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Zhao X, Kotha S, Nayyar D, Ma X, Lilly L, Castel H, Gupta S. Physiologic changes in the hepatopulmonary syndrome before and after liver transplant: A longitudinal and predictor analysis. Hepatology 2024; 79:636-649. [PMID: 37732952 PMCID: PMC10871618 DOI: 10.1097/hep.0000000000000605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 08/27/2023] [Indexed: 09/22/2023]
Abstract
BACKGROUND AND AIMS Hepatopulmonary syndrome (HPS) is a common complication of liver disease defined by abnormal oxygenation and intrapulmonary vascular dilatation, treated with liver transplantation. Little is known about changes in HPS physiological parameters over time. We sought to describe baseline clinical and physiological characteristics in HPS and their relationships, temporal changes in physiological parameters before and after transplant, and predictors of changes in oxygenation. APPROACH AND RESULTS This was a retrospective cohort study in the Canadian HPS Program (n = 132). Rates of change after diagnosis were: -3.7 (-6.4, -0.96) mm Hg/year for partial pressure of arterial oxygen (PaO 2 ); -26 (-96, 44) m/year for 6-minute walk distance, and 3.3% (-6.6, -0.011) predicted/year for diffusion capacity. Noninvasive shunt of ≥ 20% predicted a slower PaO 2 decline by 0.88 (0.36, 1.4) mm Hg/month. We identified 2 PaO 2 deterioration classes-"very severe disease, slow decliners" (PaO 2 45.0 mm Hg; -1.0 mm Hg/year); and "moderate disease, steady decliners" (PaO 2 65.5 mm Hg; -2.5 mm Hg/year). PaO 2 increased by 6.5 (5.3, 7.7) mm Hg/month in the first year after transplant. The median time to normalization was 149 (116, 184) days. Posttransplant improvement in PaO 2 was 2.5 (0.1, 4.9) mm Hg/month faster for every 10 mm Hg greater pretransplant orthodeoxia. CONCLUSIONS We present a large and long longitudinal data analysis in HPS. In addition to rates of physiological decline and improvement before and after liver transplantation, we present novel predictors of PaO 2 decline and improvement rates. Our findings enhance our understanding of the natural history of HPS and provide pathophysiologic clues. Importantly, they may assist providers in prognostication and prioritization before and after transplant.
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Affiliation(s)
- Xun Zhao
- Department of Gastroenterology and Hepatology, McGill University, Montreal, Canada
- Department of Multi-Organ Transplant, Toronto General Hospital, University of Toronto, Toronto, Canada
| | - Sreelakshmi Kotha
- Department of Hepatology, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Dhruv Nayyar
- Department of Medicine, University of Toronto, Toronto, Canada
| | - Xiayi Ma
- Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Unity Health Toronto, University of Toronto, Toronto, Canada
| | - Leslie Lilly
- Department of Multi-Organ Transplant, Toronto General Hospital, University of Toronto, Toronto, Canada
| | - Hélène Castel
- Department of Hepatology and Liver Transplantation, Centre Hospitalier de l’Université de Montréal (CHUM), Montreal, Canada
| | - Samir Gupta
- Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Unity Health Toronto, University of Toronto, Toronto, Canada
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Nayyar D, Pendrith C, Kishimoto V, Chu C, Fujioka J, Rios P, Sacha Bhatia R, Lyons OD, Harvey P, O'Brien T, Martin D, Agarwal P, Mukerji G. Quality of virtual care for ambulatory care sensitive conditions: Patient and provider experiences. Int J Med Inform 2022; 165:104812. [PMID: 35691260 PMCID: PMC9366328 DOI: 10.1016/j.ijmedinf.2022.104812] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 04/28/2022] [Accepted: 06/05/2022] [Indexed: 11/21/2022]
Abstract
Background The COVID-19 pandemic and the need for physical distancing has led to rapid uptake of virtual visits to deliver ambulatory health care. Despite widespread adoption, there has been limited evaluation of the quality of care being delivered through virtual modalities for ambulatory care sensitive conditions (ACSCs). Objective To characterize patients’ and providers’ experiences with the quality and sustainability of virtual care for ACSCs. Design This was a multi-method study utilizing quantitative and qualitative data from patient surveys, provider surveys, and provider focus groups at a large academic ambulatory care hospital between May 2020 and June 2021. We included patients and providers utilizing telephone or video visits for the following ACSCs: hypertension, angina, heart failure, atrial fibrillation, diabetes, chronic obstructive pulmonary disease, or asthma. Main measures Quantitative and qualitative patient and provider survey responses were mapped to the Six Domains of Healthcare Quality framework. Provider focus groups were coded to identify themes within each quality domain. Key results Surveys were completed by 110/352 (31%) consenting patients and 20/61 (33%) providers. 5 provider focus groups were held with 14 participants. Patients found virtual visits to be generally more convenient than in-person visits for ACSCs. The perceived effectiveness of virtual visits was dependent on the clinical and social complexity of individual encounters. Respondents reported difficulty forming effective patient-provider relationships in the virtual environment. Patients and providers felt that virtual care has potential to both alleviate and exacerbate structural barriers to equitable access to care. Conclusions In a large academic ambulatory care hospital, patients and providers experienced the quality of virtual visits for the management of ACSCs to be variable depending on the biopsychosocial complexity of the individual encounter. Our findings in each quality domain highlight key considerations for patients, providers and institutions to uphold the quality of virtual care for ACSCs.
