Donor Blood Tests do Not Predict Pancreas Graft Survival After Simultaneous Pancreas Kidney Transplantation; a National Cohort Study.

Simultaneous pancreas-kidney (SPK) transplantation improves quality of life and limits progression of diabetic complications. There is reluctance to accept pancreata from donors with abnormal blood tests, due to concern of inferior outcomes. We investigated whether donor amylase and liver blood tests (markers of visceral ischaemic injury) predict pancreas graft outcome using the UK Transplant Registry (2016-2021). 857 SPK recipients were included (619 following brainstem death, 238 following circulatory death). Peak donor amylase ranged from 8 to 3300 U/L (median = 70), and this had no impact on pancreas graft survival when adjusting for multiple confounders (aHR = 0.944, 95% CI = 0.754-1.81). Peak alanine transaminases also did not influence pancreas graft survival in multivariable models (aHR = 0.967, 95% CI = 0.848-1.102). Restricted cubic splines were used to assess associations between donor blood tests and pancreas graft survival without assuming linear relationships; these confirmed neither amylase, nor transaminases, significantly impact pancreas transplant outcome. This is the largest, most statistically robust study evaluating donor blood tests and transplant outcome. Provided other factors are acceptable, pancreata from donors with mild or moderately raised amylase and transaminases can be accepted with confidence. The use of pancreas grafts from such donors is therefore a safe, immediate, and simple approach to expand the donor pool to reach increasing demands.

Robotic versus laparoscopic versus open nephrectomy for live kidney donors.

BACKGROUND: Waiting lists for kidney transplantation continue to grow. Live kidney donation significantly reduces waiting times and improves long-term outcomes for recipients. Major disincentives to potential kidney donors are the pain and morbidity associated with surgery. This is an update of a review published in 2011. OBJECTIVES: To assess the benefits and harms of open donor nephrectomy (ODN), laparoscopic donor nephrectomy (LDN), hand-assisted LDN (HALDN) and robotic donor nephrectomy (RDN) as appropriate surgical techniques for live kidney donors. SEARCH METHODS: We contacted the Information Specialist and searched the Cochrane Kidney and Transplant Register of Studies up to 31 March 2024 using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal, and ClinicalTrials.gov. SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing LDN with ODN, HALDN, or RDN were included. DATA COLLECTION AND ANALYSIS: Two review authors independently screened titles and abstracts for eligibility, assessed study quality, and extracted data. We contacted study authors for additional information where necessary. Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes and mean difference (MD) or standardised mean difference (SMD) and 95% CI for continuous outcomes. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. MAIN RESULTS: Thirteen studies randomising 1280 live kidney donors to ODN, LDN, HALDN, or RDN were included. All studies were assessed as having a low or unclear risk of bias for selection bias. Five studies had a high risk of bias for blinding. Seven studies randomised 815 live kidney donors to LDN or ODN. LDN was associated with reduced analgesia use (high certainty evidence) and shorter hospital stay, a longer procedure and longer warm ischaemia time (moderate certainty evidence). There were no overall differences in blood loss, perioperative complications, or need for operations (low or very low certainty evidence). Three studies randomised 270 live kidney donors to LDN or HALDN. There were no differences between HALDN and LDN for analgesia requirement, hospital stay (high certainty evidence), duration of procedure (moderate certainty evidence), blood loss, perioperative complications, or reoperations (low certainty evidence). The evidence for warm ischaemia time was very uncertain due to high heterogeneity. One study randomised 50 live kidney donors to retroperitoneal ODN or HALDN and reported less pain and analgesia requirements with ODN. It found decreased blood loss and duration of the procedure with HALDN. No differences were found in perioperative complications, reoperations, hospital stay, or primary warm ischaemia time. One study randomised 45 live kidney donors to LDN or RDN and reported a longer warm ischaemia time with RDN but no differences in analgesia requirement, duration of procedure, blood loss, perioperative complications, reoperations, or hospital stay. One study randomised 100 live kidney donors to two variations of LDN and reported no differences in hospital stay, duration of procedure, conversion rates, primary warm ischaemia times, or complications (not meta-analysed). The conversion rates to ODN were 6/587 (1.02%) in LDN, 1/160 (0.63%) in HALDN, and 0/15 in RDN. Graft outcomes were rarely or selectively reported across the studies. There were no differences between LDN and ODN for early graft loss, delayed graft function, acute rejection, ureteric complications, kidney function or one-year graft loss. In a meta-regression analysis between LDN and ODN, moderate certainty evidence on procedure duration changed significantly in favour of LDN over time (yearly reduction = 7.12 min, 95% CI 2.56 to 11.67; P = 0.0022). Differences in very low certainty evidence on perioperative complications also changed significantly in favour of LDN over time (yearly change in LnRR = 0.107, 95% CI 0.022 to 0.192; P = 0.014). Various different combinations of techniques were used in each study, resulting in heterogeneity among the results. AUTHORS' CONCLUSIONS: LDN is associated with less pain compared to ODN and has comparable pain to HALDN and RDN. HALDN is comparable to LDN in all outcomes except warm ischaemia time, which may be associated with a reduction. One study reported kidneys obtained during RDN had greater warm ischaemia times. Complications and occurrences of perioperative events needing further intervention were equivalent between all methods.

