Current Outcomes Following Upper and Lower Extremity Arterial Trauma from the National Trauma Data Bank.

OBJECTIVE: The modern treatments of trauma have changed in recent years. We aim to evaluate the factors associated with limb salvage and mortality after extremity arterial trauma, especially with respect to the type of conduit utilized in revascularization. METHODS: The National Trauma Data Bank was queried to identify patients with upper and lower extremity (UE and LE) arterial injuries between 2016 - 2020. The patients were stratified by the types of arterial repair. The primary outcome was in-hospital mortality. RESULTS: 8,780 patients were found with 5,054 (58%) UE and 3,726 (42%) LE injuries. Eighty-three percent were men, and the mean age was 34 ± 15 years. Penetrating mechanism was the predominant mode of injury in both UEs and LEs (73% and 67%, respectively) with a mean injury severity score (ISS) of 14 ± 8. For UEs, the majority underwent primary repair (67%, p<0.001), while the remainder received either a bypass (20%) or interposition graft (12%). However, LEs were more likely to receive a bypass (52%, p<0.00001) than primary repair or interposition graft (34% and 14%, respectively). Compared to the extremely low rates of amputation and mortality among UE patients (2% for both), LE injuries were more likely to result in both amputation (10%, p<0.001) and death (6%, p<0.001). Notably, compared to primary repair, use of a prosthetic conduit was associated with a 6.7-fold increase in risk of amputation in UE and 2.4-fold increase in LE (p<0.0001 for both). Synthetic bypasses were associated with a nearly 3-fold increase in return to the OR in UE bypasses (p<0.05) and a 2.4-fold increase in return to the OR in LE bypasses (p<0.0001). CONCLUSIONS: In recent years, most extremity vascular trauma was due to penetrating injury with a substantial burden of morbidity and mortality. However, both limb salvage rates and survival rates have remained high. Overall, LE injuries more often led to amputation and mortality than UE injuries. The most frequently used bypass conduit was vein, which was associated with less risk of unplanned return to the OR and limb loss, corroborating current practice guidelines for extremity arterial trauma.

5-year Outcomes of Fenestrated and Branched Endovascular Repair of Complex Aortic Aneurysms Based on Aneurysm Extent.

OBJECTIVES: To evaluate the 5-year outcomes of fenestrated/branched endovascular aortic repair (F/BEVAR) for the treatment of complex aortic aneurysms stratified by the aneurysm extent. METHODS: Patients with the diagnosis of complex aortic aneurysm, who underwent F/BEVAR at a single center were included in this study and retrospectively analyzed. The cohort was divided according to the aneurysm extent, comparing group 1 (types I-III thoracoabdominal aneurysms-TAAA), group 2 (type IV TAAA), and group 3 (juxtarenal, pararenal, or paravisceral aortic aneurysms - JRAA, PRAA, PVAA). The primary endpoints were 30-day and 5-year survival. The secondary endpoints were technical success, occurrence of spinal cord ischemia, primary patency of the visceral arteries, freedom from target vessel instability, and secondary interventions. RESULTS: Of 436 patients who underwent F/BEVAR between July 2012 and May 2023, 131 presented with types I-III TAAA, 69 with type IV TAAA, and 236 with JRAA, PRAA, or PVAA. All cases were treated under a physician-sponsored IDE protocol with a patient-specific company-manufactured or off-the-shelf device. Group 1 had significantly younger patients than group 2 or 3 respectively (69.6 ± 8.7 vs 72.4 ± 7.1 vs 73.2 ± 7.3, P < .001) and had a higher percentage of females (50.4% vs 21.7% vs 17.8%, P < .001). Prior history of aortic dissection was significantly more common among patients in group 1 (26% vs 1.4% vs 0.9%, P < .001), and mean aneurysm diameter was larger in group 1 (64.5 vs 60.7 vs 63.2 mm, P = .033). Comorbidities were similar between groups, except for coronary artery disease (P < .001) and tobacco use (P = .003), which were less prevalent in group 1. Technical success was similar in the three groups (98.5% vs 98.6% vs 98.7%, P > .99). The 30-day mortality was 4.5%, 1.4%, and 0.4%, in groups 1, 2, and 3, respectively, and was significantly higher in group 1 when compared to group 3 (P = .01). The incidence of spinal cord ischemia was significantly higher in group 1 compared to group 3 (5.3 vs 4.3% vs .4%, P = .004). The 5-year survival was significantly higher in group 3 when compared to group 1 (P = .01). Freedom from secondary intervention was significantly higher in group 3 when compared to group 1 (P = .003). At 5 years, there was no significant difference in freedom from target vessel instability between groups or primary patency in the 1652 target vessels examined. CONCLUSIONS: Larger aneurysm extent was associated with lower 5-year survival, higher 30-day mortality, incidence of secondary interventions, and spinal cord ischemia. The prevalence of secondary interventions in all groups make meticulous follow-up paramount in complex aortic aneurysm patients treated with F/BEVAR.

