Author(s) Hosny K.; Clark J.; Srirangam S.J.
Source Translational Andrology and Urology; Sep 2019; vol. 8
DOI 10.21037/tau.2019.07.08
Flexible ureteroscopy is an important therapeutic and diagnostic procedure and has seen rapid rise in its utilisation in recent years. There have been numerous developments in flexible ureteroscope (fURS) technology but scope fragility, and the associated high maintenance costs, remains a concern. A comprehensive Medline search for related publications from the last 20 years was undertaken to identify common causes of fURS damage and ascertain practices to minimise this. Flexible ureteroscopy can be due to intraoperative causes (loss of the deflection mechanism, damage to the working channel due and fibreoptic bundle injury) and non-operative damage which occur during cleaning, sterilisation and handling of the fURS. The review summarises the available literature to help highlight common mechanisms of scope damage, and outlines evidence-based measures to reduce the risk of damage and maximise durability. Scope fragility remains a problem with significant associated cost implications. In a culture of rising fURS use and reducing re-imbursement for endourologists, prolonging the longevity of the fURS is imperative for maintaining profitability. There are simple and inexpensive practices which can be immediately adopted to maximise fURS use and reduce the need for repairs.Copyright © Translational Andrology and Urology. All rights reserved.

• Available in full text at Translational andrology and urology from Europe PubMed Central - Open Access

Author(s) Ramtoola S.; Nyeland M.E.; Ploug U.J.; Kragh N.; Zimmermann E. et al.
Source Primary Care Diabetes; 2019
Aims: This retrospective, longitudinal study characterised 2430 adults (mean age 40.8 +/- 16.1 years) with newly diagnosed type 1 diabetes (T1D) over the first 5 years of insulin treatment.

Method(s): Data from 1 year pre- and up to 5 years post-insulin initiation were extracted from the UK Clinical Practice Research Datalink (1990-2013). Baseline HbA1c, BMI and Charlson comorbidity index (CCI) score were compared with data at 1, 2, 3 and 5 years. Result(s): Mean HbA1c decreased significantly from baseline 95 +/- 32.8 mmol/mol (10.8 +/- 3.0%) to 61 +/- 21.9 mmol/mol (7.7 +/- 2.0%) at 1 year, remaining significantly lower at 2, 3 and 5 years (p < 0.0001). One year after initiating insulin, only 6.3% of patients had HbA1c<48 mmol/mol (<6.5%). There was no further improvement in HbA1c after 1 year. Mean BMI increased significantly from baseline 25.3 +/- 5.5 kg/m2 to 27.2 +/- 5.8 kg/m2 at 1 year; p < 0.0001), remaining significantly higher thereafter, with over two-thirds having overweight/obesity by year 5. Mean CCI score increased significantly (1.32, baseline; 1.46, year 1; 1.75, year 5). CCI patterns were similar within BMI and HbA1c strata.

​Conclusion(s): More intensive support to reach and maintain glycaemic targets soon post-diagnosis, while avoiding weight gain, and prevention and optimal management of comorbidities are warranted.Copyright © 2019 The Authors

• Available in full text at Primary care diabetes from Unpaywall

Author(s) Doherty D.T.; Coe P.O.; Rimmer L.; Subar D.A.; Lapsia S. et al.
Source Surgical Oncology; Sep 2019; vol. 30 ; p. 147-158
DOI 10.1016/j.suronc.2019.07.007
The prevalence of elevated intra-hepatic fat (IHF) is increasing in the Western world, either alone as hepatic steatosis (HS) or in conjunction with inflammation (steatohepatitis). These changes to the hepatic parenchyma are an independent risk factor for post-operative morbidity following liver resection for colorectal liver metastases (CRLM). As elevated IHF and colorectal malignancy share similar risk factors for development it is unsurprisingly frequent in this cohort. In patients undergoing resection IHF may be elevated due to excess adiposity or its elevation may be induced by neoadjuvant chemotherapy, termed chemotherapy associated steatosis (CAS). Additionally, chemotherapy is implicated in the development of inflammation termed chemotherapy associated steatohepatitis (CASH). Following cessation of chemotherapy, patients awaiting resection have a 4-6 week washout period prior to resection that is a window for prehabilitation prior to surgery. In patients with NAFLD dietary and pharmacological interventions can reduce IHF within this timeframe but this approach to modifying IHF is untested in this population. In this review, the aetiology of CAS and CASH is reviewed with recommendations to identify those at risk. We also focus on the post-chemotherapy washout period, reviewing dietary interventions applied to the metabolic population and suggest this window may be used as an opportunity to optimise IHF with such a regime as part of a pre-operative prehabilitation programme to produce improved patient outcomes.Copyright © 2019 Elsevier Ltd

Author(s) Mawer D.; Byrne F.; Drake S.; Brown C.; Prescott A. et al.
Source Journal of Hospital Infection; Oct 2019; vol. 103 (no. 2); p. 200-209
DOI 10.1016/j.jhin.2019.05.001
Background: The National Health Service in England advises hospitals collect data on hospital-onset diarrhoea (HOD). Contemporaneous data on HOD are lacking. Aim(s): To investigate prevalence, aetiology and management of HOD on medical, surgical and elderly-care wards.

