SRPK2 Mediates HBV Core Protein Phosphorylation and Capsid Assembly via Docking Interaction.

Members of the serine-arginine protein kinase (SRPK) family, SRPK1 and SRPK2, phosphorylate the hepatitis B core protein (Cp) and are crucial for pregenomic RNA encapsidation during viral nucleocapsid assembly. Among them, SRPK2 exhibits higher kinase activity toward Cp. In this study, we identified Cp sites that are phosphorylated by SRPK2 and demonstrated that the kinase utilizes an SRPK-specific docking groove to interact with and regulate the phosphorylation of the C-terminal arginine rich domain of Cp. We determined that direct interaction between the docking groove of SRPK2 and unphosphorylated Cp inhibited premature viral capsid assembly in vitro, whereas the phosphorylation of the viral protein reactivated the process. Pull-down assays together with the new cryo-electron microscopy structure of the HBV capsid in complex with SRPK2 revealed that the kinases decorate the surface of the viral capsid by interacting with the C-terminal domain of Cp, underscoring the importance of the docking interaction in regulating capsid assembly and pregenome packaging. Moreover, SRPK2-knockout in HepG2 cells suppressed Cp phosphorylation, indicating that SRPK2 is an important cellular kinase for HBV life cycle.

Comprehensive identification of pathogenic microbes and antimicrobial resistance genes in food products using nanopore sequencing-based metagenomics.

Foodborne pathogens, particularly antimicrobial-resistant (AMR) bacteria, remain a significant threat to global health. Given the limitations of conventional culture-based approaches, which are limited in scope and time-consuming, metagenomic sequencing of food products emerges as a promising solution. This method provides a fast and comprehensive way to detect the presence of pathogenic microbes and antimicrobial resistance genes (ARGs). Notably, nanopore long-read sequencing provides more accurate bacterial taxonomic classification in comparison to short-read sequencing. Here, we revealed the impact of food types and attributes (origin, retail place, and food processing methods) on microbial communities and the AMR profile using nanopore metagenomic sequencing. We analyzed a total of 260 food products, including raw meat, sashimi, and ready-to-eat (RTE) vegetables. Clostridium botulinum, Acinetobacter baumannii, and Vibrio parahaemolyticus were identified as the top three foodborne pathogens in raw meat and sashimi. Importantly, even with low pathogen abundance, higher percentages of samples containing carbapenem and cephalosporin resistance genes were identified in chicken and RTE vegetables, respectively. In parallel, our results demonstrated that fresh, peeled, and minced foods exhibited higher levels of pathogenic bacteria. In conclusion, this comprehensive study offers invaluable data that can contribute to food safety assessments and serve as a basis for quality indicators.

Editorial Commentary: Anterior Shoulder Stabilization Combining Arthroscopic Bankart and Inferior Capsular Shift Avoids Open Surgery in Athletes Without Critical Glenoid Bone Loss.

Traumatic anterior shoulder dislocations can cause a myriad of injuries, each with their own unique set of challenges with respect to surgical management. The debate of whether open or arthroscopic management is the superior approach is one that predates most currently practicing orthopaedic surgeons yet remains one of the most actively researched areas of orthopaedics. Current trends favor arthroscopic management for anterior instability secondary to a Bankart lesion in patients without other risk factors for instability, such as critical glenoid bone loss. However, excellent results are not guaranteed following arthroscopic Bankart repair, particularly in athletes, due to high rates of recurrence. While the technique of inferior to superior capsular shift is not new, transitioning a historically open technique to the arthroscopic world may represent another tool in the glenohumeral instability management toolbox. While perspectives are evolving, more evidence supporting arthroscopic techniques like the capsular shift are needed to better identify appropriate patient populations.

Enhancing Healing of Massive Rotator Cuff Tears: A Radiographic Evaluation of Bridging Allograft vs. Maximal Repair - A Randomized Control Trial.

