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Carotid endarterectomy is the procedure most commonly used for the treatment of lesions in the internal carotid artery. It is occasionally also necessary to insert an internal shunt. After surgery, the patient should be kept in intensive care for 24 h. The most serious complication that can occur is a neurological deficit. Endarterectomy of the origin of the vertebral artery is also the most common procedure used at this location. The techniques for treatment of lesions in the supra-aortic trunks are also discussed, as are the procedures used in cerebral revascularization by extra-intracranial anastomosis. [ABSTRACT FROM AUTHOR]

Background: Hamstring injuries can have a significant burden on a professional football player's career and performance. One in 4 players will suffer a lower extremity strain in their career, with the hamstring being the most common. These injuries are often fraught with extended periods of recovery and reinjury rates varying between 16% and 38%., Purpose: To determine the progression and duration of hamstring injury as well as risk factors and probability of reinjury in the National Football League (NFL)., Study Design: Descriptive epidemiology study., Methods: Data were extracted from the official publicly accessible NFL database of injuries. NFL players suffering a hamstring injury during the study period of 2008-2020 were identified. Injuries were reported weekly as mandated by the NFL. Players were deemed cleared from injury when no longer listed in the injury report (IR). Reinjury was defined as any subsequent hamstring injury after a player's initial injury. The duration of injury and factors associated with injury were analyzed. Secondary objectives included team-specific injury rates and timing of injury., Results: A total of 2101 hamstring injuries occurred among 1354 players. The mean duration of the IR was 2.4 ± 2.1 weeks. A total of 442 (33%) players suffered subsequent reinjury, 27% of which occurred during the same season. The mean duration on the IR for reinjury was 2.4 ± 1.8 weeks, with no significant difference in duration compared with initial injury (2.4 ± 1.8 vs 2.2 ± 1.7; P = .138). Defensive skill players were most frequently injured (50.4%) followed by offensive skill players (37.7%). Of the 4812 total IR listings, 1806 (38%) did not participate in practice. A total of 1590 (33.5%) had limited participation in practice, and 1353 (28.5%) had full participation in practice. Injury rates among teams varied and ranged from 0.6% (Baltimore Ravens) to 5.7% (Houston Texans), with a median of 3.1% ( P < .0001)., Conclusion: Hamstring injuries can have a lasting impact on a player's career with more than a third of players suffering subsequent reinjury. Although suffering a hamstring injury predisposes a player to reinjury, previous injury was not associated with longer recovery times. Rates of injury among organizational teams vary; thus, further research to understand the difference in preventive measures and treatment protocols may be warranted., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: C.R. has received education payments from Gotham Surgical Solutions & Devices and hospitality payments from Zimmer Biomet. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto. Ethical approval was not sought for the present study., (© The Author(s) 2024.)

Maternal undernutrition during pregnancy is associated with adverse effects in the offspring during adulthood and contributes to the risk of developing a number of chronic diseases. Historical events, such as famines, allow us to study the effects that food deprivation in utero has on the offspring's health. In particular, the Dutch Hunger Winter (1944-1945) and the Great Chinese Famine (1959-1961) have been extensively analysed, and it has been shown that prenatal exposure to starvation increases the risk of cardiometabolic, mental and kidney disease in adult life. More importantly, the risk can be transmitted to future generations. However, not all studies agree on the thresholds of risk of exposed subjects or on the timing of starvation during foetal life that could be held responsible for these deleterious lifelong consequences. Gender differences complicate the picture. In this narrative review, we discuss similarities and differences between the two famines and compare the available data, seeking to determine what can be learned from these tragedies., Competing Interests: Declarations. Conflict of interest: The authors declare no competing interests., (© 2024. The Author(s), under exclusive licence to International Pediatric Nephrology Association.)

