Author(s) Altmann E.S.; Crossingham I.; Wilson S.; Davies H.R.
Source Cochrane Database of Systematic Reviews; Oct 2019; vol. 2019 (no. 10)
Background Pleural infection, including parapneumonic effusions and thoracic empyema, may complicate lower respiratory tract infections. Standard treatment of these collections in adults involves antibiotic therapy, effective drainage of infected fluid and surgical intervention if conservative management fails. Intrapleural fibrinolytic agents such as streptokinase and alteplase have been hypothesised to improve fluid drainage in complicated parapneumonic effusions and empyema and therefore improve treatment outcomes and prevent the need for thoracic surgical intervention. Intrapleural fibrinolytic agents have been used in combination with DNase, but this is beyond the scope of this review. 

• Available in full text at The Cochrane database of systematic reviews from Cochrane Collaboration (Wiley)

Author(s) Chichareon P.; Modolo R.; Kerkmeijer L.; Kogame N.; Takahashi K. et al.
Source JAMA Cardiology; 2019
Importance: Women experience worse ischemic and bleeding outcomes after percutaneous coronary intervention (PCI). Objective(s): To assess the association of sex with patient outcomes at 2 years after contemporary PCI and with the efficacy and safety of 2 antiplatelet strategies.

Design, Setting, and Analysis: This study is a prespecified subgroup analysis of the investigator-initiated, prospective, randomized GLOBAL LEADERS study evaluating 2 strategies of antiplatelet therapy after PCI in an unselected population including 130 secondary/tertiary care hospitals in different countries. The main study enrolled 15991 unselected patients undergoing PCI between July 2013 and November 2015. Patients had an outpatient clinic visit at 30 days and 3, 6, 12, 18, and 24 months after the index procedure. Data were analyzed between January 1, 2019, and March 31, 2019. Intervention(s): Eligible patients were randomized to either the experimental or reference antiplatelet strategy. Experimental strategy consisted of 1 month of dual antiplatelet therapy (DAPT) followed by 23 months of ticagrelor monotherapy, while the reference strategy comprised of 12 months of DAPT followed by 12 months of aspirin monotherapy.

Main Outcomes and Measures: The primary efficacy end point was the composite of all-cause mortality and new Q-wave myocardial infarction at 2 years. The secondary safety end point was Bleeding Academic Research Consortium type 3 or 5 bleeding. Result(s): Of the 15968 patients included in this study, 3714 (23.3%) were women. The risk of the primary end point at 2 years was similar between women and men (adjusted hazard ratio [HR], 1.00; 95% CI, 0.83-1.20). Compared with men, women had higher risk of Bleeding Academic Research Consortium type 3 or 5 bleeding (adjusted HR, 1.32; 95% CI, 1.04-1.67) and hemorrhagic stroke at 2 years (adjusted HR, 4.76; 95% CI, 1.92-11.81). At 2 years, there was no between-sex difference in the efficacy and safety of the 2 antiplatelet strategies. At 1 year, compared with DAPT, ticagrelor monotherapy was associated with a lower risk of bleeding in men (HR, 0.72; 95% CI, 0.53-0.98) but not in women (HR, 1.23; 95% CI, 0.80-1.89; P for interaction =.045).

​Conclusions and Relevance: Compared with men, women experienced a higher risk of bleeding and hemorrhagic stroke after PCI. The effect of 2 antiplatelet strategies on death and Q-wave myocardial infarction following PCI did not differ between the sexes at 2 years. Trial Registration: ClinicalTrials.gov identifier: NCT01813435.Copyright © 2019 American Medical Association. All rights reserved.

Author(s) Menown I.B.A.; De Silva R.; Mitra R.; Balachandran K.; More R. et al.
Source European Heart Journal; Oct 2019; vol. 40 ; p. 1744
Background: Thin stent struts may be associated with reduced vessel injury and use of biodegradable polymers may further improve long term outcomes. However, data with earlier stents has been inconsistent; thus further studies with newer devices are needed. Purpose(s): To evaluate the efficacy and safety of a new ultra-thin (65um) strut cobalt chromium sirolimus-eluting stent with a hybrid design (closed cell at ends and open cells in middle to reduce edge injury and optimise conformability) in all-comers patients undergoing percutaneous coronary intervention (PCI).

Method(s): We enrolled 752 patients from 14 sites undergoing PCI into a prospective, non-randomised, multi-centre, open-label, observational registry. Inclusion of patients with complex anatomy (long stent lengths, bifurcations and chronic total occlusions) was encouraged. Clinical follow-up was scheduled at 1, 9, 12 and 24 months. The primary endpoint was incidence of major adverse cardiac events (MACE)-cardiac death, non-fatal myocardial infarction (MI), or target vessel revascularization (TVR)-at 9 months.

