A retrospective cohort study of incidental abdominal aortic aneurysms on routine abdominal computed tomography scans in Te Tairāwhiti (2018-2019)

AIM

Ruptured abdominal aortic aneurysm (rAAA) is associated with a high mortality rate which, is especially significant in rural and provincial regions. In Aotearoa New Zealand, Māori experience higher rates of AAA and worse overall medium-term survival following AAA repair. This study aimed to understand the prevalence of incidental AAA on routine abdominal computed tomography (CT) scans over 12 months.

METHOD

A retrospective review of all abdominal CT scans performed on patients ≥50 years at Gisborne Hospital between 1 December 2018-1 December 2019 was performed.

RESULTS

A total of 811 scans were reviewed, with 42 incidental AAA detected (5.2%). The majority of incidental AAA were in males aged ≥65 (65.8%), with a higher prevalence for Māori compared to New Zealand European (NZE) (16.2% vs 8.1%, p=0.052). This pattern was also seen in females, aged ≥65 (10.9% in Māori vs 3.8% in NZE, p=0.047).

CONCLUSION

The detection of AAA on routine abdominal CT scans appears to be a useful adjunct in lieu of targeted AAA screening in our region. A high prevalence of incidental AAA (5.2%) over 12 months, with a significantly higher prevalence noted in Māori males and females ≥65 years (16.2% and 10.9%), was observed.

Recurrence after transanal endoscopic microsurgery for benign and malignant rectal tumours: experience of a single New Zealand centre

BACKGROUND

Transanal endoscopic microsurgery (TEM) is an established technique for the resection of rectal adenomas and selected malignant tumours. It avoids the morbidity of radical resection for tumours not amenable to endoscopic resection. An important marker of quality is the local recurrence rate. The primary objective was to determine local recurrence rates for benign and malignant rectal tumours.

METHODS

We identified index TEM excisions of rectal adenomas and adenocarcinomas in patients age 18 and over at Dunedin Hospital, New Zealand, between 2000 and 2020, from a prospective database. Surveillance data were collected via chart review. The primary outcome was recurrence rate for adenomas and adenocarcinomas. Secondary outcomes included time to recurrence, association of recurrence with recognized risk factors, and adverse event rates.

RESULTS

We identified 100 patients for analysis. Of 75 benign cases, 11 (14.7%) developed local recurrence, with 63.6% identified within 1 year. Of the 25 malignant cases (19 T1, 5 T2, 1 T3), 9 (36%) developed recurrence, with 77.8% identified within 2 years. Adverse events occurred in 26% of patients, with no reoperations or deaths.

CONCLUSION

Our adenoma recurrence rate was at the higher end of the reported range of 2.4-16%. Minor complications were common, but not major morbidity. The propensity for rectal tumours to recur commonly and early reinforces the importance of regular standardized endoscopic surveillance.

Transfer Validity of Pediatric Supracondylar Humeral Fracture Pin Placement Practice on In-Theater Performance by Orthopedic Trainees Using an Augmented Reality Simulator: Protocol for a Pilot Interventional Cohort Study With a Retrospective Comparator Cohort

BACKGROUND

Supracondylar humeral fractures (SCHF) are a common cause of orthopedic morbidity in pediatric populations across the world. The treatment of this fracture is likely one of the first procedures involving x-ray-guided wire insertion that trainee orthopedic surgeons will encounter in their career. Traditional surgical training methods of "see one, do one, teach one" are reliant on the presence of real-world cases and must be conducted within an operative environment. We have developed an augmented reality simulator that allows trainees to practice this procedure in a radiation-free environment at no extra risk to patients.

OBJECTIVE

This study aims to examine whether training on a simulator in addition to traditional surgical training improves the in-theater performance of trainees.

METHODS

This multicenter, interventional cohort study will involve orthopedic trainees from New Zealand in their first year of advanced training between 2019 and 2023. Advanced trainees with no simulator exposure who were in their first year in 2019-2021 will form the comparator cohort, while those in the years 2022-2023 will receive additional regular simulator training as the intervention cohort. The comparator cohort's performance in pediatric SCHF surgery will be retrospectively audited using routinely collected operative outcomes and parameters over a 6-month period. Data on the performance of the intervention cohorts will be collected in the same way over a comparable period. The data collected for both groups will be used to determine whether additional training with an augmented reality training shows improved real-world surgical outcomes compared to traditional surgical training.

RESULTS

As of February 2022, a total of 8 retrospective comparator trainees have been recruited by email. The study is financially supported through an external grant from the Wishbone Orthopaedic Research Foundation of New Zealand (September 2021) and an internal research grant from the University of Otago (July 2021).

CONCLUSIONS

This protocol has been approved by the University of Otago Health Ethics committee (reference HD21/087), and the study is due for completion in 2024. This protocol may assist other researchers conducting similar studies in the field.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12623000816651; https://tinyurl.com/mtdkecwb.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/38282.

