Short- and long-term mortality after liver transplantation in patients with and without hepatocellular carcinoma in the UK

Background

The increasing demand for liver transplantation has led to considerable changes in characteristics of donors and recipients. This study evaluated the short- and long-term mortality of recipients with and without hepatocellular carcinoma (HCC) in the UK between 1997 and 2016.

Methods

First-time elective adult liver transplant recipients in the UK were identified and four successive eras of transplantation were compared. Hazard ratios (HRs) comparing the impact of era on short-term (first 90 days) and longer-term (from 90 days to 5 years) mortality were estimated, with adjustment for recipient and donor characteristics.

Results

Some 1879 recipients with and 7661 without HCC were included. There was an increase in use of organs donated after circulatory death (DCD), from 0 per cent in era 1 to 35·2 per cent in era 4 for recipients with HCC, and from 0·2 to 24·1 per cent for non-HCC recipients. The 3-year mortality rate decreased from 28·3 per cent in era 1 to 16·9 per cent in era 4 (adjusted HR 0·47, 95 per cent c.i. 0·35 to 0·63) for recipients with HCC, and from 20·4 to 9·3 per cent (adjusted HR 0·44, 0·36 to 0·53) for those without HCC. Comparing era 4 with era 1, improvements were more marked in short-term than in long-term mortality, both for recipients with HCC (0–90 days: adjusted HR 0·20, 0·10 to 0·39; 90 days to 5 years: adjusted HR 0·52, 0·35 to 0·75; P = 0·043) and for non-HCC recipients (0–90 days: adjusted HR 0·32, 0·24 to 0·42; 90 days to 5 years: adjusted HR 0·52, 0·40 to 0·67; P = 0·024).

Conclusion

In the past 20 years, the mortality rate after liver transplantation has more than halved, despite increasing use of DCD donors. Improvements in overall survival can be explained by decreases in short-term and longer-term mortality.

Management of Subdural Hematohygromas in Abusive Head Trauma

BACKGROUND

The optimal management of nonacute subdural fluid collections in infantile abusive head trauma (AHT) remains controversial.

OBJECTIVE

To review the outcomes and costs of the various treatments for symptomatic subdural fluid collections in children with AHT at a single center.

METHODS

Our AHT database was queried to identify children requiring any intervention for hematohygromas. Demographic, hospital course, radiologic, cost, readmission, and follow-up information were collected.

RESULTS

From January 2009 to March 2018, the authors identified 318 children with AHT, of whom 210 (66%) had a subdural collection of any type (blood or cerebrospinal fluid). A total of 50 required some form of intervention specifically for chronic hematohygromas. The initial management consisted of transfontanelle percutaneous aspiration (n = 31), burr holes with (n = 12) or without (n = 3) external subdural drainage, and mini-craniotomy (n = 4). Of those who were initially managed with 1 or more needle aspiration, 23 (74%) required further intervention-12 subduroperitoneal shunts and 11 nonshunt procedures. No patient who underwent burr holes/external drainage required further intervention (n = 16). Overall, the average number of interventions needed in these 50 children for definitive treatment was 1.8 (range, 1-4). A total of 15 children ultimately required a subduroperitoneal shunt. Complications (infectious, hemorrhagic, and thrombotic) were significant and occurred in all treatment groups except burr holes without drainage (n = 3). The average hospital charge for the entire cohort was $166 300.25 (range, $19 126-$739 248).

CONCLUSION

Based on our experience to date, burr hole with controlled external subdural drainage is an effective and preferred treatment for traumatic hematohygromas; complications and need for additional intervention is low.

Toxicity of organic and inorganic nickel in pancreatic cell cultures: Comparison to cadmium

Nickel compounds are Group 1 carcinogens and possibly cancer-causing in the pancreas. We examined the toxicity of nickel in both 2-D and 3-D pancreatic cell cultures, to determine the LD50 for organic and inorganic nickel in normal and cancerous cells. Assays with cadmium chloride were performed to be a comparison to potential nickel-induced toxicity. Cells were exposed to twelve concentrations of NiCl2 or Ni-(Ac)2 for 48h (2-D), or six concentrations for 48 hours (3-D). There was a significant (P=0.0016) difference between HPNE and AsPC-1 LD50 values after cadmium exposure, at 69.9 µM and 29.2 µM, respectively. Neither form of nickel exhibited toxicity in 2-D or 3-D cultures, but after 48h, changes in spheroid morphology were observed. The inability of Ni to reduce viable cell numbers suggests a toxic mechanism that differs from cadmium, also a Group 1 carcinogen. The cell microenvironment was not a factor in nickel toxicity with no changes in viable cells in either 2-D or 3-D cultures. These studies only examined cytotoxicity, and not genotoxicity, a potential mechanism of nickel carcinogenicity. Alterations in DNA function or the expression of apoptotic proteins/processes would take longer to manifest. Current work focuses on cellular changes following extended nickel exposure.

