Publications by authors named "Vincent Chan"

488 Publications

Severe acute respiratory syndrome coronavirus 2-induced acute aortic occlusion: a case report.

J Med Case Rep 2021 Mar 2;15(1):112. Epub 2021 Mar 2.

Department of Medicine, Abington Hospital-Jefferson Health, Abington, PA, USA.

Background: Severe acute respiratory syndrome coronavirus 2 infection can lead to a constellation of viral and immune symptoms called coronavirus disease 2019. Emerging literature increasingly supports the premise that severe acute respiratory syndrome coronavirus 2 promotes a prothrombotic milieu. However, to date there have been no reports of acute aortic occlusion, itself a rare phenomenon. We report a case of fatal acute aortic occlusion in a patient with coronavirus disease 2019.

Case Report: A 59-year-old Caucasian male with past medical history of peripheral vascular disease presented to the emergency department for evaluation of shortness of breath, fevers, and dry cough. His symptoms started 5-7 days prior to the emergency department visit, and he received antibiotics in the outpatient setting without any effect. He was found to be febrile, tachypneic, and hypoxemic. He was placed on supplemental oxygen via a non-rebreather mask. Chest X-ray showed multifocal opacifications. Intravenous antibiotics for possible pneumonia were initiated. Hydroxychloroquine was initiated to cover possible coronavirus disease 2019 pneumonia. During the hospitalization, the patient became progressively hypoxemic, for which he was placed on bilevel positive airway pressure. D-dimer, ferritin, lactate dehydrogenase, and C-reactive protein were all elevated. Severe acute respiratory syndrome coronavirus 2 reverse transcription polymerase chain reaction was positive. On day 3, the patient was upgraded to the intensive care unit. Soon after he was intubated, he developed a mottled appearance of skin, which extended from his bilateral feet up to the level of the subumbilical plane. Bedside ultrasound revealed an absence of flow from the mid-aorta to both common iliac arteries. The patient was evaluated emergently by vascular surgery. After a discussion with the family, it was decided to proceed with comfort-directed care, and the patient died later that day.

Discussion: Viral infections have been identified as a source of prothrombotic states due to direct injury of vascular tissue and inflammatory cascades. Severe acute respiratory syndrome coronavirus 2 appears to follow a similar pattern, with numerous institutions identifying elevated levels of thrombotic complications. We believe that healthcare providers should be aware of both venous and arterial thrombotic complications associated with coronavirus disease 2019, including possible fatal outcome.
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http://dx.doi.org/10.1186/s13256-021-02692-xDOI Listing
March 2021

American Society of Regional Anesthesia and Pain Medicine expert panel recommendations on point-of-care ultrasound education and training for regional anesthesiologists and pain physicians-part I: clinical indications.

Reg Anesth Pain Med 2021 Feb 24. Epub 2021 Feb 24.

Center for Pain Medicine, Western Reserve Hospital, Cuyahoga Falls, Ohio, USA.

Point-of-care ultrasound (POCUS) is a critical skill for all regional anesthesiologists and pain physicians to help diagnose relevant complications related to routine practice and guide perioperative management. In an effort to inform the regional anesthesia and pain community as well as address a need for structured education and training, the American Society of Regional Anesthesia and Pain Medicine (ASRA) commissioned this narrative review to provide recommendations for POCUS. The guidelines were written by content and educational experts and approved by the Guidelines Committee and the Board of Directors of the ASRA. In part I of this two-part series, clinical indications for POCUS in the perioperative and chronic pain setting are described. The clinical review addresses airway ultrasound, lung ultrasound, gastric ultrasound, the focus assessment with sonography for trauma examination and focused cardiac ultrasound for the regional anesthesiologist and pain physician. It also provides foundational knowledge regarding ultrasound physics, discusses the impact of handheld devices and finally, offers insight into the role of POCUS in the pediatric population.
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http://dx.doi.org/10.1136/rapm-2021-102560DOI Listing
February 2021

American Society of Regional Anesthesia and Pain Medicine expert panel recommendations on point-of-care ultrasound education and training for regional anesthesiologists and pain physicians-part II: recommendations.

Reg Anesth Pain Med 2021 Feb 24. Epub 2021 Feb 24.

Center for Pain Medicine, Western Reserve Hospital, Cuyahoga Falls, Ohio, USA.

Point-of-care ultrasound (POCUS) is a critical skill for all regional anesthesiologists and pain physicians to help diagnose relevant complications related to routine practice and guide perioperative management. In an effort to inform the regional anesthesia and pain community as well as address a need for structured education and training, the American Society of Regional Anesthesia and Pain Medicine Society (ASRA) commissioned this narrative review to provide recommendations for POCUS. The recommendations were written by content and educational experts and were approved by the guidelines committee and the Board of Directors of the ASRA. In part II of this two-part series, learning goals and objectives were identified and outlined for achieving competency in the use of POCUS, specifically, airway ultrasound, lung ultrasound, gastric ultrasound, the focus assessment with sonography for trauma exam, and focused cardiac ultrasound, in the perioperative and chronic pain setting. It also discusses barriers to POCUS education and training and proposes a list of educational resources. For each POCUS section, learning goals and specific skills were presented in the Indication, Acquisition, Interpretation, and Medical decision-making framework.
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http://dx.doi.org/10.1136/rapm-2021-102561DOI Listing
February 2021

Impact of sex on outcomes after percutaneous repair of functional mitral valve regurgitation.

J Card Surg 2021 Feb 22. Epub 2021 Feb 22.

Division of Cardiology, University of Ottawa, Ottawa, Ontario, Canada.

Background: The role of percutaneous repair of functional mitral regurgitation (MR) is evolving. Left ventricle remodeling is known to be different between men and women; however, outcomes following percutaneous repair of functional MR have not considered the impact of sex.

Methods: Between 2012 and 2018, 175 patients underwent percutaneous repair of functional MR with the Mitra Clip NT/NTR (Abbott) at our institution. Patients were assessed in a dedicated clinic with a follow-up that averaged 0.7 ± 1.2 years and extended to 5.7 years.

