Late Follow-up Research Articles

Interventional Radiologists Achieve Equivalent Outcomes and Lower Costs for Totally Implantable Venous Access Device Placement Compared to Operating Room Placement

PurposeTo compare the cost and outcomes of surgical and interventional radiology (IR) placement of totally implantable venous access devices (TIVADs) within a large regional health system to determine the service line with better outcomes and lower costs to the health system. Materials and MethodsA retrospective review of all chest port placements performed in the operating room (OR) and IR suite over 12 months was conducted at a large, integrated health system with 6 major hospitals. Secondary electronic health record and cost data were used to identify TIVAD placements, follow-up procedures indicating port malfunction, early adverse events (within 1 month after the surgery), late adverse events (2–12 months after the procedure), and health system cost of TIVAD placement and management. ResultsFor 799 total port placements included in this analysis, the rate of major adverse events was 1.3% and 1.9% for the IR and OR groups, respectively, during the early follow-up (P = .5655) and 4.9% and 2.8% for the IR and OR groups, respectively, during the late follow-up (P = .5437). Malfunction-related follow-up procedure rates were 1.8% and 2.6% for the IR and OR groups, respectively, during the early follow-up (P = .4787) and 12.4% and 10.5% for the IR and OR groups, respectively, during the late follow-up (P = .4354). The mean cost of port placement per patient was $4,509 and $5,247 for the IR and OR groups, respectively. The difference in per-patient cost of port placement was $1,170 greater for the OR group (P = .0074). ConclusionsThe similar rates of adverse events and follow-up procedures and significant differences in insertion cost suggest that IR TIVAD placement may be more cost effective than surgical placement without affecting the quality.

Prosthesis choice for tricuspid valve replacement: Comparison of clinical and echocardiographic outcomes

ObjectivesThere is limited evidence evaluating valve function and right heart remodeling after tricuspid valve replacement (TVR), as well as whether the choice of prosthesis has an impact on these outcomes. MethodsWe reviewed 1043 consecutive adult patients who underwent first-time TVR; 33% had previous aortic and/or mitral valve operations. Severe tricuspid valve regurgitation (TR) was the indication for surgery in 94% patients. A mechanical valve was used in 149 (14%) patients and a bioprosthetic valve in 894 (86%). Concomitant major cardiac procedures were performed in 57% of patients. ResultsThe median age of the cohort was 68.8 (range, 25-94) years, and 57% were female. Overall survival at 5 and 10 years was 50% and 31%, respectively. Adjusted survival and cumulative incidence of reoperation after TVR were similar in patients with bioprosthetic and mechanical valves. Overall, right ventricular (RV) function and dilation improved postoperatively with the estimated proportion of patients with moderate or greater RV systolic dysfunction/dilatation decreasing by around 20% at 3 years follow-up. After adjusting for preoperative degree of dysfunction/dilatation, valve type had no effect on late improvement in RV function and dilation. Bioprosthetic TVR was associated with greater rates of recurrence of moderate or greater TR over late follow-up. Overall, a slight decline in tricuspid valve gradients was observed over time. ConclusionsMechanical and bioprosthetic valves provide comparable survival, incidence of reoperation, and recovery of RV systolic function and size after TVR. Bioprosthetic valves develop significant TR over time, and mechanical valves may have an advantage for younger patients and those needing anticoagulation.

Oral Lactobacillus fermentum CECT5716 in the patients with lactational abscess treated by needle aspiration: The late follow-up of a randomized controlled trial.

Background:Lactational mastitis and breast abscess cause trouble for women. It has been shown that oral probiotics can improve breast microecology, thus alleviating inflammatory responses. Our study aims to understand the long-term effect of Lactobacillus fermentum CECT5716 on patients with lactational breast abscess after needle aspiration.Methods:Data continued in a randomized controlled study of 101 subjects with lactational abscess from 12 hospitals were included. They were randomly divided into an experimental group and a control group. After needle aspiration treatment, the experimental group was orally administrated with L fermentum CECT5716 for 4 consecutive weeks, while the control group was treated with maltodextrin in the same way). In the third month after randomized controlled trial, the subjects were followed up by an online questionnaire investigation. The observation indexes included the relief of breast pain, recurrence of mastitis from the end of oral administration to the follow-up, and the effect on continuing breastfeeding.Results:A total of 101 patients were enrolled and 83 valid questionnaires were received during follow-up, including 40 in the experimental group and 43 in the control group. The rate of stop breastfeeding due to recurrence of mastitis was 2.5% (1/40) in the experimental group and 18.6% (8/43) in the control group, with a statistically significant difference (odds ratio = 0.112, 95% confidence interval: 0.013–0.942, P < .05). The rate of stop breastfeeding was 10% (4/40) in the experimental group and 25.6% (11/43) in the control group, without significant difference. The pain relief rate in the experimental group was 80% (32/40), which showed no significant difference from that in the control group, that is, 72.1% (31/43). The recurrence rate of mastitis in the experimental group was 20% (8/40), which was not significantly different from that in the control group, that is, 16.3% (7/43).Conclusions:In lactating women with a history of breast abscess, oral L fermentum CECT5716 may reduce the risk of stop breastfeeding due to recurrence of mastitis.

