Systematic Review and Meta-analysis of Long-term survival After Elective Infrarenal Abdominal Aortic Aneurysm Repair 1969-2011: 5 Year Survival Remains Poor Despite Advances in Medical Care and Treatment Strategies

Background

Improved critical care, pre-operative optimization, and the advent of endovascular surgery (EVAR) have improved 30 day mortality for elective abdominal aortic aneurysm (AAA) repair. It remains unknown whether this has translated into improvements in long-term survival, particularly because these factors have also encouraged the treatment of older patients with greater comorbidity. The aim of this study was to quantify how 5 year survival after elective AAA repair has changed over time.

Methods

A systematic review was performed identifying studies reporting 5 year survival after elective infrarenal AAA repair. An electronic search of the Embase and Medline databases was conducted to January 2014. Thirty-six studies, 60 study arms, and 107,814 patients were identified. Meta-analyses were conducted to determine 5 year survival and to report whether 5 year survival changed over time.

Results

Five-year survival was 69% (95% CI 67 to 71%, I² = 87%). Meta-regression on study midpoint showed no improvement in 5 year survival over the period 1969–2011 (log OR −0.001, 95% CI −0.014–0.012). Larger average aneurysm diameter was associated with poorer 5 year survival (adjusted log OR −0.058, 95% CI −0.095 to −0.021, I² = 85%). Older average patient age at surgery was associated with poorer 5 year survival (adjusted log OR −0.118, 95% CI −0.142 to −0.094, I² = 70%). After adjusting for average patient age, an improvement in 5 year survival over the period that these data spanned was obtained (adjusted log OR 0.027, 95% CI 0.012 to 0.042).

Conclusion

Five-year survival remains poor after elective AAA repair despite advances in short-term outcomes and is associated with AAA diameter and patient age at the time of surgery. Age-adjusted survival appears to have improved; however, this cohort as a whole continues to have poor long-term survival. Research in this field should attempt to improve the life expectancy of patients with repaired AAA and to optimise patient selection.

Antithrombotic treatment for acute extracranial carotid artery dissections: a meta-analysis

INTRODUCTION

Carotid artery dissection is a leading cause of stroke in younger patients, with an associated prevalence of 2.6-3.0 per 100,000 population. This meta-analysis aims to determine whether in patients managed medically, treatment with anticoagulants or antiplatelet agents was associated with a better outcome with respect to mortality, ischaemic stroke, and major bleeding episodes.

PATIENTS AND METHODS

A comprehensive search strategy was employed of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (January 1966 to March 2015), and EMBASE (January 1980 to March 2015) databases. Primary outcomes were death (all causes) or disability. Secondary outcomes were ischaemic stroke, symptomatic intracranial haemorrhage, and major extracranial haemorrhage during the reported follow-up period.

RESULTS

No completed randomized trials were found. Comparing antiplatelets with anticoagulants across 38 studies (1,398 patients), there were no significant differences in the odds of death (effects size, ES, -0.007, p = .871), nor in the death and disability comparison or across any secondary outcomes.

CONCLUSION

There were no randomised trials comparing either anticoagulants or antiplatelets with control, thus there is no level 1 evidence to support their routine use for the treatment of carotid artery dissection. Also, there were no randomised trials that directly compared anticoagulants with antiplatelet drugs, and the reported non-randomised studies did not show any evidence of a significant difference between the two.

Consistency and inconsistency in network meta-analysis: concepts and models for multi-arm studies

Meta-analyses that simultaneously compare multiple treatments (usually referred to as network meta-analyses or mixed treatment comparisons) are becoming increasingly common. An important component of a network meta-analysis is an assessment of the extent to which different sources of evidence are compatible, both substantively and statistically. A simple indirect comparison may be confounded if the studies involving one of the treatments of interest are fundamentally different from the studies involving the other treatment of interest. Here, we discuss methods for addressing inconsistency of evidence from comparative studies of different treatments. We define and review basic concepts of heterogeneity and inconsistency, and attempt to introduce a distinction between ‘loop inconsistency’ and ‘design inconsistency’. We then propose that the notion of design-by-treatment interaction provides a useful general framework for investigating inconsistency. In particular, using design-by-treatment interactions successfully addresses complications that arise from the presence of multi-arm trials in an evidence network. We show how the inconsistency model proposed by Lu and Ades is a restricted version of our full design-by-treatment interaction model and that there may be several distinct Lu–Ades models for any particular data set. We introduce novel graphical methods for depicting networks of evidence, clearly depicting multi-arm trials and illustrating where there is potential for inconsistency to arise. We apply various inconsistency models to data from trials of different comparisons among four smoking cessation interventions and show that models seeking to address loop inconsistency alone can run into problems. Copyright © 2012 John Wiley & Sons, Ltd.

Paediatric CT dose: a multicentre audit of subspecialty practice in Australia and New Zealand

OBJECTIVES

To evaluate paediatric CT dosimetry in Australia and New Zealand and calculate size-specific dose estimates (SSDEs) for chest and abdominal examinations.

METHODS

Eight hospitals provided data from 12 CT systems for 1462 CTs in children aged 0-15. Imaging data were recorded for eight examinations: head (trauma, shunt), temporal bone, paranasal sinuses, chest (mass) and chest HRCT (high-resolution CT), and abdomen/pelvis (mass/inflammation). Dose data for cranial examinations were categorised by age and SSDEs by lateral dimension. Diagnostic reference ranges (DRRs) were defined by the 25th and 75th percentiles. Centralised image quality assessment was not undertaken.

RESULTS

DRRs for 201 abdominopelvic SSDEs were: 2.8-4.7, 3.6-11.5, 8.5-15.0, 7.6-15, and 10.6-16.2 for the <15 cm, 15-19 cm, 20-24 cm, 25-29 cm and >30 cm groups, respectively. For 147 chest examinations using these body width categories, SSDE DRRs were 2.0-4.4, 3.3-7.9, 4.0-9.4, 4.5-12, and 6.5-12. Kilovoltage peak (kVp), but not AEC or IR, was associated with SSDE (parameter estimate [standard error]: 0.12 (0.03); p < 0.0001).