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Affiliation(s)
- Dhruv Nayyar
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Ciara Pendrith
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Vanessa Kishimoto
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Toronto, ON, Canada
| | - Cherry Chu
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Toronto, ON, Canada
| | - Jamie Fujioka
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Toronto, ON, Canada
| | - Patricia Rios
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Toronto, ON, Canada
| | - R Sacha Bhatia
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Women's College Hospital Institute for Health System Solutions and Virtual Care, Toronto, ON, Canada; Department of Medicine, Women's College Hospital, Toronto, ON, Canada
| | - Owen D Lyons
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Women's College Hospital Institute for Health System Solutions and Virtual Care, Toronto, ON, Canada; Department of Medicine, Women's College Hospital, Toronto, ON, Canada
| | - Paula Harvey
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Women's College Hospital Institute for Health System Solutions and Virtual Care, Toronto, ON, Canada; Department of Medicine, Women's College Hospital, Toronto, ON, Canada
| | - Tara O'Brien
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Women's College Hospital Institute for Health System Solutions and Virtual Care, Toronto, ON, Canada; Department of Medicine, Women's College Hospital, Toronto, ON, Canada
| | - Danielle Martin
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Women's College Hospital Institute for Health System Solutions and Virtual Care, Toronto, ON, Canada; Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Payal Agarwal
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Women's College Hospital Institute for Health System Solutions and Virtual Care, Toronto, ON, Canada; Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Geetha Mukerji
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Women's College Hospital Institute for Health System Solutions and Virtual Care, Toronto, ON, Canada; Department of Medicine, Women's College Hospital, Toronto, ON, Canada.
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3
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Chu C, Nayyar D, Bhattacharyya O, Martin D, Agarwal P, Mukerji G. Patient and provider experience with virtual care in a large, ambulatory care hospital in Ontario, Canada during the COVID-19 pandemic: An observational study (Preprint). J Med Internet Res 2022; 24:e38604. [PMID: 36194862 PMCID: PMC9605083 DOI: 10.2196/38604] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 07/25/2022] [Accepted: 08/22/2022] [Indexed: 11/13/2022] Open
Abstract
Background Virtual care use increased during the COVID-19 pandemic. The impact of that shift on patient and provider experiences is unclear. Objective We evaluated patient and provider experiences with virtual visits across an academic, ambulatory hospital in Toronto, Canada and assessed predictors of positive experience with virtual care. Methods Survey data were analyzed from consenting patients who attended at least one virtual visit (video or telephone) and from consenting providers who delivered at least one virtual visit. Distributions for demographic variables and responses to survey questions are reported, with statistical significance assessed using chi-square tests and t tests. Ordinal logistic regression analysis was used to identify any patient predictors of responses. Results During the study period, 253 patients (mean age 45.1, SD 15.6 years) completed 517 video visit surveys, and 147 patients (mean age 41.6, SD 16.4 years) completed 209 telephone visit surveys. A total of 75 and 94 providers completed the survey in June 2020 and June 2021, respectively. On a scale from 1 to 10 regarding likelihood to recommend virtual care to others, fewer providers rated a score of 8 or above compared with patients (providers: 62/94, 66% for video and 49/94, 52% for telephone; patients: 415/517, 80% for video and 150/209, 72% for telephone). Patients of non-White ethnicity had lower odds of rating a high score of 9 or 10 compared with White patients (odds ratio 0.52, 95% CI 0.28-0.99). Conclusions Patient experiences with virtual care were generally positive, but provider experiences were less so. Findings suggest potential differences in patient experience by ethnicity, warranting further investigation into equity concerns with virtual care.
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Affiliation(s)
- Cherry Chu
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Toronto, ON, Canada
| | - Dhruv Nayyar
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Onil Bhattacharyya
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Women's College Hospital, Toronto, ON, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Danielle Martin
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Women's College Hospital, Toronto, ON, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Payal Agarwal
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Women's College Hospital, Toronto, ON, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Geetha Mukerji
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Women's College Hospital, Toronto, ON, Canada
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Pendrith C, Nayyar D, Chu C, O'Brien T, Lyons OD, Agarwal P, Martin D, Bhatia RS, Mukerji G. Outpatient visit trends for internal medicine ambulatory care sensitive conditions after the COVID-19 pandemic: a time-series analysis. BMC Health Serv Res 2022; 22:198. [PMID: 35164751 PMCID: PMC8845247 DOI: 10.1186/s12913-022-07566-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 01/31/2022] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND The COVID-19 pandemic led to a dramatic shift in the delivery of outpatient medicine with reduced in-person visits and a transition to predominantly virtual visits. We sought to understand trends in visit patterns for ambulatory care sensitive conditions (ACSCs) commonly seen in internal medicine clinics. METHODS We included adult outpatients seen for an ACSC between March 15th, 2017 and March 14th, 2021 at a single-centre in Ontario, Canada. Monthly visits were assessed by visit type (new consultation, follow-up), diagnosis, and clinic. Time series analyses compared visit volumes pre- and post-pandemic. Proportion of virtual visits were compared before and during the pandemic. Patient and visit factors were compared between in-person and virtual visits. RESULTS 8274 patients with 34,021 visits were included. Monthly visits increased by 15% during the pandemic (p < 0.0001). New consultations decreased by 10% (p = 0.0053) but follow-up visits increased by 21% (p < 0.0001). Monthly heart failure visits increased by 43% (p < 0.0001) whereas atrial fibrillation visits decreased. Pre- pandemic, < 1% of visits were virtual compared to 82% during the pandemic (p < 0.0001). Less than half of heart failure visits were virtual whereas > 95% of diabetes visits were virtual. CONCLUSIONS We found a significant increase in overall visits to internal medicine clinics driven by increased volumes of follow-up visits, which more than offset decreased new consultations. There was variability in visit trends and uptake of virtual care by visit diagnosis, which may indicate challenges with delivery of virtual care for certain conditions.
