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Background: Hyaluronic acid fillers are known for a reliable safety profile, but complications do occur, even serious vascular adverse events. Objective: To improve the treatment outcome after a vascular adverse event with use of hyaluronic acid filler treatments.Methods: Duplex ultrasonography is used to detect the hyaluronic acid filler causing the intra-arterial obstruction. Results: If treated in time, 1 single treatment of ultrasonographically guided injections of hyaluronidase into the filler deposit will prevent skin necrosis. Conclusion: Because the use of duplex ultrasonography adds extra essential information, its use may become an integral part of the prevention and treatment of injection adverse events.

Objectives We assessed the effects of 3 new elementary school–based health centers (SBHCs) in disparate Georgia communities—predominantly non-Hispanic Black semi-urban, predominantly Hispanic urban, and predominantly non-Hispanic White rural—on asthma case management among children insured by Medicaid/Children’s Health Insurance Program (CHIP). Methods We used a quasi-experimental difference-in-differences analysis to measure changes in the treatment of children with asthma, Medicaid/CHIP, and access to an SBHC (treatment, n = 193) and children in the same county without such access (control, n = 163) in school years 2011-2013 and 2013-2018. Among children with access to an SBHC (n = 193), we tested for differences between users (34%) and nonusers of SBHCs. We used International Classification of Diseases diagnosis codes, Current Procedural Terminology codes, and National Drug Codes to measure well-child visits and influenza immunization; ≥3 asthma-related visits, asthma-relief medication, asthma-control medication, and ≥2 asthma-control medications; and emergency department visits during the child–school year. Results We found an increase of about 19 ( P = .01) to 33 ( P < .001) percentage points in the probability of having ≥3 asthma-related visits per child–school year and an increase of about 22 ( P = .003) to 24 ( P < .001) percentage points in the receipt of asthma-relief medication, among users of the predominantly non-Hispanic Black and Hispanic SBHCs. We found a 19 ( P = .01) to 29 ( P < .001) percentage-point increase in receipt of asthma-control medication and a 15 ( P = .03) to 30 ( P < .001) percentage-point increase in receipt of ≥2 asthma-control medications among users. Increases were largest in the predominantly non-Hispanic Black SBHC. Conclusion Implementation and use of elementary SBHCs can increase case management and recommended medications among racial/ethnic minority and publicly insured children with asthma.

This article describes the articulation, development, and deployment of a machine learning (ML) model-driven value solution for chronic kidney disease (CKD) in a health system. The ML model activated an electronic medical record (EMR) trigger that alerted CKD patients to seek primary care. Simultaneously, primary care physicians (PCPs) received an alert that a CKD patient needed an appointment. Using structured checklists, PCPs addressed and controlled comorbid conditions, reconciled drug dosing and choice to CKD stage, and ordered prespecified laboratory and imaging tests pertinent to CKD. After completion of checklist prescribed tasks, PCPs referred patients to nephrology. CKD patients had multiple comorbidities and ML recognition of CKD provided a facile insight into comorbid burden. Operational results of this program have exceeded expectations and the program is being expanded to the entire health system. This paradigm of ML-driven, checklist-enabled care can be used agnostic of EMR platform to deliver value in CKD through structured engagement of complexity in health systems.

OBJECTIVE: To conduct a mixed-methods evaluation of an emergency telehealth intervention in unscheduled settings (emergency department [ED] and urgent care clinic [UCC]) within the Veterans Health Administration (VHA). MATERIALS AND METHODS: We used the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework to conduct a mixed-methods evaluation of a novel telehealth program implemented in the VHA (Hospital System) in March 2020. We compared the 3 months preimplementation (December 1, 2019 through February 29, 2020) with the 3 months postimplementation (April 1, 2020 through June 30, 2020), then followed sustainability through January 31, 2021. Qualitative data were obtained from surveys and semistructured interviews of staff and providers and analyzed with thematic analysis. RESULTS: Patient demographics and dispositions were similar pre- and postimplementation. The telemental health intervention was used in 319 (83%) unscheduled mental health consultations in the postimplementation phase. After implementation, we did not detect adverse trends in length of stay, 7-day revisits, or 30-day mortality. Use remained high with 82% (n = 1,010) of all unscheduled mental health consultations performed by telemental health in the sustainability phase. Staff and clinician interviews identified the following themes in the use of telemental health: (1) enhanced efficiency without compromising quality and safety, (2) initial apprehension, (3) the COVID-19 pandemic, and (4) sustainability after resolution of the COVID-19 pandemic. CONCLUSIONS: This mixed-methods evaluation of unscheduled telemental health implementation found that its use was feasible, did not impact the safety and efficacy of mental health consultations, and was highly acceptable and sustainable in unscheduled settings.

BACKGROUND & AIMS: This study aimed to assess the accuracy of functional luminal imaging probe (FLIP) Panometry to detect esophagogastric junction (EGJ) obstruction assigned by high-resolution manometry (HRM) and the Chicago Classification version 4.0 (CCv4.0). METHODS: 687 adult patients that completed FLIP and HRM for primary esophageal motility evaluation and 35 asymptomatic volunteers (“controls”) were included. EGJ opening was evaluated with 16-cm FLIP during sedated endoscopy via EGJ-distensibility index (DI) and maximum EGJ diameter. HRM was classified according to CCv4.0 and focused on studies with a conclusive disorder of EGJ outflow (i.e. achalasia subtypes I, II, or III; or EGJ outflow obstruction with abnormal timed barium esophagram) or normal EGJ outflow. RESULTS: All 35 controls had EGJ-DI >3.0mm(2)/mmHg and maximum EGJ diameter >16mm. Per HRM and CCv4.0, 245 patients had a conclusive disorder of EGJ outflow and 314 patients had normal EGJ outflow. Among the 241 patients with reduced EGJ opening (REO: EGJ-DI

Objectives To describe the trajectory of recovery following fixation of pilon fractures from baseline to 5 years follow-up. Design Prospective cohort study. Setting Level 1 trauma centre. Patients/participants Patients with pilon fractures (OTA/AO 43.C) treated with open reduction and internal fixation (ORIF). Intervention None. Main outcomes measurements Patient reported outcome measures (PROMs) were measured at baseline, 6 months, 1 year and 5 years using the Short-Form 36 Health Survey Physical and Mental Component Scores (SF-36; PCS, MCS), Short Musculoskeletal Functional Assessment (SMFA), and the Foot and Ankle Outcome Score (FAOS). Results 102 patients were enrolled: mean age was 42.6 years; 69% were males; 88% had an injury severity score (ISS) of 9; 74 patients (73%) completed 1 year follow-up; 40 patients (39%) completed 5 years follow-up. Trajectory of recovery of physical function showed a significant decline between baseline and 6 months, with significant improvement between 6 months and 1 year, and then ongoing but slower improvement between 1 year and 5 years. 64% of patients returned to baseline SF-36 PCS at 5 years. Pain was a persistent issue and remained significantly worse at 5 years when compared to baseline. Psychological wellbeing (SF-36 MCS) did not significantly change from baseline at 5 years. Conclusion Functional recovery following ORIF for pilon fractures was characterized by an initial decrease in function from baseline, followed by an increase between 6 months and 1 year, and then slower but continued increases from 1 year to 5 years. Function did not return to baseline levels, pain was a persistent issue, and mental wellbeing showed no change from baseline at 5 years. This information may be useful when counselling patients.Level of Evidence:Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Hypervolemia and vitamin D deficiency occur frequently in patients receiving peritoneal dialysis and may contribute to left ventricular (LV) hypertrophy. The effect of bioelectrical impedance analysis (BIA)-guided volume management or vitamin D supplementation on LV mass among those receiving peritoneal dialysis is uncertain.Two-by-two factorial randomized controlled trial.Sixty-five patients receiving maintenance peritoneal dialysis.BIA-guided volume management versus usual care and oral cholecalciferol 50,000 U weekly for 8 weeks followed by 10,000 U weekly for 44 weeks or matching placebo.Change in LV mass at 1 year measured by cardiac magnetic resonance imaging.Total body water decreased by 0.9 + 2.4 (SD) L in the BIA group compared with a 1.5 ± 3.4 L increase in the usual care group (adjusted between-group difference: -2.4 [95% CI, -4.1 to -0.68] L, P = 0.01). LV mass increased by 1.3 ± 14.3 g in the BIA group and decreased by 2.4 ± 37.7 g in the usual care group (between-group difference: +2.2 [95% CI, -13.9 to 18.3] g, P = 0.8). Serum 25-hydroxyvitamin D concentration increased by a mean of 17.2 ± 30.8 nmol/L in the cholecalciferol group and declined by 8.2 ± 24.3 nmol/L in the placebo group (between-group difference: 28.3 [95% CI, 17.2-39.4] nmol/L, P 0.001). LV mass decreased by 3.0 ± 28.1 g in the cholecalciferol group and increased by 2.0 ± 31.2 g in the placebo group (between-group difference: -4.5 [95% CI, -20.4 to 11.5] g, P = 0.6).Relatively small sample size with larger than expected variation in change in LV mass.BIA-guided volume management had a modest impact on volume status with no effect on the change in LV mass. Vitamin D supplementation increased serum vitamin D concentration but had no effect on LV mass.Unrestricted Baxter International extramural grant and the Kidney Foundation of Canada.Registered at ClinicalTrials.gov with study number NCT01045980.

