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Management of oesophageal perforation based on the Pittsburgh Perforation Severity Score: still a matter of debate.
No full textA systematic review and meta-analysis of the effect of dispatcher-assisted CPR on outcomes from sudden cardiac arrest in adults and children.
No full textBACKGROUND
Dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) has been reported in individual studies to significantly increase the rate of bystander CPR and survival from cardiac arrest.
METHODS
We undertook a systematic review and meta-analysis to evaluate the impact of DA-CPR programs on key clinical outcomes following out-of-hospital cardiac arrest. We searched the PubMED, EMBASE, CINAHL, ERIC and Cochrane Central Register of Controlled Trials databases from inception until July 2018. Eligible studies compared systems with and without dispatcher-assisted CPR programs. The results of included studies were classified into 3 categories for the purposes of more accurate analysis: comparison of outcomes in systems with DA-CPR programs, case-based comparison of DA-CPR to bystander CPR, and case-based comparisons of DA-CPR to no CPR before EMS arrival. The GRADE system was used to assess certainty of evidence at an outcome level. We used random-effects models to produce summary effect sizes across all outcomes.
RESULTS
Of 5,531 citations screened, 33 studies were eligible for inclusion. All included studies were observational. Evidence certainty across all outcomes was assessed as low or very low. In system-level and patient-level comparisons, the provision of DA-CPR compared with no DA-CPR was consistently associated with improved outcome across all analyses. Comparison of DA-CPR to bystander CPR produced conflicting results. Findings were consistent across sensitivity analyses and the pediatric sub-group.
CONCLUSION
These results support the recommendation that dispatchers provide CPR instructions to callers for adults and children with suspected OHCA. Review registration: PROSPERO- CRD42018091427
Contemporary (2009-2014) clinical outcomes after femoropopliteal bypass surgery for chronic limb threatening ischemia are inferior to those reported in the UK Bypass versus Angioplasty for Severe Ischaemia of the Leg (BASIL) trial (1999-2004).
No full textBACKGROUND
Bypass surgery (BS) remains the gold standard revascularization strategy in patients with chronic limb-threatening ischemia (CLTI) owing to infrainguinal disease. The Bypass versus Angioplasty for Severe Ischaemia of the Leg (BASIL)-1 trial showed that, in patients with CLTI who survived for 2 years or more, BS resulted in better clinical outcomes. Despite this finding, there has been an increasing trend toward an endovascular-first approach to infrainguinal CLTI. Our aim was to investigate whether changes in practice have impacted the clinical outcomes of BS in our unit 10 years after BASIL-1.
METHODS
Data for patients who underwent femoropopliteal (FP) BS in BASIL-1 (1999-2004) were retrieved from trial case record forms. The comparator contemporary series (CS) comprised all patients undergoing FP BS for CLTI in our unit between 2009 and 2014. Demographic and clinical outcome data on patients in the CS were collected from the prospectively collected hospital electronic notes. Anatomic patterns of disease in the BASIL-1 and CS cohorts were scored using the Bollinger and GLASS criteria. Statistical analysis was performed in SAS v9.4.
RESULTS
There were 128 patients from BASIL-1 and 50 patients in the CS. Baseline age, gender, affected limb, and diabetes prevalence were similar, as were days spent in hospital out to 12 months and length of follow-up. BASIL-1 patients were more likely to be current smokers (P = .000) and had a higher creatinine (P = .04). The 30-day morbidity and mortality were higher in BASIL-1 (45.3% vs 22%; P = .004). There was no significant difference between BASIL-1 and CS with regard to run-off Bollinger (37.7 vs 32.1; P = .167) and IP GLASS (0 vs 0; P = .390) scores, with both groups having a median of two runoff vessels. Amputation-free survival (62% vs 28%; hazard ratio [HR], 1.86; 95% confidence interval [CI], 1.18-2.93; P = .007), limb salvage (85% vs 69%; HR, 2.31; 95% CI, 1.14-4.68; P = .02), overall survival (69% vs 35%; HR, 1.66; 95% CI, 1.00-2.74; P = .05) and major adverse limb events (67% vs 47%; HR, 1.93; 95% CI, 1.15-3.22; P = .01) were all significantly better in BASIL-1.
CONCLUSIONS
Although 30-day mortality and morbidity were significantly lower, all of the examined longer term clinical outcomes after FP BS were significantly worse in the CS group a decade on from BASIL-1. Further research in the form of prospective cohort studies and randomized controlled trials is urgently required to determine if the CS data reported herein are generalizable to current vascular surgical practice and, if so, to determine the reasons for these unexpected outcomes
Systematic review with meta-analysis: risk factors for recurrent primary sclerosing cholangitis after liver transplantation.
