Utilizing Fetal Echocardiography to Risk Stratify and Predict Neonatal Outcomes in Fetuses Diagnosed with Congenital Heart Disease.

OBJECTIVE: Risk stratification of fetuses diagnosed with congenital heart disease (CHD) helps provide a delivery plan and prepare families and medical teams on expected course in the delivery room. Our aim was to assess the accuracy of echocardiographically determined risk-stratification assignments in predicting postnatal cardiac outcomes beyond the delivery room. STUDY DESIGN: This was a retrospective study at a single center evaluating all fetuses with CHD who were risk-stratified by echocardiographically determined level of care (LOC) assignment, ranging from 1a (lowest risk) to 4 (highest risk). All data were collected from January 1, 2017, to November 1, 2021. Outcomes included any unexpected cardiac interventions and neonatal clinical outcomes including in-hospital mortality, the need for prostaglandins or inotropes, and defined critical illness. These outcomes were assessed for each LOC assignment by Fisher's exact test. RESULTS: Out of 817 patients assigned a LOC, a total of 747 fetuses were included in our final cohort with a separate subanalysis of 70 fetuses diagnosed with coarctation of the aorta. The sensitivity and specificity were high for all LOC levels in predicting delivery room needs (93-100%). Higher LOC levels (3-4) had a lower positive predictive value (66-67%) indicating a high false-positive rate. Subjects with higher LOC assignments had a greater frequency of critical illness, hospital mortality, need for inotropes, need for neonatal surgical or catheterization interventions, and need for prostaglandins (p < 0.001 for all outcomes). A post-hoc analysis reviewing LOC assignments revealed a greater tendency to over-assign LOC at higher assignments (19% for LOC 3 and 4) compared to lower assignments (4% for LOC 1 and 2). CONCLUSION: Risk stratification based on fetal echocardiography can predict neonatal clinical outcomes and acuity of postnatal management needs. However, there is greater variability in expected clinical events and an expected degree of false positives for those with higher LOC assignments. KEY POINTS: · Risk stratification utilizing fetal echocardiography can be used to predict neonatal needs.. · Complex heart disease has lower positive predictive value in predicting postnatal clinical needs.. · There is a tendency to over-assign risk of acute hemodynamic instability for complex heart disease.. · False positives are expected when planning high-risk deliveries to avoid compromising situations..

Contemporary transesophageal echocardiography practice patterns among paediatric cardiology centres in the United States and Canada.

OBJECTIVE: To characterise transesophageal echocardiography practice patterns among paediatric cardiac surgical centres in the United States and Canada. METHODS: A 42-question survey was sent to 80 echocardiography laboratory directors at paediatric cardiology centres with surgical programmes in the United States and Canada. Question domains included transesophageal echocardiography centre characteristics, performance and reporting, equipment use, trainee participation, and quality assurance. RESULTS: Fifty of the 80 centres (62.5%) responded to the survey. Most settings were academic (86.0%) with 42.0% of centres performing > 350 surgical cases/year. The median number of transesophageal echocardiograms performed/cardiologist/year was 50 (26, 73). Pre-operative transesophageal echocardiography was performed in most surgical cases by 91.7% of centres. Transesophageal echocardiography was always performed by most centres following Norwood, Glenn, and Fontan procedures and by < 10% of centres following coarctation repair. Many centres with a written guideline allowed transesophageal echocardiography transducer use at weights below manufacturer recommendations (50.0 and 61.1% for neonatal and paediatric transducers, respectively). Most centres (36/37, 97.3%) with categorical fellowships had rotations which included transesophageal echocardiography participation. Large surgical centres (>350 cases/year) had higher median number of transesophageal echocardiograms/cardiologist/year (75.5 [53, 86] versus 35 [20, 52], p < 0.001) and more frequently used anaesthesia for diagnostic transesophageal echocardiography ≥ 67% of time (100.0 versus 62.1%, p = 0.001). CONCLUSIONS: There is significant variability in transesophageal echocardiography practice patterns and training requirements among paediatric cardiology centres in the United States and Canada. Findings may help inform programmatic decisions regarding transesophageal echocardiography expectations, performance and reporting, equipment use, trainee involvement, and quality assurance.

