Chelsea and Westminster Hospital NHS Foundation Trust

Increasingly, people attending HIV services are requesting long-acting injectable (LAI) antiretroviral treatment (ART). However, without HIV RNA resistance-associated mutation results, individuals are considered unsuitable for LAI ART. We present our experience of sequencing proviral HIV DNA in 30 individuals to inform suitability for LAI ART, of whom 23 were considered suitable. In conclusion, optimization of diagnostic tools such as proviral HIV DNA sequencing to confirm suitability for LAI ART would be a welcome addition.

Background There has been a recent rapid growth in the adoption of robotic systems across Europe. This study aimed to capture the current state of robotic training in gastrointestinal (GI) surgery and to identify potential challenges and barriers to training within Europe. Methods A pan-European survey was designed to account for the opinion of the following GI surgery groups: (i) experts/independent practitioners; (ii) trainees with robotic access; (iii) trainees without robotic access; (iv) robotic industry representatives. The survey explored various aspects, including stakeholder opinions on bedside assisting, console operations, challenges faced and performance assessment. It was distributed through multiple European surgical societies and industry, in addition to social media and snowball sampling, between December 2023 and March 2024. Results A total of 1360 participants responded, with valid/complete responses from 1045 participants across 38 European countries. Six hundred and ninety-five (68.0%) experts and trainees were not aware of a dedicated robotic training curriculum for trainees, with 13/23 (56.5%) industry representatives not incorporating training for trainees in their programme. Among trainees with access to robotic systems, 94/195 (48.2%) had not performed any robotic cases, citing challenges including a lack of certified robotic trainers and training lists. Both experts and trainees agreed that trainees should start bedside assisting and operating on the console earlier than they currently do. Assessment tools of trainee performance were not being used by 139/479 (29.0%) participants. Conclusion This pan-European survey highlights the need for a standardised robotic curriculum to address the gap in visceral training, assessment and certification. A greater emphasis may be required on implementing robotic training earlier through simulation training, dual console learning, bedside assisting, key clinical performance indicators, and assessment tools. The findings will guide the development of a pan-European consensus on the essential components of a comprehensive training programme for GI robotic surgery.

Objectives In England, infectious syphilis diagnoses have reached the highest annual number since 1948. Fifty per cent of syphilis testing is now provided through online postal self-sampling sexually transmitted infection (STI) testing services (OPSS). To reduce the burden of syphilis, we need to understand the syphilis prevalence and transition to treatment rates among service users of OPSS. This report aims to estimate syphilis prevalence among people accessing Sexual Health London (SHL), a regional, National Health Service (NHS)-funded OPSS. Methods Demographic, STI concurrency, sexual behaviour data and case outcomes were collected from SHL service users who received testing for syphilis between 8 March 2022 and 30 June 2023. Data were analysed to identify syphilis prevalence and transition to care rates. Results 458 520 syphilis tests were performed for 267 780 service users. 12 870 (2.8%) results were reactive. Their assigned case outcomes comprised: 10 048 (78.1%) past adequately treated syphilis; 971 (7.5%) treated for active syphilis; 1293 (10.1%) SHL results did not subsequently confirm and 558 (4.3%) had an unknown final outcome. Of unique users, 0.4% (940/267 780) received syphilis treatment at least once. They were: 89.3% aged ≥25 years, 87.3% male, 83.7% gay/bisexual. Co-infections identified were: chlamydia (14%), gonorrhoea (13.3%) and previously undiagnosed HIV (1.5%). 36.1% (339) took pre-exposure HIV prophylaxis, 30.1% engaged in sex parties/group sex and 26.8% had sex under the influence of drugs/alcohol. Individuals aged ≥35 years, of non-female gender, gay/bisexual, from indices of multiple deprivation (1–5) and from certain racially minoritised communities were statistically more likely to require treatment for syphilis than the overall testing population (p<0.05). Conclusion Estimated syphilis prevalence (0.4%) was comparable to rates within national sexual health clinics and the demographic characteristics of those most affected by syphilis were also similar. Further work is required to improve the integration between NHS OPSS and sexual health clinics and to enable OPSS to more accurately input data on treatment and diagnoses towards national surveillance statistics.