PURPOSE: The purpose of this study was to compare the radiographic results of bridging rotator cuff reconstruction (BRR) with dermal allograft and maximal repair for large or massive, irreparable rotator cuff tears. METHODS: This was a secondary analysis of data from a single-center, blinded-observer, randomized controlled trial that examined clinical outcomes of BRR compared to maximal repair. A sample size of 30 patients with MRI-proven large or massive (>3 cm), retracted rotator cuff tears and/or involvement of 2 or more tendons were randomly allocated to 1 of 2 groups: maximal repair or BRR using dermal allograft. MRIs were obtained preoperatively and 1 year postoperatively. The primary outcome of this study was the retear rate on MRI. Secondary outcomes included progression of muscle atrophy and fatty infiltration. RESULTS: There was no difference in age or preoperative tear size between the two groups. Patients treated with BRR had decreased retear rate (21%) compared with patients who received maximal repair alone (87%). There was no difference in the number of patients who had progression of muscle atrophy (p=0.088 for supraspinatus and p=0.738 for infraspinatus) or fatty infiltration (p=0.879 for supraspinatus and p=0.693 for infraspinatus) between the two groups. A significant increase in mean postoperative supraspinatus muscle atrophy was identified in the maximal repair group (p=0.034). CONCLUSION: The results of this secondary analysis of a randomized controlled trial comparing radiographic results of maximal repair vs BRR using dermal allograft in the treatment of large or massive rotator cuff tears show that BRR results in a significantly reduced structural failure rate and a trend towards better preservation of supraspinatus muscle mass compared to maximal repair.

Clinical and Radiographic Outcomes Of Primary Versus Revision Arthroscopic Anatomic Glenoid Reconstruction with Distal Tibial Allograft For Anterior Shoulder Instability With Bone Loss.

PURPOSE: The purpose of this study was to assess the clinical and radiographic outcomes of arthroscopic anatomic glenoid reconstruction (AAGR) used for primary versus revision surgery for addressing anterior shoulder instability with bone loss. METHODS: We performed a retrospective review on consecutive patients who underwent AAGR from 2012 to 2020. Patients who received AAGR for anterior shoulder instability with bone loss and had a minimum follow-up of two-years were included. Exclusion criteria included patients with incomplete primary patient reported outcome scores (PROs), multi-directional instability, glenoid fracture, non-rigid fixation and concomitant HAGL, or rotator cuff repair. Our primary outcome was measured using the Western Ontario Shoulder Instability Index (WOSI) scores. Secondary outcomes included postoperative Disabilities of Arm, Shoulder, Hand (DASH) scores, complications, recurrence of instability and CT evaluation of graft position, resorption, and healing. RESULTS: There were 73 patients (52 primary and 21 revision) finally included. Both groups had comparable demographics and preoperative WOSI and DASH scores. The primary group had significantly better postoperative WOSI and DASH scores at final follow-up when compared to the revision group (WOSI: 21.0 vs 33.8, p=0.019; DASH: 7.3 vs 17.2, p=0.001). The primary group also showed significantly better WOSI scores than the revision group at 6-month, 1-year and 2-year time points (p=0.029, 0.022 and 0.003; respectively). The overall complication rate was 9.6% (5/52) in the primary group and 23.8% (5/21) in the revision group. Both groups showed good graft healing and placement in the A to P and ML orientation and had a similar rate of graft resorption/remodeling. There was no difference between the groups in the remainder of the CT measurements. CONCLUSION: Functional outcome scores and stiffness were significantly worse in patients undergoing an AAGR procedure after a failed instability surgery when compared with patients undergoing primary AAGR. There were no differences in postoperative recurrence of instability or radiographic outcomes. As a result, AAGR should be considered as a primary treatment option within current treatment algorithms for shoulder instability.

Transcatheter aortic valve implantation in patients with anomalous coronary artery.

