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Nayar MK, Paranandi B, Dawwas MF, Leeds JS, Darne A, Haugk B, Majumdar D, Ahmed MM, Oppong KW. Comparison of the diagnostic performance of 2 core biopsy needles for EUS-guided tissue acquisition from solid pancreatic lesions. Gastrointest Endosc 2017; 85:1017-1024. [PMID: 27633157 DOI: 10.1016/j.gie.2016.08.048] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Accepted: 08/30/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS A new core biopsy needle with a novel tip, opposing bevel, and sheath design has recently been introduced for EUS-guided fine-needle biopsy (FNB). The diagnostic utility of this needle for differentiating solid pancreatic masses is currently unknown. The aim of this study was to compare the diagnostic performance and yield for tissue acquisition from solid pancreatic lesions of the opposing bevel needle with those of a reverse bevel EUS-FNB needle. METHODS Consecutive patients with solid pancreatic masses undergoing EUS-FNB using the opposing bevel (n = 101) and the reverse bevel (n = 100) core biopsy needles were included in the study. Final diagnosis was based on positive histology or at least 12 months of follow-up in cases with a negative biopsy. The primary outcome was the diagnostic performance of the 2 needles for malignant pancreatic masses. A secondary outcome was the diagnostic yield. RESULTS Compared with the reverse bevel needle, using strict criteria the opposing bevel needle provided significantly higher sensitivity (71.1% vs 90.1%; P = .0006) and overall accuracy (74% vs 92%; I = 0.0006) for discriminating malignant from benign solid pancreatic masses. The proportion of samples classified as adequate for histologic analysis was 87% for the reverse bevel needle versus 99% for the opposing bevel needle (p = 0.002) Multivariate analysis controlling the needle gauge and site did not show any significant difference in accuracy and sensitivity between the 2 groups. There were no adverse events in either group. CONCLUSIONS In this first, large, single-center preliminary cohort study, an EUS core biopsy needle with a novel tip, opposing bevel, and sheath design afforded substantially superior tissue yield and diagnostic performance compared with a reverse-bevel needle. If replicated by randomized controlled trials, our findings suggest that similarly designed needles could become the standard of care for EUS-guided tissue acquisition from solid pancreatic masses.
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Affiliation(s)
- Manu K Nayar
- HPB Unit, Freeman Hospital, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, United Kingdom
| | - Bharat Paranandi
- HPB Unit, Freeman Hospital, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, United Kingdom
| | - Muhammad F Dawwas
- HPB Unit, Freeman Hospital, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, United Kingdom; Department of Cellular Pathology, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, United Kingdom
| | - John S Leeds
- HPB Unit, Freeman Hospital, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, United Kingdom
| | - Antony Darne
- Division of Digestive Diseases and Nutrition, Department of Medicine, University of Kentucky Medical Center, Lexington, Kentucky, USA
| | - Beate Haugk
- Division of Digestive Diseases and Nutrition, Department of Medicine, University of Kentucky Medical Center, Lexington, Kentucky, USA
| | - Debasis Majumdar
- HPB Unit, Freeman Hospital, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, United Kingdom
| | - Muna M Ahmed
- Division of Digestive Diseases and Nutrition, Department of Medicine, University of Kentucky Medical Center, Lexington, Kentucky, USA
| | - Kofi W Oppong
- HPB Unit, Freeman Hospital, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, United Kingdom
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Affiliation(s)
- M F Dawwas
- Division of Digestive Diseases and Nutrition, Department of Medicine, University of Kentucky Medical Center, Lexington, Kentucky, USA,Department of Gastroenterology, Freeman Hospital, Newcastle upon Tyne, UK
| | - K W Oppong
- Department of Gastroenterology, Freeman Hospital, Newcastle upon Tyne, UK
| | - G J Webster
- Department of Gastroenterology, University College Hospital, London, UK
