Significant Differences In Outcomes Research Articles

Safety of Shunting Strategies During Carotid Endarterectomy: A Vascular Quality Initiative Data Analysis

This study aimed to evaluate in hospital outcomes after carotid endarterectomy (CEA) according to shunt usage, particularly in patients with contralateral carotid occlusion (CCO) or recent stroke. Data from CEAs registered in the Vascular Quality Initiative database between 2012 and 2020 were analysed, excluding surgeons with < 10 CEAs registered in the database, concomitant procedures, re-interventions, and incomplete data. Based on their rate of shunt use, participating surgeons were divided in three groups: non-shunters (< 5%), selective shunters (5 - 95%), and routine shunters (> 95%). Primary outcomes of in hospital stroke, death, and stroke and death rate (SDR) were analysed in symptomatic and asymptomatic patients. A total of 113 202 patients met the study criteria, of whom 31 147 were symptomatic and 82 055 were asymptomatic. Of the 1 645 surgeons included, 12.1% were non-shunters, 63.6% were selective shunters, and 24.3% were routine shunters, with 10 557, 71 160, and 31 579 procedures in each group, respectively. In the univariable analysis, in hospital stroke (2.0% vs. 1.9% vs. 1.6%; p = .17), death (0.5% vs. 0.4% vs. 0.4%; p = .71), and SDR (2.2% vs. 2.1% vs. 1.8%; p = .23) were not statistically significantly different among the three groups in the symptomatic cohort. The asymptomatic cohort also did not show a statistically significant difference for in hospital stroke (0.9% vs. 1.0% vs. 0.9%; p = .55), death (0.2% vs. 0.2% vs. 0.2%; p = .64), and SDR (1.0% vs. 1.1% vs. 1.0%; p = .43). The multivariate model did not show a statistically significant difference for the primary outcomes between the three shunting cohorts. On subgroup analysis, the SDRs were not statistically significantly different for patients with CCO (3.3% vs. 2.5% vs. 2.4%; p = .64) and those presenting with a recent stroke (2.9% vs. 3.4% vs. 3.1%; p = .60). No statistically significant differences were found between three shunting strategies for in hospital SDR, including in patients with CCO or recent stroke.

Optimal door-to-balloon time for primary percutaneous coronary intervention for ST-elevation myocardial infarction

BackgroundDoor-to-balloon time (DTBT) for ST-elevation myocardial infarction (STEMI) is a performance metric by which primary percutaneous coronary intervention (PPCI) services are assessed. MethodsConsecutive patients presenting with STEMI undergoing PPCI between January 2007 to December 2019 from the Singapore Myocardial Infarction Registry were included. Patients were stratified based on DTBT (≤60 min, 61-90 min, 91-180 min) and Killip status (I-III vs. IV). Outcomes assessed included all-cause mortality and major adverse cardiovascular events (MACE) at 30-days and 1-year. ResultsIn total, 13,823 patients were included, with 82.59% achieving DTBT ≤90 min and 49.77% achieving DTBT ≤60 min. For Killip I-III (n = 11,591,83.85%), the median DTBT was 60[46–78]min. The 30-day all-cause mortality for DTBT of ≤60 min, 61-90 min and 91-180 min was 1.08%, 2.17% and 4.33% respectively (p < 0.001). On multivariate analysis, however, there was no significant difference for 30-day and 1-year outcomes across all DTBT (p > 0.05). For Killip IV, the median DTBT was 68[51–91]min. The 30-day all-cause mortality for DTBT of ≤60 min, 61-90 min and 91-180 min was 11.74%, 20.48% and 35.06% respectively (p < 0.001). On multivariate analysis for 30-day and 1-year outcomes, DTBT 91-180 min was an independent predictor of worse outcomes (p < 0.05), but there was no significant difference between DTBT of ≤60 min and 61-90 min (p > 0.05). ConclusionIn Killip I-III patients, DTBT had no significant impact on outcomes upon adjustment for confounders. Conversely, for Killip IV patients, a DTBT of >90 min was associated with significantly higher adverse outcomes, with no differences between a DTBT of ≤60 min vs. 61-90 min. Outcomes in STEMI involve a complex interplay of factors and recommendations of a lowered DTBT of ≤60 min will require further evaluation.

Endovascular thrombectomy beyond 24 hours from last known well: a systematic review with meta-analysis

BackgroundDifferent studies have demonstrated the benefit of endovascular treatment (EVT) up to 24 hours after acute ischemic stroke (AIS) onset. Recent cohort observational studies suggest that patients with large vessel...