Endoscopic radiofrequency Stretta therapy reduces proton pump inhibitor dependency and the need for anti-reflux surgery for refractory gastroesophageal reflux disease.

BACKGROUND/AIMS: Radiofrequency treatment of the gastroesophageal junction using the Stretta procedure for treating gastroesophageal reflux disease (GERD) is observed to improve the symptoms and proton pump inhibitor (PPI) dependence and reduce the need for anti-reflux operations. As one of the largest studies in Europe, we evaluated the clinical outcomes of Stretta in patients with medically refractory GERD. METHODS: A tertiary UK center evaluated all patients with refractory GERD who underwent Stretta between 2014 and 2022. Patients and primary care professionals were contacted to obtain information regarding the initiation of PPI and reintervention after Stretta. RESULTS: Of the 195 patients (median age, 55 years; 116 women [59.5%]) who underwent Stretta, PPI-free period (PFP) data were available for 144 (73.8%) patients. Overall, 66 patients (45.8%) did not receive PPI after a median follow-up of 55 months. Six patients (3.1%) underwent further interventions. The median PFP after Stretta was 41 months. There was a significant negative correlation between PFP and age (p=0.007), with no differences between sexes (p=0.96). Patients younger than 55 years of age had a longer PFP than their older counterparts (p=0.005). Younger males had a significantly longer PFP than older males (p=0.021). However, this was not observed in the female cohort (p=0.09) or between the younger men and women (p=0.66). CONCLUSION: Our findings suggest that Stretta is a safe and feasible option for treating refractory GERD, especially in younger patients. It prevents further anti-reflux interventions in most patients and increases the lead-time to surgery in patients with refractory GERD.

Computer image analysis with artificial intelligence: a practical introduction to convolutional neural networks for medical professionals.

Artificial intelligence tools, particularly convolutional neural networks (CNNs), are transforming healthcare by enhancing predictive, diagnostic, and decision-making capabilities. This review provides an accessible and practical explanation of CNNs for clinicians and highlights their relevance in medical image analysis. CNNs have shown themselves to be exceptionally useful in computer vision, a field that enables machines to 'see' and interpret visual data. Understanding how these models work can help clinicians leverage their full potential, especially as artificial intelligence continues to evolve and integrate into healthcare. CNNs have already demonstrated their efficacy in diverse medical fields, including radiology, histopathology, and medical photography. In radiology, CNNs have been used to automate the assessment of conditions such as pneumonia, pulmonary embolism, and rectal cancer. In histopathology, CNNs have been used to assess and classify colorectal polyps, gastric epithelial tumours, as well as assist in the assessment of multiple malignancies. In medical photography, CNNs have been used to assess retinal diseases and skin conditions, and to detect gastric and colorectal polyps during endoscopic procedures. In surgical laparoscopy, they may provide intraoperative assistance to surgeons, helping interpret surgical anatomy and demonstrate safe dissection zones. The integration of CNNs into medical image analysis promises to enhance diagnostic accuracy, streamline workflow efficiency, and expand access to expert-level image analysis, contributing to the ultimate goal of delivering further improvements in patient and healthcare outcomes.

Frequency of Short- vs Long-Term Reporting of Bariatric Surgery Outcomes.

