A Randomized Controlled Trial of Two Parent-Child Parallel Interventions to Enhance Positive Adaptation of Immigrant Families in Hong Kong: The Moderating Role of Depressive Symptoms.

Parents and children who have recently immigrated from the Chinese mainland to Hong Kong face various challenges, including psychological and sociocultural adaptation difficulties. In collaboration with community partners, our research team has developed and implemented culturally sensitive and preventive parent-child parallel interventions to enhance positive adaptation among immigrant parents and children. Two interventions were conducted in this randomized controlled trial: an emotion regulation (ER) arm, which addressed psychological adaptation by reducing parent-child conflicts and improving emotions, and an information provision (IP) arm targeting sociocultural adaptation by increasing participants' knowledge about Hong Kong. The study randomly assigned 113 and 73 parent-child pairs (allocation ratio 3:2) into the ER and IP arms, respectively. Parents and children attended four two-hour weekly sessions of their assigned intervention and completed assessments before, immediately after, and one month following the intervention. The results showed that in the ER arm, parents showed improved positive affect, and children reported decreases in parent-child conflicts more than their counterparts in the IP arm. In the IP arm, parents and children increased their knowledge, and parents decreased sociocultural adaptation difficulties more than their counterparts in the ER arm. In addition, the moderation analyses showed that in both interventions, parents and children with elevated baseline depressive symptoms obtained greater benefits relative to their counterparts with fewer symptoms. Such marked improvements were seen among parents in negative affect and adaptation difficulties and among children in parent-child conflict, positive and negative affect in the ER arm. More improvements were noted among parents in negative affect and sociocultural adaptation difficulties and among children in negative affect in the IP arm. Future studies are suggested to develop and provide parent-child parallel interventions targeting both psychological and sociocultural adaptations to parents and children with heightened baseline depressive symptoms to facilitate their positive adaptation in Hong Kong.

Perceived discrimination and psychological distress among Mainland Chinese immigrant women in Hong Kong: The indirect effects of tolerance of uncertainty and common dyadic coping.

OBJECTIVES: By studying Mainland Chinese immigrant women who married Hong Kong men, this study examined the association between their perceived discrimination and psychological distress after the 2019-2020 social movement in Hong Kong. Additionally, this study examined the indirect effects of individual coping strategies (tolerance of uncertainty) and couples' coping strategies (common dyadic coping), guided by the cultural and developmental psychopathology framework. METHOD: Ninety-nine Mainland Chinese immigrant women who married Hong Kong men participated in this cross-sectional survey. RESULTS: We found a positive association between perceived discrimination and psychological distress (r = .50, p < .01). Reduced uncertainty tolerance and low levels of common dyadic coping both showed indirect effects on the discrimination-psychological distress association. Tolerance of uncertainty had a larger indirect effect than common dyadic coping. CONCLUSIONS: Focusing on the psychological adjustment of immigrant women facing discrimination, our findings underscore the importance of preserving individual- and couple-level resources. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

A Randomized Controlled Trial of Two Parenting Interventions on Enhancing Parental Resilience Resources and Reducing Children's Problem Behaviors in Chinese Cross-Boundary Families: Positive Benefits and Moderation Effects.

Daily cross-boundary schooling between Shenzhen and Hong Kong constitutes a constant challenge for Chinese cross-boundary families in terms of parenting burden. To address their most urgent parenting needs, we adapted and evaluated two intervention approaches-improving emotional regulation and providing knowledge about Hong Kong. A cluster randomized controlled trial with repeated assessments (pre-, post-intervention, and one-month follow-up) was adopted to evaluate the intervention effects on the increases of parental resilience resources and reduction of children's problem behaviors. We further conducted moderation analyses to investigate whether parents with more increases in parental resilience resources would report a greater reduction in children's problem behaviors. A total of 214 mothers of cross-boundary families were randomly assigned to the emotional regulation arm (ER, n = 120) or the information provision arm (IP, n = 94). Both intervention arms showed positive effects on emotional regulation strategies, and the IP arm outperformed the ER arm in knowledge acquisition. Both arms showed significant and comparable improvements in parental self-efficacy and children's problem behaviors. Moreover, participants in the IP arm who reported more improvements in parental resilience resources showed a greater reduction in children's problem behaviors. By adapting two interventions to a new population of cross-boundary families, this trial extended the benefits from parents to children and demonstrated that the improvement of parental resilience resources makes a difference in reducing children's problem behaviors in the IP arm. Future studies are suggested to focus on parental resilience resources and maximize the benefits on children's outcomes.

Relevance of BEST-CLI trial endpoints in a tertiary care limb preservation program.

