Do Multidisciplinary Tumor Board Discussions Correlate With Increase in 5-Year Survival? A Meta-Analysis Study.

Introduction: Due to the complex nature of cancer cases, it is imperative that the involved healthcare providers coordinate the patients care plan in union to reach the best possible outcome in the smoothest and fastest manner. This is what multidisciplinary tumor board (MTB) meetings strive to achieve. Conducting regular MTB meetings requires significant investment of time and finances. It is thus vital to assess the empirical benefits of such practice. Methods: A meta-analysis was conducted to evaluate the literature regarding the impact of MTB meetings on patient 5-year survival. Relevant studies were identified by searching Ovid MEDLINE and Embase databases from January 1995 to July 2019. Studies were included if they assessed 5-year survival in cases discussed in MTB meetings and used a comparison group and/or a pretest and posttest design. Results: Five articles met the study's inclusion criteria. Quality of studies was affected by selection bias and the use of historic cohorts. The results showed significantly improved 5-year survival in the MTB group compared with the non-MTB groups (odds ratio for 5-year death rate of 0.59, CI 0.45-0.78, p < 0.001). Conclusion: This meta-analysis showed that cancer MTB meetings have a significant impact on patients' 5-year survival. This could be because of several reasons, such as less time to treatment initiation, better adherence to guidelines, higher numbers of investigational imaging, lesser surgical complications, and recurrence rates. Future prospective studies are needed to further delineate reasons for improvement of outcome to enhance the benefits of this approach.

Early Outcomes for In Situ Pericardial Roll Repair for Distant Anomalous Pulmonary Venous Return.

BACKGROUND: Repair of anomalous pulmonary venous return (APVR) when veins are remote from the left atrium (LA) is challenging and may eventuate in a higher prevalence of pulmonary vein stenosis, superior vena cava stenosis, or intracardiac baffle obstruction. We describe our experience in 6 patients with a technique, using both anterior and posterior in situ pericardial roll repairs, which reduces these complications. METHODS: Six patients underwent in situ pericardial roll repair of APVR at Cleveland Clinic between 2018 and 2019. Median age was 40 years (range, 0.25-65 years). Three patients had partial APVR of right upper and middle veins into superior vena cava high above the right pulmonary artery without atrial septal defect; 2 had scimitar syndrome, and the infant had heterotaxy with unbalanced atrioventricular canal and mixed obstructed total APVR. The anomalous pulmonary vein drained into the respective cava far from the LA, which was not ideal for traditional repair techniques. In situ pericardial roll directed anomalous pulmonary vein to the LA. Most patients had concomitant complex cardiac procedures. RESULTS: There was no mortality. Median hospital stay was 23 days (range, 4-60 days) and median follow-up was 20 months (range, 1-36 months). The infant required percutaneous dilatation and stenting of LA anastomosis but since underwent ventricular switch. At last follow-up, pulmonary veins were unobstructed and adult patients were asymptomatic with excellent functional status. CONCLUSIONS: In situ autologous pericardial roll is a useful technique that abrogates the need for mobilization of distant anomalous pulmonary vein with direct anastomosis or complex intracardiac baffles. It is suitable for multiple anatomic configurations and can be used in infants and adults.

Early Outcomes of Transconal Repair of Transseptal Anomalous Left Coronary Artery From Right Sinus.

BACKGROUND: Anomalous aortic origin of the left coronary artery (AAOCLA) with an extended transseptal course behind the right ventricular outflow tract (RVOT) is a rare variant that poses challenges not addressed by current surgical techniques. We utilized a novel transconal approach in 7 consecutive patients. METHODS: A retrospective review was made of a prospectively collected database for consecutive patients undergoing transconal unroofing of transseptal AAOLCA. Surgical repair entails transection of the RVOT, unroofing the septal course of the AAOLCA, followed by RVOT extension with a rectangular strip of autologous pericardium. Preoperative characteristics, operative details, and postoperative course were abstracted. RESULTS: All 7 patients identified were symptomatic. Median age was 48 years (range, 12 to 62). The AAOLCA with transseptal course was confirmed by computed tomography angiography. Three patients had provocative testing demonstrating anterolateral ischemia. Four patients underwent cardiac catheterization with intravascular ultrasound and indexed fractional flow reserve, confirming flow-limiting lesion. Importantly, 3 patients had negative provocative noninvasive testing for ischemia. Median postoperative hospital length of stay was 6 days (range, 4 to 12). No mortality or major complications occurred during a median follow-up of 0.75 years. Postoperative evaluation demonstrated anatomically patent unroofed AAOLCA with improved indexed fractional flow reserve compared with preoperative (0.59 ± 0.16 vs 0.90 ± 0.03, P = .05). CONCLUSIONS: Complete unroofing of AAOLCA with transseptal course repaired with posterior extension of RVOT is an effective technique with excellent early outcome. Multimodality provocative testing is critical to evaluate these lesions as individual studies may be misleading. Intravascular ultrasound with indexed fractional flow reserve is clinically useful to confirm the hemodynamic significance of specific lesions.

