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Programme design features supporting or impeding health system effects of P4P included scope of incentivised indicators, fairness and reach of incentives, timely payments and a supportive, robust verification system that does not overburden staff. Facility bonuses are a key element of P4P, but rely on provider autonomy for maximum effect. If health system inputs are vastly underperforming pre-P4P, they are unlikely to improve only due to P4P. This is the first realist review describing how and why P4P initiatives work (or fail) in different LMIC contexts by exploring the underlying mechanisms and contextual and programme design moderators. Future studies should systematically examine health system pathways to outcomes for P4P and other health system strengthening initiatives, and offer more understanding of how programme design shapes mechanisms and effects.Many proteins are found to possess repeated structural elements, which hint at ancient evolutionary origins and ongoing evolutionary processes. β-propeller proteins are a large family of such proteins, and a popular focus of structural analysis. This review highlights recent work to understand how they arose, and how they have developed into one of the most successful of all protein folds.The peroneal artery (PeA) is often a vital target vessel for lower limb revascularization. Exploring the distal PeA can be challenging via the conventional approaches. We present a new, minimally invasive technique for a latero-anterior approach to the terminal PeA without fibular resection as either a target outflow vessel for open bypass revascularization surgery or, as in this report, the inflow for a crural-pedal bypass in a challenging case of critical limb-threatening ischemia.Spontaneous iliac vein rupture is a relatively rare but fatal disease. Herein, 2 cases are reported. The two middle-aged and elderly females complaining of abdominal pain were admitted without any history of trauma. The computed tomography image both showed one huge hematoma in the lower abdominal cavity and the left external iliac venous thrombus. Venogram showed ruptures of the left external iliac vein and stenosis of the left common iliac vein after percutaneous mechanical thrombectomy. Stent grafts were implanted by endovascular technique. Favorable outcomes were achieved in both cases.

The aim of this study was to review the efficacy of the Flixene™ (Atrium™, Hudson, NH, USA) hemodialysis arterio-venous graft (AVG) in a multiethnic Asian cohort of patients with end-stage renal failure (ESRF). Primary outcome was graft primary patency rate and secondary end points included graft usability, time to cannulation, reinterventions required for access salvage, complications, and patient mortality.

Single-center, single-arm, multi-investigator nonrandomized retrospective study. Patients with ESRF who underwent Flixene™ graft implantation over a two-year period (January 2017 – December 2018) were included to allow at least one-year follow-up. Demographics, procedural and follow-up data were collected from the hospital electronic medical records.

About 48 patients (49 AVG) were included. There were 24 (50%) men; mean age 63.7 (IQR 58.2-71.3) years. Technical success rate was 45/49 (91.8%); 4/49 (8.2%) AVG created did not reach cannulation. 11/49 (22.4%) and 28/49 (57.1%) achieved cannulation within 1 and 2weeks, respectively. 6- and 12- month primary patencies were 33.5% and 19.6%, respectively. Primary-assisted patency rates were 46.6% and 29.6% at the same time intervals. Secondary patency rate was 77.6% and 63.9% at 6 and 12months, respectively. There were 6 (12.2%) graft infections requiring explant and one-year mortality was 14%.

Our experience with the Flixene™ early cannulation graft is comparable with other AVGs in terms of patency and infection rates. However, early cannulation rates are lower than in other case series.

Our experience with the Flixene™ early cannulation graft is comparable with other AVGs in terms of patency and infection rates. However, early cannulation rates are lower than in other case series.

The choice of anesthetic for carotid endarterectomy (CEA) continues to be controversial. Recent literature suggests improved outcomes with the use of regional anesthesia (RA) compared with general anesthesia (GA). The objective of this study was to examine the utilization and outcomes of RA for CEA using a national database.

The targeted CEA files of the American College of Surgeons’ National Surgical Quality Improvement Program (2011-2017) were reviewed. Patients were stratified based on anesthesia type into RA and GA, and patients’ characteristics were compared between the 2 groups. The outcomes of CEA under GA and RA were compared after 21 propensity matching.

There were 26,206 CEAs, and 14% (n=3,664) were performed under RA, with no change in relative utilization during the study period (P=0.557). Patients treated under RA were more likely to be older than 65 years (80.6% vs. 75.8%; P<0.001) and White (90.8% vs. 83.5%; P<0.001) but less likely to have diabetes (28.2% vs. 31.2%; P=0.001), chronic obstructive pulmonary disease (10.2% vs. 10.5%; P<0.001), and heart failure (1.0% vs. 1.5%; P=0.02) and be symptomatic (37.4% vs. check details 42.7%; P<0.001). After matching, there was no significant difference in baseline characteristics between the 2 groups. Patients undergoing RA were less likely to experience the combined end point of stroke, myocardial infarction, or mortality compared with GA. GA patients were more likely to have longer operating time and hospital length of stay.

CEA performed under RA is associated with improved outcomes compared with GA. RA is underutilized in carotid surgery, and strategies to optimize its use are needed.

CEA performed under RA is associated with improved outcomes compared with GA. RA is underutilized in carotid surgery, and strategies to optimize its use are needed.

In the setting of chronic limb ischemia, lower extremity (LE) wounds require revascularization of source arteries for wound healing and limb salvage. Direct revascularization of the source artery is preferred but cannot always be performed. Our objective was to analyze the influence of arterial-arterial connections on clinical outcomes after angiosome-directed endovascular revascularization.

Consecutive LE wounds in patients with isolated infra-popliteal disease revascularized endovascularly from 2012 to 2016 within a single center were retrospectively reviewed. Treatment was classified as direct revascularization (DR) if the source artery supplying the wound angiosome was treated, indirect revascularization via collaterals (IR-C) if the source artery angiosome was revascularized by another major artery via arterial connections, or indirect revascularization (IR) if direct revascularization of the source artery angiosome was not possible. Demographics, comorbidities, and patient outcomes were collected.

Of 105 patients with 106 LE wounds, there were 35, 38, and 33 patients in the DR, IR-C, and IR groups, respectively.