Significant Reduction In Rate Research Articles

Proceedings from the Second Medical Summit on Firearm Injury Prevention, 2022: Creating a Sustainable Healthcare Coalition to Advance a Multidisciplinary Public Health Approach.

Proceedings from the Second Medical Summit on Firearm Injury Prevention, 2022: Creating a Sustainable Healthcare Coalition to Advance a Multidisciplinary Public Health Approach.

NO DIFFERENCE BETWEEN RP AND FB IN TKA AFTER TWO YEARS IN MULTIPLE PROMS: A PROSPECTIVE, MULTICENTRE, NON-RANDOMIZED STUDY

Total Knee Arthroplasty (TKA) is an effective surgery performed for knee osteoarthritis. Despite this success up to 20% of patients are less than fully satisfied. Rotating platform (RP) bearings have demonstrated significant reduction in rates of wear in laboratory studies but thus far have failed to demonstrate a clinical difference compared to fixed bearing (FB) arthroplasty in patients. This may be due to studies limited by small sample size and single centre design. Additionally, no studies have utilised modern patient-reported outcome measures (PROMs) such as PKIP to investigate differences between these bearings.A non-randomised, prospective, multi-centre study was conducted across centres in Australia, United Kingdom and the United States from November 2012 to May 2015. Knee prosthesis included were the RP and FB models of the PFC Sigma Knee (Depuy, Synthes) and the ATTUNE Knee (Depuy, Synthes). Data was collected on pre-arthroplasty interventions, demographics and PROMs. PROMs included were the KOOS, OKS, EQ53DL and PKIP. Participants were followed-up for 2 years.A total of 1,718 patients were recruited across 27 centres. 959 participants underwent a FB TKA, 759 participants underwent a RP TKA. No significant difference was found between RP and FB in change from baseline at 2 years across any parameter in all PROMs investigated at 2 years. Body Mass Index pre-operatively was the biggest indicator of change from baseline at 2 years.Our data demonstrates similar improvements in the short-term in both RP and TKA across all PROMs. Patients reported similar scores in satisfaction, confidence, mobility and stability in the PKIP PROM for both RP and FB groups. We have not found any evidence to suggest that RP TKA is disadvantageous at 2 years, and this is reassuring for any surgeon looking to utilise this bearing type in practice.Our data does not demonstrate a clinical advantage in RP TKA over FB TKA at 2 years in any PROM.

Outcomes of alpha-blockers as medical expulsive therapy following shockwave lithotripsy: a systematic review and meta-analysis.

To determine stone-free rate following shockwave lithotripsy (SWL) with/without alpha-blockers as well as complication rates (individual and classified using the Clavien-Dindo system). We performed a systematic review of all randomized controlled trials that included more than 20 patients (age > 18 years) and examined the use of alpha-blockers after SWL. Meta-analysis was performed using 'metafor' in R. We report risk ratios (RRs) with 95% confidence intervals (95% CIs). The PROSPERO ID for the trial was: CRD42021248108. We assessed 158 full-text articles and included a total of 21 studies in our review. There were 1445 patients receiving alpha-blockers and 1478 control patients. Those receiving alpha-blockers were significantly more likely to be stone-free (RR 1.12, 95% CI 1.07-1.16; P < 0.001). This effect was robust to 'trim-and-fill' adjustment. In those taking alpha-blockers there was a significant reduction in Clavien III-V complications and, on trim-and-fill adjustment, a significant reduction in Clavien I-II complications. There were also significant reduction in rates of steinstrasse, pain and requirement for auxiliary procedures. There was no significant difference in retreatment rates. These effects were robust to trim-and-fill adjustment. There is a modest increase in stone-free rates in those receiving alpha-blockers following SWL, with a reciprocal modest risk reduction for steinstrasse, pain and auxiliary procedures. However, alpha-blockers do not reduce the risk of requiring retreatment.

Outcomes of parastomal hernia repair after national centralization.

