Search

Background: Anterior cruciate ligament (ACL) rupture is a common debilitating injury that can cause instability of the knee. We aimed to investigate the best management strategy between reconstructive surgery and non-surgical treatment for patients with a non-acute ACL injury and persistent symptoms of instability. Methods: We did a pragmatic, multicentre, superiority, randomised controlled trial in 29 secondary care National Health Service orthopaedic units in the UK. Patients with symptomatic knee problems (instability) consistent with an ACL injury were eligible. We excluded patients with meniscal pathology with characteristics that indicate immediate surgery. Patients were randomly assigned (1:1) by computer to either surgery (reconstruction) or rehabilitation (physiotherapy but with subsequent reconstruction permitted if instability persisted after treatment), stratified by site and baseline Knee Injury and Osteoarthritis Outcome Score—4 domain version (KOOS4). This management design represented normal practice. The primary outcome was KOOS4 at 18 months after randomisation. The principal analyses were intention-to-treat based, with KOOS4 results analysed using linear regression. This trial is registered with ISRCTN, ISRCTN10110685, and ClinicalTrials.gov, NCT02980367. Findings: Between Feb 1, 2017, and April 12, 2020, we recruited 316 patients. 156 (49%) participants were randomly assigned to the surgical reconstruction group and 160 (51%) to the rehabilitation group. Mean KOOS4 at 18 months was 73·0 (SD 18·3) in the surgical group and 64·6 (21·6) in the rehabilitation group. The adjusted mean difference was 7·9 (95% CI 2·5–13·2; p=0·0053) in favour of surgical management. 65 (41%) of 160 patients allocated to rehabilitation underwent subsequent surgery according to protocol within 18 months. 43 (28%) of 156 patients allocated to surgery did not receive their allocated treatment. We found no differences between groups in the proportion of intervention-related complications. Interpretation: Surgical reconstruction as a management strategy for patients with non-acute ACL injury with persistent symptoms of instability was clinically superior and more cost-effective in comparison with rehabilitation management. Funding: The UK National Institute for Health Research Health Technology Assessment Programme.

Background and Aims Postinfarction ventricular septal defect (PIVSD) is a mechanical complication of myocardial infarction (MI) with a poor prognosis. Surgical repair is the mainstay of treatment, although percutaneous closure is increasingly undertaken. Methods Patients treated with surgical or percutaneous repair of PIVSD (2010-2021) were identified at 16 UK centres. Case note review was undertaken. The primary outcome was long-term mortality. Patient groups were allocated based upon initial management (percutaneous or surgical). Results 362 patients received 416 procedures (131 percutaneous, 231 surgery). 16.1% of percutaneous patients subsequently had surgery. 7.8% of surgical patients subsequently had percutaneous treatment. Times from MI to treatment were the similar (percutaneous 9[6-14] vs. surgical 9[4-22] days, p=0.18). Surgical patients were more likely to have cardiogenic shock (62.8% vs. 51.9, p=0.044). Percutaneous patients were substantially older (72 [64-77] vs. 67[61-73] years, p

Objective\ud To investigate whether early changes in fear of movement (kinesiophobia), self-efficacy and catastrophizing were mediators of the relationship between allocation to the pre-habilitation intervention and later changes in health outcomes.\ud \ud Methods\ud The original pre-habilitation trial (PREPARE, ISRCTN17115599) recruited 118 participants awaiting lumbar fusion surgery, half of whom received a prehabilitation intervention designed based on the modified fear-avoidance model and half of whom received usual care. Mediation analysis was performed to test each mediator separately. Analysis was performed on each outcome of interest separately (Oswestry disability index, patient-specific function, EQ general health and moderate/vigorous physical activity). Mediation analysis was carried out using PROCESS. Beta coefficients and bootstrapped 95% CIs were used to interpret the results.\ud \ud Results\ud None of the potential mediators was found to mediate the relationship between allocation to the intervention and 3-month scores on any of the health outcomes tested.\ud \ud Conclusions\ud Screening patients for higher levels of catastrophizing and fear avoidance and lower levels of self-efficacy could help ensure only the patients who are most likely to benefit from the intervention are included.\ud \ud Significance\ud Prehabilitation interventions for spinal fusion surgery have been found to improve health outcomes for patients. Theory-based interventions that target key mechanisms are more effective at improving outcomes than non-theory-based interventions. While no mediating effects were found for this particular intervention, the analysis suggests that the underlying theoretical model and treatment targets are appropriate and could drive improvement if more strongly targeted.

Background The purpose of this study was to evaluate the efficacy of intrathecal morphine (ITM) in combination with bupivacaine as pre-emptive analgesia in patients undergoing posterior lumbar fusion surgery. This is in comparison with traditional opioid analgesics such as intravenous (IV) morphine. Methods Two groups were identified retrospectively. The first (ITM group) included patients who had general anaesthesia (GA) with low-dose spinal anaesthesia prior to induction using 1–4 mls of 0.25% bupivacaine and 0.2 mg ITM. 1 ml of 0.25% bupivacaine was administered per hour of predicted surgery time, up to a maximum of 4 ml. The insertion level for the spinal anaesthetic corresponded to the spinal level of the iliac crest line and the level at which the spinal cord terminated. The control group had GA without any spinal anaesthesia. Patients were instead administered opioid analgesia in the form of IV morphine or diamorphine. The primary outcome was the consumption of opioids administered intraoperatively and in recovery, and over the first 48 h following discharge from the post-anaesthesia care unit (PACU). Total opioid dose was measured, and a morphine equivalent dose was calculated. Secondary outcomes included visual analogue scale (VAS) pain scores in recovery and at day two postoperatively, and the length of stay in hospital. Results For the ITM group, the median total amount of IV morphine equivalent administered intraoperatively and in recovery, was 0 mg versus 17 mg. The median total amount morphine equivalent, administered over the first 48 h following discharge from PACU was 20 mg versus 80 mg. Both are in comparison with the control group. The median length of stay was over 1 day less and the median VAS for pain in recovery was 6 points lower. No evidence was found for a difference in the worst VAS for pain at day two postoperatively. Conclusion ITM in combination with bupivacaine results in a significantly decreased use of perioperative opioids. In addition, length of hospital stay is reduced and so too is patient perceived pain intensity. Trial registration The study was approved by the ethics committee at The Robert Jones and Agnes Hunt Orthopaedic Hospital as a service improvement project (Approval no. 1617_004).

Background Artificial intelligence (AI) and machine learning (ML) are interwoven into our everyday lives and have grown enormously in some major fields in medicine including cardiology and radiology. While these specialties have quickly embraced AI and ML, orthopedic surgery has been slower to do so. Fortunately, there has been a recent surge in new research emphasizing the need for a systematic review. The primary objective of this systematic review will be to provide an update on the advances of AI and ML in the field of orthopedic surgery. The secondary objectives will be to evaluate the applications of AI and ML in providing a clinical diagnosis and predicting post-operative outcomes and complications in orthopedic surgery. Methods A systematic search will be conducted in PubMed, ScienceDirect, and Google Scholar databases for articles written in English, Italian, French, Spanish, and Portuguese language articles published up to September 2020. References will be screened and assessed for eligibility by at least two independent reviewers as per PRISMA guidelines. Studies must apply to orthopedic interventions and acute and chronic orthopedic musculoskeletal injuries to be considered eligible. Studies will be excluded if they are animal studies and do not relate to orthopedic interventions or if no clinical data were produced. Gold standard processes and practices to obtain a clinical diagnosis and predict post-operative outcomes shall be compared with and without the use of ML algorithms. Any case reports and other primary studies assessing the prediction rate of post-operative outcomes or the ability to identify a diagnosis in orthopedic surgery will be included. Systematic reviews or literature reviews will be examined to identify further studies for inclusion, and the results of meta-analyses will not be included in the analysis. Discussion Our findings will evaluate the advances of AI and ML in the field of orthopedic surgery. We expect to find a large quantity of uncontrolled studies and a smaller subset of articles describing actual applications and outcomes for clinical care. Cohort studies and large randomized control trial will likely be needed. Trial registration The protocol will be registered on PROSPERO international prospective register of systematic reviews prior to commencement.

