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Editorial: early and late mortality following unscheduled admissions for severe liver disease across England and Wales.
No full textPatient and Clinician Perspectives on Electronic Patient-Reported Outcome Measures in the Management of Advanced CKD: A Qualitative Study.
No full textRATIONALE & OBJECTIVE
Chronic kidney disease (CKD) can substantially affect patients' health-related quality of life. Electronic patient-reported outcome measures (ePROMs) may capture symptoms and health-related quality of life and assist in the management of CKD. This study explored patient and clinician views on the use of a renal ePROM system.
STUDY DESIGN
Qualitative study.
SETTING & PARTICIPANTS
12 patients with stage 4 or 5 CKD (non-dialysis dependent); 22 clinicians (6 CKD community nurses, 1 clinical psychologist, 10 nephrologists, 3 specialist registrars, and 2 renal surgeons) in the United Kingdom.
ANALYTICAL APPROACH
Semi-structured interviews and focus group discussion during which patients received paper versions of the Kidney Disease Quality of Life-36 and the Integrated Patient Outcome Scale-Renal to exemplify the type of content that could be included in an ePROM. Thematic analysis of interview transcripts.
RESULTS
4 themes were identified: (1) general opinions of PROMs, (2) potential benefits and applications of an ePROM system, (3) practical considerations for the implementation of ePROMs, and (4) concerns, barriers, and facilitators. Patients were willing to complete ePROMs on a regular basis as part of their care despite clinician concerns about patient burden. Patients assessed the questionnaires favorably. Clinicians suggested that the extent of adoption of renal ePROM systems in routine clinical settings should be based on evidence of significant impact on patient outcomes. Clinicians were concerned that an ePROM system may raise patient expectations to unrealistic levels and expose clinicians to the risk for litigation. Patients and clinicians identified potential benefits and highlighted issues and concerns that need to be addressed to ensure the successful implementation of the renal ePROM system.
LIMITATIONS
Transferability of the findings may be limited because only English-speaking participants were recruited to the study.
CONCLUSIONS
A renal ePROM system may play a supportive role in the routine clinical management of patients with advanced CKD if the concerns of clinicians and patients can be sufficiently addressed
Real-time intraoperative ultrasound in brain surgery: neuronavigation and use of contrast-enhanced image fusion.
No full textOutcomes of Liver Transplantation for Non-alcoholic Steatohepatitis: a European Liver Transplant Registry Study.
No full textBACKGROUND & AIMS
Little is known about outcomes of liver transplantation for patients with non-alcoholic steatohepatitis (NASH). We aimed to determine the frequency and outcomes of liver transplantation for patients with NASH in Europe and identify prognostic factors.
METHODS
We analyzed data from patients transplanted for end-stage liver disease between January 2002 and December 2016 using the European Liver Transplant Registry database. We compared data between patients with NASH versus other etiologies. The principle endpoints were patient and overall allograft survival.
RESULTS
Among 68,950 adults undergoing first liver transplantation, 4.0% were transplanted for NASH - an increase from 1.2% in 2002 to 8.4% in 2016. A greater proportion of patients transplanted for NASH (39.1%) had hepatocellular carcinoma (HCC) than non-NASH patients (28.9%, P65: HR 1.72, P=.017), elevated MELD (>23: HR 1.48, P=.048) and low (40kg.m: HR 1.96, P=.012) recipient BMI independently predicted death in patients transplanted for NASH without HCC. Data must be interpreted in the context of absent recognised confounders, such as pre-morbid metabolic risk factors.
CONCLUSIONS
The number and proportion of liver transplants performed for NASH in Europe has increased from 2002 through 2016. HCC was more common in patients transplanted with NASH. Survival of patients and grafts in patients with NASH is comparable to that of other disease indications.
LAY SUMMARY
NASH is a growing indication for liver transplantation in Europe, with good overall outcomes, although careful assessment for risk factors is required to maintain favorable post-transplant outcomes
Does access to a portable ophthalmoscope improve skill acquisition in direct ophthalmoscopy? A method comparison study in undergraduate medical education.
No full textBACKGROUND
Direct ophthalmoscopy (DO) is an essential skill for medical graduates but there are multiple barriers to learning this. Medical students and junior doctors typically lack confidence in DO. Most students do not own an ophthalmoscope and learn via ward devices that vary in design and usability. The Arclight ophthalmoscope (AO) is an easy to use, low-cost and portable device that could help address device access. This study aimed to assess the impact of personal ownership of an AO on DO skill acquisition and competency amongst medical students in the clinical environment.
METHODS
Method comparison study with 42 medical students randomised to either traditional device ophthalmoscope (TDO) control or AO intervention group during an 18-week medical placement. Three objective assessments of DO competency were performed at the beginning and end of the placement: vertical cup to disc ratio (VCDR) measurement, fundus photo multiple-choice questions (F-MCQ) and model slide examination (MSE). DO examinations performed during the placement were recorded via an electronic logbook.
