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Introduction: Rib fixation for ventilator dependent flail chest patients has become a mainstay of management in major trauma centres. However, the expansion of rib fixation for fractured ribs beyond this remains largely in the hands of enthusiasts with the benefits in non ventilator dependent groups largely unproven. Previous meta-analyses have largely included non-randomised and retrospective data, much of which is now more than two decades out of date. We wanted to perform an updated meta-analysis including only rigorous prospective trials which were randomised. Further we wanted to include quality of life outcomes which have not been previously examined in published meta-analyses., Methods: This meta-analysis was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines and included randomised controlled trials only, of rib fixation compared to non-operative management in adult patients., Results: Eight studies comprising 752 patients of whom 372 had been randomised to receive rib fixation were included. Benefits of rib fixation were identified with significant reductions in mechanical ventilation and lengths of stay (both ICU and hospital) as well as rates of pneumonia and tracheostomy. No significant benefit in quality of life at 6 months was identified., Conclusion: Operative intervention for rib fractures leads to significantly lower rates of pneumonia, lengths of intensive care stay and time on mechanical ventilation compared to non-operative intervention. Further study is needed to investigate quality of life improvements after rib fractures as operative rib fixation expands to non-ventilator dependent groups., Competing Interests: Declaration of competing interest SM has received honorariums for lectures given by Johnson and Johnson and Zimmer Biomet. VS, RS, YW and CK declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Crown Copyright © 2024. Published by Elsevier Ltd. All rights reserved.)

Histopathology is the gold standard for diagnosing fibrosis, but its routine use is constrained by the need for additional stains, time, personnel and resources. Vibrational spectroscopy is a novel technique that offers an alternative atraumatic approach, with short scan times, while providing metabolic and morphological data. This review evaluates vibrational spectroscopy for the assessment of fibrosis, with a focus on point-of-care capabilities. OVID Medline, Embase and Cochrane databases were systematically searched using PRISMA guidelines for search terms including vibrational spectroscopy, human tissue and fibrosis. Studies were stratified based on imaging modality and tissue type. Outcomes recorded included tissue type, machine learning technique, metrics for accuracy and author conclusions. Systematic review yielded 420 articles, of which 14 were relevant. Ten of these articles considered mid-infrared spectroscopy, three dealt with Raman spectroscopy and one with near-infrared spectroscopy. The metrics for detecting fibrosis were Pearson correlation coefficients ranging from 0.65-0.98; sensitivity from 76-100%; specificity from 90-99%; area under receiver operator curves from 0.83-0.98; and accuracy of 86-99%. Vibrational spectroscopy identified fibrosis in myeloproliferative neoplasms in bone, cirrhotic and hepatocellular carcinoma in liver, end-stage heart failure in cardiac tissue and following laser ablation for acne in skin. It also identified interstitial fibrosis as a predictor of early renal transplant rejection in renal tissue. Vibrational spectroscopic techniques can therefore accurately identify fibrosis in a range of human tissues. Emerging data show that it can be used to quantify, classify and provide data about the nature of fibrosis with a high degree of accuracy with potential scope for point-of-care use., (Crown Copyright © 2024. Published by Elsevier B.V. All rights reserved.)

We herein describe our technique of "branch first continuous perfusion arch repair (BF-CPAR)" which does away with both cerebral circulatory arrest and the need for deep hypothermia. We use this technique for all aortic surgeries including for type A acute aortic dissections., Supplementary Information: The online version contains supplementary material available at 10.1007/s12055-023-01535-2., Competing Interests: Conflict of interestVarun Sharma is a recipient of the National Heart Foundation of Australia PhD Scholarship., (© Crown 2023.)

To demonstrate that point-of-care multimodal spectroscopy using Near-Infrared (NIR) and Raman Spectroscopy (RS) can be used to diagnose human heart tissue. We generated 105 spectroscopic scans, which comprised 4 NIR and 3 RS scans per sample to generate a "multimodal spectroscopic scan" (MSS) for each heart, done across 15 patients, 5 each from the dilated cardiomyopathy (DCM), Ischaemic Heart Disease (IHD) and Normal pathologies. Each of the MSS scans was undertaken in 3 s. Data were entered into machine learning (ML) algorithms to assess accuracy of MSS in diagnosing tissue type. The median age was 50 years (IQR 49-52) for IHD, 47 (IQR 45-50) for DCM and 36 (IQR 33-52) for healthy patients (p = 0.35), 60% of which were male. MSS identified key differences in IHD, DCM and normal heart samples in regions typically associated with fibrosis and collagen (NIR wavenumbers: 1433, 1509, 1581, 1689 and 1725 nm; RS wavelengths: 1658, 1450 and 1330 cm -1 ). In principal component (PC) analyses, these differences explained 99.2% of the variation in 4 PCs for NIR, 81.6% in 10 PCs for Raman, and 99.0% in 26 PCs for multimodal spectroscopic signatures. Using a stack machine learning algorithm with combined NIR and Raman data, our model had a precision of 96.9%, recall of 96.6%, specificity of 98.2% and Area Under Curve (AUC) of 0.989 (Table 1). NIR and Raman modalities alone had similar levels of precision at 94.4% and 89.8% respectively (Table 1). MSS combined with ML showed accuracy of 90% for detecting dilated cardiomyopathy, 100% for ischaemic heart disease and 100% for diagnosing healthy tissue. Multimodal spectroscopic signatures, based on NIR and Raman spectroscopy, could provide cardiac tissue scans in 3-s to aid accurate diagnoses of fibrosis in IHD, DCM and normal hearts. Table 1 Machine learning performance metrics for validation data sets of (a) Near-Infrared (NIR), (b) Raman and (c and d) multimodal data using logistic regression (LR), stochastic gradient descent (SGD) and support vector machines (SVM), with combined "stack" (LR + SGD + SVM) AUC Precision Recall Specificity (a) NIR model  Logistic regression 0.980 0.944 0.933 0.967  SGD 0.550 0.281 0.400 0.700  SVM 0.840 0.806 0.800 0.900  Stack 0.933 0.794 0.800 0.900 (b) Raman model  Logistic regression 0.985 0.940 0.929 0.960  SGD 0.892 0.869 0.857 0.932  SVM 0.992 0.940 0.929 0.960  Stack 0.954 0.869 0.857 0.932 (c) MSS: multimodal (NIR + Raman) to detect DCM vs. IHD vs. normal patients  Logistic regression 0.975 0.841 0.828 0.917  SGD 0.847 0.803 0.793 0.899  SVM 0.971 0.853 0.828 0.917  Stack 0.961 0.853 0.828 0.917 (d) MSS: multimodal (NIR + Raman) to detect pathological vs. normal patients  Logistic regression 0.961 0.969 0.966 0.984  SGD 0.944 0.967 0.966 0.923  SVM 1.000 1.000 1.000 1.000  Stack 1.000 0.944 0.931 0.969 Bold values indicate values obtained from the stack algorithm and used for analyses., (© 2023. Crown.)

