A Novel Use for the Rigid Cystoscope: The Removal of Sacral Tacks after a Coloanal Anastamosis Dehiscence

A 69-year-old female presented as an emergency with atrial fibrillation, which was treated with warfarin. She subsequently developed fresh rectal bleeding and after further investigations a Dukes B adenocarcinoma of the rectum was found. She subsequently underwent a low anterior resection, coloanal anastamosis and a defunctioning ileostomy. Three sterile surgical metallic tacks (pins) were inserted into the sacrum to stop brisk bleeding from the presacral venous plexus. Following discharge, she was readmitted with septic shock and a CT scan revealed a presacral fluid collection in the area surrounding the sacral tacks (pins) and an anastamotic dehiscence. The patient was not fit for further pelvic surgery to remove the tacks, so an alternative minimally invasive cystoscopic procedure was performed. The sacral tacks (pins) were removed by the urologist using a rigid cystoscope and cold cup biopsy forceps. To our knowledge, this is the first reported case in the literature

Prognostic model to predict postoperative acute kidney injury in patients undergoing major gastrointestinal surgery based on a national prospective observational cohort study.

Background: Acute illness, existing co-morbidities and surgical stress response can all contribute to postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery. The aim of this study was prospectively to develop a pragmatic prognostic model to stratify patients according to risk of developing AKI after major gastrointestinal surgery. Methods: This prospective multicentre cohort study included consecutive adults undergoing elective or emergency gastrointestinal resection, liver resection or stoma reversal in 2-week blocks over a continuous 3-month period. The primary outcome was the rate of AKI within 7 days of surgery. Bootstrap stability was used to select clinically plausible risk factors into the model. Internal model validation was carried out by bootstrap validation. Results: A total of 4544 patients were included across 173 centres in the UK and Ireland. The overall rate of AKI was 14·2 per cent (646 of 4544) and the 30-day mortality rate was 1·8 per cent (84 of 4544). Stage 1 AKI was significantly associated with 30-day mortality (unadjusted odds ratio 7·61, 95 per cent c.i. 4·49 to 12·90; P < 0·001), with increasing odds of death with each AKI stage. Six variables were selected for inclusion in the prognostic model: age, sex, ASA grade, preoperative estimated glomerular filtration rate, planned open surgery and preoperative use of either an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker. Internal validation demonstrated good model discrimination (c-statistic 0·65). Discussion: Following major gastrointestinal surgery, AKI occurred in one in seven patients. This preoperative prognostic model identified patients at high risk of postoperative AKI. Validation in an independent data set is required to ensure generalizability

Cardioversion in patients with newly diagnosed non-valvular atrial fibrillation: observational study using prospectively collected registry data

OBJECTIVE To investigate the clinical outcomes of patients who underwent cardioversion compared with those who did not have cardioverson in a large dataset of patients with recent onset non-valvular atrial fibrillation. DESIGN Observational study using prospectively collected registry data (Global Anticoagulant Registry in the FIELD-AF-GARFIELD-AF). SETTING 1317 participating sites in 35 countries. PARTICIPANTS 52 057 patients aged 18 years and older with newly diagnosed atrial fibrillation (up to six weeks' duration) and at least one investigator determined stroke risk factor. MAIN OUTCOME MEASURES Comparisons were made between patients who received cardioversion and those who had no cardioversion at baseline, and between patients who received direct current cardioversion and those who had pharmacological cardioversion. Overlap propensity weighting with Cox proportional hazards models was used to evaluate the effect of cardioversion on clinical endpoints (all cause mortality, non-haemorrhagic stroke or systemic embolism, and major bleeding), adjusting for baseline risk and patient selection. RESULTS 44 201 patients were included in the analysis comparing cardioversion and no cardioversion, and of these, 6595 (14.9%) underwent cardioversion at baseline. The propensity score weighted hazard ratio for all cause mortality in the cardioversion group was 0.74 (95% confidence interval 0.63 to 0.86) from baseline to one year follow-up and 0.77 (0.64 to 0.93) from one year to two year follow-up. Of the 6595 patients who had cardioversion at baseline, 299 had a follow-up cardioversion more than 48 days after enrolment. 7175 patients were assessed in the analysis comparing type of cardioversion: 2427 (33.8%) received pharmacological cardioversion and 4748 (66.2%) had direct current cardioversion. During one year follow-up, event rates (per 100 patient years) for all cause mortality in patients who received direct current and pharmacological cardioversion were 1.36 (1.13 to 1.64) and 1.70 (1.35 to 2.14), respectively. OBJECTIVE To investigate the clinical outcomes of patients who underwent cardioversion compared with those who did not have cardioverson in a large dataset of patients with recent onset non-valvular atrial fibrillation. DESIGN Observational study using prospectively collected registry data (Global Anticoagulant Registry in the FIELD-AF-GARFIELD-AF). SETTING 1317 participating sites in 35 countries. PARTICIPANTS 52 057 patients aged 18 years and older with newly diagnosed atrial fibrillation (up to six weeks' duration) and at least one investigator determined stroke risk factor. MAIN OUTCOME MEASURES Comparisons were made between patients who received cardioversion and those who had no cardioversion at baseline, and between patients who received direct current cardioversion and those who had pharmacological cardioversion. Overlap propensity weighting with Cox proportional hazards models was used to evaluate the effect of cardioversion on clinical endpoints (all cause mortality, non-haemorrhagic stroke or systemic embolism, and major bleeding), adjusting for baseline risk and patient selection. RESULTS 44 201 patients were included in the analysis comparing cardioversion and no cardioversion, and of these, 6595 (14.9%) underwent cardioversion at baseline. The propensity score weighted hazard ratio for all cause mortality in the cardioversion group was 0.74 (95% confidence interval 0.63 to 0.86) from baseline to one year follow-up and 0.77 (0.64 to 0.93) from one year to two year follow-up.Of the 6595 patients who had cardioversion at baseline, 299 had a follow-up cardioversion more than 48 days after enrolment. 7175 patients were assessed in the analysis comparing type of cardioversion: 2427 (33.8%) received pharmacological cardioversion and 4748 (66.2%) had direct current cardioversion. During one year follow-up, event rates (per 100 patient years) for all cause mortality in patients who received direct current and pharmacological cardioversion were 1.36 (1.13 to 1.64) and 1.70 (1.35 to 2.14), respectively. CONCLUSION In this large dataset of patients with recent onset non-valvular atrial fibrillation, a small proportion were treated with cardioversion. Direct current cardioversion was performed twice as often as pharmacological cardioversion, and there appeared to be no major difference in outcome events for these two cardioversion modalities. For the overall cardioversion group, after adjustments for confounders, a significantly lower risk of mortality was found in patients who received early cardioversion compared with those who did not receive early cardioversion. STUDY REGISTRATION ClinicalTrials.gov NCT01090362

