Anaesthetic efficacy and postinduction hypotension with remimazolam compared with propofol: a multicentre randomised controlled trial.

Remimazolam, a short-acting benzodiazepine, may be used for induction and maintenance of total intravenous anaesthesia, but its role in the management of patients with multiple comorbidities remains unclear. In this phase 3 randomised controlled trial, we compared the anaesthetic efficacy and the incidence of postinduction hypotension during total intravenous anaesthesia with remimazolam vs. propofol. A total of 365 patients (ASA physical status 3 or 4) scheduled for elective surgery were assigned randomly to receive total intravenous anaesthesia with remimazolam (n = 270) or propofol (n = 95). Primary outcome was anaesthetic effect, quantified as the percentage of time with Narcotrend® Index values ≤ 60, during surgery (skin incision to last skin suture), with a non-inferiority margin of -10%. Secondary outcome was the incidence of postinduction hypotensive events. Mean (SD) percentage of time with Narcotrend Index values ≤ 60 during surgery across all patients receiving remimazolam (93% (20.7)) was non-inferior to propofol (99% (4.2)), mean difference (97.5%CI) -6.28% (-8.89-infinite); p = 0.003. Mean (SD) number of postinduction hypotension events was 62 (38.1) and 71 (41.1) for patients allocated to the remimazolam and propofol groups, respectively; p = 0.015. Noradrenaline administration events (requirement for a bolus and/or infusion) were also lower in patients allocated to remimazolam compared with propofol (14 (13.5) vs. 20 (14.6), respectively; p < 0.001). In conclusion, in patients who were ASA physical status 3 or 4, the anaesthetic effect of remimazolam was non-inferior to propofol.

All-Suture Anchors: Biomechanical Analysis of Pullout Strength, Displacement, and Failure Mode.

PURPOSE: To evaluate the biomechanical and design characteristics of all-suture anchors. METHODS: All-suture anchors were tested in fresh porcine cortical bone and biphasic polyurethane foam blocks by cyclic loading (10-100 N for 200 cycles), followed by destructive testing parallel to the insertion axis at 12.5 mm/s. Endpoints included ultimate failure load, displacement at 100 and 200 cycles, stiffness, and failure mode. Anchors tested included JuggerKnot (1.4, 1.5, and 2.8), Iconix (1, 2, and 3), Y-knot (1.3, 1.8, and 2.8), Q-Fix (1.8 and 2.8), and Draw Tight (1.8 and 3.2). RESULTS: The mean ultimate failure strength of the triple-loaded anchors (564 ± 42 N) was significantly greater than the mean ultimate failure strength of the double-loaded anchors (465 ± 33 N) (P = .017), and the double-loaded anchors were stronger than the single-loaded anchors (256 ± 35 N) (P < .0001). No difference was found between the results in porcine bone and biphasic polyurethane foam. None of these anchors demonstrated 5 mm or 10 mm of displacement during cyclic loading. The Y-Knot demonstrated greater displacement than the JuggerKnot and Q-Fix (P = .025) but not the Iconix and Draw Tight (P > .05). The most common failure mode varied and was suture breaking for the Q-Fix (97%), JuggerKnot (81%), and Iconix anchors (58%), anchor pullout with the Draw Tight (76%), whereas the Y-Knot was 50% suture breaking and 50% anchor pullout. CONCLUSIONS: The ultimate failure load of an all-suture anchor is correlated directly with its number of sutures. With cyclic loading, the Y-Knot demonstrated greater displacement than the JuggerKnot and Q-Fix but not the Iconix and Draw Tight. JuggerKnot (81%) and Q-Fix (97%) anchors failed by suture breaking, whereas the Draw Tight anchor failed by anchor pullout (76%). CLINICAL RELEVANCE: All-suture anchors vary in strength and performance, and these factors may influence clinical success. Biphasic polyurethane foam is a validated model for suture anchor testing.

Post-septal upper eyelid loading for treatment of exposure keratopathy secondary to non-cicatricial lagophthalmos.

