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Relationship of clot burden and echocardiographic severity of right ventricular dysfunction after acute pulmonary embolism
© 2014, Springer Science+Business Media Dordrecht. The impact of pulmonary embolism on right ventricular (RV) performance can be evaluated by echocardiography, however, the relationship between pulmonary vascular involvement and RV burden is controversial. To assess the effect of clot burden on RV performance we studied 85 patients (aged 53 ± 17 years, 39 female) with confirmed PE by multislice computed tomography (CT) and echocardiography within 24 h of diagnosis. A CT score ranging from 1 to 20 points according to the pulmonary arteries involved was used. RV function was evaluated with fractional area change (FAC), with dysfunction present when FAC
Immunometabolic factors in adolescent chronic disease are associated with Th1 skewing of invariant Natural Killer T cells.
Invariant Natural Killer T (iNKT) cells respond to the ligation of lipid antigen-CD1d complexes via their T-cell receptor and are implicated in various immunometabolic diseases. We considered that immunometabolic factors might affect iNKT cell function. To this end, we investigated iNKT cell phenotype and function in a cohort of adolescents with chronic disease and immunometabolic abnormalities. We analyzed peripheral blood iNKT cells of adolescents with cystic fibrosis (CF, n = 24), corrected coarctation of the aorta (CoA, n = 25), juvenile idiopathic arthritis (JIA, n = 20), obesity (OB, n = 20), and corrected atrial septal defect (ASD, n = 25) as controls. To study transcriptional differences, we performed RNA sequencing on a subset of obese patients and controls. Finally, we performed standardized co-culture experiments using patient plasma, to investigate the effect of plasma factors on iNKT cell function. We found comparable iNKT cell numbers across patient groups, except for reduced iNKT cell numbers in JIA patients. Upon ex-vivo activation, we observed enhanced IFN-γ/IL-4 cytokine ratios in iNKT cells of obese adolescents versus controls. The Th1-skewed iNKT cell cytokine profile of obese adolescents was not explained by a distinct transcriptional profile of the iNKT cells. Co-culture experiments with patient plasma revealed that across all patient groups, obesity-associated plasma factors including LDL-cholesterol, leptin, and fatty-acid binding protein 4 (FABP4) coincided with higher IFN-γ production, whereas high HDL-cholesterol and insulin sensitivity (QUICKI) coincided with higher IL-4 production. LDL and HDL supplementation in co-culture studies confirmed the effects of lipoproteins on iNKT cell cytokine production. These results suggest that circulating immunometabolic factors such as lipoproteins may be involved in Th1 skewing of the iNKT cell cytokine response in immunometabolic disease.
Plasminogen activation in unstable angina is associated with an acute phase reaction, but does not correlate with other indexes of thrombotic or fibrinolytic activity
In Unstable Angina (UA) an acute phase response and an increase in plasminogen have been reported. To assess whether plasminogen activation is related to the hemostatic or to the inflammatory systems in UA, we measured plasma levels of Plasmin-α2-antiplasmin (PAP), C-Reactive protein (CRP) and Thrombin-AntiThrombin HI (TAT), as markers of plasminogen activation, inflammation and thrombin production, respectively. We also measured plasma levels of D-Dimer (DD), a fibrin degradation product, to assess actual lysis of fibrin. We studied 47 pts admitted to our CCU for severe UA. Blood samples were taken at CCU admission. Results (median and range): Elevated levels were considered above mean +2 SD for PAP (700 ng/ml), DD (30μg/l) and TAT (6 μg/ml) and levels >3 mg/l for CRP (90° percentile of healthy subjects). Elevated levels of PAP were observed in 18/47 pts (38%), but elevated levels of DD and TAT were found only in 9/47 pts (19%). Conversely CRP was raised in 28/47 pts (60%). PAP levels (594ng/ml, 234-1899) did not correlate with levels of DD (12.1μg/1, range 1.9-182; p=ns) or of TAT (2.1μg/ml, range 0.8-39, p=ns). Conversely a significant correlation was observed between PAP and CRP (3.7 mg/1, range 0.4-82; r=0.45, p=0.005), as well as between TAT and DD (r=0.3, p=0.047). Conclusions: An increased plasminogen activation is common in UA, but is not associated to a similar activation of the hemostatic system, as detectable by TAT and DD, but correlates with levels of the acute phase protein CRP, suggesting that in unstable angina a strong endothelial activation may have place, as source of plasminogen production, possibly on an inflammatory basis.
