The SARS-CoV-19 pandemic continues to be globally related with significant morbidity and mortality, making protective measures to prevent transmission of the virus still necessary. Healthcare employees are exposed to a higher risk of infection and this is particularly true when performing aerosol-generating procedures such as bronchoscopy. Since the publication of recommendations for performing a bronchoscopy in the times of COVID-19 more than six months ago, the risk situation has not changed significantly, but due to the considerable gain in knowledge in the meantime, an update of the recommendations was necessary. The updated recommendations include the reduction of aerosol formation, the personal protection of the people involved in the procedure, as well as measures to better organize the processes in the endoscopy suite in order to perform bronchoscopic procedures securely even in times of COVID-19.

ZusammenfassungCOVID-19, ausgelöst durch Coronavirus SARS-CoV-2, ist eine neue, sich pandemisch ausbreitenden Infektionserkrankung, welche aktuell weltweit zu einer erheblichen Belastung der Gesundheitssysteme geführt hat. Krankenhausmitarbeiter stellen in Ländern mit hoher Krankheitsaktivität, wie China oder Italien, einen signifikanten Anteil der an COVID-19 Erkrankten und Verstorbenen dar. Bronchoskopische Untersuchungen führen beim untersuchten Patienten zu Hustenreiz und Aerosolbildung und beinhalten daher ein erhöhtes Infektionsrisiko für das Untersuchungsteam und für andere Patienten. In der aktuellen Pandemie sind daher besondere Maßnahmen bei der Durchführung bronchoskopischer Untersuchungen zu beachten, um das Infektionsrisiko zu senken.

COVID-19, caused by coronavirus SARS-CoV-2 is a new and ongoing infectious disease affecting healthcare systems worldwide. Healthcare worker are at high risk for COIVD-19 and many have been infected or even died in countries severely affected by COVID-19 like China or Italy. Bronchoscopy causes cough and aerosol production and has to be considered a significant risk for the staff to get infected. Particular recommendations should guide to prevent spreading COVID-19 and to protect healthcare worker when performing a bronchoscopy.

Although mastectomy is an effective procedure, it can have a negative effect on body image, sense of attractiveness, and sexuality. As opposed to the combination of breast oncologic surgery and plastic surgery, whose primary focus is on replacing lost volume, breast-conserving oncoplastic surgery (ops) redistributes remaining breast tissue in a manner that requires vision, anatomic knowledge, and an appreciation of esthetics, symmetry, and breast function. Modern surgical treatment of breast cancer can be realized only with breast and plastic surgeons working together using oncoplastic techniques to deliver superior cosmetic and cancer outcomes alike. Using this collaborative approach, oncologic and plastic surgeons in Canada have a significant opportunity to improve the care of their breast cancer patients. We propose a tri-level classification for volume displacement procedures to act as a rubric for the training of general surgeons and oncologic breast surgeons in oncoplastic breast-conserving therapy techniques. It is our position that OPS enhances outcomes for many women with breast cancer and should become part of the standard repertoire of procedures used by Canadian oncologic surgeons treating breast cancer.

Reduced Emissions from Deforestation and forest Degradation (REDD+) is an international policy initiative which is designed to incentivize tropical countries to reduce carbon emissions from deforestation and forest degradation. But what happens if a country is already a forest sink, absorbing more carbon than it is emitting? This phenomenon has been observed for a number of tropical countries already. We first demonstrate, from data derived from two rounds of the national forest inventory, that this is also the case for Mexico. Despite the fact that quite high rates of deforestation are occurring, on balance this is more than compensated for by the overall process of sequestration by forests that remain forests. We then analyze key documents from 25 countries which indicate that very little attention has been paid to the implications of this forest enhancement process in REDD+ planning. We consider what it means for national REDD+ approaches, focusing on three key elements: (1) what kind of baseline would be required under these conditions, to take into account natural forest growth levels; (2) what kinds of REDD+ activities at local level would be most suitable, given that there may be considerable scope for enhancing natural recovery rates of forests in degraded areas and (3) what kind of monitoring system could be developed to check whether these activities do indeed result in additional carbon savings.

