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Endoscopic transsphenoidal surgery reconstruction using the fibrin sealant patch Tachosil.
No full textINTRODUCTION
The incidence of CSF leak following endoscopic transsphenoidal surgery remains the most important measure in the success of any repair. The nasoseptal flap (NSF) has played a pivotal role in reconstructing defects. However, morbidity associated with the NSF includes bleeding, septal injury, altered smell and crusting. Tachosil is an absorbable fibrin sealant patch that promotes haemostasis and wound healing. The purpose of this study was to evaluate the effectiveness of Tachosil to repair intraoperative defects during an endoscopic transsphenoidal approach.
MATERIALS AND METHODS
All patients who underwent an endoscopic transsphenoidal approach with the use of Tachosil at the Queen Elizabeth Hospital Birmingham, between January 2013 and June 2020 were retrospectively analysed. Tachosil was used as an overlay patch over of the bony defect, in a multi-layered repair depending on the defect and grade of CSF leak. The primary outcome measure was post-operative CSF leak.
RESULTS
A total of 52 primary procedures where Tachosil was used as the overlay were analysed. There were 23 (44.2%) intraoperative CSF leaks. The overall post-operative CSF leak rate was 7.8% ( = 4), with all cases having had a Tachosil overlay reconstruction with no NSF. A formal NSF was harvested in only five cases alongside the Tachosil patch, where a grade 2 or more leak was identified at the time of the primary procedure, none of which developed a post-operative leak. No patient had any post-operative adverse outcomes that were attributed to Tachosil.
CONCLUSIONS
We believe this to be the largest case series evaluating the endoscopic use of Tachosil in skull base reconstruction. Our data show that in endoscopic transsphenoidal approach, Tachosil may be used safely in a multi-layered approach as an effective alternative to the NSF in low flow CSF leak cases, or alongside a NSF in higher flow leaks
Laparoscopic Conversion of Sleeve Gastrectomy to One Anastomosis Gastric Bypass in a Hostile Abdomen.
No full textPURPOSE
Failure of weight loss is the most common indication for revisional surgery following sleeve gastrectomy (SG) as reported by Guan et al. (Obes Surg. 2019; 29:1965-1975). Recent evidence suggests that the revision rates for SG can be up to 10% when patients are followed up for more than 3 years and as high as 22% after 10 years as reported by Guan et al. (Obes Surg. 2019; 29:1965-1975). Options for revisional surgery following a SG include Roux-en-Y gastric bypass (RYGB), one anastomosis gastric bypass (OAGB), and re-sleeve as the commonest procedures. There is good evidence supporting revisional surgery following failure of weight loss post-primary surgery as reported by Guan et al. (Obes Surg. 2019; 29:1965-1975); Cheung et al. (Obes Surg. 2014; 24:1757-1763); Shimizu et al. (Obes Surg. 2013; 23:1766-1773); and Mora Oliver et al. (Cirugia Espanola. 2019; 97:568-574). However, at the same time, retrospective studies suggest higher complication rates following revisional surgery with a major complication rate up to 10% as reported by Yilmaz et al. (Obes Surg. 2017; 27:2855-2860); Fulton et al. (Can J Surg J Can Chir. 2017; 60:205-211); and Abdelgawad et al. (Obes Surg. 2016; 26:2144-2149). Additionally, the durability of weight loss and morbidity reduction in re-operated patients is still debated and overall high-quality evidence in the field is lacking as discussed by Abdelgawad et al. (Obes Surg. 2016; 26:2144-2149). Aim of this educational video is to demonstrate a revisional bariatric procedure which was technically difficult due to extensive intra-abdominal adhesions and explain the available surgical options and the decision-making process adopted by the surgeons.
