Endovascular mechanical thrombectomy (MT) for the treatment of acute stroke due to large vessel occlusion has evolved significantly with the publication of multiple positive thrombectomy trials. MT is now a recommended treatment for acute ischemic stroke. Mechanical thrombectomy is associated with a number of intra-procedural or post-operative complications, which need to be minimized and effectively managed to maximize the benefits of thrombectomy. Procedural complications include: access-site problems (vessel/nerve injury, access-site hematoma and groin infection); device-related complications (vasospasm, arterial perforation and dissection, device detachment/misplacement); symptomatic intracerebral hemorrhage; subarachnoid hemorrhage; embolization to new or target vessel territory. Other complications include: anesthetic/contrast-related, post-operative hemorrhage, extra-cranial hemorrhage and pseudoaneurysm. Some complications are life-threatening and many lead to increased length of stay in intensive care and stroke units. Complications increase costs and delay the commencement of rehabilitation. Some may be preventable; the impact of others can be minimized with early detection and appropriate management. Both neurointerventionists and stroke specialists need to be aware of the risk factors, strategies for prevention, and management of these complications. With the increasing use of mechanical thrombectomy for the treatment of acute ischemic stroke, incidence and outcome of complications will need to be carefully monitored by stroke teams. In this narrative review, we examine the frequency of complications of MT in the treatment of acute ischemic stroke with an emphasis on periprocedural complications. Overall, from recent randomized controlled trials, the risk of complications with sequelae for patient from mechanical thrombectomy is ∼15%. We discuss the management of complications and identify areas with limited evidence, which need further research. Search strategy and selection criteria Relevant evidence was found by searches of Medline and Cochrane Library, reference list, cross-referencing and main journal content pages. Search terms included "brain ischemia", "acute ischemic stroke", "cerebral infarction" AND "mechanical thrombectomy", "endovascular therapy", "endovascular treatment", "endovascular embolectomy", "intra-arterial" AND "randomized controlled trial", "non-randomised trials", "observational studies" AND "complications", "procedural complications", "peri-procedural complications", "device-related complications", "management", "treatment", "outcome". The search included only human studies, and was limited to studies published in English between January 2014 and November 2016. The final reference list was selected on the basis of relevance to the topics covered in the Review. Guidelines for management of acute ischaemic stroke by the American Heart Association, the European Stroke Organisation, multi-disciplinary guidelines and the National Institute for Health and Care Excellence (NICE) wer...

IntroductionEndovascular thrombectomy is a highly effective treatment for acute ischemic stroke due to large arterial occlusion. Routine provision will require major changes in service configuration and workforce. An important first step is to quantify the population of stroke patients that could benefit. We estimated the annual UK population suitable for endovascular thrombectomy using standard or advanced imaging for patient selection.Patients and methodsEvidence from randomised control trials and national registries was combined to estimate UK stroke incidence and define a decision-tree describing the endovascular thrombectomy eligible population.ResultsBetween 9620 and 10,920 UK stroke patients (approximately 10% of stroke admissions) would be eligible for endovascular thrombectomy annually. The majority (9140–9620) would present within 4 h of onset and be suitable for intravenous thrombolysis. Advanced imaging would exclude 500 patients presenting within 4 h, but identify an additional 1310 patients as eligible who present later.DiscussionInformation from randomised control trials and large registry data provided the evidence criterion for 9 of the 12 decision points. The best available evidence was used for two decision points with sensitivity analyses to determine how key branches of the tree affected estimates. Using the mid-point estimate for eligibility (9.6% of admissions) and assuming national endovascular thrombectomy coverage, 4280 patients would have reduced disability.ConclusionA model combining published trials and register data suggests approximately 10% of all stroke admissions in the UK are eligible for endovascular thrombectomy. The use of advanced imaging based on current published evidence did not have a major impact on overall numbers but could alter eligibility status for 16% of cases.