Background General surgery residency graduates are expected to be proficient in straightforward endocrine operations. This study aimed to elucidate residents’ self-assessment of their ability to perform common endocrine procedures. Methods A fourteen-question survey was emailed to general surgery residents from seven U.S. residency programs regarding their self-assessed ability to perform each step of a straightforward thyroidectomy and parathyroidectomy. Demographics and perceived ability to perform the various procedures were collected. Results A minority of respondents (17, 27.9%) agreed they could complete a straightforward thyroidectomy for benign disease, with only 11.7% (n = 7) agreeing they could complete a straightforward thyroidectomy for malignant disease. 26.2% (n = 16) of respondents agreed they could complete a straightforward parathyroidectomy. Completed number of cases was significantly associated with greater self-assessed ability to perform the endocrine operations (p = 0.02). Conclusions Most general surgery residents surveyed did not feel capable of performing common, straightforward endocrine procedures. Although confidence in operative ability increased with PGY-level and number of cases completed, the majority of PGY-5 residents still did not feel able to perform a thyroidectomy for malignant disease unassisted.

Part of the work was done while the authors were visiting the South China University of Science and Technology (SUSTech), Shenzhen, in 2018, and we are grateful (in particular to Professor Cai Heng Li) for the hospitality that we received.The authors would like to thank the Isaac Newton Institute for Mathematical Sciences, Cambridge, for support and hospitality during the programme Groups, representations and applications: new perspectives (supported by EPSRC grant no.EP/R014604/1), where further work on this paper was undertaken. In particular we acknowledge a Simons Fellowship (Cameron) and a Kirk Distinguished Visiting Fellowship (Praeger) during this programme. Schneider thanks the Centre for the Mathematics of Symmetry and Computation of The University of Western Australia and Australian Research Council Discovery Grant DP160102323 for hosting his visit in 2017 and acknowledges the support of the CNPq projects Produtividade em Pesquisa (project no.: 308212/2019-3) and Universal (project no.:421624/2018-3). Diagonal groups are one of the classes of finite primitive permutation groups occurring in the conclusion of the O'Nan-Scott theorem. Several of the other classes have been described as the automorphism groups of geometric or combinatorial structures such as affine spaces or Cartesian decompositions, but such structures for diagonal groups have not been studied in general. The main purpose of this paper is to describe and characterise such structures, which we call diagonal semilattices. Unlike the diagonal groups in the O'Nan-Scott theorem, which are defined over finite characteristically simple groups, our construction works over arbitrary groups, finite or infinite. A diagonal semilattice depends on a dimension m and a group T. For m=2, it is a Latin square, the Cayley table of T, though in fact any Latin square satisfies our combinatorial axioms. However, for m≥3, the group T emerges naturally and uniquely from the axioms. (The situation somewhat resembles projective geometry, where projective planes exist in great profusion but higher-dimensional structures are coordinatised by an algebraic object, a division ring.) A diagonal semilattice is contained in the partition lattice on a set Ω, and we provide an introduction to the calculus of partitions. Many of the concepts and constructions come from experimental design in statistics. We also determine when a diagonal group can be primitive, or quasiprimitive (these conditions turn out to be equivalent for diagonal groups). Associated with the diagonal semilattice is a graph, the diagonal graph, which has the same automorphism group as the diagonal semilattice except in four small cases with m

Purpose To evaluate the effect of one full year of the coronavirus disease 2019 (COVID-19) pandemic on clinical presentation of acute, primary rhegmatogenous retinal detachment (RRD). Design Single-center, retrospective observational cohort study. Methods Patients were divided into two cohorts; consecutive patients treated for primary RRD during the COVID-19 pandemic (March 9, 2020 to March 7, 2021; pandemic cohort) and patients treated during the corresponding time in previous year (March 11, 2019 to March 8, 2020; control cohort). Main outcome measures Proportion of patients presenting with macula-involving (mac-off) or macula-sparring (mac-on) RRD. Results 952 patients in the pandemic cohort and 872 patients in the control cohort were included. Demographic factors were similar. Compared to the control cohort, significantly greater number of pandemic cohort patients presented with mac-off RRDs ([60.92%] pandemic, [48.17%] control, P = 0.0001) and primary proliferative vitreoretinopathy (PVR; [15.53%] pandemic, [6.9%] control, P = 0.0001). Pandemic cohort patients (10.81%) had significantly higher rates of lost to follow-up compared to control cohort (4.43%; P = 0.0001). Patients new to our clinic demonstrated significant increase in mac-off RRDs in the pandemic cohort (65.35%) compared to control cohort (50.40%; P = 0.0001). Pandemic cohort patients showed worse median final best-corrected visual acuity (BCVA; 0.30 logarithm of the minimum angle of resolution [logMAR]) compared to control cohort (0.18 logMAR; P = 0.0001). Conclusions Patients with primary RRD during the first year of the COVID-19 pandemic were more likely to have mac-off disease, present with primary PVR, be lost to follow-up, and have worse final BCVA outcomes.

BACKGROUND AND AIMS: Conditions such as irritable bowel syndrome (IBS), functional dyspepsia, and functional constipation are among the prevalent gastrointestinal (GI) disorders classified as disorders of gut-brain interaction (DGBI), which can adversely affect the lives of sufferers. This study aimed to assess the degree and consequences of overlapping DGBI in a large population-based global scale. METHODS: Internet survey data from 54,127 adults (49.1% women) in 26 countries were analyzed by 4 GI anatomic regions (esophageal, gastroduodenal, bowel, and anorectal). The number of DGBI-affected GI regions was assessed, including associations with sex, age, disease severity, quality of life, psychosocial variables, and health care utilization. RESULTS: A total of 40.3% of surveyed individuals met Rome IV criteria for a DGBI. The percentages with 1-4 DGBI-affected GI regions were 68.3%, 22.3%, 7.1%, and 2.3%, respectively. The IBS symptom severity score increased significantly from 1 (207.6) to 4 (291.6) regions, as did non-GI symptom reporting (somatization), anxiety and depression, concerns and embarrassment about bowel function, doctor visits, medications, and abdominal surgeries (all P < .0001). Quality of life decreased with increasing number of DGBI regions (P < .0001). In a logistic mixed model, non-GI symptoms (odds ratio [OR], 1.09; 95% confidence interval [CI], 1.08-1.10), being very vs not concerned (OR, 2.55; 95% CI, 2.27-2.90), being very vs not embarrassed about bowel function (OR, 1.20; 95% CI, 1.08-1.33), and mean number of doctor visits (OR, 1.23; 95% CI, 1.115-1.32) were most strongly associated with number of DGBI regions. CONCLUSIONS: DGBI in multiple anatomic GI regions is associated with increased psychological comorbidity, health care utilization, and IBS severity. Physician awareness of overlap could improve quality of care, prevent unnecessary interventions, and yield more positive health outcomes. ispartof: CLINICAL GASTROENTEROLOGY AND HEPATOLOGY vol:20 issue:5 pages:E945-E956 ispartof: location:United States status: published

