Faculty Bibliography

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BACKGROUND: A specific diagnosis of a lower respiratory viral infection is often difficult despite frequent clinical suspicion. This low diagnostic yield may be improved by use of sensitive detection methods and biomarkers. METHODS: The prevalence, clinical predictors and inflammatory mediator profile of respiratory viral infection in serious acute respiratory illness were investigated. Sequential bronchoalveolar lavage (BAL) fluids from all patients hospitalised with acute respiratory illness over 12 months (n=283) were tested for the presence of 17 respiratory viruses by multiplex PCR assay and for newly discovered respiratory viruses (bocavirus, WU and KI polyomaviruses) by single-target PCR. BAL samples also underwent conventional testing (direct immunoflorescence and viral culture) for respiratory virus at the clinician's discretion. 27 inflammatory mediators were measured in a subset of the patients (n=64) using a multiplex immunoassay. RESULTS: 39 respiratory viruses were detected in 37 (13.1% of total) patients by molecular testing, including rhinovirus (n=13), influenza virus (n=8), respiratory syncytial virus (n=6), human metapneumovirus (n=3), coronavirus NL63 (n=2), parainfluenza virus (n=2), adenovirus (n=1) and newly discovered viruses (n=4). Molecular methods were 3.8-fold more sensitive than conventional methods. Clinical characteristics alone were insufficient to separate patients with and without respiratory virus. The presence of respiratory virus was associated with increased levels of interferon gamma-inducible protein 10 (IP-10) (p<0.001) and eotaxin-1 (p=0.017) in BAL. CONCLUSIONS: Respiratory viruses can be found in patients with serious acute respiratory illness by use of PCR assays more frequently than previously appreciated. IP-10 may be a useful biomarker for respiratory viral infection.

BACKGROUND: Studies have reported the presence of KI polyomavirus (KIPyV) and WU polyomavirus (WUPyV) in respiratory secretions of young patients. So far, evidence has not supported a link between infections with either virus and respiratory tract disease; however, there has not been a large comparison of KIPyV-infected patients to age-matched patient groups. METHODS: A retrospective study comparing clinical aspects of KIPyV-positive patients with respiratory syncytial virus (RSV)-positive, WUPyV-positive, and respiratory-virus negative patients. Using real-time polymerase chain reaction, 2599 respiratory samples from patients ranging from 1 day to 88 years of age were tested for KIPyV. Electronic medical records were reviewed for 65 cases, for a comparison group consisting of 195 patients negative for common respiratory viruses, and for 56 WUPyV-positive patients drawn from the same population. Twelve patients testing positive for KIPyV as the sole pathogen were matched to 36 RSV-positive patients and clinical features of both groups were compared. RESULTS: Seventy-two (2.8%) respiratory samples were positive for KIPyV. Another virus was detected in 71% of the KIPyV-positive samples. Analysis showed no statistically significant differences in clinical manifestations between KIPyV-positive patients and patients negative for common respiratory viruses, however, clinical characteristics of KIPyV-positive patients were less severe than those of patients positive for RSV. KIPyVpositive patients >or=3 years of age were usually immunocompromised in contrast to the younger children with KIPyV. CONCLUSIONS: This study did not demonstrate a link between KIPyV infection and symptomatic respiratory disease. Patients positive for KIPyV exhibited less severe clinical symptoms than patients positive for RSV.

OBJECTIVE: : Long-term survival after off-pump surgery in patients with low ejection fraction was investigated. METHODS: : Three hundred forty-six patients with ejection fraction 30% or less with isolated off-pump coronary artery bypass surgery (OPCAB) were compared with a propensity matched historical group operated on-pump (ONCAB) and with data from literature after percutaneous coronary intervention and OPCAB surgery. RESULTS: : The lower invasiveness of OPCAB contributed to a significantly better 30-day survival, shorter postoperative length of stay, and fewer in-hospital complications. Incomplete revascularization of the posterior and lateral territories of the heart correlated with higher 1-year mortality. The probability of survival for 8 years after OPCAB was 50.1% (n = 76) versus 49.7% (n = 82) for ONCAB without comparable data from literature for OPCAB or percutaneous coronary intervention in these high-risk patients. CONCLUSIONS: : OPCAB surgery in patients with low ejection fraction is a viable alternative but so far without demonstrable long-term survival advantage to ONCAB.