Guidelines on the management of abdominal aortic aneurysms: updates from the Italian Society of Vascular and Endovascular Surgery (SICVE)

The objective of these Guidelines was to revise and update the previous 2016 Italian Guidelines on Abdominal Aortic Aneurysm Disease, in accordance with the National Guidelines System (SNLG), to guide every practitioner toward the most correct management pathway for this pathology. The methodology applied in this update was the GRADE-SIGN version methodology, following the instructions of the AGREE quality of reporting checklist as well. The first methodological step was the formulation of clinical questions structured according to the PICO (Population, Intervention, Comparison, Outcome) model according to which the Recommendations were issued. Then, systematic reviews of the Literature were carried out for each PICO question or for homogeneous groups of questions, followed by the selection of the articles and the assessment of the methodological quality for each of them using qualitative checklists. Finally, a Considered Judgment form was filled in for each clinical question, in which the features of the evidence as a whole are assessed to establish the transition from the level of evidence to the direction and strength of the recommendations. These guidelines outline the correct management of patients with abdominal aortic aneurysm in terms of screening and surveillance. Medical management and indication for surgery are discussed, as well as preoperative assessment regarding patients' background and surgical risk evaluation. Once the indication for surgery has been established, the options for traditional open and endovascular surgery are described and compared, focusing specifically on patients with ruptured abdominal aortic aneurysms as well. Finally, indications for early and late postoperative follow-up are explained. The most recent evidence in the Literature has been able to confirm and possibly modify the previous recommendations updating them, likewise to propose new recommendations on prospectively relevant topics.

Erdheim-Chester disease: An orbital MRI study.

e19085 Background: Erdheim-Chester disease (ECD) is a rare L-group histiocytosis. Orbital involvement is found in a third of cases, but few data are available concerning the radiological features of ECD-related orbital disease (ECD-ROD). Our aim was to characterize the initial radiological phenotype and outcome of patients with ECD-ROD. Methods: Initial and follow-up orbital MRI from the patients with histologically proven ECD at a national reference center were reviewed. Results: Pathological orbital findings were recorded for 45(33%) of the 137 patients included, with bilateral involvement in 38/45 (84%) cases. The mean age of these patients was 62 years (24-81) and 78% were men. Intraconal fat infiltration around the optic nerve sheath adjacent to the eye globe (52%), with intense gadolinium uptake and fibrous component was the most frequent phenotype described. Optic nerve signal abnormalities were observed in 47% of cases. Two patients presented bilateral homogeneous extraocular muscle enlargement suggestive of the myositis type of ECD-ROD. None had isolated dacryoadenitis. Only seven patients (15%) had normal brain MRI findings. ECD-associated paranasal sinus involvement and post-pituitary involvement were detected in 56% and 53% of patients respectively. A decrease/disappearance of the lesions was observed in 17/24(71%) of the patients undergoing late follow-ups. Interestingly, ECD-ROD only rarely (7/45(16%)) revealed the disease, with exophthalmos being the most frequently identified feature in this subgroup (3/45 (6%)). Conclusions: Even though ECD-ROD can be clinically silent, it constitutes a broad array of lesions often resulting in optic nerve signal abnormalities, the functional outcome of which remains to be established. ECD-ROD should thus be assessed initially and subsequently monitored by orbital MRI and ophthalmological follow-up.

The Change of Spinal Canal According to Oblique Lumbar Interbody Fusion in Degenerative Spondylolisthesis: A Prospective Observational Study.