Segmental Arterial Mediolysis (SAM) is a rare, poorly understood vasculopathy that involves vacuolization of the arterial wall, most commonly of the visceral arteries. There are no established therapeutic or monitoring guidelines for SAM, and intervention typically depends on patient presentation. The purpose of this study is to review the management and outcomes of patients with this rare vascular disease METHODS: Single center retrospective review of patients diagnosed with SAM between 2011 and 2019. Included were patients with radiological diagnosis of SAM. Demographic factors, past medical history, presenting symptoms, affected vessels, management, and lesion characteristics over time were collected. Demographic and periprocedural factors, and medical management strategies were compared for those who required operative intervention versus those managed non-operatively.Thirty patients were included, 21 (70%) were male, mean age was 53.5 years (range: 35.7-72.2). Twenty-seven patients were managed non-operatively, 3 patients required surgical intervention. Patients who underwent operative intervention were more likely to present with pain30 days (P0.05), and hemorrhage (P0.01). Abdominal pain was the most common presenting symptom (n = 24, 80%). Arterial dissection was the most common radiological finding at time of presentation (n = 20, 67%). The celiac artery and its branches were most often involved (n=22, 73%) followed by the superior mesenteric artery and its branches (n = 15, 50%). Non-operative management most often consisted of anti-hypertensive therapy (n = 13, 43%), antiplatelet agents (n = 17, 57%%), and lipid-lowering agents (n = 13, 43%), with 7 patients receiving all three. Six patients demonstrated confirmed resolution of lesions during surveillance imaging, with average time to resolution of 325.5 days.Patients who underwent intervention for SAM presented with either mesenteric ischemia or pseudoaneurysm rupture. In patients that present without those conditions, medical management consisting of anti-hypertensives, antiplatelet agents, and lipid-lowering therapy was effective. Non operative management resulted in symptom resolution in all patients and surveillance imaging showed resolution of radiographic abnormalities in 6 patients out of 27 at less than one year.

The chemical looping hydrogen production (CLHP) process is a new approach for hydrogen ( H 2 ) fuel production. The proposed process consists of three reactors which are air reactor (AR), fuel reactor (FR) and steam reactor (SR). In this study, the gas solid flow behaviour in a cold model of the proposed CLHP process was simulated using computational fluid dynamics (CFD) with kinetic theory of granular flow. The effect of drag coefficient models on the pressure profile of each reactor was investigated and the results from the modified Syamlal–O’Brien drag model agreed well with the experimental data. The model was further used to investigate effects of the operating parameters on the hydrodynamics profiles of each reactor. The solid flux increased with the increasing of inlet velocity of AR and FR but decreased with the increasing of the inlet velocity of SR. At the same time, the solid flux increased with the increasing of the solid inventory.

Segmentectomy is gaining popularity as a parenchyma-sparing alternative for anatomic lung resection. This study sought to investigate temporal changes in patient selection, case volume, and outcomes for segmentectomy using the Society of Thoracic Surgeons (STS) National Database.The STS General Thoracic Database was queried for patients who had undergone segmentectomy as the primary procedure between 2002 and 2018. The American College of Surgeons Oncology Group definition of high-risk patients on the basis of pulmonary function and major cardiovascular comorbidities was applied. Annual trends of case volume, patient risk profile, surgical indication, approach, and outcomes were analyzed.A total of 10 629 patients were analyzed from 310 contributing centers. The annual segmentectomy volume more than doubled from4 per center in 2009 to 8.6 per center by 2017. Lung cancer was the most common indication (70.1%), followed by benign disease (15.6%) and metastatic tumors (14.3%). Although the operative indication remained constant, the subset of high-risk patients (24.5%) decreased gradually over time (slope, -0.6% per year; P = .001). After 2012, segmentectomies were most commonly performed minimally invasively (video-assisted thoracoscopic surgery, 58.3%; robotic surgery, 19.4%), with a steadily declining use of thoracotomy (overall, 22.3%; slope, -2.4%/y; P = .001). Overall complication rates decreased over the study period from 41.7% to 26.1% (slope, -0.57%/y; P = .001). The overall major complication rate was 4.6% (range, 2.0%-7.1%), 30-day mortality was 1.0% (range, 0.7%-5.0%), and both have been trending downward since 2009 (P = .01).Segmentectomies are increasingly performed nationally, with a steady decline in the subset of high-risk patients over time. Complication rates have decreased significantly, parallel to the increasing use of minimally invasive techniques by video-assisted thoracoscopic surgery and robotic surgery.

Purpose Suboptimal functional outcomes following rhegmatogenous retinal detachment (RRD) repair may be related to photoreceptor abnormalities including alterations of the ellipsoid zone (EZ) which may not be apparent on cross-sectional optical coherence tomography (OCT). This study assessed EZ recovery using en face OCT following RRD repair and its association with visual acuity. Design Post hoc analysis of a randomized controlled trial. Methods Patients with macula-off RRD were followed at 3, 6, 12 and 24 months post-operatively and annually thereafter. En face OCT of the EZ slab were analyzed. Hyporeflective areas were co-localized with EZ abnormalities on cross-sectional OCT B-Scans and measured by two masked graders. Primary outcome was change in area of EZ hyporeflectivity from 3 to 24 months and its association with ETDRS visual acuity recovery was also assessed. Results 271 images of 61 patients were assessed. Mean area of hyporeflectivity significantly decreased from 3 to 24 months (-2.98 (95%CI,1.82-4.13) mm2, P Conclusions En face OCT provides a novel biomarker for visualizing and quantifying EZ recovery following RRD repair that is associated with ETDRS visual acuity recovery. A steady decline in the area of EZ hyporeflectivity was observed over many years with delayed recovery in patients with longer duration of macula-off.

Objectives This study sought to report our single-center experience with left cardiac sympathetic denervation (LCSD) for long QT syndrome (LQTS) since 1973. Background LCSD is still underutilized because clinicians are often uncertain whether to use it versus an implantable cardioverter-defibrillator (ICD). Methods We performed LCSD in 125 patients with LQTS (58% women, mean QT interval corrected for frequency [QTc] 527 ± 60 ms, 90% on beta blockers) with a follow-up of 12.9 ± 10.3 years. They were retrospectively divided into 4 groups according to the clinical/genetic status: very high risk (n = 18, symptomatic in the first year of life or with highly malignant genetics), with aborted cardiac arrest (ACA; n = 31), with syncope and/or ICD shocks on beta blockers (n = 45), in primary prevention (n = 31). Results After LCSD, 17% in the very high risk group remained asymptomatic, compared with 52%, 47%, and 97% in the other 3 groups (P Conclusions We provide definitive evidence for the long-term efficacy of LCSD in LQTS. The degree of antiarrhythmic protection is influenced by patient’s specificity and amount of QTc shortening. This novel approach to the analysis of the outcome allows cardiologists to rationally decide and tailor their management strategies to the individual features of their patients.

High-frequency water quality monitoring systems provide valuable measurements for predicting the trend of water quality, warning of abnormal activities or operating hydrological models. However, missing values are prevalent due to network miscommunication, device replacement or failure. Applying datasets with missing values can lead to biased results in statistical analysis or hydrological modelling work. We develop a cloud-based data processing system combining advanced algorithms to impute monitoring data in near real-time. The system provides high compatibility for supporting different water quality variables, imputation algorithms and extensive scalability to support numerous data streams. Based on the proposed approach, we review various imputation methods which can be applied to water quality data. Overall, this work provides a systematic design of a water quality data imputation system, explores the advantages and limitations of selected data imputation methods and analyses the imputation performance of two real-time water quality monitoring systems located in both the USA and Australia. The results provide practical guidelines for data imputation applications in water quality data.

