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Masada KM, Cristino DM, Dear KA, Hast MW, Mehta S. 3-D Printed Fracture Models Improve Resident Performance and Clinical Outcomes in Operative Fracture Management. JOURNAL OF SURGICAL EDUCATION 2023; 80:1020-1027. [PMID: 37198080 DOI: 10.1016/j.jsurg.2023.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 12/30/2022] [Accepted: 04/09/2023] [Indexed: 05/19/2023]
Abstract
OBJECTIVE To determine if preoperative examination of patient additive manufactured (AM) fracture models can be used to improve resident operative competency and patient outcomes. DESIGN Prospective cohort study. Seventeen matched pairs of fracture fixation surgeries (for a total of 34 surgeries) were performed. Residents first performed a set of baseline surgeries (n = 17) without AM fracture models. The residents then performed a second set of surgeries randomly assigned to include an AM model (n = 11) or to omit it (n = 6). Following each surgery, the attending surgeon evaluated the resident using an Ottawa Surgical Competency Operating Room Evaluation (O-Score). The authors also recorded clinical outcomes including operative time, blood loss, fluoroscopy duration, and patient reported outcome measurement information system (PROMIS) scores of pain and function at 6 months. SETTING Single-center academic level one trauma center. PARTICIPANTS Twelve orthopaedic residents, between postgraduate year (PGY) 2 and 5, participated in this study. RESULTS Residents significantly improved their O-Scores between the first and second surgery when they trained with AM models for the second surgery (p = 0.004, 2.43 ± 0.79 versus 3.73 ± 0.64). Similar improvements were not observed in the control group (p = 0.916, 2.69 ± 0.69 versus 2.77 ± 0.36). AM model training also significantly improved clinical outcomes, including surgery time (p = 0.006), fluoroscopy exposure time (p = 0.002), and patient reported functional outcomes (p = 0.0006). CONCLUSIONS Conclusions: Training with AM fracture models improves the performance of orthopaedic surgery residents during fracture surgery.
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Baig MS, Mehta S, Morales DS, Maniar HH, Dahodwala T, Horwitz DS. Successful Primary Treatment of Ankle Fractures in Diabetic Patients with Peripheral Neuropathy Using a Tibiotalocalcaneal Nail: A Case Series. Indian J Orthop 2023; 57:1068-1075. [PMID: 37384012 PMCID: PMC10293542 DOI: 10.1007/s43465-023-00882-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Accepted: 03/24/2023] [Indexed: 06/30/2023]
Abstract
Background Among diabetics, patients with peripheral neuropathy are at increased risk of developing complications following an ankle fracture. While the outcomes in these patients treated nonoperatively have been poor, the outcomes in those undergoing open reduction and internal fixation are at the best modest. We hypothesize that closed reduction and internal fixation with tibiotalocalcaneal nail is an effective primary procedure in this complication prone patient group. Methods A retrospective review of diabetic patients with peripheral neuropathy who underwent acute treatment of an ankle fracture with closed reduction and internal fixation with a tibiotalocalcaneal nail at two Level 1 trauma centers was performed. 30 patients were identified and divided into 2 groups with respect to their postoperative weight bearing protocol: 20 patients in the early weight bearing (EWB) group and 10 patients in the touch-down weight bearing (TDWB). The primary outcome was the rate of return to baseline function and the secondary outcomes included the incidence of wound dehiscence, wound infection, implant failure, loss of fixation, loss of reduction and amputation. Results In the EWB group, 15/20 patients returned to their baseline function, 5/20 had wound dehiscence and infection, 2/20 had implant failure, 5/20 had loss of fixation, 4/20 had loss of reduction, and 4/20 underwent amputation. In the TDWB group, 9/10 patients returned to their baseline function, 1/10 had implant failure, 1/10 had loss of fixation. No patients from this group had loss of reduction or underwent amputation. Conclusion Treatment with tibiotalocalcaneal nail is an effective primary procedure in this complication prone group of patients, assuming that weight bearing is delayed for six weeks to protect soft tissues and surgical incisions. Level of Evidence Level IV, retrospective case series.
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Stephen TL, Korobkova L, Breningstall B, Nguyen K, Mehta S, Pachicano M, Jones KT, Hawes D, Cabeen RP, Bienkowski MS. Machine Learning Classification of Alzheimer's Disease Pathology Reveals Diffuse Amyloid as a Major Predictor of Cognitive Impairment in Human Hippocampal Subregions. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.05.31.543117. [PMID: 37333119 PMCID: PMC10274752 DOI: 10.1101/2023.05.31.543117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Abstract
Analyzing Alzheimer's disease (AD) pathology within anatomical subregions is a significant challenge, often carried out by pathologists using a standardized, semi-quantitative approach. To augment traditional methods, a high-throughput, high-resolution pipeline was created to classify the distribution of AD pathology within hippocampal subregions. USC ADRC post-mortem tissue sections from 51 patients were stained with 4G8 for amyloid, Gallyas for neurofibrillary tangles (NFTs) and Iba1 for microglia. Machine learning (ML) techniques were utilized to identify and classify amyloid pathology (dense, diffuse and APP (amyloid precursor protein)), NFTs, neuritic plaques and microglia. These classifications were overlaid within manually segmented regions (aligned with the Allen Human Brain Atlas) to create detailed pathology maps. Cases were separated into low, intermediate, or high AD stages. Further data extraction enabled quantification of plaque size and pathology density alongside ApoE genotype, sex, and cognitive status. Our findings revealed that the increase in pathology burden across AD stages was driven mainly by diffuse amyloid. The pre and para-subiculum had the highest levels of diffuse amyloid while NFTs were highest in the A36 region in high AD cases. Moreover, different pathology types had distinct trajectories across disease stages. In a subset of AD cases, microglia were elevated in intermediate and high compared to low AD. Microglia also correlated with amyloid pathology in the Dentate Gyrus. The size of dense plaques, which may represent microglial function, was lower in ApoE4 carriers. In addition, individuals with memory impairment had higher levels of both dense and diffuse amyloid. Taken together, our findings integrating ML classification approaches with anatomical segmentation maps provide new insights on the complexity of disease pathology in AD progression. Specifically, we identified diffuse amyloid pathology as being a major driver of AD in our cohort, regions of interest and microglial responses that might advance AD diagnosis and treatment.
