was the method of choice in the management of aortic stenosis; as such, surgeons relied on the manufacturer’s predicted EOA charts to aid in the determination of the minimum valve size for any given valve model. The predicted EOA index (EOAi), which is calculated by dividing the reference value for the prosthesis model and size by the body surface area (BSA) of the patient, has been frequently used to identify PPM in the SAVR studies. Similarly, all contemporary TAVR studies have used the same index for the same purpose; but it nevertheless was measured using Doppler-echocardiography data.In this issue of JOCS, Catalano et al report that the utility of EOAi charts to predict PPM after TAVR for native aortic stenosis may be limited. Indeed, they found in their study that the pre-TAVR prediction of PPM using tables of expected EOA varies significantly from actual PPM measured on intraoperative transesophageal echocardiography using the continuity equation. Although this is a relatively small single-center study, the authors provided information worthy of additional consideration.First, they identified that EOAi charts overestimated the number of patients with PPM for Sapien 3 valves (25.3% predicted versus 13.7% actual) and underestimated the number of patients with PPM for Evolut valves (1.8% predicted versus 11.6% actual), yielding a limited utility for this instrument on pre-operative prediction of PPM in TAVR. Interestingly, a recent publication by Ternacle et al.  provides a different perspective on this topic. It reports that the predicted EOAi was found to be useful to reclassify the majority of patients diagnosed with measured PPM following TAVR to no PPM at all. Furthermore, they found that both methods had a different association with hemodynamic outcomes. In this regard, EOAi and mean transprosthetic gradient had a more powerful correlation when using the predicted EOAi versus the measured EOAi. Based on these findings, the Ternacle’s study suggests that the use of measured EOAi grossly overestimates the incidence of PPM. The discrepancy between both studies may be explained by the inherent variability in using different Doppler echocardiography imaging modalities to measure EOA. As Catalano et al rightly pointed out, the prosthesis data acquisition and measurements obtained by intraoperative transesophageal echocardiography in their study may not be comparable with its counterpart transthoracic modality, and this particular difference should be taken into account when interpreting the results above mentioned.Second, it is also clear from Catalano’s study that determining the best method to diagnose PPM following TAVR is paramount, but at the same time troublesome due to several factors. First, the pressure recovery phenomenon, a portion of the transprosthetic pressure gradient lost initially at the vena contracta level that recovers later after the prosthetic valve, is not accounted for by Doppler assessment of the maximum transvalvular flow velocities. This may cause overdiagnosis of PPM after TAVR. Second, measured EOA is influenced by the patient’s hemodynamic condition at the time of the evaluation and by the known technical pitfalls on the acquisition of images and measurement performance. Third, the use of the EOA indexed for body surface area may overestimate the severity of PPM in obese patients (body mass index ≥30 kg/m2).Certainly, Catalano’s study allows for a better discussion on the diagnosis and clinical implications of PPM following TAVR. However, the question of what method is a more accurate parameter to determine PPM remains unanswered. Clearly, further research is needed as TAVR is more frequently performed and new TAVR prostheses become available. Accurate prediction of PPM in this setting will help guide the operator’s decision on proper prosthesis size and type.
African swine fever (ASF) has spread across many countries in Europe since the introduction into Georgia in 2007. We report here on the first cases of ASF in wild boar detected in Germany close to the border with Poland. In addition to the constant risk of ASF virus (ASFV) spread through human activities, movements of infected wild boar also represent a route of introduction. Since ASF emerged in Western Poland in November 2019, surveillance efforts, in particular examination of wild boar found dead, were intensified in the regions of Germany bordering with Poland. The first case of ASF in wild boar in Germany was therefore detected by passive surveillance and confirmed on 10th September 2020. By 24th September 2020, 32 cases were recorded. Testing of samples from tissues of carcasses in different stages of decomposition yielded cycle threshold values from 18 to 36 in the OIE-recommended PCR which were comparable between the regional and national reference laboratory. Blood swabs yielded reliable results, indicating that the method is suitable also under outbreak conditions. Phylogenetic analysis of the ASFV whole-genome sequence generated from material of the first carcass detected in Germany, revealed that it groups with ASFV genotype II including all sequences from Eastern Europe, Asia and Belgium. However, some genetic markers including a 14 bp tandem repeat duplication in the O174L gene were confirmed that have so far been detected only in sequences from Poland (including Western Poland). Epidemiological investigations that include estimated postmortem intervals of wild boar carcasses of infected animals suggest that ASFV had been introduced into Germany in the first half of July 2020 or even earlier.
