BACKGROUND Pancreaticoduodenectomy(PD)is a technically complex operation,with a re-latively high risk for complications.The ability to rescue patients from post-PD complications is as a recognized quality measure.Tail...BACKGROUND Pancreaticoduodenectomy(PD)is a technically complex operation,with a re-latively high risk for complications.The ability to rescue patients from post-PD complications is as a recognized quality measure.Tailored protocols were instituted at our low volume facility in the year 2013.AIM To document the rate of rescue from post-PD complications with tailored protocols in place as a measure of quality.METHODS A retrospective audit was performed to collect data from patients who experienced major post-PD complications at a low volume pancreatic surgery unit in Trinidad and Tobago between January 1,2013 and June 30,2023.Stan-dardized definitions from the International Study Group of Pancreatic Surgery were used to define post-PD complications,and the modified Clavien-Dindo classification was used to classify post-PD complications.RESULTS Over the study period,113 patients at a mean age of 57.5 years(standard deviation[SD]±9.23;range:30-90;median:56)underwent PDs at this facility.Major complications were recorded in 33(29.2%)patients at a mean age of 53.8 years(SD:±7.9).Twenty-nine(87.9%)patients who experienced major morbidity were salvaged after aggre-ssive treatment of their complication.Four(3.5%)died from bleeding pseudoaneurysm(1),septic shock secondary to a bile leak(1),anastomotic leak(1),and myocardial infarction(1).There was a significantly greater salvage rate in patients with American Society of Anesthesiologists scores≤2(93.3%vs 25%;P=0.0024).CONCLUSION This paper adds to the growing body of evidence that volume alone should not be used as a marker of quality for patients requiring PD.Despite low volumes at our facility,we demonstrated that 87.9%of patients were rescued from major complications.We attributed this to several factors including development of rescue protocols,the competence of the pancreatic surgery teams and continuous,and adaptive learning by the entire institution,cul-minating in the development of tailored peri-pancreatectomy protocols.展开更多
AIM:To report the outcomes of three cases of corneal perforation managed with simultaneous tectonic Descemet stripping endothelial keratoplasty(t-DSEK)and tectonic Bowman layer transplant(t-BLT)as an alternative to te...AIM:To report the outcomes of three cases of corneal perforation managed with simultaneous tectonic Descemet stripping endothelial keratoplasty(t-DSEK)and tectonic Bowman layer transplant(t-BLT)as an alternative to tectonic penetrating keratoplasty(t-PKP).METHODS:Three eyes of three patients receiving simultaneous t-DSEK and t-BLT for corneal perforation were included.The technique for DSEK was modified depending on individual requirements.The t-BLT technique was standardised using an 8 mm graft and fixated with a running suture.Success was measured by the ability of this procedure to close a corneal perforation.RESULTS:All three cases achieved tectonic eye globe restoration and remained stable during the minimum 3-month observation period.Reinterventions were relatively common:2 cases required amniotic membrane transplant for persistent epithelial defects.One case required DSEK rebubbling.One case developed angle closure glaucoma requiring surgical peripheral iridectomy.CONCLUSION:Simultaneous t-DSEK and t-BLT may be a useful strategy for the management of corneal perforation as an alternative management to t-PKP for selected cases.展开更多
BACKGROUND Evidence-based guidance on return to sport following toe phalanx fractures is limited.AIM To systemically review all studies recording return to sport following toe phalanx fractures(both acute fractures an...BACKGROUND Evidence-based guidance on return to sport following toe phalanx fractures is limited.AIM To systemically review all studies recording return to sport following toe phalanx fractures(both acute fractures and stress fractures),and to collate information on return rates to sport(RRS)and mean return times(RTS)to the sport.METHODS A systematic search of PubMed,MEDLINE,EMBASE,CINAHL,Cochrane Library,Physiotherapy Evidence Database,and Google Scholar was performed in December 2022 using the keywords‘Toe’,‘Phalanx’,‘Fracture’,‘injury’,‘athletes’,‘sports’,‘non-operative’,‘conservative’,‘operative’,‘return to sport’.All studies which recorded RRS and RTS following toe phalanx fractures were included.RESULTS Thirteen studies were included:one retrospective cohort study and twelve case series.Seven studies reported on acute fractures.Six studies reported on stress fractures.For the acute fractures(n=156),63 were treated with primary conservative management(PCM),6 with primary surgical management(PSM)(all displaced intra-articular(physeal)fractures of the great toe base of the proximal phalanx),1 with secondary surgical management(SSM)and 87 did not specify treatment modality.For the stress fractures(n=26),23 were treated with PCM,3 with PSM,and 6 with SSM.For acute fractures,RRS with PCM ranged from 0 to 100%,and RTS with PCM ranged from 1.2 to 24 wk.For acute fractures,RRS with PSM were all 100%,and RTS with PSM ranged from 12 to 24 wk.One case of an undisplaced intra-articular(physeal)fracture treated conservatively required conversion to SSM on refracture with a return to sport.For stress fractures,RRS with PCM ranged from 0%to 100%,and RTS with PCM ranged from 5 to 10 wk.For stress fractures,RRS with PSM were all 100%,and RTS with surgical management ranged from 10 to 16 wk.Six cases of conservatively-managed stress fractures required conversion to SSM.Two of these cases were associated with a prolonged delay to diagnosis(1 year,2 years)and four cases with an underlying deformity[hallux valgus(n=3),claw toe(n=1)].All six cases returned to the sport after SSM.CONCLUSION The majority of sport-related toe phalanx fractures(acute and stress)are managed conservatively with overall satisfactory RRS and RTS.For acute fractures,surgical management is indicated for displaced,intra-articular(physeal)fractures,which offers satisfactory RRS and RTS.For stress fractures,surgical management is indicated for cases with delayed diagnosis and established nonunion at presentation,or with significant underlying deformity:both can expect satisfactory RRS and RTS.展开更多
