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Bhangu A. Multicentre observational study of performance variation in provision and outcome of emergency appendicectomy. Br J Surg 2013; 100:1240-52. [PMID: 23842836 DOI: 10.1002/bjs.9201] [Citation(s) in RCA: 145] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/13/2013] [Indexed: 12/16/2022] [Imported: 11/05/2023]
Abstract
BACKGROUND Identification of variation in practice is a key step towards standardization of service and determination of reliable quality markers. This study aimed to investigate variation in provision and outcome of emergency appendicectomy. METHODS A multicentre, trainee-led, protocol-driven, prospective observational cohort study was performed during May and June 2012. The main outcome of interest was the normal histopathology rate; secondary outcomes were laparoscopy and 30-day adverse event rates. Analysis included funnel plots and binary logistic regression models to identify patient- and hospital-related predictors of outcome. RESULTS A total of 3326 patients from 95 centres were included. An initial laparoscopic approach was performed in 66.3 per cent of patients (range in centres performing more than 25 appendicectomies over the study period: 8.7-100 per cent). A histologically normal appendix was removed in 20.6 per cent of patients (range in centres performing more than 25 procedures: 3.3-36.8 per cent). Funnel plot analysis revealed that 22 centres fell below three standard deviations of the mean for laparoscopy rates. Higher centre volume, consultant presence in theatre and daytime surgery were independently associated with an increased use of laparoscopy, which in turn was associated with a reduction in 30-day morbidity (adjusted for disease severity). Daytime surgery further reduced normal appendicectomy rates. Increasing volume came at the cost of higher negative rates, and low negative rates came at the cost of higher perforation rates. CONCLUSION This study reveals the extremely wide variation in practice patterns and outcomes among hospitals. Organizational factors leading to this variation have been identified and should be addressed to improve performance.
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Multicenter Study |
12 |
145 |
2
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Safety of Short, In-Hospital Delays Before Surgery for Acute Appendicitis. Ann Surg 2014; 259:894-903. [PMID: 24509193 DOI: 10.1097/sla.0000000000000492] [Citation(s) in RCA: 100] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] [Imported: 11/05/2023]
Abstract
OBJECTIVE To determine safety of short in-hospital delays before appendicectomy. BACKGROUND Short organizational delays before appendicectomy may safely improve provision of acute surgical services. METHODS The primary endpoint was the rate of complex appendicitis (perforation, gangrene, and/or abscess). The main explanatory variable was timing of surgery, using less than 12 hours from admission as the reference. The first part of this study analyzed primary data from a multicentre study on appendicectomy from 95 centers. The second part combined this data with a systematic review and meta-analysis of published data. RESULTS The cohort study included 2510 patients with acute appendicitis, of whom 812 (32.4%) had complex findings. Adjusted multivariable binary regression modelling showed that timing of operation was not related to risk of complex appendicitis [12-24 hours odds ratio (OR) 0.98 (P = 0.869); 24-48 hours OR 0.88 (P = 0.329); 48+ hours OR 0.82 (P = 0.317)]. However, after 48 hours, the risk of surgical site infection and 30-day adverse events both increased [adjusted ORs 2.24 (P = 0.039) and 1.71 (P = 0.024), respectively]. Meta-analysis of 11 nonrandomized studies (8858 patients) revealed that delay of 12 to 24 hours after admission did not increase the risk of complex appendicitis (OR 0.97, P = 0.750). CONCLUSIONS Short delays of less than 24 hours before appendicectomy were not associated with increased rates of complex pathology in selected patients. These organizational delays may aid service provision, but planned delay beyond this should be avoided. However, where optimal surgical systems allow for expeditious surgery, prompt appendicectomy will still aid fastest resolution of pain for the individual patient.
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11 |
100 |
3
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Kosmoliaptsis V, Gjorgjimajkoska O, Sharples LD, Chaudhry AN, Chatzizacharias N, Peacock S, Torpey N, Bolton EM, Taylor CJ, Bradley JA. Impact of donor mismatches at individual HLA-A, -B, -C, -DR, and -DQ loci on the development of HLA-specific antibodies in patients listed for repeat renal transplantation. Kidney Int 2014; 86:1039-48. [PMID: 24717292 DOI: 10.1038/ki.2014.106] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Revised: 01/31/2014] [Accepted: 02/13/2014] [Indexed: 12/22/2022] [Imported: 11/05/2023]
Abstract
We have analyzed the relationship between donor mismatches at each HLA locus and development of HLA locus-specific antibodies in patients listed for repeat transplantation. HLA antibody screening was undertaken using single-antigen beads in 131 kidney transplant recipients returning to the transplant waiting list following first graft failure. The number of HLA mismatches and the calculated reaction frequency of antibody reactivity against 10,000 consecutive deceased organ donors were determined for each HLA locus. Two-thirds of patients awaiting repeat transplantation were sensitized (calculated reaction frequency over 15%) and half were highly sensitized (calculated reaction frequency of 85% and greater). Antibody levels peaked after re-listing for repeat transplantation, were independent of graft nephrectomy and were associated with length of time on the waiting list (odds ratio 8.4) and with maintenance on dual immunosuppression (odds ratio 0.2). Sensitization was independently associated with increasing number of donor HLA mismatches (odds ratio 1.4). All mismatched HLA loci contributed to the development of HLA locus-specific antibodies (HLA-A: odds ratio 3.2, HLA-B: odds ratio 3.4, HLA-C: odds ratio 2.5, HLA-DRB1: odds ratio 3.5, HLA-DRB3/4/5: odds ratio 3.9, and HLA-DQ: odds ratio 3.0 (all significant)). Thus, the risk of allosensitization following failure of a first renal transplant increases incrementally with the number of mismatches at all HLA loci assessed. Maintenance of re-listed patients on dual immunosuppression was associated with a reduced risk of sensitization.