CONCLUSIONS

Australian and New Zealand paediatric CT DRRs and abdominal SSDEs are comparable to international data. SSDEs for chest examinations are proposed. Dose variations could be reduced by adjusting kVp.

KEY POINTS

• SSDEs can be calculated for all patients, CT systems, and practices • Kilovoltage peak (kVp) has the greatest association with dose in similar-sized patients • Paediatric DRRs for CT are now available for use internationally.

Towards a PBMC "virogram assay" for precision medicine: Concordance between ex vivo and in vivo viral infection transcriptomes

BACKGROUND

Understanding individual patient host-response to viruses is key to designing optimal personalized therapy. Unsurprisingly, in vivo human experimentation to understand individualized dynamic response of the transcriptome to viruses are rarely studied because of the obvious limitations stemming from ethical considerations of the clinical risk.

OBJECTIVE

In this rhinovirus study, we first hypothesized that ex vivo human cells response to virus can serve as a proxy for otherwise controversial in vivo human experimentation. We further hypothesized that the N-of-1-pathways framework, previously validated in cancer, can be effective in understanding the more subtle individual transcriptomic response to viral infection.

METHOD

N-of-1-pathways computes a significance score for a given list of gene sets at the patient level, using merely the 'omics profiles of two paired samples as input. We extracted the peripheral blood mononuclear cells (PBMC) of four human subjects, aliquoted in two paired samples, one subjected to ex vivo rhinovirus infection. Their dysregulated genes and pathways were then compared to those of 9 human subjects prior and after intranasal inoculation in vivo with rhinovirus. Additionally, we developed the Similarity Venn Diagram, a novel visualization method that goes beyond conventional overlap to show the similarity between two sets of qualitative measures.

RESULTS

We evaluated the individual N-of-1-pathways results using two established cohort-based methods: GSEA and enrichment of differentially expressed genes. Similarity Venn Diagrams and individual patient ROC curves illustrate and quantify that the in vivo dysregulation is recapitulated ex vivo both at the gene and pathway level (p-values⩽0.004).

CONCLUSION

We established the first evidence that an interpretable dynamic transcriptome metric, conducted as an ex vivo assays for a single subject, has the potential to predict individualized response to infectious disease without the clinical risks otherwise associated to in vivo challenges. These results serve as a foundational work for personalized "virograms".

Pseudo-Outbreak ofLegionella pneumophilaSerogroup 8 Infection Associated With a Contaminated Ice Machine in a Bronchoscopy Suite

Objective.

To investigate the marked increase noted over an 8-month period in the number ofLegionella pneumophilaisolates recovered from bronchoalveolar lavage fluid specimens obtained during bronchoscopy in our healthcare system.

Setting.

Bronchoscopy suite that serves a 580-bed tertiary care center and a large, multisite, faculty practice plan with approximately 2 million outpatient visits per year.

Methods.

Cultures of environmental specimens from the bronchoscopy suite were performed, including samples from the air and water filters, bronchoscopes, and the ice machine, with the aim of identifyingLegionellaspecies. Specimens were filtered and acid-treated and then inoculated on buffered charcoal yeast extract agar. Serogrouping was performed on all isolates recovered from patient and environmental samples.

Results.

AUL. pneumophilaisolates recovered from patients were serogroup 8, a serogroup that is not usually recovered in our facility. An epidemiologic investigation of the bronchoscopy suite revealed the ice machine to be contaminated withL. pneumophilaserogroup 8. Patients were exposed to the organism as a result of a recently adopted practice in the bronchoscopy suite that involved directly immersing uncapped syringes of sterile saline in contaminated ice baths during the procedures. At least 1 patient was ill as a result of the pseudo-outbreak. Molecular typing of isolates recovered from patient and environmental samples revealed that the isolates were indistinguishable.

Conclusions.

Extensive cleaning of the ice machine and replacement of the machine's water filter ended the pseudo-outbreak. This episode emphasizes the importance of using aseptic technique when performing invasive procedures, such as bronchoscopies. It also demonstrates the importance of reviewing procedures in all patient areas to ensure compliance with facility policies for providing a safe patient environment.

Multivariate meta-analysis using individual participant data

When combining results across related studies, a multivariate meta-analysis allows the joint synthesis of correlated effect estimates from multiple outcomes. Joint synthesis can improve efficiency over separate univariate syntheses, may reduce selective outcome reporting biases, and enables joint inferences across the outcomes. A common issue is that within-study correlations needed to fit the multivariate model are unknown from published reports. However, provision of individual participant data (IPD) allows them to be calculated directly. Here, we illustrate how to use IPD to estimate within-study correlations, using a joint linear regression for multiple continuous outcomes and bootstrapping methods for binary, survival and mixed outcomes. In a meta-analysis of 10 hypertension trials, we then show how these methods enable multivariate meta-analysis to address novel clinical questions about continuous, survival and binary outcomes; treatment–covariate interactions; adjusted risk/prognostic factor effects; longitudinal data; prognostic and multiparameter models; and multiple treatment comparisons. Both frequentist and Bayesian approaches are applied, with example software code provided to derive within-study correlations and to fit the models.

Laparoscopic versus open colorectal resection for cancer and polyps: a cost-effectiveness study

Background

Available evidence that compares outcomes from laparoscopic and open surgery for colorectal cancer shows no difference in disease free or survival time, or in health-related quality of life outcomes, but does not capture the short term benefits of laparoscopic methods in the early postoperative period.

Aim

To explore the cost-effectiveness of laparoscopic colorectal surgery, compared to open methods, using quality of life data gathered in the first 6 weeks after surgery.