In 2010, it was decided to centralize parastomal hernia repairs to five specialized hernia centres in Denmark to improve outcomes. The aim of this nationwide cohort study was to evaluate whether centralization of parastomal hernia repairs has had an impact on outcomes. Specifically, readmission, reoperation for complication, and operation for recurrence were analysed before and after centralization. By merging clinical and administrative outcome data from the Danish Hernia Database with those from the Danish National Patient Registry, all patients undergoing parastomal hernia repair in Denmark from 1 January 2007 to 31 December 2018 were included. Centralization was defined as having at least 70 per cent of procedures were performed at one of the five national centres. Readmission, reoperation, and recurrence rates for emergency and elective repairs were evaluated before and after centralization. In total, 1062 patients were included. Median follow-up was 992 days. Overall, the centralization process took 7 years. For elective repairs, the readmission, reoperation, mortality, and recurrence rates were comparable before and after centralization, but more patients overall and more patients with co-morbidity were offered surgery after centralization. For emergency repairs, there was a significant reduction in rates of reoperation (from 44.9 per cent (48 of 107) to 23 per cent (14 of 62); P = 0.004) and mortality (from 10.3 per cent (11 of 107) to 2 per cent (1 of 62); P = 0.034) after centralization. Centralization led to more elective operations and better outcomes when emergency repair was needed. Centralization of parastomal hernia repair led to more patients receiving elective repair and significantly improved outcomes after emergency repair.

Empagliflozin reduces cardiorenal events, healthcare resource use and mortality in Sweden compared to dipeptidyl peptidase-4 inhibitors: Real world evidence from the Nordic EMPRISE study.

To evaluate effectiveness and healthcare resource utilization (HCRU) of empagliflozin versus dipeptidyl peptidase-4 inhibitors (DPP-4i) in Swedish clinical practice, as part of the EMPRISE EU study (EUPAS27606, NCT03817463). A non-interventional, cohort study using retrospectively collected data from Swedish national registries. Adults with type 2 diabetes newly initiated on empagliflozin or DPP-4i from May 2014 to December 2018 were matched 1:1 using propensity scores based on >180 covariates. Cardiovascular outcomes included hospitalization for heart failure (HHF), all-cause mortality (ACM), myocardial infarction (MI), stroke and cardiovascular mortality (CVM), as well as their composite outcomes. Renal outcomes included end-stage renal disease (ESRD), estimated glomerular filtration rate (eGFR) decline to <60 ml/min/1.73 m2 and progression to micro/macroalbuminuria. HCRU outcomes were also assessed. Comparisons were done using Cox proportional hazards and Poisson regression models. Overall, 15,785 matched-pairs were identified, with a mean follow-up of 6.4 and 9.7months for patients initiating empagliflozin versus DPP-4i, respectively. Empagliflozin was associated with significant reduction in rates of HHF (hazard ratio [HR]=0.67; 95% confidence interval: 0.49-0.91), ACM (HR=0.53; 0.41-0.68), HHF + ACM (HR=0.59; 0.48-0.73), MI + stroke + ACM (HR=0.68; 0.57-0.81), CVM (HR=0.46; 0.29-0.73), HHF + CVM (HR=0.61; 0.47-0.79) and MI + stroke + CVM (HR=0.79; 0.63-0.98) versus DPP-4i. Empagliflozin also reduced the rates of ESRD (HR=0.13; 0.03-0.57) and eGFR decline (HR=0.83; 0.70-0.99). Regarding HCRU, empagliflozin was associated with lower risk of first inpatient stay (HR=0.87; 0.81-0.93), and lower rate of inpatient and outpatient visits (rate ratio [RR]=0.85; 0.80-0.89 and RR=0.96; 0.94-0.98) than DPP-4i. Empagliflozin treatment compared to DPP-4i reduced cardiorenal events and overall mortality, which may explain lower HCRU among empagliflozin users in Sweden.

