Postoperative outcomes in oesophagectomy with trainee involvement

BACKGROUND: The complexity of oesophageal surgery and the significant risk of morbidity necessitates that oesophagectomy is predominantly performed by a consultant surgeon, or a senior trainee under their supervision. The aim of this study was to determine the impact of trainee involvement in oesophagectomy on postoperative outcomes in an international multicentre setting. METHODS: Data from the multicentre Oesophago-Gastric Anastomosis Study Group (OGAA) cohort study were analysed, which comprised prospectively collected data from patients undergoing oesophagectomy for oesophageal cancer between April 2018 and December 2018. Procedures were grouped by the level of trainee involvement, and univariable and multivariable analyses were performed to compare patient outcomes across groups. RESULTS: Of 2232 oesophagectomies from 137 centres in 41 countries, trainees were involved in 29.1 per cent of them (n = 650), performing only the abdominal phase in 230, only the chest and/or neck phases in 130, and all phases in 315 procedures. For procedures with a chest anastomosis, those with trainee involvement had similar 90-day mortality, complication and reoperation rates to consultant-performed oesophagectomies (P = 0.451, P = 0.318, and P = 0.382, respectively), while anastomotic leak rates were significantly lower in the trainee groups (P = 0.030). Procedures with a neck anastomosis had equivalent complication, anastomotic leak, and reoperation rates (P = 0.150, P = 0.430, and P = 0.632, respectively) in trainee-involved versus consultant-performed oesophagectomies, with significantly lower 90-day mortality in the trainee groups (P = 0.005). CONCLUSION: Trainee involvement was not found to be associated with significantly inferior postoperative outcomes for selected patients undergoing oesophagectomy. The results support continued supervised trainee involvement in oesophageal cancer surgery

Warfarin anticoagulation in hemodialysis patients with atrial fibrillation: comparison of nephrologist-led and anticoagulation clinic-led management

Abstract Background There is conflicting evidence of benefit versus harm for warfarin anticoagulation in hemodialysis patients with atrial fibrillation. This equipoise may be explained by suboptimal Time in Therapeutic Range (TTR), which correlates well with thromboembolic and bleeding complications. This study aimed to compare nephrologist-led management of warfarin therapy versus that led by specialized anticoagulation clinic. Methods In a retrospective cohort of chronic hemodialysis patients from two institutions (Institution A: Nephrologist-led warfarin management, Institution B: Anticoagulation clinic-led warfarin management), we identified patients with atrial fibrillation who were receiving warfarin for thromboembolic prophylaxis. Mean TTRs, proportion of patients achieving TTR ≥ 60%, and frequency of INR testing were compared using a logistic regression model. Results In Institution A, 16.7% of hemodialysis patients had atrial fibrillation, of whom 36.8% were on warfarin. In Institution B, 18% of hemodialysis patients had atrial fibrillation, and 55.5% were on warfarin. The mean TTR was 61.8% (SD 14.5) in Institution A, and 60.5% (SD 15.8) in Institution B (p-value 0.95). However, the proportion of patients achieving TTR ≥ 60% was 65% versus 43.3% (Adjusted OR 2.22, CI 0.65–7.63) and mean frequency of INR testing was every 6 days versus every 13.9 days in Institutions A and B respectively. Conclusions There was no statistical difference in mean TTR between nephrologist-led management of warfarin and that of clinic-led management. However, the former achieved a trend toward a higher proportion of patients with optimal TTR. This improved therapeutic results was associated with more frequent INR monitoring

Catheter ablation for atrial fibrillation in heart failure with reduced ejection fraction: A systematic review and meta-analysis of randomized controlled trials

Abstract Background Previous randomized controlled trials (RCT)s showed similar outcomes in patients with atrial fibrillation (AF) and heart failure with reduced ejection fraction (HFrEF) treated with anti-arrhythmic drugs (AAD) compared to rate control therapy. We sought to evaluate whether catheter ablation is superior to medical therapy in patients with AF and HFrEF. Methods We searched electronic databases for all RCTs that compared catheter ablation and medical therapy (with or without use of AAD). We used random-effects models to summarize the studies. The primary end-point was all-cause mortality. Secondary outcomes included heart failure-related hospitalizations and change in left ventricular ejection fraction (LVEF). Results We retrieved and summarized 7 randomized controlled trials, enrolling 856 patients (429 in the catheter ablation arm and 427 in the medical therapy arm). Compared with medical therapy (including use of AAD), AF catheter ablation was associated with a significant reduction in mortality (risk ratio 0.50; 95% confidence interval [CI]: 0.34 to 0.74; P = 0.0005) and heart failure-related hospitalizations (risk ratio 0.56; 95% CI: 0.44 to 0.71; P < 0.0001). Furthermore, catheter ablation led to significant improvements in LVEF (weighted mean difference, 7.48; 95% CI: 3.71 to 11.26; P < 0.0001). Conclusions Compared to medical therapy, including use of AAD, catheter ablation for AF was associated with a significant reduction in mortality and heart failure-related hospitalizations as well as an improvement in LVEF in patients with HFrEF. Larger trials are needed to confirm whether rhythm control with ablation is superior to rate control in patients with AF and heart failure

