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A systematic review on the outcomes for acute cholecystitis patients undergoing percutaneous cholecystostomy.
Full text linkBackground: Percutaneous cholecystostomy (PC) is a treatment for acute cholecystitis (AC) which involves percutaneous insertion of a catheter into the gallbladder with local anaesthesia and under radiological guidance in order to drain the infected contents. It is being used more frequently, however, its use is inconsistent between hospitals and even clinicians, due to a lack of understanding about the outcomes. This study aimed to undertake a systematic review of the literature pertaining to what the outcomes are for AC patients undergoing PC.
Methods: Embase, Medline and Google Scholar were searched for articles from the last 10 years about the outcomes for AC patients undergoing PC (last searched 22nd March 2024). Articles with a comparison group (laparoscopic cholecystectomy or antibiotic treatment), discussing other methods of gallbladder drainage (such as endoscopic methods) or focusing on the route of PC (transhepatic or transperitoneal) were excluded from the study. The CASP cohort study checklist was used to assess risk of bias in the studies. Thematic analysis was adopted to analyse the data.
Results: Eight eligible studies were identified with a total of 1,033 participants. Study duration ranged from 3.5 years to 10 years. Thematic analysis identified 3 major themes: safety outcomes, efficacy outcomes and quality of life (QOL) outcomes. It was found that PC is a relatively effective and safe alternative treatment for AC. Its main use is in patients who are unfit for surgery as a salvage treatment or as a bridging treatment to stabilise patients prior to surgery. Mild complications such as catheter dislodgement are common, however, they can be treated in most cases, for example with catheter reinsertion. Incidences of major complications are less common. Morbidity and mortality in PC patients are rarely attributable to PC itself and more often reflect the severe associated comorbidities and high-risk nature of these patients. The requirement for follow up and burden of having an external drainage bag can have negative implications for patient QOL.
Conclusions: PC can be a relatively safe and effective treatment for AC, although careful selection of appropriate patients is required as there are implications for patient QOL. The main limitations of this study were that it was carried out by a single researcher, and thematic analysis was done instead of meta-analysis, therefore there is a risk of bias
What are the oncological outcomes of patients with oropharyngeal carcinoma undergoing trans-oral robotic surgery (TORS)? An evaluation of TORS procedures from a single hospital in the UK.
Full text linkBackground: Trans-oral robotic surgery (TORS) is a relatively new, minimally invasive approach to treating head and neck cancer. The recent rise in head and neck cancers in younger patients, predominantly in oropharyngeal squamous cell carcinoma (OPSCC) due to the HPV virus spurs the need to examine how well TORS, alongside pre-existing therapies performs in cancer treatment.
Previous research has shown good survival outcomes in early disease stages, however, it is yet unclear how TORS contributes to treatment reflecting more diverse disease stages with the use of adjuvant treatments.
Methods: This case-series study sought to evaluate the oncological and QoL outcomes of TORS among 51 head and neck patients at a single centre in the UK. Several measures were aggregated and analysed which included: disease free survival (DFS), overall survival (OS), whether adjunct treatment was used, the extent of margin control, whether the TORS procedure was diagnostic or oncological resection, cancer stage, length of hospital stay, estimated blood loss, complications at review and patient perceived QoL as assessed by the MDADI questionnaire. The chi square test was performed to assess statistical significance between all variables, and the Pearson correlation was used to demonstrate the direction of resulting statistically significant associations.
Results: Patients ranged between stages T0-4a, N0-3b and received TORS with adjuvant treatment where clinically indicated. After an average follow-up of 18 months, overall survival (OS) was 98%, disease-free survival (DFS) 94.1% and patient QoL measures reflected good treatment response and functioning.