Background The use of iliac vein stenting for the treatment of pelvic pain secondary to pelvic venous insufficiency has significantly increased. In women of childbearing age, the effect of the gravid uterus on stent function and patency is unclear. The purpose of this investigation was to determine the effect of pregnancy on stent patency and reintervention rate in women with iliac vein stents. Methods A retrospective chart review and email survey was performed to identify women treated at the Center for Vascular Medicine who were treated with iliac vein stenting and who had subsequent pregnancies. Medical and surgical comorbidities, stent type, location, length, number of stents, reintervention rates, number of pregnancies after stenting, anticoagulation usage during pregnancy, and type of delivery were assessed. Results From January 2014 to December 2020, 15 women with 16 iliac vein stents and who had 17 subsequent pregnancies were identified. The average age at stenting was 35.3 ± 4.13 years. The average interval between stenting and conception was 350 ± 287 days. Before pregnancy, stent location was in the right common/right external iliac veins in 1 patient and left common/external iliac veins in 14 patients. The average stent diameter and length were 19.6 ± 3 and 79.5 ± 20.3 mm, respectively. Thirteen Boston Scientific Wallstents and three Bard Venovo stents were used before pregnancy. One patient with a Wallstent required a stent extension before pregnancy and one patient had two stents placed at the initial procedure. Two women were pregnant twice after stenting for a total of 17 pregnancies. There were 16 term and 1 premature delivery of single infants. Patients were treated with enoxaparin (Lovenox) for stent-related thrombosis prophylaxis in 11 of 17 pregnancies, 5 had no prophylaxis, and the status of 1 pregnancy is unknown. One asymptomatic patient underwent a stent venoplasty after delivery. Conclusions Iliac vein stents tolerate a gravid uterus well. No stents thrombosed during or after pregnancy and none required reintervention secondary to pregnancy-related compression. Anticoagulation with low-molecular-weight heparin should be considered for stent thrombosis prophylaxis. Potential pregnancy should not be considered a contraindication to iliac vein stenting for the treatment of symptomatic pelvic venous insufficiency.

Purpose To assess the incidence of post-operative outer retinal folds (ORFs) in pars plana vitrectomy (PPV) vs pneumatic retinopexy (PnR) following rhegmatogenous retinal detachment (RRD) repair and to determine the association of ORFs with functional outcomes at 1 year. Design Randomized controlled trial Participants Patients with primary macula-off RRD meeting PIVOT trial criteria randomly assigned to PPV vs PnR. Methods Post-hoc analysis of the PIVOT trial. Incidence and quantitative morphological features of ORFs were assessed with en face and cross-sectional OCT at 1 month post-operatively by two masked graders. ETDRS letter score and quantitative metamorphopsia were measured at 1 year. Main Outcome Measures Proportion of patients with ORFs following PPV vs PnR at 1 month post-operatively. Secondary outcomes include the association of ORFs with visual acuity (ETDRS letter score) and metamorphopsia (M-CHARTS) at 12 months post-operatively. Results Eighty-eight of the 176 participants enrolled in PIVOT were macula-off RRD. 94.3% (83/88) of these macula-off eyes had month 1 post-operative OCT scans that were gradable, 93.2% (41/44) in the PPV group and 95.5% (42/44) in the PnR group. The incidence of ORFs formation was 34.1% (14/41) in the PPV group and 14.3% (6/42) in the PnR group (p=0.034). ETDRS letter score at 1 year was 65.7±6.6 letters in patients with ORFs versus 75.1±1.4 letters in those without ORFs (difference=9.4 letters, 95% CI=7.5-11.3, p=0.047). Among patients in the PPV group only, mean ETDRS letter score at 1 year in patients with ORFs was 62.8 ± 24.7 letters compared to 75.4 ± 9.2 letters in patients without ORF formation (difference=12.6 letters, 95% CI=0.05-24.59, p=0.04). Horizontal and vertical metamorphopsia scores were similar in patients with vs without ORFs: horizontal: 0.35 ± 0.12 versus 0.29 ± 0.07 (difference=0.06, 95% CI=0.01-0.11, p=0.69) and vertical: 0.25±0.07 versus 0.29±0.07 (difference=0.04, 95%CI=0-0.08, p=0.60) respectively. There was a negative correlation between the closest distance of the ORFs from the fovea and the vertical metamorphopsia score (r=-0.507, p=0.045). Conclusions There is a greater risk of developing ORFs following PPV compared to PnR for RRD. ORFs at 1 month are associated with significantly worse ETDRS visual acuity letter score at 1 year.

OBJECTIVES: To quantify the severity of urinary and sexual dysfunction, and to evaluate the relationship between urinary and sexual dysfunction, injury, and treatment factors in patients with pelvic fracture. DESIGN: Prospective cohort study. SETTING: Level 1 trauma center.Patients/Participants: 113 patients with surgically treated pelvic fracture (65.5% OTA/AO 61B fractures; 7 open fractures; 74 men). INTERVENTIONS: Surgical pelvic stabilization. MAIN OUTCOME MEASURES: Short Form-36 Health Survey (SF-36) and International Consultation Incontinence Questionnaire (ICIQ) responses were collected at baseline, 6 months and 1, 2 and 5 years. Patients were scored on symptoms of voiding and incontinence, and filling (for women), to derive urinary function. Sexual function was scored as a single domain. Both genders reported urinary and sexual bothersome symptoms. Regression analysis was used to isolate the importance of predictive factors on urinary and sexual function, urinary and sexual bother, and their impact on quality of life. RESULTS: Patients with pelvic fracture have significant urinary and sexual dysfunction, which is sustained or worsens over time. Male urinary function was predicted by Injury Severity Score (p=0.03) and 61C fracture (odds ratio (OR): 3.23, p=0.04). Female urinary function was predicted by urinary tract injury at admission (OR: 7.57, p=0.03). Neurologic injury and anterior fixation were identified as significant predictors for male sexual function and sexual bother, while urological injuries were important in predicting female urinary and sexual bother (p

Hyperinflammation plays an important role in severe and critical COVID-19. Using inconsistent criteria, many researchers define hyperinflammation as a form of very severe inflammation with cytokine storm. Therefore, COVID-19 patients are treated with anti-inflammatory drugs. These drugs appear to be less efficacious than expected and are sometimes accompanied by serious adverse effects. SARS-CoV-2 promotes cellular ATP release. Increased levels of extracellular ATP activate the purinergic receptors of the immune cells initiating the physiologic pro-inflammatory immune response. Persisting viral infection drives the ATP release even further leading to the activation of the P2X7 purinergic receptors (P2X7Rs) and a severe yet physiologic inflammation. Disease progression promotes prolonged vigorous activation of the P2X7R causing cell death and uncontrolled ATP release leading to cytokine storm and desensitisation of all other purinergic receptors of the immune cells. This results in immune paralysis with co-infections or secondary infections. We refer to this pathologic condition as hyperinflammation. The readily available and affordable P2X7R antagonist lidocaine can abrogate hyperinflammation and restore the normal immune function. The issue is that the half-maximal effective concentration for P2X7R inhibition of lidocaine is much higher than the maximal tolerable plasma concentration where adverse effects start to develop. To overcome this, we selectively inhibit the P2X7Rs of the immune cells of the lymphatic system inducing clonal expansion of Tregs in local lymph nodes. Subsequently, these Tregs migrate throughout the body exerting anti-inflammatory activities suppressing systemic and (distant) local hyperinflammation. We illustrate this with six critically ill COVID-19 patients treated with lidocaine.

Osteoarthritis (OA) is a debilitating condition affecting an individual’s quality of life in multiple ways. However, little is known about about the experiences of täne (men) Māori living with OA in Aotearoa New Zealand. We aimed to explore the lived experiences of ngā tāne Māori with OA. This qualitative study was guided by tikanga and kaupapa Māori philosophies. Interviews were conducted in a semi-structured method, with seven tāne Māori living with OA. Key themes were identified and developed from the data through thematic analysis, and were informed by Tā Mason Durie’s Māori health frameworks, Te Whare Tapa Whā and Te Pae Māhutonga. Four themes developed from the data and were named: (1) The interface of masculine embodiment and mana, (2) Taha whānau and connection as central to ngā tāne Māori wellbeing, (3) The benefits of taha wairua (spiritual wellbeing), and (4) Te urutau kia uru ki te punaha tiaki hauora: Adapting to access the health-care system. OA places a significant burden on ngā tāne Māori and their whānau, impacting on all aspects of hauora (health). The unique lived experiences and impact on wider whānau of Māori living with OA indicates the need to consider te ao Māori (Māori world view) when developing clinical services and a Model of Care for OA.

