Impact of osteoarthritis disease severity on treatment patterns and healthcare resource use: analysis of real-world data.

OBJECTIVE: To understand treatment patterns and healthcare resource utilization (HCRU) related to osteoarthritis (OA) disease severity in patients in five European countries. METHOD: Data were drawn from the Adelphi OA Disease Specific Programme™ (2017-18). Physicians classified their patients as having mild, moderate, or severe OA, and provided details on their current prescribed therapy and HCRU, including healthcare professional (HCP) consultations, diagnostics and testing, and hospitalizations. Comparisons between disease severity groups were made using analysis of variance and chi-squared tests. RESULTS: The study included 489 physicians (primary care physicians, rheumatologists, orthopaedic surgeons) reporting on 3596 OA patients: 24% mild, 53% moderate, and 23% severe disease. Both physicians and patients reported decreasing satisfaction with treatment with greater disease severity, despite the number of classes of prescribed drugs and increased use of opioids, which were used in almost half of patients with severe OA. For patients whose treatment was not effective, physicians prescribed the same therapeutic options, which were cycled in subsequent treatment lines, with multiple treatment regimens being commonly used. Patients with greater symptom severity also had more physician consultations, while the numbers of tests/imaging, predominantly X-rays, conducted to diagnose or monitor OA increased significantly with disease severity. The type of HCP involvement in patient management also varied by OA severity. CONCLUSIONS: Across five European countries, the use of both non-pharmacological and pharmacological treatments increases with greater disease severity. Those with more severe disease place a greater demand on healthcare resources, with HCP consultations, tests, and hospital visits increasing with severity.

Development and validation of a prognostic model for death 30 days after adult emergency laparotomy.

The probability of death after emergency laparotomy varies greatly between patients. Accurate pre-operative risk prediction is fundamental to planning care and improving outcomes. We aimed to develop a model limited to a few pre-operative factors that performed well irrespective of surgical indication: obstruction; sepsis; ischaemia; bleeding; and other. We derived a model with data from the National Emergency Laparotomy Audit for patients who had emergency laparotomy between December 2016 and November 2018. We tested the model on patients who underwent emergency laparotomy between December 2018 and November 2019. There were 4077/40,816 (10%) deaths 30 days after surgery in the derivation cohort. The final model had 13 pre-operative variables: surgical indication; age; blood pressure; heart rate; respiratory history; urgency; biochemical markers; anticipated malignancy; anticipated peritoneal soiling; and ASA physical status. The predicted mortality probability deciles ranged from 0.1% to 47%. There were 1888/11,187 deaths in the test cohort. The scaled Brier score, integrated calibration index and concordance for the model were 20%, 0.006 and 0.86, respectively. Model metrics were similar for the five surgical indications. In conclusion, we think that this prognostic model is suitable to support decision-making before emergency laparotomy as well as for risk adjustment for comparing organisations.

Caustic of colors in Newton's prism.

A single ray of white light, incident on a glass prism, emerges as a family of diverging rays, parameterized by their colors. These originate from a virtual caustic (envelope of colored rays) inside the prism, rather than a focal point. The "caustic of colors" is a singularity different from the familiar colored caustics (incoherent superpositions of monochromatic ray/wave families that themselves possess caustics). Weak dispersion enables analytical approximations: completely describing the virtual caustic, and rendering to simulate its visual colors. The caustic region is very small; observing it with a beam narrow enough to resolve its colors would require a meter-sized prism. Observability depends on the third power of dispersion, so the caustic, though not its colors, might be detectable by extension outside the visual range.

Physician and patient perceptions of surgical procedures for osteoarthritis of the knee in the United States, Europe, and Japan: results of a real-world study.