ObjectiveOblique lumbar interbody fusion (OLIF) involves inserting large cages into the interbody disc space. This expands the spinal canal and neural foramen by stretching the ligament flavum and releasing the facet joint, resulting in indirect neural decompression. Our objective was to investigate the changes in the spinal canal and ligament flavum over time after OLIF. MethodsThis was a prospective observational study involving 30 patients who underwent OLIF L4–5 between 2015 and 2018. In total, 27 of the 30 patients underwent preoperative, early follow-up (< 5 days), and late follow-up (10–14 months) magnetic resonance imaging to measure the area of the spinal canal and ligament flavum. Based on the results, the patients were divided into subsidence and nonsubsidence groups for further analysis. ResultsAfter OLIF, the spinal canal area gradually increased during the preoperative, early postoperative, and late postoperative periods (p<0.001). The thickness and area of the ligament flavum decreased gradually over the same periods (p<0.001). Low-grade subsidence (2–4.4 mm) did not influence the effects on the spinal canal and ligament. ConclusionAfter OLIF, the spinal canal and ligament flavum gradually change, which is effective for indirect neural decompression. In addition, the effects of low-grade subsidence on the remodeling of the spinal canal and ligament flavum are insignificant.

Long-term outcomes after ulna shortening osteotomy: a mean follow-up of six years.

AimsThe primary aim of this study was to describe long-term patient-reported outcomes after ulna shortening osteotomy for ulna impaction syndrome.MethodsOverall, 89 patients treated between July 2011 and November 2017 who had previously taken part in a routine outcome evaluation up to 12 months postoperatively were sent an additional questionnaire in February 2021. The primary outcome was the Patient-Rated Wrist and Hand Evaluation (PRWHE) total score. Secondary outcomes included patient satisfaction with treatment results, complications, and subsequent treatment for ulnar-sided wrist pain. Linear mixed models were used to compare preoperative, 12 months, and late follow-up (ranging from four to nine years) PRWHE scores.ResultsLong-term outcomes were available in 66 patients (74%) after a mean follow-up of six years (SD 1). The mean PRWHE total score improved from 63 before surgery to 19 at late follow-up (difference in means (Δ) 44; 95% confidence interval (CI) 39 to 50; p = <0.001). Between 12 months and late follow-up, the PRWHE total score also improved (Δ 12; 95% CI 6 to 18; p = < 0.001). At late follow-up, 14/66 of patients (21%) reported a PRWHE total score of zero, whereas this was 3/51 patients (6%) at 12 months (p = 0.039). In all, 58/66 patients (88%) would undergo the same treatment again under similar circumstances. Subsequent treatment (total n = 66; surgical n = 57) for complications or recurrent symptoms were performed in 50/66 patients (76%). The most prevalent type of reoperation was hardware removal in 42/66 (64%), and nonunion occurred in 8/66 (12%).ConclusionUlna shortening osteotomy improves patient-reported pain and function that seems to sustain at late follow-up. While satisfaction levels are generally high, reoperations such as hardware removal are common.Cite this article: Bone Jt Open 2022;3(5):375–382.

Erdheim-Chester disease: look it in the eye. An orbital magnetic resonance imaging study.

Erdheim-Chester disease (ECD) is a rare L-group histiocytosis. Orbital involvement is found in a third of cases, but few data are available concerning the radiological features of ECD-related orbital disease (ECD-ROD). Our aim was to characterize the initial radiological phenotype and outcome of patients with ECD-ROD. Initial and follow-up orbital magnetic resonance imaging (MRI) from the patients with histologically proven ECD at a national reference center were reviewed. Pathological orbital findings were recorded for 45 (33%) of the 137 patients included, with bilateral involvement in 38/45 (84%) cases. The mean age (± standard deviation) of these patients was 60 (±11.3) years and 78% were men. Intraconal fat infiltration around the optic nerve sheath adjacent to the eye globe (52%), with intense gadolinium uptake and a fibrous component was the most frequent phenotype described. Optic nerve signal abnormalities were observed in 47% of cases. Two patients had bilateral homogeneous extraocular muscle enlargement suggestive of a myositis-like involvement of ECD-ROD. None had isolated dacryoadenitis but in 17 eyes dacryodenitis was described in association with other types of orbital lesions. Only seven patients (15%) had normal brain MRI findings. ECD-associated paranasal sinus involvement and post-pituitary involvement were detected in 56% and 53% of patients, respectively. A decrease/disappearance of the lesions was observed in 17/24 (71%) of the patients undergoing late (>12 months) followups. Interestingly, ECD-ROD only rarely (7/45; 16%) revealed the disease, with exophthalmos being the most frequently identified feature in this subgroup (3/45; 6%). Even though ECD-ROD can be clinically silent, it comprises a broad array of lesions often resulting in optic nerve signal abnormalities, the functional outcome of which remains to be established. ECD-ROD should thus be assessed initially and subsequently monitored by orbital MRI and ophthalmological follow-up.