Background: Sodium-glucose cotransporter 2 inhibitors (SGLT2i) lower ambulatory blood pressure (ABP) in patients with type 2 diabetes mellitus; whether the same holds true in diabetic kidney disease (DKD) is unknown. This information is critical to the knowledge of mechanisms of nephroprotection and safety of this therapy., Methods: This multicenter prospective study evaluates the changes in ABP after 12 weeks of dapagliflozin 10 mg/day in a cohort of patients with type 2 DKD and glomerular filtration rate (GFR) >25 mL/min/1.73 m 2 . Primary endpoint was the change of nighttime systolic blood pressure (SBP). Changes of daytime SBP, prevalence of normal dipping (day/night SBP ratio <0.9) and changes in ABP patterns, that is, sustained uncontrolled hypertension (SUCH), white coat uncontrolled hypertension (WUCH), masked uncontrolled hypertension (MUCH) and controlled hypertension (CH) were secondary endpoints., Results: Eighty-three of 96 patients completed the study [age 68.7 ± 8.9 years, 73.5% males, GFR 49 ± 17 mL/min/1.73 m 2 , median albuminuria: 0.18 (interquartile range 0.10-0.38) g/24 h]. After 12 weeks of dapagliflozin, nighttime SBP declined by -3.0 mmHg (95% confidence interval -5.2/-0.8 mmHg; P  = .010) with an improvement of nighttime SBP goal (<110 mmHg) from 18.0% to 27.0% ( P  < .001). Similarly, the prevalence of normal dipping increased (from 31.3% to 50.6%, P  = .005). A decrease in daytime (-2.4 mmHg; P  = .046) and office (-7.9 mmHg; P  = .009) SBP was also found. The decline of ambulatory and office SBP was associated with increased prevalence of CH (from 6.0% to 18.0%) and significant improvement of SUCH, WUCH and MUCH ( P  = .009). Albuminuria decreased ( P  < .001), whereas eGFR did not change ( P  = .297). Urinary tract infection (4.2%) and acute kidney injury (3.6%) were the main causes of drop-out. Only one patient showed a drop of nighttime SBP below 90 mmHg., Conclusions: Dapagliflozin is associated with improvement in circadian blood pressure rhythm with no major safety signal related to excessive blood pressure decrease., Competing Interests: A.C., C.G. and D.I. have no conflict to disclose. S.B. has received fees for lectures by AstraZeneca, Baxter, Mayoli and Vifor Pharma. L.D.N. has received fees for scientific consultation and/or lectures by Astellas, AstraZeneca, Mundibiopharma and Vifor Pharma. R.M. has been member of Advisory Boards for Astellas, Bayer, GSK and Amgen, and has been an invited speaker at meetings supported by Amgen, Astellas and Vifor Pharma. M.C. is member of the CKJ Editorial Board and has been member of Advisory Boards for Astellas, Bayer, GSK, Vifor Pharma and Amgen, and has been an invited speaker at meetings supported by Amgen, Astellas and Vifor Pharma. Filippo Au.: fees for lectures and scientific consultations by CSL-Vifor, AstraZeneca, Bayer., (© The Author(s) 2024. Published by Oxford University Press on behalf of the ERA.)

Introduction: Iron deficiency is common in patients with non-dialysis-dependent chronic kidney disease (NDD-CKD). Oral iron supplementation is recommended in these patients, but it is associated with a higher incidence of gastrointestinal adverse reactions. Liposomal iron therapy has been proposed as a new iron formulation, improving iron bioavailability with less side effects; however, few data are available in patients with NDD-CKD., Methods: We designed a single-arm pilot study to evaluate the efficacy of liposomal iron administered for six months in correcting iron deficiency (defined as serum ferritin < 100 ng/mL and/or transferrin saturation < 20%) in patients with NDD-CKD stages 1-5. The primary endpoints were the achievement of serum ferritin ≥ 100 ng/mL and transferrin saturation ≥ 20%. Secondary outcomes were hemoglobin (Hb) changes and the safety of liposomal iron., Results: The efficacy population included 34/38 patients, who completed at least one visit after baseline. Liposomal iron increased the achievement of transferrin saturation targets from 11.8% at baseline to 50.0% at month 6 ( p = 0.002), while no significant correction of serum ferritin ( p = 0.214) and Hb was found ( p = 0.465). When patients were stratified by anemia (Hb < 12 g/dL in women and Hb < 13 g/dL in men), a significant improvement of transferrin saturation was observed only in anemic patients (from 13.3 ± 5.8% to 20.2 ± 8.1%, p = 0.012). Hb values slightly increased at month 6 only in anemic patients (+0.60 g/dL, 95%CI -0.27 to +1.48), but not in those without anemia (+0.08 g/dL, 95%CI -0.73 to +0.88). In patients taking at least one dose of liposomal iron (safety population, n = 38), the study drug was discontinued in eight patients due to death ( n = 2), a switch to intravenous iron ( n = 2), and the occurrence of side effects ( n = 4)., Conclusions: The use of liposomal iron in patients with NDD-CKD is associated with a partial correction of transferrin saturation, with no significant effect on iron storage and Hb levels.

Nephrology is an ever-evolving field of medicine. The importance of such a discipline is related to the high clinical impact of kidney disease. In fact, abnormalities of kidney function and/or structure are common in the general population, reaching an overall prevalence of about 10%. More importantly, the onset of kidney damage is related to a strikingly high risk of cardiovascular events, mortality, and progression to kidney failure which, in turn, compromises quality and duration of life. Attempts to comprehend the pathogenesis and molecular mechanisms involved in kidney disease occurrence have prompted the development and implementation of novel drugs in clinical practice with the aim of treating the 'specific cause' of kidney disease (including chronic kidney disease, glomerular disease, and genetic kidney disorders) and the main immunological complications following kidney transplantation. Herein, we provide an overview of the principal emerging drug classes with proved efficacy in the context of the aforementioned clinical conditions. This can represent a simplified guide for clinical nephrologists to remind them of the vast and heterogeneous armamentarium of drugs that should be used in the present and the future to improve the management of patients suffering from kidney disease.