Evaluation of the Diagnostic Accuracy of FAPI PET/CT in Oncologic Studies: Systematic Review and Metaanalysis

Fibroblast-activation protein is a promising target for oncologic molecular imaging. Studies show that fibroblast activation protein inhibitor (FAPI) radiotracers are accurate diagnostics with favorable tumor-to-background ratios across various cancers. Therefore, we performed a systematic review and metaanalysis to assess the diagnostic performance of FAPI PET/CT in comparison with [¹⁸F]FDG PET/CT, the most widely used radiotracer in oncology. Methods: We conducted a systematic search in MEDLINE, Embase, Scopus, PubMed, Cochrane Central Register of Controlled Trials, relevant trial registries, and bibliographies. The search consisted of combinations of terms for 3 topics: neoplasia, PET/CT, and FAPI. Two authors independently screened retrieved articles using predefined inclusion and exclusion criteria and extracted the data. Study quality was assessed using the criteria of QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies 2). For each study, the sensitivity, specificity, and 95% CIs were calculated to determine diagnostic accuracy for primary, nodal, and metastatic lesions. A random-effects metaanalysis was used for pooling the data, and heterogeneity was assessed (I² index). Results: Thirty-nine studies (1,259 patients) investigating the use of FAPI PET/CT were included. On a patient-based analysis, pooled sensitivity was 0.99 (95% CI, 0.97-1.0) for the detection of primary lesions. Pooled sensitivity for nodal and distant metastases was 0.91 (95% CI, 0.81-0.96) and 0.99 (95% CI, 0.96-1.0), respectively. On a paired analysis between FAPI and [¹⁸F]FDG PET/CT, FAPI had a higher sensitivity in the detection of primary, nodal, and metastatic lesions (all P < 0.001). The differences in sensitivities between FAPI and [¹⁸F]FDG were statistically significant. In terms of heterogeneity, analyses on primary lesions were moderately affected, distant metastatic lesions were highly affected, and the nodal metastatic analyses had negligible heterogeneity. Conclusion: The diagnostic performance of FAPI PET/CT is superior to that of [¹⁸F]FDG in the detection of primary, nodal, and distant metastases. However, further studies are needed to better evaluate its utility and indication in specific cancer types and clinical settings.

Association of Preoperative High-Intensity Interval Training With Cardiorespiratory Fitness and Postoperative Outcomes Among Adults Undergoing Major Surgery: A Systematic Review and Meta-Analysis

Importance

Preoperative high-intensity interval training (HIIT) is associated with improved cardiorespiratory fitness (CRF) and may improve surgical outcomes.

Objective

To summarize data from studies comparing the association of preoperative HIIT vs standard hospital care with preoperative CRF and postoperative outcomes.

Data Sources

Data sources included Medline, Embase, Cochrane Central Register of Controlled Trials Library, and Scopus databases with no language constraints, including abstracts and articles published before May 2023.

Study Selection

The databases were searched for randomized clinical trials and prospective cohort studies with HIIT protocols in adult patients undergoing major surgery. Thirty-four of 589 screened studies met initial selection criteria.

Data Extraction and Synthesis

A meta-analysis was performed according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Data were extracted by multiple independent observers and pooled in a random-effects model.

Main Outcomes and Measures

The primary outcome was change in CRF, as measured by either peak oxygen consumption (V̇o2 peak) or 6-Minute Walk Test (6MWT) distance. Secondary outcomes included postoperative complications; hospital length of stay (LOS); and changes in quality of life, anaerobic threshold, and peak power output.

Results

Twelve eligible studies including 832 patients were identified. Pooled results indicated several positive associations for HIIT when compared with standard care either on CRF (V̇o2 peak, 6MWT, anaerobic threshold, or peak power output) or postoperative outcomes (complications, LOS, quality of life), although there was significant heterogeneity in study results. In 8 studies including 627 patients, there was moderate-quality evidence of significant improvement in V̇o2 peak (cumulative mean difference, 2.59 mL/kg/min; 95% CI, 1.52-3.65 mL/kg/min; P < .001). In 8 studies including 770 patients, there was moderate-quality evidence of a significant reduction in complications (odds ratio, 0.44; 95% CI, 0.32-0.60; P < .001). There was no evidence that HIIT differed from standard care in hospital LOS (cumulative mean difference, -3.06 days; 95% CI, -6.41 to 0.29 days; P = .07). The analysis showed a high degree of heterogeneity in study outcomes and an overall low risk of bias.

Conclusions and Relevance

The results of this meta-analysis suggest that preoperative HIIT may be beneficial for surgical populations through the improvement of exercise capacity and reduced postoperative complications. These findings support including HIIT in prehabilitation programs before major surgery. The high degree of heterogeneity in both exercise protocols and study results supports the need for further prospective, well-designed studies.

The correlation between different ultrasound planes and computed tomography measures of abdominal aortic aneurysms

Introduction

Ultrasound measurements of the aorta are typically taken in the axial plane, with the transducer perpendicular to the aorta, and diameter measurements are obtained by placing the callipers from the anterior to the posterior wall and the transverse right to the left side of the aorta. While the 'conventional' anteroposterior walls in both sagittal and transverse plains may be suitable for aneurysms with less complicated geometry, there is controversy regarding the suitability of this approach for complicated, particularly tortuous aneurysms, as they may offer a more challenging situation. Previous work undertaken within our research group found that when training inexperienced users of ultrasound, they demonstrated more optimal calliper placement to the abdominal aorta when approached from a decubitus window to obtain a coronal image compared to the traditional ultrasound approach.

Purpose

To observe the level of agreement in real-world reporting between computed tomography (CT) and ultrasound measurements in three standard planes; transverse AP, sagittal AP and coronal (left to right) infra-renal abdominal aortic aneurysm (AAA) diameter.