A randomised controlled clinical trial to assess the benefits of a telecare tool delivered prior to the initial hearing assessment.

OBJECTIVE: To assess the benefits of the Ida Institute's Why improve my hearing? Telecare Tool used before the initial hearing assessment appointment. DESIGN: A prospective, single-blind randomised clinical trial with two arms: (i) Why improve my hearing? Telecare Tool intervention, and (ii) standard care control. STUDY SAMPLE: Adults with hearing loss were recruited from two Audiology Services within the United Kingdom's publicly-funded National Health Service. Of 461 individuals assessed for eligibility, 57 were eligible to participate. RESULTS: Measure of Audiologic Rehabilitation Self-efficacy for Hearing Aids (primary outcome) scores did not differ between groups from baseline to post-assessment (Mean change [Δ]= -2.28; 95% confidence interval [CI]= -6.70, 2.15, p= .307) and 10-weeks follow-up (Mean Δ= -2.69; 95% CI= -9.52, 4.15, p = .434). However, Short Form Patient Activation Measure scores significantly improved in the intervention group compared to the control group from baseline to post-assessment (Mean Δ= -6.06, 95% CI= -11.31, -0.82, p = .024, ES= .61) and 10-weeks follow-up (Mean Δ= -9.87, 95% CI= -15.34, -4.40, p = .001, ES= -.97). CONCLUSIONS: This study demonstrates that while a patient-centred telecare intervention completed before management decisions may not improve an individual's self-efficacy to manage their hearing loss, it can lead to improvements in readiness.

Minimal clinically important difference in days at home up to 30 days after surgery.

Patient-centred outcomes are increasingly recognised as crucial measures of healthcare quality. Days alive and at home up to 30 days after surgery (DAH30 ) is a validated and readily obtainable patient-centred outcome measure that integrates much of the peri-operative patient journey. However, the minimal difference in DAH30 that is clinically important to patients is unknown. We designed and administered a 28-item survey to evaluate the minimal clinically important difference in DAH30 among adult patients undergoing inpatient surgery. Patients were approached pre-operatively or within 2 days postoperatively. We did not study patients undergoing day surgery or nursing home residents. Patients ranked their opinions on the importance of discharge home using a Likert scale (from 1, not important at all to 6, extremely important) and the minimum number of extra days at home that would be meaningful using this scale. We recruited 104 patients; the survey was administered pre-operatively to 45 patients and postoperatively to 59 patients. The mean (SD) age was 53.5 (16.5) years, and 51 (49%) patients were male. Patients underwent a broad range of surgery of mainly intermediate (55%) to major (33%) severity. The median minimal clinically important difference for DAH30 was 3 days; this was consistent across a broad range of scenarios, including earlier discharge home, complications delaying hospital discharge and the requirement for admission to a rehabilitation unit. Discharge home earlier than anticipated and discharge home rather than to a rehabilitation facility were both rated as important (median score = 5). Empirical data on the minimal clinically important difference for DAH30 may be useful to determine sample size and to guide the non-inferiority margin for future clinical trials.

HEARTBEAT4D: An Open-source Toolbox for Turning 4D Cardiac CT into VR/AR.