Background: In single-ventricle patients undergoing staged-bidirectional Glenn, 36-59% have aorto-pulmonary collateral flow, but risk factors and clinical outcomes are unknown. We hypothesise that shunt type and catheter haemodynamics may predict pre-bidirectional Glenn aorto-pulmonary collateral burden, which may predict death/transplantation, pulmonary artery or aorto-pulmonary collateral intervention., Methods: Retrospective cohort study of patients undergoing a Norwood procedure for single-ventricle anatomy. Covariates included clinical and haemodynamic characteristics up to/including pre-bidirectional Glenn catheterisation and aorto-pulmonary collateral burden at pre-bidirectional Glenn catheterisation. Multivariable models used to evaluate relationships between risk factors and outcomes., Results: From January 2011 to March 2016, 104 patients underwent Norwood intervention. Male sex (odds ratio 3.36, 95% confidence interval 1.17-11.4), age at pre-bidirectional Glenn assessment (2.12, 1.33-3.39 per month), and pulmonary to systemic flow ratio (1.23, 1.08-1.41 per 0.1 unit) were associated with aorto-pulmonary collateral burden. Aorto-pulmonary collateral burden was not associated with death/transplantation (hazard ratio 1.19, 95% confidence interval 0.37-3.85), pulmonary artery (sub-hazard ratio 1.38, 0.32-2.61), or aorto-pulmonary collateral interventions (sub-hazard ratio 1.11, 0.21-5.76). Longer post-Norwood length of stay was associated with greater risk of death/transplantation (hazard ratio 1.22 per week, 95% confidence interval 1.08-1.38), but lower risk of aorto-pulmonary collateral intervention (sub-hazard ratio 0.86 per week, 95% confidence interval 0.75-0.98). Time to pre-bidirectional Glenn catheterisation was associated with lower risk of pulmonary artery (sub-hazard ratio 0.80 per month, 95% confidence interval 0.65-0.98) and aorto-pulmonary collateral intervention (sub-hazard ratio 0.79, 0.63-0.99). Probability of moderate/severe aorto-pulmonary collateral burden increased with left-to-right shunt (22.5% at <1.0, 57.6% at >1.4) and the age at pre-bidirectional Glenn catheterisation (10.6% at <2 months, 56.9% at >5 months)., Conclusions: Aorto-pulmonary collateral burden is common after Norwood procedure and increases as age at bidirectional Glenn increases. As expected, higher pulmonary to systemic flow ratio is a marker for greater aorto-pulmonary collateral burden pre-bi-directional Glenn; aorto-pulmonary collateral burden does not confer risk of death/transplantation or pulmonary artery intervention.

Objectives: In aortic root surgery, valve-sparing aortic root replacement is an attractive alternative by mitigating the risks inherent to prosthetic valves; however, little is known about the variables that impact its durability. We review our mid- to long-term outcomes after valve-sparing aortic root replacement and describe factors that impact survival and valve reintervention and insufficiency., Methods: A retrospective review of 284 consecutive patients undergoing valve-sparing aortic root replacement between November 1999 and January 2022 at Austin Health, Melbourne, Australia, was undertaken, with a median follow-up of 6.43 ± 4.83 years, but up to 22.0 years. Freedom from mortality, aortic reintervention, and insufficiency was analyzed using Kaplan-Meier methods, Cox proportional hazard models, and Fine-Gray analysis., Results: The median age of patients at intervention was 60.0 years (interquartile range, 48.0-67.0), of whom 68 (23.9%) had bicuspid aortic valve disease, 27 (9.5%) had Marfan syndrome, 119 (41.9%) had severe aortic root dilation (>50 mm), and 155 had (54.6%) severe aortic insufficiency at the time of intervention. The 30-day mortality was 1.8%, with freedom from mortality of 96.0% (95% CI, 92.6-97.8) at 5 years and 88.2% (95% CI, 81.4-92.6) at 10 years. Freedom from aortic reintervention was 92.2% (95% CI, 87.7-95.2) at 5 years and 79.8% (95% CI, 71.8-85.8) at 10 years. Factors associated with reintervention were concomitant leaflet repair (hazard ratio, 8.13, 95% CI, 1.07-61.7) and bicuspid valvulopathy (hazard ratio, 2.23, 95% CI, 1.07-4.68), with reintervention in the bicuspid aortic valve being more likely due to aortic stenosis and in the tricuspid aortic valve due to aortic insufficiency (chi-square P = .05). The freedom from aortic insufficiency was 89.1% (95% CI, 83.5-92.9), 84.9% (95% CI, 77.8-89.9) at 5 and 10 years, respectively, and 80.7% (95% CI, 71.0-87.4)., Conclusions: Valve-sparing aortic root replacement has excellent long-term outcomes, with low mortality and reintervention rates. Concomitant leaflet repair and bicuspid valve disease are the only long-term factors associated with reintervention., Competing Interests: Conflict of Interest Statement V.J.S. is a recipient of the National Heart Foundation of Australia PhD Scholarship. All other authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (Crown Copyright © 2023. Published by Elsevier Inc. All rights reserved.)