A 12-month randomised controlled trial using intensive dietary interventions for adolescents with obesity associated complications

Adolescent obesity requires effective and accessible intervention options and there is potential for intensive dietary interventions to be used as adjunctive therapy to behavioural weight management for some individuals(1). The aim of this study was to determine the effect of two novel diet therapies, delivered in the as part of an intensive behavioural weight management intervention, in adolescents with metabolic complications associated with obesity. The Fast Track to Health study (HREC/17/SCHN/164; ACTRN12617001630303) was a multi-site 52-week RCT, conducted 2018 – 2023, comparing a very-low-energy diet (800kcal/day) followed by i) an intermittent energy restricted (IER) diet; and ii) a continuous energy restricted diet (CER), for adolescents (13-17years) with ≥1 obesity associated complication. Interventions were delivered as part of an intensive behavioural weight management intervention by a multidisciplinary team2. Anthropometry, body composition and cardiometabolic health were assessed at baseline and week-52. The primary outcome was change in BMI z-score at week-52. Dyslipidaemia was defined as HDL &lt;1.03mmol/L and/or triglycerides ≥1.7mmol/l, and elevated liver function tests (LFTs) as ALT and/or GGT ≥1.5 upper limit of 30U/L3. The difference in BMI z-score between groups at week-52 (±4) was assessed using a t-test. Mixed models was used to investigate changes over time. Descriptive statistics were used to describe participants above and below clinical cut-points at baseline and week-52. In total, 141 adolescents (70 female) were enrolled and 97 (48 female) completed the intervention. At week-52, BMI z-score reduced by −0.23 [95%CI −0.37 to −0.22], BMI expressed as a percentage of 95th percentile reduced by −8.86 [95%CI −12.46 to −7.47] and Fat Mass Index reduced by −1.49 [95%CI −2.36 to −1.08]. There was no significant difference for weight or cardiometabolic outcomes between diet groups. The occurrence of dyslipidaemia was unchanged between baseline and week-52 (n = 60 [43%] and n = 37 [43%] respectively) and a small improvement in the occurrence of impaired LFTs (n = 37 [27%] to n = 15 [17.2%] respectively). There were no differences in change of occurrence of dyslipidaemia or impaired LFTs between intervention groups. These findings suggest that both IER and CER, delivered as part of an intensive behavioural weight management program, are equally effective for improving weight and cardiometabolic outcomes for adolescents with obesity.

192 Feasibility of Magnetic Resonance-Guided Focused Ultrasound Thalamotomy for Essential Tremor Patients With Low Skull Density Ratio

INTRODUCTION: Magnetic resonance-guided focused ultrasound (MRgFUS) is a safe, effective treatment for essential tremor (ET). Skull density ratio (SDR), the ratio between the densities of cancellous bone and cortical bone, affects energy penetration of the skull. Major clinical trials and guidelines have excluded patients with low skull density ratio due to concerns of disrupted treatment, though these patients represent nearly 40% of ET patients. METHODS: In this single-surgeon cohort study of prospectively collected and retrospectively analyzed data, we report the characteristics and clinical outcomes of all ET patients with low SDR (&lt;0.40) vs. high SDR (=0.40) treated at Brigham and Women’s Hospital between June 2019 and February 2023. Clinical outcomes were determined by Fahn-Tolosa-Marin (FTM) scores in the affected limb and percentage of patients with clinical improvements. RESULTS: Thirty-one patients had low SDR. 239 patients had high SDR. Mean (±SD) SDRs in the low SDR and high SDR groups were 0.36 (±0.02) and 0.51 (±0.08), respectively. There were no significant differences between the two groups in the following characteristics: sex, handedness, duration of tremor, total preoperative Fahn-Tolosa-Marin (FTM) score, intention + posture preoperative FTM score, age at treatment, treatment laterality, and rate of intraoperative complications. While there were significant differences in the clinical outcomes of low SDR vs. high SDR patients on postoperative day 1 (POD1), the clinical outcomes between the two groups were not significantly different at every follow-up time point, including up to three years post-treatment. CONCLUSIONS: While clinical outcomes were significantly different on POD1, low SDR and high SDR patients had similar long-term clinical outcomes, suggesting that MRgFUS of ET patients with SDR &lt; 0.40 is feasible and effective.

