Loculated pericardial hematoma diagnosed with point-of-care ultrasound

Pericardial hematoma is a rare but potentially lifethreatening consequence following cardiac surgery that requires prompt recognition and intervention.Patients can present with symptoms such as chest pain,dyspnea,tachycardia,and hypotension,which may mimic other post-operative issues.Loculated pericardial hematoma compressing the atria might be difficult to diagnose.Bleeding and hematoma are more common in patients receiving early anticoagulant therapy.A focused cardiac ultrasound (Fo CUS) plays a pivotal role in the diagnosis,revealing the presence of pericardial effusion and signs of cardiac compression.The aim of this report was to provide a prompt diagnosis of loculated pericardial hematoma via Fo CUS in the emergency department (ED).

Hospital-Acquired Anaemia Secondary to Phlebotomy in Elderly Patients

Introduction: Anaemia contributes to increased morbidity and mortality in hospitalised patients, yet unnecessary blood tests from inpatients may actually induce a “hospital acquired anaemia” (HAA). This study examines the incidence of phlebotomy-induced anaemia during a hospital admission. Methods: Patients admitted to the Royal Bournemouth Hospital between 2009 and 2011 for a period of more than two weeks were identified. Those with normal haemoglobins on admission (Hb > 130 g/dL in men;Hb > 120 g/dL in women) were selected to be included in the study. One hundred and sixty two patients were randomly selected from this group and their admission and discharge haemoglobin was recorded, and the change in Hb was calculated. The number of blood tests taken during admission was calculated from each patient from which volume of blood lost was determined. Age, sex and co-morbidities, bleeding complications and blood transfusions were noted. T-test for unequal variance was used for analysis. Results: Of the 162 patients, 69 (42.5%) developed a HAA (defined as haemoglobin drop from normal to <110 g/dL). The average number of blood tests taken in the anaemia group was 37, compared to only 23 in the “no-anaemia” group. i.e. 132 mls in the anaemia group vs. only 80.2 mls in no-anaemia group. Further analysis of the anaemia group revealed that 40 patients developed a “mild anaemia” (defined as drop in Hb from normal to <110 g/dL) and 29 developed a moderate/severe anaemia (drop from a normal Hb at admission to <100 g/dL). Significantly higher volume of blood was withdrawn from this moderate/severe anaemia group compared to those that developed a mild anaemia 177.9 mls vs. 121.34 mls (p-Value 0.007, F = 0.001) 95% CI 2.08 to 9.22. Conclusion: This study suggests that patients admitted for inpatient stays of more than two weeks may be at high risk of HAA as a consequence of diagnostic blood loss. This anaemia in turn may have detrimental consequences, especially in patients with pre-existing cardio-respiratory disease. There needs to be increased awareness of the risk posed to patients as a result of diagnostic phlebotomy and further studies are required to study its impact on LOS, morbidity and mortality outcomes.

Systemic treatment of hepatocellular carcinoma:Past,present and future

Hepatocellular carcinoma(HCC) is a common neoplasia which represents the second leading cause of cancer related death. Most cases occur in developing countries, but its incidence is rising in Western countries due to hepatitis C. Although hepatitis therapies have evolved and the HCC screening has increased in several areas, 40% present with advanced disease which is only amenable for palliative systemic treatment. HCC continues posing a challenge, in part due to the inherent chemoresistance of this neoplasia, the pharmacologic challenges due to an ill liver, difficulty in assessing radiological responses accurately, etc. Traditional chemotherapy have shown some responses without clear survival benefit, however, sorafenib demonstrated advantages in survival in advanced HCC when liver function is kept and recently immunotherapy seems to be a promising approach for some patients. This article will briefly expose the most relevant systemic treatment modalities to offer a general view from the past to the future.

