Vascular access surgery training in the United Kingdom is currently perceived (by trainees) to be inadequate

INTRODUCTION

Vascular access surgery (VAS) involves the creation and maintenance of arteriovenous access to facilitate haemodialysis. The prevalence of haemodialysis is rising despite increases in kidney transplants on a yearly basis. There is currently only one access surgery fellowship accredited by the Royal College of Surgeons of England. We aimed to establish the experience and perceived competence in access surgery of senior vascular surgery trainees.

METHODS

A short questionnaire (SurveyMonkey) was used to survey all senior (ST6-ST8) vascular surgery trainees in Health Education England (HEE) vascular surgery training programmes. The short survey asked trainees to report their: (1) training grade; (2) training deanery; (3) experience of access surgery; and (4) whether senior trainees thought they would be able to independently undertake primary access surgery post-completion of training (post Certificate of Completion of Training). The survey was circulated via HEE deaneries and the vascular surgery trainees' society: the Rouleaux Club.

RESULTS

Twenty-eight senior (ST6-ST8) vascular surgery trainees responded to the survey: 29.6% were ST6 level, 33.3% were ST7 and 37.1% were ST8. Deanery respondence was evenly spread, although London was overrepresented (37.1%). In total, 28.6% had been involved in fewer than 10 cases, 35.7% in 10-25 cases, and 35.7% in more than 25 cases. Almost 54% of senior vascular surgery trainees believed they would not be able to undertake independent access surgery once they had completed training.

CONCLUSIONS

Competence in access surgery is an increasing requirement of a consultant vascular surgeon. More formalised training is required to adequately train the next generation of vascular surgeons.

Vascular access surgery training in the United Kingdom is currently perceived (by trainees) to be inadequate

INTRODUCTION

Vascular access surgery (VAS) involves the creation and maintenance of arteriovenous access to facilitate haemodialysis. The prevalence of haemodialysis is rising despite increases in kidney transplants on a yearly basis. There is currently only one access surgery fellowship accredited by the Royal College of Surgeons of England. We aimed to establish the experience and perceived competence in access surgery of senior vascular surgery trainees.

METHODS

A short questionnaire (SurveyMonkey) was used to survey all senior (ST6-ST8) vascular surgery trainees in Health Education England (HEE) vascular surgery training programmes. The short survey asked trainees to report their: (1) training grade; (2) training deanery; (3) experience of access surgery; and (4) whether senior trainees thought they would be able to independently undertake primary access surgery post-completion of training (post Certificate of Completion of Training). The survey was circulated via HEE deaneries and the vascular surgery trainees' society: the Rouleaux Club.

RESULTS

Twenty-eight senior (ST6-ST8) vascular surgery trainees responded to the survey: 29.6% were ST6 level, 33.3% were ST7 and 37.1% were ST8. Deanery respondence was evenly spread, although London was overrepresented (37.1%). In total, 28.6% had been involved in fewer than 10 cases, 35.7% in 10-25 cases, and 35.7% in more than 25 cases. Almost 54% of senior vascular surgery trainees believed they would not be able to undertake independent access surgery once they had completed training.

CONCLUSIONS

Competence in access surgery is an increasing requirement of a consultant vascular surgeon. More formalised training is required to adequately train the next generation of vascular surgeons.

National guidelines for the diagnosis and treatment of hilar cholangiocarcinoma

A consensus meeting of national experts from all major national hepatobiliary centres in the country was held on May 26, 2023, at the Pakistan Kidney and Liver Institute & Research Centre (PKLI & RC) after initial consultations with the experts. The Pakistan Society for the Study of Liver Diseases (PSSLD) and PKLI & RC jointly organised this meeting. This effort was based on a comprehensive literature review to establish national practice guidelines for hilar cholangiocarcinoma (hCCA). The consensus was that hCCA is a complex disease and requires a multidisciplinary team approach to best manage these patients. This coordinated effort can minimise delays and give patients a chance for curative treatment and effective palliation. The diagnostic and staging workup includes high-quality computed tomography, magnetic resonance imaging, and magnetic resonance cholangiopancreatography. Brush cytology or biopsy utilizing endoscopic retrograde cholangiopancreatography is a mainstay for diagnosis. However, histopathologic confirmation is not always required before resection. Endoscopic ultrasound with fine needle aspiration of regional lymph nodes and positron emission tomography scan are valuable adjuncts for staging. The only curative treatment is the surgical resection of the biliary tree based on the Bismuth-Corlette classification. Selected patients with unresectable hCCA can be considered for liver transplantation. Adjuvant chemotherapy should be offered to patients with a high risk of recurrence. The use of preoperative biliary drainage and the need for portal vein embolisation should be based on local multidisciplinary discussions. Patients with acute cholangitis can be drained with endoscopic or percutaneous biliary drainage. Palliative chemotherapy with cisplatin and gemcitabine has shown improved survival in patients with irresectable and recurrent hCCA.

Genomic insights into Yak (Bos grunniens) adaptations for nutrient assimilation in high-altitudes

High-altitude environments present formidable challenges for survival and reproduction, with organisms facing limited oxygen availability and scarce nutrient resources. The yak (Bos grunniens), indigenous to the Tibetan Plateau, has notably adapted to these extreme conditions. This study delves into the genomic basis of the yak's adaptation, focusing on the positive selection acting on genes involved in nutrient assimilation pathways. Employing techniques in comparative genomics and molecular evolutionary analyses, we selected genes in the yak that show signs of positive selection associated with nutrient metabolism, absorption, and transport. Our findings reveal specific genetic adaptations related to nutrient metabolism in harsh climatic conditions. Notably, genes involved in energy metabolism, oxygen transport, and thermoregulation exhibited signs of positive selection, suggesting their crucial role in the yak's successful colonization of high-altitude regions. The study also sheds light on the yak's immune system adaptations, emphasizing genes involved in response to various stresses prevalent at elevated altitudes. Insights into the yak's genomic makeup provide valuable information for understanding the broader implications of high-altitude adaptations in mammalian evolution. They may contribute to efforts in enhancing livestock resilience to environmental challenges.

Spectral and temporal atomic coherence interaction in Eu3+ : NaYF4 and Eu3+ : BiPO4

We investigate the spectral and temporal atomic coherence interaction based on out-of-phase fluorescence (FL) and spontaneous parametric four-wave mixing (SFWM) from the hexagonal phase of Eu3+ : NaYF4 and different phases of Eu3+ : BiPO4. Spectral and temporal interactions are interrelated and reduced by about 2 times due to two-photon nested dressing in contrast to the sum of each laser excitation. As the lifetime of photons increases, off-resonance profile cross-interaction decreases because cross-interaction reverses the signal at the near time gate position and keeps it consistent at the far time gate position. Moreover, the thermal phonon dressing at 300 K exhibits 6 times more eminent and obvious temporal interaction than that at 77 K. In a different phase of Eu3+ : BiPO4, there are three dark dips having stronger self-interaction; however, Eu3+ : NaYF4 has two dark dips as Eu3+ : BiPO4 has two phonon dressing. Further, the pure hexagonal phase of Eu3+ : BiPO4 demonstrates the strongest cross-interaction and longest coherent time under the dressing effect due to the smallest dressing phonon detuning and off-resonance profile cross-interaction at PMT2 because the angle quantization is the strongest. Such results can be used for designing novel quantum devices and have potential applications in quantum memory devices.

Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Analyzing neural activity under prolonged mask usage through EEG

In recent COVID times, mask has been a compulsion at workplaces and institutes as a preventive measure against multiple viral diseases including coronavirus (COVID-19) disease. However, the effects of prolonged mask-wearing on humans' neural activity are not well known. This paper is to investigate the effect of prolonged mask usage on the human brain through electroencephalogram (EEG), which acquires neural activity and translates it into comprehensible electrical signals. The performances of 10 human subjects with and without mask were assessed on a random patterned alphabet game. Besides EEG, physiological parameters of oxygen saturation, heart rate, blood pressure, and body temperature were recorded. Spectral and statistical analysis were performed on the recorded entities along with linear discriminant analysis (LDA) on extracted spectral features. The mean EEG spectral power in alpha, beta, and gamma sub-bands of the subjects with mask was smaller than the subjects without mask. The performances on the task and the oxygen saturation level between the two groups differed significantly (p < 0.05). Whereas, the blood pressure, body temperature, and heart rate of both groups were similar. Based on the LDA analysis, the occipital and frontal lobes exhibited the greatest variability in channel measurements, with O1 and O2 channels in the occipital lobe demonstrating significant variations within the alpha band due to visual focus, while the F3, AF3, and F7 channels were found to be differentiating within the beta and gamma frequency bands due to the cognitive stimulating tasks. All other channels were observed to be non-discriminatory.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Effectiveness of conservative management versus laparoscopic cholecystectomy in the prevention of recurrent symptoms and complications in adults with uncomplicated symptomatic gallstone disease (C-GALL trial): pragmatic, multicentre randomised controlled trial

OBJECTIVE

To assess the clinical and cost effectiveness of conservative management compared with laparoscopic cholecystectomy for the prevention of symptoms and complications in adults with uncomplicated symptomatic gallstone disease.

DESIGN

Parallel group, pragmatic randomised, superiority trial.

SETTING

20 secondary care centres in the UK.

PARTICIPANTS

434 adults (>18 years) with uncomplicated symptomatic gallstone disease referred to secondary care, assessed for eligibility between August 2016 and November 2019, and randomly assigned (1:1) to receive conservative management or laparoscopic cholecystectomy.

INTERVENTIONS

Conservative management or surgical removal of the gallbladder.

MAIN OUTCOME MEASURES

The primary patient outcome was quality of life, measured by area under the curve, over 18 months using the short form 36 (SF-36) bodily pain domain, with higher scores (range 0-100) indicating better quality of life. Other outcomes included costs to the NHS, quality adjusted life years (QALYs), and incremental cost effectiveness ratio.

RESULTS

Of 2667 patients assessed for eligibility, 434 were randomised: 217 to the conservative management group and 217 to the laparoscopic cholecystectomy group. By 18 months, 54 (25%) participants in the conservative management arm and 146 (67%) in the cholecystectomy arm had received surgery. The mean SF-36 norm based bodily pain score was 49.4 (standard deviation 11.7) in the conservative management arm and 50.4 (11.6) in the cholecystectomy arm. The SF-36 bodily pain area under the curve up to 18 months did not differ (mean difference 0.0, 95% confidence interval -1.7 to 1.7; P=1.00). Conservative management was less costly (mean difference -£1033, (-$1334; -€1205), 95% credible interval -£1413 to -£632) and QALYs did not differ (mean difference -0.019, 95% credible interval -0.06 to 0.02).

CONCLUSIONS

In the short term (≤18 months), laparoscopic surgery is no more effective than conservative management for adults with uncomplicated symptomatic gallstone disease, and as such conservative management should be considered as an alternative to surgery. From an NHS perspective, conservative management may be cost effective for uncomplicated symptomatic gallstone disease. As costs, complications, and benefits will continue to be incurred in both groups beyond 18 months, future research should focus on longer term follow-up to establish effectiveness and lifetime cost effectiveness and to identify the cohort of patients who should be routinely offered surgery.

TRIAL REGISTRATION

ISRCTN registry ISRCTN55215960.

In-Situ Construction of V2 O5 Nanosheet/Nitrogen-Doped Carbon Nanosheet Heterostructures with Interfacial C─O Bridging Bonds as the Cathode Material for Zn Ion Batteries

Layered oxides are widely used as the electrode materials for metal ion batteries. However, for large radius size ions, such as Zn2+ and Al3+ , the tightly stacked layers and poor electrical conductivity of layered oxides result in restricted number of active sites and sluggish reaction kinetics. In this work, a facile in-situ construction strategy is provided to synthesize layered oxide nanosheets/nitrogen-doped carbon nanosheet (NC) heterostructure, which shows larger interlayer spacing and better electrical conductivity than the layered oxides. As a result, the Zn2+ ion diffusion inside the interlayer gallery is greatly enhanced and the storage sites inside the gallery can be better used. Meanwhile, the NC layers and oxide nanosheets are bridged by the C─O bonds to form a stable structure, which contributes to a better cycling stability than the pure layered oxides. The optimal V2 O5 @NC-400 cathode shows a capacity of 467 mA h g-1 at 0.1 A g-1 for 300 cycles, and long-term cyclic stability of 4000 cycles at 5 A g-1 with a capacity retention of 92%. All these performance parameters are among the best for vanadium oxide-based cathode materials.

Oh nuts, they've got a pelvic kidney - a tricky testicular vein embolisation

Testicular vein embolisation for varicocele is a common interventional procedure performed in predominantly young, healthy males. Cross-sectional imaging is rarely performed for treatment planning and is often not available. In this case report, we describe a case of testicular vein embolisation in an ipsilateral pelvic kidney where cross-sectional imaging aided treatment planning resulting in successful embolisation.

Improved Corrosion Resistance and Cytotoxicity of Nickel-based alloy using Novel Plasma processing technique.. [DOI: 10.21203/rs.3.rs-3200844/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Nickel-based (NiCr) alloys are mostly utilized in the dental industry because of their good corrosion resistance, ease of casting, and adequate thermal coefficient of friction with ceramic porcelain. However, leakage of toxic metal ions (Ni and Cr) due to breakage or damage of protective metal oxide layers in aggressive body fluids affects corrosion resistance, tribological properties, and cytotoxicity. These drawbacks ultimately affect the biocompatibility of NiCr alloys for medical applications. This study employs magnetron sputtering in conjunction with cathodic cage plasma nitriding (CCPN) to perform a novel duplex plasma treatment on Ni-Cr alloy. Moreover, the cathodic cage plasma-treated TiN (CCPN-TiN) samples showed further enhanced corrosion resistance and low metal ion leakage. These findings made duplex plasma treatment an efficient method for the surface modification of metallic alloys against the leaching of toxic ions in chloride-aggressive electrolytes, thus proving an excellent strategy for various biomedical applications.