Plasma-Induced Changes in the Metabolome Following Vistula Tart Cherry Consumption.

Evidence suggests that tart cherry (TC) supplementation has beneficial effects on health indices and recovery following strenuous exercise. However, little is known about the mechanisms and how TC might modulate the human metabolome. The aim of this study was to evaluate the influence of an acute high- and low-dose of Vistula TC supplementation on the metabolomic profile in humans. In a randomised, double-blind, placebo controlled, cross-over design, 12 healthy participants (nine male and three female; mean ± SD age, stature, and mass were 29 ± 7 years old, 1.75 ± 0.1 m, and 77.3 ± 10.5 kg, respectively) visited the laboratory on three separate occasions (high dose; HI, low dose; LO, or placebo), separated by at least seven days. After an overnight fast, a baseline venous blood sample was taken, followed by consumption of a standardised breakfast and dose conditions (HI, LO, or placebo). Subsequent blood draws were taken 1, 2, 3, 5, and 8 h post consumption. Following sample preparation, an untargeted metabolomics approach was adopted, and the extracts analysed by LCMS/MS. When all time points were collated, a principal component analysis showed a significant difference between the conditions (p < 0.05), such that the placebo trial had homogeneity, and HI showed greater heterogeneity. In a sub-group analysis, cyanidine-3-O-glucoside (C3G), cyanidine-3-O-rutinoside (C3R), and vanillic acid (VA) were detected in plasma and showed significant differences (p < 0.05) following acute consumption of Vistula TC, compared to the placebo group. These results provide evidence that phenolics are bioavailable in plasma and induce shifts in the metabolome following acute Vistula TC consumption. These data could be used to inform future intervention studies where changes in physiological outcomes could be influenced by metabolomic shifts following acute supplementation.

Development and Internal Validation of Machine Learning Models to Predict Mortality and Disability After Mechanical Thrombectomy for Acute Anterior Circulation Large Vessel Occlusion.

OBJECTIVE: Mechanical thrombectomy (MT) improves outcomes in patients with LVO but many still experience mortality or severe disability. We sought to develop machine learning (ML) models that predict 90-day outcomes after MT for LVO. METHODS: Consecutive patients who underwent MT for LVO between 2015-2021 at a Comprehensive Stroke Center were reviewed. Outcomes included 90-day favorable functional status (mRS 0-2), severe disability (mRS 4-6), and mortality. ML models were trained for each outcome using prethrombectomy data (pre) and with thrombectomy data (post). RESULTS: Three hundred and fifty seven patients met the inclusion criteria. After model screening and hyperparameter tuning the top performing ML model for each outcome and timepoint was random forest (RF). Using only prethrombectomy features, the AUCs for the RFpre models were 0.73 (95% CI 0.62-0.85) for favorable functional status, 0.77 (95% CI 0.65-0.86) for severe disability, and 0.78 (95% CI 0.64-0.88) for mortality. All of these were better than a standard statistical model except for favorable functional status. Each RF model outperformed Pre, SPAN-100, THRIVE, and HIAT scores (P < 0.0001 for all). The most predictive features were premorbid mRS, age, and NIHSS. Incorporating MT data, the AUCs for the RFpost models were 0.80 (95% CI 0.67-0.90) for favorable functional status, 0.82 (95% CI 0.69-0.91) for severe disability, and 0.71 (95% CI 0.55-0.84) for mortality. CONCLUSIONS: RF models accurately predicted 90-day outcomes after MT and performed better than standard statistical and clinical prediction models.

Rare Case of Abdominal Aortic and Multiple Visceral Aneurysms in a Pediatric Patient With PIK3CA Mutation and Vasculitis.

Abdominal aortic aneurysms (AAA) are most commonly observed in elderly male patients and are particularly rare in children. Among the pediatric population, they are usually diagnosed in the context of connective tissue disorders, genetic mutations, or vasculitis. The same is true of visceral arteries aneurysms. This case report describes the staged management of an 11-year-old patient presenting PIK3CA mutation and a 5.8 cm infrarenal AAA associated with bilateral common iliac arteries and multiple visceral aneurysms, the largest observed in the superior mesenteric artery (SMA = 3.2 cm). After careful evaluation, decision was made to first approach the most life-threatening lesion (the infrarenal AAA due to the large diameter) and the remaining aneurysms in secondary procedures, with special attention to the SMA aneurysm. The patient underwent a staged repair, with the first phase consisting of an aortobi-iliac graft with the distal anastomosis made at the left common iliac artery and right external iliac artery. The right hypogastric artery was ligated. The second procedure consisted of SMA aneurysm repair with a plication technique, as 7 branches were visualized coming off the aneurysm sac. Postoperative pathology analysis of the aortic and SMA aneurysms sac revealed vasculitis with a mixed inflammatory pattern and a COL3A1 gene heterozygote variant. He is currently in his 18th month after the last surgical intervention, receiving immunomodulatory therapy, with a planned follow-up by the interdisciplinary team to monitor the medications' side effects and the diameter of the remaining visceral aneurysms.