Germline Genetic Testing and Survival Outcomes Among Children With Rhabdomyosarcoma

Determining the impact of germline cancer-predisposition variants (CPVs) on outcomes could inform novel approaches to testing and treating children with rhabdomyosarcoma. To assess whether CPVs are associated with outcome among children with rhabdomyosarcoma. In this cohort study, data were obtained for individuals, aged 0.01-23.23 years, newly diagnosed with rhabdomyosarcoma who were treated across 171 Children's Oncology Group sites from March 15, 1999, to December 8, 2017. Data analysis was performed from June 16, 2021, to May 15, 2023. The presence of a CPV in 24 rhabdomyosarcoma-associated cancer-predisposition genes (CPGs) or an expanded set of 63 autosomal-dominant CPGs. Overall survival (OS) and event-free survival (EFS) were the main outcomes, using the Kaplan-Meier estimator to assess survival probabilities and the Cox proportional hazards regression model to adjust for clinical covariates. Analyses were stratified by tumor histology and the fusion status of PAX3 or PAX7 to the FOXO1 gene. In this study of 580 individuals with rhabdomyosarcoma, the median patient age was 5.9 years (range, 0.01-23.23 years), and the male-to-female ratio was 1.5 to 1 (351 [60.5%] male). For patients with CPVs in rhabdomyosarcoma-associated CPGs, EFS was 48.4% compared with 57.8% for patients without a CPV (P = .10), and OS was 53.7% compared with 65.3% for patients without a CPV (P = .06). After adjustment, patients with CPVs had significantly worse OS (adjusted hazard ratio [AHR], 2.49 [95% CI, 1.39-4.45]; P = .002), and the outcomes were not better among patients with embryonal histology (EFS: AHR, 2.25 [95% CI, 1.25-4.06]; P = .007]; OS: AHR, 2.83 [95% CI, 1.47-5.43]; P = .002]). These associations were not due to the development of a second malignant neoplasm, and importantly, patients with fusion-negative rhabdomyosarcoma who harbored a CPV had similarly inferior outcomes as patients with fusion-positive rhabdomyosarcoma without CPVs (EFS: AHR, 1.35 [95% CI, 0.71-2.59]; P = .37; OS: AHR, 1.71 [95% CI, 0.84-3.47]; P = .14). There were no significant differences in outcome by CPV status of the 63 CPG set. This cohort study identified a group of patients with embryonal rhabdomyosarcoma who had a particularly poor outcome. Other important clinical findings included that individuals with TP53 had poor outcomes independent of second malignant neoplasms and that patients with fusion-negative rhabdomyosarcoma who harbored a CPV had outcomes comparable to patients with fusion-positive rhabdomyosarcoma. These findings suggest that germline CPV testing may aid in clinical prognosis and should be considered in prospective risk-based clinical trials.

Elevated white blood cell count and long-term clinical outcomes of patients with vasospastic angina.

Inflammation is known as one of key pathophysiologic mechanisms of coronary artery disease. We aimed to investigate the relationship between white blood cell (WBC) count and long-term clinical outcomes of patients with vasospastic angina (VA). A total of 823 patients who were diagnosed as VA without significant coronary lesion by coronary angiography with ergonovine provocation test were enrolled for analysis. Patients were divided according to WBC count tertile at the time of diagnosis: group I, tertile 1 and 2 (n = 546, <7490/ml); group II, tertile 3 (n = 277, ≥7490/ml). Primary outcome was defined as major adverse cardiovascular events (MACE), a composite outcome of all-cause death, cardiac death, myocardial infarction (MI), readmission due to cardiac symptoms, and revascularization. Median follow-up duration was 4.3 years. No significant difference of primary outcome was observed between group I and group II (14.7% vs. 20.2%, hazard ratio (HR) 1.29, confidence interval (CI) 0.90-1.83, P = 0.162), while incidence of cardiac death and MI was significantly higher in group II (1.5% vs. 4.3%, HR 2.86, CI 1.14-7.17), P = 0.025). In multivariate Cox regression model, elevated WBC count at the time of diagnosis of VA was an independent predictor of MI (HR 3.43, CI 1.02-11.59, P = 0.047). Elevated WBC count at the time of diagnosis was associated with a significantly increased risk of cardiac death and MI during long-term follow-up in VA patients.