Exposure keratopathy may result in ocular surface dryness, pain, corneal ulceration and loss of vision. Upper eyelid loading is an effective surgical treatment for paralytic lagophthalmos but has been criticised for complications of implant exposure and poor cosmesis. We therefore reviewed the safety and efficacy of our technique of upper eyelid post-septal loading for exposure keratopathy in this context. A retrospective case notes analysis was undertaken of 38 patients who had upper eyelid loading, all with post-septal weight placement, for correction of lagophthalmos. Patient demographics, indications for surgery, outcomes and complications were analysed. The mean age of all patients was 59.6 years. Exposure keratopathy was secondary to facial nerve paralysis in all but two patients, with tumor excision being the commonest underlying aetiology (63.8%). The mean implant weight used was 1.4 grams. Pre-operatively, all 38 patients had ocular discomfort despite maximal use of lubricating eye drops but post-operatively, 29 patients (76.3%) were comfortable without any such drops. Mean lagophthalmos on blink and gentle closure improved from 7.42mm and 5.47mm pre-operatively to 2.18mm and 1.18mm post-operatively (p < 0.001). Similarly, before surgery all patients had some corneal staining but after surgery 37 patients (97.4%) had none. The gold weight was removed in four patients (10.5%), due to chronic inflammation in three and due to mild astigmatism in one. No patient had exposure of the weight and one patient had a ptosis repair 6 months after surgery. Upper eyelid loading was effective in reducing both signs and symptoms of exposure keratopathy related to lagophthalmos in our series. Patients were very satisfied with the surgical outcome and complications related to exposure and cosmesis were very rare.

Using Puppets to Teach Schoolchildren to Detect Stroke and Call 911.

To overcome barriers to improved outcomes, we undertook an intervention to teach schoolchildren how to detect a stroke and call emergency medical services (EMS). We obtained permission from parents and guardians to use an 8-min puppet show to instruct the fourth, fifth, and sixth graders about stroke detection, symptomatology, and calling EMS. A pretest and three posttests-one immediately following the presentation, one at 3 months, and a third at 6 months-were administered. Responses from 282 students were evaluable. Significant improvements (p < .001) in knowledge were found through all posttests in identifying what parts of the body stroke affected and through the first two posttests in recognizing symptoms stroke victims experienced. Students demonstrated at pretest a high awareness of EMS and 911 (97.5%) and showed slight, but not significant, improvement over time.

The effect of chemotherapy on health-related quality of life in mesothelioma: results from the SWAMP trial.

BACKGROUND: The effect of chemotherapy on health-related quality of life (HRQoL) in malignant pleural mesothelioma (MPM) is poorly understood. Patient-individualised prognostication and prediction of treatment response from chemotherapy is useful but little evidence exists to guide practice. METHOD: Consecutive patients with MPM who were fit for first-line chemotherapy with pemetrexed and cisplatin\carboplatin were recruited and followed up for a minimum of 12 months. This study focussed on the HRQoL outcomes of these patients using the EQ-5D, EORTC QLQ-C30 and LC13. RESULTS: Seventy-three patients were recruited of which 58 received chemotherapy and 15 opted for best supportive care (BSC). Compliance with HRQoL questionnaires was 98% at baseline. The chemotherapy group maintained HRQoL compared with the BSC group whose overall HRQoL fell (P=0.006) with worsening dyspnoea and pain. The impact of chemotherapy was irrespective of histological subtype although those with non-epithelioid disease had worse HRQoL at later time points (P=0.012). Additionally, those with a falling mesothelin or improvement on modified-RECIST CT at early follow-up had a better HRQoL at 16 weeks. CONCLUSIONS: HRQoL was maintained following chemotherapy compared with a self-selected BSC group. Once chemotherapy is initiated, a falling mesothelin or improved RECIST CT findings infer a quality-of-life advantage.

The South West Area Mesothelioma and Pemetrexed trial: a multicentre prospective observational study evaluating novel markers of chemotherapy response and prognostication.