Atypical presentation of subclavian steal syndrome with left sided sensorineural deafness.

We present a rare manifestation of a common pathology: left sided sensorineural hearing loss secondary to subclavian steal syndrome after thoracic endovascular aortic repair for complicated acute aortic dissection. We describe the vascular physiology that can result in unilateral hearing loss and provide a brief review of subclavian steal syndrome. This case report highlights the importance of avid clinical recognition of an atypical presentation of a common vascular disease.

The optimization of an EV decommissioned battery recycling network: A third-party approach.

In this paper, we solve the urgent problem to construct a recycling network of decommissioned batteries of Electric Vehicles (EVs) and clarify the recycling entities that will be responsible for its reverse logistics (RL) process. We consider the third-party recycling entities to develop a recycling network and conduct a case-study of Xi'an, a key industry of EVs in China to provide a reference for the government and enterprises to develop recycling plans. We scientifically optimize our recycling network, which will have a significant impact on the environmental and economic benefits of electric vehicles (EVs) in Xi'an in the future. Specifically, we consider the costs of transportation, construction, operation, recycling, packaging, and emission, as well as the profits achieved through sales revenue and subsidy offerings. We collect the actual data of potential facility locations in Xi'an, predict the quantity of decommissioned batteries in the future, and develop a fuzzy-based model to solve the optimal results of battery traveling path and distribution in the recycling process network. Our results show that with the rapid growth of the number of decommissioned batteries, third-party revenues will reach about 53.08 billion by 2035. When the facilities split the recycling process load appropriately, the network has increase in revenue while the utilization rate of facilities will decrease. We expect that splitting will be a major trend in the future development of recycling network in Xi'an. Finally, a sensitivity analysis finds that with the environmentally conscious and safe operation of recycling, the negative impact on the third-party enterprises' revenue will be small. Our proposed methodology can serve as a critical framework for other cities and governments to plan their recycling networks and formulate regulations, reflecting on the realistic projection of the scale of decommissioned batteries of EVs and the potential siting and sizing of the recycling facilities.

Differential impact of missed initial wound clinic visit on 6-month wound healing by race/ethnicity among patients with chronic limb-threatening ischemia.

Chronic limb-threatening ischemia (CLTI) is associated with significant morbidity, including major limb amputation, and mortality. Healing ischemic wounds is necessary to optimise vascular outcomes and can be facilitated by dedicated appointments at a wound clinic. This study aimed to estimate the association between successful wound care initiation and 6-month wound healing, with specific attention to differences by race/ethnicity. This retrospective study included 398 patients with CLTI and at least one ischaemic wound who scheduled an appointment at our wound clinic between January 2015 and July 2020. The exposure was the completion status of patients' first scheduled wound care appointment (complete/not complete) and the primary outcome was 6-month wound healing (healed/not healed). The analysis focused on how this association was modified by race/ethnicity. We used Aalen-Johansen estimators to produce cumulative incidence curves and calculated risk ratios within strata of race/ethnicity. The final adjustment set included age, revascularization, and initial wound size. Patients had a mean age of 67 ± 14 years, were 41% female, 46% non-White and had 517 total wounds. In the overall cohort, 70% of patients completed their first visit and 34% of wounds healed within 6-months. There was no significant difference in 6-month healing based on first visit completion status for White/non-Hispanic individuals (RR [95% CI] = 1.18 [0.91, 1.45]; p-value = 0.130), while non-White individuals were roughly 3 times more likely to heal their wounds if they completed their first appointment (RR [95% CI] = 2.89 [2.66, 3.11]; p-value < 0.001). In conclusion, non-White patients were approximately three times more likely to heal their wound in 6 months if they completed their first scheduled wound care appointment while White/non-Hispanic individuals' risk of healing was similar regardless of first visit completion status. Future efforts should focus on providing additional resources to ensure minority groups with wounds have the support they need to access and successfully initiate wound care.

The Influence of Body Mass Index on Outcomes in Patients Undergoing Mechanical Thrombectomy for Anterior Circulation Large Vessel Occlusion: Institutional Experience and Meta-analysis.