Renin-angiotensin-aldosterone system (RAAS) inhibitors are standard care in patients with hypertension, heart failure or chronic kidney disease (CKD). Although we have studied the RAAS for decades, there are still circumstances that remain unclear. In this review, we describe the evolution of the RAAS and pose the question of whether this survival trait is still necessary to humankind in the present age. We elucidate the benefits on cardiovascular health and kidney disease of RAAS inhibition and present promising novel medications. Furthermore, we address why more studies are needed to establish a new standard of care away from generally prescribing ACEi or ARB toward an improved approach to combine drugs tailored to the needs of individual patients.

Rationale & Objective: The standard of care (SoC) group of randomized controlled trials (RCTs) is a useful setting to explore the secular trends in kidney disease progression because implementation of best clinical practices is pursued for all patients enrolled in trials. This meta-analysis evaluated the secular trend in the change of glomerular filtration rate (GFR) decline in the SoC arm of RCTs in chronic kidney disease (CKD) published in the last 30 years., Study Design: Systematic review and meta-analysis of the SoC arms of RCTs analyzed as an observational study., Setting & Study Populations: Adult patients with CKD enrolled in the SoC arm of RCTs., Selection Criteria for Studies: Phase 3 RCTs evaluating GFR decline as an outcome in SoC arms., Data Extraction: Two independent reviewers evaluated RCTs for eligibility and extracted relevant data., Analytical Approach: The mean of GFR declines extracted in the SoC arm of selected RCTs were pooled by using a random effects model. Meta-regression analyses were performed to identify factors that may explain heterogeneity., Results: The SoC arms from 92 RCTs were included in the meta-analysis with a total of 32,202 patients. The overall mean GFR decline was-4.00 (95% CI, -4.55 to-3.44) mL/min/1.73m 2 per year in the SoC arms with a high level of heterogeneity (I 2 , 98.4% [95% CI, 98.2-98.5], P<0.001). Meta-regression analysis showed an association between publication year (β estimate, 0.09 [95% CI, 0.032-0.148], P=0.003) and reduction in GFR over time. When evaluating publication decade categorically, GFR decline was-5.44 (95% CI, -7.15 to-3.73), -3.92 (95% CI, -4.82 to-3.02), and -3.20 (95% CI, -3.75 to -2.64) mL/min/1.73m 2 per year during 1991-2000, 2001-2010, and 2011-2023, respectively. Using meta-regression, the heterogeneity of GFR decline was mainly explained by age and proteinuria., Limitations: Different methods assessing GFR in selected trials and observational design of the study., Conclusions: In the last 3 decades, GFR decline has decreased over time in patients enrolled in RCTs who received the standard of care., Trial Registration: Registered at PROSPERO with record number CRD42022357704., Plain-Language Summary: This study evaluated the secular trend in the change in glomerular filtration rate (GFR) decline in the placebo arms of randomized controlled trials (RCTs) that were studying approaches to protect the kidneys in the setting of chronic kidney disease. The placebo groups of RCTs are useful for examining whether the rate of progression of kidney disease has changed over time. We found an improvement in the slope of change in GFR over time. These findings suggest that adherence to standards of kidney care as implemented in clinical trials may be associated with improved clinical outcomes, and these data may inform the design of future RCTs in nephrology., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Popliteal artery aneurysms (PAAs) need urgent treatment in case of acute thrombosis, distal embolization, or rupture. Few data are available in the literature about the treatment results in these scenarios. The aim of the present study was to evaluate an 11-year multicenter experience in the urgent treatment of PAAs., Methods: All symptomatic PAAs surgically treated in two vascular centers between 2010 and 2021 were retrospectively analyzed. In the postoperative period periodical clinical and Duplex-Ultrasound evaluation were performed. The evaluated endpoint was the outcome of urgent PAAs treatment according to their clinical presentation. Statistical analysis was performed by Kaplan-Meier log-rank evaluation and multivariable Cox regression tests., Results: Sixty-six PAAs needed an urgent repair. Twelve (18%) patients had a PAA rupture and 54 (82%) had an acute limb ischemia (ALI) due to either distal embolization or acute thrombosis. Patients with ALI underwent bypass surgery in 51 (95%) cases, which was associated with preoperative thrombolysis in 18 (31%) cases. A primary major amputation was performed in 3 (5%) cases. The mean follow-up was 52 ± 21 months with an overall 5-year limb salvage of 83 ± 6%. Limb salvage was influenced only by the number of patent tibial arteries (pTA) [5-years limb salvage 0%, 86 ± 10%, 92 ± 8% and 100% in case of 0, 1, 2 or 3 pTA, respectively (P = .001)]. An independent association of number of pTA and limb loss was found [hazard ratio (HR): 0.14 (95% confidence interval (CI) 0.03-0.6), P = .001]. Overall 5-year survival was 71 ± 7%. Ruptured PAAs were associated with lower 5-year survival compared with the ALI group (48 ± 2% vs. 79 ± 7%, P = .001). The number of pTA (33 ± 20%, 65 ± 10%, 84 ± 10% and 80 ± 10% for 0, 1, 2 and 3 pTA, respectively, P = .001) and the thrombolysis (94 ± 6% vs. 62 ± 10%, P = .03) were associated with higher survival in patients with ALI. There was an independent association of number of pTA and long-term survival [HR 0.15 (95% CI 0.03-0.8), P = .03]., Conclusions: PAA rupture is the cause of urgent PAA treatment in almost one fifth of cases, and it is associated with lower long-term survival. ALI can benefit from thrombolysis, and long-term limb salvage and survival are associated with the number of pTA., (© 2023. BioMed Central Ltd., part of Springer Nature.)