With the increasing number of survivors with congenital heart disease (CHD) reaching adulthood, it is important for the clinician to be familiar with the various surgical options performed in this growing patient population. We describe the case of a 65-year-old female who presented with hypoxia and right-to-left shunting following a surgical repair of an atrial septal defect (ASD) secundum and anomalous pulmonary veins with a partial atrial diversion procedure in childhood. The use of multimodality cardiovascular imaging using echocardiography, computed tomography, magnetic resonance imaging, and invasive cardiac catheterization was complementary in the preoperative diagnosis and management of this unique baffling situation.

From December 2014 to April 2015, seven cases of malaria were seen in 1530 military personnel deployed to Sierra Leone on Operation GRITROCK in response to the West African Ebola outbreak, despite predeployment briefings, prescription of chemoprophylactic agents and bite prevention measures. The cases have prompted discussion regarding the efficacy of current measures and how to prevent future cases in deployed military personnel or more widely, those working in malaria-risk environments. All of the cases have made a full recovery and returned to work. We discuss what can be learnt concerning the choice of chemoprophylactic agent and whether anything further be added to standard operating procedures regarding bite prevention and treatment of cases.

Neurodevelopmental outcomes have been suggested by previous studies to be inferior in hypoplastic left heart syndrome (HLHS) as opposed to other variants of a hypoplastic left heart configuration following single ventricle palliation. Our objective was to compare survival and neurodevelopmental outcome during the same surgical era in a large, well-described cohort.

Cet article compare les impacts économiques et environnementaux de la collecte des ordures ménagères (OM) par camion à ceux de la collecte pneumatique utiliséeée sur Roosevelt Island à New York City depuis 1975. Bien que toutes les habitations soient reliées au réseau pneumatique, les entreprises et les institutions ne le sont pas, en conséquence les trois quarts des OM de l’île sont toujours collectées par camion. Afin d’évaluer les avantages potentiels de l’emploi de systèmes pneumatiques, cet article examine les résultats d’une étude de faisabilité de 2013 qui a analysé des améliorations et extensions potentielles du réseau. L’étude a montré la nature contextuelle des impacts de la collecte et a constaté que sur Roosevelt Island les camions demeurent plus économes en énergie que le système pneumatique. Cependant, les scénarios pneumatiques testés réduiraient jusqu’à 70% les distances parcourues par les camions et pourraient conduire à un système reposant à 90% sur de l’énergie électrique. Frais d’installation inclus, le coût d’opération de ces scénarios reste de 40 à 90% plus élevé que la collecte par camion. L’étude n’a pas calculé les impacts locaux dus à la circulation des camions, mais elle suggère toutefois que le surcoût de la collecte pneumatique pourrait être compensé par la réduction de ces impacts ainsi que par l’amélioration de la collecte des matières recyclables.

This study explored possibilities for using existing transportation infrastructure for the cost-effective installation of pneumatic waste-collection technology in Manhattan. If shown to be economically and operationally feasible, reducing the number of trucks used on the island’s densely encumbered streets could offer significant environmental, public-health, and quality-of-life benefits. Two cases were considered: 1) installing a pneumatic pipeline under the High Line Park (a retrofitted former elevated railroad) to collect waste from the Chelsea Market retail/office/hotel complex along with waste from the Park and adjacent buildings; and 2) installing pipelines in the space being excavated below Second Avenue for the construction of the Second Avenue Subway, in order to collect waste from residential, commercial, and hospital buildings, and from litter bins along a stretch of Second Avenue and in the subway station beneath it. Both design concepts were determined to be physically and operationally feasible and to offer significant quality-of-life benefits. Relative to conventional manual collection, the pneumatic systems would reduce energy use by 60% and greenhouse gas emissions by more than half. Direct operating costs for the proposed pneumatic installations, including the container dray from the pneumatic terminal to the transfer station, would be 30% less than those for conventional manual/truck collection in the two cases. But due to high initial capital costs, overall costs, including debt service, would be 55% higher in the High Line case and 30% higher in the Second Avenue Subway case. On a Net Present Value (NPV) basis, the cost of the pneumatic systems would be between 3.3 and 6.6 times greater than for conventional collection (for the Second Avenue Subway and High Line respectively). NPV costs would be equalized, however, if there were externality benefits on the order of $300,000 to $400,000 per year (respectively), using conservative assumptions. Given the space savings and other public-health and quality-of-life benefits associated with pneumatic systems--and the monetized value of decreased carbon emissions and energy use--externality benefits of this order of magnitude would appear to be likely.

