Endoscopic ultrasonography-guided endoscopic treatment of pancreatic pseudocysts and walled-off necrosis:New technical developments

In the last decades,the treatment of pancreatic pseudocysts and necrosis occurring in the clinical context of acute and chronic pancreatitis has shifted towards minimally invasive endoscopic interventions.Surgical procedures can be avoided in many cases by using endoscopically placed,Endoscopic ultrasonography-guided techniques and drainages.Endoscopic ultrasound enables the placement of transmural plastic and metal stents or nasocystic tubes for the drainage of peripancreatic fluid collections.The development of selfexpanding metal stents and exchange free delivering systems have simplified the drainage of pancreatic fluid collections.This review will discuss available therapeutic techniques and new developments.

Treatment of hydrofluoric acid exposure to the eye

AIM: To review the current evidence of the treatment of hydrofluoric acid(HF) exposure to the human cornea.METHODS: A comprehensive manual search of the literature was conducted through the Ovid interface to assess the mechanism and efficacy of each irrigator through a variety of clinical cases and experimental studies.· RESULTS: Ocular exposure to HF is extremely damaging to the eye and swift recognition and decontamination with an appropriate agent forms the basis of treatment. Although there are various decontamination solutions that have efficacy against the corrosive action of HF, irrigation with Hexafluorine proved to be the most safe and effective treatment for the eye.CONCLUSION: In conclusion emergency departments could benefit from the availability of Hexafluorine for the treatment of HF ocular burns in patients.

Vitamin D receptor expression in human bone tissue and dose-dependent activation in resorbing osteoclasts

The effects of vitamin D on osteoblast mineralization are well documented. Reports of the effects of vitamin D on osteoclasts, however, are conflicting, showing both inhibition and stimulation. Finding that resorbing osteoclasts in human bone express vitamin D receptor （VDR）, we examined their response to different concentrations of 25-hydroxy vitamin D3 [25（OH）D3] （100 or 500 nmol·L^-1） and 1,25-dihydroxy vitamin D3 [1,25（OH）2D3] （0.1 or 0.5 nmol·L^-1） metabolites in cell cultures. Specifically, CD14＋ monocytes were cultured in charcoal-stripped serum in the presence of receptor activator of nuclear factor kappa-B ligand （RANKL） and macrophage colony-stimulating factor （M-CSF）. Tartrate-resistant acid phosphatase （TRAP） histochemical staining assays and dentine resorption analysis were used to identify the size and number of osteoclast cells, number of nuclei per cell and resorption activity. The expression of VDR was detected in human bone tissue （ex vivo） by immunohistochemistry and in vitro cell cultures by western blotting. Quantitative reverse transcription-PCR （qRT-PCR） was used to determine the level of expression of vitamin D-related genes in response to vitamin D metabolites. VDR-related genes during osteoclastogenesis, shown by qRT-PCR, was stimulated in response to 500 nmol·L^-1 of 25（OH）D3 and 0.1-0.5 nmol·L^-1 of 1,25（OH）2D3, upregulating cytochrome P450 family 27 subfamily B member I （CYP27B1） and cytochrome P450 family 24 subfamily A member I （CYP24A1）. Osteoclast fusion transcripts transmembrane 7 subfamily member 4 （tm7sf4） and nuclear factor of activated T-cell cytoplasmic 1 （nfatcl） where downregulated in response to vitamin D metabolites. Osteoclast number and resorption activity were also increased. Both 25（OH）D3 and 1,25（OH）2D3 reduced osteoclast size and number when co-treated with RANKL and M-CSF. The evidence for VDR expression in resorbing osteoclasts in vivo and low-dose effects of 1,25（OH）2D3 on osteoclasts in vitro may therefore provide insight into the effects of clinical vitamin D treatments, further providing a counterpoint to the high-dose effects reported from in vitro experiments.