Introduction The evolving landscape of inflammatory bowel disease (IBD) necessitates refining colonoscopic surveillance guidelines. This study outlines methodology adopted by the British Society of Gastroenterology (BSG) Guideline Development Group (GDG) for updating IBD colorectal surveillance guidelines. Methods and analysis The ‘Grading of Recommendations, Assessment, Development and Evaluation’ (GRADE) approach, as outlined in the GRADE handbook, was employed. Thematic questions were formulated using either the ‘patient, intervention, comparison and outcome’ format or the ‘current state of knowledge, area of interest, potential impact and suggestions from experts in the field’ format. The evidence review process included systematic reviews assessed using appropriate appraisal tools. An extensive list of potential outcomes was compiled from literature and expert consultations and then ranked by GDG members. The top outcomes were identified for evidence synthesis in three key areas: utility of surveillance in IBD, quality of bowel preparation and use of advanced imaging techniques in colonoscopy for IBD. Risk thresholding exercises determined specific risk levels for different surveillance strategies and intervals. This approach enabled the GDG to establish precise thresholds for interventions based on relative and absolute risk assessments, directly informing the stratification of surveillance recommendations. Significance of effect sizes (small, moderate, large) will guide the final GRADE assessment of the evidence. Ethics and dissemination Ethics approval is not applicable. By integrating clinical expertise, patient experiences and innovative methodologies like risk thresholding, we aim to deliver actionable recommendations for IBD colorectal surveillance. This protocol, complementing the main guidelines, offers GDGs, clinical trialists and practitioners a framework to inform future research and enhance patient care and outcomes.

Background We aimed to provide insights into the effects of comorbidities on sleep health in people with HIV by assessing associations between multimorbidity patterns and sleep outcomes in the Pharmacokinetic and clinical Observations in PeoPle over fiftY (POPPY) sub-study. Methods Principal component analysis identified six multimorbidity patterns among participants with HIV (n = 1073) at baseline: Cardiovascular diseases (CVDs), Sexually transmitted diseases, Metabolic, Mental/Joint, Neurological and Cancer/Other. Burden z-scores were calculated for each individual/pattern. A subset of 478 participants completed sleep assessments at follow-up, including questionnaires (Insomnia Severity Index [ISI], Patient-Reported Outcomes Measurement Information System [PROMIS] Sleep Disturbance [SD] and Sleep Related Impairment [SRI]) and overnight oximetry (4% oxygen desaturation index [ODI] and percentage of time with oxygen saturation [SpO2] <90%). Multivariable regression assessed associations between burden z-scores and sleep measures. Results Amongst 309 participants (median [interquartile range] age 53 [47–59] years), 21% had insomnia (ISI≥15). Higher Mental/Joint z-scores were associated with increased odds of insomnia (aOR 1.06 [95%CI 1.03, 1.09]) and worse PROMIS-SRI (1.34 [1.22, 1.48]) and PROMIS-SD (1.27 [1.16, 1.39]) scores. Higher Metabolic and Neurological z-scores were associated with worse PROMIS-SRI scores (p < 0.01). Higher CVDs z-scores were associated with worse ISI and PROMIS-SRI scores, and a higher percentage of time with Sp02 below 90% (all p's < 0.01). Conclusion This study is among the first to describe specific multimorbidity patterns linked to poorer sleep outcomes in people with HIV. Findings suggest the need for targeted sleep interventions based on multimorbidity profiles, which may mitigate broader health risks associated with poor sleep.