BACKGROUND: Osteoarthritis (OA) is the most common form of arthritis, with the knee being the joint most frequently affected, and symptomatic knee OA affecting around one quarter of the general population. For patients who do not respond to non-pharmacologic or pharmacologic treatment, surgery is a recommended option. The objectives of this study were to compare the willingness of patients with knee OA to undergo surgery, together with reasons for delaying surgery, and factors affecting successful outcomes. METHODS: A point-in-time survey was conducted in 729 primary care physicians, rheumatologists, orthopedic surgeons, and 2,316 patients with knee OA across three geographical regions: Japan, the United States (US), and Europe (EUR: France, Spain, Italy, Germany, and the United Kingdom), in order to garner their perceptions of knee surgery. Regression models were used to identify factors that might affect patients' and physicians' perceptions of surgery, including severity of OA (mild/moderate/severe), number of affected joints, surgery status, and willingness to undergo or delay surgery. RESULTS: Baseline demographics were similar between US and EUR, although patients in Japan were more likely to be female, older, and only 7% in fulltime employment. We found that few patients with end-stage knee OA, across all regions, but particularly Japan, were willing to undergo surgery (Japan 17%, US 32%, EUR 38%), either through fear, or the lack of awareness of the risk/benefits. Moreover, surgeons are prepared to delay surgery in elderly or unwilling patients, due to their dissatisfaction with the outcome, and may defer surgery in younger patients due to the need for future revision. We also identified a disconnect between physicians, of whom over 80% consider improved functioning to be the most important outcome of surgery, and patients, who seek pain relief (Japan 60%, US 35%, EUR 14%). Since physicians across all regions considered pain reduction to be an indication of surgery success (Japan 27%, US 47%, EUR 43%), this may indicate a need for improved communication to patients on the potential benefits of surgery. CONCLUSION: Managing the expectations of patients undergoing surgery remains an important goal in the treatment of knee OA and may help guide physician choice.

Electronic prescribing systems as tools to improve patient care: a learning health systems approach to increase guideline concordant prescribing for venous thromboembolism prevention.

BACKGROUND: Venous thromboembolism (VTE) causes significant mortality and morbidity in hospitalised patients. Risk factors for VTE are well known and there are validated risk assessment tools to support the use of prophylactic therapies. In England, reporting the percentage of patients with a completed VTE risk assessment is mandated, but this does not include whether that risk assessment resulted in appropriate prescribing. Full guideline compliance, defined as an assessment which led to an appropriate action-here prescribing prophylactic low molecular weight heparin where indicated, is rarely reported. Education, audit and feedback enhance guideline compliance but electronic prescribing systems (EPS) can mandate guideline-compliant actions. We hypothesised that a systems-based EPS intervention (prescribing rules which mandate approval or rejection of a proposed prescription of prophylactic low molecular weight heparin based on the mandated VTE assessment) would increase full VTE guideline compliance more than interventions which focused on targeting individual prescribers. METHODS: All admitted patients within University Hospitals Birmingham NHS Foundation Trust were included for analysis between 2011 and 2020. The proportion of patients who received a fully compliant risk assessment and action was assessed over time. Interventions included teaching sessions and face-to-face feedback based on measured performance (an approach targeting individual prescribers) and mandatory risk assessment and prescribing rules into an EPS (a systems approach). RESULTS: Data from all 235,005 admissions and all 5503 prescribers were included in the analysis. Risk assessments were completed in > 90-95% of all patients at all times, but full guideline compliance was lower (70% at the start of this study). Face-to-face feedback improved full VTE guideline compliance from 70 to 77% (p ≤ 0.001). Changes to the EPS to mandate assessment with prescribing rules increased full VTE compliance to 95% (p ≤ 0.001). Further amendments to the EPS system to reduce erroneous VTE assessments slightly reduced full compliance to 92% (p < 0.001), but this was then maintained including during changes to the low molecular weight heparin used for VTE prophylaxis. DISCUSSION: An EPS-systems approach was more effective in improving sustained guideline-compliant VTE prevention over time. Non-compliance remained at 8-5% despite this mandated system. Further research is needed to assess the potential reasons for this.

