What can the Interventional Endoscopist Offer in the Management of Upper Gastrointestinal Malignancies?

The therapeutic possibilities of endoscopy have rapidly increased in the last decades and now allow organ-sparing treatment of early upper gastrointestinal malignancy as well as an increasing number of options for symptom palliation. This review contains an overview of the interventional endoscopic procedures in upper gastrointestinal malignancies. It describes endoscopic treatment of early oesophageal and gastric cancers, and the palliative options in managing dysphagia and gastric outlet obstruction. It also provides an overview of the therapeutic possibilities of biliary endoscopy, such as retrograde stenting and radiofrequency biliary ablation. Endoscopic ultrasound-guided therapeutic options are discussed, including biliary drainage, gastrojejunostomy and coeliac axis block. To aid in clinical decision making, the procedures are described in the context of their indication, efficacy, risks and limitations.

Effect of inpatient rehabilitation treatment ingredients on functioning, quality of life, length of stay, discharge destination, and mortality among older adults with unplanned admission: an overview review.

BACKGROUND: To synthesise the evidence for the effectiveness of inpatient rehabilitation treatment ingredients (versus any comparison) on functioning, quality of life, length of stay, discharge destination, and mortality among older adults with an unplanned hospital admission. METHODS: A systematic search of Cochrane Library, MEDLINE, Embase, PsychInfo, PEDro, BASE, and OpenGrey for published and unpublished systematic reviews of inpatient rehabilitation interventions for older adults following an unplanned admission to hospital from database inception to December 2020. Duplicate screening for eligibility, quality assessment, and data extraction including extraction of treatment components and their respective ingredients employing the Treatment Theory framework. Random effects meta-analyses were completed overall and by treatment ingredient. Statistical heterogeneity was assessed with the inconsistency-value (I2). RESULTS: Systematic reviews (n = 12) of moderate to low quality, including 44 non-overlapping relevant RCTs were included. When incorporated in a rehabilitation intervention, there was a large effect of endurance exercise, early intervention and shaping knowledge on walking endurance after the inpatient stay versus comparison. Early intervention, repeated practice activities, goals and planning, increased medical care and/or discharge planning increased the likelihood of discharge home versus comparison. The evidence for activities of daily living (ADL) was conflicting. Rehabilitation interventions were not effective for functional mobility, strength, or quality of life, or reduce length of stay or mortality. Therefore, we did not explore the potential role of treatment ingredients for these outcomes. CONCLUSION: Benefits observed were often for subgroups of the older adult population e.g., endurance exercise was effective for endurance in older adults with chronic obstructive pulmonary disease, and early intervention was effective for endurance for those with hip fracture. Future research should determine whether the effectiveness of these treatment ingredients observed in subgroups, are generalisable to older adults more broadly. There is a need for more transparent reporting of intervention components and ingredients according to established frameworks to enable future synthesis and/or replication. TRIAL REGISTRATION: PROSPERO Registration CRD42018114323 .

A Ugandan Parenting Programme to Prevent Gender-Based Violence: Description and Formative Evaluation.

Purpose: To develop a culturally-sensitive intervention for the early prevention of gender-based violence (GBV) in Uganda. Methods: Programme design followed the 6SQuID model of intervention development and multi-sectorial advice. A formative evaluation was conducted in two communities with six groups and 138 participants. Findings: Four familial predictors of GBV were identified as potentially malleable: poor parent-child attachment, harsh parenting, inequitable gendered socialization and parental conflict. A community-based parenting programme was developed to address them. Its programme theory incorporates Attachment Theory, the concept that positive behavioural control develops emotional control, and Social Learning Theory. Its rationale, structure and content are presented using the TIDieR checklist. A formative evaluation showed the programme to be widely acceptable, culturally appropriate, and perceived to be effective, but also identified challenges. Conclusion: The careful development of this community-based parenting programme shows promise for the early prevention of GBV.

