Outcomes Of Placement Research Articles

Usefulness of the obturator hook technique for guiding the initial trajectory control in infra-acetabular screw placement.

Proper placement of infra-acetabular screws is technically demanding; there is a limited safe zone for screw fixation because of the complexity of the bone anatomy around the hip joint and the vulnerability of the major neurovascular bundles in the pelvic cavity. We aimed to present the obturator hook technique as a surgical technique for infra-acetabular screw placement in acetabular and pelvic fractures and report its radiological outcomes. Patients treated with infra-acetabular screw placement using the obturator hook technique between January 2015 and August 2020 were enrolled in this study. We collected data on demographics, surgical approach, reduction status, complications, and outcomes. The radiological outcomes of infra-acetabular screw placement based on computed tomography findings were evaluated as follows: success, articular penetration, or out of the bone. Thirty-five patients underwent infra-acetabular screw placement (26 men, 9 women; mean age, 55 years; range, 27-90 years). One patient underwent bilateral infra-acetabular screw placement; therefore, 36 infra-acetabular screws were inserted in all patients. An ideal placement was achieved with 27 infra-acetabular screws (27/36, 75%). Seven infra-acetabular screws (7/36, 19%) showed articular penetration, and two infra-acetabular screws (2/36, 6%) were placed outside the bone. One patient with articular penetration and mechanical symptoms of the hip joint required screw replacement. No other complications, including obturator nerve and vascular injuries, were observed. The obturator hook technique could be a favorable and individualized method for infra-acetabular screw placement in patients with acetabular and pelvic fractures. IV, retrospective descriptive study.

Long-Term Clinical and Radiologic Outcomes after Stent-Graft Placement for the Treatment of Late-Onset Post-Pancreaticoduodenectomy Arterial Hemorrhage.

PurposeTo evaluate the long-term radiologic and clinical outcomes of stent-graft placement for the treatment of post-pancreaticoduodenectomy arterial hemorrhage (PPAH) based on the imaging findings of stent-graft patency and results of liver function tests.Materials and MethodsWe retrospectively reviewed the medical records of nine consecutive patients who underwent stent-graft placement for PPAH between June 2012 and May 2017. We analyzed the immediate technical and clinical outcomes and liver function test results. Stent-graft patency was evaluated using serial CT angiography images.ResultsAll stent-grafts were deployed in the intended position for the immediate cessation of arterial hemorrhage and preservation of hepatic arterial blood flow. Technical success was achieved in all nine patients. Eight patients survived after discharge, and one patient died on postoperative day 28. The median follow-up duration was 781 days (range: 28–1766 days). Follow-up CT angiography revealed stent-graft occlusion in all patients. However, serum aspartate aminotransferase or alanine aminotransferase levels in all patients were well below those observed in hepatic infarction cases.ConclusionStent-graft placement is a safe and effective treatment method for acute life-threatening PPAH. Liver function and distal hepatic arterial blood flow were maintained postoperatively despite the high incidence of stent-graft occlusion observed on follow-up CT.

Short-term outcomes of stents in obstructive rectal cancer: A systematic review and meta-analysis.

Background:With acute obstruction due to rectal or recto-sigmoid cancer, the safety and success of deploying self-expandable metal stents has been controversial. The aim of this systematic review was to synthesize the existing evidence on the outcomes and complication rates of stent placement in these patients.Methods:We performed a literature search of PubMed by using appropriate keywords, and manual reference screening of included articles was done. The article screening, data extraction, and quality assessment was done by four independent reviewers. A meta analyses was performed for the main outcome measures: technical and clinical success and complication rates.Results:We identified 962 articles in the search. After applying inclusion and exclusion criteria, we included 32 articles in the meta-analysis. The pooled technical success rate across 26 studies that reported it was 97% [95% confidence interval (CI): 95%-99%] without evidence of significant heterogeneity (I2= 0.0%, P = 0.84), and the clinical success rate across 26 studies that reported it was 69% (95% CI: 58%-79%) with evidence of significant heterogeneity (I2= 81.7%, P < 0.001). The pooled overall complication rate across the 32 studies was 28% (95% CI: 20%-37%) with evidence of significant heterogeneity (I2= 79.3%, P < 0.001).Conclusion:The use of rectal stents in obstructing rectal or recto-sigmoid tumors seems to be technically feasible. A high rate of technical success, however, does not always translate into clinical success. A considerable complication rate is associated with this approach. Randomized controlled trials are needed to compare the outcomes of rectal stent placement with those of surgery.