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Blumenthal SR, Fryhofer GW, Serra-Lopez V, Pierrie SN, Mehta S. Bias in Care: Impact of Ethnicity on Time to Emergent Surgery Varies Between Subspecialties. J Am Acad Orthop Surg Glob Res Rev 2023; 7:01979360-202306000-00007. [PMID: 37311114 DOI: 10.5435/jaaosglobal-d-23-00060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 03/29/2023] [Indexed: 06/15/2023]
Abstract
INTRODUCTION Disparity in access to emergency care among minority groups continues to exist despite growing awareness of the effect of implicit bias on public health. In this study, we evaluated ethnicity-based differences in time between admission and surgery for patients undergoing emergent procedures at hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program. METHODS We conducted a retrospective review of 249,296 National Surgical Quality Improvement Program cases from 2006 to 2018 involving general, orthopaedic, and vascular surgeries. Analysis of variance was used to compare "time to operating room" (OR) between ethnic groups. RESULTS Notable differences in time to OR were noted among general and vascular surgeries but not orthopaedic surgery. Post hoc comparison identified notable variation in general surgery between White and Black/African Americans. In vascular surgery, notable variations were identified between White and Black/African Americans and White and Native Hawaiian/Pacific Islanders. DISCUSSION These findings suggest that certain surgical subspecialties continue to exhibit disparities in care that may manifest as surgical delay, most notably between White and Black/African Americans. Interestingly, variation in time to OR for patients treated by orthopaedic surgery was not notable. Overall, these results highlight the need for additional research into the role of implicit bias in emergent surgical care in the United States.
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Shah N, Shah N, Mehta S, Murray E, Grodzinsky A. Spontaneous Coronary Artery Dissection (SCAD) in an Atypical Patient Without Risk Factors and Prior Asymptomatic COVID-19 Infection. Cureus 2023; 15:e40906. [PMID: 37492806 PMCID: PMC10365924 DOI: 10.7759/cureus.40906] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/23/2023] [Indexed: 07/27/2023] Open
Abstract
Spontaneous coronary artery dissection (SCAD) is a condition primarily seen in young women and is characterized by non-atherosclerotic arterial damage. It can occur with or without conventional risk factors for coronary heart disease and is often associated with chronic inflammatory conditions. Here, we present a unique instance of a 67-year-old woman without known risk factors who developed sudden onset chest pain in the setting of an asymptomatic coronavirus 2019 (COVID-19) infection three weeks earlier. Subsequent evaluation revealed SCAD in the distal left anterior descending (LAD) artery.
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Mehta S, Boyer TL, Akhtar S, He T, Zhang C, Vedadghavami A, Bajpayee AG. Sustained intra-cartilage delivery of interleukin-1 receptor antagonist using cationic peptide and protein-based carriers. Osteoarthritis Cartilage 2023; 31:780-792. [PMID: 36739939 PMCID: PMC10392024 DOI: 10.1016/j.joca.2023.01.573] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 12/20/2022] [Accepted: 01/17/2023] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Blocking the interleukin-1 (IL-1) catabolic cascade following joint trauma can be achieved using its receptor antagonist, IL-1Ra. However, its clinical translation for osteoarthritis therapy has been unsuccessful due to its rapid joint clearance and lack of targeting and penetration into deep cartilage layers at therapeutic concentrations. Here, we target the high negative charge of cartilage aggrecan-glycosaminoglycans (GAGs) by attaching cationic carriers to IL-1Ra. IL-1Ra was conjugated to the cartilage targeting glycoprotein, Avidin, and a short length optimally charged cationic peptide carrier (CPC+14). It is hypothesized that electro-diffusive transport and binding properties of IL-1Ra-Avidin and IL-1Ra-CPC+14 will create intra-cartilage depots of IL-1Ra, resulting in long-term suppression of IL-1 catabolism with only a single administration. DESIGN IL-1Ra was conjugated to Avidin or CPC+14 using site specific maleimide linkers, and confirmed using gel electrophoresis, high-performance liquid chromatography (HPLC), and mass spectrometry. Intra-cartilage transport and retention of conjugates was compared with native IL-1Ra. Attenuation of IL-1 catabolic signaling with one-time dose of IL-1Ra-CPC+14 and IL-1Ra-Avidin was assessed over 16 days using IL-1α challenged bovine cartilage and compared with unmodified IL-1Ra. RESULTS Positively charged IL-1Ra penetrated through the full-thickness of cartilage, creating a drug depot. A single dose of unmodified IL-1Ra was not sufficient to attenuate IL-1-induced cartilage deterioration over 16 days. However, when delivered using Avidin, and to a greater extent CPC+14, IL-1Ra significantly suppressed cytokine induced GAG loss and nitrite release while improving cell metabolism and viability. CONCLUSION Charge-based cartilage targeting drug delivery systems hold promise as they can enable long-term therapeutic benefit with only a single dose.
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Schemitsch EH, Nowak LL, Schulz AP, Brink O, Poolman RW, Mehta S, Stengel D, Zhang CQ, Martinez S, Kinner B, Chesser TJS, Bhandari M. Intramedullary Nailing vs Sliding Hip Screw in Trochanteric Fracture Management: The INSITE Randomized Clinical Trial. JAMA Netw Open 2023; 6:e2317164. [PMID: 37278998 DOI: 10.1001/jamanetworkopen.2023.17164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/07/2023] Open
Abstract
Importance Fractures of the hip have devastating effects on function and quality of life. Intramedullary nails (IMN) are the dominant implant choice for the treatment of trochanteric fractures of the hip. Higher costs of IMNs and inconclusive benefit in comparison with sliding hip screws (SHSs) convey the need for definitive evidence. Objective To compare 1-year outcomes of patients with trochanteric fractures treated with the IMN vs an SHS. Design, Setting, and Participants This randomized clinical trial was conducted at 25 international sites across 12 countries. Participants included ambulatory patients aged 18 years and older with low-energy trochanteric (AO Foundation and Orthopaedic Trauma Association [AO/OTA] type 31-A1 or 31-A2) fractures. Patient recruitment occurred between January 2012 and January 2016, and patients were followed up for 52 weeks (primary end point). Follow-up was completed in January 2017. The analysis was performed in July 2018 and confirmed in January 2022. Interventions Surgical fixation with a Gamma3 IMN or an SHS. Main Outcomes and Measures The primary outcome was health-related quality of life (HRQOL), measured by the EuroQol-5 Dimension (EQ5D) at 1-year postsurgery. Secondary outcomes included revision surgical procedure, fracture healing, adverse events, patient mobility (measured by the Parker mobility score), and hip function (measured by the Harris hip score). Results In this randomized clinical trial, 850 patients were randomized (mean [range] age, 78.5 [18-102] years; 549 [64.6% female) with trochanteric fractures to undergo fixation with either the IMN (n = 423) or an SHS (n = 427). A total of 621 patients completed follow-up at 1 year postsurgery (304 treated with the IMN [71.9%], 317 treated with an SHS [74.2%]). There were no significant differences between groups in EQ5D scores (mean difference, 0.02 points; 95% CI, -0.03 to 0.07 points; P = .42). Furthermore, after adjusting for relevant covariables, there were no between-group differences in EQ5D scores (regression coefficient, 0.00; 95% CI, -0.04 to 0.05; P = .81). There were no between-group differences for any secondary outcomes. There were also no significant interactions for fracture stability (β [SE] , 0.01 [0.05]; P = .82) or previous fracture (β [SE], 0.01 [0.10]; P = .88) and treatment group. Conclusions and Relevance This randomized clinical trial found that IMNs for the treatment of trochanteric fractures had similar 1-year outcomes compared with SHSs. These results suggest that the SHS is an acceptable lower-cost alternative for trochanteric fractures of the hip. Trial Registration ClinicalTrials.gov Identifier: NCT01380444.
