Background The Asthma Control Questionnaire (ACQ) is used to assess asthma symptom control. The relationship between the questionnaire items and symptom control has not been fully studied in severe asthmatic patients, and its validity for making comparisons between subgroups of patients is unknown. Methods Data was obtained from patients in the United Kingdom Severe Asthma Registry whose symptom control was assessed using the five-item ACQ (ACQ5) (n = 2,951). Confirmatory factor analysis determined whether a latent factor for asthma symptom control, as measured by the ACQ5, was consistent with the data. Measurement invariance was examined in relation to ethnicity, sex and age; this included testing for approximate measurement invariance using Bayesian Structural Equation Modelling (BSEM). The fitted models were used to estimate the internal consistency reliability of the ACQ5. Invariance of factor means across subgroups was assessed. Results A one-factor construct with residual correlations for the ACQ5 was an excellent fit to the data in all subgroups (Root Mean Square Error Approximation 0.03 [90%CI 0.02,0.05], p-close fit 0.93, Comparative Fit Index 1.00, Tucker Lewis Index 1.00}. Expected item responses were consistent for Caucasian and non-Caucasian patients with the same absolute level of symptom control. There was some evidence that females and younger adults reported wakening more frequently during the night than males and older adults respectively with the same absolute level of symptom control (p<0.001). However approximate measurement invariance was tenable and any failure to observe strong measurement invariance had minimal impact when comparing mean levels of asthma symptom control between patients of different sexes or ages. Average levels of asthma symptom control were lower for non-Caucasians (p = 0.001), females (p<0.01)and increased with age (p<0.01). Reliability of the instrument was high (over 88%) in all subgroups studied. Conclusion The ACQ5 is informative in comparing levels of symptom control between severe asthmatic patients of different ethnicities, sexes and ages. It is important that analyses are replicated in other severe asthma registries to determine whether measurement invariance is observed.
Ethnic disparities exist within asthma; however, country of birth is rarely investigated. We described demographic and clinical characteristics by ethnicity and country of birth within the UK Biobank. Lung function and asthma hospitalisations were similar for white, black and North-East Asian participants, however, South-East (SE) Asians more commonly had an FEV 1 below the lower limits of normal (LLN; 53.8% vs 32.3%, p<0.001), blood eosinophilia (38.6% vs 23.8%, p<0.001) and asthma hospitalisation (12.5% vs 8.3%, p<0.001) than white participants. First-generation SE Asian immigrants had poorer lung function (57.7% vs 27.7% FEV 1 below LLN, p<0.001) than UK/Ireland born participants. These data demonstrate inter-ethnic and intra-ethnic disparities.
Objectives Determine the incremental diagnostic yield of prenatal exome sequencing (pES) over chromosome microarray (CMA) or G‐banding karyotype in fetuses with central nervous system (CNS) abnormalities. Methods Data were collected via electronic searches from January 2010 to April 2022 in MEDLINE, Cochrane, Web of Science and EMBASE. The NHS England prenatal exome cohort was also included. Incremental yield was calculated as a pooled value using a random‐effects model. Results Thirty studies were included ( n = 1583 cases). The incremental yield with pES for any CNS anomaly was 32% [95%CI 27%–36%; I ² = 72%]. Subgroup analysis revealed apparent incremental yields in; (a) isolated CNS anomalies; 27% [95%CI 19%–34%; I ² = 74%]; (b) single CNS anomaly; 16% [95% CI 10%–23%; I ² = 41%]; (c) more than one CNS anomaly; 31% [95% Cl 21%–40%; I ² = 56%]; and (d) the anatomical subtype with the most optimal yield was Type 1 malformation of cortical development, related to abnormal cell proliferation or apoptosis, incorporating microcephalies, megalencephalies and dysplasia; 40% (22%–57%; I ² = 68%). The commonest syndromes in isolated cases were Lissencephaly 3 and X‐linked hydrocephalus. Conclusions Prenatal exome sequencing provides a high incremental diagnostic yield in fetuses with CNS abnormalities with optimal yields in cases with multiple CNS anomalies, particularly those affecting the midline, posterior fossa and cortex.
