Importance Of Appropriate Patient Selection Research Articles

A tale of 2 conversions: Dichotomous decision in the spectrum of Shone syndrome is still a dilemma

A tale of 2 conversions: Dichotomous decision in the spectrum of Shone syndrome is still a dilemma

Meta-analysis of transanal vs laparoscopic total mesorectal excision of low rectal cancer: Importance of appropriate patient selection

Achieving a clear resection margins for low rectal cancer is technically challenging. Transanal approach to total mesorectal excision (TME) was introduced in order to address the challenges associated with the laparoscopic approach in treating low rectal cancers. However, previous meta-analyses have included mixed population with mid and low rectal tumours when comparing both approaches which has made the interpretation of the real differences between two approaches in treating low rectal cancer difficult. To investigate the outcomes of transanal TME (TaTME) and laparoscopic TME (LaTME) in patients with low rectal cancer. A comprehensive systematic review of comparative studies was performed in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses standards. Intraoperative and postoperative complications, anastomotic leak, R0 resection, completeness of mesorectal excision, circumferential resection margin (CRM), distal resection margin (DRM), harvested lymph nodes, and operation time were the investigated outcome measures. We included twelve comparative studies enrolling 969 patients comparing TaTME (n = 969) and LaTME (n = 476) in patients with low rectal tumours. TaTME was associated with significantly lower risk of postoperative complications (OR: 0.74, P = 0.04), anastomotic leak (OR: 0.59, P = 0.02), and conversion to an open procedure (OR: 0.29, P = 0.002) in comparison with LaTME. Moreover, the rate of R0 resection was significantly higher in the TaTME group (OR: 1.96, P = 0.03). Nevertheless, TaTME and LaTME were comparable in terms of rate of intraoperative complications (OR: 1.87; P = 0.23), completeness of mesoractal excision (OR: 1.57, P = 0.15), harvested lymph nodes (MD: -0.05, P = 0.96), DRM (MD: -0.94; P = 0.17), CRM (MD: 1.08, P = 0.17), positive CRM (OR: 0.64, P = 0.11) and procedure time (MD: -6.99 min, P = 0.45). Our findings indicated that for low rectal tumours, TaTME is associated with better clinical and short term oncological outcomes compared to LaTME. More randomised controlled trials are required to confirm these findings and to evaluate long term oncological and functional outcomes.

Outcomes of endovascular abdominal aortic aneurysm repair conversion in octogenarians treated at a high-volume aorta center.

