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OBJECTIVE: This study aimed to assess the quality of patient information material regarding elective abdominal aortic aneurysm (AAA) repair on the internet using the Modified Ensuring Quality Information for Patients (MEQIP) tool. METHODS: A qualitative assessment of internet based patient information was performed. The 12 most used search terms relating to AAA repair were identified using Google Trends, with the first 10 pages of websites retrieved for each term searched. Duplicates were removed, and information for patients undergoing elective AAA were selected. Further exclusion criteria were marketing material, academic journals, videos, and non-English language sites. The remaining websites were then MEQIP scored independently by two reviewers, producing a final score by consensus. RESULTS: A total of 1 297 websites were identified, with 235 (18.1%) eligible for analysis. The median MEQIP score was 18 (interquartile range [IQR] 14, 21) out of a possible 36. The highest score was 33. The 99th percentile MEQIP scoring websites scored > 27, with four of these six sites representing online copies of hospital patient information leaflets, however hospital sites overall had lower median MEQIP scores than most other institution types. MEQIP subdomain median scores were: content, 8 (IQR 6, 11); identification, 3 (IQR 1, 3); and structure, 7 (IQR 6, 9). Of the analysed websites, 77.9% originated from the USA (median score 17) and 12.8% originated in the UK (median score 22). Search engine ranking was related to website institution type but had no correlation with MEQIP. CONCLUSION: When assessed by the MEQIP tool, most websites regarding elective AAA repair are of questionable quality. This is in keeping with studies in other surgical and medical fields. Search engine ranking is not a reliable measure of quality of patient information material regarding elective AAA repair. Health practitioners should be aware of this issue as well as the whereabouts of high quality material to which patients can be directed.
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Aneurisma de la Aorta Abdominal , Información de Salud al Consumidor , Procedimientos Quirúrgicos Electivos , Internet , Educación del Paciente como Asunto , Aneurisma de la Aorta Abdominal/cirugía , Humanos , Procedimientos Quirúrgicos Electivos/normas , Educación del Paciente como Asunto/normas , Información de Salud al Consumidor/normas , Procedimientos Quirúrgicos Vasculares/normasRESUMEN
OBJECTIVE: Despite widespread use, long term outcomes for fenestrated endovascular aneurysm repair (FEVAR) are uncertain. This meta-analysis reports long term survival, freedom from re-intervention, target vessel patency, and one year sac regression after FEVAR. DATA SOURCES: Systematic review and meta-analysis to pool time to event data according to PRISMA guidelines. The study was registered with the international prospective register of systematic reviews (PROSPERO) (ID: CRD42023401468). REVIEW METHODS: Medline, Embase, and Cochrane databases were searched from 1992 - 2023; articles were independently screened by two authors. Publication of complete time to event data for any outcome of interest was an inclusion criterion. Raw Kaplan-Meier probabilities were directly extracted from published curves and pooled by random effects. Risk of bias was assessed using ROBINS I and certainty with GRADE. RESULTS: A total of 3 569 records were retrieved, 2 869 screened after duplicate removal, yielding 37 included studies (n = 4 371). The pooled mean age was 73.2 years (interquartile range [IQR] 72.2, 73.7) and 87.4% were male (95% confidence interval [CI] 85.8 - 88.9). Pooled Kaplan-Meier estimated probabilities of survival (n = 34 studies, n = 4 192 patients) at one, three, and five years were 91.6% (95% CI 90.2 - 92.9), 80.8% (95% CI 78.0 - 83.2), and 65.1% (95% CI 60.9 - 69.1). For freedom from re-intervention (n = 24, n = 3 211 patients) at one, three, and five years these were 90.2% (95% CI 87.3 - 92.7), 80.9% (95% CI 76.5 - 84.9), and 73.8% (95% CI 67.1 - 79.6). For target vessel patency (n = 13, n = 5805 target vessels) at one, three, and five years, these were 96.6% (95% CI 94.9 - 98.0), 94.5% (95% CI 91.7 - 96.7), and 93.1% (95% CI 89.3 - 96.0). Pooled estimate of sac regression (n = 8, n = 560) at one year was 40.2% (95% CI 28.9 - 52.7). Risk of bias was judged as moderate in 11 studies and low for the remaining 26. CONCLUSION: There are moderate to low certainty data supporting reasonable long term outcome estimates following fenestrated endovascular aneurysm repair. Beyond five years there is a lack of data in the literature.