Objective In screening for small‐for‐gestational age ( SGA ) using third‐trimester antenatal ultrasound, there are concerns about the low detection rates and potential for harm caused by both false‐negative and false‐positive screening results. Using a selective third‐trimester ultrasound screening program, this study aimed to investigate the incidence of adverse perinatal outcomes among cases with (i) false‐negative compared with true‐positive SGA diagnosis and (ii) false‐positive compared with true‐negative SGA diagnosis. Methods This prospective cohort study was nested within the UK ‐based DESiGN trial, a prospective multicenter cohort study of singleton pregnancies without antenatally detected fetal anomalies, born at > 24 + 0 to < 43 + 0 weeks' gestation. We included women recruited to the baseline period, or control arm, of the trial who were not exposed to the Growth Assessment Protocol ( GAP ) intervention and whose birth outcomes were known. Stillbirth and major neonatal morbidity were the two primary outcomes. Minor neonatal morbidity was considered a secondary outcome. Suspected SGA was defined as an estimated fetal weight ( EFW ) < 10 th percentile, based on the Hadlock formula and fetal growth charts. Similarly, SGA at birth was defined as birth weight ( BW ) < 10 th percentile, based on UK population references. Maternal and pregnancy characteristics and perinatal outcomes were reported according to whether SGA was suspected antenatally or not. Unadjusted and adjusted logistic regression models were used to quantify the differences in adverse perinatal outcomes between the screening results (false negative vs true positive and false positive vs true negative). Results In total, 165 321 pregnancies were included in the analysis. Fetuses with a false‐negative SGA screening result, compared to those with a true‐positive result, were at a significantly higher risk of stillbirth (adjusted OR ( aOR ), 1.18 (95% CI , 1.07–1.31)), but at lower risk of major ( aOR , 0.87 (95% CI , 0.83–0.91)) and minor ( aOR , 0.56, (95% CI , 0.54–0.59)) neonatal morbidity. Compared with a true‐negative screening result, a false‐positive result was associated with a lower BW percentile (median, 18.1 (interquartile range ( IQR ), 13.3–26.9)) vs 49.9 ( IQR , 30.3–71.7)). A false‐positive result was also associated with a significantly increased risk of stillbirth ( aOR , 2.24 (95% CI , 1.88–2.68)) and minor neonatal morbidity ( aOR , 1.60 (95% CI , 1.51–1.71)), but not major neonatal morbidity ( aOR , 1.04 (95% CI , 0.98–1.09)). Conclusions In selective third‐trimester ultrasound screening for SGA , both false‐negative and false‐positive results were associated with a significantly higher risk of stillbirth, when compared with true‐positive and true‐negative results, respectively. Improved SGA detection is needed to address false‐negative results. It should be acknowledged that cases with a false‐positive SGA screening result also constitute a high‐risk population of small fetuses that warrant surveillance and timely birth. © 2024 The Author(s). Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

In perinatal medicine, the number of babies with life-limiting or life-threatening conditions is increasing and the benefits of providing palliative care with a holistic, interdisciplinary approach are well documented. It can be particularly challenging, however, to integrate palliative care into routine care where there exists uncertainty about a baby’s diagnosis or potential outcome. This framework, developed collaboratively by the British Association of Perinatal Medicine (BAPM) and the Association of Paediatric Palliative Medicine (APPM), offers supportive guidance for all healthcare professionals working in perinatal medicine across antenatal and neonatal services. It explicitly acknowledges that palliative care is not just for babies who are dying or who will certainly die in early life; incorporating a palliative approach into antenatal and neonatal care for all babies with an uncertain outcome can be particularly valuable. The framework provides guidance on recognising babies who may benefit from palliative care and outlines the key elements of perinatal palliative care: holistic family support, empowering parents to be parents, parallel planning, symptom management and loss and bereavement care. It provides recommendations for the delivery of palliative care services, advocating for a unified approach that involves all members of the perinatal team, supported by specialist services as needed. This framework calls for a shift in the philosophy and practice of perinatal care to integrate palliative care into the everyday and to recognise and embrace the challenge of uncertain prognosis.

Emotional intelligence (EQ) in healthcare leadership has been a subject of debate regarding its significance in enhancing job performance and patient-centred care. This systematic review investigates the impact of EQ on organisational performance metrics in healthcare leaders. Eleven studies meeting the inclusion criteria were identified through a comprehensive database search. The findings suggest that EQ positively influences job satisfaction, with emotionally intelligent leaders fostering a positive work environment and commitment among employees. Moreover, EQ correlates negatively with emotional exhaustion, indicating its potential in mitigating burnout rates among healthcare professionals. EQ fosters teamwork, organisational culture and enhances job performance, with higher EQ levels in leaders associated with increased team empowerment and proactivity. Despite the compelling evidence, limitations in the study methodologies and heterogeneity in the reported outcomes challenge the establishment of definitive conclusions. Nevertheless, the findings underscore the importance of EQ in healthcare leadership and its potential to improve organisational dynamics and employee wellbeing. This review highlights the need for further research on EQ’s impact on patient satisfaction and calls for the development of EQ training programmes tailored for healthcare leaders.

