Endoscopic resection(ER)of colorectal polyps has become a daily practice in most endoscopic units providing a colorectal cancer screening program and requires the availability of local experts and high-end endoscopic ...Endoscopic resection(ER)of colorectal polyps has become a daily practice in most endoscopic units providing a colorectal cancer screening program and requires the availability of local experts and high-end endoscopic devices.ER procedures have evolved over the past few years from endoscopic mucosal resection(EMR)to more advanced techniques,such as endoscopic submucosal dissection and endo-scopic full-thickness resection.Complete resection and disease eradication are the ultimate goals of ER-based techniques,and novel devices have been developed to achieve these goals.The EndoRotor®Endoscopic Powered Resection System(Interscope Medical,Inc.,Northbridge,Massachusetts,United States)is one such device.The EndoRotor is a powered resection tool for the removal of alimentary tract mucosa,including post-EMR persistent lesions with scarring,and has both CE Mark and FDA clearance.This review covers available published evidence documenting the usefulness of EndoRotor for the management of recurrent colorectal polyps.展开更多
Amyloidosis is a rare spectrum of disease which involves deposition of misfolded extracellular proteins (amyloids) in various body organs leading to progressive organ dysfunction. Clinical presentation can be variable...Amyloidosis is a rare spectrum of disease which involves deposition of misfolded extracellular proteins (amyloids) in various body organs leading to progressive organ dysfunction. Clinical presentation can be variable depending on the organ involved and type of protein. Amyloidosis can be classified based on quantity, type, and location of these proteins. Amyloid light-chain amyloidosis develops in the bone marrow, producing abnormal forms of light-chain proteins, which cannot be broken down. These proteins transform into amyloid fibrils and form amyloid deposits in different organs. Pulmonary amyloidosis is uncommonly diagnosed since it is rarely symptomatic. Diagnosis of pulmonary amyloidosis is usually made in the setting of systemic amyloidosis;however, it may present as localised pulmonary disease. Localized pulmonary Amyloidosis can present as nodular, cystic, or tracheobronchial amyloidosis. Depending on the degree of the interstitial involvement, it may affect alveolar gas exchange and cause respiratory symptoms. This is a case of a 47-year-old female with background history of interstitial lung disease presenting with progressive shortness of breath. Computed tomography scan revealed bilateral pulmonary nodules. The patient was referred to our thoracic surgery team with the suspicion of bronchogenic malignancy with metastasis. Diagnostic video assisted wedge resection was performed for this patient, and histology confirmed pulmonary amyloidosis of nodular type. Amyloid deposition simulates both inflammatory and neoplastic conditions. Definitive diagnosis requires biopsy confirmation therefore early detection and commencing the patient on appropriate treatment pathway may help in symptomatic relief and better outcome.展开更多
AIM:To evaluate the outcomes of endoscopic mucosal resection(EMR) for colorectal polyps,with particular regard to procedural complications and recurrence rate,in typical United Kingdom(UK) hospitals that perform an av...AIM:To evaluate the outcomes of endoscopic mucosal resection(EMR) for colorectal polyps,with particular regard to procedural complications and recurrence rate,in typical United Kingdom(UK) hospitals that perform an average of about 25 colonic EMRs per year.METHODS:A total of 239 colorectal polyps(≥ 10 mm) resected from 199 patients referred to Rochdale Infirmary,Salford Royal Hospital and Royal Oldham Hospital for EMR between January 2003 and January 2009 were studied.RESULTS:The mean size of polyps resected was 19.6 ± 12.4 mm(range 10-80 mm).The overall major complication rate was 2.1%.Complications were less frequent with non-adenomas compared with the other groups(Pearson's χ 2 test,P < 0.0001).Resections of largersized polyps were more likely to result in complications(unpaired t-test,P = 0.021).Recurrence was associated with histology,with carcinoma-in-situ more likely to recur compared with low-grade dysplasia [hazard ratio(HR) 186.7,95% confidence interval(95% CI):8.81-3953.02,P = 0.001].Distal lesions were also more likely to recur compared with right-sided and transverse colon lesions(HR 5.93,95% CI:1.35-26.18,P = 0.019).CONCLUSION:EMR for colorectal polyps can be performed safely and effectively in typical UK hospitals.Stricter follow-up is required for histologically advanced lesions due to increased recurrence risk.展开更多
Myeloproliferative neoplasms(MPNs)are defined as clonal disorders of the hematopoietic stem cell in which an exaggerated production of terminally differentiated myeloid cells occurs.Classical,Philadelphia-negative MPN...Myeloproliferative neoplasms(MPNs)are defined as clonal disorders of the hematopoietic stem cell in which an exaggerated production of terminally differentiated myeloid cells occurs.Classical,Philadelphia-negative MPNs,i.e.,polycythemia vera,essential thrombocythemia and primary myelofibrosis,exhibit a propensity towards the development of thrombotic complications that can occur in unusual sites,e.g.,portal,splanchnic or hepatic veins,the placenta or cerebral sinuses.The pathogenesis of thrombotic events in MPNs is complex and requires an intricate mechanism involving endothelial injury,stasis,elevated leukocyte adhesion,integrins,neutrophil extracellular traps,somatic mutations(e.g.,the V617F point mutation in the JAK2 gene),microparticles,circulating endothelial cells,and other factors,to name a few.Herein,we review the available data on Budd-Chiari syndrome in Philadelphia-negative MPNs,with a particular focus on its epidemiology,pathogenesis,histopathology,risk factors,classification,clinical presentation,diagnosis,and management.展开更多
BACKGROUND The popularity of uncemented stems in revision total hip arthroplasty(THA)has increased in the last decade.AIM To assess the outcomes of both cemented and uncemented stems after mid-term follow up.METHODS T...BACKGROUND The popularity of uncemented stems in revision total hip arthroplasty(THA)has increased in the last decade.AIM To assess the outcomes of both cemented and uncemented stems after mid-term follow up.METHODS This study was performed following both the Preferred Reporting Items for Systematic Reviews and Meta-analyses Statement and the Cochrane Handbook for systematic reviews and meta-analysis guidelines.Articles were chosen irrespective of country of origin or language utilized for the article full texts.This paper included studies that reviewed revision THA for both cemented or uncemented long stems.RESULTS Three eligible studies were included in the meta-analysis.Analysis was conducted by using Review Manager version 5.3.We computed the risk ratio as a measure of the treatment effect,taking into account heterogeneity.We used random-effect models.There were no significant differences found for intraoperative periprosthetic fractures[risk ratio(RR)=1.25;95%confidence interval(CI):0.29-5.32;P=0.76],aseptic loosening(RR=2.15,95%CI:0.81-5.70;P=0.13),dislocation rate(RR=0.50;95%CI:0.10-2.47;P=0.39),or infection rate(RR=0.99,95%CI:0.82-1.19;P=0.89),between the uncemented and the cemented long stems for revision THA after mid-term follow-up.CONCLUSION This study has evaluated the mid-term outcomes of both cemented and uncemented stems at first-time revision THA.In summary,there were no significant differences in the dislocation rate,aseptic loosening,intraoperative periprosthetic fracture and infection rate between the two cohorts.展开更多