Truncus arteriosus (TA) is an uncommon congenital cardiac lesion that portends an exceedingly poor prognosis if not repaired. The objective of this study was to assess clinical, survival and early childhood neurological and functional outcomes in a cohort who underwent TA repair and were followed prospectively.

This study examined alternatives for improving the efficiency of the pneumatic system that has been used for collecting residential municipal solid waste on Roosevelt Island, New York since 1975. Alternatives included a basic equipment upgrade; expansion to include separate recyclables streams (metal/glass/plastic; paper); and a further expansion of the system to include commercial and litter-bin waste. These three scenarios (plus the No-Action alternative, representing a continuation of the status-quo system) were compared to conventional truck collection. The No-Action alternative produced the greatest adverse economic and environmental impacts. Compared to conventional collection, all of the pneumatic scenarios offered advantages in terms of service frequency and reliability, labor and space requirements, and quality-of-life benefits. Because containers of pneumatically collected waste need to be drayed from the terminal to a transfer station or processing facility, some truck miles are still required. The simple equipment upgrade would generate 15% more truck miles than the conventional alternative, but when recyclables are included, overall truck miles would be reduced by 10%, and when commercial and litter-bin waste is included, by 70%, while diesel fuel use for the three pneumatic scenarios would decline by 10 to 90%. Since reductions in diesel fuel require increased use of electricity, and since the pneumatic scenarios collect 8 times more often, overall energy demand for these expanded systems would increase by 25% to 70% relative to manual collection. Likewise, greenhouse gas emissions for pneumatic collection would be up to twice as high as for conventional collection. Since up to 90% of the energy demand for pneumatic systems may be supplied by electricity rather than diesel fuel, electricity generated by low-carbon sources could reduce these greenhouse gas emissions. These pneumatic scenarios cost 10 to 25% less to operate, including the truck dray of containers from the pneumatic terminal to the long-haul transfer station, but when debt service for capital investments is included, overall operating costs for the pneumatic alternatives are 40 to 90% higher than for conventional collection. On a Net Present Value basis, this difference could be equalized if annual externality benefits on the order of $255,000 to $1,140,000 were realized. Given the value of potential savings by waste-generators (in space and labor costs) and of potentially monetizable public benefits (public-health and quality-of-life improvements), the pneumatic alternatives may achieve these levels of benefits.