1028 Systematic Review of Outcomes of Applications of Prineo-Dermabond

Abstract Aim The aims of this study are to assess published data regarding infection rates, delayed wound healing, cosmetic appearance and application time compared to conventional wound closure techniques across multiple surgical procedures. Method A literature search was conducted according to PRISMA guideline using PubMed, SCOPUS and Science Direct. The primary outcome was the incidence of wound infection after Prineo Dermabond compared to controls. Secondary outcome measures included allergic reactions and time for application. Literature search identified 52 studies, of which 19 were eligible for qualitative synthesis and 12 for meta-analysis. Results Studies included reflected a broad range of applications of Dermeo-Prineo to wound closure in Abdominoplasty, Mammoplasty and Arthroplasty. Overall, all studies reporting on time of application found a positive indicator of Prineo Dermabond reducing time for wound closure. Meta-analysis identified a statistically significant reduction in rates of the 6 studies that described wound infection (Prineo 1.51%, Control N=2.13%, OR 0.65 (0.46–0.91); P=0.01) and in the 5 studies reporting delayed wound healing (Prineo 0.99%, Control N=1.79%, OR 0.42 (0.18–0.98); P=0.05) in the use of Prineo Dermabond versus controls. Three studies reported outcomes of scar cosmesis or long-term maturation. All attested to better cosmetic results in comparison to sutures. Two studies discussed cost-effectiveness of Dermabond with a hypothetical model concluded that Skin Closure System of Prineo Dermabond could achieve savings of $50–76 per patient, whilst a retrospective model found no statistically significant difference in Total Hospital costs or Operating room time. Conclusions Prineo Dermabond provides an alternative method of wound closure in reported studies.

Postoperative Pain Management Following Orthopedic Spine Procedures and Consequent Acute Opioid Poisoning: An Analysis of New York State From 2009 to 2018.

Considering the high rates of opioid usage following orthopedic surgeries, it is important to explore this in the setting of the current opioid epidemic. This study examined acute opioid poisonings in postoperative spine surgery patients in New York and the rates of poisonings among these patients in the context of New York's 2016 State legislation limiting opioid prescriptions. Claims for adult patients who received specific orthopedic spine procedures in the outpatient setting were identified from 2009 to 2018 in the New York Statewide Planning and Research Cooperative System (SPARCS) database. Patients were followed to determine if they presented to the emergency department for acute opioid poisoning postoperatively. Multivariable logistic regression was performed to evaluate the effect of patient demographic factors on the likelihood of poisoning. The impact of the 2016 New York State Public Health Law Section 3331, 5. (b), (c) limiting opioid analgesic prescriptions was also evaluated by comparing rates of poisoning prelegislation and postlegislation enactment. A total of 107,456 spine patients were identified and 321 (0.3%) presented postoperatively to the emergency department with acute opioid poisoning. Increased age [odds ratio (OR)=0.954, P <0.0001] had a decreased likelihood of poisoning. Other race (OR=1.322, P =0.0167), Medicaid (OR=2.079, P <0.0001), Medicare (OR=2.9, P <0.0001), comorbidities (OR=3.271, P <0.0001), and undergoing multiple spine procedures during a single operative setting (OR=1.993, P <0.0001) had an increased likelihood of poisoning. There was also a significant reduction in rates of postoperative acute opioid poisoning in patients receiving procedures postlegislation with reduced overall likelihood (OR=0.28, P <0.0001). There is a higher than national average rate of acute opioid poisonings following spine procedures and increased risk among those with certain socioeconomic factors. Rates of poisonings decreased following a 2016 legislation limiting opioid prescriptions. It is important to define factors that may increase the risk of postoperative opioid poisoning to promote appropriate management of postsurgical pain.

Benefits and Risks Associated with Low-Dose Aspirin Use for the Primary Prevention of Cardiovascular Disease: A Systematic Review and Meta-Analysis of Randomized Control Trials and Trial Sequential Analysis.

