A retrospective analysis of magnetic resonance cholangiopancreatography investigating gallstones in a contemporary surgical setting.

BACKGROUNDS: The New Zealand Public Health System operates in a resource limited environment. Pre-operative investigation of choledocholithiasis (CDL) is variable. Protocol driven practice has improved patient outcomes and cost-effectiveness. The aim is to explore risk stratification for CDL and specific thresholds for accessing magnetic resonance cholangiopancreatography (MRCP) in this contemporary setting. METHODS: All adult (16+ years) acute inpatient MRCP requests for gallstone work-up between 1 Jan 2018 and 2031 Dec 2019 at Dunedin Hospital were included. Patients with characteristics not in fitting with an acute symptomatic examination were excluded. Receiver operating characteristic curves were estimated for bilirubin versus MRCP positive by the presence/absence of dilated ducts, indication and American Society of Gastrointestinal Endoscopy (ASGE) risk grouping. RESULTS: A 106 patients were included. Mean bilirubin at presentation and time of MRCP, 47 versus 28 µmol/L, respectively. MRCP confirmed CDL in 39 (37%) patients. 38 (97%) had biochemical changes with choledocholithiasis. 21 (40%) with CBD dilation had ductal stones versus 18 (34%) with normal ducts. ASGE risk stratification showed 36 (34%), 66 (62%) and 4 (4%) were high, intermediate and low risk, respectively. Of these groups 44%, 35% and 0% had CBD stones on MRCP, respectively. Combination thresholds involving duct size and bilirubin can yield negative predictive values >90%, substantially reducing MRCP load. CONCLUSIONS: MRCP requests can be triaged to maximize stones detected without overly increasing the rate of missed duct stones whilst protecting the limited MRI and ERCP resources. International thresholds and risk stratification alone may not be applicable in our resource limited environment.

The role of intra-operative void score during transurethral resection of prostate as a marker of efficacy: a feasibility study.

BACKGROUND: To assess the feasibility of a novel intra-operative void scoring technique. To determine if intra-operative void score (VS) could act as a marker for post-operative success following TURP. METHODS: Fifteen patients undergoing TURP were included in this single-centre feasibility study. All patients had indwelling urinary catheters for recurrent retention due to benign prostatic hyperplasia (BPH). In theatre, immediately before- and after TURP, an intra-operative VS was measured and graded 0-5. Primary outcomes were the feasibility of measuring intra-operative VS and its accuracy in predicting surgical outcome. RESULTS: A combined pre- and post-score with a threshold ≥6 correctly predicted 82% of those who were catheter free (sensitivity) and 100% of those who were not catheter free (specificity) at follow up and the positive predictive value was 100% and negative predictive value 60%. CONCLUSION: Intra-operative void score during TURP is simple, reproducible, fast and requires minimal resources. In TURP it may predict successful outcomes by identifying patients who will be catheter free post-operatively as opposed to those who will be catheter dependent despite the procedure.

In Vitro Benchmarking Study of Ventricular Assist Devices in Current Clinical Use.

BACKGROUND: Left ventricular assist devices (LVADs) offer live-saving therapy to transplant-ineligible heart failure patients. A major limitation of the technology includes pump thrombosis, bleeding, and recurrent infection that prove difficult to predict from in vivo animal testing. Shear stress introduced by the LVAD affects more than just hemolysis because platelets, leukocytes, and plasma proteins all contribute to the propensity for complications. It is important to assess overall damage by a new device against a baseline as early as possible in the development process so that design iterations can be made if required. METHODS: Explanted VADs currently in clinical use (HeartMate 2 and HVAD) were carefully cleaned, inspected, and run at 5 L/min and pressure at 100 mmHg in a standard 500 mL mock circulatory loop using bovine blood. The CentriMag was used as a control pump because of its low blood damage profile. Samples were collected at regular intervals and the following were analyzed: complete cell counts, hemolysis, platelet activation, leukocyte-derived microparticles (LMPs), and von Willebrand factor (vWF) degradation. RESULTS: The HeartMate 2 had the highest levels of hemolysis and platelet activation after 6 hours compared with the HVAD and CentriMag. A decreased granulocyte count, high numbers of LMPs and CD11bBrightHLADR- LMPs, and decreased vWF collagen binding activity was most evident in the HVAD. CONCLUSIONS: The results indicate that it is possible to observe differences between different pump designs during in vitro testing that might translate to clinical performance. This study demonstrates the importance of developing standard in vitro total blood damage methods against which device developers could use to modify design to reduce complication risk long before implantation.