Importance Handovers of anesthesia care from one anesthesiologist to another is an important intraoperative event. Despite its association with adverse events after noncardiac surgery, its impact in the context of cardiac surgery remains unclear.\ud \ud Objective To compare the outcomes of patients who were exposed to anesthesia handover vs those who were unexposed to anesthesia handover during cardiac surgery.\ud \ud Design, Setting, and Participants This retrospective cohort study in Ontario, Canada, included Ontario residents who were 18 years or older and had undergone coronary artery bypass grafting or aortic, mitral, tricuspid valve, or thoracic aorta surgical procedures between 2008 and 2019. Exclusion criteria were non-Ontario residency status and other concomitant procedures. Statistical analysis was conducted from April 2021 to June 2021, and data collection occurred between November 2020 to January 2021.\ud \ud Exposures Complete handover of anesthesia care, where the case is completed by the replacement anesthesiologist.\ud \ud Main Outcomes and Measures The coprimary outcomes were mortality within 30 days and 1 year after surgery. Secondary outcomes were patient-defined adverse cardiac and noncardiac events (PACE), intensive care unit (ICU), and hospital lengths of stay (LOS). Inverse probability of treatment weighting based on the propensity score was used to estimate adjusted effect measures. Mortality was assessed using a Cox proportional hazard model, PACE using a cause-specific hazard model with death as a competing risk, and LOS using Poisson regression.\ud \ud Results Of the 102 156 patients in the cohort, 25 207 (24.7%) were women; the mean (SD) age was 66.4 (10.8) years; and 72 843 of surgical procedures (71.3%) were performed in teaching hospitals. Handover occurred in 1926 patients (1.9%) and was associated with higher risks of 30-day mortality (hazard ratio [HR], 1.89; 95% CI, 1.41-2.54) and 1-year mortality (HR, 1.66; 95% CI, 1.31-2.12), as well as longer ICU (risk ratio [RR], 1.43; 95% CI, 1.22-1.68) and hospital (RR, 1.17; 95% CI, 1.06-1.28) LOS. There was no statistically significant association between handover and PACE (30 days: HR 1.09; 95% CI, 0.79-1.49; 1 year: HR 0.89; 95% CI, 0.70-1.13).\ud \ud Conclusions and Relevance Handover of anesthesia care during cardiac surgical procedures was associated with higher 30-day and 1-year mortality rates and increased health care resource use. Further research is needed to evaluate and systematically improve the handover process qualitatively.

ObjectivesTo understand the patient and hospital level drivers of the variation in surgical versus trascatheter aortic valve replacement (SAVR vs TAVR) for patients with aortic stenosis (AS) and to explore whether this variation translates into differences in clinical outcomes.BackgroundAdoption of TAVR has grown exponentially worldwide. Notwithstanding, a wide variation in TAVR rates has been seen within and between countries and in some jurisdictions AS is still primarily being managed by SAVR.MethodsWe conducted a population-based retrospective cohort study in Ontario, Canada, including individuals who received TAVR or SAVR between 2016 and 2020. We developed iterative hierarchical logistic regression models for the likelihood of receiving TAVR instead of SAVR examining sequentially patient characteristics, hospital factors and year of procedure, calculating the median ORs and variance partition coefficients for each. Using Cox proportional hazards models, we examined the relationship between TAVR/SAVR ratio on all-cause mortality and readmissions.ResultsAnnual procedures rates per million population increased from 171 to 201, mainly driven by the expansion of TAVR. TAVR/SAVR ratios differed substantially between hospitals, from 0.21 to 3.27. Neither patient nor hospital factors explained the between-hospital variation in AS treatment. The TAVR/SAVR ratio was significantly associated with clinical outcomes with high ratio hospitals having lower mortality and rehospitalisations.ConclusionsDespite the expansion of TAVR, dramatic variation exists that is not explained by patient or hospital factors. This variation was associated with differences in clinical outcomes, suggesting that further work is needed in understanding and addressing inequity of access.

Frailty is an established risk factor for adverse outcomes following non-cardiac surgery. The Hospital Frailty Risk Score (HFRS) is a recently described frailty assessment tool that harnesses administrative data and is composed of 109 International Classification of Disease variables. We aimed to examine the incremental prognostic utility of the HFRS in a generalizable surgical population. Using linked administrative databases, a retrospective cohort of patients admitted for non-cardiac surgery between October 1st, 2008 and September 30th, 2019 in Alberta, Canada was created. Our primary outcome was a composite of death, myocardial infarction or cardiac arrest at 30-days. Multivariable logistic regression was undertaken to assess the impact of HFRS on outcomes after adjusting for age, sex, components of the Charlson Comorbidity Index (CCI), Revised Cardiac Risk Index (RCRI) and peri-operative biomarkers. The final cohort consisted of 712,808 non-cardiac surgeries, of which 55·1% were female and the average age was 53·4 +/- 22·4 years. Using the HFRS, 86.3% were considered low risk, 10·7% were considered intermediate risk and 3·1% were considered high risk for frailty. Intermediate and high HFRS scores were associated with increased risk of the primary outcome with an adjusted odds ratio of 1·61 (95% CI 1·50–1.74) and 1·55 (95% CI 1·38–1·73). Intermediate and high HFRS were also associated with increased adjusted odds of prolonged hospital stay, in-hospital mortality, and 1-year mortality. The HFRS is a minimally onerous frailty assessment tool that can complement perioperative risk stratification in identifying patients at high risk of short- and long-term adverse events.

BackgroundTen per cent of patients diagnosed with pancreatic cancer undergo pancreaticoduodenectomy. It is known that these patients have unmet psychological support needs, and GPs are key in enabling effective coordination of care for people living with life-shortening conditions.AimTo explore patients’ perspectives on the role of primary care in their management, and their sources of support.Design & settingInductive qualitative study of patients who had undergone pancreaticoduodenectomy between 6 months and 6 years previously for pancreatic or distal biliary duct cancers. Participants were recruited by clinical nurse specialists (CNSs) from a single NHS trust in Northwest England.MethodSemi-structured interviews, either face-to-face or via video link, were conducted with 20 participants. Interviews were audio-recorded, transcribed, and anonymised. Thematic analysis utilised principles of constant comparison.ResultsParticipants described immense treatment burden and uncertainty around the role of the GP in their ongoing care. They recognised that GPs may have little experience of patients who have undergone pancreaticoduodenectomy, but felt that GPs can play a vital role in offering support. Participants wished for emotional support postoperatively, and valued support networks including family and friends. However, they found expressing their deepest fears difficult. Participants felt they would value greater recognition by primary care of both physical and psychological sequelae of major pancreatic surgery, and the impact on their families.ConclusionPatients may feel themselves to be a ‘burden’ to both healthcare professionals and their own support networks following pancreaticoduodenectomy. Primary care is in a key position to proactively offer psychological support.

