Stereotactic radiosurgery training patterns across neurosurgical programs: a multi-national survey

Cancer shared this article with you from Inoreader Stereotactic radiosurgery training patterns across neurosurgical programs: a multi-national survey Via Latest Results for Journal of Neuro-Oncology Abstract Introduction The field of neurosurgery has witnessed a dramatic increase in the use of stereotactic radiosurgery (SRS) as a modality to treat various cranial and spinal pathologies. However, studies have consistently demonstrated disparities in SRS training. Accordingly, the present study represents a cross-sectional analysis of current SRS training and practice patterns. Methods An online survey was utilized to collect data from participants. Two-sided t-tests were used in order to compare frequency tables for statistically significant differences between groups. Qualitative analyses were performed by modified thematic analyses, employing open and axial coding. Results A total of 67 participants completed the online survey (16.4% response rate). The majority of participants were neurosurgery attendings (58.2%), followed by neurosurgery residents (25.4%). The majority of participants reported that resident exposure to SRS was gained primarily through non-SRS focused rotations (52.2%). The survey found that exposure to tumor cases was most frequent, followed by functional, vascular, and spine indications. The majority of participants (49.3%) indicate that residents are not competent or exhibit a low level of competency in SRS at the completion of neurosurgical residency. Qualitative analyses demonstrated that respondents believe SRS is a critical modality in current cranial neurosurgical care and that increased training is needed. Conclusions This study provides a multi-national analysis of SRS residency training and practice patterns, and aims to stimulate improvement in SRS in training worldwide. Enhanced resident training in SRS must include wider exposure to vascular, neoplastic, functional and pediatric indications for SRS. View on the web Inoreader. Take back control of your news feed. Follow us on Twitter and Facebook.

VOICE

The Dynamic Effect of the Valleculae on Singing Voice – An Exploratory Study Using 3D Printed Vocal Tracts The valleculae can be seen as a pair of side branches of the human vocal tract like the piriform fossae. While the acoustic properties of the piriform fossae have been explored in detail , there is little evidence of full exploration of the acoustic properties of the valleculae. A recent investigation (Vampola, Horáček, & Švec, 2015), using a finite element model of a single vowel /a/, suggests that valleculae created two antiresonances and two resonances in the high frequency region (above 4kHz) along with those produced by piriform sinuses.

A Novel Source-Filter Stochastic Model for Voice Production The novel stochastic model to produce voiced sounds proposed in this paper uses the source-filter Fant theory to generate voice signals and, consequently, it does not consider the coupling between the vocal tract and the vocal folds. Two novelties are proposed in the paper. The first one is the new model obtained from the unification of two other deterministic one mass-spring-damper models obtained from the literature and the second one is to build a stochastic model which can generate and control the level of jitter resulting even in hoarse voice signals or with pathological characteristics but using a simpler model than those ones discussed in the literature.

To Explore the Changes and Differences of Microstructure of Vocal Fold in Vocal Fold Paralysis and Cricoarytenoid Joint Dislocation by Diffusion Tensor Imaging The diffusion characteristics of water molecules were measured in the vocal folds of canines exhibiting unilateral vocal fold paralysis and unilateral cricoarytenoid joint dislocation. These characteristics were used in conjunction with a histological examination of the microstructural changes of vocal fold muscle fibers to explore the feasibility of diffusion tensor imaging (DTI) in distinguishing unilateral vocal fold paralysis and unilateral cricoarytenoid joint dislocation as well as evaluating microstructural changes.

Hypertrophic Cardiomyopathy as an Unexpected Mimic of Inducible Laryngeal Obstruction: The Case for Cardiopulmonary Exercise Testing in Otolaryngology Inducible laryngeal obstruction is a common and challenging cause of exertional dyspnea. We report a case of an unanticipated cardiac condition that presented with symptoms suggestive of inducible laryngeal obstruction.

Effect of Ventricular Folds on Vocalization Fundamental Frequency in Domestic Pigs (Sus scrofa domesticus) This study investigates the effect of the ventricular folds on fundamental frequency (fo) in the voice production of domestic pigs (Sus scrofa domesticus). The excised larynges of six subadult pigs were phonated in two preparation stages, with the ventricular folds present (PS1) and removed (PS2). Vocal fold resonances were tested with a laser vibrometer, and a four-mass computational model was created. Highly significant fo differences were found between PS1 and PS2 (means at 93.7 and 409.3 Hz, respectively).

Psychological Distress in a Sample of Adult Italian Patients Affected by Vocal Nodules and Muscle-Tension Dysphonia: Preliminary Results To evaluate the correlation between voice disorders and psychological distress, in terms of anxiety, stress, and depression, in a sample of adult Italian patients and to compare our results with those obtained in a group of adult healthy controls matched by age, sex, geographic distribution, and occupation.

Vocal Fatigue in Beat Boxers Beatboxers are elite professional voice users with increased vocal loading and therefore are at high risk for developing vocal fatigue. Scientific literature has a wealth of information on self-perceived ratings of vocal fatigue in teachers and singers but not in beat boxers.

Cross-cultural Adaptation and Validation of the Hong Kong-Chinese version of Children's Voice Handicap Index-10 for Parents (CVHI-10-P(HK)) The purpose of this study was to cross-culturally adapt and validate the Hong Kong Chinese version of the Children's Voice Handicap Index-10 for Parents (CVHI-10-P(HK)), a parent-proxied quality of life (QOL) questionnaire that pairs with the Children's Voice Handicap Index-10 (CVHI-10(HK)).

Presbylarynx: Is it Possible to Predict Glottal Gap by Cut-Off Points in Auto-Assessment Questionnaires? To determine cut-off points in auto-assessment questionnaires to predict the presence and extent of presbylarynx signs.

An Assessment of Different Praat Versions for Acoustic Measures Analyzed Automatically by VoiceEvalU8 and Manually by Two Raters The purpose of the study was to assess acoustic measures of fundamental frequency (fo), standard deviation of fo (SD of fo), jitter%, shimmer%, noise-to-harmonic ratio (NHR), smoothed cepstral peak prominence (CPPS), and acoustic voice quality index analyzed through multiple Praat versions automatically by VoiceEvalU8 or manually by two raters. In addition, default settings to calculate CPPS in two Praat versions manually analyzed by two raters were compared to Maryn and Weenik20 procedures for CPPS automatically analyzed by VoiceEvalU8.

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Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,

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Organ Transplantation

Intestinal transplantation: an overview of the recent experimental studies Purpose of review Experimental intestinal transplantation (ITx ) has generated invaluable knowledge that has ultimately benefited the clinical activity. Herein, we appraise the recent publications pertaining to experimental ITx and highlight the main current research topics. Recent findings During the recent years, ischemia-reperfusion injury (IRI) and Graft-versus-host disease (GVHD) have gradually replaced acute rejection as the main research topic. New additives to established preservation solutions and relatively novel approaches such as luminal interventions during cold storage may prolong the storage time and alleviate IRI. High donor age does not seem to worsen preservation injury. The ischemic susceptibility seems to differ between species, which may impact the translatability of the experimental findings. A new experimental model of modified multivisceral transplantation including the donor spleen may offer a new tool with which to study GVHD, besides the classical Lewis–Brown Norway rat combination. Flushing the graft with fludarabine may mitigate GVHD in rats. T-cell activation inhibitor—mitochondrial was downregulated in the peripheral blood leukocytes before other signs of acute and severe chronic rejection could be observed. Summary Experimental research in ITx has largely shifted focus from acute rejection to IRI and GVHD. Several lines of research have matured toward clinical translation, yet no breakthrough is imminent. Correspondence to Mihai Oltean, MD, PhD, Transplant Institute, Sahlgrenska University Hospital, 413 45, Gothenburg, Sweden. e-mail: mihai.oltean@surgery.gu.se Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