BACKGROUND: Robust markers that predict prognosis and detect early treatment response in malignant pleural mesothelioma (MPM) would enhance patient care. METHODS: Consecutive patients with MPM who were considered fit for first-line chemotherapy were prospectively recruited. Patients of similar performance status opting for best supportive care were included as a comparator group. Baseline and interval CT, PET-CT and serum markers (mesothelin, fibulin-3 and neutrophil-lymphocyte ratio (NLR)) were obtained, and patients followed up for a minimum 12 months. FINDINGS: Seventy-three patients were recruited (58 chemotherapy/15 comparator arm). Baseline TGV (total glycolytic volume on PET-CT) was an independent predictor of worse overall survival (OS) (P=0.001). Change in interval TGV(baseline/after two cycles of chemotherapy) did not predict OS or chemotherapy response on CT. Baseline NLR<4 was an independent predictor of better OS (median survival 453 (IQR 272-576) days vs NLR⩾4, 257 (IQR 147-490), P=0.002). Although baseline serum mesothelin did not predict OS, a falling level at 8 weeks significantly predicted longer time to progression (TTP) (P<0.001). INTERPRETATION: Neutrophil-lymphocyte ratio and baseline TGV predict prognosis in malignant pleural mesothelioma (MPM), but PET-CT is unhelpful in monitoring chemotherapy response. Serum mesothelin is a useful early treatment response marker when measured serially during chemotherapy and may have a role in evaluating patients' treatment response.

A Randomized Controlled Trial of Oral Versus Intravenous Administration of a Nonnarcotic Analgesia Protocol Following Pediatric Craniosynostosis Corrections on Nausea and Vomiting Rates.

BACKGROUND: The authors' center uses a nonnarcotic postoperative regimen following craniosynostosis corrections. Despite opioid avoidance, the authors noted that some children still experienced nausea and vomiting following the oral administration of either acetaminophen or ibuprofen. This study sought to evaluate whether intravenous administration of these medications might reduce nausea and vomiting rates. METHODS: A total of 50 children undergoing craniosynostosis corrections were prospectively randomized to a control group given only oral ibuprofen (10 mg/kg) and acetaminophen (15 mg/kg), or a treatment group given only intravenous ketorolac (0.5 mg/kg) and acetaminophen (15 mg/kg). All patients were assessed for postoperative nausea and vomiting by a blinded research nurse. RESULTS: Twenty-eight patients randomized to the oral control group, and 22 to the intravenous treatment group. No statistically significant differences were identified between groups, including: age, weight, sex, before history of severe postoperative nausea and vomiting, or procedure. With similar anesthesia times there was significantly more vomiting episodes in the oral group (71% versus 41%). Using a multivariate logistic regression, controlling for age, weight and procedure, the odds ratio for vomiting in the oral control versus intravenous experimental groups was 3.61 (95% CI 1.11-1.76; P = 0.033), and for postoperative nausea was 14.0 (95% CI 1.40-71.69, P = 0.010). CONCLUSIONS: The authors found a significant reduction in nausea and vomiting among children randomized to receive intravenous medications. In addition, the intravenous delivery of medications has the theoretical advantage of insuring an effective full dose delivery. Based on these findings, our standard process is to preferentially manage all children following craniosynostosis corrections with intravenous nonnarcotics.

Cyclic loading biomechanical analysis of the pullout strengths of rotator cuff and glenoid anchors: 2013 update.