Pancreatic cystic lesions and the role of contrast enhanced endoscopic ultrasound.

An exponential rise in the use of cross-sectional imaging has led to an increase in the incidental identification of pancreatic cystic lesions (PCL); however, with many subtypes defined to date and heterogeneous morphology with often absent defining radiological features, PCLs present a diagnostic challenge. Computed tomography (CT) and/or magnetic resonance imaging (MRI) alone are frequently not sufficient to provide accurate characterisation. Endoscopic ultrasound (EUS) has an important role in the evaluation and classification of PCLs through its ability to define the internal architecture, which is further enhanced by the use of contrast medium. It is also used widely for the surveillance of larger cysts (>2 cm), which are associated with a greater malignant potential. The aim of this review is to demonstrate the role of contrast-enhanced (CE)-EUS in the diagnosis and risk stratification of PCLs. The features of the main non-neoplastic and neoplastic PCLs observed on CE-EUS are provided. When used in combination with other imaging techniques and patient characteristics, CE-EUS offers a more accurate assessment of PCLs and aids risk stratification. Additionally, CE-EUS enables assessment of parenchymal perfusion improving the precision of cyst characterisation and targeted biopsy of worrisome components. The International Consensus Guidelines recommend regular follow up for patients with mucinous or indeterminate PCLs that are fit enough for surgery. With the growing range of tools available to assess PCLs including CE-EUS, it is hoped that patients can be steered towards surgery, surveillance, or discharge with increasing accuracy.

In vitro and in vivo antioxidant potentials of the methanolic crude extract from Inula glomerata Oliv. & Hiern (Asteraceae) and Salacia kraussii (Harv) Harv (Celastraceae) / Potenciales antioxidantes in vitro e in vivo del extracto crudo metanólico de Inula glomerata Oliv. & Hiern. (Asteraceae) y Salacia kraussii (Harv) Harv (Celastraceae)

Reactive oxygen species are implicated in multiple pathological conditions including erectile dysfunction. This study evaluated the in vitro and in vivo antioxidant potential of the methanolic extracts of Inula glomerata and Salacia kraussii. The plant materials were pulverized and extracted with methanol. The phytochemical analysis, ability of the crude extracts to scavenge free radicals (ABTS, DPPH, NO.) in vitroas well as the total phenolic and flavonoid contents was investigated. In vivo, antioxidant potentials of the crude extracts (50/250 mg/kg body weight) were determined in an erectile dysfunction rat model. The phytochemical analysis revealed that both plants contain flavonoids, tannins, terpenoids, and alkaloids. The crude extracts at varying degree of efficiency, scavenged ABTS and DPPH radicals. The crude extracts at low concentrations (50 mg/kg b.w) significantly (p<0.05) diminished the level of malondialdehyde, augmented catalase activities and elevated glutathione levels. However, SOD activities were significantly boosted in a dose-dependent manner by the crude extracts. Therefore, I. glomerataand S. kraussiipossess antioxidant properties, hence, can serve as a therapeutic modality in the treatment of oxidative stress-induced erectile dysfunction.

Las especies reactivas de oxígeno están implicadas en múltiples condiciones patológicas, incluyendo la disfunción eréctil. Este estudio evaluó el potencial antioxidante in vitro e in vivo de extractos metanólicos de Inula glomeratay Salacia kraussii. Los materiales vegetales fueron pulverizados y extraídos con metanol. A estos extractos crudos se les llevó a cabo el análisis fitoquímico junto con el contenido total de fenólicos y flavonoides, así como se les investigó la capacidad in vitro para atrapar radicales (ABTS, DPPH, NO.). Los potenciales antioxidantes in vivo de los extractos crudos (50/250 mg/kg de peso corporal) se determinaron en un modelo en ratas con disfunción eréctil. El análisis fitoquímico reveló que ambas plantas contuvieron flavonoides, taninos, terpenoides y alcaloides. Los extractos crudos con un grado variable de eficiencia, atraparon a los radicales ABTS y DPPH. Los extractos crudos a bajas concentraciones (50 mg/kg p.c) significativamente (p<0.05) disminuyeron el nivel de malondialdehído, aumentaron las actividades de catalasa y elevaron los niveles de glutatión. Sin embargo, las actividades de SOD por los extractos crudos fueron significativamente dosis-dependientes. Así, los extractos de I. glomeratay S. kraussii mostraron propiedades antioxidantes, y por lo tanto, podrían servir como una alternativa terapéutica en el tratamiento de disfunción eréctil inducida por estrés oxidativo.