Results: Men had a larger body surface area than women (p < .001), and were more likely than women to have diabetes preoperatively (p = .02). There were no deaths or instances of single leaflet detachment. Immediate postprocedure MR was ≤2+ in 158 (90%) with a mean trans-mitral valve repair gradient of 3.4 ± 1.0 and 3.5 ± 2.1 mmHg, respectively for women and men (p = .8). One- and 2-year freedom from MR ≥3+ was 86.0 ± 3.5% and 77.6 ± 5.1%, respectively. After adjusting for differences between male and female patients, women were more likely to have recurrent MR ≥3+ (hazard ratio, 4.7; 95% confidence interval, 1.2-18.4; p = .03). Upon adjusted analysis, there was also no association between gender and survival (p = .2). One- and 2-year survival was 69.8 ± 4.3% and 54.3 ± 5.5%, respectively.

Conclusion: Women are more likely to have recurrent severe MR after percutaneous repair of functional MR. The mechanism for this remains undetermined.
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http://dx.doi.org/10.1111/jocs.15445DOI Listing
February 2021

A "data sharing trust" model for rapid, collaborative science.

Cell 2021 Feb;184(3):566-570

ImmunoX Initiative, Department of Microbiology and Immunology, University of California, San Francisco, 513 Parnassus Ave, San Francisco, CA 94143-0511, USA; UCSF CoLabs, University of California, San Francisco, 513 Parnassus Ave, San Francisco, CA 94143-0511, USA; Division of Rheumatology, Department of Medicine, University of California, San Francisco, 513 Parnassus Ave, San Francisco, CA 94143-0511, USA. Electronic address:

Complex datasets provide opportunities for discoveries beyond their initial scope. Effective and rapid data sharing and management practices are crucial to realize this potential; however, they are harder to implement than post-publication access. Here, we introduce the concept of a "data sharing trust" to maximize the value of large datasets.
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http://dx.doi.org/10.1016/j.cell.2021.01.006DOI Listing
February 2021

Global absence and targeting of protective immune states in severe COVID-19.

Nature 2021 Mar 25;591(7848):124-130. Epub 2021 Jan 25.

Department of Pathology, University of California San Francisco, San Francisco, CA, USA.

Although infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has pleiotropic and systemic effects in some individuals, many others experience milder symptoms. Here, to gain a more comprehensive understanding of the distinction between severe and mild phenotypes in the pathology of coronavirus disease 2019 (COVID-19) and its origins, we performed a whole-blood-preserving single-cell analysis protocol to integrate contributions from all major immune cell types of the blood-including neutrophils, monocytes, platelets, lymphocytes and the contents of the serum. Patients with mild COVID-19 exhibit a coordinated pattern of expression of interferon-stimulated genes (ISGs) across every cell population, whereas these ISG-expressing cells are systemically absent in patients with severe disease. Paradoxically, individuals with severe COVID-19 produce very high titres of anti-SARS-CoV-2 antibodies and have a lower viral load compared to individuals with mild disease. Examination of the serum from patients with severe COVID-19 shows that these patients uniquely produce antibodies that functionally block the production of the ISG-expressing cells associated with mild disease, by activating conserved signalling circuits that dampen cellular responses to interferons. Overzealous antibody responses pit the immune system against itself in many patients with COVID-19, and perhaps also in individuals with other viral infections. Our findings reveal potential targets for immunotherapies in patients with severe COVID-19 to re-engage viral defence.
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http://dx.doi.org/10.1038/s41586-021-03234-7DOI Listing
March 2021

Factors that influence adherence to surgical antimicrobial prophylaxis (SAP) guidelines: a systematic review.

Syst Rev 2021 Jan 16;10(1):29. Epub 2021 Jan 16.

Pharmacy, School of Health and Biomedical Sciences, RMIT University, Bundoora, Victoria, Australia.

Background: Despite the extensive research that has been conducted to date, practice often differs from established guidelines and will vary between individuals and organisations. It has been noted that the global uptake of local and international surgical antimicrobial prophylaxis (SAP) guidelines is poor with limited research investigating factors that affect guideline adherence. The purpose of this systematic review was to determine the reported barriers and enablers to the adherence of SAP guidelines.

Methods: A search of the literature was performed using four electronic databases (CINAHL, EMBASE, PubMed and SCOPUS) for articles published in the English language from January 1998 to December 2018. Articles were included if they were solely related to SAP and discussed the barriers or enablers to SAP guideline adherence. Articles that assessed the adherence to a range of infection control measures or discussed adherence to antibiotic treatment guidelines rather than SAP guidelines were excluded from this review. Barriers and enablers were mapped to the Theoretical Domains Framework (TDF). The Mixed Methods Appraisal Tool was used to assess the quality of included studies.

Results: A total of 1489 papers were originally retrieved, with 48 papers meeting the eligibility criteria. Barriers and enablers were mapped to 11 out of 14 TDF domains: knowledge, skills, social/professional role and identity, beliefs about capabilities, beliefs about consequences, reinforcement, memory, attention and decision processes, environmental context and resources, social influences, emotion and behavioural regulation. Barriers were further categorised into personal or organisational barriers, while enablers were arranged under commonly trialled interventions.

Conclusions: There are numerous factors that can determine the uptake of SAP guidelines. An identification and understanding of these factors at a local level is required to develop tailored interventions to enhance guideline adherence. Interventions, when used in combination, can be considered as a means of improving guideline use.
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http://dx.doi.org/10.1186/s13643-021-01577-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7811740PMC
January 2021

Imaging of knee osteoarthritis: A review of current evidence and clinical guidelines.

Musculoskeletal Care 2021 Jan 2. Epub 2021 Jan 2.

Department of Orthopaedics and Traumatology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China.