MATERIALS AND METHODS
The video describes a laparoscopic conversion of a SG to OAGB in a 37-year-old female patient due to weight regain. Her primary bariatric procedure was planned to be a RYGB but due to extensive intra-abdominal adhesions discovered at the time of primary surgery, a SG was performed. Pre-primary procedure weight was 134kg with a BMI of 52.3kg/m. After SG, the patient lost a maximum of 50kg (71.4% excess BMI loss) within the first 18 months before she started regaining weight. Her BMI was 45.4kg/m when she was referred for revisional surgery. During the procedure, dense small bowel adhesions were encountered and required meticulous dissection in order to free adequate small bowel to allow a safe, effective, and tension-free anastomosis. One hundred fifty centimeters of small bowel was the maximum length that could be safely dissected starting from the ligament of Treitz. An OAGB was preferred to RYGB as it is routine practice in our unit to bypass 200cm of small bowel for revisional RYGB procedures (50-cm biliopancreatic limb and 150-cm alimentary limb), whilst all OAGB's (primary and revisional) have an afferent limb of 150cm. A re-sleeve was also considered as a viable alternative.
RESULTS
Extensive adhesiolysis followed by OAGB were performed successfully with an uneventful post-operative course. The patient was discharged on the second post-operative day. Excess BMI loss was 58% at 1-year follow-up.
CONCLUSION
Revisional surgery can be a challenging especially in the context of extensive surgical history. OAGB can be used as an alternative to RYGB
Towards similarity-based differential diagnostics for common diseases.
No full textOntology-based phenotype profiles have been utilised for the purpose of differential diagnosis of rare genetic diseases, and for decision support in specific disease domains. Particularly, semantic similarity facilitates diagnostic hypothesis generation through comparison with disease phenotype profiles. However, the approach has not been applied for differential diagnosis of common diseases, or generalised clinical diagnostics from uncurated text-derived phenotypes. In this work, we describe the development of an approach for deriving patient phenotype profiles from clinical narrative text, and apply this to text associated with MIMIC-III patient visits. We then explore the use of semantic similarity with those text-derived phenotypes to classify primary patient diagnosis, comparing the use of patient-patient similarity and patient-disease similarity using phenotype-disease profiles previously mined from literature. We also consider a combined approach, in which literature-derived phenotypes are extended with the content of text-derived phenotypes we mined from 500 patients. The results reveal a powerful approach, showing that in one setting, uncurated text phenotypes can be used for differential diagnosis of common diseases, making use of information both inside and outside the setting. While the methods themselves should be explored for further optimisation, they could be applied to a variety of clinical tasks, such as differential diagnosis, cohort discovery, document and text classification, and outcome prediction
Acute kidney injury is more common in men than women after accounting for socioeconomic status, ethnicity, alcohol intake and smoking history.
No full textBACKGROUND
The association of several comorbidities, including diabetes mellitus, hypertension, cardiovascular disease, heart failure and chronic kidney or liver disease, with acute kidney injury (AKI) is well established. Evidence on the effect of sex and socioeconomic factors are scarce. This study was designed to examine the association of sex and socioeconomic factors with AKI and AKI-related mortality and further to evaluate the additional relationship with other possible risk factors for AKI occurrence.
METHODS
We included 3534 patients (1878 males with mean age 61.1 ± 17.7 and 1656 females 1656 with mean age 60.3 ± 20.0 years) admitted to Queen Elizabeth or Heartlands Hospitals, Birmingham, between October 2013 and January 2016. Patients were prospectively followed-up for a median 47.70 [IQR, 18.20] months. Study-endpoints were incidence of AKI, based on KDIGO-AKI Guidelines, and all-cause mortality. Data acquisition was automated, and information on mortality was collected from the Hospital Episode Statistics and Office of National Statistics. Socioeconomic status was evaluated with the Index of Multiple Deprivation (IMD).