Four-dimensional data sets are increasingly common in MRI and CT. While clinical visualization often focuses on individual temporal phases capturing the tissue(s) of interest, it may be possible to gain additional insight through exploring animated 3D reconstructions of physiological motion made possible by augmented or virtual reality representations of 4D patient imaging. Cardiac CT acquisitions can provide sufficient spatial resolution and temporal data to support advanced visualization, however, there are no open-source tools readily available to facilitate the transformation from raw medical images to dynamic and interactive augmented or virtual reality representations. To address this gap, we developed a workflow using free and open-source tools to process 4D cardiac CT imaging starting from raw DICOM data and ending with dynamic AR representations viewable on a phone, tablet, or computer. In addition to assembling the workflow using existing platforms (3D Slicer and Unity), we also contribute two new features: 1. custom software which can propagate a segmentation created for one cardiac phase to all others and export to surface files in a fully automated fashion, and 2. a user interface and linked code for the animation and interactive review of the surfaces in augmented reality. Validation of the surface-based areas demonstrated excellent correlation with radiologists' image-based areas (R > 0.99). While our tools were developed specifically for 4D cardiac CT, the open framework will allow it to serve as a blueprint for similar applications applied to 4D imaging of other tissues and using other modalities. We anticipate this and related workflows will be useful both clinically and for educational purposes.

Clinical predictors of donor antibody titre and correlation with recipient antibody response in a COVID-19 convalescent plasma clinical trial.

BACKGROUND: Convalescent plasma therapy for COVID-19 relies on transfer of anti-viral antibody from donors to recipients via plasma transfusion. The relationship between clinical characteristics and antibody response to COVID-19 is not well defined. We investigated predictors of convalescent antibody production and quantified recipient antibody response in a convalescent plasma therapy clinical trial. METHODS: Multivariable analysis of clinical and serological parameters in 103 confirmed COVID-19 convalescent plasma donors 28 days or more following symptom resolution was performed. Mixed-effects regression models with piecewise linear trends were used to characterize serial antibody responses in 10 convalescent plasma recipients with severe COVID-19. RESULTS: Donor antibody titres ranged from 0 to 1 : 3892 (anti-receptor binding domain (RBD)) and 0 to 1 : 3289 (anti-spike). Higher anti-RBD and anti-spike titres were associated with increased age, hospitalization for COVID-19, fever and absence of myalgia (all P < 0.05). Fatigue was significantly associated with anti-RBD (P = 0.03). In pairwise comparison amongst ABO blood types, AB donors had higher anti-RBD and anti-spike than O donors (P < 0.05). No toxicity was associated with plasma transfusion. Non-ECMO recipient anti-RBD antibody titre increased on average 31% per day during the first three days post-transfusion (P = 0.01) and anti-spike antibody titre by 40.3% (P = 0.02). CONCLUSION: Advanced age, fever, absence of myalgia, fatigue, blood type and hospitalization were associated with higher convalescent antibody titre to COVID-19. Despite variability in donor titre, 80% of convalescent plasma recipients showed significant increase in antibody levels post-transfusion. A more complete understanding of the dose-response effect of plasma transfusion amongst COVID-19-infected patients is needed.

OVPSYCH2: A randomized controlled trial of psychological support versus standard of care following chemotherapy for ovarian cancer.

BACKGROUND: Fear of disease progression (FOP) is a rational concern for women with Ovarian Cancer (OC) and depression is also common. To date there have been no randomized trials assessing the impact of psychological intervention on depression and FOP in this patient group. PATIENTS AND METHODS: Patients with primary or recurrent OC who had recently completed chemotherapy were eligible if they scored between 5 and 19 on the PHQ-9 depression and were randomized 1:1 to Intervention (3 standardized CBT-based sessions in the 6-12 weeks post-chemotherapy) or Control (standard of care). PHQ-9, FOP-Q-SF, EORTC QLQ C30 and OV28 questionnaires were then completed every 3 months for up to 2 years. The primary endpoint was change in PHQ-9 at 3 months. Secondary endpoints were change in other scores at 3 months and all scores at later timepoints. RESULTS: 182 patients registered; 107 were randomized; 54 to Intervention and 53 to Control; mean age 59 years; 75 (70%) had completed chemotherapy for primary and 32 (30%) for relapsed OC and 67 patients completed both baseline and 3-month questionnaires. Improvement in PHQ-9 was observed for patients in both study arms at three months compared to baseline but there was no significant difference in change between Intervention and Control. A significant improvement on FOP-Q-SF scores was seen in the Intervention arm, whereas for those in the Control arm FOP-Q-SF scores deteriorated at 3 months (intervention effect = -4.4 (-7.57, -1.22), p-value = 0.008). CONCLUSIONS: CBT-based psychological support provided after chemotherapy did not significantly alter the spontaneously improving trajectory of depression scores at three months but caused a significant improvement in FOP. Our findings call for the routine implementation of FOP support for ovarian cancer patients.