Conclusions: All consenting patients receiving TORS for a head and neck cancer were included in this study, thus patients showed ‘diverse’ characteristics – T0-4a, N0-3b, treated with TORS plus minus adjuvant therapy – CRT/CT/RT. Analysis showed good oncological outcomes with favourable MDADI scores 3.66, 75, which have been reflected by previous research. Overall TORS appears to provide a beneficial contribution to head and neck cancer treatment in the presence of good clinical decision making
Relevance of Glenoid Version in Reverse Total Shoulder Arthroplasty: Insights from Retrospective Analysis of Patients with Retroverted Glenoids (B1-B3) treated with a monoblock central tapered screw fixation.
Full text linkBackground: Management of deformed glenoids is a challenge in shoulder arthroplasty surgery. How it should be managed is unclear, and there is no universal consensus regarding optimal baseplate position. Posterior osteoarthritic erosion of the glenoid fossa, resulting in glenoid retroversion, is commonly encountered in reverse total shoulder arthroplasty (rTSA), and has previously been seen as a negative predictor of outcomes. Surgical techniques such as bony-increased offset RSA (BIO-RSA) can be used to restore bone stock and allow the glenoid baseplate to be positioned in a more neutral version, thereby, improving bone-implant contact. However, it is important to first establish if this is always necessary; studies thus far do not provide an agreement on if and how retroversion should be corrected. Implant loosening is a known complication of rTSA, yet also not clearly correlated with worse glenoid retroversion.
Methods: This study calculates the degrees of correction used for various degrees of glenoid retroversion in a consecutive series of eight patients who underwent rTSA for osteoarthritis. By determining the amount of intraoperative correction at the level of the glenoid baseplate needed at different degrees of glenoid retroversion, this study seeks to determine if preoperative glenoid retroversion directly correlates with the correction applied, and whether correction was always required. A more neutral baseplate version implies greater bone-implant contact surface area. Cases of loosening are identified and discussed in the context of glenoid version and change applied. Computed tomography (CT) images are used to measure glenoid version preoperatively, and axillary and anteroposterior X-ray views are used to measure glenoid version postoperatively. Pearson’s correlation is used to calculate correlation.
Results: Mean preoperative glenoid version was 16.8°. Mean correction applied was 9.7°. Mean postoperative glenoid version was 8.4°. There was a strong correlation between preoperative glenoid retroversion and correction applied (r = 0.86). There was a weak negative correlation between the preoperative glenoid version and postoperative glenoid version (r = 0.39). Three patients received BIO-RSA to restore bone stock where glenoid retroversion was >20.5°. There was one case of aseptic loosening which occurred in the patient with a preoperative retroversion of 21° who received BIO-RSA where a correction of 19° was applied, resulting in postoperative version of 2.0°.
Conclusions: There is a range of literature looking at the impact of glenoid retroversion in rTSA yet no definitive conclusion to guide surgical technique. Recent research suggests no prognostic implication of glenoid or baseplate retroversion. In this study, the amount of correction applied to the glenoid strongly correlated with the degree of glenoid retroversion preoperatively, indicating that abnormal glenoid morphology is usually addressed, with the glenoid baseplate being placed in a more neutral glenoid version where possible. One case of aseptic loosening was observed where a significant correction of 19° was applied using BIO-RSA. Therefore, correction to a more neutral glenoid version is not always required and reduced bone-implant contact may be acceptable without detriment to implant stability. Without expanding the data set, a correlation cannot be inferred, and an expansion of this study is warranted
Scoping Review to Assess Evidence on the Relationship Between Limited English Proficiency and Sepsis Mortality.
Full text linkBackground: Sepsis is a deadly syndrome accounting for the deaths of 48,000 people in the UK each year. Care continues to improve for these patients, but diagnosis is reliant on clear communication between patient and care provider. A significant proportion of the UK populous speaks little or no English, which poses challenges to clinicians for patient assessment.
Methods: This scoping review searched EMBASE, MEDLINE and Google Scholar. All relevant articles comparing Sepsis Mortality and Limited English Proficiency (LEP) were retrieved and screened. The primary outcome was to find articles that compared this exposure and outcome directly. Secondary outcomes assessed the risk of bias and qualitative discussion of paper results. No quantitative analyses were performed.