AIM To analyse the effect of mechanical bowel preparation vs no mechanical bowel preparation on outcome in patients undergoing elective colorectal surgery.METHODS Meta-analysis of randomised controlled trials and obse...AIM To analyse the effect of mechanical bowel preparation vs no mechanical bowel preparation on outcome in patients undergoing elective colorectal surgery.METHODS Meta-analysis of randomised controlled trials and observational studies comparing adult patients receiving mechanical bowel preparation with those receiving no mechanical bowel preparation, subdivided into those receiving a single rectal enema and those who received no preparation at all prior to elective colorectal surgery. RESULTS A total of 36 studies(23 randomised controlled trials and 13 observational studies) including 21568 patients undergoing elective colorectal surgery were included. When all studies were considered, mechanical bowel preparation was not associated with any significant difference in anastomotic leak rates(OR = 0.90, 95%CI: 0.74 to 1.10, P = 0.32), surgical site infection(OR = 0.99, 95%CI: 0.80 to 1.24, P = 0.96), intraabdominal collection(OR = 0.86, 95%CI: 0.63 to 1.17, P = 0.34), mortality(OR = 0.85, 95%CI: 0.57 to 1.27, P = 0.43), reoperation(OR = 0.91, 95%CI: 0.75 to 1.12, P = 0.38) or hospital length of stay(overall mean difference 0.11 d, 95%CI:-0.51 to 0.73, P = 0.72), when compared with no mechanical bowel preparation, nor when evidence from just randomized controlledtrials was analysed. A sub-analysis of mechanical bowel preparation vs absolutely no preparation or a single rectal enema similarly revealed no differences in clinical outcome measures. CONCLUSION In the most comprehensive meta-analysis of mechanical bowel preparation in elective colorectal surgery to date, this study has suggested that the use of mechanical bowel preparation does not affect the incidence of postoperative complications when compared with no preparation. Hence, mechanical bowel preparation should not be administered routinely prior to elective colorectal surgery.展开更多
Chronic Groin Pain (Inguinodynia) following inguinal hernia repair is a significant,though under-reported problem. Mild pain lasting for a few days is common following mesh inguinal hernia repair. However,moderate to ...Chronic Groin Pain (Inguinodynia) following inguinal hernia repair is a significant,though under-reported problem. Mild pain lasting for a few days is common following mesh inguinal hernia repair. However,moderate to severe pain persisting more than 3 mo after inguinal herniorrhaphy should be considered as pathological. The major reasons for chronic groin pain have been identified as neuropathic cause due to inguinal nerve(s) damage or non-neuropathic cause due to mesh or other related factors. The symptom complex of chronic groin pain varies from a dull ache to sharp shooting pain along the distribution of inguinal nerves. Thorough history and meticulous clinical examination should be performed to identify the exact cause of chronic groin pain,as there is no single test to confirm the aetiology behind the pain or to point out the exact nerve involved. Various studies have been performed to look at the difference in chronic groin pain rates with the use of mesh vs non-mesh repair,use of heavyweight vs lightweight mesh and mesh fixation with sutures vs glue. Though there is no convincing evidence favouring one over the other,lightweight meshes are generally preferred because of their lesser foreign body reaction and better tolerance by the patients. Identification of all three nerves has been shown to be an important factor in reducing chronic groin pain,though there are no well conducted randomised studies to recommend the benefits of nerve excision vs preservation. Both nonsurgical and surgical options have been tried for chronic groin pain,with their consequent risks of analgesic sideeffects,recurrent pain,recurrent hernia and significant sensory loss. By far the best treatment for chronic groin pain is to avoid bestowing this on the patient by careful intra-operative handling of inguinal structures and better patient counselling pre-and post-herniorraphy.展开更多
Cardiovascular disease including stroke is a major complication that tremendously increases the morbidity and mortality in patients with diabetes mellitus(DM). DM poses about four times higher risk for stroke. Cardiom...Cardiovascular disease including stroke is a major complication that tremendously increases the morbidity and mortality in patients with diabetes mellitus(DM). DM poses about four times higher risk for stroke. Cardiometabolic risk factors including obesity, hypertension, and dyslipidaemia often co-exist in patients with DM that add on to stroke risk. Because of the strong association between DM and other stroke risk factors, physicians and diabetologists managing patients should have thorough understanding of these risk factors and management. This review is an evidence-based approach to the epidemiological aspects, pathophysiology, diagnostic work up and management algorithms for patients with diabetes and stroke.展开更多
AIM:To investigate if antibiotics administered within 8 h of endoscopy reduce mortality or increase the incidence of Clostridium difficile infection(CDI).METHODS:A 2-year retrospective analysis of all patients who pre...AIM:To investigate if antibiotics administered within 8 h of endoscopy reduce mortality or increase the incidence of Clostridium difficile infection(CDI).METHODS:A 2-year retrospective analysis of all patients who presented with first variceal hemorrhage was undertaken.The primary outcome measure was 28-d mortality.Secondary outcome measures were 28-d rebleeding rates and 28-d incidence of CDI.All patients were admitted to a tertiary liver unit with a consultantled,24-h endoscopy service.Patients received standard care including terlipressin therapy.Data collection included:primary and secondary outcome measures,timing of first administration of intravenous antibiotics,eti-ology of liver disease,demographics,endoscopy details and complications.A prospective study was undertaken to determine the incidence of CDI in the study population and general medical inpatients admitted for antibiotic therapy of at least 5 d duration.Statistical analysis was undertaken using univariate,non-parametric tests and multivariate logistic regression analysis.RESULTS:There were 70 first presentations of variceal hemorrhage during the study period.Seventy percent of cases were male and 65.7% were due to chronic alcoholic liver disease.In total,64/70(91.4%) patients received antibiotics as prophylaxis during their admission.Specifically,53/70(75.7%) received antibiotics either before endoscopy or within 8 h of endoscopy [peri-endoscopy(8 h) group],whereas 17/70(24.3%) received antibiotics at > 8 h after endoscopy or not at all(non peri-endoscopy group).Overall mortality and rebleeding rates were 13/70(18.6%) and 14/70(20%),respectively.The periendoscopy(8 h) group was significantly less likely to die compared with the non peri-endoscopy group [13.2% vs 35.3%,P = 0.04,odds ratio(OR) = 0.28(0.078-0.997)] and showed a trend towards reduced rebleeding [17.0% vs 29.4%,P = 0.27,OR = 0.49(0.14-1.74)].On univariate analysis,the non peri-endoscopy group [P = 0.02,OR = 3.58(1.00-12.81)],higher model for end-stage liver disease(MELD) score(P = 0.02),presence of hepatorenal syndrome [P < 0.01,OR = 11.25(2.24-56.42)] and suffering a clinical episode of sepsis [P = 0.03,OR = 4.03(1.11-14.58)] were significant predictors of death at 28 d.On multivariate logistic regression analysis,lower MELD score [P = 0.01,OR = 1.16(1.04-1.28)] and periendoscopy(8 h) group [P = 0.01,OR = 0.15(0.03-0.68)] were independent predictors of survival at 28 d.The CDI incidence(5.7%) was comparable to that in the general medical population(5%).CONCLUSION:Antibiotics administered up to 8 h following endoscopy were associated with improved survival at 28 d.CDI incidence was comparable to that in other patient groups.展开更多