Introduction: Visual assessment and imaging of the donor liver are inaccurate in predicting fibrosis and remain surrogates for histopathology. We demonstrate that 3-s scans using a handheld near-infrared-spectroscopy (NIRS) instrument can identify and quantify fibrosis in fresh human liver samples., Methods: We undertook NIRS scans on 107 samples from 27 patients, 88 from 23 patients with liver disease, and 19 from four organ donors., Results: Liver disease patients had a median immature fibrosis of 40% (interquartile range [IQR] 20-60) and mature fibrosis of 30% (10%-50%) on histopathology. The organ donor livers had a median fibrosis (both mature and immature) of 10% (IQR 5%-15%). Using machine learning, this study detected presence of cirrhosis and METAVIR grade of fibrosis with a classification accuracy of 96.3% and 97.2%, precision of 96.3% and 97.0%, recall of 96.3% and 97.2%, specificity of 95.4% and 98.0% and area under receiver operator curve of 0.977 and 0.999, respectively. Using partial-least square regression machine learning, this study predicted the percentage of both immature ( R 2  = 0.842) and mature ( R 2  = 0.837) with a low margin of error (root mean square of error of 9.76% and 7.96%, respectively)., Conclusion: This study demonstrates that a point-of-care NIRS instrument can accurately detect, quantify and classify liver fibrosis using machine learning., Competing Interests: The authors declare no conflict of interest., (© 2023 The Authors. Health Science Reports published by Wiley Periodicals LLC.)

Background: Aortic arch surgery necessitates interruption of perfusion, thus conferring higher morbidity and mortality compared with other aortic surgery. This report describes a branch-first continuous perfusion aortic arch replacement (BF-CPAR) technique that overcomes these shortcomings and describes midterm results with this technique., Methods: This report represents the corresponding author's 15-year experience with BF-CPAR, which involves preliminary mobilization and branch reconstruction before circulatory arrest by using a modified trifurcation graft. Demographic, procedural, and outcome (mortality, reintervention, morbidity, and stroke) were analyzed with Kaplan-Meier and Cox regression., Results: Over 15 years (July 2005-February 2021), 155 patients underwent BF-CPAR, at a median age of 66.8 years, 106 (68.3%) on an elective basis and 49 (31.6%) on an emergency basis. There were no aortic deaths after the first postoperative year, thereby resulting in a 1- and 10-year freedom from aortic death constant at 95.6% in patients undergoing elective BF-CPAR and 93.3% in patients undergoing emergency BF-CPAR patients, respectively. Freedom from reintervention on the operated segment at 5 and 9 years was 93.2% and 93.2% in patients undergoing elective cases and 97.1% and 91.4% in emergency cases, respectively. The 10-year freedom from any aortic reintervention was 72.8% in elective patients and 29.2% in emergency patients; there were 38 reinterventions, 76.3% (n = 29/38) done for progression of aneurysmal or dissection disease, of which 79.3% (n = 23/29) were completed endovascularly. Freedom from cerebrovascular-related events at 5 and 10 years was 90.3% and 82.6% in patients undergoing elective BF-CPAR and 75.4% for both time points in patients undergoing emergency BF-CPAR, respectively., Conclusions: BF-CPAR has excellent 10-year results for elective and emergency cases of arch replacement., (Crown Copyright © 2023. Published by Elsevier Inc. All rights reserved.)