QTL analysis of cooking time and quality traits in dry bean (Phaseolus vulgaris L.).

KEY MESSAGE: Three robust QTL for dry bean cooking time shortened cooking time 11-26 min and co-localized with QTL for increased cooked seed protein concentration. Cooking time is a major factor associated with consumer preference of dry beans (Phaseolus vulgaris L.). The genetic control of cooking time was investigated with a quantitative trait loci (QTL) study on a recombinant inbred line (RIL) population developed from TZ-27 (slow cooking) and TZ-37 (fast cooking). The RIL population of 146 lines was grown on research farms over 2 years in Arusha and Morogoro, Tanzania. Arusha is an important mid-altitude bean-growing region, with moderate temperatures and reliable rainfall, whereas the low altitude and high temperatures in Morogoro make it unfavorable for bean production. The population exhibited large variation for cooking time with a range of 22-98 min. On average, beans grown in Arusha cooked 15 min faster than those grown in Morogoro. A linkage map developed with 1951 SNP markers was used for QTL analysis. Ten QTL were identified for cooking time, three of which were found in multiple environments. RILs with all three QTL (CT3.1, CT6.1, and CT11.2) cooked on average 11 min faster in Arusha and 26 min faster in Morogoro than RILs with none. Seed attributes were related to cooking time such that seeds with greater seed mass and less seed coat percentage cooked faster. Cooked seed protein concentration ranged from 17.8 to 30.8% across the years and locations. All three of the most robust cooking time QTL co-localized with QTL for protein concentration, and TZ-37 always contributed faster cooking time and increased protein concentration.

Electrical latency predicts the optimal left ventricular endocardial pacing site: results from a multicentre international registry.

Aims: The optimal site for biventricular endocardial (BIVENDO) pacing remains undefined. Acute haemodynamic response (AHR) is reproducible marker of left ventricular (LV) contractility, best expressed as the change in the maximum rate of LV pressure (LV-dp/dtmax), from a baseline state. We examined the relationship between factors known to impact LV contractility, whilst delivering BIVENDO pacing at a variety of LV endocardial (LVENDO) locations. Methods and results: We compiled a registry of acute LVENDO pacing studies from five international centres: Johns Hopkins-USA, Bordeaux-France, Eindhoven-The Netherlands, Oxford-United Kingdom, and Guys and St Thomas' NHS Foundation Trust, London-UK. In all, 104 patients incorporating 687 endocardial and 93 epicardial pacing locations were studied. Mean age was 66 ± 11 years, mean left ventricular ejection fraction 24.6 ± 7.7% and mean QRS duration of 163 ± 30 ms. In all, 50% were ischaemic [ischaemic cardiomyopathy (ICM)]. Scarred segments were associated with worse haemodynamics (dp/dtmax; 890 mmHg/s vs. 982 mmHg/s, P < 0.01). Delivering BiVENDO pacing in areas of electrical latency was associated with greater improvements in AHR (P < 0.01). Stimulating late activating tissue (LVLED >50%) achieved greater increases in AHR than non-late activating tissue (LVLED < 50%) (8.6 ± 9.6% vs. 16.1 ± 16.2%, P = 0.002). However, the LVENDO pacing location with the latest Q-LV, was associated with the optimal AHR in just 62% of cases. Conclusions: Identifying viable LVENDO tissue which displays late electrical activation is crucial to identifying the optimal BiVENDO pacing site. Stimulating late activating tissue (LVLED >50%) yields greater improvements in AHR however, the optimal location is frequently not the site of latest activation.

Local Expansion of Donation After Circulatory Death Kidney Transplant Activity Improves Waitlisted Outcomes and Addresses Inequities of Access to Transplantation.