Laparoscopic-Assisted Percutaneous Endoscopic Gastrostomy Reduces Major Complications in High-Risk Pediatric Patients.

PurposePercutaneous endoscopic gastrostomy (PEG) is a safe method to feed patients with feeding difficulty. This study aimed to compare the outcomes of conventional PEG and laparoscopic-assisted PEG (L-PEG) placement in high-risk pediatric patients.MethodsIn our tertiary pediatric department, 90 PEG insertions were performed between 2014 and 2019. Children with severe thoracoabdominal deformity (TAD), previous abdominal surgery, ventriculoperitoneal (VP) shunt, and abdominal tumors were considered as high-risk patients. Age, sex, diagnosis, operative time, complications, and mortality were compared among patients who underwent conventional PEG placement (first group) and those who underwent L-PEG placement (second group).ResultsWe analyzed the outcomes of conventional PEG placement (first group, n=15; patients with severe TAD [n=7], abdominal tumor [n=6], and VP shunts [n=2]) and L-PEG placement (second group, n=10; patients with VP shunts [n=5], previous abdominal surgery [n=4], and severe TAD [n=1]). Regarding minor complications, 1 (6.6%) patient in the first group underwent unplanned PEG removal and 1 (10%) patient in the second group had peristomal granuloma. We observed three major complications: colon perforation (6.6%) in a patient with VP shunt, gastrocolic fistula (6.6%) in a patient with Fallot-tetralogy and severe TAD, and pneumoperitoneum (6.6%) caused by early tube dislodgement in an autistic patient with severe TAD. All the three complications occurred in the first group (20%). No major complications occurred in the second group.ConclusionIn high-risk patients, L-PEG may be safer than conventional PEG. Thus, L-PEG is recommended for high-risk patients.

Esthetic Outcome of Computer-Guided Versus Free-Hand Immediate Implant Placement In Fresh Extraction Sockets in Esthetic Zone, A Randomized Clinical Trial

Aim: to compare the esthetic outcome of two surgical techniques used in single immediate implant placement(computer guided vs free hand) in the esthetic zone in terms of pink esthetic score (PES) and gingivalrecession (GR).Methods: This was a randomized clinical trial, where twenty patients with a failing tooth in the esthetic zonewere recruited for immediate implant placement and restored with non-functional provisional crowns. Theywere randomly allocated to either computer guided (test group) or free hand (control group). Six monthsafter surgery the patients were restored with their definitive crowns. Pink esthetic score was recorded twice(after surgery and after definitive crown), while gingival recession was recorded after the definitive crown.Results: No statistically significant difference was found between the mean differences of pink esthetic scorebetween both groups and within each group overtime. Regarding gingival recession, 2 implants showedgingival recession in the computer guided group while none in the free hand group.Conclusions: Within the limitations of this study (sample size and follow-up duration), immediate implantplacement using computer guided surgical guides would consume more time, effort and expenses yet itprovided similar results with the free hand which seems beneficial for the learning curve for unexperiencedclinicians.

Mortality and Health Outcomes for Older Adults Screened by an Area Agency on Aging Over a 4.5-Year Period

Area Agencies on Aging (AAA) screen older adults and oversee delivery of a wide range of home- and community-based services (HCBS). We examined the assessment process, services, and mortality and health outcomes for older adults screened by an Area Agency on Aging in west-central Florida. Most were self/family referred (78.9%). Using data from July 2013-December 2018, 23,225 older adults were screened. Individuals had an average of 2.6 years follow-up in the dataset, during which time 63.6% received additional assessments: follow-up screening (50.6%), comprehensive assessment for enrollment in HCBS (35.7%), or assessments for congregate meals or other services (13.7%). Results revealed differences in mortality: 22.5% of clients receiving services died compared to 32.1% of clients prioritized as lower risk and on waiting lists for services. Long-term care placement and functional decline outcomes also will be reviewed, along with implications for service delivery and managing waitlists.