BackgroundEvidence suggests the use of guideline-recommended secondary CV prevention medications in patients post-CABG surgery tends to decline from hospital discharge to 1-year post-surgery. Non-use of these medications, including ASA, beta-blockers, HMG-CoA reductase inhibitors (statins) and angiotensin converting enzyme inhibitors or angiotensin receptor blockers (ACEI/ARBs), is associated with increased death and MI. This study was designed to evaluate the utilization rate of secondary CV prevention medications at 1-year post-CABG surgery for patients discharged from the Mazankowski Alberta Heart Institute/University of Alberta Hospital in Edmonton, Alberta.Methods/ResultsPatients were identified using the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) registry. A retrospective analysis was performed using community pharmacy records for a randomly selected subset of adult patients discharged post-CABG between January 2009 and March 2010. One hundred and forty-nine patients consented to participate. Ninety-one percent were male with a mean age of 66 years. Eighty-three percent were hypertensive and approximately one-third were diabetic. The primary outcome, which was the proportion of patients receiving all 4 secondary CV prevention medications at 1-year post-CABG, was 48%. Individual rates of usage were 95% for ASA, 84% for statins and 84% for beta-blockers. The utilization rate of ACEI/ARBs was lowest at 64%. Medication adherence over the 1-year was assessed using the medication possession ratio (MPR), which demonstrated high adherence with mean ratios of 0.89 for beta-blockers, 0.86 for statins and 0.86 for ACEI/ARBs. Patients' LDL-cholesterol (LDL-C) and hemoglobin A1c (HbA1c) levels within 1-year post-CABG were evaluated using their electronic health record. Sixty-six percent of patients were below the guideline-recommended LDL-C target of <2 mmol/L. Among diabetic patients, only 54% had an at- or below-target HbA1c of ≤7%.ConclusionThe rate of usage of all 4 secondary CV prevention medications for patients 1-year post-CABG surgery was 48%. With the exception of ACEI/ARBs, individual drug class usage was good. While 84% of patients were taking a statin at 1-year post-CABG, only 66% were below the recommended LDL-C target. Almost half of the diabetic patients demonstrated suboptimal guideline-advocated glycemic control. Adherence to beta-blockers, ACEI/ARBs and statins during the year post-CABG was high with MPRs ≥0.86. Strategies to ensure that optimal CV preventative medical therapy, including goal-oriented treatment of CV risk factors such as hyperlipidemia and diabetes, persists after discharge should remain a priority to reduce CV events and death in patients post-CABG surgery.Pharmacy Services - PERC, AHS BackgroundEvidence suggests the use of guideline-recommended secondary CV prevention medications in patients post-CABG surgery tends to decline from hospital discharge to 1-year post-surgery. Non-use of these medications, including ASA, beta-blockers, HMG-CoA reductase inhibitors (statins) and angiotensin converting enzyme inhibitors or angiotensin receptor blockers (ACEI/ARBs), is associated with increased death and MI. This study was designed to evaluate the utilization rate of secondary CV prevention medications at 1-year post-CABG surgery for patients discharged from the Mazankowski Alberta Heart Institute/University of Alberta Hospital in Edmonton, Alberta. Evidence suggests the use of guideline-recommended secondary CV prevention medications in patients post-CABG surgery tends to decline from hospital discharge to 1-year post-surgery. Non-use of these medications, including ASA, beta-blockers, HMG-CoA reductase inhibitors (statins) and angiotensin converting enzyme inhibitors or angiotensin receptor blockers (ACEI/ARBs), is associated with increased death and MI. This study was designed to evaluate the utilization rate of secondary CV prevention medications at 1-year post-CABG surgery for patients discharged from the Mazankowski Alberta Heart Institute/University of Alberta Hospital in Edmonton, Alberta. Methods/ResultsPatients were identified using the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) registry. A retrospective analysis was performed using community pharmacy records for a randomly selected subset of adult patients discharged post-CABG between January 2009 and March 2010. One hundred and forty-nine patients consented to participate. Ninety-one percent were male with a mean age of 66 years. Eighty-three percent were hypertensive and approximately one-third were diabetic. The primary outcome, which was the proportion of patients receiving all 4 secondary CV prevention medications at 1-year post-CABG, was 48%. Individual rates of usage were 95% for ASA, 84% for statins and 84% for beta-blockers. The utilization rate of ACEI/ARBs was lowest at 64%. Medication adherence over the 1-year was assessed using the medication possession ratio (MPR), which demonstrated high adherence with mean ratios of 0.89 for beta-blockers, 0.86 for statins and 0.86 for ACEI/ARBs. Patients' LDL-cholesterol (LDL-C) and hemoglobin A1c (HbA1c) levels within 1-year post-CABG were evaluated using their electronic health record. Sixty-six percent of patients were below the guideline-recommended LDL-C target of <2 mmol/L. Among diabetic patients, only 54% had an at- or below-target HbA1c of ≤7%. Patients were identified using the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) registry. A retrospective analysis was performed using community pharmacy records for a randomly selected subset of adult patients discharged post-CABG between January 2009 and March 2010. One hundred and forty-nine patients consented to participate. Ninety-one percent were male with a mean age of 66 years. Eighty-three percent were hypertensive and approximately one-third were diabetic. The primary outcome, which was the proportion of patients receiving all 4 secondary CV prevention medications at 1-year post-CABG, was 48%. Individual rates of usage were 95% for ASA, 84% for statins and 84% for beta-blockers. The utilization rate of ACEI/ARBs was lowest at 64%. Medication adherence over the 1-year was assessed using the medication possession ratio (MPR), which demonstrated high adherence with mean ratios of 0.89 for beta-blockers, 0.86 for statins and 0.86 for ACEI/ARBs. Patients' LDL-cholesterol (LDL-C) and hemoglobin A1c (HbA1c) levels within 1-year post-CABG were evaluated using their electronic health record. Sixty-six percent of patients were below the guideline-recommended LDL-C target of <2 mmol/L. Among diabetic patients, only 54% had an at- or below-target HbA1c of ≤7%. ConclusionThe rate of usage of all 4 secondary CV prevention medications for patients 1-year post-CABG surgery was 48%. With the exception of ACEI/ARBs, individual drug class usage was good. While 84% of patients were taking a statin at 1-year post-CABG, only 66% were below the recommended LDL-C target. Almost half of the diabetic patients demonstrated suboptimal guideline-advocated glycemic control. Adherence to beta-blockers, ACEI/ARBs and statins during the year post-CABG was high with MPRs ≥0.86. Strategies to ensure that optimal CV preventative medical therapy, including goal-oriented treatment of CV risk factors such as hyperlipidemia and diabetes, persists after discharge should remain a priority to reduce CV events and death in patients post-CABG surgery.Pharmacy Services - PERC, AHS The rate of usage of all 4 secondary CV prevention medications for patients 1-year post-CABG surgery was 48%. With the exception of ACEI/ARBs, individual drug class usage was good. While 84% of patients were taking a statin at 1-year post-CABG, only 66% were below the recommended LDL-C target. Almost half of the diabetic patients demonstrated suboptimal guideline-advocated glycemic control. Adherence to beta-blockers, ACEI/ARBs and statins during the year post-CABG was high with MPRs ≥0.86. Strategies to ensure that optimal CV preventative medical therapy, including goal-oriented treatment of CV risk factors such as hyperlipidemia and diabetes, persists after discharge should remain a priority to reduce CV events and death in patients post-CABG surgery.