Media reporting of health interventions in New Zealand: a retrospective analysis.

AIM: To evaluate New Zealand media articles on their coverage of key issues regarding health interventions and whether it is consistent with available evidence. METHODS: A retrospective analysis was carried out of all articles published in five New Zealand media sources over a 6-week period between 15 October and 26 November 2014. Articles were included if their primary focus was on health interventions involving medications, devices or in-hospital procedures. Articles were assessed for coverage of key issues using previously validated 10-point criteria. A literature review was performed to compare content with scientific evidence. RESULTS: We identified 30 articles for review. Only 4 of 30 articles covered indications, benefits and risks, and of these, two were consistent with available evidence (7%, 95% CI 1%-22%). For articles that discussed at least one of indications, benefits or risks, and there was corresponding evidence available, there was a high level of consistency with the evidence (89%, 95% CI 77%-95%). The overall mean value of coverage from the 10-point criteria was 51% (95% CI 45%-58%). Single questions regarding the potential harm, costs associated with the intervention and the availability of alternative options were particularly poorly covered. They were rated as 'satisfactory' in 13%, 23% and 33% of the 30 articles respectively. CONCLUSION: New Zealand news articles covering medical treatments and interventions are largely consistent with available evidence but are incomplete. Vital information is being consistently missed, especially around the potential harms and costs of medical interventions.

Shear Stress-Induced Total Blood Trauma in Multiple Species.

The common complications in heart failure patients with implanted ventricular assist devices (VADs) include hemolysis, thrombosis, and bleeding. These are linked to shear stress-induced trauma to erythrocytes, platelets, and von Willebrand factor (vWF). Novel device designs are being developed to reduce the blood trauma, which will need to undergo in vitro and in vivo preclinical testing in large animal models such as cattle, sheep, and pig. To fully understand the impact of device design and enable translation of preclinical results, it is important to identify any potential species-specific differences in the VAD-associated common complications. Therefore, the purpose of this study was to evaluate the effects of shear stress on cells and proteins in bovine, ovine, and porcine blood compared to human. Blood from different species was subjected to various shear rates (0-8000/s) using a rheometer. It was then analyzed for complete blood counts, hemolysis by the Harboe assay, platelet activation by flow cytometry, vWF structure by immunoblotting, and function by collagen binding activity ELISA (vWF : CBA). Overall, increasing shear rate caused increased total blood trauma in all tested species. This analysis revealed species-specific differences in shear-induced hemolysis, platelet activation, and vWF structure and function. Compared to human blood, porcine blood was the most resilient and showed less hemolysis, similar blood counts, but less platelet activation and less vWF damage in response to shear. Compared to human blood, sheared bovine blood showed less hemolysis, similar blood cell counts, greater platelet activation, and similar degradation of vWF structure, but less impact on its activity in response to shear. The shear-induced effect on ovine blood depended on whether the blood was collected via gravity at the abattoir or by venepuncture from live sheep. Overall, ovine abattoir blood was the least resilient in response to shear and bovine blood was the most similar to human blood. These results lay the foundations for developing blood trauma evaluation standards to enable the extrapolation of in vitro and in vivo animal data to predict safety and biocompatibility of blood-handling medical devices in humans. We advise using ovine venepuncture blood instead of ovine abattoir blood due to the greater overall damage in the latter. We propose using bovine blood for total blood damage in vitro device evaluation but multiple species could be used to create a full understanding of the complication risk profile of new devices. Further, this study highlights that choice of antibody clone for evaluating platelet activation in bovine blood can influence the interpretation of results from different studies.

Dysplastic cerebellar gangliocytoma lhermitte-duclos disease imaging and magnetic resonance spectroscopy.

Lhermitte-Duclos disease (LDD) is a rare, benign, slow-growing, unilateral mass of the cerebellar cortex. Our case is that of a 71-year-old male with a superior cerebellar lesion consistent with LDD on imaging and Magnetic Resonance Spectroscopy (MRS). It has been reported that MRS can be a valuable diagnostic addition, as it allows for a non-invasive diagnosis and analysis to distinguish a benign lesion, such as an intraparenchymal lesion, and in our case, from a true neoplastic lesion.

Calvarial plasmacytoma, an unusual manifestation of multiple myeloma.

The case presented is that of a 63-year-old female with an unusually large solitary calvarial plasmacytoma as an initial manifestation of a multiple myeloma. We were able to follow the progression of the disease clinically and with diagnostic imaging.