Background: Knee osteoarthritis (OA) is one of the most common and debilitating degenerative joint diseases worldwide. While radiography is the most commonly used imaging modality, it is associated with drawbacks which newer modalities such as magnetic resonance imaging (MRI) and ultrasound could overcome. Nevertheless, the role of imaging in clinical practice and research in knee OA has not been clearly defined. Furthermore, guidelines on imaging in knee OA from different authoritative bodies have not been compared in previous studies. Therefore, the present review aims to summarise existing evidence and compare guidelines on the use of different imaging modalities in evaluating knee OA.

Methods: This is a narrative review based on a search of published clinical guidelines and the PubMed database for articles published between 1 January 1990 and 31 May 2020.

Results: There is no broad consensus on the value of imaging in patients with typical OA presentation. If imaging is required, current evidence and clinical guidelines support the use of radiography and MRI as first- and second-line diagnostic modalities respectively. Since radiographic OA features have limited sensitivity and do not manifest in early stages, MRI is the preferred option for whole-joint evaluation in OA research. Discrepancies exist regarding the use of alternative imaging modalities including ultrasound, computed tomography and nuclear medicine.

Conclusion: Radiography and MRI are the imaging modalities of choice. Other modalities have their respective advantages, and more research is warranted for the standardisation of image acquisition and interpretation methodology, in order to evaluate their validity, reliability and responsiveness in OA research.
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http://dx.doi.org/10.1002/msc.1536DOI Listing
January 2021

Fascial Plane Blocks: More Questions Than Answers?

Anesth Analg 2021 03;132(3):899-905

Department of Anesthesia and Pain Management, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada.

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http://dx.doi.org/10.1213/ANE.0000000000005321DOI Listing
March 2021

Addition of dexamethasone to local infiltration analgesia in elective total knee arthroplasty: double-blind, randomized control trial.

Reg Anesth Pain Med 2021 Feb 16;46(2):130-136. Epub 2020 Nov 16.

Department of Anesthesia and Pain Medicine, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada.

Background And Objectives: Total knee arthroplasty is associated with significant pain, and effective analgesia is beneficial to patient satisfaction and functional outcomes. Studies have demonstrated that dexamethasone may have a facilitatory role on the action of local anesthesia, but this effect, when added to a local infiltration analgesia (LIA) mixture for patients having knee arthroplasty, is underexplored. Our hypothesis was that the addition of dexamethasone to local anesthetic infiltration would improve analgesic outcomes following total knee arthroplasty.

Methods: We performed a double-blind, randomized controlled trial of 140 patients undergoing elective, unilateral, total knee arthroplasty. Patients were randomly allocated to receive either 2 mL of saline 0.9% or 2 mL of dexamethasone 4 mg/mL added to a LIA mixture. Our primary outcome was 24 hours of oral morphine equivalent consumption. Our secondary outcomes included short-term and long-term analgesic and functional outcomes and adverse events.

Results: A total of 72 patients were included in the saline group and 68 were included in the dexamethasone group. We found comparable 24 hours of morphine consumption between saline and dexamethasone groups, with a median of 60 (IQR 40-105 (range 16-230)) mg and 56 (IQR 41-75 (range 0-300)) mg, respectively (p=0.096). Dexamethasone was associated with a statistically significant reduction in total inpatient opioid consumption, incidence of requiring rescue patient-controlled analgesia, length of hospital stay, and postoperative nausea, compared with saline. Patients in the dexamethasone group had a greater range of joint movement and distance walked on postoperative day 1 than the saline group. There were no differences in rest or active pain scores, timed up and go or 3-month outcomes.

Conclusions: Dexamethasone 8 mg was associated with no improvements in 24 hours of morphine consumption but was associated with modest improvements in short-term analgesia, short-term function, length of stay and postoperative nausea. There were no long-term benefits in the use of dexamethasone in LIA for patients undergoing total knee arthroplasty.

Trial Registration Number: NCT02760043.
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http://dx.doi.org/10.1136/rapm-2020-102079DOI Listing
February 2021

Robotic-Arm Assistance Simplifies Hip Arthrodesis Conversion to Total Hip Arthroplasty.

Arthroplast Today 2020 Dec 3;6(4):877-887. Epub 2020 Nov 3.

Department of Orthopaedics and Traumatology, The University of Hong Kong, Hong Kong.

Hip fusion takedown to total hip replacement is a challenging operation. Neck osteotomy and acetabular component placement are technically demanding and often require fluoroscopic guidance. Robotic arm-assisted total hip arthroplasty enhances accuracy of preoperative planning and provides navigated guidance for neck osteotomy and haptic guidance on acetabular reaming and cup implantation. Fluoroscopic guidance is replaced by real-time navigation and on-screen data. This article describes how robotic arm assistance can simplify this complex operation.
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http://dx.doi.org/10.1016/j.artd.2020.09.020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7645377PMC
December 2020

Global Absence and Targeting of Protective Immune States in Severe COVID-19.

bioRxiv 2020 Oct 29. Epub 2020 Oct 29.

While SARS-CoV-2 infection has pleiotropic and systemic effects in some patients, many others experience milder symptoms. We sought a holistic understanding of the severe/mild distinction in COVID-19 pathology, and its origins. We performed a whole-blood preserving single-cell analysis protocol to integrate contributions from all major cell types including neutrophils, monocytes, platelets, lymphocytes and the contents of serum. Patients with mild COVID-19 disease display a coordinated pattern of interferon-stimulated gene (ISG) expression across every cell population and these cells are systemically absent in patients with severe disease. Severe COVID-19 patients also paradoxically produce very high anti-SARS-CoV-2 antibody titers and have lower viral load as compared to mild disease. Examination of the serum from severe patients demonstrates that they uniquely produce antibodies with multiple patterns of specificity against interferon-stimulated cells and that those antibodies functionally block the production of the mild disease-associated ISG-expressing cells. Overzealous and auto-directed antibody responses pit the immune system against itself in many COVID-19 patients and this defines targets for immunotherapies to allow immune systems to provide viral defense.

One Sentence Summary: In severe COVID-19 patients, the immune system fails to generate cells that define mild disease; antibodies in their serum actively prevents the successful production of those cells.
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http://dx.doi.org/10.1101/2020.10.28.359935DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7605559PMC
October 2020

Global Absence and Targeting of Protective Immune States in Severe COVID-19.

