Hepatolithiasis:Epidemiology,presentation,classification and management of a complex disease

The term hepatolithiasis describes the presence of biliary stones within the intrahepatic bile ducts,above the hilar confluence of the hepatic ducts.The disease is more prevalent in Asia,mainly owing to socioeconomic and dietary factors,as well as the prevalence of biliary parasites.In the last century,owing to migration,its global incidence has increased.The main pathophysiological mechanisms involve cholangitis,bile infection and biliary strictures,creating a self-sustaining cycle that perpetuates the disease,frequently characterised by recurrent episodes of bacterial infection referred to as syndrome of“recurrent pyogenic cholangitis”.Furthermore,long-standing hepatolithiasis is a known risk factor for development of intrahepatic cholangiocarcinoma.Various classifications have aimed at providing useful insight of clinically relevant aspects and guidance for treatment.The management of symptomatic patients and those with complications can be complex,and relies upon a multidisciplinary team of hepatologists,endoscopists,interventional radiologists and hepatobiliary surgeons,with the main goal being to offer relief from the clinical presentations and prevent the development of more serious complications.This comprehensive review provides insight on various aspects of hepatolithiasis,with a focus on epidemiology,new evidence on pathophysiology,most important clinical aspects,different classification systems and contemporary management.

Effect of ankle versus thigh tourniquets on post-operative pain in foot and ankle surgery

BACKGROUND Tourniquets are commonly used in elective extremity orthopaedic surgery to reduce blood loss,improve visualization in the surgical field,and to potentially reduce surgical time.There is a lack of consensus in existing guidelines regarding the optimal tourniquet pressure,placement site,and duration of use.There is a paucity of data on the relationship between the site of a tourniquet and postoperative pain in foot and ankle surgery.AIM To explore the relationship between tourniquet site and intensity of post-operative pain scores in patients undergoing elective foot and ankle surgery.METHODS Retrospective analysis of prospectively collected data on 201 patients who underwent foot and ankle surgery in a single institution was undertaken.Intraoperative tourniquet duration,tourniquet pressure and site,and postoperative pain scores using Visual Analogue Score were collected in immediate recovery,at six hours and at 24 h post-op.Scatter plots were used to analyse the data and to assess for the statistical correlation between tourniquet pressure,duration,site,and pain scores using Pearson correlation coefficient.RESULTS All patients who underwent foot and ankle surgery had tourniquet pressure of 250 mmHg for ankle tourniquet and 300 mmHg for thigh.There was no correlation between the site of the tourniquet and pain scores in recovery,at six hours and after 24 h.There was a weak correlation between tourniquet time and Visual Analogue Score immediately post-op(r=0.14,P=0.04)but not at six or 24 h post-operatively.CONCLUSION This study shows that there was no statistically significant correlation between tourniquet pressure,site and postop pain in patients undergoing foot and ankle surgery.The choice of using a tourniquet is based on the surgeon's preference,with the goal of minimizing the duration of its application at the operative site.

Suppressive effects of exercise-conditioned serum on cancer cells:A narrative review of the influence of exercise mode,volume,and intensity

Cancer is a major cause of morbidity and mortality worldwide,and the incidence is increasing,highlighting the need for effective strategies to treat this disease.Exercise has emerged as fundamental therapeutic medicine in the management of cancer,associated with a lower risk of recur-rence and increased survival.Several avenues of research demonstrate reduction in growth,proliferation,and increased apoptosis of cancer cells,including breast,prostate,colorectal,and lung cancer,when cultured by serum collected after exercise in vitro(i.e.,the cultivation of cancer cell lines in an experimental setting,which simplifies the biological system and provides mechanistic insight into cell responses).The underlying mechanisms of exercise-induced cancer suppressive effects may be attributed to the alteration in circulating factors,such as skeletal muscle-induced cytokines(i.e.,myokines)and hormones.However,exercise-induced tumor suppressive effects and detailed information about training interventions are not well investigated,constraining more precise application of exercise medicine within clinical oncology.To date,it remains unclear what role different training modes(i.e.,resistance and aerobic training)as well as volume and intensity have on exercise-condi-tioned serum and its effects on cancer cells.Nevertheless,the available evidence is that a single bout of aerobic training at moderate to vigorous intensity has cancer suppressive effects,while for chronic training interventions,exercise volume appears to be an influential candidate driving cancer inhibitory effects regardless of training mode.Insights for future research investigating training modes,volume and intensity are provided to further our understanding of the effects of exercise-conditioned serum on cancer cells.