An institutional analysis of graduate outcomes reveals a contemporary workforce footprint for biomedical master's degrees.

There is continued growth in the number of master's degrees awarded in the life sciences to address the evolving needs of the biomedical workforce. Academic medical centers leverage the expertise of their faculty and industry partners to develop one to two year intensive and multidisciplinary master's programs that equip students with advanced scientific skills and practical training experiences. However, there is little data published on the outcomes of these graduates to evaluate the effectiveness of these programs and to inform the return on investment of students. Here, the authors show the first five-year career outlook for master of science graduates from programs housed at an academic medical center. Georgetown University Biomedical Graduate Education researchers analyzed the placement outcomes of 1,204 graduates from 2014-2018, and the two-year outcomes of 412 graduates from 2016 and 2017. From the 15 M.S. programs analyzed, they found that 69% of graduates entered the workforce, while 28% entered an advanced degree program such as a Ph.D., allopathic or osteopathic medicine (M.D. or D.O.), or health professions degree. International students who pursue advanced degrees largely pursued Ph.D. degrees, while domestic students represent the majority of students entering into medical programs. Researchers found that a majority of the alumni that entered the workforce pursue research-based work, with 59% of graduates conducting research-based job functions across industries. Forty-nine percent of employed graduates analyzed from 2016 and 2017 changed employment positions, while 15% entered advanced degree programs. Alumni that changed positions changed companies in the same job function, changed to a position of increasing responsibility in the same or different organization, or changed to a different job function in the same or different company. Overall, standalone master's programs equip graduates with research skills, analytical prowess, and content expertise, strengthening the talent pipeline of the biomedical workforce.

Outcomes of concomitant mesh placement and intestinal procedures during open ventral hernia repair.

The concept of mesh use during open ventral hernia repair with a concomitant intestinal procedure remains controversial and it remains unclear whether the SSI profile of contaminated fields in this setting more closely resembles clean-contaminated or dirty wounds. Patients who underwent an open ventral hernia repair and intestinal procedures were extracted from the ACS-NSQIP database. Data analysis was performed for mesh versus no mesh groups in aggregate and matched cohorts. The 30-day outcomes including mortality, morbidity, surgical site infections (SSI), readmission, reoperation, and length of stay were compared between the groups. Of 5104 patients in the mesh group, 3297 patients were matched 1:1 with patients without mesh. Mesh placement was associated with higher overall morbidity (35.1% vs. 29.8%; p < 0.001), overall SSI (27.1% vs. 18%; p < 0.001), deep SSI (5.9% vs. 4.3%; p = 0.003), organ-space SSI (6.8% vs. 5.5%; p = 0.027), reoperation (9.9% vs. 8.2%; p = 0.016), readmission (16.7% vs. 12.7%; p < 0.001), and longer hospital stays (10.9 ± 15.2 vs. 9.7 ± 10.7; p < 0.001). When mesh was used, the SSI profile of contaminated fields was similar to dirty wounds (26.4% vs. 27.5%; p = 0.702), rather than clean-contaminated fields (26.4% vs. 19.2%; p < 0.001). Concomitant bowel procedure and mesh placement at the time of open ventral hernia repair was associated with worse outcomes. The SSI profile of the contaminated fields was more similar to dirty wounds. When deciding whether to place mesh during ventral hernia repairs with concomitant bowel procedures, strong consideration should be given to the increased risk of short-term complications versus the potential long-term benefits.

Hemorrhagic Complications of Invasive Intracranial Pressure Monitor Placement in Acute Liver Failure: Outcomes of a Single-Center Protocol and Comprehensive Literature Review.