The role of aspirin in cardiovascular primary prevention remains controversial. Moreover, evidence for the potential benefits of aspirin in patients with high cardiovascular risk remains limited. The aim of this study was to explore the role of low-dose aspirin in primary prevention. The PubMed, EMBASE, Cochrane Library, and ClinicalTrials.gov databases were searched for randomized clinical trials (RCTs) from the date of inception to August 2021. The efficacy outcomes were major adverse cardiovascular events (MACE), myocardial infarction (MI), ischemic stroke (IS), all-cause mortality, and cardiovascular mortality, whereas safety outcomes were major bleeding, intracranial hemorrhage, and gastrointestinal (GI) bleeding. Subgroup analyses were based on different cardiovascular risks and diabetes statuses. Pooled risk ratios (RRs) with 95% confidence intervals (CIs) were calculated using the fixed- and random-effects models, and trial sequential analysis (TSA) was conducted to determine the robustness of the results. A total of 10 RCTs fulfilled the inclusion criteria. The use of aspirin was associated with a significant reduction in the risk of MACE (RR 0.89, 95% CI 0.84-0.93), MI (RR 0.86, 95% CI 0.78-0.95), and IS (RR 0.84, 95% CI 0.76-0.93); however, aspirin also increased the risk of safety outcomes, i.e. major bleeding (RR 1.42, 95% CI 1.26-1.60), intracranial hemorrhage (RR 1.33, 95% CI 1.11-1.59), and GI bleeding (RR 1.91, 95% CI 1.44-2.54). Subgroup analyses revealed that in the absence of a statistically significant interaction, a trend toward a net benefit of lower incidence of cardiovascular events (number needed to treat of MACE: high risk: 682 vs. low risk: 2191) and lesser risk of bleeding events (number needed to harm of major bleeding: high risk: 983 vs. low risk: 819) was seen in the subgroup of high cardiovascular risk. Meanwhile, the greater MACE reduction was also detected in the high-risk group of diabetes or nondiabetes patients. Furthermore, a post hoc subgroup analysis indicated a significant rate reduction in patients aged ≤70 years but not in patients aged >70 years. TSA confirmed the benefit of aspirin for MACE up to a relative risk reduction of 10%. The current study demonstrated that the cardiovascular benefits of low-dose aspirin were equally balanced by major bleeding events. In addition, the potential beneficial effects might be seen in the population ≤70 years of age with high cardiovascular risk and no increased risk of bleeding.

Case for Epithelium-Off Corneal Cross-linking.

The question of whether the epithelium should be removed in corneal cross-linking (CXL) in the treatment of keratoconus and other corneal ectatic disorders remains controversial. The motivation for epithelium-on CXL methods, which are not yet FDA approved and vary greatly in methodology, is to reduce the risk of vision-threatening complications related to debridement. However, as discussed in this counterpoint piece, most high-level evidence suggests that removal of the epithelium facilitates greater crosslinking effectiveness as measured by primary clinical outcome metrics such as topographic flattening and stabilization of disease. Furthermore, quality evidence is still lacking for a significant reduction in rates of infectious keratitis or loss of vision that can be attributed to debridement-related complications. In the absence of comparative effectiveness trials or long-term follow-up studies that show otherwise, the FDA-approved epi-off protocol is still the standard-bearer for safe and effective stabilization of corneal ectatic disease.

An Evaluation of the Implementation of a "No Force First" Informed Organisational Guide to Reduce Physical Restraint in Mental Health and Learning Disability Inpatient Settings in the UK.

BackgroundThe use of physical restraint on vulnerable people with learning disabilities and mental health problems is one of the most controversial and criticised forms of restrictive practice. This paper reports on the implementation of an organisational approach called “No Force First” within a large mental health organisation in England, UK. The aim was to investigate changes in violence/aggression, harm, and physical restraint following implementation.MethodsThe study used a pretest-posttest quasi-experimental design. Recorded incidents of violence/aggression from 44 inpatient mental health and learning disabilities (including forensic) wards were included (n = 13,599). Two study groups were created for comparison: the “intervention” group comprising all incidents on these wards during the 24 months post-implementation (2018–2019) (n = 6,551) and the “control” group comprising all incidents in the 24 months preceding implementation (2015–2016) (n = 7,048). Incidents recorded during implementation (i.e., 2017) were excluded (n = 3,705). Incidence rate ratios (IRR) were calculated with 95% confidence intervals (95% CI). Multivariate regression models using generalised estimating equations were performed to estimate unadjusted and adjusted prevalence ratios (aPR) of physical restraint and harm, using type of wards, incident, and violence/aggression as key covariates.ResultsA significant 17% reduction in incidence of physical restraint was observed [IRR = 0.83, 95% CI 0.77–0.88, p < 0.0001]. Significant reductions in rates of harm sustained and aggression/violence were also observed, but not concerning the use of medication during restraint. The prevalence of physical restraint was significantly higher in inpatients on forensic learning disability wards than those on forensic mental health wards both pre- (aPR = 4.26, 95% CI 2.91–6.23) and post-intervention (aPR = 9.09, 95% CI 5.09–16.23), when controlling for type of incident and type of violence/aggression. Physical assault was a significantly more prevalent risk factor of restraint use than other forms of violence/aggression, especially that directed to staff (not to other patients).ConclusionsThis is a key study reporting the positive impact that organisational models and guides such as “No Force First” can have on equipping staff to focus more on primary and secondary prevention as opposed to tertiary coercive practices such as restraint in mental health and learning disabilities settings.