PURPOSE: The purpose of this study was to evaluate the biomechanical and design characteristics of newer suture anchors under cyclic loading. METHODS: Suture anchors were tested in fresh porcine cortical and cancellous bone by cyclic loading (10 to 100 N for 200 cycles) followed by destructive testing parallel to the insertion axis at 12.5 mm per second. End points included ultimate failure load, displacement at 100 and 200 cycles, failure mode, and stiffness. Anchors tested included ReelX (Stryker Endoscopy, San Jose, CA); Footprint Ultra PK (4.5 and 5.5 mm) (Smith & Nephew, Andover, MA); TwinFix (4.5, 5.5, and 6.5 mm made from polyether ether ketone [PEEK], hydroxyapatite [HA], and titanium [Ti]) (Smith & Nephew Endoscopy, Andover, MA); Morphix (2.5 and 5.5 mm) (MedShape Solutions, Atlanta, GA); CrossFT BC (ConMed-Linvatec, Largo, FL); JuggerKnot (1.5 and 2.8 mm) (Biomet Sports Medicine, Warsaw, IN); Healicoil (Smith & Nephew Endoscopy, Andover, MA); Quattro (X, Link, and GL) (Cayenne Medical, Scottsdale, AZ); Healix (Biocryl Rapide [BR], PEEK, and Ti) (DePuy Mitek, Raynham, MA); Twin Loop (3.5 mm, PEEK) (Stryker Endoscopy, San Jose, CA); PressFT (2.1 and 2.6 mm) (ConMed Linvatec, Largo FL); Y-Knot (ConMed Linvatec, Largo FL); Gryphon (BR and PEEK) (DePuy Mitek, Raynham, MA); and Iconix (1, 2, and 3) (Stryker Endoscopy, San Jose, CA). RESULTS: Rotator cuff anchors showed greater failure loads than did glenoid anchors in metaphyseal bone (rotator cuff anchors 448 N v glenoid anchors 296 N) (P = .001) and cancellous bone (rotator cuff anchors 435 N v glenoid anchors 225 N) (P < .001). No anchors reached 5 mm of displacement during cyclic loading. TwinFix anchors showed greater displacement at 100 (P = .014) and 200 cycles (P = .036) than did other rotator cuff anchors, although the ReelX and Morphix showed the greatest displacements. Rotator cuff anchors failed principally by eyelet breaking, whereas glenoid anchors failed more often by anchor pullout than by any other mode. No differences in stiffness were observed across the different rotator cuff and glenoid anchors tested. CONCLUSIONS: Rotator cuff anchors showed higher failure strengths than did glenoid anchors, regardless of bone type. TwinFix anchors showed more cyclic displacement than did other rotator cuff anchors (except the ReelX and Morphix anchors) and the glenoid anchors tested. The failure mode was dependent on the specific anchor. CLINICAL RELEVANCE: Suture anchor constructs tested showed that failure load is dependent on anchor type (rotator cuff anchor or glenoid anchor) but not on anchor location (cancellous or cortical bone).

A comparison of lateral ankle ligament suture anchor strength.

BACKGROUND: Lateral ankle ligament repairs increasingly use suture anchors instead of bone tunnels. Our purpose was to compare the biomechanical properties of a knotted and knotless suture anchor appropriate for a lateral ankle ligament reconstruction. METHODS: In porcine distal fibulae, 10 samples of 2 different PEEK anchors were inserted. The attached sutures were cyclically loaded between 10N and 60N for 200 cycles. A destructive pull was performed and failure loads, cyclic displacement, stiffness, and failure mode recorded. RESULTS: PushLock 2.5 anchors failed before 200 cycles. PushLock 100 cycle displacement was less than Morphix 2.5 displacement (p<0.001). Ultimate failure load for anchors completing 200 cycles was 86.5N (PushLock) and 252.1N (Morphix) (p<0.05). The failure mode was suture breaking for all PushLocks while the Morphix failed equally by anchor breaking and suture breakage. CONCLUSIONS: The knotted Morphix demonstrated more displacement and greater failure strength than the knotless PushLock. The PushLock failed consistently with suture breaking. The Morphix anchor failed both by anchor breaking and by suture breaking.

Food sustainability education as a route to healthier eating: evaluation of a multi-component school programme in English primary schools.

Promising approaches to the promotion of healthier eating among children in primary school settings include the opportunity to practise practical cooking and growing, promoting the take up of healthier school meals and nutritional education. However, less is known about the potential for strategies that integrate approaches through a focus on food sustainability issues--such as the promotion of awareness about local, seasonal, organic, fair trade and higher animal welfare foods. This paper presents an evaluation of the Food for Life Partnership, a multi-component programme that sought to address both the health and sustainability aspects of food. The study consisted of a two-stage cross-sectional survey of Years 5 and 6 students (ages 9-11) in 30 primary schools at enrolment and after 18-24 months, combined with an analysis of programme delivery. Higher self-reported fruit and vegetable consumption in the second stage survey was associated with a range of indicators of school participation in the programme. These included the reform of school meal procurement and preparation; experiential food growing, cooking and farm-based education and improved opportunities for stakeholder engagement. The study therefore develops a case for multilevel programmes that incorporate sustainability issues alongside experiential food education in primary school settings.