Portal hypertension in patients with nonalcoholic fatty liver disease:Current knowledge and challenges

Portal hypertension(PH)has traditionally been observed as a consequence of significant fibrosis and cirrhosis in advanced non-alcoholic fatty liver disease(NAFLD).However,recent studies have provided evidence that PH may develop in earlier stages of NAFLD,suggesting that there are additional pathogenetic mechanisms at work in addition to liver fibrosis.The early development of PH in NAFLD is associated with hepatocellular lipid accumulation and ballooning,leading to the compression of liver sinusoids.External compression and intraluminal obstacles cause mechanical forces such as strain,shear stress and elevated hydrostatic pressure that in turn activate mechanotransduction pathways,resulting in endothelial dysfunction and the development of fibrosis.The spatial distribution of histological and functional changes in the periportal and perisinusoidal areas of the liver lobule are considered responsible for the pre-sinusoidal component of PH in patients with NAFLD.Thus,current diagnostic methods such as hepatic venous pressure gradient(HVPG)measurement tend to underestimate portal pressure(PP)in NAFLD patients,who might decompensate below the HVPG threshold of 10 mmHg,which is traditionally considered the most relevant indicator of clinically significant portal hypertension(CSPH).This creates further challenges in finding a reliable diagnostic method to stratify the prognostic risk in this population of patients.In theory,the measurement of the portal pressure gradient guided by endoscopic ultrasound might overcome the limitations of HVPG measurement by avoiding the influence of the pre-sinusoidal component,but more investigations are needed to test its clinical utility for this indication.Liver and spleen stiffness measurement in combination with platelet count is currently the best-validated non-invasive approach for diagnosing CSPH and varices needing treatment.Lifestyle change remains the cornerstone of the treatment of PH in NAFLD,together with correcting the components of metabolic syndrome,using nonselective beta blockers,whereas emerging candidate drugs require more robust confirmation from clinical trials.

Incidence of exclusive extrapelvic skeletal metastasis in prostate carcinoma on bone scintigraphy

BACKGROUND Bone is one of the common sites of metastasis from prostate carcinoma.Bone scintigraphy(BS)is one of the most sensitive imaging modalities currently used for bone metastatic work-up.Skeletal metastasis in prostate carcinoma commonly involves pelvic bones but rarely involves extrapelvic-extraspinal sites.AIM To retrospectively analyze the BS data to determine the pattern of skeletal metastases in the prostate carcinoma.METHODS This retrospective observational study involves patients with biopsy-proven prostate carcinoma referred for BS for staging assessment.Patients with abnormal BS were evaluated for the pattern of skeletal involvement and data were pre-sented in descriptive format in the form of percentages.RESULTS A total of 150 patients with biopsy-proven prostate cancer who were referred for staging were included in the study.Thirteen of 150 patients(8.67%)had no abnormal uptake on planar images,ruling out metastatic disease.Twenty-four patients(16%)had heterogeneous uptake in the spine with distribution charac-teristic of degenerative disease and no scan pattern of metastatic disease.Thirty patients(20%)had multifocal uptake involving both pelvic and extra pelvic bones on planar images typical for skeletal metastasis and were considered metastatic.Eighty-three out of 150 patients(55.3%)had increased tracer uptake,which was indeterminate,thus,single photon emission computed tomography-computed tomography(SPECT-CT)was acquired,which showed 51 with metastatic disease,31 benign lesions,and one indeterminate finding.Seven of 150 patients had exclusive pelvic bone uptake,which was found to be metastatic in 4/7 patients in SPECT-CT.Fifty six out of 150 patients showed exclusive extrapelvic tracer uptake,of which only 3 had vertebral metastatic disease.None of the patients with increased uptake exclusively in the extrapelvic-extraspinal location was metastatic.CONCLUSION The incidence of exclusive extrapelvic skeletal metastatic disease in prostate carcinoma is 2%(excluding one patient with indeterminate findings).Further,none of the patients in the current study had exclusive extrapelvic-extraspinal metastasis.Thus,exclusive extrapelvic-extraspinal focal abnormality on planar BS carries a very low probability of metastatic disease and hence,further imaging or SPECT-CT can be safely avoided in such cases.