Introduction Vaccine-preventable respiratory infections (VPRI) including those caused by Streptococcus pneumoniae, influenza, respiratory syncytial virus and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pose substantial challenges to health and social care systems. In the UK, routine adult respiratory vaccination programs are in place. The objective of this article is to review the current evidence on the impact of four seasonal VPRIs in adults risk group definitions and to explore the strengths and limitations of current recommendations, and to identify evidence gaps for further research. Areas covered Relevant evidence on UK data from surveillance systems, observational studies and publicly available government documents is collated and reviewed, as well as selected global data. Expert opinion Disparities exist between adult risk group categories for different respiratory vaccination programs as defined in the current vaccination guidance. The burden of multiple respiratory pathogens signifies importance of routine multi-pathogen testing with the need for a resilient and large-scale national surveillance system. Further understanding of epidemiological trends and disease burden will help guide decision-making and planning of targeted strategies for disease prevention and control. Addressing inequalities in disease burden and vaccine coverage particularly in clinical risk groups, and promoting equitable vaccine access remain a priority.

Background The ileal pouch-anal anastomosis (IPAA) is a restorative procedure performed after proctocolectomy to improve quality of life in patients with colorectal conditions like ulcerative colitis, familial adenomatous polyposis, and selected cases of Crohn’s disease and Lynch syndrome. However, severe pouch dysfunction can occur, often necessitating further surgical intervention. Objective This technical note aims to describe the operative approach and perioperative management for diverting ileostomy as a treatment for dysfunctional ileoanal pouches. Methods Indications for the procedure include complications such as pelvic sepsis, pouchitis, fistulas, and Crohn’s disease of the pouch. Preoperative planning involves a multidisciplinary team, stoma site marking, and imaging to assess bowel integrity. The surgical technique utilizes laparoscopic access with careful adhesiolysis to minimize bowel injury, with intraoperative pouchoscopy to identify anatomical landmarks. An ileostomy is created by selecting a tension-free small bowel segment and approximating it to a pre-marked stoma site. Attention is given to preserving bowel length to allow for potential future restorative procedures. Postoperative care focuses on stoma management and addressing ongoing pouch dysfunction symptoms. Conclusions Diverting ileostomy offers symptom relief for patients with pouch dysfunction while avoiding more complex procedures like pouch excision. It is a valuable option in managing pouch failure.

Background Radical prostatectomy (RP) represents the cornerstone of surgical treatment for prostate cancer. Assessing surgical margin status intraoperatively with current techniques remains challenging due to high costs in the context of an already stretched pathology workforce. Fluorescence confocal microscopy (FCM) is a promising technique to detect margins in prostate cancer surgery not bound by such limitations. Study Design The Imperial Prostate 8 – Fluorescence Confocal Microscopy for Rapid Evaluation of Surgical Cancer Excision (IP8‐FLUORESCE) study is a multicentre, prospective, ex vivo, ‘blinded’, comparative cohort study. It aims to assess the accuracy of digital FCM for detection of prostate cancer at surgical margins compared to traditional histopathology. Endpoints The primary endpoint is the accuracy of digital FCM for detection of prostate cancer at surgical margins on a per‐patient level, reported with sensitivity, specificity, positive and negative predictive values. Patients and Methods A total of 153 patients with localised prostate cancer undergoing robot‐assisted RP across three UK National Health Service tertiary referral centres will be recruited. Following RP, prostate specimens will undergo immediate immersion in Acridine Orange solution, scanning ‘en face’ with FCM using the Histolog® Scanner, and subsequent formalin fixation and paraffin embedding. Two independent, ‘blinded’ uro‐pathologists will report both the FCM images and the histopathology slides. Recruitment commenced on 17 August 2023.

