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Histopathology of Parasellar Neoplasms.
No full textThe anatomical and histological complexity of the parasellar region as well as the presence of embryonic remnants determine the huge diversity of parasellar neoplasms. Some of them are only located in the parasellar region, whereas others can occur elsewhere, within or outside the central nervous system. Their spectrum ranges from histologically benign and low-grade malignant to high-grade malignant tumours. Although rare, metastases can pose differential diagnostic dilemmas. The severity of the clinical picture, the challenges of surgery and the risk of adverse sequelae related to surgery or radiotherapy make parasellar tumours interesting entities for the clinicians irrespective of their histological malignancy grade. Due to the different cell origins of parasellar tumours, the World Health Organization classification system does not categorise them as a distinct group. Detailed criteria for classification and malignancy grading are presented in the classification systems covering central nervous system tumours, haematological malignancies and tumours of the soft tissue and bone. In the last few years, molecular genetic features have been integrated into the diagnosis of several types of the parasellar tumours enhancing diagnostic accuracy and providing information of the value for targeting therapies. In this review, we will present histopathological and molecular genetic features, updated classification criteria and recent advances in the diagnostics and rationale for novel pharmacological therapies of selected types of parasellar neoplasms
Monitoring patients receiving dopamine agonist therapy for hyperprolactinaemia.
No full textThe surveillance strategy for patients taking low dose cabergoline for hyperprolactinaemia is controversial. As more evidence has emerged that the risks of cardiac valvulopathy in this population of patients are low, fewer and fewer endocrinologists adhere strictly to the original medicines and healthcare products agency MHRA guidance of "at least" annual echocardiography. Strict adherence to this guidance would be costly in monetary terms (£5.76 million/year in the UK) and also in resource use (90,000 extra echocardiograms/year). This article reviews the proposed pathophysiological mechanism underlying the phenomenon of dopamine agonist valvulopathy, the characteristic echocardiographic changes seen, summarises the published literature on the incidence of valvulopathy with low dose cabergoline and examines the previous and current evidence-based screening guidelines
Rapid optofluidic detection of biomarkers for traumatic brain injury via surface-enhanced Raman spectroscopy.
No full textCurrent technologies for the point-of-care diagnosis of traumatic brain injury (TBI) lack sensitivity, require specialist handling or involve complicated and costly procedures. Here, we report the development and testing of an optofluidic device for the rapid and label-free detection, via surface-enhanced Raman scattering (SERS), of picomolar concentrations of biomarkers for TBI in biofluids. The SERS-active substrate of the device consists of electrohydrodynamically fabricated submicrometre pillars covered with a plasmon-active nanometric gold layer, integrated in an optofluidic chip. We show that the device can detect N-acetylasparate in finger-prick blood samples from patients with TBI, and that the biomarker is released immediately from the central nervous system after TBI. The simplicity, sensitivity and robustness of SERS-integrated optofluidic technology might eventually help the triaging of TBI patients and assist clinical decision making at point-of-care settings
Intraosseous versus intravenous administration of adrenaline in patients with out-of-hospital cardiac arrest: a secondary analysis of the PARAMEDIC2 placebo-controlled trial.
No full textPURPOSE
To compare the effectiveness of the intravenous (IV) and intraosseous (IO) routes for drug administration in adults with a cardiac arrest enrolled in the Pre-Hospital Assessment of the Role of Adrenaline: Measuring the Effectiveness of Drug Administration in Cardiac Arrest (PARAMEDIC2) randomised, controlled trial.
METHODS
Patients were recruited from five National Health Service Ambulance Services in England and Wales from December 2014 through October 2017. Patients with an out-of-hospital cardiac arrest who were unresponsive to initial resuscitation attempts were randomly assigned to 1 mg adrenaline or matching placebo. Intravascular access was established as soon as possible, and IO access was considered if IV access was not possible after two attempts.