ObjectiveThe primary objective was to assess the performance of a new generation thin-strut sirolimus-eluting coronary stent with abluminal biodegradable polymer in an all comer population. The secondary objective was to detail differences in contemporary percutaneous coronary intervention (PCI) practice worldwide.Methodse-Ultimaster was an all-comer, prospective, global registry (NCT02188355) with independent event adjudication enrolling patients undergoing PCI with the study stent. The primary outcome measure was target lesion failure (TLF) at 1 year, defined as the composite of cardiac death, target vessel myocardial infarction and clinically driven target lesion revascularisation. Data were stratified according to 4 geographical regions.ResultsA total of 37 198 patients were enrolled (Europe 69.2%, Asia 17.8%, Africa/Middle East 6.6% and South America/Mexico 6.5%) and 1-year follow-up was available for 35 389 patients (95.1%). One-year TLF occurred in 3.2% of the patients, ranging from 2% (Africa/Middle East) to 4.1% (South America/Mexico). In patients with acute coronary syndrome, potent P2Y12 inhibitors were prescribed in 48% of patients at discharge, while at 1 year 72% were on any dual antiplatelet therapy. Lipid-lowering treatment was administered in 80.9% and 75.5% of patients at discharge and 1 year, respectively. Regional differences in the profile of the treated patients as well as in PCI practice were reported.ConclusionsIn this investigation with worldwide representation, contemporary PCI using a new generation thin-strut sirolimus-eluting coronary stent with abluminal biodegradable polymer was associated with low 1-year TLF across clinical presentations and continents. Suboptimal adherence to current recommendations around antiplatelet and lipid lowering treatments was detected.

Objectives: This study aimed to examine the cost of coronary syndrome treated with percutaneous coronary intervention (PCI) and 30-day unplanned readmissions.\ud \ud Background: There is limited understanding of the hospital cost of index PCI and 30-day unplanned readmissions.\ud \ud Methods: Patients undergoing PCI between 2010 and 2014 in the U.S. Nationwide Readmission Database were included. The primary outcome was total cost defined by cost of index PCI and first unplanned readmission within 30-days.\ud \ud Results: This analysis included 2,294,245 patients who underwent PCI, and the mean cost was $23,541±$20,730 (~$10.8 billion/year). There was a modest increase in cost over the study years of 17.5%. Of the 9.4% with an unplanned readmission within 30 days, the mean total cost was $35,333±24,230 versus $22,323±19,941 for those not readmitted. The variables most strongly associated with the highest quartile of cost were heart failure (adjusted odds ratio (aOR) 25.60 [95% CI 21.59-30.35]), need for circulatory support (aOR 11.62 [10.13-13.32]), periprocedural coronary artery bypass graft (CABG, aOR 585.08 [357.85-956.58]), and readmission within 30 days (aOR 24.49 [22.40-26.77]). An acute kidney injury (8.5%), major bleed (0.8%), vascular injury (0.8%), or need for periprodedural CABG (1.4%) had an average increased cost of $21,935, $30,898, $27,875 and $43,005, respectively, compared to PCI without adverse outcome.\ud \ud Conclusions: The annual 30-day hospital cost of PCI is approximately $10.8 billion, and the costs associated with in-hospital adverse events, particularly the need for acute kidney injury and emergency CABG, were significant.

Aspiration thrombectomy is a life-saving interventional procedure to remove a blood clot from the brain of stroke patients. The pressure and blood flow dynamics during this procedure are crucial in determining the clinical outcomes. A mathematical model based on Hagen-Poiseuille law of fluid flow in a tube is adapted to simulate the pressure and fluid flow characteristics in an in vitro model of an occluded and unoccluded cerebrovascular network that mimics a poor (unilateral) and good (symmetrical) collateral flow within the Circle of Willis. The results show that in the absence of an occlusion, the pressure and pressure drop are higher in the symmetrical network compared to that in the unilateral network. This is due to the additional limb in the symmetrical network that must be supplied, which is absent in the unilateral network. In the presence of an occlusion, the flow reduces in the obstructed vessel, the collateral flow, overall pressure and pressure drop increases in both systems, but is higher for the symmetrical network. The results compare qualitatively with those observed in in vitro studies and with clinical observations. The theoretical framework lays the foundation for more advanced models for the pressure and blood flow dynamics towards clinical applicability.

OBJECTIVES: To provide estimates for how different treatment pathways for the management of severe aortic stenosis (AS) may affect National Health Service (NHS) England waiting list duration and associated mortality. DESIGN: We constructed a mathematical model of the excess waiting list and found the closed-form analytic solution to that model. From published data, we calculated estimates for how the strategies listed under Interventions may affect the time to clear the backlog of patients waiting for treatment and the associated waiting list mortality. SETTING: The NHS in England. PARTICIPANTS: Estimated patients with AS in England. INTERVENTIONS: (1) Increasing the capacity for the treatment of severe AS, (2) converting proportions of cases from surgery to transcatheter aortic valve implantation and (3) a combination of these two. RESULTS: In a capacitated system, clearing the backlog by returning to pre-COVID-19 capacity is not possible. A conversion rate of 50% would clear the backlog within 666 (533-848) days with 1419 (597-2189) deaths while waiting during this time. A 20% capacity increase would require 535 (434-666) days, with an associated mortality of 1172 (466-1859). A combination of converting 40% cases and increasing capacity by 20% would clear the backlog within a year (343 (281-410) days) with 784 (292-1324) deaths while awaiting treatment. CONCLUSION: A strategy change to the management of severe AS is required to reduce the NHS backlog and waiting list deaths during the post-COVID-19 'recovery' period. However, plausible adaptations will still incur a substantial wait to treatment and many hundreds dying while waiting., BG is supported by the NIHR Bristol Biomedical Research Centre at the University of Bristol and University Hospitals Bristol and Weston NHS Foundation Trust. JHFR is part-supported by the NIHR Cambridge Biomedical Research Centre, the British Heart Foundation, HEFCE, the EPSRC Cambridge Centre for Mathematics of Information in Healthcare and the Wellcome Trust.

Background\ud Intravascular lithotripsy (IVL) can be used to assist stent deployment in severe coronary artery calcifications (CAC).\ud \ud Methods\ud Studies employing IVL for CAC lesions were included. The primary outcomes included clinical and angiographic success. The secondary outcomes, including lumen gain, maximum calcium thickness, and calcium angle at the final angiography site, minimal lumen area site, and minimal stent area site, were analyzed by the random-effects model to calculate the pooled standardized mean difference. Tertiary outcomes included safety event ratios.\ud \ud Results\ud Seven studies (760 patients) were included. The primary outcomes: pooled clinical and angiographic success event ratio parentage of IVL was 94.4% and 94.8%, respectively. On a random effect model for standard inverse variance for secondary outcomes showed: minimal lumen diameter increase with IVL was 4.68 mm (p-value < 0.0001, 95% CI 1.69–5.32); diameter decrease in the stenotic area after IVL session was −5.23 mm (95 CI –22.6–12.8). At the minimal lumen area (MLA) and final minimal stent area (MSA) sites, mean lumen area gain was 1.42 mm2 (95% CI 1.06–1.63; p < 0.00001) and 1.34 mm2 (95% CI 0.71–1.43; p < 0.00001), respectively. IVL reduced calcium thickness at the MLA site (SMD −0.22; 95% CI −0.40–0.04; P = 0.02); calcium angle was not affected at the MLA site. The tertiary outcomes: most common complication was major adverse cardiovascular events (n = 48/669), and least common complication was abrupt closure of the vessel (n = 1/669).\ud \ud Conclusions\ud Evidence suggests that IVL safely and effectively facilitates stent deployment with high angiographic and clinical success rates in treating severely calcified coronary lesions.

BackgroundRobust personal protective equipment is essential in preventing the transmission of coronavirus disease 2019 to head and neck surgeons who are routinely involved in aerosol generating procedures.ObjectiveThis paper describes the collective experience, across 3 institutes, of using a reusable half-face respirator in 72 head and neck surgery cases.MethodCost analysis was performed to demonstrate the financial implications of using a reusable respirator compared to single-use filtering facepiece code 3 masks.ConclusionThe reusable respirator is a cost-effective alternative to disposable filtering facepiece code 3 respirators. Supplying reusable respirators to individual staff members may increase the likelihood of them having appropriate personal protective equipment during their clinical duties.