Surgical checklists such as ‘World Health Organization (WHO) Surgical Safety Checklist’ are made to make surgery safer, simple and to reduce human errors. Similar to this concept, Ali M et al and others have implemented the ‘haemostasis checklist’ and it had shown reduction in incidence of re-exploration in patients who underwent surgery using cardiopulmonary bypass (CPB). However, there is still scarcity of literature about the effect of these checklists on re-exploration after off-pump coronary artery bypass grafting (OPCABG).
I read with interest the manuscript by Masroor and co-authors on the strategy of surgical repair for left atrial appendage perforation following implantation of Watchman device. The authors present the successful management of this complications and they comment on the preferred therapeutic strategy. This is a particular sensitive subject nowadays, since the widespread use and the constant growth of a variety of transcatheter cardiac interventions has inevitably increased the number of patients who are exposed to this type of complication.
Comment on: Langerhans cell histiocytosis with BRAF p.N486_P490del or MAP2K1 p.K57_G61del treated by the MEK inhibitor trametinib1Paige Vicenzi, OMS-IV, 2Anish Ray, MD1Texas College of Osteopathic Medicine, University of North Texas Health Science Center2Department of Pediatric Hematology/Oncology, Cook Children’s Health Care SystemCorresponding Author:Anish Ray, MD1500 Cooper St., 5th floor,Fort Worth, TX 76104Phone: 425-205-0926Anish.Ray@CookChildrens.orgWord Count: 513Number of Tables: 0Number of Figures: 0Running Title: Langerhans cell histiocytosis treated by trametinibKeywords: Langerhans cell histiocytosis, MAP2K1, trametinib, pediatricThe authors have no financial support or conflicts of interest.Langerhans cell histiocytosis (LCH) is a rare but heterogenous myeloid malignancy. The discovery of mitogen-activated protein kinase (MAPK) pathway activating mutations as key oncogenic drivers offered only equivocal implications at best; the promise of targeted therapy was often eclipsed by a more severe clinical course, risk organ involvement, poorer response to standard therapy, and higher risk of relapse.1 There is, however, mounting evidence in support of MAPK pathway inhibition for patients with BRAF V600E mutations. A recent report outlines rapid and durable response of relapsed, multisystemic LCH with either BRAF p.N486_P490 or MAP2K1 p.K57_G61 deletion to MEK inhibitor trametinib.2 Two of the three patients achieved nonactive disease, including a 2-year-old male with MAP2K1 deletion who, despite reports attributing trametinib resistance to MAP2K1 mutations3, continues to thrive. We take this opportunity to describe an analogous experience treating a relapsed LCH patient with trametinib at Cook Children’s Medical Center from early 2020 to present.Our patient is a 4-year-old male who presented in March 2017 with new onset central diabetes insipidus (DI) and skin rash; skin biopsy provided diagnosis of LCH, but skeletal survey was negative for bone involvement. He was treated with twelve cycles of cytarabine (100 milligram (mg)/m2 intravenous daily for five days, every four weeks) and DDAVP for DI. At the completion of cytarabine, a second skin biopsy revealed recurrence of LCH, which warranted treatment with hydroxyurea (20 mg/kilogram (Kg) daily) and methotrexate (2.5 mg at 0.12 mg/Kg twice a week). This was continued for 52 weeks despite a brief interruption of methotrexate due to dermatitis. Three months following completion of this therapy, brain MRI revealed a 7 mm lesion of the skull. Curettage by neurosurgery confirmed relapse of LCH in January 2020. Genetic testing of this sample was negative forBRAF mutation, but positive for a mutation in the MAP2K1 gene, specifically a point mutation resulting in a substitution of Q56P. Shortly after his biopsy, the patient developed a soft tissue swelling on his skull. Due to these results and his multiple relapses, the patient was started on trametinib (2.5 mg daily) in February 2020 with rapid resolution of skull swelling and transient but dramatic reduction of his desmopressin dose from 3.2 mg twice a day to 0.2 mg twice a day. He has not experienced toxicity and continues to tolerate the drug well.Though trametinib presents a promising treatment for high-risk, relapsed LCH, it is not without limitations. In 2020, we also treated a 15-year-old male with relapsed LCH and BRAF V600E with trametinib monotherapy. Due to skin rash (Grade II), the patient became noncompliant. Despite stopping altogether after a month of treatment, he has yet to experience disease recurrence. But as stated in the aforementioned report, sufficient dose and treatment length to attain MAPK pathway suppression merits further investigation. In our similar experience treating a young child with multisystemic LCH and MAP2K1 mutation, we remain encouraged that MEK inhibition via trametinib monotherapy is a viable treatment option. In the context of genomic landscaping, we hope to incite further exploration of targeted therapy, and consequently, greater consensus on LCH management.