Inguinodynia(chronic groin pain) is one of the recognised complications of the commonly performed Lichtenstein mesh inguinal hernia repair.This has major impact on quality of life in a significant proportion of patien...Inguinodynia(chronic groin pain) is one of the recognised complications of the commonly performed Lichtenstein mesh inguinal hernia repair.This has major impact on quality of life in a significant proportion of patients.The pain is classif ied as neuropathic and nonneuropathic related to nerve damage and to the mesh,respectively.Correct diagnosis of this problem is relatively difficult.A thorough history and clinical examination are essential,as is a good knowledge of the groin nerve distribution.In spite of the common nature of the problem,the literature evidence is limited.In this paper we discuss the diagnostic tools and treatment options,both non-surgical and surgical.In addition,we discuss the criteria for surgical intervention and its optimal timing.展开更多
AIM:To evaluate the sensitivity(Sn),specificity(Sp),positive predictive value(PPV) and negative predictive value(NPV) of 3 different techniques:high resolution white light endoscopy(WLE),Narrow Band Imaging(NBI) and C...AIM:To evaluate the sensitivity(Sn),specificity(Sp),positive predictive value(PPV) and negative predictive value(NPV) of 3 different techniques:high resolution white light endoscopy(WLE),Narrow Band Imaging(NBI) and Chromoendoscopy(CHR),all with magnification in differentiating adenocarcinomas,adenomatous and hyperplastic colorectal polyps.METHODS:Each polyp was sequentially assessed first by WLE,followed by NBI and finally by CHR.Digital images of each polyp with each modality were taken and stored.Biopsies or polypectomies were then performed followed by blinded histopathological analysis.Each image was blindly graded based on the Kudo's pit pattern(KPP).In the assessment with NBI,the mesh brown capillary network pattern(MBCN) of each polyp was also described.The Sn,Sp,PPV and NPV of differentiating hyperplastic(Type Ⅰ & Ⅱ-KPP,Type Ⅰ-MBCN) adenomatous(Types Ⅲ,Ⅳ-KPP,Type Ⅱ-MBCN) and carcinomatous polyps(Type Ⅴ-KPP,Type Ⅲ-MCBN) was then compared with reference to the final histopathological diagnosis.RESULTS:A total of 50 colorectal polyps(5 adenocarcinomas,38 adenomas,7 hyperplastic) were assessed.CHR and NBI [KPP,MBCN or the combined classification(KPP & MBCN)] were superior to WLE in the prediction of polyp histology(P < 0.001,P=0.002,P=0.001 and P < 0.001,respectively).NBI,using the MBCN pattern or the combined classification showed higher numerical accuracies compared to CHR,but this was not statistically significant(P=0.625,0.250).CONCLUSION:This feasibility study demonstrated that this combined classification with NBI could potentially be useful in routine clinical practice,allowing the endoscopist to predict histology with higher accuracies using a less cumbersome and technically less challenging method.展开更多
AIM: To study the mechanisms by which Campylobacter jejuni (C. jejuni) causes inflammation and diarrhea. In particular, direct interactions with intestinal epithelial cells and effects on barrier function are poorly u...AIM: To study the mechanisms by which Campylobacter jejuni (C. jejuni) causes inflammation and diarrhea. In particular, direct interactions with intestinal epithelial cells and effects on barrier function are poorly under- stood. METHODS: To model the initial pathogenic effects of C. jejuni on intestinal epithelium, polarized human colonic HCA-7 monolayers were grown on permeabilized filters and infected apically with clinical isolates of C. jejuni. Integrity of the monolayer was monitored by changes in monolayer resistance, release of lactate dehydrogenase, mannitol fluxes and electron microscopy. Invasion of HCA-7 cells was assessed by a modified gentamicin protection assay, translocation by counting colony forming units in the basal chamber, stimulation of mediator release by immunoassays and secretory responses in monolayers stimulated by bradykinin in an Ussing chamber. RESULTS: All strains translocated across monolayers but only a minority invaded HCA-7 cells. Strains that invaded HCA-7 cells destroyed monolayer resistance over 6 h, accompanied by increased release of lactate dehydrogenase, a four-fold increase in permeability to [3H] mannitol, and ultrastructural disruption of tight junctions, with rounding and lifting of cells off the filter membrane. Synthesis of interleukin (IL)-8 and prostaglandin E2 was increased with strains that invaded the monolayer but not with those that did not. CONCLUSION: These data demonstrate two distinct effects of C. jejuni on colonic epithelial cells and provide an informative model for further investigation of initial host cell responses to C. jejuni.展开更多
Barrett’s esophagus is a consequence of long standing gastro-esophageal reflux disease and predisposes to the development of esophageal adenocarcinoma. Regular surveillance endoscopies can detect curable early neopla...Barrett’s esophagus is a consequence of long standing gastro-esophageal reflux disease and predisposes to the development of esophageal adenocarcinoma. Regular surveillance endoscopies can detect curable early neoplasia in asymptomatic patients, which in turn could improve the prognosis compared to symptomatic cancer. Early neoplastic lesions, which are amenable for local therapy, could be treated endoscopically, avoiding a major surgery. However, in the absence of obvious mucosal lesions, random four quadrant biopsies are done, which is associated with significant sampling error. Newer imaging modalities, such as autofluorescence endoscopy, are helpful in detecting subtle lesions that could be examined in detail with narrow band imaging to characterize and target biopsies. This has the potential benefit of reducing the number of random biopsies with a better yield of dysplasia. Confocal endomicroscopy provides "optical biopsies" and is a valuable tool in targeting biopsies to improve dysplasia detection; however, this is technically challenging. Fuji intelligent chromoendoscopy and I-Scan are recent additions to the imaging armamentarium that have produced notable early results. While all these additional new imaging techniques are promising, a thorough examination by high resolution white light endoscopy after clearing the mucosa with mucolytics should be the minimum standard to improve dysplasia detection during Barrett’s surveillance.展开更多
