Since the start of the SARS-CoV-2 pandemic, it has been difficult to differentiate between SARS-CoV-2 re-infection and prolonged RNA shedding. In this report, we identified patients with positive rtPCR results for SARS-CoV-2 ≥70 days apart. Clinical and laboratory data were collected and criteria were applied to discern whether the presentation was consistent with SARS-CoV-2 re-infection or prolonged viral RNA shedding. Eleven individuals met the initial testing criteria, of which, seven met at least one criteria for re-infection and four were consistent with prolonged RNA shedding. These data demonstrate the need for criteria to differentiate SARS-CoV-2 re-infection from prolonged RNA shedding.
Regional analgesia in Cardiac anesthesia: Welcoming a new era in perioperative pain management.Soojie Yu MD1, Oscar D. Aljure MD21 Mayo Clinic Arizona, Department of Anesthesiology2University of Miami, Department of Anesthesiology, Division of Cardiovascular and Thoracic AnesthesiologyPoorly controlled post-operative pain can delay recovery and may increase the risk of morbidity in patients undergoing cardiac surgery. After surgery, the sternal incision is the most common source of pain. Historically, the mainstay for pain management in this population has been usage of narcotic analgesics but with the recognition that overprescription of opioids may be contributing to the opioid pandemic, an adoption of a multimodal approach for pain management has been gaining more popularity among institutions in the US. Neuraxial analgesia and anesthesia has been used in the past but its impact in hemodynamics added to the risk associated with heparinization and coagulopathy has limited its use in cardiac surgery. Newer regional anesthesia/analgesia methods utilizing ultrasound guidance are associated with lower risk of complications when compared to neuraxial approach. Regional blocks that cover post-sternotomy pain include transverse thoracic muscle plane (TTMP) block, parasternal block, pecto-intercostal fascial blocks (PIFB), and erector spinae plane blocks. Out of all these newer techniques, the number of published prospective double blinded studies are limited. A contributing factor to the difficulty finding literature for these type of blocks is the description of the technique by the authors. A good example is the TTMP block where the local anesthetic is deposited in the TTMP block is similar to the described approach for the parasternal nerve block[3, 4]. Nomenclature aside, Kar and Ramachandran showed there are few prospective randomized control studies published on newer non-neuraxial regional techniques for postoperative pain control after cardiac surgery.In this issue of the Journal of Cardiac Surgery, Zhang et al present a prospective double-blinded study that looks at TTMP blocks placed pre-incision for post-sternotomy pain control after induction of anesthesia. In their study, for their TTMP block, the technique defined by the authors deposits local anesthetic between the costal cartilage and the transversus thoracis muscle as described similarly in other reports .Zhang and collaborators described on their study a significantly lower consumption of intraoperative opioids in the intervention group, that goes in hand with prior studies that have shown similar results when the block is performed after induction of anesthesia[6, 7]. In a study by Padala et al, patients who received blocks pre-incision had decreased fentanyl administration intraoperatively compare to patients who received the block prior to sternotomy closure. In Zhang’s study, the block group had faster extubation times, decreased pain scores up to 24 hours after surgery and decreased post-operative opioid administration. The block group also had improved quality of sleep after extubation which can enhance recovery and decrease risk of delirium.While regional blocks are very effective as shown by Zhang et al, a common issue is the short duration of the analgesic effects. Studies based on patient satisfaction have shown that the majority of patients continue to have mild to moderate sternotomy pain especially with movement and coughing up to post-operative day three or later. Whether the block was placed post-induction or prior to sternal closure, Padala’s study showed timing of placement of regional block did not seem to affect the total opioid requirement nor the pain scores for up to 24 hours postoperatively. Another study by Lee and collaborators, evaluated if the administration of Liposomal Bupivacaine would prolong the analgesic effect of the regional block. This formulation of bupicaine can have analgesic effects up to 72 to 96 hours. In the study, the parasternal intercostal block was placed just before sternotomy closure. Overall pain scores up to 72 hours postoperatively were significantly lower when utilizing a linear mixed effects model at a 5% significance level in the Experal group compare to the placebo group. Opioid administration though was not significantly different overall nor at individual time points up to 72 hours post-operatively.In this article, Zheng discusses the placement of a continuous infusion catheter as compared to a single shot