BACKGROUND: An obesity paradox, whereby patients with higher body mass index (BMI) experience improved outcomes, has been described for ischemic stroke. It is unclear whether this applies to patients undergoing mechanical thrombectomy (MT) for large vessel occlusion (LVO). METHODS: Mechanical thrombectomies for anterior circulation LVO between 2015 and 2021 at a single institution were reviewed. Multivariable logistic regressions were used to determine the association between BMI and favorable functional outcome (90-day modified Rankin Scale 0-2), intracranial hemorrhage, and malignant middle cerebral infarction. A systematic review was performed to identify studies reporting the effect of BMI on outcomes among patients receiving MT for LVO. The data from the systematic review were combined with the institutional data by using a random effects model. RESULTS: The institutional cohort comprised 390 patients with a median BMI of 27 kg/m2. Most patients were obese [36.7% (BMI ≥ 30 kg/m2)], followed by overweight [30.5% (BMI ≥ 25 and < 30 kg/m2)], normal [27.9% (BMI ≥ 18.5 and < 25 kg/m2)], and underweight [4.9% (BMI < 18.5 kg/m2)]. As a continuous variable, BMI was not associated with any of the outcomes. When analyzing BMI ordinally, obesity was associated with lower odds of favorable 90-day modified Rankin Scale (odds ratio 0.42, 95% confidence interval 0.20-0.86). The systematic review identified three eligible studies comprising 1,348 patients for a total of 1,738 patients. In the random effects model, there was no association between obesity and favorable outcome (odds ratio 0.89, 95% confidence interval 0.63-1.24). CONCLUSIONS: Obesity is not associated with favorable outcomes in patients undergoing MT for LVO.

Gender disparities in patients with aortoiliac disease requiring open operative intervention.

OBJECTIVE: Peripheral artery disease is known to affect males and females in different proportions. Disparate surgical outcomes have been quantified after endovascular aortic aneurysm repair, arteriovenous fistula creation, and treatment of critical limb ischemia. The aim of this study is to objectively quantify the sex differences in outcomes in patients undergoing open surgical intervention for aortoiliac occlusive disease. METHODS: Patients were identified in the aortoiliac occlusive disease Vascular Quality Initiative database who underwent aorto-bifemoral bypass or aortic thromboendarterectomy as determined by Current Procedural Terminology codes between 2012 and 2019. Patients with a minimum of 1-year follow-up were included. Risk differences (RDs) by sex were calculated using a binomial regression model in 30-day and 1-year incidence of mortality and limb salvage. Additionally, incidence of surgical complications including prolonged length of stay (>10 days), reoperation, and change in renal function (>0.5 mg/dl rise from baseline), were recorded. Inverse probability weighting was used to standardize demographic and medical history characteristics. Multivariate logistic regression models were employed to conduct analyses of the before mentioned clinical outcomes, controlling for known confounders. RESULTS: Of 16,218 eligible patients from the VQI data during the study period, 6538 (40.3%) were female. The mean age, body mass index, and race were not statistically different between sexes. Although there was no statistically significant difference detected in mortality between males and females at 30 days postoperatively, females had an increased crude 1-year mortality with an RD of 0.014 (95% confidence interval, 0.01-0.02; P value < .001. Males had a higher rate of a postoperative change in renal function with an RD of -0.02 (95% confidence interval, -0.03 to -0.01; P < .001). CONCLUSIONS: Although there was no sex-based mortality difference at 30 days, there was a statistically significant increase in mortality in females after open aortoiliac intervention at 1 year based on our weighted model. Male patients are statistically significantly more likely to have a decline in renal function after their procedures when compared with females. Postoperative complications including prolonged hospital stay, reoperation, and wound disruption were similar among the sexes, as was limb preservation rates at 1 year. Further studies should focus on elucidating the underlying factors contributing to sex-based differences in clinical outcomes following aortoiliac interventions.

The influence of pre-reperfusion blood pressure on outcomes following mechanical thrombectomy for anterior circulation large vessel occlusion.

BACKGROUND: We evaluated how systolic blood pressure (SBP) and mean arterial pressure (MAP) parameters between presentation and reperfusion influence functional status and intracranial hemorrhage (ICH). METHODS: All patients who underwent MT for LVO at a single institution were reviewed. Independent variables included SBP and MAP measurements obtained on presentation, between presentation and reperfusion (pre-reperfusion), and between groin puncture and reperfusion (thrombectomy). Mean, minimum, maximum, and standard deviations (SD) for SBP and MAP were calculated. Outcomes included 90-day favorable functional status, radiographic ICH (rICH), and symptomatic ICH (sICH). RESULTS: 305 patients were included. Higher pre-reperfusion SBPmax was associated with rICH (OR 1.41, 95% CI 1.08-1.85) and sICH (OR 1.84, 95% CI 1.26-2.72). Higher SBPSD was also associated with rICH (OR 1.38, 95% CI 1.06-1.81) and sICH (OR 1.59, 95% CI 1.12-2.26). Greater SBPmax (OR 0.64, 95% CI 0.47-0.86), MAPmax (OR 0.72, 95% CI 0.52-0.97), SBPSD (OR 0.63, 95% CI 0.46-0.86), and MAPSD (0.63, 95% CI 0.45-0.84) during thrombectomy were associated with lower odds of 90-day favorable functional status. In a subgroup analysis, these associations were primarily limited to patients with intact collateral circulation. Optimal SBPmax cutoffs for predicting rICH were 171 (pre-reperfusion) and 179 mmHg (thrombectomy). Cutoffs for predicting sICH were 178 (pre-reperfusion) and 174 mmHg (thrombectomy). CONCLUSION: Greater maximum BP and variability in BP during the pre-reperfusion period are associated with unfavorable functional status and ICH after MT for anterior circulation LVO.