BACKGROUND AND AIMS: Bariatric surgery is an effective treatment for obesity. Though both short- and long-term outcomes have been reported, most of the published literature reports on short-term outcomes. Identification of post-operative weight regain and re-emergence of comorbidities requires medium- and long-term follow-up. We aimed to identify the distribution of follow-up times within the literature. METHODS: We screened through 1807 articles from 9 PubMed Indexed bariatric surgery journals published between January to June of 2015 and 2021 and selected articles reporting weight loss as a main outcome. Follow-up intervals were defined as per American Society for Metabolic and Bariatric Surgery (ASMBS) guidelines. RESULTS: Fifty-three and sixty-three articles were identified in 2015 and 2021 respectively. Reported follow-up lengths in 2015 were 60% short-, 26% medium-, and 14% long-term; while in 2021, there were 65% short-, 10% medium-, and 25% long-term articles. Of the articles reporting long-term outcomes in 2015 and 2021, 48%, and 70% of the included patients respectively had > 5 years follow-up. CONCLUSION: Though reporting of long-term outcomes increased, most published outcomes remain short-term. The UK National Bariatric Surgery Registry is helping to mitigate this. An increased effort and emphasis on reporting long-term outcomes is needed.

Reporting of weight loss outcomes in bariatric surgery following introduction of 2015 ASMBS guidelines.

BACKGROUND: Heterogeneity in reporting weight loss (WL) outcomes within the bariatric surgery literature limits synthesis and meta-analysis. In 2015, the American Society for Metabolic and Bariatric Surgery (ASMBS) published reporting guidelines to achieve consistency in the literature. OBJECTIVES: We aimed to assess the effect of the ASMBS guidelines in the bariatric surgery literature. METHODS: Nine PubMed-indexed bariatric surgery journals were screened for articles published in the first 6 months of 2015 and 2021. Of 1807 articles, 105 and 158 articles in 2015 and 2021, respectively, reported primarily on WL outcomes following surgery. RESULTS: Overall ASMBS compliance increased from 5% to 20%, P < .05. Initial weight and body mass index (BMI) was reported in all studies, but specification of this as the immediate preoperative weight reduced from 15% to 6%, P < .05. The percent total WL (%TWL) increased from 17% to 61%, P < .05. Change in the BMI (DBMI) remained 41%. The percent excess BMI or WL (%EBMIL or %EWL) did not significantly change from 76% to 69%, P = .203. In 2021, 2 of the 9 journals gave guidance on reporting WL in their instructions to authors. Thirty percent (42/142) of articles did not comply with the journals' WL reporting guidance. The number of unique WL outcomes used increased from 45 to 54. CONCLUSIONS: Significant heterogeneity in reporting WL outcomes remains, hindering robust meta-analysis of articles. Use of referral weight instead of preoperative weight can inflate WL in those with mandated preoperative WL, clarifying initial weight is needed. Use of nonstandard measures of WL remains high.

Systematic review and meta-analysis of early vs late interval laparoscopic cholecystectomy following percutaneous cholecystostomy.

BACKGROUND: High risk surgical patients with acute cholecystitis are commonly treated with percutaneous cholecystostomy (PTC) drainage. The optimal timing of subsequent interval laparoscopic cholecystectomy (LC) remains unclear. METHODS: Medline, EMBASE, and Scopus were searched to identify studies published between 01/01/2000 and 31/12/2020, reporting on interval LC outcomes in patients initially treated by PTC. Early and late interval LC were defined as <30 and ≥ 30 days respectively. The Methodological Index for Nonrandomized Studies was used for quality assessment. Meta-analysis of proportions was conducted using a random-effects model. RESULTS: A total of 512 studies were screened, 41 met the inclusion criteria. There were 22 studies in both early and late interval LC groups, with 3 included studies reporting both early and late groups. Following quality assessment, 29 studies were included in the meta-analysis. There were no significant differences between early and late interval LC in terms of conversion rates (7.2% vs 8.3%, p = 0.854), 90-day morbidity (12.8% vs 15.9%, p = 0.496), and 90-day mortality (0.25% vs 0.32%, p = 0.704). Heterogeneity was significant (I2>50%) in all groups. CONCLUSION: Current evidence of interval LC within or beyond 30 days demonstrates no significant impact on outcomes. Patient factors, clinical experience, and hospital facilities may prove more important predictors.