Elevated intracranial pressure due to cerebral edema is associated with very poor survival in patients with acute liver failure (ALF). Placing an intracranial pressure monitor (ICPm) aids in management of intracranial hypertension, but is associated with potentially fatal hemorrhagic complications related to the severe coagulopathy associated with ALF. An institutional Acute Liver Failure Clinical Protocol (ALF-CP) was created to correct ALF coagulopathy prior to placing parenchymal ICP monitoring bolts. We aimed to investigate the frequency, severity, and clinical significance of hemorrhagic complications associated with ICPm bolt placement in the setting of an ALF-CP. All assessed patients were managed with the ALF-CP and had rigorous radiologic follow-up allowing assessment of the occurrence and chronology of hemorrhagic complications. We also aimed to compare our outcomes to other studies that were identified through a comprehensive review of the literature. Fourteen ALF patients were included in our analysis. There was no symptomatic hemorrhage after ICP monitor placement though four patients were found to have minor intraparenchymal asymptomatic hemorrhages after liver transplant when the ICP monitor had been removed, making the rate of radiographically identified clinically asymptomatic hemorrhage 28.6%. These results compare favorably to those found in a comprehensive review of the literature which revealed rates as high as 17.5% for symptomatic hemorrhages and 30.4% for asymptomatic hemorrhage. This study suggests that an intraparenchymal ICPm can be placed safely in tertiary referral centers which utilize a protocol such as the ALF-CP that aggressively corrects coagulopathy. The ALF-CP led to advantageous outcomes for ICPm placement with a 0% rate of symptomatic and low rate of asymptomatic hemorrhagic complications, which compares well to results reported in other series. A strict ICPm placement protocol in this setting facilitates management of ALF patients with cerebral edema during the wait time to transplantation or spontaneous recovery.

Multicenter surgical outcomes of penile prosthesis placement in patients with corporal fibrosis and review of the literature.

Penile prosthesis (PP) insertion in the setting of corporal fibrosis can be challenging and a variety of techniques have been described to accomplish this, however the necessity of these maneuvers is debatable. Our objective was to investigate techniques and outcomes of PP placement in patients with corporal fibrosis at tertiary referral centers. Multicenter outcomes of 42 patients (mean age 53.4 ± 1.9 years) with corporal fibrosis who underwent placement of PP over a 10-year period were reviewed. The most common etiology of corporal fibrosis was prior PP explant due to either infection (40.5%) and/or erosion (16.7%). Fourteen patients (33.3%) had a history of priapism, 5 (11.9%) of which had one or more distal surgical penile shunts. Techniques used for PP placement included: sequential dilation (8-12 mm) with standard dilators in 15 (35.7%), dilation with cavernotomes in 25 (59.5%) and limited sharp corporal excision and dilation with cavernotomes in 1 (2.4%). Narrow cylinders were employed in ten patients (23.8%). Major complications occurred in one patient (2.4%) who underwent explant for infection and distal erosion. Most patients with corporal fibrosis can undergo successful placement of a PP using standard dilators or cavernotomes. Sharp corporal excision and other measures are rarely required.

Abstract 16101: Factors Associated With Implantable Cardioverter-Defibrillator Placement Among U.S. Veterans With Left Ventricular Ejection Fraction ≤35% at Least 40 Days After Acute Myocardial Infarction

Introduction: Implantable cardioverter defibrillators (ICD) reduce the risk of sudden cardiac death among patients with persistently low (≤35%) left ventricular ejection fraction (LVEF) at least 40 days following acute myocardial infarction (AMI). There are limited data about clinical factors associated with ICD placement following AMI. Hypothesis: We hypothesized that increasing age and number of comorbidities would decrease the odds of ICD placement post-AMI among patients with low (≤35%) LVEF, while revascularization for AMI would increase odds of ICD use. Methods: We used ICD-9 and 10 codes to identify all Veterans hospitalized for AMI from 2004-2017 and excluded Veterans with prior ICD and those who died during AMI hospitalization. We used a validated natural language processing algorithm to determine LVEF from echocardiograms performed 40-365 days post-AMI and identified patients with LVEF ≤35%. Using multivariable logistic regression, we examined the association of demographics, comorbidities, revascularization status for AMI, and prescription of guideline-directed medical therapy (GDMT) with the primary outcome of ICD placement 41-365 days post-AMI. Results: Of 10,447 Veterans eligible for an ICD, 1,966 (18.8%) received an ICD. Of 1,966 patients who received an ICD 7.1% died within 1-year, compared with 26.8% of patients who did not receive an ICD. In multivariable analysis, younger age, fewer comorbidities, revascularization during AMI hospitalization, and use of GDMT were associated with increased odds of receiving an ICD (Table). Eligible Black patients were less likely (OR 0.78, 95% CI 0.67-0.90) to receive an ICD than White patients. Conclusions: Many factors affect ICD placement among patients with reduced LVEF post-AMI. In particular, Black patients were less likely to receive ICDs than White patients. Future qualitative work could provide a deeper understanding of how patient and clinician factors influence decisions around ICD use.