Preoperative diagnosis of intraductal papillary neoplasm of the bile duct with endoscopic ultrasound.

Intraductal papillary mucinous neoplasm of the bile duct is a rare tumour only recently classified as a distinct pathological entity. These neoplasms, rarely encountered in clinical practice in the UK, are now considered to be important precursors for the development of cholangiocarcinoma. We present a histologically confirmed case of intraductal papillary neoplasm of the bile duct in a male patient and discuss the main radiographic manifestations of this rare condition across multiple imaging modalities, with an emphasis on the imaging features of endoscopic ultrasonography and its role in establishing the diagnosis.

Engaging male students with mental health support: a qualitative focus group study.

BACKGROUND: Males are less likely to seek help for mental health difficulties compared to females. Despite considerable interest, a paucity of evidence-based solutions exists to address this. Concerns about students' mental health has led to the United Kingdom's Department of Education to make this a priority. Studies have shown that male students hold more negative attitudes towards the use of psychological services compared to female students and are less likely to seek help. A major concern is that male students make up 69% of university suicides, which is often associated with lower rates of help-seeking. This focus group study therefore sought to identify potential approaches that would be relevant to improving mental health help-seeking in male students. METHODS: Three focus groups comprising of 24 male students at a London University were conducted. Participants were asked questions exploring: the barriers to seeking help, what would encourage help-seeking, how an appropriate intervention should be designed, and how to publicise this intervention to male students. Thematic analysis was conducted to evaluate participants responses. RESULTS: Five distinct themes were identified. These were: 1) protecting male vulnerability, 2) providing a masculine narrative of help-seeking, 3) differences over intervention format, 4) difficulty knowing when and how to seek help, and 5) strategies to sensitively engage male students. CONCLUSIONS: These themes represent important considerations that can be used, together with the existing literature about male help-seeking, to develop more male friendly interventions that are suitable for male students. This could help improve help-seeking attitudes and the uptake of mental health interventions for male students experiencing emotional distress.

Split-bolus single-pass CT for vascular complications in acute pancreatitis: assessment of radiation dose and multi-phasic contrast enhancement compared to single-bolus multi-pass CT.

AIM: To assess vascular contrast enhancement and radiation dose of split-bolus single-pass computed tomography (CT) compared to single-bolus multi-pass CT for acquiring a multi-phasic study. MATERIALS AND METHODS: Patients who underwent CT for acute pancreatitis were included retrospectively. Thirty consecutive patients scanned with a split-bolus protocol were compared to 30 consecutive patients scanned with a single-bolus protocol. Data were collected on attenuation measurements (aorta, portal vein and spleen) and images were assessed for subjective vascular enhancement quality and splenic homogeneity. Radiation dose was measured by dose-length product (DLP). RESULTS: There was no significant difference in the aortic (p = 0.88) or portal vein (p = 0.35) attenuation values between the two groups. The percentage of examinations reaching the target aortic and portal attenuation in the split-bolus group were 96.7% and 93.3%, and in the single-bolus group were 96.7% and 85.7%, respectively. The mean DLP was 492 mGy.cm for the single-bolus group and 940 mGy.cm for the split-bolus group (p < 0.0001). Subjective assessment revealed higher rates of splenic heterogeneity in the split-bolus group. DISCUSSION: In acute pancreatitis, split-bolus imaging can produce arterial and venous enhancement comparable to a multi-pass technique with a significant reduction in radiation dose. Loss of temporal resolution and increased splenic heterogeneity are the main disadvantages. The low prevalence of pseudoaneurysms favours the lower-dose imaging technique.

