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ISUOG Consensus Statement on maternal hemodynamic assessment in hypertensive disorders of pregnancy and fetal growth restriction
Get PDFRobotic versus laparoscopic cholecystectomy for difficult gallbladders: an observational study of tertiary centre cases
Get PDFBackground
Although laparoscopic cholecystectomy (LC) is considered a low-risk procedure, intraoperative bleeding, bile duct injury and bile leak occur frequently in the ‘difficult’ gallbladder. Robotic cholecystectomy (RC) can overcome difficulties related to poor vision and instrumentation in difficult cases to avoid intraoperative complications and conversion to open surgery. The aim of the study was to evaluate the outcomes of laparoscopic and robotic cholecystectomy in patients with difficult gallbladders referred to a tertiary HPB centre.
Methods
We conducted a retrospective review of all patients referred to a senior hepatobiliary and pancreatic surgeon with a ‘difficult’ gallbladder between December 2013 and March 2024. Primary outcomes were conversion to open procedure, and 30-day post-operative complications.
Results
A total of 88 difficult gallbladder cases (n = 35 laparoscopic, n = 53 robotic) were referred to a tertiary HPB centre during the study period, consisting of 21.7% of cholecystectomies (n = 404). The total complication rate (14.3% vs 3.8%, OR 4.25, 95% CI 0.77–23.28, p = 0.0951) and conversion rate (8.6% vs 0.0%, OR 11.52, 95% CI 0.57–230.32, p = 0.109) were both higher in the laparoscopic group, but these differences were not statistically significant. The median operative time was significantly higher in the laparoscopic group (108.5 min vs 50.0 min, p = 0.001).
Conclusions
Both robotic and laparoscopic cholecystectomy are viable approaches in difficult gallbladder cases, with robotic cholecystectomy being associated with potentially fewer complications and conversions to open surgery. Pre-operative referral of patients with difficult gallbladders and the intra-operative abandonment of difficult cases can both be considered safe exit strategies for difficult gallbladder cases
Accuracy of computer-aided chest x-ray interpretation for tuberculosis screening in people with diabetes mellitus: A systematic review
No full textObjectives
Diabetes mellitus significantly increases the risk of tuberculosis, and active tuberculosis screening of people with diabetes mellitus has been advocated by WHO and other international bodies. This systematic review aimed to evaluate the accuracy of computer-assisted detection for identifying pulmonary tuberculosis among people living with diabetes mellitus.
Methods
Medline, Embase, Scopus, Global Health, and Web of Science were searched from January 2010 to May 2024 using MeSH headings and keywords, supplemented with grey literature searches (Conference abstracts, Trial registries, MedRxiv.org, Google Scholar). Studies evaluating computer-assisted detection diagnostic accuracy for identifying tuberculosis in populations living with diabetes mellitus were included. Two researchers independently assessed titles, abstracts, and full texts, extracted data, and assessed the risk of bias using the QUADAS-2 instrument. Forest plots and Summary Receiver Operating Curves were generated using RevMan 5.4, and statistical pooling of studies was carried out in STATA v18 using the bivariate model.
Results
Five eligible studies, all conducted in Asia between 2013 and 2023, were identified, including a total of 1879 individuals with diabetes mellitus, of whom 391 were newly diagnosed with tuberculosis. Four different computer-assisted detection software algorithms were used. The pooled sensitivity was 0.94 (95% CI: 0.85–0.97) and specificity was 0.77 (95% CI: 0.68–0.84). Area Under the receiver operating curve values varied from 0.7 (95% CI: 0.68–0.75) to 0.9 (95% CI: 0.91–0.96). False positive proportions ranged from 0.24% to 30.5%, while false negative proportions were 0%–3.2%. Overall heterogeneity was high (i2 55% for sensitivity and 93% for specificity) but much lower for sensitivity among the three studies using the same computer-assisted detection software (i2 0% for sensitivity; 93% for specificity). The risk of bias of the five studies was generally very low, although detailed information about diabetes management was lacking.
Conclusions
Computer-assisted detection tools show potential in screening people living with diabetes for active tuberculosis and appear to show good sensitivity at the thresholds indicated, but data are scarce and performance varies across settings
Treatment patterns, outcomes and healthcare resource utilization of obstructive hypertrophic cardiomyopathy in England
Get PDFAims
Describe patient characteristics, treatment patterns, clinical outcomes, healthcare resource utilization (HCRU) and medical costs associated with patients who were diagnosed with obstructive hypertrophic cardiomyopathy (HCM) in clinical practice in England.
