Liver transplantation as an alternative for the treatment of non-resectable liver colorectal cancer: Advancing the therapeutic algorithm

Colorectal cancer is a leading cause of cancer-related mortality, with nearly half of the affected patients developing liver metastases. For three decades, liver resection (LR) has been the primary curative strategy, yet its applicability is limited to about 20% of cases. Liver transplantation (LT) for unresectable metastases was attempted unsuccessfully in the 1990s, with high rates of perioperative death and recurrence. There is now more interest in this strategy due to improvements in systemic therapies and surgical techniques. A significant study conducted by the Oslo group showed that patients receiving liver transplants had a 60% chance of survival after five years. Significantly better results have been achieved by using advanced imaging for risk stratification and further refining selection criteria, especially in the Norvegian SECA trials. This review carefully charts the development and history of LT as a treatment option for colorectal cancer liver metastases. The revolutionary path from the early days of exploratory surgery to the current situation of cautious optimism is traced, highlighting the critical clinical developments and improved patient selection standards that have made LT a potentially curative treatment for such challenging very well selected cases.

Predicting futility of upfront surgery in perihilar cholangiocarcinoma: Machine learning analytics model to optimize treatment allocation

BACKGROUND

While resection remains the only curative option for perihilar cholangiocarcinoma, it is well known that such surgery is associated with a high risk of morbidity and mortality. Nevertheless, beyond facing life-threatening complications, patients may also develop early disease recurrence, defining a "futile" outcome in perihilar cholangiocarcinoma surgery. The aim of this study is to predict the high-risk category (futile group) where surgical benefits are reversed and alternative treatments may be considered.

METHODS

The study cohort included prospectively maintained data from 27 Western tertiary referral centers: the population was divided into a development and a validation cohort. The Framingham Heart Study methodology was used to develop a preoperative scoring system predicting the "futile" outcome.

RESULTS

A total of 2271 cases were analyzed: among them, 309 were classified within the "futile group" (13.6%). American Society of Anesthesiology (ASA) score ≥ 3 (OR 1.60; p = 0.005), bilirubin at diagnosis ≥50 mmol/L (OR 1.50; p = 0.025), Ca 19-9 ≥ 100 U/mL (OR 1.73; p = 0.013), preoperative cholangitis (OR 1.75; p = 0.002), portal vein involvement (OR 1.61; p = 0.020), tumor diameter ≥3 cm (OR 1.76; p < 0.001), and left-sided resection (OR 2.00; p < 0.001) were identified as independent predictors of futility. The point system developed, defined three (ie, low, intermediate, and high) risk classes, which showed good accuracy (AUC 0.755) when tested on the validation cohort.

CONCLUSIONS

The possibility to accurately estimate, through a point system, the risk of severe postoperative morbidity and early recurrence, could be helpful in defining the best management strategy (surgery vs. nonsurgical treatments) according to preoperative features.

A Global Overview on the Evolution, Debate, and Research Output on Liver Transplant Perfusion Machines

OBJECTIVES

Machine perfusion of liver grafts has gained popularity for its abilities to preserve liver grafts,reduce cold storage damage, and evaluate graft viability before transplant. However, debate persists regarding the optimal solutions, logistics, and biomarkers for assessing graft quality. To shed light on the lengthy debates surrounding the use of machine perfusion in liver graft preservation,this study utilized bibliometric analysis to evaluate the status and development trends of main research areas.

MATERIALS AND METHODS

On December 10th, 2022, we conducted a literature search using the Web of Science database to identify articles related to liver machine perfusion. The search included only original studies and reviews and excluded meeting abstracts, letters, notes, editorials, short surveys, book chapters, and errata. We identified the number of citations and encompassed various aspects, such as annual trends, countries, institutions, authors, journals, and key words. We used VOSviewer version 1.6.18 to generate tables and figures.

RESULTS

After manually removing irrelevant papers, we included 264 articles (89 reviews; remaining were original studies). The articles were cited 5743 times, averaging 21.92 per article. We found that the United Kingdom (n = 76) was the country that produced the most articles,followed by theUnited States (66 articles). Most papers in our search were published in Liver Transplantation (n = 31) and Transplantation (n = 16).

CONCLUSIONS

Bibliometric analysis provided insights into debates and advancements in liver graft preservation using machine perfusion. The analysis showed leading countries and key research areas in the field. This overview serves as a valuable resource for researchers, offering a foundation for further exploration and guiding future investigations in the field of machine perfusion for liver graft preservation.

Unveiling transplantation research productivity of United States: A bibliometric analysis

BACKGROUND

The United States has witnessed significant advancements in the field of organ transplantation over the course of the last five decades, as demonstrated by a notable increase in the quantity of academic research. The presence of a highly dynamic research environment necessitates continuous evaluations to maintain the integrity and progress of the field.

AIM

To evaluate the total output and thematic emphasis of transplant research conducted in the United States.

METHODS

On January 10, 2023, we conducted a bibliometric search of United States research output in transplantation journals from the Web of Science database's Science Citation Index Expanded. We excluded editorials, meeting abstracts, and other non-article types. We analyzed annual trends, authors, institutions, articles, keywords, and countries collaborating with the United States, using VOSviewer 1.6.18 to create figures and tables.

RESULTS

The United States published 25956 papers (3078 reviews and 22878 articles) representing 37.7% of the world's scientific output. Canada emerged as the top collaborator with the United States, co-authoring 1263 articles. Leading institutions in United States transplantation research were the University of Pittsburgh (1749 articles), Mayo Clinic (1605 articles), Harvard Medical School (1549 articles), and Johns Hopkins University (1280 articles). The top three keywords with over 2000 occurrences were "recipients," "survival," and "outcomes," indicating a focus on graft and recipient outcome markers by United States researchers.

CONCLUSION

Our findings demonstrate the United States leadership in organ transplantation research, contributing significantly to the global scientific output in this field. However, opportunities exist for fostering expansive partnerships, particularly with developing countries. This study provides valuable insights into the transplantation research landscape in the United States, emphasizing the importance of ongoing evaluations to maintain and propel advancements in this critical medical discipline. The results may facilitate future collaborations, knowledge exchange, and the pursuit of innovative solutions in the realm of organ transplantation.

Management of Established Small-for-size Syndrome in Post Living Donor Liver Transplantation: Medical, Radiological, and Surgical Interventions: Guidelines From the ILTS-iLDLT-LTSI Consensus Conference

Small-for-size syndrome (SFSS) following living donor liver transplantation is a complication that can lead to devastating outcomes such as prolonged poor graft function and possibly graft loss. Because of the concern about the syndrome, some transplants of mismatched grafts may not be performed. Portal hyperperfusion of a small graft and hyperdynamic splanchnic circulation are recognized as main pathogenic factors for the syndrome. Management of established SFSS is guided by the severity of the presentation with the initial focus on pharmacological therapy to modulate portal flow and provide supportive care to the patient with the goal of facilitating graft regeneration and recovery. When medical management fails or condition progresses with impending dysfunction or even liver failure, interventional radiology (IR) and/or surgical interventions to reduce portal overperfusion should be considered. Although most patients have good outcomes with medical, IR, and/or surgical management that allow graft regeneration, the risk of graft loss increases dramatically in the setting of bilirubin >10 mg/dL and INR>1.6 on postoperative day 7 or isolated bilirubin >20 mg/dL on postoperative day 14. Retransplantation should be considered based on the overall clinical situation and the above postoperative laboratory parameters. The following recommendations focus on medical and IR/surgical management of SFSS as well as considerations and timing of retransplantation when other therapies fail.