Patellar Tracking in Total Knee Arthroplasty-Influence on Clinical and Functional Outcome.

Anterior knee pain is a common problem after primary total knee arthroplasty (TKA). The aim of this study was to find parameters in patellar positioning which influence the clinical and functional outcome after TKA. Included were 59 patients who underwent TKA, of which three patients were treated bilaterally (n = 62 included knees). In a periodical follow-up of up to 5 years, each patient had to answer three questionnaires (HSS, WOMAC, SF-36) and underwent three radiographies of the knee (including merchant view) and a clinical examination, including Range Of Motion (ROM). All radiographs were evaluated by a single observer blinded to clinical data, who collected multiple parameters of sagittal and axial patellar alignment including newly developed methods for measuring patellar shift and tilt. Depending on the measurement results, three groups were built for each parameter and the influence on the outcome was determined. A lateral patellar tilt of more than 4° resulted in lower scores for both the HSS and WOMAC. The rarely investigated patellar facet angle showed a significantly inferior clinical and functional outcome in late follow-up of >24 months if lower than 142°, possibly due to progressive osteosclerotic changes of the patella caused by increased contact stress with corresponding patellar morphology. No significant difference was found for all other parameters. The newly developed method for measuring patellar shift has proven to be a valuable and easy instrument in the postoperative setting.

P 46 Effects of repetitive neuromuscular magnetic stimulation targeting to the upper trapezius muscles in children with headache disorders

Question To assess clinical and muscular effects of a repetitive neuromuscular magnetic stimulation (rNMS) intervention targeting to the upper trapezius muscles (UTM) in pediatric patients with headache disorders. Methods A retrospective chart review resulted in 23 patients with migraine, migraine + tension-type headache (TTH), or post-traumatic headache (PTH), who received 28 rNMS interventions in a pediatric headache center. During 6 sessions, rNMS was delivered to UTM bilaterally (duration: 15min/side, frequency: 20 Hz, 7s ON-time, 10s OFF-time). Headache frequency, duration, and intensity 3 months before and after treatment were recorded using a customized standardized questionnaire prior to the first treatment and at follow-up (FU). We categorized patients into responder classes based on the relative reduction in headache frequency (≥25%, ≥50%, ≥75%). Effects on the muscular level were assessed by pressure pain thresholds (PPTs) above the UTM before, during rNMS treatment, and at FU after 4 to 20 weeks. Results Data from 20 patients were analyzed (14.10 ± 2.69 years; 60% females) as 2 patients were lost to FU and data of 1 patient was classified as outlier based on a late FU (3 SDs above mean FU time) and excluded from analysis. Compared to baseline, headache frequency (p=.017) and minimum and maximum headache intensities (p=.017; p=.023) were significantly reduced at FU. 11 patients (44%) were classified as ≥25% responders, with 7 patients (28%) experiencing a ≥75% reduction of monthly headache days. PPTs above the UTM significantly increased from baseline (left lateral: 2.00 ± 1.37, left medial: 1.96 ± 1.27, right medial: 1.83 ± 1.26, right lateral: 1.94 ± 1.37) to the last treatment session (left lateral: 3.28 ± 2.21, left medial: 3.17 ± 1.99, right medial: 3.17 ± 2.06, right lateral: 3.24 ± 2.25) (left lateral: p=.002, left medial: p=.002, right medial: p=.001, right lateral: p=.003). This increase from baseline sustains until FU (left lateral: 2.87 ± 2.11, left medial: 2.95 ± 2.11, right medial: 2.95 ± 2.11, right lateral: 2.81 ± 2.04) (left lateral: p=.047, left medial: p=.012, right medial: p=.002, right lateral: p=.028). After 14 rNMS interventions in the primary headache group, 6 patients (43%) were classified as ≥25% responders, with 2 patients (14%) experiencing a ≥75% reduction of monthly headache days. After 11 rNMS interventions in the PTH group, 5 patients (46%) were classified as ≥25% responders, with 5 patients (46%) experiencing a ≥75% reduction of monthly headache days. Conclusion Beneficial effects regarding headache characteristics and muscular PPTs were documented in pediatric patients with headache disorders. The latter having a sustained effect up to weeks to months. Based on the concept of the trigemino-cervical complex, rNMS of the UTM may act via neuromodulation of nociceptive processing at the central level.