New therapeutic approaches to metastatic gastroenteropancreatic neuroendocrine tumors:A glimpse into the future

Neuroendocrine(NE) gastroenteropancreatic tumors are a heterogeneous group of neoplasias arising from neuroendocrine cells of the embryological gut. Their incidence have increased significantly over the past 3 decades probably due to the improvements in imaging and diagnosis. The recent advances in molecular biology have translated into an expansion of therapeutic approaches to these patients. Somatostatin analogs, which initially were approved for control of hormonal syndromes, have recently been proven to inhibit tumor growth. Several new drugs such as antiangiogenics and others targeting mammalian target of rapamycin pathways have been approved to treat progressive pancreatic neuroendocrine tumors(NETs) although their role in nonpancreatic is still controversial. The treatment of NETs requires a coordinated multidisciplinary approach. The management of localized NETs primarily involves surgical resection followed by surveillance. However, the treatment of unresectable and/or metastatic disease may involve a combination of surgical resection, systemic therapy, and liver-directed therapies with the goal of alleviating symptoms of peptide release and controlling tumor growth. This article will review the current therapeutic strategies for metastatic gastroenteropancreatic NETs and will take a glimpse into the future approaches.

Is cardiac resynchronisation therapy feasible, safe and beneficial in the very elderly？

Objective To evaluate whether cardiac resynchronisation therapy （CRT） implantation was feasible and safe in octogenarians and the asso- ciation with symptoms. Methods Consecutive patients undergoing CRT implantation were recruited from two UK centers. Patients grouped according to age： 〈 80 ＆ ≥ 80 years. Baseline demographics, complications and outcomes were compared between those groups. Results A total of 439 patients were included in this study, of whom 26% were aged ≥ 80 years. Octogenarians more often received cardiac resynchronization therapy pacemaker in comparison to cardiac resynchronisation therapy-defibrillator. Upgrade from pacemaker was common in both groups （16% 〈 80 years vs. 22% ≥ 80 years, P = NS）. Co-morbidities were similarly common in both groups （overall diabetes： 25%, atrial fibrillation： 23%, hypertension： 45%）. More patient age ≥ 80 years had significant chronic kidney disease （CKD, estimated glomerular filtration rate 〈 45 mL/min per 1.73 m^2, 44% vs. 22%, P 〈 0.01 ）. Overall complication rates （any） were similar in both groups （16% vs. 17%, P = NS）. Both groups demonstrated symptomatic benefit. One-year mortality rates were almost four fold greater in octogenarians as compared with the younger cohort （13.9% vs. 3.7%, P 〈 0.01）. Conclusions CRT appears to be safe in the very elderly despite extensive co-morbidity, and in particular frequent severe CKD. Symptomatic improvement appears to be meaningful. Strategies to increase the appropriate identification of elderly patients with CHF who are potential candidates for CRT are required.

Trends in ophthalmology journals： a five-year bibliometric analysis （2009-2013）

AIM： To explore the trends in the ophthalmic literature over a 5-year period in relation to country, research expenditure and demographics. METHODS： Articles published between 2009 and 2013 by the 20 highest-contributing countries in the 20 top- ranked ophthalmology journals were identified by their country of affiliation. The number of articles published and mean impact factor were measured per country for each year and trends explored using regression analysis with 5-year and 10-year forecasts calculated. Data on research expenditure was collected and tested for correlation with the number of articles and mean impact factor. RESULTS： The analysis included 19 338 articles. The USA, UK and Europe accounted for 60.2% of articles published, with the USA contributing 7388 articles （34.0%）. The USA also demonstrated the highest mean impact factor （3.5）. Research expenditure was significantly correlated with both research output （r=0,86, P〈0.001） and scholarly impact （r=0.42, P〈0.001）. China （P〈0.01）, Korea （P〈0.01） and India （P〈0.02） demonstrated a significant growth in research output over the study period. The research contribution of these three countries combined is forecasted to overtake that of Europe within ten years, with China expected to be the second-largest contributor within five years. These countries were also among those demonstrating the greatest growth in research expenditure. CONCLUSION： While the USA and European countries are major contributors of ophthalmic research, the productivity of some Asian countries is growing impressively. The contribution of China, Korea and Indiais forecasted to outweigh that of Europe by 2023. Research expenditure is highly correlated with research productivity and these trends reflect the differing economic priorities across the world.