Methods

Participants were recruited in 2006–2007 in a district general hospital in the south of England; those with a diagnosis of cancer or polyps were included in the analysis. Quality of life data were collected using EQ-5D, on alternate days after surgery for 4 weeks. Costs per patient, from a National Health Service perspective (in British pounds, 2006) comprised the sum of operative, hospital, and community costs. Missing data were filled using multiple imputation methods. The difference in mean quality adjusted life years and costs between surgery groups were estimated simultaneously using a multivariate regression model applied to 20 imputed datasets. The probability that laparoscopic surgery is cost-effective compared to open surgery for a given societal willingness-to-pay threshold is illustrated using a cost-effectiveness acceptability curve.

Results

The sample comprised 68 laparoscopic and 27 open surgery patients. At 28 days, the incremental cost per quality adjusted life year gained from laparoscopic surgery was £12,375. At a societal willingness-to-pay of £30,000, the probability that laparoscopic surgery is cost-effective, exceeds 65% (at £20,000 ≈60%). In sensitivity analyses, laparoscopic surgery remained cost-effective compared to open surgery, provided it results in a saving ≥£699 in hospital bed days and takes no more than 8 minutes longer to perform.

Conclusion

The study provides formal evidence of the cost-effectiveness of laparoscopic approaches and supports current guidelines that promote use of laparoscopy where suitably trained surgeons are available.

Evertor muscle activity as a predictor of the mid-term outcome following treatment of the idiopathic and non-idiopathic clubfoot

Previous studies have identified clinical and demographic risk factors for recurrence in the treatment of idiopathic clubfoot (congenital talipes equinovarus). Evertor muscle activity is not usually considered amongst them. This study aimed to evaluate whether recurrence could be predicted by demographic, clinical and gait parameters. From a series of 103 children with clubfeet, 67 had completed a follow-up of two years: 41 male and 26 female, 38 with idiopathic and 29 with non-idiopathic deformities. The mean age was 3.2 years (2.1 to 6.3). Primary correction was obtained in all 38 children (100%) with an idiopathic deformity, and in 26 of 29 patients (90%) with a non-idiopathic deformity. Overall, 60 children (90%) complied with the abduction brace regime. At a mean follow-up of 31.4 months (24 to 62), recurrence was noted in six children (15.8%) in the idiopathic and 14 children (48.3%) in the non-idiopathic group. Significant correlation was found between poor evertor activity and recurrence in both groups. No statistically significant relationship was found between the rate of recurrence and the severity of the initial deformity, the age at the time of treatment, the number of casts required or the compliance with the brace.

After correction of idiopathic and non-idiopathic clubfoot using the Ponseti method, only poor evertor muscle activity was statistically associated with recurrence. The identification of risk factors for recurrent deformity allows clinicians to anticipate problems and advocate early additional treatment to improve muscle balance around the ankle.

Cite this article: Bone Joint J 2014;96-B:1264–8.

The effect of the environment on symptom dimensions in the first episode of psychosis: a multilevel study

BACKGROUND

The extent to which different symptom dimensions vary according to epidemiological factors associated with categorical definitions of first-episode psychosis (FEP) is unknown. We hypothesized that positive psychotic symptoms, including paranoid delusions and depressive symptoms, would be more prominent in more urban environments.

METHOD

We collected clinical and epidemiological data on 469 people with FEP (ICD-10 F10-F33) in two centres of the Aetiology and Ethnicity in Schizophrenia and Other Psychoses (AESOP) study: Southeast London and Nottinghamshire. We used multilevel regression models to examine neighbourhood-level and between-centre differences in five symptom dimensions (reality distortion, negative symptoms, manic symptoms, depressive symptoms and disorganization) underpinning Schedules for Clinical Assessment in Neuropsychiatry (SCAN) Item Group Checklist (IGC) symptoms. Delusions of persecution and reference, along with other individual IGC symptoms, were inspected for area-level variation.

RESULTS

Reality distortion [estimated effect size (EES) 0.15, 95% confidence interval (CI) 0.06-0.24] and depressive symptoms (EES 0.21, 95% CI 0.07-0.34) were elevated in people with FEP living in more urban Southeast London but disorganized symptomatology was lower (EES -0.06, 95% CI -0.10 to -0.02), after controlling for confounders. Delusions of persecution were not associated with increased neighbourhood population density [adjusted odds ratio (aOR) 1.01, 95% CI 0.83-1.23], although an effect was observed for delusions of reference (aOR 1.41, 95% CI 1.12-1.77). Hallucinatory symptoms showed consistent elevation in more densely populated neighbourhoods (aOR 1.32, 95% CI 1.09-1.61).

CONCLUSIONS

In people experiencing FEP, elevated levels of reality distortion and depressive symptoms were observed in more urban, densely populated neighbourhoods. No clear association was observed for paranoid delusions; hallucinations were consistently associated with increased population density. These results suggest that urban environments may affect the syndromal presentation of psychotic disorders.

Demonstrating compliance with protection objectives for non-human biota within post-closure safety cases for radioactive waste repositories

Over recent years, a number of approaches have been developed that enable the calculation of dose rates to animals and plants following the release of radioactivity to the environment. These approaches can be used to assess the potential impacts of activities that may release radioactivity to the environment, such as the operation of waste repositories. A number of national and international studies have identified screening criteria to indicate those assessment results below which further consideration is not generally required. However no internationally agreed criteria are currently available and consistency in criteria between countries has not been achieved. Furthermore, since screening criteria are not intended to be applied as limits, it is clear that they cannot always form a sufficient basis for assessing the adequacy of protection afforded. Typically, exceeding a screening value leads to a regulatory requirement to undertake a further, more detailed assessment. It does not, per se, imply that there is inadequate protection of the organism types at the specific site under assessment. Therefore, there is a need to develop a more structured approach to dealing with situations in which current screening criteria are exceeded. As a contribution to the developing international discussions, and as an interim measure for application where assessments are required currently, a two-tier, three zone framework is proposed here, relevant to the long term assessment of potential impacts from the deep disposal of radioactive wastes. The purpose of the proposed framework is to promote a proportionate and risk-based approach to the level of effort required in undertaking and interpreting an assessment.