New insights into the indications for intestinal transplantation Purpose of review To discuss the new guidelines on the indications for intestinal transplantation (ITx) devised in 2019 by the Intestinal Rehabilitation and Transplant Association. Recent findings Early referral of patients with intestinal failure to expert intestinal rehabilitation/transplant centre is strongly recommended. Listing for a life-saving transplantation is recommended for intestinal failure-associated liver disease (IFALD) evolving to liver failure, invasive intra-abdominal desmoids, acute diffuse intestinal infarction with hepatic failure, re-transplant, and children with loss of at least three of the four upper central venous access sites or with high morbidity intestinal failure. Developments in ITx made the probability of posttransplant survival equal to that on home parenteral nutrition (HPN) and the QoL after successful ITx better than on HPN. However, for patients who have not an actual increased risk of death on HPN, the matter of preemptive listing for ITx is still controversial. For these patients, a careful case-by-case decision is recommended. Summary The new guidelines on ITx confirm the straight referral for ITx only for patients at actual risk of death on HPN. Improvements in ITx practice and results, advances in the severity classification of intestinal failure, monitoring of the evolution of IFALD, and measuring patients' QoL are required for an immediate progression in the treatment of intestinal failure. Correspondence to Loris Pironi, Centre for Chronic Intestinal Failure, St. Orsola, University Hospital, Via Massarenti, 9, 40138 Bologna, Italy. Tel: +39 51 2144141; e-mail: loris.pironi@unibo.it Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

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Lipidology

Recent advances in ABCG5 and ABCG8 variants Purpose of review In this review, we summarize the genetics and mechanisms of sitosterolemia and sterol trafficking, and provide an update on the understanding of the prevalence of ABCG5 and ABCG8 variants and their role in human disease. Recent findings Defects in ABCG5/G8 result in the accumulation of xenosterols. It had been previously thought that near total LoF of one of the proteins was required to cause pathology. However, recently there was the first report of a patient with Sitosterolemia who was heterozygous for mutations in both genes. Moreover, large population studies have demonstrated the even simple heterozygous carriers are associated with altered lipid profiles and cardiovascular risk. Broader screening has added to the rapidly growing list of gene variants indicating that the prevalence of ABCG5/G8 variants is higher than previous thought, especially in patients with hypercholesterolemia. Summary These findings support a strategy of measuring xenosterol levels in patients with hypercholesterolemia to screen for ABCG5/G8 variants, and then tailoring treatment with a sterol absorption inhibitor, like ezetimibe, where indicated. Xenosterol trafficking affects remnant clearance and maybe pathogenically linked to the increased risk of atherosclerosis. Correspondence to Shailendra B. Patel, BM, ChB, DPhil, University of Cincinnati College of Medicine, Division of Endocrinology, Diabetes and Metabolism, 231 Albert Sabin Way, MSB 7168, Cincinnati, Ohio 45267, USA. Tel: +513 588 4444; e-mail: sbpatel@uc.edu Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Polygenic scores for dyslipidemia: the emerging genomic model of plasma lipoprotein trait inheritance Purpose of review Contemporary polygenic scores, which summarize the cumulative contribution of millions of common single-nucleotide variants to a phenotypic trait, can have effects comparable to monogenic mutations. This review focuses on the emerging use of 'genome-wide' polygenic scores for plasma lipoproteins to define the etiology of clinical dyslipidemia, modify the severity of monogenic disease, and inform therapeutic options. Recent findings Polygenic scores for low-density lipoprotein cholesterol (LDL-C), triglycerides, and high-density lipoprotein cholesterol are associated with severe hypercholesterolemia, hypertriglyceridemia, or hypoalphalipoproteinemia, respectively. These polygenic scores for LDL-C or triglycerides associate with risk of incident coronary artery disease (CAD) independent of polygenic scores designed specifically for CAD and may identify individuals that benefit most from lipid-lowering medication. Additionally, the severity of hypercholesterolemia and CAD associated with familial hypercholesterolemia—a common monogenic disorder—is modified by these polygenic factors. The current focus of polygenic scores for dyslipidemia is to design predictive polygenic scores for diverse populations and determining how these polygenic scores could be implemented and standardized for use in the clinic. Summary Polygenic scores have shown early promise for the management of dyslipidemias, but several challenges need to be addressed before widespread clinical implementation to ensure that potential benefits are robust and reproducible, equitable, and cost-effective. Correspondence to Liam R. Brunham, MSc, Centre for Heart Lung Innovation, Room 166-1081 Burrard Street, Vancouver, British Columbia, Canada, V6Z 1Y6. Tel: +604 682 2344 x63929; fax: +604 806 9274; e-mail: liam.brunham@ubc.ca Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Apolipoprotein genetic variants and hereditary amyloidosis Purpose of review Amyloidosis is caused by the deposition of misfolded aggregated proteins called amyloid fibrils that in turn cause organ damage and dysfunction. In this review, we aim to summarize the genetic, clinical, and histological findings In apolipoprotein-associated hereditary amyloidosis and the growing list of mutations and apolipoproteins associated with this disorder. We also endeavor to summarize the features of apolipoproteins that have led them to be overrepresented among amyloidogenic proteins. Additionally, we aim to distinguish mutations leading to amyloidosis from those that lead to inherited dyslipidemias. Recent findings Apolipoproteins are becoming increasingly recognized in hereditary forms of amyloidosis. Although mutations in APOA1 and APOA2 have been well established in hereditary amyloidosis, new mutations are still being detected, providing further insight into the pathogenesis of apolipoprotein-related amyloidosis. Furthermore, amyloidogenic mutations in APOC2 and APOC3 have more recently been described. Although no hereditary mutations in APOE or APOA4 have been described to date, both protein products are amyloidogenic and frequently found within amyloid deposits. Summary Understanding the underlying apolipoprotein mutations that contribute to hereditary amyloidosis may help improve understanding of this rare but serious disorder and could open the door for targeted therapies and the potential development of new treatment options. Correspondence to Amanda J. Berberich, MD, FRCPC, Cert. Endo, Department of Medicine, Saint Joseph's Healthcare London, 268 Grosvenor St. London, Ontario, Canada, N6A 4V2. e-mail: Amanda.Berberich@sjhc.london.on.ca Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

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Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,

