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Funding Acknowledgements Type of funding sources: None. Background Pulmonary vein isolation (PVI) remains the cornerstone of atrial fibrillation (AF) ablation. In patients with persistent AF (PeAF), additional posterior wall ablation (PWA) has been proposed to improve outcomes. Individual small series have included patients ablated with a cryoballoon (CB) and radiofrequency (RF) energy and have yielded controversial results. We conducted a meta-analysis of available data to assess the incremental impact of PWA based on type of energy used for ablation. Objective To evaluate whether PVI + PWA is a more effective approach for treatment of PeAF than PVI alone based on ablation energy used. Methods The online databases (Pubmed, Medline, Embase) were searched using the terms "pulmonary vein isolation", "posterior wall isolation", or "posterior wall ablation". Out of 1917 studies, eight met our strict criteria (Table). Specifically, patients were undergoing de novo ablation for treatment of PeAF using either CB or RF. Patients had PVI alone vs PVI + PWA; studies that delivered additional ablations (except for cavotricuspid isthmus) were excluded. The primary outcome was recurrence of any atrial tachyarrhythmia (AT). Results The cohort consisted of 1607 patients (66 ± 17 years, 75% male); 830 (52%) patients were ablated CB and 777 (48%) patients were ablated with RF (Table). In the CB group, AT recurrence was significantly higher in patients who underwent PVI alone as compared to those who also had additional PWA (OR 2.55, 95% CI [1.89, 3.42], P < 0.0001, Figure). In contrast, in the RF group, outcome between the 2 groups (OR 1.40, 95% CI [0.81, 2.42], P = 0.22, Figure) was similar. Conclusions Addition of CB based PWA to PVI in patients with PeAF undergoing ablation was associated with improved long-term ablation success. However, RF based PVA did not appear to confer the same benefit. Additional randomized studies are needed to determine the impact of ablation energy in patients undergoing PWA during ablation of PeAF.

Aims: Current follow-up for head and neck cancer (HNC) is ineffective, expensive and fails to address patients' needs. The PETNECK2 trial will compare a new model of patient-initiated follow-up (PIFU) with routine scheduled follow-up. This article reports UK clinicians' views about HNC follow-up and PIFU, to inform the trial design. Materials and Methods: Online focus groups with surgeons (ear, nose and throat/maxillofacial), oncologists, clinical nurse specialists and allied health professionals. Clinicians were recruited from professional bodies, mailing lists and personal contacts. Focus groups explored views on current follow-up and acceptability of the proposed PIFU intervention and randomised controlled trial design (presented by the study co-chief investigator), preferences, margins of equipoise, potential organisational barriers and thoughts about the content and format of PIFU. Data were interpreted using inductive thematic analysis. Results: Eight focus groups with 34 clinicians were conducted. Clinicians highlighted already known limitations with HNC follow-up – lack of flexibility to address the wide-ranging needs of HNC patients, expense and lack of evidence – and agreed that follow-up needs to change. They were enthusiastic about the PETNECK2 trial to develop and evaluate PIFU but had concerns that PIFU may not suit disengaged patients and may aggravate patient anxiety/fear of recurrence and delay detection of recurrence. Anticipated issues with implementation included ensuring a reliable route back to clinic and workload burden on nurses and allied health professionals. Conclusions: Clinicians supported the evaluation of PIFU but voiced concerns about barriers to help-seeking. An emphasis on patient engagement, psychosocial issues, symptom reporting and reliable, quick routes back to clinic will be important. Certain patient groups may be less suited to PIFU, which will be evaluated in the trial. Early, meaningful, ongoing engagement with clinical teams and managers around the trial rationale and recruitment process will be important to discourage selective recruitment and address risk-averse behaviour and potential workload burden.