Methodology

This is a retrospective review of the Otago Vascular Diagnostics database for AAA, where ultrasound and CT diameter data, available within 90 days of each other, were compared. In addition to patient demographics, the infrarenal aorta ultrasound diameter measurements in transverse AP and sagittal AP, along with a coronal decubitus image of the aorta was collected. No transverse measurement was performed from the left to the right of the aorta.

Results

Three hundred twenty-five participants (238 males, mean age 76.4 ± 7.5) were included. Mean ultrasound outer to the outer wall, transverse AP and sagittal AP diameters were 48.7 ± 10.5 mm and 48.9 ± 9.9 mm, respectively. The coronal diameter measurement of the aorta from left to right was 53.9 ± 12.8 mm in the left decubitus window. The mean ultrasound max was 54.3 ± 12.6 mm. The mean CT diameter measurement was 55.6 ± 12.7 mm. Correlation between the CT max and ultrasound max was r 2 = 0.90, and CT with the coronal measurement r 2 = 0.90, CT and AP transverse was r2=0.80, and CT with AP sagittal measurement was r 2 = 0.77.

Conclusion

The decubitus ultrasound window of the abdominal aorta, with measurement of the coronal plane, is highly correlated and in agreement with CT scanning. This window may offer an alternative approach to measuring the infrarenal abdominal aortic aneurysm and should be considered when performing surveillance of all infra-renal AAA.

Has network meta-analysis resolved the controversies related to bowel preparation in elective colorectal surgery?

AIM

There are discrepancies in the guidelines on preparation for colorectal surgery. While intravenous antibiotics (IV) are usually administered, the use of mechanical bowel preparation (MBP) and/or oral antibiotics (OA) is controversial. A recent network meta-analysis (NMA) demonstrated that the addition of OA reduced incisional surgical site infections (iSSIs) by more than 50%. We aimed to perform a NMA including only the highest quality randomized clinical trials (RCTs) in order to determine the ranking of different treatment strategies and assess these RCTs for methodological problems that may affect the conclusions of the NMAs.

METHOD

A NMA was performed according to PRISMA guidelines. RCTs of adult patients undergoing elective colorectal surgery with appropriate antibiotic cover and with at least 250 participants recruited, clear definition of endpoints and duration of follow-up extending beyond discharge from hospital were included. The search included Medline, Embase, Cochrane and SCOPUS databases. Primary outcomes were iSSI and anastomotic leak (AL). Statistical analysis was performed in Stata v.15.1 using frequentist routines.

RESULTS

Ten RCTs including 5107 patients were identified. Treatments compared IV (2218 patients), IV + OA (460 patients), MBP + IV (1405 patients), MBP + IV + OA (538 patients) and OA (486 patients). The likelihood of iSSI was significantly lower for IV + OA (rank 1) and MBP + IVA + OA (rank 2), reducing iSSIs by more than 50%. There were no differences between treatments for AL. Methodological issues included differences in definition, assessment and frequency of primary endpoint infections and the limited number of participants included in some treatment options.

CONCLUSION

While this NMA supports the addition of OA to IV to reduce iSSI it also highlights unanswered questions and the need for well-designed pragmatic RCTs.

The Impact of Suprarenal Diameter on Outcomes Following Endovascular Aneurysm Repair: A Retrospective Cohort Study

OBJECTIVES

To determine the association between suprarenal aortic diameters and complications that may be attributed to a dilating phenotype following endovascular abdominal aortic aneurysm repair.

DESIGN

This study is a retrospective review.

METHODS

We measured the abdominal aortas of 147 consecutive patients with a mean age of 78.5 (range 60-93) years, who had a mean Endovascular aneurysm repair (EVAR) follow-up of 3 years (6 months to 8 years) at a public Hospital. Aortic calibres measured 5 mm above the highest renal artery were recorded, patients were categorised according to suprarenal diameter; Group A: greater than 25 mm, Group B: less than or equal to 25 mm. Stent migration, aneurysmal sac growth, presence of an endoleak and its type, occlusion events, rupture, interventions and mortality, as well as clinical history and demographic data were compared between groups.

RESULTS

There was a significantly higher occurrence of stent migration (11% v 0%; P = .01) in patients with larger suprarenal aortas (Group A). The occurrence of any endoleak did not differ between the groups, however, significantly more complications resulting in secondary intervention, excluding occlusions, were noted in Group A (34% vs 17%, P = .04).

CONCLUSIONS

The results from this study suggest that patients with above-average suprarenal diameters (categorised as dilators) may have a higher occurrence of specific complications following EVAR. A more detailed study to establish the association of suprarenal calibre with types of complications following EVAR is warranted.

Near infra-red fluorescence imaging to demonstrate reflux in the superficial microvenous network of the leg

OBJECTIVE

Reflux within the superficial microvenous network may play a critical role in the development of skin changes which can be associated with chronic venous insufficiency. This study aimed to determine if near infra-red fluorescence (NIRF) imaging could be used to accurately determine superficial venous reflux in the leg.

METHODS

A total of nine limbs were examined ex vivo from patients undergoing limb amputation for peripheral arterial disease. Cannulation of the distal great saphenous vein was used to sequentially perform X-ray contrast enhanced venography, NIRF imaging and venous corrosion casts.