Convergent Data-Driven Regularizations for CT Reconstruction

The reconstruction of images from their corresponding noisy Radon transform is a typical example of an ill-posed linear inverse problem as arising in the application of computerized tomography(CT).As the(naive)solution does not depend on the measured data continuously,regularization is needed to reestablish a continuous dependence.In this work,we investigate simple,but yet still provably convergent approaches to learning linear regularization methods from data.More specifically,we analyze two approaches:one generic linear regularization that learns how to manipulate the singular values of the linear operator in an extension of our previous work,and one tailored approach in the Fourier domain that is specific to CT-reconstruction.We prove that such approaches become convergent regularization methods as well as the fact that the reconstructions they provide are typically much smoother than the training data they were trained on.Finally,we compare the spectral as well as the Fourier-based approaches for CT-reconstruction numerically,discuss their advantages and disadvantages and investigate the effect of discretization errors at differentresolutions.

Exercise training mode effects on myokine expression in healthy adults:A systematic review with meta-analysis

Background:The benefits of exercise are well known;however,many of the underlying molecular mechanisms are not fully understood.Skeletal muscle secretes myokines,which mediate muscleorgan crosstalk.Myokines regulate satellite-cell proliferation and migration,inflammatory cascade,insulin secretion,angiogenesis,fatty oxidation,and cancer suppression.To date,the effects of different exercise modes(namely,aerobic and resistance exercise)on myokine response remain to be elucidated.This is crucial considering the clinical implementation of exercise to enhance general health and wellbeing and as a medical treatment.Methods:A systematic search was undertaken in PubMed,MEDLINE,CINAHL,Embase,SPORTDiscus,andWeb of Science in April 2023.Eligible studies examining the effects of a single bout of exercise on interleukin15(IL-15),irisin,secreted protein acidic and rich in cysteine(SPARC),oncostatinM(OSM),and decorin were included.A random-effects meta-analysis was also undertaken to quantify the magnitude of change.Results:Sixty-two studies were included(n=1193).Overall,exercise appeared to induce small to large increases in myokine expression,with effects observed immediately after to 60 min post-exercise,although these were mostly not statistically significant.Both aerobic and resistance exercise resulted in changes in myokine levels,without any significant difference between training modes,and with the magnitude of change differing across myokines.Myokine levels returned to baseline levels within 180 min to 24 h post-exercise.However,owing to potential sources of heterogeneity,most changes were not statistically significant,indicating that precise conclusions cannot be drawn.Conclusion:Knowledge is limited but expanding with respect to the impact of overall and specific effects of exercise on myokine expression at different time points in the systemic circulation.Further research is required to investigate the effects of different exercise modes at multiple time points on myokine response.

Pancreatic surgery and tertiary pancreatitis services warrant provision for support from a specialist diabetes team

Pancreatic surgery units undertake several complex operations,albeit with consi-derable morbidity and mortality,as is the case for the management of complicated acute pancreatitis or chronic pancreatitis.The centralisation of pancreatic surgery services,with the development of designated large-volume centres,has contribu-ted to significantly improved outcomes.In this editorial,we discuss the complex associations between diabetes mellitus(DM)and pancreatic/periampullary disease in the context of pancreatic surgery and overall management of complex pancreatitis,highlighting the consequential needs and the indispensable role of specialist diabetes teams in support of tertiary pancreatic services.Type 3c pan-creatogenic DM,refers to DM developing in the setting of exocrine pancreatic disease,and its identification and management can be challenging,while the glycaemic control of such patients may affect their course of treatment and outcome.Adequate preoperative diabetes assessment is warranted to aid identification of patients who are likely to need commencement or escalation of glucose lowering therapy in the postoperative period.The incidence of new onset diabetes after pancreatic resection is widely variable in the literature,and depends on the type and extent of pancreatic resection,as is the case with pancreatic parenchymal loss in the context of severe pancreatitis.Early involvement of a specialist diabetes team is essential to ensure a holistic management.In the current era,large volume pancreatic surgery services commonly abide by the principles of enhanced recovery after surgery,with inclusion of provisions for optimisation of the perioperative glycaemic control,to improve outcomes.While various guidelines are available to aid perioperative management of DM,auditing and quality improvement platforms have highlighted deficiencies in the perioperative management of diabetic patients and areas of required improvement.The need for perioperative support of diabetic patients by specialist diabetes teams is uniformly underlined,a fact that becomes clearly more prominent at all different stages in the setting of pancreatic surgery and the management of complex pancreatitis.Therefore,pancreatic surgery and tertiary pancreatitis services must be designed with a provision for support from specialist diabetes teams.With the ongoing accumulation of evidence,it would be reasonable to consider the design of specific guidelines for the glycaemic management of these patients.