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Affiliation(s)
- Ciara Pendrith
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Women's College Hospital Institute for Health System Solutions & Virtual Care, 76 Grenville Street, Toronto, Ontario, M5S 1B3, Canada
| | - Dhruv Nayyar
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Cherry Chu
- Women's College Hospital Institute for Health System Solutions & Virtual Care, 76 Grenville Street, Toronto, Ontario, M5S 1B3, Canada
| | - Tara O'Brien
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Women's College Hospital, Toronto, ON, Canada
| | - Owen D Lyons
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Women's College Hospital, Toronto, ON, Canada
| | - Payal Agarwal
- Women's College Hospital Institute for Health System Solutions & Virtual Care, 76 Grenville Street, Toronto, Ontario, M5S 1B3, Canada.,Women's College Hospital, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Danielle Martin
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Women's College Hospital Institute for Health System Solutions & Virtual Care, 76 Grenville Street, Toronto, Ontario, M5S 1B3, Canada.,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Women's College Hospital, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - R Sacha Bhatia
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Women's College Hospital Institute for Health System Solutions & Virtual Care, 76 Grenville Street, Toronto, Ontario, M5S 1B3, Canada.,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Women's College Hospital, Toronto, ON, Canada.,Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Geetha Mukerji
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada. .,Women's College Hospital Institute for Health System Solutions & Virtual Care, 76 Grenville Street, Toronto, Ontario, M5S 1B3, Canada. .,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada. .,Women's College Hospital, Toronto, ON, Canada.
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5
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Nayyar D, Nguyen T, Pathan F, Vo G, Richards D, Thomas L, Dimitri H, Otton J. Cardiac magnetic resonance derived left atrial strain after ST-elevation myocardial infarction: an independent prognostic indicator. Cardiovasc Diagn Ther 2021; 11:383-393. [PMID: 33968617 DOI: 10.21037/cdt-20-879] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Background The prognostic value of cardiac magnetic resonance (CMR) derived left atrial (LA) strain, ejection fraction (LAEF) and indexed volumes (LAVImax and LAVImin) after ST-elevation myocardial infarction (STEMI) remains controversial. The aim of this study was to assess the relationship between LA function and major adverse cardiovascular events (MACE) after STEMI. Methods A total of 202 prospectively recruited patients who underwent CMR at median day 4 after STEMI had complete CMR data for feature tracking assessment. LA reservoir and booster strain were quantified based on the average of three independently repeated measurements. Results MACE occurred in 35 patients during a median follow up of 607 days. Patients with MACE had lower median LA reservoir strain (18.9% vs. 29.4%, P<0.001), LA booster strain (9.4% vs. 13.0%, P=0.002) and LAEF (41.5% vs. 49.2%, P<0.001) than patients without MACE. Kaplan-Meier analyses demonstrated a difference in MACE between high- and low-risk groups for LA reservoir strain (cutoff 19.2%, P<0.001), LA booster strain (cutoff 9.7%, P<0.001) and LAEF (cutoff 38.5%, P<0.001). The AUC increased from 0.713 (95% CI: 0.608-0.818) for LVEF to 0.775 (95% CI: 0.680-0.870) when LA reservoir strain was added to LVEF (P=0.047). Univariate Cox regression analysis showed that all LA parameters had a significant effect on MACE, while multivariate analysis found LA reservoir strain was an independent predictor of MACE (HR 0.905; 95% CI: 0.843-0.972, P=0.006). Conclusions CMR derived LA reservoir strain independently predicted MACE after STEMI when adjusted for standard risk measures.
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Affiliation(s)
- Dhruv Nayyar
- Cardiology Department, Liverpool Hospital, Sydney, NSW, Australia.,School of Medicine, Western Sydney University, Sydney, NSW, Australia
| | - Tuan Nguyen
- Cardiology Department, Liverpool Hospital, Sydney, NSW, Australia.,South West Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Faraz Pathan
- Cardiology Department, Nepean Hospital, Sydney, NSW, Australia.,Charles Perkins Centre Sydney, Nepean Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Giau Vo
- Cardiology Department, Liverpool Hospital, Sydney, NSW, Australia
| | - David Richards
- Westmead Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Liza Thomas
- South West Clinical School, University of New South Wales, Sydney, NSW, Australia.,Westmead Clinical School, University of Sydney, Sydney, NSW, Australia.,Cardiology Department, Westmead Hospital, Sydney, NSW, Australia
| | - Hany Dimitri
- Cardiology Department, Liverpool Hospital, Sydney, NSW, Australia.,South West Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - James Otton
- Cardiology Department, Liverpool Hospital, Sydney, NSW, Australia.,South West Clinical School, University of New South Wales, Sydney, NSW, Australia
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Nayyar D, Nguyen T, Pathan F, Vo T, Richards D, Thomas L, Dimitri H, Otton J. Cardiac magnetic resonance derived left atrial function after ST-elevation myocardial infarction: an important prognostic indicator. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.0235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
The prognostic value of cardiac magnetic resonance (CMR) derived left atrial (LA) strain, ejection fraction (LAEF) and volumes (LAVImax and LAVImin) after STEMI is controversial.