Heritable epigenetic diversity for conservation and utilization of epigenetic germplasm resources of clonal East African Highland banana (EAHB) accessions.

KEY MESSAGE: Genetically identical East African Highland banana (EAHB) clones are epigenetically diverse with heritable epialleles that can contribute to morphological diversity. Heritable epigenetic variation can contribute to agronomic traits in crops and should be considered in germplasm conservation. Despite the genetic uniformity arising from a genetic bottleneck of one ancestral clone, followed by subsequent vegetative propagation, East African Highland bananas (EAHBs) display significant phenotypic diversity potentially arising from somatic mutations, heritable epialleles and/or genotype-by-environment interactions. Here, we use DNA methylation profiling across EAHB accessions representing most of the primary EAHB genepool to demonstrate that the genetically uniform EAHB genepool harbours significant epigenetic diversity. By analysing 724 polymorphic DNA methylation sites by methylation-sensitive AFLP across 90 EAHB cultivars, we could differentiate the EAHB varieties according to their regions (Kenya and Uganda). In contrast, there was minimal association of DNA methylation variation with the five morphological groups that are used to classify EAHBs. We further analysed DNA methylation patterns in parent-offspring cohort, which were maintained in offspring generated by sexual (seed) and asexual (vegetative) propagation, with higher levels of altered DNA methylation observed in vegetatively generated offspring. Our results indicate that the phenotypic diversity of near-isogenic EAHBs is mirrored by considerable DNA methylation variation, which is transmitted between generations by both vegetative reproduction and seed reproduction. Genetically uniform vegetatively propagated crops such as EAHBs harbour considerable heritable epigenetic variation, where heritable epialleles could arise in offspring and contribute to functional traits. This study provides a basis for developing strategies for conservation of epigenetic resources and for integration of epimarkers into crop breeding programmes.

Defining peri-operative anaemia in pregnant women - challenging the status quo.

Peri-operative anaemia is a significant risk factor for morbidity and mortality. Anaemia during pregnancy is associated with adverse maternal and neonatal outcomes, and postpartum haemorrhage remains a leading cause of maternal mortality worldwide. Caesarean section is an operation incurring moderate risk of bleeding, and rates are rising globally. Recent international consensus guidelines recommend targeting a pre-operative haemoglobin > 130 g.l-1 for all patients having surgery with moderate-to-high risk of bleeding, regardless of sex. It is unclear how this recommendation translates to pregnant women, where anaemia is defined at a much lower haemoglobin level of < 110 g.l-1 . Long-standing definitions of anaemia during pregnancy are likely to be the result of flawed sampling of a so-called 'normal' but anaemic female population, given the high prevalence of iron deficiency and anaemia in healthy menstruating women. Contemporary data suggest that haemoglobin values in iron-replete pregnant women are higher than previously thought. The definition of anaemia has significant clinical implications, particularly for peri-operative management of women undergoing caesarean section. In addition, we should differentiate between lower reference values and optimal haemoglobin targets. The haemoglobin level associated with optimal obstetric and neonatal outcomes requires further investigation in pregnant women.

Cancer league actions against sunbed use for skin cancer prevention.

The incidence of non-melanoma and melanoma skin cancer has been rising in Europe. Although the World Health Organization's International Agency for Research on Cancer has since 2009 classified sunbeds as a Group 1 carcinogen, sunbed use, especially by those under the age of 18, continues to be a concern. As the only platform for cancer leagues in Europe, the Association of European Cancer Leagues decided to explore interest and actions by its member leagues at the national level against sunbed use, to share experiences and to provide background information on possible future collective actions at the EU level.