Results: Three relevant papers were discovered and included. There was diversity in outcomes relating to LEP depending on racial and ethnic background. The studies provided insight into a direct link between LEP and sepsis mortality. One found a 31% increase in patient mortality for Asian, White, and other races, one found a 29% increase in mortality for non-Hispanic White patients, whilst a third found a 17% decrease in all-cause mortality including sepsis patients if they had LEP.
Conclusions: Overall, there is a dearth of evidence in the subject area with no studies carried out in the UK. The research that does exist is conflicting and somewhat limited. Efforts should be focused on improving the research base with wider studies with greater varieties in patient locations
Diagnostic accuracy of PSMA PET/CT in the primary staging of patients with high-risk prostate adenocarcinoma: A Systematic Review
Full text linkBackground: Prostate cancer is the 6th most common cancer in the world and the most common in men in the UK. PSMA PET/CT is a new imaging modality to assess the spread of prostate cancer that has been demonstrated by several papers to have superior sensitivity and specificity to currently used standard imaging (bone scan and CT). Many papers have looked at its use in prostate cancer but not in the high-risk subgroup of patients. This systematic review focuses on this patient population.
Methods: A systematic review was carried out with the utilisation of a thematic analysis and descriptive statistics.
Results: Three papers were identified each demonstrating in the thematic analysis a superiority in both the identification of metastasis and staging of patients with high-risk prostate cancer. However, some false positives for metastases were noted for PSMA PET/CT, but this did not impact on the demonstration of PSMA PET/CT superiority. The descriptive statistics showed that less patients had prostate cancer confined to the prostate according to PSMA PET/CT vs comparative imaging modalities (CT, bone scan, MRI) however results were identical for MRI and PSMA PET/CT. More patients were shown to have pelvic metastases byPSMA PET/CT and more patients were shown to have extra pelvic/ bone metastases in comparison to comparative imaging modality. There was significant stage migration of patients following PSMA PET/CT.
Conclusions: PSMA PET/CT had greater sensitivity and specificity in the detection of prostate cancers in high-risk patients across all comparative imaging modalities. This led to alterations in patient stage and therefore further studies are required to consider its implementation into routine management of patients
Bowel screening uptake during the Sars-Cov-2 pandemic. Results from a primary care audit in the United Kingdom.
Full text linkIntroduction
During the COVID-19 pandemic, the United Kingdom paused its bowel screening program for 6 months, a measure estimated to produce a 16% increase of avoidable colorectal cancer deaths. The aim of this audit was to observe the impact of COVID-19 on screening of a sample population in East Kent.
Materials and methods
Data from two primary care centres were retrospectively collected. The population sample included patients eligible for screening from 2019 to 2021. The primary outcome was uptake of screening; the secondary outcomes was the relation between gender or age and uptake. National standard of 52% was used as a comparator. Chi-square and univariate analysis were considered significant at p-value <0.05.
Results and discussion
Overall, 6,919 patients were invited for screening of which 5,281 positively responded (76%). In 2019, 2020 and 2021 uptake was 73%, 75%, 80% respectively. In 2021 Screening uptake was significantly higher than 2019 (p=<.00001). Subgroup analysis showed that women were more likely to engage with screening than men (77% vs 75%, p=.02) and 60-69 years old patients were less likely to be compliant compared to those >70 years old (75% vs 78%, p=.02).
Conclusion
This study showed a statistically significant upward trend for bowel screening uptake across 2019, 2020 and 2021. Furthermore, it highlighted that men and younger patients are less likely to engage screening compared to women and ³70 years old patients. In-depth and larger studies may be needed to determine if this positive trend is truly representative of the general population
Scoping Review: What is the prognostic value in diagnosing Mild Cognitive Impairment in older adults at risk of Alzheimer’s dementia.
