Recent publications
Purpose
Acupuncture for cancer care is safe and effective and can be provided in group or individual settings. Previously, group acupuncture (GA) has been compared with individual acupuncture (IA) for specific cancer-related symptoms or patient experience, but has not correlated symptoms with patient experience between GA and IA. This service evaluation, using a mixed-methods design, aimed to compare GA with IA for symptom-related outcomes, and patients experience and explore their inter-relationships, in order to inform future development of the service.
Methods
Cancer patients referred to the acupuncture service in a UK NHS hospital received six treatments of GA or IA. Outcomes were gathered using Measure Yourself Concerns and Wellbeing (MYCaW) questionnaires pre- and post-treatment. Experience of acupuncture was gathered post-treatment using a questionnaire and analysed using reflexive thematic analysis.
Results
Forty-eight participants’ data were analysed. There were statistically significant improvements in outcomes overall, with no difference between GA and IA. Most participants had a positive experience; IA participants focused more on the relationship with their acupuncturist, whilst GA participants focused more on environmental factors. For a few GA participants, the group experience was negative, but data synthesis revealed this did not impact symptom-related outcomes.
Conclusion
In both GA and IA arms, symptom-related outcomes mostly improved alongside a positive experience. For those participants for whom GA was not an ideal setting, there was no effect on symptom-related outcomes. These results may be of relevance when establishing acupuncture services in supportive cancer care settings.
Background
There are limited data on how historical nucleoside reverse transcriptase inhibitor (NRTI) resistance-associated mutations (RAMs) other than M184V/I, affect the activity of B/F/TAF. We evaluated the outcomes of switching virologically suppressed (HIV-1 RNA < 50 copies/mL) individuals harbouring major RAMs from boosted protease inhibitor (bPI)-based therapy to B/F/TAF.
Methods
Participants had various historical genotypic patterns including M184V/I, ≤2 thymidine analogue mutations (TAMs), and other NRTI RAMs (NAMs), and no integrase resistance. Baseline RAMs were explored by retrospective sequencing of cellular HIV-1 DNA. Participants were randomised (1:1) to switching to B/F/TAF either immediately or after 24 weeks. The primary outcome was the proportion of participants maintaining virological suppression (pure virologic response) at week-24; secondary outcomes were proportion of participants with virological suppression at week-48, pre-specified safety measures, and treatment-emergent resistance.
Results
Historically, 21/72 (29.2%) participants had M184V/I, 5 (6.9%) M184V/I + 1 NAM, 31 (43.1%) 1 TAM ± M184V/I ± 1 NAM, and 15 (20.8%) 2 TAMs ± M184V/I ± 1 NAM. At week-24, proportions maintaining virological suppression were 33/33 (100%) on B/F/TAF vs. 38/39 (97.4%) on bPI (difference 2.6%; 95% CI -2.4%, 7.5%). Drug-related adverse events (AEs) were reported in 10/33 (30.3%) vs. 1/39 (2.6%), respectively. The immediate switch arm had improved lipid parameters but increased HbA1c and weight. Virological suppression was maintained at week-48. There were six discontinuations; four on B/F/TAF were drug-related and the two on bPI were not drug-related.
Conclusions
Historical NRTI resistance did not compromise the effectiveness of B/F/TAF in virologically suppressed adults. 12% experienced treatment-limiting AEs after switching.
Registration
EudraCT no: 2018-004732-30
Introduction
Multiple studies have been undertaken to assess level of knowledge on the topic of oral mucosal biopsies from a general dental practitioner perspective, but only limited data is available on undergraduate dental students' perspective. The aim of this study was to assess clinical experience and attitudes towards oral mucosal biopsies in final‐year undergraduate dental students.
Material and Methods
Online questionnaire was sent to dental students in six European countries (Croatia, France, Italy, Portugal, Spain and United Kingdom). The questionnaire assessed clinical experience, attitudes to oral biopsy, self‐perceived competence, and obstacles for performing a biopsy. Multiple choice questions and 5‐point Likert scale were used.
Results
Two hundred and ninety‐three students (response rate 24% to 88%) participated in the survey. A small proportion of students (54; 21.7%) performed a biopsy during their undergraduate education, mainly in an oral medicine setting. The majority of students did not consider themselves competent in performing a biopsy. The most common listed obstacle for performing a biopsy was lack of clinical experience with oral mucosal lesions.
Conclusion
The results suggest there is a need for more practical training in oral biopsy techniques, as well as a need for increased clinical exposure to different oral mucosal pathologies.
Objectives
Immune thrombocytopaenia (ITP) is a rare autoimmune disorder characterized by low platelet count and increased risk of bleeding. This study aimed to be the first publication to characterize the economic burden of bleeding events in patients with ITP in the UK.