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Glatt V, O'Toole R, Mehta S, Kandemir U, Ricci W, Nauth A, Schemitsch E, Hast MW. Great debates in trauma biomechanics. OTA Int 2023; 6:e249. [PMID: 37168029 PMCID: PMC10166369 DOI: 10.1097/oi9.0000000000000249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 12/22/2022] [Indexed: 05/13/2023]
Abstract
At the 2021 annual meeting of the Orthopaedic Trauma Association, the Basic Science Focus Forum hosted its first ever debate-style symposium focused on biomechanics and fracture repair. The 3 subjects of debate were "Mechanics versus Biology-Which is 'More Important' to Consider?" "Locked Plate versus Forward Dynamization versus Reverse Dynamization-Which Way Should I Go?" and "Sawbones versus Cadaver Models-What Should I Believe Most?" These debates were held because fracture healing is a highly organized synergistic response between biological factors and the local mechanical environment. Multiple studies have demonstrated that both factors play roles in governing bone healing responses, and the causal relationships between the 2 remain unclear. The lack of clarity in this space has led to a spectrum of research with the common goal of helping surgeons make good decisions. Before reading further, the reader should understand that the questions posed in the debate titles are unanswerable and might represent a false choice. Instead, the reader should appreciate that the debates were held to gain a more thorough understanding of these topics based on the current state of the art of experimental and clinical studies, by using an engaging and thought-provoking format.
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Kahan Mehta, Mehta S. Rare Manifestation of Diabetes Mellitus in COVID-19 Patient: A Case Report. INTERNATIONAL JOURNAL OF MEDICAL STUDENTS 2023. [DOI: 10.5195/ijms.2022.1743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023] Open
Abstract
Introduction: Diabetes is an endocrinopathy and rare in the case of SARS-CoV-2, the virus primarily involves the lungs by its affinity to Angiotensin Converting enzyme(ACE-2) receptors, associated symptoms include Nausea, Vomiting, and Breathlessness.
Case Presentation: We present the case of a 41-year-old male with pneumonia-like symptoms and a positive nasal swab RT-PCR test with Imaging studies highly suggestive of CO RADS-5 Progressive stage, the patient was immediately admitted to the Intensive care unit (ICU), and the treatment was started with Medical Oxygen, Intravenous Normal Saline Tablet Doxycycline, and Tablet Ivermectin as per the guidelines, he was admitted for 21 days. After 3 weeks the patient comes for a routine checkup and was found to have an elevated Fasting glucose level of 121 mg/dl (normal reference range 80-100mg/dl) further workup for diabetes revealed that he was a non-diabetic on the previous visit 2 months ago, he also had an increase in weight during this time. With the Body Mass Index(BMI) now being 30.2 from the previous 28.4 (Reference range >30 is obese), the pro-inflammatory cytokines like C-reactive protein were 111.6 (normal 0-6), and elevation in D-Dimer which is a fibrin degradation product was elevated to 1048ng/dl ( normal range 0-500 ng/dl) other measures for the increase in blood sugar also showed elevation as seen in table 1.
Discussion: There have been many hypotheses to find a causalrelationship between both Diabetes and COVID-19 like the use of Dexamethasone or that the virus produces proinflammatory cytokines like Interleukin-6(IL-6) that lead to impaired signaling and decreased lipolysis or that there is a direct action on the ACE 2 found in the pancreas by the virus and maybe the least looked upon factor being lockdown leading to sedentary life, no exercises and increase in consumption of fatty foods, whichever may be the case it could very well be a multifactorial cause with many of these ideas involved.
Conclusion: In this case, the association may be with decreased physical activity and an increase in Lipolysis or the proinflammatory states as seen by the increase in the C-reactive protein and Interleukin-6 levels.