Irreversible electroporation in renal tumours: A systematic review of safety and early oncological outcomes.

We review the safety and early oncological outcomes of irreversible electroporation (IRE), a novel non-thermal ablation technique, in small renal masses (SRMs). Following PROSPERO registration (CRD42020197943), a systematic search of MEDLINE, EMBASE and SCOPUS databases according to PRISMA guidelines was performed. Critical appraisal of the included studies was performed using the Newcastle-Ottawa Scale. Of 224 articles screened, 10 met the inclusion criteria. In total, 83 patients were identified. Except for one cohort study (n = 41), the remaining studies were case series of n < 10. Follow up was <12 months in 7/10 articles (range 3-34 months). About 10/10 articles reported safety outcomes. There were no 30-day mortalities. The most frequently reported adverse events were transient haematuria (11/83) and asymptomatic perirenal haematomas (7/83). About 62/63 patients with reported length of stay were discharged within 24 h. No significant long-term changes in renal function were reported. About 7/10 articles reported oncological outcomes. Only one article assessed histopathological outcomes, whilst the remaining studies used cross-sectional imaging modalities to assess efficacy, recurrence or disease progression. About 4/7 patients with histopathology outcomes, showed complete response (CR). About 43/55 patients with radiological outcomes showed CR. No mortalities were reported due to SRMs. These initial findings support IRE as safe and feasible in managing SRMs. However, results from larger studies with longer follow-up are needed to evaluate oncological outcomes and compare these with other ablation methods.

Alternative diagnoses and demographics associated with a raised quantitative faecal immunochemical test in symptomatic patients.

BACKGROUND: The faecal immunochemical test (FIT) has proven utility for colorectal cancer detection in symptomatic patients. However, most patients with a raised faecal haemoglobin (f-Hb) do not have colorectal cancer. We investigated alternative diagnoses and demographics associated with a raised f-Hb in symptomatic patients. METHODS: A retrospective, observational study was performed of patients with FIT submitted between August 2018 to January 2019 in NHS Greater Glasgow and Clyde followed by colonoscopy. Colonoscopy/pathology reports were searched for alternative diagnoses. Covariables were compared using the χ2 test. Multivariate binary logistic regression identified independent predictors of a raised f-Hb. RESULTS: 1272 patients were included. In addition to colorectal cancer (odds ratio (OR), 9.27 (95% confidence interval (CI): 3.61-23.83; p < 0.001)), older age (OR, 1.52 (95% CI: 1.00-2.32; p = 0.05)), deprivation (OR, 1.54 (95% CI: 1.21-1.94; p < 0.001)), oral anticoagulants (OR, 1.78 (95% CI: 1.01-3.15; p = 0.046)), rectal bleeding (OR, 1.47 (95% CI: 1.15-1.88; p = 0.002)), advanced adenoma (OR, 7.52 (95% CI: 3.90-14.49; p < 0.001)), non-advanced polyps (OR, 1.78 (95% CI: 1.33-2.38; p < 0.001)) and inflammatory bowel disease (IBD) (OR, 4.19 (95% CI: 2.17-8.07; p < 0.001)) independently predicted raised f-Hb. Deprivation (Scottish Index of Multiple Deprivation (SIMD) 1-2: OR, 2.13 (95% CI: 1.38-3.29; p = 0.001)) independently predicted a raised f-Hb in patients with no pathology found at colonoscopy. CONCLUSIONS: An elevated f-Hb is independently associated with older age, deprivation, anticoagulants, rectal bleeding, advanced adenoma, non-advanced polyps and IBD in symptomatic patients. Deprivation is associated with a raised f-Hb in the absence of pathology. This must be considered when utilising FIT in symptomatic patients.

Combining the quantitative faecal immunochemical test and full blood count reliably rules out colorectal cancer in a symptomatic patient referral pathway.