Comparison of Early and Late Postoperative Outcomes Between INTERMACS 1/2 vs. 3/4

<h3>Purpose</h3> The INTERMACS profiles are established as important selection and prognostic criteria for Left Ventricular Assist Devices (LVAD) implantation. We sought to investigate the correlation of higher acuity INTERMACS profile and post-LVAD implantation outcomes in carefully selected and optimized patients. <h3>Methods</h3> We conducted a retrospective analysis of all HeartMate 3 LVAD (HM3) implantations in our institution between September 2015 and April 2021. Baseline characteristics and clinical outcomes were compared based on pre-implantation INTERMACS profiles: 1 and 2 (IP1-2) vs. 3 and 4 (IP3-4). Our primary study endpoint was the composite of stroke events and death from time of HM3 implantation through late follow-up. <h3>Results</h3> Of 234 patients implanted with a HM3 during the study period, 116 (49.6%) presented in cardiogenic shock IP1-2, while 118 (50.4%) were less acute IP3-4 (Table 1). Patients in IP1-2 at time of LVAD implantation were younger with de-novo heart failure and worse end-organ function. Postoperatively, patients in the IP1-2 group experienced higher rates of early adverse events including severe right ventricular failure (9% vs. 3%, p=0.025) and prolonged hospital length of stay. There was no statistically significant difference in the Kaplan-Meier estimator (Figure 1.) for the composite end-point of death and stroke between IP groups. <h3>Conclusion</h3> INTERMACS 1/2 patients implanted with HM3 LVAD were younger, had longer intubation times, and longer ICU and hospital lengths of stay. Clinical outcomes were similar between the groups with INTERMACS 3/4 patients showing a trend toward a lower composite event rate of stroke and death.

Treatment of venous malformations with tumescent-assisted sclero-embolic and ablative lasers (SEALs): Safe and effective long-term outcomes.

Perivascular infiltration of tumescent anaesthesia (TA) is an essential element of endovenous thermal ablative procedures employed to treat superficial venous disease. In addition to anaesthesia, TA is administered to achieve vessel wall approximation and to protect surrounding structures from thermal damage. However, its role in the treatment of venous malformations (VMs) has not been established. To assess the safety and efficacy of tumescent-assisted thermal and chemical ablative methods in the treatment of VMs. Adult and paediatric patients presenting with VMs were treated using a combination of endovenous laser ablation, foam embolo-sclerotherapy and liquid embolisation using n-BCA. All procedures were ultrasound-guided. Treatment outcomes were assessed in early and late follow-ups. To assess the efficacy of TA in achieving vessel wall approximation, cross-sectional lesional diameters were measured by ultrasound, before and after the administration of TA during endovenous procedures. In a 12month period, 22 patients recruited in the study presented with 27 VMs which included 23 extra-truncular lesions (16 subcutaneous and seven intramuscular) and four truncular anomalies. On average the subcutaneous lesions measured 5.5mm (1.9-24.5mm) in diameter, intramuscular lesions measured 9.2mm (5.9-15.1mm) and truncular anomalies measured 4.9mm (1.2-12mm) in diameter. Perivascular infiltration of TA resulted in a significant reduction in vessel calibre (90% reduction on average). Intramuscular VMs were less compressible with TA (69.2% reduction) compared to subcutaneous lesions (98% reduction). Truncular anomalies such as the embryonic marginal vein achieved complete approximation (100% reduction). Procedures were safely tolerated with no major complications such as thromboembolism, stroke, nerve damage or tissue necrosis. Most patients had significant clinical as well as ultrasonographic improvement. Tumescent-assisted endovenous laser ablation and foam sclerotherapy provides safe and effective outcomes in patients with a variety of VMs.

Minimally Invasive Resection of the Uncinate Process of the Pancreas: Anatomical Considerations and Surgical Technique.

