Feasibility of intraoperative ultrasound of the small bowel during Crohn's disease surgery.

BACKGROUND: Intraoperative assessment of the extent and location of Crohn's disease is not standardised and relies on a mixture of surgeons' experience, tactile feedback and macroscopic appearance. To overcome this variability, we developed a protocol for full intraoperative ultrasound scan of the small bowel and we here report the results of "Assessing the Feasibility and Safety of Using Intraoperative Ultrasound in Ileocolic Crohn's Disease-The IUSS CROHN Study". METHODS: This is a prospective single centre observational study with enrolment of all patients undergoing elective surgery for terminal ileal Crohn's disease from January 2019 to March 2020. Patients underwent laparoscopic ileocolic resection, according to a standardised technique. Ultrasound intraoperative quantitative assessment was performed according to the METRIC (MREnterography or ulTRasound in Crohn's disease) scoring guide. RESULTS: Intraoperative ultrasound was successfully performed in 6 patients from the ileocaecal valve to the proximal jejunum. The median time required was 23.5 min (range 17-37 min) as compared to 6.5 min (5-12 min) required for the macroscopic evaluation performed by the surgeon. In 3 patients, intraoperative ultrasound identified more disease than surgical evaluation. CONCLUSIONS: This feasibility study demonstrated the safety of intraoperative ultrasound and allowed the development of a standardised protocol for intraoperative ultrasound and the data collection required to inform a randomised multicentre study.

The Portsmouth protocol for intra-operative ultrasound of the small bowel in Crohn's disease.

AIM: Bowel preservation is paramount in Crohn's disease surgery as affected patients are typically young adults at risk of having several abdominal surgical procedures during their lifetime. Intra-operative assessment of the extent and location of Crohn's disease is not standardized and is left to a mixture of the surgeon's experience, tactile feedback, macroscopic appearance and preoperative imaging. The aim of this study was to describe the technical steps of a standardized protocol for intra-operative ultrasound assessment of the small bowel in patients undergoing surgery for ileocolic Crohn's disease. METHOD: After laparoscopic mobilization of the bowel, a periumbilical incision is performed for extracorporeal division of the mesentery and the resection and anastomosis. A gastrointestinal consultant radiologist, with expertise in Crohn's disease imaging and abdominal ultrasound, performs full intra-operative assessment of the small bowel by applying a sterile ultrasound probe directly to the bowel, prior to resection being performed by the surgeon. The bowel is assessed through the wound protector with a sterile technique and the length, location and number of segments is documented together with further quantitative assessment using the METRIC (MR enterography or ultrasound in Crohn's disease) scoring guide. RESULTS: A step-by-step protocol for intra-operative ultrasound evaluation of the entire small bowel is described. CONCLUSIONS: A standardized approach to intra-operative evaluation of the extent and location of Crohn's disease is desirable. Intra-operative ultrasound may provide added value for assessment of proximal and multifocal Crohn's disease.

Bio-inspired sensing and actuating architectures for feedback control of civil structures.

Civil structures, such as buildings and bridges, are constantly at risk of failure due to external environmental loads, such as earthquakes or strong winds. To minimize the effects of these loads, active feedback control systems have been proposed but such systems still face numerous challenges which impede their widespread adoption. In order to overcome many of these challenges, inspiration can be drawn from the signal processing and actuating techniques employed by the biological central nervous system to develop a bio-inspired control algorithm. In this study the front-end, signal processing techniques employed by biological sensory systems, and in particular the mammalian auditory system, are drawn upon in order to alleviate computations at the actuation node. This results in a simplistic control law that is a weighted combination of input information about the structure's response such that F = WN , where F is the applied control force, W is a pre-determined weighting matrix, and N is a deconstructed representation of the structural response to the applied excitation. There is no empirical solution for deriving an optimal weighting matrix, W , and in this study numerous methods are explored in order to determine values for this matrix that produce the most effective control. These methods include particle swarm optimization, artificial neural networks, and optimal control theory. The various weighting matrices are integrated into the proposed bio-inspired control algorithm and applied in simulation to a five story benchmark structure. These methods are also compared to a traditional linear quadratic regulator (LQR) to gain insight into the overall performance of the bio-inspired control algorithm. Of the three training techniques, the particle swarm optimization technique offers the most effective control which is comparable in performance to the traditional LQR.

Faecal microbiota transplantation for Clostridium difficile infection in the United Kingdom.