Aim
To assess the relationship between LA function and major adverse cardiovascular events (MACE) within 2 years after STEMI.
Methods
We prospectively recruited 213 consecutive STEMI patients who underwent CMR at median day 4. 202 patients had complete CMR data for feature tracking assessment. LA reservoir and booster strain were quantified by one blinded observer based on the average of three independently repeated measurements from two- and four-chamber views. MACE was a composite of all-cause mortality, reinfarction, new or worsening heart failure, stroke and sustained ventricular arrhythmias.
Results
The cohort included 174 (86.1%) males, median age 56 years (IQR 50–65 years). MACE occurred in 35 (17.3%) patients. Patients with MACE had lower median reservoir strain (18.9 vs 29.4%, p<0.001), booster strain (9.4 vs 13.0%, p=0.002) and LAEF (41.5 vs 49.2%, p<0.001), and higher LAVImax (43.5 vs 38.6ml/m2, p=0.019) and LAVImin (23.7 vs 19.3ml/m2, p<0.001) than patients without MACE. Patients with reduced left ventricular ejection fraction (LVEF≤40%) had lower median reservoir strain (22.5 vs 30.1%, p<0.001), booster strain (11.3 vs 12.9%, p=0.021) and LAEF (43.3 vs 50.3%, p<0.001) than patients with LVEF>40%. AUC analyses showed reservoir strain (AUC 0.769; 95% CI 0.676–0.861, p<0.001), booster strain (AUC 0.684; 95% CI 0.558–0.810, p=0.002) and LAEF (AUC 0.698; 95% CI 0.596–0.800, p<0.001) predicted MACE. Kaplan Meier analyses showed a difference in MACE between high- and low-risk groups for reservoir strain (cutoff 21%, p<0.001), booster strain (cutoff 9.6%, p<0.001) and LAEF (cutoff 41%, p<0.001). Univariate Cox regression analyses showed all LA parameters had a significant effect on MACE, while multivariate analyses found additional prognostic utility using reservoir strain.
Conclusion
LA reservoir strain provided incremental prognostic value beyond established clinical and CMR parameters for predicting MACE after STEMI.
Kaplan Meier analyses
Funding Acknowledgement
Type of funding source: None
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Affiliation(s)
- D Nayyar
- Liverpool Hospital, Sydney, Australia
| | - T Nguyen
- Liverpool Hospital, Sydney, Australia
| | - F Pathan
- Nepean Hospital, Sydney, Australia
| | - T Vo
- Liverpool Hospital, Sydney, Australia
| | | | - L Thomas
- Westmead Hospital, Sydney, Australia
| | - H Dimitri
- Liverpool Hospital, Sydney, Australia
| | - J Otton
- Liverpool Hospital, Sydney, Australia
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Nayyar D, Kawaguchi S, Mah B. Request for medical assistance in dying after a suicide attempt in a 75-year-old man with pancreatic adenocarcinoma. CMAJ 2020; 191:E838-E840. [PMID: 31358598 DOI: 10.1503/cmaj.190175] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Affiliation(s)
- Dhruv Nayyar
- Department of Medicine (Nayyar), University of Toronto; Temmy Latner Centre for Palliative Care (Kawaguchi), Sinai Health System; Department of Psychiatry (Mah), Sinai Health System; University of Toronto (Kawaguchi, Mah), Toronto, Ont.