The Leading Transplantation Journals: A Trend Analysis, 2011-2021

Background

As the field of transplantation has expanded, so have the quantity and variety of articles published on the topic. Evaluation of publications and journals is crucial to the expansion of transplant research. This study investigated the research output and journal metrics of the leading solid organ transplant journals published between 2011 and 2021 based on estimations of the trends in the category CiteScore from the Scopus database.

Materials and Methods

We obtained data on the listed journals from the Scopus Source List. We then filtered the list for "Transplantation" journals. Only the top quartiles or quartile 1 (Q1) journals were placed in this category. This study focused specifically on transplantation journals and did not include other journals related to diseases of transplanted organs such as the kidney, liver, heart, and lungs.

Results

The number of transplantation journals increased by 42.8% in the last ten years, from 28 in 2011 to 40 in 2021. Between 2011 and 2021, nine transplantation journals ranked in the highest quartile (Q1). The American Journal of Transplantation was the top journal in both years, with a 150% increase in citations and an 11.2% increase in articles published. Open access (OA) transplant journals rose from 3 in 2011 to 10 in 2021. In 2021, OA journals earned 8,555 citations, a 125% increase from 2011. Despite this increase, non-OA journals received more citations than OA in 2021 (p value 0.026).

Conclusion

Solid organ transplantation advances lead to more publications and citations. Regular journals and publications evaluation benefits academics and policymakers by promoting the growth of research. This study examined solid organ transplantation journals and gave a global perspective on transplant journal rankings and compared their status in 2011 and 2021.

Prevalence, management and efficacy of treatment in portal vein obstruction after paediatric liver transplantation: protocol of the retrospective international multicentre PORTAL registry

INTRODUCTION

Portal vein obstruction (PVO) consists of anastomotic stenosis and thrombosis, which occurs due to a progression of the former. The aim of this large-scale international study is to assess the prevalence, current management practices and efficacy of treatment in patients with PVO.

METHODS AND ANALYSIS

The Portal vein Obstruction Revascularisation Therapy After Liver transplantation registry will facilitate an international, retrospective, multicentre, observational study, with 25 centres around the world already actively involved. Paediatric patients (aged <18 years) with a diagnosed PVO between 1 January 2001 and 1 January 2021 after liver transplantation will be eligible for inclusion. The primary endpoints are the prevalence of PVO, primary and secondary patency after PVO intervention and current management practices. Secondary endpoints are patient and graft survival, severe complications of PVO and technical success of revascularisation techniques.

ETHICS AND DISSEMINATION

Medical Ethics Review Board of the University Medical Center Groningen has approved the study (METc 2021/072). The results of this study will be disseminated via peer-reviewed publications and scientific presentations at national and international conferences.

TRIAL REGISTRATION NUMBER

Netherlands Trial Register (NL9261).

ChatGPT and Artificial Intelligence in Transplantation Research: Is It Always Correct?

INTRODUCTION

ChatGPT (OpenAI, San Francisco, California, United States) is a chatbot powered by language-based artificial intelligence (AI). It generates text based on the information provided by users. It is currently being evaluated in medical research, publishing, and healthcare. However, there has been no prior study on the evaluation of its ability to help in kidney transplant research. This feasibility study aimed to evaluate the application and accuracy of ChatGPT in the field of kidney transplantation.

METHODS

On two separate dates, February 21 and March 2, 2023, ChatGPT 3.5 was questioned regarding the medical treatment of kidney transplants and related scientific facts. The responses provided by the chatbot were compiled, and a panel of two specialists reviewed the correctness of each answer.

RESULTS

We demonstrated that ChatGPT possessed substantial general knowledge of kidney transplantation; however, they lacked sufficient information and had inaccurate information that necessitates a deeper understanding of the topic. Moreover, ChatGPT failed to provide references for any of the scientific data it provided regarding kidney transplants, and when requested for references, it provided inaccurate ones.

CONCLUSION

The results of this short feasibility study indicate that ChatGPT may have the ability to assist in data collecting when a particular query is posed. However, caution should be exercised and it should not be used in isolation as a supplement to research or decisions regarding healthcare because there are still challenges with data accuracy and missing information.

Suspected focal nodular hyperplasia in male adults: 10-year experience from a large liver centre

PURPOSE

Focal nodular hyperplasia (FNH) is commonly found in females of reproductive age. In males, the diagnosis is made more cautiously due to its lower incidence and higher incidence of hepatocellular carcinoma, which can have overlapping imaging features. Follow-up or biopsy is sometimes required. This retrospective study aims to assess management of suspected FNH in male adult patients at our institution over a 10-year period.

METHODS

Male adults (≥ 18 years) suspected of having FNH from January 2010-June 2020 were identified using a departmental radiology information system search. Data was collected from radiology reports and patient pathway manager.

RESULTS

Of 342 patients with suspected FNH, 62 were male (18.1%; F:M of 4.5:1). We only included patients investigated and followed up by MRI, total of 57 patients. Median age was 40 years (range 18-74 years). Background liver disease present in 21/57 (36.8%), majority with hepatic steatosis. Average number of lesions per patient 1.7. 22/57 (38.6%) had at least one MRI follow-up using liver-specific contrast with 7 lesions demonstrating variation in size (range growth: -3.27 mm/year to + 4 mm/year). In 7 cases, MRI was not definitive; 6 required biopsy and 1 resection. Only 2/7 demonstrated malignancy. Of the total 57 patients, 6 have deceased and none due to a misdiagnosed or mismanaged hepatic lesion.

CONCLUSION

FNH is relatively uncommon in males, however, our data suggests that lesions with typical MRI characteristics do not require follow-up and diagnosis can be made confidently, similar to females. Any atypical features should prompt a biopsy.

Long-term outcomes of pediatric liver transplantation in acute liver failure vs end-stage chronic liver disease: A retrospective observational study

BACKGROUND

Children with acute liver failure (ALF) who meet the criteria are eligible for super-urgent transplantation, whereas children with end-stage chronic liver disease (ESCLD) are usually transplanted electively. Pediatric liver transplantation (PLT) in ALF and ESCLD settings has been well described in the literature, but there are no studies comparing the outcomes in these two groups.

AIM

To determine if there is a difference in post-operative complications and survival outcomes between ALF and ESCLD in PLT.

METHODS

This was a retrospective observational study of all primary PLTs performed at a single center between 2000 and 2019. ALF and ESCLD groups were compared for pretransplant recipient, donor and operative parameters, and post-operative outcomes including graft and patient survival.

RESULTS

Over a 20-year study period, 232 primary PLTs were performed at our center; 195 were transplanted for ESCLD and 37 were transplanted for ALF. The ALF recipients were significantly older (median 8 years vs 5.4 years; P = 0.031) and heavier (31 kg vs 21 kg; P = 0.011). Living donor grafts were used more in the ESCLD group (34 vs 0; P = 0.006). There was no difference between the two groups concerning vascular complications and rejection, but there were more bile leaks in the ESCLD group. Post-transplant patient survival was significantly higher in the ESCLD group: 1-, 5-, and 10-year survival rates were 97.9%, 93.9%, and 89.4%, respectively, compared to 78.3%, 78.3%, and 78.3% in the ALF group (P = 0.007). However, there was no difference in 1-, 5-, and 10-year graft survival between the ESCLD and ALF groups (90.7%, 82.9%, 77.3% vs 75.6%, 72.4%, and 66.9%; P = 0.119).