RESULTS
Among patients with out-of-hospital cardiac arrest, 3631 received adrenaline and 3686 received placebo. Amongst these, 1116 (30.1%) and 1121 (30.4%) received the study drug via the IO route. The odds ratios were similar in the IV and IO groups for return of spontaneous circulation (ROSC) at hospital handover [adjusted odds ratio (aOR) 4.07 (95% CI 3.42-4.85) and (aOR 3.98 (95% CI 2.86-5.53), P value for interaction 0.90]; survival to 30 days [aOR 1.67 (1.18-2.35) versus 0.9 (0.4-2.05), P = 0.18]; and favourable neurological outcome [aOR 1.39 (0.93-2.06) versus 0.62 (0.23-1.67), P = 0.14].
CONCLUSION
There was no significant difference in treatment effect (adrenaline versus placebo) on ROSC at hospital handover between drugs administered by the intraosseous route or by the intravenous route. We could not detect any difference in the treatment effect between the IV and IO routes on the longer term outcomes of 30-day survival or favourable neurological outcome at discharge (ISRCTN73485024)
Correction to: Iluvien™ (Fluocinolone Acetonide 0.19 mg Intravitreal Implant) in the Treatment of Diabetic Macular Edema: A Review.
No full textThis article was originally published with the copyright: the author(s) 2018, CC-BY-NC. However, the license should be the author(s) 2018, CC-BY
Algorithm based smartphone apps to assess risk of skin cancer in adults: systematic review of diagnostic accuracy studies.
No full textOBJECTIVE
To examine the validity and findings of studies that examine the accuracy of algorithm based smartphone applications ("apps") to assess risk of skin cancer in suspicious skin lesions.
DESIGN
Systematic review of diagnostic accuracy studies.
DATA SOURCES
Cochrane Central Register of Controlled Trials, MEDLINE, Embase, CINAHL, CPCI, Zetoc, Science Citation Index, and online trial registers (from database inception to 10 April 2019).
ELIGIBILITY CRITERIA FOR SELECTING STUDIES
Studies of any design that evaluated algorithm based smartphone apps to assess images of skin lesions suspicious for skin cancer. Reference standards included histological diagnosis or follow-up, and expert recommendation for further investigation or intervention. Two authors independently extracted data and assessed validity using QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies 2 tool). Estimates of sensitivity and specificity were reported for each app.
RESULTS
Nine studies that evaluated six different identifiable smartphone apps were included. Six verified results by using histology or follow-up (n=725 lesions), and three verified results by using expert recommendations (n=407 lesions). Studies were small and of poor methodological quality, with selective recruitment, high rates of unevaluable images, and differential verification. Lesion selection and image acquisition were performed by clinicians rather than smartphone users. Two CE (Conformit Europenne) marked apps are available for download. SkinScan was evaluated in a single study (n=15, five melanomas) with 0% sensitivity and 100% specificity for the detection of melanoma. SkinVision was evaluated in two studies (n=252, 61 malignant or premalignant lesions) and achieved a sensitivity of 80% (95% confidence interval 63% to 92%) and a specificity of 78% (67% to 87%) for the detection of malignant or premalignant lesions. Accuracy of the SkinVision app verified against expert recommendations was poor (three studies).
CONCLUSIONS
Current algorithm based smartphone apps cannot be relied on to detect all cases of melanoma or other skin cancers. Test performance is likely to be poorer than reported here when used in clinically relevant populations and by the intended users of the apps. The current regulatory process for awarding the CE marking for algorithm based apps does not provide adequate protection to the public.
SYSTEMATIC REVIEW REGISTRATION
PROSPERO CRD42016033595
Massive Localized Abdominal Lymphedema Treatment Challenges.
No full textMassive localized lymphedema of the abdomen is a rare condition resulting from a neglected lower abdominal pannus associated with significant disability and morbidity. Compared to other surgical procedures, postbariatric surgery is usually considered a financial drain. In the United Kingdom, this requires National Health Service approval and delays may lead to sequelae that adversely impact on patients' quality of life with increased morbidity. We present a wheelchair-bound patient whose body mass index increased from 53 to 82, while awaiting funding approval increasing her anesthetic and surgical risks. A multidisciplinary approach is mandatory for preoperative, intraoperative, and postoperative care for these patients including anesthetic input and high dependency unit care. Managing this patient was a significant anesthetic and surgical challenge with 47-kg resected tissue. The planning and perioperative measures to minimize morbidity are discussed
Nasal columella reconstruction - A comprehensive review of the current techniques.