| | - Sarah Kawaguchi
- Department of Medicine (Nayyar), University of Toronto; Temmy Latner Centre for Palliative Care (Kawaguchi), Sinai Health System; Department of Psychiatry (Mah), Sinai Health System; University of Toronto (Kawaguchi, Mah), Toronto, Ont
| | - Bill Mah
- Department of Medicine (Nayyar), University of Toronto; Temmy Latner Centre for Palliative Care (Kawaguchi), Sinai Health System; Department of Psychiatry (Mah), Sinai Health System; University of Toronto (Kawaguchi, Mah), Toronto, Ont
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Nayyar D, Leung D, Aty W, Premawardhana U, Kadappu K. 422 Transoesophageal Echocardiography in Diagnosing Acute Aortic Dissection not Evident on CT Aortogram. Heart Lung Circ 2020. [DOI: 10.1016/j.hlc.2020.09.429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Kristanto W, Nayyar D, Kadappu K, Gibbs O, Xu J, Naguib Badie T, O'Loughlin A, Kachawalla H, Premawardhana U, Nguyen P. 126 Increased Rates of Takotsubo Cardiomyopathy During the 2019 New South Wales Bushfires. Heart Lung Circ 2020. [DOI: 10.1016/j.hlc.2020.09.133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Nayyar D, Shugman I, Nguyen Nguyen N, Nguyen T, Premawardhana U. 248 Real-World Experience Using 3D Electroanatomical Mapping to Reduce Fluoroscopy Time and Radiation Dose in Electrophysiology Studies and Ablation. Heart Lung Circ 2020. [DOI: 10.1016/j.hlc.2020.09.255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Nayyar D, Nguyen T, Pathan F, Vo T, Richards D, Thomas L, Dimitri H, Otton J. 011 Cardiac Magnetic Resonance Derived Left Atrial Strain Predicts Major Adverse Cardiovascular Events After ST-Elevation Myocardial Infarction. Heart Lung Circ 2020. [DOI: 10.1016/j.hlc.2020.09.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Nayyar D, Kadappu K, Xu J. 442 Anomalous Coronary Circulation Arising From a Solitary Coronary Ostium: First Australian Report. Heart Lung Circ 2020. [DOI: 10.1016/j.hlc.2020.09.449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Nayyar D, Kumarasinghe G, Irwin S, Sharma L, Premawardhana U, Rajaratnam R, Kadappu K. Five-Year Outcome Data from the Budyari Cardiology Outreach Program. Heart Lung Circ 2019. [DOI: 10.1016/j.hlc.2019.06.517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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14
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Nayyar D. Web Exclusive. Annals Story Slam - Chocolate Mousse. Ann Intern Med 2018; 169:SS1. [PMID: 30508449 DOI: 10.7326/w18-0033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Dhruv Nayyar
- University of Toronto, Toronto, Ontario, Canada (D.N.)
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Klein A, Qi Z, Bahin FF, Awadie H, Nayyar D, Ma M, Voermans RP, Williams SJ, Lee E, Bourke MJ. Outcomes after endoscopic resection of large laterally spreading lesions of the papilla and conventional ampullary adenomas are equivalent. Endoscopy 2018; 50:972-983. [PMID: 29768645 DOI: 10.1055/a-0587-5228] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Endoscopic resection of ampullary adenomas is a safe and effective alternative to surgical resection. A subgroup of patients have large laterally spreading lesions of the papilla Vateri (LSL-P), which are frequently managed surgically. Data on endoscopic resection of LSL-P are limited and long-term outcomes are unknown. The aim of this study was to compare the outcomes of endoscopic resection of LSL-P with those of standard ampullary adenomas. METHODS A retrospective analysis of a prospectively collected and maintained database was conducted. LSL-P was defined as extension of the lesion ≥ 10 mm from the edge of the ampullary mound. Piecemeal endoscopic mucosal resection of the laterally spreading component was followed by resection of the ampulla. Patient, lesion, and procedural data, as well as results of endoscopic follow-up, were collected. RESULTS 125 lesions were resected. Complete endoscopic resection was achieved in 97.6 % at the index procedure (median lesion size 20 mm, interquartile range [IQR] 13 - 30 mm). Compared with ampullary adenomas, LSL-Ps were significantly larger (median 35 mm vs. 15 mm), contained a higher rate of advanced pathology (38.6 % vs. 18.5 %), and had higher rates of intraprocedural bleeding (50 % vs. 24.7 %) and delayed bleeding (25.0 % vs. 12.3 %). Both groups had similar rates of histologically proven recurrence at first surveillance (16.4 % vs. 17.9 %). Median follow-up for the entire cohort was 18.5 months. For patients with at least two surveillance endoscopies (n = 68; median follow-up 29 months, IQR 18 - 48 months), 95.6 % were clear of disease and considered cured. CONCLUSIONS LSL-P can be resected endoscopically with comparable outcomes to standard ampullectomy, albeit with a higher risk of bleeding. Endoscopic treatment should be considered as an alternative to surgical resection, even for large LSL-P.