Method(s): A cross-sectional study in a volunteer sample of UK hospitals, which collected data on one winter and one summer day in 2016. Patients admitted >=72 h were screened for HOD (definition: >=2 episodes of Bristol Stool Type 5-7 the day before the study, with diarrhoea onset >48 h after admission). Data on HOD aetiology and management were collected prospectively.

Finding(s): Data were collected on 141 wards in 32 hospitals (16 acute, 16 teaching). Point-prevalence of HOD was 4.5% (230/5142 patients; 95% confidence interval (CI) 3.9-5.0%). Teaching hospital HOD prevalence (5.9%, 95% CI 5.1-6.9%) was twice that of acute hospitals (2.8%, 95% CI 2.1-3.5%; odds ratio 2.2, 95% CI 1.7-3.0). At least one potential cause was identified in 222/230 patients (97%): 107 (47%) had a relevant underlying condition, 125 (54%) were taking antimicrobials, and 195 (85%) other medication known to cause diarrhoea. Nine of 75 tested patients were Clostridium difficile toxin positive (4%). Eighty (35%) patients had a documented medical assessment of diarrhoea. Documentation of HOD in medical notes correlated with testing for C. difficile (78% of those tested vs 38% not tested, P<0.001). One-hundred and forty-four (63%) patients were not isolated following diarrhoea onset.

​Conclusion(s): HOD is a prevalent symptom affecting thousands of patients across the UK health system each day. Most patients had multiple potential causes of HOD, mainly iatrogenic, but only a third had medical assessment. Most were not tested for C. difficile and were not isolated.Copyright © 2019 The Healthcare Infection Society

Author(s) Stanton A.E.; Evison M.; Roberts M.; Latham J.; Clive A.O. et al.
Source BMJ Open Respiratory Research; Sep 2019; vol. 6 (no. 1)
DOI 10.1136/bmjresp-2018-000390
Introduction: Respiratory trainees in the UK face challenges in meeting current Royal College of Radiologists (RCR) Level 1 training requirements for thoracic ultrasound (TUS) competence, specified as attending 'at least one session per week over a period of no less than 3 months, with approximately five scans per session performed by the trainee (under supervision of an experienced practitioner)'. We aimed to clarify where TUS training opportunities currently exist for respiratory registrars.

Method(s): Data were collected (over a 4-week period) to clarify the number of scans (and therefore volume of training opportunities) within radiology departments and respiratory services in hospitals in the South West, North West deaneries and Oxford.

Result(s): 14 hospitals (including three tertiary pleural centres) provided data. Of 964 scans, 793 (82.3%) were conducted by respiratory teams who performed a mean of 17.7 scans per week, versus 3.1 TUS/week in radiology departments. There was no radiology session in any hospital with >=5 TUS performed, whereas 8/14 (86%) of respiratory departments conducted such sessions. Almost half (6/14) of radiology departments conducted no TUS scans in the period surveyed.

​Conclusions The currently recommended exposure of regularly attending a list or session to undertake five TUS is not achievable in radiology departments. The greatest volume of training opportunities exists within respiratory departments in a variety of scheduled and unscheduled settings. Revision of the competency framework in TUS, and where this is delivered, is required.Copyright © 2019 Author(s) (or their employer(s)).

• Available in full text at BMJ Open Respiratory Research from Europe PubMed Central - Open Access

Author(s) Donovan T.; Crossingham I.; Bradley P.; Milan S.J.; Wang R.
Source Cochrane Database of Systematic Reviews; Sep 2019; vol. 2019 (no. 9)
Publication Date Sep 2019
DOI 10.1002/14651858.CD013432.
This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To assess the efficacy and safety of monoclonal antibody therapies targeting IL-5 signalling (anti-IL-5 or anti-IL-5Ralpha) compared with placebo in the treatment of adults with COPD.Copyright © 2019 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

• Available in full text at Cochrane Database of Systematic Reviews from Cochrane Collaboration (Wiley)

​Author(s) Clarke N.W.; Hoyle A.; Ali A.; Ingleby F.C.; Amos C.L. et al.
Source Annals of oncology : official journal of the European Society for Medical Oncology; Sep 2019
DOI 10.1093/annonc/mdz396
BACKGROUND: STAMPEDE has previously reported that the use of upfront docetaxel improved overall survival (OS) for metastatic hormone naive prostate cancer patients starting long-term androgen deprivation therapy. We report on long-term outcomes stratified by metastatic burden for M1 patients.

