Is there a weekend effect in hip fracture patients presenting to a United Kingdom teaching hospital?

AIM To compare mortality and time-to-surgery of patients admitted with hip fracture to our teaching hospital on weekdays vs weekends. METHODS Data was prospectively collected and retrospectively analysed for 816 hip fracture patients. Multivariate logistic regression was carried out on 3 binary outcomes(timeto-surgery < 36 h; 30-d mortality; 120-d mortality), using the explanatory variables time-of-admission; age; gender; American Society of Anesthesiologist(ASA) grade; abbreviated mental test score(AMTS); fracture type; accommodation admitted from; walking ability outdoors; accompaniment outdoors and season. RESULTS Baseline characteristics were not statistically different between those admitted on weekdays vs weekends. Weekend admission was not associated with an increased time-to-surgery(P = 0.975), 30-d mortality(P = 0.842) or 120-d mortality(P = 0.425). Gender(P = 0.028), ASA grade(P < 0.001), AMTS(P = 0.041) and accompaniment outdoors(P = 0.033) were significant covariates for 30-d mortality. Furthermore, age(P < 0.001),gender(P = 0.011), ASA grade(P < 0.001), AMTS(P < 0.001) and accompaniment outdoors(P = 0.033) all significantly influenced mortality at 120 d. ASA(P < 0.001) and season(P = 0.014) had significant effect on the odds of undergoing surgery in under 36 h.CONCLUSION Weekend admission was not associated with increased time-to-surgery or mortality in hip fracture patients. Demographic factors affect mortality in accordance with previous published reports.

Adipose-derived regenerative therapies for the treatment of knee osteoarthritis

Knee osteoarthritis is a degenerative condition with a significant disease burden and no disease-modifying therapy.Definitive treatment ultimately requires joint replacement.Therapies capable of regenerating cartilage could significantly reduce financial and clinical costs.The regenerative potential of mesenchymal stromal cells(MSCs)has been extensively studied in the context of knee osteoarthritis.This has yielded promising results in human studies,and is likely a product of immunomodulatory and chondroprotective biomolecules produced by MSCs in response to inflammation.Adipose-derived MSCs(ASCs)are becoming increasingly popular owing to their relative ease of isolation and high proliferative capacity.Stromal vascular fraction(SVF)and micro-fragmented adipose tissue(MFAT)are produced by the enzymatic and mechanical disruption of adipose tissue,respectively.This avoids expansion of isolated ASCs ex vivo and their composition of heterogeneous cell populations,including immune cells,may potentiate the reparative function of ASCs.In this editorial,we comment on a multicenter randomized trial regarding the efficacy of MFAT in treating knee osteoarthritis.We discuss the study’s findings in the context of emerging evidence regarding adipose-derived regenerative therapies.An underlying mechanism of action of ASCs is proposed while drawing important distinctions between the properties of isolated ASCs,SVF,and MFAT.

Interdepartmental miscommunication regarding radiology:Addressing chronic challenges and exploring solutions

Effective communication and collaboration among healthcare professionals are crucial for delivering high-quality patient care.Interdepartmental miscommunication poses a significant challenge to healthcare systems,potentially undermining the quality of healthcare services provided.In the same manner,communication barriers between referring physicians and radiologists can specifically affect radiology services and patient outcomes.This article attempts to put the spotlight on the ever-present chronic challenges of this issue and prompt readers to recognize the relevant potential pitfalls in their daily clinical practice.Practical solutions are explored and proposed,which should be tailored to the specific needs and issues that each individual institution may face.

Time spent in hospital after liver transplantation:Effects of primary liver disease and comorbidity