A deviant anterior portal vein in the hepatoduodenal ligament with aberrant origin of hepatic arteries directly from the celiac trunk: A case report of two patients underwent pylorus preserving pancreatoduodenectomy (PPPD)

INTRODUCTION

The portal vein (PV) originates behind the neck of the pancreas, where it is formed classically by the union of the superior mesenteric vein (SMV) and the splenic vein (SV) [1]. It courses upwards towards the liver in the free margin of the lesser omentum, the hepatoduodenal ligament, along with other structures of the portal triad, i.e. proper hepatic artery (PHA) and common bile duct (CBD) anterior to it [1]. The PV is found posterior to the PHA and CBD. The abdominal aorta perfuses abdominal viscera via three ventral branches celiac trunk (CA), superior mesenteric artery (SMA), and inferior mesenteric artery (IMA). The celiac trunk supplies the derivates of the foregut and is divided into the left gastric artery (LGA), splenic artery (SA), and common hepatic artery (CHA). The CHA, after its origin, is divided into the gastroduodenal artery (GDA) and PHA. After giving off the right gastric artery (RGA), the PHA bifurcates into the right and left hepatic arteries (RHA, LHA) [2].

IMPORTANCE

This case report aims to share the rare variations in the anatomy of hepatoduodenal ligament structures to increase awareness and understanding among fellow surgeons which may reduce complications.

CASE PRESENTATION

We are reporting 2 cases in which during pancreaticoduodenectomy Portal vein was present anteriorly in the portal triad and the common hepatic artery was absent; instead, both the right and left hepatic arteries originated directly from the CA posterior to PV. This retro-portal origin of hepatic arteries directly from CA is not reported in Michel's classification of hepatic artery variations [3].

CLINICAL DISCUSSION

The confluence of SMV and SV posterior to the neck of the pancreas forms the PV. The portal vein runs upwards in the free edge of the lesser omentum. Anteriorly it is related to the CBD laterally and CHA anteromedially. Posteriorly it is related to the inferior vena cava (IVC), and PV is separated from IVC by epiploic foramen [4]. The overall reported incidence in the variation of the portal vein anatomy is 25%. Among all the variations seen, the anterior PV with posteriorly bifurcating hepatic artery is present in only 10 % of the cases [5]. There is an increased risk of hepatic artery anatomical variation in the presence of portal vein variants. Michel's classification [6] classified variations in the hepatic artery anatomy. In our cases, the hepatic artery anatomy was standard and was classified as Type 1. The bile duct was normal anatomic (lateral to the PV). Hence our cases are unique in describing isolated variant locations and courses. Detailed information about the anatomy of the portal triad and all possible variants can help reduce the incidence of iatrogenic complications during surgeries like liver transplants and pancreatoduodenectomies. Before the advancement of modern imaging techniques, the variations in the anatomy of the portal triad were clinically irrelevant and considered less significant. However, recent literature supports that variant anatomy of the hepatic portal triad can prolong the time of surgery and increase the risk of iatrogenic complications. The clinical relevance of variable hepatic artery anatomy has immense importance in hepatobiliary surgeries, including liver transplants where the viability of the graft depends on adequate arterial perfusion. In addition to that, in pancreatoduodenectomies, aberrant arterial anatomy with a reteroportal course is associated with an increased number of reconstructions [7] and bilio-enteric anastomosis disruptions since the CBD derives its blood supply from the hepatic arteries. Therefore, the imaging must be carefully interpreted with radiologists' help before surgical planning. As surgeons preoperative imaging is usually seen for the abnormal origin of hepatic arteries and vascular involvement in case of malignancies. "Eyes don't see what mind doesn't know", the anterior portal vein is a rare entity and should be considered while reviewing preoperative imaging for operative planning. In our cases, EUS and CT scans, both were done but we determined resectability on scans and abnormal origin (replaced or accessory arteries) only. Above mentioned findings were noted during surgery but now in every preoperative scan, we try to determine the presence of all possible variations including the reported ones.

CONCLUSION

Detailed knowledge about the anatomy of the portal triad and all possible variants can help reduce the incidence of iatrogenic complications during surgeries like liver transplants and pancreatoduodenectomies. It also reduces the time of surgery. A careful review of all possible variations in preoperative scans with appropriate knowledge all anatomical variations helps avoid unpleasant events and hence, reduce morbidity and mortality.

Detailed Sub-study Analysis of the SECRAB Trial: Quality of Life, Cosmesis and Chemotherapy Dose Intensity

AIMS

SECRAB was a prospective, open-label, multicentre, randomised phase III trial comparing synchronous to sequential chemoradiotherapy (CRT). Conducted in 48 UK centres, it recruited 2297 patients (1150 synchronous and 1146 sequential) between 2 July 1998 and 25 March 2004. SECRAB reported a positive therapeutic benefit of using adjuvant synchronous CRT in the management of breast cancer; 10-year local recurrence rates reduced from 7.1% to 4.6% (P = 0.012). The greatest benefit was seen in patients treated with anthracycline-cyclophosphamide, methotrexate, 5-fluorouracil (CMF) rather than CMF. The aim of its sub-studies reported here was to assess whether quality of life (QoL), cosmesis or chemotherapy dose intensity differed between the two CRT regimens.

MATERIALS AND METHODS

The QoL sub-study used EORTC QLQ-C30, EORTC QLQ-BR23 and the Women's Health Questionnaire. Cosmesis was assessed: (i) by the treating clinician, (ii) by a validated independent consensus scoring method and (iii) from the patients' perspective by analysing four cosmesis-related QoL questions within the QLQ-BR23. Chemotherapy doses were captured from pharmacy records. The sub-studies were not formally powered; rather, the aim was that at least 300 patients (150 in each arm) were recruited and differences in QoL, cosmesis and dose intensity of chemotherapy assessed. The analysis, therefore, is exploratory in nature.

RESULTS

No differences were observed in the change from baseline in QoL between the two arms assessed up to 2 years post-surgery (Global Health Status: -0.05; 95% confidence interval -2.16, 2.06; P = 0.963). No differences in cosmesis were observed (via independent and patient assessment) up to 5 years post-surgery. The percentage of patients receiving the optimal course-delivered dose intensity (≥85%) was not significantly different between the arms (synchronous 88% versus sequential 90%; P = 0.503).

CONCLUSIONS

Synchronous CRT is tolerable, deliverable and significantly more effective than sequential, with no serious disadvantages identified when assessing 2-year QoL or 5-year cosmetic differences.

A Critical Cybersecurity Analysis and Future Research Directions for the Internet of Things: A Comprehensive Review

The emergence of the Internet of Things (IoT) technology has brought about tremendous possibilities, but at the same time, it has opened up new vulnerabilities and attack vectors that could compromise the confidentiality, integrity, and availability of connected systems. Developing a secure IoT ecosystem is a daunting challenge that requires a systematic and holistic approach to identify and mitigate potential security threats. Cybersecurity research considerations play a critical role in this regard, as they provide the foundation for designing and implementing security measures that can address emerging risks. To achieve a secure IoT ecosystem, scientists and engineers must first define rigorous security specifications that serve as the foundation for developing secure devices, chipsets, and networks. Developing such specifications requires an interdisciplinary approach that involves multiple stakeholders, including cybersecurity experts, network architects, system designers, and domain experts. The primary challenge in IoT security is ensuring the system can defend against both known and unknown attacks. To date, the IoT research community has identified several key security concerns related to the architecture of IoT systems. These concerns include issues related to connectivity, communication, and management protocols. This research paper provides an all-inclusive and lucid review of the current state of anomalies and security concepts related to the IoT. We classify and analyze prevalent security distresses regarding IoT's layered architecture, including connectivity, communication, and management protocols. We establish the foundation of IoT security by examining the current attacks, threats, and cutting-edge solutions. Furthermore, we set security goals that will serve as the benchmark for assessing whether a solution satisfies the specific IoT use cases.