OBJECTIVES: The aim of this review was to analyze literature and provide systematic algorithm to guide decision making during TAVI procedure. BACKGROUND: Transcatheter aortic valve implantation (TAVI) is growing in popularity and expanding to younger patients with lower risk profiles. Currently, there is no concise guideline on the management strategy during TAVI in patients with anomalous coronary artery (ACA) anatomy undergoing this procedure. METHODS: A systematic search was conducted for relevant case reports of TAVI in patients who had confirmed ACA anatomy. Twenty-four case reports, that met the criteria for this review, were identified and included in the final study size. RESULTS: TAVI was successful in 23 out of 24 cases. Half of the cases (12) described performing balloon aortic valvuloplasty (BAV) before TAVI. The majority (15) reported using angiogram Postimplantation. Only one-third of cases (8) reported performing coronary protection (with either wire, wire and stent or wire and balloon). Two-third of case reports (16/24, 67%) mentioned using Edwards SAPIEN balloon expandable transcatheter heart valves (THV). CONCLUSIONS: Preprocedural diagnostic imaging tests play important role in determining the ACA anatomy and its relation to the aortic valve. BAV with simultaneous coronary arteries angiography or aortography should be performed before implantation of THV, as it could potentially predict whether the ACA would be compressed. Using at least a coronary wire for ACA protection is recommended in case there is high risk of ACA obstruction. Management strategy should be individualized when performing TAVI in patients with ACA.

Calculating glenoid bone loss based on glenoid height using ipsilateral three-dimensional computed tomography.

PURPOSE: To investigate the relationship between glenoid width and other morphologic parameters using three-dimensional (3D) computed tomography (CT) images of native shoulders, and to create a new measurement tool to assess glenoid defects in a Canadian population with established anterior shoulder instability. METHODS: Forty-three glenoid CT scans were analyzed for patients who underwent contralateral shoulder glenoid reconstruction for anterior shoulder instability between 2012 and 2020. Demographic data were obtained including age, gender and BMI. The subjects were excluded if they had a prior history of ipsilateral shoulder instability, shoulder fractures, or bone tumors. The following glenoid parameters were measured: width (W), height (H), anteroposterior (AP) depth, superior-inferior (SI) depth and version. The shape of the glenoid was also classified into pear, inverted comma or oval. RESULTS: There were 35 male and 8 females with a mean age of 34.5 ± 12.9 years. The glenoid width was strongly correlated with the height (R2 = 0.9) and a regression model equation was obtained: W (mm) = 2.5 + 0.7*H (mm). There was also strong correlation with gender (P < 0.001), glenoid shape (P = 0.030), AP and SI depths (P = 0.006 and P < 0.001, respectively). Male gender was associated with higher measurement values for all parameters. The most common glenoid shapes were the pear (46.5%) and oval morphotypes (39.6%) for the whole study group. CONCLUSION: The native glenoid width can be estimated based on glenoid height using ipsilateral 3D CT. This may help with preoperative planning and surgical decision-making for patients with anterior shoulder instability and glenoid bone loss. LEVEL OF EVIDENCE: III.

Probable Animal-to-Human Transmission of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Delta Variant AY.127 Causing a Pet Shop-Related Coronavirus Disease 2019 (COVID-19) Outbreak in Hong Kong.