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Aneurisma de la Aorta Abdominal , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Humanos , Masculino , Anciano , Femenino , Prótesis Vascular , Reparación Endovascular de Aneurismas , Implantación de Prótesis Vascular/efectos adversos , Aneurisma de la Aorta Abdominal/cirugía , Factores de Riesgo , Resultado del Tratamiento , Procedimientos Endovasculares/efectos adversos , Complicaciones Posoperatorias/cirugía , Diseño de PrótesisRESUMEN
OBJECTIVE: This study aimed to construct a decision aid to estimate the likelihood of independence with a prosthesis following rehabilitation for limb loss secondary to advanced ischaemia (acute or chronic limb threatening ischaemia) or diabetic foot disease (DFD). A secondary aim was to determine whether prosthetic independence is a surrogate marker of long term survival. METHODS: A retrospective cohort study of a prospectively maintained database of unilateral amputations due to ischaemia or DFD entering rehabilitation between 2007 and 2020 was performed. Predictors of independent prosthetic mobility (IPM) were used in construction of the IPM prediction model, which underwent bootstrap internal and criterion validation through correlation with predictors of other measures of function: Timed Up and Go (TUG) and two minute walk test. Kaplan-Meier and Cox regression analyses were performed to address the secondary aim. RESULTS: Of the 771 patients included, only 49.9% of amputees achieved IPM. Independent negative predictors of IPM were age > 75 years, female sex, higher amputation level, active malignancy, cerebrovascular disease, end stage renal disease, and cognitive impairment. The model yielded high discrimination (C statistic 0.778), and internal validation was demonstrated with bootstrapping (C statistic 0.778), confirming no over optimism. There was a strong correlation between IPM, TUG, and two minute distance and their predictors, confirming strong criterion validity. The IPM group had a median survival of 93.7 (80.7, 105) months, whereas the non-IPM group fared worse with a median survival of 56.6 (48.5, 66.7) months (p < .001). CONCLUSION: An internally validated decision aid for estimating the likelihood of independence with a prosthesis after major amputation was constructed. A strong association between female sex and poorer prosthetic mobility was observed. Prosthetic function was shown to be a surrogate marker of long term survival. Future research will involve external validation studies to confirm the generalisability of the decision aid in clinical practice.
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Amputación Quirúrgica , Alta del Paciente , Humanos , Femenino , Anciano , Estudios Retrospectivos , Amputación Quirúrgica/efectos adversos , Procedimientos Quirúrgicos Vasculares , Biomarcadores , Isquemia , Extremidad Inferior/cirugíaRESUMEN
AIM: The aim of this study was to determine if there is an association between statin-use and prosthetic mobility and long-term survival in patients receiving rehabilitation after major amputation for lower limb arterial disease. METHODS: A retrospective analysis of prospectively maintained data (2008-2020) from a centre for rehabilitation was performed. Patients were grouped by statin-use status and sub-grouped by the combination of statin and antithrombotic drugs (antiplatelets or anticoagulants). Outcomes were prosthetic mobility (SIGAM score, timed-up-go and 2-min walking distance) and long-term survival. Regression, Kaplan-Meier and Cox-proportional hazard analyses were performed to test associations adjusted to confounders. RESULTS: Of 771 patients, 499 (64.7%) were on a statin before amputation or prescribed a statin peri-operatively. Rate of statin-use was significantly lower among female (53.3%) compared to male (68.2%) patients, P < 0.001. Statin-use was associated with significantly better prosthetic independence (53.1% vs 44.1%, P = 0.017), timed-up-go (mean difference of 4 s, P = 0.04) and long-term survival HR 0.59 (0.48-0.72, P < 0.001). Significance persisted after adjusting for confounding factors and in subgroup analyses. The combination of statin with antiplatelet was associated with the most superior survival, HR 0.51 (0.40-0.65, P < 0.001). Sensitivity analysis (exclusion of non-users of prosthesis) showed that statin-use remained a significant indicator of longer survival, maximally when combined with antiplatelet use HR 0.52 (0.39-0.68, P < 0.001). CONCLUSIONS: Statin-use is associated with better mobility and long-term survival in rehabilitees after limb loss, particularly when used in combination with antiplatelets. Significantly lower rates of statin-use were observed in female patients. Further research is warranted on gender disparities in statin-use and causality in their association with improved mobility and survival.