From portal to splanchnic venous thrombosis:What surgeons should bear in mind

The present study aims to review the evolution of surgical management of portal(PVT) and splanch-nic venous thrombosis(SVT) in the context of liver transplantation over the last 5 decades. PVT is more commonly managed by endovenous thrombectomy, while SVT requires more complex technical expedients. Several surgical techniques have been proposed, such as extensive eversion thrombectomy, anastomosis to collateral veins, reno-portal anastomosis, cavo-portal hemi-transposition, portal arterialization and combined liver-intestinal transplantation. In order to achieve satisfactory outcomes, careful planning of the surgical strategy is mandatory. The excellent results that are ob-tained nowadays confirm that, even extended, splanch-nic thrombosis is no longer an absolute contraindication for liver transplantation. Patients with advanced portal thrombosis may preferentially be referred to specialized centres, in which complex vascular approaches and even multivisceral transplantation are performed.

Management of Extravasation Injuries in Preterm Infants

Extravasation injuries occur in up to 70% of neonates in intensive care, majority being preterm infants. Their fragile and premature anatomy makes prevention and management of extravasation extra difficult compared to those of full-term. With increasing advances of intensive care for preterm infants, the use of intravenous medication and nutrition will increase, thus lead to further potential risk of extravasation injuries, which has serious complications, such as full-thickness skin loss, tissue necrosis and acute limb compartment syndrome, with long-term functional and cosmetic sequelae. There is a current lack of evidence in the literature on the most appropriate therapeutic strategy for this vulnerable patient group. This review aims to highlight our trust regime on the management of extravasation injuries (non-chemotherapeutic) for preterm infants, including injury classification and assessment, and implementation of initial interventions.

Reality of evidence-based practice in palliative care

There has been a paradigm shift in medicine away from tradition, anecdote and theoretical reasoning from the basic sciences towards evidence-based medicine(EBM). In palliative care however, statistically significant benefits may be marginal and may not be related to clinical meaningfulness. The typical treatment vs. placebo comparison necessitated by ‘gold standard' randomised controlled trials(RCTs) is not necessarily applicable. The complex multimorbidity of end of life care involves considerations of the patient's physical, psychological, social and spiritual needs. In addition, the field of palliative care covers a heterogeneous group of chronic and incurable diseases no longer limited to cancer. Adequate sample sizes can be difficult to achieve, reducing the power of studies and high attrition rates can result in inadequate follow up periods. This review uses examples of the management of cancer-related fatigue and death rattle(noisy breathing) to demonstrate the current state of EBM in palliative care. The future of EBM in palliative care needs to be as diverse as the patients who ultimately derive benefit. Non-RCT methodologies of equivalent quality, validity and size conducted by collaborative research networks using a ‘mixed methods approach' are likely to pose the correct clinical questions and derive evidencebased yet clinically relevant outcomes.

Management of intestinal failure in inflammatory bowel disease:Small intestinal transplantation or home parenteral nutrition?

Inflammatory bowel disease and Crohn’s disease in particular, is a common cause of intestinal failure. Current therapeutic options include home parenteral nutrition and intestinal transplantation. For most patients, home intravenous therapy including parenteral nutrition, with a good probability of long-term survival, is the favoured choice. However, in selected patients, with specific features that may shorten survival or complicate home parenteral nutrition, intestinal transplantation presents a viable alternative. We present survival, complications, quality of life and economic considerations that currently influence individualised decision-making between home parenteral nutrition and intestinal transplantation.

Evaluating learning and change in orthopaedics: What is the evidence-base?

Learning and change are key elements of clinical governance and are responsible for the progression of our specialty.Although orthopaedics has been slow to embrace quality improvement,recent years have seen global developments in surgical education,quality improvement,and patient outcome research.This review covers recent advances in the evaluation of learning and change and identifies the most important research questions that remain unanswered.Research into proxies of learning is improving but more work is required to identify the best proxy for a given procedure.Learning curves are becoming commonplace but are poorly integrated into postgraduate training curricula and there is little agreement over the most appropriate method to analyse learning curve data.With various organisations promoting centralisation of care,learning curve analysis is more important than ever before.The use of simulation in orthopaedics is developing but is yet to be formally mapped to resident training worldwide.Patient outcome research is rapidly changing,with an increased focus on quality of life measures.These are key to patients and their care.Costutility analysis is increasingly seen in orthopaedic manuscripts and this needs to continue to improve evidence-based care.Large-scale international,multi-centre randomised trials are gaining popularity and updated guidance on sample size estimation needs to become widespread.A global lack of surgeon equipoise will need to be addressed.Quality improvement projects frequently employ interrupted time-series analysis to evaluate change.This technique’s limitations must be acknowledged,and more work is required to improve the evaluation of change in a dynamic healthcare environment where multiple interventions frequently occur.Advances in the evaluation of learning and change are needed to drive improved international surgical education and increase the reliability,validity,and importance of the conclusions drawn from orthopaedic research.