PURPOSE: Faecal Immunochemical Test (FIT) has proven utility for Colorectal Cancer (CRC) detection in symptomatic patients. Most studies have examined FIT in symptomatic patients subsequently referred from primary care. We investigated associations between CRC and FIT in both referred and non-referred symptomatic patients. METHODS: A retrospective, observational study of all patients with a FIT submitted Aug 2018 to Jan 2019 in NHS GG&C was performed. Referral to colorectal/gastroenterology and decision to perform colonoscopy were recorded. FIT results were grouped as f-Hb < 10/10-149/150-399/ ≥ 400 µg/g. The MCN cancer registry identified new cases of CRC. Covariables were compared using the χ2 test. Multivariate binary logistic regression identified independent predictors of CRC. RESULTS: A total of 4968 patients were included. Raised FIT correlated with decision to refer (p < 0.001) and scope (p < 0.001). With 23-month median follow-up, 61 patients were diagnosed with CRC. These patients were older (median 69 vs 59 years, cancer and no cancer respectively, p = 0.001), more likely to be male (55.7% vs 42.1%, p = 0.033), and to report rectal bleeding (51.7% vs 36.1%, p = 0.013). FIT (< 10 µg/g 8.2% vs 76.7% and ≥ 400 µg/g 55.7% vs 3.8%, p < 0.001) and anaemia (45.9% vs 19.7%, p < 0.001) were associated with CRC. On multivariate analysis, age (p = 0.023), male sex (p = 0.04), FIT (≥ 400 OR 54.256 (95% CI:20.683-142.325; p < 0.001)), and anaemia (OR 1.956 (1.071-3.574; p = 0.029)) independently predicted CRC. One patient (0.04%) with a negative FIT and normal haemoglobin had CRC. CONCLUSION: GP referral and secondary care investigation patterns were influenced by FIT. The combination of normal Hb and f-Hb excluded CRC in 99.96% of cases, providing excellent reassurance to those prioritising access to endoscopy services.

Choledocholithiasis: Long-term follow-up in patients without stone clearance at first endoscopic retrograde cholangiopancreatography.

OBJECTIVES: Complete clearance during endoscopic retrograde cholangiopancreatography (ERCP) for choledocholithiasis is not always successful and biliary stenting is commonplace. Strategies vary between temporary stent placement (TSP) with interval ERCP or permanent stent placement (PSP) and watchful waiting for recurrent biliary obstruction (RBO). This study aimed to describe outcomes in these two groups and stent patency rates in PSP. METHODS: Patients with incomplete clearance at first ERCP for choledocholithiasis between May 2015 and December 2018 were identified. Clinical outcomes were obtained by retrospective interrogation of the case notes. Median follow-up duration was 41 months (interquartile range 29-51 mo). RESULTS: Of 1263 index ERCP, 199 (15.8%) had no stone clearance, with 53.3% receiving PSP and 46.7% undergoing TSP. The TSP group had repeat ERCP after a median of 8 weeks; 75.3% had clearance on a repeat ERCP. The PSP group was elder than the TSP group (82 y vs 72 y, P < 0.001). The rates of RBO (32.1% vs 16.1%) and emergency readmissions (32.1% vs 19.4%) were higher in the PSP group (both P < 0.05). More patients died without further biliary disease in the PSP group (39.6% vs 12.9%, P = 0.001). PSP stent patency rates at 6, 12, 24, 36, and 61 months were 87.7%, 82.1%, 75.5%, 69.8% and 67.9%, respectively. CONCLUSIONS: Though PSP had higher RBO and emergency readmissions, two-thirds of patients either died or survived without recurrent biliary disease. Stent patency decreased fastest in the first 12 months. Criteria to guide decision-making for biliary stenting remain unclear.

Weight loss in adults following bariatric surgery, a systematic review of preoperative behavioural predictors.

Bariatric surgery is effective in treating obesity in many cases, yet as many as 50% of patients may not achieve the desired weight reduction. Preoperative modifiable behavioural factors could help patient selection and intervention design to improve outcomes. Medline, EMBASE, Cochrane Library and PsychINFO were searched to identify studies published between 1 January 2008 and 14 February 2019 reporting on preoperative modifiable behavioural factors associated with postoperative weight loss, with minimum 2 years follow-up. A total of 6888 articles were screened, 34 met the inclusion criteria. Maladaptive eating behaviours (MEB), preoperative weight loss (PWL), and tobacco use were reported 21, 18, and 3 times respectively. Physical activity and substance abuse were each reported once. Most articles on PWL (72.2%) and MEB (52.4%) reported no association. Positive associations were reported in 22.2% and 14.3% of articles for PWL and MEB respectively. Negative associations were reported in 5.6% and 33.3% of articles for PWL and MEB, respectively. Marked heterogeneity in outcome reporting hindered quantitative synthesis. The current paucity of evidence amenable to synthesis leads to ongoing uncertainty regarding the size and direction of association between PWL and MEB with outcomes following bariatric surgery. Long-term studies with common reporting of outcomes are needed.