The suture combination of a Krackow stitch plus a whipstitch can be used to strengthen a tendon rupture repair. We compared biomechanical outcomes of suture repair techniques for distal biceps tendon ruptures using a single Krackow stitch with and without a whipstitch and a whip-stitch alone. Data were obtained from 36 thawed porcine flexor profundus tendons. A cortical button was secured to fourth-generation composite bone using No. 2 FiberWire (Arthrex) and No. 2 FiberLoop (Arthrex). The primary outcome was maximum load to failure. Secondary outcomes were displacement at the bone-tendon interface, total construct elongation, and stiffness. The Krackow plus whipstitch group (mean, 493.82 N; SD, 209.44 N) had a greater maximum load to failure as compared with the single Krackow group (mean, 333.71 N; SD, 172.32 N) ( P =.01) and single whipstitch group (mean, 207.27 N; SD, 66.42 N) ( P <.001). The single Krackow group (mean, 1.67 mm; SD, 0.89 mm) had a greater bone-tendon interface displacement ( P =.01) after preloading and before cyclic loading than the single whipstitch group (mean, 0.83 mm; SD, 0.58 mm). There were no other secondary outcome differences between groups. A repair using Krackow plus whipstitch is biomechanically stronger with no difference in bone-tendon interface displacement, total construct elongation, or stiffness when compared with a single Krackow or single whipstitch. We recommend this repair technique for distal biceps tendon rupture repair, which may accelerate rehabilitation and decrease re-rupture rate. [ Orthopedics . 2023;46(4):224-229.].

Quadriceps tendon rupture is typically repaired using either transosseous tunnels or suture anchors. Recent literature has suggested that suture anchor repair is biomechanically superior to the use of transosseous tunnels. Augmentation of the transosseous technique with Nice knots may result in improved biomechanical properties as compared with a suture anchor construct. To compare biomechanical properties of a novel transosseous quadriceps tendon repair technique with Nice knot augmentation to those of knotless suture anchor repair, an artificial quadriceps tendon rupture was created in 10 matched pairs of cadaveric knees (n=20). Each cadaver was subjected to biomechanical testing to calculate the average ultimate load to failure, repair site gapping after early and late cyclic loading, and stiffness. Transosseous repair augmented with Nice knots as compared with knotless suture anchor repair had greater load to failure (mean±SD, 1489.5±297.6 N vs 717.7±191.4 N, P <.001), decreased gapping after early and late cyclic loading (cycles 1-20: mean±SD, 0.59±0.4 mm vs 2.1±1.2 mm, P =.008; cycles 21-250: mean±SD, 1.2±0.7 mm vs 3.9±1.7 mm, P =.002), and greater construct stiffness (mean±SD, 80.7±15.7 N/mm vs 44.4±13.4 N/mm, P =.001). The transosseous quadriceps tendon repair technique with Nice knot augmentation is biomechanically better than knotless suture anchor repair with regard to ultimate load to failure, gap formation after cyclic loading, and construct stiffness in cadaveric specimens. [ Orthopedics . 2023;46(3):135-140.].

The prevalence of recovery of kidney function (RKF) in patients under maintenance dialysis is poorly defined mainly because of different definitions of RKF. Therefore, to gain more insights into the epidemiology of RKF, we performed a systematic review and meta-analysis of studies addressing the prevalence of sustained (at least for 30 days) RKF in patients under maintenance dialysis. Acute kidney injury (AKI) and RKF in the first 90 days of dialysis were the main exclusion criteria. Overall, 7 studies (10 cohorts) including 2,444,943 chronic dialysis patients (range: 430-1,900,595 patients) were meta-analyzed. The period of observation ranged from 4 to 43 years. The prevalence of RKF was 1.49% (95% C.I.:1.05-2.11; p < 0.001] with high heterogeneity I2: 99.8%, p < 0.001. The weighted mean dialysis vintage before RKF was 294 ± 165 days; RKF persisted for a weighted mean of 27.5 months. The percentage of RKF was higher in studies from the U.S. (1.96% [95% C.I.: 1.24-3.07]) as compared to other countries (1.04% [95%C.I.: 0.66-1.62]; p = 0.049). In conclusion, sustained RKF unrelated to AKI occurs in about 1.5% of patients under maintenance dialysis. On average, RKF patients discontinue chronic dialysis about ten months after starting treatment and live free of dialysis for more than two years. The higher prevalence of RKF reported in the U.S. versus other countries suggests a major role of country-specific policies for dialysis start.