CONCLUSION

Patient survival is inferior in ALF compared to ESCLD recipients; the main reason is death in the 1^st year post-PLT in ALF group. Once the ALF children overcome the 1^st year after transplant, their survival stabilizes, and they have good long-term outcomes.

United Kingdom criteria for liver transplantation in the setting of isolated unresectable colorectal liver metastases

AIM

Studies have demonstrated that liver transplantation may be an effective treatment for isolated unresectable colorectal cancer liver metastases (CRCLM). Published data suggest that 5-year survival may be as high as 80%; however, recurrent disease is commonplace. Consequently, the Liver Transplantation for Unresectable Colorectal Liver Metastases Fixed Term Working Unit recommended to the NHS Blood and Transplant Liver Advisory Group that while CRCLM is an appropriate indication for transplantation, selection criteria should be conservative and that it should be undertaken within a clinical service evaluation programme. The aim of this work is to outline the proposed UK selection criteria and follow-up process for CRCLM transplantation.

METHOD

Consensus statement by colorectal cancer/liver transplantation patient representatives, experts in colorectal cancer surgery/oncology, liver transplantation surgery, hepatology, hepatobiliary radiology, hepatobiliary pathology and nuclear medicine.

RESULTS

This study provides a comprehensive outline of the inclusion/exclusion criteria for referral in the UK. Furthermore, the referral framework is also explained. Pretransplant assessment criteria for listing/delisting are outlined. Finally, the oncology-specific outcome measures posttransplant are described.

CONCLUSION

It is anticipated this service will begin in December 2022. A series of educational events for the referrers and transplant units will be arranged throughout 2023 to highlight CRCLM as a newly accepted UK indication for transplantation. A national audit will be undertaken to identify patients currently on treatment who meet the criteria for transplant. Data will be collected in a national registry and reviewed on an ongoing basis to confirm the safety of this treatment and to determine if the inclusion criteria require revision.

Liver transplantation for isolated unresectable colorectal liver metastases - Protocol for a service evaluation in the United Kingdom - UKCoMET study

BACKGROUND

Liver transplantation (LT) for unresectable colorectal liver metastases (CRCLM) demonstrates good overall survival for selected patients in contemporary studies, with 5-year survival of 80%. A Fixed Term Working Group (FTWG), set up by NHS Blood and Transplant (NHSBT) Liver Advisory Group (LAG), advised whether CRCLM should be considered for LT in United Kingdom. Their recommendation was that LT may be undertaken for isolated and unresectable CRCLM using strict selection criteria as a national clinical service evaluation.

METHODS

Opinions were sought from colorectal cancer/LT patient representatives, experts in colorectal cancer surgery/oncology, LT surgery, hepatology, hepatobiliary radiology, pathology, and nuclear medicine, and appropriate patient selection criteria, referral and transplant listing pathways were identified.

RESULTS

This paper summarises selection criteria for LT in United Kingdom for isolated and unresectable CRCLM patients, and highlights referral framework and pre-transplant assessment criteria. Finally, oncology-specific outcome measures to be utilised for assessing applicability of LT are described.

CONCLUSION

This service evaluation represents a significant development for colorectal cancer patients in United Kingdom and a meaningful step forward in the field of transplant oncology. This paper details the protocol for the pilot study, scheduled to begin in the fourth quarter of 2022 in United Kingdom.

Volume and flow modulation strategies to mitigate post-hepatectomy liver failure

INTRODUCTION

Post hepatectomy liver failure is the most common cause of death following major hepatic resections with a perioperative mortality rate between 40% to 60%. Various strategies have been devised to increase the volume and function of future liver remnant (FLR). This study aims to review the strategies used for volume and flow modulation to reduce the incidence of post hepatectomy liver failure.

METHOD

An electronic search was performed of the MEDLINE, EMBASE and PubMed databases from 2000 to 2022 using the following search strategy "Post hepatectomy liver failure", "flow modulation", "small for size flow syndrome", "portal vein embolization", "dual vein embolization", "ALPPS" and "staged hepatectomy" to identify all articles published relating to this topic.

RESULTS

Volume and flow modulation strategies have evolved over time to maximize the volume and function of FLR to mitigate the risk of PHLF. Portal vein with or without hepatic vein embolization/ligation, ALPPS, and staged hepatectomy have resulted in significant hypertrophy and kinetic growth of FLR. Similarly, techniques including portal flow diversion, splenic artery ligation, splenectomy and pharmacological agents like somatostatin and terlipressin are employed to reduce the risk of small for size flow syndrome SFSF syndrome by decreasing portal venous flow and increasing hepatic artery flow at the same time.

CONCLUSION

The current review outlines the various strategies of volume and flow modulation that can be used in isolation or combination in the management of patients at risk of PHLF.

Outcomes After Liver Transplantation With Incidental Cholangiocarcinoma

Cholangiocarcinoma (CCA) is currently a contraindication to liver transplantation (LT) in the United Kingdom (UK). Incidental CCA occurs rarely in some patients undergoing LT. We report on retrospective outcomes of patients with incidental CCA from six UK LT centres. Cases were identified from pathology records. Data regarding tumour characteristics and post-transplant survival were collected. CCA was classified by TNM staging and anatomical location. 95 patients who underwent LT between 1988-2020 were identified. Median follow-up after LT was 2.1 years (14 days-18.6 years). Most patients were male (68.4%), median age at LT was 53 (IQR 46-62), and the majority had underlying PSC (61%). Overall median survival after LT was 4.4 years. Survival differed by tumour site: 1-, 3-, and 5-year estimated survival was 82.1%, 68.7%, and 57.1%, respectively, in intrahepatic CCA (n = 40) and 58.5%, 42.6%, and 30.2% in perihilar CCA (n = 42; p = 0.06). 1-, 3-, and 5-year estimated survival was 95.8%, 86.5%, and 80.6%, respectively, in pT1 tumours (28.2% of cohort), and 65.8%, 44.7%, and 31.1%, respectively, in pT2-4 (p = 0.018). Survival after LT for recipients with incidental CCA is inferior compared to usual outcomes for LT in the United Kingdom. LT for earlier stage CCA has similar survival to LT for hepatocellular cancer, and intrahepatic CCAs have better survival compared to perihilar CCAs. These observations may support LT for CCA in selected cases.

Towards Autonomous Robotic Minimally Invasive Ultrasound Scanning and Vessel Reconstruction on Non-Planar Surfaces

Autonomous robotic Ultrasound (US) scanning has been the subject of research for more than 2 decades. However, little work has been done to apply this concept into a minimally invasive setting, in which accurate force sensing is generally not available and robot kinematics are unreliable due to the tendon-driven, compliant robot structure. As a result, the adequate orientation of the probe towards the tissue surface remains unknown and the anatomy reconstructed from scan may become highly inaccurate. In this work we present solutions to both of these challenges: an attitude sensor fusion scheme for improved kinematic sensing and a visual, deep learning based algorithm to establish and maintain contact between the organ surface and the US probe. We further introduce a novel scheme to estimate and orient the probe perpendicular to the center line of a vascular structure. Our approach enables, for the first time, to autonomously scan across a non-planar surface and navigate along an anatomical structure with a robotically guided minimally invasive US probe. Our experiments on a vessel phantom with a convex surface confirm a significant improvement of the reconstructed curved vessel geometry, with our approach strongly reducing the mean positional error and variance. In the future, our approach could help identify vascular structures more effectively and help pave the way towards semi-autonomous assistance during partial hepatectomy and the potential to reduce procedure length and complication rates.