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can infect human and other mammals, including hamsters. Syrian (Mesocricetus auratus) and dwarf (Phodopus sp.) hamsters are susceptible to SARS-CoV-2 infection in the laboratory setting. However, pet shop-related Coronavirus Disease 2019 (COVID-19) outbreaks have not been reported. METHODS: We conducted an investigation of a pet shop-related COVID-19 outbreak due to Delta variant AY.127 involving at least 3 patients in Hong Kong. We tested samples collected from the patients, environment, and hamsters linked to this outbreak and performed whole genome sequencing analysis of the reverse transcription polymerase chain reaction (RT-PCR)-positive samples. RESULTS: The patients included a pet shop keeper (Patient 1), a female customer of the pet shop (Patient 2), and the husband of Patient 2 (Patient 3). Investigation showed that 17.2% (5/29) and 25.5% (13/51) environmental specimens collected from the pet shop and its related warehouse, respectively, tested positive for SARS-CoV-2 RNA by RT-PCR. Among euthanized hamsters randomly collected from the storehouse, 3% (3/100) tested positive for SARS-CoV-2 RNA by RT-PCR and seropositive for anti-SARS-CoV-2 antibody by enzyme immunoassay. Whole genome analysis showed that although all genomes from the outbreak belonged to the Delta variant AY.127, there were at least 3 nucleotide differences among the genomes from different patients and the hamster cages. Genomic analysis suggests that multiple strains have emerged within the hamster population, and these different strains have likely transmitted to human either via direct contact or via the environment. CONCLUSIONS: Our study demonstrated probable hamster-to-human transmission of SARS-CoV-2. As pet trading is common around the world, this can represent a route of international spread of this pandemic virus.

The Clinical Utility of Two High-Throughput 16S rRNA Gene Sequencing Workflows for Taxonomic Assignment of Unidentifiable Bacterial Pathogens in Matrix-Assisted Laser Desorption Ionization-Time of Flight Mass Spectrometry.

Bacterial pathogens that cannot be identified using matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) are occasionally encountered in clinical laboratories. The 16S rRNA gene is often used for sequence-based analysis to identify these bacterial species. Nevertheless, traditional Sanger sequencing is laborious, time-consuming, and low throughput. Here, we compared two commercially available 16S rRNA gene sequencing tests that are based on Illumina and Nanopore sequencing technologies, respectively, in their ability to identify the species of 172 clinical isolates that failed to be identified by MALDI-TOF MS. Sequencing data were analyzed by the respective built-in programs (MiSeq Reporter software of Illumina and Epi2me of Nanopore) and BLAST+ (v2.11.0). Their agreement with Sanger sequencing on species-level identification was determined. Discrepancies were resolved by whole-genome sequencing. The diagnostic accuracy of each workflow was determined using the composite sequencing result as the reference standard. Despite the high base-calling accuracy of Illumina sequencing, we demonstrated that the Nanopore workflow had a higher taxonomic resolution at the species level. Using built-in analysis algorithms, the concordance of Sanger 16S with the Illumina and Nanopore workflows was 33.14% and 87.79%, respectively. The agreement was 65.70% and 83.14%, respectively, when BLAST+ was used for analysis. Compared with the reference standard, the diagnostic accuracy of Nanopore 16S was 96.36%, which was identical to that of Sanger 16S and better than that of Illumina 16S (69.07%). The turnaround time of the Illumina workflow and the Nanopore workflow was 78 h and 8.25 h, respectively. The per-sample cost of the Illumina and Nanopore workflows was US$28.5 and US$17.7, respectively.

Impact of implantation technique on conduction disturbances for TAVR with the self-expanding portico/navitor valve.

BACKGROUND: Use of a right-left (R-L) cusp overlap view for transcatheter aortic valve replacement (TAVR) with self-expanding valves has recently been proposed aiming to reduce permanent pacemaker implantation (PPMI). An objective, data-driven explanation for this observation is missing. AIMS: To assess the impact of different implantation techniques on the risk of PPMI following TAVR with the Portico/NavitorTM transcatheter heart valve (THV; Abbott). METHODS: A TAVR-population treated with Portico/NavitorTM had the THV implanted in a right versus left anterior oblique (RAO/LAO) fluoroscopic view with no parallax in the delivery system. The impact of these different implantation views on the spatial relationship between THV and native aortic annulus and the risk of conduction disturbances and PPMI after TAVR was studied. RESULTS: A total of 366 matched TAVR patients were studied: 183 in the RAO group and 183 in the LAO group. The degree of aortic annulus plane tilt was significantly smaller in the RAO versus LAO group (median: 0° vs. 23°, p < 0.001), with no plane tilt in 105 out of 183 cases (57.3%) in the RAO group. At 30 days after TAVR, the overall PPMI and guideline-directed PPMI rates were 12.6% versus 18.0% (p = 0.15) and 8.2% versus 15.3% (p = 0.04) in the RAO versus LAO group, respectively. CONCLUSIONS: Use of a R-L cusp overlap (RAO-caudal) view for implantation of the Portico/NavitorTM valve results in less tilt of the native aortic annulus plane and a clear trend toward a lower 30-day PPMI rate as compared to TAVR using the conventional LAO implantation view.