​Result(s): Mean patient age was 64.7+/-12.2 years, 20.7% had diabetes, 58.8% had dyslipidaemia, 40.4% had multi-vessel disease, 22% had previous PCI, 4.7% had previous coronary-artery bypass graft, and 19.6% had a clinical history of previous MI. Mean lesion length was 25.7+/-17.3 mm. The primary endpoint of cumulative MACE up to 9 months (from 624 patients reaching 9 months follow-up) occurred in 12 patients (1.92%), including 6 (0.96%) cardiac death, 5 (0.80%) MI and 6 (0.96%) clinically indicated TVR. Definite stent thrombosis was reported in 3 patients (0.48%) and probable stent thrombosis in 2 patients (0.32%). Conclusion(s): Use of an ultra-thin strut biodegradable polymer sirolimuseluting stent in all-comers patients undergoing PCI was associated with good clinical efficacy and safety.

Author(s) Muralidharan V.; Zahedi D.; Kaur B.; Goulding J.M.R.
Source Clinical and experimental dermatology; Dec 2019
Psychodermatology remains a niche sub-specialty in the United Kingdom (UK), with very few dedicated services available for patients with such problems. Despite this, up to 85% of dermatology patients say that psychosocial aspects of their skin disease are a major component of their condition, indicating an enormous unmet need.s1 Our perception is that general dermatologists and psychiatrists may lack confidence in diagnosing and managing patients with psychodermatological problems, the vast majority of whom will not be cared for in a specialist service.Copyright © 2019 British Association of Dermatologists.

• Available in full text at Clinical and experimental dermatology from Wiley Online Library Medicine and Nursing Collection 2019 - NHS

Author(s) Nevins E.J.; Strong C.; Al-Zubaidi S.; Wayman J.; Karat D. et al.
Source Journal of patient safety; Dec 2019; vol. 15 (no. 4)
OBJECTIVES: Expert opinion remains divided regarding whether routine urethral catheterization is required before nononcological laparoscopic pelvic surgery. Catheterization is thought to reduce the incidence of bladder injury when inserting a suprapubic laparoscopic port and prevent obstruction of the view of the pelvis because of bladder filling. However, catheterization comes with a risk of nosocomial infection and harbors financial cost. Moreover, indwelling catheters inhibit early mobilization and increase postoperative discomfort.

METHOD(S): A systematic review was undertaken using the Meta-Analysis of Observational Studies guidelines to identify eligible publications. End points included bladder injury, positive postoperative urinary microbiology, and postoperative urinary symptoms.

RESULT(S): The reported incidence rates of laparoscopic bladder injury in included publications ranges from 0% to 1.3%. Importantly, bladder injury has occurred during both catheterized and noncatheterized operations. Our meta-analysis also shows that patients who are catheterized have a 2.33 times relative risk of developing postoperative positive microbiology in their urine (P = 0.01) and a 2.41 times relative risk of postoperative urinary symptoms (P = 0.005), when compared with noncatheterized patients.

​CONCLUSION(S): This meta-analysis indicates that omitting a catheter in emergency and elective nononcological laparoscopic pelvic surgery may be a safe option. Catheterization does not remove the risk of bladder injury but results in more urinary tract infections and symptoms. It may be reasonable to ask a patient to void immediately before anesthesia, after which an on-table bladder scan should be performed. If there is minimal residual volume, a urinary catheter may not be necessary, unless operative time is estimated to be greater than 90 minutes.

Author(s) Chandran A.; Bhanji A.; Rao J.
Source British Journal of Oral and Maxillofacial Surgery; Dec 2019; vol. 57 (no. 10)
Introduction/Aims A surgeon's experience undertaking larger case volumes is often linked to better performance. The aim was to assess a single surgeons performance in NMHNSC excisions over five years. We analysed time and case number to reach a consistent competency with regards to excision margins. Materials/Methods Skin pathology data sets were collected retrospectively from 2014 to 2018 The data collected involved a single surgeon operating in multiple hospitals and settings. Information regarding patient demographics, histological features of NMHNSC and excision margins were collected from pathology reports for each operation.

Results/Statistics The results showed from January 2014 to April 2014 there was a 6.8% involved margin rate and a 11.4% close margin rate. This improved with further case volume over the five years. By September2018 to December 2018it was noted that the involved margin rate had reduced to 3.8% and the close margin rate had increased slightly to 13.4%. We present the longitudinal statistics.