AIM To explore the effect of primary liver disease and comorbidities on transplant length of stay(TLOS) and LOS in later admissions in the first two years after liver transplantation(LLOS). METHODS A linked United Kingdom Liver Transplant Audit- Hospital Episode Statistics database of patients who received a first adult liver transplant between 1997 and 2010 in Englandwas analysed. Patients who died within the first two years were excluded from the primary analysis, but a sensitivity analysis was also performed including all patients. Multivariable linear regression was used to evaluate the impact of primary liver disease and comorbidities on TLOS and LLOS. RESULTS In 3772 patients, the mean(95%CI) TLOS was 24.8(24.2 to 25.5) d, and the mean LLOS was 24.2(22.9 to 25.5) d. Compared to patients with cancer, we found that the largest difference in TLOS was seen for acute hepatic failure group(6.1 d; 2.8 to 9.4) and the largest increase in LLOS was seen for other liver disease group(14.8 d; 8.1 to 21.5). Patients with cardiovascular disease had 8.5 d(5.7 to 11.3) longer TLOS and 6.0 d(0.2 to 11.9) longer LLOS, compare to those without. Patients with congestive cardiac failure had 7.6 d longer TLOS than those without. Other comorbidities did not significantly increase TLOS nor LLOS.CONCLUSION The time patients spent in hospital varied according to their primary liver disease and some comorbidities. Time spent in hospital of patients with cancer was relatively short compared to most other indications. Cardiovascular disease and congestive cardiac failure were the comorbidities with a strong impact on increased LOS.

Serum cholinesterase: A predictive biomarker of hepatic reserves in chronic hepatitis D

AIM To determine the predictive performance of cholinesterase compared to existing prognostic models in evaluating liver function in patients with chronic hepatitis D.METHODS In an observational, cross-sectional and retrospective study, consecutive patients with hepatitis D cirrhosis were evaluated. Demographic, clinical and laboratory parameters were recorded. Serum cholinesterase levels were correlated with existing scoring models for chronic liver disease and Liver function tests. Receiver operating characteristic(ROC) curves were constructed to find an optimal cholinesterase level predicting ascites, Child Turcotte Pugh(CTP) score ≥ 10, model for end stage liver disease(MELD) score ≥ 15, baseline-event-anticipation(BEA) score for hepatitis D ≥ 5 and the aspartate transaminase to Platelet Ratio Index(APRI) ≥ 1.5. RESULTS This study investigated 233 patients with chronic liver disease due to hepatitis D; 192 were male, median age 42(16-69 years). Fifty patients had ascites and 15 had encephalopathy. One hundred and sixty-seven(71.7%) were in Child class A, 52(22.3%) in Child class B and 14(5.0%) in class C. A MELD score of 15 or more was seen in 24 patients. Cholinesterase levels correlated well with the INR, albumin, CTP score, MELD, MELD sodium, BEA and APRI scores(P < 0.001 each). Area under the ROC curve for ascites, CTP ≥ 10, MELD ≥ 15, BEA ≥ 5, APRI ≥ 1.5 was 0.836, 0.966, 0.913, 0.871 and 0.825 respectively(P < 0.001 each). Cut off values of cholinesterase(IU/L) for predicting ascites, CTP ≥ 10, MELD ≥ 15, BEA ≥ 5 and APRI ≥ 1.5were < 3812, < 2853, < 2829, < 4719 and < 3954 with a sensitivity of 80%, 100%, 91.67%, 82.50%, 58.0% and specificity of 81.97%, 84.79%, 87.56%, 77.06% and 55.64% respectively. CONCLUSION Serum cholinesterase demonstrates promising correlations with serum albumin, INR and CTP, MELD, BEA and APRI scores and is predictive of liver reserves in hepatitis D cirrhosis.

Successful surgical management of ruptured umbilical hernias in cirrhotic patients

Acute umbilical hernia rupture in patients with hepatic cirrhosis and ascites is an unusual,but potentially lifethreatening complication,with postoperative morbidity about 70% and mortality between 60%-80% after supportive care and 6%-20% after urgent surgical repair.Management options include primary surgical repair with or without concomitant portal venous system decompression for the control of the ascites.We present a retrospective analysis of our centre's experience over the last 6 years.Our cohort consisted of 11 consecutive patients(median age:53 years,range:36-63 years) with advanced hepatic cirrhosis and refractory ascites.Appropriate patient resuscitation and optimisation with intravenous fluids,prophylactic antibiotics and local measures was instituted.One failed attempt for conservative management was followed by a successful primary repair.In all cases,with one exception,a primary repair with non-absorbable Nylon,interrupted sutures,without mesh,was performed.The perioperative complication rate was 25% and the recurrence rate 8.3%.No mortality was recorded.Median length of hospital stay was 14 d(range:4-31 d).Based on our experience,the management of ruptured umbilical hernias in patients with advanced hepatic cirrhosis and refractory ascites is feasible without the use of transjugular intrahepatic portosystemic shunt routinely in the preoperative period,provided that meticulous patient optimisation is performed.