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Oppong KW, Dawwas MF, Charnley RM, Wadehra V, Elamin K, White S, Nayar M. EUS and EUS-FNA diagnosis of suspected pancreatic cystic neoplasms: Is the sum of the parts greater than the CEA? Pancreatology 2015; 15:531-537. [PMID: 26375415 DOI: 10.1016/j.pan.2015.08.001] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Revised: 08/04/2015] [Accepted: 08/05/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Carcinoembryonic antigen (CEA) is suggested as the single most useful EUS/EUS-FNA derived test for the diagnosis of mucinous pancreatic cysts. STUDY AIMS To investigate the yield and diagnostic performance of EUS/EUS-FNA on an intention to diagnose basis and to determine the utility of the recommended CEA and amylase cut-off values. PATIENTS AND METHODS A retrospective study of a prospectively maintained database of 433 procedures performed in a 10 year period. Diagnostic performance of EUS-FNA was determined in 133 procedures with a definite diagnosis. RESULTS CEA value was determined in significantly fewer procedures (58.6%) than EUS diagnosis was stated (83.4%; p < 0.0001), cyst fluid appearance recorded (89.4%) or adequate sample for cytology obtained (76.7%; p < 0.005). Median CEA was significantly higher in mucinous cysts than non-mucinous (175 ng/ml vs 3 ng/ml, p < 0.0001) and in malignant cysts compared to benign (8945 ng/ml vs 93 ng/ml, p < 0.001). On an intention-to-diagnose analysis, a CEA cut-off of 110 ng/ml was significantly less accurate (42.8%) than EUS diagnosis (67.7%), cytology (58.6%) or aspirate appearance (66.9%; p < 0.05 for all comparisons). However, the combination of EUS diagnosis, cytology and CEA provided higher sensitivity (91%), specificity (75%) and accuracy (85.7%) than each component test alone (p < 0.05 for all comparisons). Median amylase was significantly higher in benign compared to high-risk mucinous cysts ((11,429IU/L vs. 113IU/L; p < 0.05. CONCLUSION The combination of EUS, cytology and CEA performed well. Malignant cysts had a higher CEA value than benign cysts. On an intention to diagnose basis a CEA cut-off of 110 ng/ml performed poorly.
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Affiliation(s)
- K W Oppong
- HPB Unit, Freeman Hospital, Newcastle upon Tyne, UK; Department of Gastroenterology, Freeman Hospital, Newcastle upon Tyne, UK.
| | - M F Dawwas
- HPB Unit, Freeman Hospital, Newcastle upon Tyne, UK; Department of Gastroenterology, Freeman Hospital, Newcastle upon Tyne, UK
| | - R M Charnley
- HPB Unit, Freeman Hospital, Newcastle upon Tyne, UK; Department of Surgery, Freeman Hospital, Newcastle upon Tyne, UK
| | - V Wadehra
- Department of Cellular Pathology, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - K Elamin
- HPB Unit, Freeman Hospital, Newcastle upon Tyne, UK; Department of Gastroenterology, Freeman Hospital, Newcastle upon Tyne, UK
| | - S White
- HPB Unit, Freeman Hospital, Newcastle upon Tyne, UK; Department of Surgery, Freeman Hospital, Newcastle upon Tyne, UK
| | - M Nayar
- HPB Unit, Freeman Hospital, Newcastle upon Tyne, UK; Department of Gastroenterology, Freeman Hospital, Newcastle upon Tyne, UK
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Dawwas MF, Bruno MJ, Lee JG. Endoscopic sphincterotomy for sphincter of oddi dysfunction: inefficacious therapy for a fictitious disease. Gastroenterology 2015; 148:440-3; discussion 443-4. [PMID: 25532810 DOI: 10.1053/j.gastro.2014.12.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Affiliation(s)
- Muhammad F Dawwas
- Division of Digestive Diseases and Nutrition, Department of Medicine, University of Kentucky Medical Center, Lexington, Kentucky
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - John G Lee
- Division of Gastroenterology, Department of Medicine, University of California Irvine, Orange, California
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Dawwas MF, Aithal GP. End-stage methotrexate-related liver disease is rare and associated with features of the metabolic syndrome. Aliment Pharmacol Ther 2014; 40:938-48. [PMID: 25185870 DOI: 10.1111/apt.12912] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Revised: 05/19/2014] [Accepted: 07/21/2014] [Indexed: 12/19/2022]
Abstract