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Affiliation(s)
- Amir Klein
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney Australia
| | - Zhengyan Qi
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney Australia
| | - Farzan F Bahin
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney Australia.,Westmead Clinical School, University of Sydney, Sydney, Australia
| | - Halim Awadie
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney Australia
| | - Dhruv Nayyar
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney Australia
| | - Michael Ma
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney Australia
| | - Rogier P Voermans
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney Australia
| | - Stephen J Williams
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney Australia
| | - Eric Lee
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney Australia.,Westmead Clinical School, University of Sydney, Sydney, Australia
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Klein A, Qi Z, Bahin FF, Awadie H, Nayyar D, Ma M, Voermans RP, Williams SJ, Lee E, Bourke MJ. Correction: Outcomes after endoscopic resection of large laterally spreading lesions of the papilla and conventional ampullary adenomas are equivalent. Endoscopy 2018; 50:C11. [PMID: 30208494 DOI: 10.1055/a-0723-3188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- Amir Klein
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney Australia
| | - Zhengyan Qi
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney Australia
| | - Farzan F Bahin
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney Australia.,Westmead Clinical School, University of Sydney, Sydney, Australia
| | - Halim Awadie
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney Australia
| | - Dhruv Nayyar
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney Australia
| | - Michael Ma
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney Australia
| | - Rogier P Voermans
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney Australia
| | - Stephen J Williams
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney Australia
| | - Eric Lee
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney Australia.,Westmead Clinical School, University of Sydney, Sydney, Australia
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17
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Qian P, Nayyar D, Chik W, Zaman S, Stafford W, Hayes J, Denman R, Young G, Sanders P, Kovoor P, Sivagangabalan G. The Prognostic Impact of Implanted Cardiac Defibrillator Activation and Mode of Anti-Tachycardia Therapy on Mortality. Heart Lung Circ 2017. [DOI: 10.1016/j.hlc.2017.06.343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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18
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Klein A, Nayyar D, Bahin FF, Qi Z, Lee E, Williams SJ, Byth K, Bourke MJ. Endoscopic mucosal resection of large and giant lateral spreading lesions of the duodenum: success, adverse events, and long-term outcomes. Gastrointest Endosc 2016; 84:688-96. [PMID: 26975231 DOI: 10.1016/j.gie.2016.02.049] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Accepted: 02/26/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Large sporadic duodenal adenomas are uncommon but they harbor malignant potential, which requires consideration of definitive treatment. EMR is gaining acceptance as an effective and safe alternative to high-risk surgical procedures, but data on long-term outcomes are limited. Herein we describe the short- and long-term outcomes of these lesions in a tertiary referral center. METHODS Prospectively collected data were analyzed to identify risk factors for adverse events and outcomes. Patient demographics, lesion characteristics, and procedural technical data were collected. RESULTS From 2007 to 2015, 106 adenomas ≥10 mm were resected (mean patient age, 69 years; 54% male; median size, 25 mm; interquartile range [IQR], 19-40). Complete endoscopic resection was achieved in 96%. Intraprocedural bleeding occurred in 43% of cases and was associated with lesion size (P < .001), number of resected specimens (P = .003), and longer procedures (P = .001). Delayed bleeding occurred in 15% (56% did not require active intervention) and was associated with lesion size (P = .03). Perforation occurred in 3 patients. The 30-day mortality was 0%. Median follow-up was 22 months (IQR, 7-45). Histologically proven adenoma recurrence was identified and treated in 12 of 83 patients (14.4%) on first surveillance endoscopy. For the 53 patients for whom follow-up ≥12 months was available (median follow-up, 36 months; IQR, 24-51), 48 patients (90.6%) were free of adenoma and considered cured. CONCLUSIONS In a tertiary referral center, endoscopic resection of duodenal adenomas is a safe and effective alternative to surgery. Lesion size is strongly associated with adverse events, particularly intraprocedural bleeding and delayed bleeding. Good long-term outcomes are demonstrated.
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Affiliation(s)
- Amir Klein
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, Sydney, New South Wales, Australia
| | - Dhruv Nayyar
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, Sydney, New South Wales, Australia
| | - Farzan F Bahin
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, Sydney, New South Wales, Australia; University of Sydney, Sydney, New South Wales, Australia
| | - Zhengyan Qi
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, Sydney, New South Wales, Australia
| | - Eric Lee
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, Sydney, New South Wales, Australia
| | - Stephen J Williams
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, Sydney, New South Wales, Australia
| | - Karen Byth
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, Sydney, New South Wales, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, Sydney, New South Wales, Australia; University of Sydney, Sydney, New South Wales, Australia
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19
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Nayyar D, Chik W, Zaman S, Stafford W, Hayes J, Denman R, Young G, Sanders P, Kovoor P, Sivagangabalan G. Impact of Appropriate and Inappropriate Implantable Cardioverter Defibrillator Activations on Mortality. Heart Lung Circ 2016. [DOI: 10.1016/j.hlc.2016.06.346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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20
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Nayyar D, Lau J, Chow V, Kritharides L, Ng A. Increasing Prevalence and Decreasing In-Hospital Mortality of Acute Pulmonary Embolism in NSW - A Population Based Linkage Study. Heart Lung Circ 2016. [DOI: 10.1016/j.hlc.2016.06.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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21
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Abstract
This article presents a theoretical analysis of how the processes of industrialization and development interact with international trade in goods or services to influence a country's turning point from labor exporter to labor importer. It is concluded that trade in goods complements capital movements but substitutes for labor movements, whereas trade in services and labor movements complement each other. The proposed analytical framework suggests that both international trade and migration may contribute to, but cannot lead to, a development process that brings about a migration transition in surplus labor economies.
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22
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Abstract
BACKGROUND Chronically homeless individuals have high rates of hospitalization and death, and they may benefit from the completion of advance directives. AIM To determine the rate of advance directive completion using a counselor-guided intervention, identify characteristics associated with advance directive completion, and describe end-of-life care preferences in a group of chronically homeless individuals. DESIGN Participants completed a survey and were offered an opportunity to complete an advance directive with a trained counselor. PARTICIPANTS A total of 205 residents of a shelter in Canada for homeless men (89.1% of those approached) participated from April to June 2013. RESULTS Duration of homelessness was ⩾12 months in 72.8% of participants, and 103 participants (50.2%) chose to complete an advance directive. Socio-demographic characteristics, health status, and health care use were not associated with completion of an advance directive. Participants were more likely to complete an advance directive if they reported thinking about death on a daily basis, believed that thinking about their friends and family was important, or reported knowing their wishes for end-of-life care but not having told anyone about these wishes. Among individuals who completed an advance directive, 61.2% named a substitute decision maker, and 94.1% expressed a preference to receive cardiopulmonary resuscitation in the event of a cardiorespiratory arrest if there was a chance of returning to their current state of health. CONCLUSION A counselor-guided intervention can achieve a high rate of advance directive completion among chronically homeless persons. Most participants expressed a preference to receive cardiopulmonary resuscitation in the event of a cardiorespiratory arrest.