RESULTS

Fluorescence imaging visualised a range of different microvenous reflux patterns ex vivo, which were generally not evident by x-ray venography, but were consistent with retrograde resin vascular casts. These included both focal and diffuse regions of fluorescence within the skin and, consistent with previous observations, the vascular casts indicated that regions of venous reflux were typically associated with incompetent valves.

CONCLUSION

The findings from this study suggest a potential method for investigating early stage superficial venous disease, prior to the appearance of visible signs of advanced venous disease, such as skin changes. However, further studies are required to confirm the, in vivo, clinical utility of these observations.

Short-term High-Intensity Interval Training Improves Fitness Before Surgery: A Randomised Clinical Trial

PURPOSE

Improving cardiopulmonary reserve, or peak oxygen consumption( V ˙ O_2peak ), may reduce postoperative complications, however this may be difficult to achieve between diagnosis and surgery. Our primary aim was to assess the efficacy of an approximate 14-session, preoperative High Intensity Interval Training(HIIT) program to increase V ˙ O_2peak by a clinically-relevant 2 mL·kg^-1 ·min^-1 . Our secondary aim was to document clinical outcomes.

METHODOLOGY

In this prospective study, participants aged 45-85 undergoing major abdominal surgery were randomised to standard care or 14 sessions of HIIT over 4 weeks. HIIT sessions involved approximately thirty minutes of stationary cycling. Interval training alternated one minute of high (with the goal of reaching 90% max heart rate at least once during the session) and low/moderate intensity cycling. Cardiopulmonary exercise testing(CPET) measured the change in V ˙ O_2peak from baseline to surgery. Clinical outcomes included postoperative complications, length of stay(LOS) and Short Form-36 quality of life questionnaire(SF-36).

RESULTS

Of 63 participants, 46 completed both CPETs and 50 completed clinical follow-up. There was a significant improvement in the HIIT group's mean ± SD V ˙ O_2peak (HIIT 2.87 ± 1.94 mL·kg¹ ·min^-1 vs standard care 0.15 ± 1.93, with an overall difference of 2.73 mL·kg¹ ·min^-1 95%CI [1.53, 3.93] p<0.001). There were no statistically significant differences between groups for clinical outcomes, although the observed differences consistently favoured the exercise group. This was most notable for total number of complications (0.64 v 1.16 per patient, p=0.07), SF-36 physical component score (p=0.06), and LOS (mean 5.5 v 7.4 days, p=0.07).

CONCLUSIONS

There was a significant improvement in V ˙ O_2peak with a four-week preoperative HIIT program. Further appropriately-powered work is required to explore the impact of preoperative HIIT on postoperative clinical outcomes.

Strategies for Antibiotic Administration for Bowel Preparation Among Patients Undergoing Elective Colorectal Surgery: A Network Meta-analysis

Importance

There are discrepancies in guidelines on preparation for colorectal surgery. While intravenous (IV) antibiotics are usually administered, the use of mechanical bowel preparation (MBP), enemas, and/or oral antibiotics (OA) is controversial.

Objective

To summarize all data from randomized clinical trials (RCTs) that met selection criteria using network meta-analysis (NMA) to determine the ranking of different bowel preparation treatment strategies for their associations with postoperative outcomes.

Data Sources

Data sources included MEDLINE, Embase, Cochrane, and Scopus databases with no language constraints, including abstracts and articles published prior to 2021.

Study Selection

Randomized studies of adults undergoing elective colorectal surgery with appropriate aerobic and anaerobic antibiotic cover that reported on incisional surgical site infection (SSI) or anastomotic leak were selected for inclusion in the analysis. These were selected by multiple reviewers and adjudicated by a separate lead investigator. A total of 167 of 6833 screened studies met initial selection criteria.

Data Extraction and Synthesis

NMA was performed according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines. Data were extracted by multiple independent observers and pooled in a random-effects model.

Main Outcomes and Measures

Primary outcomes were incisional SSI and anastomotic leak. Secondary outcomes included other infections, mortality, ileus, and adverse effects of preparation.

Results

A total of 35 RCTs that included 8377 patients were identified. Treatments compared IV antibiotics (2762 patients [33%]), IV antibiotics with enema (222 patients [3%]), IV antibiotics with OA with or without enema (628 patients [7%]), MBP with IV antibiotics (2712 patients [32%]), MBP with IV antibiotics with OA (with good IV antibiotic cover in 925 patients [11%] and with good overall antibiotic cover in 375 patients [4%]), MBP with OA (267 patients [3%]), and OA (486 patients [6%]). The likelihood of incisional SSI was significantly lower for those receiving IV antibiotics with OA with or without enema (rank 1) and MBP with adequate IV antibiotics with OA (rank 2) compared with all other treatment options. The addition of OA to IV antibiotics, both with and without MBP, was associated with a reduction in incisional SSI by greater than 50%. There were minimal differences between treatments in anastomotic leak and in any of the secondary outcomes.

Conclusions and Relevance

This NMA demonstrated that the addition of OA to IV antibiotics were associated with a reduction in incisional SSI by greater than 50%. The results support the addition of OA to IV antibiotics to reduce incisional SSI among patients undergoing elective colorectal surgery.