Hepatocellular carcinoma(HCC)arises on the background of chronic liver disease.Despite the development of effective anti-viral therapeutics HCC is continuing to rise,in part driven by the epidemic of non-alcoholic fat...Hepatocellular carcinoma(HCC)arises on the background of chronic liver disease.Despite the development of effective anti-viral therapeutics HCC is continuing to rise,in part driven by the epidemic of non-alcoholic fatty liver disease.Many patients present with advanced disease out with the criteria for transplant,resection or even locoregional therapy.Currently available therapeutics for HCC are effective in a small minority of individuals.However,there has been a major global interest in immunotherapies for cancer and although HCC has lagged behind other cancers,great opportunities now exist for treating HCC with newer and more sophisticated agents.Whilst checkpoint inhibitors are at the forefront of this revolution,other therapeutics such as inhibitory cytokine blockade,oncolytic viruses,adoptive cellular therapies and vaccines are emerging.Broadly these may be categorized as either boosting existing immune response or stimulating de novo immune response.Although some of these agents have shown promising results as monotherapy in early phase trials it may well be that their future role will be as combination therapy,either in combination with one another or in combination with treatment modalities such as locoregional therapy.Together these agents are likely to generate new and exciting opportunities for treating HCC,which are summarized in this review.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
BACKGROUND Many authorities advocate for Whipple’s procedures to be performed in highvolume centers,but many patients in poor developing nations cannot access these centers.We sought to determine whether clinical out...BACKGROUND Many authorities advocate for Whipple’s procedures to be performed in highvolume centers,but many patients in poor developing nations cannot access these centers.We sought to determine whether clinical outcomes were acceptable when Whipple’s procedures were performed in a low-volume,resource-poor setting in the West Indies.AIM To study outcomes of Whipple’s procedures in a pancreatic unit in the West Indies over an eight-year period from June 1,2013 to June 30,2021.METHODS This was a retrospective study of all patients undergoing Whipple’s procedures in a pancreatic unit in the West Indies over an eight-year period from June 1,2013 to June 30,2021.RESULTS This center performed an average of 11.25 procedures per annum.There were 72 patients in the final study population at a mean age of 60.2 years,with 52.7%having American Society of Anesthesiologists scores≥III and 54.1%with Eastern Cooperative Oncology Group scores≥2.Open Whipple’s procedures were performed in 70 patients and laparoscopic assisted procedures in 2.Portal vein resection/reconstruction was performed in 19(26.4%)patients.In patients undergoing open procedures there was 367±54.1 min mean operating time,1394±656.8 mL mean blood loss,5.24±7.22 d mean intensive care unit stay and 15.1±9.53 d hospitalization.Six(8.3%)patients experienced minor morbidity,10(14%)major morbidity and there were 4(5.5%)deaths.CONCLUSION This paper adds to the growing body of evidence that volume alone should not be used as a marker of quality for patients requiring Whipple’s procedures.Low volume centers in resource poor nations can achieve good short-term outcomes.This is largely due to the process of continuous,adaptive learning by the entire hospital.展开更多
The symptom of cancer most feared by many patients is pain. The physical and psychological distress of constant pain without relief should not be underestimated, and all complaints of pain should be actively treated. ...The symptom of cancer most feared by many patients is pain. The physical and psychological distress of constant pain without relief should not be underestimated, and all complaints of pain should be actively treated. The clinician should not forget however that drugs used in the treatment展开更多
Conventional data suggest that complex operations,such as a pancreaticoduodenectomy(PD),should be limited to high volume centers.However,this is not practical in small,resource-poor countries in the Caribbean.In these...Conventional data suggest that complex operations,such as a pancreaticoduodenectomy(PD),should be limited to high volume centers.However,this is not practical in small,resource-poor countries in the Caribbean.In these settings,patients have no option but to have their PDs performed locally at low volumes,occasionally by general surgeons.In this paper,we review the evolution of the concept of the high-volume center and discuss the feasibility of applying this concept to low and middle-income nations.Specifically,we discuss a modification of this concept that may be considered when incorporating PD into low-volume and resource-poor countries,such as those in the Caribbean.This paper has two parts.First,we performed a literature review evaluating studies published on outcomes after PD in high volume centers.The data in the Caribbean is then examined and we discuss the incorporation of this operation into resource-poor hospitals with modifications of the centralization concept.In the authors’opinions,most patients who require PD in the Caribbean do not have realistic opportunities to have surgery in high-volume centers in developed countries.In these settings,their only options are to have their operations in the resource-poor,low-volume settings in the Caribbean.However,post-operative outcomes may be improved,despite low-volumes,if a modified centralization concept is encouraged.展开更多