OBJECTIVE: Major adverse limb event-free survival (MALE-FS) differed significantly by initial revascularization approach in the BEST-CLI randomized trial. The BEST-CLI trial represented a highly selected subgroup of patients seen in clinical practice; thus, we examined the endpoint of MALE-FS in an all-comers tertiary care practice setting. METHODS: This is a single-center retrospective study of consecutive, unique patients who underwent technically successful infrainguinal revascularization for chronic limb-threatening ischemia (2011-2021). MALE was major amputation (transtibial or above) or major reintervention (new bypass, open bypass revision, thrombectomy, or thrombolysis). RESULTS: Among 469 subjects, the mean age was 70 years, and 34% were female. Characteristics included diabetes (68%), end-stage renal disease (ESRD) (16%), Wound, Ischemia, and foot Infection (WIfI) stage 4 (44%), Global Limb Anatomic Staging System (GLASS) stage 3 (62%), and high pedal artery calcium score (pMAC) (22%). Index revascularization was autogenous vein bypass (AVB) (30%), non-autogenous bypass (NAB) (13%), or endovascular (ENDO) (57%). The composite endpoint of MALE or death occurred in 237 patients (51%) at a median time of 189 days from index revascularization. In an adjusted Cox model, factors independently associated with MALE or death included younger age, ESRD, WIfI stage 4, higher GLASS stage, and moderate-severe pMAC, whereas AVB was associated with improved MALE-FS. Freedom from MALE-FS, MALE, and major amputation at 30 days were 90%, 92%, and 95%; and at 1 year were 63%, 70%, and 83%, respectively. MALE occurred in 144 patients (31%) and was associated with ESRD, WIfI stage, GLASS stage, pMAC score, and index revascularization approach. AVB had superior durability, with adjusted 2-year freedom from MALE of 72%, compared with 66% for ENDO and 51% for NAB. Within the AVB group, spliced vein conduit had higher MALE compared with single-segment vein (hazard ratio, 1.8; 95% confidence interval, 0.9-3.7; P = .008 after inverse propensity weighting), but there was no statistically significant difference in major amputation. Of the 144 patients with any MALE, the first MALE was major reintervention in 47% and major amputation in 53%. Major amputation as first MALE was associated with non-AVB index approach. Indications for major reintervention were symptomatic stenosis/occlusion (54%), lack of clinical improvement (28%), asymptomatic graft stenosis (16%), and iatrogenic events (3%). Conversion to bypass occurred after 6% of ENDO cases, two-thirds of which involved distal bypass targets at the ankle or foot. CONCLUSIONS: In this consecutive, all-comers cohort, disease complexity was associated with procedural selection and MALE-FS. AVB independently provided the greatest MALE-FS and freedom from MALE and major amputation. Compared with the BEST-CLI randomized trial, MALE after ENDO in this series was more frequently major amputation, with relatively few conversions to open bypass.

Descending thoracic aortic mural ulceration is associated with postoperative spinal cord ischemia after branched endovascular aortic aneurysm repair.

OBJECTIVE: Paraplegia is one of the most feared complications after thoracoabdominal aortic aneurysm repair. The purpose of this study is to determine whether aortic thrombus characteristics are associated with spinal cord ischemia (SCI) after branched endovascular aneurysm repair (BEVAR). METHODS: From April 2011 to April 2020, 62 patients underwent elective BEVAR for thoracoabdominal aortic aneurysm and pararenal aortic aneurysms using a low-profile device and had a complete preoperative computed tomography angiography of the aorta from the sinotubular junction to the aortic bifurcation. Aortic thrombus was evaluated for thrombus thickness ≥5 mm, thrombus >2/3 of aortic circumference, and the presence of an ulcer-like thrombus. One point was assigned at each 5 mm axial image if all 3 criteria were met, resulting in a total "shaggy score" for the entire aorta. Data on demographics, procedural details, and outcomes were collected prospectively. All patients underwent a standard spinal cord protection protocol, including routine cerebrospinal fluid drainage. In July 2016, an insulin infusion protocol (IIP) was initiated to maintain postoperative blood glucose levels <120 mg/dL for 48 hours. The primary clinical end point was postoperative SCI. RESULTS: 10 (16%) patients developed postoperative SCI: 6 with transient paraparesis, 2 with persistent paraparesis, and 2 with persistent paraplegia. Patients with SCI were older, had higher shaggy scores, and were less likely to have been on an IIP. There were no significant differences in demographics, aneurysm type, or operative parameters. In a logistic multivariate regression model for SCI, age (odds ratio [OR]: 1.2 [1.1-1.4], P = .02) and shaggy score (OR: 1.2 [1.1-1.4], P = .02) were independently associated with increased risk of SCI, whereas treatment with the IIP was associated with lower risk of SCI (OR: 0.04 [0.006-0.50], P = .05). Of the individual components of the shaggy score, higher descending thoracic aortic ulcer scores were the most strongly associated with postoperative SCI (P = .009). CONCLUSIONS: Preoperative characterization of aortic wall thrombus is an important adjunctive tool for individualized clinical decision-making and patient counseling about the risk of SCI after BEVAR.

(In)congruence in child-mother relationships and depressive symptoms in cross-boundary families.