Introduction People with HIV currently face a tenfold higher risk of developing cardiovascular disease (CVD) than those without HIV. Studies have shown various off‐target effects of antiretroviral treatment (ART) on the cardiovascular system, but little is known about the effects of currently used integrase strand transfer inhibitors (INSTIs) on platelets. Platelet activation is associated with increased CVD, thrombus formation, and release of proinflammatory mediators, so exploring platelet effects from currently prescribed ART may contribute to the understanding of CVD etiopathogenesis in people with HIV. Methods We aimed to identify potential effects of INSTIs on platelet aggregation and activation markers from individuals without HIV after in vitro treatment with clinically relevant drug concentrations. We used bictegravir (BIC) and dolutegravir (DTG) individually or in the therapeutic drug combinations BIC/emtricitabine (FTC)/tenofovir alafenamide fumarate (TAF) or DTG/lamivudine (3TC). Additionally, we conducted a pilot study to compare platelet activity profiles from people with HIV on BIC/FTC/TAF and DTG/3TC. Results Changes to in vitro platelet aggregation responses upon exposure to different INSTIs were observed both upon individual drug application and when using therapeutic combinations. However, these effects were not reflected in flow‐cytometric evaluation of platelet degranulation. A pilot study in eight people with HIV and eight without HIV revealed no significant effects but established protocols for future patient studies. Conclusion There is currently no consistent evidence of an effect of INSTIs on platelet activation. Further study is warranted, focusing on models with more pathophysiological relevance, including extensive studies in people with HIV.

BACKGROUND Subtle, prognostically important ECG features may not be apparent to physicians. In the course of supervised machine learning, thousands of ECG features are identified. These are not limited to conventional ECG parameters and morphology. We aimed to investigate whether neural network–derived ECG features could be used to predict future cardiovascular disease and mortality and have phenotypic and genotypic associations. METHODS We extracted 5120 neural network–derived ECG features from an artificial intelligence–enabled ECG model trained for 6 simple diagnoses and applied unsupervised machine learning to identify 3 phenogroups. Using the identified phenogroups, we externally validated our findings in 5 diverse cohorts from the United States, Brazil, and the United Kingdom. Data were collected between 2000 and 2023. RESULTS In total, 1 808 584 patients were included in this study. In the derivation cohort, the 3 phenogroups had significantly different mortality profiles. After adjusting for known covariates, phenogroup B had a 20% increase in long-term mortality compared with phenogroup A (hazard ratio, 1.20 [95% CI, 1.17–1.23]; P <0.0001; phenogroup A mortality, 2.2%; phenogroup B mortality, 6.1%). In univariate analyses, we found phenogroup B had a significantly greater risk of mortality in all cohorts (log-rank P <0.01 in all 5 cohorts). Phenome-wide association study showed phenogroup B had a higher rate of future atrial fibrillation (odds ratio, 2.89; P <0.00001), ventricular tachycardia (odds ratio, 2.00; P <0.00001), ischemic heart disease (odds ratio, 1.44; P <0.00001), and cardiomyopathy (odds ratio, 2.04; P <0.00001). A single-trait genome-wide association study yielded 4 loci. SCN10A , SCN5A , and CAV1 have roles in cardiac conduction and arrhythmia. ARHGAP24 does not have a clear cardiac role and may be a novel target. CONCLUSIONS Neural network–derived ECG features can be used to predict all-cause mortality and future cardiovascular diseases. We have identified biologically plausible and novel phenotypic and genotypic associations that describe mechanisms for the increased risk identified.