We report a patient with obesity who underwent laparoscopic sleeve gastrectomy after pre-operative ultrasound mark up to enable safe port insertion due to presence of venous collaterals in the abdominal wall as a result of congenial IVC anomaly. This patient was falsely presumed to have NASH cirrhosis. Detailed preoperative workup ruled this out and led to the discovery of congenital IVC anomaly as the cause of engorged blood vessels in the anterior abdominal wall. On table ultrasound mark up of safe sites for port insertion enabled a safe laparosocpic sleeve gastrectomy on this patient.

Objective: To compare the clinical characteristics and outcomes in patients with stable angina who have undergone chronic total occlusion (CTO) percutaneous coronary intervention (PCI) in native arteries with or without prior coronary artery bypass grafting (CABG) surgery in a national cohort. Background: There are limited data on outcomes of patients presenting with stable angina undergoing CTO PCI with previous CABG. Methods: We identified 20,081 patients with stable angina who underwent CTO PCI between 2007–2014 in the British Cardiovascular Intervention Society database. Clinical, demographical, procedural and outcome data were analyzed in two groups; group 1-CTO PCI in native arteries without prior CABG (n = 16,848), group 2-CTO PCI in native arteries with prior CABG (n = 3,233). Results: Patients in group 2 were older, had more comorbidities and higher prevalence of severe left ventricular systolic dysfunction. Following multivariable analysis, no significant difference in mortality was observed during index hospital admission (OR:1.33, CI 0.64–2.78, p =.44), at 30-days (OR: 1.28, CI 0.79–2.06, p =.31) and 1 year (OR:1.02, CI 0.87–1.29, p =.87). Odds of in-hospital major adverse cardiovascular events (MACE) (OR:1.01, CI 0.69–1.49, p =.95) and procedural complications (OR:1.02, CI 0.88–1.18, p =.81) were similar between two groups but procedural success rate was lower in group 2 (OR: 0.34, CI 0.31–0.39, p

Background: Biomarkers are needed to predict clinical outcome for microfracture and osteotomy surgeries to ensure patients can be better stratified to receive the most appropriate treatment. \ud Hypothesis/purpose: To identify novel biomarker candidates and to investigate the potential of a panel of protein biomarkers for the prediction of clinical outcome following treatment with microfracture or osteotomy.\ud Study Design: Descriptive Laboratory Study\ud Methods: Label-free quantitation following liquid chromatography-tandem mass-spectrometry of dynamic range compressed synovial fluids (SF) from individuals who responded excellently or poorly (based on the change in Lysholm score) to microfracture (n=6) or osteotomy (n=7) was used to identify novel candidate biomarker proteins. Biomarkers which were (a) identified in this proteomic analysis, (b) which relate to OA severity or (c) with predictive value in another early OA therapy ( autologous cell implantation) were measured in the SF of 19 and 13 patients prior to microfracture or osteotomy, respectively, using commercial immunoassays and normalised to urea. These were aggrecanase-1 (ADAMTS-4), cartilage oligomeric matrix protein (COMP), hyaluronan (HA), Lymphatic Vessel Endothelial Hyaluronan Receptor-1 (LYVE-1), matrix metalloproteinase (MMP)-1 and -3, soluble CD14 (sCD14), S100 calcium binding protein A13 (S100A13) and 14-3-3 protein theta (YWHAQ). Levels of COMP and HA were also measured in the plasma of these patients. To find predictors of postoperative function multivariable regression analyses were performed. \ud Results: Proteomic analyses highlighted YWHAQ and LYVE-1 as being differentially abundant between the clinical responders/improvers and non-responders following microfracture. A linear regression model following backward variable selection could relate pre-operative concentrations of SF proteins (HA, YWHAQ, LYVE-1), activity of ADAMTS-4 and patient demographics (smoker status and gender) with 12 month post-microfracture Lysholm score. Further a generalized linear model

ObjectiveThis manuscript aims to explore the impact of race/ethnicity and socioeconomic status on in-hospital complication rates after left atrial appendage closure (LAAC).MethodsThe US National Inpatient Sample was used to identify hospitalisations for LAAC between 1 October 2015 to 31 December 2018. These patients were stratified by race/ethnicity and quartiles of median neighbourhood income. The primary outcome was the occurrence of in-hospital major adverse events, defined as a composite of postprocedural bleeding, cardiac and vascular complications, acute kidney injury and ischaemic stroke.ResultsOf 6478 unweighted hospitalisations for LAAC, 58% were male and patients of black, Hispanic and ‘other’ race/ethnicity each comprised approximately 5% of the cohort. Adjusted by the older Americans population, the estimated number of LAAC procedures was 69.2/100 000 for white individuals, as compared with 29.5/100 000 for blacks, 47.2/100 000 for Hispanics and 40.7/100 000 for individuals of ‘other’ race/ethnicity. Black patients were ~5 years younger but had a higher comorbidity burden. The primary outcome occurred in 5% of patients and differed significantly between racial/ethnic groups (pConclusionIn this study assessing racial/ethnic disparities in patients undergoing LAAC, minorities are under-represented, specifically patients of black race/ethnicity. Compared with whites, black patients had higher comorbidity burden and higher rates of in-hospital complications. Lower socioeconomic status was not associated with complication rates.

Dual antiplatelet therapy (DAPT) and subsequent P2Y12 inhibitor monotherapy, particularly ticagrelor, is an emerging treatment strategy in patients undergoing percutaneous coronary intervention (PCI). This meta‐analysis was designed to investigate whether short‐term DAPT followed by ticagrelor monotherapy is associated with a favorable outcome as compared with standard DAPT (1–3 months of DAPT was termed “short‐term” DAPT, 6–12 months DAPT was termed “standard” DAPT). The primary outcome was the composite of major adverse cardiovascular events (MACE) comprising myocardial infarction, stroke, and cardiovascular death. Secondary outcomes included all‐cause mortality and net adverse clinical events (NACE; myocardial infarction, stroke, all‐cause death, stent thrombosis, and major bleeding). The primary safety outcome was major bleeding. Three studies comprising 26,143 patients were included. The risk of MACE was similar between the two treatment groups (risk ratio (RR) 0.86, 95% confidence interval (CI), 0.72–1.02, P = 0.08, I 2 = 22%). Short‐term DAPT followed by ticagrelor monotherapy resulted in a 20% relative risk reduction of all‐cause mortality (RR 0.80, 95% CI, 0.65–0.98, P = 0.03, I 2 = 0%) and an 18% relative risk reduction of NACE (RR 0.82, 95% CI, 0.71–0.94, P = 0.005, I 2 = 33%) as compared with standard DAPT. Short‐term DAPT followed by ticagrelor monotherapy significantly decreased the risk of major bleeding (RR 0.67, 95% CI, 0.49–0.92, P = 0.01, I 2 = 65%). In patients with acute coronary syndrome, short‐term DAPT followed by ticagrelor monotherapy resulted in an unchanged ischemic risk but a significantly lower bleeding risk compared with standard DAPT. Short‐term DAPT followed by ticagrelor monotherapy compared with standard DAPT resulted in a favorable safety and efficacy profile. Direct comparisons of aspirin vs. ticagrelor monotherapy following PCI are needed.