Impact of Incisional Surgical Site Infections on Quality of Life and Patient Satisfaction after General Surgery: A Case Controlled Study

Background: Most incisional surgical site infections (ISSI) are now diagnosed after discharge from hospital. In this context, it is important to document the impact ISSI has on our patients. Patients and Methods: Our surgical department sent a validated questionnaire to patients after they had been discharged. This documented incision problems, the 36-Item Short Form Health (SF-36) qualify of life questionnaire, and a patient satisfaction survey (PSS). We retrospectively reviewed records for 115 patients with an ISSI and 115 matched controls with no documented complications. Patient demographics and outcomes were collected. Differences in physical component summary (PCS) score and mental component summary (MCS) score and the PSS score were compared. Results: A majority (87%) of ISSIs were diagnosed after discharge from hospital. There were no differences in demographics, the American Society of Anaesthesiologists grade, or length of stay (LOS) between groups. Two months after surgery, ISSI was associated with lower post-operative SF-36 scores. The PCS was 42.9 (95% confidence interval [CI], 41.3-44.8) for ISSI cases and 47.0 (95% CI, 45.1-48.7) for controls (p ≤ 0.001). The MCS was 45.8 (95% CI, 43.7-47.9) and 50.2 (95% CI, 48.0-52.3), respectively (p = 0.01). Patients had less vitality, increased pain, and a reduction in physical activities and roles. The PSS score was 82.5 (95% CI, 79.6-85.4) in the control group and 74.1 (95% CI, 71.1-77.0) in the ISSI group (p < 0.001). Patients with ISSI reported worse satisfaction ratings with the quality of information received (p = 0.005) and their satisfaction with surgery (p < 0.001). Conclusions: Incisional surgical site infection was correlated with lower quality of life and PSS scores for up to two months after surgery. Prospective studies with pre-operative and post-operative quality of life are required to confirm causality.

Safety and outcomes after oesophagectomy in southern New Zealand: a 25-year audit of a low volume centre

BACKGROUND

Over the last 2 decades, outcomes for oesophageal cancer have improved due to advances in surgical and oncological practice. Optimizing outcomes by centralization of oesophagectomy to high-volume centres has been observed. The aim of this study was to establish if technical and oncological outcomes after oesophagectomy in southern New Zealand are comparable to recent benchmarks.

METHODS

Consecutive patients undergoing oesophagectomy for cancer and benign pathology at Dunedin Hospital from 1995 to 2019 were prospectively audited. For malignant cases, histology was obtained retrospectively along with details of neo-adjuvant and adjuvant therapy. The primary outcome was disease-specific survival, stratified by time, resection margin, and TNM staging. Secondary outcomes included mortality and morbidity of oesophagectomy. Complications were graded using the Clavien-Dindo classification.

RESULTS

Oesophagectomy was performed in 108 patients, and 99 patients had surgery for oesophageal malignancy. The median survival was 35.3 (95% confidence interval (CI) 30.0-93.4) months and the 5-year survival overall was 41.7%. Comparing survival in patients undergoing oesophagectomy up to 2006 and afterwards showed an improvement in 5-year survival (30.3%, 95% CI (14.2-60.0) versus 47.8%, 95% CI (32.5, not reached), respectively, P = 0.041). There were two perioperative deaths (1.8%), six clinical anastomotic leaks (5.5%), four anastomotic strictures (3.7%) and five chylothoraces (4.6%).

CONCLUSION

This 25-year survey of oesophagectomy in southern New Zealand audits the results of a low volume centre, where a variety of neo-adjuvant treatments have been used. Despite this, perioperative morbidity, mortality and survival are comparable to those achieved by international high-volume centres.

Editorial: Impact of Aduhelm Approval on Care and Policy

The more than 6 million Americans living with Alzheimer’s disease face a future filled with progressive loss of their cognitive abilities ending with certain death (1). They will eventually require help in all aspects of daily living, and that help is provided by over 11 million unpaid caregivers (2). At this time, Alzheimer’s remains a clinical diagnosis and unfortunately, many individuals who would meet the diagnostic criteria are not diagnosed (3). The Food and Drug Administration’s (FDA) accelerated approval of aducanumab (Aduhelm™) as a treatment for Alzheimer’s makes early detection, accurate diagnosis and quality care even more critical, to ensure individuals receive the most benefit at the earliest point possible. Furthermore, the approval of this treatment opens up a new landscape in Alzheimer’s care that comes with many implications for effective public policy to enhance access to quality care.

Loop ileostomy closure: a retrospective comparison of three techniques

BACKGROUND

Loop ileostomy (LI) formation is a common practice for patients undergoing low anterior resection or restorative ileo-anal pouch surgery. Ileostomy closure can be performed using a stapled or hand-sewn technique, with or without resection. If hand-sewn, the closure can be one or two layers. Randomized controlled trials have not demonstrated one technique to be superior, and meta-analyses are limited by the heterogeneity of published studies. Our primary aim is to compare stapled ileostomy closure with single- and two-layer hand-sewn closures.

METHODS

This retrospective, single-centre cohort study included patients undergoing LI closure between January 1999 and April 2016. Patient demographics, anastomotic technique, operative time and patient outcomes were collected.