The changing landscape of the vulnerable plaque: a call for fine-tuning of preclinical models.
For decades, the pathological definition of the vulnerable plaque led to invaluable insights into the mechanisms that underlie myocardial infarction and stroke. Beyond plaque rupture, other mechanisms, such as erosion, may elicit thrombotic events underlining the complexity and diversity of the atherosclerotic disease. Novel insights, based on single-cell transcriptomics and other "omics" methods, provide tremendous opportunities in the ongoing search for cell-specific determinants that will fine-tune the description of the thrombosis prone lesion. It coincides with an increasing awareness that knowledge on lesion characteristics, cell plasticity and clinical presentation of ischemic cardiovascular events have shifted over the past decades. This shift correlates with an observed changes of cell composition towards phenotypical stabilizing of human plaques. These stabilization features and mechanisms are directly mediated by the cells present in plaques and can be mimicked in vitro via primary plaque cells derived from human atherosclerotic tissues. In addition, the rapidly evolving of sequencing technologies identify many candidate genes and molecular mechanisms that may influence the risk of developing an atherosclerotic thrombotic event - which bring the next challenge in sharp focus: how to translate these cell-specific insights into tangible functional and translational discoveries?
Right ventricular abnormalities in Takotsubo cardiomyopathy.
Takotsubo cardiomyopathy, described as transient regional contractile abnormalities limited to the apical and mid-segments of the left ventricle (LV), has also been reported to involve basal and/or mid LV segments (inverted Takotsubo); fewer reports, however, have addressed right ventricular (RV) dysfunction. To assess the distribution of regional abnormalities and RV involvement in Takotsubo cardiomyopathy and compare it to the literature. We evaluated 23 patients with both classical and inverted presentations (19 female, aged 64 ± 19 years), including 2 recurrences, totaling 25 episodes. Classical Takotsubo was observed in 15 patients, while 10 had the inverted form. LV ejection fraction (EF) was lower for classical compared to inverted presentation (30 ± 7 vs. 45 ± 4%, P < 0.001) with higher troponin values (1.3 ± 1.4 vs. 0.5 ± 0.6, P = 0.034). RV abnormalities were found in 7 patients (28%), mainly with classical presentation (6 patients), presenting with mid and apical RV impairment. One patient with inverted Takotsubo had mid-RV involvement. Patients with RV involvement had lower left ventricular ejection fraction (LVEF) (28 ± 10% vs. 40 ± 10%, P = 0.02), but not when adjusted for presentation type. Overall rate of complications was higher for classical compared to inverted presentation, and not influenced by RV involvement. RV contractile abnormalities may follow the same LV regional distribution in Takotsubo cardiomyopathy; the type of presentation rather than the presence of RV dysfunction seems to be responsible for an increased risk of complications and severity of functional impairment. © 2013, Wiley Periodicals, Inc.
Right ventricular assessment by tissue-doppler echocardiography in acute pulmonary embolism
Background: Assessment of the right ventricular (RV) function by echocardiography in patients with pulmonary thromboembolism (PE) is complex and frequently qualitative. Tissue Doppler has been used for the semiquantitative assessment of this chamber, although with some limitations. Objective: To evaluate RV function in PE using tissue-Doppler echocardiography, in addition to atrial natriuretic peptide (BNP). Methods: Patients with PE were studied using tissue-Doppler echocardiography and BNP up to 24 hours after diagnosis; myocardial velocities (s'), strain, strain rate and RV myocardial performance index were obtained. RV dysfunction was diagnosed by chamber hypokinesia, abnormal septal motion and a RV/LV ratio ≥1. According to their BNP levels, the patients were divided into Group I, BNP < 50 pg/mL and Group II, BNP ≥ 50 pg/mL. Results: Of 118 patients, 100 (60 men, age = 55 ± 17 years) were analyzed; RV dysfunction was observed in 28%, more frequently in group II (19 vs. 9 patients, p < 0.001). Patients in group II were older (64 ± 19 vs. 50 ± 15 years), and had lower s' velocity (10.5 ± 3.5 vs. 13.2 ± 3.1 cm/s), and higher pulmonary pressure (48 ± 11 vs. 35 ± 11 mmHg), p < 0.001. The cut-off point of s' for RV dysfunction was 10.8 cm/s (specificity = 85%, sensitivity = 54%), with moderate correlation between BNP and s' wave (r = -0.39). Conclusion: In PE, RV dysfunction on echocardiography is accompanied by BNP elevation; although tissue- Doppler imaging adequately confirms the presence of RV dysfunction, it has a limited sensitivity for this diagnosis.