A large number of school-aged children traveling between Mainland China and Hong Kong every day to attend school are known as cross-boundary students (). Daily cross-boundary schooling is likely to be a constant challenge for cross-boundary students and their families, putting them at great risk of mental health problems (e.g., depression). Nevertheless, intergenerational relationships may be positive contributors to their adaptation. Guided by the interdependence theory and the operations triad model, this study employed dyadic response surface analysis to take into account linear and curvilinear associations between child-mother relationships and their depressive symptoms. The cross-sectional results based on 187 child-mother dyads showed that when children and mothers reported relatively high levels of closeness and relatively low levels of conflict, they reported fewer depressive symptoms. The extreme closeness between children and their mothers posed particular risks to mothers, increasing maternal depressive symptoms. When children and mothers reported varying levels of closeness and conflict, they displayed greater depressive symptoms. One exception was that no significant association was observed between incongruence in closeness and children's depressive symptoms. Family-based interventions should be considered for promoting optimal child-mother combinations. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Iliac artery calcification score stratifies mortality risk estimation in patients with chronic limb-threatening ischemia undergoing revascularization.

OBJECTIVE: Patients with chronic limb-threatening ischemia (CLTI) are at high risk for adverse limb outcomes and mortality. Using the Vascular Quality Initiative (VQI) prediction model to estimate mortality after revascularization can assist with clinical decision-making. We aimed to improve the discrimination of the 2-year VQI risk calculator by incorporating a common iliac artery (CIA) calcification score based on computed tomography scans. METHODS: This was a retrospective analysis of patients who underwent infrainguinal revascularization for CLTI from January 2011 to June 2020 and had a computed tomography scan of the abdomen/pelvis 2 years before or up to 6 months after revascularization. CIA calcium morphology, circumference, and length were scored. Bilateral scores were summed for the total calcium burden (CB) score, which was trichotomized (mild, 0-15; moderate, 16-19; severe, 20-22). The VQI CLTI model was used to categorize patients as low, medium, or high risk for mortality. RESULTS: A total of 131 patients with a mean age of 69±12 years were included in the study, and 86 (66%) were men. CB scores were mild in 52 (40%), moderate in 26 (20%), and severe in 53 (40%) patients. Older patients (P = .0002) and those with coronary artery disease (P = .06) had higher CB scores. Patients with severe CB scores were more likely to undergo infrainguinal bypass compared with those with mild or moderate CB scores (P = .006). The 2-year VQI mortality risk was calculated to be low in 102 (78%), medium in 23 (18%), and high in 6 (4.6%) patients. In the "low-risk" VQI mortality subgroup, 46 (45%) patients had mild, 18 (18%) had moderate, and 38 (37%) had severe CB scores, and patients with severe CB scores had significantly higher risk of mortality compared with those with mild or moderate scores (hazard ratio, 2.5; 95% confidence interval, 1.2-5.1; P = .01). In this "low-risk" VQI mortality subgroup, CB score further stratified the risk of mortality (P = .04). CONCLUSIONS: Higher total CIA calcification was significantly associated with mortality in patients undergoing infrainguinal revascularization for CLTI, and preoperative assessment of CIA calcification may help with perioperative risk stratification and guide clinical decision making in this population.

Presenting limb severity is associated with long-term outcomes after infrainguinal revascularization for chronic limb-threatening ischemia.

OBJECTIVE: The SVS Wound, Ischemia, foot Infection (WIfI) limb staging system was established to estimate risk of major amputation in chronic limb-threatening ischemia (CLTI) and better stratify outcomes comparisons. There is little data on treatment outcomes beyond 1 year based on presenting WIfI stage. METHODS: This is a single-institution retrospective study of 413 patients who underwent infrainguinal revascularization for CLTI (2011-2021) with data available for WIfI staging. Patient characteristics and outcomes were gathered from the electronic medical record. Data were analyzed based on presenting WIfI stage and initial treatment received at our center. RESULTS: Presenting WIfI stages were 1 to 2 (23%), 3 (27%), and 4 (50%). Index revascularization approach was endoluminal (59%), autogenous vein bypass (29%), or non-autogenous bypass (13%). Operative mortality within 30 days was 2.9% and was not associated with WIfI stage or revascularization approach. Median limb follow-up time was 502 days (interquartile range [IQR], 112-1256 days), and median survival follow-up time was 932 days (IQR, 343-1770 days). Major amputation or death occurred in 19% and 46% of patients at median times of 119 days (IQR, 28-314 days) and 739 days (IQR, 204-1475 days), respectively. WIfI stage was independently associated with major amputation (P = .001), as was initial revascularization approach (P = .01). In a Cox proportional hazards model, factors independently associated with major amputation were male sex (hazard ratio [HR], 1.4; 95% confidence interval [CI], 1.04-2.0; P = .03), diabetes (HR, 1.8; 95% CI, 1.3-2.5; P = .001), WIfI stage 4 (HR, 2.3; 95% CI, 1.5-3.5; P < .001), and non-autogenous bypass (HR, 2.9; 95% CI, 2.1-4.2; P < .001). In a Cox proportional hazards model for mortality, independently associated factors were age (HR, 1.04; 95% CI, 1.02-1.05; P < .001), end-stage renal disease (HR, 2.8; 95% CI, 1.9-4.0; P < .001), congestive heart failure (HR, 1.9; 95% CI, 1.4-2.5; P < .001), chronic obstructive pulmonary disease (HR, 1.5; 95% CI, 1.1-2.1; P = .02), and WIfI stage 4 (HR, 1.6; 95% CI, 1.04-2.2; P = .03). Among those presenting with WIfI stage 4 limbs, Kaplan-Meier estimated rates of freedom from major amputation or death at 2 years were 71% ± 3.7% and 68% ± 3.5%, respectively. In an inverse propensity weighted Cox proportional hazards model, non-white race (HR, 1.5; 95% CI, 1.01-2.2; P = .047), diabetes (HR, 2.0; 95% CI, 1.2-3.3; P = .008), Global Anatomic Staging System infrapopliteal grade (HR, 1.2; 95% CI, 1.05-1.3; P = .005), non-autogenous bypass (HR, 3.2; 95% CI, 1.9-5.3; P < .001), and endoluminal revascularization (HR, 2.6; 95% CI, 1.6-4.3; P < .001) were independently associated with major amputation in the WIfI stage 4 subgroup. CONCLUSIONS: Presenting WIfI stage is strongly associated with long-term risks of major amputation and death following infrainguinal revascularization for CLTI and should be used to stratify outcomes comparisons. Effective revascularization is critical in WIfI stage 4 disease, and autogenous vein bypass provides durable long-term limb preservation.