We recently read with interest the article,“Novel frontiers of agents for bowel cleansing for colonoscopy”.This is a practical narrative review,which could be of particular importance to clinicians in order to impro...We recently read with interest the article,“Novel frontiers of agents for bowel cleansing for colonoscopy”.This is a practical narrative review,which could be of particular importance to clinicians in order to improve their current practice.Although we appreciate the venture of our colleagues,based on our in-depth analysis,we came across several minor issues in the article;hence,we present our comments in this letter.If the authors consider these comments further in their relevant research,we believe that their contribution would be of considerable importance for future studies.展开更多
BACKGROUND Non-alcoholic fatty liver disease(NAFLD)dominates the landscape of modern hepatology.Affecting 25%of the general population,there is critical unmet need to identify broadly available,safe and cost-effective...BACKGROUND Non-alcoholic fatty liver disease(NAFLD)dominates the landscape of modern hepatology.Affecting 25%of the general population,there is critical unmet need to identify broadly available,safe and cost-effective treatments.Cumulative evidence in animal and human models suggests that intrahepatic and skeletal muscle fatty acid oxidation is impaired in NAFLD,such that lipid accretion is not matched by efficient utilisation.L-carnitine is a crucial mediator of fatty acid metabolism in vivo,promoting mitochondrial lipidβ-oxidation and enhancing tissue metabolic flexibility.These physiological properties have generated research interest in L-carnitine as a potentially effective adjunctive therapy in NAFLD.AIM To systematically review randomised trials reporting effects of dietary L-carnitine supplementation on liver biochemistry,liver fat and insulin sensitivity in NAFLD.METHODS Search strategies,eligibility criteria and analytic methods were specified a priori(PROSPERO reference:CRD42018107063).Ovid MEDLINE,Ovid EMBASE,PubMed,Web of Science and the Cochrane Library were searched from their inception until April 2019.Outcome measures included serum concentrations of alanine and aspartate aminotransferase(ALT and AST),liver fat and insulin sensitivity assessed by the homeostasis model of insulin resistance(HOMA-IR).A random effects meta-analysis was performed for,ALT,AST and HOMA-IR measures separately.Between-study heterogeneity was measured using I2 statistics.RESULTS Five eligible randomised trials were included in the qualitative and quantitative synthesis(n=338).All of the 5 included trials assessed the effect of L-carnitine on serum ALT,identified from Italy,South Korea and Iran.Weighted mean difference(WMD)for ALT between L-carnitine and control groups after intervention was-25.34 IU/L[95%CI:-41.74-(-8.94);P=0.002].WMD for AST between L-carnitine and control groups was-13.68 IU/L(95%CI:-28.26-0.89;P=0.066).In three studies(n=204),HOMA-IR was evaluated.WMD for HOMA-IR between L-carnitine and control groups was-0.74 units[95%CI:-1.02-(-0.46);P<0.001].Two studies using validated outcome measures reported a significant reduction in liver fat in L-carnitine vs control groups post-intervention(P<0.001).CONCLUSION Pooled results indicate that L-carnitine supplementation attenuates ALT,liver fat and insulin resistance in NAFLD cohorts,confirming a beneficial effect of Lcarnitine for a highly prevalent condition with a growing economic burden.展开更多
Aim: Firstly, to quantify active healthcare professional (HCP) time and costs associated with subcutaneous (SC) administration of trastuzumab (Herceptin?) compared with the standard intravenous infusion (IV) in the tr...Aim: Firstly, to quantify active healthcare professional (HCP) time and costs associated with subcutaneous (SC) administration of trastuzumab (Herceptin?) compared with the standard intravenous infusion (IV) in the treatment of patients with HER2-positive early breast cancer within the adjuvant PrefHer trial setting;secondly, to measure patient time in the care unit and patient infusion chair time for both routes of administration. Methods: A UK multi-centre prospective, observational Time and Motion study was conducted alongside the PrefHer trial (ClinicalTrials.gov id: NCT01401166). Trained observers measured the duration of each SC and IV related task that HCPs undertook and recorded patient time in the chemotherapy unit and infusion chair. The type and quantity of medical consumables used with each route of administration were also collected. Twenty-four patient episodes were recorded (12 SC, 12 IV). Mean total administration time was calculated as the mean sum of task times, both for IV and SC formulations. The mean cost of each route of administration was calculated as the mean cost of HCP time plus the mean cost of consumables used. HCP time was costed using Personal Social Services Research Unit. Consumables were costed using hospital pharmacy data and online sources. Results: Mean active HCP time for IV administration was 92.6 minutes compared with 24.6 minutes for SC administration. The mean cost for IV preparation and administration was ￡144.96 (￡132.05 of HCP time and ￡12.92 of consumables) versus ￡33.15 (￡31.99 of HCP time and ￡1.17 of consumables) for SC administration. Mean time spent in the care unit and in the infusion chair was 94.5 minutes and 75 minutes respectively for IV, and 30.3 minutes and 19.8 minutes for SC. SC administration of trastuzumab could translate to a time saving of 68 minutes (versus IV) with a total cost saving of ￡111.81 per patient episode. This equates to a potential saving of ￡2012.58 over a full course of adjuvant treatment (18 cycles). Conclusion: Substituting IV infusion with SC administration of trastuzumab may lead to a substantial reduction in active HCP time, patient chair and unit time, consumable use and overall costs. The reduced patient chair and unit time could provide increased capacity within existing resources.展开更多
AIM To examine treatment decisions of gastroenterologists regarding the choice of prescribing 5-aminosalycilates(5ASA) with corticosteroids(CS) versus corticosteroids alone for patients with active ulcerative colitis(...AIM To examine treatment decisions of gastroenterologists regarding the choice of prescribing 5-aminosalycilates(5ASA) with corticosteroids(CS) versus corticosteroids alone for patients with active ulcerative colitis(UC). METHODS A cross-sectional questionnaire exploring physicians' attitude toward 5ASA + CS combination therapy vs CS alone was developed and validated. The questionnaire was distributed to gastroenterology experts in twelve countries in five continents. Respondents' agreement with stated treatment choices were assessed by standardized Likert scale. Background professional characteristics of respondents were analyzed for correlation with responses. RESULTS Six hundred and sixty-four questionnaires were distributed and 349 received(52.6% response rate). Of 340 eligible respondents, 221(65%) would continue 5ASA in a patient hospitalized for intravenous CS treatment due to a moderate-severe UC flare, while 108(32%) would stop the 5ASA(P < 0.001), and 11(3%) are undecided. Similarly, 62% would continue 5ASA in an out-patient starting oral CS. However, only 140/340(41%) would proactively start 5ASA in a hospitalized patient not receiving 5ASA before admission. Most(94%) physicians consider the safety profile of 5ASA as very good. Only 52% consider them inexpensive, 35% perceive them to be expensive and 12% are undecided. On multi-variable analysis, less years of practice and perception of a plausible additive mechanistic effect of 5ASA + CS were positively associated with the decision to continue 5ASA with CS. CONCLUSION Despite the absence of data supporting its benefit, most gastroenterologists endorse combination of 5ASA + CS for patients with active moderate-to-severe UC. Randomized controlled trials are needed to assess if 5ASA confer any benefit for these patients.展开更多