Full text linkBackground: Mild cognitive Impairment (MCI) is a clinical syndrome that represents the transitional risk state between changes in one’s cognition to developing Alzheimer’s dementia (AD). However, there are no changes to activities of daily living (ADLs) (Petersen, 2004). Approximately 5-15% of those with MCI progress into developing AD annually, however around half of individuals with MCI remain stable for 5 years and there is also evidence of reversal in some cases. This is due to the syndrome’s heterogeneous nature. Non-AD related causes include neurodegenerative, physical, and psychiatric conditions (Dunne et al., 2020). Therefore, rendering MCI’s prognostic value questionable, regarding identifying those at risk of AD. MCI is currently diagnosed in clinical settings by cognitive deficits seen on neuropsychological testing. However, there are variations in diagnostic criteria implemented in both clinical and research settings (Ward et al., 2013). Making an accurate diagnosis of MCI is the first step to identifying a potential prodromal state for AD. At present, there are new avenues of research to identify more accurate methods of identifying MCI-AD conversion that can complement existing cognitive testing via fluid biomarkers and neuroimaging techniques (Dunne et al., 2020). Ultimately, in the absence of licensed disease-modifying options for AD at the MCI stage (Joe and Ringman, 2019), subjecting an individual to unnecessary investigations and management needs to be justified, when considering the syndrome’s prognostic value.
Methods: This qualitative study is a scoping review of 35 research papers, where thematic analysis was conducted to answer the research aims. Papers were selected based on a specific inclusion/exclusion criterion.
Results: Thematic analysis of the 35 papers selected out of a total of 70, generated two main themes and further subthemes which reflects the scope of the literature: 1) Link between MCI and AD-conversion [subthemes of neuroimaging(N), fluid biomarkers (FB) and cognitive testing (CT)]. 91.7% (22 papers) of the studies agree that is there is a link between MCI and AD conversion. 8.3% (2 papers) did not support this theme. Clinical Outcomes of MCI diagnosis (subthemes of promising clinical utility (PCU) and limited clinical utility (LCU)). 50% of the studies demonstrated PCU regarding an MCI diagnosis whilst 50% showed LCU.
Conclusions: The findings demonstrate that there is a link between MCI and AD. However, MCI should not be viewed as a sole cause of cognitive decline, instead it can be viewed as a heterogenous syndrome. Given the lack of standardised clinical guidelines, MCI’s prognostic value lies in viewing as opportunity for treating modifiable risk factors associated with cognitive decline and patient co-morbidities. Ultimately, the results demonstrate a lack of clinical translation of research findings unless drastic changes occur in funding, standardisation of diagnostic criteria, recruitment of adequate sample sizes and conduction of longitudinal studies. With the advent of disease-modifying treatment for AD on the horizon, this may evoke such changes that are required to increase the prognostic value of MCI as a diagnosis in older adults at risk of AD.
Undertaking a Diversity Mark application for Kent and Medway Medical School: A reflection on the process.
Full text linkThis reflection describes what is involved in undertaking a University of Kent (UoK) Diversity Mark Award and what the implications are of undertaking such an application for individuals, teams and the wider University. The author will outline the principles and activities involved in the application for Kent and Medway Medical School (KMMS) modules as well as considering the benefits and challenges of applying. The author concludes by discussing future plans for expanding the reach of the award in a KMMS context
The impact of adjuvant aripiprazole on olanzapine- induced metabolic adverse effects in schizophrenic patients: a Systematic Review
Full text linkAbstract
Background: Olanzapine is a second-generation atypical antipsychotic drug which is commonly used in the treatment of psychotic disorders such as schizophrenia. It has been associated with metabolic adverse effects such as, weight gain, hyperglycaemia, dyslipidemia and this has been shown to contribute to the reduction of life expectancy of schizophrenic patients. It has been suggested that adjunctive aripiprazole (another atypical antipsychotic) reduces some of the metabolic adverse effects caused by olanzapine. This systematic review aimed to assess whether adjunctive aripiprazole is effective at reducing metabolic adverse effects induced by olanzapine.