Biomechanical testing of suture-based meniscal repair devices containing ultrahigh-molecular-weight polyethylene suture: update 2011.

PURPOSE: To evaluate the biomechanical characteristics of recently introduced ultrahigh-molecular-weight polyethylene suture-based, self-adjusting meniscal repair devices. METHODS: Updating a prior study published in 2009, we made vertical longitudinal cuts 3 mm from the periphery in fresh-frozen adult human menisci to simulate a bucket-handle meniscus tear. Each tear was then repaired by a single repair technique in 10 meniscus specimens. Group 1 menisci were repaired with a vertical mattress suture of No. 2-0 Ethibond (Ethicon, Somerville, NJ). Group 2 menisci were repaired with a vertical mattress suture of No. 2-0 OrthoCord (DePuy Mitek, Raynham, MA). Group 3 menisci were repaired with a single OmniSpan device with No. 2-0 OrthoCord suture (DePuy Mitek). Group 4 menisci were repaired with a single Meniscal Cinch device with No. 2-0 FiberWire suture (Arthrex, Naples, FL). Group 5 menisci were repaired with a single MaxFire device inserted with the MarXmen gun (Biomet Sports Medicine, Warsaw, IN). Group 6 menisci were repaired with a Sequent device with No. 0 Hi-Fi suture (ConMed Linvatec, Largo, FL) in a "V" suture configuration. Group 7 menisci were repaired with a single FasT-Fix 360 device (Smith & Nephew Endoscopy, Andover, MA). By use of a mechanical testing machine, all samples were preloaded at 5 N and cycled 200 times between 5 and 50 N. Those specimens that survived were destructively tested at 5 mm/min. Endpoints included maximum load, displacement, stiffness, and failure mode. RESULTS: Mean failure loads were as follows: Ethibond suture, 73 N; OrthoCord suture, 88 N; OmniSpan, 88 N; Cinch, 71 N; MarXmen/MaxFire, 54 N; Sequent, 66 N; and FasT-Fix 360, 60 N. Ethibond was stronger than MarXmen/MaxFire. The mean displacement after 100 cycles was as follows: Ethibond, 2.58 mm; OrthoCord, 2.75 mm; OmniSpan, 2.51 mm; Cinch, 2.65 mm; MarXmen/MaxFire, 3.67 mm; Sequent, 3.35 mm; and FasT-Fix 360, 1.13 mm. The MarXmen/MaxFire showed greater 100-cycle displacement than Ethibond and FasT-Fix 360. No difference in stiffness existed for these devices, and failure mode varied without specific trends. CONCLUSIONS: The biomechanical properties of meniscal repairs using the OmniSpan, Cinch, Sequent, and FasT-Fix 360 devices are equivalent to suture repair techniques. However, the MarXmen/MaxFire meniscal repair device showed significantly lower failure loads and survived less cyclic loading in the human cadaveric meniscus than other tested repairs. CLINICAL RELEVANCE: Most commercially available devices for all-inside meniscal repair using ultrahigh-molecular-weight polyethylene suture provide fixation comparable to the classic vertical mattress suture repair technique in human cadaveric meniscus.

Influence of surgical volume on outcomes in low-risk patients undergoing isolated surgical aortic valve replacement.

