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Evaluation of the clinical and economic impact of delays to surgery in patients with periampullary cancer.
No full textBackground
Early treatment is the only potential cure for periampullary cancer. The pathway to surgery is complex and involves multiple procedures across local and specialist hospitals. The aim of this study was to analyse variability within this pathway, and its impact on cost and outcomes.
Methods
Patients undergoing surgery for periampullary cancer (2011-2016) were identified retrospectively and their pathway to surgery was analysed. Patients who had early surgery (shortest quartile, Q1) were compared with those having late surgery (longest quartile, Q4).
Results
A total of 483 patients were included in the study, with 121 and 124 patients in Q1 and Q4 respectively. The median time from initial CT to surgery was 21 days for Q1 112 days for Q4 ( < 0·001). Diagnostic delays were common in Q4; these patients required significantly more investigations than those in Q1 (endoscopic ultrasonography (EUS): 74·2 18·2 per cent respectively, < 0·001; MRI: 33·6 20·6 per cent, = 0·036). The median time to diagnostic EUS was 13 days in Q1 59 days in Q4 ( < 0·001). Some 42·1 per cent of jaundiced patients in Q1 underwent preoperative biliary drainage, compared with all patients in Q4. There were significantly more unplanned admissions and associated longer duration of hospital stay per patient and costs in Q4 than in Q1 (median: 8 3 days respectively; €5652 €2088; both < 0·001). There was a higher likelihood of potentially curative surgery in Q1 (82·6 per cent 66·9 per cent in Q4; = 0·005).
Conclusion
There is wide variation across the entire pathway, suggesting that multiple strategies are required to enable early surgery. Defining an effective pathway by anticipating the need for investigations and avoiding biliary drainage reduces unplanned admissions and costs and increases resection rates
Opioids and their endocrine effects: A systematic review and meta-analysis.
No full textCONTEXT
The increased use of opioids has resulted in an unprecedented opioid epidemic. Chronic opioid use causes hypogonadism, but its frequency, as well as the effects of opioids on other hypothalamo-pituitary-end organ hormone axes, remains unclear.
OBJECTIVE
The aim of this systematic review and meta-analysis was to assess the effects of opioid use on pituitary function.
METHODS
Eight electronic databases were searched for articles published up to May 8, 2018. Fixed- or random-effects meta-analysis was performed to estimate pooled proportions with 95% confidence intervals. This study is reported following the PRISMA- and MOOSE-guidelines.
DATA SYNTHESIS
52 studies (22 low risk of bias) were included describing 18,428 subjects, consisting of patients with chronic pain (n=21 studies), or on maintenance treatment for opioid addiction (n=9) and healthy volunteers (n=4). The most frequently used opioid was methadone (n=13 studies), followed by morphine (n=12). Prevalence of hypogonadism was 63% (95% CI: 55-70%, 15 studies, 3,250 patients, 99.5% males). Prevalence of hypocortisolism relying on dynamic and non-dynamic testing was 15% (95% CI: 6-28%, 5 studies, 205 patients, 57.5% males) and including only studies using the insulin tolerance tests 24% (95% CI 16-33%, 2 studies, n=97 patients). In 5 out of 7 studies hyperprolactinemia was present. No clear effects on the somatotropic and hypothalamo-pituitary-thyroid axes were described.
CONCLUSIONS
Hypogonadism occurs in more than half of male opioid users, and hypocortisolism in approximately a fifth of all patients. Periodical evaluation of at least the gonadal and adrenal axes is therefore advisable
Mitigating Respiratory Motion in Radiation Therapy: Rapid, Shallow, Non-invasive Mechanical Ventilation for Internal Thoracic Targets.
No full textPURPOSE
Reducing respiratory motion during the delivery of radiation therapy reduces the volume of healthy tissues irradiated and may decrease radiation-induced toxicity. The purpose of this study was to assess the potential for rapid shallow non-invasive mechanical ventilation to reduce internal anatomy motion for radiation therapy purposes.
