bluuebunny/crossref_metadata_2025 huggingface dataset:
970 The Effect of Diabetes on the Fusion Rate of Spinal Fusion Surgery: A Comprehensive Systematic Review and Meta-Analysis
Authors: Luangboriboon J , Gibson I
Published: August 2024

Aim

Spinal fusion surgeries address back pain by limiting intervertebral movement, but pseudarthrosis, a frequent complication, necessitates further interventions. Diabetes mellitus, known for impairing bone health, may negatively impact fusion rates. This systematic review and meta-analysis were carried out to assess the relationship between diabetes and spinal fusion failure.

Method

A comprehensive literature search was conducted on Cochrane Library, Embase, PubMed, and Web of Science databases for case-control and cohort studies examining the effect of diabetes on the fusion rate of spinal fusion surgery. Data was extracted based on the pre-defined inclusion and exclusion criteria. The Review Manager software, version 5.4, was used to perform all statistical analysis.

Results

Nine studies with 2117 patients were included in the meta-analysis. The pooled odds ratio from nine studies was 0.53 (95% confidence interval 0.37-0.77, P = 0.0008), indicating a significantly lower fusion rate in diabetics. Stratifying studies by operative site showed a non-significant odds ratio for cervical but significant for lumbar. Stratification by graft type revealed a significant odds ratio for autograft and a non-significant odds ratio for allograft/synthetic.

Conclusions

The findings of this study suggest that diabetes could be a risk factor for fusion failure in spinal fusion surgeries. A comprehensive understanding of the role diabetes plays in fusion rates may help refine preoperative risk assessments and patient selection, potentially leading to improved surgical outcomes. This evidence highlights the necessity for further investigations and developing more effective strategies for diabetic patients undergoing spinal fusion.
1105 Patient Satisfaction Using Wide Awake Local Anaesthesia No Tourniquet (WALANT) in Adults Undergoing Hand Surgery: A Systematic Review and Meta-Analysis
Authors: Sze Wong R S , Siu A , Ahmed Z , Talwar C , Nikkhah D
Published: August 2024

Aim

Wide-awake local anaesthesia no-tourniquet (WALANT) is an anaesthetic technique which has grown exponentially within hand surgery. However, evidence is unclear on whether patient satisfaction differs when comparing WALANT with anaesthesia with tourniquets (local, regional, or general).

Method

A systematic review and meta-analysis comparing patient satisfaction in WALANT to anaesthetic techniques with tourniquets amongst adults undergoing elective hand surgery procedures was performed following PRISMA guidelines (PROSPERO registration number CRD42023479937). PubMed, Embase, and Cochrane databases were searched for observational and randomized controlled trials (RCT) studies up to June 2023. Standardised mean difference (SMD) scores for patient satisfaction were computed using the random effects model.

Results

904 articles were identified initially and 18 met the inclusion criteria to be included in the meta-analysis. This yielded a total of 1638 surgeries, 823 surgeries of which were performed under WALANT (50.2%). Patient satisfaction was significantly higher in patients receiving WALANT (SMD 0.58, 95%CI 0.13 - 0.84, p<0.01, I² = 0.86). Subgroup analysis by type of surgery revealed significant differences only in carpal tunnel release (SMD 0.50, 95%CI 0.06 - 0.93, p = 0.03).

Conclusions

This systematic review supports the use of WALANT in elective hand surgery from a patient experience perspective. From our results, patient satisfaction using WALANT for elective hand surgery is equivalent or superior to anaesthesia with tourniquets including general and regional anaesthesia. We can infer that higher patient satisfaction can also be achieved with patients undergoing semi-elective or urgent surgery for traumatic injuries, which can be explored in future studies.
1089 Factors That Influence Cold Ischaemia Time in Deceased Donor Simultaneous Pancreas and Kidney Transplants: Results of a National Transplant Access to Theatre (NTACT) Audit
Authors: Mujeeb M , Borbas B , Tanase A , Aroori S
Published: August 2024

Aim

Various factors prolong cold ischaemia time (CIT) during simultaneous deceased donor pancreas and kidney (SPK) utilisation across the UK, impacting graft survival. However, there is a lack of data on these obstacles; therefore, this multicentre national audit aims to identify the factors that occur between the organs’ arrival at the implanting centre and transplantation.

Method

A prospective audit examining adult deceased donor SPK transplants across five UK transplant centres from February to September 2022. Precise time intervals between pre-transplantation checkpoints and perceived reasons for delays post-arrival at the implanting centre were recorded on RedCap platform. Descriptive statistics were used for analysis.

Results

Data from 29 SPK transplants were collected, with five exclusions for incomplete/incorrect data. Among these, 12 involved donations after brainstem death (DBD) organs and 12 donations after circulatory death organs (DCD). Median CIT for DBD kidneys and pancreas were 12:08 (IQR: 10:45-12:59) and 10:13 (IQR: 8:28-10:33), respectively. For DCD organs, corresponding figures were 10:30 (IQR: 09:13-12:17) and 07:44 (IQR:07:12-09:37). 17% of DCD and 0% of DBD pancreas and 17% of DCD and 4% DBD kidneys exceeded national CIT recommendations. Median times from organ arrival to knife to skin, warm ischemia (WIT) for pancreases, and patient arrival at the theatre were 03:17 (IQR: 03:00-03:48), 00:38 (IQR 00:31-00:43), and 01:41 (IQR: 00:52-01:57), respectively. Delays were reported in 96% of transplants.