Motion capture and analysis techniques are emerging in the surgical education and surgical education research literature as viable ways to augment the assessment of technical skills. In particular, these methods provide an opportunity to reveal objective information about the efficiency of surgical procedures, above and beyond the accuracy of procedural outcomes. One assessment that is very prevalent in the literature are counts of the number of movements a surgeon makes in completing a technical performance. In this commentary, the number of movements metric is explored from kinesiology and engineering perspectives; two disciplines that have contributed heavily to the development of rigorous motion analysis methods. Furthermore, the assumption that skill efficiency improves linearly as a learner progresses along the continuum of expertise is challenged. While movement efficiency does certainly improve, this assumption does not necessarily capture the way that learners flexibly prioritize particular aspects of performance in the intermediate stages of skill learning. By way of this commentary, important a priori decisions that should proceed effective motion capture and analysis are highlighted, a call for the standardization of procedures is made, and an opportunity to better understand the way that computerized movement analysis techniques may contribute (or be detrimental) to competency constructs in surgical education and assessment is realized.
Dear Editor, We really appreciate MN van Ĳsselmuiden et al. for their efforts in conducting the first ever multicenter randomized controlled trial to compare laparoscopic sacrohysteropexy (LSH) with sacrospinous hysteropexy (SSHP).1 However, I have some questions regarding the methodology and results of this trial. What are the reasons for including patients with histories of previous pelvic floor or prolapse surgery in the exclusion criteria? Would randomly and equally allocating these patients into two surgical groups affect the study result or design? Nevertheless, we are really interested in the conduct of anterior or posterior colporrhaphy through the laparoscopic method.Patients presented with anterior vaginal wall prolapse are higher in number: POP-Q stage- Aa or Ba > 0 (LSH group:81%; SSHP group:72.6%) than those presented with apical prolapse (LSH group:46.6%; SSHP:45.6%) in Table 1. The majority of study population appears to have combined anterior and apical compartment prolapse rather than apical prolapse alone. Furthermore, Table 2 shows that the overall anterior compartment failure rates are 50.9% and 56.9% in the LSH and SSHP groups, respectively, in a 1 year follow-up interval. The failure rate is extraordinarily high compared with that in a previous study.2 Hysteropexy surgery is beneficial for patients with apical prolapse. It is not beneficial for patients with combined anterior and apical compartment prolapse with prominent cystocele. Most patients are satisfied with the 1 year surgical results and would recommend surgery to someone else (LSH: 87.7%; SSHP: 89.7%) despite the high recurrence rate of anterior wall prolapse in a 1 year follow-up.In the statistical analysis section, additional anterior vaginal wall repairs are significantly higher in the SSHP group than those in the LSH group (SSHP: n = 61, 98.4%; LSH: n = 55, 85.9%, P = 0.010). I would like to know how this small number difference (61 − 55 = 6) in these groups can cause significant difference in P value and how this P value is calculated. This trial assumes a failure rate of 3% on the basis of the outcomes of SSHP in a previous prospective study. However, the data population is relatively small, and the non-inferiority margin was set at 10%.The primary outcome is defined as a composite outcome of the surgical failure of the apical compartment after 12 months of follow-up and as the recurrence of uterine prolapse (POP-Q ≥ stage 2). Surgical success is defined as the absence of prolapse beyond the hymen. In the POP-Q stage system, POP-Q stage 2 