BackgroundFalls cause fear, anxiety and loss of confidence, resulting in activity avoidance, social isolation and increasing frailty. The umbrella term for these problems is ‘fear of falling’, seen in up to 85% of older adults who fall. Evidence of effectiveness of physical and psychological interventions is limited, with no previous studies examining the role of an individually delivered cognitive–behavioural therapy (CBT) approach.ObjectivesPrimary objective To develop and then determine the effectiveness of a new CBT intervention (CBTi) delivered by health-care assistants (HCAs) plus usual care compared with usual care alone in reducing fear of falling.Secondary objectives To measure the impact of the intervention on falls, injuries, functional abilities, anxiety/depression, quality of life, social participation and loneliness; investigate the acceptability of the intervention for patients, family members and professionals and factors that promote or inhibit its implementation; and measure the costs and benefits of the intervention.DesignPhase I CBTi development.Phase II Parallel-group patient randomised controlled trial (RCT) of the new CBTi plus usual care compared with usual care alone.SettingMultidisciplinary falls services.ParticipantsConsecutive community-dwelling older adults, both sexes, aged ≥ 60 years, with excessive or undue fear of falling per Falls Efficacy Scale–International (FES-I) score of > 23.InterventionsPhase I Development of the CBTi. The CBTi was developed following patient interviews and taught to HCAs to maximise the potential for uptake and generalisability to a UK NHS setting.Phase II RCT. The CBTi was delivered by HCAs weekly for 8 weeks, with a 6-month booster session plus usual care.Main outcome measuresThese were assessed at baseline, 8 weeks, 6 months and 12 months.Primary outcome measure Fear of falling measured by change in FES-I scores at 12 months.Secondary outcome measures These comprised falls, injuries, anxiety/depression [Hospital Anxiety and Depression Scale (HADS)], quality of life, social participation, loneliness and measures of physical function. There were process and health-economic evaluations alongside the trial.ResultsFour hundred and fifteen patients were recruited, with 210 patients randomised to CBTi group and 205 to the control group. There were significant reductions in mean FES-I [–4.02; 95% confidence interval (CI) –5.95 to –2.1], single-item numerical fear of falling scale (–1.42; 95% CI –1.87 to 1.07) and HADS (–1; 95% CI –1.6 to –0.3) scores at 12 months in the CBTi group compared with the usual care group. There were no differences in the other secondary outcome measures. Most patients found the CBTi acceptable. Factors affecting the delivery of the CBTi as part of routine practice were identified. There was no evidence that the intervention was cost-effective.ConclusionsOur new CBTi delivered by HCAs significantly improved fear of falling and depression scores in older adults who were attending falls services. There was no impact on other measures.Further workFurther work should focus on a joint CBTi and physical training approach to fear of falling, more rational targeting of CBTi, the possibility of mixed group and individual CBTi, and the cost-effectiveness of provision of CBTi by non-specialists.Trial registrationCurrent Controlled Trials ISRCTN78396615.FundingThis project was funded by the NIHR Health Technology Assessment programme and will be published in full inHealth Technology Assessment; Vol. 20, No. 56. See the NIHR Journals Library website for further project information.

Conclusions:In people with established RA, semi-rigid customised foot orthoses can improve pain and disability scores in comparison to simple insoles. From a cost effectiveness perspective the customised foot orthoses were far more expensive to manufacture, with no significant cost per QALY gain.

This is the first report on the EQ-5D utility values of patients with PSS. These patients have significantly impaired utility values compared with the UK general population. EQ-5D utility values are significantly related to pain and depression scores in PSS.

Aims The primary aim is to estimate the current and potential number of patients on NHS England orthopaedic elective waiting lists by November 2020. The secondary aims are to model recovery strategies; review the deficit of hip and knee arthroplasty from National Joint Registry (NJR) data; and assess the cost of returning to pre-COVID-19 waiting list numbers. Methods A model of referral, waiting list, and eventual surgery was created and calibrated using historical data from NHS England (April 2017 to March 2020) and was used to investigate the possible consequences of unmet demand resulting from fewer patients entering the treatment pathway and recovery strategies. NJR data were used to estimate the deficit of hip and knee arthroplasty by August 2020 and NHS tariff costs were used to calculate the financial burden. Results By November 2020, the elective waiting list in England is predicted to be between 885,286 and 1,028,733. If reduced hospital capacity is factored into the model, returning to full capacity by November, the waiting list could be as large as 1.4 million. With a 30% increase in productivity, it would take 20 months if there was no hidden burden of unreferred patients, and 48 months if there was a hidden burden, to return to pre-COVID-19 waiting list numbers. By August 2020, the estimated deficits of hip and knee arthroplasties from NJR data were 18,298 (44.8%) and 16,567 (38.6%), respectively, compared to the same time period in 2019. The cost to clear this black log would be £198,811,335. Conclusion There will be up to 1.4 million patients on elective orthopaedic waiting lists in England by November 2020, approximate three-times the pre-COVID-19 average. There are various strategies for recovery to return to pre-COVID-19 waiting list numbers reliant on increasing capacity, but these have substantial cost implications. Cite this article: Bone Jt Open 2021;2(2):103–110.