METHOD(S): We randomly allocated patients in 2:1 ratio to standard-of-care (SOC; control group) or SOC+docetaxel. Metastatic disease burden was categorised using retrospectively-collected baseline staging scans where available. Analysis used Cox regression models, adjusted for stratification factors, with emphasis on restricted mean survival time where hazards were non-proportional.

RESULT(S): Between 05 October 2005 and 31 March 2013, 1086 M1 patients were randomised to receive SOC (n=724) or SOC+docetaxel (n=362). Metastatic burden was assessable for 830/1086 (76%) patients; 362 (44%) had low and 468 (56%) high metastatic burden. Median follow-up was 78.2months. There were 494 deaths on SOC (41% more than the previous report). There was good evidence of benefit of docetaxel over SOC on OS (HR=0.81, 95% CI 0.69-0.95, P=0.009) with no evidence of heterogeneity of docetaxel effect between metastatic burden sub-groups (interaction P=0.827). Analysis of other outcomes found evidence of benefit for docetaxel over SOC in failure-free survival (HR=0.66, 95% CI 0.57-0.76, P<0.001) and progression-free survival (HR=0.69, 95% CI 0.59-0.81, P<0.001) with no evidence of heterogeneity of docetaxel effect between metastatic burden sub-groups (interaction P>0.5 in each case). There was no evidence that docetaxel resulted in late toxicity compared with SOC: after 1year, G3-5 toxicity was reported for 28% SOC and 27% docetaxel (in patients still on follow-up at 1year without prior progression).

​CONCLUSION(S): The clinically significant benefit in survival for upfront docetaxel persists at longer follow-up, with no evidence that benefit differed by metastatic burden. We advocate that upfront docetaxel is considered for metastatic hormone naive prostate cancer patients regardless of metastatic burden.Copyright © The Author(s) 2019. Published by Oxford University Press on behalf of the European Society for Medical Oncology.

• Available in full text at Annals of oncology : official journal of the European Society for Medical Oncology from Unpaywall

Author(s) Her A.-Y.; Kim Y.H.; Shin E.-S.; Zhou Q.; Saleh A. et al.
Source Clinical Hemorheology and Microcirculation; 2019; vol. 72 (no. 4); p. 353-363
DOI 10.3233/CH-180528
BACKGROUND: Magnetocardiography (MCG) is a non-invasive technique and to characterize the magnetic field, a pseudo-current conversion was used. The role of MCG in detecting left atrial (LA) dysfunction in patients with paroxysmal atrial fibrillation (PAF) is unknown. OBJECTIVE(S): The aim of this study was to evaluate LA function using MCG in patients with PAF and healthy subjects, to identify possible indices to diagnose PAF.

METHOD(S): We enrolled a total of 70 subjects including 26 healthy volunteers (group 1) and 22 marathon runners (group 2) who did not exhibit any cardiac abnormalities, and 22 patients with PAF (group 3) which was documented by electrocardiography (ECG). Spatiotemporal activation graph (STAG) in base-apex and left-right direction was reconstructed. The maximum value of LA pseudo-current under rest and peak exercise were measured between the end of the P wave and beginning of the Q wave.

RESULT(S): LA pseudo-current increase at peak exercise in PAF patients was significantly lower than in healthy volunteers and marathon runners (0.4+/-0.3 pT in group 3 vs. 0.8+/-0.3 pT in group 1 vs. 1.1+/-0.5 pT in group 2, p < 0.001). PAF patients had less pseudo-current increase in STAG at peak exercise than healthy volunteers and marathon runners (46% of 26 PAF patients, 81% of 22 healthy subjects vs. 81% of 22 marathon runners, p = 0.002). Sensitivity, specificity, and the area under the receiver-operator characteristics curve of LA pseudo-current increase at peak exercise for differentiating PAF patients from healthy subjects were 77%, 92%, and 0.896.

​CONCLUSION(S): MCG can provide important non-invasive information for detecting LA dysfunction in PAF patients. Therefore, MCG may help in differentiating PAF patients from healthy subjects.Copyright © 2019-IOS Press and the authors. All rights reserved.