Background: In an effort to reduce surgical complications, some institutions have implemented universal hemoglobin A1c (HbA1c) screening for all preoperative patients. However, the value of HbA1c screening for predicting clinically meaningful complications after elective carpal tunnel release (CTR) remains unclear. The purpose of this study was to investigate the clinically meaningful predicative value of HbA1c screening on postoperative complications following elective CTR. Methods: A retrospective cohort study of 790 patients who underwent CTR was performed. All patients had an HbA1c screening performed, regardless of whether they underwent the diagnosis for diabetes or not. Primary outcomes were overall complication rate, rates of major complications (readmission or reoperation), and rates of minor complications (surgical site infection and wound dehiscence). Patients were stratified into 3 groups based on HbA1c: HbA1c 8. Results: The overall complication rate for all groups was 4.8%. Rates of major complications were 0.4% for readmission and 0.1% for reoperation. For minor complications, the odds ratio (OR) for the HbA1c 7-8 group was 0.6 (95% confidence interval [CI], 0.14-1.77), and for the HbA1c >8 group, the OR was 1.6 (95% CI, 0.66-3.60). All minor complications resolved with outpatient treatment. There were no statistically significant differences between the groups for any comparisons. Conclusions: Elective CTR has a low complication rate. Routine preoperative screening of HbA1c is of little value in predicting clinically meaningful complications.

Refereed/Peer-reviewed

Contains fulltext : 235277.pdf (Publisher’s version ) (Closed access) BACKGROUND: Balancing the risks of recurrent ischaemic stroke and intracranial haemorrhage is important for patients treated with antithrombotic therapy after ischaemic stroke or transient ischaemic attack. However, existing predictive models offer insufficient performance, particularly for assessing the risk of intracranial haemorrhage. We aimed to develop new risk scores incorporating clinical variables and cerebral microbleeds, an MRI biomarker of intracranial haemorrhage and ischaemic stroke risk. METHODS: We did a pooled analysis of individual-patient data from the Microbleeds International Collaborative Network (MICON), which includes 38 hospital-based prospective cohort studies from 18 countries. All studies recruited participants with previous ischaemic stroke or transient ischaemic attack, acquired baseline MRI allowing quantification of cerebral microbleeds, and followed-up participants for ischaemic stroke and intracranial haemorrhage. Participants not taking antithrombotic drugs were excluded. We developed Cox regression models to predict the 5-year risks of intracranial haemorrhage and ischaemic stroke, selecting candidate predictors on biological relevance and simplifying models using backward elimination. We derived integer risk scores for clinical use. We assessed model performance in internal validation, adjusted for optimism using bootstrapping. The study is registered on PROSPERO, CRD42016036602. FINDINGS: The included studies recruited participants between Aug 28, 2001, and Feb 4, 2018. 15 766 participants had follow-up for intracranial haemorrhage, and 15 784 for ischaemic stroke. Over a median follow-up of 2 years, 184 intracranial haemorrhages and 1048 ischaemic strokes were reported. The risk models we developed included cerebral microbleed burden and simple clinical variables. Optimism-adjusted c indices were 0·73 (95% CI 0·69-0·77) with a calibration slope of 0·94 (0·81-1·06) for the intracranial haemorrhage model and 0·63 (0·62-0·65) with a calibration slope of 0·97 (0·87-1·07) for the ischaemic stroke model. There was good agreement between predicted and observed risk for both models. INTERPRETATION: The MICON risk scores, incorporating clinical variables and cerebral microbleeds, offer predictive value for the long-term risks of intracranial haemorrhage and ischaemic stroke in patients prescribed antithrombotic therapy for secondary stroke prevention; external validation is warranted. FUNDING: British Heart Foundation and Stroke Association.

BACKGROUND Obstructive sleep apnea (OSA) is often comorbid with both substance use disorders (SUD) and posttraumatic stress disorder (PTSD), yet frequently goes undiagnosed and untreated. We present data on the feasibility and acceptability of objective OSA diagnosis procedures, findings on OSA prevalence, and the relationship between OSA and baseline SUD/PTSD symptoms among veterans in residential treatment for comorbid PTSD/SUD. METHODS Participants were 47 veterans admitted to residential PTSD/SUD treatment. Participants completed questionnaires assessing PTSD and sleep symptoms, and filled out a sleep diary for seven days. Apnea-hypopnea index (AHI) was recorded using the overnight Home Sleep Apnea test (HSAT; OSA was diagnosed with AHI ≥ 5). RESULTS Objective OSA diagnostic testing was successfully completed in 95.7% of participants. Of the 45 veterans who went through HSAT, 46.7% had no OSA, 35.6% received a new OSA diagnosis, and 8.9% were previously diagnosed with OSA and were using positive airway pressure treatment (PAP); an additional 8.9% were previously diagnosed with OSA, reconfirmed with the HSAT, but were not using PAP. One hundred percent of respondents during follow-up deemed the testing protocol's usefulness as "Good" or "Excellent." CONCLUSION OSA diagnostic testing on the residential unit was feasible and acceptable by participants and was effective in diagnosing OSA. OSA testing should be considered for everyone entering a SUD and PTSD residential unit. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Background HIV and other medical complications of drug use, including overdose, are rising among people who inject drugs (PWID) in the United States (US). Risk of complications and mortality increase with injection behaviors such as syringe sharing, rushing injections, and injecting in isolated places. Studies suggest safe consumption sites (SCS) reduce high-risk injection behaviors by offering sterile syringes and a safe, supervised space to consume drugs, though this has yet to be evaluated in the US. Setting An unsanctioned SCS in an undisclosed US location. Methods From 2018 to 2019, we recruited PWID using targeted sampling methods (N=494) and conducted interviews at baseline, 6-, and 12-months. We sought to determine associations of past-month SCS use with past-month receptive syringe sharing, rushed injections, and injections in isolated places. We analyzed data using inverse probability of treatment weighted Poisson regression models. Generalized estimating equations accounted for repeated measures. Results Fifty-two (11%) participants had past-month SCS use. Participants with past-month SCS use had decreased rates of receptive syringe sharing (IRR 0.17, 95%CI 0.03-1.02) and injecting in an isolated location (IRR 0.77 95%CI 0.54-1.27) compared to those without past-month SCS use, though results were not statistically conclusive. Rate of rushed injections was only slightly lower (IRR 0.94, 95%CI 0.70-1.30). Conclusion SCS may show benefit in reducing high-risk injection practices, and legal sanctioning of an SCS may offer further advantages. SCS implementation should be considered to help reduce the spread of HIV, overdose mortality, and prevent other medical complications of injection drug use.

Several patient demographics such as race/ethnicity and comorbid chronic conditions are associated with severity of illness among COVID-19 patients. This study examines national data of COVID-19 patients to estimate the likelihood that these characteristics are associated with a hospital admission, admission to an intensive care unit (ICU), and length of hospital stay. Using logistic regressions, the authors found that minority populations (Black, Asian, and Hispanic) were 21% to 35% more likely to be hospitalized than Whites. Moreover, patients with multiple chronic conditions also were more likely to be hospitalized, admitted to the ICU, and had longer lengths of stay. Results highlight the need to target vaccines to the most vulnerable populations during COVID-19 but also for future outbreaks.

The objective of our study was to compare patient-reported outcome measures, range of motion (ROM), complication rates, and reoperation rates after reverse total shoulder arthroplasty (rTSA) for proximal humeral fractures between patients treated acutely (≤30 days after injury), those treated after initial nonoperative treatment (30 days after injury), and those treated after failed open reduction-internal fixation. Secondarily, we aimed to identify any patient-, injury-, or surgery-related factors independently associated with our response variables.We identified 576 patients who sustained a proximal humeral fracture treated with primary or revision shoulder arthroplasty between January 2003 and August 2018. The final cohort included 153 patients. Multivariable analysis was used to assess whether explanatory variables were associated with our response variables.Initial nonoperative treatment compared with acute rTSA was associated with worse Shoulder Subjective Value (P = .04), Shoulder Pain and Disability Index score (P = .03), and Shoulder Pain and Disability Index disability subscale score (P = .03). Only depression was independently associated with worse visual analog scale pain score (P = .04). There was no significant difference in postoperative ROM between the initial treatment groups. Older age was associated with decreased ROM in all planes. Additionally, ipsilateral upper-extremity injury was associated with decreased active abduction (P = .03), and cemented humeral stems were associated with decreased passive abduction (P = .03). Initial nonoperative treatment was associated with increased complication rates (odds ratio, 3.65; 95% confidence interval, 1.11-12.01), and male sex was associated with higher rates of reoperation (odds ratio, 3.53; 95% confidence interval, 1.31-9.51).Patients who undergo initial periods of nonoperative management have worse functional outcomes and higher complication rates than those who undergo acute rTSA for proximal humeral fractures. Patients who undergo rTSA after failed open reduction-internal fixation show no difference in patient-reported outcomes compared with those who undergo acute rTSA. In addition, male patients are at higher risk of reoperation, whereas older patients are at risk of decreased ROM. Patients with preoperative depression are at risk of increased pain at 2 years after surgery.

