North Shore Hospital

Rheumatoid arthritis is a chronic autoimmune disease that primarily affects the joints, causing pain, inflammation, and long-term joint damage. Transcutaneous auricular vagus nerve stimulation (taVNS) is a promising non-pharmacological intervention for managing pain and inflammation, particularly when delivered in the exhalation phase of respiration. However, until now, the lack of portable equipment has meant the respiratory phase effects have not been evaluated outside of the laboratory or in a home setting. The primary goal of this study was to determine the feasibility of a future clinical trial of home-based respiratory-gated taVNS in people with rheumatoid arthritis. This was a single-arm, non-randomised feasibility trial involving 12 individuals with active rheumatoid arthritis. Participation involved 12 respiratory-gated taVNS sessions at home and three laboratory visits for outcome assessments (day 1, day 8, and day 15). Feasibility outcomes focused on recruitment rate, intervention adherence, acceptability questionnaires, and adverse events. In addition, outcome measures related to pain, psychological distress, and key inflammatory biomarkers were assessed. Feasibility outcomes demonstrated an acceptable recruitment rate, high adherence (90% session completion), excellent usability (9/10), and acceptability (average score 66%, general score 87%), with no severe treatment-emergent adverse events. While single-armed and not powered to determine efficacy, medium to large pre- to post-intervention reductions in pain interference, grip pain intensity, psychological distress, and tumour necrosis factor-alpha levels were observed, with minimal changes in other outcomes. An adequately powered, randomised controlled trial of home-based respiratory-gated taVNS in people with rheumatoid arthritis is feasible and safe. Key Points • To the best of our knowledge, this study is the first to evaluate the feasibility of homebased respiratory-gated (RG) transcutaneous auricular vagus nerve stimulation (taVNS) for the treatment of rheumatoid arthritis (RA). • Feasibility outcomes demonstrated high adherence and excellent usability ratings with few treatment-emergent adverse events reported. • Home-based RG taVNS using the developed system is safe and feasible to evaluate in an adequately powered, controlled trial.

ABSTRACT BACKGROUND Conventional electrocardiography (ECG) has limited diagnostic accuracy for detecting coronary artery disease (CAD) in patients with stable chest pain. Advanced electrocardiography (A-ECG) may improve diagnostic performance. The study aimed to derive, externally validate, and prognostically validate an explainable A-ECG score for detecting CAD on coronary computed tomography angiography (CCTA). METHODS Participants attending an outpatient rapid access chest pain clinic (RACC) underwent a standard 12-lead ECG and CCTA. Any CAD was defined as any calcified or non-calcified plaque. Elastic net with nested resampling was used to derive an A-ECG score using measures from the conventional ECG, derived vectorcardiography, and measures of waveform complexity. RESULTS In the derivation cohort (n=171, age 59±13 years, 60% male), n=99 (58%) had any CAD on CCTA. A seven parameter A-ECG score to detect any CAD was derived. In an external validation cohort (n=762, age 57±12 years, 49% male, n=428 (56%) with any CAD), the score had an area under the receiver operating characteristic curve [95% confidence interval] of 0.72 [0.68–0.76], sensitivity 90 [88–92]%, specificity 31 [29-33]%, positive predictive value 63 [61–64]%, negative predictive value 70 [68–71]%, positive likelihood ratio 1.3 and inverse negative likelihood ratio 3.1. In the UK Biobank (n=27,239, 966 events, follow-up 1.9 [0.7–4.4] years, age 66±8 years, 50% female), higher A-ECG scores were associated with cardiovascular events after adjusting for age, sex and cardiovascular risk factors (p<0.001). CONCLUSIONS Explainable A-ECG predicts any CAD on CCTA with good overall diagnostic and prognostic performance. This scalable, low-cost approach may aid triage and risk stratification in chest pain pathways.

