The Royal Infirmary of Edinburgh, or RIE, often (but incorrectly) known as the Edinburgh Royal Infirmary, or ERI, was established in 1729 and is the oldest voluntary hospital in Scotland. The new buildings of 1879 were claimed to be the largest voluntary hospital in the United Kingdom, and later on, the Empire. The hospital moved to a new 900 bed site in 2003 in Little France. It is the site of clinical medicine teaching as well as a teaching hospital for the University of Edinburgh Medical School. In 1960, the first successful kidney transplant performed in the UK was at this hospital. In 1964, the world's first coronary care unit was established at the hospital. It is the only site for liver, pancreas and pancreatic islet cell transplantation and one of two sites for kidney transplantation in Scotland. In 2012, the Emergency Department had 113,000 patient attendances, the highest number in Scotland. It is managed by NHS Lothian.
To define the ‘patient acceptable symptom state’ (PASS) and ‘minimum important change’ (MIC) for the Oxford Hip Score (OHS) following aseptic revision total hip arthroplasty (rTHA), and identify factors associated with their achievement. A prospective cohort of 135 patients (138 hips) undergoing aseptic rTHA at a single centre were followed up at one and two years postoperatively. Demographics, health-related quality of life (HRQoL; EQ-5D) and OHS were recorded at each timepoint. Anchor techniques were used to define the MIC and PASS. Regression models identified factors associated with PASS and MIC achievement. The OHS PASS was 31.5 and 33.5 at one and two years postoperatively, respectively. The MIC was 8.5 at both timepoints. A greater preoperative EQ-5D was independently associated with PASS achievement at both timepoints. One-year MIC achievement was independently associated with lower BMI (p = 0.042) and lower preoperative OHS (p = 0.007), whilst lower preoperative OHS (p = 0.016) alone was independently associated with two year MIC achievement (p = 0.016). Lower preoperative EQ-5D and ASA grade 3 were associated with failure to achieve either PASS or MIC at one year (p = 0.030) and two years (p = 0.013) postoperatively, respectively. The PASS and MIC thresholds for the OHS following aseptic rTHA contextualise the score and can inform study design. Greater preoperative HRQoL was independently associated with PASS achievement, whilst worse preoperative function was independently associated with MIC achievement. These thresholds should be considered in conjunction when assessing outcomes following aseptic rTHA.
Background Trigeminal neuralgia associated with multiple sclerosis (MS-TN) is frequently refractory to medical and procedural therapy, particularly in the absence of neurovascular compression. Surgical options are limited when microvascular decompression is not appropriate. We report a salvage surgical approach combining internal neurolysis and targeted proximal trigeminal root glycerol injection for refractory MS-related trigeminal neuralgia. Case presentation A 50-year-old woman with relapsing-remitting multiple sclerosis presented with medically refractory right-sided trigeminal neuralgia predominantly involving the V2/V3 distributions. She had previously failed optimisation of pharmacotherapy, two percutaneous retrogasserian glycerol rhizotomies, and Gamma Knife radiosurgery performed within the preceding year. Posterior fossa exploration via a retrosigmoid approach demonstrated no neurovascular conflict. Internal neurolysis (nerve combing) was therefore performed and supplemented with targeted glycerol delivery to the proximal cisternal segment of the trigeminal root adjacent to the radiologically relevant demyelinating lesion. Postoperatively, the patient experienced immediate improvement in facial pain with preservation of trigeminal sensation and no new neurological deficits. Her early postoperative course was complicated by a wound infection requiring surgical washout and antibiotic therapy. At 43-month follow-up, she remained free of ipsilateral trigeminal neuralgia with substantially reduced medication requirements. She later developed contralateral facial pain controlled with low-dose carbamazepine without recurrence on the operated side. Conclusion This report describes, to our knowledge, the first published case of combined internal neurolysis and targeted proximal trigeminal root glycerol injection for refractory multiple sclerosis-related trigeminal neuralgia. In this highly selected case, durable ipsilateral pain control was observed. However, causal interpretation is limited by the single-case design, the combined nature of the intervention, and the potential delayed effects of prior radiosurgery. This approach should therefore be regarded as hypothesis-generating rather than practice-defining, but may merit further study as a salvage strategy in selected patients without neurovascular compression after failure of medical, percutaneous, and radiosurgical treatments.
PURPOSE OF REVIEW:Survival rates following liver transplantation now exceed 90% at one year. However, the patient group undergoing liver transplantation is increasingly complex, requiring continued focus on improving perioperative care to sustain these survival outcomes. This review highlights recent advances in the postoperative care of the liver transplantation patient. RECENT FINDINGS:Modern care integrates Enhanced Recovery After Surgery (ERAS) principles, which emphasise early mobilisation and device minimisation. Risk stratification has become increasingly sophisticated, with frailty and cardiopulmonary exercise testing providing powerful prognostic information; emerging machine learning approaches may further refine personalised risk prediction.Goal-directed haemodynamic management is advocated, with restrictive fluid strategies and viscoelastic haemostatic assays to minimise transfusion. Advances in graft optimisation have expanded the donor pool: normothermic regional perfusion reduces ischaemic cholangiopathy in donation after cardiac death grafts, while machine perfusion systems show promise in improving early graft function.Advanced organ support (extracorporeal membrane oxygenation) requires careful graft-conscious management. Infection prevention strategies include tailored prophylaxis approaches. Nutrition and structured prehabilitation/rehabilitation programmes support recovery, reduce complications and address persistent functional deficits. SUMMARY:Collectively, these developments reflect a shift toward personalised, multidisciplinary postoperative care, aimed at improving both survival and quality of life for liver transplantation recipients.