The association between depressed left ventricular ejection fraction (ejection fraction < 35%; LVEF) and increased mortality in patients undergoing coronary artery bypass graft (CABG) surgery has been well defined. There are now studies revealing that elevated pre-operative left ventricular end-diastolic pressure (LVEDP) is an independent predictor of operative mortality for patients undergoing CABG, and could be a greater risk than LVEF < 35%. Thus, whether LVEDP is a better predictor of long-term survival than LVEF in patients undergoing CABG surgery remains unclear. APPROACH, a clinical data collection and outcome initiative capturing all patients undergoing isolated CABG in Alberta, Canada, was used to identify 6790 patients between 1996 and 2011. Patients were divided into four groups based on LVEF and LVEDP: Group 1 (LVEF≥35%, LVEDP<18mmHg), Group 2 (LVEF<35%, LVEDP<18mmHg), Group 3 (LVEF≥35%, LVEDP≥18mmHg), Group 4 (LVEF<35%, LVEDP≥18mmHg). The Kaplan- Meier method was used to estimate long-term survival after revascularization and multivariate Cox proportional hazards modeling was used to determine independent risk factors of mortality. There were a total of 6790 (18.2% female) patients undergoing isolated CABG, the mean age was 66± 11 years. The 4 groups had similar pre-operative characteristics of age, history of cerebrovascular disease, renal failure, peripheral vascular disease, hypertension, and hyperlipidemia. Patients with a low LVEF (Groups 2 and 4) had a higher incidence of chronic obstructive pulmonary disease, congestive heart failure (CHF), history of smoking and history of myocardial infarction (p<0.01). The Kaplan- Meier method identified that the groups with preserved LVEF (Groups 1 and 3) had improved long-term survival compared to groups with depressed LVEF (Groups 2 and 4, p<0.001, Figure 1). As well, there was no significant correlation between elevated LVEDP and decreased survival in patients with a preserved LVEF. However, an LVEDP < 18 mmHg was associated with improved long-term survival when compared to patients with an elevated LVEDP in patients with depressed LVEF (Group 2 vs. Group 4, p<0.001). Other significant independent predictors for death were: LVEF<35%, age, COPD, peripheral vascular disease, dialysis dependence and CHF (p<0.001). Elevated LVEDP≥18mmHg was not an independent risk factor for mortality. Elevated LVEDP≥18mmHg is not an independent risk factor for mortality in patients undergoing isolated CABG. However, in patients with a depressed LVEF, an elevated LVEDP is associated with poor long-term survival when compared to patients with an LVEDP < 18 mmHg. Overall, decreased long-term survival is best correlated with low LVEF<35%.