Efficacy of Intra-Articular Corticosteroid Injection for Nonsurgical Management of Trapeziometacarpal Osteoarthritis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

As osteoarthritis (OA) of the trapeziometacarpal (TMC) joint leads to a high degree of disease burden with compromises in rudimentary and fine movements of the hand, intra-articular injections may be a desirable treatment option. However, because there are no evidence-based guidelines, the choice of intra-articular injection type is left to the discretion of the individual surgeon in collaboration with the patient. The purpose of our study was to perform a systematic review and meta-analysis using level I studies to compare outcomes following corticosteroid and alternative methods of intra-articular injections for the management of TMC OA. Our hypothesis was that intra-articular corticosteroid injections were no more effective than other methods of intra-articular injections for the management of TMC OA. A systematic literature search was performed. Eligible for inclusion were randomized control trials reporting on intra-articular corticosteroid injection for the management of TMC OA. Clinical outcomes were recorded. The 10 included studies comprised 673 patients. The mean age was 57.8 ± 8.3 years, with a mean follow-up of 6.4 ± 2.7 months. There was no significant difference in visual analog scale scores, grip strength and tip pinch strength between corticosteroids and hyaluronic acid at short- and medium-term follow-up. Further, there was no difference in visual analog scale pain scores at rest at medium-term follow-up between corticosteroids and platelet-rich plasma. Despite short-term improvement with intra-articular corticosteroid injections, there was no significant difference in pain and functional outcomes following intra-articular corticosteroid injections compared to hyaluronic acid or platelet-rich plasma administration. Given the affordability, ease of administration, and efficacy associated with corticosteroids, they are a favorable option when considering the choice of intra-articular injection for the management of TMC OA. Therapeutic II.

Clinical Effectiveness of Continuous Glucose Monitoring in Pregnancies Affected by Type 1 Diabetes.

Background: Continuous glucose monitoring (CGM) improves neonatal outcomes in type 1 diabetes pregnancies; however, its effectiveness has not been assessed in a real-world setting in the United States. Objective: The Triple C Study aimed to examine the clinical effectiveness, assessed through maternal glucose control and gestational health outcomes, of CGM use compared with self-monitoring of blood glucose (SMBG) in pregnancies associated with type 1 diabetes in a real-world setting. Research Design and Methods: We retrospectively identified 160 type 1 diabetes pregnancies at the Barbara Davis Center for Diabetes managed with CGM therapy (n = 109) or SMBG (n = 51) over a 6.5-year period (2014-2020). Obstetric care was provided at multiple practices. CGM use was defined as ≥60% wear in the second and third trimesters of pregnancy. Data were obtained from the electronic medical record system, hospital records, and vital statistics departments (Colorado and Wyoming). We used Student's t-test for continuous variables and chi-square test for categorical variables to compare outcomes between groups. Results: The CGM group had more participants meeting trimester-specific hemoglobin A1C (HbA1c) goals throughout pregnancy and postpartum (P < 0.01 in each time period). The CGM group had fewer participants never meeting HbA1c goals in any trimester than the SMBG group (P < 0.001). There were no significant differences in neonatal outcomes between groups, other than for macrosomia (12.8% CGM vs. 29.4% SMBG, P = 0.01). Infants of CGM users required a neonatal intensive care unit admission less often (52.9% CGM vs. 68.3% SMBG, P = 0.0989). Conclusions: CGM use was associated with improved maternal glucose levels in a diverse real-world cohort.

Ambulatory facial feminization surgery: a comparative analysis of outcomes and complications

BackgroundTo date, there are no studies investigating the safety and outcomes of facial feminization surgery (FFS) as an outpatient procedure. This is the first study of its kind analyzing the outcomes of ambulatory FFS based on a comparison of complications, post-operative emergency department or urgent care (ED/UC) visits, and readmissions between patients who underwent FFS with admission versus same-day surgery. MethodsA retrospective analysis was conducted on all patients who underwent FFS in a single integrated healthcare system. Patient charts were reviewed for operative details, complications, post-operative ED/UC visits, readmission, and demographic factors. Major outcomes including complications, readmissions, and ED/UC visits were compared between groups with same-day discharge and post-operative hospital admission. ResultsOf 242 patients included in the study, ED/UC visits were comparable between patients discharged same-day (18.2%) and patients admitted post-operatively (21.6%, p = 0.52). Logistic regression showed no significant difference in the composite outcomes of minor complications, major complications, and readmissions (15.6% for ambulatory versus 19.3% for admission, p = 0.46). Temporary nerve palsy, infection, and hematoma were the most common post-operative complications. However, covariates of a lower face procedure and operative time were shown to have significant differences in the composite complication outcome (p = 0.04 and p = 0.045, respectively). ConclusionAmbulatory FFS is a safe practice with no associated increase in adverse outcomes including complications, ED/UC visits, and readmission when compared to post-operative admission. Adoption of same-day FFS should be considered by high-volume gender health centers to potentially benefit from increased scheduling flexibility and efficiency, increased access to care, and lower healthcare costs.