RESULTS
Incidence of AKI was higher in men compared to women (11.3% vs 7.1%; P < 0.001). Model regression analysis revealed significant association of male sex with higher AKI risk (OR, 1.659; 95% CI, 1.311-2.099; P < 0.001); this association remained significant after adjustment for age, eGFR, IMD, smoking, alcohol consumption, ethnicity, existing comorbidities and treatment (OR, 1.599; 95% CI, 1.215-2.103; P = 0.001). All-cause mortality was higher in patients with compared to those without AKI. Males with AKI had higher mortality rates in the first 6-month and 1-year periods after the index AKI event. The association of male sex with mortality was independent of socioeconomic factors but was not statistically significant after adjustment for existing comorbidities.
CONCLUSIONS
Men are at higher risk of AKI and this association is independent from existing risk factors for AKI. The association between male sex and AKI-related mortality was not independent from existing comorbidities. A better understanding of factors associated with AKI may help accurately identify high-risk patients
Protein Source and Quality for Skeletal Muscle Anabolism in Young and Older Adults: A Systematic Review and Meta-Analysis.
No full textBACKGROUND
There is much debate regarding the source/quality of dietary proteins in supporting indices of skeletal muscle anabolism.
OBJECTIVE
We performed a systematic review and meta-analysis to determine the effect of protein source/quality on acute muscle protein synthesis (MPS) and changes in lean body mass (LBM) and strength, when combined with resistance exercise (RE).
METHODS
A systematic search of the literature was conducted to identify studies that compared the effects of ≥2 dose-matched, predominantly isolated protein sources of varying "quality." Three separate models were employed as follows: 1) protein feeding alone on MPS, 2) protein feeding combined with a bout of RE on MPS, and 3) protein feeding combined with longer-term resistance exercise training (RET) on LBM and strength. Further subgroup analyses were performed to compare the effects of protein source/quality between young and older adults. A total of 27 studies in young (18-35 y) and older (≥60 y) adults were included.
RESULTS
Analysis revealed an effect favoring higher-quality protein for postprandial MPS at rest [mean difference (MD): 0.014%/h; 95% CI: 0.006, 0.021; P < 0.001] and following RE (MD: 0.022%/h; 95% CI: 0.014, 0.030; P < 0.00001) in young (model 1: 0.016%/h; 95% CI: -0.004, 0.036; P = 0.12; model 2: 0.030%/h; 95% CI: 0.015, 0.045; P < 0.0001) and older (model 1: 0.012%/h; 95% CI: 0.006, 0.018; P < 0.001; model 2: 0.014%/h; 95% CI: 0.007, 0.021; P < 0.001) adults. However, although higher protein quality was associated with superior strength gains with RET [standardized mean difference (SMD): 0.24 kg; 95% CI: 0.02, 0.45; P = 0.03)], no effect was observed on changes to LBM (SMD: 0.05 kg; 95% CI: -0.16, 0.25; P = 0.65).
CONCLUSIONS
The current review suggests that protein quality may provide a small but significant impact on indices of muscle protein anabolism in young and older adults. However, further research is warranted to elucidate the importance of protein source/quality on musculoskeletal aging, particularly in situations of low protein intake
Abdominal ultrasound and alpha-foetoprotein for the diagnosis of hepatocellular carcinoma in adults with chronic liver disease.
No full textBACKGROUND
Hepatocellular carcinoma (HCC) occurs mostly in people with chronic liver disease and ranks sixth in terms of global instances of cancer, and fourth in terms of cancer deaths for men. Despite that abdominal ultrasound (US) is used as an initial test to exclude the presence of focal liver lesions and serum alpha-foetoprotein (AFP) measurement may raise suspicion of HCC occurrence, further testing to confirm diagnosis as well as staging of HCC is required. Current guidelines recommend surveillance programme using US, with or without AFP, to detect HCC in high-risk populations despite the lack of clear benefits on overall survival. Assessing the diagnostic accuracy of US and AFP may clarify whether the absence of benefit in surveillance programmes could be related to under-diagnosis. Therefore, assessment of the accuracy of these two tests for diagnosing HCC in people with chronic liver disease, not included in surveillance programmes, is needed.