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Affiliation(s)
- Alexander K Leung
- Centre for Research on Inner City Health, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada
| | - Dhruv Nayyar
- Centre for Research on Inner City Health, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada
| | - Manisha Sachdeva
- Centre for Research on Inner City Health, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada
| | - John Song
- Center for Bioethics, University of Minnesota, Minneapolis, MN, USA
| | - Stephen W Hwang
- Centre for Research on Inner City Health, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada Division of General Internal Medicine, Department of Medicine, University of Toronto, Toronto, Canada
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23
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Nayyar D, Hwang SW. Cardiovascular Health Issues in Inner City Populations. Can J Cardiol 2015; 31:1130-8. [DOI: 10.1016/j.cjca.2015.04.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Revised: 04/06/2015] [Accepted: 04/06/2015] [Indexed: 11/28/2022] Open
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24
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Nayyar D, Man HSJ, Granton J, Lilly LB, Gupta S. Proposed management algorithm for severe hypoxemia after liver transplantation in the hepatopulmonary syndrome. Am J Transplant 2015; 15:903-13. [PMID: 25649047 PMCID: PMC5132094 DOI: 10.1111/ajt.13177] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Revised: 12/08/2014] [Accepted: 12/19/2014] [Indexed: 01/25/2023]
Abstract
The hepatopulmonary syndrome (HPS) is defined as the triad of liver disease, intrapulmonary vascular dilatation, and abnormal gas exchange, and is found in 10-32% of patients with liver disease. Liver transplantation is the only known cure for HPS, but patients can develop severe posttransplant hypoxemia, defined as a need for 100% inspired oxygen to maintain a saturation of ≥85%. This complication is seen in 6-21% of patients and carries a 45% mortality. Its management requires the application of specific strategies targeting the underlying physiologic abnormalities in HPS, but awareness of these strategies and knowledge on their optimal use is limited. We reviewed existing literature to identify strategies that can be used for this complication, and developed a clinical management algorithm based on best evidence and expert opinion. Evidence was limited to case reports and case series, and we determined which treatments to include in the algorithm and their recommended sequence based on their relative likelihood of success, invasiveness, and risk. Recommended therapies include: Trendelenburg positioning, inhaled epoprostenol or nitric oxide, methylene blue, embolization of abnormal pulmonary vessels, and extracorporeal life support. Availability and use of this pragmatic algorithm may improve management of this complication, and will benefit from prospective validation.
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Affiliation(s)
- D. Nayyar
- Li Ka Shing Knowledge Institute of St. Michael's HospitalTorontoCanada
| | - H. S. J. Man
- Department of MedicineUniversity of TorontoTorontoCanada,Division of RespirologyDepartment of MedicineUniversity Health NetworkTorontoCanada
| | - J. Granton
- Department of MedicineUniversity of TorontoTorontoCanada,Division of RespirologyDepartment of MedicineUniversity Health NetworkTorontoCanada
| | - L. B. Lilly
- Department of MedicineUniversity of TorontoTorontoCanada,Division of Gastroenterology and MultiOrgan Transplant ProgramUniversity Health NetworkTorontoCanada
| | - S. Gupta
- Li Ka Shing Knowledge Institute of St. Michael's HospitalTorontoCanada,Department of MedicineUniversity of TorontoTorontoCanada,Division of RespirologyDepartment of MedicineSt. Michael's HospitalTorontoCanada
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25
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Nayyar D, Muthiah K, Kumarasinghe G, Hettiarachchi R, Celermajer D, Kotlyar E, Keogh A. Imatinib for the treatment of pulmonary arterial hypertension and pulmonary capillary hemangiomatosis. Pulm Circ 2014; 4:342-5. [PMID: 25006453 DOI: 10.1086/675996] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Accepted: 02/17/2014] [Indexed: 11/04/2022] Open
Abstract
Despite currently available treatments, the prognoses of pulmonary arterial hypertension (PAH) and pulmonary capillary hemangiomatosis (PCH) remain poor. Platelet-derived growth factor and its receptor (PDGFR) have been implicated in the pathogenesis of pulmonary hypertension in PAH and PCH. Imatinib, a PDGFR antagonist, may be beneficial in the treatment of both conditions because of its potent antiproliferative effect. We report two cases that demonstrate the potential for safe and efficacious use of imatinib in PAH and PCH.