Evaluation of serum carnitine levels for pediatric patients receiving carnitine-free and carnitine-supplemented parenteral nutrition

PURPOSE

Carnitine is a carrier molecule transporting long-chain fatty acids (LCFAs) into the mitochondria for fatty acid β-oxidation. The purpose of this study is to evaluate the role of carnitine supplementation in parenteral nutrition (PN) within the pediatric population. Our goal was to determine a weight range for which empiric carnitine supplementation is justified and to determine a weight range at which a carnitine level should first be drawn to confirm a deficiency prior to supplementation. Secondarily, we tried to determine a relationship among carnitine deficiency, hypoglycemia, and hypertriglyceridemia.

METHODS

This was a retrospective observational study to evaluate 2 groups of pediatric patients (weighing 0.68 kg to 60 kg) who were NPO and receiving PN. The first group of patients (n = 454) received carnitine supplementation (15 mg/kg/day) upon initiation of PN. The second group (n = 299) did not receive carnitine supplementation until they were determined to have a carnitine deficiency.

RESULTS

The data indicated that 82% of the patients weighing less than 5 kg were deficient. Patients weighing more than 5 kg had serum carnitine levels within the normal range. Therefore, patients receiving PN and weighing less than 5 kg should be supplemented with carnitine. Comparison of triglyceride, glucose, and carnitine showed no statistically significant difference (P = .1936).

CONCLUSION

Patients weighing more than 5 kg should have serum carnitine levels drawn within 7 days to determine whether supplementation is needed. There is no statistical correlation among carnitine deficiency, hypoglycemia, and hypertriglyceridemia.

Leaching of cadmium, chromium, copper, lead, and zinc from two slag dumps with different environmental exposure periods under dynamic acidic condition

Over the past few decades, zinc smelting activities in Guizhou, China have produced numerous slag dumps, which are often dispersed on roadsides and hill slopes throughout the region. During periods of acid rain, these exposed slags release heavy metals into surface water bodies. A column leaching study was designed to test the potential release of the heavy metals cadmium (Cd), chromium (Cr), copper (Cu), lead (Pb), and zinc (Zn) under simulated acid rain events. Two slags with varying environmental exposure periods were packed in columns and subjected to leaching solutions of pH 3.5, 5.5, or DI H2O at intervals of 1, 7, 14, 28, 56d. Pulse concentrations of Cd in leachate were found above 5μg/L, Cr, Pb, and Zn >10μg/L, whereas, Cu reached 10μg/L. After five leaching events, the leachability (percentage of cumulative heavy metal leached after five leaching events as in its respective total concentration in slags) of Cd was 0.05 percent and 0.035 percent from the old and young slag, respectively. Cr (0.035 percent and 0.05 percent) was greater than Cu (0.002 percent and 0.005 percent) and Zn (0.006 percent and 0.003 percent), while the lowest leachability was observed for Pb (0.0005 percent and 0.0002 percent) from the old and young slags, respectively. Reaction rates (release amount of heavy metals in certain period of leaching) of heavy metals in the leachates demonstrated the sequence of Zn>Cr>Cd, Cu>Pb. Leaching release of heavy metals was jointly affected by the pH of leaching solution and mineral composition of slags (including chemical forms of Cd, Cr, Cu, Pb, and Zn). Environmental exposure period of slags, resulting in the alteration of minerals, could affect the release process of heavy metals in leaching as well.

Integration of tuberculosis and prevention of mother-to-child transmission of HIV programmes in South Africa

SETTING

One of the rural districts in KwaZulu-Natal Province, the epicentre of the human immunodeficiency virus (HIV) and tuberculosis (TB) epidemics in South Africa.

OBJECTIVES

To assess the integration of TB services into the prevention of mother-to-child transmission of HIV (PMTCT) programme and identify barriers to the integration of services.

DESIGN

Cross-sectional survey using exit interviews with pregnant women attending 10 antenatal care (ANC) clinics. Review of ANC PMTCT facility routine data. Qualitative interviews with 26 key informants on barriers to integration of TB-PMTCT services.

RESULTS

Of 150 women interviewed, 112 (75%) reported being educated on TB symptoms on the day of their visit; 56% were screened for TB symptoms and 27% were suspected to have TB; 26 (17%) women were HIV-positive and 2 (8%) were co-infected with TB. There was no record of provision of isoniazid prophylaxis for PMTCT clients with latent tuberculous infection. The predominant barriers to the integration of TB-PMTCT services included lack of skilled providers and their supervision, the physical layout of the TB-PMTCT services and the service delivery mechanisms.

CONCLUSION

The integration of TB prevention and care into the PMTCT programme was inadequate. Integration of TB services into the ANC PMTCT programme will require strong leadership to address barriers such as training gaps, lack of supervision and service delivery mechanisms.

Community-based intervention to enhance provision of integrated TB-HIV and PMTCT services in South Africa

OBJECTIVE

To conduct an impact assessment of an intervention to enhance the provision of community-based integrated services for tuberculosis (TB), human immunodeficiency virus (HIV) and prevention of mother-to-child transmission (PMTCT).

METHODS

The intervention consisted of a combination of training of community care workers (CCWs), structural adjustments, harmonisation of scope of practice and stipend of CCWs and enhanced supervision of CCWs to provide comprehensive TB-HIV/PMTCT services in a rural South African district. A before and after study design was used with a household survey to assess the operational effectiveness of the intervention. Six clusters were randomised into intervention and control arms. Quantitative data were analysed using logistic regression, adjusting for cluster design.

RESULTS

Logistic regression analyses of the survey data show that CCWs from the intervention arm performed better in the provision of TB-HIV/PMTCT services, such as screening for TB and sexually transmitted infections, adherence to anti-tuberculosis treatment and antiretroviral therapy and counselling on infant feeding compared to the control CCWs (P < 0.05). However, intervention CCWs performed worse in the integrated management of childhood illnesses education and social welfare referrals (P < 0.05). The uptake of HIV testing increased significantly in the intervention arm, from 55% to 78% (P < 0.001).