Automated MSCT Analysis for Planning Left Atrial Appendage Occlusion Using Artificial Intelligence.

Background: The number of multislice computed tomography (MSCT) analyses performed for planning structural heart interventions is rapidly increasing. Further automation is required to save time, increase standardization, and reduce the learning curve. Objective: The purpose of this study was to investigate the feasibility of a fully automated artificial intelligence (AI)-based MSCT analysis for planning structural heart interventions, focusing on left atrial appendage occlusion (LAAO) as the selected use case. Methods: Different deep learning models were trained, validated, and tested using a cohort of 583 patients for which manually annotated data were available. These models were used independently or in combination to detect the anatomical ostium, the landing zone, the mitral valve annulus, and the fossa ovalis and to segment the left atrium (LA) and left atrial appendage (LAA). The accuracy of the models was evaluated through comparison with the manually annotated data. Results: The automated analysis was performed on 25 randomly selected patients of the test cohort. The results were compared to the manually identified landmarks. The predicted segmentation of the LA(A) was similar to the manual segmentation (dice score of 0.94 ± 0.02). The difference between the automatically predicted and manually measured perimeter-based diameter was -0.8 ± 1.3 mm (anatomical ostium), -1.0 ± 1.5 mm (Amulet landing zone), and -0.1 ± 1.3 mm (Watchman FLX landing zone), which is similar to the operator variability on these measurements. Finally, the detected mitral valve annulus and fossa ovalis were close to the manual detection of these landmarks, as shown by the Hausdorff distance (3.9 ± 1.2 mm and 4.8 ± 1.8 mm, respectively). The average runtime of the complete workflow, including data pre- and postprocessing, was 57.5 ± 34.5 seconds. Conclusions: A fast and accurate AI-based workflow is proposed to automatically analyze MSCT images for planning LAAO. The approach, which can be easily extended toward other structural heart interventions, may help to handle the rapidly increasing volumes of patients.

Comparison of Complications in X-Ray Versus Ultrasound-Guided Hip Arthroscopy.

PURPOSE: To report the complication rates and frequency of iatrogenic injury to the cartilage and labrum when using an ultrasound-guided hip arthroscopic technique compared with the standard x-ray-guided technique. METHODS: In this retrospective cohort study of prospectively collected data, intraoperative videos were evaluated for iatrogenic injury during portal establishment. Postoperative complications and revision procedures were monitored for 12 months. RESULTS: The study included 460 patients, with 38% in the ultrasound cohort. Video review showed a 2% complication rate of femoral head scuffing and <2% labral injury in both techniques, with no significant difference between techniques in cartilage injury (P = .90) or labrum puncture (P = .41). Six patients underwent revision procedures, 2 in the x-ray group and 6 in the ultrasound group. One patient developed a deep infection postoperatively. There were no other major complications. CONCLUSION: Ultrasound-guided hip arthroscopy is a safe alternative to the standard x-ray-guided procedure in patients with a BMI less than 35. LEVEL OF EVIDENCE: III, retrospective cohort.

Interposition Graft Bridging Reconstruction of Irreparable Rotator Cuff Tears Using Acellular Dermal Matrix: Medium-Term Results.