Res Sq 2020 Oct 28. Epub 2020 Oct 28.

Department of Pathology, San Francisco, 513 Parnassus Ave, HSW512, San Francisco, CA 94143-0511, USA.

While SARS-CoV-2 infection has pleiotropic and systemic effects in some patients, many others experience milder symptoms. We sought a holistic understanding of the severe/mild distinction in COVID-19 pathology, and its origins. We performed a wholeblood preserving single-cell analysis protocol to integrate contributions from all major cell types including neutrophils, monocytes, platelets, lymphocytes and the contents of serum. Patients with mild COVID-19 disease display a coordinated pattern of interferonstimulated gene (ISG) expression across every cell population and these cells are systemically absent in patients with severe disease. Severe COVID-19 patients also paradoxically produce very high anti-SARS-CoV-2 antibody titers and have lower viral load as compared to mild disease. Examination of the serum from severe patients demonstrates that they uniquely produce antibodies with multiple patterns of specificity against interferon-stimulated cells and that those antibodies functionally block the production of the mild disease-associated ISG-expressing cells. Overzealous and autodirected antibody responses pit the immune system against itself in many COVID-19 patients and this defines targets for immunotherapies to allow immune systems to provide viral defense.
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http://dx.doi.org/10.21203/rs.3.rs-97042/v1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7605560PMC
October 2020

Fabrication of polylactic acid/paclitaxel nano fibers by electrospinning for cancer therapeutics.

BMC Chem 2020 Dec 23;14(1):63. Epub 2020 Oct 23.

Department of Surgery, Far Eastern Memorial Hospital, Banqiao, New Taipei City, 22060 Taiwan.

Polylactic acid (PLA) is a thermoplastic and biodegradable polyester, largely derived from renewable resources such as corn starch, cassava starch and sugarcane. However, PLA is only soluble in a narrow range of solvents such as tetrahydrofuran, dioxane, chlorinated solvents and heated benzene. The limited choices of solvent for PLA dissolution have imposed significant challenges in the development of specifically engineered PLA nanofibers with electrospinning techniques. Generally, the electrospun polymeric materials have been rendered with unique properties such as high porosity and complex geometry while maintaining its biodegradability and biocompatibility for emerging biomedical applications. In this study, a new anticancer drug delivery system composed of PLA nanofibers with encapsulated paclitaxel was developed by the electrospinning of the respective nanofibers on top of a spin-coated thin film with the same chemical compositions. Our unique approach is meant for promoting strong bonding between PLA-based nanofibers and their respective films in order to improve the prolonged release properties and composite film stability within a fluctuative physiochemical environment during cell culture. PLA/paclitaxel nanofiber supported on respective polymeric films were probed by scanning electronic microscope, Fourier transform infrared spectrometer and water contact measurement for determining their surface morphologies, fibers' diameters, molecular vibrational modes, and wettability, respectively. Moreover, PLA/paclitaxel nanofibers supported on respective spin-coated films at different loadings of paclitaxel were evaluated for their abilities in killing human colorectal carcinoma cells (HCT-116). More importantly, MTT assays showed that regardless of the concentrations of paclitaxel, the growth of HCT-116 was effectively inhibited by the prolonged release of paclitaxel from PLA/paclitaxel nanofibers. An effective prolonged delivery system of paclitaxel based on PLA nanofiber-based film has demonstrated exciting potentials for emerging applications as implantable drug delivery patch in post-surgical cancer eradication.
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http://dx.doi.org/10.1186/s13065-020-00711-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7585315PMC
December 2020

Transmuscular quadratus lumborum block reduces opioid consumption and prolongs time to first opioid demand after laparoscopic nephrectomy.

Reg Anesth Pain Med 2021 Jan 26;46(1):18-24. Epub 2020 Oct 26.

Department of Anaesthesiology, Zealand University Hospital, Roskilde, Denmark

Background: Robotic and hand-assisted laparoscopic nephrectomies are often associated with moderate to severe postoperative pain. The aim of the current study was to investigate the analgesic efficacy of the transmuscular quadratus lumborum (TQL) block for patients undergoing robotic or hand-assisted laparoscopic nephrectomy.

Methods: Fifty patients were included in this single-center study. All patients were scheduled for elective hand-assisted or robotic laparoscopic nephrectomy under general anesthesia. Preoperatively, patients were randomly allocated to TQL block bilaterally with ropivacaine 60 mL 0.375% or 60 mL saline and all patients received standard multimodal analgesia and intravenous patient-controlled analgesia. Primary outcome was postoperative oral morphine equivalent (OME) consumption 0-12 hours. Secondary outcomes were postoperative OME consumption up to 24 hours, pain scores, time to first opioid, nausea/vomiting, time to first ambulation and hospital length of stay (LOS).

Results: Mean (95% CI) OME consumption was significantly lower in the intervention group at 12 hours after surgery 50 (28.5 to 71.5) mg versus control 87.5 (62.7 to 112.3) mg, p=0.02. At 24 hours, 69.4 (43.2 to 95.5) mg versus 127 (96.7 to 158.6) mg, p<0.01. Time to first opioid was significantly prolonged in the intervention group median (IQR) 4.4 (2.8-17.6) hours compared with 0.3 (0.1-1.0) hours in the control group, p<0.001. No significant intergroup differences were recorded for time to first ambulation, pain scores, nausea/vomiting nor for LOS.

Conclusion: Preoperative bilateral TQL block significantly reduced postoperative opioid consumption by 43% and significantly prolonged time to first opioid.

Trial Registration Number: NCT03571490.
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http://dx.doi.org/10.1136/rapm-2020-101745DOI Listing
January 2021

Transcatheter Mitral Valve Repair in Cardiogenic Shock and Mitral Regurgitation: A Patient-Level, Multicenter Analysis.

JACC Cardiovasc Interv 2021 Jan 14;14(1):1-11. Epub 2020 Oct 14.