Background: Identifying sex-related differences/variables associated with 30 day/1 year mortality in patients with chronic limb-threatening ischemia (CLTI)., Methods: Multicenter/retrospective/observational study. A database was sent to all the Italian vascular surgeries to collect all the patients operated on for CLTI in 2019. Acute lower-limb ischemia and neuropathic-diabetic foot are not included., Follow-Up: One year. Data on demographics/comorbidities, treatments/outcomes, and 30 day/1 year mortality were investigated., Results: Information on 2399 cases (69.8% men) from 36/143 (25.2%) centers. Median (IQR) age: 73 (66-80) and 79 (71-85) years for men/women, respectively ( p < 0.0001). Women were more likely to be over 75 (63.2% vs. 40.1%, p = 0.0001). More men smokers (73.7% vs. 42.2%, p < 0.0001), are on hemodialysis (10.1% vs. 6.7%, p = 0.006), affected by diabetes (61.9% vs. 52.8%, p < 0.0001), dyslipidemia (69.3% vs. 61.3%, p < 0.0001), hypertension (91.8% vs. 88.5%, p = 0.011), coronaropathy (43.9% vs. 29.4%, p < 0.0001), bronchopneumopathy (37.1% vs. 25.6%, p < 0.0001), underwent more open/hybrid surgeries (37.9% vs. 28.8%, p < 0.0001), and minor amputations (22% vs. 13.7%, p < 0.0001). More women underwent endovascular revascularizations (61.6% vs. 55.2%, p = 0.004), major amputations (9.6% vs. 6.9%, p = 0.024), and obtained limb-salvage if with limited gangrene (50.8% vs. 44.9%, p = 0.017). Age > 75 (HR = 3.63, p = 0.003) is associated with 30 day mortality. Age > 75 (HR = 2.14, p < 0.0001), nephropathy (HR = 1.54, p < 0.0001), coronaropathy (HR = 1.26, p = 0.036), and infection/necrosis of the foot (dry, HR = 1.42, p = 0.040; wet, HR = 2.04, p < 0.0001) are associated with 1 year mortality. No sex-linked difference in mortality statistics., Conclusion: Women exhibit fewer comorbidities but are struck by CLTI when over 75, a factor associated with short- and mid-term mortality, explaining why mortality does not statistically differ between the sexes.

Pectoralis major ruptures are uncommon injuries that have become more prevalent over the past 20 years due to increased participation in weight lifting. Patients often present with localized swelling and ecchymosis, muscular deformity, thinning of the anterior axillary fold, and weakness in adduction and internal rotation of the affected arm. History and physical is often augmented with radiology, magnetic resonance imaging of the chest being the gold standard. Nonoperative management is reserved for old patients with low functional demands. Operative intervention is the treatment of choice with improved functional outcomes, cosmesis, and patient satisfaction.

Introduction: As rotator cuff repairs (RCRs) are among the most common procedures in upper extremity orthopedics, healing augmentation using pharmacologic enhancement of the repaired rotator cuff muscle is of particular interest., Objective: The purpose of this study is to review the current understanding of Matrix Metalloproteinases (MMPs), Doxycycline, Testosterone, Estrogen, Growth hormone/ IGF-1, Vitamin D, and Vitamin C as a means to mitigate deleterious effects and propagate factors that support healing following RCR., Methods: A review of English language articles in PubMed and Medline was conducted in December of 2020. All articles describing the current understanding of the aforementioned therapies were reviewed. Studies were excluded if they were non-English or reported incomplete results., Results: Matrix metalloproteinases (MMP's) are fundamental to the healing process after rotator cuff tears through a delicate balance of various proteases that can be modulated by doxycycline through inhibition. While testosterone has shown to induce replication and differentiation of the tendon stem-cells, estrogen agonists have been shown to decrease inflammation and muscle atrophy. Though growth hormone being associated with elevated collagen synthesis and decreased anoxic damage when present, clinical studies have shown inconclusive and adverse effects on rotator cuff healing. Patients with Vitamin D deficiency have shown to have increased fatty infiltration in rotator cuff muscle while Vitamin C functions as an antioxidant that increases collagen and fibroblast proliferation., Conclusion: As manipulation of pharmacologic factors shows potential for enhancing healing following RCRs, future studies are needed to establish a viable augmentation strategy to improve patient outcomes., Competing Interests: The authors of this paper certify that they have NO affiliations with or involvement in any organization or entity with any financial or non-financial interests pertinent to the subject matter discussed in this manuscript.