BACKGROUND Methotrexate (MTX) is one of the most frequently prescribed drugs in contemporary medicine with a well-recognised hepatotoxic potential, for which stringent laboratory and histological surveillance has long been advocated. AIM To estimate the population burden of end-stage methotrexate-related liver disease (MTX-LD) in the United States and identify independent host risk factors for this disease entity. METHODS We analysed the records of all individuals who had been listed for, and/or received, liver transplantation in the United States, as reported to the Organ Procurement and Transplantation Network between 1 October 1987 and 31 December 2011, and identified those whose liver disease was attributed, wholly or partly, to MTX therapy. We also compared the demographic and clinical characteristics of adult individuals with MTX-LD with those listed and/or transplanted for alcoholic liver disease (ALD, n = 43,285), non-alcoholic steatohepatitis (NASH, n = 7569) and primary sclerosing cholangitis (PSC, n = 8526) using the adjusted odds ratios (AORs) derived from multi-variable logistic regression models. RESULTS Of 158 904 adults who had been listed for, and/or received, liver transplantation during the study period, only 117 (0.07%) had MTX-LD. Compared with individuals with ALD and PSC, those with MTX-LD were more likely to be older (AORs per 5-year increase: 1.27, P < 0.001 and 1.33, P < 0.001 respectively); female (AORs: 1.78, P = 0.003 and 3.87, P < 0.001); Caucasian (AORs: 3.03, P = 0.001 and 2.05, P = 0.04); and diabetic (AORs: 2.76, P < 0.001 and 4.12, P < 0.001). With the exception of Caucasian ethnicity (AOR: 1.94, P = 0.05), the odds of these characteristics did not differ from individuals with NASH. The odds of elevated body mass index among MTX-LD individuals were higher than those with PSC (AOR per 5 kg/m(2) : 1.51, P < 0.001); similar to those with ALD (AOR per 5 kg/m(2) :1.15, P = 0.1); and lower than those with NASH (AOR per 5 kg/m(2) : 0.66, P < 0.001). CONCLUSIONS The United States population burden of end-stage methotrexate-related liver disease is likely to be exceedingly small, suggesting the need for reappraisal of current hepatotoxicity surveillance guidelines. The risk factor profile of methotrexate-related liver disease supports the notion that it may share a common pathogenesis with NASH.
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Affiliation(s)
- M F Dawwas
- National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK; Division of Gastroenterology, Department of Medicine, University of California, Irvine, Orange, CA, USA
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Dawwas MF, Huang JY, Rowe A, Yim DB, Samarasena JB, Chang KJ, Lee JG. EUS diagnosis and endoscopic management of iatrogenic biliary stent placement into the portal vein. Gastrointest Endosc 2014; 80:338. [PMID: 24929482 DOI: 10.1016/j.gie.2014.04.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Accepted: 04/17/2014] [Indexed: 02/08/2023]
Affiliation(s)
- Muhammad F Dawwas
- Division of Gastroenterology and Hepatology, Department of Medicine, Department of Radiology, University of California-Irvine, Orange, California, USA
| | - Jason Y Huang
- Division of Gastroenterology and Hepatology, Department of Medicine, Department of Radiology, University of California-Irvine, Orange, California, USA
| | - Anthony Rowe
- Division of Gastroenterology and Hepatology, Department of Medicine, Department of Radiology, University of California-Irvine, Orange, California, USA
| | - Douglas B Yim
- Division of Gastroenterology and Hepatology, Department of Medicine, Department of Radiology, University of California-Irvine, Orange, California, USA
| | - Jason B Samarasena
- Division of Gastroenterology and Hepatology, Department of Medicine, Department of Radiology, University of California-Irvine, Orange, California, USA
| | - Kenneth J Chang
- Division of Gastroenterology and Hepatology, Department of Medicine, Department of Radiology, University of California-Irvine, Orange, California, USA
| | - John G Lee
- Division of Gastroenterology and Hepatology, Department of Medicine, Department of Radiology, University of California-Irvine, Orange, California, USA
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Affiliation(s)
- Muhammad F Dawwas
- University of Cambridge, Peterhouse, Trumpington Street, Cambridge, CB2 1RD, UK.