Endovascular abdominal aortic aneurysm repair (EVAR) has become the dominant treatment strategy for infrarenal abdominal aortic aneurysms but has been especially preferred for octogenarian (age ≥80years) patients because of concerns surrounding comorbidity severity and physiologic frailty. However, EVAR failure resulting in subsequent open conversion (EVAR-c) has been increasingly reported in older patients, although a paucity of literature focusing on the outcomes in this subgroup is available. The purpose of the present analysis was to evaluate our experience with EVAR-c for octogenarians (age ≥80years) compared with that for younger patients (age<80years). A retrospective review of all nonmycotic EVAR-c procedures (2002-2020) at a single high-volume academic hospital with a dedicated aorta center (available at: https://www.uf-health-aortic-disease-center) was performed. A total of 162 patients were categorized into octogenarian (age ≥80years; n= 43) and nonoctogenarian (age<80years; n= 119) cohorts and compared. The primary end point was 30-day mortality. The secondary end points included complications, 90-day mortality, and overall survival. Cox regression was used to determine the effects of selected covariates on mortality risk. The Kaplan-Meier method was used to estimate survival. No differences in the preadmission EVAR reintervention rates were present (octogenarians, 42%; nonoctogenarians, 43%; P= 1.00) although the interval to the first reintervention was longer for the octogenarians (41months) than for the nonoctogenarians (15months; P= .01). In addition, the time to EVAR-c was significantly longer for the octogenarian patients (61months) than for the nonoctogenarian patients (39months; P< .01). No difference in rupture presentation was evident (14% vs 10%; P= .6). However, elective EVAR-c occurred less frequently for octogenarians (42%) than for nonoctogenarians (59%; P= .07). The abdominal aortic aneurysm diameter was significantly larger for elective octogenarian EVAR-c (7.8± 1.9cm) than for nonoctogenarian EVAR-c (7.0± 1.5cm; P= .02), and the presence of a type Ia endoleak was the most common indication overall (58%; n= 91). A trend toward greater 30-day mortality was evident for octogenarian patients (16%) compared with nonoctogenarian patients (7%; P= .06). Similarly, the 90-day mortality was greater for the octogenarian patients (26%) than for the nonoctogenarian patients (10%; P= .02). However, the incidence of any complication (56% vs 49%; P= .5), readmission rate (12% vs 6%; P= .3), unplanned reoperation rate (10% vs 5%; P= .5), and length of stay (11days vs 9days; P= .3) were not significantly different between the two groups. Age ≥80years was predictive of short-term mortality after nonelective but not after elective surgery. However, increasing comorbidities, nonelective admission, and renal or mesenteric revascularization showed the strongest association with mortality risk. Survival at 1 and 3years was not different between the two groups when comparing all patients after the first 90days postoperatively. Although the unadjusted perioperative mortality was greater for octogenarian patients, the risk-adjusted elective outcomes were comparable to those for younger EVAR-c patients when treated at a high-volume aortic surgery center. This finding underscores the importance of appropriate patient selection and modulation of operative complexity when feasible to achieve optimal results. Providers caring for octogenarian patients with EVAR failure should consider timely elective referral to high-volume aorta centers to reduce resource usage and the frequency of nonelective presentations.

Midterm results of chronic anterior instability of the sternoclavicular joint managed using a standardized treatment algorithm.

There remains a lack of consensus regarding the management of chronic anterior sternoclavicular joint (SCJ) instability. This study aimed to assess whether a standardized treatment algorithm (incorporating physiotherapy and surgery and based on the presence of trauma) could successfully guide management and reduce the number needing surgery. Patients with chronic anterior SCJ instability managed between April 2007 and April 2019 with a standardized treatment algorithm were divided into non-traumatic (offered physiotherapy) and traumatic (offered surgery) groups and evaluated at discharge. Subsequently, midterm outcomes were assessed via a postal questionnaire with a subjective SCJ stability score, Oxford Shoulder Instability Score (OSIS, adapted for the SCJ), and pain visual analogue scale (VAS), with analysis on an intention-to-treat basis. A total of 47 patients (50 SCJs, three bilateral) responded for 75% return rate. Of these, 31 SCJs were treated with physiotherapy and 19 with surgery. Overall, 96% (48/50) achieved a stable SCJ, with 60% (30/50) achieving unrestricted function. In terms of outcomes, 82% (41/50) recorded good-to-excellent OSIS scores (84% (26/31) physiotherapy, 79% (15/19) surgery), and 76% (38/50) reported low pain VAS scores at final follow-up. Complications of the total surgical cohort included a 19% (5/27) revision rate, 11% (3/27) frozen shoulder, and 4% (1/27) scar sensitivity. This is the largest midterm series reporting chronic anterior SCJ instability outcomes when managed according to a standardized treatment algorithm that emphasizes the importance of appropriate patient selection for either physiotherapy or surgery, based on a history of trauma. All but two patients achieved a stable SCJ, with stability maintained at a median of 70 months (11 to 116) for the physiotherapy group and 87 months (6 to 144) for the surgery group.Cite this article: Bone Jt Open2022;3(10):815-825.

