Effectiveness of denosumab for fracture prevention in real-world postmenopausal women with osteoporosis: a retrospective cohort study.

To determine denosumab's effectiveness for fracture prevention among postmenopausal women with osteoporosis in East Asia, the risk of fracture was compared between patients continuing denosumab therapy versus patients discontinuing denosumab after one dose. The real-world effectiveness was observed to be consistent with the efficacy demonstrated in the phase III trial. INTRODUCTION: After therapeutic efficacy is demonstrated for subjects in global clinical trials, real-world evidence may provide complementary knowledge of therapeutic effectiveness in a heterogeneous mix of patients seen in clinical practice. This retrospective cohort study was conducted to compare the fracture risk in real-world clinical care received in Taiwan and Hong Kong between a treatment cohort (patients receiving denosumab 60 mg subcutaneously every 6 months) versus an off-treatment cohort (patients discontinuing after 1 dose of denosumab, which has no known clinical benefit) among real-world postmenopausal women. METHODS: This study included 38,906 and 2,835 postmenopausal women receiving denosumab in Taiwan and Hong Kong, respectively. The primary endpoint was hip fracture, and secondary endpoints were clinical vertebral and nonvertebral fractures. Propensity-score-matched analysis, adjusting for known covariates, was used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs). The robustness of findings was evaluated with a series of sensitivity and quantitative bias analyses. RESULTS: In this study, 554 hip fractures were included in the primary Taiwan population analysis. The crude incidence rate was 0.9 per 100 person-years in the treatment cohort (n = 25,059) and 1.7 per 100 person-years in the off-treatment cohort (n = 13,847). After adjusting for prognostic differences between cohorts, denosumab reduced the risk of hip fractures by 38% (HR = 0.62, CI:0.52-0.75). Risk reductions of similar magnitude were observed for the secondary endpoints and for the analysis of the smaller Hong Kong population. CONCLUSION: The effectiveness of denosumab for fracture reduction among real-world postmenopausal women with osteoporosis was consistent with the efficacy demonstrated in a global clinical trial. REGISTRATION: EnCePP registration number: EUPAS26372; registration date: 12/11/2018.

Partial hepatectomy for ruptured hepatocellular carcinoma.

BACKGROUND: Improvements in surgical technique and perioperative care have made partial hepatectomy a safe and effective treatment for hepatocellular carcinoma (HCC), even in the event of spontaneous HCC rupture. METHODS: A consecutive cohort of patients who underwent partial hepatectomy for HCC between 2000 and 2009 was divided into a ruptured group and a non-ruptured group. Patients with ruptured HCC were further divided into emergency and staged hepatectomy subgroups. Mortality and morbidity, overall survival and recurrence-free survival (RFS) were compared. Prognostic factors for overall survival and RFS were identified by univariable and multivariable analyses. RESULTS: A total of 1233 patients underwent partial hepatectomy for HCC, of whom 143 had a ruptured tumour. The morbidity and mortality rates were similar in the ruptured and non-ruptured groups, as well as in the emergency and staged subgroups. In univariable analyses, overall survival and RFS were lower in the ruptured group than in the non-ruptured group (both P < 0·001), and also in the emergency subgroup compared with the staged subgroup (P = 0·016 and P = 0·025 respectively). In multivariable analysis, spontaneous rupture independently predicted poor overall survival after hepatectomy (hazard ratio 1·54, 95 per cent confidence interval 1·24 to 1·93) and RFS (HR 1·75, 1·39 to 2·22). Overall survival and RFS after hepatectomy for ruptured HCC in the emergency and staged subgroups were not significantly different in multivariable analyses. CONCLUSION: Spontaneous rupture predicted poor long-term survival after hepatectomy for HCC, but surgical treatment seems possible, safe and appropriate in selected patients.

Effect of Community Treatment Orders on Mental Health Service Usage, Emergency Visits, and Violence: a Systematic Review and Meta-Analysis.