Pandemic phase-related racial and ethnic disparities in COVID-19 positivity and outcomes among patients presenting to emergency departments during the first two pandemic waves in the USA

BackgroundIn many countries including the USA, the UK and Canada, the impact of COVID-19 on people of colour has been disproportionately high but examination of disparities in patients presenting to...

O142: Current clinical applications and limitations of graft augmentation in rotator cuff repair: a systematic review

Abstract Background Rotator cuff tears (RCTs) are a leading source of chronic and acute shoulder pain globally, with causes spanning from tendon degeneration to traumatic injury. Especially prevalent in the aging population, RCTs have a significant retear rate despite surgical intervention, and recent years have seen an increase in the use of grafts in surgery to address many of the clinical issues previously encountered in tendon-healing. Objectives To compare the effectiveness of various grafts in graft-augmentation surgery for full-thickness rotator cuff tears, assessed with functional and clinical outcomes. Selection criteria Adult patients with MRI-diagnosed full-thickness RCT and subsequently underwent graft-augmentation surgery; followed-up &amp;gt;1year, with assessment for retear and quantitative clinical outcomes. Results 32 primary studies, mean follow-up of 2 years and total of 1052 patients were included. The effectiveness of graft-augmentation was assessed using retear rate, ASES, Constant, UCLA and VAS. Graft-augmentation significantly improves all functional and clinical scores (p&amp;lt;0.05), and decreases retear rate to an average of 18.5% &amp;gt;1year post-surgery (p&amp;lt;0.0001), with no significant difference in effectiveness between the 4 different types of grafts. (p&amp;gt;0.05). No significant difference in outcomes was found in graft-augmentation between different tear sizes. Conclusions Graft augmentation for RCTs shows significant improvements in clinical and functional outcomes, and significantly lowers retear rate compared to conservative treatment or surgery without graft augmentation. The choice of graft has been shown to be of less importance than the clinical decision to use surgical-intervention with graft-augmentation, which applies to full-thickness tears of all sizes; both primary and revision tears.

Simple aspiration for spontaneous pneumothorax in adults: A systematic review and meta-analysis of randomized controlled trials

BackgroundSpontaneous pneumothorax (SP) is a widespread clinical entity, and methods of managing adult SP remain controversial. The aim of this meta-analysis was to further determine the clinical efficacy and safety of simple aspiration (SA) in comparison to intercostal tube drainage (ITD) during the management of adult SP. MethodsEMBASE, Medline and the Cochrane Central Register of Controlled Trials via Ovid SP were searched (to June 2023) to identify randomized controlled trials (RCT) that reported outcomes of interest after comparing SA with ITD for the management of adult SP. ResultsThe search strategy yielded 1447 citations, of which 10 RCTs enrolling 1044 subjects were included. Compared with the ITD group, the SA group had a significantly lower the initial success rate of the procedure for the management of SP (OR 0.63, 95% CI [0.47–0.86]; P = 0.004). Moreover, SA was associated with a decreased duration of hospitalization (mean difference-2.05 days, 95% CI [−2.66 – −1.44]; P < 0.001) and a decreased need for operation (P = 0.03). For frequently reported adverse events such as subcutaneous emphysema (P = 0.32), bleeding (P = 0.0.26) and wound infection (P = 0.07), no significant difference between the SA and ITD groups was found. There was no significant difference for other outcomes. Subgroup analysis found that there was no significant difference between SA and ITD in terms of the initial success rate, 1-week success rate or any type of adverse event for PSP patients. ConclusionsIn the management of adult SP, the use of SA decreased the initial success rate but also decreased the duration of hospitalization and the need for operation compared with ITD. The incidence of adverse events did not differ between the two approaches.The research plan was registered at PROSPERO, and the registration number was CRD42023436770.