The COVID-19 pandemic has forever changed health care, spurring a revolution in digital health technologies. Across the world, hundreds of thousands of health care systems are considering a central question: how do we connect with our patients? Digital health has been used as a stopgap in many cases to continue the essential functions of health systems. As the post-pandemic world and our "new normal" come into focus, further needs will have to be met with a digital patient interaction, with an eye toward value transformation. One barrier to fully leveraging digital tools is the lack of a framework for classifying the type of digital health care. This can limit our ability to design, deploy, evaluate, and communicate through digital means. This article presents 3 categories of digital health and their relationships to value metrics: (1) telehealth or direct care delivery, (2) digital access tools, and (3) digital monitoring. An evidence-based discussion reveals past successes, current promises, and future challenges in reducing defects in value through digital care. In the coming years, value transformation will become more crucial to the success of health care systems. By using the taxonomy in this article, health systems can better implement digital tools with a value-driven purpose. Defining the role of digital health in the post-pandemic world is needed to assist health systems and practices to build a bridge to value-based care.

Background Riociguat is effective in delaying the time to clinical worsening (TCW) in patients with groups 1 and 4 pulmonary hypertension. Research Question Is riociguat more effective than placebo in prolonging TCW in sarcoidosis-associated pulmonary hypertension (SAPH)? Study Design and Methods This was a double-blind placebo-controlled trial. Patients with SAPH confirmed by right heart catheterization were randomized 1:1 to riociguat or placebo. Patients underwent 6-min walk distance (6MWD) and spirometry testing every 8 weeks. The primary end point was TCW, which was defined by the time to the first of the following: (1) all-cause mortality, (2) need for hospitalization because of worsening cardiopulmonary status attributable to progression of disease, (3) > 50 m decrease in the 6MWD test, or (4) worsening of World Health Organization functional class. Results A total of 16 patients were randomized to riociguat (n = 8) or placebo (n = 8). No difference was found in pulmonary artery mean, pulmonary vascular resistance, initial 6MWD, or FVC between the two groups. Five of eight patients who received placebo met TCW criteria, whereas none of the patients who received riociguat experienced a qualifying event. By log-rank analysis, patients who received riociguat were in the study for a significantly longer period (χ 2 = 6.259; P = .0124). The 6MWD decreased in the placebo group (median, –55.9 m; range, –176.8 to 60 m), but rose in the riociguat group (median, +42.7 m; range, –7.5 to +91.4 m; P = .0149), with a placebo-corrected difference of 94 m (P 30-m improvement in 6MWD (P > .05). No significant adverse events associated with riociguat occurred. Interpretation Over the 1 year of the study, riociguat was effective in preventing clinical worsening and improving exercise capacity in patients with SAPH. Trial Registry ClinicalTrials.gov ; No.: NCT02625558 ; URL: www.clinicaltrials.gov

The rapid development and deployment of mRNA and adenovirus-vectored vaccines against coronavirus disease 2019 (COVID-19) continue to astound the global scientific community, but these vaccine platforms and production approaches have still not achieved global COVID-19 vaccine equity. Immunizing the billions of people at risk for COVID-19 in the world's low- and middle-income countries (LMICs) still relies on the availability of vaccines produced and scaled through traditional technology approaches. Vaccines based on whole inactivated virus (WIV) and protein-based platforms, as well as protein particle-based vaccines, are the most produced by LMIC vaccine manufacturing strategies. Three major WIV vaccines are beginning to be distributed widely. Several protein-based and protein particle-based vaccines are advancing with promising results. Overall, these vaccines are exhibiting excellent safety profiles and in some instances have shown their potential to induce high levels of virus neutralizing antibodies and T cell responses (and protection) both in nonhuman primates and in early studies in humans. There is an urgent need to continue accelerating these vaccines for LMICs in time to fully vaccinate these populations by the end of 2022 at the latest. Achieving these goals would also serve as an important reminder that we must continue to maintain expertise in producing multiple vaccine technologies, rather than relying on any individual platform. Expected final online publication date for the Annual Review of Medicine, Volume 73 is January 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Rationale: The ability of peripheral blood biomarkers to assess COPD risk and progression is unknown. Genetics and gene expression may capture important aspects of COPD-related biology that predict...

Discutem-se os mecanismos que presidem a obtenção de imagens por métodos não invasivos (medicina nuclear, ultrassonografia, tomografia computorizada de transmissão e de emissão). Introduzem-se definições para sensibilidade, especificidade, valor de previsão e precisão. Defendem-se estratégias de diagnóstico clínico para lesões ocupantes de espaço e sugerem-se orientações para futuro desenvolvimento.

Biallelic mutations of the CEBPA gene (CEBPAbi) define a distinct entity associated with favorable prognosis; however, the role of monoallelic mutations (CEBPAsm) is poorly understood. We retrospectively analyzed 4708 adults with acute myeloid leukemia (AML) who had been recruited into the Study Alliance Leukemia trials, to investigate the prognostic impact of CEBPAsm. CEBPA mutations were identified in 240 patients (5.1%): 131 CEBPAbi and 109 CEBPAsm (60 affecting the N-terminal transactivation domains [CEBPAsmTAD] and 49 the C-terminal DNA-binding or basic leucine zipper region [CEBPAsmbZIP]). Interestingly, patients carrying CEBPAbi or CEBPAsmbZIP shared several clinical factors: they were significantly younger (median, 46 and 50 years, respectively) and had higher white blood cell (WBC) counts at diagnosis (median, 23.7 × 109/L and 35.7 × 109/L) than patients with CEBPAsmTAD (median age, 63 years, median WBC 13.1 × 109/L; P < .001). Co-mutations were similar in both groups: GATA2 mutations (35.1% CEBPAbi; 36.7% CEBPAsmbZIP vs 6.7% CEBPAsmTAD; P < .001) or NPM1 mutations (3.1% CEBPAbi; 8.2% CEBPAsmbZIP vs 38.3% CEBPAsmTAD; P < .001). CEBPAbi and CEBPAsmbZIP, but not CEBPAsmTAD were associated with significantly improved overall (OS; median 103 and 63 vs 13 months) and event-free survival (EFS; median, 20.7 and 17.1 months vs 5.7 months), in univariate and multivariable analyses. Additional analyses revealed that the clinical and molecular features as well as the favorable survival were confined to patients with in-frame mutations in bZIP (CEBPAbZIP-inf). When patients were classified according to CEBPAbZIP-inf and CEBPAother (including CEBPAsmTAD and non-CEBPAbZIP-inf), only patients bearing CEBPAbZIP-inf showed superior complete remission rates and the longest median OS and EFS, arguing for a previously undefined prognostic role of this type of mutation.

Objectives We investigated how health technology assessment (HTA) organizations around the world have handled drug genericization (an allowance for future generic drug entry and subsequent drug price declines) in their guidelines for cost-effectiveness analyses (CEAs). We also analyzed a large sample of published CEAs to examine prevailing practices in the field. Methods We reviewed 43 HTA guidelines to determine whether and how they addressed drug genericization in their CEAs. We also selected a sample of 270 US-based CEAs from the Tufts Medical Center’s CEA Registry, restricting the sample to studies on pharmaceuticals published from 1991 to 2019 and to analyses taking a lifetime time horizon. We determined whether each CEA examined genericization (and if so, whether in base case or sensitivity analyses), and how inclusion of genericization influenced the estimated incremental cost-effectiveness ratios. Results Fourteen (33%) of the 43 HTA guidelines mention genericization for CEAs and 4 (9%) recommend that base case analyses include assumptions about future drug price changes due to genericization. Most published CEAs (95%) do not include assumptions about future generic prices for intervention drugs. Only 2% include such assumptions about comparator drugs. Most studies (72%) conduct sensitivity analyses on drug prices unrelated to genericization. Conclusions The omission of assumptions about genericization means that CEAs may misrepresent the long run opportunity costs for drugs. The field needs clearer guidance for when CEAs should account for genericization, and for the inclusion of other price dynamics that might influence a drug’s cost-effectiveness.