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Carmain M, Mehta S, Dalal S, Lundsberg L, St. Martin B, Harmanli O. The effect of an educational video on patient adherence and completeness of intake and voiding diaries: a randomized control trial. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.12.150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
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Manimaran P, Shah R, Trivedi P, Mehta S. Primary cutaneous neuroendocrine tumor with axillary lymph node metastasis: A clinical masquerade. J Postgrad Med 2023; 69:118-119. [PMID: 36751760 DOI: 10.4103/jpgm.jpgm_254_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Elshaer A, Jones S, Hayden J, Mehta S, cockbain AJ, Sarela A, Dexter S. The future insights of evaluating the circumferential resection margin (CRM) status in oesophageal cancer: A 12-year cohort study. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023. [DOI: 10.1016/j.ejso.2022.11.146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
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Snow M, Middleton L, Mehta S, Roberts A, Gray R, Richardson J, Kuiper JH, Smith A, White S, Roberts S, Griffiths D, Mohammed A, Moholkar K, Ashraf T, Green M, Hutchinson J, Bhullar T, Chitnis S, Shaw A, van Niekerk L, Hui A, Drogset JO, Knutsen G, McNicholas M, Bowditch M, Johnson D, Turner P, Chugh S, Hunt N, Ali S, Palmer S, Perry A, Davidson A, Hill P, Deo S, Satish V, Radford M, Langstaff R, Houlihan-Burne D, Spicer D, Phaltankar P, Hegab A, Marsh D, Cannon S, Briggs T, Pollock R, Carrington R, Skinner J, Bentley G, Price A, Schranz P, Mandalia V, O'Brien S. A Randomized Trial of Autologous Chondrocyte Implantation Versus Alternative Forms of Surgical Cartilage Management in Patients With a Failed Primary Treatment for Chondral or Osteochondral Defects in the Knee. Am J Sports Med 2023; 51:367-378. [PMID: 36661257 DOI: 10.1177/03635465221141907] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND There are limited randomized controlled trials with long-term outcomes comparing autologous chondrocyte implantation (ACI) versus alternative forms of surgical cartilage management within the knee. PURPOSE To determine at 5 years after surgery whether ACI was superior to alternative forms of cartilage management in patients after a failed previous treatment for chondral or osteochondral defects in the knee. STUDY DESIGN Randomized controlled trial; Level of evidence, 1. METHODS In total, 390 participants were randomly assigned to receive either ACI or alternative management. Patients aged 18 to 55 years with one or two symptomatic cartilage defects who had failed 1 previous therapeutic surgical procedure in excess of 6 months prior were included. Dual primary outcome measures were used: (1) patient-completed Lysholm knee score and (2) time from surgery to cessation of treatment benefit. Secondary outcome measures included International Knee Documentation Committee and Cincinnati Knee Rating System scores, as well as number of serious adverse events. Analysis was performed on an intention-to-treat basis. RESULTS Lysholm scores were improved by 1 year in both groups (15.4 points [95% CI, 11.9 to 18.8] and 15.2 points [95% CI, 11.6 to 18.9]) for ACI and alternative, with this improvement sustained over the duration of the trial. However, no evidence of a difference was found between the groups at 5 years (2.9 points; 95% CI, -1.8 to 7.5; P = .46). Approximately half of the participants (55%; 95% CI, 47% to 64% with ACI) were still experiencing benefit at 5 years, with time to cessation of treatment benefit similar in both groups (hazard ratio, 0.97; 95% CI, 0.72 to 1.32; P > .99). There was a differential effect on Lysholm scores in patients without previous marrow stimulation compared with those with marrow stimulation (P = .03; 6.4 points in favor of ACI; 95% CI, -0.4 to 13.1). More participants experienced a serious adverse event with ACI (P = .02). CONCLUSION Over 5 years, there was no evidence of a difference in Lysholm scores between ACI and alternative management in patients who had previously failed treatment. Previous marrow stimulation had a detrimental effect on the outcome of ACI. REGISTRATION International Standard Randomised Controlled Trial Number: 48911177.
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Elshaer A, Jones S, Hayden J, Mehta S, Cockbain AJ, Sarela A, Dexter S, Grabsch H. OGC P19 The future insights of evaluating the circumferential resection margin (CRM) status in oesophageal cancer: A 12-year cohort study. Br J Surg 2022. [DOI: 10.1093/bjs/znac404.182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Abstract
Background
The definition of CRM (circumferential resection margins) for oesophageal cancers varies among the international pathological bodies with an ongoing controversy about the optimal definition. There is also no enough data about the prognostic relevance of different sites in CRM. In this study, we examined the prognostic impacts of different CRM distances and sites.
Methods
This study included patients who had curative oesophagectomy for oesophageal cancer between 2010 till June 2021. Follow up till April 2022 was achieved. CRM status was carefully examined for the distance and site of involved tumour cells. Patients with involved proximal or distal margins were excluded. The outcomes between different CRM margins were retrospectively analysed. The long-term follow up data was obtained via direct contact with the patients during our oncological clinics, cross-checked with our hospital/national patients’ electronic databases.
Results
456 patients were included in this study. Involved tumour cells within 1mm of CRM was observed in 192 patients (42.1%). CRM+ (<1mm) was associated with worse overall (OS) and disease-free survival (DFS) (22.8 and 16.3 months respectively) compared to CRM-negative (47.7 and 45.1 months respectively), (p-value <0.001 for both). CRM+ (0mm) had worse OS and DFS (20.5 and 12 months respectively) compared to CRM+(0.1–1mm) (26.4 and 20 months respectively), (p-values 0.028 and 0.006 respectively). CRM-positive posterior margin was the most common involved site (32%), but was associated with better OS and DFS compared to anterior and lateral sites, (p-values 0.1 and 0.08 respectively).
Conclusions
The site and distance of tumour cells within CRM should be rigorously assessed in oesophagectomy specimens. The presence of tumour cells within 1mm of CRM was an independent factor for OS and DFS. The CRM+(0 mm) had significant lower survival rates compared to other CRM+ distances (0.1–1 mm). The involved margin sites within CRM had different survival rates, with superiority towards posterior resection margins.
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Phillips MR, Harrison A, Mehta S, Nolte PA, Bhandari M, Zura R. A scoping review of operative and non-invasive management in the treatment of non-unions. Injury 2022; 53:3872-3878. [PMID: 36424685 DOI: 10.1016/j.injury.2022.09.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 09/14/2022] [Accepted: 09/15/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Non-union occurs when a fracture fails to adequately heal, and requires additional intervention to achieve union. The purpose of this scoping review is to provide a high-level overview of the existing non-union management literature. This review aims to highlight the current literature on non-union management, as well as identify key areas that require future research to provide a better understanding of potential non-union management strategies. METHODS This study utilized the scoping review framework from Arksey and O'Malley All relevant literature on non-union management was systematically searched for within the OVID Medline, OVID Embase, and Web of Science databases. As a scoping review, this study aimed to identify the high-level trends in non-union literature. This was assessed through a visual and numerical summary of the general themes in non-union literature, as well as the timeline in which these trends have occurred. RESULTS The literature search identified 8081 articles, of which 2210 articles were included. There is a large body of evidence for various surgical treatment options for non-union. The literature suggests healing rates between 80 and 100 percent for commonly utilized surgical procedures, such as plating with bone graft for long bones. Despite these beneficial healing rates, the requirement of a surgery creates a large socioeconomic burden. The possibility for bone growth stimulator (BGS) options to achieve non-union healing rates in a similar realm as surgical options suggests that the use of a BGS may be a beneficial option prior to surgical intervention, as this would potentially reduce the number of patients who would otherwise require surgery. CONCLUSION A large body of evidence exists on non-union management, which is largely comprised of case series and reports. The most commonly assessed non-unions include the tibia, wrist, and femur. Bone grafting, plating, and nailing are the most investigated treatment options. BGS are a non-operative treatment options for non-union that provide similar healing rates to surgical options in certain indications within initial observational data. BGS are a potential option for non-operative management of non-unions to reduce socioeconomic burdens of surgical intervention, with a need for further high-quality investigation in this therapeutic area.