Conclusions

This audit highlights significant proportions of organs exceeding national CIT cut-offs and identifies delays in organ utilisation requiring improvement.
1090 A UK-Wide Audit on Peri-Operative Practices During Deceased Donor Kidney Transplantation: Results from a Prospective National Transplant Access to Theatre (NTACT) Audit
Authors: Borbas B , Mujeeb M , Tanase A , Aroori S
Published: August 2024

Aim

The outcomes of deceased donor kidney transplants are mainly affected by donor and recipient factors. There is little data on whether variations in perioperative practices could also affect the outcomes and there is also little data on the standard perioperative practices across the UK. This study aims to identify current perioperative practices from a prospective National Transplant Access to Theatre (NTACT) audit.

Method

A multicentre, prospective audit of adult deceased donor kidney-only transplants was conducted across 14 UK transplant centres from February to September 2022. Data collected via RedCap focused on pre-operative antibiotic use, surgeon's grade, post-operative destination, crossmatch, and advanced haemodynamic monitoring. Descriptive statistics were used for analysis.

Results

Among 476 kidney-only transplants, 29 were excluded, leaving 446 transplants for analysis. Pre-operatively, 98.4% received antibiotics, with co-amoxiclav (n=147), ciprofloxacin (n=92), and amikacin (n=69) being most common. Consultant surgeons led 91.7% (n=409) of operations, while consultant anaesthetists led 61.4%. Notably, central lines (67.7% n=302), arterial lines (44.2% n=197), and advanced hemodynamic monitoring (27.6% n=123) were employed. Goal-directed fluid therapy was administered in 71.7% (n=320) of cases, with 71.6% (n=229) using static parameters. Post-operatively, 76.9% (n=343) were sent to a transplant ward, while 9.4% (n=42) and 10.8% (n=48) were directed to the intensive care unit and high dependency unit, respectively.

Conclusions

This audit highlights significant variations in perioperative practices, prompting further exploration into their potential impact on postoperative outcomes such as graft function and mortality.
672 The Management of Distal Radius Buckle Fractures
Authors: Ferns J , Yan A , Blong J , Hodhody G
Published: August 2024

Aim

To evaluate the management of distal radius buckle fractures in children and improve out-patient clinic utilisation.

Method

From April to June 2023, data was retrospectively collected across 4 emergency departments, including a specialist Children’s hospital, 2 DGH Emergency Departments and an Urgent Care Centre on all children aged 4-15 who had the code of distal radius fracture. Data was collected on the initial treatment comparing casts and splints, the number of out-patient appointments and the complications. These were analysed and the significance calculated using the chi-square test.

Results

416 fractures were screened of which 216 fractures were buckle fractures. Of these, 153 (71%) were splinted and 63 (29%) were casted. No patients or carers expressed concern about deformities. 108 patients were directly discharged from the emergency department with 33 patients discharged from the Virtual fracture clinic and other 75 patients generating 124 clinic appointments. Complications included 10 re-attendances to the emergency department for pain/swelling/cast problems/to arrange follow up, 1 re-fracture and 1 pressure sore from a cast. The rate of complications was significantly greater in the cast group (9.5%) vs the splint group (3.3%) (p value = 0.008).

Conclusions

Casts have a higher rate of re-attendance and complications than splints. Splints should be first line and local ED protocols should be altered to reflect this. Direct discharge from the emergency department is safe and can result in better utilisation of outpatient services. This will be improved locally through a series of education events.
778 Predicting Flexor Tendon Complications Following Volar Plate Fixation of Distal Radius Fractures
Authors: Yang J , Parkes R , Yip C R , Chojnowski A
Published: August 2024

Introduction

For distal radius fractures which are complex or unstable, volar locking plates are an effective means of fracture stabilisation, however patients may later develop flexor tendon complications. The Soong grading system was devised to determine which patients are most at risk of these by grading them between 0 (least likely) and 2 (most likely). Presently, however, this classification does not form part of our national guidelines.

Aim

We wanted to assess our current practice against the Soong classification, including testing its predictive value in identifying patients who developed flexor tendon issues.

Method

We performed a search of digital records for all patients who underwent volar plating following distal radius fractures in Norfolk and Norwich University Hospital between September 2022 and February 2023. Each fracture was graded using the post-operative X-rays and clinical outcomes were determined through review of clinic letters.

Results

102 patients were initially identified although 3 were excluded due to the inadequacy of available imaging. Of the remaining 99 patients, the most common grade was grade 1 (47.5%), followed by grade 0 (44.4%) then grade 2 (8.1%). Flexor tendon complications occurred in 25% (2/8) of grade 2 patients and 2% (1/47) of grade 1 patients but never in grade 0 (0/44).

Conclusions

The Soong classification effectively identified patients at higher risk of flexor tendon complications. It remains unclear, however, what follow-up these patients should receive to mitigate this risk. This will require prospective studies, although close follow-up and early plate removal should be considered in the interim.
1073 Optimising the Acute Management of Distal Radius Fractures: Re-Audit
Authors: Hopkinson-Woolley D , Khatri C , Carlos J , Ramoutar D
Published: August 2024

Aim

Distal radius fractures are a common presentation and early management is often in the emergency department (ED). Good, early management in the ED has been shown to reduce the number of people requiring operative treatment. We aimed to evaluate the impact of a staff training programme intervention on the number of patients requiring theatre.