European Specialty Examination in Gastroenterology and Hepatology examination-improving education in gastroenterology and hepatology

The Federation of Royal Colleges,the British Society of Gastroenterology(BSG)and the European Section and Board of Gastroenterology and Hepatology developed the European Specialty Examination in Gastroenterology and Hepatology(ESEGH)from the United Kingdom Specialty Certificate Examination,which was the original examination.Since 2018 the Specialty Certificate Examination and the ESEGH were combined into a single exam,identical across Europe and the rest of the world.The ESEGH is mandated in 4 countries(United Kingdom,Switzerland,The Netherlands and Malta)and the number of entries increased from 50 in 2014 to 490 in 2019.Candidates from countries were the ESEGH is not mandated are sitting the Exam,showing us they realize the enormous interest of holding a certificate for knowledge in their Curriculum.We also have an increasing number of candidates from countries outside Europe.

Improving Confidence and Practical Skills in Plastic Surgery for Medical Students and Junior Doctors: A One-Day Session

Objectives: The current medical school curriculum offers scant exposure to plastic surgery. Medical students and junior doctors are often inadequately prepared for in-hospital placements which may impact on patient safety and quality of care. We aimed to deliver a one-day “hands-on” practical session on basic surgical skills and principles in plastic surgery, and to assess its effectiveness at improving confidence to the specialty among junior trainees. Methods: The one-day practical session covered knot tying, suturing, LA administration, skin lesion excision and local flaps, with short concurrent lectures on principles of plastic surgery. Self-assessment confidence scores were recorded before and after the course on seven domains: a) knowledge: wound assessment and management, suture selection, and concepts of flaps;b) practical skills: Handling of surgical instrument, suturing, LA administration, and skin lesion excision. Results: Thirty-five participants attended: Six core surgical trainees, fifteen foundation doctors, and fourteen medical students. The overall course satisfaction was 9.13/10. Self-assessment confidence scores in all domains significantly improved after the course (p < 0.0001). Suturing (58.6%) and skin lesion excision (74.5%) demonstrated the largest improvement. Qualitative feedback was extremely positive. Conclusions: The hands-on nature of the course offered participants great opportunities to acquire the necessary confidence and practical skills required for in-hospital placements. It is vital for students and doctors interested in a career in plastic surgery to prepare adequately for this diverse specialty, which is covered in limited depth in medical school. The need for more practical skills courses on plastic surgery for this demographic is intuitive.

Poroid Hidradenoma: Case Report and Excision Rationale

Poroid hidradenoma is a benign eccrine neoplasm of the poroma family. We report a 65-year-old male patient who presented to his general practitioner with a poroid hidradenoma in zone 2 of the flexor surface of his left middle finger. Diagnosis was confirmed histologically, after which the patient was referred to us for wider excision. Although poroid hidradenoma is a benign tumour, wide local excision is mandatory. Here we discuss the reasoning behind this and present a rationale for excision margins.