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Dawwas MF, Oppong KW, John SK, Vallance AE, French JJ, Scott J, Nayar MK. Endoscopic ultrasound diagnosis of an ERCP-related portobiliary fistula. Endoscopy 2014; 45 Suppl 2 UCTN:E214-6. [PMID: 23888463 DOI: 10.1055/s-0033-1344065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- M F Dawwas
- Hepato-Pancreato-Biliary Centre, Freeman Hospital, Newcastle upon Tyne, UK.
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Gerada J, Ganeshanantham G, Dawwas MF, Winterbottom AP, Sivaprakasam R, Butler AJ, Alexander GJ. Infectious aortitis in a liver transplant recipient. Am J Transplant 2013; 13:2479-82. [PMID: 23919247 DOI: 10.1111/ajt.12353] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2013] [Accepted: 05/27/2013] [Indexed: 01/25/2023]
Abstract
The development of an abdominal aortic aneurysm secondary to infectious aortitis following solid organ transplantation is a rare event that in the absence of surgical intervention, can lead to uncontrolled sepsis, catastrophic hemorrhage and death. Arterial allografts have been a viable surgical option for the past 30 years, although operative modalities have undergone a paradigm shift in recent years. We describe the first case in the literature of a liver transplant recipient who developed an infrarenal aortic aneurysm secondary to Salmonella bacteraemia, which was treated successfully with aortic allograft transplantation.
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Affiliation(s)
- J Gerada
- Liver Transplant Unit, Addenbrooke's Hospital, Cambridge, UK
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Carbone M, Mells GF, Pells G, Dawwas MF, Newton JL, Heneghan MA, Neuberger JM, Day DB, Ducker SJ, Sandford RN, Alexander GJ, Jones DEJ. Sex and age are determinants of the clinical phenotype of primary biliary cirrhosis and response to ursodeoxycholic acid. Gastroenterology 2013; 144:560-569.e7; quiz e13-4. [PMID: 23246637 DOI: 10.1053/j.gastro.2012.12.005] [Citation(s) in RCA: 269] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2012] [Revised: 11/30/2012] [Accepted: 12/06/2012] [Indexed: 12/02/2022]
Abstract
UNLABELLED BACKGROUND, & AIMS: Studies of primary biliary cirrhosis (PBC) phenotypes largely have been performed using small and selected populations. Study size has precluded investigation of important disease subgroups, such as men and young patients. We used a national patient cohort to obtain a better picture of PBC phenotypes. METHODS We performed a cross-sectional study using the United Kingdom-PBC, patient cohort. Comprehensive data were collected for 2353 patients on diagnosis reports, response to therapy with ursodeoxycholic acid (UDCA), laboratory results, and symptom impact (assessed using the PBC-40 and other related measures). RESULTS Seventy-nine percent of the patients reported current UDCA, therapy, with 80% meeting Paris response criteria. Men were significantly less likely to have responded to UDCA than women (72% vs 80% response rate; P < .05); male sex was an independent predictor of nonresponse on multivariate analysis. Age at diagnosis was associated strongly and independently with response to UDCA; response rates ranged from 90% among patients who presented with PBC when they were older than age 70, to less than 50% for those younger than age 30 (P < .0001). Patients who presented at younger ages also were significantly more likely not to respond to UDCA therapy, based on alanine aminotransferase and aspartate aminotransferase response criteria, and more likely to report fatigue and pruritus. Women had mean fatigue scores 32% higher than men's (P < .0001). The increase in fatigue severity in women was related strongly (r = 0.58; P < .0001) to higher levels of autonomic symptoms (P < .0001). CONCLUSIONS Among patients with PBC, response to UDCA, treatment and symptoms are related to sex and age at presentation, with the lowest response rates and highest levels of symptoms in women presenting at younger than age 50. Increased severity of fatigue in women is related to increased autonomic symptoms, making dysautonomia a plausible therapeutic target.