BACKGROUND: Medical treatment of inappropriate sinus tachycardia (IST) remains suboptimal. Radiofrequency sinus node (RF-SN) ablation has poor success and higher complication rates. OBJECTIVE: We aimed to compare clinical outcomes of the novel SN sparing hybrid ablation technique with those of RF-SN modification for IST management. METHODS: This is a multicenter prospective registry comparing the SN sparing hybrid ablation strategy with RF-SN modification. The hybrid procedure was performed using an RF bipolar clamp, isolating superior vena cava/inferior vena cava with the creation of a lateral line across the crista terminalis while sparing the SN region (identified by endocardial 3-dimensional mapping). RF-SN modification was performed by endocardial and/or epicardial mapping and ablation at the site of earliest atrial activation. RESULTS: Of the 100 patients (hybrid ablation group, n = 50; RF-SN group, n = 50), 82% were women, and the mean age was 22.8 years. Normal sinus rhythm and rate were restored in all patients in the hybrid group (vs 84% in the RF-SN group; P = .006). Hybrid ablation was associated with significantly better improvement in mean daily heart rate and peak 6-minute walk heart rate compared with RF-SN ablation. The RF-SN group had a significantly higher rate of redo procedures (100% vs 8%; P < .001), phrenic nerve injury (14% vs 0%; P = .012), lower acute pericarditis (48% vs 92%; P < .0001), permanent pacemaker implantation (50% vs 4%; P < .0001) than did the hybrid ablation group. CONCLUSION: The novel sinus node sparing hybrid ablation procedure appears to be more efficacious and safer in patients with symptomatic drug-resistant IST with long-term durability than RF-SN ablation.

Background The purpose of this study was to review the literature to ascertain the functional outcomes, recurrence rates, and subsequent revision rates following revision arthroscopic Bankart repair. Methods Two independent reviewers performed a literature search based on PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines using the Embase, MEDLINE, and Cochrane Library databases. Studies in which arthroscopic Bankart repair was performed as a revision procedure were included. The clinical outcomes extracted and analyzed were functional outcomes, return to play, and recurrent instability. Results Fourteen studies with 433 patients met the inclusion criteria. The majority of patients were male patients (63.7%); the average age was 26.1 years (range, 14-58 years), and the mean follow-up period was 37.6 months (range, 10-144 months). The mean Rowe score was 84.2, and 79.7% of patients had good to excellent outcomes. The rate of return to play was 78.5%, with 47.5% of patients returning to their preinjury level of play across 10 studies. The rate of recurrent instability was reported in 12 studies, with 328 shoulders demonstrating 86 instability events (26.2%). The rate of recurrent instability due to dislocation was reported in 7 studies (n = 176), with 19 events (10.8%), whereas the rate of subluxation was reported in 4 studies (n = 76), with 6 events (7.9%). Conclusions Revision arthroscopic Bankart repair for anterior shoulder instability was shown to result in a high rate of recurrent shoulder instability. There was a relatively poor rate of return to sport among athletes, and only about half of the patients were able to return at or above their preoperative level of ability.

Little is known of the impact of individual saturated fatty acids (SFAs) and their isoenergetic substitution with other SFAs or unsaturated fatty acids (UFAs) on the prevention of cardiometabolic disease (CMD). This systematic literature review (POSPERO registration: CRD42020084241) assessed the impact of such dietary substitutions on a range of fasting CMD risk markers, including lipid profile, markers of glycemic control and inflammation, and metabolic hormone concentrations. Eligible randomized controlled trials (RCTs) investigated the effect of isoenergetic replacements of individual dietary SFAs for at least 14 days on one or more CMD risk markers in humans. Searches of PubMed, Embase, Scopus and Cochrane CENTRAL databases on 14th February 2021 identified 44 RCTs conducted in participants aged 39.9y (SD 15.2). Studies' risk of bias was assessed using the Cochrane Risk of Bias tool 2.0 for RCTs. Random-effect meta-analyses assessed the effect of at least three similar dietary substitutions on the same CMD risk marker. Other dietary interventions were described in qualitative syntheses. We observed reductions in low-density lipoprotein cholesterol concentrations after the replacement of palmitic acid (C16:0) with UFA (-0.36 mmol/L, 95%CI [-0.50, -0.21], I2 = 96.0%, n = 18 RCTs) or oleic acid (C18:1) (-0.16 mmol/L, 95% CI [-0.28, -0.03], I2 = 89.6%, n = 9 RCTs), with a similar impact on total cholesterol and apolipoprotein B concentrations. No effects on other CMD risk markers, including high-density lipoprotein cholesterol, triacylglycerol, glucose, insulin, or C-reactive protein concentrations, were evident. Similarly, we found no evidence of a benefit from replacing dietary stearic acid with UFA on CMD risk markers (n = 4 RCTs). In conclusion, the impact of replacing dietary palmitic acid with UFA on lipid biomarkers is aligned with current public health recommendations. However, due to the high heterogeneity and limited studies, relationships between all individual SFAs and biomarkers of cardiometabolic health need further confirmation from RCTs.

Presented in this paper is a methodology for combining a Bayesian statistical approach with Data Quality Objectives (a structured decision-making method) to provide increased levels of confidence in analytical data when approaching a waste boundary. Development of sampling and analysis plans for the characterisation of radioactive waste often use a simple, one pass statistical approach as underpinning for the sampling schedule. Using a Bayesian statistical approach introduces the concept of Prior information giving an adaptive sample strategy based on previous knowledge. This aligns more closely with the iterative approach demanded of the most commonly used structured decision-making tool in this area (Data Quality Objectives) and the potential to provide a more fully underpinned justification than the more traditional statistical approach. The approach described has been developed in a UK regulatory context but is translated to a waste stream from the Fukushima Daiichi Nuclear Power Station to demonstrate how the methodology can be applied in this context to support decision making regarding the ultimate disposal option for radioactive waste in a more global context.

Background Venous stenting for iliac vein outflow obstruction is associated with excellent long-term stent patency and symptom resolution. However, the safety of iliac vein stenting performed in an office-based laboratory (OBL) setting is not well-defined. The purpose of our investigation was to determine the safety profile of iliac vein stenting in an OBL setting. Methods Data were prospectively collected in the Center for Vascular Medicine electronic medical record system (NextGen Healthcare Information System, Irvine, Calif) and retrospectively analyzed. Standardized patient safety and sedation protocols were used in accordance with the accreditation standards of the Joint Commission for Accreditation of Hospital Organizations for office-based surgery centers. Patient consultations, interventions, and follow-up at 1 to 6 weeks were included in the present analysis. All the patients had received moderate sedation during their procedure. Complications requiring hospitalization were classified as major complications. Minor complications consisted of bleeding, hematoma, vasovagal response, in-stent thrombosis resulting in complete occlusion of the iliac vein stent, an allergic reaction, hematemesis, hypotension, pelvic discomfort, and pseudoaneurysm. Results Between January 2015 and January 2019, 1223 iliac vein stents were placed in 1104 patients (23.7% male; 76.3% female). A total of 90 minor complications (7.36%) and 5 major complications (0.41%) were observed. The major complications included the following: one allergic reaction, one episode of atrial fibrillation, one episode of supraventricular tachycardia, one episode of chest pain, and one case of acute stent occlusion. The minor complications were primarily insertion site hematomas. No complications were related to sedation or acute renal failure. No patient died. Conclusions Major complications were rare after iliac vein stenting in an OBL setting. Minor complications were primarily insertion site hematomas, which did not require inpatient hospitalization. Our analysis has shown that iliac vein stenting in an OBL setting is a safe and well-tolerated procedure.