RESULTS

Our analysis included 244 patients (median age 67 years, 43.4% female). There were no significant differences in mean operative times (71.5, 73.1 and 88.5 min, for stapled, single- and two-layer hand-sewn closures, respectively, adjusted overall P = 0.262), or morbidity (21.5% versus 20.4% versus 17.6%, adjusted overall P = 0.934) between stapled or hand-sewn anastomoses, and no mortality. Once adjusting for age, sex, American College of Anaesthesiology grade, and consultant surgeon, the length of stay was different (overall P = 0.034), being similar between stapled and single-layer closures (4.2 versus 5.5 days, P = 0.105), but significantly different between stapled and two-layer closures (4.2 versus 8.3 days, P = 0.026).

CONCLUSION

Stapled and single-layered hand-sewn closures are similar in length of procedure, length of stay and complication rates. A two-layer, hand-sewn technique is associated with a significant increase in stay compared to a stapled ileostomy closure.

Computed tomography in suppurative ear disease: does it influence management?

The value of high resolution computerized tomography (CT) prior to routine mastoid surgery for cholesteatoma remains controversial. Doubts about sensitivity and specificity, in detecting the extent of underlying pathology and in predicting asymptomatic complications, prevent widespread adoption. This retrospective study looks at the influence of pre-operative scanning on the surgical management of chronic suppurative otitis media over an 18-month period. The radiological findings determined the choice of surgical approach, but contributed less to the decision to operate and the prediction of potential hazards. CT is of most value when the otologist can be flexible in surgical technique, tailoring it to imaging findings.

CT scanning of middle ear cholesteatoma: what does the surgeon want to know?

The history of surgery for middle ear cholesteatoma is of an evolution of techniques to meet the challenges of inaccessible disease and of post-operative cavity management. The concept has traditionally been of exploration guided by awareness and anticipation of all, possibly asymptomatic, complications. Modern imaging reliably demonstrates surgical anatomy, dictating the ideal approach, forewarns of complications and may reveal the extent of disease. An apparent resistance amongst otologists to universal CT scanning prior to mastoidectomy contrasts with the enthusiasm of skull base surgeons or rhinologists for appropriate imaging.

A primary glomus tumour of the facial nerve canal

Glomus tumours can present in several sites in the head and neck. A red mass in the middle ear, visible on otoscopy generally indicates a glomus tympanicum or glomus jugulare. We present photographic and radiologic evidence of such a lesion arising from the course of the intra-tympanic facial nerve, the Fallopian canal, and review the differential diagnoses.

A systematic approach to interpretation of computed tomography scans prior to surgery of middle ear cholesteatoma

The foundation of mastoid surgery for cholesteatoma has traditionally been a thorough knowledge of the anatomy and familiarity with landmarks, constant alertness to detect unsuspected complications and the experience to tailor the surgery to the pathology encountered. Whilst not indispensable, computed tomography (CT) scanning is a useful adjunct whose potential predictive value is only truly appreciated by skilled interpretation. We present a guide to analysis to maximize the value of pre-operative radiology.

Endometrial CD56+ natural killer cells in women with recurrent miscarriage: a histomorphometric study

Endometrial natural killer (NK) cells were compared in luteal-phase endometrial samples from women with recurrent miscarriage and from normal subjects. Cryostat sections were labelled using a monoclonal antibody to CD56 using an avidin-biotin complex method and a morphometric study performed. Increased mean numbers of CD56+ cells were documented in the endometrium of women with recurrent early miscarriage only. These findings suggest a possible role for NK cells in the pathogenesis of recurrent early pregnancy loss.

Double-blind comparative trial of ciprofloxacin versus clarithromycin in the treatment of acute bacterial sinusitis. Sinusitis Infection Study Group

This multicenter, randomized, double-blind trial compared the efficacy and safety of ciprofloxacin (CIP; 500 mg twice daily for 10 days, placebo for 4 days) to those of clarithromycin (CLARI; 500 mg twice daily for 14 days) in 560 adults with clinically documented and radiologically confirmed acute sinusitis. Of 457 efficacy-valid adults (236 CIP, 221 CLARI), clinical resolution plus improvement at the end of therapy was 84% for CIP-treated patients compared to 91% of CLARI recipients (CI95 = -0.131, -0.013). At the 1-month follow-up, more than twice as many CLARI-treated patients, 18 (10%), experienced a relapse, compared to 7 (4%) CIP-treated patients. The combined clinical response analyses (end of therapy and 1 -month follow-up) demonstrated that CIP and CLARI were statistically equivalent (CI95 = -0.106, 0.044). Diarrhea, nausea, headache, and dizziness were the most frequently reported drug-related adverse events in both treatment groups; diarrhea and taste perversion were reported more frequently among CLARI recipients. In summary, the combined end of therapy and follow-up clinical evaluation analyses revealed that CIP and CLARI were equally effective in the management of acute sinusitis, although twice as many relapses were reported among CLARI recipients.