CAPITAL Research Group, University of Ottawa Heart Institute, Ottawa, Ontario, Canada; Department of Cellular and Molecular Medicine, University of Ottawa, Ottawa, Ontario, Canada; Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada. Electronic address:

Objectives: The aim of this study was to evaluate the outcome of transcatheter mitral valve repair (TMVr) in patients with cardiogenic shock and significant mitral regurgitation (MR).

Background: Patients in cardiogenic shock with severe MR have a poor prognosis in the setting of conventional medical therapy. Because of its favorable safety profile, TMVr is being increasingly used as an acute therapy in this population, though its efficacy remains unknown.

Methods: A multicenter, collaborative, patient-level analysis was conducted. Patients with cardiogenic shock and moderate to severe (3+) or severe (4+) MR who were not surgical candidates were treated with TMVr. The primary outcome was in-hospital mortality. Secondary outcomes included 90-day mortality, heart failure (HF) hospitalization, and the combined event rate of 90-day mortality and HF hospitalization following dichotomization by TMVr device success.

Results: Between January 2011 and February 2019, 141 patients across 14 institutions met the inclusion criteria. In-hospital mortality occurred in 22 patients (15.6%), at 90 days in 38 patients (29.5%), and at one year in 55 patients (42.6%). Median length of hospital stay following TMVr was 10 days (interquartile range: 6 to 20 days). HF hospitalization occurred in 26 patients (18.4%) at a median of 73 days (interquartile range: 26 to 546 days). When stratified by TMVr procedural results, successful TMVr reduced rates of in-hospital mortality (hazard ratio [HR]: 0.36; 95% confidence interval [CI]: 0.13 to 0.98; p = 0.04), 90-day mortality (HR: 0.36; 95% CI: 0.16 to 0.78; p = 0.01), and the composite of 90-day mortality and HF hospitalization (HR: 0.41; 95% CI: 0.19 to 0.90; p = 0.03).

Conclusions: TMVr may improve short- and intermediate-term mortality in high-risk patients with cardiogenic shock and moderate to severe MR. Randomized studies are needed to definitively establish MR as a therapeutic target in patients with cardiogenic shock.
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http://dx.doi.org/10.1016/j.jcin.2020.08.037DOI Listing
January 2021

An Investigation of the Practices of Australian Adults Experiencing Pain and Their Views of Australian Community Pharmacy Pain Management Services.

Pharmacy (Basel) 2020 Oct 13;8(4). Epub 2020 Oct 13.

Pharmacy, School of Health and Biomedical Sciences, RMIT University, Bundoora, VIC 3083, Australia.

Pain is a common and debilitating condition requiring appropriate assessment and management. The consequences of inadequate treatment of pain is well known; however, research investigating pain management practices and the benefits Australian community pharmacies offer in pain management are more limited. This study investigated the knowledge and practices of Australian adults experiencing pain, and their views of community pharmacy pain management services. A cross-sectional study was conducted using a pre-tested anonymous self-administered questionnaire. Participants were recruited from ten community pharmacies across metropolitan Melbourne, Australia. A total of 120 participants completed the questionnaire. Most reported that their pain interfered with their quality/functionality-of-life. Paracetamol was the pharmacological preference irrespective of pain severity experienced. Approximately 30% did not believe that visiting a community pharmacy is helpful in pain management, but many reported their pain management knowledge could be improved, yet more than 60% disagreed when asked whether they would rather visit a supermarket than their pharmacy to purchase analgesics. More than half believed that community pharmacies can and should offer more pain management services. This suggests that enhancing the involvement of community pharmacists can help bridge gaps in pain management knowledge, which may provide greater positive outcomes for patients experiencing pain symptoms.
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http://dx.doi.org/10.3390/pharmacy8040187DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7711846PMC
October 2020

Randomized, Controlled Trial Comparing Mitral Valve Repair With Leaflet Resection Versus Leaflet Preservation on Functional Mitral Stenosis: The CAMRA CardioLink-2 Study.

Circulation 2020 Oct 5;142(14):1342-1350. Epub 2020 Oct 5.

Division of Cardiac Surgery (A.Q., A.D., D.A.L., H.T., S.V.), Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada.

Background: Equipoise exists between the use of leaflet resection and preservation for surgical repair of mitral regurgitation caused by prolapse. We therefore performed a randomized, controlled trial comparing these 2 techniques, particularly in regard to functional mitral stenosis.

Methods: One hundred four patients with degenerative mitral regurgitation surgically amenable to either leaflet resection or preservation were randomized at 7 specialized cardiac surgical centers. Exclusion criteria included anterior leaflet or commissural prolapse, as well as a mixed cause for mitral valve disease. Using previous data, we determined that a sample size of 88 subjects would provide 90% power to detect a 5-mm Hg difference in mean mitral valve gradient at peak exercise, assuming an SD of 6.7 mm with a 2-sided test with α=5% and 10% patient attrition. The primary end point was the mean mitral gradient at peak exercise 12 months after repair.

Results: Patient age, proportion who were female, and Society of Thoracic Surgeons risk score were 63.9±10.4 years, 19%, and 1.4±2.8% for those who were assigned to leaflet resection (n=54), and 66.3±10.8 years, 16%, and 1.9±2.6% for those who underwent leaflet preservation (n=50). There were no perioperative deaths or conversions to replacement. At 12 months, moderate mitral regurgitation was observed in 3 subjects in the leaflet resection group and 2 in the leaflet preservation group. The mean transmitral gradient at 12 months during peak exercise was 9.1±5.2 mm Hg after leaflet resection and 8.3±3.3 mm Hg after leaflet preservation (=0.43). The participants had similar resting peak (8.3±4.4 mm Hg versus 8.4±2.6 mm Hg; =0.96) and mean resting (3.2±1.9 mm Hg versus 3.1±1.1 mm Hg; =0.67) mitral gradients after leaflet resection and leaflet preservation, respectively. The 6-minute walking distance was 451±147 m for those in the leaflet resection versus 481±95 m for the leaflet preservation group (=0.27).