In the United Kingdom, donation after circulatory death (DCD) kidney transplant activity has increased rapidly, but marked regional variation persists. We report how increased DCD kidney transplant activity influenced waitlisted outcomes for a single center. Between 2002-2003 and 2011-2012, 430 (54%) DCD and 361 (46%) donation after brain death (DBD) kidney-only transplants were performed at the Cambridge Transplant Centre, with a higher proportion of DCD donors fulfilling expanded criteria status (41% DCD vs. 32% DBD; p = 0.01). Compared with U.K. outcomes, for which the proportion of DCD:DBD kidney transplants performed is lower (25%; p < 0.0001), listed patients at our center waited less time for transplantation (645 vs. 1045 days; p < 0.0001), and our center had higher transplantation rates and lower numbers of waiting list deaths. This was most apparent for older patients (aged >65 years; waiting time 730 vs. 1357 days nationally; p < 0.001), who received predominantly DCD kidneys from older donors (mean donor age 64 years), whereas younger recipients received equal proportions of living donor, DBD and DCD kidney transplants. Death-censored kidney graft survival was nevertheless comparable for younger and older recipients, although transplantation conferred a survival benefit from listing for only younger recipients. Local expansion in DCD kidney transplant activity improves survival outcomes for younger patients and addresses inequity of access to transplantation for older recipients.

Late asymptomatic atrial lead perforation, a fortuitous finding during lead extraction using thoracoscopic surveillance: a case report and review of the literature.

A 61-year-old male patient was referred for lead extraction of an infected two-chamber pacemaker system first implanted 18 years ago. A new atrial lead was implanted 9 years later because of loss of capture of the original lead. Video-assisted thoracoscopic surgery (VATS) that we use in high-risk cases showed extensive fibrous adhesion between the right atrium wall and the right lung. Dissection of the adhesion revealed the presence of an atrial lead perforated into the lung. After cutting off the lead tip, the residual lead was removed endovascularly from the subclavian site. A literature review of 25 reported cases of late atrial lead perforation was added to the findings in our case report.

Male long-tailed macaques (Macaca fascicularis) understand the target of facial threat.

The cognitive demands of group living have resulted in the development of social competences in a wide range of animal species. Primates are well aware of the complex social structure within their group and infer information about social status by observing interactions of others. A capacity used to infer this information, Visual Perspective Taking (VPT), is present in apes and in monkeys. However, it is unclear whether monkeys really understand that another individual is looking at a specific target. We investigated whether monkeys understand the target of attention of conspecifics using a new paradigm, based on expectancy violation. Subjects were exposed to pictures of scenes involving group members. These pictures either represented congruent (agonistic signals consistent with the dominance hierarchy) or incongruent (signals contradict the dominance hierarchy) social situations. The only difference between scenes concerned the looking direction, that is, the target of attention, and facial expression of the central monkey in the picture. Female subjects did not differ in their looking times to incongruent and congruent scenes, but results may be confounded by their longer looking times at scenes involving kin than non-kin. Male subjects looked significantly longer at incongruent than congruent scenes, suggesting that they understand the target of attention of other individuals. Alternative explanations involving simpler cognitive capacities were excluded. This implies that monkey species share social cognitive capacities underlying VPT with apes and humans. Am. J. Primatol. 78:720-730, 2016. © 2016 Wiley Periodicals, Inc.

The RBMX gene as a candidate for the Shashi X-linked intellectual disability syndrome.

A novel X-linked intellectual disability (XLID) syndrome with moderate intellectual disability and distinguishing craniofacial dysmorphisms had been previously mapped to the Xq26-q27 interval. On whole exome sequencing in the large family originally reported with this disorder, we identified a 23 bp frameshift deletion in the RNA binding motif protein X-linked (RBMX) gene at Xq26 in the affected males (n = 7), one carrier female, absent in unaffected males (n = 2) and in control databases (7800 exomes). The RBMX gene has not been previously causal of human disease. We examined the genic intolerance scores for the coding regions and the non-coding regions of RBMX; the findings were indicative of RBMX being relatively intolerant to loss of function variants, a distinctive pattern seen in a subset of XLID genes. Prior expression and animal modeling studies indicate that loss of function of RBMX results in abnormal brain development. Our finding putatively adds a novel gene to the loci associated with XLID and may enable the identification of other individuals affected with this distinctive syndrome.