Autologous blood in the management of ocular surface disorders

Autologous blood therapy has emerged as a promising modality in managing ocular surface disorders.This review provides a comprehensive overview of the current literature regarding the use of autologous blood in ocular surface disorders,encompassing its physiological basis,clinical applications,techniques,challenges,and future perspectives.The ocular surface,comprising the cornea,conjunctiva,and tear film,plays a critical role in maintaining visual function,and its disruption can lead to various pathological conditions.With its rich composition of growth factors,cytokines,and other bioactive molecules,autologous blood offers therapeutic potential in promoting corneal wound healing,reducing inflammation,and improving tear film stability.Clinical studies have demonstrated the efficacy and safety of autologous blood therapy in diverse ocular surface disorders,including persistent epithelial defects,neurotrophic keratopathy,and dry eye disease.However,challenges such as variability in treatment response,adverse effects,and optimal patient selection remain areas of concern.Further research is needed to elucidate the underlying mechanisms of action,refine treatment protocols,and explore synergistic approaches with other therapeutic modalities.Despite these challenges,autologous blood therapy holds promise as a valuable adjunctive treatment option for ocular surface disorders,offering new avenues for improving patient outcomes and quality of life.This review examines the mechanisms underlying ocular surface disorders while discussing existing autologous blood-based therapies for managing these disorders.Current clinical trials are also summarized,and a comparison between autologous blood therapy and conventional eyedrops is attempted.Finally,safe techniques and protocols for autologous blood medicine are elucidated,and adverse effects and future perspectives of this novel therapy are reviewed.

Response of Rice Growth and Nutrient Absorption in a SalineAlkali Paddy to Different Nitrogen Fertilizer Applications

Nitrogen(N),phosphorus(P)and carbon(C)are essential nutrients for rice growth and development,but the response of nutrient absorption by rice plants to different types of nitrogen fertilizer(N-fertilizer)under saline-alkali conditions is unclear.This study conducted a 147-day field-scale experiment to evaluate rice biomass and nutrient absorption capacity with five N-fertilizer applications.The results showed that the biomass.

Possible viral agents to consider in the differential diagnosis of blepharoconjunctivitis

BACKGROUND Blepharoconjunctivitis poses a diagnostic challenge due to its diverse etiology,including viral infections.Blepharoconjunctivits can be acute or chronic,selflimiting,or needing medical therapy.AIM To review possible viral agents crucial for accurate differential diagnosis in cases of blepharoconjunctivitis.METHODS The PubMed database was searched for records relating to viral blepharoconjunctivitis.The search string generated was“("virally"[All Fields]OR"virals"[All Fields]OR"virology"[MeSH Terms]OR"virology"[All Fields]OR"viral"[All Fields])AND"Blepharoconjunctivitis"[All Fields]".RESULTS A total of 24 publications were generated from the search string.Reference lists from each relevant article were also searched for more information and included in this review.Viral etiologies such as adenovirus,herpes simplex virus(HSV),varicella-zoster virus(VZV),and Epstein-Barr virus(EBV)are frequently implicated.Adenoviral infections manifest with follicular conjunctivitis and preauricular lymphadenopathy,often presenting as epidemic keratoconjunctivitis.HSV and VZV infections can result in herpetic keratitis and may exhibit characteristic dendritic corneal ulcers.EBV,although less common,can cause unilateral or bilateral follicular conjunctivitis,particularly in immunocompromised individuals.Other potential viral agents,such as enteroviruses and molluscum contagiosum virus,should also be considered,especially in pediatric cases.CONCLUSION Prompt recognition of these viral etiologies is essential for appropriate management and prevention of complications.Thus,a thorough understanding of the clinical presentation,epidemiology,and diagnostic modalities is crucial for accurate identification and management of viral blepharoconjunctivitis.