METHODS AND MATERIALS
Ten healthy volunteers (mean age, 38 years; range, 22-54 years; 6 female and 4 male) were scanned using magnetic resonance imaging during normal breathing and at 2 ventilator-induced frequencies: 20 and 25 breaths per minute for 3 minutes. Sagittal and coronal cinematic data sets, centered over the right diaphragm, were used to measure internal motions across the lung-diaphragm interface. Repeated scans assessed reproducibility. Physiologic parameters and participant experiences were recorded to quantify tolerability and comfort.
RESULTS
Physiologic observations and experience questionnaires demonstrated that rapid shallow non-invasive ventilation technique was tolerable and comfortable. Motion analysis of the lung-diaphragm interface demonstrated respiratory amplitudes and variations reduced in all subjects using rapid shallow non-invasive ventilation compared with spontaneous breathing: mean amplitude reductions of 56% and 62% for 20 and 25 breaths per minute, respectively. The largest mean amplitude reductions were found in the posterior of the right lung; 40.0 mm during normal breathing to 15.5 mm (P < .005) and 15.2 mm (P < .005) when ventilated with 20 and 25 breaths per minute, respectively. Motion variations also reduced with ventilation; standard deviations in the posterior lung reduced from 14.8 mm during normal respiration to 4.6 mm and 3.5 mm at 20 and 25 breaths per minute, respectively.
CONCLUSIONS
To our knowledge, this study is the first to measure internal anatomic motion using rapid shallow mechanical ventilation to regularize and minimize respiratory motion over a period long enough to image and to deliver radiation therapy. Rapid frequency and shallow, non-invasive ventilation both generate large reductions in internal thoracic and abdominal motions, the clinical application of which could be profound-enabling dose escalation (increasing treatment efficacy) or high-dose ablative radiation therapy
Regular performance feedback may be key to maintain good quality DKA management: results from a five-year study.
No full textObjectives
We postulate that performance feedback is a prerequisite to ensure sustained improvement in diabetic ketoacidosis (DKA) management.
Design
The study was based on 'theory of change' concept that suggests changes of primary drivers determine the main outcome. A set of secondary drivers can be implemented to achieve improvements in these primary drivers and thus the main outcome.
Setting
This study was conducted at a large tertiary care center in the West Midlands, UK. The region has above average prevalence of diabetes and DKA admissions in the country.
Participants
All participants diagnosed with DKA as per national guidelines, except those managed in intensive care unit from April 2014 to March 2018, were included in this study.
Interventions
Monthly feedback of performance was the main intervention. Development of a real-time live DKA audit tool, automatic referral system of DKA to the specialist team, electronic monitoring of blood gas measurements and education and redesigning of local (trust) guidelines were the other interventions in this study.
Main outcome measures
Total DKA duration, appropriateness of fixed rate intravenous insulin infusion, fluid prescription, glucose monitoring, ketone monitoring and referral to specialists.
Results
There was a significant reduction in the duration of DKA postintervention compared with baseline results. However, in the absence of regular feedback, the duration of DKA showed an upward trend nearing baseline values. Similar trends were noted in secondary drivers influencing DKA duration.
Conclusion
Based on these results, we recommend regular audit and feedback is required to sustain improvements in DKA management
Response to the recently published UK National Guideline on the Sexual Health Care of Men who Have Sex with Men.
No full textStage III Non-small Cell Lung Cancer Management in England.
No full textAIMS
We present the first analysis of the management and outcomes of stage III non-small cell lung cancer (NSCLC) conducted in England using National Lung Cancer Audit data.
MATERIALS AND METHODS
Patients diagnosed with stage III NSCLC in 2016 were identified. Linked datasets (including Hospital Episode Statistics, the National Radiotherapy Dataset, the Systemic Anti-Cancer Dataset, pathology reports and death certificate data) were used to categorise the treatment received. Kaplan-Meier survival curves were obtained, with survival defined from the date of diagnosis to the date of death.
RESULTS
In total, 6276 cases of stage III NSCLC were analysed: 3827 stage IIIA and 2449 stage IIIB; 1047 (17%) patients were treated with radical radiotherapy with 676 (11%) of these also receiving chemotherapy. Twenty per cent of patients with stage IIIA disease underwent surgery, with half of these also receiving chemotherapy, predominantly delivered in the adjuvant setting. Of note, 2148 (34%) patients received palliative-intent treatment and 2265 (36%) received no active anti-cancer treatment. The 1-year survival was 32.9% (37.4% for stage IIIA), with the highest survival seen for those patients receiving chemotherapy and surgery.