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Research Support, Non-U.S. Gov't |
11 |
53 |
4
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Tiboni S, Bhangu A, Hall NJ. Outcome of appendicectomy in children performed in paediatric surgery units compared with general surgery units. Br J Surg 2014; 101:707-14. [PMID: 24700440 DOI: 10.1002/bjs.9455] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/14/2014] [Indexed: 11/11/2022] [Imported: 11/05/2023]
Abstract
BACKGROUND Appendicectomy for acute appendicitis in children may be performed in specialist centres by paediatric surgeons or in general surgery units. Service provision and outcome of appendicectomy in children may differ between such units. METHODS This multicentre observational study included all children (aged less than 16 years) who had an appendicectomy at either a paediatric surgery unit or general surgery unit. The primary outcome was normal appendicectomy rate (NAR). Secondary outcomes included 30-day adverse events, use of ultrasound imaging and laparoscopy, and consultant involvement in procedures. RESULTS Appendicectomies performed in 19 paediatric surgery units (242 children) and 54 general surgery units (461 children) were included. Children treated in paediatric surgery units were younger and more likely to have a preoperative ultrasound examination, a laparoscopic procedure, a consultant present at the procedure, and histologically advanced appendicitis than children treated in general surgery units. The unadjusted NAR was significantly lower in paediatric surgery units (odds ratio (OR) 0.37, 95 per cent confidence interval 0.23 to 0.59; P < 0.001), and the difference persisted after adjusting for age, sex and use of preoperative ultrasound imaging (OR 0.34, 0.21 to 0.57; P < 0.001). Female sex and preoperative ultrasonography, but not age, were significantly associated with normal appendicectomy in general surgery units but not in paediatric surgery units in this adjusted model. The unadjusted 30-day adverse event rate was higher in paediatric surgery units than in general surgery units (OR 1.90, 1.18 to 3.06; P = 0.011). When adjusted for case mix and consultant presence at surgery, no statistically significant relationship between centre type and 30-day adverse event rate existed (OR 1.59, 0.93 to 2.73; P = 0.091). CONCLUSION The NAR in general surgery units was over twice that in paediatric surgery units. Despite a more severe case mix, paediatric surgery units had a similar 30-day adverse event rate to general surgery units. Service provision differs between paediatric and general surgery units.
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Observational Study |
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47 |
5
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Chatzizacharias NA, Tsai S, Griffin M, Tolat P, Ritch P, George B, Barnes C, Aldakkak M, Khan AH, Hall W, Erickson B, Evans DB, Christians KK. Locally advanced pancreas cancer: Staging and goals of therapy. Surgery 2018; 163:1053-1062. [PMID: 29331400 DOI: 10.1016/j.surg.2017.09.012] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 09/25/2017] [Accepted: 09/25/2017] [Indexed: 12/25/2022] [Imported: 11/05/2023]
Abstract
BACKGROUND Patients with locally advanced pancreatic cancer have historically been considered inoperable. The purpose of this report was to determine resectability rates for patients with locally advanced pancreatic cancer based on our recently described definitions of type A and type B locally advanced pancreatic cancer. METHODS An institutional prospective pancreas cancer database was queried for consecutive patients with locally advanced pancreatic cancer treated between January 2009 and June 2017. All pretreatment imaging was re-reviewed and patients were categorized as locally advanced pancreatic cancer type A or type B. Demographics, induction therapy, resection type, and outcomes were reviewed. RESULTS We identified 108 consecutive patients; 12 were excluded from analysis due to the absence of available pretreatment imaging or they had not yet completed all intended neoadjuvant therapy. Of the remaining 96 patients (45 type A, 51 type B), disease progression occurred in 19 (20%) during induction therapy and 30 (31%) were deemed inoperable at final preoperative restaging. Therefore, 47 (49%) of 96 patients were taken to surgery and 40 (42%) underwent successful resection (28 [62%] of 45 type A and 12 [24%] of 51 type B); an RO resection was achieved in 32 (80%). Metastatic disease was found intraoperatively (6 at laparoscopy, 1 at laparotomy) in 7 (15%) of 47 patients. There were no mortalities; 6 (15%) patients experienced major postoperative complications. Resected patients had a median overall survival of 38.9 months. CONCLUSION Locally advanced pancreatic cancer can be dichotomized into type A and B with distinctly different probabilities of completing all therapy to include surgery; thereby allowing goals of therapy to be established at the time of diagnosis. Multimodality therapy that includes surgery can be accomplished in selected patients with locally advanced pancreatic cancer and is associated with a median overall survival that approximates earlier stages of disease. (Surgery 2017;160:XXX-XXX.).