Techniques in Hand &Upper Extremity Surgery

The use of tendon transfer to restore functions of extremities was initially recognised in the 19th century, and its advancement was further amplified by the polio epidemic towards the turn of that century. Tendon transfer surgery extended to the use for traumatic reconstructive surgery during World War I, with key surgical pioneers, including Mayer, Sterling Bunnell, Guy Pulvertaft and Joseph Boyes. In 1921, Robert Jones first described the transfer of pronator teres (PT) to the wrist extensors for irreparable radial nerve paralysis in infantile hemiplegia. Although, a detailed description of its indication and surgical outcomes were not published until 1959 and 1970 by Stelling and Meyer, and Keats, respectively. Pronator teres is often the tendon of choice for reconstructing wrist extensors, and used in a multiple of pathologies, including radial nerve palsy, cerebral palsy, and tetraplegia. Reconstruction of finger extensors are less straightforward and options include flexor carpi radialis (FCR), flexor carpi ulnaris (FCU), and flexor digitorum superficialis (FDS). Our article describes the techniques and outcomes of 25 patients that undergone pronator teres transfer. A good understanding of the pronator teres anatomical location and potential variations, aids efficient harvesting and limits unnecessary tissue dissection. Pronator teres tendon harvest is best performed through a systematic and anatomic approach.

合理检查：中性粒细胞减少的初级诊疗

本系列文章探讨了如何对初诊发现常见或重要的临床症状提供具有诊断价值的最佳关键性检查的进展。我们邀请康奈尔医学院的Steve Atkin医学教授，英国赫尔皇家医学院及赫尔皇家医院临床生化部的Eric Kilpartick荣誉教授作为本系列顾问。读者如对本系列议题有何建议，可通过发电子邮件至practice@bmj．com联系我们。

儿童及青少年糖尿病的诊断和管理:NICE指南更新概要

在英国儿童及青少年中,有25000多例1型糖尿病患者,500例2型糖尿病患者,且这两种类型的糖尿病都越来越常见^(1)。包括糖尿病酮症酸中毒(DKA)在内的各类并发症都会威胁到1型和2型糖尿病患者的生命。对糖尿病及其相关并发症给予及时诊断及有效管理非常重要。

病例回顾 呼吸困难伴水肿的年轻女性

一名25岁的女性因呼吸困难加重和外周水肿5天被收入院治疗。她10年前诊断为1型糖尿病且血糖控制不佳。在过去的两年中,她患上了慢性肾脏病(CKD),并且估算肾小球滤过率(eGFR)逐渐下降,肌酐水平升高(既往无症状)。查体发现患者双手肌肉痉挛、双侧大腿凹陷性水肿、腹部膨隆、颜面水肿。听诊双肺呼吸音减低,双侧肺底细小湿啰音。胸部X线片显示节段性肺不张和肺血流重新分布。

合理的影像学检查——急性膝关节损伤的检查

普通x线片对于膝关节损伤的评估可能是不适当的；可能还需要其他的影像学技术，特别是核磁共振。

Dog bite injuries to the face: A narrative review of the literature

Objective: Dog bite injuries remain a public health concern for two key reasons: the physical threat to health following attack and the infective sequelae a canine bite can incur. Facial bite injuries can result in significant emotional, psychological and physical trauma to victims involved. This narrative review elucidates the current presentation and management of dog bite injuries to the face.Data Sources and Methods: A literature search was conducted electronically using the search terms "dog bite" and "face" and "management" using the National Library of Medicine (Pubmed) and the Cochrane Library. There were no time nor language restrictions. A total of 79 studies were initially retrieved using the search algorithm. After screening of the titles and abstracts, 9 full texts were retrieved, and a total of 7 studies included.Results: The number of patients included in each study following a dog bite ranged from 40 to 223. The percentage of children included in each study (aged <18 years old) ranged from 27.5% to 100%. The majority of dog bite injuries to the face were managed by primary repair, ranging from 56.3% to 100%. Prophylactic antibiotics were used in most studies for dog bite injuries, ranging from 81% to 100%. The secondary infection rate following a dog bite ranged from 0 to 35%.Conclusion: This review highlights that children are disproportionately affected by canine bite injuries to the face relative to adults. The dog involved in the attack is typically known to the victim, with the lips, the cheek and the nose representing the most common sites of facial injury. More units are managing such injuries with primary repair and prophylactic antibiotics. Reconstructive procedures most commonly involve a local or advancement flap, a full thickness skin graft or a split skin graft. These are typically performed by Plastic Surgery and Maxillofacial Surgery specialists.