Contemporary incidence, outcomes, and survival associated with endovascular aortic aneurysm repair conversion to open repair among Medicare beneficiaries

ObjectiveThe widespread application of endovascular abdominal aortic aneurysm repair (EVAR) has ushered in an era of requisite postoperative surveillance and the potential need for reintervention. The national prevalence and results of EVAR conversion to open repair, however, remain poorly defined. The purpose of this analysis was to define the incidence of open conversion and its associated outcomes. MethodsThe SVS Vascular Quality Initiative EVAR registry linked to Medicare claims via Vascular Implants Surveillance and Interventional Outcomes Network was queried for open conversions after initial EVAR procedures from 2003 to 2016. Cumulative conversion incidence within up to 5 years after EVAR and outcomes after open intervention were determined. Multivariable logistic regressions were used to identify independent predictors of conversion and mortality. ResultsAmong 15,937 EVAR patients, 309 (1.9%) underwent an open conversion: 43% (n = 132) early (<30 days) and 57% (n = 177) late (>30 days). The longitudinally observed rate of conversion was constant over time, as well as by geographic region. Independent predictors of conversion included female sex (hazard ratio [HR], 1.49; P < .001), aneurysm diameter or more than 6.0 cm at the time of index EVAR (HR, 1.74; P < .001), nonelective repair (compared with elective presentation: HR, 1.72; P < .001), and aortouni-iliac repairs (HR, 2.19; P < .001). In contrast, adjunctive operative procedures such as endo-anchors or cuff extensions (HR, 0.62; P = .06) were protective against long-term conversion. Both early (HR, 1.6; P < .001) and late (HR, 1.26; P = .07) open conversions were associated with significant 30-day (total cohort, 15%) and 1-year mortality (total cohort, 25%). Patients undergoing open conversion experienced high rates of 30-day readmission (42%) and cardiac (45%), renal (32%), and pulmonary (30%) complications. ConclusionsThis large, registry-based analysis is among the first to document the incidence and outcomes for open conversion after EVAR in a national cohort with long-term follow-up. Importantly, women, patients with large aneurysms, and complex anatomy, as well as urgent or emergent EVARs are at an increased risk for open conversion. It seems that more conversions are performed in the early postoperative period, despite perceptions that conversion is a delayed phenomenon. In all instances, conversion is associated with significant morbidity and mortality and highlights the importance of appropriate patient selection at the time of index EVAR.

Antenatal late preterm steroids: Patterns of use at a tertiary care center

Emerging concern for short- and long-term adverse outcomes of antenatal late preterm steroids (ALPS) supports the importance of appropriate patient selection and judicious application. We aimed to assess patterns of ALPS use in a tertiary care center and identify factors associated with liberal utilization.

Non-Invasive Evaluation of Patients Undergoing Percutaneous Coronary Intervention for Chronic Total Occlusion.

Background: As percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) gains wider acceptance as a therapeutic option for coronary artery disease, the importance of appropriate patient selection has increased. Although cardiovascular magnetic resonance imaging (MRI) allows segmental and quantitative analyses of myocardial ischemia and scar transmurality, it has limitations, including contraindications, cost, and accessibility. This study established a non-invasive method to evaluate patients undergoing CTO-PCI using two-dimensional speckle-tracking echocardiography (2D-STE). Methods: Overall, we studied 55 patients who underwent successful CTO-PCI. Cardiovascular MRI and 2D-STE were performed before and 8 ± 2 months after CTO-PCI. Segmental findings of strain parameters were compared with those obtained with late gadolinium enhancement and stress-perfusion MRI. Results: With a cutoff of −10.7, pre-procedural circumferential strain (CS) showed reasonable sensitivity (71%) and specificity (73%) for detecting segments with transmural scar. The discriminatory ability of longitudinal strain (LS) for segments with transmural scar significantly improved during follow-up after successful CTO-PCI in the territory of the recanalized artery (area under the curve (AUC) 0.70 vs. 0.80, p < 0.001). LS accuracy was lower than that of CS at baseline (AUC 0.70 vs. 0.79, p = 0.048), and was increased at follow-up (AUC 0.80 vs. 0.82, p = 0.81). Changes in myocardial perfusion reserve from baseline to follow-up were significantly associated with those in LS but not in CS. Conclusions: Use of 2D-STE may allow the non-invasive evaluation of patients undergoing CTO-PCI to assess the indication before the procedure and treatment effects at follow-up.