Low-grade lesions may benefit from pancreatic-sparing techniques. Resection of the uncinate process is rarely performed and reported due to its complexity that requires careful patient selection and accurate knowledge of the pancreatic anatomy. This study describes relevant anatomical elements to safely perform this complex operation in the minimally invasive setting. In this study, consecutive patients undergoing resection of the uncinate process of the pancreas were studied. Patients undergoing open approach were used for comparison. Preoperative and intraoperative variables were recorded, and the diagnosis and tumor size were determined from the pathology reports. Immediate postoperative results and hospital stay were analyzed. Follow-up was used to assess long-term complications and endocrine and exocrine functions. Twenty-nine patients underwent resection of the uncinate process. The median age was 57 years. There were 21 males and eight females. Twenty patients underwent minimally invasive resection (14 laparoscopic and six by robotic approach) and nine were operated by open approach. A clinically relevant postoperative pancreatic fistula was observed in one patient (3.4%). Biochemical leakage was present in 44.8% of our patients. Mean follow-up was 62 months (3-147). Two patients needed reoperation during follow-up. No patient presented exocrine or endocrine insufficiency during late follow-up. Minimally invasive resection of the uncinate process of the pancreas is a complex but a feasible procedure that preserves the pancreatic endocrine and exocrine functions. This pancreas-sparing procedure is an interesting alternative to pancreaticoduodenectomy in selected patients.

Predictors of survival in paediatric mitral valve surgery: the impact of age at operation at late follow-up.

The aim of this study was to elucidate predictors of death and reintervention after mitral valve (MV) surgery in children. A single-centre retrospective study was performed enrolling 142 patients younger than 18 years who underwent primary index surgical mitral repair or replacement at Bambino Gesù Children's Hospital in Rome from July 1982 to April 2020. Patients with complete, transitional or partial atrioventricular septal defect and patients with single ventricle physiology were excluded. Patients were stratified according to the age group: group 1 (<1 year old), group 2 (1-5 years old) and group 3 (>5 years old). The composite primary outcome was freedom from death or transplant. The secondary outcome was freedom from redo MV surgery. Transplant-free survival was 89% at 5 years and 88% at 10 years. Stratified by age, group 1 had poorer outcome in comparison with other groups (log-rank test P = 0.105). Both univariate and multivariate analyses showed that age <1 year was a significant risk factor for death or transplant (P = 0.044). Age <1 year was associated with increased risk of reoperation (aHR = 3.38, P = 0.009), while the presence of genetic syndrome (aHR = 0.22) and preoperative EF% (aHR = 0.97) were protective factors for reoperation. The overall survival and freedom from reoperation in children undergoing MV surgery still need improvements. Younger age was a significant risk factor for death and reintervention both after repair and replacement of the MV. In particular, infants and neonates have a three-fold risk for death compared to children.

Hypertrophic Obstructive Cardiomyopathy: Comparison of Outcomes After Myectomy or Alcohol Ablation.

Introduction and ObjectivesThe risk of ventricular arrhythmia and heart failure in patients with hypertrophic obstructive cardiomyopathy (HOCM) is much higher than that in the general population. More and more pieces of evidence showed that HOCM is the leading cause of sudden cardiac death in young people. We reported our experience in a study, comparing surgical myectomy, alcohol septal ablation (ASA), and medical therapy.MethodsThe original cohort included 965 consecutive patients with HOCM. The patients were divided into three groups according to treatment strategies: myectomy group (n = 502), ASA group (n = 138), and medical treatment group (n = 325). The median follow-up duration was 42.99 ± 18.32 months, and the primary endpoints were all-cause mortality and heart transplantation.ResultsBoth in short- and long-term observations, surgical myectomy reduced the left ventricular outflow tract (LVOT) gradients more effectively (7 days, 16.15 ± 12.07 mmHg vs. 42.33 ± 27.76 mmHg, p < 0.05; 1 year, 14.65 ± 13.18 mmHg vs. 41.17 ± 30.76 mmHg, p < 0.05). Among the three groups, the patients in the medical treatment group were at a higher risk of mortality and cardiac transplantation (vs. the myectomy group, p < 0.001 by log-rank test; vs. the alcohol septal ablation group, p = 0.017 by log-rank test), and the myectomy group shows a lower risk of reaching the primary endpoint than the two other groups. In the multivariate Cox regression analysis, previous atrial fibrillation (AF), N terminal pro B type natriuretic peptide (NT-pro-BNP), and surgical myectomy predicted an HOCM prognosis. However, the impact of surgical myectomy on HOCM prognosis seems to be limited to the <56 years group.ConclusionsThe patients with medical treatments seemed to suffer from the highest risk of achieving an all-cause mortality and the endpoint of heart transplantation. In the long-term survival and clinical outcome, myectomy seemed better than alcohol septal ablation, especially the younger patients. Due to the less-controllable degree, periprocedural complication frequency after alcohol septal ablation was higher, compared with myectomy. Furthermore, gradients after myectomy are lower at late follow-up. To sum up, when selecting treatment strategies, the patients should be individually evaluated by a multidisciplinary team of cardiologists and surgeons.