Conclusions: In this adequately powered randomized trial, repair of mitral prolapse with either leaflet resection or leaflet preservation was associated with similar transmitral gradients at peak exercise at 12 months postoperatively. These data do not support the hypothesis that a strategy of leaflet resection (versus preservation) is associated with a risk of functional mitral stenosis. Registration: URL: https://www.clinicaltrials.gov; Unique identifier NCT02552771.
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http://dx.doi.org/10.1161/CIRCULATIONAHA.120.046853DOI Listing
October 2020

Hamman-Rich Syndrome: A Diagnosis of Exclusion in the COVID-19 Pandemic.

Cureus 2020 Aug 19;12(8):e9866. Epub 2020 Aug 19.

Pulmonary and Critical Care, Abington Hospital- Jefferson Health, Abington, USA.

Hamman-Rich syndrome is a rapidly progressive interstitial lung disease with acute respiratory distress syndrome physiology. It carries a grave prognosis and a high early mortality rate. It is often distinguished from other similar pulmonary pathologies based on the clinical course, laboratory findings, bronchoalveolar lavage testing, and pathology report. We detail a 77-year-old lady with no prior pulmonary disease, smoking history, or occupational and environmental exposures present to the emergency department found to be in acute hypoxic respiratory failure with impressive progressive radiographic findings. The presumptive diagnosis of Hamman-Rich syndrome was made based on a combination of factors after ruling out other similar clinical entities, especially in the setting of an ongoing COVID-19 pandemic.
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http://dx.doi.org/10.7759/cureus.9866DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7500727PMC
August 2020

Is the minimal clinically important difference (MCID) in acute pain a good measure of analgesic efficacy in regional anesthesia?

Reg Anesth Pain Med 2020 Dec 7;45(12):1000-1005. Epub 2020 Sep 7.

Department of Anesthesia & Pain Management, University Health Network, University of Toronto, Toronto Western Hospital, Toronto, Ontario, Canada

In the field of acute pain medicine research, we believe there is an unmet need to incorporate patient related outcome measures that move beyond reporting pain scores and opioid consumption. The term "minimal clinically important difference" (MCID) defines the clinical benefit of an intervention as perceived by the patient, as opposed to a mathematically determined statistically significant difference that may not necessarily be clinically significant. The present article reviews the concept of MCID in acute postoperative pain research, addresses potential pitfalls in MCID determination and questions the clinical validity of extrapolating MCID determined from chronic pain and non-surgical pain studies to the acute postoperative pain setting. We further suggest the concepts of minimal clinically important improvement, substantial clinical benefit and patient acceptable symptom state should also represent aspirational outcomes for future research in acute postoperative pain management.
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http://dx.doi.org/10.1136/rapm-2020-101670DOI Listing
December 2020

Preoperative optimization to prevent periprosthetic joint infection in at-risk patients.

J Orthop Surg (Hong Kong) 2020 Sep-Dec;28(3):2309499020947207

Division of Joint Replacement Surgery, Department of Orthopaedics and Traumatology, The University of Hong Kong, 26473Queen Mary Hospital, Hong Kong, SAR, China.

Periprosthetic joint infection (PJI) remains an important complication with devastating consequences after total joint arthroplasties. With the increasing number of arthroplasties worldwide, the number of PJI will increase correspondingly with a significant economic burden to our healthcare system. It is likely impossible to completely eradicate PJI; hence, assessment and optimization of its risk factors to preventing such a disastrous complication will be the key. There are many strategies to prevent PJI in the preoperative, intraoperative, or postoperative phases. The preoperative assessment provides a unique opportunity to screen and diagnose underlying comorbidities and optimize modifiable risk factors before elective surgeries. In this review, we will focus on current literature in preoperative assessment of various modifiable risk factors and share the experience and practical approach in our institution in preoperative optimization to reduce PJI in total joint arthroplasties.
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http://dx.doi.org/10.1177/2309499020947207DOI Listing
August 2020

The role of the pharmacist in low back pain management: a narrative review of practice guidelines on paracetamol vs non-steroidal anti-inflammatory drugs.

Pharm Pract (Granada) 2020 Jul-Sep;18(3):2075. Epub 2020 Aug 6.

BPharm, MPH, PhD. Senior Lecturer. Pharmacy, School of Health and Biomedical Sciences, RMIT University. Bundoora, VIC (Australia).

Low back pain (LBP) is a common and costly condition and a leading cause of disabilities across the globe. In Australia and other countries, there has been changes in LBP management guidelines and evidence in recent years, including the use of pharmacotherapy. Inadequately treated LBP is a burden with significant health and economic impacts. Although there is some variability, non-steroidal anti-inflammatory drugs (NSAIDs) have largely replaced paracetamol as the first-choice analgesic for non-specific LBP in many international clinical guidelines, including the current Australian Therapeutic Guidelines. More recent clinical evidence also supports that targeting LBP with the use of NSAIDs can provide superior and more effective relief of LBP symptoms compared with paracetamol. Community pharmacists are one of the most accessible and frequently visited health professionals that offer vital primary healthcare services aimed to provide enhanced clinical outcomes for patients. The position of a community pharmacist is pivotal in LBP assessment and management, from both a pharmacological and non-pharmacological standpoint, including the use of clinical guidelines, yet their roles are often not fully utilized in LBP therapy. Studies investigating the community pharmacist's views, practices, knowledge, and roles, specifically in LBP management in Australia are variable and limited. This narrative review will briefly cover the impacts of LBP, and to provide a summary on recent evidence, updates and a comparison of the Australian and international low back pain management guidelines on paracetamol vs NSAIDs in LBP, as well as pharmacists' roles and interventions in a primary healthcare setting in this context.
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http://dx.doi.org/10.18549/PharmPract.2020.3.2075DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7416311PMC
August 2020

Presentation and outcomes of mitral valve surgery in France in the recent era: a nationwide perspective.

Open Heart 2020 08;7(2)

Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada.