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Cardiology

Resurgence of the edge-to-edge repair of the mitral valve Purpose of review To provide a critical review of the application and outcomes of surgical edge-to-edge (E2E) or Alfieri repair for mitral valvulopathy. Recent findings The E2E repair is a surgical technique to address mitral regurgitation, particularly suited when the responsible mechanism is bileaflet prolapse combined with enlarged annular area. It can also be used for a range of mitral valve pathologies. Surgically, the technique has been employed as a bailout for unsuccessful repair including residual mitral regurgitation because of systolic anterior motion (SAM). E2E repair should be accompanied by a ring annuloplasty for long-term repair durability. The simplicity of this approach makes it an ideal strategy during minimally-invasive mitral valve repair. It may also be performed via a transaortic approach at the time of aortic valve surgery to address less-than-severe mitral regurgitation or to address residual SAM following myectomy for hypertrophic obstructive cardiomyopathy. We review the surgical indication, potential complications including risk of mitral stenosis and the long-term outcomes of E2E repair. Summary The E2E surgical repair is a simple and effective surgical strategy to address a wide range of mitral regurgitation. This is an important technique in the surgical armamentarium especially in cases of minimally-invasive mitral valve surgery. Correspondence to Bobby Yanagawa, MD, PhD, FRCSC, Assistant Professor, Department of Surgery, University of Toronto, Division of Cardiac Surgery, St. Michael's Hospital, 30 Bond Street, 8th Floor, Bond Wing, Toronto, ON M5B 1W8, Canada. Tel: +1 416 864 5706; fax: +1 416 864 5031; e-mail: yanagawab@smh.ca Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Ambulatory advanced heart failure patients: timing of mechanical circulatory support – delaying the inevitable? Purpose of review Current indications for continuous-flow left ventricular assist device (cfLVAD) implantation is for patients in cardiogenic shock or inotrope-dependent advanced heart failure. Risk stratification of noninotrope dependent ambulatory advanced heart failure patients is a subject of registries designed to help shared-decision making by clinicians and patients regarding the optimal timing of mechanical circulatory support (MCS). Recent findings The Registry Evaluation of Vital Information for VADs in Ambulatory Life enrolled ambulatory noninotrope dependent advanced systolic heart failure patients who had 25% annualized risk of death, MCS, or heart transplantation (HT). Freedom from composite clinical outcome at 1-year follow-up was 23.5% for the entire cohort. Seattle Heart Failure Model Score and Natriuretic pepides were predictors with modest discriminatory power. Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) profile 4 patients had the highest risk (3.7-fold) of death, MCS or HT compared to INTERMACS profile 7. Summary We propose individualized risk stratification for noninotrope dependent ambulatory advanced heart failure patients and include serial changes in end-organ function, nutritional parameters, frailty assessment, echocardiographic and hemodynamic data. The clinical journey of a patient with advanced heart failure should be tracked and discussed at each clinic visit for shared decision-making regarding timing of cfLVAD. Correspondence to Indranee Rajapreyar, MD, Section of Heart Failure and Transplantation Cardiology, Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, 1900 University Blvd, THT 311, Birmingham, Alabama 35233, USA;. e-mail: irajapreyar@uabmc.edu Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Update of clinical echocardiographic assessment of heart failure with preserved ejection fraction Purpose of review Heart failure with preserved ejection fraction (HFpEF) has an increasing global prevalence. Diastolic dysfunction is the predominant cause of symptoms, most commonly, exertional dyspnea. Although prevalent, the syndrome is challenging to identify due to the comorbid conditions that can present similarly. This paper will review established, guideline recommended, echocardiographic variables, and pathophysiology. Recent findings Echocardiography is the primary diagnostic modality. The latest advances in strain analysis, algorithmic use of multiple parameters, and deeper understanding of exercise hemodynamics have improved our classification of those with HFpEF. Summary There remains a paucity of therapies with mortality benefit in this subgroup. Thus, improving diagnostic efficacy is important as it can clarify epidemiologic, phenotypic, and pathologic features of HFpEF. Correspondence to Mehnaz Rahman, MD, LSU Health Sciences Section of Cardiology, 533 Bolivar Street CSRB 3–42, New Orleans, Louisiana 70112, USA. Tel: +504 568 1276; fax: +504 568 2127; e-mail: mrahm3@lsuhsc.edu Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Cardiovascular implications and complications of the coronavirus disease-2019 pandemic: a world upside down Purpose of review The new pandemic of coronavirus disease-2019 (COVID-19) has produced a global tumult and has overburdened national health systems. We herein discuss the cardiovascular implications and complications of this pandemic analyzing the most recent data clustered over the last several months. Recent findings COVID-19 afflicts the cardiovascular system producing acute cardiac injury in 10–20% of cases with mild disease but in greater than 50–60% in severe cases, contributing to patients' demise. Other cardiovascular complications include arrhythmias, heart failure, pulmonary embolism and shock. Off-label therapies are being trialed with their own inherent cardiovascular risks, while supportive therapies currently dominate, until more specific and effective antiviral therapies and vaccinations become available. A controversial issue relates to the safety of drugs blocking the renin--angiotensin system as an angiotensin-converting enzyme (ACE) homologue, ACE2, serves as the receptor for viral entry into host cells. However, to-date, no harm has been proven for these drugs. Summary In the cardiovascular system, COVID-19 can induce acute cardiac injury, arrhythmias, heart failure, pulmonary embolism, shock and death, whereas anti-COVID therapies also confer serious cardiovascular side-effects. Ongoing extensive efforts focus on specific vaccines and antivirals. Meanwhile, cardiovascular risk factors and diseases should be jointly controlled according to current evidence-based guidelines. Correspondence to Antonis S. Manolis, MD, First Department of Cardiology, Ippokrateio Hospital, Vas. Sofias 114, Athens 11527, Greece. Tel: +30 213 2088470; e-mail: asm@otenet.gr Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Novel technologies in the management of heart failure with preserved ejection fraction: a promise during the time of disappointment from pharmacological approaches? Purpose of review Despite numerous attempts, none of a wide variety of tested drugs achieved meaningful improvement in the outcomes of heart failure with preserved ejection fraction (HFpEF), making new therapeutic strategies a major unmet medical need. The medical device industry embraced the challenge, developing novel technologies directed to face specific aspects of the pathophysiology of HFpEF. This review focuses on some of the most promising technologies attaining meaningful clinical progress recently in the field of HFpEF therapy. Recent findings Implantable pulmonary artery pressure, monitoring for optimization of medical therapy, proved to be beneficial in heart failure admissions in a large postmarketing clinical study. Investigational devices, such as inter-atrial shunts and transvenous phrenic nerve stimulators for the treatment of central sleep apnea with Cheyne–Stokes breathing, are currently being evaluated in HFpEF cohorts in recent trials. Summary Device-based therapies for HFpEF demonstrated encouraging safety and efficacy results in various stages of the disease. Further efforts are needed to ensure that these devices will reach clinical use and contribute to the management of HFpEF patients. Correspondence to Dr Dean Nachman, MD, Heart Institute, Hadassah Medical Center, POB 12272, Jerusalem, 91120, Israel. Tel: +972-50-2217665, +972-2-6757657; fax: +972-2-6757660; e-mail: Dean@hadassah.org.il Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Skeletal muscle (dys)function in heart failure with preserved ejection fraction Purpose of review Skeletal muscle dysfunction contributes to exercise intolerance, which manifests as dyspnea and fatiguability in patients with heart failure with preserved ejection fraction (HFpEF). This review aims to summarize the current understanding of skeletal muscle dysfunction in HFpEF. Recent findings Animal and human studies in HFpEF provide insights into the pathophysiological alterations in skeletal muscle structure and function with the identification of several molecular mechanisms. Exercise training and novel pharmacological therapies that target skeletal muscle are proposed as therapeutic interventions to treat HFpEF. Summary There is evidence that skeletal muscle dysfunction plays a pathophysiological role in HFpEF. However, precise mechanistic insights are needed to understand the contribution of skeletal muscle dysfunction in HFpEF. Correspondence to Flora Sam, MD, Whitaker Cardiovascular Institute, Boston University School of Medicine, 700 Albany Street, W507, Boston, MA 02118, USA. Tel: +1 617 358 8208; e-mail: florasam@bu.edu Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Review of transapical off-pump mitral valve intervention with NeoChord implantation Purpose of review Mitral valve repair surgery has recently shifted from resection-based techniques to leaflet sparing approaches using synthetic neochordae. This has facilitated the growth of a new strategy of transapical off-pump mitral valve intervention with neochord implantation. Recent findings Minimally invasive approaches for mitral valve repair with robotic or video-assisted mini-right anterolateral thoracotomy have been developed to mitigate the morbidity associated with conventional median sternotomy. Recently, an alternative, less invasive surgical strategy has emerged. This transapical off-pump technique employs the NeoChord DS1000 (NeoChord, Inc., Minneapolis, MN, USA) system to achieve repair with neochordae via a left minithoracotomy incision. With appropriate patient selection, advanced cardiac imaging, and training in device deployment are important for procedural success. Summary Early results suggest that transapical off-pump mitral valve intervention with NeoChord implantation is a safe procedure with favorable outcomes for select patients with degenerative mitral regurgitation. Continued experience and clinical trials will assess the potential of this minimally invasive strategy, but this technique is likely to become part of the surgical repertoire for managing chronic degenerative mitral valve disease. Correspondence to Corey Adams, MD, MSc, FRCSC, Department of Cardiac Sciences, Section of Cardiac Surgery, Libin Cardiovascular Institute of Alberta, Foothills Medical Centre, 1403 29th Street, NW, Office 880C, Calgary, AB, Canada T2N 2T9. Tel: +1 403 944 1090; fax: +1 403 944 4895; e-mail: corey.adams@albertahealthservice.ca Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