Imaging of adult intestinal failure.

Intestinal failure is the inability to maintain adequate nutrition or hydration through the gut. It is caused by a diverse range of benign and malignant aetiologies. Imaging takes a central role in the multidisciplinary assessment of patients with intestinal failure.

Imaging of intestinal transplantation.

Intestinal transplant is considered in a small number of patients with intestinal failure or locally invasive benign abdominal tumours to improve both quality of life and survival. The complexity of the underlying diseases and postoperative findings are reflected in the imaging undertaken to support this patient group. Increasing numbers of patients are undergoing these procedures. Radiologists are increasingly likely to encounter these patients before and after surgery. This article will discuss the imaging findings that may prompt referral for transplantation assessment. It will also describe surgical anatomy and postoperative complications.

Community perceptions of paediatric severe anaemia in Uganda.

BACKGROUND: Severe anaemia remains a major cause of morbidity and mortality among children in sub-Saharan Africa. There is limited research on the beliefs and knowledge for paediatric severe anaemia in the region. The effect of these local beliefs and knowledge on the healthcare seeking of paediatric severe anaemia remains unknown. OBJECTIVE: To describe community perceptions of paediatric severe anaemia in Uganda. METHODS: Sixteen in-depth interviews of caregivers of children treated for severe anaemia and six focus group discussions of community members were conducted in three regions of Uganda between October and November 2017. RESULTS: There was no common local name used to describe paediatric severe anaemia, but the disease was understood in context as 'having no blood'. Severe anaemia was identified to be a serious disease and the majority felt blood transfusion was the ideal treatment, but concomitant use of traditional and home remedies was also widespread. Participants articulated signs of severe pediatric anemia, such as palmar, conjunctival, and tongue pallor. Other signs described included jaundice, splenomegaly, difficulty in breathing and poor appetite. Poor feeding, malaria, splenomegaly and evil spirits were perceived to be the common causes of severe anaemia. Other causes included: human immunodeficiency virus (HIV), haemoglobinuria, fever, witchcraft, mosquito bites, and sickle cell. Splenomegaly and jaundice were perceived to be both signs and causes of severe anaemia. Severe anaemia was interpreted to be caused by evil spirits if it was either recurrent, led to sudden death, or manifested with cold extremities. CONCLUSION: The community in Uganda perceived paediatric severe anaemia as a serious disease. Their understanding of the signs and perceived causes of severe anaemia to a large extent aligned with known clinical signs and biological causes. Belief in evil spirits persists and may be one obstacle to seeking timely medical care for paediatric severe anaemia.

Incidence, patterns and risk factors for injuries among Ugandan children.

There is limited epidemiological data on childhood injuries in developing countries. This study assessed the incidence, patterns and risk factors for injuries among children aged 0-5 years in Wakiso District, Uganda. To determine differences, chi-square and Wilcoxon rank sum tests were used. Risk factors were assessed using Poisson regression. Overall, information from 359 children of mean age 32 months (SD: 18.4) was collected. Annual incidence of injuries was 69.8 per 1000 children/year (95% CI 58.8-80.8). One fatal injury due to burns was reported. Incidence of injuries was less associated with being female (IRR: 0.56, 95% CI 0.34-0.90) and increasing age of the caretaker (IRR: 0.96, 95% CI 0.92-0.99). The high incidence of childhood injuries necessitates the need for interventions to reduce injuries among children.

Pancreatic allograft thrombosis: Suggestion for a CT grading system and management algorithm.

