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An Analysis of the Risk Factors for the Development of Parastomal Hernia: A Single Institutional Experience.
No full textOBJECTIVES
To study the frequency of risk factors affecting the development of parastomal hernias in patients undergoing stoma formation.
STUDY DESIGN
A retrospective descriptive cross-sectional study. Duration of Study: This study was conducted at the Department of General Surgery between January 2017 to December 2020.
METHODOLOGY
A total of 163 patients aged between 20 and 100 years and who required a stoma formation were included in the study. The patients with incomplete data and those lacking post-operative imaging were excluded. According to this selection criteria, 80 patients were excluded. The data was collected for all patients from the hospital database. This included patient's demographic information, co-morbidities, pre-surgery patient characteristics, an indication of stoma formation, the location of stoma exit, type of surgery, associated comorbidities, subcutaneous fat thickness, and type of stoma formed. Data were analyzed using IBM Corp. Released 2019. IBM SPSS Statistics for Windows, Version 26.0. Armonk, NY: IBM Corp.
RESULTS
The mean age was 68.46 ± 16.50 years, with males in the majority: 48 (57.8%). Most of the patients, 53 (63.8%), had malignant disease. Post-stoma formation, a total of 38 (45.9%) patients developed parastomal hernias, mostly involving the sigmoid colon (n=62, 74.7%). However, there was a statistically significant relationship between paroxysmal sympathetic hyperactivity (PSH) incidence with non-trans-rectus stomas (trans-oblique n=07, junctional n=28) (OR 3.04, CI 1.23-7.5, p=0.014). Furthermore, malignancy was also not an independent predictor of PSH (OR 0.408, CI 0.15-1.2, p=0.056). All other risk factors included in this study were nonsignificant.
CONCLUSION
Our study shows that the incidence of parastomal hernias is rising with a high rate demonstrated in our patients. There was no statistically significant association between patient-related preoperative and operative factors with increased risk of parastomal hernias in our population except for a non-trans-rectus stoma, which was identified as an independent risk factor for parastomal hernias. Based on our findings, we would recommend a trans-rectus stoma over all other stoma sites. However, a much larger study is needed to validate this finding further
Teleophthalmology-enabled and artificial intelligence-ready referral pathway for community optometry referrals of retinal disease (HERMES): a Cluster Randomised Superiority Trial with a linked Diagnostic Accuracy Study-HERMES study report 1-study protocol.
No full textINTRODUCTION
Recent years have witnessed an upsurge of demand in eye care services in the UK. With a large proportion of patients referred to Hospital Eye Services (HES) for diagnostics and disease management, the referral process results in unnecessary referrals from erroneous diagnoses and delays in access to appropriate treatment. A potential solution is a teleophthalmology digital referral pathway linking community optometry and HES.
METHODS AND ANALYSIS
The HERMES study (Teleophthalmology-enabled and artificial intelligence-ready referral pathway for community optometry referrals of retinal disease: a cluster randomised superiority trial with a linked diagnostic accuracy study) is a cluster randomised clinical trial for evaluating the effectiveness of a teleophthalmology referral pathway between community optometry and HES for retinal diseases. Nested within HERMES is a diagnostic accuracy study, which assesses the accuracy of an artificial intelligence (AI) decision support system (DSS) for automated diagnosis and referral recommendation. A postimplementation, observational substudy, a within-trial economic evaluation and discrete choice experiment will assess the feasibility of implementation of both digital technologies within a real-life setting. Patients with a suspicion of retinal disease, undergoing eye examination and optical coherence tomography (OCT) scans, will be recruited across 24 optometry practices in the UK. Optometry practices will be randomised to standard care or teleophthalmology. The primary outcome is the proportion of false-positive referrals (unnecessary HES visits) in the current referral pathway compared with the teleophthalmology referral pathway. OCT scans will be interpreted by the AI DSS, which provides a diagnosis and referral decision and the primary outcome for the AI diagnostic study is diagnostic accuracy of the referral decision made by the Moorfields-DeepMind AI system. Secondary outcomes relate to inappropriate referral rate, cost-effectiveness analyses and human-computer interaction (HCI) analyses.
ETHICS AND DISSEMINATION
Ethical approval was obtained from the London-Bromley Research Ethics Committee (REC 20/LO/1299). Findings will be reported through academic journals in ophthalmology, health services research and HCI.
TRIAL REGISTRATION NUMBER
ISRCTN18106677 (protocol V.1.1)
Adenoviral Subacute Focal Meningoencephalitis Complicating Polatuzumab, Bendamustine and Rituximab Chemo-Immunotherapy for Aggressive B-Cell Lymphoma.
No full textEffects of Transplantation-Related Immunosuppression on Co-Existent Neuroendocrine Tumours.
No full textBACKGROUND
Here we detail our experience of managing patients found to have a neuroendocrine neoplasm (NEN) whilst on immunosuppression for a transplanted organ.
AIM
We aimed to quantify the behaviour of NENs under solid-organ transplant-related immunosuppression.
DESIGN
This was an observational, retrospective case series.
METHODS
10 patients were identified from a prospectively kept database. 3 were excluded.