Tissue-resident memory T (T RM ) cells provide immune defense against local infection and can inhibit cancer progression. However, it is unclear to what extent chronic inflammation impacts T RM activation and whether T RM cells existing in tissues before tumor onset influence cancer evolution in humans. We performed deep profiling of healthy lungs and lung cancers in never-smokers (NSs) and ever-smokers (ESs), finding evidence of enhanced immunosurveillance by cells with a T RM -like phenotype in ES lungs. In preclinical models, tumor-specific or bystander T RM -like cells present prior to tumor onset boosted immune cell recruitment, causing tumor immune evasion through loss of MHC class I protein expression and resistance to immune checkpoint inhibitors. In humans, only tumors arising in ES patients underwent clonal immune evasion, unrelated to tobacco-associated mutagenic signatures or oncogenic drivers. These data demonstrate that enhanced T RM -like activity prior to tumor development shapes the evolution of tumor immunogenicity and can impact immunotherapy outcomes., Competing Interests: Declaration of interests C.S. acknowledges grant support from AstraZeneca, Boehringer-Ingelheim, Bristol-Myers Squibb, Pfizer, Roche-Ventana, Invitae (previously Archer Dx Inc–collaboration in minimal residual disease sequencing technologies), and Ono Pharmaceutical. C.S. is an AstraZeneca Advisory Board member and Chief Investigator for the AZ MeRmaiD 1 and 2 clinical trials and is also Co-Chief Investigator of the NHS Galleri trial funded by GRAIL and a paid member of GRAIL’s SAB. He receives consultant fees from Achilles Therapeutics (also SAB member), Bicycle Therapeutics (also a SAB member), Genentech, Medicxi, Roche Innovation Centre– Shanghai, Metabomed (until July 2022), and the Sarah Cannon Research Institute. He had stock options in Apogen Biotechnologies and GRAIL until June 2021, and currently has stock options in Epic Bioscience, Bicycle Therapeutics, and has stock options and is co-founder of Achilles Therapeutics. C.S. is an inventor on a European patent application relating to assay technology to detect tumour recurrence (PCT/GB2017/053289), the patent has been licensed to commercial entities, and under his terms of employment, C.S. is due a revenue share of any revenue generated from such licence(s). C.S. holds patents relating to targeting neoantigens (PCT/EP2016/059401), identifying patient response to immune checkpoint blockade (PCT/EP2016/071471), determining HLA LOH (PCT/GB2018/052004), predicting survival rates of patients with cancer (PCT/GB2020/050221), identifying patients who respond to cancer treatment (PCT/GB2018/051912), a US patent relating to detecting tumour mutations (PCT/US2017/28013), methods for lung cancer detection (US20190106751A1) and both a European and US patent related to identifying insertion/deletion mutation targets (PCT/GB2018/051892) and is co-inventor to a patent application to determine methods and systems for tumour monitoring (PCT/EP2022/077987). C.S has received honoraria from Amgen, AstraZeneca, Pfizer, Novartis, GlaxoSmithKline, MSD, Bristol Myers Squibb, Illumina, and Roche-Ventana., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Disorders of bone integrity carry a high global disease burden, frequently requiring intervention, but there is a paucity of methods capable of noninvasive real-time assessment. Here we show that miniaturized handheld near-infrared spectroscopy (NIRS) scans, operated via a smartphone, can assess structural human bone properties in under three seconds. A hand-held NIR spectrometer was used to scan bone samples from 20 patients and predict: bone volume fraction (BV/TV); and trabecular (Tb) and cortical (Ct) thickness (Th), porosity (Po), and spacing (Sp). NIRS scans on both the inner (trabecular) surface or outer (cortical) surface accurately identified variations in bone collagen, water, mineral, and fat content, which then accurately predicted bone volume fraction (BV/TV, inner R 2 = 0.91, outer R 2 = 0.83), thickness (Tb.Th, inner R 2 = 0.9, outer R 2 = 0.79), and cortical thickness (Ct.Th, inner and outer both R 2 = 0.90). NIRS scans also had 100% classification accuracy in grading the quartile of bone thickness and quality. We believe this is a fundamental step forward in creating an instrument capable of intraoperative real-time use., Competing Interests: K. Stok reports payment for participation on the RegMed XB Moonshot International Scientific Advisory Board, unrelated to this study. K. Stok is also an executive committee member of OCTA Research, the co-chair of SPECTRA, and a member of the ARC College of Experts., (© 2023 Author(s) et al.)

Objective: Remodeling of the coronary arteries is a common feature in severe cases of Kawasaki disease (KD). This pathology is driven by the dysregulated proliferation of vascular fibroblasts, which can lead to coronary artery aneurysms, stenosis, and myocardial ischemia. We undertook this study to investigate whether inhibiting fibroblast proliferation might be an effective therapeutic strategy to prevent coronary artery remodeling in KD., Method: We used a murine model of KD (induced by the injection of the Candida albicans water-soluble complex [CAWS]) and analyzed patient samples to evaluate potential antifibrotic therapies for KD., Results: We identified the mechanistic target of rapamycin (mTOR) pathway as a potential therapeutic target in KD. The mTOR inhibitor rapamycin potently inhibited cardiac fibroblast proliferation in vitro, and vascular fibroblasts up-regulated mTOR kinase signaling in vivo in the CAWS mouse model of KD. We evaluated the in vivo efficacy of mTOR inhibition and found that the therapeutic administration of rapamycin reduced vascular fibrosis and intimal hyperplasia of the coronary arteries in CAWS-injected mice. Furthermore, the analysis of cardiac tissue from KD fatalities revealed that vascular fibroblasts localizing with inflamed coronary arteries up-regulate mTOR signaling, confirming that the mTOR pathway is active in human KD., Conclusion: Our findings demonstrate that mTOR signaling contributes to coronary artery remodeling in KD, and that targeting this pathway offers a potential therapeutic strategy to prevent or restrict this pathology in high-risk KD patients., (© 2022 American College of Rheumatology.)

We aimed to facilitate the donation of tissue samples for research by establishing a centralized system integrated in the organ donation program for collection, storage, and distribution of samples (the Australian Donation and Transplantation Biobank [ADTB])., Methods: Feasibility of a research biobank integrated within the deceased organ and tissue donation program was assessed. DonateLife Victoria sought consent for ADTB donation after consent was received for organ donation for transplantation from the donor's senior available next of kin. ADTB samples were collected during donation surgery and distributed fresh to researchers or stored for future research. The main outcome measures were ADTB donation rates, ADTB sample collection, ADTB sample use, and to identify ethical considerations., Results: Over 2 y, samples were collected for the ADTB from 69 donors (28% of 249 donors). Samples were obtained from the spleen (n = 59, 86%), colon (n = 57, 83%), ileum (n = 56, 82%), duodenum (n = 55, 80%), blood (n = 55, 80%), bone marrow (n = 55, 80%), skin (n = 54, 78%), mesenteric lymph nodes (n = 56, 81%), liver (n = 21, 30%), lung (n = 29, 42%), and lung-draining lymph node (n = 29, 42%). Heart (n = 20), breast (n = 1), and lower urinary tract (n = 1) samples were obtained in the second year. Five hundred fifty-six samples were used in 19 ethics-approved research projects spanning the fields of immunology, microbiology, oncology, anatomy, physiology, and surgery., Conclusions: The integration of routine deceased donation and transplantation activities with a coordinated system for retrieval and allocation of donor samples for use in a range of research projects is feasible and valuable., Competing Interests: The authors declare no conflicts of interest, (Copyright © 2022 The Author(s). Transplantation Direct. Published by Wolters Kluwer Health, Inc.)