Optimal diabetes self‐management requires the balancing of physical, behavioural and psychological health. Although ownership lies with the person living with diabetes, the interaction and relationship between the individual and their health care professionals play a key role in achieving that outcome. This paper presents key summaries generated from the 6th International Diabetes Self‐Management Alliance conference workshop, exploring barriers to emotional support in routine diabetes care. In particular, we explored barriers around: (a) not having sufficient time during consultations to routinely address emotional well‐being; (b) the lack of confidence expressed by health care professionals in their ability to have emotional conversations with their patients; (c) training, bringing a focus to a more person‐centred approach for existing service models; and (d) the fear of opening Pandora's Box and discovering complex or emotionally overwhelming topics. The aim of this practice point paper is to provide a platform for researchers and policymakers to further explore these barriers and generate ideas to inform future research aimed at improving the landscape of emotional support in diabetes care. Copyright © 2023 John Wiley & Sons.
Objective Determine the incremental yield of prenatal exome sequencing (PES) over chromosome microarray (CMA) and/or karyotype for urinary tract malformations (UTMs). Method A prospective cohort study encompassing data from the English Genomic Medicine Service North Thames Laboratory Hub for fetuses with bilateral echogenic kidneys (BEKs) was combined with data from a systematic review. MEDLINE, EMBASE, Web of Science, MedRxiv and GreyLit were searched from 01/2010‐02/2023 for studies reporting on the yield of PES over CMA or karyotype in fetuses with UTMs. Pooled incremental yield was determined using a random effects model. PROSPERO CRD42023364544. Results Fourteen studies (410 cases) were included. The incremental yield for multisystem UTMs, any isolated UTMs, and BEKs was 31% [95% CI, 18%–46%; I ² = 78%], 16% [95% CI, 6%–26%; I ² = 80%] and 51% [95% CI, 27%–75%; I ² = 34%]. The most common clinical diseases and syndromes identified, based on the variant genes detected, were Bardet‐Biedl syndrome ( BBS genes), dominant and recessive polycystic kidney diseases ( PKD1 , PKD2 and PKHD1 ) and renal cysts and diabetes syndrome ( HNF1B ). Conclusion There was a notable incremental genetic diagnostic yield when PES was applied to multisystem UTMs and BEKs. There was a modest incremental yield when this technique was used for UTMs other than BEKs.
Aim Heart failure is an escalating burden on global health care systems. Modernizing heart failure care is inevitable, with eHealth products poised to play an important role. However, eHealth devices that can initiate and adjust heart failure medication are currently lacking. Consequently, this study aimed to develop an artificial intelligence-based decision engine to provide guideline-based recommendations for disease-modifying medication in heart failure patients. Methods and Results We developed the decision engine by converting the ESC heart failure guidelines into Business Process Model and Notation, a visual modeling language suitable for developing complex decision engines. A safety evaluation, based on clinical parameters, was conducted to ascertain the system’s applicability to specific cases. The decision engine renders specific decisions concerning disease- modifying therapy for heart failure patients. We defined 72 virtual heart failure patient scenarios, encompassing a broad spectrum of baseline characteristics and background medication. All recommendations offered by the engine were evaluated by an independent heart failure specialist. All but three recommendations (94%) were identical to the treatment decisions by the heart failure specialist and all (100%) were in line with the 2021 ESC heart failure guidelines. Conclusion The decision engine offers guideline-based recommendations for disease-modifying therapy, positioning it as a tool to enhance self-care among heart failure patients. To validate our results, the decision engine is being prospectively tested in real-world patients in a multicenter clinical trial (NCT04699253).