CONCLUSION

The intervention was effective in enhancing the provision of community-based TB-HIV and PMTCT services. However, attention to other primary health care services is required to ensure that all key services are provided.

Influence of co-payment levels on patient and surgeon acceptance of advanced technology intraocular lenses

PURPOSE

To investigate patients' willingness to pay for advanced technology intraocular lenses and surgeons' willingness to recommend them.

METHODS

In this study, 370 cataract surgeons and 700 patients undergoing cataract surgery from seven countries underwent online interviews in which they were shown unbranded profiles of three advanced technology intraocular lenses (ie, biconvex toric aspheric optic, symmetric biconvex diffractive optic, and biconvex diffractive aspheric toric) and asked to indicate their willingness to accept (for patients) or suggest (for surgeons) each lens. Acceptance was assessed assuming there was either no co-payment or co-payments of €500 to €1,500 +15%.

RESULTS

All three lenses were widely accepted by patients, with 68% to 99% indicating acceptance when there was no co-payment. In contrast, surgeons' willingness to suggest them was markedly lower (20% to 43%). Both patients' acceptance of the lenses and surgeons' willingness to suggest them decreased with increasing co-payment levels to 19% to 74% (patients) and 5% to 31% (surgeons) at the highest co-payment levels.

CONCLUSIONS

There is a marked discrepancy between patients' acceptance of the three lenses and surgeons' willingness to suggest them. Although patients' acceptance is high, it decreases with increasing out-of-pocket expenditure. Manufacturers should communicate the relative benefits and costs of their lenses to both surgeons and patients.

Should we reconsider lung transplantation through uncontrolled donation after circulatory death?

Lung transplantation through controlled donation after circulatory death (cDCD) has slowly gained universal acceptance with reports of equivalent outcomes to those through donation after brain death. In contrast, uncontrolled DCD (uDCD) lung use is controversial and requires ethical, legal and medical complexities to be addressed in a limited time. Consequently, uDCD lung use has not previously been reported in the United States. Despite these potential barriers, we present a case of a patient with multiple gunshot wounds to the head and the body who was unsuccessfully resuscitated and ultimately became an uDCD donor. A cytomegalovirus positive recipient who had previously consented for CDC high-risk, DCD and participation in the NOVEL trial was transplanted from this uDCD donor, following 3 h of ex vivo lung perfusion. The postoperative course was uneventful, and the recipient was discharged home on day 9. While this case represents a "best-case scenario," it illustrates a method for potential expansion of the lung allograft pool through uDCD after unsuccessful resuscitation in hospitalized patients.

Gene splicing of an invertebrate beta subunit (LCavβ) in the N-terminal and HOOK domains and its regulation of LCav1 and LCav2 calcium channels

The accessory beta subunit (Ca(v)β) of calcium channels first appear in the same genome as Ca(v)1 L-type calcium channels in single-celled coanoflagellates. The complexity of this relationship expanded in vertebrates to include four different possible Ca(v)β subunits (β1, β2, β3, β4) which associate with four Ca(v)1 channel isoforms (Ca(v)1.1 to Ca(v)1.4) and three Ca(v)2 channel isoforms (Ca(v)2.1 to Ca(v)2.3). Here we assess the fundamentally-shared features of the Ca(v)β subunit in an invertebrate model (pond snail Lymnaea stagnalis) that bears only three homologous genes: (LCa(v)1, LCa(v)2, and LCa(v)β). Invertebrate Ca(v)β subunits (in flatworms, snails, squid and honeybees) slow the inactivation kinetics of Ca(v)2 channels, and they do so with variable N-termini and lacking the canonical palmitoylation residues of the vertebrate β2a subunit. Alternative splicing of exon 7 of the HOOK domain is a primary determinant of a slow inactivation kinetics imparted by the invertebrate LCa(v)β subunit. LCa(v)β will also slow the inactivation kinetics of LCa(v)3 T-type channels, but this is likely not physiologically relevant in vivo. Variable N-termini have little influence on the voltage-dependent inactivation kinetics of differing invertebrate Ca(v)β subunits, but the expression pattern of N-terminal splice isoforms appears to be highly tissue specific. Molluscan LCa(v)β subunits have an N-terminal "A" isoform (coded by exons: 1a and 1b) that structurally resembles the muscle specific variant of vertebrate β1a subunit, and has a broad mRNA expression profile in brain, heart, muscle and glands. A more variable "B" N-terminus (exon 2) in the exon position of mammalian β3 and has a more brain-centric mRNA expression pattern. Lastly, we suggest that the facilitation of closed-state inactivation (e.g. observed in Ca(v)2.2 and Ca(v)β3 subunit combinations) is a specialization in vertebrates, because neither snail subunit (LCa(v)2 nor LCa(v)β) appears to be compatible with this observed property.

Mini-probe ultrasonography for the staging of colon cancer: a systematic review and meta-analysis

AIM

With an increasing array of treatment modalities available for colon cancer, it is increasingly important to stage tumours accurately to allocate the appropriate management. This study evaluated the accuracy of mini-probe endoscopic ultrasound (EUS) in assigning clinical stage to colon cancer.

METHOD

An electronic search was performed in January 2013 using the Embase, MEDLINE and Cochrane databases. This was supplemented by a hand search of published abstracts from scientific meetings. Trials evaluating the accuracy of the mini-probe EUS compared with histopathological grade in determining the clinical stage of colon cancer were included in this pooled analysis. The main outcome measures included accuracy, sensitivity and specificity for T and N staging.

RESULTS

Ten studies were identified which compared the mini-probe EUS staging of 642 colon or rectal cancers with the histopathological specimen. The pooled sensitivity and specificity for staging were 0.91 and 0.98 for T1 tumours, 0.78 and 0.94 for T2 tumours, 0.97 and 0.90 for T3/T4 tumours and 0.63 and 0.82 for nodal staging. Eight per cent of T1/T2 tumours were upstaged to T3/T4 tumours and 5% of T3/T4 tumours were downstaged.