COVID-19 myocarditis and long-term heart failure sequelae Purpose of review The clinical syndrome of coronavirus disease 2019 (COVID-19) has become a global pandemic leading to significant morbidity and mortality. Cardiac dysfunction is commonly seen in these patients, often presenting as clinical heart failure. Accordingly, we aim to provide a comprehensive review on COVID-19 myocarditis and its long-term heart failure sequelae. Recent findings Several suspected cases of COVID-19 myocarditis have been reported. It is often not clear if the acute myocardial dysfunction is caused by myocarditis or secondary to generalized inflammatory state of cytokine release or microvascular thrombotic angiopathy. Ischemia may also need to be ruled out. Regardless, myocardial dysfunction in these patients is associated with poor overall prognosis. Laboratory testing, echocardiography, cardiac magnetic resonance imaging, and even endomyocardial biopsy may be needed for timely diagnosis. Several treatment strategies have been described, including both supportive and targeted therapies. Summary COVID-19 can cause a spectrum of ventricular dysfunction ranging from mild disease to fulminant myocarditis with hemodynamic instability. Future research is needed to understand the true prevalence of COVID-19 myocarditis, as well as to better define various diagnostic protocols and treatment strategies. Correspondence to Umair Khalid, MD, FACC, Section of Cardiology, Department of Medicine Michael E. DeBakey VA Medical Center & Baylor College of Medicine, Houston, TX;. e-mail: mukhalid@bcm.edu Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Mitral valve surgery for rheumatic heart disease: replace, repair, retrain? Purpose of review Rheumatic heart disease (RHD) affects over 30 million people worldwide. Substantial variation exists in the surgical treatment of patients with RHD. Here, we aim to review the surgical techniques to treat RHD with a focus on rheumatic mitral valve (MV) repair. We introduce novel educational paradigms to embrace repair-oriented techniques in cardiac centers. Recent findings Due to the low prevalence of RHD in high-income countries, limited expertise in MV surgery for RHD, technical complexity of MV repair for RHD and concerns about durability, most surgeons elect for MV replacement. However, in some series, MV repair is associated with improved outcomes, fewer reinterventions, and avoidance of anticoagulation-related complications. In low- and middle-income countries, the RHD burden is large and MV repair is more commonly performed due to high rates of loss-to-follow-up and barriers associated with anticoagulation, international normalized ratio monitoring, and risk of reintervention. Summary Increased consideration for MV repair in the setting of RHD may be warranted, particularly in low- and middle-income countries. We suggest some avenues for increased exposure and training in rheumatic valve surgery through international bilateral partnership models in endemic regions, visiting surgeons from endemic regions, simulation training, and courses by professional societies. Correspondence to Bobby Yanagawa, MD, PhD, FRCSC, Program Director, Division of Cardiac Surgery, University of Toronto Assistant Professor, Division of Cardiac Surgery, St. Michael's Hospital 30 Bond Street, 8th Floor, Bond Wing Toronto, ON M5B 1W8, Canada. Tel: +416 864 5706; fax: +416 864 5031; e-mail: yanagawab@smh.ca Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Antithrombotic therapy after transcatheter aortic valve replacement: current perspective Purpose of review Transcatheter aortic valve replacement (TAVR) has expanded as a treatment option for severe aortic stenosis throughout the surgical risk spectrum. Decreasing procedural risk and inclusion of lower risk population has shifted the focus to optimization of postprocedural management and balancing the thrombotic and bleeding complications. In this review, we outline various patient and procedure related factors affecting choice of antithrombotic therapy post TAVR and provide an update of recent development in this area. Recent findings Multiple studies have confirmed the high incidence of both ischemic and bleeding complications in the early to midterm post-TAVR. In addition, new data has emerged for the role of high resolution computed tomography to detect decreased leaflet mobility and leaflet micro thrombi associated with implications for bioprosthetic valve dysfunction and cerebrovascular events post TAVR. Randomized clinical trials have reported increased bleeding with dual antiplatelet therapy (DAPT) and oral anticoagulation (OAC) plus antiplatelet therapy. These findings suggest that aspirin monotherapy or OAC monotherapy likely provides the appropriate balance for antithrombotic protection and risk of bleeding. Summary Majority of patients undergoing TAVR have multiple comorbidities and are at increased risk of ischemic and bleeding complications. In the absence of robust clinical evidence, there is significant variability among guideline recommendations and antithrombotic therapy post TAVR across institutions. The available evidence confirms a high rate of bleeding with more potent and prolonged antithrombotic regimens without a documented benefit for clinical endpoints. The authors favor a conservative anti thrombotic approach and suggest monotherapy with aspirin or systemic anticoagulation based upon an individual's risk of thromboembolic complications. DAPT is reserved for patients with recent stenting and OAC plus aspirin is prescribed for patients with established CAD in the post TAVR setting. Correspondence to Dr Asim N. Cheema, Southlake Regional Health Centre, 596 Davis Drive, Newmarket, Ontario, Canada L3Y 2P9. E-mail: acheema@southlakeregional.org Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

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Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,

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Lung

Is there a role for inhaled ciclesonide in the treatment of COVID-19? Sundeep Santosh Salvi Lung India 2021 38(1):1-4