ECG in suspected pulmonary embolism.

OBJECTIVE: To establish the diagnostic value of prespecified ECG changes in suspected pulmonary embolism (PE). METHODS: Retrospective case-control study in a district general hospital setting. We identified 189 consecutive patients with suspected PE whose CT pulmonary angiogram (CTPA) was positive for a first PE and for whom an ECG taken at the time of presentation was available. We matched these for age±3 years with 189 controls with suspected PE whose CTPA was negative. We considered those with large (n=76) and small (n=113) clot load separately. We scored each ECG for the presence or absence of eight features that have been reported to occur more commonly in PE. RESULTS: 20%-25% of patients with PE, including those with large clot load, had normal ECGs. The most common ECG abnormality in patients with PE was sinus tachycardia (28%). S1Q3T3 (3.7%), P pulmonale (0.5%) and right axis deviation (4.2%) were infrequent findings. Right bundle branch block (9.0%), atrial dysrhythmias (10.1%) and clockwise rotation (20.1%) occurred more frequently but were also common in controls. Right ventricular (RV) strain pattern was significantly more commonly in patients than controls, 11.1% vs 2.6% (sensitivity 11.1%, specificity 97.4%; OR 4.58, 95% CI 1.63 to 15.91; p=0.002), particularly in those with large clot load, 17.1% vs 2.6% (sensitivity 17.1%, specificity 97.4%; OR 7.55, 95% CI 1.62 to 71.58; p=0.005). CONCLUSION: An ECG showing RV strain in a breathless patient is highly suggestive of PE. Many of the other ECG changes that have been described in PE occur too infrequently to be of predictive value.

Irreversible electroporation (Nanoknife® treatment) in the field of hepatobiliary surgery: Current status and future perspectives.

PURPOSE: We aimed to provide an overview of current understanding on the potential use of irreversible electroporation (IRE) in the field of hepatobiliary surgery with a focus on current results in hepatic and pancreatic cancers, its limitations, and its current directions. METHODS: Through a review of the literature we have gathered the key articles and trials that are shaping our understanding of the current status of IRE and its prospective uses, and organized them in an easily understandable format showcasing the most up to date results. RESULTS: IRE appears to be comparable in effectiveness and postoperative pain to the more established thermal ablation methods, while having the benefit of avoiding their detrimental thermal effects. In liver cancer, IRE was shown to be efficacious with low levels of local recurrences and only minimal complications. In pancreatic cancer it proved to have significant survival benefits but more significant (although rare) complications compared to the ones seen when IRE is used in liver cancer. Current evidence suggests a promising future for IRE, but clinical randomized control trials, and further developments of treatment protocols are required to come to more stable conclusions on the effectiveness and safety of IRE. CONCLUSIONS: IRE is proving to be an adequate method for the treatment of tumors of the pancreas and liver in cases where traditional methods are unavailable. It has been proven particularly efficacious in patients with masses in close proximity to vital structures such as vessels, as well as major biliary and hepatic structures where thermal methods of ablation would cause significant complications.

Anomalous radiological and clinical demonstration of gallbladder duplication in an asymptomatic pregnant female.

Gallbladder duplication is an uncommon congenital anatomical deviation encompassing a number of variants. The morphological difference occurs during budding of the hepatic diverticulum. We report the case of an asymptomatic pregnant woman who was incidentally found to have a large subhepatic cyst on ultrasound. The case highlights the difficulty in diagnosing large gallbladder duplication and the different radiological imaging available to surgeons to aid in mapping such anatomical variants. We propose that this case holds valuable lessons for both radiologists and surgeons when considering the differential diagnosis and management of large hepatobiliary cysts.

Ablation of the locally advanced pancreatic cancer: An introduction and brief summary of techniques.