SARS-CoV-2 binds to ACE2 receptors and enters cells. The symptoms are cough, breathlessness, loss of taste/smell and X-ray evidence of infiltrates on chest imaging initially caused by oedema, and subsequently by a lymphocytic pneumonitis. Coagulopathy, thrombosis and hypotension occur. Worse disease occurs with age, obesity, ischaemic heart disease, hypertension and diabetes. These features may be due to abnormal activation of the contact system. This triggers coagulation and the kallikrein-kinin system, leading to accumulation of bradykinin and its derivatives, which act on receptors B1R and B2R. Receptor activation causes cough, hypotension, oedema and release of the cytokine interleukin-6 (IL-6) which recruits lymphocytes. These effects are core features seen in early SARS CoV-2 infection. Methods and analysis In this study, hypoxic patients with COVID-19 with symptom onset ≤7 days will be randomised to either a bradykinin inhibitor (icatibant) or placebo. Patients and investigators will be blinded. The primary outcome will be blood oxygenation, measured by arterial blood sampling. The secondary outcome will be cardiovascular status. Retinal imaging will be performed to assess vessel size. Blood samples will be taken for measurement of inflammatory analyses including IL-6. As a separate substudy, we will also take comparator blood inflammatory samples from a COVID-19-negative cohort. Ethics and dissemination The study has received the following approvals: West Midlands–Edgbaston Research Ethics Committee. Medicines and Healthcare products Regulatory Agency has issued a clinical trial authorisation. Belfast Health and Social Care Trust is the study sponsor. Results will be made available to participants upon request and findings will be presented and published. Trial registration number NCT05407597
Objectives National guidelines (NICE – Epilepsies: diagnosis and management; NICE-Quality standards: epilepsy in adults) set clinical standards for first seizure management. NAPIER assesses adherence of these standards across outpatient neurologist clinics in the UK and Ireland. Methods This retrospective multicentre audit included suspected first seizure patients (≥16 years) referred to neurologist clinics from 31st December 2019 going backwards (30 consecutive patients per centre). Patients with pre-existing diagnosis of epilepsy were excluded. Referral, clinic, and follow-up data are reported with descriptive statistics. Results 748 patients were included from 26 hospitals (median age 41 years; 51% males). 17.2% of referred patients did not attend their clinic. Most referrals came from emergency departments (43.2%) and general practice (42.9%). Median time to review was 49 days from referral, with 13.5% of patients assessed within 2 weeks. 12.4% experienced seizure recurrence whilst awaiting clinic review. Specialist diagnoses were as follows: seizure mimic (30.3%), first seizure (28.9%), new diagnosis epilepsy (18%), unexplained event (17.8%). Initial specialist diagnoses remain unchanged in 78.9% of patients and 10.2% developed epilepsy (24 months minimum follow-up). Conclusion Many first seizure patients did not receive specialist assessment within 2 weeks of referral, with subsequent management and outcomes not meeting NICE clinical standards.
Adenoid basal carcinoma (ABC) is a rare clinically indolent human papillomavirus–associated cervical neoplasm with uniformly bland morphology which in pure form does not metastasize. Many cases co-exist with a human papillomavirus–associated high-grade squamous intraepithelial lesion (HSIL) or squamous cell carcinoma (SCC). The ABC and high-grade squamous components may be clearly separate, albeit intermingled, and when the high-grade squamous component is invasive, the tumor is designated a mixed carcinoma, with clinical behavior determined by the non-ABC component. In other cases, discrete nests of high-grade atypical squamous cells are intimately admixed and incorporated within the ABC. These are more difficult to classify but are also usually reported as mixed carcinomas. Herein, we report a series of 9 cases of ABC in patients aged 33 to 89 years (mean age: 63 y) with a high-grade squamous component. In 7 cases, the high-grade squamous cells partly replaced and expanded the nests of ABC, sometimes with a residual cuff of ABC cells, while in the other 2 cases the ABC and SCC were clearly separate. We propose that the aforementioned 7 cases represent colonization of ABC by HSIL rather than mixed carcinomas; as far as we are aware, this concept has not been proposed before. In all cases which we feel represent colonization of ABC by HSIL, the tumors were confined to the cervix (stages IA1 [3 tumors], IA2 [2 tumors], IB1 [2 tumors]) and follow-up was unremarkable with no evidence of metastasis. One case with separate components of ABC and SCC was stage IVA at diagnosis and the patient died of disease. The other was stage IB1 at diagnosis and the patient died of unrelated causes at 13 months. We discuss the clinical implications of distinguishing true mixed carcinomas from colonization of ABC by HSIL and provide an approach to diagnosis. We also report a unique case of colonization of so-called cervical ectopic prostatic tissue by HSIL.