Survival predictors of interstitial lung disease in India: Follow-up of Interstitial Lung Disease India registry Sheetu Singh, Mohan Bairwa, Bridget F Collins, Bharat Bhushan Sharma, Jyotsana M Joshi, Deepak Talwar, Nishtha Singh, Khushboo Pilania, Parthasarathi Bhattacharya, Neeraj Gupta, Ravindran Chetambath, Aloke G Ghoshal, Surya Kant, Parvaiz A Koul, Raja Dhar, Rajesh Swarnakar, Virendra Singh, Ganesh Raghu Lung India 2021 38(1):5-11 Background: Predictors of survival for interstitial lung disease (ILD) in the Indian population have not been studied. The primary objective of the study was to assess the Modified-Gender Age and Physiology (M-GAP) score to predict survival in patients with ILD seen in clinical practice. We also analyzed the role of demographic and radiological characteristics in predicting the survival of patients with ILD. Materials and Methods: In the ILD India registry, data were collected from 27 centers across 19 cities in India between March 2012 and June 2015. A single follow-up was conducted at 18 centers who agreed to participate in the follow-up in 2017. M-GAP score (range 0–5) was calculated with the following variables: age (≤60 years 0, 61–65 years 1, and >65 years 2), gender (female 0, male 1), and forced vital capacity% (>75% 0, 50%–75% 1, and >75% 2). A score of 0–3 and score of 4 and 5 were classified into Stage 1 and 2, respectively. Other predictors of survival, such as the history of tuberculosis, smoking, and the presence of honeycombing on computed tomography scan, were also evaluated. Results: Nine hundred and seven patients were contacted in 2017. Among them, 309 patients were lost to follow-up; 399 were alive and 199 had died. M-GAP was significantly associated with survival. Similarly, other predictors of survival were ability to perform spirometry (hazard ratio [HR]: 0.49, 95% confidence interval [CI]: 0.34–0.72), past history of tuberculosis (HR: 1.57, 95% CI: 1.07–2.29), current or past history of smoking (HR: 1.51, 95% CI: 1.06–2.16), honeycombing (HR: 1.81, 95% CI: 1.29–2.55), a diagnosis of connective tissue disease -ILD (HR: 0.41, 95% CI: 0.22–0.76), and sarcoidosis (HR: 0.24, 95% CI: 0.08–0.77). Conclusion: In a subgroup of patients with newly diagnosed ILD enrolled in ILD India registry and who were available for follow-up, M-GAP score predicted survival. Honeycombing at the time of diagnosis, along with accurate history of smoking, and previous history of tuberculosis were useful indices for predicting survival.

Co-existing obstructive sleep apnea among patients with chronic obstructive pulmonary disease Loganathan Nattusami, Vijay Hadda, Gopi C Khilnani, Karan Madan, Saurabh Mittal, Pawan Tiwari, Anant Mohan, Maroof Ahmad Khan, Randeep Guleria Lung India 2021 38(1):12-17 Background and Objectives: Chronic obstructive pulmonary disease (COPD) is a common airway disease that is frequently associated with comorbidities. In this study, we assessed the co-existence of obstructive sleep apnea (OSA) among patients with stable COPD. Methodology: This cross-sectional study included patients with stable COPD who were screened with Epworth&#39;s Sleepiness Scale (ESS). Those with ESS score of &#62;10 were subjected to in-lab polysomnography (PSG). PSG was manually analyzed and reported. Patients with apnea&#8211;hypopnea index of &#62;5/h were diagnosed as OSA. Results: This study included 301 patients (78.1&#37; male, 76.4&#37; smokers, age 59.6 &#177; 10 years) with stable COPD. ESS score of &#62;10 was observed in 47 (15.6&#37;) patients. Among patients with ESS score of &#62;10, OSA was observed in 34 (72.3&#37;) patients. The overall prevalence of OSA among patients with COPD was 10.9&#37;. Patients with co-existing OSA were older and had thicker neck and higher body mass index (BMI) as compared to COPD alone. In addition, patients with associated OSA had worse health-related quality of life (QOL) as shown by higher St. George&#39;s Respiratory Questionnaire score (42.42 &#177; 7.22 vs. 25.22 &#177; 8.66;P < 0.001). Conclusions: Co-existing OSA is common among patients with COPD and has a significant adverse effect on the QOL. Among COPD patients, older age, thick neck, and high BMI may predict co-existing OSA and require PSG for the confirmation.

Lung preservation in mucoepidermoid carcinoma of tracheobronchial tree: A case series Sukhram Bishnoi, Harsh Vardhan Puri, Belal Bin Asaf, Mohan Venkatesh Pulle, Akhil Kumar, Arvind Kumar Lung India 2021 38(1):18-22 Introduction: Mucoepidermoid carcinoma (MEC) is a primary salivary gland tumor also arising from nonsalivary gland organs of the body such as submucosal glands of tracheobronchial tree. Surgical resection with negative margins is the treatment of choice. All efforts should be made to preserve as much lung parenchyma as possible, by various bronchoplastic procedures. We present our experience with mucoepidermoid tumors and review their management options including lung preservation techniques and outcome of surgery. Materials and Methods: This is a retrospective analysis of prospectively maintained data of 14 patients who underwent surgery for MEC. Their demographic data; clinical presentation; and preoperative, intraoperative, and postoperative details were recorded. All patients underwent contrast-enhanced computed tomography of chest and bronchoscopy as part of workup for diagnosis and to assess the location, size, and extent of tumor; extraluminal component; and status of distal lung parenchyma. Results: There were eight male and six female patients. The median age at the time of surgery was 28.36 years (range 22&#8211;45 years). The procedures performed included right upper lobectomy and right pneumonectomy in one patient each, left main bronchus sleeve resection in six patients, left upper sleeve lobectomy in three patients, and carinal resection and reconstruction of neo carina in three patients. Twelve (85.7&#37;) of our patients underwent lung-preserving surgery. The median hospital stay and chest tube removal duration was 4 and 3 days, respectively. The median tumor size was 1.91 cm (range 1&#8211;8 cm). The median follow-up was 24 months (ranging from 6 to 78 months). Conclusion: Radical surgery to achieve R &#8220;0&#8221; resection with aggressive emphasis on lung preservation is the mainstay of treatment of MEC. Greater awareness of these tumors is necessary to avoid misdiagnosis and to prevent delaying of potential complete resection of MEC.

A survey of medical thoracoscopy practices in India Karan Madan, Pawan Tiwari, Balamugesh Thankgakunam, Saurabh Mittal, Vijay Hadda, Anant Mohan, Randeep Guleria Lung India 2021 38(1):23-30 Background: Medical thoracoscopy (MT) is a useful diagnostic and therapeutic procedure for a variety of pleural conditions. There is a lack of literature on prevalent practices of MT in India. Aims and Objectives: The objective of the study was to study the prevalent practices of MT in India. Materials and Methods: A structured online survey on various aspects of thoracoscopy was designed on the &#8220;Google Forms&#8221; web software. Results: One hundred and eight responses were received, of which 100 respondents performed MT. The majority were pulmonologists, and most had started performing thoracoscopy within the last 5 years. Rigid thoracoscope was the most commonly used instrument. The common indications of procedure included undiagnosed pleural effusion, talc pleurodesis, and adhesiolysis. Local anesthesia with conscious sedation was the preferred anesthetic modality. Midazolam, along with fentanyl, was the most widely used sedation combination. 2&#37; lignocaine was the most commonly used concentration for local infiltrative anesthesia. Nearly two-thirds of the respondents reported having encountered any complication of thoracoscopy. Significant reported complications included empyema, incision/port-site infection, re-expansion pulmonary edema, and procedure-related mortality. Conclusion: MT is a rapidly evolving interventional pulmonology procedure in India. There is, however, a significant variation in practice and variable adherence to available international guidelines on thoracoscopy. Formal training programs within India and national guidelines for pleuroscopy considering the local resources are required to improve the safety and yield of this useful modality.