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Bhandari S, Mehta S, Khwaja A, Cleland JGF, Ives N, Brettell E, Chadburn M, Cockwell P. Renin-Angiotensin System Inhibition in Advanced Chronic Kidney Disease. N Engl J Med 2022; 387:2021-2032. [PMID: 36326117 DOI: 10.1056/nejmoa2210639] [Citation(s) in RCA: 79] [Impact Index Per Article: 39.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Renin-angiotensin system (RAS) inhibitors - including angiotensin-converting-enzyme (ACE) inhibitors and angiotensin-receptor blockers (ARBs) - slow the progression of mild or moderate chronic kidney disease. However, the results of some studies have suggested that the discontinuation of RAS inhibitors in patients with advanced chronic kidney disease may increase the estimated glomerular filtration rate (eGFR) or slow its decline. METHODS In this multicenter, open-label trial, we randomly assigned patients with advanced and progressive chronic kidney disease (eGFR, <30 ml per minute per 1.73 m2 of body-surface area) either to discontinue or to continue therapy with RAS inhibitors. The primary outcome was the eGFR at 3 years; eGFR values that were obtained after the initiation of renal-replacement therapy were excluded. Secondary outcomes included the development of end-stage kidney disease (ESKD); a composite of a decrease of more than 50% in the eGFR or the initiation of renal-replacement therapy, including ESKD; hospitalization; blood pressure; exercise capacity; and quality of life. Prespecified subgroups were defined according to age, eGFR, type of diabetes, mean arterial pressure, and proteinuria. RESULTS At 3 years, among the 411 patients who were enrolled, the least-squares mean (±SE) eGFR was 12.6±0.7 ml per minute per 1.73 m2 in the discontinuation group and 13.3±0.6 ml per minute per 1.73 m2 in the continuation group (difference, -0.7; 95% confidence interval [CI], -2.5 to 1.0; P = 0.42), with a negative value favoring the outcome in the continuation group. No heterogeneity in outcome according to the prespecified subgroups was observed. ESKD or the initiation of renal-replacement therapy occurred in 128 patients (62%) in the discontinuation group and in 115 patients (56%) in the continuation group (hazard ratio, 1.28; 95% CI, 0.99 to 1.65). Adverse events were similar in the discontinuation group and continuation group with respect to cardiovascular events (108 vs. 88) and deaths (20 vs. 22). CONCLUSIONS Among patients with advanced and progressive chronic kidney disease, the discontinuation of RAS inhibitors was not associated with a significant between-group difference in the long-term rate of decrease in the eGFR. (Funded by the National Institute for Health Research and the Medical Research Council; STOP ACEi EudraCT number, 2013-003798-82; ISRCTN number, 62869767.).
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Vassantachart A, Ballas L, Bian S, Lock D, Jang J, Fossum C, Han H, Mehta S, Cheng K, Miller K, Stal J, Ragab O. Do Patients Understand Radiation Therapy? Radiation Oncology Knowledge Assessment and Health Literacy among Culturally Diverse Breast Cancer Patients at a Safety-Net Hospital. Int J Radiat Oncol Biol Phys 2022. [DOI: 10.1016/j.ijrobp.2022.07.632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Mehta S, Liu K, Vassantachart A, Tamrazi B, Lee N, Sianto K, Olch A, Wong K. Incidence and Dosimetric Parameters of Brainstem Toxicity in Pediatric Patients after Photon Irradiation for Posterior Fossa Tumors. Int J Radiat Oncol Biol Phys 2022. [DOI: 10.1016/j.ijrobp.2022.07.1752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Lock D, Vassantachart A, Mehta S, Cui J, Gallogly A, Jennelle R, Hong D. A Structural Solution for Task Management in a Resident-Directed, Team-Based Radiotherapy Clinic. Int J Radiat Oncol Biol Phys 2022. [DOI: 10.1016/j.ijrobp.2022.07.1717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Slobogean GP, Sprague S, Wells JL, Bhandari M, Harris AD, Mullins CD, Thabane L, Wood A, Della Rocca GJ, Hebden JN, Jeray KJ, Marchand LS, O'Hara LM, Zura RD, Lee C, Patterson JT, Gardner MJ, Blasman J, Davies J, Liang S, Taljaard M, Devereaux PJ, Guyatt G, Heels-Ansdell D, Marvel D, Palmer JE, Friedrich J, O'Hara NN, Grissom F, Gitajn IL, Morshed S, O'Toole RV, Petrisor B, Mossuto F, Joshi MG, D'Alleyrand JCG, Fowler J, Rivera JC, Talbot M, Pogorzelski D, Dodds S, Li S, Del Fabbro G, Szasz OP, Bzovsky S, McKay P, Minea A, Murphy K, Howe AL, Demyanovich HK, Hoskins W, Medeiros M, Polk G, Kettering E, Mahal N, Eglseder A, Johnson A, Langhammer C, Lebrun C, Nascone J, Pensy R, Pollak A, Sciadini M, Degani Y, Phipps H, Hempen E, Johal H, Ristevski B, Williams D, Denkers M, Rajaratnam K, Al-Asiri J, Gallant JL, Pusztai K, MacRae S, Renaud S, Adams JD, Beckish ML, Bray CC, Brown TR, Cross AW, Dew T, Faucher GK, Gurich Jr RW, Lazarus DE, Millon SJ, Moody MC, Palmer MJ, Porter SE, Schaller TM, Sridhar MS, Sanders JL, Rudisill Jr LE, Garitty MJ, Poole AS, Sims ML, Walker CM, Carlisle R, Hofer EA, Huggins B, Hunter M, Marshall W, Ray SB, Smith C, Altman KM, Pichiotino ER, Quirion JC, Loeffler MF, Cole AA, Maltz EJ, Parker W, Ramsey TB, Burnikel A, Colello M, Stewart R, Wise J, Anderson M, Eskew J, Judkins B, Miller JM, Tanner SL, Snider RG, Townsend CE, Pham KH, Martin A, Robertson E, Bray E, Sykes JW, Yoder K, Conner K, Abbott H, Natoli RM, McKinley TO, Virkus WW, Sorkin AT, Szatkowski JP, Mullis BH, Jang Y, Lopas LA, Hill LC, Fentz CL, Diaz MM, Brown K, Garst KM, Denari EW, Osborn P, Pierrie SN, Kessler B, Herrera M, Miclau T, Marmor MT, Matityahu A, McClellan RT, Shearer D, Toogood P, Ding A, Murali J, El Naga A, Tangtiphaiboontana J, Belaye T, Berhaneselase E, Pokhvashchev D, Obremskey WT, Jahangir AA, Sethi M, Boyce R, Stinner DJ, Mitchell PP, Trochez K, Rodriguez E, Pritchett C, Hogan N, Fidel Moreno A, Hagen JE, Patrick M, Vlasak R, Krupko T, Talerico M, Horodyski M, Pazik