Radiofrequency ablation for early oesophageal squamous neoplasia:Outcomes form United Kingdom registry

AIM:To report outcomes on patients undergoing radiofrequency ablation(RFA)for early oesophageal squamous neoplasia from a National Registry.METHODS:A Prospective cohort study from 8 tertiary referral centres in the United Kingdom.Patients with squamous high grade dysplasia(HGD)and early squamous cell carcinoma(ESCC)confined to the mucosa were treated.Visible lesions were removed by endoscopic mucosal resection(EMR)before RFA.Following initial RFA treatment,patients were followed up 3monthly.Residual flat dysplasia was treated with RFA until complete reversal dysplasia(CR-D)was achieved or progression to invasive Squamous cell cancer defined as infiltration into the submucosa layer or beyond.The main outcome measures were CR-D at 12 mo from start of treatment,long term durability,progression to cancer and adverse events.RESULTS:Twenty patients with squamous HGD/ESCC completed treatment protocol.Five patients(25%)had EMR before starting RFA treatment.CR-D was 50%at12 mo with a median of 1 RFA treatment,mean 1.5(range 1-3).Two further patients achieved CR-D with repeat RFA after this time.Eighty per cent with CR-D remain dysplasia free at latest biopsy,with median follow up 24 mo(IQR 17-54).Six of 20 patients(30%)progressed to invasive cancer at 1 year.Four patients(20%)required endoscopic dilatations for symptomatic structuring after treatment.Two of these patients have required serial dilatations thereafter for symptomatic dysphagia with a median of 4 dilatations per patient.The other 2 patients required only a single dilatation to achieve an adequate symptomatic response.One patient developed cancer during follow up after end of treatment protocol.CONCLUSION:The role of RFA in these patients re-mains unclear.In our series 50%patients responded at12 mo.These figures are lower than limited published data.

Blindly inserted nasogastric feeding tubes and thoracic complications in intensive care

Purpose of review: This article reviews the thoracic complications from malpositioned blindly inserted nasogastric feeding tubes in mechanically ventilated patients in intensive care and the methods to check the position and promote safe placement of the feeding tubes. Recent findings: Malpositioned feeding tubes are not included in risk management databases. The reported incidence is 1-3% and more than half occur in mechanically ventilated patients. Eighty three mechanically ventilated patients were reported with malpositioned nasogastric tubes and 66% of them developed serious thoracic complications. Pneumothoraces accounted for 80% of thoracic complications that were evenly distributed between tubes with and without stylet. Repeated misplacements appear to increase the risk. Non-radiological confirmation of the position of the tube has suboptimal performance. Protocols to place feeding tubes and new technology are promising candidates. Summary: Malpositioned nasogastric feeding tubes are underreported and associated with serious thoracic complications in mechanically ventilated patients. We need more data to answer whether we can afford to prevent them.

General review of magnetic resonance elastography

Magnetic resonance elastography(MRE) is an innovative imaging technique for the non-invasive quantification of the biomechanical properties of soft tissues via the direct visualization of propagating shear waves in vivo using a modified phase-contrast magnetic resonance imaging(MRI) sequence. Fundamentally,MRE employs the same physical property that physicians utilize when performing manual palpation- that healthy and diseased tissues can be differentiated on the basis of widely differing mechanical stiffness. By performing "virtual palpation ",MRE is able to provide information that is beyond the capabilities of conventional morphologic imaging modalities. In an era of increasing adoption of multi-parametric imaging approaches for solving complex problems,MRE can be seamlessly incorporated into a standard MRI examination to provide a rapid,reliable and comprehensive imaging evaluation at a single patient appointment. Originally described by the Mayo Clinic in 1995,the technique represents the most accurate non-invasive method for the detection and staging of liver fibrosis and is currently performed in more than 100 centers worldwide. In this general review,the mechanical properties of soft tissues,principles of MRE,clinical applications of MRE in the liver and beyond,and limitations and future directions of this discipline-are discussed. Selected diagrams and images are provided for illustration.