Potential benefit of lymph node dissection during radical nephrectomy for kidney cancer:A review and critical analysis of current literature

Objective:The role of lymph node dissection(LND)is still controversial in patients with renal cell carcinoma undergoing surgery.We aimed to provide a comprehensive review of the literature about the effect of LND on survival,prognosis,surgical outcomes,as well as patient selection and available LND templates.Methods:Recent literature(from January 2011 to December 2021)was assessed through PubMed and MEDLINE databases.A narrative review of most relevant articles was provided.Results:The frequencies in which LNDs are being carried out are decreasing due to an increase in minimally invasive and nephron sparing surgery.Moreover,randomized clinical trials and meta-analyses failed to show any survival advantage of LND versus no LND.However,retrospective studies suggest a survival benefit of LND in high-risk patients(bulky tumors,T3-4 stage,and cN1 patients).Moreover,extended LND might provide important staging information,which could be of interest for adjuvant treatment planning.Conclusion:No level 1 evidence of any survival advantage deriving from LND is currently available in literature.Thus,the role of LND is limited to staging purposes.However,low grade evidence suggests a possible role of LND in high-risk patients.Randomized clinical trials are warranted to corroborate these findings.

结肠检查前服用磷酸钠进行肠道准备后的血清电解质及磷酸盐的测定:一项评估报道

Our purpose was to observe the effects of sodium phosphate (NaP) colonoscopy preparation on serum electrolytes, phosphate, and calcium and to identify factors associated with any adverse effects. In an unselected group of 100 consecutive patients attending for out patient colonoscopy, 45% of patients had raised serum phosphate, which was positively correlated with creatinine and age. There was a negative association of phosphate with calcium; 16% of patients had hypocalcemia and 26% had hypokalemia. Patients taking ACE inhibitors, AT2 antagonists, or diuretics were associated with hyperphosphatemia. Significant electrolyte and metabolic disturbance from colonoscopy preparation has been shown with NaP preparation, without overt clinical effects. We recommend that elderly patients and those with significant comorbidity have their electrolytes and calcium measured, and diuretics and ACE inhibitors stopped, before NaP administration. Endoscopy units should be alert for patients who might be suffering from electrolyte disturbance postpreparation and be prepared to measure their electrolytes.

Psychological themes that influence self-management of type 1 diabetes

It has long been accepted that psychological factors adversely influence efforts to optimise glycaemic control.These are often unrecognised in terms of clinical assessment and therefore under reported.This essay presents an introduction to psychological issues that interact with psychiatric co-morbidities and diabetesspecific distress,and a case scenario illustrating the interconnectedness of presenting problems and themes.In the way that we cannot separate carbohydrate counting,blood glucose monitoring and insulin doseadjustment in the understanding of a presenting problem such as poor control,so we cannot separate the concurrent thoughts,feelings,and behaviours.Each of these emotional aspects are self-managed either through avoidance,or by delayed disclosure and are frequently associated with poor health outcomes.There is a requirement for the healthcare team to be sensitised to these issues and to develop styles of communication that are empathic,reflective and non judgemental.A brief outline of evidence-based psychotherapy treatments is given.

Diagnostic CT: Are Patients Adequately Informed?

AIM: CT scanning is a widely utilised effective diagnostic tool. We aimed to establish whether patients are adequately informed prior to undergoing CT investigations. Methods: All adult patients with mental capacity attending the department for a CT study over a week period were invited to fill out a brief questionnaire prior to their scan. Results: 57 patients returned completed questionnaires. Overall 23% of patients were unsure or incorrect about the type of scan scheduled. Of patients attending with a new condition, 46% of them did not know their provisional diagnosis. Only 32 % of patients had insight into how a CT scan worked. This was taken to mean that the patient had included some reference to either x-rays, radiation or cross sectional imaging. Only 23% of patients were aware of potential complications of CT scans. Conclusion: Although written consent prior to CT scan is probably a step too far in providing patients with relevant risks/benefits of their investigation, we propose all patients undergoing CT have prior access to a written information sheet should they wish to be further informed regarding their procedure.