Keeping It Simple With Febrile Seizures

Keeping It Simple With Febrile Seizures

496 Perioperative Utility of Tranexamic Acid in Oncological Breast Surgery: A Systematic Review and Meta-Analysis

Abstract Background Tranexamic acid (TXA) is a synthetic anti-fibrinolytic agent used in various surgical procedures to achieve haemostasis and reduce blood loss. Recently TXA has seen an increase in perioperative utility as a result of its ease of administration, high therapeutic index and low cost. Its safety and effectiveness in oncological breast surgery (OBS) remain understudied. Method PubMed, EMBASE, SCOPUS and other relevant sources were searched for studies investigating the effect of TXA in OBS, published up to October 2020. Primary outcomes of interest were local wound effects. Estimates of effect, when quantitative data was available, were pooled with a random effects model to estimate summary hazard ratios and 95% confidence intervals. Qualitative data was reported using descriptive statistics. Evidence quality was assessed using the Cochrane Collaboration tool. Results 7 studies involving 1844 patients were included. Quantitative data was available for: mean total drainage volume, duration of drain in-situ and rates of seroma and haematoma formation. A significant reduction in rate of haematoma formation (OR 0.40, 95% CI 0.18-0.89, P = 0.02, I2=28%) was observed in the TXA group. There were no significant differences in the other outcomes. There was no significant increase in rates of adverse events. Conclusions Trends were observed in the present meta-analysis, although TXA did not appear to significantly alter the OBS outcomes. Current studies are insufficiently powered to isolate the effects of TXA on surgical morbidity. Further large prospective studies are needed to assess complications and determine the ideal dosage regime. At this juncture, prophylactic TXA in OBS cannot be recommended.

Assessing Reduction of Antibiotic Prescribing for Acute, Non-Complicated Infections in Primary Care in Germany: Multi-Step Outcome Evaluation in the Cluster-Randomized Trial ARena.

The three-armed cluster-randomized trial ARena (sustainable reduction of antibiotic-induced antimicrobial resistance) aimed to foster appropriate antibiotic use and reduce overprescribing in German ambulatory care to counter antibiotic resistance. Multi-faceted interventions targeted primary care physicians, teams and patients. This study examined the effectiveness of the implementation program. ARena was conducted in 14 primary care networks with 196 practices. All arms received data-based feedback on antibiotics prescribing and quality circles. Arms II and III received different add-on components each. Primary outcome examined is the prescribing rate for systemic antibiotics for cases with non-complicated acute infections (upper respiratory tract, bronchitis, sinusitis, tonsillitis, otitis media). Secondary outcomes refer to the prescribing of quinolones and guideline-recommended antibiotics. Based on pseudonymized quarterly claims data, mixed logistic regression models examined pre-post intervention antibiotic prescribing rate changes and compared to matched standard care. A significant rate reduction (arm I 11.7%; arm II 9.9%; arm III 12.7%) and significantly lower prescribing rates were observed for all arms (20.1%, 18.9% and 23.6%) compared to matched standard care (29.4%). Fluoroquinolone prescribing was reduced in all intervention arms and rates for recommended substances generally increased. No significant post-interventional difference between intervention arms was detected. Findings indicate implementation program impact compared to standard care.

The effect of use of Dexmeditomidine hydrochloride as an adjuvant in general anesthesia on rate of awareness