The More the Better, Only in the Longer Term: A Cluster Randomized Controlled Trial to Evaluate a Compound Intervention Among Mainland Chinese Immigrants in Hong Kong.

Barriers to adaptation faced by mainland Chinese immigrants to Hong Kong can be reduced by improving two targets of adaptation: information about negotiating their new environment and psychological well-being. We developed and evaluated a Compound intervention to address these two domains simultaneously and compared its effects to two separate interventions exclusively targeting either information about Hong Kong or psychological well-being. This cluster randomized controlled trial assigned 251 immigrants to an information provision arm (IP, n = 84) targeting knowledge and adaptation difficulties, a psychological well-being enhancement arm (WBE, n = 80) targeting resilience and mental health, or a Compound arm (i.e., IP + WBE, n = 87). The Compound arm showed stronger effects from baseline to postintervention on knowledge than the WBE arm. From postintervention to 6-month follow-up, the Compound arm showed better sustained effects on knowledge and adaptation difficulties than the IP arm and on resilience and mental health than the WBE arm. Additionally, participants in the Compound arm with more baseline depressive symptoms showed greater improvements in adaptation difficulties and general mental health than those with fewer symptoms. The study demonstrated the longer-term effectiveness of the Compound intervention and its greater benefits for immigrants with more depressive symptoms.

Pedal arterial calcification score is associated with hemodynamic change and major amputation after infrainguinal revascularization for chronic limb-threatening ischemia.

OBJECTIVE: Pedal medial arterial calcification (pMAC) is associated with major amputation in patients with chronic limb-threatening ischemia (CLTI). We hypothesize that this association would be related to unresolved distal ischemia. We investigated relationships across pMAC score, hemodynamic change, and major amputation after infrainguinal revascularization for CLTI. METHODS: This is a single-institution, retrospective study of 306 patients who underwent technically successful infrainguinal revascularization for CLTI (2011-2020) and had foot x-rays for blinded pMAC scoring (0-5). A total of 136 (44%) patients had toe pressure measurements performed within 90 days before and 60 days after revascularization. Ischemia grade (0-3) was assigned using the Society for Vascular Surgery Wound, Ischemia, foot Infection (WIfI) system. RESULTS: The revascularization approach was open bypass in 118 (38%) and endovascular in 188 (62%) patients. pMAC scores were trichotomized (0-1 [125; 41%], 2-4 [116; 38%], 5 [65; 21%]). Post-revascularization WIfI ischemia grade was improved in 78 of 136 (57%) and unchanged/worsened in 58 of 136 (43%). A lower pMAC score was associated with hemodynamic improvement (P = .004). Failure to improve the ischemia grade was associated with major amputation (P = .0002). In the endovascular subgroup, WIfI ischemia grade was improved in 43 of 90 (48%) with available measurements, and 37 of 188 (20%) underwent major amputation. In a multivariate logistic model, pMAC 5 was the only factor independently associated with unimproved ischemia grade after endovascular treatment (odds ratio: 4.0 [1.1-16.6], P = .04). In a Cox proportional hazards model, factors independently associated with major amputation after endoluminal revascularization were WIfI stage 4 (hazard ratio [HR]: 2.7 [1.3-5.7], P = .007) and pMAC score (pMAC: 2-4: HR: 10.6 [1.4-80.7], P = .02; pMAC: 5: HR: 15.5 [2.0-119], P = .008). In the bypass subgroup, WIfI ischemia grade was improved in 35 of 46 (76%) with available measurements but was not associated with pMAC score (P = .88) or any other baseline patient or limb characteristics. A total of 19 of 118 (16%) patients underwent major amputation. In a Cox proportional hazards model including bypass conduit, WIfI stage, and pMAC score, the only factor independently associated with major amputation after bypass was use of nonautologous conduit (HR: 5.6 [1.8-17.6], P = .003). CONCLUSIONS: The pMAC score is independently associated with persistent distal ischemia and major amputation after technically successful revascularization for CLTI. These data suggest that pMAC may be a marker for hemodynamic response to revascularization and risk of limb loss, and it may have a stronger influence on the outcome of endoluminal interventions.