OBJECTIVES
Primary: the diagnostic accuracy of US and AFP, alone or in combination, for the diagnosis of HCC of any size and at any stage in adults with chronic liver disease, either in a surveillance programme or in a clinical setting. Secondary: to assess the diagnostic accuracy of abdominal US and AFP, alone or in combination, for the diagnosis of resectable HCC; to compare the diagnostic accuracy of the individual tests versus the combination of both tests; to investigate sources of heterogeneity in the results.
SEARCH METHODS
We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Hepato-Biliary Group Diagnostic-Test-Accuracy Studies Register, Cochrane Library, MEDLINE, Embase, LILACS, Science Citation Index Expanded, until 5 June 2020. We applied no language or document-type restrictions.
SELECTION CRITERIA
Studies assessing the diagnostic accuracy of US and AFP, independently or in combination, for the diagnosis of HCC in adults with chronic liver disease, with cross-sectional and case-control designs, using one of the acceptable reference standards, such as pathology of the explanted liver, histology of resected or biopsied focal liver lesion, or typical characteristics on computed tomography, or magnetic resonance imaging, all with a six-months follow-up.
DATA COLLECTION AND ANALYSIS
We independently screened studies, extracted data, and assessed the risk of bias and applicability concerns, using the QUADAS-2 checklist. We presented the results of sensitivity and specificity, using paired forest-plots, and tabulated the results. We used a hierarchical meta-analysis model where appropriate. We presented uncertainty of the accuracy estimates using 95% confidence intervals (CIs). We double-checked all data extractions and analyses.
MAIN RESULTS
We included 373 studies. The index-test was AFP (326 studies, 144,570 participants); US (39 studies, 18,792 participants); and a combination of AFP and US (eight studies, 5454 participants). We judged at high-risk of bias all but one study. Most studies used different reference standards, often inappropriate to exclude the presence of the target condition, and the time-interval between the index test and the reference standard was rarely defined. Most studies with AFP had a case-control design. We also had major concerns for the applicability due to the characteristics of the participants. As the primary studies with AFP used different cut-offs, we performed a meta-analysis using the hierarchical-summary-receiver-operating-characteristic model, then we carried out two meta-analyses including only studies reporting the most used cut-offs: around 20 ng/mL or 200 ng/mL. AFP cut-off 20 ng/mL: for HCC (147 studies) sensitivity 60% (95% CI 58% to 62%), specificity 84% (95% CI 82% to 86%); for resectable HCC (six studies) sensitivity 65% (95% CI 62% to 68%), specificity 80% (95% CI 59% to 91%). AFP cut-off 200 ng/mL: for HCC (56 studies) sensitivity 36% (95% CI 31% to 41%), specificity 99% (95% CI 98% to 99%); for resectable HCC (two studies) one with sensitivity 4% (95% CI 0% to 19%), specificity 100% (95% CI 96% to 100%), and one with sensitivity 8% (95% CI 3% to 18%), specificity 100% (95% CI 97% to 100%). US: for HCC (39 studies) sensitivity 72% (95% CI 63% to 79%), specificity 94% (95% CI 91% to 96%); for resectable HCC (seven studies) sensitivity 53% (95% CI 38% to 67%), specificity 96% (95% CI 94% to 97%). Combination of AFP (cut-off of 20 ng/mL) and US: for HCC (six studies) sensitivity 96% (95% CI 88% to 98%), specificity 85% (95% CI 73% to 93%); for resectable HCC (two studies) one with sensitivity 89% (95% CI 73% to 97%), specificity of 83% (95% CI 76% to 88%), and one with sensitivity 79% (95% CI 54% to 94%), specificity 87% (95% CI 79% to 94%). The observed heterogeneity in the results remains mostly unexplained, and only in part referable to different cut-offs or settings (surveillance programme compared to clinical series). The sensitivity analyses, excluding studies published as abstracts, or with case-control design, showed no variation in the results. We compared the accuracy obtained from studies with AFP (cut-off around 20 ng/mL) and US: a direct comparison in 11 studies (6674 participants) showed a higher sensitivity of US (81%, 95% CI 66% to 90%) versus AFP (64%, 95% CI 56% to 71%) with similar specificity: US 92% (95% CI 83% to 97%) versus AFP 89% (95% CI 79% to 94%). A direct comparison of six studies (5044 participants) showed a higher sensitivity (96%, 95% CI 88% to 98%) of the combination of AFP and US versus US (76%, 95% CI 56% to 89%) with similar specificity: AFP and US 85% (95% CI 73% to 92%) versus US 93% (95% CI 80% to 98%).