Background: To investigate the effects of the COVID-19 lockdowns on the vasculopathic population. Methods: The Divisions of Vascular Surgery of the southern Italian peninsula joined this multicenter retrospective study. Each received a 13-point questionnaire investigating the hospitalization rate of vascular patients in the first 11 months of the COVID-19 pandemic and in the preceding 11 months. Results: 27 out of 29 Centers were enrolled. April-December 2020 (7092 patients) vs. 2019 (9161 patients): post-EVAR surveillance, hospitalization for Rutherford category 3 peripheral arterial disease, and asymptomatic carotid stenosis revascularization significantly decreased (1484 (16.2%) vs. 1014 (14.3%), p = 0.0009; 1401 (15.29%) vs. 959 (13.52%), p = 0.0006; and 1558 (17.01%) vs. 934 (13.17%), p < 0.0001, respectively), while admissions for revascularization or major amputations for chronic limb-threatening ischemia and urgent revascularization for symptomatic carotid stenosis significantly increased (1204 (16.98%) vs. 1245 (13.59%), p < 0.0001; 355 (5.01%) vs. 358 (3.91%), p = 0.0007; and 153 (2.16%) vs. 140 (1.53%), p = 0.0009, respectively). Conclusions: The suspension of elective procedures during the COVID-19 pandemic caused a significant reduction in post-EVAR surveillance, and in the hospitalization of asymptomatic carotid stenosis revascularization and Rutherford 3 peripheral arterial disease. Consequentially, we observed a significant increase in admissions for urgent revascularization for symptomatic carotid stenosis, as well as for revascularization or major amputations for chronic limb-threatening ischemia.

Increasing potassium intake ameliorates blood pressure (BP) and cardiovascular (CV) prognoses in the general population; therefore the World Health Organization recommends a high-potassium diet (90-120 mEq/day). Hyperkalaemia is a rare condition in healthy individuals due to the ability of the kidneys to effectively excrete dietary potassium load in urine, while an increase in serum K + is prevalent in patients with chronic kidney disease (CKD). Hyperkalaemia prevalence increases in more advanced CKD stages, and is associated with a poor prognosis. This scenario generates controversy on the correct nutritional approach to hyperkalaemia in CKD patients, considering the unproven link between potassium intake and serum K + levels. Another concern is that drug-induced hyperkalaemia leads to the down-titration or withdrawal of renin-angiotensin system inhibitors (RASI) and mineralocorticoids receptors antagonists (MRA) in patients with CKD, depriving these patients of central therapeutic interventions aimed at delaying CKD progression and decreasing CV mortality. The new K + -binder drugs (Patiromer and Sodium-Zirconium Cyclosilicate) have proven to be adequate and safe therapeutic options to control serum K + in CKD patients, enabling RASI and MRA therapy, and possibly, a more liberal intake of fruit and vegetables.

Major adverse cardiac events, defined as death or myocardial infarction, are common causes of perioperative mortality and major morbidity in patients undergoing non-cardiac surgery. Reduction of perioperative cardiovascular risk in relation to non-cardiac surgery requires a stepwise patient evaluation that integrates clinical risk factors, functional status and the estimated stress of the planned surgical procedure. Major guidelines on preoperative cardiovascular risk assessment recommend to establish, firstly, the risk of surgery per se (low, moderate, high) and the related timing (elective vs. urgent/emergent), evaluate the presence of unstable cardiac conditions or a recent coronary revascularization (percutaneous coronary intervention or coronary artery bypass grafting), assess the functional capacity of the patient (usually expressed in metabolic equivalents), determine the value of non-invasive and/or invasive cardiovascular testing and then combine these data in estimating perioperative risk for major cardiac adverse events using validated scores (Revised Cardiac Risk Index (RCRI) or National Surgical Quality Improvement Program (NSQIP)). This stepwise approach has the potential to guide clinicians in determining which patients could benefit from cardiovascular therapy and/or coronary artery revascularization before non-cardiac surgery towards decreasing the incidence of perioperative morbidity and mortality. Finally, it should be highlighted that there is a need to implement specific strategies in the 2019 Coronavirus disease (COVID-19) pandemic to minimize the risk of transmission of COVID-19 infection during the preoperative risk assessment process.