Development of a Retinopathy of Prematurity Activity Scale and Clinical Outcome Measures for Use in Clinical Trials

Importance

To facilitate drug and device development for neonates, the International Neonatal Consortium brings together key stakeholders, including pharmaceutical companies, practitioners, regulators, funding agencies, scientists, and families, to address the need for objective, standardized clinical trial outcome measurements to fulfill regulatory requirements. Retinopathy of prematurity (ROP) is a disease that affects preterm neonates. The current International Classification of Retinopathy of Prematurity does not take into account all of the characteristics of ROP and does not adequately discriminate small changes in disease after treatment. These factors are critical for evaluating outcomes in clinical trials.

Observations

There is need for an updated ROP acute disease activity and structure scale as well as end-stage structure and ophthalmologic outcome measures designed for use at different ages. The scale and measures, based on current diagnostic methods and treatments, could be used as a guideline for clinical intervention trials. The scale is intended to be validated against retrospective data and revised for use in future trials. An iterative revision process can be accomplished if new measures are added to clinical trials and evaluated at the end of each trial for prognostic value. The new measures would then be incorporated into a new version of the activity scale and the outcome measures revised.

Conclusions and Relevance

An ROP activity scale and outcome measures to obtain the most robust and discriminatory data for clinical trials are needed. The scales should be dynamic and modified as knowledge and imaging modalities improve and then validated using data from well-documented clinical trials. This approach is relevant to improving clinical trial data quality.

How Does the Media Portray Neurosurgeons?

BACKGROUND

It is not unusual to find neurosurgeons in the news and entertainment. The present study examined the portrayal of neurosurgeons by major print and online media sources.

METHODS

Two search strategies identified articles from October 1, 2012 to October 1, 2017 containing the keyword "neurosurgeon." The top 25 newspapers in the United States, determined by their circulation, were searched using the LexisNexis Academic or NewsBank databases; a layman's Google News search was used to collect online stories. Each identified article was evaluated to confirm the relevance and then examined for content. Relevant characteristics for each article and neurosurgeon were determined and analyzed.

RESULTS

Our searches returned 1005 articles comprising 561 unique stories about 203 different neurosurgeons. One particular neurosurgeon had 459 reports (45.7%). More articles were reported in 2015 (405; 40.3%) than any other single year. Most articles featured male neurosurgeons (879; 87.1%) and neurosurgeons who had been practicing for >20 years (636; 63.0%), with just 10 institutions accounting for the training of most of them (733; 72.6%). The articles were classified as positive (270; 26.9%), negative (356; 35.4%), or neutral (379; 37.7%) in terms of their reflection on the field of neurosurgery. The odds of a negative story were greater for male neurosurgeons, within 10 years of residency completion, and in a nonacademic position.

CONCLUSIONS

Neurosurgeons are naturally subject to media coverage, and we must be cognizant that this predilection can serve as both an occupational advantage and an occupational hazard.

Reoperation for Medulloblastoma Prior to Adjuvant Therapy

BACKGROUND

Surgery remains an integral part of the treatment of medulloblastoma. We present our experience with repeat surgery for this tumor before initiation of adjuvant therapy.

OBJECTIVE

To report what was found intraoperatively and where at time of second-look surgery and detail any postoperative events or readmissions within 90 days of surgery.

METHODS

Two separate institutional databases were queried to identify patients who underwent repeat resection of suspected residual medulloblastoma from January 2003 to January 2017.

RESULTS

We identified 51 patients (36 male, 15 female) who underwent repeat surgery. Average age at diagnosis was 8.31 years (range, 1.3-21.2). Imaging prior to repeat surgery demonstrated unequivocal residual tumor in 37 patients, but indeterminate in 14 patients. All but 1 patient had histopathologically confirmed residual tumor (50/51, 98%). The fourth ventricle was the primary site in 39 (76%) cases, compared with hemispheric in 12 cases (24%). Thirty (59%) tumors were non-WNT/non-SHH. All indeterminate cases (except for 1 patient) had residual tumor. Hemostatic agents were found within the resection cavity in 80% of indeterminate cases. The most common sites of residual tumor were lateral (26/39, 67%, lateral recess and/or foramen of Luschka) and roof (25/39, 64%); the superior medullary velum was the most common region of the roof (19/25, 76%). Eight (16%) patients developed new neurological deficits: cranial nerve palsies in 5 patients and posterior fossa syndrome in 3 patients.