​Conclusions/Clinical relevance This study has shown that there appears to be improvement in performance of excisions of NMHNSC as the surgeon gains experience over time to reach a consistent performance. There was a clear initial learning curve to achieve this which took several cases. This likely differs from numbers presented in the literature believed to achieve competency in other bodily surgical procedures.Copyright © 2019

Author(s) Markose G.; Corsar K.; Graham R.M.
Source British Journal of Oral and Maxillofacial Surgery; Dec 2019; vol. 57 (no. 10)
With advances in CT scanning and 3D printing facilities the use of surgical models / stents in maxillofacial surgical planning for implants and oncological work is fairly routine. We present a case where the use of custom cutting guides aided 3D sculpting of a rather overgrown mandible in a young girl with a central giant cell granuloma. En bloc resection can be challenging due to the variable size and location of the tumours and their proximity to surrounding vital tissues. To overcome the challenge of precise resection, computer-aided models were used to assess vital structures, the extent of the affected area and plan surgery.

​The models were able to accurately identify the course of the mandibular canal. A mirror image of the normal side of the mandible was superimposed on the overgrown mandible and patient-specific guiding templates for resection were fabricated which allowed significant recontouring of the mandible with relative ease. The guiding templates provide significant advantages by guiding surgery, leading to more precise resection of the bone with less blood loss, shorter operation time and avoiding damage to the inferior alveolar nerve. We discuss the pre-operative and operative steps in the surgery and review the results.Copyright © 2019

Author(s) Semkova K.; Calonje E.; Carr R.; Grainger M.; Green R. et al.
Source Journal of the American Academy of Dermatology; Dec 2019; vol. 81 (no. 6); p. 1257-1270
Background: We present a distinctive type of acquired vascular proliferation, for which we propose the name of poikilodermatous plaque-like hemangioma. Objective(s): The aim of this study was to summarize the clinical and histopathologic features in a case series of poikilodermatous plaque-like hemangioma.

Method(s): Sixteen cases were identified from the routine clinical and referral practices of the authors. Clinical characteristics, including demographic details and clinical morphology, were collated. The salient histopathologic features, including immunohistochemical staining results, were summarized.

​Result(s): The lesions were usually solitary erythematous-to-violaceous poikilodermatous plaques on the lower extremities and pelvic girdle, with an indolent clinical course. Mean age of affected patients was 72 (range 58-80) years, and there was a male predominance. Histology comprised a distinctive band-like proliferation of vascular channels suggestive of postcapillary venules within the superficial dermis with a background of fibrosis, edema, and loss of elastic fibers. Despite the clinical atrophic appearance, acanthosis was a frequent finding. Limitation(s): Retrospective study. Conclusion(s): Poikilodermatous plaque-like hemangioma is a distinctive and previously undescribed vascular proliferation defined by a constellation of consistent and reproducible clinical and histologic features.Copyright © 2019 American Academy of Dermatology, Inc.

Author(s) Garg S.; Chichareon P.; Modolo R.; Tomaniak M.; Onuma Y. et al.
Source European Heart Journal; Oct 2019; vol. 40 ; p. 3108
Objectives: To investigate the impact of ticagrelor monotherapy following one-month dual antiplatelet therapy (DAPT) on clinical outcomes after percutaneous coronary intervention (PCI) in patients with established cardiovascular disease (CVD) who were enrolled in the Global Leaders Trial. 

Author(s) Franzone A.; Piccolo R.; McFadden E.; Leonardi S.; Ferrario M. et al.
Source Journal of the American College of Cardiology; Nov 2019; vol. 74 (no. 18); p. 2223-2234
Background: The GLOBAL LEADERS (GLOBAL LEADERS: A Clinical Study Comparing Two Forms of Anti-platelet Therapy After Stent Implantation) study randomly assigned 15,991 patients undergoing percutaneous coronary intervention to 1-month dual antiplatelet therapy (DAPT) followed by 23-month ticagrelor monotherapy or conventional 12-month DAPT followed by 12-month aspirin. Apart from Q-wave myocardial infarction (MI), all study endpoints were analyzed as investigator reported.

Objective(s): This was a pre-specified ancillary study assessing whether experimental therapy is noninferior, and if met, superior, to conventional treatment for the coprimary efficacy endpoint of all-cause death, nonfatal MI, nonfatal stroke, or urgent target vessel revascularization and superior in preventing BARC 3 (Bleeding Academic Research Consortium) or 5 bleeding (coprimary safety endpoint) at 2 years with a 0.025 significance level to preserve nominal 5% alpha error. Method(s): An independent clinical event committee adjudicated investigator-reported and eventually unreported events of 7,585 patients from the 20 top-enrolling participating sites.