Introduction: Ischemic cardiomyopathy (IC) is a significant contributor to cardiovascular mortality, especially among older adults in the United States. Understanding mortality trends related to IC can help identify at-risk populations and make informed targeted healthcare strategies. This study investigates IC-related mortality trends and disparities among older adults aged ≥75 years in the US population. Methods: The CDC Wide-ranging Online Data for Epidemiologic Research (CDC WONDER) was used to analyze the National Vital Statistics System data from 1999 to 2020. Deaths with IC as the primary cause of mortality were identified, and results were presented as age-adjusted mortality rates (AAMR) per 100,000 population. Joinpoint regression was used to assess changes in trends and annual percentage change (APC). Results: A total of 186,136 deaths occurred in patients with IC from 1999 to 2020 (AAMR = 42.9, 95% CI: 42.7 - 43.2). Males had higher mortality rates (AAMR = 67.8) compared to females (AAMR = 27.7). Non-Hispanic Whites (NHW) had the highest AAMR (45.2, 95% CI: 45-45.4), followed by Hispanics (29.8, 95% CI: 29.1-30.5), non-Hispanic Blacks (NHB) (29.6, 95% CI: 29-30.1), non-Hispanic American Indian/Alaska Native (NH-AIAN) (29.1, 95% CI: 26.8-31.3). Non-Hispanic Asian/Pacific Islanders (NH-API) had the lowest AAMR (16.9, 95% CI: 16.2-17.6). Regionally, the South had the highest mortality rates (47.8, 95% CI: 47.5-48.2), followed by the Midwest (47.4, 95% CI: 46.9-47.8), the West (36.7, 95% CI: 36.3-37.1), and the Northeast (36.3, 95% CI: 35.9-36.7). Mortality rates were higher in rural areas (44.1, 95% CI: 43.5-44.7) compared to urban areas (36.5, 95% CI: 36.1-36.8). Overall, the AAMR increased from 51.3 in 1999 to 51.9 in 2005, followed by a decline to 31.5 in 2020 (APC: -2.0, 95% CI: -2.2, -1.7). Noteworthy declines in AAMR were observed in both men (APC: -2.0) and women (APC: -2.9) throughout the study (Figure, Panel A). Moreover, significant downward trends were evident in NH-AIAN (APC: -3.5), NHB (APC: -1.2), NHW (APC: -2.7 since 2004), Hispanics (APC: -5.5 since 2016), and NH-API (APC: -2.4) racial groups (Figure, Panel B). Conclusion: Our study reveals disparities in IC-related mortality, highlighting males, NHW, and the residents in the South and Midwest as well as those living in rural areas are at increased risk. Targeted interventions and resource allocation are essential to improve outcomes for vulnerable populations.

Background: The favorable safety profile of sodium-glucose cotransporter 2 (SGLT2) inhibitors, notably empagliflozin and dapagliflozin, make them a suitable treatment option for type 2 diabetes mellitus (T2DM). However, their comparative efficacy and cardiovascular (CV) benefits still remain unclear. This meta-analysis aims to compare the CV outcomes between Dapagliflozin and Empagliflozin in T2DM patients, exploring their varying effectiveness. Methods: A comprehensive search of electronic databases, PubMed, Embase, and Google Scholar was conducted from inception till May 2024. The study was conducted adhering to the PRISMA guidelines. Following a thorough screening and quality assessment, primary outcomes including major adverse cardiovascular events (MACE), cardiovascular (CV) mortality, and all-cause death along with secondary outcomes including stroke, myocardial infarction (MI), and heart failure (HF), were extracted. The random effects model was used to pool the odds ratio (OR) along with the corresponding 95% confidence intervals (CIs) for all outcomes. A p-value of less than 0.05 was considered statistically significant. Results: We pooled 6 studies with a total of 172,293 participants. The evaluation of pool results showed a significant association between the use of empagliflozin and dapagliflozin for reducing CV mortality (OR 1.15, 95 % CI 1.01- 1.30; p=0.04) and MACE (OR 1.15, 95 % CI 1.01- 1.30; p=0.04). However, we found no statistically significant difference between the two drugs for reducing MI (OR 1.04, 95 % CI 0.90- 1.19; p=0.59), Stroke (OR 0.92, 95 % CI 0.76- 1.11; p=0.40), HF (OR 1.30, 95 % CI 0.93- 1.81; p=0.13) and all-cause death (OR 1.33, 95 % CI 0.46- 3.88; p=0.60). After running the sensitivity analysis, a statistically significant result was observed between use of empagliflozin and dapagliflozin for HF (OR 1.47, 95 % CI 1.13- 1.90; p=0.004). Conclusion: The use of dapagliflozin significantly reduces CV mortality and MACE when compared with empagliflozin. However, the incidence of MI, stroke, HF, and all-cause death is comparable across the two groups. Our results should be considered hypothesis generating and evidence from large-scale multi-centric randomized controlled trials (RCTs) is required to reach a definitive conclusion