Liver transplantation in the management of cholangiocarcinoma:Evolution and contemporary advances

Cholangiocarcinoma(CCA)is an aggressive malignancy arising from the biliary epithelium.It may occur at any location along the biliary tree with the perihilar area being the most common.Prognosis is poor with 5-year overall survival at less than 10%,typically due to unresectable disease at presentation.Radical surgical resection with clear margins offers a chance of cure in patients with resectable tumours,but is frequently not possible due to locally advanced disease.On the other hand,orthotopic liver transplantation(LT)allows for a radical and potentially curative resection for these patients,but has been historically controversial due to the limited supply of donor grafts and previously poor outcomes.In patients with perihilar CCA,within specific criteria and following the implementation of a protocol combining neoadjuvant chemoradiation and LT,excellent results have been achieved in the last decades,resulting in its increasing acceptance as an indication for LT and the standard of care in several centres with significant experience.However,in intrahepatic CCA,the role of LT remains controversial and owing to dismal previous results it is not an accepted indication.Nevertheless,more recent studies have demonstrated favourable results with LT in early intrahepatic CCA,indicating that,under defined criteria,its role may increase in the future.This review highlights the history and contemporary advances of LT in CCA,with particular focus on the improving outcomes of LT in intrahepatic and perihilar CCA and future perspectives.

Role of routine lymph node dissection alongside resection ofintrahepatic cholangiocarcinoma: Systematic review and metaanalysis

BACKGROUND The global incidence of intrahepatic cholangiocarcinoma(ICCA)is soaring.Due to often delayed presentation,only a narrow spectrum of the disease is usually surgically resectable.To more accurately stage the disease,reduce recurrence,and improve overall survival,surgical teams are increasingly performing intraoperative lymph node dissection(LND)as well.This procedure has its associated morbidity,while there is no consensus or formal guidelines on its role in this setting.Hence,there is a need to better delineate the evidence for performing LND alongside surgical resection of the ICCA.AIM To perform a systematic review and meta-analysis on the role of LND in improving prognostication and survival post-resection of ICCA.METHODS We performed a systematic literature search using Pubmed,Medline,Embase,and the Cochrane Library,for all studies involving LND,ICCA,and surgical resection using several keywords,Medical Subject Headings(MeSH)tags,and appropriate synonyms.All clinical studies comparing curative intent resection of ICCA with LND vs resection without LND were included,while single-arm case series,studies with insufficient data,and duplicates were excluded.We included all English-language studies from the different academic databases up till early December 2022.The primary outcome measures were set for overall survival(OS)and disease-free survival(DFS).RESULTS This systematic review and meta-analysis included 15 studies that fulfilled the selection criteria comprising 11413 patients with surgically-resectable ICCA,of whom 6424(56.3%)underwent hepatectomy with LND while the remainder underwent hepatectomy only.In patients who underwent LND,on average,27.7%of the resected lymph nodes were positive for metastatic disease.Overall,the results showed that performing LND did not significantly improve OS or DFS.However,the effect of LND on OS showed a degree of variability by geographical region,in Eastern and Western countries.As LND is increasingly being performed,further time-based analysis was undertaken to identify time-dependent changes in the role of LND.An increasing adoption of LND was not associated with improved OS.Furthermore,no roles were identified for neoadjuvant/adjuvant chemotherapy or increasing lymph node retrieval in improving OS either.CONCLUSION LND might aid in staging,prognosticating,and deciding further management of resected ICCA,but does not improve OS and DFS and is unsuitable for high-risk patients unlikely to benefit from further treatments.

Time to consider the potential role of alternative resistance training methods in cancer management?