Methods and results
This observational, retrospective, cohort study of adults who were diagnosed with obstructive HCM in routine clinical practice in England used electronic health records from Clinical Practice Research Datalink (CPRD) GOLD/Aurum and linked Hospital Episode Statistics (HES) databases (1 April 2007 to 30 October 2020). Adults (≥18 years at index date) with at least one diagnosis code (ICD-10, Read, SNOMED, or OPCS) indicative of HCM with ≥1 year of continuous registration in CPRD, data of acceptable research quality and eligibility for HES linkage were included. Outcomes from the obstructive HCM cohort were stratified by New York Heart Association (NYHA) class at baseline and during follow-up. Owing to the paucity of NYHA coding, patients with obstructive HCM and no record of NYHA class were assigned a proxy NYHA classification using an algorithm that considered patient symptoms and treatments. The study included 6440 patients in the overall HCM cohort with a mean follow-up duration of 4.84 [standard deviation (SD): 2.95] years. The study population was predominantly male (61.9%) and white (79.1%), with a mean (SD) age of 61.02 (15.61) years. The proportion of patients with obstructive HCM who had a pre-specified prior medical condition relevant to understanding disease burden increased with higher NYHA class (66.5% vs. 83.0% for NYHA class I and NYHA class II+, respectively), as did the proportion of patients with at least one baseline active prescription for cardiovascular-related medication. Among patients with at least one record of a prescription for the treatment of symptomatic obstructive HCM, 41.7% experienced a treatment change during the follow-up period. Atrial fibrillation or flutter, ischaemic stroke and heart failure were the most observed clinical events among patients in the obstructive HCM cohort, and the first in-study incidence of these events increased with higher NYHA class. Total HCRU costs per patient-year increased from £3033 to £4517 for NYHA classes I and II+, respectively, with secondary care costs consistently being the main driver in the obstructive HCM cohort.
Conclusions
Obstructive HCM is associated with a large clinical and economic burden in England, and this burden increases with higher NYHA class. These findings support the need for new and more effective strategies for the management of HCM
The role of cardiovascular multimodality imaging in the evaluation of Anderson-Fabry disease: from early diagnosis to therapy monitoring A clinical consensus statement of the ESC Working Group on Myocardial & Pericardial Diseases and the European Association of Cardiovascular Imaging of the ESC.
No full textAnderson-Fabry disease (AFD) is a rare genetic disease with X-linked transmission characterized by a defect in the enzyme alpha-galactosidase A (alpha-GAL), which impairs glycosphingolipid metabolism and leads to an excessive storage of globotriaosylceramide (Gb3) within lysosomes. AFD involves renal, cardiac, vascular, and nervous systems and is mainly observed in male patients with onset in childhood, although cardiac manifestation is often shown in adults. AFD cardiomyopathy is caused by the accumulation of Gb3 within myocytes first showed by left ventricular (LV) hypertrophy and diastolic dysfunction, leading to restrictive cardiomyopathy and systolic heart failure with biventricular involvement. The diagnosis of AFD cardiomyopathy may be insidious in the first stages and requires accurate differential diagnosis with other cardiomyopathies with hypertrophic phenotype. However, it is fundamental to promptly initiate specific therapies that have shown promising results, particularly for early treatment. A careful integration between clinical evaluation, genetic tests, and cardiac imaging is required to diagnose AFD with cardiac involvement. Basic and advanced echocardiography, cardiac magnetic resonance, and nuclear imaging may offer pivotal information for early diagnosis (Central illustration) and the management of these patients is often limited to centres with high expertise in the field. This clinical consensus statement, developed by experts from the European Society of Cardiology (ESC) Working Group on Myocardial & Pericardial Diseases and the European Association of Cardiovascular Imaging of the ESC, aims to provide practical advice for all clinicians regarding the use of multimodality imaging to simplify the diagnostic evaluation, prognostic stratification, and management of cardiac involvement in AFD
Placental transfer of SARS-CoV-2 antibodies in mother-neonate pairs: a prospective nested cohort study
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Newborns depend on the transfer of IgG across the placenta to acquire protection against pathogens. We assessed the placental transfer of SARS-CoV-2 antibodies, primarily derived from infection, from seropositive pregnant women enrolled in a pregnancy cohort in Kilifi, Kenya.
Methods
The study was nested within a prospective observational multi-country cohort study. All available paired maternal delivery and cord blood samples were selected. Maternal sera were tested for SARS-CoV-2 receptor binding domain (RBD) IgM/IgG total antibodies using the Wantai assay. For positive samples, maternal and corresponding cord blood samples were tested for SARS-CoV-2 IgG antibodies against the spike (anti-spike) and nucleocapsid proteins (anti-NCP) using ELISA kits from Euroimmun.
Results
A total of 492 (56.1%) out of 877 maternal delivery samples were positive for RBD IgM/IgG total antibodies. Of these, 416 (84.6%) were seropositive for either anti-NCP IgG, anti-spike IgG antibodies or both. A total of 412 out of 496 (83%) cord blood samples tested positive for either anti-NCP or anti-spike antibodies. The geometric mean ratio was 1.04 (95% CI: 0.90, 1.21), indicating no significant difference between the anti-spike IgG concentration in cord and maternal blood samples. The log-transformed maternal and cord blood anti-spike IgG concentrations showed a weak positive correlation (r = 0.364, n = 496, p < 0.001). No maternal or neonatal factors were associated with the anti-spike IgG placental transfer ratio.