​Result(s): The 2-year coprimary efficacy endpoint occurred in 271 (7.14%) and in 319 (8.41%) patients in the experimental and conventional groups, respectively (rate ratio [RR]: 0.85; 95% confidence interval [CI]: 0.72 to 0.99), fulfilling noninferiority (p noninferiority <0.001), but not superiority (p superiority = 0.0465). The rates of BARC 3 or 5 bleeding did not differ (RR: 1.00; 95% CI: 0.75 to 1.33; p = 0.986). A time-dependent treatment effect was observed with the experimental strategy being associated with a lower risk of MI (RR: 0.54; 95% CI: 0.33 to 0.88; p interaction = 0.062) and definite stent thrombosis (RR: 0.14; 95% CI: 0.03 to 0.63; p interaction = 0.007) after 1-year post-percutaneous coronary intervention. Conclusion(s): Ticagrelor monotherapy after 1-month DAPT was noninferior, but not superior, to conventional treatment in the prevention of ischemic events, and it did not decrease major bleeding risk as compared with conventional treatment. (GLOBAL LEADERS Adjudication Sub-Study [GLASSY]; NCT03231059).Copyright © 2019 American College of Cardiology Foundation

Author(s) Gupta A.; Paria A.
Source Surgery (United Kingdom); 2019
DOI 10.1016/j.mpsur.2019.09.004
This article provides an overview of the key physiological changes that take place as the fetus transtitions to neonatal life. It provides and an overview of fetal transition with a focus on respiratory and cardiovascular changes.Copyright © 2019

Author(s) Dorey S.; Gray L.; Tootell A.; Higgins R.; Hogg P. et al.
Source Radiography; Nov 2019; vol. 25 (no. 4); p. 301-307
DOI 10.1016/j.radi.2019.02.008
Introduction: Smart glasses can be adapted to display radiographic images to allow clinician's gaze not to be directionally fixed or predetermined by computer monitor location. This study presents an analysis of eye lens dose during interventional fluoroscopy guided procedures, comparing fixed monitor positions against the use of smart glasses.

Method(s): Using a head phantom (simulating the clinician), thermoluminescent dosimeters and lead shielded glasses, the dose to the eye was measured for different head 'rotations and tilts' for: gaze directed towards the main scattering source (patient/primary beam) to represent potential gaze direction if smart glasses are used; gaze directed to a range of potential computer monitor positions. An anthropomorphic pelvis phantom was utilised to simulate the patient. Accumulated dose rates (muGy s1) from five 10-second exposures at 75 kV 25.2 mAs were recorded.

Result(s): An average DAP reading of 758.84 cGy cm2 was measured during each 10 second exposure. Whilst wearing lead shielded glasses a 6.10 - fold reduction in dose rate to the lens is possible (p < 0.05). Influence of the direction of gaze by the clinician demonstrated a wide range of dose rate reduction from 3.13% (p = 0.16) to 143.69% (p < 0.05) when the clinician's gaze was towards the main scattering source. Increased dose rate to the clinician's eyes was received despite wearing lead shielded glasses, as the angle of gaze moved 45degree and 90degree from 0degree.

​Conclusion(s): If the clinician's gaze is directed towards the main scattering source a potential exists for reducing eye lens dose compared with fixed location computer monitors. Introduction of lead lined smart glasses into interventional radiology may lead to improvements in patient care, reducing the need for the clinician to look away from the patient to observe a radiographic image.Copyright © 2019

Author(s) Tebbutt J.E.; Graham R.M.; Markose G.
Source Annals of the Royal College of Surgeons of England; Nov 2019; vol. 101 (no. 8); p. 619-620
Database EMBASE

• Available in full text at Annals of the Royal College of Surgeons of England from EBSCO (MEDLINE Complete)

Author(s) Hansrani V.; Muhammad K.; Charlswood N.; Al-Khaffaf H.
Source Journal of Vascular Access; Nov 2019; vol. 20 (no. 6); p. 592-596
Background: Dialysis-associated steal syndrome remains a difficult clinical scenario for vascular access surgeons. The ideal treatment would improve blood flow to the hand without compromising the fistula; however, most treatment options rarely allow for both. The study describes an innovative technique used in clinical practice over a 17-year period for the treatment of dialysis-associated steal syndrome. The procedure and long-term results are discussed.

Method(s): 27 patients with dialysis-associated steal syndrome were recruited over 17 years at two large UK University Teaching Hospitals and treated with the extension technique. All patients included were assessed for resolution of their symptoms, patency of the fistula and adequacy of needling.

