Why, When and How Should Clinicians Use Physiology in Patients with Acute Coronary Syndromes?

Current data support the use of coronary physiology in patients with acute coronary syndrome (ACS). In patients with ST-elevation MI, the extent of myocardial damage and microvascular dysfunction create a complex conundrum to assimilate when considering clinical management and risk stratification. In this setting, the index of microcirculatory resistance emerged as an accurate tool to identify patients at risk of suboptimal myocardial reperfusion after primary percutaneous coronary intervention who may benefit from novel adjunctive therapies. In the context of non-ST-elevation ACS, coronary physiology should be carefully interpreted and often integrated with intracoronary imaging, especially in cases of ambiguous culprit lesion. Conversely, the functional assessment of bystander coronary disease is favoured by the available evidence, aiming to achieve complete revascularisation. Based on everyday clinical scenarios, the authors illustrate the available evidence and provide recommendations for the functional assessment of infarct-related artery and non-culprit lesions in patients with ACS

Gender Disparities in Authorships and Citations in Transplantation Research

Background: Over the past decades, there has been a rapid change in the gender ratio of medical doctors, whereas gender differences in academia remain apparent. In transplantation research, a field already understaffed with female doctors and researchers, there is little published data on the development in proportion, citations, and funding of female researchers over the past years. Methods: To evaluate the academic impact of female doctors in transplantation research, we conducted a bibliometric analysis (01 January 1999 to 31 December 2018) of high-impact scientific publications, subsequent citations, and funding in this field. Web of Science data was used in combination with software R-Package "Gender," to predict gender by first names. Results: For this study, 15 498 (36.2% female; 63.8% male) first and 13 345 (30.2% female; 69.8% male) last author gender matches were identified. An increase in the percentage of female first and last authors is seen in the period 1999-2018, with clear differences between countries (55.1% female authors in The Netherlands versus 13.1% in Japan, for example). When stratifying publications based on the number of citations, a decline was seen in the percentage of female authors, from 34.6%-30.7% in the first group (≤10 citations) to 20.8%-23.2% in the fifth group (>200 citations), for first (P < 0.001) and last (P = 0.014) authors, respectively. From all first author name-gender matches, 6574 (41.6% female; 58.4% male, P < 0.001) publications reported external funding, with 823 (35.5% female; 64.5% male, P = 0.701) reported funding by pharmaceutical companies and 1266 (36.6% female; 63.4% male, P < 0.001) reporting funding by the National Institutes of Health. Conclusions: This is the first analysis of gender bias in scientific publications, subsequent citations, and funding in transplantation research. We show ongoing differences between male and female authors in citation rates and rewarded funding in this field. This requires an active approach to increase female representation in research reporting and funding rewarding

The Effect of Frailty on Outcome After Vascular Surgery

OBJECTIVES: Frailty is a state of increased vulnerability and is a stronger predictor for post-operative outcome than age alone. The aim of this study was to determine whether frailty is associated with adverse 30 day outcome in vascular surgery patients. METHODS: This was a prospective cohort study. All electively operated vascular surgery patients between March 2010 and October 2017 (n = 1201), aged ≥ 60 years were evaluated prospectively. Exclusion criteria were arteriovenous access surgery, percutaneous interventions and minor amputations, resulting in 825 patients for further analysis whereas 195 had incomplete data on Groningen Frailty Indicator (GFI) and were excluded. Frailty was measured using the GFI, a screening tool covering 16 items in the domains of functioning. Patients with a total score of ≥4 were classified as frail. The primary outcome parameter was 30 day morbidity (based on the Comprehensive Complication Index). Secondary outcome measures were 30 day mortality, hospital readmission, and type of care facility after discharge. Outcomes were adjusted for sex, body mass index, smoking status, hypertension, Charlson Comorbidity Index, and type of intervention. RESULTS: There was an unequal sex distribution (77.6% male). The mean age was 72.1 years. One hundred and eighty-four patients (22.3%) were considered frail. The mean Comprehensive Complication Index was 8.5. Frail patients had a significantly higher Comprehensive Complication Index (3.7 point increase, p = .005). Patients with impaired cognition and reduced psychosocial condition, two domains of the GFI, had a significantly higher Comprehensive Complication Index. Also, the 30 day mortality rate was higher in frail patients (2.7 point increase; p = .05), and they were discharged to a care facility more often (7.7 point increase; p < .001). There was no significant difference in readmission rates between frail and non-frail patients. CONCLUSIONS: Frailty is associated with a higher risk of post-operative complications and discharge to a nursing home after vascular surgery. Some frailty domains (mobility, nutrition, cognition and psychosocial condition) appear to have a more pronounced impact