Continuous wound infusion of local anaesthetic agents following colorectal surgery:Systematic review and meta-analysis

AIM:To provide a specifi c review and meta-analysis of the available evidence for continuous wound infusion of local anaesthetic agents following midline laparoto-my for major colorectal surgery. METHODS: Medline, Embase, trial registries, conference proceedings and article reference lists were searched to identify randomised, controlled trials of continuous wound infusion of local anaesthetic agents following colorectal surgery. The primary outcomes were opioid consumption, pain visual analogue scores (VASs), return to bowel function and length of hospital stay. Weighted mean difference were calculated for continuous outcomes. RESULTS: Five trials containing 542 laparotomy wounds were eligible for inclusion. There was a sig- nificant decrease in post-operative pain VAS at rest on day 3 (weighted mean difference: -0.43; 95% CI: -0.81 to -0.04; P = 0.03) but not on post-operative day 1 and 2. Local anaesthetic infusion was associated with a signifi cant reduction in pain VAS on movement on all three post-operative days (day 1 weighted mean difference: -1.14; 95% CI: -2.24 to -0.041; P = 0.04, day 2 weighted mean difference: -0.97, 95% CI: -1.91to -0.029; P = 0.04, day 3 weighted mean difference: -0.61; 95% CI: 1.01 to -0.20; P = 0.0038). Local an- aesthetic wound infusion was associated with a signifi - cant decrease in total opioid consumption (weighted mean difference: -40.13; 95% CI: -76.74 to -3.53; P = 0.03). There was no signifi cant decrease in length of stay (weighted mean difference: -20.87; 95% CI: -46.96 to 5.21; P = 0.12) or return of bowel function (weighted mean difference: -9.40; 95% CI: -33.98 to 15.17; P = 0.45). CONCLUSION: The results of this systematic re- view and meta-analysis suggest that local anaesthetic wound infusion following laparotomy for major color- ectal surgery is a promising technique but do not pro- vide conclusive evidence of benefi t. Further research is required including cost-effectiveness analysis.

Incidental non-benign gallbladder histopathology after cholecystectomy in an United Kingdom population: Need for routine histological analysis?

AIM To analyse the range of histopathology detected in the largest published United Kingdom series of cholecystectomy specimens and to evaluate the rational for selective histopathological analysis.METHODS Incidental gallbladder malignancy is rare in the United Kingdom with recent literature supporting selective histological assessment of gallbladders after routine cholecystectomy.All cholecystectomy gallbladder specimens examined by the histopathology department at our hospital during a five year period between March 2008 and March 2013 were retrospectively analysed.Further data was collected on all specimens demonstrating carcinoma,dysplasia and polypoid growths.RESULTS The study included 4027 patients.The majority(97%) of specimens exhibited gallstone or cholecystitis related disease.Polyps were demonstrated in 44(1.09%),the majority of which were cholesterol based(41/44).Dysplasia,ranging from low to multifocal high-grade was demonstrated in 55(1.37%).Incidental primary gallbladder adenocarcinoma was detected in 6 specimens(0.15%,5 female and 1 male),and a single gallbladder revealed carcinoma in situ(0.02%).This large single centre study demonstrated a full range of gallbladder disease from cholecystectomy specimens,including more than 1% neoplastic histology and two cases of macroscopically occult gallbladder malignancies.CONCLUSION Routine histological evaluation of all elective and emergency cholecystectomies is justified in a United Kingdom population as selective analysis has potential to miss potentially curable life threatening pathology.

Double-layered covered stent for the treatment of malignant oesophageal obstructions: Systematic review and meta-analysis