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We show that the wide-band gap compound semiconductors ZnO, ZnS, and CdS feature large photoplastic and photoelastic effects that are mediated by point defects. We measure the mechanical properties of ceramics and single crystals using nanoindentation, and we find that elasticity and plasticity vary strongly with moderate illumination. For instance, the elastic stiffness of ZnO can increase by greater than 40% due to blue illumination of intensity 1.4 mW/cm^{2}. Above-band-gap illumination (e.g., uv light) has the strongest effect, and the relative effect of subband gap illumination varies between samples-a clear sign of defect-mediated processes. We show giant optomechanical effects can be tuned by materials processing, and that processing dependence can be understood within a framework of point defect equilibrium. The photoplastic effect can be understood by a long-established theory of charged dislocation motion. The photoelastic effect requires a new theoretical framework which we present using density functional theory to study the effect of point defect ionization on local lattice structure and elastic tensors. Our results update the longstanding but lesser-studied field of semiconductor optomechanics, and suggest interesting applications.
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Aneurisma de la Aorta Abdominal , Endofuga , Procedimientos Endovasculares , Tomografía Computarizada por Rayos X , Humanos , Aneurisma de la Aorta Abdominal/cirugía , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/métodos , Endofuga/diagnóstico por imagen , Endofuga/etiología , Tomografía Computarizada por Rayos X/métodos , RadiómicaAsunto(s)
Enfermedades de la Aorta , Humanos , Enfermedades de la Aorta/cirugía , Enfermedades de la Aorta/diagnóstico por imagen , Enfermedades de la Aorta/terapia , Procedimientos Quirúrgicos Vasculares , Servicios Centralizados de Hospital/organización & administración , Procedimientos EndovascularesRESUMEN
Deterioration in renal function has been described after endovascular repair of abdominal aortic aneurysms (EVRs). The etiology is multifactorial and represents an important therapeutic target. A need exists to quantitatively summarize incidence and severity of renal dysfunction after EVR to allow better-informed attempts to preserve renal function and improve life expectancy. Here a systematic search was performed using Medline and Embase for renal function after EVR applying PRISMA statements. Univariate and multivariate random-effects meta-analyses were performed to estimate pooled postoperative changes in serum creatinine and creatinine clearance at four time points after EVR. Clinically relevant deterioration in renal function was also estimated at 1 year or more after EVR. Pooled probability of clinically relevant deterioration in renal function at 1 year or more was 18% (95% confidence interval of 14-23%, I2 of 82.5%). Serum creatinine increased after EVR by 0.05 mg/dl at 30 days/1 month, 0.09 mg/dl at 1 month to 1 year, and 0.11 mg/dl at 1 year or more (all significant). Creatinine clearance decreased after EVR by 5.65 ml/min at 1 month-1 year and by 6.58 ml/min at 1 year or more (both significant). Thus, renal dysfunction after EVR is common and merits attention.