BACKGROUND: Intermediate- and high-risk patients undergoing isolated surgical aortic valve replacement have superior outcomes at higher-volume compared with lower-volume hospitals. This study examines the impact of hospital volume on outcomes in low-risk patients undergoing aortic valve replacement. METHODS: Using data from our 29 North Texas hospital collaborative, we examined 2066 low-risk cases (Society of Thoracic Surgeons Predicted Risk of Mortality of ≤3%) undergoing aortic valve replacement surgery between January 1, 2012, and December 31, 2017. Cases from 3 high-volume hospitals (≥200 aortic valve replacement cases total) and 26 low-volume hospitals (<200 cases total) were examined. RESULTS: Some 53.5% of the cases were at high-volume hospitals. No statistical differences were seen in the Predicted Risk of Mortality or pertinent demographics between the high-volume and low-volume hospitals. Significant differences in outcomes were seen between the 2 groups in operative mortality (2.28% vs 1.19%, P = .007), renal failure (2.14% vs 1.00%, P = .003), and readmission within 30 days (9.72% vs 6.25%, P < .001) when comparing low-volume with high-volume hospitals. In patients undergoing aortic valve replacement, undergoing the procedure in a low-volume hospital was an independent predictor for operative mortality (odds ratio, 1.95; 95% confidence interval, 1.20-3.20; P = .008) and renal failure (odds ratio, 2.25; 95% confidence interval, 1.33-3.81; P = .003). CONCLUSIONS: Operative mortality in low-risk patients undergoing aortic valve replacement is higher in low-volume compared with high-volume hospitals. The probability of a major complication, such as renal failure, is also greater in low-volume hospitals. The relationship between volume and outcomes in low-risk patients will require more research to understand the causes and design appropriate interventions.

Effect of ethnicity on the hypnotic and cardiovascular characteristics of propofol induction.

We compared the propofol dose causing loss of verbal response and suppression of bispectral index to 50, between 50 white and 50 black patients, aged 18-65 years. Propofol was administered at 40 mg.kg⁻¹.h⁻¹ and reduced to 8 mg.kg⁻¹.h⁻¹ when bispectral index fell to 50. We recorded heart rate and mean arterial pressure for 15 min in total and calculated, for this period, maximal percentage change from baseline for each. A statistician, blinded to patient ethnicity, found mean (SD) propofol dose for loss of verbal response in white and black patients to be 1.41 (0.37) mg.kg⁻¹ and 1.16 (0.25) mg.kg⁻¹, respectively (p < 0.001). Corresponding figures for maximal percentage change in heart rate were 14.1 (12.6) % and 7.5 (14.0) % (p = 0.015). Other differences were non-significant. The dose of propofol required for loss of verbal response, but not for suppression of bispectral index to 50, is lower in black than in white patients.

Biomechanical analysis of pullout strengths of rotator cuff and glenoid anchors: 2011 update.

PURPOSE: To evaluate the biomechanical and design characteristics of newer suture anchors. METHODS: Suture anchors were tested in fresh porcine metaphyseal cortex and cancellous troughs by use of an established protocol. A mechanical testing machine applied tensile loads parallel to the axis of insertion at 12.5 mm/s until failure, and mean anchor failure strengths were calculated. The mode of failure was recorded. Rotator cuff anchors tested included the Doubleplay and Opus SpeedScrew (ArthroCare Sports Medicine, Sunnyvale, CA); PEEK Intraline and PEEK Zip (Stryker, San Jose, CA); Paladin, SuperRevo FT, and CrossFT (ConMed Linvatec, Largo, FL); Piton (Tornier, Warsaw, IN); Ti Screw, ALLthread PEEK, LactoScrew, ALLthread Ti, and ALLthread PEEK knotless (Biomet Sports Medicine, Warsaw, IN). Glenoid anchors included the Gryphon BR P (DePuy-Mitek, Raynham, MA) and JuggerKnot 1.4 (Biomet Sports Medicine). RESULTS: Mean cortical failure loads for cuff anchors were as follows: Doubleplay 5.0, 279 N; Doubleplay 6.5, 338 N; Opus SpeedScrew 5.5, 356 N; Opus SpeedScrew 6.5, 336 N; PEEK Intraline 5.5, 263 N; PEEK Intraline 6.5, 344 N; PEEK Zip 5.5, 435 N; PEEK Zip 6.5, 502 N; Paladin 5.0, 500 N; Paladin 6.5, 521 N; SuperRevo FT, 496 N; CrossFT, 569 N; Piton, 379 N; Ti Screw 5.0, 457 N; Ti Screw 6.5, 443 N; ALLthread PEEK 5.5, 476 N; LactoScrew 5.5, 403 N; ALLthread Ti 5.0, 526 N; ALLthread Ti 6.5, 653 N; and ALLthread PEEK knotless, 441 N). Mean cortical failure loads for glenoid anchors were 161 N for Gryphon BR P and 239 N for JuggerKnot 1.4. Mean cancellous bone failure loads for cuff anchors were Doubleplay 5.0, 263 N; Doubleplay 6.5, 340 N; Opus SpeedScrew 5.5, 356 N; Opus SpeedScrew 6.5, 344 N; PEEK Intraline 5.5, 274 N; PEEK Intraline 6.5, 327 N; PEEK Zip 5.5, 401 N; PEEK Zip 6.5, 396 N; Paladin 5.0, 427 N; Paladin 6.5, 491 N; SuperRevo FT, 483 N; CrossFT, 547 N; Piton, 365 N; Ti Screw 5.0, 420 N; Ti Screw 6.5, 448 N; ALLthread PEEK 5.5, 475 N; LactoScrew 5.5, 435 N; ALLthread Ti 5.0, 512 N; ALLthread Ti 6.5, 612 N; and ALLthread PEEK knotless, 466 N). Mean cancellous failure loads for glenoid anchors were 117 N for Gryphon BR P and 194 N for JuggerKnot 1.4. None of the anchors had pullout as the predominant failure mode. Eyelet failure was the predominant failure mode for Doubleplay, Opus SpeedScrew, PEEK Intraline, Gryphon BR P, ALLthread Ti 6.5, ALLthread PEEK 5.5, and LactoScrew. CONCLUSIONS: Failure load was not dependent on anchor location (cancellous or cortical bone) (P = .58) but was dependent on anchor type (cuff anchor or glenoid anchor) (P < .001). CLINICAL RELEVANCE: Whereas larger fully threaded screw anchors designed for rotator cuff repair showed higher failure strengths than smaller non-screw anchors designed for glenoid repairs (P < .05), the larger version of a screw anchor for a cuff repair did not provide a statistically greater failure load than the smaller screw anchor.