PURPOSE: In this study, we aimed to evaluate the medium-term clinical outcomes for patients who underwent bridging reconstruction. METHODS: A retrospective chart review was conducted for all patients who underwent bridging reconstruction between 2010 and 2018. Patients who were missing either pre- or postoperative outcome scores were excluded. All included patients completed self-reported questionnaires (Western Ontario Rotator Cuff [WORC] and Disabilities of the Arm, Shoulder and Hand [DASH]) pre- and postoperatively at 6 months, 1 year, and annually thereafter. All scores were reported out of 100. RESULTS: Ninety-one patients initially met our inclusion criteria, and 33 were excluded owing to lack of either pre- or postoperative outcome scores. Nine patients were lost to follow-up; therefore, 49 patients were finally evaluated, including 30 males (61.2%) and 19 females (38.8%) with an age of 59.6 ± 10.4 years (mean ± standard deviation) and mean follow-up of 5.3 years (range 2 to 9). Both WORC and DASH scores significantly improved from pre- to postoperatively (WORC: 69.6 ± 12.2 to 27.9 ± 23.7, P < .001; DASH: 51.5 ± 17.5 to 24.5 ± 23.0, P = .001). For WORC and DASH, 92% and 74% of patients, respectively, met the minimal clinical importance difference. CONCLUSION: Our results showed that patients' clinical outcome scores significantly improved with an average of 5-year follow-up, which demonstrates that bridging reconstruction is a safe procedure with promising midterm clinical outcomes. LEVEL OF EVIDENCE: IV, retrospective case series.

Anterior Shoulder Instability Part III-Revision Surgery, Rehabilitation and Return to Play, and Clinical Follow-Up-An International Consensus Statement.

PURPOSE: The purpose of this study was to establish consensus statements via a modified Delphi process on revision surgery, rehabilitation and return to play, and clinical follow-up for anterior shoulder instability. METHODS: A consensus process on the treatment using a modified Delphi technique was conducted, with 65 shoulder surgeons from 14 countries across 5 continents participating. Experts were assigned to one of 9 working groups defined by specific subtopics of interest within anterior shoulder instability. RESULTS: The primary relative indications for revision surgery include symptomatic apprehension or recurrent instability, additional intra-articular pathologies, and symptomatic hardware failure. In revision cases, the differentiating factors that dictate treatment are the degree of glenohumeral bone loss and rotator cuff function/integrity. The minimum amount of time before allowing athletes to return to play is unknown, but other factors should be considered, including restoration of strength, range of motion and proprioception, and resolved pain and apprehension, as these are prognostic factors of reinjury. Additionally, psychological factors should be considered in the rehabilitation process. Patients should be clinically followed up for a minimum of 12 months or until a return to full, premorbid function/activities. Finally, the following factors should be included in anterior shoulder instability-specific, patient-reported outcome measures: function/limitations impact on activities of daily living, return to sport/activity, instability symptoms, confidence in shoulder, and satisfaction. CONCLUSION: Overall, 92% of statements reached unanimous or strong consensus. The statements that reached unanimous consensus were indications and factors affecting decisions for revision surgery, as well as how prior surgeries impact procedure choice. Furthermore, there was unanimous consensus on the role of psychological factors in the return to play, considerations for allowing return to play, as well as prognostic factors. Finally, there was a lack of unanimous consensus on recommended timing and methods for clinical follow-up. LEVEL OF EVIDENCE: Level V, expert opinion.

Anterior Shoulder Instability Part II-Latarjet, Remplissage, and Glenoid Bone-Grafting-An International Consensus Statement.