Objectives: Unbiased information regarding the surgical management of patients with mitral regurgitation (MR) at the nationwide level are scarce and mainly US-based. The Programme de Médicalisation des Systèmes d'Information, a mandatory national database, offers the unique opportunity to assess the presentation and outcomes of all consecutive mitral valve (MV) surgeries performed in France in the contemporary era.

Methods: We collected all MV surgeries performed for MR in France in 2014-2016. MR aetiology was classified as degenerative (DMR), secondary (SMR) or Other (rheumatic or congenital disease and infective endocarditis).

Results: During the 3-year period, 18 167 MV surgeries were performed in France (55% repair and 45% replacement; 52% isolated). Age was 66±12 years and 59% were male. Aetiology was DMR in 42%, SMR in 16% and other in 42% including 19% with uncertain aetiologies. Overall, in-hospital mortality was 6.5% and increased with age, female gender, Charlson Comorbidity Index, type of surgery (replacement vs repair), associated surgery (combined vs isolated) and MR aetiology (all p<0.01). In-hospital mortality and rate of death/readmission for heart failure (HF) at 1 year were 3.4% and 13%, respectively for DMR (2.4% and 11% for isolated DMR) and 7.8% and 27%, respectively for SMR (5.5% and 23% for isolated SMR). Repair rate was 55% overall, 68% in DMR and 72% for isolated DMR surgery (70% of all DMR). Repair rates decreased with age, Charlson Comorbidity Index and female sex (all p<0.0001).

Conclusion: In this cross-sectional contemporary prospective nationwide database, in-hospital mortality and 1 year rate of death and HF readmission were considerable overall and in all subsets. Repair rates were suboptimal overall especially in the elderly and women subsets. These results underline the need to develop strategies to improve management and outcomes of patients with both DMR and SMR.
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http://dx.doi.org/10.1136/openhrt-2020-001339DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7422639PMC
August 2020

Combination Effect of High-Dose Preoperative and Periarticular Steroid Injection in Total Knee Arthroplasty. A Randomized Controlled Study.

J Arthroplasty 2021 Jan 18;36(1):130-134.e2. Epub 2020 Jul 18.

Division of Joint Replacement Surgery, Department of Orthopaedics and Traumatology, The University of Hong Kong, Queen Mary Hospital, Hong Kong SAR, China.

Background: Postoperative pain remains a major barrier to a patient's recovery after total knee arthroplasty (TKA). Periarticular corticosteroids in local infiltration analgesics (LIA) and high-dose intravenous corticosteroids have individually shown to improve pain control after TKA. However, potential interactions between them have not been investigated. This study aims to evaluate any combination effect of both routes of corticosteroids in TKA.

Methods: This is a double-blinded, paired, randomized controlled trial involving 1-stage bilateral TKAs. All received 16 mg of dexamethasone intravenously. One knee was randomized to receive LIA with 40 mg of triamcinolone, while the other knee receives LIA without corticosteroids. For each patient, one knee was affected by intravenous steroids only, while the other was under the combined effect of intravenous and periarticular steroids (IVPAS). Knee pain, Southampton wound scores, and functional knee scores (Knee Society Knee Score and Oxford Knee Scores) were compared between knees of the same patient.

Results: Forty-six patients (92 TKAs) were included. IVPAS knees showed significantly lower visual analog scale scores from day 1 to 6 weeks (P < .05) and a larger range of movement from day 2 to 4 (P < .05). IVPAS knees achieved active straight leg raise earlier than intravenous steroids (1.6 vs 2.3 days, P < .05). No differences in Southampton wound scores and functional knee scores for up to 1 year.

Conclusion: Combining intravenous and periarticular corticosteroids improved pain control and recovery after TKA with no increase in wound complications up to 1 year.
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http://dx.doi.org/10.1016/j.arth.2020.07.033DOI Listing
January 2021

Improving Care for Patients With Degenerative Mitral Regurgitation.

Ann Thorac Surg 2021 02 19;111(2):486-487. Epub 2020 Jul 19.

Division of Cardiac Surgery, University of Ottawa Heart Institute, 40 Ruskin St, Ottawa, Ontario K1Y4W7, Canada.

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http://dx.doi.org/10.1016/j.athoracsur.2020.05.116DOI Listing
February 2021

Dismal Outcomes and High Societal Burden of Mitral Valve Regurgitation in France in the Recent Era: A Nationwide Perspective.

J Am Heart Assoc 2020 08 22;9(15):e016086. Epub 2020 Jul 22.

Mayo ClinicDivision of Cardiovascular DiseaseMayo Medical School Rochester MN.

Background Although US recent data suggest that mitral regurgitation (MR) is severely undertreated and carries a poor outcome, population-based views on outcome and management are limited. We aimed to define the current treatment standards, clinical outcomes, and costs related to MR at the nationwide level. Methods and Results In total, 107 412 patients with MR were admitted in France in 2014 to 2015. Within 1 year, 8% were operated and 92% were conservatively managed and constituted our study population (68% primary MR and 32% secondary MR). The mean age was 77±15 years; most patients presented with comorbidities. In-hospital and 1-year mortality rates were 4.1% and 14.3%, respectively. Readmissions were common (63% at least once and 37% readmitted ≥2 times). Rates of 1-year mortality or all-cause readmission and 1-year mortality or heart failure readmission were 67% and 34%, respectively, and increased with age, Charlson index, heart failure at admission, and secondary MR etiology; however, the event rate remained notably high in the primary MR subset (64% and 28%, respectively). The mean costs of hospital admissions and of readmissions were 5345±6432 and 10 080±10 847 euros, respectively. Conclusions At the nationwide level, MR was a common reason for admission and affected an elderly population with frequent comorbidities. Less than 10% of patients underwent a valve intervention. All subsets of patients who were conservatively managed incurred high mortality and readmissions rates, and MR represented a major societal burden with an extrapolated annual cost of 350 to 550 million euros (390-615 million US dollars). New strategies to improve the management and outcomes of patients with both primary and secondary MR are critical and warranted.
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http://dx.doi.org/10.1161/JAHA.120.016086DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7792268PMC
August 2020

Effect of Steroid in Local Infiltration Analgesia in One-Stage Bilateral Total Knee Arthroplasty: A Paired-Randomized Controlled Study.