Pancreatic ductal adenocarcinoma is a lethal and late presenting malignancy with dismal survival rates. An estimated total of 330,000 people died from this malignancy in 2012. Although there have been improvements in diagnostic and treatment methods, the survival of late stage pancreatic cancer has not shown significant improvement in the past 4 decades. Multiple treatment approaches are available including chemotherapy, radiotherapy, and immunotherapy, but to this day surgical resection remains the only curative treatment option. Ablative techniques use various forms of energy to cause local tissue destruction through necrosis or apoptosis. They are relevant in pancreatic ductal adenocarcinoma as they are a treatment option in non-resectable tumors where their use ranges from symptom control to reducing tumor size for resection. In this narrative review we have grouped and outlined the various ablative methods, classifying them into thermal (Radiofrequency ablation, Microwave ablation, High Intensity Focused Ultrasound ablation, Cryoablation), and non-thermal ablative methods (Irreversible Electroporation (NanoKnife®), Photodynamic Therapy). This is followed by a description and review of the available evidence on survival and complications for each of these ablative methods. According to the literature, thermal ablative methods appear to be more accessible but are implicated with more complications than non thermal ablative methods which show the most promise.

Opioid substitution therapy: Lowering the treatment thresholds.

BACKGROUND: Opioid substitution therapy (OST) has been established as the gold standard in treating opioid use disorders. Nevertheless, there is still a debate regarding the qualitative characteristics that define the optimal OST intervention, namely the treatment threshold. The aim of this review is twofold: first, to provide a summary and definition of "treatment thresholds", and second, to outline these thresholds and describe how they related to low and high threshold treatment characteristics and outcomes. METHOD: We searched the main databases of Medline, PubMed, PsycInfo, EMBASE, CINAHL and the Cochrane Library. Original published research papers, reviews, and meta-analyses, containing the eligible keywords: "opioid substitution", "OST", "low threshold", "high threshold" were searched alone and in combination, up to June, 2015. RESULTS: Treatment thresholds were defined as barriers a patient may face prior to and during treatment. The variables of these barriers were classified into treatment accessibility barriers and treatment design barriers. There are increasing numbers of studies implementing low threshold designs with an increasing body of evidence suggesting better treatment outcomes compared to high threshold designs. CONCLUSION: Clinical characteristics of low threshold treatments that were identified to increase the effectiveness of OST intervention include increasing accessibility so as to avoid waiting lists, using personalized treatment options regarding medication choice and dose titration, flexible treatment duration, a treatment design that focuses on maintenance and harm reduction with emphasis on the retention of low adherence patients.

A Case of Pneumococcal Peritonitis after Caesarean Section in a Healthy Woman.

Pneumococcal peritonitis is prevalent in children and adults with comorbidities but extremely rare in healthy adults. Here we describe a case of pneumococcal peritonitis in a previously healthy woman with no known risk factors who presented with constipation, abdominal pain, and distention. Her only past medical history was an uncomplicated C-section two months prior to presentation. A laparotomy revealed a pneumococcal peritonitis without visible source of infection. The patient remained hospitalized until completion of antibiotic regimen with Ceftriaxone and resolution of symptoms. This report adds to the small body of evidence showing possible pneumococcal peritonitis in healthy young adults.

Inheritance and perinatal consequences of inherited thrombophilia in Greece.

OBJECTIVE: To investigate the impact of inherited thrombophilic factors on the gestational outcome of unselected pregnant women. METHOD: A total of 392 women with spontaneous pregnancy were investigated for Factor V Leiden, prothrombin G20210A, and MTHFR C677T mutations. Adverse pregnancy outcomes were recorded. RESULTS: Thrombophilic genotypes were significantly higher in women with placental abruption. Heterozygocity for Factor V Leiden increased the risk for placental abruption 9.1 times. The MTHFR T677T genotype increased the risk for placental abruption 4.8 times despite folate supplements, and normal serum folate and B(12) levels. Women with inherited thrombophilia and previous obstetric complications were at significant risk for complications in a subsequent pregnancy (P<0.05). CONCLUSION: Women with placental abruption should be screened for thrombophilic factors and plasma homocysteine should be measured. Subgroups of women with inherited thrombophilia and obstetric complications might benefit from prophylactic anticoagulation in subsequent pregnancies.