No full textThe nasal columella is often described as being one of the most difficult nasal subunits to reconstruct. There are a wide range of indications for columella reconstruction, with defects resulting from ischaemic injuries, trauma, tumour resection, vascular malformations and congenital agenesis/dysgenesis of nasal anatomy. There is a variety of columella reconstruction techniques reported in the literature, giving reconstructive surgeons options when approaching different columella defects. Each technique has surgical pearls and pitfalls as well as advantages and disadvantages. This review aims to give reconstructive surgeons a comprehensive review of currently used columella reconstruction techniques
Efficacy of Upadacitinib in a Randomized Trial of Patients With Active Ulcerative Colitis.
No full textBACKGROUND & AIMS
We evaluated the efficacy and safety of upadacitinib, an oral selective inhibitor of Janus kinase 1, as induction therapy for ulcerative colitis (UC).
METHODS
We performed a multicenter, double-blind, phase 2b study of 250 adults with moderately to severely active UC and an inadequate response, loss of response, or intolerance to corticosteroids, immunosuppressive agents, and/or biologic therapies. Patients were randomly assigned to groups that received placebo or induction therapy with upadacitinib (7.5 mg, 15 mg, 30 mg, or 45 mg, extended release), once daily for 8 weeks. The primary endpoint was the proportion of subjects who achieve clinical remission according to the Adapted Mayo score at week 8. No multiplicity adjustments were applied.
RESULTS
At week 8, 8.5%, 14.3%, 13.5%, and 19.6% of patients receiving 7.5 mg, 15 mg, 30 mg, or 45 mg upadacitinib, respectively, achieved clinical remission compared with none of the patients receiving placebo (P = .052, P = .013, P = .011, and P = .002, compared with placebo, respectively). Endoscopic improvement at week 8, defined as endoscopic subscore ≤ 1, was achieved in 14.9%, 30.6%, 26.9%, and 35.7% of patients receiving upadacitinib 7.5 mg, 15 mg, 30 mg, or 45 mg, respectively compared with 2.2% receiving placebo (P = .033, P < .001, P < .001, P < .001, compared with placebo, respectively). One event of herpes zoster and 1 subject with pulmonary embolism and deep venous thrombosis (diagnosed 26 days after treatment discontinuation) were reported in the group that received upadacitinib 45 mg once daily. Increases in serum lipid levels and creatine phosphokinase with upadacitinib were observed.
CONCLUSION
In a phase 2b trial, 8 weeks treatment with upadacitinib was more effective than placebo for inducing remission in patients with moderately to severely active UC. ClinicalTrials.gov no: NCT02819635
Effects of heat: UK exercise Saif Sareea 3 and interpreting military climatic guidance.
No full textINTRODUCTION
Over recent years much research, both civilian and military, has occurred in the field of heat illness. This has helped force health protection and medical management of service personnel operating in hot climates. Exercise Saif Sareea 3 in Oman saw a collection of presentations to the deployed UK medical treatment facilities due to the effects of heat.
METHOD
This paper aims to describe the case series of 24 casualties that presented to the deployed primary care facilities and 17 that were admitted to the deployed secondary care facility due to the effects of heat.
RESULTS
Only 10 casualties fulfilled the in-theatre diagnostic criteria for heat illness, of which two were of moderate severity and required aeromedical evacuation to the UK.
CONCLUSIONS
Commanders appeared extremely well read on Joint Service Publication 539 (JSP539; May 2017) Heat Illness and Cold Injury: Prevention and Management, following the Brecon enquiry, and were proactive in managing their force in preventative measures. This likely contributed towards the low numbers of patients with heat illness seen on the exercise. JSP539 did, however, appear to have some limitations when trying to apply it to all patients seen within the operational patient care pathway, and some areas for development are discussed