Background: Forearm fractures amongst children are quite a common presentation. The accuracy of correct alignment in forearm bones is important as it determines the degree of forearm rotation (pronation-supination). H...Background: Forearm fractures amongst children are quite a common presentation. The accuracy of correct alignment in forearm bones is important as it determines the degree of forearm rotation (pronation-supination). However in children due to the potential for continuous growth, a degree of angulation is acceptable. The aim of this study was to determine the effect of angulation of forearm fracture on forearm rotation using computer stimulation. Methods: Using a 3D computer modelling software (Wildfire Pro Engineer 4.0, Creo by PTC, Needham, MA), an accurate to scale model of the radius and ulna was replicated from a 7 year old forearm. A realistic representation of pronation/supination of the forearm was applied and a fracture at the junction of proximal one third and distal two third was created. A rotational simulation was created and ended when maximum pronation and supination was reached. Maximum pronation and supination was reached when either no more rotation could occur due to a misalignment of the radius and ulna or there was a collision of the bones. The simulation was repeated in increments of angulation of 2° up to 26°. The angulations that resulted in a combined range of motion (50° pronation and 80° supination) less than 130° were recorded as unacceptable and the others were as acceptable. Findings: The study showed that radius angulation fracture of >16° in the proximal third of the radius would result in an unacceptable reduction of pronation-supination to less than 130°. Conclusion: Patients with more >16° of radius angulation in a distal third shaft fracture of the radius may result in clinical reduction in forearm rotation.展开更多
文摘Endoscopic resection(ER)of colorectal polyps has become a daily practice in most endoscopic units providing a colorectal cancer screening program and requires the availability of local experts and high-end endoscopic devices.ER procedures have evolved over the past few years from endoscopic mucosal resection(EMR)to more advanced techniques,such as endoscopic submucosal dissection and endo-scopic full-thickness resection.Complete resection and disease eradication are the ultimate goals of ER-based techniques,and novel devices have been developed to achieve these goals.The EndoRotor®Endoscopic Powered Resection System(Interscope Medical,Inc.,Northbridge,Massachusetts,United States)is one such device.The EndoRotor is a powered resection tool for the removal of alimentary tract mucosa,including post-EMR persistent lesions with scarring,and has both CE Mark and FDA clearance.This review covers available published evidence documenting the usefulness of EndoRotor for the management of recurrent colorectal polyps.
文摘Amyloidosis is a rare spectrum of disease which involves deposition of misfolded extracellular proteins (amyloids) in various body organs leading to progressive organ dysfunction. Clinical presentation can be variable depending on the organ involved and type of protein. Amyloidosis can be classified based on quantity, type, and location of these proteins. Amyloid light-chain amyloidosis develops in the bone marrow, producing abnormal forms of light-chain proteins, which cannot be broken down. These proteins transform into amyloid fibrils and form amyloid deposits in different organs. Pulmonary amyloidosis is uncommonly diagnosed since it is rarely symptomatic. Diagnosis of pulmonary amyloidosis is usually made in the setting of systemic amyloidosis;however, it may present as localised pulmonary disease. Localized pulmonary Amyloidosis can present as nodular, cystic, or tracheobronchial amyloidosis. Depending on the degree of the interstitial involvement, it may affect alveolar gas exchange and cause respiratory symptoms. This is a case of a 47-year-old female with background history of interstitial lung disease presenting with progressive shortness of breath. Computed tomography scan revealed bilateral pulmonary nodules. The patient was referred to our thoracic surgery team with the suspicion of bronchogenic malignancy with metastasis. Diagnostic video assisted wedge resection was performed for this patient, and histology confirmed pulmonary amyloidosis of nodular type. Amyloid deposition simulates both inflammatory and neoplastic conditions. Definitive diagnosis requires biopsy confirmation therefore early detection and commencing the patient on appropriate treatment pathway may help in symptomatic relief and better outcome.
文摘AIM:To evaluate the outcomes of endoscopic mucosal resection(EMR) for colorectal polyps,with particular regard to procedural complications and recurrence rate,in typical United Kingdom(UK) hospitals that perform an average of about 25 colonic EMRs per year.METHODS:A total of 239 colorectal polyps(≥ 10 mm) resected from 199 patients referred to Rochdale Infirmary,Salford Royal Hospital and Royal Oldham Hospital for EMR between January 2003 and January 2009 were studied.RESULTS:The mean size of polyps resected was 19.6 ± 12.4 mm(range 10-80 mm).The overall major complication rate was 2.1%.Complications were less frequent with non-adenomas compared with the other groups(Pearson's χ 2 test,P < 0.0001).Resections of largersized polyps were more likely to result in complications(unpaired t-test,P = 0.021).Recurrence was associated with histology,with carcinoma-in-situ more likely to recur compared with low-grade dysplasia [hazard ratio(HR) 186.7,95% confidence interval(95% CI):8.81-3953.02,P = 0.001].Distal lesions were also more likely to recur compared with right-sided and transverse colon lesions(HR 5.93,95% CI:1.35-26.18,P = 0.019).CONCLUSION:EMR for colorectal polyps can be performed safely and effectively in typical UK hospitals.Stricter follow-up is required for histologically advanced lesions due to increased recurrence risk.
文摘Myeloproliferative neoplasms(MPNs)are defined as clonal disorders of the hematopoietic stem cell in which an exaggerated production of terminally differentiated myeloid cells occurs.Classical,Philadelphia-negative MPNs,i.e.,polycythemia vera,essential thrombocythemia and primary myelofibrosis,exhibit a propensity towards the development of thrombotic complications that can occur in unusual sites,e.g.,portal,splanchnic or hepatic veins,the placenta or cerebral sinuses.The pathogenesis of thrombotic events in MPNs is complex and requires an intricate mechanism involving endothelial injury,stasis,elevated leukocyte adhesion,integrins,neutrophil extracellular traps,somatic mutations(e.g.,the V617F point mutation in the JAK2 gene),microparticles,circulating endothelial cells,and other factors,to name a few.Herein,we review the available data on Budd-Chiari syndrome in Philadelphia-negative MPNs,with a particular focus on its epidemiology,pathogenesis,histopathology,risk factors,classification,clinical presentation,diagnosis,and management.