CONCLUSION

Meticulous inspection of the resection cavity is necessary, paying particular attention to the roof and lateral recess. Hemostatic agents can conceal residual tumor.

Assessing the Need for Mobile Health (mHealth) in Monitoring the Diabetic Lower Extremity

Background

Complications of the diabetic lower extremity (such as diabetic foot ulcers, DFUs) occur when monitoring is infrequent, and often result in serious sequelae like amputation or even death.

Objective

To evaluate the potential application of mobile health (mHealth) to diabetic foot monitoring. We surveyed the self-management routines of a group of diabetic patients, as well as patient and clinician opinions on the use of mHealth in this context.

Methods

Patients with DFUs in Toronto, Ontario, Canada completed a 25-item questionnaire addressing their foot care practices, mobile phone use, and views on mHealth. Wound care clinicians across Canada were also surveyed using a 9-item questionnaire.

Results

Of the patients surveyed, 59/115 (51.3%) spend less than a minute checking their feet, and 17/115 (15%) of patients find it difficult to see their doctor or get to the hospital regularly. Mobile phone use was widespread in our patient cohort (93/115, 80.9%). Of mobile phone users, 68/93 (73.1%) would use a device on their mobile phone to help them check their feet. Of the clinicians who completed the questionnaire, only 7/202 (3.5%) were familiar with mHealth; however, 181/202 (92%) of clinicians expressed interest in using mHealth to monitor their patients between visits.

Conclusions

Patient education or motivation and clinician training were identified as the major barriers to mHealth use in the diabetic lower extremity, which may be a viable mechanism to improve DFU monitoring practices.

Maternal anaemia and maternal, fetal, and neonatal outcomes in a prospective cohort study in India and Pakistan

OBJECTIVE

To describe the association of maternal anaemia with maternal, fetal, and neonatal outcomes.

DESIGN

Prospective cohort study.

SETTING

Rural India and Pakistan.

POPULATION

Pregnant women residing in the study catchment area.

METHODS

We performed an analysis of a prospective pregnancy registry in which haemoglobin is commonly obtained as well as maternal, fetal, and neonatal outcomes for 42 days post-delivery. Women 40 years or older who delivered before 20 weeks or had a haemoglobin level of <3.0 g/dl were excluded. Our primary exposure was maternal anaemia, which was categorised in keeping with World Health Organization criteria based on a normal (≥11 g/dl), mild (>10-10.9 g/dl), moderate (7-9.9 g/dl) or severe (<7 g/dl). haemoglobin level. The primary maternal outcome was maternal death, the primary fetal outcome was stillbirth, and the primary neonatal outcome was neonatal mortality <28 days.

RESULTS

A total of 92 247 deliveries and 93 107 infants were included, of which 87.8% were born to mothers who were anaemic (mild 37.9%, moderate 49.1%, and severe 0.7%). Maternal mortality (number per 100 000) was not associated with anaemia: normal 124, mild 106, moderate 135, and severe 325 (P = 0.64). Fetal and neonatal mortality was associated with severe anaemia: stillbirth rate (n/1000)-normal 27.7, mild 25.8, moderate 30.1, and severe 90.9; P < 0.0001; 28-day neonatal mortality (n/1000)-normal 24.7, mild 22.9, moderate 28.1, and severe 72.6 (P < 0.0001). Severe maternal anaemia was also associated with low birthweight (<2500 and <1500 g), preterm birth, and postpartum haemorrhage.

CONCLUSION

Severe maternal anaemia is associated with higher risks of poor maternal, fetal, and neonatal outcomes but other degrees of anaemia are not. Interventions directed at preventing severe anaemia in pregnant women should be considered.

TWEETABLE ABSTRACT

Severe maternal anaemia is associated with adverse fetal and neonatal outcomes in low/middle-income countries.