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Aneurisma de la Aorta Abdominal/cirugía , Procedimientos Endovasculares/efectos adversos , Riñón/fisiopatología , Creatinina/sangre , Humanos , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/fisiopatología , Insuficiencia Renal/etiología , Insuficiencia Renal/fisiopatología , Factores de TiempoRESUMEN
PURPOSE: To describe the imaging characteristics of the Nellix Endovascular Aneurysm Sealing (EVAS) System on serial computed tomography (CT) surveillance. METHODS: Sixty-eight patients undergoing EVAS were enrolled in a surveillance protocol that included CT scans prior to hospital discharge and at 3, 6, and 9 months postoperatively. Images were analyzed for the presence of gas within the endobag, endoleak, and for maximum radiodensity measured in Hounsfield units (HU) within the uppermost, middle, and lowermost regions of each endobag. RESULTS: Gas was seen within the endobags of all 68 EVAS repairs at the first postoperative CT compared with 2 (5.6%) of 36 undergoing the 3-month scan. The endobags appeared radiodense during initial imaging, and the median (interquartile range) radiodensity of the Nellix polymer decreased from 158.3 HU (149.5; 169.5) at the postoperative CT to 81.0 HU (74.0; 88.0) at 3 months, excluding 3 cases in which contrast pre-fill was utilized. Type I endoleak was seen at the periphery of the aneurysm sac or in the cleft between the endobags, with a substantially different appearance to endoleak after endovascular aneurysm repair. CONCLUSION: The evolution of CT appearances after EVAS was characteristic and predictable. The device endobags were initially radiodense, which may impact the detection of endoleak within 3 months of EVAS. Endoleaks after EVAS were seen in a different anatomical area to endoleaks after conventional stent-graft repair.
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Aneurisma de la Aorta Abdominal/cirugía , Aortografía/métodos , Implantación de Prótesis Vascular/instrumentación , Prótesis Vascular , Endofuga/diagnóstico por imagen , Procedimientos Endovasculares/instrumentación , Stents , Tomografía Computarizada por Rayos X , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Implantación de Prótesis Vascular/efectos adversos , Endofuga/etiología , Procedimientos Endovasculares/efectos adversos , Humanos , Valor Predictivo de las Pruebas , Diseño de Prótesis , Factores de Tiempo , Resultado del TratamientoRESUMEN
PURPOSE: To quantitatively summarize the incidence of misdiagnosis of ruptured abdominal aortic aneurysms (rAAA), the most common presenting features, and the commonest incorrect differential diagnoses. METHODS: A systematic search according to PRISMA guidelines was performed using EMBASE and MEDLINE databases to identify studies reporting the initial rate of misdiagnosis of patients with rAAA. Random-effects meta-analyses were performed to estimate the rate of misdiagnosis, presenting features, and commonest differential diagnoses. A sensitivity analysis was performed for studies reporting after 1990. RESULTS: Nine studies comprising 1109 patients contributed to the pooled analysis, which found a 42% incidence of rAAA misdiagnosis (95% CI 29% to 55%). In studies reporting after 1990, misdiagnosis was seen in 32% (95% CI 16% to 49%). The most common erroneous differential diagnoses were ureteric colic and myocardial infarction. Abdominal pain, shock, and a pulsatile mass were presenting features in 61% (49%-72%), 46% (32%-61%), and 45% (29%-62%) of rAAAs, respectively. CONCLUSION: The rate of misdiagnosis of rAAA has remained consistent over time and is concerning. There is a need for an effective clinical decision tool to enable accurate diagnosis and triage at the scene of the emergency.