Faecal microbiota transplantation (FMT) has been shown to be highly effective in treating recurrent Clostridium difficile infection, but to date there have been no data from the United Kingdom. An electronic survey was developed at Portsmouth Hospitals' National Health Service (NHS) Trust and sent out to UK hospital specialists utilizing the contact databases of the British Infection Association and the Royal College of Gastroenterologists. A total of 162 responses were received, representing nearly one in every seven of the United Kingdom's infection specialists and a response from one in every two UK NHS acute trusts or boards. Ninety-six per cent believe that the evidence base supports the use of FMT, and 94% reported consulting on at least one patient a year in whom they would recommend FMT. However, only 22% reported FMT use in their institution in the last 10 years, and 6% reported performing more than ten FMTs in the last 10 years. Concerns with patient acceptance, donor selection, availability of screened faecal solution, feasibility of procedure and availability of local expertise were reported as inhibiting the use of FMT. More than 90% of respondents would like access to regional guidelines, prescreened faecal solution and expert advice to facilitate implementation, and more than two thirds of respondents would support a regional FMT referral centre. A large gap exists in the United Kingdom between physicians desire to use FMT and the ability and facilities to provide it as a therapy at the bedside.

Utilization of fentanyl buccal tablets in England: exploring off-label use reported in a cohort study.

BACKGROUND: Fentanyl citrate buccal tablets are indicated for the treatment of breakthrough pain (BTP) in cancer, in adults who are receiving maintenance opioid therapy for chronic cancer pain. OBJECTIVE: One of the objectives of this study was to describe the utilization characteristics of patients prescribed fentanyl buccal and to assess how the product is being used in relation to the terms of license of marketing approval. METHODS: An observational post-marketing cohort study was conducted. For the analysis of this study, exposure data were collected from dispensed prescriptions issued by general practitioners (GPs) between March 2009 and June 2011. Outcome data (indication, event, patient demographic and selected clinical characteristics) were collected by sending questionnaires to GPs at least 6 months after the drug was first prescribed. Summary descriptive statistics were calculated. RESULTS: The cohort consisted of 551 patients, of which 54.8% (n = 302 patients) were female. The median age for the cohort was 62 years (interquartile range: 50-72 years), with one patient (0.2%) aged less than 18 years. A primary indication of BTP in cancer was reported for 61.9% (n = 341) patients. Regular opioid therapy was reported upon starting the treatment for 383 patients (69.5% of cohort). In total, 69 patients (12.5%) had one or more contraindications for use. The most frequent initial titration dose was 100 µg/day (n = 247). CONCLUSIONS: The final study results show that fentanyl buccal is largely being prescribed according to the terms of the license in general practice in England, but off-licence use and use in the presence of contraindications and warnings have been reported.

The epidemiology of malaria in adults in a rural area of southern Mozambique

Background: Epidemiological studies of malaria in adults who live in malaria endemic areas are scarce. More attention to the natural history of malaria affecting adults is needed to understand the dynamics of malaria infection and its interaction with the immune system. The present study was undertaken to investigate the clinical; parasitological and haematological status of adults exposed to malaria; and to characterize parasites in these individuals who progressively acquire protective immunity. Methods: A cross-sectional survey of 249 adults was conducted in a malaria endemic area of Mozambique. Clinical; parasitological and haematological status of the study population was recorded. Sub-microscopic infections and multiplicity of infections were investigated using polymerase chain reaction (PCR) and restriction fragment length polymorphism of Plasmodium falciparum merozoite surface protein 2 (msp2). Results: Prevalence of P. falciparum infection by microscopy (14) and PCR (42) decreased progressively during adulthood; in parallel with an increase in the prevalence of sub-microscopic infections. Anaemia was only related to parasitaemia as detected by PCR. Multiplicity of infection decreased with age and was higher in subjects with high P. falciparum densities; highlighting density-dependent constraints upon the PCR technique. Conclusions: Adults of Manhica progressively develop non-sterile; protective immunity against P. falciparum malaria. The method of parasite detection has a significant effect on the observed natural history of malaria infections. A more sensitive definition of malaria in adults should be formulated; considering symptoms such as diarrhoea; shivering and headache; combined with the presence of parasitaemia

The precision of T1 hypointense lesion volume quantification in multiple sclerosis treatment trials: a multicenter study.

The volume of hypointense lesions on T1 weighted brain MRI represents an increasingly used MR endpoint in phase III MS treatment trials. In this study we evaluated the reproducibility of hypointense T1 lesion volume quantification in a cohort of Multiple Sclerosis (MS) patients. The gadolinium enhanced T1 weighted brain MR images of 33 MS patients from three European centers were used in this study. These images were acquired as part of a phase III trial of interferon beta-1b in secondary progressive MS. The MRI machine manufacturers and imaging parameters varied according to the MRI acquisition center. Three experienced observers used a semi-automated local thresholding technique to quantify the hypointense T1 lesion volume on two occasions, separated by a delay. The intra and inter observer coefficients of variation were 3.7% and 4.9% respectively, with similar values derived for images obtained at all three sites. There was a generally high level of agreement between the lesion volumes obtained by the three raters. However, a modest but significant measurement drift was identified between the first and second sessions for one of the three raters, highlighting the very real possibility of measurement drift even for experienced observers. Our results support the increasing role for T1 hypointense lesion volume as an outcome measure in multicenter phase III MS treatment trials. Multiple Sclerosis (2000) 6 237 - 240