Pancreatic allograft thrombosis (PAT) remains the leading cause of nonimmunologic graft failure. Here, we propose a new computed tomography (CT) grading system of PAT to identify risk factors for allograft loss and outline a management algorithm by retrospective review of consecutive pancreatic transplantations between 2009 and 2014. Triple-phase CT scans were graded independently by 2 radiologists as grade 0, no thrombosis; grade 1, peripheral thrombosis; grade 2, intermediate non-occlusive thrombosis; and grade 3, central occlusive thrombosis. Twenty-four (23.3%) of 103 recipients were diagnosed with PAT (including grade 1). Three (2.9%) grafts were lost due to portal vein thrombosis. On multivariate analysis, pancreas after simultaneous pancreas-kidney transplantation/solitary pancreatic transplantation, acute rejection, and CT findings of peripancreatic edema and/or inflammatory change were significant risk factors for PAT. Retrospective review of CT scans revealed more grade 1 and 2 thromboses than were initially reported. There was no significant difference in graft or patient survival, postoperative stay, or morbidity of recipients with grade 1 or 2 thrombosis who were or were not anticoagulated. Our data suggest that therapeutic anticoagulation is not necessary for grade 1 and 2 arterial and grade 1 venous thrombosis. The proposed grading system can assist clinicians in decision-making and provide standardized reporting for future studies.

Imaging features of myeloproliferative neoplasms.

Myeloproliferative neoplasms (MPNs) are a heterogeneous group of haematological disorders including polycythaemia vera (PV), essential thrombocythaemia (ET), primary myelofibrosis (PMF), and chronic myeloid leukaemia (CML). These disorders show large overlap in genetic and clinical presentations, and can have many different imaging manifestations. Unusual thromboses, embolic events throughout the systemic or pulmonary vasculature, or osseous findings can often be clues to the underlying disease. There is limited literature about the imaging features of these disorders, and this may result in under-diagnosis. Multiple treatments are available for symptom control, and the development of multiple new pharmacological inhibitors has significantly improved morbidity and prognosis. Knowledge of these conditions may enable the radiologist to suggest an MPN as a possible underlying cause for certain imaging findings, particularly unexplained splanchnic venous thrombosis, i.e. in the absence of chronic liver disease or pancreatitis. The aim of the present review is to outline using examples the different categories of MPN and illustrate the variety of radiological findings associated with these diseases.

Relationship dynamics and sexual risk behaviour of male partners of female sex workers in Kampala, Uganda.

Regular male partners of female sex workers (FSWs) represent an important population to reach with HIV-prevention interventions. This paper discusses the relationship dynamics and HIV/sexually transmitted infection risk behaviour of men involved with self-identified FSWs in Kampala. Between 2011 and 2014 we conducted repeat in-depth interviews with 42 male partners of FSWs attending a clinic for women at high risk of HIV-infection in Kampala. Men publicly struggled with the stigma of dating women who are considered to be engaged in a shamed profession, but privately saw meaning in these relationships. In coping with the stigma, some described the work of their partners in terms that distanced them from sex work, while others struggled to have the control that "being a man" demanded since they could not monitor all movements of their partners. Dealing with HIV disclosure was hard and seeking support was difficult for some of the men, leading to missed opportunities and guilt. Despite challenges, relationships with sex workers offered men some benefits such as access to much needed care and treatment. A few men also admitted to being motivated by material and financial benefits from sex workers who they perceived as being rich and this was one factor that helped them sustain the relationships. These findings offer insights into the complex relationship dynamics within high risk sexual partnerships. However, the findings suggest that effective interventions that are couple centred can be established to promote better health.

Postoperative CT in pancreas transplantation.