To investigate if the effect of cardiac computed tomography (CT) vs. invasive coronary angiography (ICA) on cardiovascular events differs based on smoking status. This pre-specified subgroup analysis of the pragmatic, prospective, multicentre, randomised DISCHARGE trial (NCT02400229) involved 3561 patients with suspected coronary artery disease (CAD). The primary endpoint was major adverse cardiovascular events (MACE: cardiovascular death, non-fatal myocardial infarction, or stroke). Secondary endpoints included an expanded MACE composite (MACE, transient ischaemic attack, or major procedure-related complications). Of 3445 randomised patients with smoking data (mean age 59.1 years + / − 9.7, 1151 men), at 3.5-year follow-up, the effect of CT vs. ICA on MACE was consistent across smoking groups (p for interaction = 0.98). The percutaneous coronary intervention rate was significantly lower with a CT-first strategy in smokers and former smokers (p = 0.01 for both). A CT-first strategy reduced the hazard of major procedure-related complications (HR: 0.21, 95% CI: 0.03, 0.81; p = 0.045) across smoking groups. In current smokers, the expanded MACE composite was lower in the CT- compared to the ICA-first strategy (2.3% (8) vs 6.0% (18), HR: 0.38; 95% CI: 0.17, 0.88). The rate of non-obstructive CAD was significantly higher in all three smoking groups in the CT-first strategy. For patients with stable chest pain referred for ICA, the clinical outcomes of CT were consistent across smoking status. The CT-first approach led to a higher detection rate of non-obstructive CAD and fewer major procedure-related complications in smokers. This pre-specified sub-analysis of the DISCHARGE trial confirms that a CT-first strategy in patients with stable chest pain referred for invasive coronary angiography with an intermediate pre-test probability of coronary artery disease is as effective as and safer than invasive coronary angiography, irrespective of smoking status. ClinicalTrials.gov NCT02400229. • No randomised studies have assessed smoking status on CT effectiveness in symptomatic patients referred for invasive coronary angiography. • A CT-first strategy results in comparable adverse events, fewer complications, and increased coronary artery disease detection, irrespective of smoking status. • A CT-first strategy is safe and effective for stable chest pain patients with intermediate pre-test probability for CAD, including never smokers.
Meticulous macroscopic examination of specimens and tissue sampling are crucial for accurate histopathology reporting. However, macroscopy has generally received less attention than microscopy and may be delegated to relatively inexperienced practitioners with limited guidance and supervision. This introductory paper in the minisymposium, Macroscopy Under the Microscope , focuses on issues regarding macroscopic examination and tissue sampling that have been insufficiently addressed in the published literature. It highlights the importance of specimen examination and sampling, discusses some general principles, outlines challenges and suggests potential solutions. It is critical to get macroscopy right the first time as it may not be possible to rectify errors even with expert histological assessment or to retrospectively collect missing data after the specimen retention period. Dissectors must, therefore, receive adequate guidance and supervision until they are proficient in macroscopic specimen examination. We emphasise the importance of the clinical context, optimal specimen fixation, succinct and clinically relevant macroscopic descriptions, macrophotography and judicious tissue sampling. We note that current recommendations based on the number of blocks to be submitted per maximum tumour dimension are ambiguous as the amount of tissue submitted in a cassette is not standardised and it is unclear whether ‘block’ refers to a tissue block or a paraffin block. Concerns around potential oversampling of ‘therapeutic’ specimens that could result in overdiagnosis due to detection of incidentalomas are also discussed. We hope that the issues discussed in this paper will engender debate on this clinically critical aspect of pathology practice.
Background Inconsistent nomenclature and anatomical descriptions of regional anesthetic techniques hinder scientific communication and engender confusion; this in turn has implications for research, education and clinical implementation of regional anesthesia. Having produced standardized nomenclature for abdominal wall, paraspinal and chest wall regional anesthetic techniques, we aimed to similarly do so for upper and lower limb peripheral nerve blocks. Methods We performed a three-round Delphi international consensus study to generate standardized names and anatomical descriptions of upper and lower limb regional anesthetic techniques. A long list of names and anatomical description of blocks of upper and lower extremities was produced by the members of the steering committee. Subsequently, two rounds of anonymized voting and commenting were followed by a third virtual round table to secure consensus for items that remained outstanding after the first and second rounds. As with previous methodology, strong consensus was defined as ≥75% agreement and weak consensus as 50%–74% agreement. Results A total of 94, 91 and 65 collaborators participated in the first, second and third rounds, respectively. We achieved strong consensus for 38 names and 33 anatomical descriptions, and weak consensus for five anatomical descriptions. We agreed on a template for naming peripheral nerve blocks based on the name of the nerve and the anatomical location of the blockade and identified several areas for future research. Conclusions We achieved consensus on nomenclature and anatomical descriptions of regional anesthetic techniques for upper and lower limb nerve blocks, and recommend using this framework in clinical and academic practice. This should improve research, teaching and learning of regional anesthesia to eventually improve patient care.