M, Lossada-Soto E, Gary JL, Warner SJ, Munz JW, Choo AM, Achor TS, Routt ML“C, Kutzler M, Boutte S, Warth RJ, Prayson MJ, Venkatarayappa I, Horne B, Jerele J, Clark L, Boulton C, Lowe J, Ruth JT, Askam B, Seach A, Cruz A, Featherston B, Carlson R, Romero I, Zarif I, Dehghan N, McKee M, Jones CB, Sietsema DL, Williams A, Dykes T, Guerra-Farfan E, Tomas-Hernandez J, Teixidor-Serra J, Molero-Garcia V, Selga-Marsa J, Porcel-Vazquez JA, Andres-Peiro JV, Esteban-Feliu I, Vidal-Tarrason N, Serracanta J, Nuñez-Camarena J, del Mar Villar-Casares M, Mestre-Torres J, Lalueza-Broto P, Moreira-Borim F, Garcia-Sanchez Y, Marcano-Fernández F, Martínez-Carreres L, Martí-Garín D, Serrano-Sanz J, Sánchez-Fernández J, Sanz-Molero M, Carballo A, Pelfort X, Acerboni-Flores F, Alavedra-Massana A, Anglada-Torres N, Berenguer A, Cámara-Cabrera J, Caparros-García A, Fillat-Gomà F, Fuentes-López R, Garcia-Rodriguez R, Gimeno-Calavia N, Martínez-Álvarez M, Martínez-Grau P, Pellejero-García R, Ràfols-Perramon O, Peñalver JM, Salomó Domènech M, Soler-Cano A, Velasco-Barrera A, Yela-Verdú C, Bueno-Ruiz M, Sánchez-Palomino E, Andriola V, Molina-Corbacho M, Maldonado-Sotoca Y, Gasset-Teixidor A, Blasco-Moreu J, Fernández-Poch N, Rodoreda-Puigdemasa J, Verdaguer-Figuerola A, Cueva-Sevieri HE, Garcia-Gimenez S, Viskontas DG, Apostle KL, Boyer DS, Moola FO, Perey BH, Stone TB, Lemke HM, Spicer E, Payne K, Hymes RA, Schwartzbach CC, Schulman JE, Malekzadeh AS, Holzman MA, Gaski GE, Wills J, Pilson H, Carroll EA, Halvorson JJ, Babcock S, Goodman JB, Holden MB, Williams W, Hill T, Brotherton A, Romeo NM, Vallier HA, Vergon A, Higgins TF, Haller JM, Rothberg DL, Olsen ZM, McGowan AV, Hill S, Dauk MK, Bergin PF, Russell GV, Graves ML, Morellato J, McGee SL, Bhanat EL, Yener U, Khanna R, Nehete P, Potter D, VanDemark III R, Seabold K, Staudenmier N, Coe M, Dwyer K, Mullin DS, Chockbengboun TA, DePalo Sr. PA, Phelps K, Bosse M, Karunakar M, Kempton L, Sims S, Hsu J, Seymour R, Churchill C, Mayfield A, Sweeney J, Jaeblon T, Beer R, Bauer B, Meredith S, Talwar S, Domes CM, Gage MJ, Reilly RM, Paniagua A, Dupree J, Weaver MJ, von Keudell AG, Sagona AE, Mehta S, Donegan D, Horan A, Dooley M, Heng M, Harris MB, Lhowe DW, Esposito JG, Alnasser A, Shannon SF, Scott AN, Clinch B, Weber B, Beltran MJ, Archdeacon MT, Sagi HC, Wyrick JD, Le TT, Laughlin RT, Thomson CG, Hasselfeld K, Lin CA, Vrahas MS, Moon CN, Little MT, Marecek GS, Dubuclet DM, Scolaro JA, Learned JR, Lim PK, Demas S, Amirhekmat A, Dela Cruz YM. Aqueous skin antisepsis before surgical fixation of open fractures (Aqueous-PREP): a multiple-period, cluster-randomised, crossover trial. Lancet 2022; 400:1334-1344. [PMID: 36244384 DOI: 10.1016/s0140-6736(22)01652-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 08/18/2022] [Accepted: 08/23/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Chlorhexidine skin antisepsis is frequently recommended for most surgical procedures; however, it is unclear if these recommendations should apply to surgery involving traumatic contaminated wounds where povidone-iodine has previously been preferred. We aimed to compare the effect of aqueous 10% povidone-iodine versus aqueous 4% chlorhexidine gluconate on the risk of surgical site infection in patients who required surgery for an open fracture. METHODS We conducted a multiple-period, cluster-randomised, crossover trial (Aqueous-PREP) at 14 hospitals in Canada, Spain, and the USA. Eligible patients were adults aged 18 years or older with an open extremity fracture treated with a surgical fixation implant. For inclusion, the open fracture required formal surgical debridement within 72 h of the injury. Participating sites were randomly assigned (1:1) to use either aqueous 10% povidone-iodine or aqueous 4% chlorhexidine gluconate immediately before surgical incision; sites then alternated between the study interventions every 2 months. Participants, health-care providers, and study personnel were aware of the treatment assignment due to the colour of the solutions. The outcome adjudicators and data analysts were masked to treatment allocation. The primary outcome was surgical site infection, guided by the 2017 US Centers for Disease Control and Prevention National Healthcare Safety Network reporting criteria, which included superficial incisional infection within 30 days or deep incisional or organ space infection within 90 days of surgery. The primary analyses followed the intention-to-treat principle and included all participants in the groups to which they were randomly assigned. This study is registered with ClinicalTrials.gov, NCT03385304. FINDINGS Between April 8, 2018, and June 8, 2021, 3619 patients were assessed for eligibility and 1683 were enrolled and randomly assigned to povidone-iodine (n=847) or chlorhexidine gluconate (n=836). The trial's adjudication committee determined that 45 participants were ineligible, leaving 1638 participants in the primary analysis, with 828 in the povidone-iodine group and 810 in the chlorhexidine gluconate group (mean age 44·9 years [SD 18·0]; 629 [38%] were female and 1009 [62%] were male). Among 1571 participants in whom the primary outcome was known, a surgical site infection occurred in 59 (7%) of 787 participants in the povidone-iodine group and 58 (7%) of 784 in the chlorhexidine gluconate group (odds ratio 1·11, 95% CI 0·74 to 1·65; p=0·61; risk difference 0·6%, 95% CI -1·4 to 3·4). INTERPRETATION For patients who require surgical fixation of an open fracture, either aqueous 10% povidone-iodine or aqueous 4% chlorhexidine gluconate can be selected for skin antisepsis on the basis of solution availability, patient contraindications, or product cost. These findings might also have implications for antisepsis of other traumatic wounds. FUNDING US Department of Defense, Canadian Institutes of Health Research, McMaster University Surgical Associates, PSI Foundation.