Clinical Profile and Outcome of Covid-19 Intensive Care Patients with Nosocomial Infections: A Single-Centred Experience from India

Background: Incidences of nosocomial infections in COVID-19 patients admitted to the intensive care unit (ICU) have become a common occurrence. Hospital-acquired infections (HAI) present increased mortality, cost-of-care, especially relevant in multidrug resistant (MDR) infections. Our study aimed to assess the clinical implications associated with HAI-infected COVID-19 patients. Patients and Methods: We conducted retrospective single-centred study on ICU-admitted adult COVID-19 patients for a year i.e., 2021-22 at a tertiary Indian institute and collated data of HAI epidemiological, clinical and microbiological reports. Results: Rate of HIA at our centre was estimated to be 10.29% and the mortality rate was 40.4%. 10 different organisms(Bacteria: 8, Fungi: 2) were detected in HAI, of which the incidence of Gram-negative infections (GNI) was highest i.e., 60% and that of Gram-positive infections (GPI)/Fungi (Fungi infected) were 20% each. Mortality was highest among GPI (36.67%), FI (13.46%), followed by and GPI (7.69%). Tocilizumab treatment decreased the risk of survivability with no significant difference in the treatment outcomes. Conclusion: This study provides a comprehensive picture of nosocomial infections characteristics among COVID-19patients and provides insights regarding the impact of treatment on the outcome of these patients with suggestions for strategies. We found that critically ill patients with COVID- 19 are at a high risk of developing HAI, especially MDR mediated CLABSI and CAUTI. Clinicians must therefore be cautious and mindful during implementing protocols for management of infectious complications with COVID-19 patients.

Early vs Late Fixation of Extremity Fractures Among Adults With Traumatic Brain Injury

The optimal timing for fixation of extremity fractures after traumatic brain injury (TBI) remains controversial. To investigate whether patients who underwent extremity fixation within 24 hours of TBI experienced worse outcomes than those who had the procedure 24 hours or more after TBI. This cohort study used data from the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study. Patients 16 years or older with TBI who underwent internal extremity fixation met inclusion criteria. To compare outcomes, patients who underwent the procedure within 24 hours were propensity score matched with those who underwent it 24 hours or later. Patients were treated from December 9, 2014, to December 17, 2017. Data analysis was conducted between August 1, 2022, and December 25, 2023. The primary outcome was an unfavorable functional status at 6 months (Glasgow Outcome Scale-Extended [GOSE] score ≤4). A total of 253 patients were included in this study. The median age was 41 (IQR, 27-57) years, and 184 patients (72.7%) were male. The median Injury Severity Score (ISS) was 41 (IQR, 27-49). Approximately half of the patients (122 [48.2%]) had a mild TBI while 120 (47.4%) had moderate to severe TBI. Seventy-four patients (29.2%) underwent an internal extremity fixation within 24 hours, while 179 (70.8%) had the procedure 24 hours or later. At 6 months, 86 patients (34.0%) had an unfavorable functional outcome. After propensity score matching, there were no statistically significant differences in unfavorable functional outcomes at 6 months (odds ratio [OR], 1.12 [95% CI, 0.51-1.99]; P = .77) in patients with TBI of any severity. Similar results were observed in patients with mild TBI (OR, 0.71 [95% CI, 0.22-2.29]; P = .56) and moderate to severe TBI (OR, 1.08 [95% CI, 0.32-3.70]; P = .90). The outcomes of extremity fracture fixation performed within 24 hours after TBI appear not to be worse than those of procedures performed 24 hours or later. This finding suggests that early fixation after TBI could be considered in patients with mild head injuries.

Reverse-sequence endoscopic nipple-sparing mastectomy with immediate implant-based breast reconstruction: an improvement of conventional minimal access breast surgery.

Our center proposes a new technique that effectively provides space to broaden the surgical field of view and overcomes the limitations of endoscopy-assisted nipple-sparing mastectomy (E-NSM) by changing the dissection sequence and combining it with air inflation. The purpose of this study was to compare the clinical outcomes of the new technique designated "reverse-sequence endoscopic nipple-sparing mastectomy (R-E-NSM) with subpectoral breast reconstruction (SBR)" and the conventional E-NSM (C-E-NSM) with SBR. All patients undergoing E-NSM with SBR at our breast center between April 2017 and December 2022 were included in this study. The cohort was divided into the C-E-NSM group and the R-E-NSM group. The operation time, anesthesia time, medical cost, complications, cosmetic outcomes, and oncological safety were compared. Twenty-six and seventy-nine consecutive patients were included in the C-E-NSM and R-E-NSM groups, with average ages of 36.9 ± 7.0 years and 39.7 ± 8.4 years (P=0.128). Patients in the R-E-NSM group had significantly shorter operation time (204.6 ± 59.2 vs. 318.9 ± 75.5 minutes, p<0.001) and anesthesia time (279.4 ± 83.9 vs. 408.9 ± 87.4 minutes, p<0.001) and decreased medical costs [5063.4 (4439.6-6532.3) vs. 6404.2 (5152.5-7981.5), USD, p=0.001] and increase SCAR-Q scores (77.2 ± 17.1 vs. 68.8 ± 8.7, P=0.002) compared to the C-E-NSM group. Although trends increased in both the excellent rate of Ueda scores (53.8% vs. 42.3%, P = 0.144), excellent rate of Harris scores (44.0% vs. 63.1%, P=0.102), and decreased surgical complications (7.6% vs. 19.2%, P = 0.135) were observed in the R-E-NSM group, the differences were not significant. There were no significant differences in oncological outcomes between the two groups. R-E-NSM improves cosmetic outcomes and efficiency of C-E-NSM, reduces medical costs, and has a trend of lower surgical complications while maintaining the safety of oncology. It is a safe and feasible option for oncological procedures that deserves to be promoted and widely adopted in practice.