Pre-Bed Casein Protein Supplementation Does Not Enhance Acute Functional Recovery in Physically Active Males and Females When Exercise is Performed in the Morning

This study examined whether consuming casein protein (CP) pre-sleep could accelerate acute recovery following muscle-damaging exercise. Thirty-nine active males and females performed 100 drop jumps in the morning, consumed their habitual diet during the day, and then within 30 min pre-bed consumed either ~40 g of CP (n = 19) or ~40 g of a carbohydrate-only control (CON) (n = 20). Maximal isometric voluntary contractions (MIVC), countermovement jumps (CMJ), pressure-pain threshold (PPT), subjective muscle soreness and the brief assessment of mood adapted (BAM+) were measured pre, 24 and 48 h following the drop jumps. MIVC decreased in CP and CON post-exercise, peaking at 24 h post (CP: -8.5 ± 3.5 vs. CON: -13.0 ± 2.9%, respectively); however, no between-group differences were observed (p = 0.486; η_p² =0.02). There were also no group differences in the recovery of CMJ height, PPT and BAM+ (p > 0.05). Subjective muscle soreness increased post-exercise, but no group differences were present at 24 h (CP: 92 ± 31 mm vs. CON: 90 ± 46 mm) or 48 h (CP: 90 ± 44 mm vs. CON: 80 ± 58 mm) (p > 0.05). These data suggest that pre-bed supplementation with ~40 g of CP is no more beneficial than CON for accelerating the recovery following muscle-damaging exercise.

The effects of protective factors and adverse childhood experiences on behavioral health services use: Findings from a population-based sample

Adverse childhood experiences (ACEs) are linked to later life health problems such as behavioral health (BH) service use but less is known about how to counter this association. Using a population based sample of 807 adults, we examined the effects of protective factors in countering this association. ACEs were associated with increased BH service use while protective factors were associated with decreased BH service use. However, no significant interaction effect was found. Research is needed to develop a better measure of protective factors. Social workers need to be aware of ACE prevalence among clients and can foster protective factors.

Perforated caecal carcinoma masquerading as lower limb necrotising fasciitis: lessons learnt

A 69-year-old man was admitted with non-resolving right leg cellulitis. Subsequent skin changes over the calf and discharging pus suggested necrotising fasciitis. After several wound debridements of the leg and imaging, the patient was found to have an iliopsoas abscess due to a metastatic perforated caecal tumour extending along the medial thigh to the calf. No micro-organisms indicative of typical necrotising fasciitis were isolated from the wound. The patient had an ileocaecal resection, and his leg was reconstructed with a split thickness skin graft. He continues to do well postoperatively. This case highlights key lessons when dealing with an unusual presentation leading to challenges in diagnosis such as: (1) the need for good interspecialty liaison, (2) prompt senior review and plan, and (3) 'thinking outside the box' when faced with a diagnostic challenge.

Taking the next step in publication productivity analysis in pediatric neurosurgery

OBJECTIVE There has been an increasing interest in the quantitative analysis of publishing within the field of neurosurgery at the individual, group, and institutional levels. The authors present an updated analysis of accredited pediatric neurosurgery training programs. METHODS All 28 Accreditation Council for Pediatric Neurosurgery Fellowship programs were contacted for the names of pediatric neurosurgeons who were present each year from 2011 through 2015. Faculty names were queried in Scopus for publications and citations during this time period. The 5-year institutional Hirsch index [i h(5)-index] and revised 5-year institutional h-index [i r(5)-index] were calculated to rank programs. Each publication was reviewed to determine authorship value, tier of research, clinical versus basic science research, subject matter, and whether it was pediatrics-specific. A unique 3-tier article classification system was introduced to stratify clinical articles by quality and complexity, with tier 3 being the lowest tier of publication (e.g., case reports) and tier 1 being the highest (e.g., randomized controlled trials). RESULTS Among 2060 unique publications, 1378 (67%) were pediatrics-specific. The pediatrics-specific articles had a mean of 15.2 citations per publication (median 6), whereas the non-pediatrics-specific articles had a mean of 23.0 citations per publication (median 8; p < 0.0001). For the 46% of papers that had a pediatric neurosurgeon as first or last author, the mean number of citations per publication was 12.1 (median 5.0) compared with 22.5 (median 8.0) for those in which a pediatric neurosurgeon was a middle author (p < 0.0001). Seventy-nine percent of articles were clinical research and 21% were basic science or translational research; however, basic science and translational articles had a mean of 36.9 citations per publication (median 15) compared with 12.6 for clinical publications (median 5.0; p < 0.0001). Among clinical articles, tier 1 papers had a mean of 15.0 citations per publication (median 8.0), tier 2 papers had a mean of 18.7 (median 8.0), and tier 3 papers had a mean of 7.8 (median 3.0). Neuro-oncology papers received the highest number of citations per publication (mean 25.7). The most common journal was the Journal of Neurosurgery: Pediatrics (20%). MD/PhD faculty members had significantly more citations per publication than MD faculty members (mean 26.7 vs 14.0; p < 0.0001) and also a higher number of publications per author (mean 38.6 vs 20.8). The median i h(5)- and i r(5)-indices per program were 14 (range 5-48) and 10 (range 5.6-37.2), respectively. The mean i r(5)/i h(5)-index ratio was 0.8. The top 5 fellowship programs (in descending order) as ranked by the i h(5)-index corrected for number of faculty members were The Hospital for Sick Children, Toronto; Children's Hospital of Pittsburgh; University of California, San Francisco Benioff Children's Hospital; Seattle Children's Hospital; and St. Louis Children's Hospital. CONCLUSIONS About two-thirds of publications authored by pediatric neurosurgeons are pediatrics-specific, although non-pediatrics-specific articles averaged more citations. Most of the articles authored by pediatric neurosurgeons are clinical, with basic and translational articles averaging more citations. Neurosurgeons with PhD degrees averaged more total publications and more citations per publication. In all, this is the most advanced and informative analysis of publication productivity in pediatric neurosurgery to date.