Small-bore catheter is more than an alternative to the ordinary chest tube for pleural drainage Abdel-Mohsen Mahmoud Hamad, Seham Ezzat Alfeky Lung India 2021 38(1):31-35 Background: Pleural collection is a common medical problem. For decades, the chest tube of different designs was the commonly used toll for pleural drainage. Over the past few years, small-bore catheter (SBC) has gained more popularity. We present our experience of using SBCs for the drainage of pleural collection of different etiologies. Patients and Methods: A total of 398 small-bore pleural catheters were inserted in 369 patients with pleural collection during the period from January 2013 to October 2019. Data were collected regarding the efficacy of drainage, experienced chest pain, duration of drainage, and the occurrence of complications. Results: Malignant associated (59.24&#37;) and parapneumonic (19.57&#37;) effusions constituted the most common causes. The drainage was successful in 382/398 (95.98&#37;) occasions; six cases had incomplete fluid evacuation that required decortications; five cases (1.26&#37;) had nonexpendable lung. Catheter reinsertion was needed due to dislodgment in 2 (0.50&#37;) cases and obstruction in 3 (0.75&#37;) cases. Sixty-two cases (15.58&#37;) experienced chest pain. No patient developed empyema or cellulites at the site of catheter insertion. The duration of drainage ranged from 2 to 7 days, with an average of 3.5 days. Conclusions: SBC is equivalent to conventional chest tube for the drainage of pleural collection. Moreover, it has the advantages of less associated pain, versatility of insertion site, and relative safety of the technique in some risky and difficult situations.

Video-assisted thoracoscopic surgery management of primary spontaneous pneumothorax: Results in 110 consecutive cases Harsh Vardhan Puri, Belal Bin Asaf, Mohan Venkatesh Pulle, Sukhram Bishnoi, Arvind Kumar Lung India 2021 38(1):36-40 Background: Primary spontaneous pneumothorax (PSP) results from the rupture of small blebs or bullae in a patient without any pre-existing lung disease. Last decade witnessed a paradigm shift in the surgical management of pneumothorax from open to video-assisted thoracoscopic surgery (VATS) method. In this study, we aim to report our single center experience of surgical management of PSP along with surgical outcomes in 110 consecutive cases of PSP. Materials and Methods: This is a retrospective study of 110 operated cases of PSP over 5 years. Demography, computed tomography findings, operative technique, endoscopic classification (Vanderschueren), surgical duration, intraoperative and postoperative complications, duration of Intercostal Drain (ICD), hospital stay, and recurrence in follow-up were recorded. Results: The average age of patients was 27.59 years (range 9&#8211;68 years). The average number of episodes before the presentation was 2 (range 1&#8211;5). The average number of loss of working days because of symptoms, conservative management, or long-term intercostal drainage was 13.33 days (range 5&#8211;60 days). As per intra-operative findings, patients were categorized as per Vanderschueren&#39;s classification and managed accordingly. Conversion rate was in 1.8&#37; (n &#61; 2). Mean time to removal of chest tubes was 4 days (2&#8211;12 days). Mean hospital stay was 3.83 days (2&#8211;9 days). There were no postoperative deaths. The mean follow-up was 25.05 months (6&#8211;60 months). Overall complication rate was 3.6&#37; (n &#61; 4) and recurrence happened in 2.7&#37; (n &#61; 3) cases. Conclusions: VATS is an efficient and safe treatment modality for PSP with low recurrence rates and high level of patient satisfaction.

Percutaneous core needle biopsy in the diagnosis of lung lesions: An experience on 280 consecutive cases from a university hospital in southern India Madhavi Parigi, Monalisa Hui, Shantveer G Uppin, Anu Kapoor, N Narendra Kumar, K Bhaskar, Bala Joseph Stalin, G Sadashivudu, GK Paramjyothi Lung India 2021 38(1):41-52 Context: Percutaneous needle biopsy of lung (PCNBL) is advantageous over bronchoscopic biopsies to obtain adequate sample for peripheral lung lesions. Objective: The objective was to evaluate the diagnostic yield of image-guided PCNBL in the diagnosis of lung lesions and to classify lung carcinomas as per the recently proposed International Association for the Study of Lung Cancer (IASLC)/American Thoracic Society/European Respiratory Society classification for small biopsies modified and adopted by the World Health Organization, 2015. Materials and Methods: A total of 280 image-guided PCNBL were analyzed. The radiological findings and routine hematoxylin and eosin (H&#38;E)-stained sections along with immunohistochemistry (IHC) were analyzed in all the cases. Molecular testing was done depending on tissue diagnosis and availability. Results: Majority (81&#37;) were diagnosed as malignant lesions, with adenocarcinoma (ADC) being the most common. More than 70&#37; were diagnosed on H&#38;E morphology alone, with thirty cases requiring IHC to categorize as ADC. Nearly 60&#37; were categorized as squamous cell carcinoma on morphology alone and the rest required IHC. Though TTF1 showed higher sensitivity than napsin A, the latter is more specific. Both p63 and p40 were found to be highly sensitive for squamous cell carcinoma, but p40 was more specific than p63. Epidermal growth factor receptor could be evaluated on 94.4&#37; of ADC samples, indicating good yield for molecular testing. Conclusion: PCNBL yields adequate sampling for tissue diagnosis and ancillary testing with minimal complications. The use of IHC markers reduces the number of non-small-cell not otherwise specified cases significantly.

Study of respiratory viruses and their coinfection with bacterial and fungal pathogens in acute exacerbation of chronic obstructive pulmonary diseases Rahat Jahan, Baijayantimala Mishra, Bijayini Behera, Prasanta Raghab Mohapatra, Ashok Kumar Praharaj Lung India 2021 38(1):53-58 Background: Patients with chronic obstructive pulmonary disease (COPD) develop acute exacerbations (AE), with varying natural history. The exacerbation is triggered by infection, leading to increased morbidity and mortality. The study on infectious aetiology of AECOPD is largely restricted to only viral or only bacterial aetiology. There are no studies from India that have investigated multiple viral, bacterial, and fungal associations from the same group of patients. This prospective study was conducted over 2 years to estimate the incidence and profile of viral infections in AECOPD patients, their coinfection with other bacterial and fungal agents, and association of the type and pattern of infective agent with the clinical severity. Materials and Methods: Seventy-four AECOPD cases were included in the study. Multiplex polymerase chain reaction was performed from nasopharyngeal swab using Fast Track Diagnostics Respiratory Pathogens 21 Plus Kit. Ziehl&#8211;Neelsen (ZN) stain, Modified ZN, and potassium hydroxide (KOH) mount were performed for Mycobacteria, Nocardia, and fungal elements. Bacterial cultures and fungal cultures were done as per the standard techniques. Serum samples were tested for Mycoplasma and Chlamydia pneumoniae immunoglobulin M enzyme-linked immunosorbent assay. Results: The number of AECOPD events involving only viral infection, only bacterial infection, bacterial&#8211;viral coinfection, and no infection were 43 (58.1&#37;), 32 (43.2&#37;), 20 (27&#37;), and 19 (25.7&#37;), respectively. Influenza A virus was the most common virus (22/43, 51&#37;) identified. In 26 patients, monoviral infections were found, and in 17 patients, polyviral infections were identified, the most common pattern being influenza A and B virus, followed by human rhinovirus and human parainfluenza. The most common bacteria isolated were Pseudomonas aeruginosa (9/32,28&#37;) followed by Acinetobacter baumanii and Klebsiella pneumoniae (7/32, 21&#37;). Among the viral&#8211;bacterial coinfection, human coronavirus NL63 infection was always associated with a bacterial infection. Conclusion: This information on the various viral and bacterial etiologies of respiratory infections in AECOPD in this part of India will improve the understanding of the management of AECOPD using a timely institution of antivirals and reduce the overuse of antibiotics and the implementation of routine influenza vaccination.