AUTHORS' CONCLUSIONS
In the clinical pathway for the diagnosis of HCC in adults, AFP and US, singularly or in combination, have the role of triage-tests. We found that using AFP, with 20 ng/mL as a cut-off, about 40% of HCC occurrences would be missed, and with US alone, more than a quarter. The combination of the two tests showed the highest sensitivity and less than 5% of HCC occurrences would be missed with about 15% of false-positive results. The uncertainty resulting from the poor study quality and the heterogeneity of included studies limit our ability to confidently draw conclusions based on our results
Contemporary use of excimer laser in percutaneous coronary intervention with indications, procedural characteristics, complications and outcomes in a university teaching hospital.
No full textBACKGROUND
Excimer laser coronary atherectomy (ELCA) can be used as an adjunctive percutaneous coronary intervention treatment for challenging, heavily calcified lesions. Although previous studies have documented high rates of complication and restenosis, these predate the introduction of the smaller 0.9 mm laser catheter. As the coronary complexity has increased, there has been a renewed interest in the ELCA. This study investigates the indications, procedural characteristics, complications and outcomes of ELCA in a contemporary coronary interventional practice.
METHODS
This single-centre study retrospectively analysed 50 patients treated with ELCA between January 2013 and January 2019.
RESULTS
Patients had a mean age of 67.9±11.4 years with a male predominance (65.3%). 25 (50%) cases were performed in patients with stable angina. Failure to deliver the smallest available balloon/microcatheter was the most frequent indication in 32 (64%) cases for ELCA use. 30 (60%) of the procedures were performed via radial access. The 0.9 mm X-80 catheter was used in 41 (82%) of cases, delivering on average 9000±3929 pulses. ELCA-related complications included 2 coronary dissections and 1 perforation, all of which were covered with stents. No major complications could be directly attributed to the use of ELCA. There was one death and one case of stent thrombosis within 30 days of the procedure.
CONCLUSION
ELCA can be performed safely via the radial approach with a 0.9 mm catheter with a high success rate by suitably trained operators. The low procedure-related complications with contemporary techniques make this a very useful tool for complex coronary interventions, especially for difficult to dilate lesions and chronic total occlusion vessels
Impact of cumulative experience on the quality of screening colonoscopy: A 13-year observational study.
No full textOBJECTIVE
To investigate trends in quality of screening colonoscopy (using the Global Rating Score) in the 13 years since introduction of the Bowel Cancer Screening Programme in England.
SETTING
An English Bowel Cancer Screening Programme colonoscopy service from 2007 to 2019.
METHODS
A retrospective observational study was undertaken using a prospectively collected database in order to analyse trends in screening endoscopies (including patients following positive faecal occult blood test or with high-risk findings on flexible sigmoidoscopy). The Global Rating Score quality indicators for Bowel Cancer Screening Programme colonoscopy were used as outcome measures, and trends over time were analysed. These included caecal intubation rate, adenoma detection rate, colorectal cancer detection rate, proportion of patients with minimal or mild discomfort scores, proportion of patients who required intravenous sedation, and adverse events.