BACKGROUND: Rotator cuff injury in the setting of type II superior labrum anterior posterior lesions is a common finding. Although predictable surgical outcomes can be expected after type II superior labrum anterior posterior repair, the effect of rotator cuff tears on surgical outcome is unknown. HYPOTHESIS: Rotator cuff tears will not negatively affect surgical outcome of type II superior labrum anterior posterior repairs. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: The study group included 93 patients younger than 50 years who underwent arthroscopic type II superior labrum anterior posterior repair and were available for review at a minimum of 2 years after surgery. Group 1 patients were identified as having normal rotator cuffs at the time of repair. Group 2 patients were identified as having rotator cuff injury at the time of repair (either partial-thickness or full-thickness tears). Statistical analysis was performed comparing the postoperative University of California, Los Angeles shoulder scores and overall improvement in University of California, Los Angeles score using the Student t test for significance. RESULTS: Mean follow-up was 2.54 years; 52.7% of patients had evidence of rotator cuff tears at the time of surgery. The mean postoperative University of California, Los Angeles score for group 1 was 32.9 (improvement of 11.0), and the mean postoperative University of California, Los Angeles score for group 2 was 33.3 (improvement of 12.2). There was not a significant difference in any of the outcome measures between groups. CONCLUSION: Predictable short-term surgical results and return to activity can be expected after repair of type II superior labrum anterior posterior lesions in patients younger than 50 years who have coexistent rotator cuff tear. Although cuff lesions did not have a negative effect on the short-term outcome in patients with type II superior labrum anterior posterior lesions, longer-term follow-up is needed to determine natural history of this pathologic condition.

AIMS: Reliable assessment of the aortic valvar apparatus (AVAp) is essential as it may facilitate consistent outcomes with percutaneous aortic valvar therapies. The commonly referenced aortic annulus is problematic since this measurement does not correspond to any actual anatomic structure. We aim to describe a reliable method of measuring relevant structures of the AVAp based on widely available computed tomography analyses. METHODS AND RESULTS: Retrospective analysis of computed tomograms of 75 patients with severe aortic stenosis (45 females, age 81.2 +/- 7.8 years). Curved multiplaner reconstruction technique was used to measure average diameters of the 'Aortic Leaflets Basal Attachment Plane' (ALBAP), sinuses of Valsalva (SV), sinutubular junction (STJ), ascending aorta (AA), and distance from coronary arteries to the base of the cusps. Angulation between the AA and the left ventricle (LV) was measured in one plane that included the LV inflow long axis and the maximum visualization of the aortic root. Inter-rater reliability and absolute agreement among three raters were evaluated. Intra-class correlation coefficients for ALBAP, SV, STJ, and AA diameters were 0.90, 0.99, 0.95, and 0.94, respectively (P < 0.001) with 95% limits of agreement of the observed differences falling in the less than 1 mm range. Intra-class correlation coefficients were 0.82 for the angle and 0.61 and 0.78 for distances to the right and left coronary arteries (P < 0.001). CONCLUSION: This method showed a high degree of inter-rater reliability and absolute agreement for AVAp diameters. Agreement was lower for AA-LV angle and distance to coronary artery measurements, emphasizing the need for software improvements and standardized image acquisition protocols.

In conflict or post-conflict situations, health system reconstruction becomes a critical component of ensuring stability. The purpose of this study was to determine the priorities for health system reconstruction among Iraqi physicians residing in the northern region of the country. A convenience sample of practicing male and female physicians residing in the Kurdish region completed a 13-item survey about health system reconstruction. A total of 1001 practitioners completed the survey with gender breakdown of 29% female and 71% male, all working in different specialty areas. Significant differences between the providers based on gender (p=0.001), specialty (p=0.001) and geographic location (p=0.004) were found to affect the responses of the participants. This study demonstrates that input from healthcare professionals is important for health system reconstruction, but that gender, geography and medical specialty make the process complex.