AIM:To investigate and characterise patients with chronic hepatitis C virus(HCV) infection presenting with hepatocellular carcinoma(HCC) in the absence of cirrhosis.METHODS:Patients with chronic hepatitis C infection ...AIM:To investigate and characterise patients with chronic hepatitis C virus(HCV) infection presenting with hepatocellular carcinoma(HCC) in the absence of cirrhosis.METHODS:Patients with chronic hepatitis C infection without cirrhosis presenting with HCC over a 2-year period were identified.The clinical case notes,blood test results and histological specimens were reviewed to identify whether additional risk factors for the development of HCC were present.RESULTS:Six patients(five male,one female) with chronic hepatitis C infection without cirrhosis presented to a single centre with HCC over a 2-year period.Five patients were treated by surgical resection and one patient underwent liver transplantation.Evaluation of generous histological specimens confirmed the presence of HCC and the absence of cirrhosis in all cases.The degree of fibrosis of the background liver was staged as mild(n = 1),moderate(n = 4) or bridging fibrosis(n = 1).Review of the clinical case notes revealed that all cases had an additional risk factor for the development of HCC(four had evidence of past hepatitis B virus infection;two had a history of excessive alcohol consumption;a further patient had prolonged exposure to immune suppression).CONCLUSION:HCC does occur in patients with non-cirrhotic HCV infection who have other risk factors for hepatocarcinogenesis.展开更多
Pancreatic surgery has been one of the last areas for the application of minimally invasive surgery(MIS)because there are many factors that make laparoscopic pancreas resections difficult.The concept of service centra...Pancreatic surgery has been one of the last areas for the application of minimally invasive surgery(MIS)because there are many factors that make laparoscopic pancreas resections difficult.The concept of service centralization has also limited expertise to a small cadre of high-volume centres in resource rich countries.However,this is not the environment that many surgeons in developing countries work in.These patients often do not have the opportunity to travel to high volume centres for care.Therefore,we sought to review the existing data on MIS for the pancreas and to discuss.In this paper,we review the evolution of MIS on the pancreas and discuss the incorporation of this service into low-volume and resource-poor countries,such as those in the Caribbean.This paper has two parts.First,we performed a literature review evaluating all studies published on laparoscopic and robotic surgery of the pancreas.The data in the Caribbean is examined and we discuss tips for incorporating this operation into resource poor hospital practice.Low pancreatic case volume in the Caribbean,and financial barriers to MIS in general,laparoscopic distal pancreatectomy,enucleation and cystogastrostomy are feasible operations to integrate in to a resource-limited healthcare environment.This is because they can be performed with minimal to no consumables and require an intermediate MIS skillset to complement an open pancreatic surgeon’s peri-operative experience.展开更多
Background: Vitamin D insufficiency is common in women of childbearing age and increasing evidence suggests that the risk of osteoporotic fracture in adulthood could be determined partly by environmental factors durin...Background: Vitamin D insufficiency is common in women of childbearing age and increasing evidence suggests that the risk of osteoporotic fracture in adulthood could be determined partly by environmental factors during intrauterine and early postnatal life. We investigated the effect of maternal vitamin D status during pregnancy on childhood skeletal growth. Methods: In a longitudinal study, we studied 198 children born in 1991-92 in a hospital in Southampton, UK; the body build, nutrition, and vitamin D status of their mothers had been characterised during pregnancy. The children were followed up at age 9 years to relate these maternal characteristics to their body size and bone mass. Findings: 49 (31%) mothers had insufficient and 28 (18%) had deficient circulating concentrations of 25(OH)-vitamin D during late pregnancy. Reduced concentration of 25(OH)-vitamin D in mothers during late pregnancy was associated with reduced whole-body (r = 0.21, p = 0.0088) and lumbar-spine (r = 0.17, p = 0.03) bone-mineral content in children at age 9 years. Both the estimated exposure to ultraviolet B radiation during late pregnancy and the maternal use of vitamin D supplements predicted maternal 25(OH)-vitamin D concentration (p < 0.0001 and p = 0.0110, respectively) and childhood bone mass (p = 0.0267). Reduced concentration of umbilical-venous calcium also predicted reduced childhood bone mass (p = 0.0286). Interpretation: Maternal vitamin D insufficiency is common during pregnancy and is associated with reduced bone-mineral accrual in the offspring during childhood; this association is mediated partly through the concentration of umbilical venous calcium. Vitamin D supplementation of pregnant women, especially during winter months, could lead to longlasting reductions in the risk of osteoporotic fracture in their offspring.展开更多
BACKGROUND Variations in the anatomy of hepatic veins are of interest to transplant surgeons,interventional radiologists,and other medical practitioners who treat liver diseases.The drainage patterns of the right hepa...BACKGROUND Variations in the anatomy of hepatic veins are of interest to transplant surgeons,interventional radiologists,and other medical practitioners who treat liver diseases.The drainage patterns of the right hepatic veins(RHVs)are particularly relevant to transplantation services.AIM The aim was to identify variations of the patterns of venous drainage from the right side of the liver.To the best of our knowledge,there have been no reports on RHV variations in in a Caribbean population.METHODS Two radiologists independently reviewed 230 contrast-enhanced computed tomography scans performed in 1 year at a hepatobiliary referral center.Venous outflow patterns were observed and RHV variants were described as:(1)Tributaries of the RHV;(2)Variations at the hepatocaval junction(HCJ);and(3)Accessory RHVs.RESULTS A total of 118 scans met the inclusion criteria.Only 39%of the scans found conventional anatomy of the main hepatic veins.Accessory RHVs were present 49.2%and included a well-defined inferior RHV draining segment VI(45%)and a middle RHV(4%).At the HCJ,83 of the 118(70.3%)had a superior RHV that received no tributaries within 1 cm of the junction(Nakamura and Tsuzuki type I).In 35 individuals(29.7%)there was a short superior RHV with at least one variant tributary.According to the Nakamura and Tsuzuki classification,there were 24 type II variants(20.3%),six type III variants(5.1%)and,five type IV variants(4.2%).CONCLUSION There was significant variation in RHV patterns in this population,each with important relevance to liver surgery.Interventional radiologists and hepatobiliary surgeons practicing in the Caribbean must be cognizant of these differences in order to minimize morbidity during invasive procedures.展开更多