Method

Three training sessions were held, training ED staff on fracture management standards according to BOAST guidelines. These included manipulation with finger traps (instead of in-line traction) and application of effective three-point moulded plaster. We assessed reduction from radiographs pre- and post-reduction. Data on patients’ requirement for further management were collected and compared to previous years.

Results

Satisfactory reduction in ED was achieved in 42.8% of patients. Requirement for eventual operative reduction in theatre was reduced to 17.3% from 45% and 24.1% in 2018 and 2020 respectively. This may be attributable to adoption of reduction with finger traps after training sessions, although no patients received a three-point moulded plaster in the ED.

Conclusions

This study found that the staff training sessions improved the quality of reduction of distal radius fractures. This lowered the operative intervention rate (17.3%), which is still higher than seen in the literature (10%). This could be improved by further interventions to standardise application of appropriately moulded plaster.
1077 Surgical vs Non-Surgical Interventions for Distal Radius Fractures: A Quantitative Analysis of Patient-Rated Wrist Evaluation Measures
Authors: Namireddy S , Gill S
Published: August 2024

Aim

Trials to assess differences in PRWE (Patient Related Wrist Evaluation) over time, for both surgical and non-surgical interventions post DRFs (distal radius fractures) are rare. The DASH (Disabilities of the Arm, Shoulder and Hand) questionnaire has been shown to be improved by a greater margin in the medium term for surgical interventions, than non-surgical interventions. However, a study found that PRWE can be considered superior to the DASH questionnaire for DRFs, due to greater specificity to wrist pain and function. This study aims to determine surgical vs non-surgical superiority for DRF’s over time with PRWE as a recovery metric.

Method

PubMed and Cochrane were searched for randomised controlled trials up to 31.8.23, reporting PRWE over 3, and 12 months. Data was extracted by 2 researchers. The differences in PRWE over time post-surgical and non-surgical interventions was assessed using unpaired T testing.

Results

1226 records were screened. 4 studies enrolling 817 participants met the eligibility criteria and were analysed. Significantly lower PRWE in surgical intervention has been identified at the 3-month mark (p<0.001). There was greater significant change in non-surgical intervention between months 3 and 12 (p<0.001).

Conclusions

Change in PRWE over time may be a good indicator of functional outcomes in DRFs post-surgical or non-surgical interventions. This could inform future clinical trial design and surgical decision-making. Further work is required to design even more user-friendly and digital patient-reported outcomes specifically for DRFs.
1093 Risk Factors for Spinal Cord Monitoring Alerts in Paediatric Patients Undergoing Spinal Deformity Surgery
Authors: Lee M , James S , McCarthy M , Kefalas D , Jones A , Ahuja S , Moideen N , Howes J
Published: August 2024

Aim

Intraoperative neurophysiological monitoring (IONM) is used during spinal deformity surgery to detect potential neurological insult. This study aims to determine clinical factors that increase the risk of IONM changes in this patient population.

Method

All patients ≤ 18 years old who underwent scoliosis correction surgery in a single institute between 2017 and 2022 were reviewed. Patients with IONM alerts were identified and demographic, clinical, operative and radiological details were obtained.

Results

There were 206 cases during which there were 9 significant neuromonitoring alerts. Compared to the non-alert group, the alert group had a significantly greater EBL (P < 0.001), operative time (P < 0.001), preoperative major Cobb angle (P = 0.022) and postoperative major Cobb angle (P = 0.015). There were no significant differences in age (P = 0.618), sex (P = 0.255), mean corrective rate (P = 0.401) and type of scoliosis (P = 0.185) between the two groups. IONM alerts were found to be triggered by the insertion of screws in 4 patients (44.4%), rod application and curve correction manoeuvres in 4 patients (44.4%) and corpectomy procedure in 1 patient (11.1%). In the alert group, no patients experienced postoperative neurological deficits and only 1 operation (11.1%) was aborted due to repeated IONM alerts.

Conclusions

Our study reaffirms the previously described risk factors in the literature. Greater operative time, EBL and preoperative and postoperative major Cobb angle are associated with an increased risk of potential spinal cord insult. IONM alerts commonly occur during and after the insertion of instrumentation and curve correction manoeuvres.
1165 The Effect of Stem Length on Stem Alignment: A Comparison of the 125mm and 150mm Exeter V40 Stems
Authors: Reece A , Clarke J
Published: August 2024

Aim

The Exeter V40 hip replacement stem is available in two lengths – 125mm and 150mm. The 150mm stem has been the standard for decades, however, the 125mm stem is a new option which may be more suited to certain femoral shapes. The aim of this study was to assess whether inserting a shorter stem (125mm) would affect stem alignment.

Method

This was a prospective cohort of 70 patients undergoing cemented total hip replacement at the Golden Jubilee National Hospital, a high-volume national arthroplasty centre. Patients were randomly assigned either the 125mm or the 150mm stem. The post-operative pelvic radiographs were evaluated for stem position. The angle between the midline of the stem and the anatomical axis of the femur was measured. Patient demographics were evaluated for any effect on stem alignment.

Results

Stems were positioned in significantly increased relative varus in the 125mm group (3.53° varus) compared to the 150mm group (2.21° varus) (p=0.009). Other factors such as BMI, surgeon, sex, and side of operation had no correlation to the stem position in either group.