CONCLUSION

Mini-probe EUS is highly effective for assigning clinical stage in colon cancer and in identifying patients who may be suitable for nonsurgical treatment including neoadjuvant chemotherapy or endoscopic resection.

A refined method for multivariate meta-analysis and meta-regression

Making inferences about the average treatment effect using the random effects model for meta-analysis is problematic in the common situation where there is a small number of studies. This is because estimates of the between-study variance are not precise enough to accurately apply the conventional methods for testing and deriving a confidence interval for the average effect. We have found that a refined method for univariate meta-analysis, which applies a scaling factor to the estimated effects’ standard error, provides more accurate inference. We explain how to extend this method to the multivariate scenario and show that our proposal for refined multivariate meta-analysis and meta-regression can provide more accurate inferences than the more conventional approach. We explain how our proposed approach can be implemented using standard output from multivariate meta-analysis software packages and apply our methodology to two real examples. © 2013 The Authors. Statistics in Medicine published by John Wiley & Sons, Ltd.

Indirect effects of a fungal entomopathogen, Lecanicillium lecanii (Hypocreales: Clavicipitaceae), on a coffee agroecosystem ant community

Fungal entomopathogens are widely distributed across natural and managed systems, with numerous host species and likely a wide range of community impacts. While the potential for fungal pathogens to provide biological control has been explored in some detail, less is known about their community interactions. Here we investigate the effects of fungal epizootics of the entomopathogen Lecanicillium lecanii (Zimmerman) on a keystone mutualism between Azteca instabilis (F. Smith), a dominant arboreal ant, and the green coffee scale (Coccus viridis Green), as well as broader impacts on a coffee agroecosystem ant community. We hypothesized that seasonal epizootics cause shifts in the foraging ranges of A. instabilis as the ants adapt to the loss of the resource. We further hypothesized that the magnitude of these shifts depends on the availability of alternate resources located in neighboring shade trees. To test these hypotheses, we induced an epizootic in experimental sites, which were compared with control sites. Surveys of ant activity were undertaken pre- and post-epizootic. We found a decrease in foraging activity of A. instabilis and increase in activity of other ant species in the experimental sites post-epizootic. The decrease in abundance of A. instabilis foragers was greater on plants in which an epizootic was induced than in other plants. This relationship was modified by shade tree density where higher shade tree density was associated with larger decreases in A. intabilis foraging activity in coffee plants. These results demonstrate the potential for fungal entomopathogens to influence the structure and diversity of ecological communities.

Meta-analysis of contemporary short- and long-term mortality rates in patients diagnosed with critical leg ischaemia

BACKGROUND

Critical leg ischaemia (CLI) has been associated with high mortality rates. There is a lack of contemporary data on both short- and long-term mortality rates in patients diagnosed with CLI.

METHODS

This was a systematic literature search for studies prospectively reporting mortality in patients diagnosed with CLI. Meta-analysis and meta-regression models were developed to determine overall mortality rates and specific patient-related factors that were associated with death.

RESULTS

A total of 50 studies were included in the analysis The estimated probability of all-cause mortality in patients with CLI was 3·7 per cent at 30 days, 17·5 per cent at 1 year, 35·1 per cent at 3 years and 46·2 per cent at 5 years. Men had a statistically significant survival benefit at 30 days and 3 years. The presence of ischaemic heart disease, tissue loss and older age resulted in a higher probability of death at 3 years.

CONCLUSION

Early mortality rates in patients diagnosed with CLI have improved slightly compared with previous historical data, but long-term mortality rates are still high.

Melanocortin receptor accessory proteins in adrenal gland physiology and beyond

The melanocortin receptor (MCR) family consists of five G-protein-coupled receptors (MC1R-MC5R) with diverse physiological roles. MC1R controls pigmentation, MC2R is a critical component of the hypothalamic-pituitary-adrenal axis, MC3R and MC4R have a vital role in energy homeostasis and MC5R is involved in exocrine function. The melanocortin receptor accessory protein (MRAP) and its paralogue MRAP2 are small single-pass transmembrane proteins that have been shown to regulate MCR expression and function. In the adrenal gland, MRAP is an essential accessory factor for the functional expression of the MC2R/ACTH receptor. The importance of MRAP in adrenal gland physiology is demonstrated by the clinical condition familial glucocorticoid deficiency, where inactivating MRAP mutations account for ∼20% of cases. MRAP is highly expressed in both the zona fasciculata and the undifferentiated zone. Expression in the undifferentiated zone suggests that MRAP could also be important in adrenal cell differentiation and/or maintenance. In contrast, the role of adrenal MRAP2, which is highly expressed in the foetal gland, is unclear. The expression of MRAPs outside the adrenal gland is suggestive of a wider physiological purpose, beyond MC2R-mediated adrenal steroidogenesis. In vitro, MRAPs have been shown to reduce surface expression and signalling of all the other MCRs (MC1,3,4,5R). MRAP2 is predominantly expressed in the hypothalamus, a site that also expresses a high level of MC3R and MC4R. This raises the intriguing possibility of a CNS role for the MRAPs.

Salmon lice--impact on wild salmonids and salmon aquaculture

Salmon lice, Lepeophtheirus salmonis, are naturally occurring parasites of salmon in sea water. Intensive salmon farming provides better conditions for parasite growth and transmission compared with natural conditions, creating problems for both the salmon farming industry and, under certain conditions, wild salmonids. Salmon lice originating from farms negatively impact wild stocks of salmonids, although the extent of the impact is a matter of debate. Estimates from Ireland and Norway indicate an odds ratio of 1.1:1-1.2:1 for sea lice treated Atlantic salmon smolt to survive sea migration compared to untreated smolts. This is considered to have a moderate population regulatory effect. The development of resistance against drugs most commonly used to treat salmon lice is a serious concern for both wild and farmed fish. Several large initiatives have been taken to encourage the development of new strategies, such as vaccines and novel drugs, for the treatment or removal of salmon lice from farmed fish. The newly sequenced salmon louse genome will be an important tool in this work. The use of cleaner fish has emerged as a robust method for controlling salmon lice, and aquaculture production of wrasse is important towards this aim. Salmon lice have large economic consequences for the salmon industry, both as direct costs for the prevention and treatment, but also indirectly through negative public opinion.