Objectives\ud The ability to predict which patients will improve following routine surgeries aimed at preventing the progression of osteoarthritis is needed to aid patients being stratified to receive the most appropriate treatment. This study aimed to investigate the potential of a panel of biomarkers for predicting (prior to treatment) the clinical outcome following treatment with microfracture or osteotomy.\ud \ud Methods\ud Proteins known to relate to OA severity, with predictive value in autologous cell implantation treatment or that had been identified in proteomic analyses (aggrecanase-1/ ADAMTS-4, cartilage oligomeric matrix protein (COMP), hyaluronic acid (HA), Lymphatic Vessel Endothelial Hyaluronan Receptor-1, matrix metalloproteinases-1 and −3, soluble CD14, S100 calcium binding protein A13 and 14-3-3 protein theta) were assessed in the synovial fluid (SF) of 19 and 13 patients prior to microfracture or osteotomy, respectively, using commercial immunoassays. Levels of COMP and HA were measured in the plasma of these patients. To find predictors of postoperative function, multiple linear regression analyses were performed.\ud \ud Results\ud Linear regression analyses demonstrated that a lower concentration of HA in pre-operative SF was predictive of improved knee function (higher Lysholm score) following microfracture surgery. Further, lower pre-operative activity of ADAMTS-4 in SF was a significant, independent predictor of higher post-operative Lysholm score (improved joint function) following osteotomy surgery.\ud \ud Conclusion\ud This study is novel in identifying biomarkers with the potential to predict clinical outcome in patients treated with microfracture or osteotomy of the knee. Lower concentrations of HA and undetectable activity of ADAMTS-4 in the joint fluid of individuals with cartilage defects/early-OA may be used in algorithms to stratify patients to the most appropriate surgery.

Context More than half of all spinal cord injuries (SCI) occur at the cervical level leading to loss of upper limb function, restricted activity and reduced independence. Several technologies have been developed to assist with upper limb functions in the SCI population. Objective There is no clear clinical consensus on the effectiveness of the current assistive technologies for the cervical SCI population, hence this study reviews the literature in the years between 1999 and 2019. Methods A systematic review was performed on the state-of-the-art assistive technology that supports and improves the function of impaired upper limbs in cervical SCI populations. Combinations of terms, covering assistive technology, SCI, and upper limb, were used in the search, which resulted in a total of 1770 articles. Data extractions were performed on the selected studies which involved summarizing details on the assistive technologies, characteristics of study participants, outcome measures, and improved upper limb functions when using the device. Results A total of 24 articles were found and grouped into five categories, including neuroprostheses (invasive and non-invasive), orthotic devices, hybrid systems, robots, and arm supports. Only a few selected studies comprehensively reported characteristics of the participants. There was a wide range of outcome measures and all studies reported improvements in upper limb function with the devices. Conclusions This study highlighted that assistive technologies can improve functions of the upper limbs in SCI patients. It was challenging to draw generalizable conclusions because of factors, such as heterogeneity of recruited participants, a wide range of outcome measures, and the different technologies employed.

Chlorhexidine digluconate (CHG) is a cationic bisbiguanide used in the UK as the first-line skin antiseptic prior to surgery in the UK due to its favourable efficacy and safety profile, high affinity for skin binding and minimal reports of resistance. Despite this, bacteria remain within deeper skin layers, furrows and appendages that are considered inaccessible to CHG, due to its poor dermal penetration. In this study a third generation, polyamidoamine dendrimer (G3 PAMAM-NH2) was utilised to improve dermal penetration of CHG. A topical gel formulation was optimised to maximise CHG delivery (containing 0.5% gelling agent and 4% drug), followed by drug and dendrimer co-formulation into a commercially viable gel. The gel containing 4% CHG and 1 mM PAMAM dendrimer significantly increased the depth permeation of CHG compared to the commercial benchmark (Hibiscrub®, containing 4% w/v CHG) (p < 0.05). The optimised formulation was further characterised using Time-of-Flight Secondary Ion Mass Spectrometry (ToF-SIMS), which indicated that the depth of dermal penetration achieved was sufficient to reach the skin strata that typically harbours pathogenic bacteria, which is currently inaccessible by commercial CHG formulations. This study therefore indicates that a G3 PAMAM-NH2 dendrimer gel may be viable as a permeation enhancer of CHG, for improved skin antisepsis in those at risk of a skin or soft tissue infection as a result of surgical intervention.

Introduction The role of tourniquet during knee arthroplasty is controversial. The present study compares various tourniquet protocols using a Bayesian network meta-analysis of peri-operative data. Material and methods The present study was conducted in accordance with the PRISMA extension statement for reporting systematic reviews incorporating network meta-analyses of health interventions. The literature search was conducted in September 2020. All clinical trials investigating the role of tourniquet in knee arthroplasty were considered for inclusion. Methodological quality was assessed using Review Manager 5.3. A Bayesian hierarchical random-effects model analysis was used in all comparisons. Results Ultimately, pooled data from 68 studies (7413 procedures) were analysed. Significant inconsistency was found in the data relating to total estimated blood lost; no assumption could be made on this outcome. Full-time tourniquet resulted in the shortest surgical duration and lowest intra-operative blood lost, in both cases followed by incision-to-suture. The incision-to-suture protocol achieved the smallest drop in haemoglobin during the first 72 h post-operatively and the lowest rate of blood transfusion, both followed by full-time tourniquet. Hospitalisation was shortest in the absence (no-tourniquet) group, followed by the cementation-to-end group. Conclusion For knee arthroplasty, longer tourniquet use is associated with the shorter duration of surgery, lower intra-operative blood lost, lower drops in haemoglobin and fewer transfusion units. The shortest average hospitalisation was associated with no tourniquet use.

Background: Pulvertaft Weave (PTW) is an established method of tenorrhapy in tendon transfers. Previous studies have suggested that a Side-to-Side (STS) tenorrhapy is easier to perform has the same advantages and has greater load to failure, ultimate load and stiffness compared to PTW. However, there is insufficient data comparing behaviour of STS and PTW during cyclical loading. The aim of this study is to compare these two methods in terms of creep after cyclic landing. Methods: Fresh porcine flexor digitorum tendons were used. Ten tendon PTW and ten STS repairs were performed. Cross sectional diameter was measured. The tendon repairs were tested by applying tension up to 25N for 100 cycles, followed by tension up to 75N for 100 cycles, followed by loading to failure. Force-displacement data was used to determine the creep of the repaired tendon. Results: All tendons survived 100 cycles of loading at 25N. After 1 cycle of loading, the mean cyclic creep in the PTW group was almost 3 mm larger than in the STS group (p = 0.046). After 100 cycles, the mean cyclic creep in the PTW group was 4.4 mm larger (p = 0.008). The cyclic creep rate was significantly larger in the PTW group (p < 0.001). All STS but only four PTW repairs survived after cyclic loading at 75N (p = 0.01). After 1 cycle and 100 cycles, mean creep of the surviving PTW samples was almost 7 mm (p = 0.006) and almost 9 mm (p = 0.004) larger than the STS group. The mean load to failure was four times larger in the STS group than the PTW group (p = 0.004). Conclusions: STS repairs have a significantly smaller permanent elongation after cyclic loading at 25N and 75N, a significantly smaller cyclic creep rate, require a significantly larger load to fail. This implies that STS repairs are less likely to elongate after cyclic loading and can withstand greater loads. These properties can be valuable in allowing patients to commence mobilisation immediately after surgery.

Purpose: Nowadays, surgical treatment of acute avulsions of the Achilles tendon represents a hard challenge. There is often the possibility that the calcaneus remains completely uncovered from the tendon, making the reinsertion of its distal stub complex. At the same time, the standard open surgical technique could cause difficult wound healing because of the weak blood supply, the increasing possibility of rupture, and the bacterial contamination. To overcome these risks, less invasive procedures should be considered. Methods: We developed an innovative minimally invasive procedure for fixation of acute avulsions of the Achilles tendon employing an integration of four longitudinal stab incisions and one distal semicircular Cincinnati incision. In this way, the distal Achilles tendon stub and the calcaneal insertion are exhibited. Results: We basted the tendon through percutaneous sutures performed across the four stab incisions with a Mayo needle threaded with Ultrabraid. The procedure is repeated with another loop of Ultrabraid. After having bruised the calcaneus bone insertion of the tendon, two sites for two suture anchors were prepared using a specific hole preparation device for the anchors’ footprint. Finally, we placed two suture anchors to reinsert the tendon to the calcaneal insertion. Conclusion: Our new less invasive technique is a promising alternative optional procedure for the Achilles tendon (AT) avulsion repair allowing clear exposure of the Achilles tendon insertion, maintaining the longitudinal wholeness of the dermis, and minimizing possible associated complications.