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Research Support, Non-U.S. Gov't |
7 |
37 |
6
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Singh P, Turner EJH, Cornish J, Bhangu A. Safety assessment of resident grade and supervision level during emergency appendectomy: analysis of a multicenter, prospective study. Surgery 2014; 156:28-38. [PMID: 24882763 DOI: 10.1016/j.surg.2014.04.007] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2013] [Accepted: 04/14/2014] [Indexed: 12/31/2022] [Imported: 11/05/2023]
Abstract
BACKGROUND Resident surgeons have been identified as a risk factor for worse outcome after appendectomy. The context of grade of resident and impact of supervision require further investigation. The objective of this study was to determine whether grade and supervision level of resident-performed appendectomy affects patient outcome. METHODS A multicenter, prospective cohort study was performed for consecutive patients undergoing appendectomy during May and June 2013. The primary endpoint for this analysis was the 30-day adverse event rate. Supervision was defined as resident-performed appendectomy with an attending scrubbed. Multivariable binary logistic regression was used to take into account case mix and produce adjusted odds ratios (OR). RESULTS From 2,867 appendectomies, 87% were performed by residents, and 72% were performed unsupervised. Residents operated on significantly younger patients with lower American Society of Anesthesiologists scores. Although wound infection rates were similar between attendings, and senior and junior residents (4.1%, 3.8%, 3.4% respectively; P = .486), pelvic abscess rate was greater for attendings (5.2%, 2.7%, 2.4%; P = .045). In adjusted models, supervised senior, supervised junior, and unsupervised junior residents showed no difference in 30-day adverse event rates compared with attendings (OR, 1.07 [P = .834], 0.93 [P = .773], and 0.83 [P = .264] respectively); unsupervised senior residents had a lesser rate of adverse events (OR, 0.71; P = .045). All resident groups showed no difference for rates of histopathologically normal appendectomy compared with attendings. CONCLUSION Resident-performed appendectomy does not worsen patient outcomes. These findings support independent resident operating rights for selected cases. The system relies on mutual credentialing of competency between residents and supervising attendings.
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Multicenter Study |
11 |
34 |
7
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Chatzizacharias NA, Bradley JA, Harper S, Butler A, Jah A, Huguet E, Praseedom RK, Allison M, Gibbs P. Successful surgical management of ruptured umbilical hernias in cirrhotic patients. World J Gastroenterol 2015; 21:3109-3113. [PMID: 25780312 PMCID: PMC4356934 DOI: 10.3748/wjg.v21.i10.3109] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2014] [Revised: 09/11/2014] [Accepted: 11/19/2014] [Indexed: 02/06/2023] [Imported: 11/05/2023] Open
Abstract
Acute umbilical hernia rupture in patients with hepatic cirrhosis and ascites is an unusual, but potentially life-threatening complication, with postoperative morbidity about 70% and mortality between 60%-80% after supportive care and 6%-20% after urgent surgical repair. Management options include primary surgical repair with or without concomitant portal venous system decompression for the control of the ascites. We present a retrospective analysis of our centre’s experience over the last 6 years. Our cohort consisted of 11 consecutive patients (median age: 53 years, range: 36-63 years) with advanced hepatic cirrhosis and refractory ascites. Appropriate patient resuscitation and optimisation with intravenous fluids, prophylactic antibiotics and local measures was instituted. One failed attempt for conservative management was followed by a successful primary repair. In all cases, with one exception, a primary repair with non-absorbable Nylon, interrupted sutures, without mesh, was performed. The perioperative complication rate was 25% and the recurrence rate 8.3%. No mortality was recorded. Median length of hospital stay was 14 d (range: 4-31 d). Based on our experience, the management of ruptured umbilical hernias in patients with advanced hepatic cirrhosis and refractory ascites is feasible without the use of transjugular intrahepatic portosystemic shunt routinely in the preoperative period, provided that meticulous patient optimisation is performed.
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Case Report |
10 |
32 |
8
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Chatzizacharias NA, Kouraklis GP, Theocharis SE. Focal adhesion kinase: a promising target for anticancer therapy. Expert Opin Ther Targets 2007; 11:1315-28. [PMID: 17907961 DOI: 10.1517/14728222.11.10.1315] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] [Imported: 11/05/2023]
Abstract
Focal adhesion kinase (FAK) is a protein tyrosine kinase acting as an early modulator of the integrin signalling cascade, thus regulating various basic cellular functions. In transformed cells, upregulation of FAK protein expression and uncontroled signalling were held responsible for the promotion of malignant phenotypic characteristics, as well as resistance to chemotherapy and radiotherapy. Direct FAK targeting resulted in the inhibition of the malignant phenotype of cancer cells, whereas increased apoptotic rates of cancer cells, either used alone or in combination with conventional chemotherapeutic agents, radiotherapy or hormonal therapy. Furthermore, drugs used in cancer chemotherapy, besides their basic mode of action, were also shown to act through altering FAK signalling. Finally, positive results were noted by the transfection of cancer cells with fak mutants or genes that suppress FAK expression or activity, such as phosphatase and tensin homolog deleted on chromosome Ten (PTEN), ribonucleotide reductase M1 polypeptide (RRM1) and melanoma differentiation-associated gene-7 (mda-7). The purpose of this article is a comprehensive review of the existing data on the possible use of FAK targeting in anticancer therapy.
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18 |
30 |
9
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D'Souza MA, Valdimarsson VT, Campagnaro T, Cauchy F, Chatzizacharias NA, D'Hondt M, Dasari B, Ferrero A, Franken LC, Fusai G, Guglielmi A, Hagendoorn J, Hidalgo Salinas C, Hoogwater FJH, Jorba R, Karanjia N, Knoefel WT, Kron P, Lahiri R, Langella S, Le Roy B, Lehwald-Tywuschik N, Lesurtel M, Li J, Lodge JPA, Martinou E, Molenaar IQ, Nikov A, Poves I, Rassam F, Russolillo N, Soubrane O, Stättner S, van Dam RM, van Gulik TM, Serrablo A, Gallagher TM, Sturesson C. Hepatopancreatoduodenectomy -a controversial treatment for bile duct and gallbladder cancer from a European perspective. HPB (Oxford) 2020; 22:1339-1348. [PMID: 31899044 DOI: 10.1016/j.hpb.2019.12.008] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Revised: 11/22/2019] [Accepted: 12/09/2019] [Indexed: 02/08/2023] [Imported: 11/05/2023]
Abstract
BACKGROUND Hepatopancreatoduodenectomy (HPD) is an aggressive operation for treatment of advanced bile duct and gallbladder cancer associated with high perioperative morbidity and mortality, and uncertain oncological benefit in terms of survival. Few reports on HPD from Western centers exist. The purpose of this study was to evaluate safety and efficacy for HPD in European centers. METHOD Members of the European-African HepatoPancreatoBiliary Association were invited to report all consecutive patients operated with HPD for bile duct or gallbladder cancer between January 2003 and January 2018. The patient and tumor characteristics, perioperative and survival outcomes were analyzed. RESULTS In total, 66 patients from 19 European centers were included in the analysis. 90-day mortality rate was 17% and 13% for bile duct and gallbladder cancer respectively. All factors predictive of perioperative mortality were patient and disease-specific. The three-year overall survival excluding 90-day mortality was 80% for bile duct and 30% for gallbladder cancer (P = 0.013). In multivariable analysis R0-resection had a significant impact on overall survival. CONCLUSION HPD, although being associated with substantial perioperative mortality, can offer a survival benefit in patient subgroups with bile duct cancer and gallbladder cancer. To achieve negative resection margins is paramount for an improved survival outcome.