The expansion of coronavirus disease 2019 (COVID-19) prompted measures of disease containment by the Italian government with a national lockdown on March 9, 2020. The purpose of this study is to evaluate the rate of hospitalization and mode of in-hospital treatment of patients with chronic limb-threatening ischemia (CLTI) before and during lockdown in the Campania region of Italy. The study population includes all patients with CLTI hospitalized in Campania over a 10-week period: 5 weeks before and 5 weeks during lockdown ( n = 453). Patients were treated medically and/or underwent urgent revascularization and/or major amputation of the lower extremities. Mean age was 69.2 ± 10.6 years and 27.6% of the patients were women. During hospitalization, 21.9% of patients were treated medically, 78.1% underwent revascularization, and 17.4% required amputations. In the weeks during the lockdown, a reduced rate of hospitalization for CLTI was observed compared with the weeks before lockdown (25 vs 74/100,000 inhabitants/year; incidence rate ratio: 0.34, 95% CI 0.32-0.37). This effect persisted to the end of the study period. An increased amputation rate in the weeks during lockdown was observed (29.3% vs 13.4%; p < 0.001). This study reports a reduced rate of CLTI-related hospitalization and an increased in-hospital amputation rate during lockdown in Campania. Ensuring appropriate treatment for patients with CLTI should be prioritized, even during disease containment measures due to the COVID-19 pandemic or other similar conditions.

Objective: Delays to surgery for patients with geriatric hip fracture are associated with increased morbidity and mortality. The American Heart Association (AHA) and American College of Cardiology (ACC) Clinical Practice Guidelines (CPG) were created to standardize preoperative cardiology consultation and transthoracic echocardiogram (TTE). This study's purpose is to determine if these practices are over used and delay time to surgery at a safety net hospital., Design: Retrospective review., Setting: Level 1 trauma center and safety net hospital., Patients: Charts were reviewed for indications of preoperative cardiology consultation or TTE per AHA and ACC CPG in 412 patients admitted with geriatric hip fracture., Intervention: Criteria meeting the AHA/ACC guidelines for preoperative TTE and cardiac consultations., Main Outcome Measurements: Time to surgical intervention., Results: Despite 17.7% of patients meeting criteria, 44.4% of patients received cardiology consultation. Of those patients, 33.8% met criteria for receiving preoperative TTE but 89.4% received one. Time to surgery was greater for patients receiving cardiology consultation (25.42 ± 14.54 hours, P-value <0.001) versus those who did not (19.27 ± 13.76, P-value <0.001) and for those receiving preoperative TTE (26.00 ± 15.33 hours, P-value <0.001) versus those who did not (18.94 ± 12.92, P-value <0.001)., Conclusions: Cardiology consultation and TTE are frequently used against AHA/ACC CPG. These measures are expensive and delay surgery, which can increase morbidity and mortality. These findings persisted despite limited resources available in a safety net hospital. Hospitals should improve adherence to CPG, or modify protocols., Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: The authors report no conflict of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

This study sought to postoperatively compare femoral cortical button (FCB) placement in anterior cruciate ligament (ACL) reconstruction performed using an adjustable loop cortical femoral fixation button under direct arthroscopic visualization vs indirect methods. The authors conducted a retrospective review of postoperative knee radiographs from 76 patients who had undergone ACL reconstruction with an adjustable loop cortical femoral fixation button. Operative reports were reviewed to determine the technique used for graft placement. Two sports fellowship-trained surgeons reviewed the collected radiographs, and the position of the FCB in each patient was subsequently graded. Of the 76 patients reviewed, 42 cases were performed using direct visualization, whereas 34 cases used indirect methods. This analysis showed that FCBs placed with direct visualization were more likely to have optimal position directly on the femoral cortex compared with indirect methods (chi-square test, P=.046). The grading scores demonstrated moderate strength of interobserver reliability (kappa coefficient=0.62). Direct arthroscopic visualization while placing an FCB during ACL reconstruction with an adjustable loop cortical fixation button can help ensure optimal button placement. [Orthopedics. 2020;43(3):191-195.]., (Copyright 2020, SLACK Incorporated.)

Objectives: To determine the efficacy of a preoperative fascia iliaca compartment block in decreasing postoperative pain and improving functional recovery after hip fracture surgery., Design: Randomized prospective Level 1 therapeutic., Setting: Academic Level 1 trauma center., Patients: Geriatric patients with fractures of the proximal femur (neck, intertrochanteric, or subtrochanteric regions) were prospectively randomized into an experimental (A) or control (B) groups. Forty-seven patients met inclusion criteria, 23 randomized to the experimental group and 24 to the control group., Intervention: Patients randomized to the experimental group received an ultrasound-guided fascia iliaca compartment block administered by a board-certified anesthesiologist immediately before the initiation of anesthesia., Main Outcome Measurements: Primary outcome measure was postoperative pain medication consumption until postoperative day 3. Secondary outcomes included functional recovery and a study-specific patient-reported satisfaction survey assessed on postoperative day 3., Results: There was no significant difference in consumption of acetaminophen for mild pain, tramadol for moderate pain, or functional recovery between the 2 groups. There was a statistically significant decrease in morphine consumption (0.4 mg vs. 19.4 mg, P = 0.05) and increase in patient-reported satisfaction (31%, P = 0.01)., Conclusions: Preoperative fascia iliaca compartment block significantly decreases postoperative opioid consumption while improving patient satisfaction. We recommend the integration of this safe and efficacious modality into institutional geriatric hip fracture protocols as an adjunctive pain control strategy., Level of Evidence: Therapeutic Level II See Instructions for Authors for a complete description of levels of evidence.