Methods: A systematic review was conducted and due to heterogeneity in the data, a narrative synthesis was completed. A systematic search strategy was developed, recorded, and applied to multiple academic search engines. Using the PRISMA flow diagram, the literature search found a total of 853 results with final inclusion of 7 research articles. Based on a specific inclusion and exclusion criteria, a wide range of study designs were included in the review such as randomised control trials (RCTs), open label trials and case series. Key outcomes were identified which included: glucose levels, lipid profile (which included triglycerides as well as HDL, LDL, and total cholesterol), body weight, BMI and waist circumference. The results were recorded and analysed using narrative synthesis, and conclusions were drawn based on the results reported.
Results: Statistically significant decreases in fasting triglycerides were consistent across multiple studies, supporting the hypothesis that aripiprazole may counteract some of the metabolic adverse effects of olanzapine. Adjunctive aripiprazole shows potential weight loss benefits, with some studies reporting significant reductions in weight and BMI, while one other found no meaningful change. However, this may be a dose dependent outcome, as the study that found no significant change in weight used a substantially lower dose of aripiprazole compared to other studies. Effects on cholesterol and fasting glucose showed non statistically significant reductions and others showed minimal or no impact. Psychiatric symptom control remained stable in most studies, suggesting that aripiprazole does not negatively affect schizophrenia symptoms while potentially providing metabolic advantages.
Conclusions: Adjunctive aripiprazole had variable effects on metabolic parameters in patients on olanzapine therapy, however reductions in triglycerides appeared consistent among the majority of the data and some studies reported significant weight loss. This highlighted that aripiprazole does have some effect in reducing metabolic adverse effects caused by olanzapine. However, there are many possible factors that could influence the metabolic changes shown. This highlights a need for further research and investigations, investigations that will address the gaps in the current research, such as longer randomised control trials (RCTs) with more participants and more information regarding effective dose response.
Keywords: Adjunctive aripiprazole | Olanzapine | Schizophrenia | Metabolic adverse effects
a Stephen Simmons, 4th Year Medical Student, Kent and Medway Medical School, Canterbury, United Kingdom
bDr Soban Sadiq, Senior lecturer, Kent and Medway Medical School, Canterbury, United Kingdom
Main contact email: [email protected]
 
The Role of Judicial Literacy in Climate Change
Full text linkAs climate change litigation increasingly emerges as a crucial instrument in global environmental governance, courts are frequently tasked with the interpretation of complex scientific and technological evidence. This paper critically investigates whether legal frameworks genuinely shape the global response to climate change or whether this response is becoming more influenced by corporate technological power, leaving courts struggling to keep pace. Through case studies such as Milieudefensie v. Shell[1], the paper argues that while the law seeks to serve as a check on both states and corporations, judicial responses often demonstrate a limited understanding of the technological systems that underpin contemporary climate claims—ranging from emissions targets to speculative carbon offsetting schemes as demonstrated in the decision in Milieudefensie[2].
The paper also examines the increasing influence of corporate-controlled data within climate litigation and questions how judges are adequately engaged with these critically. When courts heavily rely on expert testimony or corporate disclosures without possessing the literacy to scrutinise them effectively, legal accountability risks becoming more performative than substantive. This technological blind spot not only undermines the efficacy of climate law but also allows transnational corporations to subtly shape legal narratives surrounding climate change and sustainability, often without significant challenge.
By integrating environmental law, judicial studies, and the theoretical framework of Foucault’s power and knowledge, this paper advocates for a more profound investigation into how legal actors interpret—or fail to interpret—the technological landscape of climate governance. Ultimately, it argues that without climate-literate judiciaries, there is a risk for dangerous precedents and an overall delay in climate change action.
[1] Milieudefensie et al. v Royal Dutch Shell Plc (Case No C/09/571932 / HA ZA 19-379.
[2] Ibid
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