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25 |
10
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Chatzizacharias NA, Kouraklis GP, Theocharis SE. Clinical significance of FAK expression in human neoplasia. Histol Histopathol 2008; 23:629-50. [PMID: 18283648 DOI: 10.14670/hh-23.629] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] [Imported: 11/05/2023]
Abstract
Focal Adhesion Kinase is a 119-121 kDa nonreceptor protein kinase widely expressed in various tissues and cell types. Several studies showed that FAK plays an important role in integrin signaling. Once activated by integrin and non-integrin stimuli, it binds and activates several other molecules, such as Src, p130Cas, Grb2, PI3K and paxillin, thus promoting signaling transduction. In normal cells FAK activity is under constant regulation by mechanisms such as gene amplification, alternative splicing and action of phosphatases. On the contrary, in vitro studies showed that in transformed cells unopposed FAK signaling promoted cancer cells' malignant characteristics. FAK was held responsible for cancer cells' uninhibited proliferation, protection from apoptosis, invasion, migration, adhesion and spreading, as well as tumor angiogenesis. Several in vivo studies supported the above observations and further correlated FAK expression with various clinicopathological parameters of several types of human malignancies. The purpose of this article is a comprehensive review of the existing data on FAK expression and signaling and their clinical significance in human malignancy.
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Review |
17 |
24 |
11
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Strong S, Blencowe N, Bhangu A. How good are surgeons at identifying appendicitis? Results from a multi-centre cohort study. Int J Surg 2015; 15:107-12. [PMID: 25644545 DOI: 10.1016/j.ijsu.2015.01.032] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Revised: 01/13/2015] [Accepted: 01/26/2015] [Indexed: 01/07/2023] [Imported: 11/05/2023]
Abstract
BACKGROUND Convincing arguments for either removing or leaving in-situ a macroscopically normal appendix have been made, but rely on surgeons' accurate intra-operative assessment of the appendix. This study aimed to determine the inter-rater reliability between surgeons and pathologists from a large, multicentre cohort of patients undergoing appendicectomy. MATERIALS AND METHODS The Multicentre Appendicectomy Audit recruited consecutive patients undergoing emergency appendicectomy during April and May 2012 from 95 centres. The primary endpoint was agreement between surgeon and pathologist and secondary endpoints were predictors of this disagreement. RESULTS The final study included 3138 patients with a documented pathological specimen. When surgeons assessed an appendix as normal (n = 496), histopathological assessment revealed pathology in a substantial proportion (n = 138, 27.8%). Where surgeons assessed the appendix as being inflamed (n = 2642), subsequent pathological assessment revealed a normal appendix in 254 (9.6%). There was overall disagreement in 392 cases (12.5%), leading to only moderate reliability (Kappa 0.571). The grade of surgeon had no significant impact on disagreement following clinically normal appendicectomy. Females were at the highest risk of false positives and false negatives and pre-operative computed tomography was associated with increased false positives. CONCLUSIONS This multi-centre study suggests that surgeons' judgements of the intra-operative macroscopic appearance of the appendix is inaccurate and does not improve with seniority and therefore supports removal at the time of surgery.
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Multicenter Study |
10 |
24 |
12
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Chatzizacharias NA, Rosich-Medina A, Dajani K, Harper S, Huguet E, Liau SS, Praseedom RK, Jah A. Surgical management of hepato-pancreatic metastasis from renal cell carcinoma. World J Gastrointest Oncol 2017; 9:70-77. [PMID: 28255428 PMCID: PMC5314203 DOI: 10.4251/wjgo.v9.i2.70] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Revised: 09/22/2016] [Accepted: 11/22/2016] [Indexed: 02/05/2023] [Imported: 11/05/2023] Open
Abstract
AIM To investigate the outcomes of liver and pancreatic resections for renal cell carcinoma (RCC) metastatic disease.
METHODS This is a retrospective, single centre review of liver and/or pancreatic resections for RCC metastases between January 2003 and December 2015. Descriptive statistical analysis and survival analysis using the Kaplan-Meier estimation were performed.
RESULTS Thirteen patients had 7 pancreatic and 7 liver resections, with median follow-up 33 mo (range: 3-98). Postoperative complications were recorded in 5 cases, with no postoperative mortality. Three patients after hepatic and 5 after pancreatic resection developed recurrent disease. Median overall survival was 94 mo (range: 23-94) after liver and 98 mo (range: 3-98) after pancreatic resection. Disease-free survival was 10 mo (range 3-55) after liver and 28 mo (range 3-53) after pancreatic resection.