Highlights France, Belgium and Canada have varied degrees of governance. Higher data integration and resource coordination is achieved in centralized France. But decentralized Canada built testing capacity quickly, with variation across provinces. Shared decision making between national and subnational in Belgium may be least effective.

BackgroundMany glaucoma referrals from the community to hospital eye services are unnecessary. Imaging technologies can potentially be useful to triage this population.ObjectivesTo assess the diagnostic performance and cost-effectiveness of imaging technologies as triage tests for identifying people with glaucoma.DesignWithin-patient comparative diagnostic accuracy study. Markov economic model comparing the cost-effectiveness of a triage test with usual care.SettingSecondary care.ParticipantsAdults referred from the community to hospital eye services for possible glaucoma.InterventionsHeidelberg Retinal Tomography (HRT), including two diagnostic algorithms, glaucoma probability score (HRT-GPS) and Moorfields regression analysis (HRT-MRA); scanning laser polarimetry [glaucoma diagnostics (GDx)]; and optical coherence tomography (OCT). The reference standard was clinical examination by a consultant ophthalmologist with glaucoma expertise including visual field testing and intraocular pressure (IOP) measurement.Main outcome measures(1) Diagnostic performance of imaging, using data from the eye with most severe disease. (2) Composite triage test performance (imaging test, IOP measurement and visual acuity measurement), using data from both eyes, in correctly identifying clinical management decisions, that is ‘discharge’ or ‘do not discharge’. Outcome measures were sensitivity, specificity and incremental cost per quality-adjusted life-year (QALY).ResultsData from 943 of 955 participants were included in the analysis. The average age was 60.5 years (standard deviation 13.8 years) and 51.1% were females. Glaucoma was diagnosed by the clinician in at least one eye in 16.8% of participants; 37.9% of participants were discharged after the first visit. Regarding diagnosing glaucoma, HRT-MRA had the highest sensitivity [87.0%, 95% confidence interval (CI) 80.2% to 92.1%] but the lowest specificity (63.9%, 95% CI 60.2% to 67.4%) and GDx had the lowest sensitivity (35.1%, 95% CI 27.0% to 43.8%) but the highest specificity (97.2%, 95% CI 95.6% to 98.3%). HRT-GPS had sensitivity of 81.5% (95% CI 73.9% to 87.6%) and specificity of 67.7% (95% CI 64.2% to 71.2%) and OCT had sensitivity of 76.9% (95% CI 69.2% to 83.4%) and specificity of 78.5% (95% CI 75.4% to 81.4%). Regarding triage accuracy, triage using HRT-GPS had the highest sensitivity (86.0%, 95% CI 82.8% to 88.7%) but the lowest specificity (39.1%, 95% CI 34.0% to 44.5%), GDx had the lowest sensitivity (64.7%, 95% CI 60.7% to 68.7%) but the highest specificity (53.6%, 95% CI 48.2% to 58.9%). Introducing a composite triage station into the referral pathway to identify appropriate referrals was cost-effective. All triage strategies resulted in a cost reduction compared with standard care (consultant-led diagnosis) but with an associated reduction in effectiveness. GDx was the least costly and least effective strategy. OCT and HRT-GPS were not cost-effective. Compared with GDx, the cost per QALY gained for HRT-MRA is £22,904. The cost per QALY gained with current practice is £156,985 compared with HRT-MRA. Large savings could be made by implementing HRT-MRA but some benefit to patients will be forgone. The results were sensitive to the triage costs.ConclusionsAutomated imaging can be effective to aid glaucoma diagnosis among individuals referred from the community to hospital eye services. A model of care using a triage composite test appears to be cost-effective.Future workThere are uncertainties about glaucoma progression under routine care and the cost of providing health care. The acceptability of implementing a triage test needs to be explored.FundingThe National Institute for Health Research Health Technology Assessment programme.