AIM To investigate the efficacy of double-layered covered stent in the treatment of malignant oesophageal obstructions.METHODS A systematic review and meta-analysis was performed following the PRISMA process. Pub Med(Medline),EMBASE(Excerpta Medical Database),AMED(Allied and Complementary medicine Database),Scopus and online content,were searched for studies reporting on the Ni Ti-S polyurethane-covered double oesophageal stent for the treatment of malignant dysphagia. Weighted pooled outcomes were synthesized with a random effects model to account for clinical heterogeneity. All studies reporting the outcome of palliative management of dysphagia due to histologically confirmed malignant oesophageal obstruction using double-layered covered nitinol stent were included. The level of statistical significance was set at α = 0.05.RESULTS Six clinical studies comprising 250 patients in total were identified. Pooled technical success of stent insertion was 97.2%(95%CI: 94.8%-98.9%; I2 = 5.8%). Pooled complication rate was 27.6%(95%CI: 20.7%-35.2%; I2 = 41.9%). Weighted improvement of dysphagia on a scale of 0-5 scoring system was-2.00 [95%CI:-2.29%-(-1.72%); I2 = 87%]. Distal stent migration was documented in 10 out of the 250 cases examined.Pooled stent migration rate was 4.7%(95%CI: 2.5%-7.7%; I2 = 0%). Finally,tumour overgrowth was reported in 34 out of the 250 cases with pooled rate of tumour overgrowth of 11.2%(95%CI: 3.7%-22.1%; I2 = 82.2%). No funnel plot asymmetry to suggest publication bias(bias = 0.39,P = 0.78). In the sensitivity analysis all results were largely similar between the fixed and random effects models.CONCLUSION The double-layered nitinol stent provides immediate relief of malignant dysphagia with low rates of stent migration and tumour

Six intragastric balloons:Which to choose?

Endoscopically placed intragastric balloons(IGBs)have played a significant role in obesity treatment over the last 30 years,successfully bridging the gap between lifestyle modification/pharmacotherapy and bariatric surgery.Since they provide a continuous sensation of satiety that helps the ingestion of smaller portions of food,facilitating maintenance of a low-calorie diet,they have generally been considered an effective and reversible,less invasive,non-surgical procedure for weight loss.However,some studies indicate that balloons have limited sustainable effectiveness for the vast majority attempting such therapy,resulting in a return to the previous weight after balloon removal.In this review we try to summarize the pros and cons of various balloon types,to guide decision making for both the physician and the obese individual looking for effective treatment.We analyzed the six most commonly used IGBs,namely the liquid-filled balloons Orbera,Spatz3,ReShape Duo and Elipse,and the gas-filled Heliosphere and Obalon-also including comments on the adjustable Spatz3,and the swallowable Obalon and Elipse-to optimize the choice for maximum efficacy and safety.

Surgical management of hepato-pancreatic metastasis from renal cell carcinoma

AIM To investigate the outcomes of liver and pancreatic resections for renal cell carcinoma(RCC) metastatic disease. METHODS This is a retrospective, single centre review of liver and/or pancreatic resections for RCC metastases between January 2003 and December 2015. Descriptive statistical analysis and survival analysis using the Kaplan-Meier estimation were performed.RESULTS Thirteen patients h ad 7 pancreatic and 7 liver resections, with median follow-up 33 mo(range: 3-98). Postoperative complications were recorded in 5 cases, with no postoperative mortality. Three patients after hepatic and 5 after pancreatic resection developed recurrent disease. Median overall survival was 94 mo(range: 23-94) after liver and 98 mo(range: 3-98) after pancreatic resection. Disease-free survival was 10 mo(range 3-55) after liver and 28 mo(range 3-53) after pancreatic resection. CONCLUSION Our study shows that despite the high incidence of recurrence, long term survival can be achieved with resection of hepatic and pancreatic RCC metastases in selected cases and should be considered as a management option in patients with oligometastatic disease.

Room for improvement in the treatment of pancreatic cancer: Novel opportunities from gene targeted therapy

Pancreatic cancer is one of the highest and in fact,unchanged mortality-associated tumor,with an exceptionally low survival rate due to its challenging diagnostic approach.So far,its treatment is based on a combination of approaches(such as surgical resection with or rarely without chemotherapeutic agents),but with finite limits.Thus,looking for additional space to improve pancreatic tumorigenesis therapeutic approach,research has focused on gene therapy with unexpectedly growing horizons not only for the treatment of inoperable pancreatic disease,but also for its early stages.In vivo gene delivery viral vectors,despite few disadvantages(possible immunogenicity,toxicity,mutagenicity,or high cost),could be one of the most efficient cancer gene therapeutic strategies for clinical application due to their superiority compared with other systems(ex vivo delivery strategies).Their dominance consists of simple preparation,easy operation and a wide range of functions.Adenoviruses are one of the most common used vectors,inducing strong immune as well as inflammatory reactions.Oncolytic virotherapy,using the above mentioned in vivo viral vectors,is one of the most promising nonpathogenic,highly-selective cytotoxic anti-cancer therapy using anti-cancer agents with high anti-tumor potency and strong oncolytic effect.There have been a variety of targeted therapeutic and pre-clinical strategies tested for gene therapy in pancreatic cancer such as gene-editing systems(e.g.,clustered regularly interspaced palindromic repeats-Cas9),RNA interference technology(e.g.,microRNAs,short hairpin RNA or small interfering RNA),adoptive immunotherapy and vaccination(e.g.,chimeric antigen receptor T-cell therapy)with encouraging results.