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Affiliation(s)
- Marco Carbone
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Cambridge, Cambridge, United Kingdom
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Dawwas MF, Davies SE, Griffiths WJH, Lomas DA, Alexander GJ. Prevalence and Risk Factors for Liver Involvement in Individuals with PiZZ-related Lung Disease. Am J Respir Crit Care Med 2013; 187:502-8. [DOI: 10.1164/rccm.201204-0739oc] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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Dawwas MF, Taha H, Leeds JS, Nayar MK, Oppong KW. Diagnostic accuracy of quantitative EUS elastography for discriminating malignant from benign solid pancreatic masses: a prospective, single-center study. Gastrointest Endosc 2012; 76:953-61. [PMID: 22854060 DOI: 10.1016/j.gie.2012.05.034] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2012] [Accepted: 05/23/2012] [Indexed: 02/08/2023]
Abstract
BACKGROUND Recent data suggest that quantitative EUS elastography, a novel technique that allows real-time quantification of tissue stiffness, can accurately differentiate malignant from benign solid pancreatic masses. OBJECTIVE To externally validate the diagnostic utility of this technique in an independent cohort. DESIGN AND SETTING Prospective, single-center study. PATIENTS, INTERVENTIONS, AND METHODS: A total of 104 patients with evidence of a solid pancreatic mass on cross-sectional imaging and/or endosonography underwent 111 quantitative EUS elastography procedures. Multiple elastographic measurements of the mass lesion and soft-tissue reference areas were undertaken, and the corresponding strain ratios (SRs) were calculated. The final diagnosis was based on pancreatic cytology or histology. MAIN OUTCOME MEASUREMENTS The area under the receiver-operating characteristic curve, sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy of quantitative EUS elastography for discriminating malignant from benign pancreatic masses. RESULTS The final diagnoses were primary pancreatic carcinoma (71.2%), neuroendocrine tumor (10.6%), metastatic cancer (1.9%), and pancreatitis (16.3%). Malignant masses had a higher SR (P = .01) and lower mass elasticity (P = .003) than inflammatory ones. The areas under the receiver-operating characteristic curve for the detection of pancreatic malignancy of both SR and mass elasticity (0.69 and 0.72, respectively) were less favorable than reported recently. At the cut points providing the highest accuracy in this cohort (4.65 for SR and 0.27% for mass elasticity), quantitative EUS elastography had a sensitivity of 100.0% and 95.7%, specificity of 16.7% and 22.2%, positive predictive value of 86.1% and 86.4%, negative predictive value of 100.0% and 50.0%, and overall accuracy of 86.5% and 83.8%, respectively. LIMITATIONS Relatively small number of patients with benign disease. CONCLUSION In the largest single-center study to date, the diagnostic utility of quantitative EUS elastography for discriminating pancreatic masses was modest, suggesting that it may only supplement rather than supplant the role of pancreatic tissue sampling in the future.
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Affiliation(s)
- Muhammad F Dawwas
- Hepato-Pancreato-Biliary Unit, Freeman Hospital, Newcastle upon Tyne, United Kingdom
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Dawwas MF, Charnley RM, Nayar MK, Oppong KW. Post-ERCP mortality and provider volume in England. Gastrointest Endosc 2012; 75:1119; author reply 1119-20. [PMID: 22520883 DOI: 10.1016/j.gie.2011.11.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2011] [Accepted: 11/17/2011] [Indexed: 02/08/2023]
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Dawwas MF, Jah A, Griffiths WJH, Winterbottom AP, Huguet EL, Gimson AE. Image of the month. Jejunal diverticular perforation secondary to delayed distal migration of biliary endoprosthesis. Arch Surg 2011; 146:483-4. [PMID: 21502461 DOI: 10.1001/archsurg.2011.54-a] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Muhammad F Dawwas
- Cambridge Hepatobiliary Service, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom.