Conclusion
Placental transfer of SARS-CoV-2 antibodies was evident in a population of pregnant women whose immunity was primarily derived from infection given the low SARS-CoV-2 vaccine coverage in the study area. The positive correlation between maternal and cord blood anti-spike concentrations suggests that interventions that increase maternal antibody concentrations such as vaccination may increase passive immunity and protection against severe COVID-19 disease in neonates
Self- versus caregiver-reported apathy across neurological disorders
Get PDFApathy is a prevalent and persistent neuropsychiatric syndrome across many neurological disorders, significantly impacting both patients and caregivers. We systematically quantified discrepancies between self- and caregiver-reported apathy in 335 patients with a variety of diagnoses, such as frontotemporal dementia (behavioural variant and semantic dementia subtypes), Parkinson’s disease, Parkinson’s disease dementia, dementia with Lewy bodies, Alzheimer’s disease dementia, mild cognitive impairment, small vessel cerebrovascular disease, subjective cognitive decline and autoimmune encephalitis. Using the Apathy Motivation Index (AMI) and its analogous caregiver version (AMI-CG), we found that caregiver-reported apathy consistently exceeded self-reported levels across all conditions. Moreover, self-reported apathy accounted for only 14.1% of the variance in caregiver ratings. This apathy reporting discrepancy was most pronounced in conditions associated with impaired insight, such as behavioural variant frontotemporal dementia, and was significantly correlated with cognitive impairment. Deficits in memory and fluency explained an additional 11.2% of the variance in caregiver-reported apathy. Specifically, executive function deficits (e.g. indexed by fluency) and memory impairments may contribute to behavioural inertia or recall of it. These findings highlight the need to integrate patient and caregiver perspectives in apathy assessments, especially for conditions with prominent cognitive impairment. To improve diagnostic accuracy and deepen our understanding of apathy across neurological disorders, we highlight the need for adapted apathy assessment strategies that account for cognitive impairment particularly in individuals with insight or memory deficits. Understanding the cognitive mechanisms underpinning discordant apathy reporting in dementia might help inform targeted clinical interventions and reduce caregiver burden
Comparing the Power of Low vs High-Precision Methods for Measuring E. coli in Drinking Water in Low-Resource Settings
No full textMethods to measure Escherichia coli concentrations in water vary in precision, complexity, and cost. Low-precision methods are more affordable, faster, and simpler to implement in low-resource settings but may reduce statistical power. We compared the statistical power of low- and high-precision methods using data from UNICEF’s Multiple Indicator Cluster Surveys across 11 low-income regions, and from a birth cohort study in Ecuador. Both data sets included continuous E. coli concentrations from high-precision methods, which we categorized to emulate low-precision methods outcomes. Using logistic regression, we modeled associations between water quality and two dichotomous outcomes: water treatment (treated/untreated) and water storage (stored/not stored). We compared the sample size needed to reach 80% power for detecting statistically significant differences between these groups. Power was calculated using a bootstrap-based algorithm. Compared to continuous measures, categorizing E. coli concentrations required 10–90% larger sample sizes in treatment models and about 10% in storage models, except in regions with good water quality, where similar or lower sample sizes were sufficient. Our findings indicate that low-precision methods can reliably infer associations between water practices and water quality but often require larger sample sizes, highlighting a trade-off between cost and statistical power in resource-limited settings
Early use of the novel antifungal rezafungin: a case series and literature review
No full textObjectives
Rezafungin is a novel echinocandin with a unique structural configuration enabling weekly IV dosing. We report on early use of rezafungin in our outpatient parenteral antibiotic therapy (OPAT) service, reviewing indications, treatment regimens, outcomes and adverse events in adult patients receiving rezafungin at a tertiary infectious disease centre. We also review published cases of rezafungin use, licensing trials, spectrum and pharmacokinetics/pharmacodynamics and how that might relate to its propensity to generate resistance (in comparison with daily echinocandins).
Methods
All adult patients who received rezafungin therapy via the OPAT service in 2024–25 were included. Patient demographics, infections, treatment regimens and outcomes were recorded.
Results
Six patients (age range 30–84 years) received rezafungin therapy between July 2024 and February 2025. Indications included invasive and mucocutaneous candidiasis, predominantly caused by azole-resistant Candida species. We also report the first case of using rezafungin in combination with voriconazole to treat azole-refractory pulmonary aspergillosis. Rezafungin courses were a median length of 4 doses (range: 2–5) and were generally well tolerated with no laboratory adverse events. Reasons for choosing rezafungin over daily echinocandins were patient preference/convenience (n = 5), concern regarding azole resistance (n = 4) and facilitation of earlier discharge (n = 2). One hundred and fifty-seven days with an IV catheter were saved through once-weekly dosing. Outcomes were positive, with all patients showing mycological clearance.
Conclusions
Early use of rezafungin at our centre and in the international literature suggests it is a well-tolerated, convenient and useful addition to the antifungal armamentarium, particularly in the outpatient setting
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