Receptor for AGEs (RAGE) blockade may exert its renoprotective effects in patients with diabetic nephropathy via induction of the angiotensin II type 2 (AT2) receptor.

AIMS/HYPOTHESIS: The receptor for AGEs (RAGE) contributes to the development and progression of diabetic nephropathy. In this study, we examined whether the protective effects of RAGE blockade are exerted via modulation of the renal angiotensin II type 2 (AT2) receptor. METHODS: Control and streptozotocin diabetic mice, wild-type or deficient in the AT2 receptor (At2 knockout [KO]) or RAGE (Rage KO), were studied for 24 weeks. Adenoviral overexpression of full-length Rage in primary rat mesangial cells was also used to determine the effects on AT2 production. RESULTS: With diabetes, Rage-deficient mice had less albuminuria, and an attenuation of hyperfiltration and glomerulosclerosis as compared with diabetic wild-type and At2 KO mice. Renal gene and protein expression of RAGE was elevated with diabetes. Diabetic Rage KO mice had a greater increase in renal AT2 receptor protein than was seen in diabetic wild-type mice. Diabetes-induced increases in renal cytosolic and mitochondrial superoxide generation were prevented in diabetic Rage KO mice, but enhanced in all At2 KO mice. Adenoviral overexpression of RAGE or AGE treatment decreased cell surface AT2 expression, in association with increasing superoxide generation; both were reversed using antioxidants N-acetylcysteine and apocynin, and soluble RAGE in primary mesangial cells. CONCLUSIONS/INTERPRETATION: RAGE appears to be a common and key modulator of AT2 receptor expression, a finding that would implicate a newly defined RAGE-AT2 axis in the development and progression of diabetic nephropathy.

Mitral valve surgery: comparison of outcomes in matched sternotomy and port access groups.