Methods
We performed a microcosting analysis to estimate the costs associated with bleeding events in patients with ITP. Healthcare resources utilized in the management of bleeds of different severity were costed using well-established UK cost sources. The results were validated through semi-structured interviews with clinical experts.
Results
The severity of bleeding events was classified into four categories, ranging from bleeding managed at home, through mild bleeding managed in the outpatient or day case setting, to serious and life-threatening bleeding events requiring inpatient admission. Total medical costs per event ranged from £2,930 for managing a mild bleeding event, through £16,711 for a serious bleeding event to £32,461 for a life-threatening event. The major cost driver for mild and serious events were intravenous immunoglobulin (IVIg) costs, amounting to £1,614 and £8,071 for the two severity categories, respectively. For life-threatening events, the costs of intensive care unit stay (£9,089) exceeded those of IVIg (£8,071).
Conclusion
Real-world costs of managing bleeding in patients with ITP in the UK are substantial and greater than costs set only based on the UK NHS Tariff. Mitigating the risk of bleeding in patients with ITP is likely to yield not only clinical advantages for patients but also offer substantial cost savings to the health system.
Objectives
The primary objectives were to identify the predictors of new permanent pacemaker implantation in patients with aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI). The secondary objectives were to investigate the temporal changes in permanent pacemaker implantation following TAVI and its impact on long-term prognosis.
Design
Prospective observational cohort study of patients with AS undergoing TAVI.
Setting
Single-centre study conducted at a tertiary hospital in Western Norway between 2012 and 2019.
Participants
Among 600 consecutive patients with severe AS who were treated with TAVI, 52 patients with permanent pacemaker prior to TAVI were excluded. The remaining 548 patients were included in the present study.
Baseline measures
An evaluation of baseline risk factors, 12-lead ECG and echocardiography.
Primary outcome measures
The need for a new pacemaker implantation ≤30 days following TAVI and all-cause death.
Results
The mean age was 80.6±6.7 years, and 50% were males. Among the 548 eligible patients, 173 (31.6%) underwent pacemaker implantation ≤30 days following TAVI, evenly distributed between females and males (29.6% vs 33.6%, p=0.317), with higher implant rates at low-volume phase (2012–2015) and lower implant rates at high-volume phase (2016–2019) (45.8% vs 23.9%, p<0.001). On multivariable analysis, an abnormal electrocardiogram (OR 1.73; 95% CI 1.14 to 2.63, p=0.010), right bundle branch block (OR 2.23; 95% CI 1.09 to 4.59, p=0.028) and atrial fibrillation (OR 1.89; 95% CI 1.24 to 2.88, p=0.003) at baseline were strong predictors of pacemaker implantation. The type of bioprosthesis, but not size, was associated with permanent pacemaker implantation (mechanically expandable valves OR 3.48, 95% CI 2.16 to 5.59; balloon-expandable valves OR 0.07, 95% CI 0.02 to 0.29, both p<0.001)—irrespective of age and sex. During a median follow-up of 60.4 months (range 3–131 months), permanent pacemaker implantation following TAVI was not associated with all-cause mortality (HR 0.89; 95% CI 0.69 to 1.16, p=0.403).
Conclusions
In the current study, the rates of permanent pacemaker implantation following TAVI decreased substantially from the early low-volume phase to the late high-volume phase. An abnormal baseline ECG, right bundle branch block, atrial fibrillation and bioprosthesis selection remained important predictors of permanent pacemaker implantation. Permanent pacemaker implantation following TAVI had no impact on short or long-term survival.
Ethics and dissemination
The Regional Committees for Medical and Health Research Ethics (approval number: REK vest 33814/2019) and the Institutional Data Protection Services approved the study protocol. The dissemination of study findings was through peer-reviewed publication, presentation at national and international scientific meetings and conferences.
Trial registration number
NCT04417829 .
Fitness assessment in patients with acute myeloid leukemia (AML) is critical to deliver the right therapy to the right patient. While several scoring systems are available to aid in determining fitness, the absence of validation studies has resulted in the lack of universally accepted assessment procedures. This limitation, combined with the increasing availability of novel agents expanding the spectrum of less-intensive options, has introduced additional complexity to the fitness assessment process. In this evolving context, fitness should reflect eligibility for a specific treatment among the several available, rather than a generic binary classification of eligibility for intensive chemotherapy. Moreover, the growing emphasis on patient-centered care, further highlights the importance of integrating quality of life, patients' preferences, patients' self-reported physical and social functioning status, social support, and early integration of palliative care into the assessment framework. A modern interpretation of fitness assessment should incorporate a comprehensive evaluation that extends beyond traditional clinical and biological disease characteristics. Thus, fitness assessment in patients with AML represents only one piece of a larger puzzle, encompassing the patient's overall capacity to sustain and benefit from a specific therapeutic program.
