Clinical Response to Procedural Stroke Following Carotid Endarterectomy: A Delphi Consensus Study

Objective: No dedicated studies have been performed on the optimal management of patients with an acute stroke related to carotid intervention nor is there a solid recommendation given in the European Society for Vascular Surgery guideline. By implementation of an international expert Delphi panel, this study aimed to obtain expert consensus on the optimal management of in hospital stroke occurring during or following CEA and to provide a practical treatment decision tree. Methods: A four round Delphi consensus study was performed including 31 experts. The aim of the first round was to investigate whether the conceptual model indicating the traditional division between intra- and post-procedural stroke in six phases was appropriate, and to identify relevant clinical responses during these six phases. In rounds 2, 3, and 4, the aim was to obtain consensus on the optimal response to stroke in each predefined setting. Consensus was reached in rounds 1, 3, and 4 when ≥ 70% of experts agreed on the preferred clinical response and in round 2 based on a Likert scale when a median of 7 – 9 (most adequate response) was given, IQR ≤ 2. Results: The experts agreed (> 80%) on the use of the conceptual model. Stroke laterality and type of anaesthesia were included in the treatment algorithm. Consensus was reached in 17 of 21 scenarios (> 80%). Perform diagnostics first for a contralateral stroke in any phase, and for an ipsilateral stroke during cross clamping, or apparent stroke after leaving the operation room. For an ipsilateral stroke during the wake up phase, no formal consensus was achieved, but 65% of the experts would perform diagnostics first. A CT brain combined with a CTA or duplex ultrasound of the carotid arteries should be performed. For an ipsilateral intra-operative stroke after flow restoration, the carotid artery should be re-explored immediately (75%). Conclusion: In patients having a stroke following carotid endarterectomy, expedited diagnostics should be performed initially in most phases. In patients who experience an ipsilateral intra-operative stroke following carotid clamp release, immediate re-exploration of the index carotid artery is recommended

Erectile dysfunction following retropubic prostatectomy

Prostate cancer is the most common cancer to affect men in the UK. Treatment options depend on the grade of tumour, the patient's co-existing diseases and choice of treatment. One potentially curative option is surgery, specifically a radical retropubic prostatectomy or variation thereof. As a consequence of the surgery, men commonly experience two side-effects: urinary incontinence and erectile dysfunction (ED). This paper outlines the clinical management of ED following surgery and aims to provide an overview of how to assess a man who has developed ED and discuss the various treatment options available, along with the efficacy in terms of recovery of erections

Inpatient rehabilitation did not positively affect 6-month patient-reported outcomes after hip or knee arthroplasty

Background: The aim of this study was to compare patient-reported outcomes 6 months after hip or knee arthroplasty in subjects who were discharged to home compared to those who attended inpatient rehabilitation. Methods: Seven hundred and forty-eight consecutive total hip or knee replacement patients were identified from a prospective database. Preoperative and 6-month post-operative patient-reported outcome measures were recorded. Forty-four patients discharged directly to home were cohort matched by age, gender, procedure and surgeon to 44 patients from the cohort who received inpatient care. Patient outcomes were compared using SPSS version 24 software. Results: Both cohorts saw significant improvements from baseline at 6 months. Median length of rehabilitation for the inpatient group was 7 days (4 – 16 days). There was no significant difference between the groups based on patient-reported outcomes. There was a clinically significant difference (P = 0.047) in the body mass index of the Home Group (mean = 27) to Rehab Group (mean = 29). Conclusion: Our study has shown that inpatient rehabilitation after hip or knee arthroplasty did not positively affect 6-month patient-reported satisfaction, expectation, pain, quality of life, activities of daily living scores, when compared with subjects who were discharged direct to home. A significant average saving of $5600 per patient with the use of home dis- charge is a promising avenue for health cost reduction, and health resource distribution

FIGO consensus guidelines on placenta accreta spectrum disorders: Nonconservative surgical management

Non peer reviewe

Relationship of Insulin Resistance and Related Metabolic Variables to Coronary Artery Disease: A Mathematical Analysis