Assessing the Influence of Failed Implant Reconstruction on Patient Satisfaction and Decision Regret after Salvage Free-Flap Breast Reconstruction.

Free-flap breast reconstruction after failed implant reconstruction is associated with improved patient outcomes. How the level of satisfaction achieved compares between patients with and without previously failed implant reconstruction remains unknown. The aim of this study was to assess the influence of prior failed implant-based reconstruction on long-term patient-reported outcomes after free-flap breast reconstruction. All patients undergoing free-flap breast reconstruction between 2015 and 2019 were identified. Patient satisfaction using the BREAST-Q and decisional regret using the Decision Regret Scale were compared between patients with and without a history of implant breast reconstruction. Overall, 207 patients were contacted and 131 completed the BREAST-Q and Decision Regret Scale. A total of 23 patients had a history of failed implant-based reconstruction requiring free-flap-flap salvage, most commonly due to infection (39.1%), chronic pain (34.8%), capsular contracture (26%), and implant malposition (26.1%). Following definitive free-flap reconstruction, patients with prior failed implant reconstruction had significantly lower BREAST-Q scores for satisfaction with breast (61.2 ± 16.7 vs. 70.4 ± 18.7; p = 0.04) and sexual well-being (38.5 ± 18.2 vs. 52.8 ± 24.7; p = 0.01) and reported higher decision regret (19.1 ± 18.6 vs. 9.6 ± 15.6, respectively). There were no significant differences for psychosocial well-being (p = 0.67), physical well-being (chest; p = 0.27), and physical well-being (abdomen; p = 0.91). A history of failed implant-based reconstruction is associated with reduced satisfaction and increased decision regret with the final reconstructive outcome. This data underscores the importance of appropriate patient selection at the initial consultation, and informed preoperative counseling regarding long-term outcomes in patients presenting for free-flap reconstruction after a failed implant-based reconstruction.

B-PO03-012 LEFT ATRIAL APPENDAGE CLOSURE DEVICE ASSOCIATED WITH LARGE THROMBUS

The left atrial appendage (LAA) is an important source of embolic strokes in atrial fibrillation (AF). LAA occlusion (LAAO) devices have become accepted as an alternative to chronic anticoagulation (AC) therapy. However, the risk of thrombus post LAAO is not well defined. Reiterate the importance of appropriate patient selection for LAAO and relevance of transesophageal echo (TEE) prior to cardioversion (CV) in patients with LAAO. NA In 2018, a 73year-old male with a paroxysmal AF and intolerance to AC enrolled in Amulet™ LAA Occluder Trial. In 2016, his ejection fraction (EF) was 25% and improved to 40% by 2018. TEE 45 days post implant confirmed proper placement without thrombus. He was compliant with study protocol, discontinuing AC 45 days post implant and continued dual anti-platelet therapy secondary to extensive coronary disease. In 2020, he presented for TEE and CV secondary to symptomatic AF. TEE revealed severe left atrial enlargement with a large LAA thrombus attached to the surface of well-seated Amulet device, measuring 3.2x 3.3 x 2.5cm; EF 25-30%. He subsequently underwent surgical removal of Amulet device with thrombectomy and excision of LAA. Surgical intervention was chosen over AC therapy given recurrent falls and recent intracranial bleed. Major trials investigating LAAO devices excluded patients with an EF <30%. Thus, selecting participants for LAAO devices with significant LV dysfunction should be done with caution. Additionally, patients with LAAO devices undergoing CV should be screened for LAA thrombus to avoid potential catastrophic complications.