is defined as the most distal prolapse between 1 cm above and 1 cm beyond the hymen.3 The most prominent prolapse, which descends beyond hymen, is the stage 2 prolapse. It elicits clinical controversy and conflicts with regard to the definitions of surgical failure and success. We hope that this letter will deliver the message that precise preoperative patient selection and study design are crucial, as they may have substantial impacts on clinical outcomes and treatment success.Min-syuan Huang,2, 3 Zi-Xi Loo,1Kun- Ling Lin,1, 2 Cheng-Yu Long1, 21 Department of Obstetrics and Gynecology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan2 Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan3 Department of Obstetrics and Gynecology, Kuo General Hospital, Tainan, Taiwan
Dear Sir, Whilst the primary focus of our commentary was to reflect upon the multitude of clinical and institutional changes prompted by COVID-19 to help adopt a more streamlined approach to healthcare,1we thank Herron et al for highlighting the importance of partner support during labour.2 However, we note that even during the peak of the first wave of infections, the Royal College of Obstetricians and Gynaecologists (RCOG) continued to advocate the presence of a single birth partner throughout labour. Many obstetric units, including our own, managed to successfully adhere to this practice throughout the pandemic. However, guidance from the RCOG for women attending antenatally, for face to face clinic appointments or ultrasound scans, was to attend alone. This was subsequently implemented in most hospitals in order to reduce the number of visitors.1 Whilst necessary during the initial fear and uncertainty surrounding COVID-19, moving forward it is important to consider the potential negative impact of partner non-attendance antenatally, as well as intrapartum. Partners often positively encourage women to seek care and prepare for birth complications, thereby preventing delay in treatment and helping to manage expectations, which have been shown to positively impact outcomes.3 Whilst undoubtedly an exciting time for many, pregnancy and the prospect of motherhood is daunting to others. Partners provide support and facilitate decision making throughout the antenatal process, particularly in difficult circumstances such as following the diagnosis of a missed miscarriage, during counselling for pregnancies affected by genetic abnormalities, or after an intrauterine death. The restrictions on partner attendance may therefore inadvertently prevent a number of women seeking care during pregnancy, for fear of having to face procedures or receiving bad news alone. Evidence from a London hospital supports this notion after demonstrating a significant increase in stillbirth rate during the pandemic compared to pre-pandemic (9.31 per 1000 births Vs 2.38 per 1000 births; p=0.01). Of significance, no cases were affected by COVID-19, nor were there any post-mortem findings suggestive of the virus.4The utilisation of remote consultations with a woman and her partner offers a suitable option in appropriately triaged cases.1 Even in remote consultations where inadvertent difficult decisions arise, the presence and support of their partner facilitates collaborative decision making. Ironically, those with high risk enough pregnancies to warrant in person consultations, where additional support could offer significant value, are those whereby partners are not permitted. Prior to the pandemic, partners often reported feeling excluded, fearful of the uncertainty of pregnancy and labour and frustrated by perceived lack of support from healthcare professionals.5 This may subsequently negatively impact their relationship because of the inability to adequately support their partners. Their exclusion from the majority of antenatal care therefore, may not only negatively impact psychological wellbeing of women which may in turn result in suboptimal outcomes, but also negatively impact their future relationship. As such, we agree with Herron et al and support their notion that attempts should be made towards delivering individualised patient centred care both antenatally and intrapartum.Lorraine S Kasaven1,2, Srdjan Saso1,2, Jen Barcroft1,2, Joseph Yazbek1,2, Karen Joash1, Catriona Stalder1, Jara Ben Nagi,2 J Richard Smith,1,2 Christoph Lees1,2, Tom Bourne1,2, Benjamin P Jones1,21 Queen Charlotte’s and Chelsea Hospital, Department of Cancer and Surgery, Imperial College NHS Trust, W12 0HS London, UK.2 Imperial College London, Department of Cancer and Surgery, London W12 0NN, UK.