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Aneurisma de la Aorta Abdominal/diagnóstico , Rotura de la Aorta/diagnóstico , Errores Diagnósticos , Aneurisma de la Aorta Abdominal/complicaciones , Aneurisma de la Aorta Abdominal/terapia , Rotura de la Aorta/etiología , Rotura de la Aorta/terapia , Diagnóstico Diferencial , Humanos , Valor Predictivo de las Pruebas , PronósticoRESUMEN
OBJECTIVES: The aim of this study was to compare outcomes of major lower limb amputation (MLA) in patients with and without cancer and with cancer patients receiving palliation over amputation for their unsalvageable limb. METHODS: Cancer patients who underwent a major amputation or palliation between 2013 and 2018 were included. Comparison groups were cancer-MLA (active/managed cancers), non-cancer MLA (historic cancer or no cancer history) and cancer-palliation at presentation with unsalvageable limbs. Prospectively collected data was retrospectively analysed for outcomes including survival, postoperative complications, length of stay, suitability for rehabilitation and discharge destination. RESULTS: 262 (cancer and non-cancer) patients underwent MLA and 18 patients with cancer received palliation. Of those amputated, 26 (9.9%) had active or managed cancer, of which 12 were diagnosed in the 6 months before MLA. Cancer-MLA patients presented with more acute ischaemia compared to non-cancer patients. Median survival was significantly different between the cancer-MLA (14.1 [9.5 - 29.5, 95% CI] months), non-cancer MLA (57.7 [45 - 73.6, 95% CI] months) and cancer-palliation (.6 [.4 - 2.3, 95% CI] months) groups, P < .001. A significantly higher proportion of cancer-MLA patients (10/26, 38.5%) were deemed unsuitable for rehabilitation in post-operative assessment compared to non-cancer MLA (21/236, 8.9%) patients, P < .001. There was a variation in destinations of discharge, with a greater proportion of cancer-MLA patients (4/26, 15.4%) going to a nursing home compared to non-cancer MLA (10/236, 4.2%) patients, P = .016. CONCLUSION: Cancer is prevalent among vascular amputees, with a large proportion being occult diagnoses. Cancer is associated with poorer outcomes following amputation, but survival remains significantly better compared to palliation in cancer patients presenting with unsalvageable limbs.
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Pierna , Neoplasias , Humanos , Estudios Retrospectivos , Resultado del Tratamiento , Neoplasias/complicaciones , Neoplasias/diagnóstico , Amputación QuirúrgicaRESUMEN
Experimental and density functional theory (DFT) studies are described that are focused on outlining the reactivity of the known photochemical nitric oxide precursor trans-Cr(cyclam)(ONO)(2)(+) ("CrONO", cyclam = 1,4,8,11-tetrazacycltetradecane). Studies in both aerated and deaerated aqueous media are described as are the roles of both the oxidant O(2) and a reductant such as glutathione in trapping the apparent Cr(IV) photoreaction intermediate trans-Cr(cyclam)(O)(ONO)(+). Also reported and characterized structurally is the Cr(V) product of long-term photolysis in the absence of reducing agents, the trans-dioxo species [trans-Cr(cyclam)(O)(2)](ClO(4)). Photosensitization experiments indicate that at least a significant fraction of the reaction occurs from the lowest energy doublet excited state(s). Lastly, cell culture experiments demonstrate that CrONO has little or no acute toxicity either before or after photolysis.
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Cromo/química , Compuestos Heterocíclicos/metabolismo , Monocitos/efectos de los fármacos , Monocitos/efectos de la radiación , Óxido Nítrico , Fotólisis , Fármacos Fotosensibilizantes/metabolismo , Profármacos/metabolismo , Línea Celular Tumoral , Cromo/metabolismo , Cristalografía por Rayos X , Espectroscopía de Resonancia por Spin del Electrón , Glutatión/química , Glutatión/metabolismo , Compuestos Heterocíclicos/síntesis química , Compuestos Heterocíclicos/farmacología , Humanos , Cinética , L-Lactato Deshidrogenasa/análisis , Luz , Estructura Molecular , Terapia Molecular Dirigida/métodos , Monocitos/patología , Óxido Nítrico/química , Óxido Nítrico/metabolismo , Oxidación-Reducción/efectos de los fármacos , Oxidación-Reducción/efectos de la radiación , Fotoquímica/métodos , Fotólisis/efectos de los fármacos , Fotólisis/efectos de la radiación , Fármacos Fotosensibilizantes/síntesis química , Fármacos Fotosensibilizantes/farmacología , Fototerapia/métodos , Profármacos/síntesis química , Profármacos/farmacología , Estereoisomerismo , TermodinámicaRESUMEN
Highlighted by the discovery of high-temperature superconductivity, strongly correlated oxides with highly distorted perovskite structures serve as intriguing model systems for pursuing emerging materials physics and testing technological concepts. While 3d correlated oxides with a distorted perovskite structure are not uncommon, their 4d counterparts are unfortunately rare. In this work, we report the tuning of the electrical and optical properties of a quasi-2D perovskite niobate CsBiNb2O7 via hydrogenation. It is observed that hydrogenation induces drastic changes of lattice dynamics, optical transmission, and conductance. It is suggested that changing the orbital occupancy of Nb d orbitals could trigger the on-site Coulomb interaction in the NbO6 octahedron. The observed hydrogen doping-induced electrical plasticity is implemented for simulating neural synaptic activity. Our finding sheds light on the role of hydrogen in 4d transition metal oxides and suggests a new avenue for the design and development of novel electronic phases.