A Socio-Ecological Framework for Cancer Prevention in Low and Middle-Income Countries.

Cancer incidence and mortality rates continue to rise globally, a trend mostly driven by preventable cancers occurring in low-and middle-income countries (LMICs). There is growing concern that many LMICs are ill-equipped to cope with markedly increased burden of cancer due to lack of comprehensive cancer control programs that incorporate primary, secondary, and tertiary prevention strategies. Notably, few countries have allocated budgets to implement such programs. In this review, we utilize a socio-ecological framework to summarize primary (risk reduction), secondary (early detection), and tertiary (treatment and survivorship) strategies to reduce the cancer burden in these countries across the individual, organizational, community, and policy levels. We highlight strategies that center on promoting health behaviors and reducing cancer risk, including diet, tobacco, alcohol, and vaccine uptake, approaches to promote routine cancer screenings, and policies to support comprehensive cancer treatment. Consistent with goals promulgated by the United Nations General Assembly on Noncommunicable Disease Prevention and Control, our review supports the development and implementation of sustainable national comprehensive cancer control plans in partnership with local communities to enhance cultural relevance and adoption, incorporating strategies across the socio-ecological framework. Such a concerted commitment will be necessary to curtail the rising cancer and chronic disease burden in LMICs.

Capturing the complexity of open abdominal aortic surgery in the endovascular era.

OBJECTIVE: Volume and quality benchmarks for open abdominal aortic surgery and particularly open aortic aneurysm repair (OAR) in the endovascular era are guided by the Society for Vascular Surgery guidelines, but the Vascular Quality Initiative (VQI) OAR module fails to capture the full spectrum of complex OAR. We hypothesized that VQI-ineligible complex OAR would be the dominant form of open repairs performed at a VQI-participating tertiary center. METHODS: All OAR cases performed at a single tertiary care center from 2007 to 2020 were reviewed. The VQI OAR criteria were applied with exclusions (non-VQI) defined as concomitant renal bypass, clamping above the superior mesenteric artery or celiac artery, repairs performed for trauma, anastomotic aneurysm, isolated iliac aneurysm, or infected aneurysms. Linear regression was used to assess temporal trends. RESULTS: Among a total of 481 open abdominal aortic operations, 355 (74%) were OAR. The average annual OAR volume remained stable over 14 years (25 ± 6; P = .46). Non-VQI OAR comprised 54% of all cases and persisted over time (R2 = 0.047, P = .46). Supraceliac clamping (35%) was often necessary. The proportion of endograft explantation cases significantly increased over time from 4% in 2007 to 20% in 2019 (P = .01). Infectious indications represented 20% (n = 70) of cases. Visceral branch grafts were performed in 16% of all cases. OAR for ruptured aneurysm constituted 10% of cases. Thirty-day mortality was significantly higher in non-VQI vs VQI-eligible OAR cases (10% vs 4%; P = .04). CONCLUSIONS: Complex OAR comprises a majority of OAR cases in a contemporary tertiary referral hospital, yet these cases are not accounted for in the VQI. Creation of a "complex OAR" VQI module would capture these cases in a quality-driven national registry and help to better inform benchmarks for volume and outcomes in aortic surgery.

Limb-based patency as a measure of effective revascularization for chronic limb-threatening ischemia.