Disease-specific quality of life in patients with lupus nephritis

Background

Patient-reported outcomes in lupus nephritis (LN) are not well studied. Studies with disease-targeted PRO tool in LN do not exist. Herein, we describe quality of life (QOL: HRQOL & non-HRQOL) among LN patients using LupusPRO.

Methods

International, cross-sectional data from 1259 patients with systemic lupus erythematosus (SLE) and LupusPRO were compared, stratified by (a) presence of LN (ACR classification criteria (ACR-LN)) at any time and, (b) active LN (on SLEDAI) at study visit. Damage was assessed by SLICC/ACR-SDI. Multivariate regression analyses for QOL against ACR-LN (active LN) after adjusting for age, gender, ethnicity and country of recruitment were performed.

Results

Mean (SD) age was 41.7 (13.5) yrs, 93% were women. Five hundred and thirty-nine of 1259 SLE patients had ACR-LN. ACR-LN group was younger, were more often on immunosuppressive medications, had worse QOL on lupus medications and procreation than non-ACR-LN patients. HRQOL and non-HRQOL scores were similar in both groups. One hundred and twenty-nine of 539 ACR-LN patients had active LN. Active LN group was younger, had greater disease activity and had worse HRQOL and non-HRQOL compared to patients without active LN. Specific domains adversely affected were lupus symptoms, lupus medications, procreation, emotional health, body image and desires-goals domains. Patients with ACR-LN and active LN fared significantly worse in lupus medications and procreation HRQOL domains, even after adjusting for age, ethnicity, gender and country of recruitment.

Conclusions

Lupus nephritis patients have poor QOL. Patients with active LN have worse HRQOL and non-HRQOL. Most domains affected are not included in the generic QOL tools used in SLE. LN patients must receive discussion on lupus medications and procreation issues. Patients with active LN need comprehensive assessments and addressal of QOL, along with treatment for active LN.

The management of pretibial lacerations

Introduction Pretibial lacerations are common injuries, often presenting in the elderly and infirm. Unclear management pathways often result in inappropriate care. We identify patient demographics, morbidity risk factors, injury severity and management options. Materials and methods This retrospective study involved analysing databases and hardcopy notes for patients admitted with pretibial lacerations to Addenbrooke's Hospital, January to December 2012. Microsoft Excel and Fishers exact test were used to analyse the data with a P-value of less than 0.05 representative of statistical significance. Information on patient demographics, site of lesion, preoperative symptoms, management, operative details and clinical outcomes were collected. Results A total of 36 patients were identified; the mean age was 79 years (± 16 years, 1 standard deviation) with a three to two female to male preponderance; 57% of injuries were caused by mechanical fall, 33% traumatic blunt impact and 7% road traffic accidents. American Society of Anesthesiologists physical status classification was 43% level III, 40% II, 9% I and 9% IV. Dunkin classification of severity was 33% grade III, 30% grade I, 24% grade IV and 12% grade II. Median inpatient duration was 11 days for surgically managed compared with 15 days for conservatively managed patients. Discussion Pretibial lacerations tend to affect the elderly. Management is compounded by polypharmacy and comorbidities. If inadequately managed, such injuries can adopt characteristics of chronic wounds, with lengthy inpatient stays. Surgical intervention may be appropriate where injuries are severe and the patient stable enough for theatre. Conclusions We believe that surgical management with autologous tissue repair, with minimal delay between presentation and theatre, is warranted for extensive injuries wherever possible, with conservative management used for predominantly less extensive pretibial lacerations.