Aims NTRK ‐rearranged sarcomas of the female genital tract mainly occur in the uterus (more commonly cervix than corpus) and are characterized by a “fibrosarcoma‐like” morphology and NTRK gene rearrangements. These neoplasms may exhibit histological overlap with other entities and can present diagnostic difficulties without molecular confirmation. Pan‐TRK immunohistochemistry was developed to identify tumours harbouring NTRK rearrangements. The aim of this study was to characterize pan‐TRK immunohistochemical expression in a large cohort of gynaecological mesenchymal neoplasms and investigate the utility of pan‐TRK immunohistochemistry to distinguish NTRK ‐rearranged sarcoma from its mimics. Methods and results A total of 473 gynaecological mesenchymal tumours (461 without known NTRK fusions and 12 NTRK ‐rearranged sarcomas) were selected. Pan‐TRK immunohistochemistry (EPR17341, Abcam) was performed on whole tissue sections and tissue microarrays. Molecular interrogation of pan‐TRK positive tumours was performed by RNA sequencing or fluorescence in situ hybridization (FISH). Of the 12 NTRK ‐rearranged sarcomas, 11 (92%) exhibited diffuse (≥70%) cytoplasmic pan‐TRK staining with moderate/marked intensity, while the other was negative. Eleven (2.4%) additional tumours also exhibited pan‐TRK immunohistochemical expression: three low‐grade endometrial stromal sarcomas, seven high‐grade endometrial stromal sarcomas, and an undifferentiated uterine sarcoma. Molecular confirmation of the absence of NTRK rearrangements was possible in nine of these tumours. Of these nine neoplasms, seven exhibited focal/multifocal (<70%) pan‐TRK cytoplasmic staining with weak/moderate intensity. Conclusion Even though pan‐TRK immunohistochemical expression is not entirely sensitive or specific for NTRK ‐rearranged sarcomas, these neoplasms tend to exhibit diffuse staining of moderate/strong intensity, unlike its mimics. Pan‐TRK should be performed in monomorphic uterine (corpus and cervix) spindle cell neoplasms that are negative for smooth muscle markers and hormone receptors and positive for CD34 and/ or S100. Ultimately, the diagnosis requires molecular confirmation.
Background Accurate staging of locally advanced oesophageal cancer plays a pivotal role in treatment planning and prognostic counselling for the patients. Clinical staging employs various imaging modalities to guide treatment decisions and predict outcomes. This study aimed to compare clinical staging (post neoadjuvant chemotherapy) with the final histopathological staging in patients with locally advanced oesophageal adenocarcinoma undergoing oesophagectomy at Belfast Health and Social Care Trust. Methods A retrospective analysis was conducted on a cohort of 81 patients diagnosed with locally advanced oesophageal adenocarcinoma who underwent neo-adjuvant chemotherapy followed by oesophagectomy at Belfast Trust between March 2020 and March 2022. Patients with squamous cell carcinoma, those who proceeded directly to surgery and those treated with salvage oesophagectomy following previous radical chemo-radiotherapy were excluded from the study to minimise heterogeneity. Two independent radiologists reviewed the restaging PETCT scans and validated the clinical staging. The post neoadjuvant clinical staging was subsequently compared to the final histopathological staging obtained from surgical resection specimens. Results Among the 81 patients included in this study, a significant proportion of patients were upstaged (53%) or downstaged (31%). The combined T&N staging accuracy was observed in only 13 patients (16%). 21 patients (26.3%) had their T staging downstaged on final assessments. Nodal staging discrepancies were observed in 35 cases (43.2%) upon final histopathological assessment. These isolated nodal discrepancies primarily involved nodal upstaging, with 14 patients upstaged from N0 to N1 and 13 patients upstaged from N0 to N2. Conclusions The accuracy of clinical staging for oesophageal adenocarcinoma remains poor. Our study revealed notable discrepancies in nodal staging between clinical and final histopathological staging. Approximately 43.2% of patients had isolated nodal discrepancies, primarily involving nodal upstaging. These findings emphasize the challenges in accurately assessing nodal involvement and highlight the need for improved staging methods to guide optimal treatment for locally advanced oesophageal adenocarcinoma. The topic of whether the routine use of EUS is justified for evaluating regional lymphnodes and enhancing staging remains a subject of debate, notwithstanding the limitations and challenges inherent to EUS.
