Revisional laparoscopic parastomal hernia repair

Background: We herein report a laparoscopically performed re-do operation on a patient who had previously undergone a laparoscopic parastomal hernia repair. Case Report: We describe the case of a 71-year-old patient who presented within 3 months of her primary laparoscopic parastomal hernia repair with recurrence. On relaparoscopy, dense adhesions to the mesh were found, and the mesh had migrated into the hernia sac. This had allowed loops of small bowel to herniate into the sac. The initial part of the procedure involved the lysis of adhesions. A piece of Gore-Tex DualMesh with a central keyhole and a radial slit was cut so that it could provide at least 3 cm to 5 cm of overlap of the fascial defect. The tails of the mesh were wrapped around the bowel, and the mesh was secured to the margins of the hernia with circumferential metal tacking and 4 transfascial sutures. The patient remains in satisfactory condition and no recurrence or any surgery-related problem has been observed during 8 months of follow-up. Conclusion: Revisional laparoscopic repair of parastomal hernias seems feasible and has been shown to be safe and effective in this case. The success of this approach depends on longer follow-up reports and standardization of the technical elements

Is antenatal screening for hepatitis C virus cost-effective? A decade's experience at a London centre

BACKGROUND & AIMS: This study aims to assess the cost-effectiveness of a routine universal antenatal hepatitis C virus (HCV) screening programme at a London centre. METHODS: Ten years’ retrospective antenatal screening and outcome data informed a cost-effectiveness analysis using the previously validated MONARCH model. The cost and quality of life outcomes associated with the screening and treatment of newly identified hepatitis C cases were used to generate cost-effectiveness estimates for the screening programme. RESULTS: A total of 35,355 women were screened between 1st November 2003 and 1st March 2013; 136 women (0.38%) were found to be HCV antibody positive. Of 78 (0.22%) viraemic cases, 44 (0.12%) were newly diagnosed. In addition, the screening programme identified three (6.8%) vertical transmissions in children of newly diagnosed mothers. Of 16 newly diagnosed mothers biopsied, all were in the F0-F2 METAVIR disease stages, and 50% had HCV genotype 1. Postnatal treatment with pegylated interferon and ribavirin was initiated in 19 women, with 14 (74%) achieving sustained virologic response. The total cost of screening and confirmation of diagnoses was estimated to be £240,641. This translates to £5469 per newly diagnosed individual. The incremental cost-effectiveness ratio of this screening and treatment strategy was £2400 per QALY gained. Treatment with newer direct-acting antiviral regimens would have a projected cost of £9139 per QALY gained, well below the £20,000-30,000/QALY gained willingness-to-pay threshold applied by policy advisory bodies. CONCLUSIONS: This study demonstrates that an antenatal screening and treatment programme is feasible and effective, at a cost considered acceptable

In-hospital mortality is associated with inflammatory response in NAFLD patients admitted for COVID-19

Background & aims Although metabolic risk factors are associated with more severe COVID-19, there is little evidence on outcomes in patients with non-alcoholic fatty liver disease (NAFLD). We here describe the clinical characteristics and outcomes of NAFLD patients in a cohort hospitalised for COVID-19. Methods This study included all consecutive patients admitted for COVID-19 between February and April 2020 at Imperial College Healthcare NHS Trust, with either imaging of the liver available dated within one year from the admission or a known diagnosis of NAFLD. Clinical data and early weaning score (EWS) were recorded. NAFLD diagnosis was based on imaging or past medical history and patients were stratified for Fibrosis-4 (FIB-4) index. Clinical endpoints were admission to intensive care unit (ICU)and in-hospital mortality. Results 561 patients were admitted. Overall, 193 patients were included in the study. Fifty nine patients (30%) died, 9 (5%) were still in hospital, and 125 (65%) were discharged. The NAFLD cohort (n = 61) was significantly younger (60 vs 70.5 years, p = 0.046) at presentation compared to the non-NAFLD (n = 132). NAFLD diagnosis was not associated with adverse outcomes. However, the NAFLD group had higher C reactive protein (CRP) (107 vs 91.2 mg/L, p = 0.05) compared to non-NAFLD(n = 132). Among NAFLD patients, male gender (p = 0.01), ferritin (p = 0.003) and EWS (p = 0.047) were associated with in-hospital mortality, while the presence of intermediate/high risk FIB-4 or liver cirrhosis was not. Conclusion The presence of NAFLD per se was not associated with worse outcomes in patients hospitalised for COVID-19. Though NAFLD patients were younger on admission, disease stage was not associated with clinical outcomes. Yet, mortality was associated with gender and a pronounced inflammatory response in the NAFLD group

Cost-effectiveness of strategies to improve HCV screening, linkage-to-care and treatment in remand prison settings in England.

BACKGROUND: A simplified cascade-of-care may improve screening and treatment uptake among incarcerated individuals. We assessed the cost-effectiveness of traditional and simplified screening and treatment in a London remand prison. METHODS: Using empirical data from Her Majesty's Prison (HMP) Wormwood Scrubs, London, we designed a decision tree and Markov transition state model using national average data for HCV screening and treatment for the base-case scenario. This was compared two alternative strategies; (1) general prison population screening and treatment and (2) prioritising screening and treatment among people who inject drugs (PWID) combined with general prison population screening and treatment. Strategies varied the rates of screening (47-90%), linkage-to-care (60-86%) and treatment (21-85%). Cost, utility and disease transition rates were obtained from existing literature. Outcome measures were; screening, treatment and disease-related costs per admitted individual, quality-adjusted life years (QALYs). Incremental cost-effectiveness ratios (ICERs) were calculated for each intervention. All costs and utilities were discounted at a rate of 3.5% per annum. Both univariate and probabilistic sensitivity analyses have been conducted. RESULTS: In our cohort of 5,239 incarcerated individuals with an estimated chronic HCV prevalence of 2.6%, all strategy ICER values (£3,565-10,300) fell below the national willingness to pay threshold (£30,000). Increased successful treatment (7-54%) was observed by an optimising cascade-of-care. A robust sensitivity analysis identified treatment cost of, QALY for mild liver disease and probability of completing treatment as important factors that impact the ICER value. CONCLUSION: In our remand setting, optimising adherence to the cascade-of-care is cost-effective. Where universal screening is not practical, a stratified approach focused on intensive screening and treatment of PWID also results in increased treatment uptake and is highly cost-effective