No full textBACKGROUND
After liver transplantation primary sclerosing cholangitis (PSC), the condition returns in the transplanted liver in a subset of patients (recurrent primary sclerosing cholangitis, rPSC).
AIM
To define risk factors for rPSC.
METHODS
We searched Pubmed, Embase, Web of Science, and Cochrane library for articles published until March 2018. Studies addressing risk factors for developing rPSC were eligible for inclusion. A random effects meta-analysis was conducted using hazard ratios (HR) as effect measure. Study quality was evaluated with the Newcastle Ottawa scale. Statistical analysis was performed using Cochrane Review Manager.
RESULTS
The electronic database search yielded 449 results. Twenty-one retrospective cohort studies met the inclusion criteria for the review; 14 were included in the meta-analysis. The final cohort included 2159 patients (age range 31-49 years, 68.8% male), of whom 17.7% developed rPSC. Colectomy before liver transplantation, HR 0.65 (95% CI: 0.42-0.99), cholangiocarcinoma before liver transplantation, HR 2.42 (95% CI: 1.20-4.86), inflammatory bowel disease, HR 1.73 (95% CI: 1.17-2.54), donor age, HR 1.24 (95% CI 1.0-1.45) per ten years, MELD score, HR 1.05 (95% CI: 1.02-1.08) per point and acute cellular rejection, HR of 1.94 (95% CI: 1.32-2.83) were associated with the risk of rPSC.
CONCLUSIONS
Multiple risk factors for rPSC were identified. Colectomy before liver transplantation reduced the risk of rPSC
Liver disease in the young adult: the challenges and rewards.
No full textIncreasing numbers of children are surviving into adulthood with a diagnosis of liver disease or having undergone liver transplantation. This population presents some challenges for the adult hepatologist, and a formal transition service clearly improves outcomes for patients in this group. Evidence of ongoing neurological development in young people up to the age of 25 years exists, and understanding these physiological processes is important in overcoming some of the challenges that caring for this population presents. A well designed transition service is key to maximising potential for these patients, and should enable young people to take control of their illness and achieve their life goals
A comparison of pseudo-continuous arterial spin labelling and dynamic susceptibility contrast MRI with and without contrast agent leakage correction in paediatric brain tumours.
No full textOBJECTIVE:
To investigate correlations between MRI perfusion metrics measured by dynamic susceptibility contrast and arterial spin labelling in paediatric brain tumours.
METHODS:
15 paediatric patients with brain tumours were scanned prospectively using pseudo-continuous arterial spin labelling (ASL) and dynamic susceptibility contrast (DSC-) MRI with a pre-bolus to minimise contrast agent leakage. Cerebral blood flow (CBF) maps were produced using ASL. Cerebral blood volume (CBV) maps with and without contrast agent leakage correction using the Boxerman technique and the leakage parameter, K, were produced from the DSC data. Correlations between the metrics produced were investigated.
RESULTS:
Histology resulted in the following diagnoses: pilocytic astrocytoma (n = 7), glioblastoma (n = 1), medulloblastoma (n = 1), rosette-forming glioneuronal tumour of fourth ventricle (n = 1), atypical choroid plexus papilloma (n = 1) and pilomyxoid astrocytoma (n = 1). Three patients had a non-invasive diagnosis of low-grade glioma. DSC CBV maps of T-enhancing tumours were difficult to interpret without the leakage correction. CBV values obtained with and without leakage correction were significantly different (p < 0.01). A significant positive correlation was observed between ASL CBF and DSC CBV (r = 0.516, p = 0.049) which became stronger when leakage correction was applied (r = 0.728, p = 0.002). K values were variable across the group (mean = 0.35, range = -0.49 to 0.64).
CONCLUSION:
CBV values from DSC obtained with and without leakage correction were significantly different. Large increases in CBV were observed following leakage correction in highly T-enhancing tumours. DSC and ASL perfusion metrics were found to correlate significantly in a range of paediatric brain tumours. A stronger relationship between DSC and ASL was seen when leakage correction was applied to the DSC data. Leakage correction should be applied when analysing DSC data in enhancing paediatric brain tumours.
ADVANCES IN KNOWLEDGE:
We have shown that leakage correction should be applied when investigating enhancing paediatric brain tumours using DSC-MRI. A stronger correlation was found between CBF derived from ASL and CBV derived from DSC when a leakage correction was employed
People, systems and safety: resilience and excellence in healthcare practice.