Background: Endovascular aneurysm repair (EVAR) is currently accepted as an alternative to open repair for the treatment of abdominal aortic aneurysm (AAA). Approximately 40-60% of AAA patients are not considered eligible for EVAR due to unfavorable anatomy. There is currently no consensus on the definition of "hostile" aortic neck for EVAR procedure., Methods: An Expert Panel (EP), made up of 9 Italian vascular surgeons from high-volume centers (>50 EVAR procedures/year), was assembled to share their opinion about the definition of hostile aortic neck anatomy for EVAR procedure. The process included a review of the current literature by the EP, a face-to-face meeting, and an on-line survey completed by the EP prior to and following the face-to-face meeting, using the Delphi method., Results: Of the 66 reviewed studies, only 38 (58%) reported at least 1 aortic neck hostility criterion. Five anatomic parameters were identified, namely, aortic neck length, aortic neck angulation, aortic neck diameter, conical neck, and presence of circumferential calcification. Based on the results of the first survey round, these criteria and related definitions were discussed in depth during the face-to-face meeting. For 3 parameters (aortic neck diameter, aortic neck angulation, conical neck), the agreement among the EP members was already high during the first survey round while for the remaining 2 (aortic neck length, circumferential calcification) it remarkably increased from the first to the second survey round. For each of these criteria, as well as combinations of at least 2 of these criteria, specific threshold values were identified above or below which a standard EVAR approach was not considered ideal by the EP due to high/moderate risk of complications., Conclusions: EP agreed on the definition of 5 aortic neck hostility criteria, according to which they gave their opinion on the feasibility and risks of a standard EVAR approach. Further agreement will be needed and examined on the best nonstandard EVAR technique which may be offered in the presence of different combinations of hostility criteria., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Pectoralis major (PM) rupture is an uncommon sports injury that has become more prevalent in the past 20 years as a result of an increase in recreational weight lifting and sports participation. Ruptures occur most commonly at the tendon insertion (65%) and musculotendinous junction (27%). This study describes an open technique and clinical outcomes after reconstruction of a PM rupture at the musculotendinous junction., Methods: In this case series, 6 patients with PM ruptures at the musculotendinous junction were enrolled, with a 12-month follow-up period. The diagnosis was made with magnetic resonance imaging and correlated with clinical examination findings. All patients underwent PM reconstruction with a semitendinosus allograft, followed by a graduated rehabilitation protocol. Postoperative outcomes were assessed using the American Shoulder and Elbow Surgeons score, Constant score, visual analog scale score, cosmesis, return of strength, and overall satisfaction., Results: The average age at the time of surgery was 39.5 years. At the 12-month follow-up visit, the average outcome scores were as follows: American Shoulder and Elbow Surgeons score, 98.3; Constant score, 98; and visual analog scale score, 0.67. All patients were pleased with their cosmetic outcomes, as well as return of strength, and showed overall satisfaction with their postoperative results., Conclusions: On review of the literature, this study is the first to describe the use of an isolated semitendinosus allograft to reconstruct a PM tendon following rupture at the musculotendinous junction. The excellent clinical outcomes suggest that the described technique can be a reliable tool in the orthopedic surgeon's armamentarium when approaching this uncommon PM tear., (© 2019 The Author(s).)

Background: Hip fractures in patients 65 years and older are associated with significant morbidity and mortality. With the steady increase in the elderly population, we implemented an evidence-based clinical practice guideline for the management of hip fractures to optimize patient care and surgical outcomes., Aims: To evaluate the effects of a multidisciplinary hip fracture care pathway on patient outcomes in the care of elderly patients., Methods: A retrospective analysis of the differences in outcomes prior to (January-October 2014) and after (November 2014-April 2016) implementation of a hip fracture care pathway at a regional Level I trauma center was performed., Results: There were 80 patients in the pre-pathway group and 191 patients in the post-pathway group with an average age of 83.18 ± 8.24 years. The analysis demonstrated that the post-pathway group had a lower incidence of in-hospital complications (9.95 vs 30.00%; p ≤ 0.001), shorter emergency room length of stay (3.76 ± 2.43 vs 6.78 ± 2.88 h; p ≤ 0.0001), and shorter overall hospital length of stay (5.03 ± 3.46 vs 7.44 ± 6.66 days; p = 0.0028). The in-hospital mortality rate was similar between groups (4.71 vs 6.25%; p = 0.6018)., Discussion: The development of a multidisciplinary approach to the care of elderly patients with hip fractures improved morbidity and showed a downward trend in mortality., Conclusions: Elderly patients with hip fractures treated at our trauma center had improved clinical outcomes after the implementation of a multidisciplinary care pathway.