Future pregnancy outcome in unexplained recurrent first trimester miscarriage

The future pregnancy outcome of 201 consecutive women, median age 34 years (range 22-43), with a history of unexplained recurrent first trimester miscarriage (median 3; range 3-13), was studied. All women and their partners had normal peripheral blood karyotypes; none had antiphospholipid antibodies and none hypersecreted luteinizing hormone (LH). No pharmacological treatment was prescribed and early pregnancy supportive care was encouraged. Women aged < or = 30 years had a subsequent miscarriage rate of 25% (14/57) which rose to 52% (13/25) in women aged > or = 40 years (P = 0.02). After three consecutive miscarriages, the risk of miscarriage of the next pregnancy was 29% (34/119) but increased to 53% (9/17) after six or more previous losses (P = 0.04). A past history of a livebirth did not influence the outcome of the next pregnancy. Supportive care in early pregnancy conferred a significant beneficial effect on pregnancy outcome. Of 160 women who attended the early pregnancy clinic, 42 (26%) miscarried in the next pregnancy compared with 21 out of 41 (51%) who did not attend the clinic (P = 0.002). After thorough investigation, women with unexplained recurrent first trimester miscarriage have an excellent pregnancy outcome without pharmacological intervention if offered supportive care alone in the setting of a dedicated miscarriage clinic.

Does suppressing luteinising hormone secretion reduce the miscarriage rate? Results of a randomised controlled trial

OBJECTIVE

To determine whether prepregnancy pituitary suppression of luteinising hormone secretion with a luteinising hormone releasing hormone analogue improves the outcome of pregnancy in ovulatory women with a history of recurrent miscarriage, polycystic ovaries, and hypersecretion of luteinising hormone.

DESIGN

Randomised controlled trial.

SETTING

Specialist recurrent miscarriage clinic.

SUBJECTS

106 women with a history of three or more consecutive first trimester miscarriages, polycystic ovaries, and hypersecretion of luteinising hormone.

INTERVENTIONS

Women were randomised before conception to receive pituitary suppression with a luteinising hormone releasing hormone analogue followed by low dose ovulation induction and luteal phase progesterone (group 1) or were allowed to ovulate spontaneously and then given luteal phase progesterone alone or luteal phase placebo alone (group 2). No drugs were prescribed in pregnancy.

MAIN OUTCOME MEASURES

Conception and live birth rates over six cycles.

RESULTS

Conception rates in the pituitary suppression and luteal phase support groups were 80% (40/50 women) and 82% (46/56) respectively (NS). Live birth rates were 65% (26/40) and 76% (35/46) respectively (NS). In the luteal phase support group there was no difference in the outcome of pregnancy between women given progesterone and those given placebo pessaries. Live birth rates from an intention to treat analysis were 52% (26/50 pregnancies) in the group given pituitary suppression and 63% (35/56) in the controls (NS).

CONCLUSIONS

Prepregnancy suppression of high luteinising hormone concentrations in ovulatory women with recurrent miscarriage and hypersecretion of luteinising hormone does not improve the outcome of pregnancy. The outcome of pregnancy without pituitary suppression is excellent.

High prospective fetal loss rate in untreated pregnancies of women with recurrent miscarriage and antiphospholipid antibodies

Antiphospholipid antibodies (APA), lupus anticoagulant (LA) and/or anticardiolipin antibodies (ACA), are associated with thrombosis and recurrent miscarriage. We studied the outcome of 20 pregnancies in women (median age 32 years; range 23-41) with APA (14 LA positive; three immunoglobulin (Ig) G ACA positive; two IgM ACA positive and one LA and IgG ACA positive) and history of recurrent miscarriage (median 4; range 3-11) who declined pharmacological treatment in their next pregnancy. Comparison was made with a cohort of 100 consecutive women (median age 33 years; range 23-44) with recurrent miscarriage (median 4; range 3-10), in whom no underlying cause to account for their pregnancy losses was found. Of the 20 women with APA, 18 (90%) miscarried compared to 34 of the 100 women (34%) with normal investigations (P < 0.001). The majority (94%) of miscarriages in women with APA occurred in the first trimester. Fetal heart activity was seen prior to fetal death in 86% of women with APA compared to 43% of women with normal investigations (P < 0.01). The first trimester loss of embryonic pregnancies is the most common type of miscarriage in women with APA. This may be a result of defective implantation and subsequent placentation.

Antiphospholipid antibodies and beta 2-glycoprotein-I in 500 women with recurrent miscarriage: results of a comprehensive screening approach

Five hundred consecutive women (median age 33 years; range 19-45) with a history of recurrent miscarriage (median 4; range 3-16) were screened for the presence of antiphospholipid antibodies (APA)-lupus anticoagulant (LA) and/or anticardiolipin antibodies (ACA). The prevalence of persistently positive tests for LA was 9.6% and for immunoglobulin G (IgG) and immunoglobulin M (IgM) ACA was 3.3 and 2.2% respectively. Only seven women (1.4%) were LA and ACA positive. Repeat testing, after an interval of at least 8 weeks, demonstrated that only 65.7% of LA positive, 36.6% IgG ACA positive and 36.0% IgM ACA positive women on initial testing had a second positive test result. The dilute Russell's viper venom time detected the LA significantly more often than either the activated partial thromboplastin time or the kaolin clotting time (P < 0.001). There was no difference in the gestation of previous miscarriages between APA positive and APA negative women. There was no difference in the plasma beta 2-glycoprotein-I concentrations between APA positive and APA negative women with miscarriages and normal women. All women with a history of recurrent miscarriage should be tested for the presence of both LA and ACA. A second confirmatory test should be performed in those with an initial positive test result.