Background: Effective postoperative analgesia after lower segment caesarean section (LSCS) is very important for early ambulation and early breast feeding and has a role to play in decreasing postpartum depression. Quadratus lumborum (QL) block, a fascial plane block, is gaining popularity for pain management in lower abdominal surgeries. The aim of the present study was to compare the ultrasound-guided (USG) transversus abdominis plane (TAP) block and QL block in patients undergoing LSCS under spinal anaesthesia., Methods: Double-blinded, randomized, controlled, single-centre study done between Aug 2019 and Oct 2019, randomised 80 patients scheduled for LSCS into two groups, QL (N = 40) and TAP (N = 40), receiving USG TAP or QL block 20 ml of 0.25% bupivacaine with 4 mg dexamethasone bilaterally, postoperatively., Results: SSPS 20 was used for the statistical analysis Patients were evaluated for 24-h using visual analogue scale (VAS) for pain scores, time to rescue analgesia and the analgesic dose requirement at regular time intervals. Fifteen percent patients in QL block and 75% in TAP block required rescue analgesia (P < 0.001). Significant differences were observed in pain scores at 10 h postoperatively, VAS in QL=1.18 (0.55), TAP=3.08 (1.66) (P < 0.001). By 24 h postoperatively the difference ceased to be statistically significant. Time to rescue analgesia in QL group was 1353 min (+/-224.07) and TAP group 915 min (+/-391.62) (P < 0.001). Average requirement of rescue analgesia (paracetamol) in QL group was 153.84 mg, TAP group 756.09 mg., Conclusions: Patients receiving QL block had prolonged analgesic effects and required less use of rescue analgesia in comparison with TAP group in the first 24 h postoperatively., Trial Number: CTRI/2019/07/020475., Competing Interests: The authors have none to declare., (© 2020 Director General, Armed Forces Medical Services. Published by Elsevier, a division of RELX India Pvt. Ltd.)

Objective: Vasculitis is characterised by inflammation of the blood vessels. While all layers of the vessel can be affected, inflammation within the intimal layer can trigger thrombosis and arterial occlusion and is therefore of particular clinical concern. Given this pathological role, we have examined how intimal inflammation develops by exploring which (and how) macrophages come to populate this normally immune-privileged site during vasculitis., Methods: We have addressed this question for Kawasaki disease (KD), which is a type of vasculitis in children that typically involves the coronary arteries. We used confocal microscopy and flow cytometry to characterise the macrophages that populate the coronary artery intima in KD patient samples and in a mouse model of KD, and furthermore, have applied an adoptive transfer system to trace how these intimal macrophages develop., Results: In KD patients, intimal hyperplasia coincided with marked macrophage infiltration of the coronary artery intima. Phenotypic analysis revealed that these 'intimal macrophages' did not express markers of resident cardiac macrophages, such as Lyve-1, and instead, were uniformly positive for the chemokine receptor Ccr2, suggesting a monocytic lineage. In support of this origin, we show that circulating monocytes directly invade the intima via transluminal migration during established disease, coinciding with the activation of endothelial cells lining the coronary arteries., Conclusions: During KD, intimal macrophages develop from circulating monocytes that infiltrate the inflamed coronary artery intima by transluminal migration., Competing Interests: IPW has received funding from CSL and Med‐Immune for research on cytokine antagonists. The remaining authors declare no conflict of interest., (© 2022 The Authors. Clinical & Translational Immunology published by John Wiley & Sons Australia, Ltd on behalf of Australian and New Zealand Society for Immunology, Inc.)

Objectives: Type A aortic dissection (ATAAD) is hypothesised as a progression of aneurysmal dilation, but 60% of patients in the International Registry of Acute Aortic Dissection (iRAD) registry had a maximum aortic diameter (MAD)<55 mm. We aim to demonstrate that size ratios and aortic wall stress, assessed using a simplified markers, are unique to aortic patients who have had adverse events (ATAAD) compared to those who have not (thoracic aortic aneurysm [TAA])., Methods: A retrospective cohort analysis of patients who underwent aortic intervention at Waikato Hospital, New Zealand between 2015-2020, comparing dissection (ATAAD) to TAA patients. MAD; ratio of MAD to standardised-points within the aorta; and MAD-to-height collected from computed tomography (CT)-scans of all patients was undertaken. Receiver operating characteristic (ROC)-analysis to determine cut-off point for each marker was undertaken together with multivariable logistic regression comparing both cohorts, cross-validated by propensity-score matched analysis., Results: Cohort of 215 patients, 78 (36.3%) ATAAD and 137 (63.7%) TAA; median age at intervention 63.3 years, 52 (24.2%) females, both cohorts matched for size. Using the entire cohort, the MAD: sinus of Valsalva (SoV) ratio>1.06 (cut-off value) had 4.5-times greater association with ATAAD (95%CI 1.46-13.8) and a 0.1-unit increased conferred 1.45-times greater association with ATAAD (95%CI 1.00-2.08). MAD>55 mm only seen in 33.3% of ATAAD (n=26/78), and not associated with ATAAD (OR 1.88, 95%CI 0.64-5.51). Compared to MAD, MAD:SoV ratio had greater sensitivity (33% vs 73%), lower number-needed-to-treat (17.9 vs 2.7) and superior discrimination (area under the curve [AUC] 0.54 vs 0.71). Findings were consistent with propensity score matched analysis., Conclusions: MAD:SoV ratio significantly correlates with ATAAD (4.5 times), with superior sensitivity, discrimination, and attributable-risk-percentage compared to MAD alone., Competing Interests: Conflict of Interest None declared., (Crown Copyright © 2022. Published by Elsevier B.V. All rights reserved.)