Excision and suture in the midline versus Karydakis flap surgery for pilonidal sinus: randomized clinical trial.

BackgroundThere are several surgical options for the management of pilonidal disease, including midline and off midline closure, but prospective studies are rare. The study hypothesis was that Karydakis flap surgery would result in shorter wound healing and fewer recurrences than excision of pilonidal sinus and suture in the midline.MethodsA randomized clinical trial was conducted in two hospitals in Sweden between 2006 and 2015 to compare excision and suture in the midline with Karydakis flap surgery. Adult patients with a chronic pilonidal sinus disease were randomized 1:1 at the outpatient clinic without blinding. Power calculation based on recurrence of 2 per cent for Karydakis flap and 10 per cent for excision and primary closure in the midline required 400 patients with 90 per cent statistical power at 5 per cent significance assuming 10 per cent loss during follow-up. Participants were followed up until complete wound healing; late follow-up after 6–13 years was performed by telephone by two blinded assessors. The two co-primary outcomes were time to complete wound healing and recurrence rate.ResultsThe study was terminated early at a planned interim analysis due slow recruitment and a significant difference in primary outcome. In total, 125 patients were randomized, of whom 116 were available for the present analysis. Median wound healing time was 49 days (95 per cent confidence interval (c.i.) 32 to 66) for excision with suture in the midline and 14 days (95 per cent c.i. 12 to 20) for Karydakis flap surgery (P < 0.001). There were five recurrences in each group, after a median follow-up of 11 years (P = 0.753).ConclusionKarydakis flap surgery for pilonidal sinus disease led to a shorter wound healing time than excision and suture in the midline but no difference in recurrence rates.Registration number: NCT00412659 (http://www.clinicaltrials.gov)

Association between admission blood glucose and prognosis in non-diabetic patients with first-ever acute myocardial infarction

Background: Admission hyperglycemia has been associated with major adverse cardiovascular and cerebrovascular events (MACCEs) in patients with acute coronary syndrome.Methods: In this study we sought to determine the association between admission blood sugar (ABS) and the outcomes of non-diabetic patients with first-ever acute myocardial infarction (MI). Non-diabetic patients with MI were evaluated from March 2016 to March 2019. Baseline characteristics, laboratories, electrocardiogram, and baseline left ventricular ejection fraction (LVEF) were recorded. All patients were followed up and outcomes were obtained. Follow-up data comprised of repeating electrocardiogram and echocardiography at 1 year, and MACCE, including re-MI, stroke, and mortality.Results: A total of 312 patients with a mean age of 54.2 ± 11.9 years were evaluated. All patients were followed up for a median of 38 months. The frequencies of in-hospital mortality and MACCE at late follow-up were higher in third tertile of ABS compared with those in first and second tertiles (both p <0.05). Based on the Cox regression analysis, the independent predictors of MACCE included age (hazard ratio [HR] 1.068, 95% confidence interval [CI] 1.033 - 1.105, p <0.001), third tertile of ABS >172 mg/dL (HR 21.257, 95% CI 2.832 - 159.577, p=0.003), and baseline LVEF (HR 0.947, 95% CI 0.901 - 0.995, p=0.031).Conclusion: Admission stress hyperglycemia is associated with increased rates of in-hospital mortality and MACCE at late follow-up in non-diabetic patients with MI. Moreover, elevated ABS, older ages, and a decreased value of baseline LVEF predicted MACCE during follow-up.