Acute hemodynamic effects of single- and dual-site left ventricular pacing employing a dual cathodal coronary sinus lead.

BACKGROUND: We studied the acute hemodynamic effect of left ventricular (LV) pacing from a dual cathodal coronary sinus (CS) lead in a both single- and dual-site electrode configuration. METHODS: In 17 patients who underwent implantation of a cardiac resynchronization therapy-defibrillator system with dual cathodal CS leads, LV stimulation was performed from the distal and proximal electrode separately and from both electrodes simultaneously. The acute hemodynamic response was evaluated by invasive measurement of LVdP/dtmax. Timing of LV electrical activation time measured from onset QRS to LV sense during intrinsic rhythm at both electrodes were determined from simultaneous intracardiac recordings. The latter results were compared to those of an additional group of 26 patients in whom no hemodynamic effects were evaluated. RESULTS: Baseline LVdP/dtmax was 897 ± 222 mm Hg/s. Single-site LV pacing resulted in a rise of LVdP/dtmax to 1,053 ± 266 mm Hg/s (+17.4%) taking the best of the two sites and 1,020 ± 254 mm Hg (+13.7%) at the worst site (P = 0.0001). In the dual-site pacing configuration LVdP/dtmax was 1,026 ± 243 mm Hg/s (+14.1%). P value for single best versus dual site was 0.005, and for dual site versus worst single site was 0.18 (n.s.). CONCLUSION: Even with a relatively small distance of 20-21 mm between stimulation electrodes, there is a significant difference in acute hemodynamic effect from the single best and worst site. Dual-site LV pacing offers no hemodynamic benefit over the best single pacing site. The short electrode distance may have been a limitation and results may not be applicable to other forms of multisite pacing.

Induction chemoradiation therapy prior to esophagectomy is associated with superior long-term survival for esophageal cancer.

The purpose of this study was to examine the role of induction chemoradiation in the treatment of potentially resectable locally advanced (T2-3N0 and T1-3N+) esophageal cancer utilizing a large national database. The National Cancer Data Base (NCDB) was queried for all patients undergoing esophagectomy for clinical T2-3N0 and T1-3N+ esophageal cancer of the mid- or lower esophagus. Patients were stratified by the use of induction chemoradiation therapy versus surgery-first. Trends were assessed with the Cochran-Armitage test. Predictors of receiving induction therapy were evaluated with multivariable logistic regression. A propensity-matched analysis was conducted to compare outcomes between groups, and the Kaplan-Meier method was used to estimate long-term survival. Within the NCDB, 7921 patients were identified, of which 6103 (77.0%) were treated with chemoradiation prior to esophagectomy, while the remaining 1818 (23.0%) were managed with surgery-first. Use of induction therapy increased over time, with an absolute increase of 11.8% from 2003-2011 (P < 0.001). As revealed by the propensity model, induction therapy was associated with higher rates of negative margins and shorter hospital length of stay, but no differences in unplanned readmission and 30-day mortality rates. In unadjusted survival analysis, induction therapy was associated with better long-term survival compared to a strategy of surgery-first, with 5-year survival rates of 37.2% versus 28.6%, P < 0.001. Following propensity score matching analysis, the use of induction therapy maintained a significant survival advantage over surgery-first (5-year survival: 37.9% vs. 28.7%, P < 0.001). Treatment with induction chemoradiation therapy prior to surgical resection is associated with significant improvement in long-term survival, even after adjusting for confounders with a propensity model. Induction therapy should be considered in all medically appropriate patients with resectable cT2-3N0 and cT1-3N+ esophageal cancer, prior to esophagectomy.

Intussusception in Children: A Clinical Review.