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Dawwas MF, Ibrahim AK, Lee YM. Colonic polyposis: more than meets the eye. Metastatic melanoma. Gastroenterology 2010; 139:1097, 1426. [PMID: 20800657 DOI: 10.1053/j.gastro.2009.09.075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2009] [Accepted: 09/30/2009] [Indexed: 12/02/2022]
Affiliation(s)
- Muhammad F Dawwas
- Addenbrooke's Hospital, Cambridge University Hospitals NHS FoundationTrust, Cambridge, United Kingdom
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Affiliation(s)
- Muhammad F Dawwas
- Liver Transplant Unit, Addenbrooke's Hospital, Cambridge University Hospitals National Health Service Foundation Trust, Cambridge, United Kingdom.
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Abstract
Optimal candidate selection and organ allocation should offer liver transplantation to those who are sufficiently sick to justify the procedure but not too sick to benefit from it, in an order determined by patients' projected survival benefit, matching organs of sufficiently good quality to the appropriate recipients. Significant steps have been made in recent years toward devising selection and allocation criteria based on more objective and evidence-based definitions of candidate disease severity, transplant futility, organ quality, and appropriate donor-recipient matching. However, much work remains to be done in the future.
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Affiliation(s)
- Muhammad F Dawwas
- Liver Transplant Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Dawwas MF, Gimson AE, Lewsey JD, Copley LP, van der Meulen JHP. Survival after liver transplantation in the United Kingdom and Ireland compared with the United States. Gut 2007; 56:1606-13. [PMID: 17356039 PMCID: PMC2095676 DOI: 10.1136/gut.2006.111369] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Revised: 02/01/2007] [Accepted: 02/28/2007] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND OBJECTIVE Surgical mortality in the US is widely perceived to be superior to that in the UK. However, previous comparisons of surgical outcome in the two countries have often failed to take sufficient account of case-mix or examine long-term outcome. The standardised nature of liver transplantation practice makes it uniquely placed for undertaking reliable international comparisons of surgical outcome. The objective of this study is to undertake a risk-adjusted disease-specific comparison of both short- and long-term survival of liver transplant recipients in the UK and Ireland with that in the US. METHODS A multicentre cohort study using two high quality national databases including all adults who underwent a first single organ liver transplant in the UK and Ireland (n = 5925) and the US (n = 41,866) between March 1994 and March 2005. The main outcome measures were post-transplant mortality during the first 90 days, 90 days to 1 year and beyond the first year, adjusted for recipient and donor characteristics. RESULTS Risk-adjusted mortality in the UK and Ireland was generally higher than in the US during the first 90 days (HR 1.17; 95% CI 1.07 to 1.29), both for patients transplanted for acute liver failure (HR 1.27; 95% CI 1.01 to 1.60) and those transplanted for chronic liver disease (HR 1.18; 95% CI 1.07 to 1.31). Between 90 days and 1 year post-transplantation, no statistically significant differences in overall risk-adjusted mortality were noted between the two cohorts. Survivors of the first post-transplant year in the UK and Ireland had lower overall risk-adjusted mortality than those transplanted in the US (HR 0.88; 95% CI 0.81 to 0.96). This difference was observed among patients transplanted for chronic liver disease (HR 0.88; 95% CI 0.81 to 0.96), but not those transplanted for acute liver failure (HR 1.02; 95% CI 0.70 to 1.50). CONCLUSIONS Whilst risk-adjusted mortality is higher in the UK and Ireland during the first 90 days following liver transplantation, it is higher in the US among those liver transplant recipients who survived the first post-transplant year. Our results are consistent with the notion that the US has superior acute perioperative care whereas the UK appears to provide better quality chronic care following liver transplantation surgery.
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Affiliation(s)
- M F Dawwas
- Hepatobiliary and Liver Transplant Unit, Box 210, Addenbrooke's Hospital, Hills Road, Cambridge CB2 2QQ, UK.