Partial breast irradiation with intraoperative radiotherapy in the ELIOT trial – Authors' reply

We would like to thank our colleagues for their interest in the updated ELIOT trial.1 By showing a higher local relapse rate in the accelerated partial breast irradiation group, we do not intend to discourage the use of electron intraoperative radiotherapy (ELIOT)—let alone of accelerated partial breast irradiation in general—but rather to underscore the importance of appropriate patient selection. The ELIOT trial has identified a subgroup of patients with a notably low rate of local recurrence after either accelerated partial breast irradiation or whole-breast irradiation.

Outcomes of 1,098 Patients Following Transcatheter Aortic Valve Implantation: A Statewide Population-Linkage Cohort Study

The increasing implementation of transcatheter aortic valve implantation (TAVI) in Australia warrants real-world data on the prevalence and outcomes of these patients. The aim of this study is to describe trends in case-volumes of TAVI in New South Wales (NSW), Australia and associated mortality outcomes. From the Centre of Health Record Linkage registry, all NSW residents who underwent TAVI between 5 June 2013 and 30 June 2018 were identified. Cause-specific mortality was tracked from the statewide death registry. Temporal trends in case-volumes between 2013 and 2018 were assessed by linear regression. Binary logistic regression was used to compare differences in in-hospital and 30-day mortality, while Cox proportional hazards regression was used to compare mortality beyond 30 days. Case-volumes increased from 30 in 2013 to 345 by 2017. The cohort comprised 1,098 persons (mean[±SD] age: 83.3±7.7 yrs). Cumulative in-hospital, 180-day and at end-of-study (mean: 1.8±1.2 yrs) all-cause mortality were 1.3% (n=14), 4.9% (n=54) and 20.3% (n=224) respectively. Heart failure (14.3%, n=2), myocardial infarction (14.3%, n=2), and sepsis (14.3%, n=2) were the primary causes of in-hospital death. Post-discharge, sepsis (25.2%, n=53) was the main cause-specific death, while combined cardiovascular deaths accounted for 46% (n=97), mostly from heart failure (n=35). Heart failure, chronic kidney disease, and requirement for ventilation post-TAVI were independent predictors of in-hospital death and at 180 days. TAVI procedure in low-volume public centres was a predictor of mortality at 180 days. The number of TAVI procedures increased 10-fold between 2013 and 2017 state-wide, with mortality rates comparable to international cohorts at short and medium-term follow-up. Pre-existing comorbidities and site-specific caseloads may be important determinants of outcome, emphasising the importance of appropriate patient selection and treating centre.

Surgical Options for Migraine: An Overview.

The goal of this manuscript was to provide a comprehensive review of the surgical treatment for migraine headaches with a focus on trigger points and their clinical presentations, and to emphasize the importance of appropriate patient selection. Migraine is a prevalent neurological disease with headache being a disabling component of it. Surgical treatment for migraine headache became available two decades ago, which is based on proper identification and the deactivation of the specific trigger sites in the head and neck area. This manuscript reviews the discovery and evolution of migraine surgery with changes in patients' selection throughout the years. Patients with migraine headaches who do not respond or cannot tolerate the medical treatment might benefit from trigger site deactivation surgery. The success of the surgery is closely related to proper identification of trigger point (s) and close collaboration with a neurologist or a headache specialist. This collaboration would enhance patients' positive outcomes and help to rule out other causes of the headache.