RESULTS
Four patients received a liver, two a kidney, and one a heart transplant. All but one received calcineurin-based immunosuppression.NENs were found in five patients post-transplant: one had surgery for transverse colonic neuroendocrine carcinoma NEC (pT4N1M0, Ki67 60%), was cancer-free after four years; one had cold biopsy of duodenal NEN (pT1N0M0, Ki67 2%), cancer-free at four months; one 7 mm pancreatic NEN (pT1N0M0), untreated and stable for seven years;; one small bowel NEN with mesenteric metastasis (pTxNxM1), alive four years after diagnosis; and one untreated small-bowel NEN with mesenteric metastasis, stable at 1 year after liver transplantation.Two NENs were discovered pre-transplant, one pancreatic NEN (pT1N0M0, Ki67 5%), remains untreated and stable at three years. One gastric NEN (type 3, pT1bN0M0, Ki67 2%) remains stable without treatment for two years.
CONCLUSIONS
NENs demonstrate indolent behaviour in the presence of transplant-related immunosuppression
Robotic and laparoscopic right anterior sectionectomy and central hepatectomy: multicentre propensity score-matched analysis.
No full text
Consensus-based recommendations for optical coherence tomography angiography reporting in uveitis.
No full textBACKGROUND/AIMS
To establish a consensus in the nomenclature for reporting optical coherence tomography angiography (OCTA findings in uveitis.
METHODS
The modified Delphi process consisted of two rounds of electronic questionnaires, followed by a face-to-face meeting conducted virtually. Twenty-one items were included for discussion. The three main areas of discussion were: wide field OCTA (WF-OCTA), nomenclature of OCTA findings and OCTA signal attenuation assessment and measurement. Seventeen specialists in uveitis and retinal imaging were selected by the executive committee to constitute the OCTA nomenclature in Uveitis Delphi Study Group. The study endpoint was defined by the degree of consensus for each question: 'strong consensus' was defined as >90% agreement, 'consensus' as 85%-90% and 'near consensus' as >80% but <85%.
RESULTS
There was a strong consensus to apply the term 'wide field' to OCTA images measuring over 70° of field of view, to use the terms 'flow void' and 'non-detectable flow signal' to describe abnormal OCTA flow signal secondary to vessels displacement and slow flow respectively, to use the terms 'loose' and 'dense' to describe the appearance of inflammatory choroidal neovascularisation, and to use the percentage of flow signal decrease to measure OCTA ischaemia with a threshold greater than or equal to 30% as a 'large area'.
CONCLUSIONS
This study sets up consensus recommendations for reporting OCTA findings in uveitis by an expert panel, which may prove suitable for use in routine clinical care and clinical trials
Prediagnosis pathway benchmarking audit in patients with Duchenne muscular dystrophy.
No full textOBJECTIVE
To describe age and time at key stages in the Duchenne muscular dystrophy (DMD) prediagnosis pathway at selected centres to identify opportunities for service improvement.
DESIGN
A multicentre retrospective national audit.
SETTING
Nine tertiary neuromuscular centres across the UK and Ireland. A prior single-centre UK audit of 20 patients with no DMD family history provided benchmark criteria.
PATIENTS
Patients with a definitive diagnosis of DMD documented within 3 years prior to December 2018 (n=122).
MAIN OUTCOME MEASURES
Mean age (months) at four key stages in the DMD diagnostic pathway and mean time (months) of presentational and diagnostic delay, and time from first reported symptoms to definitive diagnosis. Type of symptoms was also recorded.
RESULTS
Overall, mean age at definitive diagnosis, age at first engagement with healthcare professional (HCP) and age at first reported symptoms were 53.9±29.7, 49.9±28.9 and 36.4±26.8 months, respectively. The presentational delay and time to diagnosis were 21.1 (±21.1) and 4.6 (±7.9) months, respectively. The mean time from first reported symptoms to definitive diagnosis was 24.2±20.9. The percentages of patients with motor and/or non-motor symptoms recorded were 88% (n=106/121) and 47% (n=57/121), respectively.
CONCLUSIONS
Majority of data mirrored the benchmark audit. However, while the time to diagnosis was shorter, a presentational delay was observed. Failure to recognise early symptoms of DMD could be a contributing factor and represents an unmet need in the diagnosis pathway. Methods determining how to improve this need to be explored
Outcomes of normothermic machine perfusion of liver grafts in repeat liver transplantation (NAPLES initiative).
No full textBACKGROUND
Retransplantation candidates are disadvantaged owing to lack of good-quality liver grafts. Strategies that can facilitate transplantation of suboptimal grafts into retransplant candidates require investigation. The aim was to determine whether late liver retransplantation can be performed safely with suboptimal grafts, following normothermic machine perfusion.
METHODS
A prospectively enrolled group of patients who required liver retransplantation received a suboptimal graft preserved via normothermic machine perfusion. This group was compared with both historical and contemporaneous cohorts of patient who received grafts preserved by cold storage. The primary outcome was 6-month graft and patient survival.
RESULTS
The normothermic machine perfusion group comprised 26 patients. The historical (cold storage 1) and contemporaneous (cold storage 2) groups comprised 31 and 25 patients respectively. The 6-month graft survival rate did not differ between groups (cold storage 1, 27 of 31, cold storage 2, 22 of 25; normothermic machine perfusion, 22 of 26; P = 0.934). This was despite the normothermic machine perfusion group having significantly more steatotic grafts (8 of 31, 7 of 25, and 14 of 26 respectively; P = 0.006) and grafts previously declined by at least one other transplant centre (5 of 31, 9 of 25, and 21 of 26; P < 0.001).
CONCLUSION
In liver retransplantation, normothermic machine perfusion can safely expand graft options without compromising short-term outcomes