block as an option to prolong the analgesic effects of the TTMP block. On a similar study, Ueshima, et al placed bilateral catheters after performing a TTMP block in two patients undergoing a median sternotomy. These catheters were administering intermittent and on demand boluses of levobupivacine for two days postoperatively. Both patients did not require any additional analgesics. A limitation for this technique is that the catheters were placed after induction of general anesthesia and this could not be feasible in all cardiac surgeries with median sternotomy. The internal mammary artery (IMA) and vein courses through the TTMP therefore administration of local anesthetic or placement of a catheter could be an issue in patients undergoing coronary artery bypass grafting with IMA harvesting.TTMP blocks are relatively quick and easy to place but complications which include pneumothorax, local anesthetic allergy, infection  and injury to the internal mammary artery and vein can occur. One particular study showed tissue plane separation after the TTMP block that did not affect directly the ability to harvest the IMA nor did it have any obvious effect on the IMA. In this study, Zheng had a very low incidence of complications adding to the safety profile of this block in cardiac surgery.Another popular technique that has been recently described that also targets the anterior intercostal nerves is the pecto-intercostal fascial block (PIFB) also called parasternal intercostal nerve block (PINB). For PIFB, local anesthetic is deposited between the pectoralis major and intercostal muscles making the location more superficial to TTMP block. The more superficial location potentially decreases the risk of pneumothorax while still providing post-sternotomy pain control. Similar to TTMP blocks, patients who received PIFB had decreased pain scores but the amount of opioid consumption was not significant decreased compared to placebo control. There has not yet been a study published comparing TTMP to PIFB for post-sternotomy pain control and risk of complications.In this issue of the Journal of Cardiac surgery, Zheng adds supporting evidence to the use of the newer non-neuraxial regional techniques as a feasible, practical option for the management of postoperative pain control in patients undergoing open cardiac surgery. This study adds to the growing evidence that TTMP blocks cover median sternotomy pain which is the main source of pain in post-cardiac surgery patients. The TTMP blocks are safe, easy to perform in the operating room after anesthesia and the incidence of complications is very low as reported in other studies. Limitations exist with TTMP blocks which include the relative short duration of analgesia. More studies will be needed to evaluate the continuous infusion of local anesthetic or other supplemental regional techniques to prolong the beneficial effects of this block.1. Mueller, X.M., et al., Pain location, distribution, and intensity after cardiac surgery. Chest, 2000. 118(2): p. 391-6.2. Kar, P. and G. Ramachandran, Pain relief following sternotomy in conventional cardiac surgery: A review of non neuraxial regional nerve blocks. Ann Card Anaesth, 2020. 23(2): p. 200-208.3. Del Buono, R., F. Costa, and F.E. Agro, Parasternal, Pecto-intercostal, Pecs, and Transverse Thoracic Muscle Plane Blocks: A Rose by Any Other Name Would Smell as Sweet. Reg Anesth Pain Med, 2016. 41(6): p. 791-792.4. Fujii, S., Transversus thoracis muscle plane block and parasternal block. Reg Anesth Pain Med, 2020. 45(4): p. 317.5. Ueshima, H. and H. Otake, Where is an appropriate injection point for an ultrasound-guided transversus thoracic muscle plane block?J Clin Anesth, 2016. 33: p. 190-1.6. Cardinale, J.P., et al., Incorporation of the Transverse Thoracic Plane Block Into a Multimodal Early Extubation Protocol for Cardiac Surgical Patients. Semin Cardiothorac Vasc Anesth, 2020: p. 1089253220957484.7. Padala, S., et al., Comparison of preincisional and postincisional parasternal intercostal block on postoperative pain in cardiac surgery. J Card Surg, 2020. 35(7): p. 1525-1530.8. Ranjbaran, S., et al., Poor Sleep Quality in Patients after Coronary Artery Bypass Graft Surgery: An Intervention Study Using the PRECEDE-PROCEED Model. J Tehran Heart Cent, 2015. 10(1): p. 1-8.9. Lahtinen, P., H. Kokki, and M. Hynynen, Pain after cardiac surgery: a prospective cohort study of 1-year incidence and intensity.Anesthesiology, 2006. 105(4): p. 794-800.10. Lee, C.Y., et al., A Randomized Controlled Trial of Liposomal Bupivacaine Parasternal Intercostal Block for Sternotomy. Ann Thorac Surg, 2019. 107(1): p. 128-134.11. Ueshima, H. and H. Otake, Continuous transversus thoracic muscle plane block is effective for the median sternotomy. J Clin Anesth, 2017. 37: p. 174.12. Ueshima, H. and H. Otake, Ultrasound-guided transversus thoracic muscle plane block: Complication in 299 consecutive cases. J Clin Anesth, 2017. 41: p. 60.13. Khera, T., et al., Ultrasound-Guided Pecto-Intercostal Fascial Block for Postoperative Pain Management in Cardiac Surgery: A Prospective, Randomized, Placebo-Controlled Trial. J Cardiothorac Vasc Anesth, 2021. 35(3): p. 896-903.