Objectives\ud We explore whether same day discharge (SDD) is a feasible and safe practice following rotational atherectomy (ROTA) treatment during elective percutaneous coronary intervention (PCI), and examine which baseline characteristics are independently associated with SDD. \ud Background \ud SDD following elective ROTA PCI is not recommended as per the recent SCAI consensus. However, reports show it is practiced and no previous study has evaluated its safety and feasibility. \ud Methods\ud Our dataset included 4,591 patients undergoing elective ROTA PCI in England & Wales within an 8-years period. Independent associations with SDD were quantified via a multiple logistic regression model and the BCIS 30-day mortality risk model was used to evaluate the safety of SDD. \ud Results\ud The majority of elective ROTA PCI cases remain at the hospital for overnight (ON) observation, although SDD rates increased substantially from 6.7% in 2007 to 35.5% in 2014. The use of glycoprotein IIb/IIIa antagonists, Q wave AMI, left main PCI and valvular heart disease were independently associated with ON, while patients operated underwent transradial PCI were more likely to be SDD (OR=1.77, 95% CI [1.45-2.15]). Over the study period, observed mortality rates were not significantly higher than those expected from the BCIS risk model.\ud Conclusions\ud Our findings did not show superiority of the ON strategy over SDD for higher risk cases undergoing elective ROTA PCI, in terms of 30-day mortality. This is the first study to examine the safety of SDD after elective ROTA PCI and more should follow.

There is limited national data regarding emergency cardiac surgery for complications sustained after percutaneous coronary intervention (PCI). This study aimed to examine emergency cardiac surgery after PCI in England and Wales and postsurgical patient outcomes. We analyzed patients in the British Cardiovascular Intervention Society database who underwent PCI between 2007 and 2014 and compared characteristics and outcomes for patients with and without emergency cardiac surgery. A total of 549,303 patients were included in the analysis and 362 (0.07%) underwent emergency cardiac surgery. There was a modest decline in the annual rate of emergency cardiac surgery from 0.09% to 0.06% between 2007 and 2014. Variables associated with emergency cardiac surgery included receipt of circulatory support (Odds ratio (OR) 39.20 95% confidence interval (CI) 27.75 to 55.36), aortic dissection (OR 28.39 95%CI 14.59 to 55.26), coronary dissection (OR 18.50 95%CI 13.60 to 25.18), coronary perforation (OR 7.86 95%CI 4.27 to 14.46), cardiac tamponade (OR 6.77 95%CI 3.13 to 14.66), and on-site surgical cover (OR 2.15 95%CI 1.56 to 2.97). After adjustments, patients with emergency cardiac surgery were at increased odds of 30-day mortality (OR 4.41 95%CI 2.94 to 6.62) and in-hospital major adverse cardiac and cerebrovascular events (OR 1.63 95%CI 1.07 to 2.48). On site surgical cover was independently associated with increased odds of mortality (OR 1.26 95%CI 1.20 to 1.33) following emergency cardiac surgery. In conclusion, emergency cardiac surgery after PCI is a rarely required procedure and in England and Wales there appears to be a decline in recent years. Patients who underwent emergency cardiac surgery have higher risk of adverse outcomes and longer length of hospital stay.

OBJECTIVE: To investigate the management strategies, temporal trends, and clinical outcomes of patients with a history of coronary artery bypass graft (CABG) surgery and presenting with acute myocardial infarction (MI). PATIENTS AND METHODS: We undertook a retrospective cohort study using the National Inpatient Sample database from the United States (January 2004-September 2015), identified all inpatient MI admissions (7,250,768 records) and stratified according to history of CABG (group 1, CABG-naive [94%]; group 2, prior CABG [6%]). RESULTS: Patients in group 2 were older, less likely to be female, had more comorbidities, and were more likely to present with non-ST-elevation myocardial infarction compared with group 1. More patients underwent coronary angiography (68% vs 48%) and percutaneous coronary intervention (PCI) (44% vs 26%) in group 1 compared with group 2. Following multivariable logistic regression analyses, the adjusted odd ratio (OR) of in-hospital major adverse cardiovascular and cerebrovascular events (OR, 0.98; 95% CI, 0.95 to 1.005; P=.11), all-cause mortality (OR, 1; 95% CI, 0.98 to 1.04; P=.6) and major bleeding (OR, 0.99; 95% CI, 0.94 to 1.03; P=.54) were similar to group 1. Lower adjusted odds of in-hospital major adverse cardiovascular and cerebrovascular events (OR, 0.64; 95% CI, 0.57 to 0.72; P

'No abstract'

Author(s): Winters, ZE; Horsnell, J; Elvers, KT; Maxwell, AJ; Jones, LJ; Shaaban, AM; Schmid, P; Williams, NR; Beswick, A; Greenwood, R; Ingram, JC; Saunders, C; Vaidya, JS; Esserman, L; Jatoi, I; Brunt, AM | Abstract: BackgroundThe clinical effectiveness of treating ipsilateral multifocal (MF) and multicentric (MC) breast cancers using breast-conserving surgery (BCS) compared with the standard of mastectomy is uncertain. Inconsistencies relate to definitions, incidence, staging and intertumoral heterogeneity. The primary aim of this systematic review was to compare clinical outcomes after BCS versus mastectomy for MF and MC cancers, collectively defined as multiple ipsilateral breast cancers (MIBC).MethodsComprehensive electronic searches were undertaken to identify complete papers published in English between May 1988 and July 2015, primarily comparing clinical outcomes of BCS and mastectomy for MIBC. All study designs were included, and studies were appraised critically using the Newcastle-Ottawa Scale. The characteristics and results of identified studies were summarized.ResultsTwenty-four retrospective studies were included in the review: 17 comparative studies and seven case series. They included 3537 women with MIBC undergoing BCS; breast cancers were defined as MF in 2677 women, MC in 292, and reported as MIBC in 568. Six studies evaluated MIBC treated by BCS or mastectomy, with locoregional recurrence (LRR) rates of 2-23 per cent after BCS at median follow-up of 59·5 (i.q.r. 56-81) months. BCS and mastectomy showed apparently equivalent rates of LRR (risk ratio 0·94, 95 per cent c.i. 0·65 to 1·36). Thirteen studies compared BCS in women with MIBC versus those with unifocal cancers, reporting LRR rates of 2-40 per cent after BCS at a median follow-up of 64 (i.q.r. 57-73) months. One high-quality study reported 10-year actuarial LRR rates of 5·5 per cent for BCS in 300 women versus 6·5 per cent for mastectomy among 887 women.ConclusionThe available studies were mainly of moderate quality, historical and underpowered, with limited follow-up and biased case selection favouring BCS rather than mastectomy for low-risk patients. The evidence was inconclusive, weakening support for the St Gallen consensus and supporting a future randomized trial.

