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The value of sestamibi single-photon emission computed tomography/computed tomography in differentiating and staging renal cell carcinomas: A systematic review.
No full textMisdiagnosis of benign renal neoplasms can lead to unnecessary surgical resections, which increases the risk of other morbidities and mortality. Therefore, it is crucial to find a diagnostic modality for differentiation between benign and malignant renal masses. In the current study, we summarized published pieces of evidence concerning the use of technetium-99m (Tc)-sestamibi single-photon emission computed tomography/computed tomography (SPECT/CT) as a promising diagnostic nuclear imaging modality for the differentiation of renal neoplasms. The study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement for Systematic Reviews and Meta-Analyses. We conducted a systematic electronic database search for suitable studies from inception till February 20, 2020 in 9 databases. The risk of bias was assessed for the included studies using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. We identified 9373 records after exclusion of 8978 duplicates using EndNote software. Title and abstract screening resulted in 761 records for further full-text screening. Finally, four studies were included with total sample size of 80 patients. The overall risk of bias was low to moderate. The results of all the included studies supported using Tc-sestamibi SPECT/CT for the differentiation between benign and malignant renal neoplasms. The use of Tc-sestamibi SPECT/CT could be a rapid, less invasive, promising diagnostic modality for histological diagnosis and staging of renal neoplasm, as well as monitoring post-therapy tumor's response. However, more studies with large sample sizes are essential to confirm the reliability and accuracy of this modality for usage
Carvedilol reduces the risk of decompensation and mortality in patients with compensated cirrhosis in a competing-risk meta-analysis.
No full textWhether non-selective β-blockers can prevent decompensation of cirrhosis needs clarification. Carvedilol might be particularly effective since its intrinsic vasodilatory activity may ameliorate hepatic vascular resistance, a major mechanism of portal-hypertension in early cirrhosis. We assessed whether carvedilol may prevent decompensation and improve survival in compensated cirrhosis with clinically significant portal hypertension (CSPH).
METHODS
By systematic review we identified RCTs comparing carvedilol vs control therapy (no-active treatment or EVL) in patients with cirrhosis and CSPH without previous bleeding. We performed a competing-risk time-to-event meta-analysis using individual patient data (IPD) obtained from principal investigators of RCTs. Only compensated patients were included. Primary outcomes were prevention of decompensation (OLT and death were competing-events) and death (OLT, competing-event). Models were adjusted using propensity score for baseline covariates with the IPTW approach.
RESULTS
Among 125 full-text studies evaluated, 4 RCTs were eligible. The four provided IPD and were included, comprising 352 patients with compensated cirrhosis, 181 treated with carvedilol and 171 controls (79 received EVL and 92 placebo). Baseline characteristics were similar between groups. Standardized differences were <10% by IPTW. The risk of developing decompensation of cirrhosis was lower with carvedilol than in controls (SHR=0.506, 95%CI=0.289-0.887, P=0.017; I=0.0%, Q-statistic-P=0.880), mainly due to a reduced risk of ascites (SHR=0.491, 95%CI=0.247-0.974, P=0.042; I=0.0%, Q-statistic-P=0.384). The risk of death was also lower with carvedilol (SHR=0.417, 95%CI=0.194-0.896, P=0.025; I=0.0%, Q-statistic-P=0.989).
CONCLUSIONS
Long-term carvedilol therapy reduced decompensation of cirrhosis and significantly improved survival in compensated patients with CSPH. This suggests that screening patients with compensated cirrhosis for CSPH to start therapy with carvedilol can improve outcomes.
LAY SUMMARY
Portal hypertension is a main determinant of the progression of cirrhosis from compensated to decompensation with the consequent increase in morbidity and worsening of life expectancy. It has been suggested that NSBBs can prevent decompensation, but this has not been clarified. Carvedilol might be particularly useful since its intrinsic vasodilatory activity may ameliorate hepatic vascular resistance, which is a major mechanism of portal hypertension in compensated cirrhosis. We aimed to investigate such possibility using an individual participant data with competing-risk meta-analysis, to optimize sample size and properly investigate cirrhosis as a multistate disease and outcomes as time-dependent events. The study shows that carvedilol significantly decreases the risk of decompensation in patients with compensated cirrhosis and CSPH, mainly by reducing the risk of developing ascites. Even more importantly, carvedilol improved survival in these patients. The findings suggest that screening patients with compensated cirrhosis for CSPH to start therapy with carvedilol, can prevent the progression of compensated cirrhosis to decompensation improving survival.