Ureteric calculus with a colicky pain is a common issue faced by surgeons and urologists in the ER and OPD with a major universal health and financial strain on the health care system. Different studies have shown promising outcomes for ureteric calculus with medical expulsive therapy (MET) in relation to the expulsion rate and mean duration of expulsion, decrease hospital stay and less requirements of analgesics. The aim of this study is to compare the efficacy and safety of Tamsulosin alone or in combination of Deflazacort in medical expulsive therapy of ureteric calculus of less than 10 mm (sub-centric).Effect was studied on two groups. Group-A patient received standard medical treatment plus Tamsulosin. Group-B patients received standard medical treatment and Tamsulosin plus Deflazacort.MET with Tamsulosin and Deflazacort has major advantages, with very mild, reasonable side effects and substantially lower healthcare system costs.Medical therapy with Tamsulosin is effective and have been found to increase and hasten the expulsion of ureteric calculus, but expulsion rate is more, mean expulsion time and duration of hospital stays, and the episodes of pain is less when tamsulosin is combined with Deflazacort.

Introduction: Lipomas are the most common benign mesenchymal tumor. The solitary subcutaneous lipoma accounts for approximately one-quarter to one-half of all soft-tissue tumors. Giant lipomas involving the upper extremities are rare tumors. This case report presents a subcutaneous giant lipoma in the upper arm weighing 350 g. Due to its long-term presence, the lipoma caused discomfort and pressure effects in the arm. Gross underestimation on magnetic resonance imaging (MRI) made its removal challenging and difficult. Case Report: Through this case, we report a 64-year-old female who consulted us in the clinic with complaints of discomfort, feeling of heaviness, and a mass in the right arm since 5 years. On clinical examination, there was asymmetry in her arms with her right upper arm showing a visible swelling (8 cm × 6 cm) over its posterolateral aspect. On palpation, the mass was soft, boggy, not attached to the underlying bone or muscle, and not involving the skin. A provisional diagnosis of lipoma was made and the patient was asked to undergo plain and contrast-enhanced MRI for the confirmation of the diagnosis, the extent of the lesion, and infiltration into the surrounding soft tissue. The MRI revealed a lobulated deep lipoma in the subcutaneous plane with pressure effects over the posterior fibers of the deltoid muscle. Surgical excision of the lipoma was carried out. The cavity was closed using retention stitches to prevent the formation of a seroma or ematoma. Complaints of pain, weakness, heaviness, and discomfort completely subsided by the 1st month follow-up. The patient was then followed up every 3 months for 1 year. No complication or recurrence was noted throughout this period of time. Conclusion: The extent of lipomas can be underestimated on radiological imaging. It is common to find a bigger lesion than reported and to plan and execute the incision and surgical approach accordingly. Blunt dissection should be preferred when there are chances of neurovascular involvement or injury. Keywords: Giant lipoma, benign, upper arm, surgical excision, debridement.

Introduction: Intraosseous hemangiomas (IH) are one of the rarest bone tumors that an orthopedic surgeon comes across, more so in the long bones. It most often affects adult females, severely blunting their activities of daily living, coupled with potential debilitating complications such as pathological fracture. Case Presentation: We present a case of a 38-year-old female who presented with long standing pain and swelling in the left knee. Radiology, in the form of plain radiographs and magnetic resonance imaging, narrowed the diagnosis down to a benign form of osteoblastoma or hemangioma. With this in mind, the patient underwent radical excision of the lytic lesion, along with a margin of the surrounding normal bone. The defect was filled with impaction bone grafting and supplemented by a hydroxyapatite block and a poly ethyl ether ketone plate. The patient had excellent clinical, functional, and radiological outcomes at 6 months follow-up. Conclusion: With the inherent rarity of IH, especially when it affects the long bones, it has barely been reported in orthopedic literature. Subsequently, management protocols for such lesions are ill-defined, which can be deleterious to the patient as well as the surgeon. Through this case report, we show how to approach a patient presenting with associated complaints, and show a detailed outline of an efficacious management regime that gave excellent outcomes in our patient.