Conclusions

There was a greater incidence of varus malalignment observed in the group undergoing THR using the shorter 125mm Exeter stem. This was statistically significant, but the clinical significance was not evaluated as part of this study, which will be investigated in future research.
555 Do Patients Want a Day Case BOO Procedure?
Authors: Blackburn J , Nitkunan T , Akiboye D
Published: August 2024

Aim

According to Getting It Right First Time (GIRFT) guidance, 25% of all Bladder Outflow Obstruction (BOO) surgery should be performed as a day-case procedure. The common practice amongst NHS trusts that achieve this target is to discharge patients home with a catheter, to return at a later date for trial without catheter (TWOC). The aim of this study was to determine if patients want to be discharged with a catheter.

Method

Data was collected at a single trust from 31 patients attending a Urology CNS clinic following their BOO surgery. All patients underwent either a TURP, HoLEP or BNI between 29/12/2022 to 13/06/2023. All patients were asked ‘If you were to go home on the day of your surgery with your catheter and come back in the following day to have your catheter removed, would you be agreeable to this?’. Patient responses were documented in clinic notes.

Results

84% of patients did not want to go home with a catheter following their surgery. Specific reasons included concerns if something were to go wrong with the catheter (4), catheter size (2) and catheter management (1). 13% of patients would be happy to go home with a catheter and one patient was ambivalent.

Conclusions

Over 80% of patients that underwent BOO surgery did not want to go home with a catheter. We suggest a solution to this would be removal of the catheter on the day of surgery. To date, 9 patients have undergone successful, same day catheter removal without complications.
878 The Outcome of Prophylactic Antibiotics Use in Local Anaesthetic Trans-Perineal Ultrasound-Guided Prostate Biopsy (LATP) - a District General Hospital Review
Authors: Balasubaramaniam V , Kailasa A , Donev K
Published: August 2024

Aim

Over the past few years, LATP has been gaining popularity over transrectal ultrasound guided (TRUS) as the modality of choice for prostate biopsy given the reduced risk of infection and hospital admission. LATP was implemented in our district general hospital in North Wales in November 2021. The benefit of prophylactic antibiotics for LATP remains uncertain. This study aims to investigate the benefits of prophylactic antibiotic use.

Method

A retrospective audit of patients who underwent LATP under one urologist over a 10-month period (11/02/2022-27/11/2022) were included in the study. All patients received a single dose of Gentamicin 240mg intravenously before the procedure. Pre-and post-procedure urine dipstick and mid-stream urine (MSU) found in patient notes and online record system was recorded. General practitioner and medical records were checked to identify if patients presented with urinary tract infections.

Results

A total of 53 male patients were included in the study. The mean age was 71.6 years old. 2 patients were admitted immediately after the procedure for urinary retention, however, MSU was negative. No patients (0%) developed urinary tract infection (UTI) post-operation.

Conclusions

The use of prophylactic Gentamicin pre-LATP minimises the chances of developing UTI post-procedure. Studies with large sample sizes and that investigate patients without prophylactic antibiotics should be carried out to determine if it is a safe alternative.
1036 Does Nephroureterectomy Decision Necessitates Prior Ureteric Biopsy in Cases with Upper Urothelial Tract Cancer?
Authors: Farag A , Sali G , Radnaeva I , Subramonian K
Published: August 2024

Introduction

Objective of study: assess need for ureteroscopic biopsy prior to nephroureterectomy (NU) for upper urothelial tract cancer (UTUC).

Method

Patients referred during 2015-2022 with suspected UTUC were included. Clinicopathological characteristics included presentation, CT results, urine cytology, ureteric biopsy and final histopathology. Analysis done using SPSS.

Results

Mode of presentation for 161 patients: 48% hematuria, 54 % CT filling defect, 8% ureteric thickening, 11% locally advanced and 17% inconclusive. Urine cytology was positive in 13% (n=21).

89 patients underwent nephroureterectomy. This cohort was subdivided into: Group1 with prior ureteric biopsy (n=39) and Group 2 without prior biopsy (n=50).

Histopathological analysis comparison of NU specimen of two groups is shown in Table1. 4 patients in Group 1 and 10 in group 2 had histological diagnosis of disease other than UTUC suggesting that 10% of group 1 avoided NU while 20% of Group2 could have had alternative treatment than NU if they had prior biopsy.

Amongst patients with prior biopsy, 5 had upstaging of histological grade on nephroureterectomy specimen. There was significant association (p=0.04) between histological grade on biopsy and NU specimen, especially in high grade disease.

Conclusions

Initial diagnostic ureteroscopy is useful in identifying UTUC requiring radical surgery and ruling out conditions which could be managed by alternative treatments. Prior Ureteroscopy may be avoided in patients with clear CT scan findings suggestive of UTUC associated with previous bladder cancer and/or abnormal urine cytology.
1069 What Is the Diagnostic Test Accuracy of Urinary Biomarkers for Prostate Cancer? A Systematic Review
Authors: Smith S , Manley K , Mills R
Published: August 2024

Aim

To conduct an up-to-date systematic review to evaluate the diagnostic accuracy of urinary biomarkers in isolation for prostate adenocarcinoma diagnosis in biopsy-naïve men presenting with suspected prostate cancer.