文摘BACKGROUND The popularity of uncemented stems in revision total hip arthroplasty(THA)has increased in the last decade.AIM To assess the outcomes of both cemented and uncemented stems after mid-term follow up.METHODS This study was performed following both the Preferred Reporting Items for Systematic Reviews and Meta-analyses Statement and the Cochrane Handbook for systematic reviews and meta-analysis guidelines.Articles were chosen irrespective of country of origin or language utilized for the article full texts.This paper included studies that reviewed revision THA for both cemented or uncemented long stems.RESULTS Three eligible studies were included in the meta-analysis.Analysis was conducted by using Review Manager version 5.3.We computed the risk ratio as a measure of the treatment effect,taking into account heterogeneity.We used random-effect models.There were no significant differences found for intraoperative periprosthetic fractures[risk ratio(RR)=1.25;95%confidence interval(CI):0.29-5.32;P=0.76],aseptic loosening(RR=2.15,95%CI:0.81-5.70;P=0.13),dislocation rate(RR=0.50;95%CI:0.10-2.47;P=0.39),or infection rate(RR=0.99,95%CI:0.82-1.19;P=0.89),between the uncemented and the cemented long stems for revision THA after mid-term follow-up.CONCLUSION This study has evaluated the mid-term outcomes of both cemented and uncemented stems at first-time revision THA.In summary,there were no significant differences in the dislocation rate,aseptic loosening,intraoperative periprosthetic fracture and infection rate between the two cohorts.
基金Matilde Monteiro-Soares的工作由国家基金通过FCT Fundacao para a Ciência e a Technology,I.P.在“RISE-LA/P/0053/2020”项目范围内资助Emma Hamilton得到了雷恩医学研究基金会临床医生研究奖学金的支持David Russell得到了国家卫生研究院(NIHR300633)的高级奖学金的支持
文摘AIM To analyse the effect of mechanical bowel preparation vs no mechanical bowel preparation on outcome in patients undergoing elective colorectal surgery.METHODS Meta-analysis of randomised controlled trials and observational studies comparing adult patients receiving mechanical bowel preparation with those receiving no mechanical bowel preparation, subdivided into those receiving a single rectal enema and those who received no preparation at all prior to elective colorectal surgery. RESULTS A total of 36 studies(23 randomised controlled trials and 13 observational studies) including 21568 patients undergoing elective colorectal surgery were included. When all studies were considered, mechanical bowel preparation was not associated with any significant difference in anastomotic leak rates(OR = 0.90, 95%CI: 0.74 to 1.10, P = 0.32), surgical site infection(OR = 0.99, 95%CI: 0.80 to 1.24, P = 0.96), intraabdominal collection(OR = 0.86, 95%CI: 0.63 to 1.17, P = 0.34), mortality(OR = 0.85, 95%CI: 0.57 to 1.27, P = 0.43), reoperation(OR = 0.91, 95%CI: 0.75 to 1.12, P = 0.38) or hospital length of stay(overall mean difference 0.11 d, 95%CI:-0.51 to 0.73, P = 0.72), when compared with no mechanical bowel preparation, nor when evidence from just randomized controlledtrials was analysed. A sub-analysis of mechanical bowel preparation vs absolutely no preparation or a single rectal enema similarly revealed no differences in clinical outcome measures. CONCLUSION In the most comprehensive meta-analysis of mechanical bowel preparation in elective colorectal surgery to date, this study has suggested that the use of mechanical bowel preparation does not affect the incidence of postoperative complications when compared with no preparation. Hence, mechanical bowel preparation should not be administered routinely prior to elective colorectal surgery.
文摘Chronic Groin Pain (Inguinodynia) following inguinal hernia repair is a significant,though under-reported problem. Mild pain lasting for a few days is common following mesh inguinal hernia repair. However,moderate to severe pain persisting more than 3 mo after inguinal herniorrhaphy should be considered as pathological. The major reasons for chronic groin pain have been identified as neuropathic cause due to inguinal nerve(s) damage or non-neuropathic cause due to mesh or other related factors. The symptom complex of chronic groin pain varies from a dull ache to sharp shooting pain along the distribution of inguinal nerves. Thorough history and meticulous clinical examination should be performed to identify the exact cause of chronic groin pain,as there is no single test to confirm the aetiology behind the pain or to point out the exact nerve involved. Various studies have been performed to look at the difference in chronic groin pain rates with the use of mesh vs non-mesh repair,use of heavyweight vs lightweight mesh and mesh fixation with sutures vs glue. Though there is no convincing evidence favouring one over the other,lightweight meshes are generally preferred because of their lesser foreign body reaction and better tolerance by the patients. Identification of all three nerves has been shown to be an important factor in reducing chronic groin pain,though there are no well conducted randomised studies to recommend the benefits of nerve excision vs preservation. Both nonsurgical and surgical options have been tried for chronic groin pain,with their consequent risks of analgesic sideeffects,recurrent pain,recurrent hernia and significant sensory loss. By far the best treatment for chronic groin pain is to avoid bestowing this on the patient by careful intra-operative handling of inguinal structures and better patient counselling pre-and post-herniorraphy.
文摘Cardiovascular disease including stroke is a major complication that tremendously increases the morbidity and mortality in patients with diabetes mellitus(DM). DM poses about four times higher risk for stroke. Cardiometabolic risk factors including obesity, hypertension, and dyslipidaemia often co-exist in patients with DM that add on to stroke risk. Because of the strong association between DM and other stroke risk factors, physicians and diabetologists managing patients should have thorough understanding of these risk factors and management. This review is an evidence-based approach to the epidemiological aspects, pathophysiology, diagnostic work up and management algorithms for patients with diabetes and stroke.
文摘AIM:To investigate if antibiotics administered within 8 h of endoscopy reduce mortality or increase the incidence of Clostridium difficile infection(CDI).METHODS:A 2-year retrospective analysis of all patients who presented with first variceal hemorrhage was undertaken.The primary outcome measure was 28-d mortality.Secondary outcome measures were 28-d rebleeding rates and 28-d incidence of CDI.All patients were admitted to a tertiary liver unit with a consultantled,24-h endoscopy service.Patients received standard care including terlipressin therapy.Data collection included:primary and secondary outcome measures,timing of first administration of intravenous antibiotics,eti-ology of liver disease,demographics,endoscopy details and complications.A prospective study was undertaken to determine the incidence of CDI in the study population and general medical inpatients admitted for antibiotic therapy of at least 5 d duration.Statistical analysis was undertaken using univariate,non-parametric tests and multivariate logistic regression analysis.RESULTS:There were 70 first presentations of variceal hemorrhage during the study period.Seventy percent of cases were male and 65.7% were due to chronic alcoholic liver disease.In total,64/70(91.4%) patients received antibiotics as prophylaxis during their admission.Specifically,53/70(75.7%) received antibiotics either before endoscopy or within 8 h of endoscopy [peri-endoscopy(8 h) group],whereas 17/70(24.3%) received antibiotics at > 8 h after endoscopy or not at all(non peri-endoscopy group).Overall mortality and rebleeding rates were 13/70(18.6%) and 14/70(20%),respectively.The periendoscopy(8 h) group was significantly less likely to die compared with the non peri-endoscopy group [13.2% vs 35.3%,P = 0.04,odds ratio(OR) = 0.28(0.078-0.997)] and showed a trend towards reduced rebleeding [17.0% vs 29.4%,P = 0.27,OR = 0.49(0.14-1.74)].On univariate analysis,the non peri-endoscopy group [P = 0.02,OR = 3.58(1.00-12.81)],higher model for end-stage liver disease(MELD) score(P = 0.02),presence of hepatorenal syndrome [P < 0.01,OR = 11.25(2.24-56.42)] and suffering a clinical episode of sepsis [P = 0.03,OR = 4.03(1.11-14.58)] were significant predictors of death at 28 d.On multivariate logistic regression analysis,lower MELD score [P = 0.01,OR = 1.16(1.04-1.28)] and periendoscopy(8 h) group [P = 0.01,OR = 0.15(0.03-0.68)] were independent predictors of survival at 28 d.The CDI incidence(5.7%) was comparable to that in the general medical population(5%).CONCLUSION:Antibiotics administered up to 8 h following endoscopy were associated with improved survival at 28 d.CDI incidence was comparable to that in other patient groups.