RESULTS
There were 5352 colonoscopies included, performed by 3 endoscopists; 73.8% were index procedures (i.e. first Bowel Cancer Screening Programme colonoscopy) and the remainder were follow-up or surveillance colonoscopies. The mean age of patients was 66 (standard deviation 5) years, and 59.8% were male. Mean age increased over time (=0.033; < 0.001). There were significant trends over time towards higher caecal intubation rate ( = 0.015), higher adenoma detection rate ( < 0.001), lower proportion requiring intravenous sedation ( < 0.001). There were no significant trends in comfort scores ( = 0.606), adverse events ( = 0.503) or colorectal cancer detection ( = 0.089).
CONCLUSION
There was a consistent improvement in the Global Rating Score for Bowel Cancer Screening Programme colonoscopies since the start of the programme, even when quality was already high at the start. Patients can expect high-quality colonoscopy when participating in the Bowel Cancer Screening Programme
Introducing a day-case arthroplasty pathway significantly reduces overall length of stay.
No full textAIMS
Day-case arthroplasty is gaining popularity in Europe. We report outcomes from the first 12 months following implementation of a day-case pathway for unicompartmental knee arthroplasty (UKA) and total hip arthroplasty (THA) in an NHS hospital.
METHODS
A total of 47 total hip arthroplasty (THA) and 24 unicompartmental knee arthroplasty (UKA) patients were selected for the day-case arthroplasty pathway, based on preoperative fitness and agreement to participate. Data were likewise collected for a matched control group (n = 58) who followed the standard pathway three months prior to the implementation of the day-case pathway. We report same-day discharge (SDD) success, reasons for delayed discharge, and patient-reported outcomes. Overall length of stay (LOS) for all lower limb arthroplasty was recorded to determine the wider impact of implementing a day-case pathway.
RESULTS
Patients on the day-case pathway achieved SDD in 47% (22/47) of THAs and 67% (16/24) of UKAs. The most common reasons for failed SDD were nausea, hypotension, and pain, which were strongly associated with the use of fentanyl in the spinal anaesthetic. Complications and patient-reported outcomes were not significantly different between groups. Following the introduction of the day-case pathway, the mean LOS reduced significantly by 0.7, 0.6, and 0.5 days respectively in THA, UKA, and total knee arthroplasty cases (p < 0.001).
CONCLUSION
Day-case pathways are feasible in an NHS set-up with only small changes required. We do not recommend fentanyl in the spinal anaesthetic for day-case patients. An important benefit seen in our unit is the so-called 'day-case effect', with a significant reduction in mean LOS seen across all lower limb arthroplasty. Cite this article: 2021;2(11):900-908
Refining mass casualty plans with simulation-based iterative learning.
No full textBACKGROUND
Preparatory, written plans for mass casualty incidents are designed to help hospitals deliver an effective response. However, addressing the frequently observed mismatch between planning and delivery of effective responses to mass casualty incidents is a key challenge. We aimed to use simulation-based iterative learning to bridge this gap.
METHODS
We used Normalisation Process Theory as the framework for iterative learning from mass casualty incident simulations. Five small-scale 'focused response' simulations generated learning points that were fed into two large-scale whole-hospital response simulations. Debrief notes were used to improve the written plans iteratively. Anonymised individual online staff surveys tracked learning. The primary outcome was system safety and latent errors identified from group debriefs. The secondary outcomes were the proportion of completed surveys, confirmation of reporting location, and respective roles for mass casualty incidents.
RESULTS
Seven simulation exercises involving more than 700 staff and multidisciplinary responses were completed with debriefs. Usual emergency care was not affected by simulations. Each simulation identified latent errors and system safety issues, including overly complex processes, utilisation of space, and the need for clarifying roles. After the second whole hospital simulation, participants were more likely to return completed surveys (odds ratio=2.7; 95% confidence interval [CI], 1.7-4.3). Repeated exercises resulted in respondents being more likely to know where to report (odds ratio=4.3; 95% CI, 2.5-7.3) and their respective roles (odds ratio=3.7; 95% CI, 2.2-6.1) after a simulated mass casualty incident was declared.
CONCLUSION
Simulation exercises are a useful tool to improve mass casualty incident plans iteratively and continuously through hospital-wide engagement of staff