Thoracic endovascular aortic repair for uncomplicated Type B aortic dissection: What is the optimal time window for intervention?
Author(s) Al-Tawil M.; Chikhal R.; Abdelhaliem A. (email@example.com)
Institution(s) (Al-Tawil) Faculty of Medicine, Al-Quds University, Jerusalem, Palestine
(Chikhal) Hull York Medical School, University of York, York, United Kingdom
(Abdelhaliem) Department of Vascular and Endovascular Surgery, Royal Blackburn Teaching Hospital, Blackburn, United Kingdom
Source Journal of Cardiac Surgery; 2021
AbstractBackground: Uncomplicated Type B aortic dissection (un-TBAD) is still managed conservatively with optimal medical therapy (OMT) despite evidence in favour of thoracic endovascular aortic repair (TEVAR) for un-TBAD. OMT aims to regulate heart rate and blood pressure and patients require long-term follow-up to evaluate the extent of dissection, however, many un-TBAD patients are lost to follow-up. Several trials and observational studies evaluated the use of TEVAR in combination with OMT in un-TBAD and proved the safety, effectiveness, and comparability of TEVAR relative to OMT alone. What remains in question is the optimal time window to intervene with TEVAR. This was recently addressed in a fascinating review by Jubouri et al. Aim(s): This commentary aims to discuss the recent review by Jubouri et al. which further proved that TEVAR is safe and effective in un-TABD and investigated the optimal timing of TEVAR in un-TBAD. Material(s) and Method(s): We carried out a literature search using multiple electronic databases including PUBMED and Scopus in order to collate research evidence on intervention timeframe and outcomes of TEVAR in un-TBAD. Result(s): Performing TEVAR during the subacute phase of dissection (15-90 days since symptom onset) seems to be associated with less periprocedural complications compared to the acute phase, however, late outcomes (>30 days post-TEVAR) are comparable between the two groups and are superior to the chronic phase. Discussion(s): The introduction of TEVAR in un-TBAD presents a paradigm shift in the management of un-TBAD and a potential move towards becoming the gold-standard treatment option for un-TBAD. Intervening with TEVAR within the first 90 days since symptom onset (acute and subacute un-TBAD) gives favourable outcomes relative to intervention in the chronic phase of dissection (>90 days since symptom onset), this is due to the dissecting septum becoming less compliant over time. Conclusion(s): TEVAR is a safe and effective treatment modality for un-TBAD with a survival benefit compared to OMT alone. Offering TEVAR during the subacute phase of dissection yields optimal results which are comparable to the acute phase but superior to the chronic phase.Copyright © 2021 Wiley Periodicals LLC
Author(s) Lewis J.A.; Kinross J.M.; Souvatzi M.; Khan S.; Singh B.; Tilney H.S.; Wilson J.M.; Vitone L.J.