An informative protocol for the investigation of recurrent miscarriage: preliminary experience of 500 consecutive cases

A total of 500 consecutive women (mean age 32.9 years; SD 5 years) presenting with a history of recurrent miscarriages (median 4; range 3-17) were investigated for the presence of antiphospholipid antibodies (APA), polycystic ovaries (PCO), hypersecretion of luteinizing hormone (LH) and chromosome abnormalities in order to detect an underlying cause of their pregnancy losses. All women had details of their previous reproductive history, investigations and treatment documented: 76% of the women had experienced only early pregnancy losses (miscarriage < 13 weeks gestation); 32% had a history of subfertility; and significant parental chromosome rearrangements were present in 3.6% of couples. An ultrasound diagnosis of PCO was made in 56% of women, 58% of whom were demonstrated to hypersecrete LH, based on early morning urinary LH analysis. Circulating APA were found in 14% of women. An underlying cause of recurrent miscarriage--genetic, endocrine or autoimmune--was found in > 50% of couples. Women in the latter two groups are being recruited to randomized treatment trials which are discussed.

The clinical value of Clearplan home ovulation detection kits in infertility practice

A home ovulation testing kit, Clearplan, that detects the urinary luteinizing hormone (LH) surge was used by 32 patients on a donor insemination programme for 50 cycles to indicate when to first attend the clinic for a serum LH test to determine ovulation. Using Clearplan significantly reduced the number of clinic attendances (4.06 +/- 1.5) compared to the preceding control cycle (7.06 +/- 2.0 p less than 0.001). One serum LH peak was missed using Clearplan. Ovulation was predicted within 2 days of the serum LH surge in 77% of cycles. Home ovulation determination has the potential to reduce the stress and cost of fertility programmes.

A soluble form of the interleukin 4 receptor in biological fluids

Murine biological fluids and murine cell culture supernatants were analyzed for the presence of soluble murine interleukin 4 receptor (sIL4R) with the use of two monoclonal antibodies directed against the receptor. Mouse urine, serum, ascitic fluid, and cell culture supernatants contained varying levels of immunoreactive protein. All of the immunoreactive protein possessed interleukin 4 (IL 4) binding activity. Following partial purification of ascitic fluid a protein was isolated that binds IL 4 with high affinity. This data is consistent with the fact that murine biological fluids contain a soluble version of the murine IL 4 receptor that arises via secretion of the soluble receptor and/or via shedding of the extracellular portion of the full-length receptor from the cell surface.

Assessment of broadband ultrasound attenuation in the os calcis in vitro

1. We have examined the relationship between the attenuation of broadband ultrasound in the os calcis in vitro and its bone mineral density measured by quantitative computed tomography and by physical density. 2. Broadband ultrasound attenuation was found to correlate closely with physical density (r = 0.85, P less than 0.0001), but the correlation was less than that observed between quantitative computed tomography and physical density (r = 0.92, P less than 0.0001). Measurements of broadband ultrasound attenuation and quantitative computed tomography were significantly correlated (r = 0.80, P less than 0.0001). 3. Partial correlation analysis showed a significant relationship between broadband ultrasound attenuation and bone density, but when the effect of physical density was taken into account no significant correlation was found between broadband ultrasound attenuation and quantitative computed tomography (r = 0.08, not significant). 4. Broadband ultrasound attenuation in three prospective amputees showed a high degree of concordance between measurements in vivo and in vitro, with no interference by surrounding soft tissues. 5. The correlation between physical density and broadband ultrasound attenuation was independent of quantitative computed tomography, suggesting that the technique measures aspects of density which differ from its mineral density. Broadband ultrasound attenuation holds promise as a reproducible, rapid, radiation-free assessment of skeletal status.

Glucagon and infusion cholangiography

It has been previously suggested that glucagon improves the bile duct and gall-bladder opacification obtained by infusion cholangiography. One hundred and ninety consecutive patients referred for intravenous cholangiography were entered into a double-blind study designed to see if glucagon would in fact significantly improve bile duct opacification. All patients received a one hour intravenous infusion of iotroxamide at a rate of 3.15 mg/kg body weight/min. Glucagon did not enhance bile duct opacification, the mean post-injection scores for the two groups being 2.47 +/- 1.11 and 2.29 +/- 1.15 respectively. On the basis of the present study we cannot recommend the routine use of glucagon following infusion cholangiography.

Recovery of coliphages from wastewater effluents and polluted lake water by the magnetite-organic flocculation method

A magnetite-organic flocculation method was developed for the concentration of coliphages from wastewater effluents and polluted lake water. A high percent (68 to 100%) recovery of coliphages from sewage effluents was achieved by this procedure. Coliphage recovery from Lake Alice, a sewage-contaminated lake, showed phage concentrations ranging from 2.3 X 10(2) to 1.9 X 10(3) plaque-forming units per liter. This method is simple and inexpensive and may be carried out under field conditions.

Drip infusion cholangiography using iotroxamide. Double blind comparison with ioglycamide

A double blind clinical trial was carried out in 200 unselected patients to compare the efficacy and tolerance of ioglycamide and iotroxamide as contrast media for intravenous cholangiography. The two agents were administered by slow infusion at a rate of 2.6 mumoles/kg bodyweight/minute for one hour. Radiological opacification of the bile duct was assessed independently by two radiologists. In patients with serum bilirubin levels of less than 34 mumoles/litre visualization of the bile duct was significantly better with iotroxamide than with ioglycamide (P < 0.001). Toxic side effects were observed in 8% of patients receiving ioglycamide and in only 3% of the patients given iotroxamide.