Does ALT Correlate with Survival After Liver Resection for Colorectal Liver Metastases?

Background

The pringle manoeuvre is commonly used during hepatectomy, which may cause ischaemia-reperfusion injury and transient liver dysfunction. Post-operative liver transaminases are often used to assess ischaemia-reperfusion injury, although there is conflicting evidence on survival outcomes. The primary aim was to assess post-operative alanine aminotransferase (ALT) with survival outcomes. Secondary aims were to assess ALT level with the length of stay and overall complications.

Methods

Post-operative day 2 ALT levels of five times the upper limit of normal (i.e. 280 U/L) were considered as clinically significant transaminitis. Kaplan-Meier survival curves were studied using log-rank analysis to identify the predictors of overall survival (OS) and recurrence-free survival (RFS).

Results

Out of 752 patients who underwent hepatectomy, 527 (70.1%) patients had low ALT (<280 U/L) and 225 (29.9%) patients had high ALT on day 2 post-op. Post-operative ALT did not affect OS (P = 0.883) or RFS (P = 0.063). Factors associated with a worse OS and RFS on multivariate analysis were pre-operative chemotherapy, number of tumours and largest tumour size (>4 cm). A high post-operative ALT was not associated with the increased length of stay or more complications.

Conclusions

Post-operative ALT does not affect survival outcomes post-hepatectomy for colorectal liver metastases.

Long-Term Outcomes and Exploratory Analyses of the Randomized Phase III BILCAP Study

PURPOSE

The BILCAP study described a modest benefit for capecitabine as adjuvant therapy for curatively resected biliary tract cancer (BTC), and capecitabine has become the standard of care. We present the long-term data and novel exploratory subgroup analyses.

METHODS

This randomized, controlled, multicenter, phase III study recruited patients age 18 years or older with histologically confirmed cholangiocarcinoma or muscle-invasive gallbladder cancer after resection with curative intent and an Eastern Cooperative Oncology Group performance status of < 2. Patients were randomly assigned 1:1 to receive oral capecitabine (1,250 mg/m2 twice daily on days 1-14 of a 21-day cycle, for eight cycles) or observation. The primary outcome was overall survival (OS). This study is registered with EudraCT 2005-003318-13.

RESULTS

Between March 15, 2006, and December 4, 2014, 447 patients were enrolled; 223 patients with BTC resected with curative intent were randomly assigned to the capecitabine group and 224 to the observation group. At the data cutoff of January 21, 2021, the median follow-up for all patients was 106 months (95% CI, 98 to 108). In the intention-to-treat analysis, the median OS was 49.6 months (95% CI, 35.1 to 59.1) in the capecitabine group compared with 36.1 months (95% CI, 29.7 to 44.2) in the observation group (adjusted hazard ratio 0.84; 95% CI, 0.67 to 1.06). In a protocol-specified sensitivity analysis, adjusting for minimization factors, nodal status, grade, and sex, the OS hazard ratio was 0.74 (95% CI, 0.59 to 0.94). We further describe the prognostic impact of R status, grade, nodal status, and sex.

CONCLUSION

This long-term analysis supports the previous analysis, suggesting that capecitabine can improve OS in patients with resected BTC when used as adjuvant chemotherapy after surgery and should be considered as the standard of care.

Predictors of patient and graft survival following pediatric liver transplantation: Long-term analysis of more than 300 cases from single centre

BACKGROUND

Pediatric liver transplant (PLT) activity has flourished over time although with limited expansion in the graft pool. The study aims to identify pre-transplant factors that predict post-transplant patient and graft survival in the PLT population.

METHODS

Retrospective review of PLTs at a single tertiary transplant unit from 2000 to 2019. Univariate and multivariate analyses of pre-transplant factors were performed to identify predictors of patient and graft survival.

RESULTS

Two hundred and seventy-six patients received 320 PLTs. The most common cause of graft loss was hepatic artery thrombosis (n = 13, 29.6%). The most common cause of mortality was sepsis (n = 11, 29.7%). Univariate analysis showed that the following variables had a significant (p < .05) impact on patient survival: recipient age, weight, height, graft type (technical variant graft), transplant category (acute liver failure), the era of transplant, and invasive ventilation. The following variables had a significant (p < .05) impact on graft survival: recipient age, weight, height, transplant category (acute liver failure), and the era of transplant. Multivariate analysis precluded the era of transplant as the only significant factor for patient survival; patients transplanted after 2005 had significantly higher patient survival. No independent factor predicting graft survival was identified. For children transplanted after 2005, the only factor that predicted patient survival was pre-transplant invasive ventilation.

CONCLUSIONS

Our study suggests that the learning curve and pre-transplant invasive ventilation in the recipient have a significant impact on patient survival. The traditional view of worse outcomes of smaller PLT candidates should be changed.

Hepatectomy risk assessment with functional magnetic resonance imaging (HEPARIM)

Background

Post hepatectomy liver failure (PHLF) remains a significant risk in patients undergoing curative liver resection for cancer, however currently available PHLF risk prediction investigations are not sufficiently accurate.

The Hepatectomy risk assessment with functional magnetic resonance imaging trial (HEPARIM) aims to establish if quantitative MRI biomarkers of liver function & perfusion can be used to more accurately predict PHLF risk and FLR function, measured against indocyanine green (ICG) liver function test.

Methods

HEPARIM is an observational cohort study recruiting patients undergoing liver resection of 2 segments or more, prior to surgery patients will have both Dynamic Gadoxetate-enhanced (DGE) liver MRI and ICG testing.

Day one post op ICG testing is repeated and R15 compared to the Gadoxetate Clearance (GC) of the future liver remnant (FLR-GC) as measure by preoperative DGE- MRI which is the primary outcome, and preoperative ICG R15 compared to GC of whole liver (WL-GC) as a secondary outcome.

Data will be collected from medical records, biochemistry, pathology and radiology reports and used in a multi-variate analysis to the value of functional MRI and derive multivariant prediction models for future validation.

Discussion

If successful, this test will potentially provide an efficient means to quantitatively assess FLR function and PHLF risk enabling surgeons to push boundaries of liver surgery further while maintaining safe practice and thereby offering chance of cure to patients who would previously been deemed inoperable. MRI has the added benefit of already being part of the routine diagnostic pathway and as such would have limited additional burden on patients time or cost to health care systems. (Hepatectomy Risk Assessment With Functional Magnetic Resonance Imaging - Full Text View -ClinicalTrials.gov, n.d.)

Trial registration

ClinicalTrials.gov, ClinicalTrials.gov NCT04705194 - Registered 12th January 2021 – Retrospectively registered

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-08830-4.

764 Is Consent Valid in Common Orthopaedic Surgeries?

Aim

Consent is at the heart of the doctor-patient relationship. Valid consent should be voluntary, informed and the patient must have the capacity to make the decision. It is the doctor’s responsibility to ensure the patient can make an informed decision. The aim of this audit is to assess the validity of consent within Salford Royal Foundation Trust Orthopaedic department.

Method

We retrospectively reviewed 225 consent forms for four common orthopaedic trauma procedures: 44 wrist ORIF, 48 ankle fixation, 71 hip hemiarthroplasty and 62 fixations with DHS. BOA-endorsed OrthoConsent and SRFT-produced leaflets were utilised as a standard for reported surgical risks and complications. Collated patient consents were compared against these standards. Exclusion criteria included consent four and polytrauma patients.