CONCLUSION Our study shows that despite the high incidence of recurrence, long term survival can be achieved with resection of hepatic and pancreatic RCC metastases in selected cases and should be considered as a management option in patients with oligometastatic disease.
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Retrospective Study |
8 |
22 |
13
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Pathanki AM, Attard JA, Bradley E, Powell-Brett S, Dasari BVM, Isaac JR, Roberts KJ, Chatzizacharias NA. Pancreatic exocrine insufficiency after pancreaticoduodenectomy: Current evidence and management. World J Gastrointest Pathophysiol 2020; 11:20-31. [PMID: 32318312 PMCID: PMC7156847 DOI: 10.4291/wjgp.v11.i2.20] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 03/13/2020] [Accepted: 03/22/2020] [Indexed: 02/06/2023] [Imported: 11/05/2023] Open
Abstract
Pancreaticoduodenectomy (PD) is the commonest procedure performed for pancreatic cancer. Pancreatic exocrine insufficiency (PEI) may be caused or exacerbated by surgery and remains underdiagnosed and undertreated. The aim of this review was to ascertain the incidence of PEI, its consequences and management in the setting of PD for indications other than chronic pancreatitis. A literature search of databases (MEDLINE, EMBASE, Cochrane and Scopus) was carried out with the MeSH terms “pancreatic exocrine insufficiency” and “Pancreaticoduodenectomy”. Studies that analysed PEI and its complications in the setting of PD for malignant and benign disease were included. Studies reporting PEI in the setting of PD for chronic pancreatitis, conference abstracts and reviews were excluded. The incidence of PEI approached 100% following PD in some series. The pre-operative incidence varied depending on the characteristics of the patient cohort and it was higher (46%-93%) in series where pancreatic cancer was the predominant indication for surgery. Variability was also recorded with regards to the method used for the diagnosis and evaluation of pancreatic function and malabsorption. Pancreatic enzyme replacement therapy is the mainstay of the management. PEI is common and remains undertreated after PD. Future studies are required for the identification of a well-tolerated, reliable and reproducible diagnostic test in this setting.
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Review |
5 |
20 |
14
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Evaluation of the clinical significance of focal adhesion kinase and SRC expression in human pancreatic ductal adenocarcinoma. Pancreas 2010; 39:930-6. [PMID: 20431421 DOI: 10.1097/mpa.0b013e3181d7abcc] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022] [Imported: 11/05/2023]
Abstract
OBJECTIVES Focal adhesion kinase (FAK) and Src, 2 protein tyrosine kinases, have been suggested to regulate several fundamental cellular activities that promote the malignant phenotype in various human tumors, including pancreatic adenocarcinoma. Even though research has already turned in laboratory investigations and clinical trials on the possible use of agents blocking the 2 enzymes in cancer management, the data on the clinical significance of FAK and Src in pancreatic adenocarcinoma are still scarce. METHODS The FAK and Src protein expression was assessed immunohistochemically in tumor specimens of 65 patients with pancreatic ductal adenocarcinoma and was statistically analyzed in relation to various clinicopathological characteristics, tumor proliferative capacity, and patients' survival. RESULTS The FAK expression correlated significantly with the T stage of the tumor (P = 0.037), whereas FAK staining intensity with patients' age (P = 0.030), tumors' histopathological grade of differentiation (P = 0.041), and M stage (P = 0.029). The Src expression correlated significantly with the stage of the tumor (P = 0.013) and patients' survival (log-rank test, P = 0.027), being also identified as an independent prognostic factor in multivariate analysis (P = 0.047). Furthermore, trends that did not reach statistical significance were noted between FAK and Src expression and staining intensity and several clinicopathological parameters. CONCLUSIONS The FAK and Src immunohistochemical expression was associated with certain clinicopathological parameters that are crucial for the patients' management.
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19 |
15
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Page AE, Sashittal SG, Chatzizacharias NA, Davies RJ. The role of laparoscopic surgery in the management of children and adolescents with inflammatory bowel disease. Medicine (Baltimore) 2015; 94:e874. [PMID: 26020394 PMCID: PMC4616422 DOI: 10.1097/md.0000000000000874] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] [Imported: 11/05/2023] Open
Abstract
Although laparoscopic surgery is readily used in the management of inflammatory bowel disease (IBD) in adults, its role in the surgical treatment of IBD in the pediatric population is not well established. The aim of this narrative review was to analyze the published evidence comparing laparoscopic and open resection in the management of children and adolescents with IBD. The Pubmed and Embase databases were searched using the terms "inflammatory bowel disease," "children," "adolescents," "laparoscopic," and "colectomy." The review identified 10 appropriate studies. Even though laparoscopic surgery generally resulted in longer operating times (between a mean of 40 and 140 min), benefits included reduced postoperative pain (mean duration of opiate use 3 vs 6 days) and reduced length of stay (median length of stay 5-8 vs 10.5-19 days) compared with open surgery. Postoperative complication rates were similar following both approaches. Due to the limited available data and the small sample size of the published series, definite recommendations are not able to be drawn. Nevertheless, current evidence indicates that laparoscopic colorectal resection is safe and feasible in the management of IBD in the paediatric population, with reductions in postoperative pain and length of hospital stay achievable.