OBJECTIVES: The aim of this study was to describe the early (inpatient and 30-day) and late (1-year) outcomes of percutaneous coronary intervention (PCI) in saphenous vein grafts (SVGs), with and without the use of embolic protection devices (EPD), in a large, contemporary, unselected national cohort from the database of the British Cardiovascular Intervention Society.\ud \ud BACKGROUND: There are limited, and discrepant, data on the clinical benefits of the adjunctive use of EPDs during PCI to SVGs in the contemporary era.\ud \ud METHODS: A longitudinal cohort of patients (2007 to 2014, n = 20,642) who underwent PCI to SVGs in the British Cardiovascular Intervention Society database was formed. Clinical, demographic, procedural, and outcome data were analyzed by dividing into 2 groups: no EPD (PCI to SVGs without EPDs, n = 17,730) and EPD (PCI to SVGs with EPDs, n = 2,912).\ud \ud RESULTS: Patients in the EPD group were older, had more comorbidities, and had a higher prevalence of moderate to severe left ventricular systolic dysfunction. Mortality was lower in the EPD group during hospital admission (0.70% vs. 1.29%; p = 0.008) and at 30 days (1.44% vs. 2.01%; p = 0.04) but similar at 1 year (6.22% vs. 6.01%; p = 0.67). Following multivariate analyses, no significant difference in mortality was observed during index admission (odds ratio [OR]: 0.71; 95% confidence interval [CI]: 0.42 to 1.19; p = 0.19), at 30 days (OR: 0.87; 95% CI: 0.60 to 1.25; p = 0.45), and at 1 year (OR: 0.92; 95% CI: 0.77 to 1.11; p = 0.41), along with similar rates of in-hospital major adverse cardiovascular events (OR: 1.16; 95% CI: 0.83 to 1.62; p = 0.39) and stroke (OR: 0.68; 95% CI: 0.20 to 2.35; p = 0.54). In propensity score-matched analyses, lower inpatient mortality was observed in the EPD group (OR: 0.46; 95% CI: 0.13 to 0.80; p = 0.002), although the adjusted risk for the periprocedural no-reflow or slow-flow phenomenon was higher in patients in whom EPDs were used (OR: 2.16; 95% CI: 1.71 to 2.73; p

OBJECTIVES: This review aims to evaluate the adverse outcomes for patients after treatment with covered stents. BACKGROUND: Coronary perforation is a potentially fatal complication of percutaneous coronary revascularization which may be treated using covered stents. Studies have evaluated long-term outcomes among patients who received these devices, but hitherto no literature review has taken place. METHODS: We conducted a systematic review of adverse outcomes for patients after treatment with covered stents. Data from studies were pooled and outcomes were compared according to stent type. RESULTS: A total of 29 studies were analyzed with data from 725 patients who received covered stents. The proportion of patients with chronic total occlusions, vein graft percutaneous coronary intervention (PCI), intracoronary imaging and rotational atherectomy were 16.9, 11.5, 9.2, and 6.6%, respectively. The stents used were primarily polytetrafluoroethylene (PTFE) (70%) and Papyrus (20.6%). Mortality, major adverse cardiovascular events, pericardiocentesis/tamponade and emergency surgery were 17.2, 35.3, 27.1, and 5.3%, respectively. Stratified analysis by use of PTFE, Papyrus and pericardial stents, suggested no difference in mortality (p = .323), or target lesion revascularization (p = .484). Stent thrombosis, pericardiocentesis/tamponade and emergency coronary artery bypass surgery (CABG) occurred more frequently in patients with PTFE stent use (p = .011, p = .005, p = .012, respectively). In-stent restenosis was more common with pericardial stent use (

Surgical techniques such as trabeculectomy aim to treat glaucoma by making an incision into the scleral tissue, to create an alternative drainage pathway for aqueous to flow into the sub-Tenon’s/subconjunctival space. However, tissue fibrosis and wound healing occurring after the procedures can reduce the success rate. This study aims to investigate the synergistic effects of aqueous humor in combination with shear stress on the fibrosis response occurring in Tenon’s capsule and conjunctival tissue (TCCT) after glaucoma surgery. Two-dimensional (2D) and 3D in vitro TCCT models were constructed by seeding porcine Tenon’s capsule + conjunctival fibroblasts in collagen gel. These were used to investigate key growth factors (singular and natural form) with shear stress, which are believed to influence tissue fibrosis after glaucoma surgery. In addition to cell proliferation assessments, a nondestructive assay to quantify neocollagen synthesis in TCCT models, in response to these factors, has been applied up to 14 days. TCCT fibroblast proliferation increased significantly with doses of TGF-β, TNF-α, and VEGF, in comparison with the control. Furthermore, fibroblasts exposed to 50% aqueous humor had significantly increased proliferation and actin expression. Shear stress–induced mechanotransduction was also found to promote metabolic activity across experimental conditions. Neocollagen labeling cross validated the fibrosis process. Shear stress appeared to enhance the influence of key growth factors and further promoted fibrotic response within the model. These findings offer a useful insight for further study into the wound-healing response triggered by aqueous fluid outflow after glaucoma surgery.

Background— The transradial access (TRA) site has become the default access site for percutaneous coronary intervention in the United Kingdom, with randomized trials and national registry data showing reductions in mortality associated with TRA use. This study evaluates regional changes in access site practice in England and Wales over time, examines whether changes in access site practice have been uniform nationally and across different patient subgroups, and provides national estimates for the potential number of lives saved or lost associated with regional differences in access site practice. Methods and Results— Using the British Cardiovascular Intervention Society database, we investigated outcomes for growth of TRA in different regions in England and Wales in 448 853 patients who underwent percutaneous coronary intervention from 2005 to 2012. Multiple logistic regression was used to quantify the effect of TRA on 30-day mortality and quantify lives saved and lost by differences in TRA adoption. TRA use increased from 14.0% to 58.6% in 417 038 PCI patients with large variations in different parts of the country. TRA was independently associated with a decreased risk of 30-day mortality (odds ratio=0.70; 95% confidence interval=0.66–0.74), with significant but small differences observed across different regions. The number of estimated lives saved was 450 (95% confidence interval=275–650), and we estimate that an additional 264 (95% confidence interval=153–399) lives would have been saved if TRA adoption were uniform nationally. Conclusions— TRA has become the dominant percutaneous coronary intervention approach in the United Kingdom, with a wide variation in different parts of the country. Changes in practice have contributed to mortality reductions, and inequalities have resulted in missed opportunities for further improvements.

Background: Transradial access (TRA) for percutaneous coronary intervention (PCI) is associated with a reduced risk of mortality compared with transfemoral access, access site–related bleeding complications, and shorter length of stay. The budget impact from a healthcare system that has largely transitioned to TRA for PCI has not been previously published. Methods and Results: Data from 323 656 patients undergoing PCI between 2010 and 2014 were obtained from the British Cardiovascular Intervention Society database. Costs for TRA and transfemoral access PCI were estimated based on procedure cost, length of stay, and differences in the rates of complications (major bleeding and vascular complications). In the base case, a propensity-matched data set between transfemoral access and TRA was used to directly compare the cost per PCI, whereas in the real-world analysis, the full data set was used. Across all indications and all years, TRA offered an average cost saving of £250.59 per procedure (22% reduction) versus transfemoral access with the majority of cost saving derived from reduced length of stay (£190.43) rather than direct costs of complications (£3.71). In the real-world analysis, adoption of TRA was estimated to have provided cost savings of £13.31 million across England between 2010 and 2014; however, if operators in all regions had adopted TRA at the rate of the region with the highest utilization, cost savings of £33.40 million could have been achieved. Conclusions: The transition to TRA in England has been associated with significant cost savings across the national healthcare system, in addition to the well-established clinical benefits.