Method

Eligibility criteria: prospective cohort studies or randomised clinical trials including adult men with their first presentation of elevated PSA and/or abnormal DRE findings and evaluating urinary biomarkers for prostate adenocarcinoma diagnosis as compared to the reference standard of prostate biopsy with histological diagnosis. Studies of urinary biomarkers were included where the index test was applied in isolation (not in combination with additional serum biomarkers and/or risk scores). MEDLINE, Embase, Cochrane Library and Scopus were searched for studies published from 1st January 2000 to July 2023. Assessment of bias and applicability were performed using the QUADAS-2 tool. PROSPERO registration: CRD42023445178.

Results

2828 studies were identified, of which 7 prospective cohort studies were included (1688 patients). The studies evaluated exosome assay EXO106, 25 gene panel, Alpha-methylacyl-CoA racemase (AMACR) score, ExoDxÔ Prostate Intelliscore (EPI), prostate cancer gene 3 (PCA3), Hyaluronic acid (HA), Hyaluronidase (HAase) and exosomal prostate specific membrane antigen (PSMA).

Conclusions

The 25 gene panel (D score) biomarker had the highest AUC value of 0.901, followed by exosomal PSMA (AUC 0.854) and then PCA3 (AUC 0.83). In all but one study, the reference standard was based upon 10-12 core transrectal ultrasound-guided prostate biopsy without MRI. Future studies employing pre-biopsy mpMRI and transperineal biopsy in larger cohorts are needed to ascertain diagnostic accuracy and cost-effectiveness in the current NHS prostate cancer pathway.
382 Introduction of a New Diabetic Foot Treatment Protocol Using an Antibiotic Carrying Biocomposite
Authors: Shaw C , Vaidya A , Vig S , Kelleher D
Published: August 2024

Aim

Incidence of diabetes is increasing in the UK. This risks diabetic foot infections which are hard to treat and increase burden on the NHS with recurrent admissions for wound management and antibiotics. Stimulan is an absorbable calcium sulfate antibiotic carrier designed to mix with antibiotics and be applied to open wounds to treat infection including osteomyelitis; this delivers targeted local antibiotics at a higher concentration with ability to disregard renal function. This treats infection and ultimately stops recurrent hospital admissions. This quality improvement project looks at the use of Stimulan in a new protocol for the management of diabetic foot infections at a District General Hospital.

Method

All diabetic foot infections received a protocolled standard of care pathway aimed at grading severity of diabetic foot infection and treating appropriately. When there was a need for debridement of necrotic/infected tissue or drainage of collections, we introduced an intra-operative protocol to debride back to healthy bone, obtain tissue for micro analysis and pack with Stimulan for antibiotic cover.

Results

12 patients received a new standard of care including use of Stimulan intra-operatively combined with antibiotics to treat swab proven infections including Proteus Mirabilis, Enterococcous Faecalis/Coli, Staph Aureus/Epidermidis and Klebsiella. 6–12-month follow-up of these patients showed that they had a downgrading of their foot ulcer severity on the Wagner diabetic foot ulcer classification.

Conclusions

A new protocolled standard of care with the introduction of topical Stimulan mixed with appropriate antibiotics proved effective at treating diabetic foot ulcers complicated by infection.
517 Treatment of Steal Syndrome from a Brachioaxillary Haemodialysis Graft
Authors: Arumuga Jothi A , Mouhsen M I M M , Kordzadeh A , Thapar A , Dindyal S
Published: August 2024

Aim

High flow steal syndrome is a rare complication of arteriovenous (AV) prosthetic grafts used for haemodialysis access. It can be classified as high flow (due to flow diversion away from the hand) or low flow (due to forearm arterial occlusion) The conventional method of treatment is ligation of the graft and use of a tunnelled line. However, dialysis via a graft reduces mortality and hospitalisation for sepsis and reduces central vein stenosis. The aim of this case was to establish the feasibility of flow restriction of a brachioaxillary graft that was causing high flow steal syndrome.

Method

A 70-year-old lady with a new left brachioaxillary graft developed early hand pain at rest (Tordoir 3 class ischaemic steal). Duplex demonstrated patent radial and ulnar arteries with flow reversal in the radial artery. There was high volume flow through the graft. Waveforms at the radial artery improved with external compression of the graft. A multi-disciplinary decision was made to attempt to salvage the graft rather than ligate it. Under local anaesthesia the GORE® ACUSEAL graft was exposed at the arterial anastomosis and 3 large metal Ligaclips were applied 1cm apart to flow restrict the AV graft.

Results

There was return of triphasic radial signal after the 3rd Ligaclip with preserved graft flow. 2 weeks following the procedure the patient resumed dialysis and had resolution of ischaemic rest pain.

Conclusions

Flow restriction through the application of Ligaclips is a new way of treating high flow steal syndrome in AV grafts.
1258 Statin Therapy Following Carotid Revascularization Is Associated with Optimised Operative Outcomes and Long-Term Survival: A Literature Review
Authors: Alhussaini N
Published: August 2024

Aim

Statin therapy is the standardized care for patients with coronaryartery stenosis, given its established cardiovascular benefits. However, it is poorly researched in noncoronary atherosclerosis patients. This review investigates the relationship between statin therapy and clinical outcomes after carotid endarterectomy, transcarotid artery revascularization and transfemoral carotid artery stenting.

Method

This study was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA). Through a comprehensive search of PubMed and Journal of Vascular Surgery until August 2018, eligible studies were identified. A total of 12 studies were included.