Outcome Analysis Comparing Asymptomatic Juxtarenal Aortic Aneurysms Treated with Custom-Manufactured Fenestrated-Branched Devices and the "Off-The-Shelf" Zenith p-Branch Device.

BACKGROUND: Numerous endovascular options have been used for the repair of juxtarenal aortic aneurysms (JRAAs) over the last 15 years. This study aims to compare the performance between the Zenith p-branch device and custom-manufactured fenestrated-branched devices (CMD) for the treatment of asymptomatic JRAA. METHODS: A single-center retrospective analysis of prospectively collected data was performed. Patients with a diagnosis of JRAA submitted to endovascular repair between July 2012 and November 2021 were included in the study, being divided into 2 groups: CMD and Zenith p-branch. The following variables were analyzed: preoperative information: demographics, comorbidities, and maximum aneurysm diameter; procedural data: contrast volume, fluoroscopy time, radiation dose, estimated blood loss, and technical success; and postoperative data: 30-day mortality, duration of intensive care unit and hospital stay, major adverse events, secondary interventions, target vessel instability, and long-term survival. RESULTS: From a total of 373 physician-sponsored investigational device exemption (Cook Medical devices) cases performed at our institution, 102 patients presented the diagnosis of JRAA. Of these, 14 patients were treated with the p-branch device (13.7%) and 88 (86.3%) with a CMD. Both groups presented similar demographic composition and maximum aneurysm diameter. All devices were successfully deployed, with no type I or III endoleaks observed at procedure completion. The contrast volume (P = 0.023) and radiation dose (P = 0.001) were significantly higher in the p-branch group. No significant difference was observed between the groups for the remaining intraoperative data. No paraplegia or ischemic colitis has been observed during the first 30 days after the surgical procedures. There was no 30-day mortality in either group. One major cardiac adverse event was registered in the CMD group. Early outcomes were similar in both groups. No significant difference was found between the groups with respect to the presence of type I or III endoleaks during the follow-up. From a total of 313 target vessels stented in the CMD group (mean of 3.55 per patient) and 56 in the p-branch group (mean of 4 per patient), 4.79% and 5.35% presented instability, respectively, with no difference observed between the groups (P = 0.743). Secondary interventions were required in 36.4% of the CMD cases and 50% of the p-branch group, but this was not statistically different (P = 0.382). In the p-branch cohort, 2 of 7 reinterventions (28.5%) were target vessel-related and in the CMD group, 10 of 32 secondary interventions (31.2%) were target vessel-related. CONCLUSIONS: Comparable perioperative outcomes were obtained when appropriately selected patients were treated with either the off-the-shelf p-branch or CMD for JRAA. The long-term target vessel instability does not appear impacted by the presence of pivot fenestrations in comparison to other target vessel configurations. Given these outcomes, delay in CMD production time should be considered when treating patients with large juxtarenal aneurysms.

Back Pain According to Roland-Morris Low Back Pain Scale After Abdominoplasty With Plication: A Prospective Case Series.

INTRODUCTION: Chronic back pain is a physically debilitating condition that affects more than 80% of adults in the United States. A recent case series highlighted how abdominoplasty with plication can offer an alternative surgical approach for treating chronic back pain. These results have been corroborated by a large prospective series. However, this study excluded male and nulliparous subjects, who may also benefit from this surgery. Our group aims to investigate the effect of abdominoplasty on back pain in a more diverse patient population. METHODS: Subjects older than 18 years undergoing abdominoplasty with plication were recruited. An initial survey called the Roland-Morris Disability Questionnaire (RMQ) was administered at the preoperative visit. This questionnaire inquiries about and grades the patient's history of back pain and surgery. Demographic, medical, and social history was also obtained. A follow-up survey and RMQ was then given 6 months after surgery. RESULTS: Thirty subjects were enrolled. Subjects had a mean age of 43.4 ± 14.3 years. Twenty-eight subjects were female and 26 were postpartum. Twenty-one subjects reported initial back pain on the RMQ scale. Of these, 19 reported a decrease in RMQ score after surgery, including male and nulliparous subjects. A significant decrease in mean RMQ score was demonstrated 6 months after surgery (2.94-0.44, P < 0.001). Further subgroup analysis of female subjects demonstrated significantly decreased final RMQ score in parous women, vaginal or cesarean section delivery, and absence of twin gestation. CONCLUSIONS: Abdominoplasty with plication significantly decreases self-reported back pain 6 months after surgery. These results support that abdominoplasty is not purely a cosmetic procedure but can also be applied therapeutically to improve functional symptoms of back pain.

Machine learning prediction of malignant middle cerebral artery infarction after mechanical thrombectomy for anterior circulation large vessel occlusion.