OBJECTIVE: In 2019, the Global Vascular Guidelines on chronic limb-threatening ischemia (CLTI) introduced the concept of limb-based patency (LBP) defined as maintained patency of a target artery pathway after intervention. The purpose of this study was to investigate the relationship between LBP and major adverse limb events (MALE) after infrainguinal revascularization for CLTI. METHODS: Consecutive patients undergoing revascularization for CLTI between 2016 and 2019 at a single tertiary institution with a dedicated limb preservation team were included. Subjects with aortoiliac disease, prior infrainguinal stents, or existing bypass grafts were excluded. Demographics, Global Limb Anatomic Staging System scores, Wound, Ischemia, foot Infection (WIfI) stages, revascularization details, and limb-specific outcomes were reviewed. LBP was defined by the absence of reintervention, occlusion, critical stenosis (>70%), or hemodynamic compromise with ongoing symptoms of CLTI. MALE included thrombectomy or thrombolysis, new bypass, open surgical graft revision and/or major amputation. RESULTS: We analyzed 184 unique limbs in 163 patients. This cohort was composed of 66.9% male patients with a mean age of 72 years. Baseline characteristics included diabetes (66%), tissue loss (91%), and advanced WIfI stages (30% stage 3, 51% stage 4). Global Limb Anatomic Staging System stage 3 anatomic patterns were common (n = 119 [65%]). Sixty limbs were treated with open bypass (65% involving tibial targets) and 124 underwent endovascular intervention (70% including infrapopliteal targets). The 12-month freedom from MALE and loss of LBP were 74.0% ± 3.7% and 48.6% ± 4.2%, respectively. Diabetes (hazard ratio [HR], 2.56; 95% confidence interval [CI], 1.13-5.83; P = .025) and loss of LBP (HR, 4.12; 95% CI, 1.96-8.64; P < .001) were independent predictors of MALE in a Cox proportional hazard model. Loss of LBP was the sole independent predictor of major limb amputation after revascularization (HR, 4.97; 95% CI, 1.89-13.09; P = .001). Loss of LBP impacted both intermediate-risk limbs (HR, 2.85; 95% CI, 1.02-7.97; P = .047 in WIfI stages 1-3) and high-risk limbs (HR, 3.99; 95% CI, 1.32-12.11; P = .014 in WIfI stage 4). However, the loss of LBP had the greatest impact on patients presenting with WIfI stage 4 disease (31% vs 8% major limb amputation at 12 months in limbs without vs with maintained LBP). CONCLUSIONS: The anatomic durability of revascularization, as measured by LBP, is a key determinant of treatment outcomes in CLTI regardless of the initial mode of intervention undertaken. Loss of LBP is most detrimental in patients presenting with advanced limb threat (WIfI stage 4).

Pedal arterial calcification score is associated with the risk of major amputation in chronic limb-threatening ischemia.

OBJECTIVE: The medial arterial calcification (MAC) score is a simple metric that describes the burden of inframalleolar calcification using a plain foot radiograph. We hypothesized that a higher MAC score would be independently associated with the risk of major amputation in patients with chronic limb-threatening ischemia (CLTI). METHODS: We performed a single-institution, retrospective study of 250 patients who had undergone infrainguinal revascularization for CLTI from January 2011 to July 2019 and had foot radiographs available for MAC score calculation. A single blinded reviewer assigned MAC scores of 0 to 5 using two-view minimum plain foot radiographs, with 1 point each for calcification of >2 cm in the dorsalis pedis, plantar, and metatarsal arteries and >1 cm in the hallux and non-hallux digital arteries. RESULTS: The MAC score was 0 in 36%, 1 in 5.2%, 2 in 8.4%, 3 in 14%, 4 in 14%, and 5 in 21%. The MAC score was trichotomized to facilitate analysis and clinical utility (mild, MAC score 0-1; moderate, MAC score 2-4; and severe, MAC score 5). The variables independently associated with a higher MAC score were male sex, diabetes, end-stage renal disease, and the global limb anatomic staging system pedal score. The MAC score was not associated with the Society for Vascular Surgery WIfI (wound, ischemia, foot infection) grade or overall WIfI stage (P = .58). The median follow-up was 759 days (interquartile range, 264-1541 days). A higher MAC score was significantly associated with the risk of major amputation (P < .0001). In a Cox proportional hazards multiple regression model for major amputation that included the trichotomized MAC score, diabetes, end-stage renal disease, and WIfI stage (1-3 vs 4). The MAC score (MAC score 5: hazard ratio [HR], 4.9; 95% confidence interval [CI], 1.9-13.1; P = .001; MAC score 2-4: HR, 3.4; 95% CI, 1.3-8.8; P = .01) and WIfI stage (WIfI stage 4: HR, 2.1; 95% CI, 1.1-3.9; P = .03) were significantly associated with the risk of major amputation. In the subsets of patients with the most advanced WIfI stage of 3 to 4 (191 of 250; 76%) and patients with diabetes (185 of 250; 74%), the MAC score further stratified the risk of major amputation on univariate and multivariate analyses. CONCLUSIONS: The MAC score is a simple, practical tool and a strong independent predictor of major amputation in patients with CLTI. It provides novel clinical data that are currently unmeasured using any validated CLTI staging system. The MAC score is a promising standardized measure of inframalleolar disease burden that can be used in conjunction with the WIfI staging system to help improve outcomes stratification and determine the optimal treatment strategies for patients with CLTI.

Utility of a Simplified Iliac Artery Calcium Scoring System to Guide Perioperative Management for Renal Transplantation.