Pathogens identified in the internal tissues and placentas of stillbirths: results from the prospective, observational PURPOSe study

OBJECTIVE

To examine internal organ tissues and placentas of stillbirths for various pathogens.

DESIGN

Prospective, observational study.

SETTINGS

Three study hospitals in India and a large maternity hospital in Pakistan.

POPULATION

Stillborn infants delivered in a study hospital.

METHODS

A prospective observational study.

MAIN OUTCOME MEASURES

Organisms identified by pathogen polymerase chain reaction (PCR) in internal organs and placental tissues of stillbirths.

RESULTS

Of 2437 stillbirth internal tissues, 8.3% (95% CI 7.2-9.4) were positive. Organisms were most commonly detected in brain (12.3%), cerebrospinal fluid (CSF) (9.5%) and whole blood (8.4%). Ureaplasma urealyticum/parvum was the organism most frequently detected in at least one internal organ (6.4% of stillbirths and 2% of all tissues). Escherichia coli/Shigella was the next most common (4.1% one or more internal organ tissue sample and 1.3% of tissue samples), followed by Staphylococcus aureus in at least one internal organ tissue (1.9% and 0.9% of all tissues). None of the other organisms was found in more than 1.4% of the tissue samples in stillbirths or more than 0.6% of the internal tissues examined. In the placenta tissue, membrane or cord blood combined, 42.8% (95% CI 40.2-45.3) had at least one organism identified, with U. urealyticum/parvum representing the most commonly identified (27.8%).

CONCLUSIONS

In about 8% of stillbirths, there was evidence of a pathogen in an internal organ. Ureaplasma urealyticum/parvum was the most common organism found in the placenta and in the internal tissues, especially in the fetal brain.

Description of novel variants in consanguineous Pakistani families affected with intellectual disability

BACKGROUND

Intellectual disability (ID) is a neurodevelopmental condition, affecting 1-3% of the population. Genetic factors play a key role causing the limitation in intellectual functioning and adaptive behavior. The heterogeneity of ID makes it more difficult for genetic and clinical diagnosis. Mapping of variants through next generation DNA sequencing in consanguineous families would help to understand the molecular parthenogenesis of ID.

OBJECTIVE

The aim of this study was to describe the genetic variants of ID in consanguineous Pakistani families.

METHODS

We analyzed four unrelated consanguineous Pakistani families having an intellectual disability through whole exome sequencing (WES). Data was analyzed using different bioinformatics tools and software.

RESULTS

We mapped four novel variants in different ID genes. Each variant is found in different family, co-segregating with a recessive pattern of inheritance. The variants found are; c.1437delG:p.Asn480Thrfs*10, mapped in FKRP, c.2041 C>A:p.Leu681Met in HIRA, c.382 C>T:p.Arg128Cys in BDH1 and c.267+1G>A:p.? identified in TRAPPC6B.

CONCLUSIONS

These variants help in demonstration of status and molecular basis of intellectual disability in Pakistani population leading to provision of genetic counseling services and a contribution in disease variant database.

The dilemma of the disappearing colorectal liver metastases: defining international trends in management

OBJECTIVE

This survey sought to appraise the degree of consistency in the management of disappeared colorectal liver metastases (dCRLM) among liver surgeons in different countries.

BACKGROUND

Colorectal liver metastases (CRLM) account for half of the deaths secondary to colorectal cancer. Due to the high utilization of chemotherapy before surgery, some or all CRLM can disappear (dCRLM) but management of dCRLMs remains unclear.

METHODS

Seven simulated scenarios of dCRLM were presented to experienced liver surgeons using an online platform. Treatment decisions were submitted and analysed using the multi-rater kappa method. The effect of the experience, complexity of scenarios, and location and number of dCRLM on treatment decision were analysed.

RESULTS

Sixty-seven liver surgeons from 25 countries completed the survey. There was no agreement about the therapeutic strategies of dCRLM in all scenarios (kappa 0.12, IQR 0.20-0.32). In scenarios with lower difficulty scores, surgeons tended to offer surgical resection for dCRLM alongside the visible CRLM (vCRLM), however, with poor agreement (kappa 0.32, IQR 0.19-0.51). No agreement was seen for clinical scenario in which all CRLM lesions disappeared (kappa 0.20).

CONCLUSION

There are clear inconsistencies in the management decisions of dCRLM. Better evidence is required to define optimal management strategies.

Safety and efficacy of the Mynx Control vascular closure device in peripheral arterial procedures: A prospective study

OBJECTIVES

This article aims to present a prospective study investigating the safety and efficacy of the Mynx Control extravascular closure device (Cordis Corporation, FL, USA), for femoral arterial closure in patients undergoing peripheral arterial procedures.

METHODS

Between January 2020 and February 2021, 100 Mynx Control devices were deployed in 91 consecutive patients (mean age: 67.5 ± 16.9 years) who underwent peripheral arterial procedures. We used ultrasound and/or fluoroscopy during Mynx Control deployment and ultrasound post-procedure to detect complications. Femoral artery punctures included 62 (62%) antegrade and 38 (38%) retrograde punctures. The mean activated clotting time at time of device deployment was 221s. The primary endpoints were technical success, device failure, and complication rates up to 30 days.

RESULTS

A 5F vascular sheath was used in 43 cases (43%) (36 (36%) 6F and 21 (21%) 7F). The majority of our cases had antegrade access (62%). Overall technical success rate was 97% in both antegrade and retrograde cases. In total, there were 4 minor complications: 3 (3%) cases of pseudoaneurysm and 1 (1%) case of haematoma. No major complications were recorded post-procedure or 30 days post index procedure.

CONCLUSION

The Mynx Control vascular closure device is safe and effective in achieving haemostasis in patients undergoing antegrade and retrograde peripheral angioplasty procedures.

Lithium in breast milk transiently affects the renal electrolytic balance of infants

BACKGROUND

The use of lithium during breast-feeding has not been comprehensively investigated in humans due to concerns about lithium toxicity.

PROCEDURE

We analyzed lithium in the kidneys of nursed pups of lithium medicated mothers, using analytical spectroscopy in a novel rat model. The mothers were healthy rats administered lithium via gavage (1000 mg/day Li₂ CO₃ per 50 kg body weight).

RESULTS

Lithium was detected in the breast milk, and in the blood of pups (0.08 mM), of lithium-exposed dams at post-natal day 18 (P18), during breast-feeding. No lithium was detected after breast-feeding, at P25 (4 days after cessation of nursing). The lithium pups blood had elevated urea nitrogen at P18 and reduced total T₄ at P18 and P25, indicating a longer-term effect on the kidneys and the thyroid gland. Multivariate machine-learning analysis of spectroscopy data collected from the excised kidneys of pups showed elevated potassium in lithium-exposed animals both during- and after breast-feeding. The elevated renal potassium was associated with low nephrin expression in the kidneys measured immunohistochemically during breast-feeding. After lithium exposure is stopped, the filtration of lithium from the kidneys reverses these effects. Our study showed that breastfeeding during lithium use has an effect on the kidneys of the offspring in rats.