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Review |
10 |
18 |
16
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Kalisvaart M, Broadhurst D, Marcon F, Pande R, Schlegel A, Sutcliffe R, Marudanayagam R, Mirza D, Chatzizacharias N, Abradelo M, Muiesan P, Isaac J, Ma YT, McConville C, Roberts K. Recurrence patterns of pancreatic cancer after pancreatoduodenectomy: systematic review and a single-centre retrospective study. HPB (Oxford) 2020; 22:1240-1249. [PMID: 32046922 DOI: 10.1016/j.hpb.2020.01.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Revised: 11/29/2019] [Accepted: 01/06/2020] [Indexed: 02/06/2023] [Imported: 11/05/2023]
Abstract
BACKGROUND Positive margins in pancreatoduodenectomy (PD) for pancreatic cancer, specifically the superior mesenteric artery (SMA) margin, are associated with worse outcomes. Local therapies targeting these margins could impact on recurrence. This study analysed recurrence-patterns to identify whether strategies to control local disease could have a meaningful impact. METHODS (I) Systematic review to define recurrence patterns and resection margin status. (II) Additional retrospective study of PD performed at our centre. RESULTS In the systematic review, 23/617 evaluated studies were included (n = 3815). Local recurrence was observed in 7-69%. SMA margin (6 studies) was positive in 15-35%. In the retrospective study (n = 204), local recurrence was more frequently observed with a positive SMA margin (66 vs.45%; p = 0.005). Furthermore, in a multivariate cox-proportional hazard model, only a positive SMA margin was associated with disease recurrence (HR 1.615; 95%CI 1.127-2.315; p = 0.009). Interestingly, median overall survival was 20 months and similar for patients who developed local only, metastases only or simultaneous recurrence (p = 0.124). CONCLUSION Local recurrence of pancreatic cancer is common and associated with similar mortality rates as those who present with simultaneous or metastatic recurrence. Involvement of the SMA margin is an independent predictor for disease progression and should be the target of future adjuvant local therapies.
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Systematic Review |
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17
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Patel K, Dajani K, Iype S, Chatzizacharias NA, Vickramarajah S, Singh P, Davies S, Brais R, Liau SS, Harper S, Jah A, Praseedom RK, Huguet EL. Incidental non-benign gallbladder histopathology after cholecystectomy in an United Kingdom population: Need for routine histological analysis? World J Gastrointest Surg 2016; 8:685-692. [PMID: 27830040 PMCID: PMC5081550 DOI: 10.4240/wjgs.v8.i10.685] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Revised: 06/26/2016] [Accepted: 08/16/2016] [Indexed: 02/06/2023] [Imported: 11/05/2023] Open
Abstract
AIM To analyse the range of histopathology detected in the largest published United Kingdom series of cholecystectomy specimens and to evaluate the rational for selective histopathological analysis.
METHODS Incidental gallbladder malignancy is rare in the United Kingdom with recent literature supporting selective histological assessment of gallbladders after routine cholecystectomy. All cholecystectomy gallbladder specimens examined by the histopathology department at our hospital during a five year period between March 2008 and March 2013 were retrospectively analysed. Further data was collected on all specimens demonstrating carcinoma, dysplasia and polypoid growths.
RESULTS The study included 4027 patients. The majority (97%) of specimens exhibited gallstone or cholecystitis related disease. Polyps were demonstrated in 44 (1.09%), the majority of which were cholesterol based (41/44). Dysplasia, ranging from low to multifocal high-grade was demonstrated in 55 (1.37%). Incidental primary gallbladder adenocarcinoma was detected in 6 specimens (0.15%, 5 female and 1 male), and a single gallbladder revealed carcinoma in situ (0.02%). This large single centre study demonstrated a full range of gallbladder disease from cholecystectomy specimens, including more than 1% neoplastic histology and two cases of macroscopically occult gallbladder malignancies.
CONCLUSION Routine histological evaluation of all elective and emergency cholecystectomies is justified in a United Kingdom population as selective analysis has potential to miss potentially curable life threatening pathology.
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Retrospective Cohort Study |
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18
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Michailidi C, Giaginis C, Stolakis V, Alexandrou P, Klijanienko J, Delladetsima I, Chatzizacharias N, Tsourouflis G, Theocharis S. Evaluation of FAK and Src Expression in Human Benign and Malignant Thyroid Lesions. Pathol Oncol Res 2010; 16:497-507. [PMID: 20405349 DOI: 10.1007/s12253-010-9269-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2009] [Accepted: 04/05/2010] [Indexed: 11/28/2022] [Imported: 11/05/2023]
Abstract
Focal Adhesion Kinase (FAK) and Src have been reported to regulate tumor growth, invasion, metastasis and angiogenesis. The present study aimed to evaluate by immunohistochemistry the clinical significance of FAK and Src expression in 108 patients with benign and malignant thyroid lesions. Total FAK expression provided a distinct discrimination between malignant and benign (p = 0.00001), as well as between papillary carcinoma and hyperplastic nodules thyroid lesions (p = 0.00005), being also associated with follicular cells' proliferative capacity (p = 0.0003). In malignant thyroid lesions, total FAK expression was associated with tumor size (p = 0.0455), and presence of capsular (p = 0.0102) and lymphatic (p = 0.0173) invasion. Total Src expression was borderline increased in cases of papillary carcinoma compared to hyperplastic nodules (p = 0.0993), being also correlated with tumor size (p = 0.0169). FAK and Src expression was ascribed to a significant extent to the phosphorylated forms of the enzymes, which provided a better discrimination between malignant and benign thyroid lesions. The current data revealed that FAK and to a lesser extent Src expression could be considered of clinical utility in thyroid neoplasia with potential use as therapeutic targets.