Institution(s) (Lewis, Kinross) Department of Surgery and Cancer, Imperial College London, London, United Kingdom
(Lewis, Souvatzi, Kinross) Imperial College Healthcare National Health Service Trust, London, United Kingdom
(Khan, Singh) University Hospitals of Leicester National Health Service Trust, Leicestershire, United Kingdom
(Tilney) Frimley Health National Health Service Foundation Trust, Frimley, United Kingdom
(Wilson) Whittington Health National Health Service Trust, Whittington, United Kingdom
(Vitone) East Lancashire Hospitals National Health Service Trust, Blackburn, United Kingdom
Source Diseases of the colon and rectum; Dec 2021; vol. 64 (no. 12)
Publication Date Dec 2021
AbstractBACKGROUND: This is an analysis of the first 50 in-human uses of a novel digital rigid sigmoidoscope. The technology provides digital image capture, telemedicine capabilities, improved ergonomics, and the ability to biopsy under pneumorectum while maintaining the low cost of conventional rigid sigmoidoscopy. The primary outcome was adverse events, and the secondary outcome was diagnostic view. PRELIMINARY RESULTS: Fifty patients underwent outpatient (n = 25) and surgical rectal assessment (n = 25), with a mean age of 60 years. This included 31 men and 19 women with 12 different clinical use indications. No adverse events were reported, and no defects were reported with the instrumentation. Satisfactory diagnoses were obtained in 48 (96%) of 50 uses, images were captured in 48 (96%) of 50 uses, and biopsies were successfully taken in 13 uses (26%). No adverse events were recorded. Independent reviewers of recorded videos agreed on the quality and diagnostic value of the images with a kappa of 0.225 (95% CI, 0.144-0.305) when assessing whether the target pathology was adequately visualized. IMPACT OF INNOVATION: The improved views afforded by digital rectoscopy facilitated a satisfactory clinical diagnosis in 96% of uses. The device was successfully deployed in the operating room and outpatients irrespective of bowel preparation method, where it has the potential to replace flexible sigmoidoscopy for specific use cases. The technology provides a high-quality image and video that can be securely recorded for documentation and medicolegal purposes with agreement between blinded users despite a lack of standardized training and heterogenous pathology. We perceive significant impact of this technology for the assessment of colorectal anastomoses, the office management of colitis, "watch and wait," and for diagnostic support in rectal cancer diagnosis. The technology has significant potential to facilitate proctoring and training, and it now requires prospective trials to validate its diagnostic accuracy against more costly flexible sigmoidoscopy systems.Copyright © The ASCRS 2021.
Author(s) Jubouri M.; Abdelhaliem A. (firstname.lastname@example.org)
Institution(s) (Jubouri) Hull York Medical School, University of York, York, United Kingdom
(Abdelhaliem) Department of Vascular and Endovascular Surgery, Royal Blackburn Teaching Hospital, Blackburn, United Kingdom
Source Journal of Cardiac Surgery; 2021
AbstractBackground: The introduction of the single-step total arch replacement (TAR) with frozen elephant trunk (FET) has revolutionised the field of aortic surgery. TAR is indicated when the aortic arch is involved in aortic pathologies such as Type A aortic dissection and thoracic aortic aneurysms. Several FET devices are available commercially for global use, and example is the E-Vita Open NEO hybrid prosthesis (HP) developed by CryoLife-JOTEC. Unlike other FET devices available, this HP in particular features a design that puts it at a disadvantage as it does not incorporate gelatine or collagen in its structure, which makes it permeable to blood. Several studies have reported incidence of post-anastomotic blood oozing through the E-Vita Open NEO right after weaning from cardiopulmonary bypass. Aim(s): This commentary aims to discuss the recent study by Tan et al. which investigated E-Vita NEO device oozing as well as the implications of using BioGlue to overcome this serious complications. Method(s): We carried out a literature search on multiple electronic databases including PUBMED and Scopus in order to collate research evidence on E-Vita NEO device oozing, BioGlue health risks, and other commercially available and globally used FET devices such as Thoraflex Hybrid. Result(s): It is proven fact that the E-Vita NEO excessively oozes blood, and while BioGlue is a safe and effective agent when used in small amounts, the amount needed to coat the E-Vita Open NEO and achieve haemostasis exceeds this by a wide margin which poses patients to great potential health risks. The Thoraflex Hybrid Prosthesis developed by Terumo Aortic is a commercially available and globally used FET device with long-standing favourable outcomes. Discussion(s): Tan et al. recently conducted an interesting study which proved that the E-Vita NEO HP does excessively ooze blood and tackled the issue of pre-emptive BioGlue use to tackle this complication as suggested by Ho et al. This leads on to the main question, is the use of BioGlue with E-Vita Open NEO to overcome oozing a long-term sustainable solution or is it merely a band aid?. Conclusion(s): In the face of fierce commercial competition, the choice of design and material of the E-Vita Open NEO HP would benefit from reconsideration.Copyright © 2021 Wiley Periodicals LLC
Author(s) Papamichail M. (email@example.com); M P.; ND H.; Pizanias M.; Heaton N.D.