Immediate surgery compared with short-course neoadjuvant gemcitabine plus capecitabine, FOLFIRINOX, or chemoradiotherapy in patients with borderline resectable pancreatic cancer (ESPAC5): a four-arm, multicentre, randomised, phase 2 trial

BACKGROUND

Patients with borderline resectable pancreatic ductal adenocarcinoma have relatively low resection rates and poor survival despite the use of adjuvant chemotherapy. The aim of our study was to establish the feasibility and efficacy of three different types of short-course neoadjuvant therapy compared with immediate surgery.

METHODS

ESPAC5 (formerly known as ESPAC-5f) was a multicentre, open label, randomised controlled trial done in 16 pancreatic centres in two countries (UK and Germany). Eligible patients were aged 18 years or older, with a WHO performance status of 0 or 1, biopsy proven pancreatic ductal adenocarcinoma in the pancreatic head, and were staged as having a borderline resectable tumour by contrast-enhanced CT criteria following central review. Participants were randomly assigned by means of minimisation to one of four groups: immediate surgery; neoadjuvant gemcitabine and capecitabine (gemcitabine 1000 mg/m2 on days 1, 8, and 15, and oral capecitabine 830 mg/m2 twice a day on days 1-21 of a 28-day cycle for two cycles); neoadjuvant FOLFIRINOX (oxaliplatin 85 mg/m2, irinotecan 180 mg/m2, folinic acid given according to local practice, and fluorouracil 400 mg/m2 bolus injection on days 1 and 15 followed by 2400 mg/m2 46 h intravenous infusion given on days 1 and 15, repeated every 2 weeks for four cycles); or neoadjuvant capecitabine-based chemoradiation (total dose 50·4 Gy in 28 daily fractions over 5·5 weeks [1·8 Gy per fraction, Monday to Friday] with capecitabine 830 mg/m2 twice daily [Monday to Friday] throughout radiotherapy). Patients underwent restaging contrast-enhanced CT at 4-6 weeks after neoadjuvant therapy and underwent surgical exploration if the tumour was still at least borderline resectable. All patients who had their tumour resected received adjuvant therapy at the oncologist's discretion. Primary endpoints were recruitment rate and resection rate. Analyses were done on an intention-to-treat basis. This trial is registered with ISRCTN, 89500674, and is complete.

FINDINGS

Between Sept 3, 2014, and Dec 20, 2018, from 478 patients screened, 90 were randomly assigned to a group (33 to immediate surgery, 20 to gemcitabine plus capecitabine, 20 to FOLFIRINOX, and 17 to capecitabine-based chemoradiation); four patients were excluded from the intention-to-treat analysis (one in the capecitabine-based chemoradiotherapy withdrew consent before starting therapy and three [two in the immediate surgery group and one in the gemcitabine plus capecitabine group] were found to be ineligible after randomisation). 44 (80%) of 55 patients completed neoadjuvant therapy. The recruitment rate was 25·92 patients per year from 16 sites; 21 (68%) of 31 patients in the immediate surgery and 30 (55%) of 55 patients in the combined neoadjuvant therapy groups underwent resection (p=0·33). R0 resection was achieved in three (14%) of 21 patients in the immediate surgery group and seven (23%) of 30 in the neoadjuvant therapy groups combined (p=0·49). Surgical complications were observed in 29 (43%) of 68 patients who underwent surgery; no patients died within 30 days. 46 (84%) of 55 patients receiving neoadjuvant therapy were available for restaging. Six (13%) of 46 had a partial response. Median follow-up time was 12·2 months (95% CI 12·0-12·4). 1-year overall survival was 39% (95% CI 24-61) for immediate surgery, 78% (60-100) for gemcitabine plus capecitabine, 84% (70-100) for FOLFIRINOX, and 60% (37-97) for capecitabine-based chemoradiotherapy (p=0·0028). 1-year disease-free survival from surgery was 33% (95% CI 19-58) for immediate surgery and 59% (46-74) for the combined neoadjuvant therapies (hazard ratio 0·53 [95% CI 0·28-0·98], p=0·016). Three patients reported local disease recurrence (two in the immediate surgery group and one in the FOLFIRINOX group). 78 (91%) patients were included in the safety set and assessed for toxicity events. 19 (24%) of 78 patients reported a grade 3 or worse adverse event (two [7%] of 28 patients in the immediate surgery group and 17 [34%] of 50 patients in the neoadjuvant therapy groups combined), the most common of which were neutropenia, infection, and hyperglycaemia.

INTERPRETATION

Recruitment was challenging. There was no significant difference in resection rates between patients who underwent immediate surgery and those who underwent neoadjuvant therapy. Short-course (8 week) neoadjuvant therapy had a significant survival benefit compared with immediate surgery. Neoadjuvant chemotherapy with either gemcitabine plus capecitabine or FOLFIRINOX had the best survival compared with immediate surgery. These findings support the use of short-course neoadjuvant chemotherapy in patients with borderline resectable pancreatic ductal adenocarcinoma.

FUNDING

Cancer Research UK.

Paroxysmal Nocturnal Hemoglobinuria in Systemic Lupus Erythematosus: A Rare Manifestation

Paroxysmal nocturnal haemoglobinuria (PNH) is a rare disorder of hematopoietic stem cells. The occurrence of PNH in a patient with systemic lupus erythematosus (SLE) is even rarer. One such presentation was seen in a 19 years old woman who presented with fever, multiple joint pain, photosensitivity, oral ulcer, hair loss and was diagnosed as a case of SLE and was admitted in Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh on 7th February 2019. Subsequently she developed progressive anaemia and passing of dark colored urine. Flow cytometry analysis showed PNH clone within red cells. We report this case so that clinicians are aware about this association between PNH and SLE. Informed written consent was obtained from the patient for the publication of this case report, the copy of which is available with the authors.

Endovascular salvage of thrombosed haemodialysis vascular access

Background: Haemodialysis access thrombosis is associated with significant morbidity and access abandonment rates, for which endovascular salvage is a well described treatment option. This study aimed to evaluate the outcomes of endovascular salvage procedures of thrombosed vascular access circuits and identify factors influencing outcomes. Patients and methods: Retrospective review of 328 consecutive procedures performed over 10 years at our institution between January 2010 and December 2019. Patient demographics, access circuit characteristics, procedure details and outcome data were collected. Kaplan-Meier survival curves were used to estimate patency rates and Cox multivariate regression analysis to identify factors affecting outcomes. Results: Technical and clinical success rates were 87.8% and 75.9% respectively. The primary, primary assisted and secondary patency rates at 6 months were 42.2%, 46.7% and 59.1%; and at 12 months were 23.4%, 28.3% and 41.8% respectively. Median access circuit survival was 9.2 months. Major complication rate was 5.2% including 3 procedure-related deaths. Native AVF, lower time from thrombosis to intervention and pharmacomechanical thrombectomy using AngioJet^TM predicted positive outcomes. Previous thrombectomy within 3 months and residual thrombus at completion were associated with poorer outcomes. Age and hypertension predicted higher complication rates. Conclusions: This is one of the largest single center series of endovascular salvage of thrombosed haemodialysis access and demonstrates that endovascular treatment is effective and provides durable access circuit survival. Careful patient screening is essential to optimize outcomes.