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Disruption of FAK signaling: a side mechanism in cytotoxicity. Toxicology 2007; 245:1-10. [PMID: 18215454 DOI: 10.1016/j.tox.2007.12.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2007] [Revised: 12/05/2007] [Accepted: 12/06/2007] [Indexed: 11/21/2022] [Imported: 11/05/2023]
Abstract
Focal adhesion kinase (FAK) is a non-receptor protein tyrosine kinase (PTK) which acts as an early modulator in the integrin signaling cascade. FAK phosphorylation and its consequent activation regulate several basic biological cellular functions. On the contrary, dysregulation of FAK signaling is implicated in the malignant transformation of cells, as well as in nonmalignant pathological conditions. With respect to cytotoxicity, accumulating data indicate that FAK participates in the mechanism of action of the known cytotoxic reactive oxygen species (ROS). Additionally, evidence was presented that different cytotoxic substances, such as arsenic (As), lead (Pb), acrylamide, methylisothiazolinone (MIT), dichlorovinylcysteine (DCVC) and halothane, acted, at least in part, by downregulating FAK tyrosine phosphorylation, while the bacterial toxins Pasteurella multocida toxin and Escherichia coli cytotoxic necrotizing factor, have been shown to exert cytotoxic effects by inducing FAK tyrosine phosphorylation. The observation that upregulation as well as downregulation of FAK activity both result in cytotoxic effects seems contradictory. Even though a common mode of action, with respect to the dysregulation of FAK signaling, for these cytotoxic substances has not yet been discovered, a cumulative approach could be established by focusing on FAK activation and signaling cascade. According to these data, interfering with FAK signaling might be of a potential use in blocking these cytotoxic effects. Further studies are needed on the possible implication of FAK in substance-induced cytotoxicity, as well as the possibility that such effects might be hindered or even blocked by restoring FAK signaling.
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Review |
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The effects of resection margin and KRAS status on outcomes after resection of colorectal liver metastases. HPB (Oxford) 2021; 23:90-98. [PMID: 32417170 DOI: 10.1016/j.hpb.2020.04.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 04/23/2020] [Indexed: 12/12/2022] [Imported: 11/05/2023]
Abstract
BACKGROUND The aim of this study was to investigate the influence of resection margin status in patients with KRAS mutations (mt-KRAS) when compared to those with wild-type KRAS (wt-KRAS) on long-term outcomes in patients with resected CRLM. METHODS All patients who underwent resection of CRLM with curative intent between January 2011 and December 2016 and had a KRAS type recorded were included in the study. Overall survival (OS), as well as death-censored overall (RFS) and liver-specific (LS-RFS) recurrence-free survival between KRAS types and the margin status within KRAS subgroups were compared using Cox regression models. RESULTS Data were available for N = 500 patients (30.4% mt-KRAS). mt-KRAS status was independently associated with significantly shorter OS. Within the wt-KRAS subgroup, smaller margins were found to be associated with significantly shorter death-censored LS-RFS (p < 0.001), with HRs of 1.93 (p = 0.005) for 1-4 mm margins and 2.83 (p < 0.001) for <1 mm margins, relative to those with clear margins. No such association was observed in the mt-KRAS subgroup (p = 0.721). CONCLUSION The resection margin status is of greater importance in patients with wt-KRAS. Such information could be useful in the operative planning, especially for those with multiple metastatic deposits, and also in the post-operative counselling and surveillance based on the margin and KRAS status.
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Ferguson HJM, Hall NJ, Bhangu A. A multicentre cohort study assessing day of week effect and outcome from emergency appendicectomy. BMJ Qual Saf 2014; 23:732-40. [PMID: 24508682 DOI: 10.1136/bmjqs-2013-002290] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] [Imported: 11/05/2023]
Abstract
BACKGROUND There is evidence to suggest that patients undergoing treatment at weekends may be subject to different care processes and outcomes compared with weekdays. This study aimed to determine whether clinical outcomes from weekend appendicectomy are different from those performed on weekdays. METHOD Multicentre cohort study during May-June 2012 from 95 centres (89 within the UK). The primary outcome was the 30-day adverse event rate. Multilevel modelling was used to account for clustering within hospitals while adjusting for case mix to produce adjusted ORs and 95% CIs. RESULTS When compared with Monday, there were no significant differences for other days of the week considering 30-day adverse events in adjusted models. On Sunday, rates of simple appendicitis were highest, and rates of normal (OR 0.62, 95% CI 0.42 to 0.90) and complex appendicitis (OR 0.65, 95% CI 0.46 to 0.93) lowest. This was accompanied by a 43% lower likelihood in use of laparoscopy on Sunday (OR 0.47, 95% CI 0.32 to 0.69), accompanied by the lowest level of consultant presence for the week. When pooling weekends and weekdays, laparoscopy use remained less likely at the weekend (OR 0.68, 95% CI 0.55 to 0.83), with no significant difference for 30-day adverse event rate (OR 1.01, 95% CI 0.80 to 1.29). CONCLUSIONS This study found that weekend appendicectomy was not associated with increased 30-day adverse events. It cannot rule out smaller increases that may be shown by larger studies. It further illustrated that patients operated on at weekends were subject to different care processes, which may expose them to risk.