Abstract 16772: Aerobic Capacity (VO 2peak ) in Congenital Heart Disease: Prognostic Implications

Introduction: Cardiopulmonary exercise testing provides information about functional capacity via direct measurement of respiratory gas exchange. Whether peak oxygen consumption during exercise (VO 2peak ) is predictive of outcomes in patients with congenital heart disease is controversial. Hypothesis: VO 2peak has prognostic implications for death, left ventricular assist device (LVAD) placement, and cardiac transplant in adult patients with congenital cardiac diseases. Methods: Congenital heart disease patients were selected from a registry of cardiac patients who completed a VO 2peak exercise test at Washington University School of Medicine between May 1993 and October 2012. Diagnoses were verified by chart review and classified according to American Heart Association guidelines. Outcome data were verified via medical record, Social Security Death Index, or phone interview. A Cox proportional-hazard regression analysis was used to investigate the association between patient survival time and one or more predictor variables. Survival time was defined as the time elapsed between VO 2peak test and the earliest outcome of death, heart transplant, or LVAD placement. Results: The sample included 149 patients (49% women, mean ± SD age of 33.4 ± 11.5 years and body mass index of 25.7 ± 5.4 kg/m 2 ). Mean follow-up time was 11.8 ± 3.2 years. Mean VO 2peak was 23.0 ± 7.3 mL/kg/min for men and 20.0 ± 6.4 mL/kg/min for women. Age was comparable between men and women in the sample. In the univariate analysis, higher VO 2peak was associated with longer event-free survival time (HR 0.91, 95% CI 0.85-0.98, p= 0.01). In the multivariable analysis, higher VO 2peak was shown to be protective, independent of age and sex (HR 0.90, 95% CI 0.83-0.97, p=0.004). Conclusions: Among patients with congenital cardiac disease, higher VO 2peak independently predicted longer event-free survival. VO 2peak is a valuable clinical prognostic tool for patients with congenital cardiac disease.

Pregnancy outcomes following elective abdominal cerclage following cervical excision surgery for neoplastic disease

BackgroundLocal excisional treatment of neoplastic disease of the cervix in the form of loop excision (LLETZ) and conisation has been associated with adverse pregnancy outcomes including prelabour premature rupture of membranes (PPROM) and spontaneous preterm birth (SPTB). Insertion of a cervical cerclage is indicated for women with a short cervix <25 mm between 16 and 24 weeks gestation who also have a history of either PPROM or a history of cervical excisional treatment. The optimum timing of the cerclage and surgical technique used are both open to debate.This retrospective review of cases was performed to examine the outcomes of elective pre pregnancy placement of abdominal cervical cerclage in women who have undergone cervical excision surgery for neoplastic disease. MethodsThis was a retrospective review of case notes. Over a 10 year period 20 women who had previous cervical excision surgery had pre-pregnancy abdominal cerclage placed became pregnant with 26 pregnancies. One woman had a cone biopsy, 9 had a single LLETZ procedure, 8 had 2 LLETZ procedures and 2 women had 3 LLETZ procedures prior to the cerclage. Results21 pregnancies were achieved spontaneously, 1 by intrauterine insemination (IUI) and 4 were conceived by in-vitro fertilisation (IVF). Overall, 22 of 26 (84.6 %) pregnancies were delivered at term. There was a single 7 week miscarriage and 3 premature deliveries (12 %) including 1 preterm birth at 29 + 4 weeks gestation after an antepartum haemorrhage (APH) and 2 late preterm births at 36 + 3 (following APH) and 36 + 4 weeks gestation following preterm labour. All 25 women were delivered by Caesarean section and all 25 babies survived. ConclusionThere results of prophylactic minimally invasive insertion of a transabdominal cerclage in women with LLETZ treatments or cone biopsy prior to pregnancy demonstrated 84.6 % of pregnancies resulted in a live birth. The premature delivery rate was 12 %.

