Frailty predicts increased risk of reintervention in the 2 years after arteriovenous fistula creation.

INTRODUCTION: Frailty is associated with adverse survival and increased hospital use in patients with end-stage kidney disease (ESKD). Dialysis access failure is an important source of morbidity and mortality for these patients. There is limited evidence about the interactions between frailty and haemodialysis access failure. This population-based cohort study aimed to determine if haemodialysis access reintervention was predicted by frailty. METHODS: Routinely-collected hospital data linked with death records were analyzed for all patients with ESKD who had a new arteriovenous fistula or graft (AVF) created between 2010 and 2012 in New South Wales, Australia. Frailty risk was assigned by the Hospital Frailty Risk Score. Multivariate Cox-proportional hazard ratios (HR), adjusted for patient and procedural variables, quantified if frailty was prognostic for adverse haemodialysis access outcomes in the 2 years after AVF creation. RESULTS: Almost one quarter of the 2302 patients who had a new AVF created during the study period were classified as high frailty risk (554, 24.1%). Compared to low frailty risk patients, patients with high frailty had a significantly greater risk of reintervention for AVF failure in the 2 years after creation (HR 1.68; 95% CI 1.45-1.96), adjusted for age, sex and prior AVFs. Frailer patients were also more likely to have perioperative complications, longer hospital length of stay and readmission to hospital. Frailty was associated with a higher risk of mortality at 2 years after AVF creation (adjusted HR 2.65; 95% CI 1.72-4.10). CONCLUSION: Frailty predicted adverse haemodialysis access outcomes, with frailer patients having higher rates of AVF reinterventions. These results can assist clinicians engaging in shared decision-making discussions about dialysis access risks and help personalize dialysis access decisions.

Frail patients having vascular surgery during the early COVID-19 pandemic experienced high rates of adverse perioperative events and amputation.

BACKGROUND: Frailty predicts adverse perioperative outcomes and increased mortality in patients having vascular surgery. Frailty assessment is a potential tool to inform resource allocation, and shared decision-making about vascular surgery in the resource constrained COVID-19 pandemic environment. This cohort study describes the prevalence of frailty in patients having vascular surgery and the association between frailty, mortality and perioperative outcomes. METHODS: The COVID-19 Vascular Service in Australia (COVER-AU) prospective cohort study evaluates 30-day and six-month outcomes for consecutive patients having vascular surgery in 11 Australian vascular units, March-July 2020. The primary outcome was mortality, with secondary outcomes procedure-related outcomes and hospital utilization. Frailty was assessed using the nine-point visual Clinical Frailty Score, scores of 5 or more considered frail. RESULTS: Of the 917 patients enrolled, 203 were frail (22.1%). The 30 day and 6 month mortality was 2.0% (n = 20) and 5.9% (n = 35) respectively with no significant difference between frail and non-frail patients (OR 1.68, 95%CI 0.79-3.54). However, frail patients stayed longer in hospital, had more perioperative complications, and were more likely to be readmitted or have a reoperation when compared to non-frail patients. At 6 months, frail patients had twice the odds of major amputation compared to non-frail patients, after adjustment (OR 2.01; 95% CI 1.17-3.78), driven by a high rate of amputation during the period of reduced surgical activity. CONCLUSION: Our findings highlight that older, frail patients, experience potentially preventable adverse outcomes and there is a need for targeted interventions to optimize care, especially in times of healthcare stress.

Protocol for a qualitative study exploring haemodialysis dependent patients' arteriovenous fistula experience, values and concerns in Sydney, Australia.

INTRODUCTION: The experiences of patients from culturally and linguistically diverse backgrounds, with chronic mental illness, disabilities or who identify as sexual or religious minorities are under-represented in clinical research on arteriovenous fistula (AVF) for haemodialysis access. A greater understanding of the experiences, values and concerns of these diverse patient groups are needed to provide haemodialysis access care that addresses the needs of all haemodialysis-dependent patients. This study seeks to describe a broad range of patient experiences related to the creation, care and surveillance of AVFs, including interactions with healthcare teams. METHODS AND ANALYSIS: This qualitative study will use semistructured interviews with individual patients purposefully selected to provide a diverse patient population. A deliberate strategy will be used to recruit a demographically broad range of participants. Thematic analysis of interview transcripts, using a constant comparative methodology, will generate themes that describe patient experiences, values and concerns. Findings from this study will give a nuanced insight into the experiences of patients on haemodialysis with respect to their AVF. ETHICS AND DISSEMINATION: Ethical approval for this study was provided by the Sydney Local Health District Human Research Ethics Committee (REGIS identifier: 2021/ETH00362, CH reference number: CH62/6/2021-033). Results will be made available to the participants, local health district, funders and other researchers through various hospital and academic forums. Data will also be published in peer-reviewed journals and be part of a larger body of work looking into patient-reported outcome measures for patients with AVF.

Laparoscopic totally extra-peritoneal groin hernia repair with self-gripping polyester mesh: a series of 780 repairs.