Objective
To use artificial intelligence (AI) to automatically extract video clips of the fetal heart from a stream of ultrasound video, and to assess the performance of these when used for remote second review.
Methods
Using a dataset from a previous clinical trial of AI to assist in fetal ultrasound scanning, AI was used to automatically extract video clips of the fetal heart from ultrasound scans of 48 fetuses in which the diagnosis was known: 24 normal and 24 with congenital heart disease (CHD). These, and manually still saved images, were shown in a random order to expert clinicians, who were asked to detect cardiac abnormalities.
Results
The initial manual scan had a sensitivity of 0.792 and specificity of 0.917 for detecting CHD in this cohort. The addition of second review improved the sensitivity to 0.975 using video clips, which was significantly higher than using still images (0.892, p = 0.002). There was a significant drop in specificity to 0.767 and 0.833 ( p < 0.001) for the video and still method, respectively, which were statistically similar to each other ( p = 0.117). The median review time was 1.0 min (IQR 0.71) for the still images, and 3.75 min (IQR 3.12) for the AI‐generated video clips.
Conclusion
AI can be used to automatically extract fetal cardiac video clips, and these can be used for remote second review to improve detection rates. Video clips are superior to still images, but both methods result in a significant drop in specificity.
Background
Survival for cardiac arrest remains poor, and the use of extracorporeal cardiopulmonary resuscitation (ECPR) has been suggested as a potential therapy to improve outcomes. Harefield Hospital has been performing ECPR for over a decade; however outcomes have been historically poor.
Methods
A retrospective analysis was performed of all ECPR cases at Harefield Hospital between April 2018 and April 2023. A new structured system including a systematic screening process, strict exclusion criteria, assessment of resuscitation adequacy through physiological stop criteria, drilled and standardised cannulation process, post-resuscitation care and neuroprognostication was rolled out on 1 April 2023. A comparison of ECPR performed pre and post was undertaken.
Results
With the institution of the new system, 13 patients were treated with ECPR over 1 year; of which nine (69.2%) survived with good neurological outcomes at 6 months. In the preceding 3 years, there had been 22 cases; of which, two survived (9.1%). This was a statistically significant higher survival with HR of 4.56 (CI 2.1, 10.2, p<0.05).
The average length of hospital stay in the new system was 61.3 days; of which, 32.4 days were in the intensive care unit.
Conclusions
This study shows that it is possible to significantly improve outcomes in ECPR in a single centre by introducing into standard practice, a high-quality bundle of care.
There has been an increase in the availability and utilization of commercially available 3D printers in radiotherapy, with applications in phantoms, brachytherapy applicators, bolus, compensators, and immobilization devices. Additive manufacturing in the form of 3D printing has the advantage of rapid production of personalized patient specific prints or customized phantoms within a short timeframe. One of the barriers to uptake has been the lack of guidance. The aim of this topical review is to present the radiotherapy applications and provide guidance on important areas for establishing a 3D printing service in a radiotherapy department including procurement, commissioning, material selection, establishment of relevant quality assurance, multidisciplinary team creation and training.
Increasing lines of evidence suggest cerebral overgrowth in autism spectrum disorder (ASD) children in early life, but few studies have examined the effect of ASD common genetic variants on brain volumes in a general paediatric population. This study examined the association between ASD polygenic risk score (PRS) and volumes of the frontal, temporal, parietal, occipital, fronto-temporal and parieto-occipital lobes in 273 term-born infants of European ancestry in the developing Human Connectome Project. ASD PRS was positively associated with frontal (β = 0.027, pFDR = 0.04) and fronto-temporal (β = 0.024, pFDR = 0.01) volumes, but negatively with parietal (β = −0.037, pFDR = 0.04) and parieto-occipital (β = −0.033, pFDR = 0.01) volumes. This preliminary result suggests the potential involvement of ASD common genetic variants in early structural variations linked to ASD.
Background and study aims
There are far fewer female, independent endoscopic retrograde cholangiopancreatography (ERCP) practitioners than men in the UK. This study aimed to explore what lies behind the disparity by examining the current state of training, attitudes, and other factors that may influence trainees’ decision to pursue ERCP training, with a view to identifying modifiable factors.
Methods
Anonymized responses to an electronic survey distributed to gastroenterology trainees and independent ERCP practitioners in the UK were collected and analyzed.
Results
Of 214 respondents 45% were female. Whereas gender distribution in non-hepatobiliary therapeutic endoscopy was balanced, only 29% of ERCP trainees were female. Eighty percent of those who worked less than full time (LTFT) were female, but 32% felt that LTFT was incompatible with ERCP training. Concerningly, one-quarter of female respondents reported that they had been discouraged. It was noted that females are often treated differently within endoscopy units, including by patients. Fifty percent of females indicated that radiation exposure affected their decision to train in ERCP, compared with 22% of males. A question specific to trainers revealed that 95% felt that male gender was associated with increased confidence. In free-text responses, valuable insights into trainees’ personal experiences were provided, and a selection is presented. Finally, strategies to redress the gender imbalance are proposed.