Result(s): 27 patients were admitted with dialysis-associated steal syndrome and underwent surgery using the extension technique. Complete symptom resolution was seen in 26 of the 27 patients (96%), with improvements in pain, sensori-motor disturbance and temperature. All 26 patients had a patent fistula at 6-months' follow-up. At 12 months, 3 of 27 (11.1%) developed fistula thrombosis which could not be salvaged and 2 of 27 (7.4%) developed thrombosis successfully salvaged by fistulaplasty.

​Conclusion(s): Our study shows that the Extension Technique is an effective treatment method for dialysis-associated steal syndrome and results have demonstrated a high level of fistula patency and a low rate of complications. It has several advantages when compared with other established treatment methods and has the versatility to be used as a method for dialysis-associated steal syndrome prevention in high-risk groups as well as treatment.Copyright © The Author(s) 2019.

Author(s) Katsogridakis E.; Perricone V.; Pokusevski G.
Source Interactive Cardiovascular and Thoracic Surgery; 2019; vol. 28 (no. 4); p. 635-637
A best evidence topic in vascular surgery was written according to a structured protocol. The question addressed was whether sartorius muscle flaps (SMF) can be effectively used in the setting of complex groin wounds with exposed prosthetic grafts for graft salvage and limb salvage. The literature review identified 33 articles reporting on the use of SMF for complex vascular wounds. Of these, 7 articles reporting on the use of 539 SMFs were considered the best evidence to answer the clinical question. Indications included surgical site infections with or without wound dehiscence, lymph leaks, graft infection and groin pseudoaneurysms, whereas in 98 of the included 539 cases, the flaps were performed prophylactically. Vacuum-assisted closure systems were used in 25 cases to promote healing. The use of an SMF is associated with low rates of muscle flap and graft complications, whereas outcomes seem to be independent of the presence of occlusive disease in the superficial femoral artery. They can be effectively combined with aggressive debridement strategies and vacuum-assisted closure devices to optimize outcomes. The published literature supports the use of SMF in the management of complex groin wounds following vascular reconstruction and is associated with encouraging flap, limb and graft salvage rates.Copyright © 2018 The Author(s).

• Available in full text at Interactive cardiovascular and thoracic surgery from Unpaywall

Author(s) Chichareon P.; Modolo R.; Kogame N.; Takahashi K.; Wykrzykowska J. et al.
Source Journal of the American College of Cardiology; Oct 2019; vol. 74 (no. 13)
DOI 10.1016/j.jacc.2019.08.754
Background: Diabetes has been well recognized as a strong predictor of adverse outcomes after percutaneous coronary intervention (PCI), but studies in the era of drug-eluting stents and potent P2Y12 inhibitors have shown conflicting results. We assessed ischemic and bleeding outcomes after contemporary PCI according to diabetic status.

Method(s): We studied 15,957 patients in the GLOBAL LEADERS study with known baseline diabetic status. The primary endpoint was all-cause death or new Q-wave myocardial infarction at 2 years. The secondary safety endpoint was major bleeding defined as Bleeding Academic Research Consortium (BARC) type 3 or 5.

Result(s): A quarter of the study cohort had diabetes (4,038 of 15,957), and these patients had a significantly higher risk for the primary endpoint at 2 years compared with those without diabetes (adjusted hazard ratio [HR]: 1.36; 95% confidence interval [CI]: 1.14 to 1.61). The difference was driven by a significantly higher risk for all-cause mortality at 2 years in patients with diabetes (adjusted HR: 1.44; 95% CI: 1.18 to 1.75). The risk for BARC type 3 or 5 bleeding was comparable between the 2 groups (adjusted HR: 1.18; 95% CI: 0.92 to 1.50). The antiplatelet strategy (experimental vs. reference strategy) had no significant effect on the rates of the primary endpoint and secondary safety endpoint at 2 years in patients with and without diabetes.

​Conclusion(s): Patients with diabetes had a higher risk for ischemic events after PCI than those without diabetes, while bleeding risk was comparable. The outcomes of patients with diabetes following PCI were not affected by the 2 different antiplatelet strategies. Categories: CORONARY: Pharmacology/PharmacotherapyCopyright © 2019

• Available in full text at Journal of the American College of Cardiology from Unpaywall

Author(s) Ryan N.A.J.; Crosbie E.J.; Evans D.G.; Glaire M.A.; Blake D. et al.
Source Genetics in Medicine; Oct 2019; vol. 21 (no. 10); p. 2167-2180
Purpose: Endometrial cancer (EC) is often the sentinel cancer in women with Lynch syndrome (LS). However, efforts to implement universal LS screening in EC patients have been hampered by a lack of evidence detailing the proportion of EC patients that would be expected to screen positive for LS.