Institution(s) (Papamichail, M, M, ND) Department of Hepato-Pancreato-Biliary Surgery, Royal Blackburn Hospital, Blackburn, UK BB2 3HH, United Kingdom
(Pizanias, M, M, ND) Department of General Surgery, Whittington Hospital, London, UK N19 5NF, United Kingdom
(Heaton, M, M, ND) Department of Liver Transplant and Hepato-Pancreato-Biliary Surgery, Institute of Liver Studies, Kings Health Partners at King's College Hospital NHS Trust, London, UK SE5 9RS, United Kingdom
Source Hepatobiliary and Pancreatic Diseases International; 2021
Publication Type(s) Review
AbstractBackground: Primary and secondary liver tumors are not always amenable to resection due to location and size. Inadequate future liver remnant (FLR) may prevent patients from having a curative resection or may result in increased postoperative morbidity and mortality from complications related to small-for-size syndrome (SFSS). Data sources: This comprehensive review analyzed the principles, mechanism and risk factors associated with SFSS and presented current available options in the evaluation of FLR when planning liver surgery. In addition, it provided a detailed description of specific modalities that can be used before, during or after surgery, in order to optimize the conditions for a safe resection and minimize the risk of SFSS. Result(s): Several methods which aim to reduce tumor burden, preserve healthy liver parenchyma, induce hypertrophy of FLR or prevent postoperative complications help minimize the risk of SFSS. Conclusion(s): With those techniques the indications of radical treatment for patients with liver tumors have significantly expanded. The successful outcome depends on appropriate patient selection, the individualization and modification of interventions and the right timing of surgery.Copyright © 2021
‘It’s always in the back of my mind’: understanding the psychological impact of recovery following pancreaticoduodenectomy for cancer: a qualitative study
Taylor AK; School of Medicine, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK firstname.lastname@example.org.
Chang D; Department of General Surgery, Royal Blackburn Hospital, East Lancashire Hospitals NHS Trust, Blackburn, UK.
Chew-Graham C; School of Medicine, Keele University, Keele, UK.
Rimmer L; Department of General Surgery, Blackpool Victoria Hospital, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK.
Kausar A; Department of General Surgery, Blackpool Victoria Hospital, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK.
Source: BMJ open 2021 Dec 16; Vol. 11 (12), pp. e050016. Date of E-Publication: 2021 Dec 16.
Publication Type: Journal Article
Objectives: Ten per cent of patients diagnosed with pancreatic cancer undergo pancreaticoduodenectomy. There is limited previous research focusing on psychological well-being; unmet support needs impact negatively on quality of life. This paper reports the psychological impact of a pancreatic cancer diagnosis and subsequent pancreaticoduodenectomy, exploring how patients' lives alter following surgery and how they seek support.
Design: Inductive qualitative study involving in-depth semistructured interviews with 20 participants who had undergone pancreaticoduodenectomy for pancreatic or distal biliary duct cancer. Interviews were audiorecorded, transcribed and anonymised, and thematic analysis used principles of constant comparison.
Setting: Single National Health Service Trust in Northwest England.
Participants: Patients were eligible for inclusion if they had had pancreaticoduodenectomy for head of pancreas cancer, periampullary cancer or distal cholangiocarcinoma between 6 months and 6 years previously, and had completed adjuvant chemotherapy.
Results: Analysis identified the following main themes: diagnosis and decision making around surgery; recovery from surgery and chemotherapy; burden of monitoring and ongoing symptoms; adjusting to 'a new normal'; understanding around prognosis; support-seeking. Participants seized the chance to have surgery, often without seeming to absorb the risks or their prognosis. They perceived that they were unable to control their life trajectory and, although they valued close monitoring, experienced anxiety around their appointments. Participants expressed uncertainty about whether they would be able to return to their former activities. There were tensions in their comments about support-seeking, but most felt that emotional support should be offered proactively.
