With a median of 4.1 days lapsing between onset of symptoms and surgery in the Ma et al. study, Dr. Shrestha argued that "although on the basis of classification, you can still say they’re acute, there has been some sort of natural selection. So, I think that means, at least for your conclusions, that you need to clarify the statement that there is no difference between acute and chronic, because these are obviously not the same subset of patients that we see in the Western world."
Dr. Ma agreed that natural selection was indeed at play in their series, in that about 80% of their patients were referrals that were transferred in some cases from hundreds of miles away, with many dying en route or before surgery. He also concurred that had their mean and median number of days in their acute cohort been less, indeed, mortality might have been higher.
Dr. Ma reported having no conflicts of interest. Dr. Shrestha is a consultant for Edwards Lifesciences.