Impact of Lepeophtheirus salmonis infestations on migrating Atlantic salmon , Salmo salar L., smolts at eight locations in Ireland with an analysis of lice-induced marine mortality

Sea lice infestation as a source of marine mortality of outwardly migrating Atlantic salmon smolts has been investigated by treating groups of ranched salmon, prior to release, with a prophylactic sea lice treatment conferring protection from sea lice infestation. A number of studies have been carried out in Ireland using both established ranched populations and groups of hatchery reared fish imprinted for 5-8 weeks in the sites of experimental releases. In this study, data on 352 142 migrating salmon from twenty-eight releases, at eight locations along Ireland's South and West coasts covering a 9-year period (2001 to 2009) are reviewed. Both published and new data are presented including a previously unpublished time series. The results of a meta-analysis of the combined data suggest that while sea lice-induced mortality on outwardly migrating smolts can be significant, it is a minor and irregular component of marine mortality in the stocks studied and is unlikely to be a significant factor influencing conservation status of salmon stocks.

Sea lice levels on wild Atlantic salmon, Salmo salar L., returning to the coast of Ireland

The sea lice population structure, prevalence and intensity of Lepeophtheirus salmonis have been studied over a period extending from 2004 to 2011. Infestation data were collected from the interceptor drift net fishery from 2004 until it was closed in 2006. From 2010, data were collected from the inshore draft net fishery. In all, 34 samples from the drift and draft net fisheries have been analysed to date. Prevalence of infestation with L. salmonis regularly approached 100% in samples of hosts recovered from the offshore drift net fishery. Abundance was variable both within and between years with a maximum mean abundance of 25.8 lice per fish recorded in 2004. The population structure of L. salmonis on hosts recovered in the inshore and estuarine draft net fisheries was different from that observed in the more offshore drift net samples. There is clear evidence of recent infestation with L. salmonis in the draft net samples.

Quality of life in the first 6 weeks following laparoscopic and open colorectal surgery

OBJECTIVES

Evidence of how health-related quality of life (HRQOL) changes following laparoscopic and open colorectal surgery in the first 6 weeks of postoperative recovery is needed to inform cost-effectiveness evaluations.

METHODS

Pragmatic prospective cohort study design. Consecutive patients requiring elective colorectal surgery were allocated to either laparoscopic or open surgery by administrative staff in a district general hospital in England, 2006-2007. Patients completed two validated, generic measures of HRQOL at baseline (preoperatively) and on multiple occasions in the first 6 weeks postsurgery using diaries (EuroQol five-dimensional [EQ-5D] questionnaire: 16 times; short-form 36 health survey [SF-36]: 4 times; HRQOL was compared between groups at each time point, and overall using repeated-measures analysis.

RESULTS

Of 201 consecutive patients recruited, 32 (15.1%) were unable to complete diaries. Of the remaining 169 patients, 120 (71%) returned completed diaries at 28 days and 105 (62.1%) at 42 days. There was no difference in preoperative HRQOL scores between surgical groups, but the postoperative EQ-5D questionnaire and SF-36 scores were significantly higher in the laparoscopic group (EQ-5D questionnaire P = 0.005, SF-36 P = 0.007). Subgroup analysis showed that patients with a stoma have worse HRQOL than those without. HRQOL did not differ between the laparoscopic and open stoma patients.

CONCLUSIONS

This study presents unique prospective data demonstrating that laparoscopic surgery confers HRQOL benefits for patients in the early recovery period following colorectal surgery, compared with open surgery. Consideration of these data in the context of a cost-effectiveness analysis will be reported separately.

Long-term survival after gastrectomy for cancer in randomized, controlled oncological trials: comparison between West and East

BACKGROUND

The presence of mixed evidence about the value of lymphadenectomy in gastric cancer surgery coupled with the difference in patients' demographics and tumor stage between the West and East have doubted the needs to standardize surgical techniques in Western clinical practice. The purpose of this study was to compare survival rates between the West and East following gastrectomy in randomized, controlled, oncological trials with appropriate adjustment for confounding variables.

METHODS

Systematic search revealed 25 trials that have randomization into surgery and chemotherapy versus surgery alone between 1995 and 2012 (n = 7 (East) and n = 18 (West)). End points were 5-year survival and cancer recurrence.

RESULTS

There was association between gastrectomy performed in the East and improved 5-year survival (pooled odds ratio (OR) 4.83; 95 % confidence interval (CI) 3.27-7.12) and reduced cancer recurrence (pooled OR 0.33; 95 % CI 0.2-0.54). Association of improved 5-year survival with surgery in the East remained when meta-regression adjusted for the effect of age, sex, chemotherapy, tumor depth and nodal status, and gastrectomy type. Association of reduced cancer recurrence also persisted with meta-regression adjusting for age, chemotherapy, nodal status, and gastrectomy type. However, when adjustment for the percentage of patients with tumor depth T1 or 2 was made statistical significance was lost.

CONCLUSIONS

This analysis shows association between gastrectomy performed in Eastern countries and improved survival. The known difference in surgical techniques between the East and the West is one potential unexamined variable that may be responsible in part for such discrepancy in outcomes.

A population-level prediction tool for the incidence of first-episode psychosis: translational epidemiology based on cross-sectional data

OBJECTIVES

Specialist early intervention services (EIS) for people aged 14-35 years with first episodes of psychosis (FEP) have been commissioned throughout England since 2001. A single estimate of population need was used everywhere, but true incidence varies enormously according to sociodemographic factors. We sought to develop a realistically complex, population-based prediction tool for FEP, based on precise estimates of epidemiological risk.