Quantitative ethnobotanical knowledge is important in guiding sustainable resource use, yet for many medicinal plants such as Harpagophytum (Devil's claw), this information is scanty. Thus, we documented the ethnobotanical knowledge of Devil's claw in Hwange, Gwanda, Matobo, and Tsholotsho, western Zimbabwe, in relation to a person's age, gender, level of education, and locality. Using a semi-structured questionnaire, we interviewed 205 respondents on their knowledge of the physical features, distribution, uses and use-values, part used, and the method of preparation of Devil's claw. Physical identification was assessed based on the frequency of knowledge of plant parts. Binomial General Linear Models were used to test the effect of age, education, gender, and locality on the respondent's knowledge. Relationships of age, gender, level of education, and locality to ethnoecological perceptions were assessed using Pearson's Chi-square test. Use values were assessed based on Plant Part Value (PPV), Use Value category (UVk), and Overall Use Value (OUV). Ethnobotanical knowledge varied with locality and age, with better physical description in most adults and senior respondents in Hwange and Tsholotsho. Respondent's perceptions showed that Devil's claw was more abundant in Hwange and Tsholotsho relative to Matobo and Gwanda. Tubers (53%) were most valued in all localities followed by leaves (29%), and fruits (18%). Of the five identified categories of use, medicinal (UVk of 0.38) was the most important while ethnoveterinary, rituals, personal care, and food were least important (all UVks ≤0.02). OUVs were dependent on locality, significantly higher in Hwange and Tsholotsho (0.64 and 0.58, respectively) as compared to Gwanda (0.1) and Matobo (0.28). This study provides a wealth of knowledge that contributes to the preservation of indigenous knowledge of Devil's claw, sustainable management of the plant as well as further contribute to pharmacological interventions.

Intraocular transmission of exogenous pathogens in cataract surgery can lead to endophthalmitis. This review evaluates the features of endophthalmitis clusters secondary to pathogen transmission in cataract surgery. Articles reporting on pathogen transmission in cataract surgery were identified via searches of Ovid MEDLINE, EMBASE, and Cochrane CENTRAL, and a total of 268 eyes from 24 studies were included. The most common source of infectious transmission was attributed to a contaminated intraocular solution (ie, irrigation solution, viscoelastic, or diluted antibiotic; n = 10). Visual acuity at presentation with infectious features was 1.89 logMAR (range: 1.35 to 2.58; ∼counting fingers) and 1.33 logMAR (range: 0.04 to 3.00; Snellen: ∼20/430) at last follow-up. Patients with diabetes had worse outcomes compared with patients without diabetes. The most frequently isolated pathogen from the infectious sources was Pseudomonas sp. (50.0%). This review highlights the various routes of pathogen transmission during cataract surgery and summarizes recommendations for the detection, prevention, and management of endophthalmitis clusters.

Background Because of ongoing shortages of donors for heart transplantation, the use of donor candidates whose availabilities are the result of drug overdoses (ODs) has become increasingly prevalent, even though these donors carry a high preponderance of the now curable hepatitis C virus (HCV). This study investigated temporal trends and regional variabilities in HVC-positive (HCV+) allograft use in heart transplantation and assessed the relationship between the use of HCV+ graft donors and the use of OD donors as well as assessing waitlist and post-transplant outcomes. Methods and Results A retrospective review of the United Network for Organ Sharing database assessed adults listed for heart transplantation. Patients were stratified both temporally into pre-HCV and HCV eras related to HCV+ graft use trends and regionally by degree of HCV+ allograft use. Regions of high HCV+ donor use were associated with an increase in OD donor access by 7.8% across eras compared to 0.4% in low HCV+ donor-use regions. One-year waitlist mortality decreased from 4.7% to 2.5% across eras in high HCV+ donor-use regions (P= 0.001) and remained roughly the same as before in low HCV+ donor-use regions (3.0% vs 2.4%; P= 0.244.). Post-transplant survival at 1 year remained similar across eras. Conclusions HCV+ donor allograft use can help to optimize donor use, decreasing waitlist mortality without compromising early survival. Ongoing assessment is essential to ensure long-term safety and efficacy of using HCV+ donors.

Background Use of oral contraceptives (OCs) may modulate the clinical course of women with congenital long QT syndrome (LQTS). The safety of OC use by sex hormone content has not been assessed in women with LQTS. Objective We aimed to evaluate the association of OCs with the risk of cardiac events (CEs) in women with LQTS. Methods Beginning in 2010, information on menarche onset, OC use, pregnancy, and menopause were obtained from women enrolled in the Rochester LQTS Registry. Type of OC was categorized as progestin-only, estrogen-only, or combined (estrogen/progestin). Andersen-Gill multivariate modeling was used to evaluate the association of time-dependent OC use with the burden of CE (total number of syncope, aborted cardiac arrest, and LQTS-related sudden cardiac death) from menarche onset through 40 years. Findings were adjusted for genotype, corrected QT duration, and time-dependent β-blocker therapy. Results A total of 1659 women with LQTS followed through March 2021, of whom 370 (22%) were treated with an OC. During a cumulative follow-up of 35,797 years, there were a total of 2027 CE. Multivariate analysis showed that progestin-only OC was associated with a pronounced 2.8-fold (P = .01) increased risk of CEs in women who did not receive β-blocker therapy, while β-blockers were highly protective during progestin-only OC treatment (hazard ratio 0.22; P = .01; P = .006 for β-blocker-by-OC interaction). The risk associated with OC use without concomitant β-blocker treatment was pronounced in women with LQTS type 2. Conclusion Our findings suggest that progestin-only OC should not be administered in women with LQTS without concomitant β-blocker therapy. OCs should be used with caution in women with LQTS type 2.

Take Home Message This systematic review and meta-analysis, based on updated individual participant data, demonstrates that cisplatin-based adjuvant chemotherapy is a valid option for improving outcomes for muscle-invasive bladder cancer., Context Our prior systematic review and meta-analysis of individual participant data (IPD) suggesting a benefit of adjuvant chemotherapy for muscle-invasive bladder cancer was limited by the number and size of included randomised trials. We have updated results to include additional trials, providing the most up-to-date and reliable evidence of the effects of this treatment. Objective To investigate the role of adjuvant cisplatin-based chemotherapy in the treatment of muscle-invasive bladder cancer. Evidence acquisition Published and unpublished trials were sought via searches of bibliographic databases, trials registers, conference proceedings, and hand searching. Updated IPD were centrally collected, checked, and analysed. Results from individual randomised controlled trials (RCTs) were combined using a two-stage fixed-effect model. Prespecified analyses explored any variation in effect by trial and participant characteristics. Evidence synthesis Analyses of ten RCTs (1183 participants) demonstrated a benefit of cisplatin-based adjuvant chemotherapy on overall survival (hazard ratio [HR] = 0.82, 95% confidence interval [CI] = 0.70–0.96, p = 0.02). This represents an absolute improvement in survival of 6% at 5 yr, from 50% to 56%, and a 9% absolute benefit when adjusted for age, sex, pT stage, and pN category (HR = 0.77, 95% CI = 0.65–0.92, p = 0.004). There was no clear evidence that the effect varied by trial or participant characteristics. Adjuvant chemotherapy was also shown to improve recurrence-free survival (HR = 0.71, 95% CI = 0.60–0.83, p

The majority of coronary atherothrombotic events presenting as myocardial infarction (MI) occur as a result of plaque rupture or erosion. Understanding the evolution from a stable plaque into a life-threatening, high-risk plaque is required for advancing clinical approaches to predict atherothrombotic events, and better treat coronary atherosclerosis. Unfortunately, none of the coronary imaging approaches used in clinical practice can reliably predict which plaques will cause an MI. Currently used imaging techniques mostly identify morphological features of plaques, but are not capable of detecting essential molecular characteristics known to be important drivers of future risk. To address this challenge, engineers, scientists, and clinicians have been working hand-in-hand to advance a variety of multimodality intravascular imaging techniques, whereby 2 or more complementary modalities are integrated into the same imaging catheter. Some of these have already been tested in early clinical studies, with other next-generation techniques also in development. This review examines these emerging hybrid intracoronary imaging techniques and discusses their strengths, limitations, and potential for clinical translation from both an engineering and clinical perspective.