We investigate the interaction between a singular surface and a strong shock in the self-gravitating interstellar gas clouds with the assumption of spherical symmetry. Using the method of the Lie group of transformations, a particular solution of the flow variables and the cooling–heating function for an infinitely strong shock is obtained. This paper explores an application of the singular surface theory in the evolution of an acceleration wave front propagating through an unperturbed medium. We discuss the formation of an acceleration, considering the cases of compression and expansion waves. The influence of the cooling–heating function on a shock formation is explained. The results of a collision between a strong shock and an acceleration wave are discussed using the Lax evolutionary conditions.

Background Mucoid degeneration of the anterior cruciate ligament (ACL) has been shown to cause restricted terminal range of motion and rest pain. If present in a patient undergoing unicompartmental knee arthroplasty, it can deteriorate the final outcome. This study aims to compare functional and clinical outcomes of debulking the mucoid ACL in patients undergoing mobile-bearing unicompartmental knee arthroplasty (UKA). Methods Patients with mucoid ACL undergoing mobile-bearing UKA at five different centres by five different arthroplasty surgeons were included. They were segregated into two groups matched for all demographic and pre-operative values: group A did not undergo debulking; group B underwent open debulking by a 15-number blade prior to UKA. Patient-related outcome measures, rest pain, clinical outcomes, and subjective patient satisfaction were recorded and compared at 2 years follow-up. Results A total of 442 patients (226 patients underwent debulking, 216 patients did not undergo debulking) were included. Both groups showed overall improvement after surgery, however, patients who underwent debulking performed better at 2 years follow-up in terms of Knee Society functional score, International Knee Documentation Committee scores, range of motion, rest pain and overall patient satisfaction (p Conclusions Debulking of mucoid ACL in patients undergoing unicompartmental knee arthroplasty significantly reduces the rest pain and improves the final range of motion of the knee joint, subsequently improving the overall functional and clinical outcome of the patient and resulting in greater patient satisfaction.

Background The body's natural immune response to cardiac implantable electronic device (CIED) implantation results in capsule formation with healthy surrounding tissue. Alternatively, chronic inflammation and infection can disrupt healing, cause pocket instability, and increase morbidity and cost, while complicating future interventions. Two envelopes are currently available to provide CIED stabilization: the TYRX absorbable antibacterial envelope and the CanGaroo envelope derived from porcine extracellular matrix (ECM). Effects of these envelopes on CIED pocket healing are not well known. Purpose To compare TYRX, ECM, and no envelope on CIED pocket healing. Methods An ovine model was used for time-course evaluation of pocket healing. CIEDs were implanted with TYRX or ECM per manufacturer's instructions or with negative control (no envelope) to allow for direct comparison. Envelope type was rotated across animals to minimize localized effects associated with implant location. At least one control was implanted in each animal. Across 18 sheep, a total of 50 CIED pockets were evaluated (TYRX=16, control=20, ECM=14). Morphometric and histopathologic analyses were completed for pockets at 3 days, 7 days, 4 wks, and 12 wks post-implant. An independent pathologist completed blinded histopathology assessment of all tissue blocks using ISO 10993–6:2016 scoring standards. For capsule thickness comparisons, a mixed effects model with a random subject (sheep) effect and fixed time and treatment effects was used. Results The TYRX inflammatory response was low, as indicated by scoring measurements of neutrophils, fibrin, and macrophages (Figure 1). Neutrophil infiltration scores with TYRX and control declined from moderate (≤2) at 3 days to absent (score = 0) at 4 and 12 wks, whereas ECM scoring showed an elevated response at 3 days (3.2) and 7 days (2.2). A lower rate of fibrin deposition was observed with TYRX at 3 days compared to control and ECM (0.8 vs 1.6 vs 2.0). Macrophage scoring was lower at 7 days for TYRX compared to control and ECM (2.2 vs 2.8 vs 3.0). Rapid tissue repair with TYRX was evidenced by increased fibrosis at 7 days compared to control (1.8 vs 1.0), with substantial resolution by 12 wks. Tissue granulation and neovascularization progressed similarly for pockets with TYRX and control over time. Capsule thickness peaked at 4 wks for all groups (TYRX 1.3±0.4, control 0.9±0.4, ECM 2.3±0.1), was reduced at 12 wks (TYRX 0.7±0.2, control 0.7±0.2, ECM 1.2±0.2), and ECM was significantly different compared to TYRX and control (p Conclusion The TYRX absorbable antibacterial envelope was associated with a more rapid natural healing response with less inflammation and thin uniform capsule formation compared to ECM. These healing conditions can foster development of a well-healed pocket that may ease secondary procedures when required. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): Medtronic, Inc.