OBJECTIVE: Prediction of malignant middle cerebral artery infarction (MMI) could identify patients for early intervention. We trained and internally validated a ML model that predicts MMI following mechanical thrombectomy (MT) for ACLVO. METHODS: All patients who underwent MT for ACLVO between 2015 - 2021 at a single institution were reviewed. Data was divided into 80% training and 20% test sets. 10 models were evaluated on the training set. The top 3 models underwent hyperparameter tuning using grid search with nested 5-fold CV to optimize the area under the receiver operating curve (AUROC). Tuned models were evaluated on the test set and compared to logistic regression. RESULTS: A total of 381 patients met the inclusion criteria. There were 50 (13.1%) patients who developed MMI. Out of the 10 ML models screened on the training set, the top 3 performing were neural network (median AUROC 0.78, IQR 0.72 - 0.83), support vector machine ([SVM] median AUROC 0.77, IQR 0.72 - 0.83), and random forest (median AUROC 0.75, IQR 0.68 - 0.81). On the test set, random forest (median AUROC 0.78, IQR 0.73 - 0.83) and neural network (median AUROC 0.78, IQR 0.73 - 0.83) were the top performing models, followed by SVM (median AUROC 0.77, IQR 0.70 - 0.83). These scores were significantly better than those for logistic regression (AUROC 0.72, IQR 0.66 - 0.78), individual risk factors, and the Malignant Brain Edema score (p < 0.001 for all). CONCLUSION: ML models predicted MMI with good discriminative ability. They outperformed standard statistical techniques and individual risk factors.

Outcomes After Endovascular Treatment of Direct Carotid Cavernous Fistulas: Systematic Review and Meta-Analysis.

BACKGROUND: Direct carotid cavernous fistulas (dCCF) involve pathologic shunting from the internal carotid artery into the cavernous sinus. We systematically reviewed the methods and outcomes of endovascular therapy for dCCF. METHODS: PubMed, Scopus, and EMBASE were used to identify studies that reported outcomes for patients undergoing embolization of dCCF. Outcomes included rates of occlusion, complications, symptom improvement, and recurrence. Pooled rates for each outcome were obtained with random effects models. The influence of embolization method on outcomes was assessed with meta-regressions. RESULTS: There were 16 studies comprising 270 patients. The mean age was 39.6 years, there were 36.3% females, and the mean follow-up was 19.7 months. Coils were the most common method of embolization (69.3%), followed by Onyx (31.1%), covered stent (22.2%), N-butyl cyanoacrylate (6.7%), and flow diversion (4.8%). The pooled overall occlusion rate was 92.1% (95% confidence interval [CI], 86.3-95.6; I2 = 29.2%). The pooled complication rate was 10.9% (95% CI, 7.3-16; I2 = 0%). Use of coils were associated with a slightly lower odds of overall complications (odds ratio, 0.98; 95% CI, 0.97-0.99) and cranial nerve palsy (odds ratio, 0.98; 95% CI, 0.97-0.99). The pooled fistula recurrence rate was 8.3% (95% CI, 4.3-15.4; I2 = 30.9%). CONCLUSIONS: Endovascular therapy for dCCF is associated with high occlusion and low complication rates. Recurrence is not uncommon, highlighting the need for close follow-up.

Analysis of wound healing time and wound-free period in patients with chronic limb-threatening ischemia treated with and without revascularization.

BACKGROUND: The traditionally reported outcomes for patients with ischemic wounds have centered on amputation-free survival. However, that discounts the importance of other patient-centered outcomes such as the wound healing time (WHT) and wound-free period (WFP). We evaluated the long-term wound outcomes of patients treated for chronic limb-threatening ischemia at our institution. METHODS: From 2014 to 2017, we identified all patients with chronic limb-threatening ischemia and ischemic wounds using symptomatic and hemodynamic criteria. The primary data included the wound size, wound location, WIfI (wound, ischemia, foot infection) grade, WHT, WFP, minor and major amputation, and death. Wounds were not considered healed if the patient had required a major amputation or had died before wound healing. The WHT was calculated as the interval in days between the diagnosis and determination of a healed wound. The WFP was calculated as the interval in days between a healed wound and wound recurrence, major amputation, death, or the end of the study period. A comparison of the wound healing parameters stratified by revascularization status was performed using the Student t test. A generalized linear model adjusted for age, sex, initial wound size, and WIfI grade was used to evaluate the risk of wound healing with and without revascularization. RESULTS: A total of 256 patients had presented with 372 wounds. Of the 256 patients, 48% had undergone revascularization. During the study period, 97 minor amputations and 100 major amputations had been required, and 132 patients had died. The average wound size was 13.9 ± 52.0 cm2; however, for the 155 wounds that had healed, the average size was only 4.0 ± 9.6 cm2 (P = .002). No differences were found in the wound size when stratified by revascularization status (P = .727). Adjusted for the initial wound size, the risk of wound healing was not different when stratified by revascularization (risk ratio, 1.22; 95% confidence interval, 0.80-1.87; P = .354). For those whose wounds had healed, the average WHT and WFP were 173 ± 169 days and 775 ± 317 days, respectively. The WHT was not faster for the revascularized group (155 days vs 188 days; P = .221). When stratified by revascularization status, the rate of wound recurrence was 4.6 vs 8.9 wounds per 100 person-years for the revascularized and nonrevascularized groups, respectively (P = .125). CONCLUSIONS: In our study, we found that, except for patients who presented with severe ischemia, revascularization was not associated with improved rates of wound healing. Among the wounds that healed, regardless of the initial ischemia grade, revascularization was not associated with a faster WHT or longer WFPs.