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Active metasurfaces promise reconfigurable optics with drastically improved compactness, ruggedness, manufacturability and functionality compared to their traditional bulk counterparts. Optical phase-change materials (PCMs) offer an appealing material solution for active metasurface devices with their large index contrast and non-volatile switching characteristics. Here we report a large-scale, electrically reconfigurable non-volatile metasurface platform based on optical PCMs. The optical PCM alloy used in the devices, Ge2Sb2Se4Te (GSST), uniquely combines giant non-volatile index modulation capability, broadband low optical loss and a large reversible switching volume, enabling notably enhanced light-matter interactions within the active optical PCM medium. Capitalizing on these favourable attributes, we demonstrated quasi-continuously tuneable active metasurfaces with record half-octave spectral tuning range and large optical contrast of over 400%. We further prototyped a polarization-insensitive phase-gradient metasurface to realize dynamic optical beam steering.
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The timing of carotid endarterectomy (CEA) for symptomatic ipsilateral carotid artery stenosis has evolved in practice over time. Key landmark trials outlined the benefit of performing CEA in the recently symptomatic carotid artery stenosis, defined as revascularisation within 6 months of the index neurological event. Further evidence and sub-analysis demonstrate that performing CEA within 2 weeks of symptoms has the maximal benefit in reducing stroke free survival and is associated with a safe perioperative complication profile. This has translated into guideline recommendations and widespread clinical practice. The case for performing urgent CEA (within 48 hours of index neurological event) over early CEA (within 2 weeks) has been put forward and studied. Data examining perioperative complications for urgent CEA are mostly derived from retrospective single series studies. A moderate balance exists in the literature for the safety and risk of urgent CEA. Although many studies present acceptable perioperative stroke and mortality rates associated with urgent CEA, evidence still exists that the perioperative complications may not be insignificant. This is particularly the case if the presenting neurology is a stroke, rather than a transient ischaemic attack (TIA) or amaurosis fugax. This should be contextualised in the practice of modern aggressive medical therapy with dual antiplatelets and statins, with evidence suggesting a reduction in recurrent ischaemic events prior to surgical intervention. Careful patient selection, presenting neurology and medical therapy is likely to be a key feature in considering urgent CEA versus early CEA.
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Amid the global COVID-19 pandemic, adaptation of healthcare systems, with strong medical leadership, has been integral to coping with the ever-changing situation. This article is based on the personal experiences of doctors in the NHS and insights into the frontline response to this situation. It reflects on leadership dilemmas and strategies implemented to overcome them, with a focus on systems thinking and adaptive leadership.
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Infecciones por Coronavirus/epidemiología , Liderazgo , Pandemias , Médicos , Neumonía Viral/epidemiología , Medicina Estatal/organización & administración , Análisis de Sistemas , Betacoronavirus , COVID-19 , Humanos , SARS-CoV-2 , Reino Unido/epidemiologíaRESUMEN
The coronavirus disease 2019 (COVID-19) pandemic has had significant implications for society, with the introduction of restrictive social measures. Antibody tests provide a way of identifying patients who have been previously exposed to the virus and thus may have a degree of immunity. This is important in the development of public health policy, as local and national bodies seek to relax social restrictions in an attempt to mitigate the socioeconomic impact of the pandemic. This article explores the essential statistical concepts used to interpret the findings of diagnostic investigations, with examples illustrated using COVID-19 antibody tests.