Background Cryoballoon (CB) pulmonary vein isolation (PVI) is an accepted method for ablation in patients with paroxysmal and persistent atrial fibrillation (PAF, PeAF). Freedom from AF in the blanking period (BP), conventionally defined as the first 3-months post-PVI, has been associated with the best long-term outcomes. However, the influence of antiarrhythmic drugs (AADs) during the BP on long-term outcomes is not well understood. Objective To compare long-term outcomes between patients who were and were not on an AAD prior to ablation and remained free from AF during the 3-month BP post CB PVI. Methods We enrolled consecutive AF patients undergoing CB PVI; all pts had an implantable loop recorder (ILR). No patient had any AF in the first 90 days post CB PVI. We divided the patients into three groups: (1) never had exposure to an AAD; (2) were intolerant to/failed AAD and thus were not taking an AAD at time of ablation; and (3) were on AAD at time of ablation. In the latter group, every effort was made to stop the AAD before the end of the BP. Results The cohort included 96 pts (66±10 years; 60 [63%] male; 55 [57%] PAF; CHA2DS2-VASc 2.5±1.4). There were 23 (24%) patients in group 1, 13 (14%) patients in group 2, and 60 (63%) pts in group 3. Patients in group 3 were more likely to have PeAF; AADs were stopped at a median of 36 days IQR (27, 91) in this group. Patients were followed for 1-year during which time 28 (29%) patients had recurrent AF (despite having no AF during the BP). The best outcome was seen in patients who never used an AAD; the worst outcome was seen in patients who were on an AAD at time of ablation (Figure 1). Conclusion Our data show that absence of AF during a 3-month post CB PVI BP alone does not guarantee good-long term outcome, unless the patient was never treated with an AAD. In contrast, in patients ablated while taking an AAD, recurrent AF was observed in 37% even though they were completely AF-free during the BP. Funding Acknowledgement Type of funding sources: None.

Background Cryoballoon (CB) pulmonary vein isolation (PVI) is an accepted method for ablation in patients with paroxysmal and persistent atrial fibrillation (PAF, PeAF). However, there are a paucity of data about the impact of body mass index (BMI) on one-year and longer-term outcomes following ablation. Objective To objectively understand the impact of BMI on outcomes following CB PVI. Methods We enrolled consecutive AF patients undergoing CB PVI; all patients had an implantable loop recorder (ILR), which transmitted data wirelessly daily. We assessed AF recurrences after excluding an initial 3-month post-ablation blanking period. Results The cohort included 222 pts (66±9 years; 143 [64%] male; 120 [54%] PAF; CHA2DS2-VASc 2.6±1.6). The mean BMI was 30±5. Patients were followed for 763±347 days, during which time 50% and 68% had recurrent AF 1- and 3-years post ablation. We divided the cohort based on the mean BMI into 2 groups: BMI 30. Heavier patients were younger and more likely to have PeAF. Over 1-year of follow-up, patients with a BMI 30 (46% vs, 56%, p=0.0.097, Figure 1, left). However, as patients were followed for 3-years, freedom from AF was significantly higher in patients with a BMI 30, p=0.002, Figure 1, right). Conclusions Our data show that although patients had similar outcomes 1-year post-ablation, during longer-term follow-up patients with a BMI >30 had a much worse outcome. Our study uniquely offers objective (using an ILR) assessment of the impact of BMI on long-term outcomes following CB PVI (homogenous ablation strategy). These data highlight the need to identify strategies to improve outcomes in obese patients. Funding Acknowledgement Type of funding sources: None.