Atrial function in the Fontan circulation: comparison with invasively assessed systemic ventricular filling pressure.

Abnormal atrial mechanics in biventricular circulations have been associated with elevated left heart filling pressures. Similar associations in the Fontan circulation are unknown. The aim of this study was to examine the relationship between atrial mechanics and invasively assessed hemodynamic parameters late after the Fontan operation. Thirty-nine Fontan patients with echocardiographic and invasive hemodynamic studies done within 48 h were included and were compared to 40 age-matched healthy controls. Atrial and ventricular strain measurements were measured offline using 2-dimensional speckle-tracking. Mean age was 10.2 ± 6.7 years and 24 (62%) were male. Atrial strain measures were lower in Fontan patients compared to healthy controls. There was no significant association between atrial strain measurements and Fontan systemic ventricular filling pressures (SVFP) as indicated by pulmonary artery occlusion pressures, direct left atrial pressure or systemic ventricular end-diastolic pressure. Global atrial strain was not correlated with segmental atrial strain in the pulmonary venous atrium. Global atrial reservoir strain was positively correlated with pulmonary vascular resistance (r = 0.508, p = 0.045). Global atrial conduit strain was positively correlated with E/A ratio of the AV valve inflow (r = 0.555, p = 0.002). Atrial and ventricular strain measurements were not significantly correlated. In patients with a Fontan, global atrial function is significantly depressed, and is uncoupled from segmental left lateral atrial function. Global as well as segmental atrial mechanics are not significantly associated with SVFPs in Fontan patients. Instead, global atrial reservoir function appears to parallel pulmonary vascular resistance.

The Adult Patient with a Fontan.

The authors summarize the most important anatomic and physiologic substrates of Fontan circulation. Common anatomic substrates include hypoplastic left heart syndrome, tricuspid atresia, double inlet left ventricle, and unbalanced atrioventricular septal defects. After the Fontan operation exercise capacity is limited and the key hemodynamic drivers is limited preload due to a relatively fixed pulmonary vascular resistance. The authors provide contemporary data on survival, morbidity, and need for reintervention. Operative morality is now expected to be less than 1% and 30 year survival approximately 89%. The authors delineate potential therapeutic approaches for the potential late complications.

Management principles in patients with COVID-19: perspectives from a growing global experience with emphasis on cardiovascular surveillance.

The COVID-19, due to SARS-CoV-2, has uncovered many real-world issues when it comes to healthcare management and has led to a widespread mortality. Observations thus far from the reports of COVID-19 have indicated that certain risk groups for example, those with pre-existing cardiovascular (CV) disease, hypertension, diabetes, chronic kidney disease and tobacco use are prone to disease development and specifically development of severe disease and possible fatality. It is increasingly evident that many CV conditions occur frequently. These include myopericarditis, acute coronary syndromes, thrombosis, arrhythmias, hypertension and heart failure. Many professional organisations and societies related to cardiology have produced guidelines or recommendations on most of the above-mentioned aspects. Given these rapid developments, the aims of this review manuscript were to summarise and integrate recent publications with newly developed guidelines and with the first-hand experience of frontline physicians and to yield a pragmatic insight and approach to CV complications of COVID-19. We emphasise on a strategic tier-based approach for initial assessment and management of COVID-19, and then delve into focused areas within CV domains, and additionally highlighting the role of point-of-care ultrasound especially lung ultrasound, echocardiography and electrocardiography, in the management of these patients. We hope this paper will serve as a useful tool in the CV management of COVID-19 for clinicians practicing in both developing and developed countries.

Can blended learning and the flipped classroom improve student learning and satisfaction in Saudi Arabia?

OBJECTIVES: To evaluate student academic performance and perception towards blended learning and flipped classrooms in comparison to traditional teaching. METHODS: This study was conducted during the hematology block on year three students. Five lectures were delivered online only. Asynchronous discussion boards were created where students could interact with colleagues and instructors. A flipped classroom was introduced with application exercises. Summative assessment results were compared with previous year results as a historical control for statistical significance. Student feedback regarding their blended learning experience was collected. RESULTS: A total of 127 responses were obtained. Approximately 22.8% students felt all lectures should be delivered through didactic lecturing, while almost 35% felt that 20% of total lectures should be given online. Students expressed satisfaction with blended learning as a new and effective learning approach. The majority of students reported blended learning was helpful for exam preparation and concept clarification. However, a comparison of grades did not show a statistically significant increase in the academic performance of students taught via the blended learning method. CONCLUSIONS: Learning experiences can be enriched by adopting a blended method of instruction at various stages of undergraduate and postgraduate education. Our results suggest that blended learning, a relatively new concept in Saudi Arabia, shows promising results with higher student satisfaction. Flipped classrooms replace passive lecturing with active student-centered learning that enhances critical thinking and application, including information retention.