Radiofrequency Ablation (RFA) as A Cytoreductive Strategy for Hepatic Metastasis from Breast Cancer

INTRODUCTION. Patients with liver metastasis from breast cancer have a poor prognosis, although this may be improved by hepatectomy in a selected group with disease confined to the liver. We evaluate the effectiveness of radiofrequency ablation (RFA) as a cytoreductive strategy in the management of liver metastasis from primary breast cancer.PATIENTS AND METHODS Nineteen patients with hepatic metastasis from primary breast cancer underwent RFA of their liver lesions between April 1998 and August 2004.RESULTS The median age of the patients was 52 years (range, 32-69 years), 8 had disease confined to the liver, with 11 having stable extrahepatic disease in addition. Seven patients with disease confined to the liver at presentation are alive, as are 6 with extrahepatic disease, median follow-up after RFA was 15 months (range, 0-77 months). Survival at 30 months was 41.6%. In addition, 7 patients followed up for a median of 14 months (range, 2-29 months) remain alive and disease-free. RFA failed to control hepatic disease in 3 patients. RFA was not associated with any mortality or major morbidity.CONCLUSIONS Control of hepatic metastasis from breast cancer is possible using RFA and may lead to a survival benefit, particularly in those patients with disease confined to the liver

Effect of Thermal Indices on Yield of Garlic (Allium sativum L.) Varieties under Variable Weather Conditions of South Saurastra Agro-climatic Zone of Gujarat, India

A field experiment was conducted during Rabi (spring) season of year 2017-2018 at Junagadh Agricultural University, Junagadh, Gujarat, India. Four varieties of Garlic (GG-4, GJG-5, Promising and Local variety) were sown on four different dates for generating different weather condition during various phenological stages of crop. Results revealed that sowing between 7th to 21st November produced significantly higher growth due to fulfillment of optimum thermal requirement for various plant processes. Timely sown garlic crop recorded significantly higher GDD (growing degree days), HTU (helio-thermal units) and PTU (photo-thermal units) and HTU (Heat use efficiency). Delay in sowing (after 21st November) reduced the crop duration and yield. Yield had higher value in local variety followed by GG-4and GJG-5 in all weather conditions. Yield was more in timely sown crop as compared to late and very late sown crop. Local variety was found more conducive for growth and higher thermal unit.</jats:p

Effect of Thermal Indices on Yield of Garlic (Allium sativum L.) Varieties under Variable Weather Conditions of South Saurastra Agro-climatic Zone of Gujarat, India

A field experiment was conducted during Rabi (spring) season of year 2017-2018 at Junagadh Agricultural University, Junagadh, Gujarat, India. Four varieties of Garlic (GG-4, GJG-5, Promising and Local variety) were sown on four different dates for generating different weather condition during various phenological stages of crop. Results revealed that sowing between 7th to 21st November produced significantly higher growth due to fulfillment of optimum thermal requirement for various plant processes. Timely sown garlic crop recorded significantly higher GDD (growing degree days), HTU (helio-thermal units) and PTU (photo-thermal units) and HTU (Heat use efficiency). Delay in sowing (after 21st November) reduced the crop duration and yield. Yield had higher value in local variety followed by GG-4and GJG-5 in all weather conditions. Yield was more in timely sown crop as compared to late and very late sown crop. Local variety was found more conducive for growth and higher thermal unit