ISDE Presidential Biography: David B. Skinner, MD.

Dr. David Skinner, the 4th President of the ISDE, was a world-renowned surgeon, educator, scholar, and leader. He participated in the formation of the ISDE, hosted two international congresses in 1983 and 1989, and made important advances in the ISDE during his presidential tenure 1992-1995.

Routine germline BRCA1 and BRCA2 testing in patients with ovarian carcinoma: analysis of the Scottish real-life experience.

OBJECTIVE: To determine the rates of germline BRCA1 and BRCA2 mutations in Scottish patients with ovarian cancer, before and after a change in testing policy. DESIGN: Retrospective cohort study. SETTING: Four cancer/genetics centres in Scotland. POPULATION: Patients with ovarian cancer undergoing germline BRCA1 and BRCA2 (gBRCA1/2) sequencing before 2013 (under the 'old criteria', with selection based solely on family history), after 2013 (under the 'new criteria', with sequencing offered to newly presenting patients with non-mucinous ovarian cancer), and in the 'prevalent population' (who presented before 2013, but were not eligible for sequencing under the old criteria but were sequenced under the new criteria). METHODS: Clinicopathological and sequence data were collected before and for 18 months after this change in selection criteria. MAIN OUTCOME MEASURES: Frequency of germline BRCA1, BRCA2, RAD51C, and RAD51D mutations. RESULTS: Of 599 patients sequenced, 205, 236, and 158 were in the 'old criteria', 'new criteria', and 'prevalent' populations, respectively. The frequency of gBRCA1/2 mutations was 30.7, 13.1, and 12.7%, respectively. The annual rate of gBRCA1/2 mutation detection was 4.2 before and 20.7 after the policy change. A total of 48% (15/31) 'new criteria' patients with gBRCA1/2 mutations had a Manchester score of <15 and would not have been offered sequencing based on family history criteria. In addition, 20 patients with gBRCA1/2 were identified in the prevalent population. The prevalence of gBRCA1/2 mutations in patients aged >70 years was 8.2%. CONCLUSIONS: Sequencing all patients with non-mucinous ovarian cancer gives a much higher annual gBRCA1/2 mutation detection rate, with the frequency of positive tests still exceeding the 10% threshold upon which many family history-based models operate. TWEETABLE ABSTRACT: BRCA sequencing all non-mucinous cancer patients increases mutation detection five fold.

A pilot study of cardiopulmonary exercise testing and cardiac stress positron emission tomography before major non-cardiac surgery.

Cardiac events are a common cause of peri-operative morbidity. Cardiopulmonary exercise testing can objectively assess risk, but it does not quantify myocardial ischaemia. With appropriate dietary preparation to suppress basal myocardial glucose uptake, positron emission tomography with 18 F-fluorodeoxyglucose can identify post-ischaemic myocardium, providing an attractive complement to exercise testing. We aimed to investigate the feasibility of this diagnostic algorithm. Patients referred for cardiopulmonary exercise testing before major cancer surgery were prospectively recruited. Exercise testing and positron emission tomography imaging were performed after a high fat-low carbohydrate meal. Protocol feasibility (primary end-point) included compliance with pre-test diet instructions and the completion of tests. Stress myocardial perfusion imaging was performed if either exercise testing or positron emission tomography was equivocal or positive for ischaemia. We recorded cardiac complications for 30 postoperative days. We enrolled 26 participants, 20 of whom completed protocol. Twenty-one participants proceeded to surgery: myocardial injury or infarction was diagnosed in three participants, two of whom had positive or equivocal positron emission tomography but negative myocardial perfusion imaging. We have shown that pre-operative cardiac positron emission tomography after cardiopulmonary exercise testing is feasible; protocol deviations were minor and did not affect image quality. Our findings warrant further investigation to compare the diagnostic utility of cardiac positron emission tomography imaging with standard pre-operative stress tests.