Feasibility of a wearable self-management application for patients with COPD at home: a pilot study

BackgroundAmong people with COPD, smartphone and wearable technology may provide an effective method to improve care at home by supporting, encouraging, and sustaining self-management. The current study was conducted to determine if patients with COPD will use a dedicated smartphone and smartwatch app to help manage their COPD and to determine the effects on their self-management.MethodsWe developed a COPD self-management application for smartphones and smartwatches. Participants were provided with the app on a smartphone and a smartwatch, as well as a cellular data plan and followed for 6 months. We measured usage of the different smartphone app functions. For the primary outcome, we examined the change in self-management from baseline to the end of follow up. Secondary outcomes include changes in self-efficacy, quality of life, and COPD disease control.ResultsThirty-four patients were enrolled and followed. Mean age was 69.8 years, and half of the participants were women. The most used functions were recording steps through the smartwatch, entering a daily symptom questionnaire, checking oxygen saturation, and performing breathing exercises. There was no significant difference in the primary outcome of change in self-management after use of the app or in overall total scores of health-related quality of life, disease control or self-efficacy.ConclusionWe found older patients with COPD would engage with a COPD smartphone and smartwatch application, but this did not result in improved self-management. More research is needed to determine if a smartphone and smartwatch application can improve self-management in people with COPD.Trial registrationClinicalTrials.Gov NCT03857061, First Posted February 27, 2019.

Effects of combined dietary intervention and physical-cognitive exercise on cognitive function and cardiometabolic health of postmenopausal women with obesity: a randomized controlled trial

BackgroundPostmenopausal women with obesity are markedly at risk of cognitive impairment and several health issues. Emerging evidence demonstrated that both diet and exercise, particularly physical-cognitive exercise are involved in cognitive and health benefits. However, the comparative effect of diet, exercise, and combined interventions in postmenopausal women with obesity on cognition and cardiometabolic health is still lacking. Identifying the effective health promotion program and understanding changes in cardiometabolic health linking these interventions to cognition would have important medical implications. This RCT aimed to examine the effect of single and combined interventions of diet and exercise on cognitive function and cardiometabolic health in postmenopausal women with obesity.MethodsNinety-two postmenopausal women with obesity were randomly assigned to diet group (intermittent fasting 2 days/week, 3 months), exercise group (physical-cognitive exercise 3 days/week, 3 months), combined group, or control group (n = 23/group). All cognitive outcomes and cardiometabolic outcomes were measured at baseline and post-3 months. Primary outcomes were executive functions, memory, and plasma BDNF levels. Secondary outcomes were global cognition, attention, language domain, plasma adiponectin levels, IL-6 levels, metabolic parameters, and physical function.ResultsAt the end of the 3-month intervention, the exercise and combined group demonstrated significant memory improvement which was accompanied by significant improvements in plasma BDNF level, insulin levels, HOMA-IR, %body fat, and muscle strength when compared to controls (p < 0.05). Only the combined intervention group demonstrated a significant improvement in executive function and increased plasma adiponectin levels when compared to control (p < 0.05). Surprisingly, no cognitive improvement was observed in the diet group (p > 0.05). Significant reduction in cholesterol levels was shown in the diet and combined groups when compared to controls (p < 0.05). Among the three intervention groups, there were no significant differences in all cognitive outcomes and cardiometabolic outcomes (p > 0.05). However, all three intervention groups showed significant improvements in plasma BDNF levels, weight, BMI, WHR, fat mass, and predicted VO2 max, when compared to control (p < 0.05).ConclusionThese findings suggest that combined physical-cognitive exercise and dietary intervention are promising interventions to improve cognition and obesity-related complications of postmenopausal women with obesity.Trial registrationNCT04768725 (https://clinicaltrials.gov) 24th February 2021.