Background The lack of public bariatric surgical services in Northern Ireland has favoured the growth of bariatric tourism. This retrospective study aimed to analyse the data extracted from the records of bariatric patients who presented with complications to Belfast Health and Social Care Trust following their surgery abroad and investigate the costs associated with managing these complications. It also aimed to explore other factors, such as emotional trauma, that may be associated with bariatric tourism. Methods This was a retrospective study including all patients, who had their bariatric procedure abroad, presenting acutely to our hospital between August 2016 and February 2023. Data were collected from hospital records and included demographic characteristics, type of surgery, nature of complications, and costs associated with managing these complications. Descriptive statistics were used to analyse the data. Results 42 patients included in the study. Majority were female (n=35, 83.3%) with a mean age of 46.6 years. Sleeve gastrectomy was the most common surgery (n=22,52.3%), followed by AGB (n=11,26.1%), Gastric bypass (n=6,14.2%) and Gastric balloon (3,7.1%). Operations were performed in 7 countries, majority were done in Turkey (n= 22). The most common complication was leak (n=14), followed by band erosion (n=7) and nutritional failure (n=7). The total cost was estimated to be (£737,126), which includes hospital-stay costs (£553,179), non-surgical intervention (£55,607), scans (£41,728), and surgical intervention (£75,413). The total cost of dietetic inputs were about £17,390,including 410 hours. Conclusions Most patients experienced emotional trauma related to lack of adequate perioperative care, and difficulties in communication with their overseas surgeons. The results of this study highlight significant costs associated with managing such complications in Northern Ireland. The findings suggest investing in public bariatric surgical services may be more cost-effective than relying on bariatric tourism. Furthermore, Bariatric care is delivered by MDTs which are actively involved in management of these patients throughout their care-pathway. The study highlights lack of perioperative care and follow up needed to minimize complications and associated costs, as well as addressing the emotional trauma of those patients.
Background In the Belfast Trust (BHSCT), general surgery provision is complex- segregated into emergency and elective care, across multiple sites. The Emergency Surgical Unit (EmSU) provides ‘hot’ laparoscopic cholecystectomy (LC), and aside from a brief pause, continued throughout COVID. Elective LC was offered on another site in conjunction with the HPB service. This site became a COVID centre and surgical wards closed. Few cholecystectomies were performed during 2020/1. In an effort to restore provision, two ambulatory lists were established on the emergency site in December 2021. Subsequently, a regional ‘over-night stay’ unit opened on the original elective site in April 2023. Methods Previous BHSCT data demonstrated 300-350 elective LCs are undertaken annually with 66% as day cases. Since COVID, anecdotally significantly less LCs have been performed, and the length of stay (LOS) appeared greater. We performed a retrospective study looking at three time periods for comparison. “Pre-pandemic era” January 2019 to February 2020, “pandemic era” March 2020 to December 2021, and “pandemic recovery” from January 2022 to present. Patients were identified using the local HPB database and the electronic care record was reviewed for each patient. Information was gathered on demographics, day-case rate and LOS, as well as conversion and complication rates. Results In all, 827 patients have undergone cholecystectomy since the beginning of 2019. This is significantly less than the projected 1575, based on previous unit volume. Patient demographics are unchanged with mean age of 51.2 years, BMI of 30.27 and M:F ratio of 1:2.3. With the onset of the pandemic, we observed an increase in the average length of stay from 1.22 to 1.77 days with an associated fall in the day-case rate from 63.1% to 35.1%(figure 1). As demonstrated in figure 2, complication rates increased across the board and have been slow to fall in the recovery phase. Conclusions COVID decimated elective surgery globally. Locally, LC provision is an obvious example, with only urgent cases undertaken (76 in 2021 vs 363 in 2019). Unsurprisingly, conversion and complication rates increased. Despite attempts to reinstate the service, previous volume and outcomes have not been matched for multiple reasons. Increased time to surgery (waiting list >1600pts) means patients present with more severe disease. Ambulatory patients are nursed in EmSU where the environment is not orientated to rapid turnaround surgery. In addition, major losses of experienced nursing staff further impact theatre turnover and added to the challenge of setting up new elective facilities.