The 2018 ISDE achalasia guidelines.

Achalasia is a relatively rare primary motor esophageal disorder, characterized by absence of relaxations of the lower esophageal sphincter and of peristalsis along the esophageal body. As a result, patients typically present with dysphagia, regurgitation and occasionally chest pain, pulmonary complication and malnutrition. New diagnostic methodologies and therapeutic techniques have been recently added to the armamentarium for treating achalasia. With the aim to offer clinicians and patients an up-to-date framework for making informed decisions on the management of this disease, the International Society for Diseases of the Esophagus Guidelines proposed and endorsed the Esophageal Achalasia Guidelines (I-GOAL). The guidelines were prepared according the Appraisal of Guidelines for Research and Evaluation (AGREE-REX) tool, accredited for guideline production by NICE UK. A systematic literature search was performed and the quality of evidence and the strength of recommendations were graded according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE). Given the relative rarity of this disease and the paucity of high-level evidence in the literature, this process was integrated with a three-step process of anonymous voting on each statement (DELPHI). Only statements with an approval rate >80% were accepted in the guidelines. Fifty-one experts from 11 countries and 3 representatives from patient support associations participated to the preparations of the guidelines. These guidelines deal specifically with the following achalasia issues: Diagnostic workup, Definition of the disease, Severity of presentation, Medical treatment, Botulinum Toxin injection, Pneumatic dilatation, POEM, Other endoscopic treatments, Laparoscopic myotomy, Definition of recurrence, Follow up and risk of cancer, Management of end stage achalasia, Treatment options for failure, Achalasia in children, Achalasia secondary to Chagas' disease.

eHealth readiness of dietitians.

BACKGROUND: The present study aimed to determine the eHealth readiness and changes over time of dietitians in Australia. METHODS: Two cross-sectional analyses of Australian dietitians were conducted in 2013 and 2016, using a survey adapted from one conducted in 2011 by the US Academy of Nutrition and Dietetics. The survey encompassed 30 questions on eHealth readiness across five dimensions: access, standards, attitude, aptitude and advocacy. Descriptive statistics, independent t-tests, chi-squared tests and Z-tests were computed to compare responses from the 2013 and 2016 surveys. RESULTS: The survey completion rate represented 14.5% (747) of the Dietitians Association of Australia members in 2013 and 8% (417) in 2016. The survey responses in relation to access and standards suggest that dietitians are well positioned for eHealth. For attitude and aptitude, there is a moderate level of preparedness, with minor improvements over time. Although showing significant improvement (P < 0.05), advocacy highlights the area requiring the most development because the majority of dietitians (61%) reported 'no role' in eHealth solutions. CONCLUSIONS: Dietitians are progressing in relation to access, attitudinal and aptitudinal readiness for eHealth, although they rate poorly with respect to advocacy readiness. It was concluded that dietitians are not yet ready, and also that valuable opportunities to achieve the benefits that eHealth can deliver will be missed, if dietitians do not take the lead in guiding the development, selection and implementation of nutrition-related technologies. Strengthening the dimension of advocacy and ensuring collaboration across the profession, drawing on the varying expertise demonstrated across the practice areas and by the different generations, will be central to improving dietitian eHealth readiness.

Nutritional monitoring of patients post-bariatric surgery: implications for smartphone applications.