PROSPERO REGISTRATION NUMBER
CRD42019144786
Oligometastatic deposits of prostate cancer found within the sigmoid pericolic fat that was resected for colonic adenocarcinoma: a case report.
No full textBACKGROUND
Prostate cancer may rarely metastasize to the colon and colonic lymph nodes, and local treatment of oligometastatic deposits may improve oncological outcomes. Immunohistochemical stains are used to determine the most likely source of metastatic deposits when they are seen within surgical specimens. The aim of this case report is to illustrate how such techniques were used to identify unexpected prostatic metastases within the pericolic fat of a sigmoid colon resection specimen following elective curative surgery for colorectal cancer. To our knowledge, this is the first report of complete excision of oligometastatic deposits of prostate cancer found incidentally within the specimen of another cancer.
CASE REPORT
An 89-year-old Caucasian man underwent sigmoid colectomy for an obstructing colorectal cancer in the sigmoid colon with some mesenteric lymphadenopathy. He had previously received radical radiotherapy for prostate cancer 10 years earlier. When the specimen was examined by the histopathologist, it was noted that the pericolic fat adjacent to the colorectal adenocarcinoma contained some metastatic deposits. Positive immunohistochemical staining for prostate-specific antigen and prostate-specific acid phosphatase with negative staining for CDX2 and CK20 revealed these to be prostatic metastases rather than colonic. Since these were completely excised, and there were no other metastases, this represented a serendipitous, curative excision of oligometastatic deposits of an additional cancer to the one that was being treated.
CONCLUSIONS
This case illustrates how immunohistochemical staining may be used to distinguish the source of metastatic deposits based on the likelihood of primary tumor from a careful and thorough patient history
Breast satisfaction in adult women with Turner syndrome-An international survey employing the BREAST-Q questionnaire.
No full textOBJECTIVE
Turner syndrome (TS) is associated with short stature, delayed puberty, primary ovarian insufficiency, and other features. Most girls with TS require oestrogen replacement for pubertal induction. There is paucity of data in adult TS on pubertal outcomes, including breast satisfaction. Here, we assess breast satisfaction in TS with the BREAST-Q questionnaire, a well-validated patient-related outcome measure (PROM).
DESIGN
International survey distributed online through TS support groups.
PATIENTS
Adult women aged 18-45 years with TS (self-reported).
MEASUREMENTS
The questionnaire contained demographics, health history and the four domains of the BREAST-Q. BREAST-Q scores were matched on a one-to-one basis for age, body mass index (BMI) and educational background to a normative data set derived from the 'Army of Women', an online community of healthy volunteers.
RESULTS
Of 97 total responses, 74 could be matched to the control cohort. Median age was 32 years (18-45 years) and 97% were White Caucasian. Median age at menarche was 15.5 years (12-34 years), 86% had received pubertal induction therapy as teenagers. We found significantly lower BREAST-Q scores in TS in the domains 'Satisfaction with Breast' (p = .021), 'Psychosocial Wellbeing' (p < .0001) and 'Sexual Wellbeing' (p < .0001). TS who had received oestrogen replacement therapy reported lower scores compared to TS who had not received oestrogen therapy (p < .0001). Lower BMI and previous growth hormone therapy were associated with lower breast satisfaction.
CONCLUSIONS
TS women who received oestrogen replacement for pubertal induction self-report lower breast satisfaction scores and late menarche, suggesting that type, mode of delivery, dose and timing of hormone supplements merit prospective study
Interventions for the prevention of adrenal crisis in adults with primary adrenal insufficiency: a systematic review.