Treatment of Large Hepatocellular Carcinoma using Transarterial Chemoembolisation Combined with Sorafenib

Introduction: Hepatocellular Carcinoma (HCC) is the most common primary malignant tumour of liver, accounts for 90% of all primary hepatic tumours, with second most common cause for cancer-related deaths worldwide. Majority of HCC presents in Barcelona Clinic Liver Cancer (BCLC) intermediate stage (B), for which Transarterial Chemoembolisation (TACE) is the most commonly available treatment . Even though overall prognosis of these locally advanced tumours is poor, significant improvement can still be made in overall survival and recurrence free survival with locoregional therapy like TACE. Aim: To assess the efficiency, safety and limitations of TACE in large HCC with specific focus on importance of appropriate patient selection. Materials and Methods: The study was conducted on 30 histopathologically proven cases of HCC with BCLC intermediate stage. All cases underwent TACE followed by repeat TACE or treated with sorafenib depending on their response and clinical status. Treatment-related complications, treatment response, recurrence free survival was assessed. Results: Of the 30 cases, six cases had lesion size less than 5 cm, six cases with lesion size 5-10 cm and remaining 18 cases had lesion size more than 10 cm, with the largest lesion being 16 cm. Twenty-one cases had elevated Alfa Fetoprotein (AFP), chronic liver disease was seen in 10 cases, with five cases having at least two lesions. Total 50% of cases with lesion less than 5 cm showed complete response at 15 months, four of six cases with lesion size of 5-10 cm showed partial response at 15 months, other two cases were lost for follow-up. Cases with lesion size more than 10 cm showed mixed response, at 15 months follow-up, 10 cases showed stable response, six cases showed progressive disease and two patients died due to liver dysfunction. Conclusion: Transarterial Chemoembolisation combined with sorafenib prolonged the overall survival in selected large tumours with high disease burden status.

Supercharge End-to-Side Anterior Interosseous-to-Ulnar Motor Nerve Transfer Restores Intrinsic Function in Cubital Tunnel Syndrome.

The supercharge end-to-side anterior interosseous nerve-to-ulnar motor nerve transfer offers a viable option to enhance recovery of intrinsic function following ulnar nerve injury. However, in the setting of chronic ulnar nerve compression where the timing of onset of axonal loss is unclear, there is a deficit in the literature on outcomes after supercharge end-to-side anterior interosseous nerve-to-ulnar motor nerve transfer. A retrospective study of patients who underwent supercharge end-to-side anterior interosseous nerve-to-ulnar motor nerve transfer for severe cubital tunnel syndrome over a 5-year period was performed. The primary outcomes were improvement in first dorsal interosseous Medical Research Council grade at final follow-up and time to reinnervation. Change in key pinch strength; grip strength; and Disabilities of the Arm, Shoulder and Hand questionnaire scores were also evaluated using paired t tests and Wilcoxon signed rank tests. Forty-two patients with severe cubital tunnel syndrome were included in this study. Other than age, there were no significant clinical or diagnostic variables that were predictive of failure. There was no threshold of compound muscle action potential amplitude below which supercharge end-to-side anterior interosseous nerve-to-ulnar motor nerve transfer was unsuccessful. This study provides the first cohort of outcomes following supercharge end-to-side anterior interosseous nerve-to-ulnar motor nerve transfer in chronic ulnar compression neuropathy alone and underscores the importance of appropriate patient selection. Prospective cohort studies and randomized controlled trials with standardized outcome measures are required. Therapeutic, IV.