Right ventricular abnormalities in Takotsubo cardiomyopathy.
Takotsubo cardiomyopathy, described as transient regional contractile abnormalities limited to the apical and mid-segments of the left ventricle (LV), has also been reported to involve basal and/or mid LV segments (inverted Takotsubo); fewer reports, however, have addressed right ventricular (RV) dysfunction. To assess the distribution of regional abnormalities and RV involvement in Takotsubo cardiomyopathy and compare it to the literature. We evaluated 23 patients with both classical and inverted presentations (19 female, aged 64 ± 19 years), including 2 recurrences, totaling 25 episodes. Classical Takotsubo was observed in 15 patients, while 10 had the inverted form. LV ejection fraction (EF) was lower for classical compared to inverted presentation (30 ± 7 vs. 45 ± 4%, P < 0.001) with higher troponin values (1.3 ± 1.4 vs. 0.5 ± 0.6, P = 0.034). RV abnormalities were found in 7 patients (28%), mainly with classical presentation (6 patients), presenting with mid and apical RV impairment. One patient with inverted Takotsubo had mid-RV involvement. Patients with RV involvement had lower left ventricular ejection fraction (LVEF) (28 ± 10% vs. 40 ± 10%, P = 0.02), but not when adjusted for presentation type. Overall rate of complications was higher for classical compared to inverted presentation, and not influenced by RV involvement. RV contractile abnormalities may follow the same LV regional distribution in Takotsubo cardiomyopathy; the type of presentation rather than the presence of RV dysfunction seems to be responsible for an increased risk of complications and severity of functional impairment. © 2013, Wiley Periodicals, Inc.
Thrombotic-fibrinolytic system balance and prognosis in unstable angina
The balance between thrombotic and fibrinolytic system is supposed to play an important role in the pathophysiology of unstable angina (UA). To assess whether an imbalance between thrombotic and fibrinolytic factors is responsible for different outcomes in UA, we assessed in 50 patients with severe UA plasma levels of thrombin-antithrombin III complex (TAT) and prothrombin fragment 1+2 (F1+2) as markers of thrombotic activation, and plasma levels of D-Dimer (DD) and Plasmin-antiplasmin complex (PAP), as markers of fibrinolyic activation. Samples were taken on admission and six hourly in the first 24 h and daily for 3 days. We assessed the mean values of each marker (TAT, F1+2, DD, PAP) through the whole study, and calculated the following ratios of the means: DD/TAT, DD/F1+2, PAP/TAT, PAP/F1+2. We also considered the number of samples with elevated levels of TAT, F1+2, PAP and DD for each pts throughout the study. Results: Twenty-seven pts (Gl) had a complicated in-hospital outcome, and 23 (G2) had a spontaneous waning of symptoms. No differences in the DD/TAT, DD/F1+2, PAP/TAT, PAP/F1+2 ratios were observed between Gl and G2 (respectively 2.76 vs 4.55, 12.8 vs 13, 135.8 vs 172.2 and 518.4 vs 490.2, all p=ns). However in Gl significantly more samples had elevated levels of TAT and F1+2 than in G2 (respectively 42 and 61 of 148 samples, vs 10 and 22/103 samples, p<0.01) whereas there was no difference in the number of samples with elevated levels of PAP and DD between Gl and G2. Conclusions: Our data show that there is not an overall imbalance between thrombotic and fibrinolytic factors as an underlying characteristic differentiating UA pts with different outcomes, but suggest that acute imbalance of these factors may suddendly develops in UA pts with complicated in-hospital course and possibly be the cause of the waxing of symptoms in these patients.