Results

The absence of perioperative statins in CEA and tfCAS correlated with higher in-hospital stroke and death, 1.7% vs 1.4% for CEA and 4.8% vs 2.8% for tfCAS. However, this association wasn't observed in TCAR patients. Long-term statistics demonstrated that excluding statins at discharge was linked to increased 5-year mortality post-CEA (15% vs 10%) and tfCAS (18% vs 14%). Symptomatic patients on statins during admission showed 25% reduced complications.

A population-level study signified that postoperative statins at moderate to high doses associates with lower adverse cardiac and cerebrovascular events at 1 year (adjusted hazard ratio: 0.76) and persistent benefits at 5 years (adjusted hazard ratio: 0.75). Additionally, late anatomic failure of the surgical patch was associated with elevated serum cholesterol and lipid-lowering drugs were protective.

Conclusions

Continuous statin therapy perioperatively demonstrated lower short- and long-term adverse events in atherosclerotic disease. This aligns with Vascular Surgery Society recommendations and exhibits a quality improvement opportunity. In conjunction with other collaborative research, statin use is warranted following revascularization, both endovascular and open repair.
Randomized Trial of Occlusive Wrap for Heat Loss Prevention in Preterm Infants
Authors: Katheria Anup
Published: August 2024

Occlusive wrap placed on preterm infants immediately after birth can reduce postnatal evaporative heat loss. The HeLP trial determined whether use of occlusive wrap reduces in-hospital mortality among infants born at 24 to 27 weeks’ gestation. Of 817 infants who were randomized to wrap or no wrap at birth, 801 were included in the analysis. There was no difference in the primary outcome of death (odds ratio [OR] 1.0; 95% CI 0.7 to 1.5, p = 0.85). Infants randomized to occlusive wrap had higher baseline (p <0.001) and post-stabilization (p = 0.007) temperatures, and a lower incidence of pulmonary hemorrhage (OR 0.6; 95% CI 0.3 to 0.9). The study was stopped early for futility after 50% of the projected sample size had been enrolled.
Effect of Sustained Inflations vs Intermittent Positive Pressure Ventilation on Bronchopulmonary Dysplasia or Death Among Extremely Preterm Infants
Authors: Hay Susanne , Zupancic John
Published: August 2024

Sustained inflation (SI) was recommended in some countries, and was compelling on physiological grounds. SAIL investigated the benefit and safety of SI in a large, international trial. Four hundred sixty extremely preterm infants requiring positive pressure resuscitation at birth were randomized to SI (peak pressure of 20 cm H2O for 15 seconds) or routine intermittent positive pressure ventilation. There was no difference in the composite primary outcome of death or bronchopulmonary dysplasia at 36 weeks’ postmenstrual age (63.7% SI, 59.2% control; p = 0.29). The SI group demonstrated increased mortality at 48 hours (7.4% vs 1.4%; p = 0.002), leading to early trial closure.
Long-term Effects of Caffeine Therapy for Apnea of Prematurity
Authors: Bassler Dirk
Published: August 2024

Caffeine was a long-accepted treatment for AoP and one of the most frequently used medications in the NICU; however, at the time of this trial, reasonable doubt had emerged among the neonatal community about its safety and long-term effects. The international Caffeine for Apnea of Prematurity (CAP) trial was launched to determine whether survival without neurodevelopmental disability is improved if apnea of prematurity is managed without caffeine. Infants with birth weights of 500 to 1250 g were randomized to receive either caffeine or placebo. The primary composite outcome of death or neurodevelopmental disability was measured at a corrected age of 18 to 21 months. The CAP trial showed that neonatal caffeine therapy decreased death or neurodevelopmental disability (odds ratio adjusted for center 0.77, 95% confidence interval 0.64 to 0.93, p = 0.008).
Target Ranges of Oxygen Saturation in Extremely Preterm Infants
Authors: Hagadorn James I.
Published: August 2024

Observational studies had suggested that maintaining low pulse oximeter oxygen saturation (SpO2) in extremely preterm infants reduce retinopathy of prematurity (ROP). However, the benefits and risks of different SpO2 ranges had not been adequately studied. SUPPORT randomized 1316 infants 24 to 27 weeks’ gestation to SpO2 85% to 89% versus 91% to 95% during routine care. The composite outcome of severe retinopathy or death did not differ between groups (adjusted relative risk [aRR] 0.90, 95% CI 0.76 to 1.06, p = 0.21). However, in the lower SpO2 group, death before discharge occurred more frequently (aRR 1.27, 95% CI 1.01 to 1.60, p = 0.04), while severe ROP was less frequent among survivors (aRR 0.52, 95% CI 0.37 to 0.73, p <0.001). Ideal SpO2 management for extremely preterm infants on supplemental oxygen remains unclear, and requires trade-offs to be made dependent upon local rates of ROP and death.
High-Flow Nasal Cannulae in Very Preterm Infants After Extubation
Authors: Roehr Charles Christoph
Published: August 2024