Short and long-term follow-up results of soleus muscle rotation flap for coverage of soft tissue defects of proximal and middle leg

Objective: &#x0D; To observe the short and long-term outcomes of the soleus muscle rotation flap for coverage of soft tissue defects of proximal and middle leg.&#x0D; Study Design:&#x0D; Case series&#x0D; Place and duration of study&#x0D; Departments of Plastic and Reconstructive Surgery of Bahawal Victoria Hospital Bahawalpur, Combined Military Hospital Bahawalpur, and Combined Military Hospital Quetta from December 2014 to February 2020..&#x0D; Materials and methods&#x0D; In total, 36 patients were enrolled for the study through consecutive sampling. Data was processed using SPSS-17. All patients were reviewed at first and second week (early morbidity), and then at six months (late morbidity) from operation. During early follow up, they were examined for hematoma at donor site, wound infection, sural nerve injury, graft loss, and flap necrosis. In late follow-up, patients were examined for reduced knee mobility, muscle weakness, sensory abnormalities, hypertrophic scarring, hyperkeratosis, and soleus muscle contractures.&#x0D; Results &#x0D; The studied patients consisted of 30 (90.9%) men and 3 (0.9%) women. The mean age was 35 years (range: 16 to 64) years. Hematoma was the commonest complication. It occurred in 6.1%. Wound infection, partial loss of flap, partial loss of skin graft and wound infection occurred in 3.03% patients. Late follow up revealed reduced knee mobility in 9.09% patients (n=3) and bothersome contraction of soleus muscle in same number of patients.&#x0D; Conclusion&#x0D; The soleus flap is reliable, versatile, and very useful for provision of supple soft tissue coverage for defects in upper and middle leg.

Ratio of the false lumen to the true lumen is associated with long-term prognosis after surgical repair of acute type A aortic dissection

ObjectivesThe aim of this study was to assess potential predictors of aortic events after an emergency surgery for acute type A aortic dissection, especially paying attention to the findings of computed tomography (CT) performed immediately after the surgery. MethodsBetween January 2001 and December 2015, 72 patients, who were diagnosed as having Stanford type A acute aortic dissection with a patent false lumen in the descending thoracic aorta, survived the emergency operation, and had postoperative CT scan data, were included in this study (mean follow-up, 8.2 ± 3.8 years; range 0.8-17.4 years). From the CT scan data, the diameter of the false lumen (FL-D) and true lumen (TL-D) were measured, and the FL-D:TL-D ratio was calculated. Long-term outcomes of the FL-D > TL-D group (n = 30) and the FL-D < TL-D group (n = 42) were compared. ResultsIn the late follow-up, 17 aortic events in the downstream aorta were observed. The FL-D:TL-D ratio (P = .01) was an adjusted risk of aortic events in multivariable analysis. The rates of freedom from aortic events at 5 and 9 years were superior in the FL-D < TL-D group than in the FL-D > TL-D group (92.0% and 88.6% vs 81% and 60.7%; log rank P < .05). ConclusionsOur results suggest that the false lumen:true lumen ratio predicts long-term prognosis after surgical repair of acute type A aortic dissection.

A Prospective Randomized Study Comparing Ceftolozane/Tazobactam to Standard of Care in the Management of Neutropenia and Fever in Patients With Hematological Malignancies.

BackgroundWith increased use of antibiotics in high-risk patients, the investigation of new antibiotics to cover potentially resistant pathogens is warranted. In this prospective randomized trial, we compared ceftolozane/tazobactam (C/T), a new cephalosporin/β-lactamase inhibitor, to the standard of care (SOC) for the empiric treatment of neutropenia and fever in patients with hematological malignancies.MethodsWe enrolled 100 patients to receive intravenous (IV) C/T or SOC antibiotics (cefepime, piperacillin/tazobactam, or meropenem) in combination with gram-positive antibacterial agents. We evaluated responses at the end of IV therapy (EOIV), test of cure (TOC; days 21–28), and late follow-up (LFU; days 35–42).ResultsWe analyzed 47 C/T patients and 50 SOC patients. C/T patients had a higher rate of favorable clinical response at EOIV (87% vs 72%). A 1-sided noninferiority analysis indicated that C/T was at least not inferior to the SOC for favorable clinical response at EOIV (P = .002), TOC (P = .004), and LFU (P = .002). Superiority tests showed that C/T led to significantly lower rates of clinical failure at TOC (6% vs 30%; P = .003) and LFU (9% vs 30%; P = .008). C/T and SOC patients with documented infections had similar rates of favorable microbiological response. Serious adverse events leading to drug discontinuation (2% vs 0%; P = .48) and overall mortality (6% vs 4%; P = .67) were similar in both groups.ConclusionsThe empiric use of C/T in high-risk patients with hematological malignancies and febrile neutropenia is safe and associated with better clinical outcomes than SOC antimicrobial agents.Clinical Trials RegistrationNCT03485950.