PURPOSE: The purpose of this study was to establish consensus statements via a modified Delphi process on the Latarjet procedure, remplissage, and glenoid-bone grafting for anterior shoulder instability. METHODS: A consensus process on the treatment utilizing a modified Delphi technique was conducted, with 65 shoulder surgeons from 14 countries across 5 continents participating. Experts were assigned to one of 9 working groups defined by specific subtopics of interest within anterior shoulder instability. RESULTS: The technical approaches identified in the statements on the Latarjet procedure and glenoid bone-graft were that a subscapularis split approach should be utilized, and that it is unclear whether a capsular repair is routinely required. Furthermore, despite similar indications, glenoid bone-grafting may be preferred over the Latarjet in patients with bone-loss greater than can be treated with a coracoid graft, and in cases of surgeon preference, failed prior Latarjet or glenoid bone-grafting procedure, and epilepsy. In contrast, the primary indications for a remplissage procedure was either an off-track or engaging Hill-Sachs lesion without severe glenoid bone loss. Additionally, in contrast to the bone-block procedure, complications following remplissage are rare, and loss of shoulder external rotation can be minimized by performing the tenodesis via the safe-zone and not over medializing the fixation. CONCLUSION: Overall, 89% of statements reached unanimous or strong consensus. The statements that reached unanimous consensus were the prognostic factors that are important to consider in those undergoing a glenoid bone-grafting procedure including age, activity level, Hill-Sachs Lesion, extent of glenoid bone-loss, hyperlaxity, prior surgeries, and arthritic changes. Furthermore, there was unanimous agreement that it is unclear whether a capsular repair is routinely required with a glenoid bone graft, but it may be beneficial in some cases. There was no unanimous agreement on any aspect related to the Latarjet procedure or Remplissage. LEVEL OF EVIDENCE: Level V, expert opinion.

Anterior Shoulder Instability Part I-Diagnosis, Nonoperative Management, and Bankart Repair-An International Consensus Statement.

PURPOSE: The purpose of this study was to establish consensus statements via a modified Delphi process on the diagnosis, nonoperative management, and Bankart repair for anterior shoulder instability. METHODS: A consensus process on the treatment using a modified Delphi technique was conducted, with 65 shoulder surgeons from 14 countries across 5 continents participating. Experts were assigned to one of 9 working groups defined by specific subtopics of interest within anterior shoulder instability. RESULTS: The independent factors identified in the 2 statements that reached unanimous agreement in diagnosis and nonoperative management were age, gender, mechanism of injury, number of instability events, whether reduction was required, occupation, sport/position/level played, collision sport, glenoid or humeral bone-loss, and hyperlaxity. Of the 3 total statements reaching unanimous agreement in Bankart repair, additional factors included overhead sport participation, prior shoulder surgery, patient expectations, and ability to comply with postoperative rehabilitation. Additionally, there was unanimous agreement that complications are rare following Bankart repair and that recurrence rates can be diminished by a well-defined rehabilitation protocol, inferior anchor placement (5-8 mm apart), multiple small-anchor fixation points, treatment of concomitant pathologies, careful capsulolabral debridement/reattachment, and appropriate indications/assessment of risk factors. CONCLUSION: Overall, 77% of statements reached unanimous or strong consensus. The statements that reached unanimous consensus were the aspects of patient history that should be evaluated in those with acute instability, the prognostic factors for nonoperative management, and Bankart repair. Furthermore, there was unanimous consensus on the steps to minimize complications for Bankart repair, and the placement of anchors 5-8 mm apart. Finally, there was no consensus on the optimal position for shoulder immobilization. LEVEL OF EVIDENCE: Level V, expert opinion.

VA-ECMO With Pericardiocentesis and Autologous Blood Transfusion - Stabilisation Strategy in Acute Cardiac Free Wall Rupture.

A 68-year old lady present with left ventricular free wall rupture and cardiac arrest post-myocardial infarction. This article illustrates a strategy combining pericardiocentesis with autologous transfusion together with VA-ECMO as a bridge to definitive surgical repair.

Prophylactic permanent pacemaker strategy in patients with right bundle branch block undergoing transcatheter aortic valve replacement.