Objectives: Our objective is to assess whether the presence of myocardial viability is a predictor of mortality among patients undergoing coronary artery bypasss grafting (CABG) through a systematic review meta-analysis., Methods: Comprehensive review of EMBASE and PubMed in accordance with PRISMA guidelines, including studies of patients undergoing CABG with assessment of myocardial viability and recorded long-term mortality, age and sex. Studies were restricted to the last decade, and data were stratified by imaging modality (magnetic resonance imaging [MRI] or nuclear medicine). Random-effects model for assessing pooled effect, heterogeneity assessment using Chi-square and I 2 statistics, publication bias assessed by funnel plots and Egger's test., Results: Meta-analysis of contemporary data (January 2010 to October 2020) yielded 3,621 manuscripts of which 92 were relevant, and 6 appropriate for inclusion with 993 patients. Pooled analysis showed that patients with non-viable myocardium undergoing CABG are at 1.34 times the risk of mortality compared to those with viable myocardium (95% CI 1.01-1.79, p=0.05). Subgroup analysis of the MRI or nuclear medicine modalities was not statistically significant and there was no confounding by age or sex in meta-regression. There was significant heterogeneity in imaging modality and diagnostic criteria, but heterogeneity between study findings was low with an I 2 statistic of 29%. The risk of publication bias was moderate on the Newcastle-Ottawa Scale), but not statistically significant (Egger's Test coefficient=1.3, 95%CI -0.35-2.61, p=0.10)., Conclusions: There is a multitude of methods for assessing cardiac viability for coronary revascularisation surgery, making meta-analyses fraught with limitations. Our meta-analysis demonstrates that the finding of non-viable myocardium can not be used draw conclusions for risk assessment in coronary surgery., (Crown Copyright © 2022. Published by Elsevier B.V. All rights reserved.)

Background: Aortic-arch surgery often necessitates interruption of perfusion conferring higher morbidity and mortality compared to other aortic segments. We describe our Branch-first continuous-perfusion aortic-arch replacement (BF-CPAR) technique which overcomes these shortcomings, describing technique, results and improved outcomes., Methods: This represents the senior author's 15-year experience with BF-CPAR. Description of demographics, procedures and outcomes have been stratified by dissection and aneurysm etiology, with prediction of mortality, cerebrovascular events, renal failure, and end-organ ischemia undertaken using multivariable logistic regression analysis., Results: From July 2005 to February 2021, 155 patients underwent BF-CPAR, 93 for aneurysms and 62 for dissections. Median age at intervention was 66.8 years, 96 (61.9%) male, 18 (11.6%) with history of previous dissection repair, and 49 (31.6%) on an emergent basis. We observed an overall mortality of 4.5% (N.=7) and stroke of 3.2% (N.=5). Comparing elective to urgent cases, the mortality and stroke rates were significantly lower at 0.0% and 1.9% versus 14.2% and 6.1% (risk differences: 14.3% and 2.3%, P<0.01) respectively. Predictors of mortality were age (1.11 per year, 95% CI: 1.00-1.23, P=0.05); of stroke were hypercholesterolemia (14.4, 1.84-111.9, P=0.01) and hypertension (0.07, 0.01-0.84, P<0.01); and of dialysis were dissection (6.60, 1.76-24.7, P<0.01)., Conclusions: BF-CPAR is safe and adds to the armamentarium of aortic arch repair. In elective and uncomplicated acute-dissection cases, it has no mortality and low stroke (1.9%), and vital organ dysfunction risk. Its results which are comparable to many of the best currently reported series, is driven by avoidance of cerebral circulatory arrest and reduction of cardiac and visceral ischemic time.

Aim: To clinically evaluate the nature of precancerous and cancerous lesions associated with tobacco consumption habit and to correlate clinical profile with the histopathological findings of clinically suspected precancerous and cancerous lesions., Materials and Methods: These included the examination of patients who visited the outpatient department (OPD) of the institute that includes 1,500 patients who had tobacco chewing habits were classified into the following two groups according to their characteristics. The study group comprised 270 patients, of which 170 gave consent for biopsy and 100 patients who not gave consent were counseled for tobacco cessation., Results: Among 270 patients, the highest number of patients, 146 (54.07%) patients, were found to be smokeless tobacco consumers followed by 65 (24.07%) patients who were smoked tobacco consumers while 59 (21.85%) patients were found to have both the habits. Wide variation was noted in duration and frequency of habit. Most prevalent site was the buccal mucosa affected in 138 (51.11%) patients who consumed both smoked as well as smokeless tobacco. And on clinical examination, 138 (51%) patients had leukoplakia followed by 54 (20%) patients with oral squamous cell carcinoma and 40 (15%) patients with oral submucous fibrosis (OSMF). Other patients were tobacco pouch keratosis 17 (6%), smoker's melanosis 8 (3%), smoker's palate 7 (3%), and erythroplakia 6 (2%). The patients who gave consent (170 patients) were evaluated histopathologically to correlate with clinical findings., Conclusion: Tobacco-related oral lesions are also high, which brings an alarming signal toward the development of cancer. Our contribution as healthcare providers can be made by conducting more oral health education programs and educating the general population about the adverse effects of tobacco. The appropriate clinical assessment and categorization of all these lesions aided us in motivating patients to undergo necessary treatments and also to discontinue their habits in order to prevent deterioration of their conditions., Clinical Significance: Set up de-addiction centers in dental colleges and help tobacco users in discontinuing their habits. Interestingly, this study also served as a mirror for those patients who were unaware of the lesions they were giving abode to in their oral cavities.