Business Models of Chinese Firms Impacted by the Crisis Based on Case Studies

The Covid-19 pandemic has hit businesses extremely hard. Because of reduced social contact, many business models (BMs) have been limited, and some have become unviable. In the current external crisis, timely BM changes are crucial for more effective responses to challenges of critical importance. Based on the resource-based view theory, this study adopts a multi-case study approach to investigate the core competencies demonstrated by firms in different industries in adjusting to the external environment. Integrating and adapting existing BMs to form new BMs presents significant differences in operational outcomes between firms. This study focuses on the response and development of firm crisis management during the Covid-19 pandemic. Successful BM can enable firms to survive the crisis and even achieve improvement in the crisis. In addition, this paper distinguishes between business model innovation (BMI) and business model adaptation (BMA) at the theoretical and substantive levels, mainly from the perspective of firm value, including value proposition, value creation, value capture and value transfer, to differentiate between BMI and BMA. This study explains the impact of various BM changes on sustainable firm profitability and value through a detailed collection of media and company official reports. The emphasis on strategic flexibility has positively impacted firm BMs and value, which has implications for providing insights into companies’ long-term development.&#x0D; &#x0D; Received: 15 November 2023 / Accepted: 9 February 2024 / Published: 5 March 2024

Safety and effectiveness of stent-assisted coiling with adjunctive techniques in ruptured acute aneurysms: a propensity score-matched cohort study.

The use of stent-assisted coiling (SAC) in acute subarachnoid hemorrhage cases is associated with higher incidence rates of bleeding and ischemic complications. The aim of this study was to evaluate the safety and efficacy of the SAC technique in the treatment of ruptured intracranial aneurysms (RIAs). A retrospective analysis was conducted on patients with RIAs treated with SAC or coiling alone (CA). Univariate analysis compared clinical information between the two groups. Propensity score matching was used to select patients for comparison and analyze surgical complications, prognosis, and imaging outcomes in both groups. A total of 394 aneurysms were included, and 272 aneurysms remained after application of propensity score matching, with an equal distribution of 136 cases in both the SAC and CA groups. There was no statistically significant difference in the immediate postoperative outcomes between the two groups (63.2% of SAC patients achieved class 1 on the Raymond-Roy occlusion classification scale vs 58.8% of CA patients, difference [95% CI] 4.4% [-0.076 to 0.163]; 33.1% achieved class 2 vs 38.2%, 5.1% [-0.065 to 0.170]; 3.7% achieved class 3 vs 2.9%, 0.8% [-0.047 to 0.062], p = 0.506). At the 1-year follow-up, the SAC group exhibited higher rates of complete occlusion (59.5% vs 42.4%, 17.1% [0.040-0.294]) and stability (24.0% vs 19.2%, 4.8% [-0.061 to 0.156]), while experiencing lower rates of improvement (12.4% vs 22.4%, 10.0% [0.001-0.201]) and recanalization (4.1% vs 16.0%, 11.9% [0.036-0.120]), with statistically significant differences in these outcomes (p < 0.001). No significant disparities were observed in clinical outcomes in terms of modified Rankin Scale (mRS) scores at discharge (76.5% vs 77.2% had mRS score 0-2, 0.7% [-0.098 to 0.113]; 23.5% vs 22.8% had mRS score 3-6, 0.7% [-0.098 to 0.113], p = 0.886) and 1-year follow-up (90.8% vs 92.2% had mRS score 0-2, 1.4% [-0.063 to 0.091]; 9.2% vs 7.8% had mRS score 3-6, 1.4% [-0.063 to 0.091], p = 0.683). Intraoperative rupture occurred more frequently in the SAC group compared with the CA group, although the difference was not statistically significant (5.1% vs 2.9%, 2.2% [-0.035 to 0.081], p = 0.356). The SAC group demonstrated a higher incidence of intraoperative thrombosis, but the difference was not statistically significant (8.1% vs 2.9%, 5.2% [-0.010 to 0.117], p = 0.063). Postoperative thrombosis in the SAC group was 3 times higher, but this difference was not statistically significant (6.6% vs 2.2%, 4.4% [-0.013, 0.106], p = 0.076). The surgery-related mortality rates did not differ significantly between the two groups (4.4% vs 5.9%, 1.5% [-0.048 to 0.077], p = 0.583). Although stent treatment for RIA results in some incidents of complications, it is safe and effective. Besides, the SAC group showed better vascular imaging results compared with the CA group.