Editors' note: A multicenter comparison of MOG-IgG cell-based assays

In “A multicenter comparison of MOG-IgG cell-based assays,” Waters et al. compared 3 myelin oligodendrocyte glycoprotein immunoglobulin G (MOG-IgG) cell-based assays (CBAs) from 3 international centers and found that the specificity was highest for the 2 live CBAs as compared to the fixed CBA (99.6% and 100% vs 98.1%). Furthermore, they reported that the positive predictive values (PPVs) were highest for the 2 live CBAs as compared to the fixed CBA (95.5% and 100% vs 82.1%). Budhram questions the value of these PPV calculations, noting that PPV is dependent on knowledge of disease prevalence, which is not always accurate in a case-control study, and clinician ordering practices. He recommends that clinicians be aware of the importance of appropriate patient selection when ordering MOG-IgG, particularly when using a fixed CBA. In “A multicenter comparison of MOG-IgG cell-based assays,” Waters et al. compared 3 myelin oligodendrocyte glycoprotein immunoglobulin G (MOG-IgG) cell-based assays (CBAs) from 3 international centers and found that the specificity was highest for the 2 live CBAs as compared to the fixed CBA (99.6% and 100% vs 98.1%). Furthermore, they reported that the positive predictive values (PPVs) were highest for the 2 live CBAs as compared to the fixed CBA (95.5% and 100% vs 82.1%). Budhram questions the value of these PPV calculations, noting that PPV is dependent on knowledge of disease prevalence, which is not always accurate in a case-control study, and clinician ordering practices. He recommends that clinicians be aware of the importance of appropriate patient selection when ordering MOG-IgG, particularly when using a fixed CBA.

Practical considerations in the use of regorafenib in metastatic colorectal cancer.

Over the past 20 years, management of patients with metastatic colorectal cancer (mCRC) has improved considerably, leading to increased overall survival and more patients eligible for third- or later-line therapy. Currently, two oral therapies are recommended in the third-line treatment of mCRC, regorafenib and trifluridine/tipiracil. Selecting the most appropriate treatment in the third-line setting poses different challenges compared with treatment selection at earlier stages. Therefore, it is important for physicians to understand and differentiate between available treatment options and to communicate the benefits and challenges of these to patients. In this narrative review, practical information on regorafenib is provided to aid physicians in their decision-making and patient communications in daily practice. We discuss the importance of appropriate patient selection and adverse events management through close patient monitoring and dose adjustments to ensure patients stay on treatment for longer and receive as much benefit as possible. We also highlight key physician–patient communication points to facilitate shared decision-making.

Risk of death without appropriate defibrillator shock in patients with advanced renal dysfunction.

Heart failure patients with advanced chronic kidney disease (CKD) may experience an increased rate of non-arrhythmic mortality due to associated comorbidities. We aimed to evaluate the risk of mortality without appropriate implantable cardioverter-defibrillator (ICD) shocks in this high-risk population. The study population comprised 3542 patients who received an ICD, were enrolled, and prospectively followed-up in the Israeli ICD registry. Study patients were categorized into two groups: those with advanced CKD [defined by a glomerular filtration rate of <30 mL/min/1.73 m2 or being on dialysis at time of implantation (n = 197)], and those without advanced CKD (n = 3344). The primary endpoint was the risk of death without receiving appropriate ICD shock. Kaplan-Meier survival analysis showed that at 5 years of follow-up the rates of death without prior ICD shock were significantly higher in the advanced kidney disease group (46%) compared with the non-advanced CKD group (19%; log-rank P-value <0.001). Consistently, multivariate analysis showed that the risk of death without receiving appropriate ICD shock therapy at 5 years was 2.5-fold (P < 0.001) higher among advanced CKD patients. In contrast, the rate of appropriate ICD shock therapy at 5 years among advanced CKD patients was only 9%, with a very high mortality rate (63%) within 3.5 years subsequent to shock therapy. Nearly one-half of ICD with advanced CKD die within 5 years without receiving an appropriate ICD shock. These findings stress the importance of appropriate patient selection for primary ICD implantation in this high-risk population.

SELECTIVE DORSAL RHIZOTOMY IN CEREBRAL PALSY: SELECTION CRITERIA AND POSTOPERATIVE PHYSICAL THERAPY PROTOCOLS.