BACKGROUND: Laparoscopic groin hernia repair is an increasingly common procedure with benefits of reduced post-operative pain and infection. Post-operative chronic pain remains an ongoing concern in about 10% of patients. Parietex ProGrip™, a polyester self-gripping mesh, has a theoretical benefit of avoiding tacks for mesh-fixation. This case series reflects our long-term experience of this technique. METHODS: We conducted a retrospective case series from November 2011 to December 2017. Patients were identified through an operative Medicare Benefits Schedule item number search. Clinical documentation was reviewed with length of stay, mesh infection, chronic pain, recurrence and re-operation as primary data points. RESULTS: A total of 514 patients underwent 780 laparoscopic inguinal hernia repairs with self-gripping polyester mesh during this period. There were 53 female (10.3%) and 461 male patients (89.7%). Unilateral hernia repair was performed in 248 patients (48.2%) and bilateral repair in 266 patients (51.8%). Almost all repairs (779, 99.8%) were primary hernias. There were no mesh infections. Four recurrences were noted (0.51%) and three of these subsequently underwent open redo-hernia repairs (0.38%). Post-operative follow-up was up to 4.4 years. CONCLUSIONS: Our series of laparoscopic groin hernia repair with self-gripping mesh demonstrate this is a safe and reliable mesh and effective technique with low recurrence rates.

Management of Zenker's diverticulum using flexible endoscopy.

BACKGROUND AND AIMS: Zenker's diverticulum is a false diverticulum through Killian's dehiscence. Symptoms include halitosis, dysphagia, regurgitation, cough, and aspiration pneumonia. Treatment options include open transcervical cricopharyngeal myotomy, trans-oral rigid endoscopic stapling, and minimally invasive endoscopic myotomy. Although open surgical techniques have historically been the criterion standard for treatment, endoscopic options have become increasingly used. We propose the use of flexible endoscopy in the management of Zenker's diverticulum. METHODS: We present a retrospective case series of 9 patients undergoing endoscopic cricopharyngeal myotomy from 2014 to 2018 using our endoscopic technique. RESULTS: We demonstrate that endoscopic technique provided adequate symptomatic relief in 7 of 9 patients, with no operative adverse events. CONCLUSIONS: Cricopharyngeal myotomy using flexible endoscopy is a safe and effective technique for the management of Zenker's diverticulum. Potential benefits of this approach include shorter operative times, shorter postoperative admissions, and earlier progression of diet. Initial treatment with endoscopic technique does not preclude future open repairs.

Cardiovascular Adverse Effects of Phenylephrine Eyedrops: A Systematic Review and Meta-analysis.

IMPORTANCE: Topical phenylephrine hydrochloride is routinely administered with few safety precautions, but evidence regarding its systemic safety to date is controversial. As even short-term variations in 24-hour blood pressure (BP) and heart rate (HR) can adversely affect cardiovascular health, better evidence on phenylephrine's effects on HR and BP is required. OBJECTIVE: To perform a meta-analysis of available evidence regarding cardiovascular adverse effects of topical phenylephrine. DATA SOURCES: PubMed, MEDLINE, and the Cochrane Database of Systematic Reviews and Clinical Trials were searched for relevant literature from January 1, 1970, to January 1, 2014, using a combination of the following search terms: topical, ocular, ophthalmic, phenylephrine, tropicamide, cardiovascular effect, side effect, blood pressure, heart rate, mydriatic, and eye drops. A total of 70 articles related to the topic were identified and all full texts were retrieved. STUDY SELECTION: Randomized clinical trials reporting change in BP and HR for adults were included in this review. All studies reporting results for neonates or infants, not reporting standard deviations, or not specifying the time of measurement or the concentration of phenylephrine used were excluded. DATA EXTRACTION AND SYNTHESIS: Data from randomized clinical trials that reported BP and/or HR as well as the time following administration of topical phenylephrine at which measurements were obtained by concentration of phenylephrine as a mean change and its standard deviation were extracted. Data were synthesized by concentration of phenylephrine and time of measurement following topical application using random-effects models with inverse variance weighting to account for heterogeneity across studies. MAIN OUTCOMES AND MEASURES: Difference in BP and HR after topical administration of phenylephrine. RESULTS: Eight RCTs with a total of 916 participants were included. Data were available for phenylephrine, 2.5%, at 20 to 30 minutes and 60 minutes or longer after administration, and neither BP nor HR changed at either time. Following application of phenylephrine, 10%, BP increased at 5 and 10 minutes (mean difference for both, +15 mm Hg; 95% CI, 11.94-18.54; P < .001) but decreased at 20 to 30 minutes and 60 minutes or longer with no changes detected against baseline. A mean increase in HR by 4.48 beats/min (95% CI, 1.09-7.88; P = .01) was present at 20 to 30 minutes following application of phenylephrine, 10%, and HR decreased by 60 minutes or longer with no changes detected compared with baseline. CONCLUSIONS AND RELEVANCE: Phenylephrine, 2.5%, leads to no clinically relevant change in BP or HR, and the changes in BP and HR seen with phenylephrine, 10%, are short lived. Thus, phenylephrine, 2.5%, is safe to use in clinical routine.