Results

96 forms were excluded leaving 129 consent forms. In all four procedures, 86%-100% had documented infection, nerve injury and bleeding. Compartment syndrome was not documented for any wrist ORIF patients. CRPS was recorded in only 57% of wrist and 31% of ankle ORIF patients. Wound healing complications was documented in 17% of ankle ORIF. In 71% of DHS and 64% of hemiarthroplasty patients, risk of death was not recorded.

Conclusions

Targets for achieving satisfactory consent form documentation were not met and showed significant variation amongst clinicians. It suggests that patients are not being fully informed of benefits and risks of surgery. Recommendations include the introduction of posters and encouraging printing off patient information leaflets and improving education on valid consent for rotational doctors.

Do Multiple Drug Resistance Transporters Interfere with Cell Functioning under Normal Conditions?

Eukaryotic cells rely on multiple mechanisms to protect themselves from exogenous toxic compounds. For instance, cells can limit penetration of toxic molecules through the plasma membrane or sequester them within the specialized compartments. Plasma membrane transporters with broad substrate specificity confer multiple drug resistance (MDR) to cells. These transporters efflux toxic compounds at the cost of ATP hydrolysis (ABC-transporters) or proton influx (MFS-transporters). In our review, we discuss the possible costs of having an active drug-efflux system using yeast cells as an example. The pleiotropic drug resistance (PDR) subfamily ABC-transporters are known to constitutively hydrolyze ATP even without any substrate stimulation or transport across the membrane. Besides, some MDR-transporters have flippase activity allowing transport of lipids from inner to outer lipid layer of the plasma membrane. Thus, excessive activity of MDR-transporters can adversely affect plasma membrane properties. Moreover, broad substrate specificity of ABC-transporters also suggests the possibility of unintentional efflux of some natural metabolic intermediates from the cells. Furthermore, in some microorganisms, transport of quorum-sensing factors is mediated by MDR transporters; thus, overexpression of the transporters can also disturb cell-to-cell communications. As a result, under normal conditions, cells keep MDR-transporter genes repressed and activate them only upon exposure to stresses. We speculate that exploiting limitations of the drug-efflux system is a promising strategy to counteract MDR in pathogenic fungi.

Alcohol functionality in the fatty acid backbone of sphingomyelin guides the inhibition of blood coagulation

Cell-surface sphingomyelin (SM) inhibits binary and ternary complex activity of blood coagulation by an unknown mechanism. Here we show the OH functionality of SM contributes in forming the close assembly through intermolecular H-bond and through Ca²⁺ chelation, which restricts the protein–lipid/protein–protein interactions and thus inhibits the coagulation procedure.

Cell-surface sphingomyelin (SM) inhibits binary and ternary complex activity of blood coagulation.

Cancer in Lockdown: Impact of the COVID-19 Pandemic on Patients with Cancer

The lockdown measures of the ongoing COVID‐19 pandemic have disengaged patients with cancer from formal health care settings, leading to an increased use of social media platforms to address unmet needs and expectations. Although remote health technologies have addressed some of the medical needs, the emotional and mental well‐being of these patients remain underexplored and underreported. We used a validated artificial intelligence framework to conduct a comprehensive real‐time analysis of two data sets of 2,469,822 tweets and 21,800 discussions by patients with cancer during this pandemic. Lung and breast cancer are most prominently discussed, and the most concerns were expressed regarding delayed diagnosis, cancellations, missed treatments, and weakened immunity. All patients expressed significant negative sentiment, with fear being the predominant emotion. Even as some lockdown measures ease, it is crucial that patients with cancer are engaged using social media platforms for real‐time identification of issues and the provision of informational and emotional support.

Oncology patients have been severely affected by the ongoing COVID‐19 pandemic that has caused disruption in the traditional health care setting. Although remote health technologies have addressed some of the medical needs, the emotional and mental well‐being of these patients remain underreported. This article reports the primary challenges experienced by cancer patients due to COVID‐19 lockdown measures.

Additional Value of Dynamic Contrast-enhanced Sequences in Multiparametric Prostate Magnetic Resonance Imaging: Data from the PROMIS Study

BACKGROUND

Multiparametric magnetic resonance imaging (MP-MRI) is established in the diagnosis of prostate cancer, but the need for enhanced sequences has recently been questioned.

OBJECTIVE

To assess whether dynamic contrast-enhanced imaging (DCE) improves accuracy over T2 and diffusion sequences.

DESIGN, SETTING, AND PARTICIPANTS

PROMIS was a multicentre, multireader trial, with, in this part, 497 biopsy-naïve men undergoing standardised 1.5T MP-MRI using T2, diffusion, and DCE, followed by a detailed transperineal prostate mapping (TPM) biopsy at 5 mm intervals. Likert scores of 1-5 for the presence of a significant tumour were assigned in strict sequence, for (1) T2 + diffusion and then (2) T2 + diffusion + dynamic contrast-enhanced images.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

For the primary analysis, the primary PROMIS outcome measure (Gleason score ≥4 + 3 or ≥6 mm maximum cancer length) on TPM was used, and an MRI score of ≥3 was considered positive.

RESULTS AND LIMITATIONS

Sensitivity without and with DCE was 94% and 95%, specificity 37% and 38%, positive predictive value 51% and 51%, and negative predictive value 90% and 91%, respectively (p >  0.05 in each case). The number of patients avoiding biopsy (scoring 1-2) was similar (123/497 vs 121/497, p =  0.8). The number of equivocal scores (3/5) was slightly higher without DCE (32% vs 28% p =  0.031). The proportion of MRI equivocal (3/5) and positive (4-5) cases showing significant tumours were similar (23% and 71% vs 20% and 69%). No cases of dominant Gleason 4 or higher were missed with DCE, compared with a single case with T2 + diffusion-weighted imaging. No attempt was made to correlate lesion location on MRI and histology, which may be considered a limitation. Radiologists were aware of the patient's prostate-specific antigen.

CONCLUSIONS

Contrast adds little when MP-MRI is used to exclude significant prostate cancer.

PATIENT SUMMARY

An intravenous injection of contrast may not be necessary when magnetic resonance imaging is used as a test to rule out significant tumours in the prostate.

Sphingosine-1-phosphate lyase (SGPL1) deficiency is associated with mitochondrial dysfunction

Deficiency in Sphingosine-1-phosphate lyase (S1P lyase) is associated with a multi-systemic disorder incorporating primary adrenal insufficiency (PAI), steroid resistant nephrotic syndrome and neurological dysfunction. Accumulation of sphingolipid intermediates, as seen with loss of function mutations in SGPL1, has been implicated in mitochondrial dysregulation, including alterations in mitochondrial membrane potentials and initiation of mitochondrial apoptosis. For the first time, we investigate the impact of S1P lyase deficiency on mitochondrial morphology and function using patient-derived human dermal fibroblasts and CRISPR engineered SGPL1-knockout HeLa cells. Reduced cortisol output in response to progesterone stimulation was observed in two patient dermal fibroblast cell lines. Mass spectrometric analysis of patient dermal fibroblasts revealed significantly elevated levels of sphingosine-1-phosphate, sphingosine, ceramide species and sphingomyelin when compared to control. Total mitochondrial volume was reduced in both S1P lyase deficient patient and HeLa cell lines. Mitochondrial dynamics and parameters of oxidative phosphorylation were altered when compared to matched controls, though differentially across the cell lines. Mitochondrial dysfunction may represent a major event in the pathogenesis of this disease, associated with severity of phenotype.