Method(s): Studies were identified by electronic searches of Medline, Embase, Cochrane CENTRAL and Web of Science. Proportions of test positivity were calculated by random and fixed-effects meta-analysis models. I2 score was used to assess heterogeneity across studies.

​Result(s): Fifty-three studies, including 12,633 EC patients, met the inclusion criteria. The overall proportion of endometrial tumors with microsatellite instability or mismatch repair (MMR) deficiency by immunohistochemistry (IHC) was 0.27 (95% confidence interval [CI] 0.25-0.28, I2: 71%) and 0.26 (95% CI 0.25-0.27, I2: 88%), respectively. Of those women with abnormal tumor testing, 0.29 (95% CI 0.25-0.33, I2: 83%) had LS-associated pathogenic variants on germline testing; therefore around 3% of ECs can be attributed to LS. Preselection of EC cases did increase the proportion of germline LS diagnoses.

Conclusion(s): The current study suggests that prevalence of LS in EC patients is approximately 3%, similar to that of colorectal cancer patients; therefore our data support the implementation of universal EC screening for LS.Copyright © 2019, The Author(s).

Author(s) Choudhury A.; Garg S.; Smith J.; Sharp A.; Nabais De Araujo S. et al.
Source BMJ Open; 2019; vol. 9 (no. 10)
Objective To prospectively evaluate safety and efficacy of the ultrathin strut biodegradable polymer-coated Supraflex sirolimus-eluting stent (S-SES) in real world' patient population requiring percutaneous coronary intervention (PCI).

Methods National, prospective, multicentre, single-arm, all-comers, observational registry of 469 patients treated with S-SES from July 2015 and November 2016 in 11 centres in UK. Primary endpoint was target lesion failure (TLF) at 12 months (cardiac death, target vessel myocardial infarction (MI) or clinically driven target lesion revascularisation (TLR)). Secondary endpoints included safety and performance outcomes at 12 months-overall stent thrombosis (ST), all-cause mortality, any MI, target vessel failure (TVF) and major adverse cardiac events (MACE-composite of cardiac death, MI, emergent or repeat revascularisation).

Results At 12 months, the primary endpoint occurred in 11 (2.4%) of 466 patients, consisting of 4 (0.9%) cardiac deaths, 3 (0.6%) target vessel MI and 7 (1.5%) TLR. Secondary endpoints findings included all-cause mortality in 6 (1.3%), TVF of 14 (3%), no definite ST, 1 (0.2%) probable ST and 3 (0.6%) possible ST. Overall MACE was observed in 18 (3.9%).

​Conclusions The S-FLEX UK registry showed that the S-SES is safe with a low incidence of TLF in routine clinical practise in patients with coronary artery disease being treated by PCI.Copyright © 2019 Author(s).

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

Author(s) Hajibandeh S.; Clark M.C.; Barratt O.A.; Taktak S.; Henley N. et al.
Source Surgical Laparoscopy, Endoscopy and Percutaneous Techniques; Oct 2019; vol. 29 (no. 5); p. 321-327
Objective:The objective of this study was to evaluate the comparative efficacy of gallbladder retrieval via the epigastric and umbilical port during laparoscopic cholecystectomy. Method(s):We systematically searched MEDLINE, EMBASE, CINAHL, CENTRAL, the World Health Organization International Clinical Trials Registry, ClinicalTrials.gov, ISRCTN Register, and bibliographic reference lists. Postoperative pain intensity, port-site infection, hernia, bleeding, and retrieval time were outcome parameters. Combined overall effect sizes were calculated using fixed-effect or random-effects models.

Result(s):We identified 5 randomized controlled trials and 1 prospective cohort study reporting a total of 2394 patients who underwent laparoscopic cholecystectomy with retrieval of the gallbladder via the umbilical port (n=1194) or epigastric port (n=1200). Our initial analysis demonstrated that gallbladder retrieval via the umbilical port was associated with a nonsignificant reduction in pain assessed by visual analogue scale at 24 hours [mean difference (MD): -0.49, 95% confidence interval (CI): -1.06 to 0.08, P=0.09] compared with the epigastric port. However, after sensitivity analysis and eliminating the source of heterogeneity, it reached statistical significance (MD: -0.66, 95% CI: -0.85 to -0.48, P<0.00001). Moreover, gallbladder retrieval via the umbilical port was associated with significantly shorter retrieval time (MD: -1.83, 95% CI: -3.18 to -0.49, P=0.008) but similar risk of port-site infection (odds ratio: 1.99, 95% CI: 0.53-7.44, P=0.31) and hernia (odds ratio: 0.33, 95% CI: 0.03-3.20, P=0.34).