The cost of inpatient percutaneous coronary interventions (PCI) procedure is related to length of stay (LOS). It is unknown, how LOS may be associated with readmission rates and costs of index PCI and readmissions in elective PCI. This study aims to evaluate rates, predictors, causes, and costs associated with 30-day unplanned readmissions according to lLOS in patients, who underwent elective PCI. We included patients in the Nationwide Readmission Database, who were admitted to hospital from 2010 to 2014, who underwent uncomplicated elective PCI. LOS was defined as 0, 1, 2, and ≥3 days. A total of 324,345 patients were included in the analysis and the 30-day unplanned readmission was 4.75%, 4.67%, 6.44%, and 9.42% in the LOS groups 0, 1, 2, and ≥3 days, respectively. Prolonged LOS was associated with increased average total 30-day cost (index and readmission cost, 0 days $15,063, 1 day $14,693, 2 days $18,136, and ≥3 days $24,336). Compared with 0 days, the odds of readmissions were greater for 2 days (odds ratio 1.41, 95% confidence interval 1.07 to 1.87, p = 0.016) and ≥3 days (odds ratio 1.70, 95% confidence interval 1.28 to 2.24, p

Introduction\ud 40 mm large diameter heads offer the advantages of lesser dislocation rates and better stability while highly cross linked polyethylene have lower wear rates than ultra high molecular weight polyethylene. Studies of the survivorship of 40 mm heads in hybrid hip replacements with Exeter stem and second generation highly cross linked polyethylene are limited. The purpose of the study is to report the short term of survivorship of the large diameter heads (40 mm) with Exeter stem with the secondary aim being the survival analysis of the thinnest second generation highly cross linked polyethylene.\ud \ud Methods\ud Retrospective case series of survivorship of patients with hybrid hip replacements of Exeter stems with 40 mm heads articulating with second generation triple annealed highly cross linked polyethylene liner on a uncemented acetabular shell was performed. As a subset, survival of thinnest second generation highly cross linked polyethylene survival (3.8 mm) at short term was assessed. Survival of the implants was confirmed from the hospital records and National joint registry as of 2015. Revision for any cause was taken as end point.\ud \ud Results\ud 324 hybrid hip replacements with 40 mm heads had been performed for primary hip osteoarthritis. Of the 324 hip replacements, 154 hip replacements had thinnest second generation highly cross linked polyethylene (3.8 mm). Two patients had revision of components, one for periprosthetic fracture and one for deep infection. Mean age of the patients was 70.5 years (range 42–88 years, median 71, SD 8.3 years). None of the patients had revision due to trunion wear or loosening of components. The overall 5-year implant survival probability of hips with 40 mm heads was 99.4% (95% CI 98 to 100%) while the subset group of hip replacements with thinnest second generation highly cross linked polyethylene (3.8 mm) had 5-year implant survival probability of 99.3% (95% CI 97.1 to 100%).\ud \ud Conclusion\ud Short term survivorship does not show significant evidence of early failure or higher rate of revision in our series of hybrid hip replacements with large diameter heads and second generation triple annealed highly cross linked polyethylene. Dislocation rate at the short term is none. Results from this series have to be carefully interpreted due to the relatively short follow up but so far results are encouraging. Long term follow up is required to conclude whether there is early or higher rate of failure. It is our intention to follow up this cohort and further publish our results at longer term.

Objectives To compare susceptibility of five different stent platforms with longitudinal stent deformation (LSD) using a clinically relevant bench testing model simulating both short and long malapposed lengths.Background Recent data suggest that design modifications to the Promus Element stent which led to the Promus Premier stent has reduced susceptibility to LSD. However, susceptibility to LSD at long malapposed lengths has not been tested. Furthermore, the mechanisms behind susceptibility to LSD are as yet unclear.Methods The Omega, Integrity, Multilink 8, Biomatrixand Promus Premier stent platforms were tested. The Omega, Integrity and Multilink 8 platforms were used in place of their drug-eluting equivalents. 3.5 mm stents were deployed in a stepped tube with the distal portion fixed and the proximal test section exposed. The force required to compress stents by a fixed distance at different exposed lengths was compared. Symmetrical and point loading were used.Results The Promus Premier was longitudinally as strong as Multilink and Integrity at a short exposed length (4 mm) but weaker, in between Omega and the other platforms, at longer exposed lengths (12 mm). As previously noted, the Omega (Promus Element) platform was significantly weaker than the other stents and Biomatrix was the strongest stent.Conclusion Susceptibility to LSD varies depending on length of malapposed segment when tested using a clinically relevant model as in this study. The mechanisms behind the susceptibility are likely multifactorial, including connector number, strut thickness, connector alignment and ring orientation but remain to be elucidated.

Background Up to half of patients undergoing percutaneous coronary intervention have multivessel coronary artery disease ( MVD ) with conflicting data regarding optimal revascularization strategy in such patients. This paper assesses the evidence for complete revascularization ( CR ) versus incomplete revascularization in patients undergoing percutaneous coronary intervention, and its prognostic impact using meta‐analysis. Methods and Results A search of PubMed, EMBASE , MEDLINE , Current Contents Connect, Google Scholar, Cochrane library, Science Direct, and Web of Science was conducted to identify the association of CR in patients with multivessel coronary artery disease undergoing percutaneous coronary intervention with major adverse cardiac events and mortality. Random‐effects meta‐analysis was used to estimate the odds of adverse outcomes. Meta‐regression analysis was conducted to assess the relationship with continuous variables and outcomes. Thirty‐eight publications that included 156 240 patients were identified. Odds of death ( OR 0.69, 95% CI 0.61‐0.78), repeat revascularization ( OR 0.60, 95% CI 0.45‐0.80), myocardial infarction ( OR 0.64, 95% CI 0.50‐0.81), and major adverse cardiac events ( OR 0.63, 95% CI 0.50‐0.79) were significantly lower in the patients who underwent CR . These outcomes were unchanged on subgroup analysis regardless of the definition of CR . Similar findings were recorded when CR was studied in the chronic total occlusion ( CTO ) subgroup ( OR 0.65, 95% CI 0.53‐0.80). A meta‐regression analysis revealed a negative relationship between the OR for mortality and the percentage of CR . Conclusion CR is associated with reduced risk of mortality and major adverse cardiac events, irrespective of whether an anatomical or a score‐based definition of incomplete revascularization is used, and this magnitude of risk relates to degree of CR . These results have important implications for the interventional management of patients with multivessel coronary artery disease.

Background Preimplantation balloon aortic valvuloplasty ( BAV ) is considered a routine procedure during transcatheter aortic valve implantation ( TAVI ) to facilitate prosthesis implantation and expansion; however, it has been speculated that fewer embolic events and/or less hemodynamic instability may occur if TAVI is performed without preimplantation BAV . The aim of this study was to systematically review the clinical outcomes associated with TAVI undertaken without preimplantation BAV . Methods and Results We conducted a search of Medline and Embase to identify studies that evaluated patients who underwent TAVI with or without preimplantation BAV for predilation. Pooled analysis and random‐effects meta‐analyses were used to estimate the rate and risk of adverse outcomes. Sixteen studies involving 1395 patients (674 with and 721 without preimplantation BAV ) fulfilled the inclusion criteria. Crude device success was achieved in 94% (1311 of 1395), and 30‐day all‐cause mortality occurred in 6% (72 of 1282) of patients. Meta‐analyses evaluating outcomes of strategies with and without preimplantation BAV showed no statistically significant differences in terms of mortality (relative risk [ RR ] 0.61, 95% CI 0.32–1.14, P =0.12), safety composite end point ( RR 0.85, 95% CI 0.62–1.18, P =0.34), moderate to severe paravalvular leaks ( RR 0.68, 95% CI 0.23–1.99, P =0.48), need for postdilation ( RR 0.86, 95% CI 0.66–1.13, P =0.58), stroke and/or transient ischemic attack ( RR 0.72, 95% CI 0.30–1.71, P =0.45), and permanent pacemaker implantation ( RR 0.80, 95% CI 0.49–1.30, P =0.37). Conclusions Our analysis suggests that TAVI procedures with or without preimplantation BAV were associated with similar outcomes for a number of clinically relevant end points. Further studies including a large number of patients are needed to ascertain the impact of TAVI without preimplantation BAV as a standard practice.