Role of pre-operative frailty status in relation to outcome after carotid endarterectomy:a systematic review

Carotid endarterectomy (CEA) is a surgical treatment option to prevent ischemic cerebrovascular accidents. Patients that present with pre-operative frailty might have an elevated risk for unfavorable outcomes after the CEA. A systematic search, using Medline, Embase, Web of Science and Cochrane Database, was performed for relevant literature on frailty in patients undergoing CEA. The study protocol was registered with PROSPERO (CRD42020190345). Eight articles were included. The pooled prevalence for pre-operative frailty was 23.9% (95% CI: 12.98-34.82). A difference in the incidence of complications between frail and non-frail patients (6.4% vs. 5.2%, respectively) and a difference in hospital length of stay [2 (IQR: 2-3) days vs. 1 (IQR: 1-2) day, respectively] were described. The 30-day mortality after CEA was 0.6% for non-frail patients, 2.6% for frail patients, and 4.9% for very frail patients (P 0.001). For 3-year mortality, a 1.5-fold increased risk was found for frail patients (OR 1.7, 95% CI: 1.4-2.0) and a &gt;2.5-fold increased risk for very frail patients (OR 2.6, 95% CI: 2.2-3.1). In conclusion, this review shows the impact of frailty on outcome after CEA. Pre-operative frailty assessment with a validated, multi-domain tool should be implemented in the clinical setting as it will provide information on post-operative surgical outcomes and mortality risk but also frailty trajectory and cognitive decline.</p

The effect of immunomodulatory drugs on aortic stenosis: a Mendelian randomisation analysis

There are currently no approved pharmacological treatment options for aortic stenosis (AS), and there are limited identified drug targets for this chronic condition. It remains unclear whether inflammation plays a role in AS pathogenesis and whether immunomodulation could become a therapeutic target. We evaluated the potentially causal association between inflammation and AS by investigating the genetically proxied effects of tocilizumab (IL6 receptor, IL6R, inhibitor), canakinumab (IL1β inhibitor) and colchicine (β-tubulin inhibitor) through a Mendelian randomisation (MR) approach. Genetic proxies for these drugs were identified as single nucleotide polymorphisms (SNPs) in the gene, enhancer or promoter regions of IL6R, IL1β or β-tubulin gene isoforms, respectively, that were significantly associated with serum C-reactive protein (CRP) in a large European genome-wide association study (GWAS; 575,531 participants). These were paired with summary statistics from a large GWAS of AS in European patients (653,867 participants) to then perform primary inverse-variance weighted random effect and sensitivity MR analyses for each exposure. This analysis showed that genetically proxied tocilizumab was associated with reduced risk of AS (OR 0.56, 95% CI 0.45–0.70 per unit decrease in genetically predicted log-transformed CRP). Genetically proxied canakinumab was not associated with risk of AS (OR 0.80, 95% CI 0.51–1.26), and only one suitable SNP was identified to proxy the effect of colchicine (OR 34.37, 95% CI 1.99–592.89). The finding that genetically proxied tocilizumab was associated with reduced risk of AS is concordant with an inflammatory hypothesis of AS pathogenesis. Inhibition of IL6R may be a promising therapeutic target for AS management

Variation in emergency percutaneous coronary intervention in ventilated patients in the UK: insights from a national database

Aims Pre-procedural ventilation is a marker of high risk in PCI patients. Causes include out-of-hospital cardiac arrest (OHCA) and cardiogenic shock. OHCA occurs in approximately 60,000 patients in the UK per annum. No consensus exists regarding the need/timing of coronary angiography ± revascularization without ST elevation. The aim was to describe the national variation in the rate of emergency PCI in ventilated patients. Methods and Results Using the UK national database for PCI in 2013, we identified all procedures performed as ‘emergency’ or ‘salvage’ for whom ventilation had been initiated before the PCI. Of the 92,589 patients who underwent PCI, 1342 (5.5%) fulfilled those criteria. There was wide variation in practice. There was no demonstrable relationship between the number of emergency PCI patients with pre-procedure ventilation per annum and (i) total number of PPCIs in a unit (r = −0.186), and (ii) availability of 24 h PCI, (iii) on-site surgical cover. Conclusion We demonstrated a wide variation in practice across the UK in rates of pre-procedural ventilation in emergency PCI. The majority of individuals will have suffered an OHCA. In the absence of a plausible explanation for this discrepant practice, it is possible that (a) some patients presenting with OHCA that may benefit from revascularization are being denied treatment and (b) procedures may be being undertaken that are futile. Further prospective data are needed to aid in production of guidelines aiming at standardized care in OHCA