Consequences of twinning induction to Noemi ewes by a recombinant human follicle-stimulating hormone compared with pituitary-derived porcine follicle-stimulating hormone on follicular dynamics, maternal biochemical attributes, and neonatal traits

Aim: The aim of this study was to investigate the effectiveness of using recombinant human follicle-stimulating hormone (FSH) compared with pituitary-derived porcine FSH given as one dose or multiple doses on the neonatal traits, follicular dynamics, and maternal blood biochemical constituents in Noemi ewes. Materials and Methods: A 3×2 factorial arrangement was designed utilizing 60 adults Noemi ewes to test the effects of using two sources of FSH (human vs. porcine) in addition to control, either given as a single total dose or six descending doses to provoke twinning. Six treatments (T) were tested (n=10 ewes/T). C1 and C6 served as control ewes given saline as one dose and six doses, respectively; H1 and H6 ewes were given human FSH as one and six doses; and P1 and P6 ewes were given porcine FSH similar to the above treatments. Saline and/or FSH administration were administered at days 8, 9, and 10 of the 10-day controlled internal drug release (CIDR) implant. At CIDR removal, fertile rams were used for natural mating. Blood samples for the assessment of serum metabolites were collected. Results: Twinning increased in FSH-treated ewes than control. However, giving FSH of either source as a single dose resulted in a higher incidence of stillbirths. Pregnancy rates were 30, 40, 50, 60, 70, and 80% in C1, C6, P1, P6, H1, and H6, respectively. Respective percent of ewes delivering twins/multiple birth was 0, 0, 80, 66.7, 71.4, and 87.5%. FSH of human source was more efficient for folliculogenesis than porcine FSH. Administration of FSH increased blood cholesterol, decreased high-density lipoprotein; however, low-density lipoprotein levels were not different than control. Moreover, an interaction (p<0.05) exists between source and type of FSH administration on blood glucose. Six doses of FSH elevated blood protein. Blood albumin decreased by porcine-FSH but not affected by human-FSH. Blood globulins were not different due to source of FSH, whereas giving FSH as six doses increased globulins than in single-dose protocol. Contrariwise, an interaction was found between source and type of FSH administration on elevating the activity of alanine aminotransferase and reducing the activity of aspartate aminotransferase. Conclusion: Administration of human FSH at 180 IU in six descending doses resulted in the best neonatal outcomes and maternal health in Noemi ewes

Phospholipase C zeta profiles are indicative of optimal sperm parameters and fertilisation success in patients undergoing fertility treatment.

Oocyte activation is driven by intracellular calcium (Ca ) oscillations induced by sperm-specific PLCζ, abrogation of which causes oocyte activation deficiency in humans. Clinical PLCζ investigations have been limited to severe male infertility conditions, while PLCζ levels and localisation patterns have yet to be associated with general sperm viability. PLCζ profiles were examined within a general population of males attending a fertility clinic (65 patients; aged 29-53), examining PLCζ throughout various fractions of sperm viability. Male recruitment criteria required a minimum sperm count of 5 × 10 spermatozoa/mL, while all female patients included in this study yielded at least five oocytes for treatment. Sperm count, motility and semen volume were recorded according to standard WHO reference guidelines and correlated with PLCζ profiles examined via immunoblotting and immunofluorescence. Appropriate fertility treatments were performed following routine clinical standard operating protocols, and fertilisation success determined by successful observation of second polar body extrusion. Four distinct PLCζ patterns were observed at the equatorial, acrosomal + equatorial regions of the sperm head, alongside a dispersed pattern, and a population of spermatozoa without any PLCζ. Acrosomal + equatorial PLCζ correlated most to sperm health, while dispersed PLCζ correlated to decreased sperm viability. Total levels of PLCζ exhibited significant correlations with sperm parameters. PLCζ variance corresponded to reduced sperm health, potentially underlying cases of male sub-fertility and increasing male age. Finally, significantly higher levels of PLCζ were exhibited by cases of fertilisation success, alongside higher proportions of Ac + Eq, and lower levels of dispersed PLCζ. PLCζ potentially represents a biomarker of sperm health, and fertilisation capacity in general cases of patients seeking fertility treatment, and not just cases of repeated fertilisation. Further focused investigations are required with larger cohorts to examine the full clinical potential of PLCζ.Healthcare Research Fellowship Award (HF-14-16) made by Health and Care Research Wales (HCRW). JK was supported by a Healthcare Research Fellowship Award (HF‐14‐16) made by Health and Care Research Wales (HCRW). This study was also supported by a National Science, Technology and Innovation plan (NSTIP) project grant (15‐MED4186‐20) awarded by the King Abdulaziz City for Science and Technology (KACST) to JK, AMA and FAL