​Conclusion(s):Our analysis demonstrated that retrieval of the gallbladder via the umbilical port may be associated with less postoperative pain in patients undergoing laparoscopic cholecystectomy compared with epigastric port retrieval. It may also be associated with shorter gallbladder retrieval time. However, the available evidence is limited.Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Author(s) Ismail D.; Owen C.M.
Source Clinical and Experimental Dermatology; Oct 2019; vol. 44 (no. 7); p. 753-758
Publication Date Oct 2019
DOI 10.1111/ced.13894
Background: Lichen sclerosus (LS) is a chronic inflammatory dermatosis with a predilection for the anogenital region, which mainly affects prepubertal girls and postmenopausal women. The cause is unknown, but a number of potential aetiological factors have been identified.

Aim(s): To examine a cohort of patients with prepubertal-onset vulval LS (VLS) and assess baseline characteristics, clinical presentation, potential precipitating and predisposing factors, and response to treatment. Method(s): Data were collected from case notes on patients aged < 18 years diagnosed with prepubertal-onset VLS attending a specialist vulval dermatology service. Data included clinical presentation, comorbidities, family history, therapy and response to treatment.

Result(s): In total, 26 paediatric patients were identified. The median age at onset of symptoms was 5 years (range 2-8.5 years). Many previously identified potential aetiological factors for the development of VLS were identified, including family history, trauma, autoimmune disease and hormonal factors. A significant proportion of patients had a history of urinary tract symptoms, including incontinence and urinary tract infection. Most patients responded well to a standard course of induction topical therapy followed by maintenance therapy, but some, including three patients with ongoing urinary incontinence and three postpubertal patients, continued to have active disease.

​Conclusion(s): A detailed assessment is essential in patients with VLS so that potential predisposing factors and comorbidities can be identified and managed. Urinary incontinence may be implicated in the development of paediatric VLS and may prevent adequate disease control. Paediatric VLS can persist through puberty, thus long-term follow-up is advised.Copyright © 2019 British Association of Dermatologists

• Available in full text at Clinical and experimental dermatology from Wiley Online Library Medicine and Nursing Collection 2019 - NHS

​Author(s) Takahashi K.; Chichareon P.; Modolo R.; Kogame N.; Tijssen J.G.P. et al.
Source Journal of the American College of Cardiology; Oct 2019; vol. 74 (no. 16); p. 2015-2027
DOI 10.1016/j.jacc.2019.08.997
Background: Data on optimal antiplatelet treatment regimens in patients who undergo multivessel percutaneous coronary intervention (PCI) are sparse. Objective(s): This post hoc study investigated the impact of an experimental strategy (1-month dual antiplatelet therapy [DAPT] followed by 23-month ticagrelor monotherapy) versus a reference regimen (12-month DAPT followed by 12-month aspirin monotherapy) according to multivessel PCI.

Method(s): The GLOBAL LEADERS trial is a prospective, multicenter, open-label, randomized controlled trial, allocating all-comer patients in a 1:1 ratio to either the experimental strategy or the reference regimen. The primary endpoint was the composite of all-cause death or new Q-wave myocardial infarction at 2 years. The secondary safety endpoint was Bleeding Academic Research Consortium type 3 or 5 bleeding.

Result(s): Among the overall study population (n=15,845), 3,576 patients (22.4%) having multivessel PCI experienced a significantly higher risk of ischemic and bleeding events at 2 years, compared to those having single-vessel PCI. There was an interaction between the experimental strategy and multivessel PCI on the primary endpoint (hazard ratio: 0.62; 95% confidence interval: 0.44 to 0.88; pinteraction = 0.031). This difference was largely driven by a lower risk of all-cause mortality. In contrast, the risk of Bleeding Academic Research Consortium type 3 or 5 bleeding was statistically similar between the 2 regimens (hazard ratio: 0.92; 95% confidence interval: 0.61 to 1.39; pinteraction = 0.754).