No full textThis article outlines recent developments in safety science. It describes the progression of three 'ages' of safety, namely the 'age of technology', the 'age of human factors' and the 'age of safety management'. Safety science outside healthcare is moving from an approach focused on the analysis and management of error ('Safety-1') to one which also aims to understand the inherent properties of safety systems that usually prevent accidents from occurring ('Safety-2'). A key factor in the understanding of safety within organisations relates to the distinction between 'work as imagined' and 'work as done'. 'Work as imagined' assumes that if the correct standard procedures are followed, safety will follow as a matter of course. However, staff at the 'sharp end' of organisations know that to create safety in their work, variability is not only desirable but essential. This positive adaptability within systems that allows good outcomes in the presence of both favourable and adverse conditions is termed resilience. We argue that clinical and organisational work can be made safer, not only by addressing negative outcomes, but also by fostering excellence and promoting resilience. We outline conceptual and investigative approaches for achieving this that include 'appreciative inquiry', 'positive deviance' and excellence reporting
Quality of Life Benefits from Arrhythmia Ablation: A longitudinal study using the C-CAP questionnaire and EQ5D.
No full textAIMS
To investigate long term efficacy of cardiac ablation for symptomatic arrhythmia by gathering generic and arrhythmia related quality of life data using patient reported outcome measures before and after ablation.
METHODS
Consecutive patients undergoing cardiac ablation procedures at three sites in the UK were enrolled (n = 561). Data were collected at baseline, at 8-16 weeks and 12 months after the ablation with responses from 390 patients received at all three time points. Non-parametric tests were used to identify any changes in patient outcomes due to non-normal data.
RESULTS
There were significant improvements in symptom severity, impact on life scores, EQ-5D-5L indices and VAS scores at pre- versus three months and at pre-ablation versus 1 year. Impact on life score showed additional improvement at 1 year versus three months, while improvements in symptom severity, EQ-5D-5L indices and VAS scores continued to be maintained between 3 months and 1 year.
CONCLUSION
Cardiac ablation provides patients with arrhythmias relief from symptoms, and results in an improvement in quality of life. Improvements observed at 3 months are maintained at 1 year follow up. This article is protected by copyright. All rights reserved
CD117 (c-Kit) Is Expressed During CD8 T Cell Priming and Stratifies Sensitivity to Apoptosis According to Strength of TCR Engagement.
No full textCD117 (cKit) is the receptor for stem cell factor (SCF) and plays an important role in early haemopoiesis. We show that CD117 is also expressed following priming of mature human CD8 T cells and is detectable following primary infection . CD117 expression is mediated through an intrinsic pathway and is suppressed by IL-12. Importantly, the extent of CD117 expression is inversely related to the strength of the activating stimulus and subsequent engagement with cell-bound SCF markedly increases susceptibility to apoptosis. CD117 is therefore likely to shape the pattern of CD8 T cell immunodominance during a primary immune response by rendering cells with low avidity for antigen more prone to apoptosis. Furthermore, CD117 T cells are highly sensitive to apoptosis mediated by galectin-1, a molecule commonly expressed within the tumor microenvironment, and CD117 expression may therefore represent a novel and potentially targetable mechanism of tumor immune evasion
Testosterone Therapy: An Assessment of the Clinical Consequences of Changes in Hematocrit and Blood Flow Characteristics.
No full textINTRODUCTION
Clinical guidelines indicate that hematocrit should be monitored during testosterone replacement therapy (TTh), with action taken if a level of 0.54 is exceeded.
AIM
To consider the extent of changes in hematocrit and putative effects on viscosity, blood flow, and mortality rates after TTh.
METHODS
We focused on literature describing benefits and possible pitfalls of TTh, including increased hematocrit. We used data from the BLAST RCT to determine change in hematocrit after 30 weeks of TTh and describe a clinical case showing the need for monitoring. We consider the validity of the current hematocrit cutoff value at which TTh may be modified. Ways in which hematocrit alters blood flow in the micro- and macro-vasculature are also considered.
MAIN OUTCOME MEASURES
The following measures were assessed: (i) change in hematocrit, (ii) corresponding actions taken in clinical practice, and (iii) possible blood flow changes following change in hematocrit.
RESULTS
Analysis of data from the BLAST RCT showed a significant increase in mean hematocrit of 0.01, the increase greater in men with lower baseline values. Although 0 of 61 men given TTh breached the suggested cutoff of 0.54 after 30 weeks, a clinical case demonstrates the need to monitor hematocrit. An association between hematocrit and morbidity and mortality appears likely but not proven and may be evident only in patient subgroups. The consequences of an increased hematocrit may be mediated by alterations in blood viscosity, oxygen delivery, and flow. Their relative impact may vary in different vascular beds.
CONCLUSIONS
TTh can effect an increased hematocrit via poorly understood mechanisms and may have harmful effects on blood flow that differ in patient subgroups. At present, there appears no scientific basis for using a hematocrit of 0.54 to modify TTh; other values may be more appropriate in particular patient groups. König CS, Balabani S, Hackett GI, et al. Testosterone Therapy: An Assessment of the Clinical Consequences of Changes in Hematocrit and Blood Flow Characteristics. Sex Med Rev 2019;XX:XXX-XXX