DESIGN AND PARTICIPANTS

Data from 1037 participants in two cross-sectional population-based FEP studies were fitted to several negative binomial regression models to estimate risk coefficients across combinations of different sociodemographic and socioenvironmental factors. We applied these coefficients to the population at-risk of a third, socioeconomically different region to predict expected caseload over 2.5 years, where the observed rates of ICD-10 F10-39 FEP had been concurrently ascertained via EIS.

SETTING

Empirical population-based epidemiological data from London, Nottingham and Bristol predicted counts in the population at-risk in the East Anglia region of England.

MAIN OUTCOME MEASURES

Observed counts were compared with predicted counts (with 95% prediction intervals (PI)) at EIS and local authority district (LAD) levels in East Anglia to establish the predictive validity of each model.

RESULTS

A model with age, sex, ethnicity and population density performed most strongly, predicting 508 FEP participants in EIS in East Anglia (95% PI 459, 559), compared with 522 observed participants. This model predicted correctly in 5/6 EIS and 19/21 LADs. All models performed better than the current gold standard for EIS commissioning in England (716 cases; 95% PI 664-769).

CONCLUSIONS

We have developed a prediction tool for the incidence of psychotic disorders in England and Wales, made freely available online (http://www.psymaptic.org), to provide healthcare commissioners with accurate forecasts of FEP based on robust epidemiology and anticipated local population need. The initial assessment of some people who do not require subsequent EIS care means additional service resources, not addressed here, will be required.

Meta-analysis of prospective trials determining the short- and mid-term effect of elective open and endovascular repair of abdominal aortic aneurysms on quality of life

Background

Repair of an abdominal aortic aneurysm (AAA) is undertaken to prevent rupture. Intervention is by either open repair (OR) or a more minimally invasive endovascular repair (EVAR). Quality-of-life (QoL) analysis is an important health outcome and a number of single studies have assessed QoL following OR and EVAR. This was a meta-analysis of published studies to assess the effect of an intervention on QoL in patients with an AAA.

Methods

A systematic literature search was undertaken for studies prospectively reporting QoL analysis in patients with an AAA undergoing elective intervention. A multivariable meta-analysis model was developed in which the outcomes were mean changes in QoL scores over time, both for all AAA repairs (OR and EVAR) and comparing OR with EVAR.

Results

Data were collated from 16 studies (14 OR, 12 EVAR). The results suggested that treating an AAA had an effect on patient-reported QoL, evident from the statistically significant changes predominantly in domains assessing physical ability and pain. QoL was affected most within the first 3 months after any form of intervention, and was more pronounced following OR. Furthermore, a deterioration in the Physical Component Summary score following an AAA repair (either OR or EVAR) was evident at 12 months after intervention.

Conclusion

Treating an AAA deleteriously affects patient-reported QoL over the first year following intervention.

Systematic review and meta-analysis of duplex ultrasonography, contrast-enhanced ultrasonography or computed tomography for surveillance after endovascular aneurysm repair

BACKGROUND

Previous analyses suggested that duplex ultrasonography (DUS) detected endoleaks after endovascular aneurysm repair (EVAR) with insufficient sensitivity; they did not specifically examine types 1 and 3 endoleak, which, if untreated, may lead to aneurysm-related death. In light of changes to clinical practice, the diagnostic accuracy of DUS and contrast-enhanced ultrasonography (CEUS) for types 1 and 3 endoleak required focused reappraisal.

METHODS

Studies comparing DUS or CEUS with computed tomography (CT) for endoleak detection were identified. CT was taken as the standard in bivariable meta-analysis.

RESULTS

Twenty-five studies (3975 paired scans) compared DUS with CT for all endoleaks. The pooled sensitivity was 0·74 (95 per cent confidence interval 0·62 to 0·83) and the pooled specificity was 0·94 (0·90 to 0·97). Thirteen studies (2650 paired scans) reported detection of types 1 and 3 endoleak by DUS; the pooled sensitivity of DUS was 0·83 (0·40 to 0·97) and the pooled specificity was 1·00 (0·97 to 1·00). Eleven studies (961 paired scans) compared CEUS with CT for all endoleaks. The pooled sensitivity of CEUS was 0·96 (0·85 to 0·99) and the pooled specificity was 0·85 (0·76 to 0·92). Eight studies (887 paired scans) reported detection of types 1 and 3 endoleak by CEUS. The pooled sensitivity of CEUS was 0·99 (0·25 to 1·00) and the pooled specificity was 1·00 (0·98 to 1·00).

CONCLUSION

Both CEUS and DUS were specific for detection of types 1 and 3 endoleak. Estimates of their sensitivity were uncertain but there was no evidence of a clinically important difference. DUS detects types 1 and 3 endoleak with sufficient accuracy for surveillance after EVAR.

Laparoscopic and open colorectal surgery: a prospective cost analysis

AIM

Cost has been perceived to be a factor limiting the development of laparoscopic colorectal surgery. This study aimed to compare the costs of laparoscopic and open colorectal surgery.

METHOD

Patients undergoing laparoscopic or open elective colorectal surgery were recruited into a prospective study to evaluate the healthcare costs of each operative procedure in a district general hospital in England. All healthcare resources used (operation, hospital and community) were recorded and converted to costs in British pounds, 2006-2007. Costs of laparoscopic and open surgery were compared.

RESULTS

In all, 201 consecutive patients consented and were recruited (131 laparoscopic, 70 open). Operative costs were greater in the laparoscopic group (£2049 vs£1263, P < 0.001) due to the costs of disposable instruments, but the hospital costs were less (£1807 vs£3468, P < 0.001) due to longer lengths of stay in the open group. Community costs were similar in the two groups and had little impact on the overall costs, which were not significantly different (£3875 laparoscopic vs£4383 open, P = 0.308). In the subgroup of patients with a stoma, overall costs in the laparoscopic group are higher (not significant).

CONCLUSION

The costs of laparoscopic and open colorectal surgery are broadly equivalent. If there is an associated improvement in patient benefit, then laparoscopic colorectal surgery may be considered to be cost effective compared with open surgery.