Complementary and alternative medicine(CAM) use is increasing worldwide; specifically it appears that these treatment modalities are popular among rheumatology patients.The most commonly reported CAM therapies are her...Complementary and alternative medicine(CAM) use is increasing worldwide; specifically it appears that these treatment modalities are popular among rheumatology patients.The most commonly reported CAM therapies are herbal medicines,homeopathy,chiropractic,acupuncture and reflexology.Despite high reported rates of CAM use,the number of patients disclosing use to their rheumatologists remains low.This review highlights rates of current CAM use in rheumatology in studies performed worldwide,and discusses potential reasons for nondisclosure of CAM use to clinicians.展开更多
We aimed to establish gestation age specific reference intervals for Doppler indices of fetal cardiac function from 12 to 40 weeks of pregnancy. In a cross-sectional observational study of singleton pregnancies, exami...We aimed to establish gestation age specific reference intervals for Doppler indices of fetal cardiac function from 12 to 40 weeks of pregnancy. In a cross-sectional observational study of singleton pregnancies, examinations were performed in 221 women evenly distributed across each week of pregnancy. Blood flow through the four cardiac valves was examined with Doppler. For the atrioventricular valves, velocity and duration of early (E) and atrial (A) waves and the interval (a) between E/A complexes was recorded. For the outflow valves, the duration (b), peak and average velocity of flow in systole was measured. Myocardial performance index (MPI) was calculated as (a - b)/b. Outlet valve diameters were measured and cardiac outputs were calculated. Gestation age specific ranges were constructed for all these parameters. We demonstrated that the cardiac output, peak systolic and time-averaged velocity increase with advancing gestation. However the MPI and E/A ratios show little change across gestation. Fetal cardiac physiology can be studied and Doppler indices reliably measured as early as the late first trimester of pregnancy. Establishing gestation age specific ranges for various cardiac indices throughout pregnancy will help the study of development of fetal cardiac function.展开更多
BACKGROUND: Children with bilateral permanent hearing impairment often have impaired language and speech abilities. However, the effects of universal newborns creening for permanent bilateral childhood hearing impairm...BACKGROUND: Children with bilateral permanent hearing impairment often have impaired language and speech abilities. However, the effects of universal newborns creening for permanent bilateral childhood hearing impairment and the effects of confirmation of hearing impairment by nine months of age on subsequent verbal abilities are uncertain. METHODS: We studied 120 children with bilateral permanent hearing impairment identified from a large birth cohort in southern England,at a mean of 7.9 years of age. Of the 120 children, 61 were born during periods with universal newborn screening and 57 had hearing impairment that was confirmed by nine months of age. The primary outcomes were languageas compared with nonverbal ability and speech expressed as z scores (the number of standard deviations by which the score differed from the mean score among 63 age-matched children with normal hearing),adjusted for the severity of the hearing impairment and for maternal education. RESULTS: Confirmation of hearing impairment by nine months of age was associated with higher adjusted mean z scores for language as compared with nonverbal ability (adjusted mean difference for receptive language, 0.82; 95 percent confidence interval,0.31 to 1.33; and adjusted mean difference for expressive language, 0.70; 95 percent confidence interval, 0.13 to 1.26). Birth during periods with universal newborns creening was also associated with higher adjusted z scores for receptive language as compared with nonverbal ability (adjusted mean difference, 0.60; 95 percent confidence interval, 0.07 to 1.13), although the z scores for expressive language as compared with nonverbal ability were not significantly higher. Speech scores did not differ significantly between those who were exposed to newborn screening or early confirmation and those who were not. CONCLUSIONS: Early detection of childhood hearing impairment was associated with higher scores for language but not for speech in midchildhood.展开更多
Purpose: To determine whether topical ketorolac (Acular) is more effective than artificial tears in treating the signs and symptoms of idiopathic episcleritis. Methods: In this prospective, randomised, double-blind st...Purpose: To determine whether topical ketorolac (Acular) is more effective than artificial tears in treating the signs and symptoms of idiopathic episcleritis. Methods: In this prospective, randomised, double-blind study, 38 eyes of 37 patients presenting with idiopathic episcleritis were allocated to receive either topical ketorolac (0.5% ) or artificial tears three times a day for 3 weeks. The severity of patients’ signs (episcleral injection and the number of clock hours affected)were recorded at weekly intervals. Patients’ symptoms (perceived redness and pain scores) were recorded using a daily diary. Results: There was no significant difference in the ophthalmic signs between the two groups at each assessment, including intensity of episcleral injection and the number of clock hours affected. No significant difference was found in the time to halve the baseline redness intensity scores (4.4 vs 6.1 days, P=0.2) or pain scores (3.6 vs 4.3 days, P=0.55). Significantly more patients on ketorolac reported stinging at the first follow-up visit (P < 0.001). Conclusion: Topical ketorolac is not significantly better than artificial tears in treating the signs or symptoms of idiopathic episcleritis.展开更多
基金This study was approved by the Campus Research Ethics Committee,St.Augustine.