Conclusions
Gender disparity in HPB endoscopy exists and is stark. Underlying this are attitudes, assumptions, and environmental factors that will require systemic and sustained correction. Ideas about how to address this challenge need to be explored.
Autologous DIEP free flap is considered the gold standard in breast reconstruction. Pleural injury is a rare complication mentioned in the literature, however, the evidence base of intraoperative management of pleural injury is sparse. We present the first case of a pleural injury that resulted in lung herniation in a unilateral bipedicled DIEP flap breast reconstruction, which was reconstructed with a pleural patching technique using the pectoralis major fascia.
In the clinical care of people with disproportionate short stature, healthcare practitioners need to accurately collect anthropometric measurements over time, including height, weight, head circumference, and lengths of affected limb and body segments. Accurate anthropometric measurements are important for diagnostic evaluation, tracking growth, measuring response to pharmacologic therapies or surgeries, and monitoring for potential complications. However, for this clinical population, anthropometric measurements may need to be adjusted or modified to accommodate characteristics such as body disproportions, joint contractures, long bone deformities, spinal deformities, or muscle hypotonia. This article provides guidance for key anthropometric measurements in children and adults with disproportionate short stature, with a focus on people with achondroplasia. The measurements described in this article and illustrated in the infographics can be performed without expensive specialized equipment and are suitable for a variety of clinical settings.
Chronic postsurgical pain (CPSP) is a common adverse outcome following surgical procedures. Despite ongoing research, the risk factors and effective strategies for mitigating CPSP remain uncertain. Regional anesthesia is a potentially beneficial yet debated intervention for mitigating the risk of CPSP. This review will delve into the mechanistic aspects of regional anesthesia and critically assess the current literature to provide a thorough understanding of its role and effectiveness. The incidence and severity of CPSP are linked to nerve damage, neuroplastic changes and immunological responses. Although numerous mechanisms contributing to CPSP have been identified, translational research is sparse, and findings are often inconsistent. Evidence suggests that regional anesthetic techniques could have a role in reducing CPSP risk across various clinical scenarios. Techniques studied include wound infiltration, peripheral nerve blocks, fascial plane blocks, thoracic paravertebral blocks and epidural anesthesia. Current data indicate that epidural anesthesia might decrease CPSP risk following thoracotomy, wound infiltration may be effective after major breast surgery and cesarean delivery, and serratus anterior plane block or pectoralis/interpectoral plane blocks might be beneficial in breast surgery. However, the existing evidence is limited and marked by several constraints especially the multifactorial causes, underscoring the need for further research in this area.
Primary results of the JADE DARE trial (NCT04345367) demonstrated that abrocitinib was superior to dupilumab in reducing the signs and symptoms of moderate-to-severe atopic dermatitis (AD). This post hoc analysis evaluated the efficacy and safety of abrocitinib in patients with moderate-to-severe AD who were responders or nonresponders to dupilumab using various definitions of response.
Data included dupilumab-treated patients from JADE DARE who switched to abrocitinib 200 mg when enrolled in the ongoing JADE EXTEND trial (NCT03422822). For this analysis, various response criteria at Week 26 of JADE DARE were defined post hoc based on Investigator’s Global Assessment (IGA), Eczema Area and Severity Index (EASI), Peak Pruritus Numerical Rating Scale (PP-NRS), and Dermatology Life Quality Index (DLQI) scores or responses. Efficacy was analyzed at Week 12 of JADE EXTEND based on patients’ fulfillment of the various response criteria at Week 26 of JADE DARE. EASI scores and percentage changes from baseline in EASI and PP-NRS at Week 26 in JADE DARE were compared with the corresponding scores and percentage changes at Week 12 in EXTEND. Safety was assessed.
Of 365 dupilumab-treated patients in JADE DARE, 316 were enrolled in JADE EXTEND and 312 received abrocitinib 200 mg. Most dupilumab responders for IGA, EASI, PP-NRS, and DLQI at DARE Week 26 maintained their responses 12 weeks after switching to abrocitinib, while a considerable proportion of IGA, EASI, PP-NRS, or DLQI dupilumab nonresponders gained response after switching to abrocitinib. Lower EASI scores and greater percentage changes from baseline in EASI and PP-NRS scores were observed with abrocitinib at EXTEND Week 12 than with dupilumab at DARE Week 26. No new safety signals were observed.
Abrocitinib 200 mg may be an effective treatment option for patients with moderate-to-severe AD who do not achieve an optimal response with dupilumab treatment.
Clinicaltrials.gov: NCT04345367 (JADE DARE) and NCT03422822 (JADE EXTEND).
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