Background: Intravascular ultrasound (IVUS) guidance during percutaneous coronary intervention (PCI) allows better visualization of atherosclerotic plaques than angiography alone. We conducted a systematic review and meta-analysis to comprehensively synthesize the available evidence regarding the efficacy of IVUS-guidance compared to angiography-guided PCI. Moreover, we conducted a sensitivity analysis to determine the applicability of IVUS guidance in complex PCI. Methods: We conducted a comprehensive literature search of major bibliographic databases from inception until May 2024 to identify randomized controlled trials (RCTs) comparing IVUS-guided versus angiography-guided PCI. Risk ratios (RR) with their corresponding 95% confidence intervals (CI) were pooled using the random-effects model, with a p-value <0.05 considered statistically significant. We conducted meta-regression to determine the moderating of baseline covariates on pooled outcomes. Results: Sixteen RCTs were included with 10,993 patients undergoing PCI (IVUS-guided PCI: 5684 patients; angiography-guided PCI: 5157 patients). IVUS-guided PCI demonstrated a significantly lower risk of cardiac death [RR: 0.49; 95% CI: 0.35, 0.68], major adverse cardiovascular events [RR: 0.64; 95% CI: 0.51, 0.80], myocardial infarction [RR: 0.73; 95% CI: 0.59, 0.89], stent thrombosis [RR: 0.45; 95% CI: 0.27, 0.75], target lesion revascularization [RR: 0.60; 95% CI: 0.49, 0.74], and target vessel revascularization [RR: 0.56; 95% CI: 0.45, 0.70] than angiography-guided PCI. IVUS-guided PCI demonstrated a nonsignificant trend toward a reduced risk of all-cause mortality [RR: 0.79; 95% CI: 0.61, 1.04]. Meta-regression showed a nonsignificant moderating effect of the duration of follow-up, age of patients, baseline dyslipidemia, and hypertension status on pooled outcomes. A sensitivity analysis was conducted for patients undergoing complex PCI. The sensitivity analysis showed the superiority of IVUS-guided PCI compared to angiography-guided PCI by resulting in a significant improvement in the clinical outcomes. Conclusion: This meta-analysis concluded that IVUS-guided PCI resulted in a reduction in cardiac death, major adverse cardiovascular events, myocardial infarction, stent thrombosis, target lesion revascularization, and target vessel revascularization, compared to angiography-guided PCI. Moreover, we observed the superiority of IVUS guidance in complex PCI as well.

Introduction: Coronary artery disease (CAD) is the third leading cause of death in the US for adults aged >35 years. Almost half of the adult US population has obesity, which predisposes to atherosclerosis and may lead to poor prognosis in CAD. We aim to identify CAD-related mortality trends in patients with obesity in the US stratified by age, sex, race, and geographical location. Methods: The CDC-WONDER database was used to extract death certificate data for adults aged ≥25 years. Crude mortality rates (CMR) and age-adjusted mortality rates (AAMRs) per 100,000 persons were calculated, and temporal trends were delineated by calculating annual percent change (APC) and the average APC (AAPC) in the rates using JoinPoint regression analysis. Results: From 1999 to 2020, a total of 182,436 CAD-related deaths occurred in individuals with obesity. The AAMR increased consistently from 1999 to 2018 (APC: 4.48) and surged thereafter till 2020 (APC: 13.91). The AAMR for males (4.91) was almost double that of females (2.76). Non-Hispanic (NH) American Indians or Alaska Natives displayed the highest AAMR (5.37) while NH Asians or Pacific Islanders displayed the lowest (0.88). NH Blacks or African Americans displayed an AAMR of 5.06, followed by NH Whites (3.88) and Hispanics or Latinos (2.6). AAMRs also varied substantially by region (Midwest: 4.09; West: 4; Northeast: 3.67; South: 3.53). States with the highest AAMRs were Vermont and Oklahoma. Non-metropolitan regions exhibited a higher AAMR (4.42) than metropolitan regions (3.64). The adults aged 65-74 years exhibited the greatest CMR (8.99). Conclusion: We observed increasing trends in CAD-related deaths in adults with obesity throughout the study period. The highest mortality was exhibited by males and NH American Indians or Alaska Natives, residents of the Midwest and non-metropolitan areas, and individuals aged 65-74 years. Better healthcare practices and lifestyle modifications should be promoted in these high-risk populations to reduce the CAD-related mortality rates in adults with obesity.