Histoprotective effect of rutin against cisplatin-induced toxicities in tumor-bearing mice: Rutin lessens cisplatin-induced toxicities

Cisplatin is an effective anticancer drug used against a variety of cancers. The full therapeutic potential of cisplatin is often hampered due to concurrent development of various side effects in the hosts. Rutin, a naturally occurring bioflavonoid shows several pharmacological activities. It has been earlier reported by us that rutin and cisplatin in combination show better antitumor activity against murine ascites Dalton's lymphoma. As cisplatin is given to cancer-bearing hosts only, the present study was undertaken to explore the histoprotective effect of rutin against some toxicities induced by cisplatin in tumor-bearing mice. Cisplatin treatment caused severe damages in tissue architecture such as degenerated hepatocytes with nuclear condensation and sinusoidal dilatation in the liver, glomerular deterioration, infiltration of cells, and tubular congestion in the kidney, and vacuolization of Sertoli cells or dense granules in the cytoplasm and damaged seminiferous tubules in the testes. In the rutin plus cisplatin combination-treated mice, all the abnormal tissue architectural features were decreased. Further, as compared to cisplatin treatment, combination treatment did not show any significant elevation in the liver functional biomarkers (serum aspartate aminotransferase, alanine aminotransferase and alkaline phosphatase) and renal functional biomarkers (serum urea and creatinine levels). The combination treatment reduced the sperm abnormalities also as compared to the cisplatin alone treatment. The in vitro hemolysis assay of red blood cells and scanning electron microscopy revealed that combination treatment lessened the cisplatin-induced hemolysis and abnormalities in RBCs. Thus, the present findings demonstrate that rutin has histoprotective ability against cisplatin-induced toxicities in tumor-bearing mice.

AB1271 PATIENT EDUCATION IN PSORIATIC ARTHRITIS: A SERVICE EVALUATION AT ONE YEAR

Background:

Recent studies have demonstrated an increasing burden of musculoskeletal (MSK) diseases worldwide.1The importance of patient education (PE) is often overlooked in the management of long term inflammatory conditions. The European League Against Rheumatism recommends that PE should be integral to standard of care in inflammatory arthritis.2PE increases patients’ knowledge, skills and confidence in managing their condition and improves patient activation (PA). Evidence shows that improved PA results in better outcomes and improved experiences of care. We previously reported on improved knowledge and confidence amongst a small patient group with psoriatic arthritis (PsA) who had attended a pilot education session.3This education session was delivered to a wider group of patients with PsA over a 12 month period; we report on the evaluation received from this service.

Objectives:

To provide a PE programme to a wider group of patients with PsA, using a multi-disciplinary team (MDT) approach and to evaluate whether this improved patients’ knowledge, skills and confidence in managing their PsA.

Methods:

Adult patients with PsA attending their rheumatology clinic appointments were invited to a 2.5 hour MDT education session which covered: 1) a general overview of PsA; 2) medications used in PsA; 3) the role of physiotherapy and occupational therapy; 4) flares and self- management. These were interactive sessions, held in a small group setting to allow for informal discussion and questions to the MDT. Written materials including several booklets and online resources were also provided. Patients evaluated their knowledge or understanding before and after each topic covered, on the same day, using an evaluation tool with1-10 Likert scale items. Changes in ratings were analysed using student’s t-tests. Patients were also asked: which aspects they found particularly helpful; if there was anything they would like to have added/ have more of in the session; whether they found the session helpful; whether they would recommend it to other patients; whether they would be interested in developing a PsA patient support group.

Results:

Four sessions were held over a 12 month period. A total of 32 patients attended; 10 males and 22 females, across a range of age categories. Disease duration varied from less than1 year to over 10 years. There were statistically significant improvements in all topics covered: mean improvement of 91% in how well informed patients felt about PsA overall (p<0.0001); mean improvement of 74% in confidence in accessing help from the MDT (p<0.0001); mean improvement of 122% in how well informed patients were about medications used in PsA (p<0.0001); mean improvement of 99% in patients’ confidence in self-managing a flare (p<0.0001). Aspects that patients found particularly helpful included “The whole session”, “Asking questions to all different professionals”, “Meeting other sufferers”, “Management of flares”, “Fatigue information” and “Online resources”. Overall, 97% of patients (31 out of 32) found the session helpful and would recommend it to others. Over 40% of patients expressed interest in developing a local PsA support group.

Conclusion:

Following a 2.5 hour education session, improved knowledge, skills and confidence in managing their PsA was reported by 97% of patients, including patients with disease duration of > 10 years. This supports our previous finding that an interactive, group PsA education programme is a feasible and important adjunct to patient care.

References:

[1]Sebbag E, Felten R, Sagez F, et al. The world-wide burden of musculoskeletal diseases: a systematic analysis of the World Health Organization Burden of Diseases Database. Annals of the Rheumatic Diseases 2019;78:844-848.

[2]Zangi HA, Ndosi M, Adams J, et al. EULAR recommendations for patient education for people with inflammatory arthritis. Ann Rheum Dis. 2015;74(6):954-62

[3]Austin K, Jones N, Prasad R. Patient Education in psoriatic arthritis: addressing an unmet need. Ann Rheum Dis. 2019;78(suppl 2):A2134.

Disclosure of Interests:

Keziah Austin: None declared, Roopa Prasad Speakers bureau: Received speaker fees for Celgene, honorarium from Merck, advisory board fees from Bristol-Myers Squibb; all unrelated to the contents of this abstract.

VARIOUS ANALYTICAL MODELS FOR SUPERCAPACITORS: A MATHEMATICAL STUDY

Supercapacitors (SCs) are used extensively in high-power potential energy applications like renewable energy systems, electric vehicles, power electronics, and many other industrial applications. This is due to SCs containing high-power density and the ability to respond spontaneously with fast charging and discharging demands. Advancements in material and fabrication techniques have induced a scope for research to improve the application of SCs. Many researchers have studied various SC properties and their effects on energy storage and management performance. In this paper, various fractional calculus-based SC models are summarized, with emphasis on analytical studies from derived classical SC models. Study prevails such parameterized resistor–capacitor networks have simplified the representation of electrical behavior of SCs to deal with the complicated internal structure. Fractional calculus has been used to develop SC models with the aim of understanding their complicated structure. Finally, the properties of different SC models utilized by various researchers to understand the behavior of SCs are listed using an equivalent circuit.

Liver resection surgery compared with thermal ablation in high surgical risk patients with colorectal liver metastases: the LAVA international RCT

BACKGROUND

Although surgical resection has been considered the only curative option for colorectal liver metastases, thermal ablation has recently been suggested as an alternative curative treatment. There have been no adequately powered trials comparing surgery with thermal ablation.

OBJECTIVES

Main objective - to compare the clinical effectiveness and cost-effectiveness of thermal ablation versus liver resection surgery in high surgical risk patients who would be eligible for liver resection. Pilot study objectives - to assess the feasibility of recruitment (through qualitative study), to assess the quality of ablations and liver resection surgery to determine acceptable standards for the main trial and to centrally review the reporting of computed tomography scan findings relating to ablation and outcomes and recurrence rate in both arms.