Clinical significance of prostate 18F-labelled fluorodeoxyglucose uptake on positron emission tomography/computed tomography:A five-year review

AIM To determine the significance and need for investigation of incidental prostatic uptake in men undergoing ^(18)F-labelled fluorodeoxyglucose(^(18)F-FDG) positron emission tomography/computed tomography(PET/CT) for other indications.METHODS Hospital databases were searched over a 5-year period for patients undergoing both PET/CT and prostate magnetic resonance imaging(MRI). For the initial analysis, the prostate was divided into six sectors and suspicious or malignant sectors were identified using MRI and histopathology reports respectively. Maximum and mean ^(18)F-FDG standardised uptake values were measured in each sector by an investigator blinded to the MRI and histopathology findings. Two agematched controls were selected per case. Results were analysed using a paired t-test and one-way ANOVA. For the second analysis, PET/CT reports were searched for prostatic uptake reported incidentally and these patients were followed up. RESULTS Over a 5-year period, 15 patients underwent both PET/CT and MRI and had biopsy-proven prostate cancer.Malignant prostatic sectors had a trend to higher ^(18)F-FDG uptake than benign sectors, however this was neither clinically nor statistically significant(3.13 ±0.58 vs 2.86 ± 0.68, P > 0.05). ^(18)F-FDG uptake showed no correlation with the presence or histopathological grade of tumour. ^(18)F-FDG uptake in cases with prostate cancer was comparable to that from age-matched controls. Forty-six(1.6%) of 2846 PET/CTs over a 5-year period reported incidental prostatic uptake. Of these, 18(0.6%) were investigated by PSA, 9(0.3%)were referred to urology, with 3(0.1%) undergoing MRI and/or biopsy. No cases of prostate cancer were diagnosed in patients with incidental ^(18)F-FDG uptake in our institute over a 5-year period.CONCLUSION ^(18)F-FDG uptake overlaps significantly between malignant and benign prostatic conditions. Subsequent patient management was not affected by the reporting of incidental focal prostatic uptake in this cohort.

Yttrium-90 radioembolization for unresectable hepatic metastases of breast cancer: A systematic review

BACKGROUND Liver metastases secondary to breast cancer are associated with unfavourable prognosis.Radioembolization with ytrrium-90 is an emerging option for management of liver metastases of breast cancer when other systemic therapies have failed to achieve disease control.However,unlike the case of other liver tumours(colorectal/melanoma metastases/cholangiocarcinoma),its role in the management of breast liver metastases is yet to be elucidated.AIM The aims of this systematic review were to(1)assess the effect of radioembolization with yttrium-90 on tumour response;and(2)to estimate patient survival post radioembolization.METHODS The review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses.A systematic literature search was performed using the PubMed and EMBASE databases from January 2007 to December 2018.The initial search yielded 265 reports which were potentially suitable for inclusion in this review.Studies published in English reporting at least one outcome of interest were considered to be suitable for inclusion.Conference abstracts;case reports,animal studies and reports not published in English were excluded from this review.Data was retrieved from each individual report on the name of primary author,year of publication,patient demographics,type of microspheres used,radiation dose delivered to tumour,duration of follow-up,disease control rate(%),tumour response,and overall patient survival.RESULTS The final number of studies which met the inclusion criteria was 12 involving 452 patients.There were no randomized controlled trials identified after the literature search.The age of the patients included in this review ranged from 52 to 61 years.The duration of the follow up period post-radioembolization ranged from 6 to 15.7 mo.The total number of patients with breast metastases not confined to the liver was 236(52.2%).Cumulative analysis revealed that radioembolization with yttrium-90 conferred tumour control rate in 81%of patients.Overall survival post-radioembolization ranged from 3.6 to 20.9 mo with an estimated mean survival of 11.3 mo.CONCLUSION Radioembolization with ytrrium-90 appears to confer control of tumour growth rate in most patients,however its effect on patient survival need to be elucidated further.Furthermore,quality evidence in the form of randomized trials is needed in order to assess the effect of radioembolization in more depth.