Atypical fibroxanthoma (AFX) is a rare low-grade sarcoma that occurs mainly in the elderly and may recur locally. There are multiple variants including keloidal AFX (KAF). KAF is characterised by a proliferation of atypical spindled and epithelioid cells admixed with bizarre pleomorphic cells. These cells intersect among broad bands of keloidal collagen. AFX is a diagnosis of exclusion so a broad panel of immunohistochemical staining should be applied to rule out other differentials (squamous cell carcinoma (SCC), melanoma, leiomyosarcoma, etc). There is added difficulty with the diagnosis of KAF as it may mimic multiple keloidal lesions, including exuberant scarring, as in this case. p53 immunohistochemistry staining can be useful in highlighting the presence of tumour cells. Additionally, next generation sequencing can detect genetic mutations identified in clonal proliferations consistent with tumour formation. KAF is easily overlooked and it should be included in the differential diagnosis for keloidal lesions showing even mild atypia.
Background and Objectives This multicenter retrospective series of consecutive extra‐spinal aneurysmal bone cysts aims to identify risk factors for treatment failure. Methods Aneurysmal bone cysts treated within seven collaborating centers with over 12‐months follow‐up were eligible for inclusion. Survival analyses were performed to identify variables associated with recurrence using log‐rank tests and Cox proportional hazard regression. Results One hundred and fifteen (M:F 60:55) patients were included. Median age at presentation was 13 years and median follow‐up was 27 months. Seventy‐five patients underwent surgical curettage and 27% of these required further intervention for recurrence. Of the 30 patients who underwent biopsy with limited percutaneous curettage as initial procedure, 47% required no further treatment. Patients under 13 years (log‐rank p = 0.006, HR 2.3, p = 0.011) and those treated who had limited curettage (log‐rank p = 0.001, HR 2.7, p = 0.002) had a higher risk of recurrence/persistence. Conclusions There is a high risk of recurrence following surgical treatment for aneurysmal bone cysts and this risk is higher in young patients. However, the cyst heals in a substantial number of patients who have a limited curettage at the time of biopsy.
Background The Synergy Megatron TM is an everolimus‐drug eluting stent that may offer advantages in the treatment of aorto‐ostial disease and large proximal vessels. Aims To report the short‐ to medium‐term clinical outcomes from the European Synergy Megatron TM Implanters' Registry. Methods This registry was an investigator‐initiated study conducted at 14 European centers. The primary outcome was target lesion failure (TLF), defined as the composite of cardiovascular death, target vessel myocardial infarction (MI), and target lesion revascularisation. Results Five hundred seventy‐five patients underwent PCI with Megatron TM between 2019 and 2021. Patients were 69 ± 12 years old, 26% had diabetes mellitus, 24% had moderate‐severe left ventricular impairment and 59% presented with an acute coronary syndrome. 15% were deemed prohibitively high risk for surgical revascularisation. The target vessel involved the left main stem in 55%, the ostium of the RCA in 13% and was a true bifurcation (Medina 1,1,1) in 50%. At 1 year, TLF was observed in 40 patients, with 26 (65%) occurring within the first 30 days. The cumulative incidence of TLF was 4.5% at 30 days and 8.6% (95% CI 6.3–11.7) at 1 year. The incidence of stent thrombosis was 0.5% with no late stent thromboses. By multivariate analysis, the strongest independent predictors of TLF were severe left ventricular impairment (HR 3.43, 95% CI: 1.67–6.76, p < 0.001) and a target vessel involving the left main (HR 4.00 95% CI 1.81–10.15 p = 0.001). Conclusions Use of the Synergy Megatron TM everolimus eluting stent in a ‘real‐world’ setting shows favorable outcomes at 30 days and 1 year.
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