DESIGN

A prospective, international (UK and the Netherlands), multicentre, open, pragmatic, parallel-group, randomised controlled non-inferiority trial with a 1-year internal pilot study.

SETTING

Tertiary liver, pancreatic and gallbladder (hepatopancreatobiliary) centres in the UK and the Netherlands.

PARTICIPANTS

Adults with a specialist multidisciplinary team diagnosis of colorectal liver metastases who are at high surgical risk because of their age, comorbidities or tumour burden and who would be suitable for liver resection or thermal ablation.

INTERVENTIONS

Thermal ablation conducted as per local policy (but centres were encouraged to recruit within Cardiovascular and Interventional Radiological Society of Europe guidelines) versus surgical liver resection performed as per centre protocol.

MAIN OUTCOME MEASURES

Pilot study - patients' and clinicians' acceptability of the trial to assist in optimisation of recruitment. Primary outcome - disease-free survival at 2 years post randomisation. Secondary outcomes - overall survival, timing and site of recurrence, additional therapy after treatment failure, quality of life, complications, length of hospital stay, costs, trial acceptability, and disease-free survival measured from end of intervention. It was planned that 5-year survival data would be documented through record linkage. Randomisation was performed by minimisation incorporating a random element, and this was a non-blinded study.

RESULTS

In the pilot study over 1 year, a total of 366 patients with colorectal liver metastases were screened and 59 were considered eligible. Only nine participants were randomised. The trial was stopped early and none of the planned statistical analyses was performed. The key issues inhibiting recruitment included fewer than anticipated patients eligible for both treatments, misconceptions about the eligibility criteria for the trial, surgeons' preference for one of the treatments ('lack of clinical equipoise' among some of the surgeons in the centre) with unconscious bias towards surgery, patients' preference for one of the treatments, and lack of dedicated research nurses for the trial.

CONCLUSIONS

Recruitment feasibility was not demonstrated during the pilot stage of the trial; therefore, the trial closed early. In future, comparisons involving two very different treatments may benefit from an initial feasibility study or a longer period of internal pilot study to resolve these difficulties. Sufficient time should be allowed to set up arrangements through National Institute for Health Research (NIHR) Research Networks.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN52040363.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 21. See the NIHR Journals Library website for further project information.

Diagnoses and management of adult cough: An Indian Environmental Medical Association (EMA) position paper

BACKGROUND

Cough is a common yet distressing symptom that results in significant health care costs from outpatient visits and related consultations.

OBJECTIVE

The understanding of the pathobiology of cough in recent times has undergone an evolution with Cough hypersensitivity syndrome (CHS) being suggested in most cases of dry cough. However, in the case of productive cough, ancillary mechanisms including impaired Mucociliary clearance, in addition to hypermucosecretory bronchospastic conditions of Smoker's cough, asthma-COPD overlap, bronchiectasis, and allergic bronchopulmonary aspergillosis, need to be critically addressed while optimizing patient care with symptomatic therapy in outpatient settings of India.

METHODS

In this review, evidence-based graded recommendations on use of antitussives - & protussives as a Position Paper were developed based on the Level and Quality of Scientific evidence as per Agency for Health Care and Quality (AHRQ) criteria listing and Expert opinions offered by a multidisciplinary EMA panel in India.

RESULTS

Management of acute or chronic cough involves addressing common issues of environmental exposures and patient concerns before instituting supportive therapy with antitussives or bronchodilatory cough formulations containing mucoactives, anti-inflammatory, or short-acting beta-2 agonist agents.

CONCLUSION

The analyses provides a real world approach to the management of acute or chronic cough in various clinical conditions with pro- or antitussive agents while avoiding their misuse in empirical settings.

Adult liver transplantation: UK clinical guideline - part 2: surgery and post-operation

Survival rates for patients following liver transplantation exceed 90% at 12 months and approach 70% at 10 years. Part 1 of this guideline has dealt with all aspects of liver transplantation up to the point of placement on the waiting list. Part 2 explains the organ allocation process, organ donation and organ type and how this influences the choice of recipient. After organ allocation, the transplant surgery and the critical early post-operative period are, of necessity, confined to the liver transplant unit. However, patients will eventually return to their referring secondary care centre with a requirement for ongoing supervision. Part 2 of this guideline concerns three key areas of post liver transplantation care for the non-transplant specialist: (1) overseeing immunosuppression, including interactions and adherence; (2) the transplanted organ and how to initiate investigation of organ dysfunction; and (3) careful oversight of other organ systems, including optimising renal function, cardiovascular health and the psychosocial impact. The crucial significance of this holistic approach becomes more obvious as time passes from the transplant, when patients should expect the responsibility for managing the increasing number of non-liver consequences to lie with primary and secondary care.

Adult liver transplantation: A UK clinical guideline - part 1: pre-operation

Liver transplantation is a highly successful treatment for all types of liver failure, some non-liver failure indications and liver cancer. Most referrals come from secondary care. This first part of a two-part guideline outlines who to refer, and how that referral should be made, including patient details and additional issues such as those relevant to alcohol and drug misuse. The process of liver transplant assessment involves the confirmation of the diagnosis and non-reversibility, an evaluation of comorbidities and exclusion of contraindications. Finally, those making it onto the waiting list require monitoring and optimising. Underpinning this process is a need for good communication between patient, their carers, secondary care and the liver transplant service, synchronised by the transplant coordinator. Managing expectation and balancing the uncertainty of organ availability against the inevitable progression of underlying liver disease requires sensitivity and honesty from all healthcare providers and the assessment of palliative care needs is an integral part of this process.

Stigma among healthcare workers towards hepatitis B infection in Bangalore, India: a qualitative study

BACKGROUND

With about 50 million people infected with hepatitis B (HBV) in India the burden of disease is high. Stigma has been identified to have a major negative impact on screening, diagnosis and treatment of hepatitis B patients. The aim of this study was to assess the stigma in nurses and physicians in Bangalore, India; studies on stigma in HBV have only been published outside of India.

METHODS

Semi-structured in-depth-interviews were conducted in the period of March 20th and April 16th 2018 to study stigma and other problems in the care of hepatitis B patients. Stigma was pragmatically defined as a mark of disgrace associated with having a hepatitis B infection. Thirty physicians and nurses in different clinics and hospitals across the city of Bangalore were selected by purposeful sampling and snowball effect until theoretical saturation was reached.

RESULTS

The following themes were identified during the interviews: feelings when treating a patient; pregnancy and marriage; confidentiality; morality; improvement in care and the difference with HIV. The most stigma was discovered in the theme morality. The majority of our participants mentioned lack of awareness as biggest obstacle in health care of hepatitis B patients.

CONCLUSIONS

This is the first qualitative study in India exploring hepatitis B stigma among health care workers. Stigma was found in certain themes, such as morality. Though, no unwillingness to treat was found. There was a general lack of awareness amongst patients according to our participants and could jeopardize proper treatment. These results will further help in developing strategies to tackle hepatitis B in India.