CONCLUSIONS
We highlight important gaps in the optimal care of patients with stage III NSCLC in England. Multimodality treatment with either surgery or radical radiotherapy combined with chemotherapy was delivered to less than one-fifth of patients, even though these regimens are considered optimal. Timely access to specialist resources and staff, the practice of effective shared decision making and challenging preconceptions have the potential to optimise management
CHEST COMPRESSION COMPONENTS (RATE, DEPTH, CHEST WALL RECOIL AND LEANING): A SCOPING REVIEW.
No full textAIM
To understand whether the science to date has focused on single or multiple chest compression components and identify the evidence related to chest compression components to determine the need for a full systematic review.
METHODS
This review was undertaken by members of the International Liaison Committee on Resuscitation and guided by a specific methodological framework and the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR). Studies were eligible for inclusion if they were peer-reviewed human studies that examined the effect of different chest compression depths or rates, or chest wall or leaning, on physiological or clinical outcomes. The databases searched were MEDLINE complete, Embase, and Cochrane.
RESULTS
Twenty-two clinical studies were included in this review: five observational studies involving 879 patients examined both chest compression rate and depth; eight studies involving 14,285 patients examined chest compression rate only; seven studies involving 12,010 patients examined chest compression depth only, and two studies involving 1,848 patients examined chest wall recoil. No studies were identified that examined chest wall leaning. Three studies reported an inverse relationship between chest compression rate and depth.
CONCLUSION
This scoping review did not identify sufficient new evidence that would justify conducting new systematic reviews or reconsideration of current resuscitation guidelines. This scoping review does highlight significant gaps in the research evidence related to chest compression components, namely a lack of high-level evidence, paucity of studies of in-hospital cardiac arrest, and failure to account for the possibility of interactions between chest compression components
Editorial: gut microbial profile associated with primary sclerosing cholangitis-what is new and how do we progress from here?
No full textDo Learning Disabilities Affect Testicular Cancer Survival: A National Cohort Study Between 2001 and 2015.
No full textBACKGROUND
Some 1.5 million people in the UK have a learning disability (LD). This vulnerable group derives less benefit from population-based education programs. They are prone to underenrolment in screening programs and may lack the ability to perform self-examination.
OBJECTIVE
To identify patients with LD in England and assess their testicular cancer (TC) survival in comparison to the general population.
DESIGN, SETTING, AND PARTICIPANTS
Patient records were identified from the Hospital Episode Statistics database. All patients resident in England with a diagnosis of mental debility, "developmental disorder of scholastic skills", or attending under the specialty of LD between April 1, 2001 and June 30, 2015 were included.
OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS
We measured survival outcomes according to the Kaplan-Meier method and used log-rank tests to assess survival difference between demographic groups.
RESULTS AND LIMITATIONS
Of 158138 male patients with LD, 331 had TC and 32 died of cancer. LD patients had a poorer prognosis, with 10-yr TC-specific survival of 88.4% (95% confidence interval [CI] 84.5-92.4%) in the LD group versus 96.8% (95% CI 96.6-97.1%) in the non-LD group. LD patients also had lower all-cause survival rates. The 10-yr survival rate was 77.6% (95% CI 72.2-83.3%) for LD patients versus 89.9% (95% CI 89.4-90.3%) for non-LD patients, while the corresponding 5-yr rates were 84% (95% CI 79.9-88.4%) versus 92.2% (95% CI 91.8-92.5%).
CONCLUSIONS
Education regarding self-examination for TC must be provided in a format suitable for those with LD. Carers for male patients with LD should be informed about testicular examination and sinister signs.
PATIENT SUMMARY
Testicular cancer patients who also have a learning disability (LD) have a one in nine chance of dying, compared to a one in 36 chance for testicular cancer patients without LD. This is because patients with LD are less likely to detect the disease at an earlier stage