文摘BACKGROUND Pancreaticoduodenectomy(PD)is a technically complex operation,with a re-latively high risk for complications.The ability to rescue patients from post-PD complications is as a recognized quality measure.Tailored protocols were instituted at our low volume facility in the year 2013.AIM To document the rate of rescue from post-PD complications with tailored protocols in place as a measure of quality.METHODS A retrospective audit was performed to collect data from patients who experienced major post-PD complications at a low volume pancreatic surgery unit in Trinidad and Tobago between January 1,2013 and June 30,2023.Stan-dardized definitions from the International Study Group of Pancreatic Surgery were used to define post-PD complications,and the modified Clavien-Dindo classification was used to classify post-PD complications.RESULTS Over the study period,113 patients at a mean age of 57.5 years(standard deviation[SD]±9.23;range:30-90;median:56)underwent PDs at this facility.Major complications were recorded in 33(29.2%)patients at a mean age of 53.8 years(SD:±7.9).Twenty-nine(87.9%)patients who experienced major morbidity were salvaged after aggre-ssive treatment of their complication.Four(3.5%)died from bleeding pseudoaneurysm(1),septic shock secondary to a bile leak(1),anastomotic leak(1),and myocardial infarction(1).There was a significantly greater salvage rate in patients with American Society of Anesthesiologists scores≤2(93.3%vs 25%;P=0.0024).CONCLUSION This paper adds to the growing body of evidence that volume alone should not be used as a marker of quality for patients requiring PD.Despite low volumes at our facility,we demonstrated that 87.9%of patients were rescued from major complications.We attributed this to several factors including development of rescue protocols,the competence of the pancreatic surgery teams and continuous,and adaptive learning by the entire institution,cul-minating in the development of tailored peri-pancreatectomy protocols.
文摘AIM:To report the outcomes of three cases of corneal perforation managed with simultaneous tectonic Descemet stripping endothelial keratoplasty(t-DSEK)and tectonic Bowman layer transplant(t-BLT)as an alternative to tectonic penetrating keratoplasty(t-PKP).METHODS:Three eyes of three patients receiving simultaneous t-DSEK and t-BLT for corneal perforation were included.The technique for DSEK was modified depending on individual requirements.The t-BLT technique was standardised using an 8 mm graft and fixated with a running suture.Success was measured by the ability of this procedure to close a corneal perforation.RESULTS:All three cases achieved tectonic eye globe restoration and remained stable during the minimum 3-month observation period.Reinterventions were relatively common:2 cases required amniotic membrane transplant for persistent epithelial defects.One case required DSEK rebubbling.One case developed angle closure glaucoma requiring surgical peripheral iridectomy.CONCLUSION:Simultaneous t-DSEK and t-BLT may be a useful strategy for the management of corneal perforation as an alternative management to t-PKP for selected cases.