Exercise has emerged as fundamental therapeutic medicine in the management of cancer.Exercise improves health-related outcomes,including quality of life,neuromuscular strength,physical function,and body composition,and it is associated with a lower risk of disease recurrence and increased survival.Moreover,exercise during or post cancer treatments is safe,can ameliorate treatment-related side effects,and may enhance the effectiveness of chemotherapy and radiation therapy.To date,traditional resistance training(RT)is the most used RT modality in exercise oncology.However,alternative training modes,such as eccentric,cluster set,and blood flow restriction are gaining increased attention.These training modalities have been extensively investigated in both athletic and clinical populations(e.g.,age-related frailty,cardiovascular disease,type 2 diabetes),showing considerable benefits in terms of neuromuscular strength,hypertrophy,body composition,and physical function.However,these training modes have only been partially or not at all investigated in cancer populations.Thus,this study outlines the benefits of these alternative RT methods in patients with cancer.Where evidence in cancer populations is sparse,we provide a robust rationale for the possible implementation of certain RT methods that have shown positive results in other clinical populations.Finally,we provide clinical insights for research that may guide future RT investigations in patients with cancer and suggest clear practical applications for targeted cancer populations and related benefits.

精神疾病病耻感量表中文版在精神分裂症患者中应用的信效度

目的:考察精神疾病病耻感量表中文版(Stigma Scale for Mental Illness,SSMI-C)的信度和效度。方法:方便选取339名门诊和住院精神分裂症患者,用其中172名进行探索性因素分析,其余167名进行验证性因素分析。间隔2周后,随机抽取其中101名患者进行重测,评定重测信度。以自编精神疾病患者病耻感面谈提纲(Stigma Interview for Mental Illness,SIMI)及罗森伯格自尊量表(Rosenberg Self-Esteem Scale,SES)为效标关联效度。结果:(1)探索性因素分析中设定3个因子,解释变异量的39.3%,除第6条目外,将个别项目根据结果调整后,各条目的因子载荷均在0.415～0.791之间。验证性分析指标GFI=0.89、NNFI=0.92、CFI=0.94、χ2/df=1.81、REMEA=0.07。SSMI-C与SIMI及罗森伯格自尊量表得分相关(r=0.78,-0.40,均P<0.01)。(2)SSMI-C的Cronbachα系数为0.82(P<0.01),重测相关系数为0.75(P<0.01)。总分与各因子的相关系数在0.48～0.83之间,各因子间的相关系数在0.12～0.34之间。结论:精神疾病病耻感量表中文版的信度和效标关联效度均较理想,结构效度在分析调整后也较理想,符合心理测量学要求,可以用于国内精神分裂症患者病耻感的研究。

基于樽海鞘算法的教育资源分配

为改善现阶段教育资源分配不均衡的问题,提出了基于樽海鞘算法的教育资源分配模型。首先收集到当前各高校教育资源配置的真实数据,分析当前的教育资源分配情况;其次在基于樽海鞘算法的基础上改进参数值,使算法能快速稳定地收敛,更适用于教育资源分配问题;最后利用改进后的樽海鞘模型对假想分配资源进行智能分配,并对结果进行分析。结果证明樽海鞘算法可以有效地改善教育资源分配不均衡的问题。

Molecular mechanisms of liver ischemia reperfusion injury:Insights from transgenic knockout models

Ischemia reperfusion injury is a major obstacle in liver resection and liver transplantation surgery.Understanding the mechanisms of liver ischemia reperfusion injury(IRI) and developing strategies to counteract this injury will therefore reduce acute complications in hepatic resection and transplantation,as well as expanding the potential pool of usable donor grafts.The initial liver injury is initiated by reactive oxygen species which cause direct cellular injury and also activate a cascade of molecular mediators leading to microvascular changes,increased apoptosis and acute inflammatory changes with increased hepatocyte necrosis.Some adaptive pathways are activated during reperfusion that reduce the reperfusion injury.IRI involves a complex interplay between neutrophils,natural killer T-cells cells,CD4+ T cell subtypes,cytokines,nitric oxide synthases,haem oxygenase-1,survival kinases such as the signal transducer and activator of transcription,Phosphatidylinositol 3-kinases/Akt and nuclear factor κβ pathways.Transgenic animals,particularly genetic knockout models,have become a powerful tool at elucidating mechanisms of liver ischaemia reperfusion injury and are complementary to pharmacological studies.Targeted disruption of the protein at the genetic level is more specific and maintained than pharmacological inhibitors or stimulants of the same protein.This article reviews the evidence from knockout models of liver IRI about the cellular and molecular mechanisms underlying liver IRI.