Review of rifaximin: a summary of the current evidence and its benefits beyond its licensed use

Antibiotic resistance in patients with cirrhosis continues to draw significant attention. With a propensity to frequent hospitalisations, cirrhotics are subject to frequent antibiotic prescription. This increases their risk of developing resistance to one or more antimicrobial agents, making management of their condition particularly challenging. Despite advancements being made in the management of liver disease, mortality rates continue to rise; almost fivefold in those under 65 years, whilst remaining the leading cause of death in those between the ages of 35-49 years. Urgent alternative therapeutic options to prevent disease progression and cirrhosis-associated complications are urgently required. Rifaximin is one such example, with its use in patients with cirrhosis demonstrating additional benefits beyond its current licensed use. Its current licensed use in the UK is for the prevention of hepatic encephalopathy and traveller’s diarrhoea; however, its use in the context of enteric-driven pathologies has been explored. Through rifaximin’s key central action as a broad-spectrum antimicrobial, it has the ability to modulate the gut-liver axis via removal of gut microbial products associated with the progression of cirrhosis and its sequalae. The benefits of rifaximin use continues to gather some momentum, given its non-absorbable nature and well tolerated side-effect profile, and these require consideration. With broad spectrum antimicrobial properties, its use may assist in overcoming the conundrum posed of antibiotic resistance amongst cirrhotics. This literature review discusses the chemical and antimicrobial properties of rifaximin, its licenced indication for use, and its reported benefits beyond this. We also consider concerns regarding rifaximin resistance

Multidisciplinary crisis simulations: the way forward for training surgical teams.

BACKGROUND: High-reliability organizations have stressed the importance of non-technical skills for safety and of regularly providing such training to their teams. Recently safety skills training has been applied in the practice of medicine. In this study, we developed and piloted a module using multidisciplinary crisis scenarios in a simulated operating theatre to train entire surgical teams. METHODS: Twenty teams participated (n = 80); each consisted of a trainee surgeon, anesthetist, operating department practitioner (ODP), and scrub nurse. Crisis scenarios such as difficult intubation, hemorrhage, or cardiac arrest were simulated. Technical and non-technical skills (leadership, communication, team skills, decision making, and vigilance), were assessed by clinical experts and by two psychologists using relevant technical and human factors rating scales. Participants received technical and non-technical feedback, and the whole team received feedback on teamwork. RESULTS: Trainees assessed the training favorably. For technical skills there were no differences between surgical trainees' assessment scores and the assessment scores of the trainers. However, nurses overrated their technical skill. Regarding non-technical skills, leadership and decision making were scored lower than the other three non-technical skills (communication, team skills, and vigilance). Surgeons scored lower than nurses on communication and teamwork skills. Surgeons and anesthetists scored lower than nurses on leadership. CONCLUSIONS: Multidisciplinary simulation-based team training is feasible and well received by surgical teams. Non-technical skills can be assessed alongside technical skills, and differences in performance indicate where there is a need for further training. Future work should focus on developing team performance measures for training and on the development and evaluation of systematic training for technical and non-technical skills to enhance team performance and safety in surgery

A clinician's guide to the cost and health benefits of hepatitis C cure assessed from the individual patient perspective

Background and aims: The hepatitis C virus (HCV) remains a considerable public health challenge. Novel direct-acting antiviral (DAA) regimens offer high cure rates and the promise of reduced HCV incidence and prevalence following the up-scaling of treatment. This has focused attention towards affordability. This study aimed to estimate the economic value of cure to evaluate the treatment costs justifiable from the patient perspective. Patients and methods: A published, validated HCV model was utilized to contrast clinical and cost outcomes for patients aged 30–70 years, stratified by METAVIR F0–F4, for (i) no treatment and (ii) successful treatment [i.e. sustained virologic response (SVR)] ignoring the cost of treatment. Regression equations were fitted and used to determine the financial expenditure justifiable to achieve a cost-neutral or a cost-effective [£20 000 per quality-adjusted life-year (QALY)] cure. Model inputs were derived from UK literature; costs and utilities were discounted at 3.5% over a lifetime horizon. Results: To achieve cost-neutrality, the maximum discounted expenditure justifiable for SVR was £3774–43 607 across ages and fibrosis stages. Spending between £19 745 (70 years, F0) and £188 420 (30 years, F4) on SVR is expected to be cost-effective at £20 000/QALY willingness-to-pay threshold. Conclusion: Heterogeneity across HCV patients is considerable, which can obscure the relevance of conventional cohort-based economic models evaluated at the mean, particularly when considering the value of treatment at the individual patient level. By quantifying the full exposition of HCV cost-savings and health benefits realizable following HCV cure, this study provides insight into the economic value of successful treatment from the patient perspective.Phil McEwan, Nowlan Selvapatt, Ashley Brown, Mark Thursz, Hayley Bennett, Samantha Webster, Anupama Kalsekar, Yong Yuan, Michael Brenner, Jason Gordo