Outcomes of Pediatric Central Venous Access Device Placement With Concomitant Surgical Procedures

BackgroundChildren frequently undergo placement of a tunneled central venous catheter or port (CVAD) concomitantly with other surgical procedures (CVAD-CP), but the risk factors for early CVAD complications with this practice are unclear. MethodsChildren undergoing CVAD-CP were identified from the National Surgical Quality Improvement Program-Pediatric 2012-2016 database. Predictor variables included demographics, CP characteristics, malignancy, and CVAD type. Outcome variables were CVAD-associated bloodstream infection (CLABSI) or new deep venous thrombosis (nDVT) within 30 d. Patients with and without CLABSI or nDVT were compared, and the temporal relationship of nDVT and CLABSI was investigated. Multivariable logistic regression modeling was used to assess independent risk factors for CLABSI. ResultsOf 2036 patients included, median age was 1.5 y, 35% had malignancy, and 40% had a clean concomitant procedure. Overall, 1.3% developed CLABSI and 0.7% developed nDVT. Multivariable regression modeling revealed higher risk of CLABSI with clean CPs (odds ratio [OR] 2.4, 95% confidence interval [CI] 1.06-5.34, P = 0.035), tunneled catheters (OR 3.2, 95% CI 1.18-8.56, P = 0.022), and longer anesthesia duration (OR 1.02 per 10 min, 95% CI 1.00-1.04, P = 0.042). nDVT was strongly associated with CLABSI (21% CLABSI among those with DVT, 0.5% among those without, P ≤ 0.0001). In all cases of nDVT with CLABSI, the diagnosis of DVT preceded diagnosis of CLABSI, by a median of 7 d. ConclusionsThe type of CVAD and characteristics of the concomitant procedure influence early CLABSI after CVAD-CP. The unexpected finding of higher CLABSI rates among clean concomitant procedures suggests that perioperative prophylactic antibiotics should not be withheld in this setting, but requires prospective validation. nDVT is frequently diagnosed prior to CLABSI, suggesting a possible role for antibiotics in the treatment of postoperative DVT after CVAD placement.

Do Thoracic Spinal Deformities Affect Outcomes of Spinal Cord Stimulators: A Retrospective Chart Review.

Retrospective chart review. The aim of this study was to ascertain whether the presence of structural thoracic deformities affects outcomes of permanent SCS placement. Neural modulation via spinal cord stimulators (SCSs) has become an accepted treatment option for various chronic pain syndromes. In most cases, the surgeon desires accurate midline positioning of the paddle lead, allowing for flexibility of unilateral or bilateral coverage of pain patterns. Structural spinal deformities (scoliosis or kyphosis) often result from coronal, sagittal, and rotatory deformity that can make midline placement more difficult. Between 2013 and 2017, two-hundred forty-one charts of patients who underwent permanent SCS placement at our suburban hospital were reviewed. Demographic information, numerical rating system (NRS) pain scores, Oswestry Disability Index (ODI) scores, and opioid medication usage were recorded at baseline and after permanent stimulator placement. Thoracic scoliosis and kyphosis angles were measured using spinal radiographs. The effect of each structural deformity on NRS, ODI, and narcotic medication usage changes from baseline was analyzed. Overall, 100 patients were included in our cohort. Fifty-six patients had measured thoracic spinal deformities (38% with scoliosis, 31% with kyphosis). There was no significant difference in NRS scores, ODI scores, or narcotic usage change between patients with scoliosis and those without (P = 0.66, P = 0.57, P = 0.75) or patients with kyphosis and those without (P = 0.51, P = 0.31, P = 0.63). Bivariate linear regression analysis showed that scoliotic and kyphotic angles were not significant predictors of NRS (P = 0.39, P = 0.13), ODI (P = 0.45, P = 0.07), and opioid usage (P = 0.70, P = 0.90) change, with multivariate regression analyses confirming these findings. SCSs can be effective options for treating lumbar back pain and radiculopathy. Our study suggests that the presence of mild structural deformities does not adversely affect outcomes of permanent SCS placement and as such should not preclude this population from benefiting from such therapies.Level of Evidence: 4.