Abstract Background: Dexmedetomidine can be used as a safe and helpful adjunct in many clinical situations. Objective: To evaluate the role of Dexmedetomidine as an adjuvant in general anesthesia in relation to rate of awareness. Patients and methods: This was a prospective quasi experimental study conducted at Al-Sadder medical city during May to November 2016, included 400 patients, assigned randomly into two groups to receive the traditional anesthesia regimen (group I) or traditional anesthesia regimen and Dexmedetomidine (group II). Awareness was assessed via postoperative interview. Appropriate statistical tests were applied accordingly. Results: rates of awareness and possible awareness in group II were (0.5%) and (1.0%), respectively, and were significantly lower than that of group I (3.5%) and 4.5%), respectively, (P<0.05). Conclusion: Dexmedetomidine can improve the outcome of general anesthesia by significant reduction of rate of awareness during operation. How to Cite this Article Pubmed Style Nasser M. Meazher, Jaafar Hameed Mahboba, Zuhair Abdul Sada Dhahir. effect of use of Dexmeditomidine hydrochloride as an adjuvant in general anesthesia on rate of awareness. SRP. 2020; 11(5): 733-737. doi:10.31838/srp.2020.5.105 Web Style Nasser M. Meazher, Jaafar Hameed Mahboba, Zuhair Abdul Sada Dhahir. effect of use of Dexmeditomidine hydrochloride as an adjuvant in general anesthesia on rate of awareness. http://www.sysrevpharm.org/?mno=125907 [Access: March 28, 2021]. doi:10.31838/srp.2020.5.105 AMA (American Medical Association) Style Nasser M. Meazher, Jaafar Hameed Mahboba, Zuhair Abdul Sada Dhahir. effect of use of Dexmeditomidine hydrochloride as an adjuvant in general anesthesia on rate of awareness. SRP. 2020; 11(5): 733-737. doi:10.31838/srp.2020.5.105 Vancouver/ICMJE Style Nasser M. Meazher, Jaafar Hameed Mahboba, Zuhair Abdul Sada Dhahir. effect of use of Dexmeditomidine hydrochloride as an adjuvant in general anesthesia on rate of awareness. SRP. (2020), [cited March 28, 2021]; 11(5): 733-737. doi:10.31838/srp.2020.5.105 Harvard Style Nasser M. Meazher, Jaafar Hameed Mahboba, Zuhair Abdul Sada Dhahir (2020) effect of use of Dexmeditomidine hydrochloride as an adjuvant in general anesthesia on rate of awareness. SRP, 11 (5), 733-737. doi:10.31838/srp.2020.5.105 Turabian Style Nasser M. Meazher, Jaafar Hameed Mahboba, Zuhair Abdul Sada Dhahir. 2020. effect of use of Dexmeditomidine hydrochloride as an adjuvant in general anesthesia on rate of Reviews in Pharmacy, 11 (5), 733-737. doi:10.31838/srp.2020.5.105 Chicago Style Nasser M. Meazher, Jaafar Hameed Mahboba, Zuhair Abdul Sada Dhahir. The effect of use of Dexmeditomidine hydrochloride as an adjuvant in general anesthesia on rate of awareness. Systematic Reviews in Pharmacy 11 (2020), 733-737. doi:10.31838/srp.2020.5.105 MLA (The Modern Language Association) Style Nasser M. Meazher, Jaafar Hameed Mahboba, Zuhair Abdul Sada Dhahir. The effect of use of Dexmeditomidine hydrochloride as an adjuvant in general anesthesia on rate of awareness. Systematic Reviews in Pharmacy 11.5 (2020), 733-737. Print. doi:10.31838/srp.2020.5.105 APA (American Psychological Association) Style Nasser M. Meazher, Jaafar Hameed Mahboba, Zuhair Abdul Sada Dhahir (2020) effect of use of Dexmeditomidine hydrochloride as an adjuvant in general anesthesia on rate of Reviews in Pharmacy, 11 (5), 733-737. doi:10.31838/srp.2020.5.105

Comparison of Different Stenting Techniques of Coronary Bifurcation Lesions: A Network Meta-Analysis of 7601 Patients

IntroductionIntervention on coronary bifurcations lesions (CBL) is challenging. While provisional side branch (PS) stenting is the recommended method in most cases, there is no consensus on the preferred 2-stent technique.Material and methodsWe performed a network meta-analysis including randomized controlled trials (RCT) and observational studies comparing stenting techniques in CBL with reported clinical outcomes. A mixed treatment comparison model generation was performed to compare culotte, T and protrusion (TAP), crush and provisional techniques.ResultsWe included 14 RCT and 14 observational studies comprising 7,601 patients among whom 2,516 were treated with PS, 792 with TAP, 1,493 with culotte and 2,808 with crush. A Bayesian network meta-analysis showed a significant rate reduction of major adverse cardiovascular events (OR=0.73; 95%CI 0.52-0.99) and a trend for reduction in lesion revascularization (OR=0.72; 95%CI 0.48-1.11) and myocardial infarction (OR=0.62; 95%CI 0.3-1.08) with the crush technique, mainly driven by the double kissing (DK) crush, compared with all other stenting techniques. Other clinical outcomes, including mortality and stent thrombosis (ST) did not differ significantly between methods.ConclusionsThe crush technique, and especially DKcrush, is associated with improved outcomes compared to culotte, T and protrusion (TAP) and provisional techniques for CBL treatment. Further research is required to determine the optimal stenting technique for CBL.