Intussusception is the most common cause of small bowel obstruction in young infants. Therefore a high index of suspicion and thorough knowledge of this condition is of major importance to be able to diagnose and treat this potentially life threatening condition. In this review we describe epdidemiology, etiology and clinical symptoms of intussuception. Furthermore, we describe diagnostic modalties, especially ultrasonography as the primary choice for diagnosis. In addition, non-operative treatment with different types of enema reduction techniques, and operative treatment by laparotomy and laparoscopy, and outcomes have been reviewed.

Percutaneous transtracheal ventilation in an obstructed airway model in post-apnoeic sheep.

BACKGROUND: Temporizing oxygenation by percutaneous transtracheal ventilation (PTV) is a recommended emergency technique in 'can't intubate, can't oxygenate' (CICO) situations. Barotrauma risk increases if expiration is obstructed. The Ventrain(®) is a new PTV device that assists expiration. Our aim was to compare key physiological outcomes after PTV with the Ventrain and the Manujet(®) in a large animal obstructed airway model. METHODS: Five anaesthetized sheep had post-apnoea PTV performed for 15 min using the Ventrain or Manujet with the proximal airway completely or critically obstructed, yielding four ventilation protocols per sheep. After apnoeic desaturation ([Formula: see text]70%), a 4 s rescue breath was delivered. Subsequent 2 s breaths were delivered whenever the airway pressure fell <10 cm H2O. RESULTS: Both devices achieved rapid re-oxygenation. There were marked device differences (Ventrain vs Manujet) in peak airway pressures with rescue (16 vs 40 cm H2O) breaths, minute ventilation (4.7 vs 0.1 litre min(-1)), and end-protocol pH (7.34 vs 7.01). There was no clinical evidence of barotrauma in any sheep after any ventilation protocol. An equilibration phase prevented large subatmospheric intrathoracic pressure development with Ventrain ventilation. CONCLUSIONS: The Ventrain provided stable oxygenation and effective ventilation at low airway pressures during emergency PTV in critically obstructed airways. The Manujet provided effective temporizing oxygenation in this situation with hypoventilation necessary to minimize barotrauma risk. The nature and extent of airway obstruction may not be known in a CICO emergency but an understanding of device differences may help inform optimal ventilation device and method selection.

Trends and outcomes in the use of surgery and radiation for the treatment of locally advanced esophageal cancer: a propensity score adjusted analysis of the surveillance, epidemiology, and end results registry from 1998 to 2008.

We examined outcomes and trends in surgery and radiation use for patients with locally advanced esophageal cancer, for whom optimal treatment isn't clear. Trends in surgery and radiation for patients with T1-T3N1M0 squamous cell or adenocarcinoma of the mid or distal esophagus in the Surveillance, Epidemiology, and End Results database from 1998 to 2008 were analyzed using generalized linear models including year as predictor; Surveillance, Epidemiology, and End Results doesn't record chemotherapy data. Local treatment was unimodal if patients had only surgery or radiation and bimodal if they had both. Five-year cancer-specific survival (CSS) and overall survival (OS) were analyzed using propensity-score adjusted Cox proportional-hazard models. Overall 5-year survival for the 3295 patients identified (mean age 65.1 years, standard deviation 11.0) was 18.9% (95% confidence interval: 17.3-20.7). Local treatment was bimodal for 1274 (38.7%) and unimodal for 2021 (61.3%) patients; 1325 (40.2%) had radiation alone and 696 (21.1%) underwent only surgery. The use of bimodal therapy (32.8-42.5%, P = 0.01) and radiation alone (29.3-44.5%, P < 0.001) increased significantly from 1998 to 2008. Bimodal therapy predicted improved CSS (hazard ratios [HR]: 0.68, P < 0.001) and OS (HR: 0.58, P < 0.001) compared with unimodal therapy. For the first 7 months (before survival curve crossing), CSS after radiation therapy alone was similar to surgery alone (HR: 0.86, P = 0.12) while OS was worse for surgery only (HR: 0.70, P = 0.001). However, worse CSS (HR: 1.43, P < 0.001) and OS (HR: 1.46, P < 0.001) after that initial timeframe were found for radiation therapy only. The use of radiation to treat locally advanced mid and distal esophageal cancers increased from 1998 to 2008. Survival was best when both surgery and radiation were used.