Background: Simulation training is a useful adjunct to surgical training and education (SET) in Cardiothoracic Surgery yet training opportunities outside the Royal Australasian College of Surgery or industry-sponsored workshops are rare due to high cost and limited training faculty, time, assessment tools or structured curricula. We describe our experience in establishing a low-cost cardiac simulation programme., Methods: We created low-cost models using hospital facilities, hardware stores, abattoirs and donations from industry. Three workshops were conducted on coronary anastomoses, aortic and mitral valve replacement., Results: Whole porcine hearts were sourced from local farms. Industry donations of obsolete stock were used for suture and valve material-stations constructed using ironing-board, 2-L buckets and kebab-skewers. Suture ring holders were fashioned from recycled cardboard or donated. All participants were asked to complete pre and post simulation self-assessment forms. Across three workshops, 45 participants (57.8% female) with a median age 27 (interquartile range 24-31) attended. Training level consisted of nurses (8, 17.8%), medical students (17, 37.8%), residents/house officers (6, 13.3%) and registrars (14, 31.1%). There were improvements in knowledge of anatomy (mean difference 18%; 95% confidence interval 12%-24%), imaging (16%; 10%-22%) and procedural components (34%; 28%-42%); and practical ability to describe steps (30%; 24%-38%), partially (32%; 26%-38%) or fully complete (32%; 28%-38%) the procedure., Conclusions: Simulation-based training in cardiac surgery is feasible in a hospital setting with low overhead costs. It can benefit participants at all training levels and has the potential to be implemented in training hospitals as an adjunct to the SET programme., (© 2021 Royal Australasian College of Surgeons.)

Objectives: Protein losing enteropathy and plastic bronchitis are severe complications in Fontan circulation, with 5-year survival ranging from 46% to 88%. We report risk factors and outcomes of protein losing enteropathy and plastic bronchitis in patients undergoing the Fontan., Methods: We performed a retrospective analysis of 1561 patients from the Australia New Zealand Fontan Registry. Two end points were death and cardiac transplantation examined with Cox regression (if no competing risks) or cumulative incidence curves and cause-specific Cs regression., Results: A total of 55 patients with protein losing enteropathy/plastic bronchitis were included. Their median age at the Fontan was 5.7 years, and time to onset after the Fontan for protein losing enteropathy was 5.0 years and plastic bronchitis was 1.7 years. Independent predictors for developing protein losing enteropathy/plastic bronchitis were right-ventricular morphology with hypoplastic left-heart syndrome (hazard ratio, 2.30; confidence interval, 1.12-4.74), older age at Fontan (hazard ratio, 1.13; confidence interval, 1.03-1.23), and pleural effusions after Fontan (hazard ratio, 2.43; confidence interval, 1.09-5.41); left-ventricular morphology was protective (hazard ratio, 0.36; confidence interval, 0.18-0.70). In the protein losing enteropathy/plastic bronchitis population, freedom from death or transplantation after protein losing enteropathy/plastic bronchitis diagnosis at 5, 10, and 15 years was 70% (confidence interval, 58-85), 65% (confidence interval, 51-83), and 43% (confidence interval, 26-73), respectively; only older age (hazard ratio, 1.23; confidence interval, 1.01-1.52) was an independent predictor. Twenty-six surgical interventions were performed in 20 patients, comprising Fontan revisions (n = 5), fenestrations (n = 11), Fontan conversions (n = 5), atrioventricular valve repairs (n = 3), and hepatic vein diversion (n = 2)., Conclusions: Protein losing enteropathy and plastic bronchitis remain severe complications, preferably affecting patients with dominant right single ventricle, with older age at Fontan being a predictor of developing protein losing enteropathy/plastic bronchitis and poorer prognosis. Heart transplantation remains the ultimate treatment, with 30% dying or requiring transplantation within 5 years, and the remaining being stable for long periods., (Crown Copyright © 2020. Published by Elsevier Inc. All rights reserved.)

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'in patients with ascending aortic or aortic arch disease what are the outcomes with endovascular repair in terms of survival, complications and reintervention?' Altogether 585 papers were found using the reported search, of which 9 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We found that the endovascular operative techniques with the greatest evidence were ascending aortic chimney grafts (AACs), branched thoracic endovascular aortic repair (bTEVAR) aortic grafts and fenestrated TEVAR (fTEVAR) aortic grafts. The best evidence available were small case-series or retrospective cohort studies (n < 100), with 1 systematic review, at a short follow-up period (range 0-5 years). Intraoperatively, these techniques have a high technical success rate (84-100%). We found rates of endoleak comparable between AAC (7.4-16%) and bTEVAR/fenestrated TEVAR (11.1-21.4%). Stroke rates are higher in bTEVAR (3.1-42% vs 1-26% in AACs), attributed to more proximal pathology and technically challenging procedures. Following the immediate postoperative period, the 30-day mortality is 0-10.8% and patency is 97-100%. Stroke and reintervention rates remain higher in the bTEVAR group (3.1-42.0% and 0.5-33.3%) compared to the AAC group (1.0-11.1% and 6.7-16.7%). The 3- and 5-year survival ranges from 59% to 90%, but is driven by non-aortic pathology in a high-risk population; 3-year freedom from aortic death is 93-97%. Patency is 97-100% at up to 3 years, conformation and supra-aortic occlusions thereafter remain unknown. We conclude that AACs, bTEVARs and fenestrated TEVARs are safe endovascular options in high-risk elective patients, with results comparable to open or hybrid repair. They remain unverified in acute settings or in patients fit for open intervention., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Competing Interests: There are no conflicts of interest.

Background: Adenoid cystic carcinoma is a rare cause of thoracic malignancy, and the prognosis may depend on the extent of surgical resection and adjuvant radiotherapy. Complete resection has low rates of local recurrence but is complicated by the involvement of central airways. Adjuvant radiotherapy is frequently recommended but unproven., Methods: We describe the technicalities of radical resection and adjuvant radiotherapy using the primary endpoint of local recurrence and secondary endpoints of locoregional (mediastinal) recurrence and distant metastasis. Resections were classed as microscopically and macroscopically clear (R0) or only macroscopically clear (R1)., Results: Twelve patients (eight males) diagnosed between 1999 and 2016, with an average age of 44 ± 12 years, were included. Six of these were operable (operative group), and six had non-resectable lesions (radiotherapy group). In the operative group, three had tracheal disease and three had bronchial disease. Tracheal lesions underwent excision with tracheal anastomosis (all R1 resections). Main bronchial lesions underwent complete excision via pneumonectomy (two R0 and one R1 resections). All these patients received 50-60 Gray of adjuvant radiotherapy. At an average follow-up of 6.1 ± 4.3 years, no patient had local recurrence, two had locoregional recurrence and four had distant metastasis. The radiotherapy group received 60-70 Gray as definitive therapy, and at an average follow-up of 5.4 ± 4.2 years, three had locoregional recurrence and four had distant metastasis., Conclusion: Our case series consolidates evidence that early radical resection and radiotherapy is associated with a low risk of local recurrence in patients with thoracic adenoid cystic carcinoma., (© 2019 Royal Australasian College of Surgeons.)