Conversion Total Knee Arthroplasty After Tibial Plateau Fixation Is Associated With Lower Reimbursement, Greater Complication Rates, and Similar Opioid Use.

Objective Total knee replacement after previous open reduction and internal fixation for tibial plateau fracture (conversion total knee) increases the complexity of the procedure and the complication rate. However, very little research exists to report on opioid use and cost associated with total knee arthroplasty (TKA) following tibial plateau fracture fixation as compared to primary TKA patients with no history of tibial plateau fracture. The aim of this study is to compare the differences in opioid use, reimbursements, and complication rates between patients with and without a history of tibial plateau fracture undergoing TKA. Methods and materials This is a retrospective large database review study. The study included patients across the country and in various clinical settings including, but not limited to, institutions, primary and tertiary care centers, and private practice. The PearlDiver database was reviewed for patients undergoing TKA between 2010 and 2019. Patients who underwent TKA following surgical repair of a tibial plateau fracture were identified using Common Procedural Terminology (CPT) codes and the appropriate International Classification of Diseases Ninth and Tenth Revision (ICD-9, ICD-10) codes. This group was then matched by age, gender, Charleston Comorbidity Index (CCI) score, Elixhauser Comorbidity Index (ECI) score, obesity, tobacco use, and diabetes to a group of similar patients who underwent TKA with no history of tibial plateau fracture. Opioid use over the episode of care, evaluated by morphine milligram equivalents (MME), and 30-day reimbursed cost were compared between groups using an unequal variance t-test. Complication rates at 30 days, 90 days, and one year postoperatively, and revision rates at one and two years postoperatively were compared using the odd's ratio (OR) with 95% confidence intervals (95%CI). Results The episode of care cost for TKA was significantly lower for patients with a history of tibial plateau fracture ($11,615 ± $15,704) than it was for patients without a history of tibial plateau fracture ($16,088 ± $18,573) (p = 3.56E-14). At 30 days after knee arthroplasty, patients with a history of tibial plateau fracture had significantly more episodes of dehiscence (OR 2.665 [95% CI 1.327-5.351]; p = 0.006) and surgical site infection (SSI) (OR 1.698 [95% CI 1.058-2.724]; p = 0.028), which was significant at 90 days postop for both dehiscence (OR 1.358 [95% CI 0.723-2.551]; p = 0.001) and SSI (OR 1.634 [95% CI 1.100-1.802]; p = 0.015), as well as mechanical complications of the implant device (OR 2.420 [95% CI 1.154-5.076]; p = 0.019). There was no significant difference in the number of opioids prescribed postoperatively to patients with a history of tibial plateau fracture (2218 ± 3255 MME) compared to those without prior tibial plateau fracture (2400 ± 4843 MME) (p = 0.258). However, there was a small but statistically significant increase in the number of days postoperatively patients with a history of tibial plateau fracture were prescribed opioids (11.99 ± 7.73 days) compared to non-tibial plateau fracture patients (11.15 ± 7.18 days) (p = 0.004). Conclusion Patients with a history of tibial plateau fracture who then underwent conversion TKA have a lower reimbursed cost of TKA but a higher postoperative risk for dehiscence, mechanical complications, and surgical site infections. There is no significant difference in postoperative opioid use between the two groups.

Gender Disparities in Aortoiliac Revascularization in Patients with Aortoiliac Occlusive Disease.