Mortality Inequality in England over the Past 20 Years*

AbstractIn this paper, we study the evolution of age‐group‐ and gender‐specific mortality and mortality inequality in England between 2003 and 2016, by comparing small geographic areas ranked by deprivation and grouped into bins of similar population size. We show that across all age groups, but especially in the older age groups (65+), there has been a clear and significant reduction in rates of mortality since 2003. In spite of these improvements, we continue to see significant inequalities in mortality across most age groups in 2016 and evidence of rising inequalities among women in the 65+ and men in the 80+ age groups. Furthermore, we see a striking stalling of the downwards trend in mortality and mortality inequality observed between 2003 and 2010 during the years of economic austerity in the aftermath of the 2008 financial crisis in England between 2010 and 2016. Analysis of specific causes of death among adults aged 20–79 allows us to examine the drivers and dynamics of these trends in more depth, as well as to consider scope for, and types of, interventions that would be appropriate at different ages.

Novel Implantable Cardioverter Defibrillator Programming With High Rate Cut-Off, Long Detection Intervals and Multiple Anti-Tachycardia Pacing Reduces Mortality.

Implantable cardioverter defibrillator (ICD) therapies, even when appropriate, are associated with increased risk. Therapy-reducing strategies have been shown to reduce the mortality rate.Methods and Results:In total, 895 patients with ICD and cardiac resynchronization therapy with defibrillation function (CRT-D) were included in the study; of these, 506 (57%) patients undergoing secondary prevention were included. Devices implanted before May 2014 were programmed according to conventional programming (CP), the others according to our novel programming (NP) with high rate cut-off, longer detection intervals and 4-6 anti-tachycardia pacing (ATP) trains in the ventricular tachycardia (VT) zone. Time-to-first-event for mortality, appropriate and inappropriate therapies were analyzed. Follow-up time was 24.0 months (IQR 13.0-24.0 months). There was a significant reduction in mortality rate (11.4% vs. 25.4%, P<0.001) and in the rate of appropriate (18.8% vs. 42.2%, P<0.001) and inappropriate therapies (5.2% vs. 18.0%, P<0.001) with NP according to Kaplan-Meier analyses. In multivariate analysis, NP (hazard ratio [HR]=0.35; P<0.001), chronic kidney disease (HR=1.55), reduced ejection fraction (EF) (HR=1.35), secondary ICD indication (HR=2.35) and age at implantation (HR=1.02) were associated with mortality reduction. NP was also associated with significant reduction in the rate of appropriate and inappropriate therapies. These results were consistent after stratification for primary and secondary prevention. Novel ICD programming reduced mortality and morbidity due to appropriate or inappropriate ICD therapies in secondary as well as in primary ICD indication.

The impact of COVID-19 lockdown on infectious diseases epidemiology: The experience of a tertiary Italian Pediatric Emergency Department.

IntroductionThe aim of this study was to describe the rate and types of community-acquired respiratory infections observed in a pediatric ED during the SARS-CoV-2 related lockdown in Italy and to compare data with the same period of previous year.MethodsA retrospective analysis of medical charts of patients arrived at the ED of Gaslini Children's Hospital from 10th March 2020 to 30th April 2019 and the same frame of 2020 were performed. We compared two groups by demographics, duration of fever before ED admission, triage code, number of patients hospitalized after ED evaluation. We calculated proportion and incidence rate for airborne infections, fever, and urinary tract infections (UTI), appendicitis, and gastroenteritis for control.Results1362 children arrived at the ED during the lockdown compared to 5628 in the same period of 2019 (−75,8%). No difference was noticed (27.7% vs 28.4%) in the total amount of infectious episodes. A significant reduction in rate of incidence and proportion were observed for upper respiratory tract infections (21,4% vs 28%), otitis (2,6% vs 16,2%), streptococcal infections (0,5% vs 5,2%) and bronchiolitis (2,1% vs 5,7%). Conversely, FUO (27,8 vs 11,1%), infectious mononucleosis (2,6% vs 0,4%), UTI (7,4% vs 2,9%) and appendicitis (6,8% vs 1,1%) significantly increased. Median time from the onset of fever and arrival in ED was significantly lower in 2020 group.ConclusionOur results demonstrated a reduction in community-acquired respiratory infections during the lockdown for COVID-19. The increase in rate of FUO and febrile conditions, together with the short time from fever onset and ED visit could be related to the fear for a SARS-CoV-2 infection.