BACKGROUND AND AIM OF THE STUDY: The 30-day outcomes were compared between matched groups of patients undergoing mitral valve procedures through Port Access (femoral cannulation, percutaneous retrograde cardioplegia and aortic occlusion), and through a sternotomy. METHODS: By using a Society of Thoracic Surgeons (STS)-certified, audited database, a total of 1108 patients was identified who were operated on between January 1996 and November 2008. A total of 608 mitral valve repair (MV-Rpr) patients (including 241 with Port Access procedures) and 500 mitral valve replacement (MVR) patients (including 45 with Port Access procedures) was included. Matching groups were created for 177 MV-Rpr patients (matched on preoperative cerebrovascular accident (CVA), previous coronary artery bypass grafting (CABG) and valve procedures, urgent operative status, mitral stenosis, heart failure, NYHA class IV, and age) and for MVR patients with 43 matches (matched for previous CABG surgery, operative status, NYHA class IV, and mitral insufficiency). RESULTS: Patients with Port Access procedures for MV-Rpr had a shorter length of hospital stay (5.4 +/- 2.8 versus 7.3 +/- 5.8 days), less postoperative ventilator usage (8.4 +/- 36.0 versus 24.8 +/- 81.6 h) and a shorter intensive care unit (ICU) stay (34.0 +/- 40.5 versus 81.7 +/- 133.8 h) when compared to sternotomy cases. Port Access also resulted in fewer patients requiring postoperative ventilation (50.3% versus 76.9%; p < 0.001) or reoperation for bleeding (2.3% versus 6.8%; p = 0.048). In MVR patients, Port Access use led to reductions in mortality (11.6% versus 0%; p = 0.021), ventilation time (13.8 +/- 40.3 versus 38.1 +/- 83.0 h), ICU stay (51.9 +/- 83.4 versus 152.4 +/- 125.0 h) and postoperative hospital stay (8.2 +/- 8.0 versus 11.0 +/- 8.6 days). In both groups, the cross-clamp time was longer with Port Access (107.7 +/- 26.8 versus 92.8 +/- 35.2 min for MV-Rpr; 130.2 +/- 44.2 versus 102.7 +/- 64.6 min for MVR). CONCLUSION: The performance of mitral valve surgery through a Port Access approach led to a reduction in ICU time, ventilator time, and hospital stay when compared to sternotomy. No increase in morbidity was observed with Port Access compared to sternotomy.

Biomechanical advantages of triple-loaded suture anchors compared with double-row rotator cuff repairs.

PURPOSE: To evaluate the strength and suture-tendon interface security of various suture anchors triply and doubly loaded with ultrahigh-molecular weight polyethylene-containing sutures and to evaluate the relative effectiveness of placing these anchors in a single-row or double-row arrangement by cyclic loading and then destructive testing. METHODS: The infraspinatus muscle was reattached to the original humeral footprint by use of 1 of 5 different repair patterns in 40 bovine shoulders. Two single-row repairs and three double-row repairs were tested. High-strength sutures were used for all repairs. Five groups were studied: group 1, 2 triple-loaded screw suture anchors in a single row with simple stitches; group 2, 2 triple-loaded screw anchors in a single row with simple stitches over a fourth suture passed perpendicularly ("rip-stop" stitch); group 3, 2 medial and 2 lateral screw anchors with a single vertical mattress stitch passed from the medial anchors and 2 simple stitches passed from the lateral anchors; group 4, 2 medial double-loaded screw anchors tied in 2 mattress stitches and 2 push-in lateral anchors capturing the medial sutures in a "crisscross" spanning stitch; and group 5, 2 medial double-loaded screw anchors tied in 2 mattress stitches and 2 push-in lateral anchors creating a "suture-bridge" stitch. The specimens were cycled between 10 and 180 N at 1.0 Hz for 3,500 cycles or until failure. Endpoints were cyclic loading displacement (5 and 10 mm), total displacement, and ultimate failure load. RESULTS: A single row of triply loaded anchors was more resistant to stretching to a 5- and 10-mm gap than the double-row repairs with or without the addition of a rip-stop suture (P < .05). The addition of a rip-stop stitch made the repair more resistant to gap formation than a double row repair (P < .05). The crisscross double row created by 2 medial double-loaded suture anchors and 2 lateral push-in anchors stretched more than any other group (P < .05). CONCLUSIONS: Double-row repairs with either crossing sutures or 4 separate anchor points were more likely to fail (5- or 10-mm gap) than a single-row repair loaded with 3 simple sutures. CLINICAL RELEVANCE: The triple-loaded anchors with ultrahigh-molecular weight polyethylene-containing sutures placed in a single row were more resistant to stretching than the double-row groups.