Activation of the hemostatic system does not cause neutrophil degranulation in unstable angina
To assess whether activation of the thrombotic system may induce neutrophil degranulation in unstable angina (UA), we studied the time course of the intracellular index of myeloperoxidase (MPXI), a marker of neutrophil activation, in relation to levels of Thrombin-antithrombin III complexes (TAT) and of Fragment 1+2 (FI +2) as markers of activation of the coagulation system in 20 patients (pts) with UA and in 20 healthy volunteeres (N). Samples were taken on admission, and at 6, 24, 48 and 72 hours. Results (median and range): On admission no differences were found between UA and N in TAT e F1+2 values: TAT: 2.05 ng/ml (range 0.5/14.4) vs 2.1 ng/ml (range 1.05/4.2); F1+2: 0.83 nmol/1 (range 0.14/-1.65) vs 0.59 nmol/1 (range 0.41/0.98), conversely MPXI levels were significantly different in UA vs N: respectively -4 (range +5/-15) vs -1.3 (range +5.S/-7, p<0.01). During the study 11 episodes of elevation of TAT and/or F1 +2 (6 symptomatic and 5 asymptomatic) followed by at least one sample for MPXI were observed. No changes in MPXI values after the episodes of activation of the coagulation as compared to baseline values were observed (-3.5, range -11.4/1.2 vs -4.7, range -13.1/4.5 respectively). There was no correlation between MPXI and TAT, and MPXI and F[+2. Conclusions: Our data suggest that activation of the coagulation system doesn't elicit systemic neutrophil activation in unstable angina; this may suggests that a primary, yet unknown inflammatory cause, may be responsible for the neutrophil activation observed in unstable angina.
Elevated blood pressure, antihypertensive medications and bone health in the population: revisiting old hypotheses and exploring future research directions.
Blood pressure and bone metabolism appear to share commonalities in their physiologic regulation. Specific antihypertensive drug classes may also influence bone mineral density. However, current evidence from existing observational studies and randomised trials is insufficient to establish causal associations for blood pressure and use of blood pressure-lowering drugs with bone health outcomes, particularly with the risks of osteoporosis and fractures. The availability and access to relevant large-scale biomedical data sources as well as developments in study designs and analytical approaches provide opportunities to examine the nature of the association between blood pressure and bone health more reliably and in greater detail than has ever been possible. It is unlikely that a single source of data or study design can provide a definitive answer. However, with appropriate considerations of the strengths and limitations of the different data sources and analytical techniques, we should be able to advance our understanding of the role of raised blood pressure and its drug treatment on the risks of low bone mineral density and fractures. As elevated blood pressure is highly prevalent and blood pressure-lowering drugs are widely prescribed, even small effects of these exposures on bone health outcomes could be important at a population level.
A Primer on RECIST 1.1 for Oncologic Imaging in Clinical Drug Trials.
Drug discovery and approval in oncology is mediated by the use of imaging to evaluate drug efficacy in clinical trials. Imaging is performed while patients receive therapy to evaluate their response to treatment. Response criteria, specifically Response Evaluation Criteria in Solid Tumors version 1.1 (RECIST 1.1), are standardized and can be used at different time points to classify response into the categories of complete response, partial response, stable disease, or disease progression. At the trial level, categorical responses for all patients are summated into image-based trial endpoints. These outcome measures, including objective response rate (ORR) and progression-free survival (PFS), are characteristics that can be derived from imaging and can be used as surrogates for overall survival (OS). Similar to OS, ORR and PFS describe the efficacy of a drug. U.S. Food and Drug Administration (FDA) regulatory approval requires therapies to demonstrate direct evidence of clinical benefit, such as improved OS. However, multiple programs have been created to expedite drug approval for life-threatening illnesses, including advanced cancer. ORR and PFS have been accepted by the FDA as adequate predictors of OS on which to base drug approval decisions, thus substantially shortening the time and cost of drug development (1). Use of imaging surrogate markers for drug approval has become increasingly common, accounting for more than 90% of approvals through the Accelerated Approval Program and allowing for use of many therapies which have altered the course of cancer. Keywords: Oncology, Tumor Response RSNA, 2021.
Adiposity and bone microarchitecture in the GLOW study.