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Mehta S, Vieira D, Guillen V, Zerpa D, Quintana A, Sanchez C, Ozair S, Brena-Pastor L, Pinos D, Fleming M, Carrera K, Rossitto F, Martinez F, Gonzalez A, Rodriguez K. Artificial intelligence-guided, single-lead EKG may be a game-changer for symptom-to-balloon time reduction in ST-elevated myocardial infarction. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Over decades, efforts to shave off life-saving minutes from ST-Elevated Myocardial Infarction (STEMI) care centred on reducing door-to-needle and door-to-balloon times. We firmly believe that symptom-to-balloon time should prove a better focus to this end. Challenges come with this goal as it heavily relies on a patient's perception and initiative to seek care, which we deem intelligent and wearable Artificial Intelligence (AI)-driven Single Lead EKG technologies as an attractive solution in modern-day cardiology.
Purpose
To provide an accurate, accessible, and cost-effective AI-driven Single Lead STEMI detection algorithm that can be embedded into wearable devices and employed in a self-administered fashion.
Methods
Database: EKG records from Mexico, Colombia, Argentina, and Brazil from April 2014 to December 2019. Dataset: A total of 11,567 12-lead EKG records of 10[s] length with a sampling frequency of 500 Hz, including the following balanced classes: angiographically confirmed and unconfirmed STEMI, branch blocks, non-specific ST-T abnormalities, normal and abnormal (200+ CPT codes, excluding those mentioned above). Cardiologists manually checked the label of each record to ensure precision. Pre-processing: We discard the first and last 250 samples as they may contain a standardisation pulse. The study applied a digital low pass filter of order 5 with a frequency cut-off of 35 Hz. The mean was subtracted from each Lead. Classification: The determined classes were “STEMI” (Including STEMI in different locations of the myocardium – anterior, inferior, and lateral); and “Not-STEMI” (Combination of randomly sample, branch blocks, non-specific ST-T changes, and abnormal records – 25% of each). Training and Testing: A 1-D Convolutional Neural Network was trained and tested with a dataset proportion of 90/10, respectively. A different model was trained and tested for each Lead, using the central 4,500 samples of the records. The last dense layer outputs a probability for each report of being STEMI or Not-STEMI. Lead V2 showed the best overall results. The model was further tested through the same methodology using the best Lead with a subset of the previous data, excluding the unconfirmed STEMI EKG records (Total 7,230 12-lead EKG records for Confirmed Only STEMI dataset). Performance metrics were reported for each experiment and compared.
Results
Combined STEMI data: Accuracy: 91.2%; Sensitivity: 89.6%; Specificity: 92.9%. Confirmed STEMI Only dataset: Accuracy: 92.4%; Sensitivity: 93.4%; Specificity: 91.4% (Figure 1).
Conclusion
By assiduously improving the quality of the model's input, we continue to assess our algorithm's performance and reliability for future clinical validation as a potential remote monitoring and early STEMI detection device.
Funding Acknowledgement
Type of funding sources: None.
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Bunting KV, Mehta S, Gill SK, Steeds RP, Kotecha D. Digoxin improves systolic cardiac function in patients with AF and HFpEF: the RATE-AF randomised trial. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
The RAte control Therapy Evaluation in permanent AF trial (RATE-AF; NCT02391337) was the first head-to-head controlled trial of beta-blockers versus digoxin in patients with permanent atrial fibrillation (AF) and symptoms of heart failure. Patients randomised to digoxin had similar physical-related quality of life and heart rate, with significantly improved functional class, reduced N-terminal pro-brain natriuretic peptide (NT-proBNP) and substantially less adverse events. The impact of rate control therapy on measures of cardiac function is not currently understood.
Purpose
To compare the effect of digoxin versus beta-blockers on systolic and diastolic cardiac function according to heart failure sub-type.
Methods
Blinded echocardiograms assessing systolic and diastolic function were performed at baseline and 12 month follow-up, using a robust method to account for rhythm irregularity (average of three index-beats acquired in appropriate cardiac cycles). Outcomes were the change in left-ventricular ejection fraction (LVEF), systolic tissue Doppler velocity (s'), stroke volume, global longitudinal strain (GLS), diastolic tissue Doppler (e'), mitral E wave deceleration time, E/e', pulmonary vein diastolic deceleration time, isovolumic relaxation time and left atrial ejection fraction. Analyses were stratified by baseline LVEF (≥50%, 40–50% and <40%).
Results
160 patients were randomised, of which 145 patients survived to 12-month follow-up with median age 75 years (IQR 69–82) and 44% women. Median baseline heart rate was 96 beats/min (IQR 86–112), blood pressure 135/85 mmHg (IQR 124/77–146/91), NTproBNP 1049 pg/mL (744–1463) and mean NYHA class 2.4 (SD 0.6). In 119 patients with LVEF ≥50% at baseline, diastolic and systolic parameters improved over time with digoxin therapy. There was a significantly greater improvement in systolic function in 63 patients on digoxin compared to 67 with beta-blockers; Figure 1. Patients randomised to digoxin had a higher LVEF at follow-up (adjusted mean difference [AMD] 2.3%, 95% CI 0.3–4.2; p=0.021), higher s' (1.1cm/s, 1.0–1.2; p=0.003) and higher stroke volume (6.5mL, 0.4–12.6; p=0.037) compared to beta-blockers, without any difference in diastolic parameters (Figure 2). In 16 patients with LVEF 40–50% at baseline, s' significantly increased with digoxin compared to beta-blockers (AMD 1.5 cm/s, 1.2–1.7; p=0.001), with no difference for other systolic or diastolic parameters. 10 patients with LVEF <40% at baseline showed no difference between digoxin and beta-blockers for any echocardiographic measures.
Conclusion
Patients randomised to digoxin with permanent AF, heart failure symptoms and preserved LVEF have significantly greater improvement in multiple parameters of systolic function compared to conventional treatment with beta-blockers.