Barriers to pulmonary rehabilitation – A narrative review and perspectives from a few stakeholders Anulucia Augustine, Anup Bhat, K Vaishali, Rahul Magazine Lung India 2021 38(1):59-63 Pulmonary Rehabilitation (PR) is an essential and comprehensive intervention recommended in the management of people with chronic respiratory diseases (CRD). Scientific evidence suggests significant health benefits with respect to repeated hospital admissions, exercise tolerance and Health Related Quality of Life (HRQoL). However, the uptake and completion of PR programs are globally low. In order to understand the factors contributing to underutilization of PR, it is important to review and recognize the barriers to PR program. A literature search was conducted on Medline (PubMed) database. After reviewing the title and abstracts, full text articles were scrutinized for their relevance. Twenty-two studies involving factors affecting the uptake, participation and completion of PR program were included in this review. Reported barriers to PR were healthcare system, healthcare professional and patient related factors. Primary factors related to healthcare system and healthcare professionals were fewer PR centers, accessibility inconvenience, lack of awareness of PR program, low knowledge of referral process and lack of interdisciplinary teamwork. Difficulties faced by patients to take up and/or to complete PR programs were lack of transportation, co-morbidities, lack of perceived benefits, socio-economic status and lack of funding facilities. Identified and reported barriers resulted into discontinuity between knowledge of health benefits and utilization of PR service for patients with CRDs. Addressing the barriers would accelerate the healthcare professionals&#39; referral and patients to avail the health benefits of rehabilitation service.

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Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,

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Nephrology and Hypertension

Cardiovascular autonomic nervous system dysfunction in chronic kidney disease and end-stage kidney disease: disruption of the complementary forces Purpose of review Several nontraditional risk factors have been the focus of research in an attempt to understand the disproportionately high cardiovascular morbidity and mortality in chronic kidney disease (CKD) and end-stage kidney disease (ESKD) populations. One such category of risk factors is cardiovascular autonomic dysfunction. Its true prevalence in the CKD/ESKD population is unknown but existing evidence suggests it is common. Due to lack of standardized diagnostic and treatment options, this condition remains undiagnosed and untreated in many patients. In this review, we discuss current evidence pointing toward the role of autonomic nervous system (ANS) dysfunction in CKD, building off of crucial historical evidence and thereby highlighting the areas in need for future research interest. Recent findings There are several key mediators and pathways leading to cardiovascular autonomic dysfunction in CKD and ESKD. We review studies exploring the mechanisms involved and discuss the current measurement tools and indices to evaluate the ANS and their pitfalls. There is a strong line of evidence establishing the temporal sequence of worsening autonomic function and kidney function and vice versa. Evidence linking ANS dysfunction and arrhythmia, sudden cardiac death, intradialytic hypotension, heart failure and hypertension are discussed. Summary There is a need for early recognition and referral of CKD and ESKD patients suspected of cardiovascular ANS dysfunction to prevent the downstream effects described in this review. There are many unknowns in this area and a clear need for further research. Correspondence to David M. Charytan, MD, MSc, Chief, Nephrology Division, NYU Langone Medical Center, 462 1st Avenue C & D 689, New York, New York 10010, USA. Tel: +646 501 9086; e-mail: David.charytan@nyulangone.org Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Challenges in communication, prognostication and dialysis decision-making in the COVID-19 pandemic: implications for interdisciplinary care during crisis settings Purpose of review Using case vignettes, we highlight challenges in communication, prognostication, and medical decision-making that have been exacerbated by the coronavirus disease-19 (COVID-19) pandemic for patients with kidney disease. We include best practice recommendations to mitigate these issues and conclude with implications for interdisciplinary models of care in crisis settings. Recent findings Certain biomarkers, demographics, and medical comorbidities predict an increased risk for mortality among patients with COVID-19 and kidney disease, but concerns related to physical exposure and conservation of personal protective equipment have exacerbated existing barriers to empathic communication and value clarification for these patients. Variability in patient characteristics and outcomes has made prognostication nuanced and challenging. The pandemic has also highlighted the complexities of dialysis decision-making for older adults at risk for poor outcomes related to COVID-19. Summary The COVID-19 pandemic underscores the need for nephrologists to be competent in serious illness communication skills that include virtual and remote modalities, to be aware of prognostic tools, and to be willing to engage with interdisciplinary teams of palliative care subspecialists, intensivists, and ethicists to facilitate goal-concordant care during crisis settings. Correspondence to Devika Nair, MD, MSCI, Instructor of Medicine, Vanderbilt University Medical Center, Division of Nephrology and Hypertension, Vanderbilt Center for Health Services Research, 2525 West End Avenue, Suite 450, Office 416, Nashville, Tennessee 37203, USA. Tel: +615 322 7285; e-mail: Devika.nair@vumc.org Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Angiotensin-converting enzyme 2: from a vasoactive peptide to the gatekeeper of a global pandemic Purpose of review We provide a comprehensive overview of angiotensin-converting enzyme 2 (ACE2) as a possible candidate for pharmacological approaches to halt inflammatory processes in different pathogenic conditions. Recent findings ACE2 has quickly gained prominence in basic research as it has been identified as the main entry receptor for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). This novel pathogen causes Coronavirus Disease 2019 (COVID-19), a pathogenic condition that reached pandemic proportion and is associated with unprecedented morbidity and mortality. Summary The renin–angiotensin system is a complex, coordinated hormonal cascade that plays a pivotal role in controlling individual cell behaviour and multiple organ functions. ACE2 acts as an endogenous counter-regulator to the pro-inflammatory and pro-fibrotic pathways triggered by ACE through the conversion of Ang II into the vasodilatory peptide Ang 1–7. We discuss the structure, function and expression of ACE2 in different tissues. We also briefly describe the role of ACE2 as a pivotal driver across a wide spectrum of pathogenic conditions, such as cardiac and renal diseases. Furthermore, we provide the most recent data concerning the possible role of ACE2 in mediating SARS-CoV-2 infection and dictating COVID-19 severity. Correspondence to Luca Perico, PhD, Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, Via Stezzano 87, 24126 Bergamo, Italy. Tel: +39 035 42131; fax: +39 035 319331; e-mail: luca.perico@marionegri.it Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Sodium bicarbonate therapy for acute respiratory acidosis Purpose of review Respiratory acidosis is commonly present in patients with respiratory failure. The usual treatment of hypercapnia is to increase ventilation. During the recent surge of COVID-19, respiratory acidosis unresponsive to increased mechanical ventilatory support was common. Increasing mechanical ventilation comes at the expense of barotrauma and hemodynamic compromise from increasing positive end-expiratory pressures or minute ventilation. Treating acute respiratory acidemia with sodium bicarbonate remains controversial. Recent findings There are no randomized controlled trials of administration of sodium bicarbonate for respiratory acidemia. A recent review concluded that alkali therapy for mixed respiratory and metabolic acidosis might be useful but was based on the conflicting and not conclusive literature regarding metabolic acidosis. This strategy should not be extrapolated to treatment of respiratory acidemia. Low tidal volume ventilation in acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) has beneficial effects associated with permissive hypercapnia. Whether the putative benefits will be negated by administration of alkali is not known. Hypercapnic acidosis is well tolerated, with few adverse effects as long as tissue perfusion and oxygenation are maintained. Summary There is a lack of clinical evidence that administration of sodium bicarbonate for respiratory acidosis has a net benefit; in fact, there are potential risks associated with it. Correspondence to David S. Goldfarb, MD, Clinical Chief, Nephrology Division, NYU Langone Health, Professor of Medicine and Physiology, New York University School of Medicine, Nephrology Section 111G, 423 E. 23 Street, New York, NY 10010, USA. Tel: +1 212 686 7500, x3877; fax: +1 212 951 6842; e-mail: david.goldfarb@nyulangone.org Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Controversies in nephrologic covidology No abstract available