Low body mass index (BMI) is an established risk factor for fractures in postmenopausal women but the interaction of obesity with bone microarchitecture is not fully understood. In this study, obesity was associated with more favourable bone microarchitecture parameters but not after parameters were normalised for body weight. INTRODUCTION: To examine bone microarchitecture in relation to fat mass and examine both areal bone mineral density (aBMD) and microarchitecture in relation to BMI categories in the UK arm of the Global Longitudinal Study of Osteoporosis in Women. METHODS: Four hundred and ninety-one women completed questionnaires detailing medical history; underwent anthropometric assessment; high-resolution peripheral quantitative computed tomography (HRpQCT) scans of the radius and tibia and DXA scans of whole body, proximal femur and lumbar spine. Fat mass index (FMI) residuals (independent of lean mass index) were derived. Linear regression was used to examine HRpQCT and DXA aBMD parameters according to BMI category (unadjusted) and HRpQCT parameters in relation to FMI residuals (with and without adjustment for anthropometric, demographic and lifestyle covariates). RESULTS: Mean (SD) age was 70.9 (5.4) years; 35.0% were overweight, 14.5% class 1 obese and 7.7% class 2/3 obese. There were significant increasing trends according to BMI category in aBMD of whole body, hip, femoral neck and lumbar spine (p ≤ 0.001); cortical area (p
Intramuscular lipid concentration increased in localized regions of the lumbar muscles following 60-day bedrest.
BACKGROUND CONTEXT: Prolonged bedrest induces accumulation of intramuscular lipid concentration (ILC) in the lumbar musculature; however, spatial distribution of ILC has not been determined. Artificial gravity (AG) mitigates some adaptations induced by 60-day bedrest by creating a head-to-feet force while participants are in a supine position. PURPOSE: To quantify the spatial distribution of accumulation of ILC in the lumbar musculature after 60-day bedrest, and whether this can be mitigated by AG exposure. STUDY DESIGN: Prospective longitudinal study. PATIENT SAMPLE: Twenty-four healthy individuals (8 females) participated in the study: Eight received 30 min continuous AG (cAG); Eight received 6 × 5min AG (iAG), interspersed with rests; Eight were not exposed to AG (CRTL). OUTCOME MEASURES: From 3T magnetic resonance imaging (MRI), axial images were selected to assess lumbar multifidus (LM), lumbar erector spinae (LES), quadratus lumborum (QL), and psoas major (PM) muscles from L1/L2 to L5/S1 intervertebral disc levels. Chemical shift-based 2-echo lipid/water Dixon sequence was used to measure tissue composition. Each lumbar muscle was segmented into four equal quartiles (from medial to lateral). METHODS: Participants arrived at the facility for the baseline data collection before undergoing a 60-day strict 6° head-down tilt (HDT) bedrest period. MRI of the lumbopelvic region was conducted at baseline and Day-59 of bedrest. Participants performed all activities, including hygiene, in 6° HDT and were discouraged from moving excessively or unnecessarily. RESULTS: At the L4/L5 and L5/S1 intervertebral disc levels, 60-day bedrest induced a greater increase in ILC in medial and lateral regions (∼+4%) of the LM than central regions (∼+2%; P<0.05). A smaller increase in ILC was induced in the lateral region of LES (∼+1%) at L1/L2 and L2/L3 than at the centro-medial region (∼+2%; P<0.05). There was no difference between CRTL and intervention groups. CONCLUSIONS: Inhomogeneous spatial distribution of accumulation of ILC was found in the lumbar musculature after 60-day bedrest. These findings might reflect pathophysiological mechanisms related to muscle disuse and contribute to localized lumbar spine dysfunction. Altered spatial distribution of ILC may impair lumbar spine function after prolonged body unloading, which could increase injury risk to vulnerable soft tissues, such as the lumbar intervertebral discs. These novel results may represent a new biomarker of lumbar deconditioning for astronauts, bedridden, sedentary individuals, or those with chronic back pain. Changes are potentially modifiable but not by the AG protocols tested here.
Chlorhexidine versus povidone-iodine skin antisepsis before upper limb surgery (CIPHUR): an international multicentre prospective cohort study.
INTRODUCTION: Surgical site infection (SSI) is the most common and costly complication of surgery. International guidelines recommend topical alcoholic chlorhexidine (CHX) before surgery. However, upper limb surgeons continue to use other antiseptics, citing a lack of applicable evidence, and concerns related to open wounds and tourniquets. This study aimed to evaluate the safety and effectiveness of different topical antiseptics before upper limb surgery. METHODS: This international multicentre prospective cohort study recruited consecutive adults and children who underwent surgery distal to the shoulder joint. The intervention was use of CHX or povidone-iodine (PVI) antiseptics in either aqueous or alcoholic form. The primary outcome was SSI within 90 days. Mixed-effects time-to-event models were used to estimate the risk (hazard ratio (HR)) of SSI for patients undergoing elective and emergency upper limb surgery. RESULTS: A total of 2454 patients were included. The overall risk of SSI was 3.5 per cent. For elective upper limb surgery (1018 patients), alcoholic CHX appeared to be the most effective antiseptic, reducing the risk of SSI by 70 per cent (adjusted HR 0.30, 95 per cent c.i. 0.11 to 0.84), when compared with aqueous PVI. Concerning emergency upper limb surgery (1436 patients), aqueous PVI appeared to be the least effective antiseptic for preventing SSI; however, there was uncertainty in the estimates. No adverse events were reported. CONCLUSION: The findings align with the global evidence base and international guidance, suggesting that alcoholic CHX should be used for skin antisepsis before clean (elective upper limb) surgery. For emergency (contaminated or dirty) upper limb surgery, the findings of this study were unclear and contradict the available evidence, concluding that further research is necessary.