BACKGROUND: Gender disparities have been previously reported in aortic aneurysm and critical limb ischemia outcomes; however, limited info is known about disparities in aortoiliac occlusive disease. We sought to characterize potential disparities in this specific population. MATERIAL AND METHODS: Patients who underwent aortobifemoral bypass and aortic thromboendarterectomy (Current Procedural Terminology codes 35646 and 35331) between 2012 and 2019 were identified in the National Surgical Quality Improvement Program database. A binomial regression model was used to estimate gender differences in 30-day morbidity and mortality. Inverse probability weighting was used to standardize demographic and surgical characteristics. RESULTS: We identified 1,869 patients, of which 39.8% were female and the median age was 61 years. Age, body composition, and other baseline characteristics were overall similar between genders; however, racial data were missing for 26.1% of patients. Females had a higher prevalence of preexisting chronic obstructive pulmonary disease (20.9% vs. 14.7%, prevalence difference 6.1%, P < 0.01), diabetes mellitus (25.4% vs. 19.4%, prevalence difference 6.0%, P < 0.01), and high-risk anatomical features (39.4% vs. 33.7%, prevalence difference 5.8%, P = 0.01). Preprocedural medications included a statin in only 68.2% of patients and antiplatelet agent in 76.7% of patients. Females also had a higher incidence of bleeding events when compared to males (25.2% vs. 17.5%, standardized risk difference 7.2%, P < 0.01), but were less likely to have a prolonged hospitalization greater than 10 days (18.2% vs. 20.9%, standardized risk difference -5.0%, P = 0.01). The 30-day mortality rate was not significantly different between genders (4.7% vs. 3.6%, standardized risk difference 1.2%, P = 0.25). CONCLUSIONS: Female patients treated with aortobifemoral bypass or aortic thromboendarterectomy are more likely to have preexisting chronic obstructive pulmonary disease, diabetes mellitus, and high-risk anatomical features. Regardless of a patient's gender, there is poor adherence to preoperative medical optimization with both statins and antiplatelet agents. Female patients are more likely to have postoperative bleeding complications while males are more likely to have a prolonged hospital stay greater than 10 days. Future work could attempt to further delineate disparities using databases with longer follow-up data and seek to create protocols for reducing these observed disparities.

The integrated impact of GDP growth, industrialization, energy use, and urbanization on CO2 emissions in developing countries: Evidence from the panel ARDL approach.

Developing economies are an important engine of world economic growth. However, ensuring the quality of environmental assets is maintained amid rapid economic change remains a major challenge for most developing countries. Using the Panel Autoregressive Distributed Lag (ARDL) approach and the heterogeneous causality test, this study analyzes the combined effects of energy usage, industrialization, gross domestic product (GDP) growth, and urbanization on CO2 emissions for 23 developing countries across the 1995 to 2018 period. From our analysis, the long-run results reveal that a 1% increase in energy use, economic growth, industrialization, and urbanization increases CO2 emissions by 0.23%, 0.17%, 0.54%, and 2.32%, respectively. Moreover, our model's short- to long-term equilibriums are adjusted at a yearly rate of 0.19%. Finally, to verify the panel ARDL long-run results, robustness tests were carried out using the Fully Modified Ordinary Least Squares (FMOLS) and Dynamic Ordinary Least Squares (DOLS) approaches. Our results confirm that in the case of developing countries, CO2 emissions are primarily influenced by GDP growth, energy use, industrialization, and urbanization. Furthermore, the panel causality analysis identified a bidirectional causal relationship between energy use, GDP growth, urbanization, industrialization, and CO2 emissions. While these results can play an instrumental role in formulating CO2 emission policies among our selected countries, our research can also assist policy makers and stakeholders in other developing economies implement important policy initiatives. These include, tax incentives and infrastructural developments that nurture environmentally friendly industrialization, deploy low-carbon technologies, promote sustainable forms of urbanization and urban planning, while also facilitating increases in both the investment in and adoption of renewable energy platforms. The establishment of such a comprehensive policy agenda can help emerging economies achieve strong and environmentally sustainable GDP growth over the long-term.

Self-Reported Cannabis Use Is Not Associated With Increased Opioid Use or Costs After Hip Arthroscopy.

PURPOSE: Our purpose is to determine the difference in cost, opioid use, and complication rates following hip arthroscopy with or without perioperative cannabis use. METHODS: Data were collected from a large commercial insurance database (PearlDiver) between the years 2010 and 2019. Patients who underwent hip arthroscopy with reported cannabis use were identified using Common Procedural Terminology codes and the appropriate International Classification of Diseases codes. This group was then matched by age, procedure, gender, Charleston Comorbidity Index, Elixhauser Comorbidity Index), obesity, tobacco use, diabetes to a group of similar patients without self-reported cannabis use. Opioid use over the episode of care, evaluated by morphine milligram equivalents (MME), and 30-day cost were compared between groups using unequal variance t-test. RESULTS: Of queried patients, 360 (.71%) had a diagnosis of preoperative cannabis use, abuse, or dependence within 5 years prior to their hip arthroscopy. A total of 300 patients (172 female, 128 male) were matched into each hip arthroscopy group, with and without cannabis. Of those patients, 171 without cannabis use and 174 with cannabis use had full financial and opioid use data for analysis. Prescription opioid use was not significantly different over the episode of care in patients with reported cannabis use (1,840 ± 2,743 MME) than those without reported cannabis use (2,129 ± 3,383 MME) (P = .3848). Additionally, episode of care reimbursement cost following hip arthroscopy did not differ significantly between patients with cannabis use ($2957 ± $4428) and those without reported cannabis use ($2,651 ± $3,762) (P = .3620). CONCLUSIONS: Following hip arthroscopy, patients with reported cannabis use do not appear to have significantly different postoperative opioid use or cost of hip arthroscopy episode of care compared with patients without reported cannabis use. LEVEL OF EVIDENCE: III, cohort study.