BACKGROUND: Optimal results from bariatric surgery are contingent on patient commitment to dietary and lifestyle changes and follow-up care. The present study aimed to investigate the attitudes and use of mobile health (mHealth) smartphone applications (apps) as a potential tool for maintaining connectivity between dietitians and patients post-bariatric surgery. METHODS: A cross-sectional online survey was developed and distributed to a purposeful sample of bariatric dietitians and bariatric patients in Australia. The survey questions explored technology penetration (smartphone and app use), communication preferences, nutrition monitoring methods, professional relationship expectations and reasons for loss to follow-up. RESULTS: Survey completion rate was 85% (n = 50/59) for dietitians and 80% (n = 39/49) for patients. Smartphone ownership was 98% and 95% for dietitians and patients, respectively. Common reasons given for losing patients to follow-up suggest that a traditional in-clinic practice setting could be a barrier for some. Most dietitians (n = 48; 91%) prefer to see patients face-to-face in their clinic, whereas patient preferences extended to e-mail and mobile messaging. Sixty-eight percent of bariatric patients were receptive to two-way communication with dietitians via an app between clinic visits. Both cohorts recognised the potential for emerging technologies to be used in practice, although there was no single routinely recommended mHealth app. CONCLUSIONS: The present study provides the first insight into the use of mobile devices and apps by post-bariatric patients and the dietitians who support them. A mixture of traditional methods and smartphone technology is desirable to both dietitians and patients. The utility and effectiveness of such technologies should be confirmed in future intervention studies.

QTL associated with resistance to cassava brown streak and cassava mosaic diseases in a bi-parental cross of two Tanzanian farmer varieties, Namikonga and Albert.

KEY MESSAGE: QTL consistent across seasons were detected for resistance to cassava brown streak disease induced root necrosis and foliar symptoms. The CMD2 locus was detected in an East African landrace, and comprised two QTL. Cassava production in Africa is compromised by cassava brown streak disease (CBSD) and cassava mosaic disease (CMD). To reduce costs and increase the precision of resistance breeding, a QTL study was conducted to identify molecular markers linked to resistance against these diseases. A bi-parental F1 mapping population was developed from a cross between the Tanzanian farmer varieties, Namikonga and Albert. A one-step genetic linkage map comprising 943 SNP markers and 18 linkage groups spanning 1776.2 cM was generated. Phenotypic data from 240 F1 progeny were obtained from two disease hotspots in Tanzania, over two successive seasons, 2013 and 2014. Two consistent QTLs linked to resistance to CBSD-induced root necrosis were identified in Namikonga on chromosomes II (qCBSDRNFc2Nm) and XI (qCBSDRNc11Nm) and a putative QTL on chromosome XVIII (qCBSDRNc18Nm). qCBSDRNFc2Nm was identified at Naliendele in both seasons. The same QTL was also associated with CBSD foliar resistance. qCBSDRNc11Nm was identified at Chambezi in both seasons, and was characterized by three peaks, spanning a distance of 253 kb. Twenty-seven genes were identified within this region including two LRR proteins and a signal recognition particle. In addition, two highly significant CMD resistance QTL (qCMDc12.1A and qCMDc12.2A) were detected in Albert, on chromosome 12. Both qCMDc12.1A and qCMDc12.2A lay within the range of markers reported earlier, defining the CMD2 locus. This is the first time that two loci have been identified within the CMD2 QTL, and in germplasm of apparent East African origin. Additional QTLs with minor effects on CBSD and CMD resistance were also identified.

Extremes of body mass index and postoperative complications after esophagectomy.

Obesity has been variously associated with reduced or similar rates of postoperative complications compared to normal weight patients undergoing esophagectomy for cancer. In contrast, little is known about esophagectomy risks in the underweight population. The relationship between the extremes of body mass index (BMI) and postoperative complications after esophagectomy was evaluated. Consecutive esophagectomy patients (2000-2013) were reviewed. The patients were stratified based on BMI at the time of diagnosis: underweight (<18.5), normal (18.5-24.9), overweight (25-29.9), obese I (30-34.9), and obese II or III (≥35). Hospital length of stay as well as postoperative complications and their accordion severity grading were evaluated according to the BMI category. Of 388 patients, 78.6% were male with a median age of 62 years at the time of operation. Pathologic cancer stage was 0 to I in 53%. BMI distribution was as follows: 5.6% underweight, 28.7% normal, 31.4% overweight, 22.8% obese I, and 11.5% obese II or III. Performance status was 0 or 1 in 99.2%. Compared to normal BMI patients, underweight patients had increased pulmonary complications (odds ratio (OR) 3.32, P = 0.014) and increased other postoperative complications (OR 3.00, P = 0.043). Patients who were overweight did not have increased complications compared to normal BMI patients. BMI groups did not differ in mortality rates or complication accordion severity grading. Hospital length of stay trended toward a longer duration in the underweight population (P = 0.06). Underweight patients are at increased risk for postoperative pulmonary and other complications. Underweight patients may benefit from preoperative nutritional repletion and mitigation for sarcopenia. Aggressive postoperative pulmonary care may help reduce complications in these patients. In contrast, the operative risk in overweight and obese patients is similar to normal BMI patients.