Development of orthotopic tumour models using ultrasound-guided intrahepatic injection

Mouse models of human diseases are an essential part of the translational pipeline. Orthotopic tumour mouse models are increasingly being used in cancer research due to their increased clinical relevance over subcutaneous xenograft models, particularly in relation to metastatic disease. In this study, we have developed orthotopic colorectal cancer liver metastases (CRCLM) and primary cholangiocarcinoma (CCA) models in BALB/c nude mice using minimally invasive ultrasound-guided intrahepatic injection. Due to its minimally invasive nature, the method reduced risk from surgical complications whilst being fast and easy to perform and resulted in measurable tumour volumes 1 to 3 weeks post-injection. Tumour volumes were monitored in vivo by weekly high-frequency ultrasound (HF-US) and/or twice weekly bioluminescence imaging (BLI) and confirmed with end-point histology. Take rates were high for human CRC cells (>73%) and for CCA cells (90%). We have demonstrated that this method reliably induces CRCLM and CCAs, in which tumour volume can be monitored throughout using HF-US and/or BLI. This provides a promising experimental tool for future testing of cancer therapeutics in an orthotopic model.

An online beam profiler for laser-accelerated protons

The design and operation of an online energy and spatially resolving detector based on three different scintillators for laser-driven protons are described. The device can be used for a multi-Hertz recording rate. The spatial resolution is <0.5 mm, allowing to retrieve details of the proton beam which is of interest, e.g., for radiographic applications. At the same time, the particle energy is divided into three energy bands between 1 MeV and 5 MeV to retrieve the proton energy spectrum. The absolute response of the detector was calibrated at a conventional proton accelerator.

Capecitabine compared with observation in resected biliary tract cancer (BILCAP): a randomised, controlled, multicentre, phase 3 study

BACKGROUND

Despite improvements in multidisciplinary management, patients with biliary tract cancer have a poor outcome. Only 20% of patients are eligible for surgical resection with curative intent, with 5-year overall survival of less than 10% for all patients. To our knowledge, no studies have described a benefit of adjuvant therapy. We aimed to determine whether adjuvant capecitabine improved overall survival compared with observation following surgery for biliary tract cancer.

METHODS

This randomised, controlled, multicentre, phase 3 study was done across 44 specialist hepatopancreatobiliary centres in the UK. Eligible patients were aged 18 years or older and had histologically confirmed cholangiocarcinoma or muscle-invasive gallbladder cancer who had undergone a macroscopically complete resection (which includes liver resection, pancreatic resection, or, less commonly, both) with curative intent, and an Eastern Cooperative Oncology Group performance status of less than 2. Patients who had not completely recovered from previous surgery or who had previous chemotherapy or radiotherapy for biliary tract cancer were also excluded. Patients were randomly assigned 1:1 to receive oral capecitabine (1250 mg/m2 twice daily on days 1-14 of a 21-day cycle, for eight cycles) or observation commencing within 16 weeks of surgery. Treatment was not masked, and allocation concealment was achieved with a computerised minimisation algorithm that stratified patients by surgical centre, site of disease, resection status, and performance status. The primary outcome was overall survival. As prespecified, analyses were done by intention to treat and per protocol. This study is registered with EudraCT, number 2005-003318-13.

FINDINGS

Between March 15, 2006, and Dec 4, 2014, 447 patients were enrolled; 223 patients with biliary tract cancer resected with curative intent were randomly assigned to the capecitabine group and 224 to the observation group. The data cutoff for this analysis was March 6, 2017. The median follow-up for all patients was 60 months (IQR 37-60). In the intention-to-treat analysis, median overall survival was 51·1 months (95% CI 34·6-59·1) in the capecitabine group compared with 36·4 months (29·7-44·5) in the observation group (adjusted hazard ratio [HR] 0·81, 95% CI 0·63-1·04; p=0·097). In a protocol-specified sensitivity analysis, adjusting for minimisation factors and nodal status, grade, and gender, the overall survival HR was 0·71 (95% CI 0·55-0·92; p=0·010). In the prespecified per-protocol analysis (210 patients in the capecitabine group and 220 in the observation group), median overall survival was 53 months (95% CI 40 to not reached) in the capecitabine group and 36 months (30-44) in the observation group (adjusted HR 0·75, 95% CI 0·58-0·97; p=0·028). In the intention-to-treat analysis, median recurrence-free survival was 24·4 months (95% CI 18·6-35·9) in the capecitabine group and 17·5 months (12·0-23·8) in the observation group. In the per-protocol analysis, median recurrence-free survival was 25·9 months (95% CI 19·8-46·3) in the capecitabine group and 17·4 months (12·0-23·7) in the observation group. Adverse events were measured in the capecitabine group only, and of the 213 patients who received at least one cycle, 94 (44%) had at least one grade 3 toxicity, the most frequent of which were hand-foot syndrome in 43 (20%) patients, diarrhoea in 16 (8%) patients, and fatigue in 16 (8%) patients. One (<1%) patient had grade 4 cardiac ischaemia or infarction. Serious adverse events were observed in 47 (21%) of 223 patients in the capecitabine group and 22 (10%) of 224 patients in the observation group. No deaths were deemed to be treatment related.

INTERPRETATION

Although this study did not meet its primary endpoint of improving overall survival in the intention-to-treat population, the prespecified sensitivity and per-protocol analyses suggest that capecitabine can improve overall survival in patients with resected biliary tract cancer when used as adjuvant chemotherapy following surgery and could be considered as standard of care. Furthermore, the safety profile is manageable, supporting the use of capecitabine in this setting.

FUNDING

Cancer Research UK and Roche.

Genetic Status and Endosymbionts Diversity of Bemisia tabaci (Gennadius) on Hosts Belonging to Family Malvaceae in India

A study was instigated to examine the genetic status and distribution of known endosymbionts namely Portiera, Rickettsia, Wolbachia, Cardinium, and Arsenophonus in the populations of Bemisia tabaci (Gennadius) from three host plants: cotton (Gossypium herbaceum), okra (Abelmoschus esculentus L.), and China rose (Hibiscus rosa-sinensis) belonging to the family Malvaceae. The presence of four secondary endosymbionts Rickettsia, Wolbachia, Cardinium, and Arsenophonus was checked in Bemisia tabaci populations. Phylogenetic analyses grounded on the mitochondrial cytochrome oxidase I gene (mtCO1) unveiled the presence of Asia 1, Asia II 1, and Asia II 7 genetic groups for Bemisia tabaci on abovementioned crops. Individuals were examined for symbiotic bacterial infection with specific primers amplifying the 16S rRNA gene for Portiera, Rickettsia, Cardinium, and Wolbachia, and the 23S rRNA gene for Arsenophonus. The results show that Portiera was present in all the Bemisia tabaci samples. However, variations were noted in the circulation frequencies of secondary endosymbionts among the Bemisia tabaci populations. A significant difference was noticed in the distribution frequency of Rickettsia between cotton and China rose or okra with their p values as 0.016 and 0.033 respectively. The uneven incidence of secondary endosymbionts ropes the assumption that each endosymbiotic bacterium not only has a role in the endurance but may contribute to the polyphagous nature of Bemisia tabaci. It also brings an uncomplicated evidence for progressive studies on control measures of this notorious insect pest.

Nm-sized cryogenic hydrogen clusters for a laser-driven proton source

A cryogenic hydrogen cluster-jet target is described which has been used for laser-plasma interaction studies. Major advantages of the cluster-jet are, on the one hand, the compatibility to pulsed high repetition lasers as the target is operated continuously and, on the other hand, the absence of target debris. The cluster-jet target was characterized using the Mie-scattering technique allowing to determine the cluster size and to compare the measurements with an empirical formula. In addition, an estimation of the cluster beam density was performed. The system was implemented at the high power laser system ARCTURUS, and the measurements show the acceleration of protons after irradiation of the cluster target by high intensity laser pulses with a repetition rate of 5 Hz.