Funding Acknowledgement
Type of funding sources: Public Institution(s). Main funding source(s): National Institute of Health Research
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Mehta S, Vieira D, Zerpa D, Guillen V, Gonzalez A, Brena-Pastor L, Siyam T, Stoica S, Ozair S, Pinos D, Martinez F, Fleming M, Carrera K, Rossitto F, Whuking C. Performance metrics of AI-enhanced single lead EKG maintained after entry of organised clustered data. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Our experience in creating innovative Artificial Intelligence-guided single lead EKG methodologies for ST-Elevation Myocardial Infarction (STEMI) detection within complex EKG records has been previously validated.
Purpose
By expanding the intricate variables of our previously tested algorithm input, we seek to further improve our STEMI detecting tool.
Methods
11,567 12-lead EKG records (10-s length, 500 Hz sample frequency) derived from the Latin America Telemedicine Infarct Network database from April 2014 to December 2019. From these records, we included the following balanced classes: angiographically confirmed and unconfirmed STEMI (divided by wall affected), branch blocks, non-specific ST-T changes, normal, and abnormal (Remaining 200+ CPT codes). Cardiologist annotations ensured precision (Ground truth). Determined classes were “STEMI” and “Not-STEMI”. A 1-D Convolutional Neural Network model was trained and tested for each lead with dataset proportions of 90/10, respectively. The last dense layer outputs a probability for each record being STEMI/Not-STEMI. The analysis also included performance metrics and false-negative reports.
Results
Overall, the most promising Single lead for STEMI detection was V2 (91.2% Accuracy, 89.6% Sensitivity, and 92.9% Specificity). 55% of false negatives were inferior wall STEMI (Table 1).
Conclusion
Appreciable progress of our new methodology compared to our previous experiences in AI-guided Single Lead for STEMI detection, especially for lead V2. By performing a thorough analysis of false-negative reports, we aspire to identify potential areas of STEMI detection weakness which will become the focus of future ventures.
Funding Acknowledgement
Type of funding sources: None.
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Mehta S, Vieira D, Zerpa D, Guillen V, Carrasquel M, Ramadan S, Martinez F, Rossitto F, Carrera K, Fleming M, Pinos D, Brena-Pastor L, Ozair S, Gonzalez A, Barco A. No need for a cardiologist for AMI diagnosis – progress of transforming a behemoth telemedicine program with artificial intelligence. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
The Latin American Telemedicine Infarct Network (LATIN) Telemedicine is a mammoth hub and spoke model that provides an umbrella of AMI protection for 100 million patients. In the program, 826,043 patients had a telemedicine encounter; 7,400 with AMI were diagnosed; 4,332 of them managed with guidelines-based strategies. We have gradually begun implementing a system for using Artificial Intelligence (AI) algorithms embedded into EKGs for rapid and accurate STEMI detection and validated the results with a cardiologist's interpretations.
Purpose
To test whether an AI-driven EKG algorithm can effectively substitute a cardiologist for STEMI telemedicine protocols.
Methods
The AI algorithm construction was in the following fashion. Sample: a selection of 8,511 EKG and 90,592 classified heartbeats. Pre-processing: segmentation of each EKG into individual heartbeats. Training & testing: 90% and 10% of the total dataset, respectively. Classification: 1-D Convolutional Neural Network; the study constructed classes for each heartbeat. The algorithm was next deployed on a consecutive series of LATIN EKG records to diagnose STEMI. We afterwards compared the algorithm's results with eight expert cardiologists' interpretations of the same sample.
Results
This study achieved a concordance of 91% between the AI algorithm and cardiologist interpretation (Figure 1).
Conclusions
The initial results with AI algorithms for STEMI diagnosis are encouraging and may provide the base work for new tools for cardiologists to improve their efficiency. Moreover, implementing this innovative tool may overcome current limitations associated with the telemedical management of this disease.
Funding Acknowledgement
Type of funding sources: None.
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Mendieta Badimon G, Mehta S, Baber U, Collier T, Dangas G, Sharma SK, Cohen DJ, Angiolillo D, Briguori C, Escaned J, Gabriel Steg P, Huber K, Michael Gibson C, Pocock S, Mehran R. Effect of aspirin discontinuation according to individualised patient bleeding and ischemic risks after PCI: a TWILIGHT trial sub-analysis. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
The TWILIGHT trial demonstrated a reduction in BARC 2, 3 or 5 (BARC-235) bleeding without an increase in ischemic events at 1-year in high-risk PCI patients randomized to placebo or aspirin (ASA) on a background of ticagrelor 3-months after PCI. However, the effect of ASA discontinuation according to baseline risk of bleeding and ischemic events remain unclear.
Purpose
To a) develop separate models to predict the risk of bleeding and ischemic events, and b) to assess treatment effect of ASA discontinuation across the risk strata.
Methods
Using the TWILIGHT patient database (N=7,119), two multivariable models, one for BARC-235 bleeding and one for CV death, nonfatal MI or nonfatal ischemic stroke (ischemic endpoint) were developed, and their predictive capacity was assessed. The effect of randomized treatment on bleeding and ischemic events across different patient risk-group categories as determined by the risk scores was investigated.
Results
At 1-year, 350 (5.4%) patients experienced a BARC-235 bleeding event and 258 (3.6%) experienced an ischemic event. Independent predictors of BARC-235 included haemoglobin levels at index PCI, proton-pump inhibitor non-use at discharge, age, liver disease and active smoking (c-statistic 0.64). Independent predictors of the ischemic outcome included a positive troponin ACS, prior CABG, diabetes, age, peripheral artery disease, prior PCI, a history of congestive heart failure, active smoking, the level of index PCI complexity, and prior MI (c-statistic 0.71). The risk of a BARC-235 almost doubled between patients in lower versus higher bleeding risk categories (4.3% versus 7.9%) and ischemic risk more than tripled between patients in lower versus higher ischemic risk categories (2.0% versus 7.0%) (see Figure 1). There was no evidence of a differential treatment effect for dual antiplatelet therapy versus ticagrelor monotherapy across the different risk categories of bleeding (interaction P=0.54) and ischemic risk (interaction P=0.95) (Table 1).
Conclusion
Individual patient bleeding and ischemic risks after PCI can both be readily characterised with good discrimination. The effect of ASA discontinuation in preventing bleeding in ticagrelor-treated patients was consistent regardless of baseline bleeding risk. There was no evidence for increased ischemic events with ASA discontinuation according to baseline ischemic risk.
Funding Acknowledgement
Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): AstraZenecaIcahn School of Medicine at Mount Sinai
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