Risk of surgical site infection in hand trauma, and the impact of the SARS-CoV-2 pandemic: A cohort study.
BACKGROUND: Despite the ubiquity of hand trauma, there remains insufficient published data to reliably inform these patients of surgical site infection (SSI) risk. We describe the risk of SSI in a single-centre cohort of patients with hand trauma, with an analysis of the impact of the coronavirus disease-2019 (COVID-19) pandemic. METHODS: Retrospective data collection of consecutive patients who underwent surgery for hand and wrist trauma in a single plastic surgery centre over two, three-month periods. Demographic, injury and operative details, alongside prophylactic antibiotic use, were recorded. Burn injuries and wounds infected at presentation were excluded. Presence of SSI at 30 days (90 days if a surgical implant was used) was assessed. RESULTS: Overall, 556 patients - 'Pre-COVID-19' (n = 310) and 'During COVID-19' (n = 246) - were included. Risk of SSI was 3.6% in the aggregated cohort. Female patients were more likely to develop an SSI, even when adjusted for their greater prevalence of bite aetiologies (adj OR 2.5; 95% CI, 1.00-6.37 and p
Developing a core outcome set for hand fractures and joint injuries in adults: a systematic review.
This study identifies the treatment outcome domains used in recently published studies on the treatment of hand fractures and joint injuries with the aim to inform development of a core outcome set. Seven databases were searched from January 2014 to March 2019 for randomized and quasi-randomized studies and large prospective observational studies. We identified 1777 verbatim outcomes in 160 eligible studies. From the verbatim outcomes we distinguished 639 unique outcomes, which we categorized into 74 outcome domains based on the World Health Organization International Classification of Functioning, Disability, and Health framework. The primary outcome was appropriately identified in only 65% (72/110) of randomized and quasi-randomized controlled trials. Of the 72 studies with a primary outcome identified, 74% (53/72) had an appropriate power calculation. The vast heterogeneity in outcome selection across studies highlights the need for a core outcome set of what outcomes to measure in future clinical research on hand fractures and joint injuries.
The surgical management of hidradenitis suppurativa in the United Kingdom: a national survey of care pathways informing the THESEUS study.
BACKGROUND: The evidence-base underpinning treatment efficacy and effectiveness for hidradenitis suppurativa (HS) is limited, as has been highlighted in the wide-ranging research priorities established by a James Lind Alliance priority-setting partnership (PSP). Understanding the landscape of surgical practice is a key step towards tackling undesired variation in care and resolving treatment uncertainties. This survey of current surgical practice aimed to describe care pathways involving surgeons for the management of HS and surgical approaches to management. METHODS: In the development of the prospective cohort Treatment of Hidradenitis Suppurativa Evaluation Study (THESEUS), a bespoke electronic surgeon survey was conducted to describe variation in care pathways and surgical preferences in the management of HS. This was disseminated to a pre-defined denominator list of surgeons using local collaborators through the reconstructive surgery trials network (RSTN). RESULTS: Key results were small numbers of surgeons working in formal multidisciplinary teams (MDTs) (8/198, 4%), heterogeneity of first-line intervention, low rates of guideline endorsed treatments (laser and deroofing in particular), variation in wound closure methods and follow-up length, and that over half of respondents do not use well-validated outcome instruments to determine treatment success/failure (110/198, 56%). CONCLUSIONS: This survey demonstrated variation in care, which is likely to be undesirable. Surgeons treating HS patients might consider developing MDTs or referring patients to those with an interest in HS and considering routine outcome measurement. Such steps might reduce variation, increase standardisation of care and improve access to specific treatments.