Obesity (body mass index [BMI] > 30 kg/m2) is a chronic disease that is increasing rapidly worldwide. Currently, the prevalence of obesity (BMI ≥ 30) has exceeded 10% and is expected to continue to increase over the next decade. A similar trend may be observed in cardiac transplantation. Despite recipient obesity being a relative contraindication for cardiac transplantation there is a paucity literature to clarify this issue. It remains debatable as to whether increased BMI leads to increased morbidity and mortality in heart transplant patients. The purpose of this study was to compare the outcomes of patients stratified by BMI undergoing cardiac transplantation. APPROACH, a clinical data collection and outcome monitoring initiative for the province of Alberta, Canada, was used to identify 155 patients, aged 18 and older, undergoing cardiac transplantation between 2004 and 2011. Patients were divided into four groups based on BMI (Group 1 - BMI< 20 [n=11], Group 2 - BMI 20-25 [n=50], Group 3 BMI 25.1 - 30 [n=59], Group 4 BMI > 30 [n=35]). The Kaplan- Meier method was used to estimate long-term survival after revascularization and multivariate Cox proportional hazards modeling was used to determine independent risk factors of mortality. There were a total of 155 (26% female) patients undergoing isolated cardiac transplantation. Patients with higher BMIs in Group 3 and 4 had increased pre-operative risk factors including advanced age, hypertension, hyperlipidemia, type II diabetes, history of prior myocardial infarction, and prior coronary artery bypass graft surgery (p<0.01). There were no significant intra-operative differences in mean aortic cross-clamp time, cardiopulmonary bypass time, and total operating room time between the four groups. Furthermore, patients undergoing cardiac transplantation, stratified by BMI, had no significant difference in survival at 1,3, 5 and 7 years. As well, post-operatively there were no significant differences in sternal wound infection, sepsis, stroke and acute allograft rejection between the BMI stratified groups. Despite increased pre-operative co-morbidities, patients who are over-weight (BMI 25-30) and obese (BMI > 30) do not experience decreased long-term survival post-cardiac transplantation. Collectively, these findings challenge the previously suggested role of obesity leading to adverse outcomes in cardiac transplantation. Further research exploring the factors leading to patient selection for cardiac transplantation is required.

BackgroundThe bidirectional superior cavopulmonary anastomosis (BCPA) is performed as the 2nd stage of palliation for the hypoplastic left heart syndrome (HLHS) and reduces volume load and improves effective pulmonary blood flow. However, there is little data to support a change in tricuspid valve (TV) or right ventricular morphology. We sought to measure right ventricular area and TV morphology pre and post BCPA in patients with HLHS.MethodsWe reviewed retrospectively the 2 D echocardiograms of children with HLHS, 1 month pre BCPA and 1 month post BCPA performed between 2005-11. We excluded patients with severe tricuspid regurgitation (TR) who underwent valvuloplasty at the time of the BCPA. From the 4 chamber view we measured the coaptation length, vena contracta of TR and right ventricular end-diastolic (RVED) area, TV tenting area and TV end diastolic annular diameter pre and post BCPA. We graded the severity of TR subjectively. We compared values pre and post BCPA using a paired t test.ResultsWe reviewed 35 patients (Male 23: Female 12, median age 6 months, range 3-10). Data is summarized in the table.Tabled 1ConclusionIn children with HLHS post BCPA, the coaptation lengths of the lateral and septal leaflets of the TV increased concomitantly with decreased TV end diastolic annular diameter, TV tenting area, vena contracta width and RVED area despite unchanged subjective TV regurgitation grade. This suggests that post BCPA reduction in RV volume load is accompanied by favorable right ventricular and TV remodeling. BackgroundThe bidirectional superior cavopulmonary anastomosis (BCPA) is performed as the 2nd stage of palliation for the hypoplastic left heart syndrome (HLHS) and reduces volume load and improves effective pulmonary blood flow. However, there is little data to support a change in tricuspid valve (TV) or right ventricular morphology. We sought to measure right ventricular area and TV morphology pre and post BCPA in patients with HLHS. The bidirectional superior cavopulmonary anastomosis (BCPA) is performed as the 2nd stage of palliation for the hypoplastic left heart syndrome (HLHS) and reduces volume load and improves effective pulmonary blood flow. However, there is little data to support a change in tricuspid valve (TV) or right ventricular morphology. We sought to measure right ventricular area and TV morphology pre and post BCPA in patients with HLHS. MethodsWe reviewed retrospectively the 2 D echocardiograms of children with HLHS, 1 month pre BCPA and 1 month post BCPA performed between 2005-11. We excluded patients with severe tricuspid regurgitation (TR) who underwent valvuloplasty at the time of the BCPA. From the 4 chamber view we measured the coaptation length, vena contracta of TR and right ventricular end-diastolic (RVED) area, TV tenting area and TV end diastolic annular diameter pre and post BCPA. We graded the severity of TR subjectively. We compared values pre and post BCPA using a paired t test. We reviewed retrospectively the 2 D echocardiograms of children with HLHS, 1 month pre BCPA and 1 month post BCPA performed between 2005-11. We excluded patients with severe tricuspid regurgitation (TR) who underwent valvuloplasty at the time of the BCPA. From the 4 chamber view we measured the coaptation length, vena contracta of TR and right ventricular end-diastolic (RVED) area, TV tenting area and TV end diastolic annular diameter pre and post BCPA. We graded the severity of TR subjectively. We compared values pre and post BCPA using a paired t test. ResultsWe reviewed 35 patients (Male 23: Female 12, median age 6 months, range 3-10). Data is summarized in the table.Tabled 1 We reviewed 35 patients (Male 23: Female 12, median age 6 months, range 3-10). Data is summarized in the table. ConclusionIn children with HLHS post BCPA, the coaptation lengths of the lateral and septal leaflets of the TV increased concomitantly with decreased TV end diastolic annular diameter, TV tenting area, vena contracta width and RVED area despite unchanged subjective TV regurgitation grade. This suggests that post BCPA reduction in RV volume load is accompanied by favorable right ventricular and TV remodeling. In children with HLHS post BCPA, the coaptation lengths of the lateral and septal leaflets of the TV increased concomitantly with decreased TV end diastolic annular diameter, TV tenting area, vena contracta width and RVED area despite unchanged subjective TV regurgitation grade. This suggests that post BCPA reduction in RV volume load is accompanied by favorable right ventricular and TV remodeling.