Doppler-Guided Transanal Haemorrhoidal Dearterialisation is a Safe and Effective Daycase Procedure for All Grades of Symptomatic Haemorrhoids

Purpose: Doppler-guided transanal haemorrhoidal dearterialisation (THD), with the addition of rectal mucopexy, has been gaining popularity as a minimally invasive haemorrhoidal treatment. The aim of this study was to assess the outcomes of THD in patients with symptomatic haemorrhoids. Methods: All consecutive patients undergoing THD by a single surgeon over a 2 year period from 1st January 2010 were included. Results: THD was performed on 58 consecutive patients, with 46 (79.3%) having had previous haemorrhoidal treatment(s). Haemorrhoid grades were: 1 (n = 6);2 (n = 12);3 (n = 32);4 (n = 8). The median number of THD ligations was 7 (range 4 to 9) and rectal mucopexies 3 (range 1 to 3). All procedures (100%) were carried out as daycase, with 1 readmission within 30 days (anal fissure). No patients required return to theatre. After median follow-up of 10.5 weeks (range 1 to 48 weeks, 2 lost to follow-up), 53 (91%) patients reported symptomatic resolution or significant improvement. Two (3.4%) patients had post-operative complications (anal fissure). Two (3.4%) patients had further haemorrhoidal surgery following THD. Conclusions: THD is a safe daycase procedure for symptomatic haemorrhoids of all grades. It is an effective treatment in the short term, but longer-term follow-up is required to assess its symptomatic benefit more formally.

Sleeping on an Anti-Wrinkle Pillow Reduces Facial Wrinkles: Results from an Anatomical Study

Background: A special pillow was designed to redistribute mechanical stress during sleeping in order to slow down the formation of facial skin wrinkles. Objective: To investigate whether sleeping on a specially designed pillow reduces facial skin wrinkles. Participants and Methods: A 28-day pilot study was carried out in which fifteen healthy female volunteers aged 23 - 55 years (mean age 35. 6 ± 8.5) slept on an antiwrinkle pillow. Evaluation of facial wrinkles was conducted before commencing the study (T0), following at 14 days (T14), and at 28 days (T28) when the study ended. Wrinkle density was assessed by computerized analysis of 2D images of participants’ faces. Results: A statistically significant decrease in wrinkle density was detected while smiling around both eyes, around the right eye in a relaxed facial expression, on average in all observed facial areas, around the left periorbital area in participants who predominantly slept on their left side of the body, but not on the frontal area. Limitations: A 3D camera could be used to better visualize and analyze wrinkle density. Conclusions: Sleeping on the specially designed pillow reduces facial wrinkles.

Colonic and anal metastases from pancreato-biliary malignancies

Pancreato-biliary malignancies often present with locally advanced or metastatic disease.Surgery is the mainstay of treatment although less than 20%of tumours are suitable for resection at presentation.Common sites for metastases are liver,lungs,lymph nodes and peritoneal cavity.Metastatic disease carries poor prognosis,with median survival of less than 3 mo.We report two cases where metastases from pancreato-biliary cancers were identified in the colon and anal canal.In both cases specific immunohistochemical staining was utilised in the diagnosis.In the first case,the pre-senting complaint was obstructive jaundice due to an ampullary tumour for which a pancreato-duodenectomy was carried out.However,the patient re-presented 4wk later with an atypical anal fissure which was found to be metastatic deposit from the primary ampullary adenocarcinoma.In the second case,the patient presented with obstructive jaundice due to a biliary stricture.Subsequent imaging revealed sigmoid thickening,which was confirmed to be a metastatic deposit.Distal colonic and anorectal metastases from pancreatobiliary cancers are rare and can masquerade as primary colorectal tumours.The key to the diagnosis is the specific immunohistochemical profile of the intestinal lesion biopsies.