Impact of gamma radiation, potassium sorbate and low temperature on shrimp (Penaeus monodon) preservation

The objective this study was to assess the effect of gamma radiation and 2% potassium sorbate with low temperature (4 °C) for shrimp (Penaeus monodon) preservation. Fresh samples were prepared for treatment with gamma radiation at 1.0 and 1.5 kGy doses and potassium sorbate (2%) soaked for 30 s (PS 30 s) and 60 s (PS 60 s). Organoleptic score (OS), biochemical composition and microbiological analysis were performed to evaluate the shelf-life extension and quality changes during the storage periods. Data showed that combination treatment of gamma irradiation at 1.5 kGy with low temperature was the most effective in extending shelf-life of shrimp. The isolated bacteria associated with shrimp samples were identified through PCR technique. Antibiotic sensitivity test was examined using ten commonly used antibiotics against these pathogenic isolates. Gentamicin and Imipenem showed up to 50% resistance on Gram-positive (Bacillus cereus and Staphylococcus aureus). This study indicates that gamma irradiation treatment with low temperature was most effective way for shelf-life extension of shrimp which might reduce the wastage of this important nutritional source.

HPB P01 Volatile Organic Compounds for the Detection of Hepatocellular Carcinoma – a Scoping Review

Background

Hepatocellular carcinoma (HCC) is an increasingly common disease and is classified as one of the most common cancers leading to mortality worldwide. Only a small percentage of patients with this disease are eligible to curative treatment. Quite often the main reason is the late diagnosis of the disease. In the last decade, a Nobel prize awarded discovery of the volatile organic compounds in the breath opened the frontiers for new diagnostic tools and methods for several diseases. Cancer is one of the target diseases that appears to have unique biomarkers in the breath of the affected individuals. This have been found true in colorectal, breast, lung cancers. This systematic review aims to answer the question if markers specific to hepatocellular carcinoma exist in exhaled breath and what is the current knowledge regarding its detection.

Methods

A systematic search was conducted by two reviewers and the Royal College of Surgeons of Edinburgh librarian using the Embase, Medline, PubMed and Web od Science databases. Search strategy included all studied published until the 24th of March 2021 containing combination of keywords (Hepatocellular carcinoma, hepatocellular neoplasm, hepatocellular cancer, hepatocellular tumor, hepatocellular tumour, HCC, liver cancer, liver carcinoma, liver neoplasm, liver tumor, liver tumour AND volatile organic compound, VOC, volatilome, volatilomics, metabolome, metabolomics, breath analysis).

Results

The search yielded 6 publications using PRISMA pathway. Two of the studies described in vitro experiments and four were conducted on a small number of groups of patients. Overall, in the in vitro studies 42 headspace gases were analysed. Clinical studies included 164 patients with HCC and as control groups - 110 patients with cirrhosis and 130 healthy individuals.

Multiple VOCs were found in the studies. Following their identification in PubChem library, a pathway analysis was performed using the Kyoto Encyclopaedia of Genes and Genomes (KEGG). Only three VOCs were annotated in the KEGG maps and out of those, two could be traced back to their biological pathways. These are acetaldehyde and ethanol which participate in glycolysis and gluconeogenesis (Figure 1).

Conclusions

At present time there are no specific volatile biomarker in exhaled breath characterising hepatocellular carcinoma. Data on extracted studies emphasised lack of unified methodology. This review, however, highlighted metabolic pathway which might be the source of VOCs produced by cancerous hepatocytes. Large population studies are required to verify this finding.

Photon-Phonon Atomic Coherence Interaction of Nonlinear Signals in Various Phase Transitions Eu3+: BiPO4

We report photon-phonon atomic coherence (cascade- and nested-dressing) interaction from the various phase transitions of Eu³⁺: BiPO₄ crystal. Such atomic coherence spectral interaction evolves from out-of-phase fluorescence to in-phase spontaneous four-wave mixing (SFWM) by changing the time gate. The dressing dip switch and three dressing dips of SFWM result from the strong photon-phonon destructive cross- and self-interaction for the hexagonal phase, respectively. More phonon dressing results in the destructive interaction, while less phonon dressing results in the constructive interaction of the atomic coherences. The experimental measurements of the photon-phonon interaction agree with the theoretical simulations. Based on our results, we proposed a model for an optical transistor (as an amplifier and switch).

Highly sensitive work function type room temperature gas sensor based on Ti doped hBN monolayer for sensing CO2, CO, H2S, HF and NO. A DFT study

The adsorptions of toxic gas molecules (CO2, CO, H2S, HF and NO) on pristine and Ti atom doped hexagonal boron nitride (hBN) monolayer are investigated by density functional theory. Weak physisorption of gas molecules on pristine hBN results in micro seconds recovery time, limiting the gas sensing ability of pristine hBN. However Ti atom doping significantly enhances the adsorption ability. Ti atom best fits to be doped at B vacancy in hBN with lowest formation energy (-3.241 eV). Structural analysis reveals that structures of gas molecules change after being chemisorbed to Ti doped hBN monolayer. Partial density of states analysis illustrates strong hybridization among Ti-3d, gas-2p and BN-2p orbitals, moreover Bader charge transfer indicates that gas molecules act as charge acceptors. Ti doped hBN monolayer undergoes transition from semiconductor to narrow band semiconductor with adsorption of CO2, H2S and NO, while with CO and HF adsorption it transforms into metal. The change of conductance of Ti doped hBN monolayer in response to adsorption of gas molecules reveals its high sensitivity, however it is not selective to HF and NO gases. The recovery times of gas molecules desorption from monolayer are too long at ambient condition however it can significantly be shortened by annealing at elevated temperature with UV exposure. Since recovery time for NO removal from monolayer is still very long at 500 K with UV exposure, Ti doped hBN monolayer is more suitable as a scavenger of NO gas rather than as a gas sensor. It is thus predicted that Ti doped hBN monolayer can be a work-function type CO2, CO, H2S and HF sensor and NO gas scavenger.

Identifying Patients at Risk for Venous Thromboembolic Events After Isolated Upper Extremity Trauma: A Predictive Scale

Previous studies have defined risk factors for development of venous thromboembolisms (VTEs) among patients with lower extremity orthopedic trauma. Limited data exist on this risk after upper extremity orthopedic trauma. A total of 269,137 incidents of upper extremity orthopedic trauma (fractures of the clavicle, scapula, humerus, elbow, or lower arm) were identified in the State Inpatient Database for 4 states included in the analysis (California, Florida, New York, and Washington) from 2006 to 2014. These patients were split into 2 cohorts, a derivation cohort (California and New York) and a validation cohort (Florida and Washington). Univariate and multivariate logistic regression analyses of risk factors for VTE within 90 days of discharge in the derivation group were used to develop the Thromboembolic Risk after Upper Extremity Trauma (TRUE-T) scale. Linear regression was used to determine fit of the TRUE-T scale to the 2 cohorts. We found that 2.61% of patients in the derivation cohort and 2.72% of patients in the validation cohort had a VTE within 90 days of discharge. Risk factors associated with increased rates of VTE were age older than 40 years, Medicare payer, anemia, chronic lung disease, coagulopathy, heart failure, malignancy, obesity, renal failure, head injury, chest injury, abdominal injury, rib fracture, humerus fracture, elbow fracture, and closed reduction. Application of the TRUE-T scale to the validation cohort showed an R² value of 0.88. The patient factors, concomitant injuries, and fracture treatment modalities included in the TRUE-T scale can be used to identify patients at increased risk for VTE after upper extremity orthopedic trauma. [Orthopedics. 2022;45(6):345-352.].