Atrioventricular valve regurgitation (AVVR) is the most common reason for reoperation after surgical repair of primum defects. Descriptions of pre-operative anatomical risk factors predicting significant post-operative AVVR are limited. This study utilized real-time three-dimensional echocardiography (RT-3DE) to examine pre-operative anatomical and functional characteristics of left atrioventricular valves in patients with primum defects for insights into post-operative valve failure. We reviewed 41 consecutive children (median age 3 years, range 2 months to 13 years) presenting to our institution for primum defect repair. Pre-operative two-dimensional echocardiography (2DE) was analyzed with 34 of 41 patients having RT-3DE available. At pre-operative and post-operative follow-up left AVVR (LAVVR) was graded by conventional 2DE. We assessed for specific pre-operative valvar or sub-valve risk factors, such as abnormally short chordae, commissural deformities and an eccentric cleft, using RT-3DE (n=34) and surgical reports (n=41). We compared the pre-operative valvar anatomy and function between patients who developed post-operative moderate LAVVR and those who did not. Thirty four percent had moderate pre-operative LAVVR. The mean post-operative follow-up was 23±16 months with 39% of patients having moderate LAVVR. In the cohort of 34 children with RT-3DE, we identified pre-operative valve or subvalve risk factors in 74% by RT-3DE and in 56% by surgical findings. Patients with moderate post-operative LAVVR were more likely to have significant pre-op LAVVR and abnormal RT-3DE findings than patients with mild post-operative LAVVR. There was no difference in the rate of abnormal surgical findings between these two groups. Moderate pre-operative LAVVR had a positive predictive value (PPV) for post-operative regurgitation of 77%. Abnormal RT-3DE findings had a negative predictive value of 100%. Combining these variables improved PPV marginally (83%). Surgical findings were lower than both of these values. In addition to moderate pre-operative LAVVR, valve and sub-valve abnormalities are risk factors for significant regurgitation after primum repair. RT-3DE is a sensitive tool to identify these anatomical risk factors. Early identification of these patients has the potential to facilitate surgical planning and procedure modification, and to improve the morbidity outcome of this difficult lesion.

Objective: The increase in O2 delivery (DO2) by dopamine may be offset by a greater increase in O2 consumption (VO2) in neonates due to β adrenergic receptors in abundant brown fat tissue, particul...

Earlier work has shown that retrospectively measured quality of life (QOL) may significantly differ from prospectively measured QOL. This phenomenon, called "response-shift" represents a change in how patients views their overall health status and its impact on their QOL prior to and after suffering an injury or undergoing treatment. A patient's perceived outcomes after lumbar spine surgery may also be influenced by the response shift. This study analyzes the occurrence of response shift and characterizes its effect in patients undergoing lumbar spine surgery.