OBJECTIVES: To report on the experience with a selective prophylactic permanent pacemaker (PPx-PPM) implantation strategy in patients with pre-existing right bundle branch block (RBBB) undergoing transcatheter aortic valve replacement (TAVR). BACKGROUND: Pre-existing RBBB is an independent predictor for PPM after TAVR and has been linked to increased mortality. METHODS: Hospital patient flow and longer-term clinical endpoints were compared for TAVR patients with pre-existing RBBB treated in a period with and without selective PPx-PPM strategy (2013-2020). RESULTS: A total of 260 patients were included: 170 in the early period without PPx-PPM strategy and 90 patients in the late period with selective PPx-PPM strategy. A PPx-PPM was implanted in 44% of patients in the late period. Overall, 69% versus 80% of all patients in the early versus late period ended up with a PPM (p = .06). Streamlined transfemoral TAVR was routinely used from 2017-in this series of patients, both TAVR procedural time and hospital length of stay (LoS) were significantly shorter in the late versus early period (mean procedural time: 70 vs. 83 min and LoS ≥5 days: 15% vs. 40%; p < .05). No difference in all-cause/cardiovascular mortality was observed between both strategies, whereas cardiac rehospitalization was significantly higher for patients treated in the early versus late period (hazard ratio 2.33 [1.04-5.26]; p = .042)-this mainly due to (sub)acute PPM-implantation early after discharge. CONCLUSIONS: Selective prophylactic PPM implantation in TAVR candidates with pre-existing RBBB results in shorter TAVR procedural time and hospital LoS and prevents early cardiac rehospitalization related to complete heart block.

Think outside the coronary artery: Extremely rare case of STEMI in young man.

Acute myocardial infarction caused by a bronchogenic cyst is a very rare pathology. It occurs as a result of external compression of the coronary artery by the cyst, leading to myocardial ischemia. The present case illustrates that a bronchogenic cyst, which is generally considered to be a chronic disease entity with gradual onset of symptoms, can manifest acutely as a life-threatening condition. Timely invasive coronary intervention is critical in the acute management of this complication while multimodality imaging assessment is essential in the subsequent management of the underlying etiology.

High-Frequency Percussive Ventilation Rescue Therapy in Morbidly Obese Patients Failing Conventional Mechanical Ventilation.

BACKGROUND: Morbidly obese patients with respiratory failure who do not improve on conventional mechanical ventilation (CMV) often undergo rescue therapy with extracorporeal membrane oxygenation (ECMO). We describe our experience with high-frequency percussive ventilation (HFPV) as a rescue modality. METHODS: In a retrospective analysis from 2009 to 2016, 12 morbidly obese patients underwent HFPV after failing to wean from CMV. Data were collected regarding demographics, cause of respiratory failure, ventilation settings, and hospital course outcomes. Our end point data were pre- and post-HFPV partial pressure of arterial oxygen and PaO2 to fraction of inspired oxygen (PF) ratios measured at initiation, 2, and 24 hours. RESULTS: Twelve morbidly obese patients required HFPV for respiratory failure. Causes of respiratory failure overlapped and included cardiogenic pulmonary edema (n = 8), pneumonia (n = 5), septic shock (n = 5), and asthma (n = 1). After HFPV initiation, mean fraction of inspired oxygen FiO2 was tapered from 98% to 82% and 66% at 2 and 24 hours, respectively. Mean PaO2 increased from 60.9 mm Hg before HFPV to 175.1 mm Hg (P < .05) at initiation of HFPV, then sustained at 129.5 mm Hg (P < .05) and 88.1 mm Hg (P < .005) at 2 and 24 hours, respectively. Mean PF ratio improved from 66.1 before HFPV to 180.3 (P < .05), 181.0 (P < .05) and 148.9 (P < .0005) at initiation, 2, and 24 hours, respectively. The improvement in mean PaO2 and PF ratios was durable at 24 hours whether or not the patient was returned to CMV (n = 10) or remained on HFPV (n = 2). Survival to discharge was 66.7%. CONCLUSION: In our cohort of morbidly obese patients, HFPV was successfully utilized as a rescue therapy precluding the need for ECMO. Despite our small sample size, HFPV should be considered as a rescue therapy in morbidly obese patients failing CMV prior to the initiation of ECMO. Our retrospective analysis supports consideration for HFPV as another form of rescue therapy for obese patients with refractory hypoxemia and respiratory failure who are not improving with CMV.