Atrial Fibrillation and Transcatheter Repair of Functional Mitral Regurgitation: Evidence From a Meta-Regression.

The aim of this study was to assess the impact of atrial fibrillation (AF) on mortality and efficacy in patients with functional mitral regurgitation (FMR) undergoing MitraClip implantation. AF is a common arrhythmia in patients with severe FMR undergoing transcatheter mitral valve repair with the MitraClip device. Although AF has been consistently shown to be associated with poor outcomes after mitral valve surgery, the impact of AF on outcomes of MitraClip placement in patients with FMR has not been well studied. Prospective, retrospective registries, observational studies, and randomized controlled trials on MitraClip reporting AF and FMR as one of the variables from inception until January 2019 were included. Of the initial 1,694 studies, 15 studies met the inclusion criteria. From a total of 5,184 patients, 2,105 patients were identified to have FMR and AF. All-cause 30-day mortality in patients with FMR was 3.7% (95% confidence interval: 2.87 to 4.66) and 1-year mortality was 17.9% (95% confidence interval: 16.01 to 19.71). The meta-regression analysis studying the impact of AF among patients with FMR treated with the MitraClip demonstrated no difference in mortality at 30days but demonstrated significantly increased mortality at 1 year (95% confidence interval: 0.0006 to 0.0027) (p=0.004). AF did not influence procedural success. This meta-regression identifies AF as an independent negative predictor of long-term mortality after MitraClip implantation in patients with FMR. The mechanism of worse outcomes in patients with AF requires further study.

Outcomes of Definitive Draining Seton Placement for Complex Anal Fistula in Crohn's Disease.

Definitive draining seton (DDS) alone is an accepted treatment for complex refractory anal fistulas in Crohn's disease (CD). We evaluated the long-term success of DDS in CD patients. DDS was defined as draining seton placed definitively for at least 12months. Primary end point was clinical response (CR) defined as a lack of induration, pain, swelling, abscess recurrence, or unintended dislodgement. The study cohort of 23 patients had a median age of 29 (range; 9-61) years and included 14 males (61%). Reasons for DDS included anal stenosis (n = 9; 39%), active proctitis (n = 9; 39%), and/or anal canal ulceration (n = 9; 39%). Median number of setons was 2 (range; 1-6) and 65% had multiple fistula tracts. Almost all patients (n = 22; 96%) were on a biologic postoperatively. At 12-month follow-up, only 39% (n = 9) had a CR. The remaining 14 patients failed due to new abscess formation (n = 6; 26%), new fistula formation (n = 6; 26%), and seton dislodgement (n = 2; 9%). Six (26%) patients required fecal diversion. No patients required proctectomy. DDS for complex CD fistula results in a mediocre CR with many patients developing recurrent abscess/fistula or requiring diversion despite biologic therapy.

Aerobic Capacity (V̇O2peak) In Congenital Heart Disease Versus Heart Failure: Prognostic Implications