文摘BACKGROUND Evidence-based guidance on return to sport following toe phalanx fractures is limited.AIM To systemically review all studies recording return to sport following toe phalanx fractures(both acute fractures and stress fractures),and to collate information on return rates to sport(RRS)and mean return times(RTS)to the sport.METHODS A systematic search of PubMed,MEDLINE,EMBASE,CINAHL,Cochrane Library,Physiotherapy Evidence Database,and Google Scholar was performed in December 2022 using the keywords‘Toe’,‘Phalanx’,‘Fracture’,‘injury’,‘athletes’,‘sports’,‘non-operative’,‘conservative’,‘operative’,‘return to sport’.All studies which recorded RRS and RTS following toe phalanx fractures were included.RESULTS Thirteen studies were included:one retrospective cohort study and twelve case series.Seven studies reported on acute fractures.Six studies reported on stress fractures.For the acute fractures(n=156),63 were treated with primary conservative management(PCM),6 with primary surgical management(PSM)(all displaced intra-articular(physeal)fractures of the great toe base of the proximal phalanx),1 with secondary surgical management(SSM)and 87 did not specify treatment modality.For the stress fractures(n=26),23 were treated with PCM,3 with PSM,and 6 with SSM.For acute fractures,RRS with PCM ranged from 0 to 100%,and RTS with PCM ranged from 1.2 to 24 wk.For acute fractures,RRS with PSM were all 100%,and RTS with PSM ranged from 12 to 24 wk.One case of an undisplaced intra-articular(physeal)fracture treated conservatively required conversion to SSM on refracture with a return to sport.For stress fractures,RRS with PCM ranged from 0%to 100%,and RTS with PCM ranged from 5 to 10 wk.For stress fractures,RRS with PSM were all 100%,and RTS with surgical management ranged from 10 to 16 wk.Six cases of conservatively-managed stress fractures required conversion to SSM.Two of these cases were associated with a prolonged delay to diagnosis(1 year,2 years)and four cases with an underlying deformity[hallux valgus(n=3),claw toe(n=1)].All six cases returned to the sport after SSM.CONCLUSION The majority of sport-related toe phalanx fractures(acute and stress)are managed conservatively with overall satisfactory RRS and RTS.For acute fractures,surgical management is indicated for displaced,intra-articular(physeal)fractures,which offers satisfactory RRS and RTS.For stress fractures,surgical management is indicated for cases with delayed diagnosis and established nonunion at presentation,or with significant underlying deformity:both can expect satisfactory RRS and RTS.
文摘Hepatocellular carcinoma(HCC)arises on the background of chronic liver disease.Despite the development of effective anti-viral therapeutics HCC is continuing to rise,in part driven by the epidemic of non-alcoholic fatty liver disease.Many patients present with advanced disease out with the criteria for transplant,resection or even locoregional therapy.Currently available therapeutics for HCC are effective in a small minority of individuals.However,there has been a major global interest in immunotherapies for cancer and although HCC has lagged behind other cancers,great opportunities now exist for treating HCC with newer and more sophisticated agents.Whilst checkpoint inhibitors are at the forefront of this revolution,other therapeutics such as inhibitory cytokine blockade,oncolytic viruses,adoptive cellular therapies and vaccines are emerging.Broadly these may be categorized as either boosting existing immune response or stimulating de novo immune response.Although some of these agents have shown promising results as monotherapy in early phase trials it may well be that their future role will be as combination therapy,either in combination with one another or in combination with treatment modalities such as locoregional therapy.Together these agents are likely to generate new and exciting opportunities for treating HCC,which are summarized in this review.
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BACKGROUND Many authorities advocate for Whipple’s procedures to be performed in highvolume centers,but many patients in poor developing nations cannot access these centers.We sought to determine whether clinical outcomes were acceptable when Whipple’s procedures were performed in a low-volume,resource-poor setting in the West Indies.AIM To study outcomes of Whipple’s procedures in a pancreatic unit in the West Indies over an eight-year period from June 1,2013 to June 30,2021.METHODS This was a retrospective study of all patients undergoing Whipple’s procedures in a pancreatic unit in the West Indies over an eight-year period from June 1,2013 to June 30,2021.RESULTS This center performed an average of 11.25 procedures per annum.There were 72 patients in the final study population at a mean age of 60.2 years,with 52.7%having American Society of Anesthesiologists scores≥III and 54.1%with Eastern Cooperative Oncology Group scores≥2.Open Whipple’s procedures were performed in 70 patients and laparoscopic assisted procedures in 2.Portal vein resection/reconstruction was performed in 19(26.4%)patients.In patients undergoing open procedures there was 367±54.1 min mean operating time,1394±656.8 mL mean blood loss,5.24±7.22 d mean intensive care unit stay and 15.1±9.53 d hospitalization.Six(8.3%)patients experienced minor morbidity,10(14%)major morbidity and there were 4(5.5%)deaths.CONCLUSION This paper adds to the growing body of evidence that volume alone should not be used as a marker of quality for patients requiring Whipple’s procedures.Low volume centers in resource poor nations can achieve good short-term outcomes.This is largely due to the process of continuous,adaptive learning by the entire hospital.
文摘The symptom of cancer most feared by many patients is pain. The physical and psychological distress of constant pain without relief should not be underestimated, and all complaints of pain should be actively treated. The clinician should not forget however that drugs used in the treatment
文摘Conventional data suggest that complex operations,such as a pancreaticoduodenectomy(PD),should be limited to high volume centers.However,this is not practical in small,resource-poor countries in the Caribbean.In these settings,patients have no option but to have their PDs performed locally at low volumes,occasionally by general surgeons.In this paper,we review the evolution of the concept of the high-volume center and discuss the feasibility of applying this concept to low and middle-income nations.Specifically,we discuss a modification of this concept that may be considered when incorporating PD into low-volume and resource-poor countries,such as those in the Caribbean.This paper has two parts.First,we performed a literature review evaluating studies published on outcomes after PD in high volume centers.The data in the Caribbean is then examined and we discuss the incorporation of this operation into resource-poor hospitals with modifications of the centralization concept.In the authors’opinions,most patients who require PD in the Caribbean do not have realistic opportunities to have surgery in high-volume centers in developed countries.In these settings,their only options are to have their operations in the resource-poor,low-volume settings in the Caribbean.However,post-operative outcomes may be improved,despite low-volumes,if a modified centralization concept is encouraged.