Diagnosis of amyloid beyond Congo red Purpose of review Amyloidoses are a group of rare and heterogeneous diseases in which abnormally folded proteins deposit in tissues and lead to organ damage. A brief review of advances in the diagnosis of extracerebral systemic amyloidoses in the context of recent advances in their clinical management is provided. Recent findings Although steady progress in the treatment of AL and AA has evolved over many years, significant advances in the treatment of ATTR, transthyretin-derived amyloidosis, have been achieved only recently. This coincides with the emergence of nontissue diagnosis of cardiac ATTR in both the hereditary and wild-type settings. The latter is emerging as possibly the most prevalent type of systemic amyloidosis. Available treatments are amyloid protein type dependent and, hence, following amyloid detection, amyloid protein typing is necessary. Although mass spectrometry has emerged as the preferred method of amyloid typing, careful application of immune methods is still clinically useful but caution and experience, as well as awareness of the limitations of each method, are necessary in their interpretation. Summary Despite significant advances in the treatment of the systemic amyloidoses, outcomes remain poor, primarily due to delays in diagnosis. Precise diagnosis of the amyloid protein type is critical for treatment selection. Correspondence to Maria M. Picken, MD, PhD, Loyola University Medical Center, Pathology, 2160S. First Avenue, Maywood, IL 60153, USA. Tel: +1 708 327 2607; e-mail: mpicken@lumc.edu Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

WNK4 kinase: role of chloride sensing in the distal convoluted tubule Purpose of review This review focuses on recent efforts in identifying with-no-lysine kinase 4 (WNK4) as a physiological intracellular chloride sensor and exploring regulators of intracellular chloride concentration ([Cl-]i) in the distal convoluted tubule (DCT). Recent findings The discovery of WNK1's chloride-binding site provides the mechanistic details of the chloride-sensing regulation of WNK kinases. The subsequent in-vitro studies reveal that the chloride sensitivities of WNK kinases were variable. Because of its highest chloride sensitivity and dominant expression, WNK4 emerges as the leading candidate of the chloride sensor in DCT. The presentation of hypertension and increased sodium-chloride cotransporter (NCC) activity in chloride-insensitive WNK4 mice proved that WNK4 is inhibitable by physiological [Cl-]i in DCT. The chloride-mediated WNK4 regulation is responsible for hypokalemia-induced NCC activation but unnecessary for hyperkalemia-induced NCC deactivation. This chloride-sensing mechanism requires basolateral potassium and chloride channels or cotransporters, including Kir4.1/5.1, ClC-Kb, and possibly KCCs, to modulate [Cl-]i in response to the changes of plasma potassium. Summary WNK4 is both a master NCC stimulator and an in-vivo chloride sensor in DCT. The understanding of chloride-mediated regulation of WNK4 explains the inverse relationship between dietary potassium intake and NCC activity. Correspondence to Chih-Jen Cheng, MD, PhD, Division of Nephrology, Department of Medicine, Tri-Service General Hospital, No. 325, Section 2, Cheng-Kung Road, Neihu, 114, Taipei, Taiwan. Tel: +886 2 87927213; fax: +886 2 87927322; e-mail: laurence1234kimo@yahoo.com.tw;chih-jen-cheng@uiowa.edu Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Bisphosphonates and management of kidney stones and bone disease Purpose of review Kidney stones are strongly associated with low bone density and bone fracture. Clinical management focuses on prevention of kidney stones and bone fracture. We reviewed literature of kidney stones and bone disease with a special focus on updates in therapeutic strategies. We will review the literature regarding dietary management, supplements, and medications and emphasize the recent studies on bisphosphonates and kidney stone management. Recent findings Bisphosphonate medications are commonly used in management of low bone density. Previous studies showed that they reduce urinary calcium. A recent large prospective study found that bisphosphonates may reduce the risk of kidney stones in individuals who have low bone density. In addition to lowering urinary calcium, a recent study found that bisphosphonates may act as an inhibitor in the urinary space. Summary There are multiple dietary and pharmacologic strategies that can be considered for kidney stones and bone disease, such as low salt and normal calcium diet, as well as thiazides, alkali, and bisphosphonate medications. Bisphosphonates may have an important role in reducing bone resorption and reducing overall risk of kidney stone and bone disease. Correspondence to Megan Prochaska, 5841 S. Maryland Avenue, MC 5100, Chicago, IL 60637, USA. Tel: +1 773 702 1041; e-mail: mprocha2@medicine.bsd.uchicago.edu Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Contribution of Th17 cells to tissue injury in hypertension Purpose of review Hypertension has been demonstrated to be a chief contributor to morbidity and mortality throughout the world. Although the cause of hypertension is multifactorial, emerging evidence, obtained in experimental studies, as well as observational studies in humans, points to the role of inflammation and immunity. Many aspects of immune function have now been implicated in hypertension and end-organ injury; this review will focus upon the recently-described role of Th17 cells in this pathophysiological response. Recent findings Studies in animal models and human genetic studies point to a role in the adaptive immune system as playing a contributory role in hypertension and renal tissue damage. Th17 cells, which produce the cytokine IL17, are strongly pro-inflammatory cells, which may contribute to tissue damage if expressed in chronic disease conditions. The activity of these cells may be enhanced by physiological factors associated with hypertension such as dietary salt or Ang II. This activity may culminate in the increased sodium retaining activity and exacerbation of inflammation and renal fibrosis via multiple cellular mechanisms. Summary Th17 cells are a distinct component of the adaptive immune system that may strongly enhance pathways leading to increased sodium reabsorption, elevated vascular tone and end-organ damage. Moreover, this pathway may lend itself towards specific targeting for treatment of kidney disease and hypertension. Correspondence to David P. Basile, Department of Anatomy, Cell Biology & Physiology, Indiana Univ. School of Medicine, 635 Barnhill Dr MS 2063, Indianapolis, IN 46202, USA. Fax: +1 317 274 3318; e-mail: dpbasile@iupui.edu Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Gut–brain–bone marrow axis in hypertension Purpose of review Rapidly emerging evidence implicates an important role of gut–brain–bone marrow (BM) axis involving gut microbiota (GM), gut epithelial wall permeability, increased production of pro-inflammatory BM cells and neuroinflammation in hypertension (HTN). However, the precise sequence of events involving these organs remains to be established. Furthermore, whether an impaired gut–brain–BM axis is a cause or consequence of HTN is actively under investigation. This will be extremely important for translation of this fundamental knowledge to novel, innovative approaches for the control and management of HTN. Therefore, our objectives are to summarize the latest hypothesis, provide evidence for and against the impaired gut, BM and brain interactions in HTN and discuss perspectives and future directions. Recent findings Hypertensive stimuli activate autonomic neural pathways resulting in increased sympathetic and decreased parasympathetic cardiovascular modulation. This directly affects the functions of cardiovascular-relevant organs to increase blood pressure. Increases in sympathetic drive to the gut and BM also trigger sequences of signaling events that ultimately contribute to altered GM, increased gut permeability, enhanced gut- and brain-targeted pro-inflammatory cells from the BM in perpetuation and establishment of HTN. Summary In this review, we present the mechanisms involving the brain, gut, and BM, whose dysfunctional interactions may be critical in persistent neuroinflammation and key in the development and establishment of HTN. Correspondence to Mohan K. Raizada, PhD, Department of Physiology and Functional Genomics, University of Florida College of Medicine, PO Box 100274, Gainesville, FL 32610, USA. Tel: +352 392 9299; e-mail: mraizada@ufl.edu Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

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Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,

Telephone consultation 11855 int 1193,