Introduction VO2peak (peak oxygen consumption) during cardiopulmonary exercise testing is a key prognostic test in patients with non-congenital heart failure (HF). It helps physicians decide which HF patients would derive the greatest survival benefit from cardiac transplant. The predictive value of VO2peak in patients with congenital heart disease on outcomes is not as clear. Hypotheses 1) VO2peak will predict event-free survival in patients with congenital cardiac disease; 2) Patients with congenital heart disease will have longer event-free survival for the primary outcome of death, heart transplant, or LVAD placement compared to patients with heart failure with reduced ejection fraction (HFrEF) even after adjustment for VO2peak. Methods Patients were from a registry of cardiac patients who completed an exercise test in the VO2 Laboratory at Washington University School of Medicine between May 1993 and October 2012. Patients with HFrEF (left ventricular ejection fraction Results A total of 276 patients (138 congenital, 138 HFrEF) were included. Mean (±SD) age was 33.9 ± 11.7y in the congenital group and 40.3 ± 9.7 in the HFrEF group (p=0.00001). Women made up 44.9% of each sample. VO2peak was 21.56 ± 7.15 ml•kg−1•min−1 in the congenital group and 15.99 ± 5.95 ml•kg−1•min−1 in the HFrEF group (p Conclusions A congenital cardiac diagnosis portends longer event-free survival compared to patients with non-congenital HFrEF. Further studies are warranted to investigate if peak VO2 can be used to guide timing for cardiac transplant in the congenital cardiac population.

Comparison of Accuracy and Clinical Outcomes of Robot-Assisted Versus Fluoroscopy-Guided Pedicle Screw Placement in Posterior Cervical Surgery.

Study Design:This was a prospective controlled study.Objective:To compare the accuracy and clinical outcomes of robot-assisted (RA) and fluoroscopy-guided (FG) pedicle screw placement in posterior cervical surgery.Methods:This study included 58 patients. The primary outcome measures were the 1-time success rate and the accuracy of pedicle screw placement according to the Gertzbein-Robbins scales. The secondary outcome measures, including the operative time, intraoperative blood loss, hospital stay, cumulative radiation time, radiation dose, intraoperative advent events, and postoperative complications, were recorded and analyzed. The Japanese Orthopedics Association (JOA) scores and Neck Disability Index (NDI) were used to assess the neurological function of patients before and at 3 and 6 months after surgery.Results:The rate of grade A was significantly higher in the RA group than in the FG group (90.6% and 71.1%; P < .001). The clinically acceptable accuracy was 97.2% in the RA group and 90.7% in the FG group (P = .009). Moreover, the 1-time success rate was significantly higher in the RA group than in the FG group. The RA group had less radiation time (P < .001) and less radiation dose (P = .002) but longer operative time (P = .001). There were no significant differences in terms of intraoperative blood loss, hospital stay, intraoperative adverse events, postoperative complications, JOA scores, and NDI scores at each follow-up time point between the 2 groups.Conclusions:The RA technique achieved higher accuracy and 1-time success rate of pedicle screw placement in posterior cervical surgery while achieving comparable clinical outcomes.

Comparing outcomes of percutaneous cholecystostomy drain placement between patients within and outside of Tokyo guidelines diagnostic criteria for acute cholecystitis.

To compare outcomes following percutaneous cholecystostomy drain placement based on presence or absence of Tokyo Guidelines diagnostic criteria for acute cholecystitis. Chart review was performed to identify the presence or absence of Tokyo Guidelines diagnostic criteria for acute cholecystitis in 146 patients who underwent percutaneous cholecystostomy between 2012 and 2015. Those who met criteria were compared to those who did not in terms of demographics, laboratory values, drain indwelling time, treatment response, eventual surgical management, and 30-day mortality. 94 patients (64%) met Tokyo Guidelines diagnostic criteria, while 52 did not (36%). Patients within criteria had a shorter mean length of stay (13.5days vs 18.9days), were more likely to have a positive gallbladder fluid culture (64.5% vs 28.6%), demonstrated greater response to treatment (87.2% vs 32.7%), and had lower 30-day mortality (6.4% vs 37.8%). There was no significant difference in terms of ICU requirement (38.3% vs 38.9%), mean drain indwelling time (58.8days vs 65.3days), eventual laparoscopic cholecystectomy (40.4% vs 25.0%), or open cholecystectomy performed (9.5% vs 9.6%). Patients outside of Tokyo Guidelines diagnostic criteria for acute cholecystitis were less likely to respond to treatment with percutaneous cholecystostomy and had worse outcomes. Further research may be indicated to better define the indications for percutaneous cholecystostomy placement in this group.