Continued decline in the prevalence of the Clostridioides difficile BI/NAP1/027 strain across the United States Veterans Health Administration

In 2018, we demonstrated a decreased prevalence of the hypervirulent Clostridioides difficile BI/NAP1/027 strain across the United States (US) Veterans Health Administration (VHA) from 2011 through 2016. The objective of this retrospective study was to update the prevalence of the BI/NAP1/027 strain within the VHA from 2017 through 2020. Patients with positive tests for the presence of toxigenic C. difficile at any Veterans Affairs Medical Center found to also routinely test for BI/NAP1/027 strain presence were included between July 1, 2016 and June 30, 2020.In total, 7490 patients had 8148 positive C. difficile tests that had a corresponding BI/NAP1/027 test. Of those, there were 1031 (12.6%) presumptive positive tests for the BI/NAP1/027 strain. The overall prevalence of BI/NAP1/027 decreased from a high of 15.4% in 2017 to 8.21% in 2020. Statistically significant reductions in rates from 2017 to 2020 occurred in 4 of 9 US Census Bureau regions.

Clinical utility of viscoelastic testing in chronic liver disease: A systematic review

BACKGROUNDConventional coagulation tests are widely used in chronic liver disease to assess haemostasis and to guide blood product transfusion. This is despite the fact that conventional tests do not reliably separate those with a clinically significant coagulopathy from those who do not. Viscoelastic testing such as thromboelastography (TEG) correlate with bleeding risk and are more accurate in identifying those who will benefit from blood product transfusion. Despite this, viscoelastic tests have not been widely used in patients with chronic liver disease outside the transplant setting.AIMTo assess the utility of Viscoelastic Testing guided transfusion in chronic liver disease patients presenting with bleeding or who require an invasive procedure.METHODSPubMed and Google Scholar searches were performed using the key words “thromboelastography”, “TEG” or “viscoelastic” and “liver transplantation”, “cirrhosis” or “liver disease” and “transfusion”, “haemostasis”, “blood management” or “haemorrhage”. A full text review was undertaken and data was extracted from randomised control trials that evaluated the outcomes of viscoelastic test guided transfusion in those with liver disease. The study subjects, inclusion and exclusion criteria, methods, outcomes and length of follow up were examined. Data was extracted by two independent individuals using a standardized collection form. The risk of bias was assessed in the included studies.RESULTSA total of five randomised control trials included in the analysis examined the use of TEG guided blood product transfusion in cirrhosis prior to invasive procedures (n = 118), non-variceal haemorrhage (n = 96), variceal haemorrhage (n = 60) and liver transplantation (n = 28). TEG guided transfusion was effective in all five studies with a statistically significant reduction in overall blood product transfusion compared to standard of care. Four of the five studies reported a significant reduction in transfusion of fresh frozen plasma and platelets. Two studies showed a significant reduction in cryoprecipitate transfusion. No increased risk of bleeding was reported in the three trials where TEG was used perioperatively or prior to an invasive procedure. Two trials in the setting of cirrhotic variceal and non-variceal bleeding showed no difference in control of initial bleeding. In those with variceal bleeding, there was a statistically significant reduction in rate of re-bleeding at 42 d in the TEG arm 10% (vs 26.7% in the standard of care arm P = 0.012). Mortality data reported at various time points for all five trials from 6 wk up to 3 years was not statistically different between each arm. One trial in the setting of non-variceal bleeding demonstrated a significant reduction in adverse transfusion events in the TEG arm 30.6% (vs 74.5% in the control arm P < 0.01). In this study there was no significant difference in total hospital stay although length of stay in intensive care unit was reduced by an average of 2 d in the TEG arm (P = 0.012).CONCLUSIONViscoelastic testing has been shown to reduce blood product usage in chronic liver disease without compromising safety and may enable guidelines to be developed to ensure patients with liver disease are optimally managed.