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Multicenter Study |
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14 |
22
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Kamarajah S, Giovinazzo F, Roberts KJ, Punia P, Sutcliffe RP, Marudanayagam R, Chatzizacharias N, Isaac J, Mirza DF, Muiesan P, Dasari BV. The role of down staging treatment in the management of locally advanced intrahepatic cholangiocarcinoma: Review of literature and pooled analysis. Ann Hepatobiliary Pancreat Surg 2020; 24:6-16. [PMID: 32181423 PMCID: PMC7061034 DOI: 10.14701/ahbps.2020.24.1.6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 11/02/2019] [Accepted: 11/14/2019] [Indexed: 12/12/2022] [Imported: 11/05/2023] Open
Abstract
Backgrounds/Aims Approximately 60–80% of patients with intrahepatic cholangiocarcinoma (iCCA) are not suitable for surgical resection due to advanced disease at presentation. This review assesses the role of surgical resection followed by down staging treatment in the management of patients with locally advanced iCCA. Methods A systematic review and pooled analysis were performed of the relevant published studies published between January 2000-December 2018. The primary outcome measure was overall survival. Secondary outcome measures were rates of clinical benefit, margin-negative (R0) resections, overall and surgery-specific complications, and post-operative mortality. Results Eighteen cohort studies with 1880 patients were included in the review. The median overall survival in all patients was 14 months (range, 7–18 months). Patients undergoing resection following down staging had significantly longer survival than those who did not (median: 29 vs. 12 months, p<0.001). The Clinical Benefit Rate with this strategy (complete response+partial response+stable disease) was 64% (244/383), ranging from 33-90%. Thirty-eight percent of the patients underwent resections with a 60% R0 resection rate and 6% postoperative mortality. Conclusions Although the evidence to support the benefits of NAT for iCCA is limited, the review supports the use of down staging treatment and also surgical resection in the cohort with response to NAT in order to improve long-term survival in patients with locally advanced iCCA.
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Review |
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Pournaras DJ, Photi ES, Barnett N, Challand CP, Chatzizacharias NA, Dlamini NP, Doulias T, Foley A, Hernon J, Kumar B, Martin J, Nunney I, Oglesby F, Panagiotopoulou I, Sengupta N, Shivakumar O, Sinclair P, Stather P, Than MM, Wells AC, Xanthis A, Dhatariya K. Assessing the quality of primary care referrals to surgery of patients with diabetes in the East of England: A multi-centre cross-sectional cohort study. Int J Clin Pract 2017; 71. [PMID: 28618177 DOI: 10.1111/ijcp.12971] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Accepted: 05/10/2017] [Indexed: 01/10/2023] [Imported: 11/05/2023] Open
Abstract
AIM Peri-operative hyperglycaemia is associated with an increased incidence of adverse outcomes. Communication between primary and secondary care is paramount to minimise these harms. National guidance in the UK recommends that the glycated haemoglobin (HbA1c) should be measured within 3 months prior to surgery and that the concentration should be less that 69 mmol/mol (8.5%). In addition, national guidance outlines the minimum dataset that should be included in any letter at the time of referral to the surgeons. Currently, it is unclear how well this process is being carried out. This study investigated the quality of information being handed over during the referral from primary care to surgical outpatients within the East of England. METHODS Primary care referrals to nine different NHS hospital Trusts were gathered over a 1-week period. All age groups were included from 11 different surgical specialties. Referral letters were analysed using a standardised data collection tool based on the national guidelines. RESULTS A total of 1919 referrals were received, of whom 169 (8.8%) had previously diagnosed diabetes mellitus (DM). However, of these, 38 made no mention of DM in the referral letter but were on glucose-lowering agents. Only 13 (7.7%) referrals for patients with DM contained a recent HbA1c, and 20 (11.8%) contained no documentation of glucose-lowering medication. CONCLUSION This study has shown that the quality of referral letters to surgical specialties for patients with DM in the East of England remain inadequate. There is a clear need for improving the quality of clinical data contained within referral letters from primary care. In addition, we have shown that the rate of referral for surgery for people with diabetes is almost 50% higher than the background population with diabetes.
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Multicenter Study |
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Chatzizacharias NA, Kouraklis GP, Giaginis CT, Theocharis SE. Clinical significance of Src expression and activity in human neoplasia. Histol Histopathol 2012; 27:677-92. [PMID: 22473690 DOI: 10.14670/hh-27.677] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] [Imported: 11/05/2023]
Abstract
Src, a 60 kDa non-receptor tyrosine kinase, is the product of normal c-src of the human genome and member of the Src protein tyrosine kinases family (SFK). As described by Martin and Rous, a genetic recombination between c-src and the RSV oncogene of Rous sarcoma virus results in a modified Src protein, with increased intrinsic activity and transforming potential in animal and human tissues. Several in vitro and in vivo studies supported this theory providing insight in the signalling pathways involved. Accumulating evidence from studies on clinical samples supported the role of Src in the process of carcinogenesis and disease progression in several human malignancies. Some studies have further reinforced the significance of the kinase in malignacy by correlating its expression and/or activity with important clinicopathological parameters, such as tumour stage, histopathological grade, proliferative capacity and most importantly patient's survival. This review is a comprehensive report of the published evidence on the expression and clinical significance of Src in human malignancy, which constitutes the background of the current studies and clinical trials on the use of Src inhibitors as novel potent antineoplastic strategy.
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Review |
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25
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Chatzizacharias NA, Kouraklis GP, Theocharis SE. The role of focal adhesion kinase in early development. Histol Histopathol 2010; 25:1039-55. [PMID: 20552554 DOI: 10.14670/hh-25.1039] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] [Imported: 11/05/2023]
Abstract
FAK is a tyrosine kinase enzyme demonstrated to play an important regulatory role in several basic cellular activities. Scientific evidence have suggested that FAK possessing a central position in the integrin signaling cascade, is responsible, at least in part, for the modulation of cellular proliferation, protection from apoptosis, adhesion, spreading and migration. The role of FAK in the development of different species, including human, is under study. Various published data supported the role of the molecule in the development of the placenta, as well as of several organ systems, like the musculoskeletal, nervous, cardiovascular, genitourinary and respiratory organ systems. Additionally, FAK has been shown to be implicated in the pathophysiology of pregnancy related disorders and congenital neonatal diseases and defects. The purpose of this article is a comprehensive review of the existing literature with a view to the future and the potential conclusions that can be drawn by the study of FAK signaling on the events of early life and species development.
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Review |
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10 |