Management of Splanchnic Vein Thrombosis in Patients With Acute Pancreatitis: An International Survey of Current Practice

OBJECTIVES

Splanchnic venous thrombosis (SpVT) is a complication of acute pancreatitis (AP). There is scarce literature on the prevalence and treatment of SpVT in AP. The aim of this international survey was to document current approaches to the management of SpVT in patients with AP.

METHODS

An online survey was designed by a group of international experts in the management of AP. Twenty-eight questions covered the level of experience of the respondents, disease demographics, and management of SpVT.

RESULTS

There were 224 respondents from 25 countries. Most respondents (92.4%, n = 207) were from tertiary hospitals and predominantly consultants (attendings, 86.6%, n = 194). More than half of the respondents (57.2%, n = 106) "routinely" prescribed prophylactic anticoagulation for AP. Less than half of the respondents (44.3%, n = 82) "routinely" prescribed therapeutic anticoagulation for SpVT. A clinical trial was considered justified by most respondents (85.4%, n = 157) and 73.2% (n = 134) would be willing to enroll their patients.

CONCLUSIONS

The approach to anticoagulation in the treatment of patients with SpVT complicating AP was highly variable. Respondents indicate that a position of equipoise exists to justify randomized evaluation.

Mesh fixation techniques for inguinal hernia repair: an overview of systematic reviews of randomised controlled trials

PURPOSE

Inguinal hernia repair using surgical mesh is a very common surgical operation. Currently, there is no consensus on the best technique for mesh fixation. We conducted an overview of existing systematic reviews (SRs) of randomised controlled trials to compare the risk of chronic pain and recurrence following open and laparoscopic inguinal hernia repairs using various mesh fixation techniques.

METHODS

We searched major electronic databases in April 2020 and assessed the methodological quality of identified reviews using the AMSTAR-2 tool.

RESULTS

We identified 20 SRs of variable quality assessing suture, self-gripping, glue, and mechanical fixation. Across reviews, the risk of chronic pain after open mesh repair was lower with glue fixation than with suture and comparable between self-gripping and suture. Incidence of chronic pain was lower with glue fixation than with mechanical fixation in laparoscopic repairs. There were no significant differences in recurrence rates between fixation techniques in open and laparoscopic mesh repairs, although fewer recurrences were reported with suture. Many reviews reported wide confidence intervals around summary estimates. Despite no clear evidence of differences among techniques, two network meta-analyses (one assessing open repairs and one laparoscopic repairs) ranked glue fixation as the best treatment for reducing pain and suture for reducing the risk of recurrence.

CONCLUSION

Glue fixation may be effective in reducing the incidence of chronic pain without increasing the risk of recurrence. Future research should consider both the effectiveness and cost-effectiveness of fixation techniques alongside the type of mesh and the size and location of the hernia defect.

The first international Delphi consensus statement on Laparoscopic Gastrointestinal surgery

BACKGROUND

Laparoscopic surgery has almost replaced open surgery in many areas of Gastro-Intestinal (GI) surgery. There is currently no published expert consensus statement on the principles of laparoscopic GI surgery. This may have affected the training of new surgeons. This exercise aimed to achieve an expert consensus on important principles of laparoscopic GI surgery.

METHODS

A committee of 38 international experts in laparoscopic GI surgery proposed and voted on 149 statements in two rounds following a strict modified Delphi protocol.

RESULTS

A consensus was achieved on 133 statements after two rounds of voting. All experts agreed on tailoring the first port site to the patient, whereas 84.2% advised avoiding the umbilical area for pneumoperitoneum in patients who had a prior midline laparotomy. Moreover, 86.8% agreed on closing all 15 mm ports irrespective of the patient's body mass index. There was a 100% consensus on using cartridges of appropriate height for stapling, checking the doughnuts after using circular staplers, and keeping the vibrating blade of the ultrasonic energy device in view and away from vascular structures. An 84.2% advised avoiding drain insertion through a ≥10 mm port site as it increases the risk of port-site hernia. There was 94.7% consensus on adding laparoscopic retrieval bags to the operating count and ensuring any surgical specimen left inside for later removal is added to the operating count.

CONCLUSION

Thirty-eight experts achieved a consensus on 133 statements concerning various aspects of laparoscopic GI Surgery. Increased awareness of these could facilitate training and improve patient outcomes.

Association between sociodemographic characteristics and knowledge and practice of COVID-19 measures among households in Mombasa and Kilifi County, Kenya

BACKGROUND

Coronavirus disease 2019 (COVID-19), declared a global pandemic by the World Health Organization (WHO), is a severe acute respiratory disease. The Kenyan Ministry of Health (MoH) put in place measures that included mandatory face masking, hand and cough hygiene and social and physical distancing to reduce disease transmission and increase prevention efforts. The primary objective of this study was to determine how sociodemographic characteristics affect knowledge and practice of the above measures.

METHODS

A cross-sectional study was conducted to assess water, sanitation and hygiene practices for the prevention and control of COVID-19 in Kilifi and Mombasa Counties, Kenya. Data collection was accomplished through a mobile data collection tool. Principal component analysis was used to create a wealth index using data on asset ownership and housing characteristics. Bloom cut-off points of 80-100%, 60-79% and ≤59% were used to determine knowledge and practice.

RESULTS

Of the 612 households, 339 (55.4%) were from Kilifi County and 273 (44.6%) were from Mombasa County. A total of 431 (70.4%) were female and the mean age of the household members was 38.2±14.8 y.Almost all (99.2%) respondents were aware of COVID-19, with 60% knowing prevention, symptoms and persons at a higher risk of contracting the virus. Females had the highest knowledge of COVID-19 and were likely to practice prevention and control measures, unlike males. Age was significant (p<0.05) with knowledge and practice.

CONCLUSIONS

The sociodemographic characteristics of populations play a key role in behavioural aspects as far as prevention and control of COVID-19 are concerned. There is a need for partnerships between the MoH and county governments to put in place a multisectoral community approach to advance feasible behavioural interventions among targeted populations towards combating the spread of COVID-19.

Data-driven design of high-performance MASnxPb1-xI3 perovskite materials by machine learning and experimental realization

The photovoltaic performance of perovskite solar cell is determined by multiple interrelated factors, such as perovskite compositions, electronic properties of each transport layer and fabrication parameters, which makes it rather challenging for optimization of device performances and discovery of underlying mechanisms. Here, we propose and realize a novel machine learning approach based on forward-reverse framework to establish the relationship between key parameters and photovoltaic performance in high-profile MASn_xPb_1-xI₃ perovskite materials. The proposed method establishes the asymmetrically bowing relationship between band gap and Sn composition, which is precisely verified by our experiments. Based on the analysis of structural evolution and SHAP library, the rapid-change region and low-bandgap plateau region for small and large Sn composition are explained, respectively. By establishing the models for photovoltaic parameters of working photovoltaic devices, the deviation of short-circuit current and open-circuit voltage with band gap in defective-zone and low-bandgap-plateau regions from Shockley-Queisser theory is captured by our models, and the former is due to the deep-level traps formed by crystallographic distortion and the latter is due to the enhanced susceptibility by increased Sn⁴⁺ content. The more difficulty for hole extraction than electron is also concluded in the models and the prediction curve of power conversion efficiency is in a good agreement with Shockley-Queisser limit. With the help of search and optimization algorithms, an optimized Sn:Pb composition ratio near 0.6 is finally obtained for high-performance perovskite solar cells, then verified by our experiments. Our constructive method could also be applicable to other material optimization and efficient device development.