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Abstract
BACKGROUND The UK and Ireland Liver Transplant Audit collects information on all liver transplantations that are carried out in both countries. In this paper, we describe these transplantations and their outcomes in adult patients according to primary liver disease diagnosis, type of transplantation and period. METHODS A prospective cohort study of 7906 orthotopic liver transplantations carried out between April 1994 and June 2005 in the United Kingdom and Ireland. Multivariable logistic regression was used to investigate improvements in mortality according to period of transplantation adjusted for recipient and donor characteristics. RESULTS A total of 6,850 transplantations were done in adults (patients 16 years or older). Of these, 836 (12.2%) were first super-urgent procedures (33.7% men; median age 36 years), and 5,072 (74.0%) first elective procedures (60.0% men; median age 52 years). The percentage of patients who received a donor organ with abnormal appearance gradually increased, especially in patients receiving an elective transplant. Mortality at 90 days after first super-urgent transplant decreased from 29.6% (95% confidence interval: 23.5% to 36.9%) before October 1, 1996 to 16.0% (11.7% to 21.7%) after October 1, 2002. Considering the same time periods, mortality at 90 days after first elective transplant decreased from 10.6% (8.9% to 12.7%) to 7.7% (6.3% to 9.3%). Multivariable analysis demonstrated that these improvements cannot be explained by changes in the risk profile of recipients and donors. CONCLUSIONS Patients undergoing a liver transplantation in the most recent years had a better survival than patients with similar characteristics transplanted 10 years earlier. Posttransplant survival has improved despite a deteriorating quality of donor organs.
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Affiliation(s)
- Jan H P van der Meulen
- Health Services Research Unit, Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom.
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Dawwas MF, Lewsey JD, Neuberger JM, Gimson AE. The impact of serum sodium concentration on mortality after liver transplantation: a cohort multicenter study. Liver Transpl 2007; 13:1115-24. [PMID: 17663412 DOI: 10.1002/lt.21154] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Modification of the current allocation system for donor livers in the United States to incorporate recipient serum sodium concentration ([Na]) has recently been proposed. However, the impact of this parameter on posttransplantation mortality has not been previously examined in a large risk-adjusted analysis. We assessed the effect of recipient [Na] on the survival of all adults with chronic liver disease who received a first single organ liver transplant in the UK and Ireland during the period March 1, 1994 to March 31, 2005 (n=5,152) at 3 years, during the first 90 days, and beyond the first 90 days, adjusting for a wide range of recipient, donor, and graft characteristics. Compared to those with normal [Na] (135-145 meq/L; n=3,066), severely hyponatremic recipients ([Na]<130 meq/L, n=541), had a higher risk-adjusted mortality at 3 years (hazard ratio [HR] 1.28; 95% confidence interval [CI], 1.04-1.59; P<0.02). The excess mortality was, however, confined to the first 90 days (HR 1.55; 95% CI, 1.18-2.04; P<0.002) with no significant difference thereafter. This was also true for hypernatremic recipients ([Na]>45 meq/L, n=81), who had an even greater risk-adjusted mortality compared to normonatremic recipients (overall: HR 1.85; 95% CI, 1.25-2.73; P<0.002; <or=90 days: HR 2.29; 95% CI, 1.42-3.70; P<0.001; >90 days: HR 1.12; 95% CI, 0.55-2.29; P=0.8), whereas mildly hyponatremic recipients ([Na] 130-134 meq/L, n=1,127) had similar risk-adjusted mortality to those with normal [Na] at the same time points. In conclusion, recipient [Na] is an independent predictor of death following liver transplantation. Attempts to correct the [Na] toward the normal reference range are an important aspect of pretransplantation management.
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Affiliation(s)
- Muhammad F Dawwas
- Hepatobiliary and Liver Transplant Unit, Addenbrooke's Hospital, Cambridge University Hospitals National Health Service (NHS) Foundation Trust, Cambridge, UK.
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Dawwas MF. Tolvaptan for hyponatremia. N Engl J Med 2007; 356:961-2; author reply 962-3. [PMID: 17338051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
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