Non-alcoholic Fatty Liver Disease:A Clinical Update

Non-alcoholic fatty liver disease(NAFLD)is currently the most common chronic liver disease in developed countries because of the obesity epidemic.The disease increases liverrelated morbidity and mortality,and often increases the risk for other comorbidities,such as type 2 diabetes and cardiovascular disease.Insulin resistance related to metabolic syndrome is the main pathogenic trigger that,in association with adverse genetic,humoral,hormonal and lifestyle factors,precipitates development of NAFLD.Biochemical markers and radiological imaging,along with liver biopsy in selected cases,help in diagnosis and prognostication.Intense lifestyle changes aiming at weight loss are the main therapeutic intervention to manage cases.Insulin sensitizers,antioxidants,lipid lowering agents,incretin-based drugs,weight loss medications,bariatric surgery and liver transplantation may be necessary for management in some cases along with lifestyle measures.This review summarizes the latest evidence on the epidemiology,natural history,pathogenesis,diagnosis and management of NAFLD.

Seasonal and geographical distribution of bacillary dysentery(shigellosis)and associated climate risk factors in Kon Tum Province in Vietnam from 1999 to 2013

Background:Bacillary dysentery(BD)is an acute bacterial infection of the intestine caused by Shigella spp.,with clinical symptoms ranging from fever to bloody diarrhoea to abdominal cramps to tenesmus.In Vietnam,enteric bacterial pathogens are an important cause of diarrhoea and most cases in children under 5 years of age are due to Shigella strains.The serogroups S.flexneri and S.sonnei are considered to be the most common.The main objective of this study was to,for the first time,assess the seasonal patterns and geographic distribution of BD in Vietnam,and to determine the climate risk factors associated with the incidence of BD in Kon Tum Province,where the highest rate of bacillary dysentery was observed from 1999 to 2013.Methods:The seasonal patterns and geographic distribution of BD was assessed in Vietnam using a seasonaltrend decomposition procedure based on loess.In addition,negative binomial regression models were used to determine the climate risk factors associated with the incidence of BD in Kon Tum Province,from 1999 to 2013.Results:Overall,incidence rates of BD have slightly decreased over time(except for an extremely high incidence in 2012 in the north of Vietnam).The central regions(north/south central coast and central highlands)had relatively high incidence rates,whereas the northwest/east and Red River Delta regions had low incidence rates.Overall,seasonal plots showed a high peak in the mid-rainy reason and a second smaller peak in the early or late rainy season.The incidence rates significantly increased between May and October(“wet season”)across the country.In Kon Tum Province,temperature,humidity,and precipitation were found to be positively associated with the incidence of BD.Conclusions:Our findings provide insights into the seasonal patterns and geographic distribution of BD in Vietnam and its associated climate risk factors in Kon Tum Province.This study may help clinicians and the general public to better understand the timings of outbreaks and therefore equip them with the knowledge to plan better interventions(such as improving water,sanitation,and hygiene conditions)during peak seasons.This can,in turn,prevent or reduce outbreaks and onwards transmission during an outbreak.

Medium-term mortality after hip fractures and COVID-19:A prospective multicentre UK study

Purpose:The COVID-19 pandemic has caused 1.4 million deaths globally and is associated with a 3-4 times increase in 30-day mortality after a fragility hip fracture with concurrent COVID-19 infection.Typically,death from COVID-19 infection occurs between 15 and 22 days after the onset of symptoms,but this period can extend up to 8 weeks.This study aimed to assess the impact of concurrent COVID-19 infection on 120-day mortality after a fragility hip fracture.Methods:A multi-centre prospective study across 10 hospitals treating 8%of the annual burden of hip fractures in England between 1st March and 30th April,2020 was performed.Patients whose surgical treatment was payable through the National Health Service Best Practice Tariff mechanism for"fragility hip fractures"were included in the study.Patients'120-day mortality was assessed relative to their perioperative COVID-19 status.Statistical analysis was performed using SPSS version 27.Results:A total of 746 patients were included in this study,of which 87(11.7%)were COVID-19 positive.Mortality rates at 30-and 120-day were significantly higher for COVID-19 positive patients relative to COVID-19 negative patients(p<0.001).However,mortality rates between 31 and 120-day were not significantly different(p=0.107),16.1%and 9.4%respectively for COVID-19 positive and negative patients,odds ratio 1.855(95%CI 0.865-3.978).Conclusion:Hip fracture patients with concurrent COVID-19 infection,provided that they are alive at day-31 after injury,have no significant difference in 120-day mortality.Despite the growing awareness and concern of "long-COVID"and its widespread prevalence,this does not appear to increase mediumterm mortality rates after a hip fracture.