Counseling Practices for Fetal Hypoplastic Left Heart Syndrome.

While counseling parents of a fetus diagnosed with hypoplastic left heart syndrome (HLHS), pediatric cardiologists play a critical role in shaping a family's expectations for the months and years to come. However, techniques for the most effective counseling practices have not been studied, and significant variation among physicians is likely present. Web-based survey of pediatric cardiologists that perform fetal echocardiography using snowball sampling. 201 physicians responded (61% male, 81% from academic centers, and 95% from the U.S.), with an average experience of 12 years. The majority of respondents (73%) typically received initial referrals for HLHS between 20 and 24 weeks of gestation. Most physicians counsel families alone (54%), while others counsel with a nurse (35%), social worker (12%), and/or maternal-fetal medicine colleague (15%). Termination of pregnancy was discussed by 79% of respondents, although 15% did not know their state's legal limit for termination. While initial counseling sessions routinely described the typical earlier ramifications of HLHS, many long-term sequelae of the disease were not commonly discussed. Content of counseling was affected by region of the country, but not by practice setting, experience, or fetal volume. Respondents identified multiple barriers that limited their counseling practices. Our data suggest that current counseling practices often fail to cover important information. Perceived barriers to a full discourse on long-term sequelae of HLHS are common and may lead to a disconnect between reality and a family's understanding of the natural history of palliated HLHS. Opportunities to improve counseling practices exist, and there may be benefits to gain from more formal training.

Worldwide Esophageal Cancer Collaboration: pathologic staging data.

We report data-simple descriptions of patient characteristics, cancer categories, and non-risk-adjusted survival-for patients with pathologically staged cancer of the esophagus and esophagogastric junction after resection or ablation with no preoperative therapy from the Worldwide Esophageal Cancer Collaboration (WECC). Thirty-three institutions from six continents submitted de-identified data using standard definitions: demographics, comorbidities, clinical cancer categories, and all-cause mortality from first management decision. Of 13,300 patients, 5,631 had squamous cell carcinoma, 7,558 adenocarcinoma, 85 adenosquamous carcinoma, and 26 undifferentiated carcinoma. Patients were older (62 years) men (80%) with normal body mass index (51%), little weight loss (1.8 kg), 0-2 ECOG performance status (83%), and a history of smoking (70%). Cancers were pT1 (24%), pT2 (15%), pT3 (50%), pN0 (52%), pM0 (93%), and pG2-G3 (78%); most involved distal esophagus (71%). Non-risk-adjusted survival for both squamous cell carcinoma and adenocarcinoma was monotonic and distinctive across pTNM. Survival was more distinctive for adenocarcinoma than squamous cell carcinoma when pT was ordered by pN. Survival for pTis-1 adenocarcinoma was better than for squamous cell carcinoma, although monotonic and distinctive for both. WECC pathologic staging data is improved over that of the 7th edition, with more patients studied and patient and cancer variables collected. These data will be the basis for the 8th edition cancer staging manuals following risk adjustment for patient, cancer, and treatment characteristics, and should direct 9th edition data collection. However, the role of pure pathologic staging as the principal point of reference for esophageal cancer staging is waning.