CHRONIC JOINT PAIN MANAGEMENT

Introduction: In the year 2010, the Pain Management Task Force of the American College of Rheumatology (ACR) stated on their guidelines regarding pain as a crucial consideration within the clinical practice of rheumatologists and rheumatology around the world. The Executive Committee of the ACR later recommended the task force to raise the knowledge of a rheumatologist’s part during the management of pain and the place of pain in rheumatology-related research, practice, and clinical education protocols. The report included guidelines to be recommended by the ACR and the Association of Rheumatology Health Professionals (ARHP). Since the year 2010, the Institute of Medicine published their guidelines with the title “Relieving Pain in America,” which focused on the importance of tailoring pain care to the special needs of the level of individual patients; these guidelines also emphasized on the high importance of inter-disciplinary clinical care. however, in the last decade, the guidelines of ACR Pain Management Task Force have achieved only limited goals as had occurred similarly with similar guidelines published by other association like the Institute of Medicine. With the 2010 Task Force guidelines in mind, this review will provide an update of the status of the place of pain as a general concern during the practice of the subspecialty of rheumatology.Aim of work: In this review, we will discuss Chronic joint pain management.Methodology: We did a systematic search for Chronic joint pain management in the emergency department using PubMed search engine (http://www.ncbi.nlm.nih.gov/) and Google Scholar search engine (https://scholar.google.com). All relevant studies were retrieved and discussed. We only included full articles.Conclusions: The issue of pain and its therapy is still an area of research, debates and clinical significance. Our understanding of pain pathophysiology is improving but remains not complete. Pain therapies remain insufficient in benefits and linked to with several toxicities. Despite this, rheumatologists and physicians continue to treat patients with painful rheumatic conditions on a daily basis. The specialty of rheumatology, through its professional organizations ACR and ARHP must keep the forefront of advances in the elucidation of pain and its impact on patients with rheumatic diseases. The ACR and ARHP must be committed to supporting pain research and informing its membership, including trainees, about advances in this field. Key words: Chronic joint pain, causes, management

Impact of question order on prioritisation of outcomes in the development of a core outcome set: A randomised controlled trial

Background: Core outcome set (COS) developers increasingly employ Delphi surveys to elicit stakeholders' opinions of which outcomes to measure and report in trials of a particular condition or intervention. Research outside of Delphi surveys and COS development demonstrates that question order can affect response rates and lead to 'context effects', where prior questions determine an item's meaning and influence responses. This study examined the impact of question order within a Delphi survey for a COS for oesophageal cancer surgery. Methods: A randomised controlled trial was nested within the Delphi survey. Patients and health professionals were randomised to receive a survey including clinical and patient-reported outcomes (PROs), where the PRO section appeared first or last. Participants rated (1-9) the importance of 68 items for inclusion in a COS (ratings 7-9 considered 'essential'). Analyses considered the impact of question order on: (1) survey response rates; (2) participants' responses; and (3) items retained at end of the survey. Results: In total, 116 patients and 71 professionals returned completed surveys. Question order did not affect response rates among patients, but fewer professionals responded when clinical items appeared first (difference = 31.3%, 95% confidence interval [CI] = 13.6-48.9%, P = 0.001). Question order led to different context effects within patients and professionals. While patients rated clinical items highly, irrespective of question order, more PROs were rated essential when appearing last rather than first (difference = 23.7%, 95% CI = 10.5-40.8%). Among professionals, the greatest impact was on clinical items; a higher percentage rated essential when appearing last (difference = 11.6%, 95% CI = 0.0-23.3%). An interaction between question order and the percentage of PRO/clinical items rated essential was observed for patients (P = 0.025) but not professionals (P = 0.357). Items retained for further consideration at the end of the survey were dependent on question order, with discordant items (retained by one question order group only) observed in patients (18/68 [26%]) and professionals (20/68 [29%]). Conclusions: In the development of a COS, participants' ratings of potential outcomes within a Delphi survey depend on the context (order) in which the outcomes are asked, consequently impacting on the final COS. Initial piloting is recommended with consideration of the randomisation of items in the survey to reduce potential bias. Trial registration: The randomised controlled trial reported within this paper was nested within the development of a core outcome set to investigate processes in core outcome set development. Outcomes were not health-related and trial registration was not therefore applicable.</p