ABSTRACTObjective: To identify selection criteria for selective dorsal rhizotomy (SDR) in cerebral palsy, to analyze the instruments used for evaluation, and to describe the characteristics of physical therapy in postoperative protocols.Data sources: Integrative review performed in the following databases: SciELO, PEDro, Cochrane Library, and PubMed. The terms in both Portuguese and English for “cerebral palsy”, “selective dorsal rhizotomy”, and “physical therapy” were used in the search. Studies whose samples enrolled individuals with cerebral palsy who had attended physical therapy sessions for selective dorsal rhizotomy according to protocols and describing such protocols’ characteristics were included. Literature reviews were excluded and there was no restriction as to period of publication.Data synthesis: Eighteen papers were selected, most of them being prospective cohort studies with eight-month to ten-year follow-ups. In most studies, the instruments of assessment encompassed the domains of functions, body structure, and activity. The percentage of posterior root sections was close to 50%. Primary indications for SDR included ambulatory spastic diplegia, presence of spasticity that interfered with mobility, good strength of lower limbs and trunk muscles, no musculoskeletal deformities, dystonia, ataxia or athetosis, and good cognitive function. Postoperative physical therapy is part of SDR treatment protocols and should be intensive and specific, being given special emphasis in the first year.Conclusions: The studies underline the importance of appropriate patient selection to obatin success in the SDR. Postoperative physical therapy should be intensive and long-term, and must necessarily include strategies to modify the patient’s former motor pattern.

An update on interventional cardiology: management of CTO, performance of absorbable scaffolds, coronary vasomotion after DES, and antithrombotics

In spite of all the progress made over the last decades,1 coronary artery disease remains the most important cause of morbidity and mortality in Western countries2 as well as in the developing world. Atherosclerotic plaques, the underlying cause of the disease, can lead to stenosis or occlusion of epicardial coronary arteries, resulting in ischaemia and angina.3 Acute plaque rupture leads to occlusion and ST-segment myocardial infarction,4 while patients with slowly developing plaques may develop collaterals5 and will therefore present with stable angina rather than infarction even in the presence of coronary occlusion. ![Graphic][1] Coronary chronic total occlusions are commonly encountered in patients undergoing coronary angiography, and their current management is updated in a timely review entitled ‘ Appropriateness of percutaneous revascularization of coronary chronic total occlusions: an overview ’ by Alfredo Galassi and colleagues from the Cannizzaro Hospital in Catania, Italy.6 Observational studies have demonstrated that successful revascularization of chronic total occlusions is associated with improved quality of life and better outcomes.7–9 However, in the absence of randomized trials, its prognostic benefit remains debatable. Over the past decade, important developments in dedicated equipment and techniques10 have resulted in higher success and lower complication rates. Both European and American guidelines have assigned a class IIa (level of evidence B) recommendation for the percutaneous revascularization of coronary chronic total occlusions. The authors, all experienced operators, stress the importance of appropriate patient selection, and provide a critical assessment of the … [1]: /embed/inline-graphic-1.gif

Short and medium-term outcomes for general surgery in nonagenarian patients in a district general hospital.

Introduction Surgeons are increasingly performing surgery on older patients. There are currently no tools specifically for risk prediction in this group. The aim of this study was to review general surgical operations carried out on patients aged over 90 years and their outcome, before comparing these with predictors of morbidity and mortality. Methods A retrospective review was carried out at our district general hospital of all general surgery patients aged over 90 years who underwent a general surgical operation over a period of 14 years. Information collected included demographics, details of procedures, P-POSSUM (Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity), complications and outcomes. Results A total of 119 procedures were carried out, 72 involving entry into the peritoneal cavity. Overall, 14 patients (12%) died within 30 days and 34 (29%) died within one year. Postoperative complications included infection (56%), renal failure (24%), need for transfusion (17%) and readmission within 30 days (11%). Logistical regression analysis showed that the P-POSSUM correlated well with observed mortality and infection was a significant predictor of in-hospital mortality (p=0.003). Conclusions The P-POSSUM correlates significantly with outcome and should be used when planning major elective or emergency surgery in patients over 90 years of age. Infective complications appear to be a significant predictor of postoperative mortality. This study supports operative intervention as an option in this extreme age group but we emphasise the importance of appropriate patient selection and judicious clinical care.