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Sleep and liver disease: a bidirectional relationship.
No full textSleep is a complex, highly regulated process essential for human health and wellbeing. Increasingly, sleep-wake disturbance has been implicated in the pathogenesis of chronic liver disease, particularly the development and progression of non-alcoholic fatty liver disease and alcohol-related liver disease. Patients with cirrhosis also have a high burden of sleep abnormalities with substantial implications for their quality of life and physical health. This Review summarises the epidemiology and pathophysiology of sleep-wake disturbance in liver disease and discusses the multiple converging pathways leading to abnormal sleeping patterns in patients with cirrhosis. This includes contributions from altered melatonin metabolism, neuromuscular complications, and aberrant thermoregulation. In turn, a vicious cycle is established whereby disrupted sleep can further contribute to liver disease progression. We also begin to unravel the complex, interlinking relationship between sleep-wake disturbance and hepatic encephalopathy, discussing both overlapping and distinct mechanisms and clinical features. Finally, we summarise the current and future therapeutic approaches aiming to improve sleep quality in patients with cirrhosis
Intra-operative use of biological products - are we aware of their derivatives?
No full textINTRODUCTION
Global medical advances within healthcare have subsequently led to the widespread introduction of biological products such as grafts, haemostats, and sealants. Although these products have been used for many decades, this subject is frequently not discussed during the consent process and remains an area of contention.
METHODS
A nationwide confidential online survey was distributed to UK-based junior registrars (ST3-5), senior registrars (ST6-8), post-CCT fellows, specialist associates/staff grade doctors and consultants working in general/vascular surgery, neurosurgery, otolaryngology, oral & maxillofacial surgery and plastic surgery.
RESULTS
Data was collected from a total of 308 survey respondents. Biological derivatives were correctly identified in surgical products by only 25% of survey respondents, only 19% stated that they regularly consent for use of these products. Our results demonstrate that most participants in this study do not routinely consent (81%) to the intra-operative use of biological materials. An overwhelming 74% of participants agreed that further education on the intra-operative use of biological materials would be valuable.
DISCUSSION
This study highlights deficiencies in knowledge that results in potential compromise of the consenting process for surgical procedures. A solution to this would be for clinicians to increase their awareness via educational platforms and to incorporate an additional statement on the consent form which addresses the potential intraoperative use of biological products and what their derivatives may be.
CONCLUSION
Modernising the current consent process to reflect the development and use of surgical biological products will help to ensure improved patient satisfaction, fewer future legal implications as well as a better surgeon-patient relationship
A Novel Capacitive Cochlear Implant Electrode Array Sensing System to Discriminate Failure Patterns.
No full textOBJECTIVES
The research is to propose a sensing system to ensure the electrode array being correctly placed inside the cochlea. Instead of applying extra sensors to the array, the capacitive information from multiple points of the array is gathered and analyzed to determine the state and behavior of the electrode array.
METHODS
The sensing system measures electrode bipolar capacitances between multiple pairs of electrodes during the insertion. The principal component analysis (PCA) method is then applied to analysis the recorded data to discriminate insertion patterns.
RESULTS
In total, 384 capacitance profiles from electrode pair (1, 2), and electrode pair (15, 16) were analyzed and compared. In an account of both the electrode pairs, the threshold distance was examined to be d = 1.99 at the average comparison type. The experiment results showed the success rate is over 80% to identify buckling during the insertion on a 2D cochlear model.
CONCLUSION
This early-stage investigation shows great potential compared with the current practice, which does not provide any feedback to surgeons. The system demonstrates the feasibility of a sensing method for auto-reoccupation electrodes behavior, and it will help surgeons to avoid misplacement of the electrode array inside the cochlea
Lack of Evidence Does Not Equal Lack of Benefit: Neoadjuvant Chemotherapy and Trimodality Therapy in Selected Patients with Muscle-Invasive Bladder Cancer : In response to: Dirk Böhmer and Arne Grün. Lacking Evidence to Recommend Neoadjuvant Chemotherapy and Definitive Radiotherapy in Muscle-Invasive Bladder Cancer.
No full text
The epidemiology and outcomes of combat ocular trauma among local nationals managed at a deployed military hospital in Afghanistan.