J Knee Surg 2020 Jul 20. Epub 2020 Jul 20.

Division of Joint Replacement Surgery, Department of Orthopaedics and Traumatology, The University of Hong Kong, Queen Mary Hospital, Hong Kong, SAR, People's Republic of China.

Although local infiltration analgesia (LIA) is effective in relieving pain after total knee arthroplasty (TKA), its effect is short lasting and the optimal combination of drugs is unknown. Steroids being a potent and long-acting anti-inflammatory drug might extend LIA's effect. This study aims to evaluate the role of steroids in LIA. This is a paired-randomized controlled study involving one-stage bilateral TKA patients. LIA containing ropivacaine, ketorolac, and adrenaline with or without triamcinolone was given. One knee was randomized to receive LIA with steroids, while the other received LIA without steroids. The primary outcome was knee pain in terms of the visual analog scale (VAS). Secondary outcomes were rehabilitation progress, functional scores, and complications. Outcomes were compared between the knees of the same patient and documented up to 1 year. A total of 45 patients (90 TKAs) were included. LIA with steroid knees showed lower VAS score at rest and during activity from postoperation day 1 to 5 and at 6 weeks ( < 0.05). Passive and active range of movement was also greater in LIA with steroid group from day 1 to 7 and day 2 to 5, respectively ( < 0.05). Steroid-treated knees also achieved active straight leg raise earlier (1.2 vs. 2.0 days,  < 0.05). No differences in Knee Society Score and complication rates between both groups. Steroids in LIA offer additional and extended benefit in pain control and rehabilitation after TKA, while no adverse effects were found up to 1-year follow-up.
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http://dx.doi.org/10.1055/s-0040-1713811DOI Listing
July 2020

Comparative accuracy of non-invasive imaging versus right heart catheterization for the diagnosis of pulmonary hypertension: A systematic review and meta-analysis.

Int J Cardiol Heart Vasc 2020 Aug 1;29:100568. Epub 2020 Jul 1.

Thomas Jefferson University, PA, United States.

Background: Right heart catheterization (RHC) is the gold-standard in the diagnosis of pulmonary hypertension (PH) but at the cost of procedure-related complications. We sought to determine the comparative accuracy of RHC versus non-invasive imaging techniques such as computed tomography (CT), magnetic resonance imaging (MRI), and transthoracic echocardiography (TTE).

Methods: Pulmonary hypertension was defined as a mean pulmonary artery pressure (mPAP) of>20 mmHg. Multiple databases were queried for relevant articles. Raw data were pooled using a bivariate model to calculate the measures of diagnostic accuracy and to estimate Hierarchical Summary Receiver Operating Characteristic (HSROC) on Stata 13.

Results: A total of 51 studies with a total patient population of 3947 were selected. The pooled sensitivity and specificity of MRI for diagnosing PH was 0.92(95% confidence interval (CI) 0.88-0.96) and 0.86 (95% CI, 0.77-0.95), respectively. The net sensitivities for CT scan and TTE were 0.79 (95% CI 0.72-0.89) and 0.85 (95% CI 0.83-0.91), respectively. The overall specificity was 0.82 (0.76-0.92) for the CT scan and 0.71 (95% CI 0.61-0.84) for TTE. The diagnostic odds ratio (DOR) for MRI was 124 (95% CI 36-433) compared to 30 (95% CI 11-78) and 24 (95% 11-38) for CT scan and TTE, respectively. Chi-squared (2) test showed moderate heterogeneity on the test for equality of sensitivities and specificities.

Conclusions: MRI has the highest sensitivity and specificity compared to CT and TTE. MRI can potentially serve as a surrogate technique to RHC for the diagnosis of PH.
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http://dx.doi.org/10.1016/j.ijcha.2020.100568DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7334462PMC
August 2020

Acute Renal Failure in Critically Ill COVID-19 Patients With a Focus on the Role of Renal Replacement Therapy: A Review of What We Know So Far.

Cureus 2020 Jun 3;12(6):e8429. Epub 2020 Jun 3.

Internal Medicine, Abington Hospital, Jefferson Health, Abington, USA.

Acute renal failure remains a significant concern in all patients with the coronavirus disease 2019 (COVID-19) infection. Management is particularly challenging in critically ill patients requiring intensive care unit (ICU) level of care. Supportive care in the form of accurate volume correction and avoiding nephrotoxic agents are the chief cornerstone of the management of these patients. The pathophysiology of acute renal failure in COVID-19 is multifactorial, with significant contributions from excessive cytokine release. Gaining a better insight into the pathophysiology of renal failure will hopefully help develop more directed treatment options. A considerable number of these patients deteriorate despite adequate supportive care owing to the complexity of the disease and multi-organ involvement. Renal replacement therapy is used for a long time in critically ill septic patients who develop progressive renal failure despite adequate conservative support. Timing and choice of renal replacement therapy in critically ill COVID-19 patients remains an area of future research that may help decrease mortality in this patient population.
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http://dx.doi.org/10.7759/cureus.8429DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7336623PMC
June 2020

Correction of Bileaflet Mitral Valve Prolapse Through Reduction of Posterior Leaflet Height.

Ann Thorac Surg 2021 01 20;111(1):e55-e56. Epub 2020 Jun 20.

Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada. Electronic address:

Mitral regurgitation due to bileaflet prolapse can be corrected with height reduction of the posterior leaflet through detachment at its base, division of accompanying secondary chordae, and leaflet-annular reapproximation. This technique lowers the posterior leaflet height to approximately 1.5 cm, thereby displacing the line of coaptation posteriorly to achieve symmetry without the need for additional artificial chordae. Of 37 patients who underwent this type of repair at our institution, no patient had recurrent mitral regurgitation ≥ 2 at an average follow-up of 1.9 years (range, 0.2-4.5).
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http://dx.doi.org/10.1016/j.athoracsur.2020.04.131DOI Listing
January 2021