Aims The Oxford Knee Score (OKS) is a validated questionnaire for measuring outcomes following knee arthroplasty. Of the 12 individual questions, some may have more clinical importance than others. The aim of this study was to identify the OKS question(s) most associated with patient satisfaction to inform clinical practice and future research. Patients and methods The New Zealand Joint Registry (NZJR) has captured patient satisfaction data for all knee arthroplasty patients since 2021. A total of 9,384 total knee (TKA) and 2,424 unicompartmental knee arthroplasty (UKA) with satisfaction scores recorded in the NZJR up to 15-year follow-up were included. Associations between individual OKS questions and satisfaction were assessed using logistic regression and receiver operating characteristic analyses. Results The most important question associated with patient satisfaction was on ‘overall pain’ for both TKA (6 months: odds ratio (OR) 1.6, p<0.01; 5 years: OR 1.5, p=0.04; 10 years: OR 1.7, p=0.02; 15 years: OR 1.7, p=0.05) and UKA (6 months: odds ratio (OR) 1.9, p<0.01; 5 years: OR 2.0, p=0.01; 10 years: OR 1.7, p=0.15; 15 years: OR 1.4, p=0.49). Additional questions found to be associated with satisfaction were ‘getting in and out of the car’, ‘limping when walking’ and ‘knee giving way’, however these were mostly limited to TKA patients at early to mid-term follow-up (prior to 5 years). Conclusion The best predictor of patient satisfaction following knee arthroplasty was ‘overall pain’. Future research and clinical practice focused on improving knee arthroplasty patient satisfaction should take into consideration patients’ level of post-operative pain.

Introduction While large-scale data on total knee arthroplasty (TKA) failures are well established in national joint registries, recorded reasons for failure lack granularity. Understanding reasons for TKA failures is crucial for optimising patient outcomes. This study aimed to identify reasons for TKA failures and trends in failure over the last two decades. Methods A total of 20,235 primary TKAs were identified across the three Auckland tertiary hospitals from 2000–2023. Clinical coding and national joint registry data were cross-referenced to identify any ‘failures’, defined as subsequent revision or reoperation for periprosthetic joint infection (PJI). Failure reasons were determined from systematic review of operative notes, microbiology, and imaging. For revisions outside of Auckland, records were obtained from operating surgeons. For analysis, failures were grouped by time from index procedure (five-year bands) and by year (2000-2014, 2014-2023) and compared using chi-squared tests. Results A total of 714 failures were identified (3.5%). The three most common reasons were PJI (51.2%), patellofemoral (PF) arthrosis (15%), and aseptic loosening (12.2%). The proportion of PJI failures was greatest at early follow-up (56% within 5 years of index procedure vs. 21% at 15-20 years, p<0.001), whereas aseptic loosening was more prevalent at late follow-up (29% at 15-20 years vs. 9% within 5 years, p<0.001). PF arthrosis rates were consistent across 20 years (p=0.14). PJI failures increased from 43% of all failures in 2000-2014 to 61% in 2014-2024 (p=0.02). There was no difference for aseptic loosening (2000-2014: 14% vs. 2014- 2024: 10%, p=0.51) or PF arthrosis (2000-2014: 14% vs. 2014-2024: 16%, p=0.84). Discussion and Conclusion PJI remains the leading cause for failure, while proportions of failures due to aseptic loosening and PF arthrosis are unchanged over the last two decades. These findings emphasize the need for continued optimisation of infection control, implant development and patient selection strategies for TKA.

Pulsed Field Ablation (PFA) has been rapidly adopted as a method of Pulmonary Vein Isolation (PVI) for patients with atrial fibrillation (AF). As a non-thermal, tissue-selective technique it may reduce or eliminate some of the complications observed with radiofrequency or cryo-ablation including oesophageal fistula formation and phrenic nerve palsy. It appears to be as efficacious and safer than thermal based ablations. We evaluated the first 100 patients who underwent ablation using the PulseSelect PFA system (Medtronic, Minneapolis, USA) at our centre. All patients who underwent AF ablation using the PulseSelect PFA system between May 2024 and February 2025 were identified from our local, prospective registry. Primary outcome was successful intra-procedural PVI. Secondary outcomes included adverse events, procedure duration, fluoroscopy time and same-day discharge. All of the patients achieved PVI. Additional non-PV target ablations were performed in 39 patients (22 radiofrequency CTI line ablations, 18 other targets). Five (5%) had procedural complications, two of which related to vascular access. Median procedural time was 85min for all procedures, and 70min for PVI-only, with improved times as user experience increased. Median fluoroscopy time was 20min. Same-day discharge was achieved in 49 patients. PFA using Medtronic's PulseSelect System is an effective and safe method of achieving PVI. Our data would suggest it is a quicker procedure than thermal based ablation, which rapidly improved with user experience. The long-term durability of PVI requires further follow-up.

Why do reports of harassment in surgery go unheard? New analysis shows systemic flaws in support and reporting structures that leave trainees vulnerable and silent.

The authors declare no conflicts of interest. Data sharing is not applicable to this article as no new data were created or analyzed in this study.