文摘AIM:To investigate and characterise patients with chronic hepatitis C virus(HCV) infection presenting with hepatocellular carcinoma(HCC) in the absence of cirrhosis.METHODS:Patients with chronic hepatitis C infection without cirrhosis presenting with HCC over a 2-year period were identified.The clinical case notes,blood test results and histological specimens were reviewed to identify whether additional risk factors for the development of HCC were present.RESULTS:Six patients(five male,one female) with chronic hepatitis C infection without cirrhosis presented to a single centre with HCC over a 2-year period.Five patients were treated by surgical resection and one patient underwent liver transplantation.Evaluation of generous histological specimens confirmed the presence of HCC and the absence of cirrhosis in all cases.The degree of fibrosis of the background liver was staged as mild(n = 1),moderate(n = 4) or bridging fibrosis(n = 1).Review of the clinical case notes revealed that all cases had an additional risk factor for the development of HCC(four had evidence of past hepatitis B virus infection;two had a history of excessive alcohol consumption;a further patient had prolonged exposure to immune suppression).CONCLUSION:HCC does occur in patients with non-cirrhotic HCV infection who have other risk factors for hepatocarcinogenesis.
文摘Pancreatic surgery has been one of the last areas for the application of minimally invasive surgery(MIS)because there are many factors that make laparoscopic pancreas resections difficult.The concept of service centralization has also limited expertise to a small cadre of high-volume centres in resource rich countries.However,this is not the environment that many surgeons in developing countries work in.These patients often do not have the opportunity to travel to high volume centres for care.Therefore,we sought to review the existing data on MIS for the pancreas and to discuss.In this paper,we review the evolution of MIS on the pancreas and discuss the incorporation of this service into low-volume and resource-poor countries,such as those in the Caribbean.This paper has two parts.First,we performed a literature review evaluating all studies published on laparoscopic and robotic surgery of the pancreas.The data in the Caribbean is examined and we discuss tips for incorporating this operation into resource poor hospital practice.Low pancreatic case volume in the Caribbean,and financial barriers to MIS in general,laparoscopic distal pancreatectomy,enucleation and cystogastrostomy are feasible operations to integrate in to a resource-limited healthcare environment.This is because they can be performed with minimal to no consumables and require an intermediate MIS skillset to complement an open pancreatic surgeon’s peri-operative experience.
文摘Background: Vitamin D insufficiency is common in women of childbearing age and increasing evidence suggests that the risk of osteoporotic fracture in adulthood could be determined partly by environmental factors during intrauterine and early postnatal life. We investigated the effect of maternal vitamin D status during pregnancy on childhood skeletal growth. Methods: In a longitudinal study, we studied 198 children born in 1991-92 in a hospital in Southampton, UK; the body build, nutrition, and vitamin D status of their mothers had been characterised during pregnancy. The children were followed up at age 9 years to relate these maternal characteristics to their body size and bone mass. Findings: 49 (31%) mothers had insufficient and 28 (18%) had deficient circulating concentrations of 25(OH)-vitamin D during late pregnancy. Reduced concentration of 25(OH)-vitamin D in mothers during late pregnancy was associated with reduced whole-body (r = 0.21, p = 0.0088) and lumbar-spine (r = 0.17, p = 0.03) bone-mineral content in children at age 9 years. Both the estimated exposure to ultraviolet B radiation during late pregnancy and the maternal use of vitamin D supplements predicted maternal 25(OH)-vitamin D concentration (p < 0.0001 and p = 0.0110, respectively) and childhood bone mass (p = 0.0267). Reduced concentration of umbilical-venous calcium also predicted reduced childhood bone mass (p = 0.0286). Interpretation: Maternal vitamin D insufficiency is common during pregnancy and is associated with reduced bone-mineral accrual in the offspring during childhood; this association is mediated partly through the concentration of umbilical venous calcium. Vitamin D supplementation of pregnant women, especially during winter months, could lead to longlasting reductions in the risk of osteoporotic fracture in their offspring.