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Affiliation(s)
- Dhruv Nayyar
- St. Vincent's Hospital, Sydney, Australia ; University of New South Wales, Kensington, Australia
| | | | | | - Ravin Hettiarachchi
- St. Vincent's Hospital, Sydney, Australia ; University of New South Wales, Kensington, Australia
| | | | | | - Anne Keogh
- St. Vincent's Hospital, Sydney, Australia
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26
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Nayyar D, Man HSJ, Granton J, Gupta S. Defining and characterizing severe hypoxemia after liver transplantation in hepatopulmonary syndrome. Liver Transpl 2014; 20:182-90. [PMID: 24142412 DOI: 10.1002/lt.23776] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2013] [Accepted: 10/16/2013] [Indexed: 02/07/2023]
Abstract
Hepatopulmonary syndrome is defined as a triad of liver disease, intrapulmonary vascular dilatations, and abnormal gas exchange, and it carries a poor prognosis. Liver transplantation is the only known cure for this syndrome. Severe hypoxemia in the early postoperative period has been reported to be a major complication and often leads to death in this population, but it has been poorly characterized. We sought to propose an objective definition for this complication and to describe its risk factors, incidence, and outcomes. We performed a systematic literature search and reviewed our single-center experience to characterize this complication. On the basis of the most commonly applied definition in 27 identified studies, we objectively defined severe postoperative hypoxemia as hypoxemia requiring a 100% fraction of inhaled oxygen to maintain a saturation ≥ 85% and out of proportion to any concurrent lung process. Nineteen of the 27 reports (70%) fulfilled this definition, as did 4 of the 21 patients (19%) at our center. We determined the prevalence and mortality of this complication from reports including 10 or more consecutive patients and providing sufficient postoperative details to determine whether this complication had occurred. In these reports, the prevalence of this complication was 12% (25/209). For the 11 cases with reported outcomes, the posttransplant mortality rate was 45% (5/11). There was a trend toward an increased risk of developing this complication in patients with very severe preoperative hypoxemia, defined as a partial pressure of arterial oxygen ≤ 50 mm Hg (8/41 with very severe hypoxemia versus 3/49 without severe hypoxemia, P = 0.053), and there was a significantly increased risk for patients with anatomic shunting ≥ 20% (7/25 with anatomic shunting ≥ 20% versus 1/25 without anatomic shunting ≥ 20%, P = 0.049). In conclusion, increased preoperative vigilance for this common complication is required among high-risk patients, and further research is required to identify the best management strategies.
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Affiliation(s)
- Dhruv Nayyar
- Li Ka Shing Knowledge Institute, Department of Medicine, St. Michael's Hospital, Toronto, Canada
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27
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Pandey SC, Zhang D, Mittal N, Nayyar D. Potential role of the gene transcription factor cyclic AMP-responsive element binding protein in ethanol withdrawal-related anxiety. J Pharmacol Exp Ther 1999; 288:866-78. [PMID: 9918601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023] Open
Abstract
This investigation examined the effects of acute and chronic ethanol exposure and its withdrawal on the cAMP-responsive element binding protein (CREB) and the activator protein-1 (AP-1) gene transcription factors in the rat brain. The anxiogenic effects of ethanol withdrawal after acute or protracted ethanol treatment of rats were measured by the elevated plus-maze (EPM) test. It was observed that ethanol withdrawal after acute ethanol treatment has no effect on open-arm activity (percent of open-arm entries and the mean percent of time spent on the open arms) of rats on the EPM test. On the other hand, the time course studies of the development of anxiety during ethanol withdrawal (0, 12, 24, and 72 h) after 15 days of ethanol treatment indicate that peak anxiety (significant decrease in open-arm activity) occurred at 24 h of ethanol withdrawal in rats. It was observed that acute ethanol treatment and its withdrawal (24 h) had no effect on CRE- or AP-1 DNA-binding activities in the rat cortex as determined by the electrophoretic gel-mobility shift assay. It was also found that chronic ethanol treatment and its withdrawal (24 h) had no effect on AP-1 DNA-binding activity in the rat cortex. Investigation of the time course studies of changes in CRE-DNA-binding activity during ethanol withdrawal (0, 12, 24, and 72 h) after 15 days of ethanol treatment indicated that the peak reduction of CRE-DNA-binding activity occurred at 24 h of ethanol withdrawal. The changes in the immunolabeling of the CREB-related target, that is, brain-derived neurotrophic factor (BDNF), in the rat cortex during chronic ethanol treatment and its withdrawal (24 h) were examined using western blotting. It was found that 24 h but not 0 h of ethanol withdrawal after 15 days of ethanol treatment caused a significant decrease in the immunolabeling of BDNF in the rat cortex. Fluoxetine (alone) treatment of rats for 1 or 15 days had no effect on open-arm activity and cortical CRE-DNA-binding activity. However, when fluoxetine was administered concurrently with ethanol treatment for 15 days, it caused a reversal of the anxiogenic effects of ethanol withdrawal and antagonized the down-regulation of CRE-DNA-binding activity and of the decrease in immunolabeling of BDNF in the cortices of ethanol-withdrawn rats. On the other hand, acute fluoxetine treatment produced normalization of the reduction of cortical CRE-DNA binding in ethanol-withdrawn rats (24 h) but did not reach the level of significance compared with normal control rats. Acute fluoxetine treatment had no effect on anxiety in ethanol-withdrawn rats. Taken together, these results suggest the possibility that decreased CRE-DNA-binding activity in the rat cortex may be associated with the molecular mechanisms of ethanol dependence (i.e., ethanol withdrawal-related anxiety).
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Affiliation(s)
- S C Pandey
- The Psychiatry Research Institute, Department of Psychiatry, College of Medicine, University of Illinois, Veterans Administration Chicago Health Care System (West Side Division) 60612, USA
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