Abstract Background: Transcatheter aortic valve implantation (TAVI) is thought to be more effective than surgery for patients with small aortic annulus (SAA), however, the comparative efficacy of different transcatheter heart valves (THVs) remains uncertain. The objective of this meta-analysis was to compare the effects of balloon-expandable valves (BEVs) and self-expanding valves (SEVs) on hemodynamic parameters and clinical outcomes in patients with SAA who underwent TAVI. Methods: A thorough literature search was performed across PubMed/MEDLINE, Embase, and the Cochrane Library from their inception until May 2024 to identify eligible randomized controlled trials (RCTs) and propensity-score matched (PSM) studies. Clinical outcomes were evaluated using a random-effects model to pool risk ratios (RRs) with 95% confidence intervals (CIs). Results: The analysis included 8 studies; 2 RCTs and 6 PSM studies, with a total of 2,180 patients with SAA. BEVs were associated with a smaller indexed effective orifice area (MD: -0.18, 95% CI: -0.31 to -0.05) and a higher transvalvular mean pressure gradient (MD: 5.23, 95% CI 3.44 to 7.02) than SEVs. The risk for prosthesis-patient mismatch (PPM) (RR= 1.82, 95% CI: 1.27 to 2.60) and severe PPM (RR= 2.77, 95% CI: 1.93 to 3.98) was significantly higher for patients receiving BEVs than those receiving SEVs. However, no significant difference was observed between BEVs and SEVs regarding the risk of paravalvular leak (RR= 0.98, 95% CI: 0.57 to 1.69) and the permanent pacemaker implantation (RR= 0.78, 95% CI: 0.50 to 1.23). Although patients receiving BEVs showed a slightly lower risk of major bleeding events (RR= 0.69, 95% CI: 0.49 to 0.99), BEVs were associated with a significantly increased risk of 1-year cardiovascular mortality (RR= 1.61, 95% CI: 1.05 to 2.47) compared to those receiving SEVs. However, no significant differences were observed between BEVs and SEVs regarding 30-day all-cause mortality (RR= 1.19, 95% CI: 0.57 to 2.49), 1-year all-cause mortality (RR= 1.17, 95% CI: 0.89 to 1.53), stroke rates (RR= 0.83, 95% CI: 0.52 to 1.31) and any vascular complication (RR= 1.13, 95% CI: 0.72 to 1.75). Conclusion: In patients with SAA, SEVs showed reduced risks of PPM and severe PPM compared to BEVs, along with a larger indexed effective orifice area. Moreover, SEVs were associated with a lower risk of 1-year cardiovascular mortality.

Background: Fractional flow reserve (FFR) guided complete revascularization (CR) is an approach that can be used to improve clinical outcomes in patients with acute myocardial infarction (MI) and multivessel disease (MVD). The objective of the present meta-analysis was to investigate whether FFR-guided CR leads to better cardiovascular outcomes as compared to culprit-only revascularization (COR) in acute MI and MVD by pooling recently published data. Methods: A comprehensive literature search was conducted using PubMed/MEDLINE, Embase, and the Cochrane Library from inception until April 2024 to retrieve eligible randomized controlled trials (RCTs). Clinical outcomes were assessed using the random-effects model by pooling risk ratios (RRs) along with 95% confidence intervals (CIs). We assessed the quality of evidence using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. Results: Four RCTs were pooled with 3,175 patients. FFR-guided CR significantly reduced the risk of repeat revascularization as compared to COR (RR = 0.52; 95% CI: 0.33-0.81, p = 0.004) [absolute risk difference 83 fewer per 1,000 patients (95% confidence interval: 116 to 33 fewer) moderate certainty]. Though there was a reduction in the risk of MACE with FFR-guided CR (RR = 0.68, 95% CI: 0.44-1.04, p = 0.08; moderate certainty), it didn't attain statistical significance. Clinical outcomes such as all-cause death (RR = 1.10, 95% CI: 0.84-1.45, p = 0.48; moderate certainty), cardiac death (RR = 0.79, 95% CI: 0.53-1.17, p = 0.24; high certainty), risk of MI (RR = 0.94, 95% CI: 0.54-1.66, p = 0.84; moderate certainty) and major bleeding (RR = 0.95, 95% CI: 0.54-1.67, p = 0.87; moderate certainty) were comparable between the two groups. Conclusion: FFR-guided CR in patients with MI and MVD can lead to a decreased risk of repeat revascularizations while not affecting all-cause and cardiac deaths.