The HIPERSPACE trial compared high-flow nasal cannula (HFNC) with continuous positive airway pressure (CPAP) as post-extubation support, at a time when HFNC was being increasingly used for this indication, with minimal guiding evidence. In this multicenter, non-inferiority trial, 303 infants <32 weeks’ gestation were randomized to either 6 to 8 cm H2O CPAP or 5 to 8 L/min HFNC after extubation. HFNC was found to be noninferior to CPAP for the primary outcome of extubation failure within 7 days, with a 20% margin of non-inferiority (34.2% HFNC versus 25.8% CPAP; risk difference [RD] 8.4, 95% CI –1.9 to 18.7). For infants with GA <26 weeks’ (n = 62), failure rate was high in both treatment groups, but the RD was 20% in favor of CPAP (95% CI –1.9 to 41.8). Apart from less nasal trauma in the HFNC group, no statistically significant difference was observed between groups for secondary outcomes.
The Influence of the Thermal Environment Upon the Survival of Newly Born Premature Infants
Authors: Osborn David
Published: August 2024

A previous study had shown improved survival of premature infants nursed in a relative humidity of 80%–90% compared with 30%–60%. This study tested the derived normothermic hypothesis, that supplying ample heat to premature infants to minimize metabolic demands improved survival. To test this hypothesis, premature infants were randomized to a “normothermic” group (incubator set at 31.7°C) or a “hypothermic” group (incubator set at 28.9°C) from admission to 120 hours age. Infants in the normothermic group had lower mortality at 5 days (16% versus 32%; RR 0.52, 95% CI 0.30 to 0.90, p = 0.02) and 28 days (22% versus 45%; RR 0.49, 95% CI 0.31 to 0.76, p = 0.002). This trial represents one of a series of path-breaking trials performed by Silverman and colleagues that largely introduced the concept of RCTs to identify critical needs of preterm infants.
Probiotic Effects on Late-Onset Sepsis in Very Preterm Infants
Authors: Thomas Deena , Shankar M. Jeeva
Published: August 2024

Different probiotic strains have been suggested to reduce the risk of necrotizing enterocolitis (NEC) in very preterm infants. However their effect on late-onset sepsis is less clear. This trial was designed to evaluate the impact of a combination of 3 probiotics (Bifidobacterium infantis, Streptococcus thermophilus, and Bifidobacterium lactis) on the incidence of culture-positive late-onset sepsis in very preterm infants. A total of 1099 infants were randomized to daily probiotics or placebo. There was no difference in the incidence of late-onset sepsis (13.1% versus 16.2%; RR 0.81, 95% CI 0.61 to 1.08, p = 0.16). Among the secondary outcomes, the risk of NEC (Bell stage 2 or more) was significantly reduced in the probiotic group (2.0% versus 4.4%; RR 0.46, 95% CI 0.23 to 0.93, p = 0.03), but there was no apparent effect on mortality.
Higher or Lower Hemoglobin Transfusion Thresholds for Preterm Infants
Authors: Franz Axel R.
Published: August 2024

Preterm infants universally develop anemia of prematurity, potentially impairing oxygen delivery to the brain. The TOP trial investigated the effect of higher versus lower hemoglobin transfusion thresholds on death or neurodevelopmental impairment (NDI). 1824 infants with a birth weight ≤ 1000 grams or a gestational age <29 weeks were randomized to either higher or lower transfusion trigger thresholds, achieving a 1.9 g/dL (1.18 mmol/L) difference in the pre-transfusion hemoglobin concentration between groups. There was no difference in the incidence of the primary outcome of death or NDI (50.1% high versus 49.8% low; relative risk adjusted for birth-weight stratum and center, 1.00, 95% confidence interval 0.92 to 1.10, p = 0.93), nor was there any difference in common serious complications of prematurity.
Effect of a Higher vs Lower Platelet Transfusion Threshold on Death or Major Bleeding in Preterm Infants
Authors: Patel Ravi Mangal
Published: August 2024

Platelet transfusions administered at a platelet count threshold of 50 × 109/L or greater is common in neonates. The PlaNeT-2 trial investigated the effect of higher versus lower platelet transfusion thresholds in infants <34 weeks’ gestation with severe thrombocytopenia and without evidence of significant hemorrhage within 72 hours of study entry. This multicenter trial in the United Kingdom and European centers randomized 660 infants to a platelet count threshold of 25 versus 50 × 109/L for prophylactic platelet transfusions. The risk of new major bleeding or death was greater in infants randomized to the higher threshold (26% versus 19%; adjusted odds ratio 1.57, 95% CI 1.06 to 2.32, p = 0.02). Infants randomized to the higher threshold group had a higher risk of survival with BPD (63% versus 54%; OR 1.54, 95% CI 1.03 to 2.30).
Whole-Body Hypothermia for Neonates with Hypoxic-Ischemic Encephalopathy
Authors: Onland Wes , van Kaam Anton H.
Published: August 2024

The incidence of death or severe neurodevelopmental impairment in infants born after perinatal asphyxia having hypoxic ischemic encephalopathy is very high. The NICHD 2005 study investigated the benefit and safety of therapeutic hypothermia treatment in a large, multicenter trial. Two hundred eight infants ≥36 weeks’ gestation diagnosed with moderate to severe hypoxic ischemic encephalopathy were randomized to therapeutic hypothermia (33.5°C by a commercial servomechanism) or standard care. This study showed that hypothermia treatment initiated within 6 hours after birth for 72 hours significantly reduces the risk of death or neurodevelopmental impairment (adjusted relative risk 0.72, 95% confidence interval 0.54 to 0.95, p = 0.01), without any serious adverse effects. No significant difference was found in any individual component of the composite primary outcome. Twenty-four percent of the infants died in the hypothermia group, and 37% in the control group (RR 0.68, 95% CI 0.44 to 1.05, p = 0.08).
Preoperative Pregnancy Testing in Minors
Authors: Pealy Elizabeth Starker , Choi Ellen Y.
Published: August 2024