AIM: To examine the usage and value of computed tomography (CT) following simultaneous pancreas and kidney (SPK) transplantation. MATERIALS AND METHODS: Indications for postoperative CT, key findings, and their influence on management were determined by retrospective analysis. RESULTS: Ninety-eight patients underwent 313 CT examinations. Common indications for the examinations included suspected intra-abdominal collection (31.1%) and elevated serum amylase/lipase (24.1%). CT findings most frequently showed non-specific mild inflammation (27.6%), a normal scan (17.1%) and fluid collections (16.3%). High capillary blood glucose (CBG) was associated with resultant CT demonstration of graft vascular abnormalities, but otherwise, particular clinical indications were not associated with specific CT findings. CONCLUSION: Clinical findings in patients with SPK transplants are non-specific. The pattern of abnormalities encountered is significantly different to those seen in native pancreatic disease and demands a tailored protocol. CT enables accurate depiction of vascular abnormalities and fluid collections, thus reducing the number of surgical interventions that might otherwise be required. Elevated CBG should prompt urgent CT to exclude potentially reversible vascular complications.

Susceptibility to large-joint osteoarthritis (hip and knee) is associated with BAG6 rs3117582 SNP and the VNTR polymorphism in the second exon of the FAM46A gene on chromosome 6.

Family with sequence similarity 46, member A (FAM46A) gene VNTR and BCL2-Associated Athanogene 6 (BAG6) gene rs3117582 polymorphisms were genotyped in a case-control study with 474 large-joint (hip and knee) osteoarthritis (OA) patients and 568 controls in Croatian population by candidate-gene approach for association with OA. We found that BAG6 rs3117582 SNP genotypes were associated with protection (major allele homozygote) and susceptibility (major-minor allele heterozygote) to OA. BAG6 rs3117582 major allele (A) was associated with reduced risk to OA while the minor allele (C) was associated with increased risk to OA. We identified 6 alleles harboring 2 to 7 repeats making 20 genotypes for FAM46A. A rare FAM46A VNTR genotype comprising VNTR alleles with four and seven repeats (c/f) was associated with increased OA risk in both genders. The genotype with four and six repeats (c/e) was also associated with increased risk to OA in males. A polymorphic FAM46A allele with six repeats (e) was associated with reduced risk to OA in females. Our results suggest association between the FAM46A gene, BAG6 gene and OA in Croatian population, respectively. This is the first study to show associations between these genetic loci and OA.

Maternal experiences of caring for an infant with neurological impairment after neonatal encephalopathy in Uganda: a qualitative study.

PURPOSE: The study investigated maternal experiences of caring for a child affected by neurological impairment after neonatal encephalopathy (NE) ("birth asphyxia") in Uganda. METHODS: Between September 2011 and October 2012 small group and one-on-one in-depths interviews were conducted with mothers recruited to the ABAaNA study examining outcomes from NE in Mulago hospital, Kampala. Data were analysed thematically with the aid of Nvivo 8 software. FINDINGS: Mothers reported caring for an infant with impairment was often complicated by substantial social, emotional and financial difficulties and stigma. High levels of emotional distress, feelings of social isolation and fearfulness about the future were described. Maternal health-seeking ability was exacerbated by high transport costs, lack of paternal support and poor availability of rehabilitation and counselling services. Meeting and sharing experiences with similarly affected mothers was associated with more positive maternal caring experiences. CONCLUSION: Mothering a child with neurological impairment after NE is emotionally, physically and financially challenging but this may be partly mitigated by good social support and opportunities to share caring experiences with similarly affected mothers. A facilitated, participatory, community-based approach to rehabilitation training may have important impacts on maximising participation and improving the quality of life of affected mothers and infants. Implications for Rehabilitation Caring for an infant with neurological impairment after NE in Uganda has substantial emotional, social and financial impacts on families and is associated with high levels of emotional stress, feelings of isolation and stigma amongst mothers. Improved social support and the opportunity to share experiences with other similarly affected mothers are associated with a more positive maternal caring experience. High transport costs, lack of paternal support and poor availability of counselling and support services were barriers to maternal healthcare seeking. Studies examining the feasibility, acceptability and impact of early intervention programmes are warranted to maximise participation and improve the quality of life for affected mothers and their infants.