文摘BACKGROUND Variations in the anatomy of hepatic veins are of interest to transplant surgeons,interventional radiologists,and other medical practitioners who treat liver diseases.The drainage patterns of the right hepatic veins(RHVs)are particularly relevant to transplantation services.AIM The aim was to identify variations of the patterns of venous drainage from the right side of the liver.To the best of our knowledge,there have been no reports on RHV variations in in a Caribbean population.METHODS Two radiologists independently reviewed 230 contrast-enhanced computed tomography scans performed in 1 year at a hepatobiliary referral center.Venous outflow patterns were observed and RHV variants were described as:(1)Tributaries of the RHV;(2)Variations at the hepatocaval junction(HCJ);and(3)Accessory RHVs.RESULTS A total of 118 scans met the inclusion criteria.Only 39%of the scans found conventional anatomy of the main hepatic veins.Accessory RHVs were present 49.2%and included a well-defined inferior RHV draining segment VI(45%)and a middle RHV(4%).At the HCJ,83 of the 118(70.3%)had a superior RHV that received no tributaries within 1 cm of the junction(Nakamura and Tsuzuki type I).In 35 individuals(29.7%)there was a short superior RHV with at least one variant tributary.According to the Nakamura and Tsuzuki classification,there were 24 type II variants(20.3%),six type III variants(5.1%)and,five type IV variants(4.2%).CONCLUSION There was significant variation in RHV patterns in this population,each with important relevance to liver surgery.Interventional radiologists and hepatobiliary surgeons practicing in the Caribbean must be cognizant of these differences in order to minimize morbidity during invasive procedures.
文摘Complementary and alternative medicine(CAM) use is increasing worldwide; specifically it appears that these treatment modalities are popular among rheumatology patients.The most commonly reported CAM therapies are herbal medicines,homeopathy,chiropractic,acupuncture and reflexology.Despite high reported rates of CAM use,the number of patients disclosing use to their rheumatologists remains low.This review highlights rates of current CAM use in rheumatology in studies performed worldwide,and discusses potential reasons for nondisclosure of CAM use to clinicians.
文摘We aimed to establish gestation age specific reference intervals for Doppler indices of fetal cardiac function from 12 to 40 weeks of pregnancy. In a cross-sectional observational study of singleton pregnancies, examinations were performed in 221 women evenly distributed across each week of pregnancy. Blood flow through the four cardiac valves was examined with Doppler. For the atrioventricular valves, velocity and duration of early (E) and atrial (A) waves and the interval (a) between E/A complexes was recorded. For the outflow valves, the duration (b), peak and average velocity of flow in systole was measured. Myocardial performance index (MPI) was calculated as (a - b)/b. Outlet valve diameters were measured and cardiac outputs were calculated. Gestation age specific ranges were constructed for all these parameters. We demonstrated that the cardiac output, peak systolic and time-averaged velocity increase with advancing gestation. However the MPI and E/A ratios show little change across gestation. Fetal cardiac physiology can be studied and Doppler indices reliably measured as early as the late first trimester of pregnancy. Establishing gestation age specific ranges for various cardiac indices throughout pregnancy will help the study of development of fetal cardiac function.
文摘BACKGROUND: Children with bilateral permanent hearing impairment often have impaired language and speech abilities. However, the effects of universal newborns creening for permanent bilateral childhood hearing impairment and the effects of confirmation of hearing impairment by nine months of age on subsequent verbal abilities are uncertain. METHODS: We studied 120 children with bilateral permanent hearing impairment identified from a large birth cohort in southern England,at a mean of 7.9 years of age. Of the 120 children, 61 were born during periods with universal newborn screening and 57 had hearing impairment that was confirmed by nine months of age. The primary outcomes were languageas compared with nonverbal ability and speech expressed as z scores (the number of standard deviations by which the score differed from the mean score among 63 age-matched children with normal hearing),adjusted for the severity of the hearing impairment and for maternal education. RESULTS: Confirmation of hearing impairment by nine months of age was associated with higher adjusted mean z scores for language as compared with nonverbal ability (adjusted mean difference for receptive language, 0.82; 95 percent confidence interval,0.31 to 1.33; and adjusted mean difference for expressive language, 0.70; 95 percent confidence interval, 0.13 to 1.26). Birth during periods with universal newborns creening was also associated with higher adjusted z scores for receptive language as compared with nonverbal ability (adjusted mean difference, 0.60; 95 percent confidence interval, 0.07 to 1.13), although the z scores for expressive language as compared with nonverbal ability were not significantly higher. Speech scores did not differ significantly between those who were exposed to newborn screening or early confirmation and those who were not. CONCLUSIONS: Early detection of childhood hearing impairment was associated with higher scores for language but not for speech in midchildhood.
文摘Purpose: To determine whether topical ketorolac (Acular) is more effective than artificial tears in treating the signs and symptoms of idiopathic episcleritis. Methods: In this prospective, randomised, double-blind study, 38 eyes of 37 patients presenting with idiopathic episcleritis were allocated to receive either topical ketorolac (0.5% ) or artificial tears three times a day for 3 weeks. The severity of patients’ signs (episcleral injection and the number of clock hours affected)were recorded at weekly intervals. Patients’ symptoms (perceived redness and pain scores) were recorded using a daily diary. Results: There was no significant difference in the ophthalmic signs between the two groups at each assessment, including intensity of episcleral injection and the number of clock hours affected. No significant difference was found in the time to halve the baseline redness intensity scores (4.4 vs 6.1 days, P=0.2) or pain scores (3.6 vs 4.3 days, P=0.55). Significantly more patients on ketorolac reported stinging at the first follow-up visit (P < 0.001). Conclusion: Topical ketorolac is not significantly better than artificial tears in treating the signs or symptoms of idiopathic episcleritis.