No full textObjective
The incidence of adrenal crisis (AC) remains high, particularly for people with primary adrenal insufficiency, despite the introduction of behavioural interventions. The present study aimed to identify and evaluate available evidence of interventions aiming to prevent AC in primary adrenal insufficiency.
Design
This study is a systematic review of the literature and theoretical mapping.
Methods
MEDLINE, MEDLINE in Process, EMBASE, ERIC, Cochrane CENTRAL, CINAHL, PsycINFO, the Health Management Information Consortium and trial registries were searched from inception to November 2021. Three reviewers independently selected studies and extracted data. Two reviewers appraised the studies for the risk of bias.
Results
Seven observational or mixed methods studies were identified where interventions were designed to prevent AC in adrenal insufficiency. Patient education was the focus of all interventions and utilised the same two behaviour change techniques, 'instruction on how to perform a behaviour' and 'pharmacological support'. Barrier and facilitator themes aiding or hindering the intervention included knowledge, behaviour, emotions, skills, social influences and environmental context and resources. Most studies did not measure effectiveness, and assessment of knowledge varied across studies. The study quality was moderate.
Conclusion
This is an emerging field with limited studies available. Further research is required in relation to the development and assessment of different behaviour change interventions to prevent AC
Radiotherapy to the prostate for men with metastatic prostate cancer in the UK and Switzerland: Long-term results from the STAMPEDE randomised controlled trial.
No full textBACKGROUND
STAMPEDE has previously reported that radiotherapy (RT) to the prostate improved overall survival (OS) for patients with newly diagnosed prostate cancer with low metastatic burden, but not those with high-burden disease. In this final analysis, we report long-term findings on the primary outcome measure of OS and on the secondary outcome measures of symptomatic local events, RT toxicity events, and quality of life (QoL).
METHODS AND FINDINGS
Patients were randomised at secondary care sites in the United Kingdom and Switzerland between January 2013 and September 2016, with 1:1 stratified allocation: 1,029 to standard of care (SOC) and 1,032 to SOC+RT. No masking of the treatment allocation was employed. A total of 1,939 had metastatic burden classifiable, with 42% low burden and 58% high burden, balanced by treatment allocation. Intention-to-treat (ITT) analyses used Cox regression and flexible parametric models (FPMs), adjusted for stratification factors age, nodal involvement, the World Health Organization (WHO) performance status, regular aspirin or nonsteroidal anti-inflammatory drug (NSAID) use, and planned docetaxel use. QoL in the first 2 years on trial was assessed using prospectively collected patient responses to QLQ-30 questionnaire. Patients were followed for a median of 61.3 months. Prostate RT improved OS in patients with low, but not high, metastatic burden (respectively: 202 deaths in SOC versus 156 in SOC+RT, hazard ratio (HR) = 0·64, 95% CI 0.52, 0.79, p < 0.001; 375 SOC versus 386 SOC+RT, HR = 1.11, 95% CI 0.96, 1.28, p = 0·164; interaction p < 0.001). No evidence of difference in time to symptomatic local events was found. There was no evidence of difference in Global QoL or QLQ-30 Summary Score. Long-term urinary toxicity of grade 3 or worse was reported for 10 SOC and 10 SOC+RT; long-term bowel toxicity of grade 3 or worse was reported for 15 and 11, respectively.
CONCLUSIONS
Prostate RT improves OS, without detriment in QoL, in men with low-burden, newly diagnosed, metastatic prostate cancer, indicating that it should be recommended as a SOC.
TRIAL REGISTRATION
ClinicalTrials.gov NCT00268476, ISRCTN.com ISRCTN78818544
Caring in the silences: why physicians and surgeons do not discuss emergency care and treatment planning with their patients - an analysis of hospital-based ethnographic case studies in England.
No full textBACKGROUND
Despite increasing emphasis on integrating emergency care and treatment planning (ECTP) into routine medical practice, clinicians continue to delay or avoid ECTP conversations with patients. However, little is known about the clinical logics underlying barriers to ECTP conversations.