Preoperative pregnancy testing in a minor patient is commonly performed prior to a procedure, and this has many important ethical, legal, and financial considerations. These point-of-care tests help healthcare practitioners provide complete informed consent for the procedure based on pregnancy status. However, testing is not absolutely required and should be utilized after consideration of a patient’s legal and ethical rights, as well as financial cost to an institution. This chapter also discusses the ethical issues surrounding informed consent, informed assent, decision-making capacity, and confidentiality for minor patients with regards to preoperative pregnancy testing and pregnancy status. It is important for the practitioner to be familiar with state statutes on reproductive health in minors, including the medical decision-making rights of the pregnant minor.
Decision-Making Capacity and Surrogate Decision-Making for a Patient Who Lacks It
Authors: Caruso Brown Amy E. , Robins Berklee
Published: August 2024

When patients have decisional capacity (decision-making capacity), respect for autonomy requires that healthcare decisions made by the patient be honored. However, when a patient lacks or loses decisional capacity, either temporarily or permanently, healthcare professionals turn to a surrogate decision-maker who is charged with making decisions that align best with what the patient would choose if they had the ability to do so. Both ethics and the law provide guidance in this area. Surrogate decision-makers and healthcare professionals look first to the patient’s previously expressed preferences regarding their health and treatment. In the absence of such explicit known wishes, the surrogate decision-maker can help identify approaches that are most concordant with the patient’s values and views. When the surrogate decision-makers are not in agreement, or there is no identified surrogate decision-maker, the task of making important decisions about healthcare becomes even more complicated.
The Ethics of Research
Authors: Jotwani Rohan , Pryor Kane O. , Goldstein Peter A.
Published: August 2024

A thorough understanding of the ethics involved in human subject research is essential to ensuring the safe and humane treatment of participants. Research ethics establishes a framework to guide principled and just decisions with respect to trial design, investigator conflicts of interest, and participant recruitment. Each person involved in conducting human subject research has a moral obligation to protect the dignity, autonomy, and natural rights of the individuals they hope to enroll in a research trial. Only with an unwavering commitment to ethical principles can investigators advance and improve human health through research and innovation without compromising the very ideals that inspire us.
Bloom’s Taxonomy
Authors: Pla Raymond A. , Cohen Ira Todd
Published: August 2024

The psychomotor domain is the third domain of Bloom’s taxonomy. It is central to teaching skills and procedures. Inherent in the development of technical skills are physical movement, coordination, speed, and precision. By the mid-1970s, three models had been developed and published. Each model depicts categories that increase in complexity, drafted in a stepwise fashion to support the learner’s development of the skills and techniques necessary to effectively complete complex tasks. In the psychomotor domain, learners develop, refine, and master techniques to execute procedures. Once mastery is achieved, learners can apply their newly acquired abilities in novel and creative ways.
Understanding the Physician Code of Conduct
Authors: Marcucci Catherine , Alberts Carol Bodenheimer , Sandson Neil B.
Published: August 2024

This chapter examines the ethical, legal, and practical duties to report physician colleagues who are struggling with alcoholism, drug use and/or dependence, mental illness, and a number of other personal and professional impairments that can impact the delivery of safe and appropriate care and the stability of the practice environment. A brief history of the physician health movement is discussed, as well as practical, real-life advice and tips on recognizing physician impairment. Guidance is provided on overcoming the barriers that physicians contemplating the reporting of a colleague might face. A short discussion on reporting the unethical and incompetent physician is also included.
Human Telencephalization
Authors: Ströckens Felix , Amunts Katrin
Published: August 2024

The extension of the telencephalic neocortex (i.e., telencephalization) is one of the most prominent features of human brain evolution and has been related to an increase in telencephalic processing capacity, including cognitive performance. However, it might have had also adverse effects, in shape of neurological diseases, which are less common or even absent in nonhuman mammals, including the traditional neuroscientific model species. Within this chapter, the authors briefly outline the evolutionary history of humans and give an overview of the general anatomy of the mammalian brain. They then highlight specific differences in neuroanatomical macro- and microstructure between humans and most common animal model species and discuss their possible implications. Furthermore, this chapter serves as a basis for the following chapters, introducing important terminology and concepts, allowing for an easier access even for readers without a strong neuroscientific background.
Evolutionary Aspects of Glial Cells
Authors: Calì Corrado , Ackermans Nicole L. , Hof Patrick R. , Magistretti Pierre J.
Published: August 2024

Glial cells play a crucial role in brain development, function, and pathology. Despite substantial progress in understanding the many roles played by oligodendrocytes, microglia, and astrocytes in synaptic transmission, neurological diseases, and brain health, the specific contributions and underlying mechanisms are still poorly understood. In relation to glial cell types and phylogenic origin, the current chapter summarizes knowledge on the evolutionary aspects of glial cells and their various roles in the emergence of neurodegenerative diseases such as Alzheimer’s disease, multiple sclerosis, and neuroinflammation. Furthermore, the prospects for this field’s future are encouraging as glial cells have the ability to reveal fundamental principles underpinning brain function. They also offer innovative treatment options for neurological illnesses.