Conclusions: Patients should be made aware of potential psychological sequelae, and that treatment completion may trigger the need for more support. Clinical nurse specialists (CNSs) were identified as key members of the team in proactively offering support; further training for CNSs should be encouraged. Understanding patients' experience of living with cancer and the impact of treatment is crucial in enabling the development of improved support interventions.
Available at BMJ Open
Ultrasound to identify systemic lupus erythematosus patients with musculoskeletal symptoms who respond best to therapy: the US Evaluation for Musculoskeletal Lupus longitudinal multicentre study.
Author(s) Mahmoud; Zayat, Ahmed S; Yusof, Md Yuzaiful Md; Dutton, Katherine; Teh, Lee Suan; Yee, Chee-Seng; D'Cruz, David; Ng, Nora; Isenberg, David; Ciurtin, Coziana; Conaghan, Philip G; Emery, Paul; Edwards, Christopher J; Hensor, Elizabeth M A; Vital, Edward M
Source Rheumatology; Nov 2021; vol. 60 (no. 11); p. 5194-5204
AbstractObjectives To determine whether SLE patients with inflammatory joint symptoms and US synovitis/tenosyovitis achieve better clinical responses to glucocorticoids compared with patients with normal scans. Secondary objectives included identification of clinical features predicting US synovitis/tenosynovitis. Methods In a longitudinal multicentre study, SLE patients with physician-diagnosed inflammatory joint pain received intramuscular methylprednisolone 120 mg once. Clinical assessments, patient-reported outcomes and bilateral hand/wrist USs were collected at 0, 2 and 6 weeks. The primary outcome (determined via internal pilot) was the early morning stiffness visual analogue scale (EMS-VAS) at 2 weeks, adjusted for baseline, comparing patients with positive (greyscale ≥2 and/or power Doppler ≥1) and negative US. Post hoc analyses excluded FM. Results Of 133 patients, 78 had a positive US. Only 53 (68%) of these had one or more swollen joint. Of 66 patients with one or more swollen joint, 20% had a negative US. A positive US was associated with joint swelling, symmetrical small joint distribution and serology. The primary endpoint was not met: in the full analysis set (N = 133) there was no difference in baseline-adjusted EMS-VAS at week 2 [−7.7 mm (95% CI −19.0, 3.5); P = 0.178]. After excluding 32 patients with FM, response was significantly better in patients with a positive US at baseline [baseline-adjusted EMS-VAS at 2 weeks −12.1 mm (95% CI −22.2, −0.1); P = 0.049]. This difference was greater when adjusted for treatment [−12.8 mm (95% CI −22, −3); P = 0.007]. BILAG and SLEDAI responses were higher in US-positive patients. Conclusion In SLE patients without FM, those with a positive US had a better clinical response to therapy. Imaging-detected synovitis/tenosynovitis may be considered to decide on therapy and enrich clinical trials.
Author(s) Wong ; Viyasar, Thevarajah; Layton, Benjamin; Lauder, Joshua
Source British Journal of Hospital Medicine (17508460); Nov 2022; vol. 82 (no. 11); p. 369-376
Publication Date Nov 2022
Nitrous oxide, also known as 'laughing gas', is one of the most widely used recreational drugs among teenagers in the UK. Copious inhalation of nitrous oxide may increase intra-alveolar pressure, resulting in barotrauma secondary to alveolar rupture. Pneumomediastinum and subcutaneous emphysema are common clinical findings in nitrous oxide-associated barotrauma. Prolonged nitrous oxide misuse may inactivate vitamin B12 through the alteration of its metabolism, causing demyelination of the central and peripheral nervous system. A spectrum of neurological manifestations has been reported, including peripheral neuropathy, myelopathy and subacute combined degeneration of the spinal cord. Medical therapies and psychosocial interventions aiming at nitrous oxide cessation are important treatment steps to achieve partial or complete recovery from the adverse effects associated with inhalation of nitrous oxide.
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