No full textBACKGROUND/OBJECTIVES
There is limited published data on combat ocular trauma (COT) among local nationals managed at deployed United States (US) and United Kingdom (UK) military hospitals in recent conflicts. We report the epidemiology and outcomes of COT from a deployed military hospital in Afghanistan.
SUBJECTS/METHODS
In this retrospective case series, consecutive injuries requiring ophthalmic surgery at a military hospital in Afghanistan where the sole US and UK ophthalmologist(s) were deployed between January 2017 and September 2019 were reviewed. The main outcomes were mean post-operative visual acuity (VA) in open and closed globe injury and the incidence of retinal detachment after open globe repair.
RESULTS
There were 102 eyes of 84 patients who had ocular injuries and underwent ophthalmic surgery at the military hospital. Most patients were male (81 [96%]) and were local nationals (71 [85%]). Blast exposure (82 [80%]) was the most common mechanism of injury. Mean post-operative VA was 1.24 ± 2.29 logMAR (20/348 Snellen equivalent) in open globe injury and 1.59 ± 1.17 logMAR (20/778 Snellen equivalent) in closed globe injury. After open globe repair, retinal detachment developed in 8 of 18 (44%) eyes.
CONCLUSIONS
COT injuries often resulted in poor post-operative VA and retinal detachment after open globe repair was common. The high incidence and severity of COT sustained by local civilians and combatants in this study may support programs to increase the availability and wear of combat eye protection among local nationals partnered with US and coalition troops
Hypofractionated radiotherapy in locally advanced bladder cancer: an individual patient data meta-analysis of the BC2001 and BCON trials.
No full textBACKGROUND
Two radiotherapy fractionation schedules are used to treat locally advanced bladder cancer: 64 Gy in 32 fractions over 6·5 weeks and a hypofractionated schedule of 55 Gy in 20 fractions over 4 weeks. Long-term outcomes of these schedules in several cohort studies and case series suggest that response, survival, and toxicity are similar, but no direct comparison has been published. The present study aimed to assess the non-inferiority of 55 Gy in 20 fractions to 64 Gy in 32 fractions in terms of invasive locoregional control and late toxicity in patients with locally advanced bladder cancer.
METHODS
We did a meta-analysis of individual patient data from patients (age ≥18 years) with locally advanced bladder cancer (T1G3 [high-grade non-muscle invasive] or T2-T4, N0M0) enrolled in two multicentre, randomised, controlled, phase 3 trials done in the UK: BC2001 (NCT00024349; assessing addition of chemotherapy to radiotherapy) and BCON (NCT00033436; assessing hypoxia-modifying therapy combined with radiotherapy). In each trial, the fractionation schedule was chosen according to local standard practice. Co-primary endpoints were invasive locoregional control (non-inferiority margin hazard ratio [HR]=1·25); and late bladder or rectum toxicity, assessed with the Late Effects Normal Tissue Task Force-Subjective, Objective, Management, Analytic tool (non-inferiority margin for absolute risk difference [RD]=10%). If non-inferiority was met for invasive locoregional control, superiority could be considered if the 95% CI for the treatment effect excluded the null effect (HR=1). One-stage individual patient data meta-analysis models for the time-to-event and binary outcomes were used, accounting for trial differences, within-centre correlation, randomised treatment received, baseline variable imbalances, and potential confounding from relevant prognostic factors.
FINDINGS
782 patients with known fractionation schedules (456 from the BC2001 trial and 326 from the BCON trial; 376 (48%) received 64 Gy in 32 fractions and 406 (52%) received 55 Gy in 20 fractions) were included in our meta-analysis. Median follow-up was 120 months (IQR 99-159). Patients who received 55 Gy in 20 fractions had a lower risk of invasive locoregional recurrence than those who received 64 Gy in 32 fractions (adjusted HR 0·71 [95% CI 0·52-0·96]). Both schedules had similar toxicity profiles (adjusted RD -3·37% [95% CI -11·85 to 5·10]).