OBJECTIVE—People with diabetes have an increased risk of coronary artery disease (CAD). An unanswered question is what portion of CAD can be attributed to insulin resistance, related metabolic variables, and other known CAD risk factors

The management of type 2 diabetes with fixed‐ratio combination insulin degludec/liraglutide (IDegLira) versus basal‐bolus therapy (insulin glargine U100 plus insulin aspart): a short‐term cost‐effectiveness analysis in the UK setting

Aim: To evaluate the cost‐effectiveness of IDegLira versus basal‐bolus therapy (BBT) with insulin glargine U100 plus up to 4 times daily insulin aspart for the management of type 2 diabetes in the UK. Methods: A Microsoft Excel model was used to evaluate the cost‐utility of IDegLira versus BBT over a 1‐year time horizon. Clinical input data were taken from the treat‐to‐target DUAL VII trial, conducted in patients unable to achieve adequate glycaemic control (HbA1c <7.0%) with basal insulin, with IDegLira associated with lower rates of hypoglycaemia and reduced body mass index (BMI) in comparison with BBT, with similar HbA1c reductions. Costs (expressed in GBP) and event‐related disutilities were taken from published sources. Extensive sensitivity analyses were performed. Results: IDegLira was associated with an improvement of 0.05 quality‐adjusted life years (QALYs) versus BBT, due to reductions in non‐severe hypoglycaemic episodes and BMI with IDegLira. Costs were higher with IDegLira by GBP 303 per patient, leading to an incremental cost‐effectiveness ratio (ICER) of GBP 5924 per QALY gained for IDegLira versus BBT. ICERs remained below GBP 20 000 per QALY gained across a range of sensitivity analyses. Conclusions: IDegLira is a cost‐effective alternative to BBT with insulin glargine U100 plus insulin aspart, providing equivalent glycaemic control with a simpler treatment regimen for patients with type 2 diabetes inadequately controlled on basal insulin in the UK

Interventions to improve patient access to and utilisation of genetic and genomic counselling services.

Primary objective The primary objective is to assess the effectiveness of interv entions to improve patient identification, access to and utilis ation of genetic and genomic counselling services when compared to: i) No intervention; ii) Usual or current practice; and iii) Other active intervention. Secondary objective The secondary objective is to explore the resource use and costs associated with interventions aimed at improving patient identification, access to and utilisation of genetic and genomic counselling services from studies meeting the eligibility criteria. We will report on factors that may explain variation in the eff ectiveness of interventions aimed at improving patient iden tification, access to and utilisation of genetic and genomic counselling services from studies meeting the eligibility criteria. Another secondary objective is to explore how interventions w hich target improved patient identification, access to and utili sation of genetic and genomic counselling services affect the subsequent appropriate use of health services for the prevention or early detection of disease. It is also possible that the genetic counselling interaction itself will contribute to the possible use of preventative services

Measuring capital in active addiction and recovery: the development of the strengths and barriers recovery scale (SABRS).

BACKGROUND: The international Life In Recovery (LiR) surveys have provided an important message to the public and policy makers about the reality of change from addiction to recovery, consistently demonstrating both that there are marked gains across a range of life domains and that the longer the person is in recovery the better their recovery strengths and achievements. However, to date, no attempt has been made to quantify the Life In Recovery scales and to assess what levels of change in removing barriers and building strengths is achieved at which point in the recovery journey. METHODS: The current study undertakes a preliminary analysis of strengths and barriers from the Life in Recovery measure, using data from a European survey on drug users in recovery (n = 480), and suggests that the instrument can be edited into a Strengths And Barriers Recovery Scale (SABRS). The new scale provides a single score for both current recovery strengths and barriers to recovery. RESULTS: The resulting data analysis shows that there are stepwise incremental changes in recovery strengths at different recovery stages, but these occur with only very limited reductions in barriers to recovery, with even those in stable recovery typically having at least two barriers to their quality of life and wellbeing. Greater strengths in active addiction are associated with greater strengths and resources in recovery. CONCLUSION: As well as demonstrating population changes in each of the domains assessed, the current study has shown the potential of the Life In Recovery Scale as a measure of recovery capital that can be used to support recovery interventions and pathways