OBJECTIVE
This study aims to develop an ethnographic account of how and why clinicians defer and avoid ECTP conversations, and how they rationalise these decisions as they happen.
DESIGN
A multisited ethnographic study.
SETTING
Medical, orthopaedic and surgical wards in hospitals within four acute National Health Service trusts in England.
PARTICIPANTS
Thirty-four doctors were formally observed and 32 formally interviewed. Following an ethnographic case study approach, six cases were selected for in-depth analysis.
ANALYSIS
Fieldnote data were triangulated with interview data, to develop a 'thick description' of each case. Using a conceptual framework of care, the analysis highlighted the clinical logics underlying these cases.
RESULTS
The deferral or avoidance of ECTP conversations was driven by concerns over caring well, with clinicians attempting to optimise both medical and bedside practice. Conducting an ECTP conversation carefully meant attending to patients' and relatives' emotions and committing sufficient time for an in-depth discussion. However, conversation plans were often disrupted by issues related to timing and time constraints, leading doctors to defer these conversations, sometimes indefinitely. Additionally, whereas surgeons and geriatricians deferred conversations because they did not have the time to offer detailed discussions, emergency and acute medicine clinicians deferred conversations because the high-turnover ward environment, combined with patients' acute conditions, meant triaging conversations to those most in need.
CONCLUSION
Overcoming barriers to ECTP conversations is not simply a matter of enhancing training or hospital policies, but of promoting good conversational practices that take into account the affordances of hospital time and space, as well as clinicians' understandings of caring well
Inflammatory bowel disease-related colorectal cancer: Past, present and future perspectives.
No full textInflammatory bowel disease-related colorectal cancer (IBD-CRC) is one of the most serious complications of IBD contributing to significant mortality in this cohort of patients. IBD is often associated with diet and lifestyle-related gut microbial dysbiosis, the interaction of genetic and environmental factors, leading to chronic gut inflammation. According to the "common ground hypothesis", microbial dysbiosis and intestinal barrier impairment are at the core of the chronic inflammatory process associated with IBD-CRC. Among the many underlying factors known to increase the risk of IBD-CRC, perhaps the most important factor is chronic persistent inflammation. The persistent inflammation in the colon results in increased proliferation of cells necessary for repair but this also increases the risk of dysplastic changes due to chromosomal and microsatellite instability. Multiple pathways have been identified, regulated by many positive and negative factors involved in the development of cancer, which in this case follows the 'inflammation-dysplasia-carcinoma' sequence. Strategies to lower this risk are extremely important to reduce morbidity and mortality due to IBD-CRC, among which colonoscopic surveillance is the most widely accepted and implemented modality, forming part of many national and international guidelines. However, the effectiveness of surveillance in IBD has been a topic of much debate in recent years for multiple reasons - cost-benefit to health systems, resource requirements, and also because of studies showing conflicting long-term data. Our review provides a comprehensive overview of past, present, and future perspectives of IBD-CRC. We explore and analyse evidence from studies over decades and current best practices followed globally. In the future directions section, we cover emerging novel endoscopic techniques and artificial intelligence that could play an important role in managing the risk of IBD-CRC
The Neurology and Neurosurgery Interest Group (NANSIG)-ten years of cultivating interest in clinical neurosciences.
No full textCollaboration and successful teamworking are important components of clinical practise, and these skills should be cultivated early in medical school. The breadth of current medical school curricula means that students often have limited exposure to clinical neurosciences. Since its inception in 2009, the Neurology and Neurosurgery Interest Group (NANSIG) has become a national (UK and Republic of Ireland) example of student and junior doctor synergistic collaboration to deliver educational materials, research, conferences, seminars and workshops, as well as advocating for diversity in this field. Recently, it has expanded to incorporate an international audience and cater for a larger group of young medical professionals. The organisation has overcome numerous challenges and is constantly innovating new approaches to harness the necessary knowledge, skills and network to succeed in a career in neurosciences, neurology and neurosurgery. This article summarises the initiatives undertaken by the group over its first 10 years of existence and its organisational structure, as well as its future plans