How Depletion Layers Govern the Dynamic Plasmonic Response of In-Doped CdO Nanocrystals.

Doped metal oxide nanocrystals exhibit a localized surface plasmon resonance that is widely tunable across the mid- to near-infrared region, making them useful for applications in optoelectronics, sensing, and photocatalysis. Surface states pin the Fermi level and induce a surface depletion layer that hinders conductivity and refractive index sensing but can be advantageous for optical modulation. Several strategies have been developed to both synthetically and postsynthetically tailor the depletion layer toward particular applications; however, this understanding has primarily been advanced in Sn-doped In2O3 (ITO) nanocrystals, leaving open questions about generalizing to other doped metal oxides. Here, we quantitatively analyze the depletion layer in In-doped CdO (ICO) nanocrystals, which is shown to have an intrinsically wide depletion layer that leads to broad plasmonic modulation via postsynthetic chemical reduction and ligand exchange. Leveraging these insights, we applied depletion layer tuning to enhance the inherently weak plasmonic coupling in ICO nanocrystal superlattices. Our results demonstrate how an electronic band structure dictates the radial distribution of electrons and governs the response to postsynthetic modulation, enabling the design of tunable and responsive plasmonic materials.

Social environment and HIV risk among MSM in Hanoi and Thai Nguyen.

Little is known about the effect of the social environment on HIV risk in gay men in northern Vietnam, particularly in rural areas. This qualitative research study conducted 4 key informant interviews and 30 in-depth interviews of men in two northern Vietnamese cities: Hanoi, a large city, and Thai Nguyen, a smaller town. Hanoi has experienced a growth in the number of places where gay men can socialize, access HIV prevention services, and discuss health issues. Thai Nguyen lacks these open venues. However, homosexuality is still highly stigmatized in the general population in both cities. This stigma affects the number of partners and level of sexual risk of participants. Also, men generally reported little communication between partners about sexual risk. While stigma in the general community is difficult to change, social environments where gay men can openly communicate creates an opportunity for HIV prevention and social support.

The Needle's Eye Snare as a primary tool for pacing lead extraction.

AIMS: The femoral approach for lead extraction is typically used as a bailout procedure. We describe the results of a femoral approach with a Needle's Eye Snare and Femoral Workstation as a primary tool for extracting pacing leads. PATIENTS AND METHODS AND RESULTS: Four hundred and seventy-six pacing leads implanted for >6 months were extracted in 229 consecutive patients (178 male, age 70.4 ± 12.7 years). First, traction was performed with a standard stylet, and if unsuccessful this was followed by the femoral approach with a Needle's Eye Snare. Traction sufficed for 136 leads and a femoral approach was required in 340 leads, their respective implant times were 3.7 ± 2.9 and 9.2 ± 5.8 years. The Needle's Eye Snare failed or was only partial successful (leaving a lead remnant of <4 cm) in, respectively, 1.8 and 3.8% of all leads, 2.7 and 7.1% of 182 right ventricular, 0.7 and 0% of 144 atrial leads, and in none of 14 coronary sinus leads. All leads implanted for <10 years were removed with a clinical success. Two patients were successfully operated after pericardial tamponade. There were no procedure-related deaths. CONCLUSION: Needle's Eye Snare lead extraction has a low complication rate. The technique should be considered as a primary tool for extraction of pacing leads, particularly atrial and coronary sinus pacing leads. The results for extracting ventricular leads might be improved if larger bore sheaths with a better cutting edge were available.