RESULTS
Students in both groups recorded a median number of six examinations each during an eighteen-week placement. There was no statistically significant difference between the groups in any of the objective assessment measures (VCDR p = 0.561, MCQ p = 0.872, Model p = 0.772). Both groups demonstrated a minor improvement in VCDR measurement but a negative performance change in F-MCQ and MSE assessments.
CONCLUSIONS
Students do not practice ophthalmoscopy often, even with constant access to their own portable device. The lack of significant difference between the groups suggests that device access alone is not the major factor affecting frequency of DO performance and consequent skill acquisition. Improving student engagement with ophthalmoscopy will require a more wide-ranging approach
Suicide amongst anaesthetists - an Association of Anaesthetists survey.
No full textFollowing a 2-3-month period of publicity, anaesthetists were invited to participate in an online survey that was administered by a third party company on behalf of the Association of Anaesthetists and ran between 3 September and 31 October 2018. Anaesthetists working in the UK or Ireland were asked about the presence or absence of welfare/support structures or resources in their workplace in the case of mental illness, addiction and/or suicide. Anaesthetists working anywhere in the world were also asked for their experiences of a colleague's suicide, defined as a colleague's taking his or her own life - whether intentional or not - while practising as an anaesthetist in the UK or Ireland, in the same department and at the same time as the respondent. Respondents were also asked about experiences of other suicides not meeting this definition. A total of 3638 responses were received. Most respondents were unaware of the existence of policies/guidance on mental illness, addiction or suicide, or of welfare leads, within their Trust or department. A total of 1916 cases of suicide meeting the survey's definition were reported by 1397 respondents, although the actual number of discrete cases is unknown because of likely multiple reporting of the same cases. A third of respondents who reported a suicide had experience of more than one case. Most reports were of suicide in the last 10 years, and most reported cases involved anaesthetic drugs. Deficiencies were noted in the support available and in the way the deaths were handled, although examples of good support were also described. A further 1715 respondents reported suicides that did not meet the primary definition. Overall, 92% of respondents reporting suicide experienced it through work, and 41% outside of work (total > 100% as some reported both). Although unable to provide estimates of suicide rates, or numerical associations between the features of the deaths, this survey highlights the considerable emotional and mental burden of suicide on anaesthetists
Granulomatosis polyangiitis.
No full textA 22-year-old female patient was admitted to hospital after being referred from the oral medicine clinic where she had been seen for persistent gingivitis and mouth ulcers. She described an insidious history of persistent fevers, dry cough and unexplained weight loss over 4-6 weeks. Imaging showed extensive bilateral pulmonary nodules with mediastinal lymphadenopathy and two lesions in the pancreas. MRI revealed these lesions to be well-defined fluid-filled cysts in the tail of the pancreas, without features of malignancy. Core biopsies taken from her lung nodules demonstrated features of vasculitis with granulomata. This was consistent with her positive immunology for c-antinuclear cytoplasmic antibodies and proteinase-3, which were sent after her fever failed to settle with antibiotic treatment. In keeping with a diagnosis of vasculitis, the patient showed a significant clinical and biochemical response to intravenous methylprednisolone and high-dose daily prednisolone thereafter
Cone-Beam Computed Tomography Allows Accurate Registration to Surgical Navigation Systems: A Multidevice Phantom Study.
No full textUncontrolled donation after circulatory death and liver transplantation: evidence and unresolved issues.
No full textThis review aims at summarizing the available evidence on liver transplantation from uncontrolled Donation after Circulatory Death (uDCD) on differences in protocols, donor management, in and ex vivo perfusion techniques from center to center. Uncontrolled DCDs represent an unique, complex model of ischemia-reperfusion injury, so far not completely understood. Nevertheless, results on liver transplantation from uDCDs are promising in terms of long term graft survival. True difficulties still remain since common/shared protocols are not achievable due to legal differences between countries (i.e. no touch period duration). To date, there is no reliable metrics to determine whether a liver is safe to be ex situ perfused or to be transplanted since existing criteria, as stated by investigators themselves, are so far arbitrary. Values and kinetics of transaminanes during normothermic regional perfusion (nRP) should not considered absolute contraindication at least for ex vivo perfusion. Intraoperative evaluation at organ recovery remains pivotal since macroscopic alterations (i.e. hepatic rupture, an abnormal appearance of gall bladder and choledocus) still represent contraindications for organ retrieval. Concerning ex vivo perfusion, the debate is still open, since the choice of type of machine perfusion (mainly hypothermic vs normothermic) varies from center to center, mainly relying to the single center experience (especially in controlled DCD), surgeons' believes and/or criteria translated from animal models