Surveys in Surgical Education:A Systematic Review and Reporting Guideline

Objectives: Survey studies are a commonly used method for data collection in surgical education research. Nevertheless, studies investigating survey design and response rates in surgical education research are lacking. The aim of this study was to gain an insight into survey response rates among surgical residents and medical students, and provide an initial reporting guideline for future survey studies in this field.Design: PubMed (MEDLINE) was systematically searched for survey studies in surgical education from January 2007 until February 2020, according to the PRISMA statements checklist. Study selection was conducted by 2 authors, independently. Surveys directed at surgical residents and/or medical students were included if data on response rates was available. Studies reporting solely from nonsurgical fields of medicine, paramedicine, or nursing were excluded. Subgroup analyses were performed, comparing response rates for varying modes of survey, per country, and for the 10 journals with the most identified surveys.Results: From the 5,693 records screened for a larger surgical survey database, a total of 312 surveys were included; 173 studies focused on surgical residents and 139 on medical students. The mean (SD) response rate was 55.7% (24.7%) for surgical residents and 69.0% (20.8%) for medical students. The number of published surveys increased yearly, mostly driven by an increase in surgical resident surveys. Although most surveys were Web-based (n = 166, 53.2%), this survey mode resulted in the lowest response rates (mean 52.6%). The highest response rates, with a mean of 79.8% (13.1%), were seen in in-person surveys (n = 89, 28.5%). Wide variations in response rates were seen between different countries and journals.Conclusions: Web-based surveys are gaining popularity for medical research in general and for surgical education specifically; however, this mode results in lower response rates than those of in-person surveys. The response rate of in-person surveys is especially high when focusing on medical students. To improve reporting of survey studies, we present the first step towards a reporting guideline.</p

Risk Factors for Delirium after Vascular Surgery:A Systematic Review and Meta-Analysis

Background: Vascular surgery is considered a risk factor for the development of postoperative delirium (POD). In this systematic review we provide a report on the incidence and risk-factors of POD after vascular surgery. Methods: A systematic literature search was conducted using Pubmed with the MeSH terms and key words "delirium" or "confusion", "vascular surgery procedures" and "risk factors or "risk assessment". Studies were selected for review after meeting the following inclusion cr iter ia: vascular surgery, POD diagnosed using validated screening tools, and DSM-derived criteria to assess delirium. A meta-analysis was performed for each endpoint if at least two studies could be combined. Results: Sixteen articles met the abovementioned cr iter ia. The incidence of delir ium ranged from 5% to 39%. Various preoperative risk factors were identified that is, age (Random MD 3.96, CI 2.57-5.35), hypertension (Fixed OR 1.30, CI 1.05-1.59), diabetes mellitus (Random OR 2.15, CI 1.30-3.56), hearing impairment (Fixed OR 1.89, CI 1.28-2.81), history of cerebrovascular incident or transient ischemic attack (Fixed OR 2.20, CI 1.68-2.88), renal failure (Fixed OR 1.61, CI 1.19-2.17), and pre-operative low haemoglobin level (fixed MD-0.76, CI-1.04 to-0.47). Intra-operative risk factors were duration of surgery (Random MD 15.68; CI 2.79-28.57), open aneurysm repair (Fixed OR 4.99, CI 3.10-8.03), aortic cross clamping time (fixed MD 7.99, CI 2.56-13.42), amputation surgery (random OR 3.77, CI 2.13-6.67), emergency surgery (Fixed OR 4.84, CI 2.81-8.32) and total blood loss (Random MD 496.5, CI 84.51-908.44) and need for blood transfusion (Random OR 3.72, CI 1.57-8.80). Regional anesthesia on the other hand, had a protective effect. Delirium was associated with longer ICU and hospital length of stay, and more frequent discharge to a care facility. Conclusions: POD after vascular surgery is a frequent complication and effect-size pooling supports the concept that delirium is a heterogeneous disorder. The risk factors identified can be used to either design a validated risk factor model or individual preventive strategies for high-risk patients