It has been long believed that ischemic mitral regurgitation is secondary to left ventricular remodelling and the mitral per se remains unaffected. This proviso has recently been challenged and the mitral valve has been described as a structure that responds and adapts to challenges and attempts to correct the mitral regurgitation. The response of mitral valves in this setting can be incomplete or can even be mal-adapted. The ability of the mitral valve to respond in this manner has been described as “mitral plasticity”. Endothelial to Mesenchymal transition and Valvular Interstitial Cells are key to this mitral plasticity and function through a complex array of signalling pathways. Identification and manipulation of these pathways may provide a possibility to correct the incomplete or mal-adapted mitral valve responses. Surgical treatment can also be tailored based on whether the valve has maladapted or has undergone incomplete adaptation.
Primary cardiac lymphoma is rare, with a frequency of 1.0% to 1.6% among cardiac malignant tumors. Chemotherapy is often selected as first-line treatment for primary cardiac lymphoma. However, when the tumor causes heart failure or life-threatening hemodynamic collapse, antecedent urgent surgery is required. We herein report a successful case of complete tumor resection and reconstruction of the right atrium and right ventricle using a bovine pericardial patch combined with tricuspid valve replacement in a patient with a huge primary cardiac lymphoma filling the right heart that manifested as tricuspid valve stenosis and subsequent heart failure.
Left ventricular surgical remodeling (LVSR) has been, for long time, the procedure applied for large dyskinetic, or akinetic, areas as a consequence of a myocardial infarction, manly located in the left anterior descending area. Many surgical techniques were developed, aimed to a pure reduction of the volume of the left ventricular cavity or to add to volume reduction a more physiologic conical shape. The expansion of interventional procedures invaded most of the fields before treated only by cardiac surgeons. In this issue, Pillay describes an hybrid technique, involving both interventional cardiologists and cardiac surgeons, aimed to LV volume reduction after an anterior myocardial infarction. A series of internal (right ventricular septum) and external (anterior wall) anchors are implanted to approximate the LV free wall to the anterior septum, consequently excluding the scarred myocardium. Although some limitations of this study, the Authors have to be commended for having revitalized a procedure almost eliminated from the surgical scenario
Spirometry, a gold standard technique for measuring lung functions, has been restricted to a select cohort of patients in current COVID-19 pandemic due to the enhanced risk of disease dissemination. To monitor pulmonary functions in various obstructive (e.g., asthma) and restrictive diseases (e.g., COVID-19 pneumonia) on in- and out-patients serially, there is an urgent requirement of an alternate reliable test. Impulse Oscillometry (IOS) measures lung functions by working at tidal volumes and thus reduces the risk of potential aerosol generation. Feasibility of IOS in smaller children and its ability to detect parenchymal and peripheral airway involvement are other advantages over conventional spirometry. IOS could be a potential solution to periodically monitor lung functions in current pandemic situation to keep a check on diseases affecting lung functionality.
The evolution of individual crystals of ellipsoidal shape in supercooled one-component and binary melts as well as in supersaturated solutions is studied theoretically. The crystal volume growth rate is derived using the prolate ellipsoidal coordinates. We show that this rate is a function of the current crystal volume and supercooling/supersaturation of the ambient liquid. Also, we demonstrate that the particle growth rate increases with increasing the volume of ellipsoidal crystals and supercooling.