Systematic review of novel ablative methods in locally advanced pancreatic cancer

Unresectable locally advanced pancreatic cancer with or without metastatic disease is associated with a very poor prognosis.Current standard therapy is limited to chemotherapy or chemoradiotherapy.Few regimens have been shown to have a substantial survival advantage and novel treatment strategies are urgently needed.Thermal and laser based ablative techniques are widely used in many solid organ malignancies.Initial studies in the pancreas were associated with significant morbidity and mortality,which limited widespread adoption.Modifications to the various applications,in particular combining the techniques with high quality imaging such as computed tomography and intraoperative or endoscopic ultrasound has enabled real time treatment monitoring and significant improvements in safety.We conducted a systematic review of the litera-ture up to October 2013.Initial studies suggest that ablative therapies may confer an additional survival benefit over best supportive care but randomised studies are required to validate these findings.

Transfusion and coagulation management in liver transplantation

There is wide variation in the management of coagulation and blood transfusion practice in liver transplantation. The use of blood products intraoperatively is declining and transfusion free transplantations take place ever more frequently. Allogenic blood products have been shown to increase morbidity and mortality. Primary haemostasis, coagulation and fibrinolysis are altered by liver disease. This, combined with intraoperative disturbances of coagulation, increases the risk of bleeding. Meanwhile, the rebalancing of coagulation homeostasis can put patients at risk of hypercoagulability and thrombosis. The application of the principles of patient blood management to transplantation can reduce the risk of transfusion. This includes: preoperative recognition and treatment of anaemia, reduction of perioperative blood loss and the use of restrictive haemoglobin based transfusion triggers. The use of point of care coagulation monitoring using whole blood viscoelastic testing provides a picture of the complete coagulation process by which to guide and direct coagulation management. Pharmacological methods to reduce blood loss include the use of anti-fibrinolytic drugs to reduce fibrinolysis, and rarely, the use of recombinant factor VIIa. Factor concentrates are increasingly used; fibrinogen concentrates to improve clot strength and stability, and prothrombin complex concentrates to improve thrombin generation. Non-pharmacological methods to reduce blood loss include surgical utilisation of the piggyback technique and maintenance of a low central venous pressure. The use of intraoperative cell salvage and normovolaemic haemodilution reduces allogenic blood transfusion. Further research into methods of decreasing blood loss and alternatives to blood transfusion remains necessary to continue to improve outcomes after transplantation.

The future of wireless capsule endoscopy

We outline probable and possible developments with wireless capsule endoscopy. It seems likely that capsule endoscopy will become increasingly effective in diagnostic gastrointestinal endoscopy. This will be attractive to patients especially for cancer or varices detection because capsule endoscopy is painless and is likely to have a higher take up rate compared to conventional colonoscopy and gastroscopy. Double imager capsules with increased frame rates have been used to image the esophagus for Barrett's and esophageal varices. The image quality is not bad but needs to be improved if it is to become a realistic substitute for flexible upper and lower gastrointestinal endoscopy. An increase in the frame rate, angle of view, depth of field, image numbers, duration of the procedure and improvements in illumination seem likely. Colonic, esophageal and gastric capsules will improve in quality, eroding the supremacy of flexible endoscopy, and become embedded into screening programs. Therapeutic capsules will emerge with brushing, cytology, fluid aspiration, biopsy and drug delivery capabilities. Electrocautery may also become possible. Diagnostic capsules will integrate physiological measurements with imaging and optical biopsy, and immunologic cancer recognition. Remote control movement will improve with the use of magnets and/or electrostimulation and perhaps electromechanical methods. External wireless commands will influence capsule diagnosis and therapy and will increasingly entail the use of real-time imaging. However, it should be noted that speculations about the future of technology in any detail are almost always wrong.