Importance:In the emergency department, patients at low risk of myocardial infarction can be identified at presentation using a single cardiac troponin measurement with high-sensitivity assay. Objectives:To define a threshold to identify patients at low risk of myocardial infarction for the sixth-generation high-sensitivity cardiac troponin T (hs-cTnT) assay and to evaluate the impact of applying this in an early rule-out pathway. Design, Setting, and Participants:This was a prospective multicenter cohort study conducted from 2022 to 2025 (derivation cohort) and 2014 to 2019 (validation cohort). The setting included emergency departments at hospitals in Scotland (derivation cohort) and Czechia, Italy, Poland, Spain, and Switzerland (validation cohort). Participants included adults with possible non-ST-segment elevation myocardial infarction (both cohorts). Study data were analyzed from May to October 2025. Exposures:Cardiac troponin concentration measured at presentation and on serial samples using fifth-generation and novel sixth-generation hs-cTnT assays. Main Outcomes and Measures:Outcomes included the highest threshold at presentation with negative predictive value (NPV) greater than or equal to 99.5% and sensitivity greater than or equal to 99% for an adjudicated primary outcome of type 1, 4b, or 4c myocardial infarction or cardiac death at 30 days. Performance of an early rule-out pathway with the sixth-generation assay. Results:In total, 987 patients (median [IQR] age, 59 [50-70] years; 611 male [62%]) were recruited, with 82 (8.3%) meeting the primary outcome. At presentation, 601 patients (61%) had a cardiac troponin T concentration less than 13 ng/L using the sixth-generation hs-cTnT assay, with an NPV of 99.9% (95% credible interval [CrI], 99.7%-100%) and sensitivity of 99.4% (95% CrI, 97.7%-100%). More patients were identified as low risk at presentation in the early rule-out pathway when using the sixth-generation assay compared with fifth-generation assay (376 [41.0%] vs 160 [17.4%]; P < .001). In the external validation cohort, 782 of 1721 patients (45.4%) had a sixth-generation hs-cTnT measurement less than 13 ng/L at presentation with an NPV of 99.0% (95% Cr, 98.3%-99.6%) and sensitivity of 97.5% (95% Cr, 95.8%-99.0%), compared with 118 (6.9%) below the low risk-stratification threshold of the fifth-generation hs-cTnT assay (P < .001). Conclusions and Relevance:Results of this cohort study suggest that compared with the fifth-generation hs-cTnT assay, use of the sixth-generation assay with a risk-stratification threshold based on clinical performance could double identification of patients at low risk of myocardial infarction or cardiac death at presentation. Prospective studies are required to evaluate the impact of implementation on practice.
BACKGROUND:Implantation of drug eluting stents (DESs) is currently the default approach for percutaneous coronary interventions, but long-term adverse events still exist. An approach with minimal stenting deserves to be assessed in a randomized trial. We studied a novel sirolimus-eluting balloon (SEB) that elutes sirolimus over a 90-day period using a biodegradable polymer microreservoir technology. METHODS:In a multicenter, open-label, randomized trial, we compared an SEB-based strategy with provisional DES with one of systematic DES for de novo lesions in coronary arteries between 2 and 5 mm in diameter. Subjects were randomized 1:1 before percutaneous coronary intervention. The primary end point was target vessel failure, a composite of cardiac death, target vessel-related myocardial infarction, and clinically driven target vessel revascularization. It was tested for noninferiority at 1 year with the use of an absolute margin equal to 50% of the combined event rate at a significance level of 0.025. The primary analysis population included all randomized subjects with completed or attempted percutaneous revascularization, analyzed according to the intention-to-treat principle. A sensitivity analysis was performed on the per-protocol population. RESULTS:Between August 27, 2021, and July 29, 2024, 3323 participants were randomized and treated in 62 sites. Among 1661 participants in the SEB strategy group, bailout stenting was performed in 343 (20.7%). Target vessel failure occurred over 365 days in 88 (5.3%) and 73 (4.4%) participants in the SEB and the systematic DES strategy groups, respectively (risk difference, 0.91% [95% CI -0.55% to 2.38%]; 1-sided P=0.02 for noninferiority with a 2.44% noninferiority margin). Clinically driven target vessel revascularization occurred more frequently in the SEB strategy group (3.3% versus 2.1%; risk difference, 1.22% [95% CI, 0.11%-2.33%). Safety events, including lesion thrombosis, were low and similar in both groups. Although the results of the per-protocol population (3194 participants, 96%) did not confirm noninferiority (upper boundary of the 95% CI, 2.63; P=0.04), they were similar to the intention-to-treat results in both magnitude and direction. CONCLUSIONS:At 1 year, in the primary intention-to-treat analysis population, a strategy of percutaneous coronary intervention with SEB and provisional DES was noninferior to the systematic use of DES for the primary end point of target vessel failure. The per-protocol population sensitivity analysis did not confirm noninferiority. Clinically driven target vessel revascularization occurred more frequently in the SEB strategy group. At 5 years, target vessel failure will be tested again for noninferiority and for superiority if noninferiority is achieved. REGISTRATION:URL: https://www.clinicaltrials.gov; Unique identifier: NCT04859985.