Non-contrast computed tomography scans of the abdomen and pelvis (CTAP) are often obtained prior to renal transplant to evaluate the iliac arteries and help guide surgical implantation. The purpose of this study was to describe the association of iliac calcification scores with operative and clinical outcomes using a simplified scoring system. A retrospective review of 204 patients who underwent renal transplant from 1/2013 to 11/2014 and who had a CTAP within 3 years prior to transplant was performed. Data were collected from the electronic medical record. Common iliac artery (CIA) and external iliac artery (EIA) calcification on CTAP were assessed using a simple scoring system. Descriptive statistics, logistic regression, and survival analyses were performed. A total of 204 patients were included in the analysis. The mean age was 57.4 ± 11.2 years and 134/204 (66%) were men. Nineteen patients (9%) had a history of peripheral artery disease (PAD), 78 (38%) had coronary artery disease, and 22 (11%) had a previous cerebrovascular accident (CVA). Patients with severe right EIA plaque morphology were significantly more likely to require arterial reconstruction compared to those without severe plaque (3/14[21%] 4/153 [3%], p = 0.03). Eleven patients (5%) had one or more amputations (toe, foot, or transtibial) following transplant. In UV logistic regression, severe EIA plaque morphology (OR 8.1, CI 2.2-29.6, p = 0.002) and PAD (OR 10.7, CI 2.8-39.9, p = 0.0004) were associated with increased odds of amputation. In the MV model containing both variables, EIA plaque morphology (OR 4.4, CI 0.99-18.3, p = 0.04) and PAD (OR 6.3, CI 1.4-26.4, p = 0.01) remained independently associated with increased odds of amputation. Over a median follow up of 3.3 years (IQR 2.9-3.6), 21 patients (10%) had post-operative major adverse cardiac events (MACE, defined as myocardial infarction, coronary intervention, or CVA), and 23 patients died (11%). In unadjusted Kaplan Meier analysis, CIA plaque (p = 0.00081) and >75% CIA length calcification (p = 0.0015) were significantly associated with MACE. Plaque burden in the EIA is associated with increased need for intra-operative arterial reconstruction and post-operative lower extremity amputations, while CIA plaque is associated with post-operative MACE. Assessment of CIA and EIA calcification scores on pre-transplant CT scans in high risk patients may guide operative strategy and perioperative management to improve clinical outcomes.

Long-term Lower Extremity and Cardiovascular Complications after Simultaneous Pancreas-Kidney Transplant.

Lower extremity (LE) vascular disease and adverse cardiovascular events (ACEs) cause significant long-term morbidity after simultaneous pancreas-kidney (SPK) transplantation. This study's purpose was to describe the incidence of, and risk factors associated with, LE vascular complications and related ACEs following SPK. All SPKs performed at the authors' institution from 2000 to 2019 were retrospectively analyzed. The primary outcome was any LE vascular event, defined as LE endovascular intervention, open surgery, amputation, or invasive podiatry intervention. Secondary outcomes included post-SPK ACE. A total of 363 patients were included, of whom 54 (14.9%) required at least one LE vascular intervention following SPK. Only 3 patients received pre-SPK ankle brachial indices (ABIs). A history of peripheral artery disease (PAD) (HR 2.95, CI 1.4-6.2) was a risk factor for post-SPK LE vascular intervention even after adjustment for other factors. Fifty-nine (16.3%) patients experienced an ACE in follow-up. Requiring a LE intervention post-SPK was associated with a subsequent ACE (HR 2.3, CI 1.2-4.5). LE vascular and cardiovascular complications continue to be significant sources of morbidity for SPK patients, especially for patients with preexisting PAD. The highest risk patients may benefit from more intensive pre- and post-SPK workup with ABIs and follow-up with a vascular surgeon.

Retransplantation After Living Donor Liver Transplantation: Data from the Adult to Adult Living Donor Liver Transplantation Study.

BACKGROUND: The use of living donor liver transplantation (LDLT) for primary liver transplantation (LT) may quell concerns about allocating deceased donor organs if the need for retransplantation (re-LT) arises because the primary LT did not draw from the limited organ pool. However, outcomes of re-LT after LDLT are poorly studied. The purpose of this study was to analyze the Adult to Adult Living Donor Liver Transplantation Study (A2ALL) data to report outcomes of re-LT after LDLT, with a focus on long-term survival after re-LT. METHODS: A retrospective review of A2ALL data collected between 1998 and 2014 was performed. Patients were excluded if they received a deceased donor LT. Demographic data, postoperative outcomes and complications, graft and patient survival, and predictors of re-LT and patient survival were assessed. RESULTS: Of the 1065 patients who underwent LDLT during the study time period, 110 recipients (10.3%) required re-LT. In multivariable analyses, hepatitis C virus, longer length of stay at LDLT, hepatic artery thrombosis, biliary stricture, infection, and disease recurrence were associated with an increased risk of re-LT. Patient survival among re-LT patients was significantly inferior to those who underwent primary transplant only at 1 (86% versus 92%), 5 (64% versus 82%), and 10 years (44% versus 68%). CONCLUSIONS: Approximately 10% of A2ALL patients who underwent primary LDLT required re-LT. Compared with patients who underwent primary LT, survival among re-LT recipients was worse at 1, 5, and 10 years after LT, and re-LT was associated with a significantly increased risk of death in multivariable modeling (hazard ratios, 2.29; P < 0.001).