文摘Inguinodynia(chronic groin pain) is one of the recognised complications of the commonly performed Lichtenstein mesh inguinal hernia repair.This has major impact on quality of life in a significant proportion of patients.The pain is classif ied as neuropathic and nonneuropathic related to nerve damage and to the mesh,respectively.Correct diagnosis of this problem is relatively difficult.A thorough history and clinical examination are essential,as is a good knowledge of the groin nerve distribution.In spite of the common nature of the problem,the literature evidence is limited.In this paper we discuss the diagnostic tools and treatment options,both non-surgical and surgical.In addition,we discuss the criteria for surgical intervention and its optimal timing.
文摘AIM:To evaluate the sensitivity(Sn),specificity(Sp),positive predictive value(PPV) and negative predictive value(NPV) of 3 different techniques:high resolution white light endoscopy(WLE),Narrow Band Imaging(NBI) and Chromoendoscopy(CHR),all with magnification in differentiating adenocarcinomas,adenomatous and hyperplastic colorectal polyps.METHODS:Each polyp was sequentially assessed first by WLE,followed by NBI and finally by CHR.Digital images of each polyp with each modality were taken and stored.Biopsies or polypectomies were then performed followed by blinded histopathological analysis.Each image was blindly graded based on the Kudo's pit pattern(KPP).In the assessment with NBI,the mesh brown capillary network pattern(MBCN) of each polyp was also described.The Sn,Sp,PPV and NPV of differentiating hyperplastic(Type Ⅰ & Ⅱ-KPP,Type Ⅰ-MBCN) adenomatous(Types Ⅲ,Ⅳ-KPP,Type Ⅱ-MBCN) and carcinomatous polyps(Type Ⅴ-KPP,Type Ⅲ-MCBN) was then compared with reference to the final histopathological diagnosis.RESULTS:A total of 50 colorectal polyps(5 adenocarcinomas,38 adenomas,7 hyperplastic) were assessed.CHR and NBI [KPP,MBCN or the combined classification(KPP & MBCN)] were superior to WLE in the prediction of polyp histology(P < 0.001,P=0.002,P=0.001 and P < 0.001,respectively).NBI,using the MBCN pattern or the combined classification showed higher numerical accuracies compared to CHR,but this was not statistically significant(P=0.625,0.250).CONCLUSION:This feasibility study demonstrated that this combined classification with NBI could potentially be useful in routine clinical practice,allowing the endoscopist to predict histology with higher accuracies using a less cumbersome and technically less challenging method.
基金Supported by The Medical Research Council (UK), No. G9716348
文摘AIM: To study the mechanisms by which Campylobacter jejuni (C. jejuni) causes inflammation and diarrhea. In particular, direct interactions with intestinal epithelial cells and effects on barrier function are poorly under- stood. METHODS: To model the initial pathogenic effects of C. jejuni on intestinal epithelium, polarized human colonic HCA-7 monolayers were grown on permeabilized filters and infected apically with clinical isolates of C. jejuni. Integrity of the monolayer was monitored by changes in monolayer resistance, release of lactate dehydrogenase, mannitol fluxes and electron microscopy. Invasion of HCA-7 cells was assessed by a modified gentamicin protection assay, translocation by counting colony forming units in the basal chamber, stimulation of mediator release by immunoassays and secretory responses in monolayers stimulated by bradykinin in an Ussing chamber. RESULTS: All strains translocated across monolayers but only a minority invaded HCA-7 cells. Strains that invaded HCA-7 cells destroyed monolayer resistance over 6 h, accompanied by increased release of lactate dehydrogenase, a four-fold increase in permeability to [3H] mannitol, and ultrastructural disruption of tight junctions, with rounding and lifting of cells off the filter membrane. Synthesis of interleukin (IL)-8 and prostaglandin E2 was increased with strains that invaded the monolayer but not with those that did not. CONCLUSION: These data demonstrate two distinct effects of C. jejuni on colonic epithelial cells and provide an informative model for further investigation of initial host cell responses to C. jejuni.
文摘Barrett’s esophagus is a consequence of long standing gastro-esophageal reflux disease and predisposes to the development of esophageal adenocarcinoma. Regular surveillance endoscopies can detect curable early neoplasia in asymptomatic patients, which in turn could improve the prognosis compared to symptomatic cancer. Early neoplastic lesions, which are amenable for local therapy, could be treated endoscopically, avoiding a major surgery. However, in the absence of obvious mucosal lesions, random four quadrant biopsies are done, which is associated with significant sampling error. Newer imaging modalities, such as autofluorescence endoscopy, are helpful in detecting subtle lesions that could be examined in detail with narrow band imaging to characterize and target biopsies. This has the potential benefit of reducing the number of random biopsies with a better yield of dysplasia. Confocal endomicroscopy provides "optical biopsies" and is a valuable tool in targeting biopsies to improve dysplasia detection; however, this is technically challenging. Fuji intelligent chromoendoscopy and I-Scan are recent additions to the imaging armamentarium that have produced notable early results. While all these additional new imaging techniques are promising, a thorough examination by high resolution white light endoscopy after clearing the mucosa with mucolytics should be the minimum standard to improve dysplasia detection during Barrett’s surveillance.
文摘We recently read with interest the article,“Novel frontiers of agents for bowel cleansing for colonoscopy”.This is a practical narrative review,which could be of particular importance to clinicians in order to improve their current practice.Although we appreciate the venture of our colleagues,based on our in-depth analysis,we came across several minor issues in the article;hence,we present our comments in this letter.If the authors consider these comments further in their relevant research,we believe that their contribution would be of considerable importance for future studies.