It is an elegant albeit limited study reporting effects of pre op LVEF on long term results in patients with RHD undergoing DVR. Study includes146 pqtients out of 201 who underwent DVR in the study period. Although all had some improvement immediate post op, those with preserved EF and smaller left ventricles regardless of type of prostheses used, surgical techniques ( partial or full Sub-valvular Apparatus Preservation), had more sustained improvement after 3-4 years than those with lower EF and more dilation . It can be partially explained by more prevalence of aortic insufficiency in patients with pre op lower EF <50 and dilation ( average LVESD 49 mm vs 32 mm in EF >50). There are myocardial factors which also play a part , those with abnormal LV function have more extensive loss of myofibrils either due to disproportion of mitochondria-to-myofibril ratio or myofibrillar degeneration exhibiting the extent RHD involves myocardium. Structural adaptation may not all be just a result of hemodynamic abnormalities in these patients (1). The recommendation that surgical intervention should occur before the LV starts to dilate or EF drops is well founded and would be impactful in the developing world, an estimated 250,000 deaths occur annually worldwide and 10.5 million disability adjusted life years due to RHD, mostly in young people.
The surgical treatment of pulmonary hypertension (PH), with or without pulmonary artery aneurysm, has evolved during the last 40 years from heart-lung transplants to bilateral lung transplants as the treatment of choice for PH patients with preserved right and left ventricular function and without complex cardiac abnomalies.
Summary: This study evaluates through modeling the possible individual and combined effect of three populational parameters of pathogens (reproduction rate; rate of novelty emergence; and propagule size) on the colonization of new host species – putatively the most fundamental process leading to the emergence of new infectious diseases. The results are analyzed under the theoretical framework of the Stockholm Paradigm using IBM simulations to better understand the evolutionary dynamics of the pathogen population and the possible role of Ecological Fitting. The simulations suggest that all three parameters positively influence the success of colonization of new hosts by a novel parasite population but contrary to the prevailing belief, the rate of novelty emergence (e.g. mutations) is the least important factor. Maximization of all parameters result in a synergetic facilitation of the colonization and emulates the expected scenario for pathogenic microorganisms. The simulations also provide theoretical support for the retention of the capacity of fast-evolving lineages to retro-colonize their previous host species/lineage by ecological fitting. Capacity is, thus, much larger than we can anticipate. Hence, the results support the empirical observations that opportunity of encounter (i.e. the breakdown in mechanisms for ecological isolation) is a fundamental determinant to the emergence of new associations – especially Emergent Infectious Diseases - and the dynamics of host exploration, as observed in SARS-CoV-2. Insights on the dynamics of Emergent Infectious Diseases derived from the simulations and from the Stockholm Paradigm are discussed.
Reintubation in the pediatric intensive care unit (PICU) increases morbidity, mortality, and the overall cost of care. Post-extubation airway obstruction (PEAO) is a potentially predictable cause of extubation failure and may be prevented by the use of corticosteroids. Defining which patients are most at risk for the development of POAE as well as the optimal dose and timing of corticosteroids for prevention is critical. We review the current literature regarding the use of corticosteroids surrounding extubation in the PICU and discuss the implications that a clear algorithm for identification and treatment of these patients would have in the care of critically ill children.