Computational Insights into the Structural and Functional Impacts of nsSNPs of Bone Morphogenetic Proteins

BMPs (bone morphogenetic proteins) are multipurpose (transforming growth factor)TGF-superfamily released cytokines. These glycoproteins, acting as disulfide-linked homo- or heterodimers, are highly potent regulators of bone and cartilage production and repair, cell proliferation throughout embryonic development, and bone homeostasis in the adults. Due to the fact that genetic variation might influence structural functions, this study is aimed to determine the pathogenic effect of nonsynonymous single-nucleotide polymorphisms (nsSNPs) in BMP genes. The implications of these variations, investigated using computational analysis and molecular models of the mature TGF-β domain, revealed the impact of modifications on the function of BMP protein. The three-dimensional (3D) structure analysis was performed on the nsSNP Y316S, V386G, E387G, C389G, and C391G nsSNP in the TGF-β domain of chicken BMP2 and H344P, S347P, V357A nsSNP in the TGF-β domain of chicken BMP4 protein that was anticipated to be harmful and of high risk. The ability of the proteins to perform variety of tasks interact with other molecules depends on their tertiary structural composition. The current analysis revealed the four most damaging variants (Y316S, V386G, E387G, C389G, and C391G), highly conserved and functional and are located in the TGF-beta domain of BMP2 and BMP4. The amino acid substitutions E387G, C389G, and C391G are discovered in the binding region. It was observed that the mutations in the TGF-beta domain caused significant changes in its structural organization including the substrate binding sites. Current findings will assist future research focused on the role of these variants in BMP function loss and their role in skeletal disorders, and this will possibly help to develop practical strategies for treating bone-related conditions.

Distal Humerus Traction Radiographs: Is the Interobserver and Intraobserver Reliability Comparable With Computed Tomography?

OBJECTIVES

To compare the interobserver and intraobserver reliability of traction radiographs with 2-dimensional computed tomography (2D CT) in distal humerus fracture classification and characterization.

DESIGN

Randomized controlled radiographic review of retrospectively collected data.

SETTING

Academic Level 1 trauma center.

PATIENTS/PARTICIPANTS

Skeletally mature patients with intra-articular distal humerus fractures with both traction radiographs and CT scans were reviewed by 11 orthopaedists from different subspecialties and training levels.

INTERVENTION

The intervention involved traction radiographs and 2D CT.

MAIN OUTCOME MEASUREMENTS

The main outcome measurements included interobserver and intraobserver reliability of fracture classification by the OTA/AO and Jupiter-Mehne and determination of key fracture characteristics.

RESULTS

For the OTA/AO and Jupiter-Mehne classifications, we found a moderate intraobserver agreement with both 2D CT and traction radiographs (κ = 0.70-0.75). When compared with traction radiographs, 2D CT improved the interobserver reliability of the OTA/AO classification from fair to moderate (κ = 0.3 to κ = 0.42) and the identification of a coronal fracture from slight to fair (κ = 0.2 to κ = 0.34), which was more pronounced in a subgroup analysis of less-experienced surgeons. When compared with 2D CT, traction radiographs improved the intraobserver reliability of detecting stable affected articular fragments from fair to substantial (κ = 0.4 to κ = 0.67).

CONCLUSIONS

Traction radiographs provide similar diagnostic characteristics as 2D CT in distal humerus fractures. For less-experienced surgeons, 2D CT may improve the identification of coronal fracture lines and articular comminution.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Investigating the Effects of Capital Structure and Corporate Governance on Firm Performance: An Analysis of the Sugar Industry

The objective of this paper is to investigate the impact of capital structure and corporate governance on firm performance. To test the hypothesis of study, data was collected from annual reports of sugar sector companies listed in PSX. This study data covers from 2015 to 2020. The results of study showed that both proxies of capital structure, i.e., D/A and D/E negatively influence the company performance. Whereas two out of three proxies of corporate governance, i.e., board size and chairman/CEO duality negatively indicate association with company performance while audit committee size has a positive impact on the company performance.

Learning from failure to enhance performance: a systematic literature review of retail failure

Purpose

The objective of this paper is to develop a map of the contours of the phenomenon of retailer failure by aggregating, parsing and extracting known findings regarding business failure in marketing, business and other streams of inquiry to provide a comprehensive understanding of research on the topic. Defined as the converse of retailer performance, an understanding of retail failure is expected to yield insights for performance measurement and benchmarking studies.

Design/methodology/approach

The paper includes a systematic literature review, employing state-of-the-art tools such as VOSViewer.

Findings

The analysis reveals patterns in the intellectual structure of the research on retail failure, as well as patterns of influence. While the discipline of marketing has been surprisingly limited in the study of retail failure, study of retail failure has been pursued by other branches of the business discipline, and even some disciplines other than business.

Originality/value

This paper provides a comprehensive and systematic literature review on the topic of retail failure.

A case report of a large right atrial myxoma: the role of virtual consultations and imaging during the COVID-19 pandemic

We present a case report of a right atrial myxoma first diagnosed on a transthoracic echocardiogram after telephone consultations held in lieu of face-to-face consultations during the first wave of the COVID-19 pandemic. The echocardiogram was requested on the second telephone consultation 3 months after an initial presentation with a dry cough and fatigue due to new symptoms of palpitations and shortness of breath raising suspicion of heart failure. Virtual consultations continue to replace face-to-face consultations to avoid unnecessary exposure to COVID and reduce health care costs. This case report focuses on the importance of obtaining a systematic history, identifying red flags, referring to appropriate specialties and requesting the right investigations for early diagnosis and management of conditions with serious complications.

Temporal and spectral hybrid bound state in continuum and its reliance on the correlation

We study the hybrid bound states in continuum (BIC) in time and spectral domain obtained from Eu³⁺/Pr³⁺ doped YPO₄ and BiPO₄ crystals. The spectral and time domain BIC originates from the interference between broadband fluorescence (FL) and narrowband super-florescence (SP-FWM) due to the dressing effect and crystal phase transition. We present a relationship between BIC and correlation and investigate two-mode and three-mode noise correlation/squeezing when the wavelength of the applied field is fixed at the bright state and dark state. In contrast to the BIC peak, we observe a switch and anti-bunching-like phenomenon at the BIC dip. We realize at the BIC peak point that correlation exhibits multi-oscillations and long coherence time in Pr³⁺:YPO₄ in contrast with Eu³⁺:YPO₄. Further, our two-mode intensity noise correlation experimental results suggest a controllable bandstop filter with an 80% bandwidth contrast and a dual-channel amplifier with an 89% amplitude contrast.