INTERPRETATION
A hypofractionated schedule of 55 Gy in 20 fractions is non-inferior to 64 Gy in 32 fractions with regard to both invasive locoregional control and toxicity, and is superior with regard to invasive locoregional control. 55 Gy in 20 fractions should be adopted as a standard of care for bladder preservation in patients with locally advanced bladder cancer.
FUNDING
Cancer Research UK
Resuscitation highlights in 2020.
No full textBACKGROUND
This review is the latest in a series of regular annual reviews undertaken by the editors and aims to highlight some of the key papers published in Resuscitation during 2020. The number of papers submitted to the Journal in 2020 increased by 25% on the previous year.MethodsHand-searching by the editors of all papers published in Resuscitation during 2020. Papers were selected based on then general interest and novelty and were categorised into general themes.ResultsA total of 103 papers were selected for brief mention in this review.ConclusionsResuscitation science continues to evolve rapidly and incorporate all links in the chain of survival
Intention to treat outcomes among patients with pancreatic cancer treated using International Study Group on Pancreatic Surgery recommended pathways for resectable and borderline resectable disease.
No full textBACKGROUND
The International Study Group on Pancreatic Surgery recommends upfront surgery for resectable pancreatic cancer or borderline resectable-venous (BR-V) disease and neoadjuvant therapy (NAT) among those with arterial involvement (BR-A or locally advanced, LA). Though neoadjuvant therapy (NAT) is a promising strategy, outcomes are rarely reported on intention-to-treat (ITT) basis. This study presents ITT outcomes where pathways to surgery were in line with International Study Group on Pancreatic Surgery guidelines.
METHODS
Patients recommended for potentially curative treatment with PDAC between 2012 and 2017 (n = 345) were classified as resectable, BR-A/BR-V or LA, according to NCCN criteria. The primary outcome was overall survival. Secondary outcomes were resection rates, positive margins and toxicity among patients receiving NAT.
RESULTS
At surgery, the resection rates were 78% (172/221), 65% (35/54) and 54% (21/39) for those with resectable, BR-V and BR-A/LA disease, respectively (P < 0.0001). The median survival of those resected in the BR-A/LA cohort was 31 months. However, on an ITT basis, there was no significant difference in survival between resectable, BR-V and BR-A/LA disease (median: 19 versus 15 versus 19 months; P = 0.585). On review, some 31 (44%) patients of the BR-A/LA cohort either did not receive or did not complete NAT.
CONCLUSION
To realize benefits of NAT, more patients need to complete NAT and to undergo resection. Upfront resection for BR-V disease is associated with equivalent outcomes to upfront surgery for resectable disease or NAT for BR-A/LA disease. Strategies to increase the proportion of patients who complete NAT and undergo resection are needed
The Ever-Present Costs of Cosmetic Surgery Tourism: A 5-Year Observational Study.
No full textBACKGROUND
Cosmetic surgery tourism is an ever-growing industry. Despite its associated risks, an increasing number of patients are presenting to NHS services with resulting complications. This study aims to evaluate the current presentation patterns for complications in cosmetic surgery tourism, and the financial burden to the NHS reported by a single UK level one trauma centre in Birmingham, UK.
METHODS
From 2015 to 2020, all patients presenting to the department of plastic surgery with complications of cosmetic surgery performed outside of the UK were included. Data were collected for patients' characteristics including demographics, performed procedures, complications and treatment. A cost analysis was performed for each patient using published "National Schedule of NHS Costs."
RESULTS
A total of 26 patients presented to our hospital within the study period. All patients were female, with the mean age being 35.1 years (range 22-55years). A total of 32 cosmetic procedures were undertaken, with the majority performed in Turkey (n = 14). Abdominoplasty was the most common procedure, followed by gluteal enhancement surgery. The total financial cost to the NHS from all cosmetic surgery-related complications was £152,946, with an average cost per patient of £5,882.54 (range £362-£26,585).
CONCLUSION
Patients seek out medical tourism for multiple reasons including cost savings, shorter waiting times and surgical expertise. The costs displayed should predominantly be viewed as a reflection of the detrimental effect these complications can have on patients' lives. Global governing bodies should focus efforts on educating patients and raising awareness on this ever-prevalent issue.
LEVEL OF EVIDENCE IV
This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266