​Conclusion(s): Long-term ticagrelor monotherapy following 1-month DAPT can favorably balance ischemic and bleeding risks in patients with multivessel PCI. These findings should be interpreted as hypothesis-generating and need to be replicated in future dedicated randomized trials. (GLOBAL LEADERS: A Clinical Study Comparing Two Forms of Anti-platelet Therapy After Stent Implantation; NCT01813435).Copyright © 2019 American College of Cardiology Foundation

Author(s) Chichareon P.; Modolo R.; Kogame N.; Takahashi K.; van Klaveren D. et al.
Source Journal of the American College of Cardiology; Oct 2019; vol. 74 (no. 13)
DOI 10.1016/j.jacc.2019.08.512
Background: The logistic clinical SYNTAX score combined anatomic SYNTAX score and 7 variables to predict 2-year all-cause mortality after percutaneous coronary intervention (PCI). The score was derived from 7 stent trials in which new-generation drug-eluting stent and potent antiplatelet inhibitors were not widely utilized. The original logistic clinical SYNTAX score has been shown to overestimate 2-year all-cause mortality in the GLOBAL LEADERS study. This study aimed to revise and update the logistic clinical SYNTAX score to predict 2-year all-cause mortality after contemporary PCI using the population in the GLOBAL LEADERS study.

Method(s): The authors analyzed 15,883 patients in the GLOBAL LEADERS study who underwent PCI. The original model of the logistic clinical SYNTAX score was revised by re-estimating the predictor effects in Cox regression model (revised model). The authors updated the score by combining the original model with additional independent predictors of 2-year mortality identified in the GLOBAL LEADERS study population (updated model). Internal validation with bootstrap method was used to quantify and correct for overfitting and optimism.

Result(s): This study has identified 5 additional independent predictors of 2-year all-cause mortality: hemoglobin level; white blood cell count; chronic obstructive pulmonary disease; prior stroke; and current smoker. The updated model (C-index: 0.78; 95% confidence interval [CI]: 0.76 to 0.80) better discriminated 2-year all-cause mortality than the previous version (C-index: 0.75; 95% CI: 0.73 to 0.77), in an internal validation using bootstrap method. The updated model performed better in differentiating mortality among non-high-risk patients. The calibration of both models was appropriate. Currently the updated model is tested in an external validation cohort of 10,724 patients.

​Conclusion(s): By adding 5 predictors to the logistic clinical SYNTAX score, the score better predicts 2-year all-cause mortality after PCI. The score can be used for risk stratification and prediction in patients undergoing PCI in the contemporary practice. Categories: CORONARY: Stents: Drug-ElutingCopyright © 2019

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Author(s) Anderson S.; Garg S.; Saluja S.; Aghamohammadzadeh R.; Thiru S. et al.
Source Journal of the American College of Cardiology; Oct 2019; vol. 74 (no. 13)
DOI 10.1016/j.jacc.2019.08.990
Background: The impact of socioeconomic class on outcomes of percutaneous coronary intervention (PCI) in populations with access to universal unrestricted health care is limited. Furthermore, prior reports have focused mainly on patients with ST-segment elevation myocardial infarction (STEMI).

Method(s): We performed a retrospective analysis of centrally tracked outcomes from index PCI procedures entered in the British Cardiovascular Intervention Society database between 2007 and 2014 stratified according to quintiles of index of multiple deprivation (IMD; from the least deprived to the most deprived). The analyses were restricted to procedures performed in England. The primary endpoint was 30-day all-cause mortality, with secondary endpoints of mortality at 1 and 5 years. Hazard ratios (HRs) for mortality were determined from multivariate Cox regression models allowing for clustering by hospital.

Result(s): Among 437,024 eligible patients with 1.78 million person-years of observation, 40% of patients had PCI for stable coronary artery disease (CAD), 37.7% with non-STEMI, and 21.6% were treated for STEMI. A total of 52,258 patients (11.9%) died during a median of 3.5 years (interquartile range: 1.8 to 5.5 years) of follow-up. There was a trend toward an increase in crude mortality rates (per 1,000 person-years) with increasing quintile of IMD (from 26.7 per 1,000 in least deprived to 28.5 per 1,000 in the most deprived; p for trend <0.0001. When assessed by indication for PCI, only those undergoing intervention for non-STEMI or unstable angina had increased mortality rates as IMD worsened. In an age-, sex-, and indication for PCI-adjusted Cox regression multivariate analysis, mortality rates at 30 days were 14% greater (HR: 1.14; 95% confidence interval [CI]: 1.06 to 1.24; p < 0.0001) in patients from the most deprived areas compared with those with the least deprived IMD. These findings were similar for mortality at 1 year (HR: 1.09; 95% CI: 1.04 to 1.14) and at 5 years (HR: 1.10; 95% CI: 1.06 to 1.16).

​Conclusion(s): This very large, real-world dataset of patients demonstrates that deprivation is an independent marker of mortality following presentation with non-STEMI, and efforts should be directed at overcoming this. Reassuringly, in the setting of universal health care, deprivation does not influence outcomes from stable or STEMI presentation. Categories: OTHER: Political, International and Societal IssuesCopyright © 2019

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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

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