文摘BACKGROUND Non-alcoholic fatty liver disease(NAFLD)dominates the landscape of modern hepatology.Affecting 25%of the general population,there is critical unmet need to identify broadly available,safe and cost-effective treatments.Cumulative evidence in animal and human models suggests that intrahepatic and skeletal muscle fatty acid oxidation is impaired in NAFLD,such that lipid accretion is not matched by efficient utilisation.L-carnitine is a crucial mediator of fatty acid metabolism in vivo,promoting mitochondrial lipidβ-oxidation and enhancing tissue metabolic flexibility.These physiological properties have generated research interest in L-carnitine as a potentially effective adjunctive therapy in NAFLD.AIM To systematically review randomised trials reporting effects of dietary L-carnitine supplementation on liver biochemistry,liver fat and insulin sensitivity in NAFLD.METHODS Search strategies,eligibility criteria and analytic methods were specified a priori(PROSPERO reference:CRD42018107063).Ovid MEDLINE,Ovid EMBASE,PubMed,Web of Science and the Cochrane Library were searched from their inception until April 2019.Outcome measures included serum concentrations of alanine and aspartate aminotransferase(ALT and AST),liver fat and insulin sensitivity assessed by the homeostasis model of insulin resistance(HOMA-IR).A random effects meta-analysis was performed for,ALT,AST and HOMA-IR measures separately.Between-study heterogeneity was measured using I2 statistics.RESULTS Five eligible randomised trials were included in the qualitative and quantitative synthesis(n=338).All of the 5 included trials assessed the effect of L-carnitine on serum ALT,identified from Italy,South Korea and Iran.Weighted mean difference(WMD)for ALT between L-carnitine and control groups after intervention was-25.34 IU/L[95%CI:-41.74-(-8.94);P=0.002].WMD for AST between L-carnitine and control groups was-13.68 IU/L(95%CI:-28.26-0.89;P=0.066).In three studies(n=204),HOMA-IR was evaluated.WMD for HOMA-IR between L-carnitine and control groups was-0.74 units[95%CI:-1.02-(-0.46);P<0.001].Two studies using validated outcome measures reported a significant reduction in liver fat in L-carnitine vs control groups post-intervention(P<0.001).CONCLUSION Pooled results indicate that L-carnitine supplementation attenuates ALT,liver fat and insulin resistance in NAFLD cohorts,confirming a beneficial effect of Lcarnitine for a highly prevalent condition with a growing economic burden.
文摘Aim: Firstly, to quantify active healthcare professional (HCP) time and costs associated with subcutaneous (SC) administration of trastuzumab (Herceptin?) compared with the standard intravenous infusion (IV) in the treatment of patients with HER2-positive early breast cancer within the adjuvant PrefHer trial setting;secondly, to measure patient time in the care unit and patient infusion chair time for both routes of administration. Methods: A UK multi-centre prospective, observational Time and Motion study was conducted alongside the PrefHer trial (ClinicalTrials.gov id: NCT01401166). Trained observers measured the duration of each SC and IV related task that HCPs undertook and recorded patient time in the chemotherapy unit and infusion chair. The type and quantity of medical consumables used with each route of administration were also collected. Twenty-four patient episodes were recorded (12 SC, 12 IV). Mean total administration time was calculated as the mean sum of task times, both for IV and SC formulations. The mean cost of each route of administration was calculated as the mean cost of HCP time plus the mean cost of consumables used. HCP time was costed using Personal Social Services Research Unit. Consumables were costed using hospital pharmacy data and online sources. Results: Mean active HCP time for IV administration was 92.6 minutes compared with 24.6 minutes for SC administration. The mean cost for IV preparation and administration was ￡144.96 (￡132.05 of HCP time and ￡12.92 of consumables) versus ￡33.15 (￡31.99 of HCP time and ￡1.17 of consumables) for SC administration. Mean time spent in the care unit and in the infusion chair was 94.5 minutes and 75 minutes respectively for IV, and 30.3 minutes and 19.8 minutes for SC. SC administration of trastuzumab could translate to a time saving of 68 minutes (versus IV) with a total cost saving of ￡111.81 per patient episode. This equates to a potential saving of ￡2012.58 over a full course of adjuvant treatment (18 cycles). Conclusion: Substituting IV infusion with SC administration of trastuzumab may lead to a substantial reduction in active HCP time, patient chair and unit time, consumable use and overall costs. The reduced patient chair and unit time could provide increased capacity within existing resources.
文摘AIM To examine treatment decisions of gastroenterologists regarding the choice of prescribing 5-aminosalycilates(5ASA) with corticosteroids(CS) versus corticosteroids alone for patients with active ulcerative colitis(UC). METHODS A cross-sectional questionnaire exploring physicians' attitude toward 5ASA + CS combination therapy vs CS alone was developed and validated. The questionnaire was distributed to gastroenterology experts in twelve countries in five continents. Respondents' agreement with stated treatment choices were assessed by standardized Likert scale. Background professional characteristics of respondents were analyzed for correlation with responses. RESULTS Six hundred and sixty-four questionnaires were distributed and 349 received(52.6% response rate). Of 340 eligible respondents, 221(65%) would continue 5ASA in a patient hospitalized for intravenous CS treatment due to a moderate-severe UC flare, while 108(32%) would stop the 5ASA(P < 0.001), and 11(3%) are undecided. Similarly, 62% would continue 5ASA in an out-patient starting oral CS. However, only 140/340(41%) would proactively start 5ASA in a hospitalized patient not receiving 5ASA before admission. Most(94%) physicians consider the safety profile of 5ASA as very good. Only 52% consider them inexpensive, 35% perceive them to be expensive and 12% are undecided. On multi-variable analysis, less years of practice and perception of a plausible additive mechanistic effect of 5ASA + CS were positively associated with the decision to continue 5ASA with CS. CONCLUSION Despite the absence of data supporting its benefit, most gastroenterologists endorse combination of 5ASA + CS for patients with active moderate-to-severe UC. Randomized controlled trials are needed to assess if 5ASA confer any benefit for these patients.
文摘Background: Forearm fractures amongst children are quite a common presentation. The accuracy of correct alignment in forearm bones is important as it determines the degree of forearm rotation (pronation-supination). However in children due to the potential for continuous growth, a degree of angulation is acceptable. The aim of this study was to determine the effect of angulation of forearm fracture on forearm rotation using computer stimulation. Methods: Using a 3D computer modelling software (Wildfire Pro Engineer 4.0, Creo by PTC, Needham, MA), an accurate to scale model of the radius and ulna was replicated from a 7 year old forearm. A realistic representation of pronation/supination of the forearm was applied and a fracture at the junction of proximal one third and distal two third was created. A rotational simulation was created and ended when maximum pronation and supination was reached. Maximum pronation and supination was reached when either no more rotation could occur due to a misalignment of the radius and ulna or there was a collision of the bones. The simulation was repeated in increments of angulation of 2° up to 26°. The angulations that resulted in a combined range of motion (50° pronation and 80° supination) less than 130° were recorded as unacceptable and the others were as acceptable. Findings: The study showed that radius angulation fracture of >16° in the proximal third of the radius would result in an unacceptable reduction of pronation-supination to less than 130°. Conclusion: Patients with more >16° of radius angulation in a distal third shaft fracture of the radius may result in clinical reduction in forearm rotation.