Background: Cleaning and shaping of the pulp canal is one of the most important steps of endodontic therapy. Serious complications occur by the apical extrusion of bacteria during the instrumentation procedures. Both crown-down (CD) and full-length linear motion (FM) techniques are routinely used as a component of taper rotary instrument procedures for achievement of thorough cleaning and shaping of the pulp canal space. Hence, we aimed for this study to assess the change in the amount of apically extruded bacteria using CD and FM instrumentation techniques produced by differences in taper between the instruments used during biomechanical preparation of root canals., Materials and Methods: The present study included assessments of 132 extracted maxillary central incisor teeth. To achieve a uniform teeth length of 21 mm, the height of the tooth crown was reduced for preserving the coronal portion of teeth. A modified glass vial model was constructed for the estimation of amount of bacterial extrusion through the apical region. For filling of each pulp canal specimen, 20 mL of Enterococcus faecalis suspension was used followed by the use of a number 10 K-file for carrying the bacteria down the lengths of pulp canals. All the contaminated teeth specimens were divided into six study groups with groups I to III containing specimens prepared in the CD manner, while groups IV to VI contained specimens prepared in the FM manner. Six teeth were taken as negative control with three specimens with each technique, and another six specimens were taken as positive controls. Cultivable bacterial counts were determined by evaluating 100 mL saline solution from each vial followed by its inoculation on blood agar. All the colony-forming unit (CFU) values were log-transformed (base 10), and the results were analyzed by Statistical Package for the Social Sciences software., Results: A significantly lower quantity of CFU values was observed during CD instrumentation procedures with 0.02 files in comparison with all other study groups. However, while comparing both the instrumentation procedures when different taper files, other than 0.02 taper, were used for biomechanical preparation of root canal, nonsignificant results were obtained., Conclusion: With 0.02 taper preparations, significantly less amount of extrusion of bacteria is associated when done with CD technique., Clinical Significance: No change in the amount of apical extrusion of bacteria will be seen by changing the type of instrumentation procedures. Amount of bacteria extruded can be minimized using 0.02 taper. Key words: Bacteria, Instrumentation, Taper.

Objectives: Heart transplantation in children after univentricular palliation is a technical challenge. As the national referral centre for heart transplantation in children, we review national trends in transplantation and describe technical innovations used in the current era., Methods: Children undergoing heart transplantation were separated into patients with (i) structural congenital heart disease (sCHD; subdivided into univentricular and biventricular) and (ii) cardiomyopathy (CM). The operation notes and surgeons' diagrams were reviewed with particular attention to surgical innovations introduced after 2000., Results: Between January 1988 and December 2012, 111 primary transplantations were performed: 50 for sCHD (30 univentricular and 20 biventricular) and 61 for CM. Thirty-day mortality for univentricular patients compared to those with CM was significantly higher before 2000 (21 vs 0%, 3/14 vs 0/20, P = 0.023) and not different after 2000 (8 vs 6%, 3/38 vs 1/16, P = 0.852). At the same time, the percentage of patients with univentricular physiology increased from 47% (14 of 30 patients) to 80% (16 of 20 patients) versus those with biventricular physiology. After 2000, 12 of 16 patients (75%) with univentricular sCHD required reconstruction of the great vessels. Of these, 8 (50%) patients had reached the stage of Fontan, 5 had reached bidirectional cavopulmonary shunt, 2 had reached Kawashima procedure and 1 had only a Blalock-Taussig shunt. The following techniques were employed in 12 transplantations: aortic arch replacement (n = 3), hilum-to-hilum pulmonary artery (PA) reconstruction (n = 5), PA patch reconstruction (n = 5), reconstruction of the PA bifurcation using donor bifurcation (n = 2) and left superior vena cava (SVC) to donor SVC reconstruction (n = 3)., Conclusions: In the current era, the majority of children undergoing heart transplantation for sCHD have had univentricular palliation. These patients pose challenges because of prior surgeries and complex anatomy, but the techniques described here in may enable improved outcome., (© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Recent significant improvement in surgical management of patients with univentricular palliations has resulted in an increasing number of patients with complex univentricular heart repairs surviving to heart transplantation. Heart transplantation in these patients can be challenging and may require extensive vascular reconstruction during transplantation. Herein, we describe the surgical reconstruction in a complex patient that was required prior to heart transplantation.

Laboratory-scale experiments were conducted to determine the effect of heavy metals viz. copper (Cu), cadmium (Cd), chromium (Cr), lead (Pb), and zinc (Zn) on the different vital tissues of earthworm Eudrillus eugeniae such as head, gizzard, clitellum, and intestine after the worms were placed in municipal solid waste (MSW) substrate spiked with heavy metals in the concentration range of 0.05 g/kg to 1.0 g/kg of the waste for Cu, Cr, PB, and Zn and 0.05 g/kg for Cd. The experiments were conducted for 100 days with periodic observations and sample collection for investigation after every 10th day. Copper and lead metals were found to cause more deleterious effect in head, gizzard, and intestine. Chromium metal caused cellular damage to the intestinal region. In comparison, cadmium metal severity was more than copper, lead, and chromium metal. Zinc metal did not show deleterious effect on tissues. In general, earthworms can be used as biomarkers in toxicity studies related to heavy metals at cellular levels.