Interpreting Complex Atrial Tachycardia Maps Using Global Atrial VectorsEditorial on: The Utility of a Novel Mapping Algorithm Utilizing Vectors and Global Pattern of Propagation for Scar-Related Atrial TachycardiasMiguel Rodrigo, PhD1-2Sanjiv M. Narayan MD, PhD11Stanford University, Stanford, CA, USA2Electronic Engineering Department, Universitat de Valencia, Spain1500 words excluding title and references12 or less references1-3 tables/figures
COVID-19 has been associated with both transient and persistent systemic symptoms that do not appear to be a direct consequence of viral infection. The generation of autoantibodies has been proposed as a mechanism to explain these symptoms. To understand this phenomenon in more detail, we investigated the frequency and specificity of clinically relevant autoantibodies in 84 individuals previously infected with SARS-CoV-2, suffering from COVID-19 of varying severity in both the acute and convalescent setting. These were compared with results from 32 individuals who were on ITU for non COVID reasons. We demonstrate a higher frequency of autoantibodies in the COVID-19 ITU group compared with non-COVID-19 ITU disease control patients and that autoantibodies were also found in the serum 3-5 months post COVID-19 infection. Non-COVID patients displayed a diverse pattern of autoantibodies; in contrast, the COVID-19 groups had a more restricted panel of autoantibodies including skin, skeletal muscle and cardiac antibodies. Our results demonstrate that severe COVID-19 induces a pattern of autoantibodies that may correlate with and contribute to the immune pathology associated with the long-term sequelae of infection.
Background: The treatment of complex thoracic aorta pathologies remains a challenge for cardiovascular surgeons. After introducing Frozen Elephant Trunk (FET), a significant evolution of surgical techniques has been achieved. The present meta-analysis aimed to assess the efficacy of FET in acute type A aortic dissection (ATAAD) and the effect of circulatory arrest time on post-operative neurologic outcomes. Methods: A standard Preferred Reporting Items for Systematic Reviews and Meta-Analyses search was conducted for all observational studies of patients diagnosed with ATAAD undergoing total arch replacement with FET reporting in-hospital mortality, bleeding, and neurological outcomes. A random-effect meta-analysis was performed using STATA software (StataCorp, TX, USA). Results: Thirty-five studies were eligible for the present meta-analysis, including 3211 patients with ATAAD who underwent total arch replacement with FET. The pooled estimate for in-hospital mortality, postoperative stroke, and spinal cord injury were 7% (95% CI 5 – 9; I2 = 68.65%), 5% (95% CI 4 – 7; I2 = 63.93%), and 3% (95% CI 2 – 4; I2 = 19.56%), respectively. Univariate meta-regression revealed that with increasing the duration of hypothermic circulatory arrest time, the effect sizes for postoperative stroke and SCI enhances. Conclusions: It seems that employing the FET procedure for acute type A dissection is associated with acceptable neurologic outcomes and a similar mortality rate comparing with other aorta pathologies. Besides, increasing hypothermic circulation arrest time appears to be a significant predictor of adverse neurologic outcomes after FET.
Objective: To evaluate the accuracy of radiological staging, especially renal venous and perirenal fat invasion, in renal cell carcinoma (RCC). Material & Methods: Data of 4823 renal tumor patients from Renal Tumor Database of Association of Uro-oncology in Turkey were evaluated. Of 4823 patients, 3309 RCC patients had complete radiological and histopathological data were included to this study. The Pearson Chi-squared test (χ2) was used to compare radiological and histopathological stages. Results: The mean (SD) age of 3309 patients was 58 (12.3). Preoperative radiological imaging was performed using computed tomography (CT) (n=2510, 75.8%) or magnetic resonance imaging (MRI) (n=799, 24.2%). There was a substantial concordance between radiological and pathological staging (к=0.52, p<0.001). Sensitivities of radiological staging in stage I, II, III and IV were 90.7%, 67.3%, 27.7% and 64.2%, respectively. The sensitivity in stage III was lower than the other stages. Sub-analysis of stage IIIa cases revealed that, for perirenal fat invasion and renal vein invasion, sensitivity values were 15.4% and 11.3%, respectively. Conclusions: There was a substantial concordance between radiological (CT and/or MRI) and pathological T staging in RCC. However, this is not true for T3 cases. Sensitivity of preoperative radiological imaging in patients with pT3a tumors is insufficient and lower than the other stages. Consequently, preoperative imaging in patients with T3 RCC has to be improved, in order to better inform the patients regarding prognosis of their disease.