Live Donor Liver Transplantation in the United States: Impact of Share 35 on Live Donor Utilization.

BACKGROUND: Share 35 was a policy implemented in 2013 to increase regional sharing of deceased donor livers to patients with model for end-stage liver disease ≥ 35 to decrease waitlist mortality for the sickest patients awaiting liver transplantation (LT). The purpose of this study was to determine whether live donor liver transplantation (LDLT) volume was impacted by the shift in allocation of deceased donor livers to patients with higher model for end-stage liver disease scores. METHODS: Using Network for Organ Sharing/Organ Procurement and Transplantation Network Standard Transplant Analysis and Research files, we identified all adults who received a primary LT between October 1, 2008, and March 31, 2018. LT from October 1, 2008, through June 30, 2013, was designated as the pre-Share 35 era and July 1, 2013, through March 31, 2018, as the post-Share 35 era. Primary outcomes included transplant volumes, graft survival, and patient survival in both eras. RESULTS: In total, 48 779 primary adult single-organ LT occurred during the study period (22 255 pre-Share 35, 26 524 post). LDLT increased significantly (6.8% post versus 5.7% pre, P < 0.001). LDLT volume varied significantly by region (P < 0.001) with regions 2, 4, 5, and 8 demonstrating significant increases in LDLT volume post-Share 35. The number of centers performing LDLT increased only in regions 4, 6, and 11. Throughout the 2 eras, there was no difference in graft or patient survival for LDLT recipients. CONCLUSIONS: Overall, LDLT volume increased following the implementation of Share 35, which was largely due to increased LDLT volume at centers with experience in LDLT, and corresponded to significant geographic variation in LDLT utilization.

Dimerization and structure formation of colloids via capillarity at curved fluid interfaces.

Capillary interactions are ubiquitous between colloids trapped at fluid interfaces. Generally, colloids in fluid interfaces have pinned, undulated contact lines that distort the interface around them. To minimize the area, and therefore the energy of these distortions, colloids interact and assemble in a manner that depends on the shape of the host interface. On curved interfaces, capillary interactions direct isolated colloid motion along deviatoric curvature gradients. This directed motion relies on the leading order, long-ranged quadrupolar distortions made by the colloids' undulated pinned contact lines. Here we study pair interactions and dimer formation of colloids on non-uniformly curved fluid interfaces. Pair interaction energies are inferred to be order of 104kBT, and interacting forces are of order 10-1 pN for 10 micron particles adsorbed on interfaces formed around a 250 micron micropost. We compare experiments to analysis for the pair interaction energy, and identify criteria for dimers to form. We also study the formation of trapped structures by multiple particles to discern the influence of the underlying interface shape and the contact line undulations. By comparison to Monte Carlo simulations with potentials of interactions based on analysis, we find that higher order terms in the distortion fields generated by the particles play a major role in the structure formation on the curved interface. These interactions are determined by the particle's contact line and the host interface shape, and can be used to assemble particles independent of their material properties.

Transformation of Australian Community Pharmacies Into Good Clinical Practice Compliant Trial Pharmacies for HIV Pre-Exposure Prophylaxis.

Background: In Australia, clinical trial drugs are conventionally dispensed through clinical trial pharmacies only, while community pharmacies dispense drugs approved by Australia's regulatory body. A large HIV pre-exposure prophylaxis study aimed to deliver clinical trial drug through community pharmacies to improve convenience and mimic real world prescribing. This paper describes the process of making community trials compliant with good clinical practice and reports outcomes of delivering clinical trial drug through community pharmacies. Methods: Eight community and four clinical trial pharmacies across three Australian states were approached to participate. A good clinical practice checklist was generated and pharmacies underwent a number of changes to meet clinical trial pharmacy requirements prior to study opening. Changes were made to community pharmacies to make them compliant with good clinical trial practice including; staff training, structural changes, and implementing monitoring of study drug and prescribing practices. Study drug was ordered through standard clinical trial processes and dispensed from study pharmacies by accredited pharmacists. Throughout the trial, record logs for training, prescriber signature and delegation, temperature, participant, and drug accountability were maintained at each pharmacy. The study team monitored each log and delivered on-site training to correct protocol variations. Results: Each pharmacy that was approached agreed to participate. All community pharmacies achieved good clinical practice compliance prior to dispensing study drug. Over the course of the study, 20,152 dispensations of study drug occurred, 83% of these occurred at community pharmacies. Only 2.0% of dispensations had an error, and errors were predominantly minor. On five occasions a pharmacist who was not accredited dispensed study drug. Conclusions: Community based pharmacies can undergo training and modifications to achieve good clinical practice compliance and dispense clinical trial study drug. Community based pharmacies recorded few variations from study protocol. Community based pharmacies offer a useful alternative to clinical trial pharmacies to increase convenience for study participants and expanded use of these pharmacies should be considered for large clinical trials, including HIV prevention trials.