INTRODUCTION: Community treatment orders (CTOs) enable patients to actively engage in mental health services while being supervised in the community outside the hospital setting. However, the efficacy of CTOs remains controversial in terms of mental health services usage or service contacts, emergency visits, and violence. METHODS: The databases PsychINFO, Embase, and Medline were searched on 11 March 2022 by 2 independent reviewers through the Covidence website (www.covidence.org). Randomised or non-randomised case-control studies and pre-post studies were included if they examine the effect of CTOs on service contacts, emergency visits, and violence in individuals with mental illnesses by comparing with control groups or pre-CTO conditions. Conflicts were resolved by consultation of the third independent reviewer. RESULTS: Sixteen studies provided sufficient data in the target outcome measures and were included in analysis. Variability in the risk of bias was high among studies. Meta-analyses were conducted separately for case-control studies and pre-post studies. For service contacts, a total of 11 studies with 66,192 patients reported changes in the number of service contacts under CTOs. In 6 case-control studies, a small non-significant increase in service contacts was observed in those under CTOs (Hedge's g = 0.241, z = 1.535, p = 0.13). In 5 pre-post studies, a large and significant increase in service contacts was noted after CTOs (Hedge's g = 0.830, z = 5.056, p < 0.001). For emergency visits, a total of 6 studies with 930 patients reported changes in the number of emergency visits under CTOs. In 2 case-control studies, a small non-significant increase in emergency visits was noted in those under CTOs (Hedge's g = -0.196, z = -1.567, p = 0.117). In 4 pre-post studies, a small significant decrease in emergency visits was noted after CTOs (Hedge's g = 0.553, z = 3.101, p = 0.002). For violence, a total of 2 pre-post studies reported a moderate significant reduction in violence after CTOs (Hedge's g = 0.482, z = 5.173, p < 0.001). CONCLUSION: Case-control studies showed inconclusive evidence, but pre-post studies showed significant effects of CTOs in promoting service contacts and reducing emergency visits and violence. Future studies on cost-effectiveness analysis and qualitative analysis for specific populations with various cultures and backgrounds are warranted.

Selective hepatic vascular exclusion versus Pringle manoeuvre in liver resection for tumours encroaching on major hepatic veins.

BACKGROUND: Control of bleeding is crucial during liver resection, and several techniques have been developed to achieve this. This study compared the safety and efficacy of selective hepatic vascular exclusion (SHVE) and Pringle manoeuvre in partial hepatectomy for liver tumours compressing or involving major hepatic veins. METHODS: All patients undergoing liver resection between January 2003 and December 2010 for liver tumours compressing or involving one or more major hepatic veins were identified retrospectively from a prospective institutional database. Either SHVE or Pringle manoeuvre was used to minimize blood loss during hepatectomy. Data on demographics and the intraoperative and postoperative course were analysed. RESULTS: From the database of 3900 patients, 1420 were identified who underwent liver resection for tumours encroaching on major hepatic veins using either SHVE (550) or the Pringle manoeuvre (870). Intraoperative blood loss (mean(s.d.) 480(210) versus 830(340) ml; P = 0·007) and transfusion requirements (mean(s.d.) 1·3(0·6) versus 2·9(1·4) units; P = 0·008) were significantly less in the SHVE group. In the Pringle group, hepatic vein injury resulted in major intraoperative bleeding of over 1000 ml in 65 patients (7·5 per cent) and air embolism in 14 (1·6 per cent), and three patients (0·3 per cent) died during surgery, whereas there was no major bleeding, air embolism or intraoperative death in the SHVE group. Postoperative liver failure, multiple organ failure and in-hospital death were significantly more common in the Pringle group (P = 0·019, P = 0·032 and P = 0·004 respectively). CONCLUSION: SHVE was more efficacious than the Pringle manoeuvre in minimizing intraoperative bleeding and air embolism during partial hepatectomy for tumours encroaching on major hepatic veins, and decreased the postoperative liver failure rate.

The relation of falls to fatigue, depression and daytime sleepiness in Parkinson's disease.

OBJECTIVE: To characterize non-motor symptoms in individuals with Parkinson's disease (PD) who experience falls compared to those who do not fall. METHODS: Fifty-four individuals with PD were studied. Thirty-six were fallers and 18 were non-fallers. Fatigue was assessed by the Iowa Fatigue Scale. Excessive daytime sleepiness was assessed by the Epworth Sleepiness Scale, and depressive symptomatology was assessed by the short-form Center for Epidemiologic Studies Depression Scale. RESULTS: Compared to non-fallers, fallers had more severe disability, greater general physical fatigue (p = 0.024), lower energy levels (p = 0.042) and less productivity (p = 0.007). Fallers had more depressive symptomatology than the non-fallers (p = 0.01). Excessive daytime sleepiness was not different between the two groups (p = 0.695). CONCLUSIONS: Individuals with PD who fell had more severe motor and non-motor symptoms than those who did not fall. These non-motor symptoms included physical fatigue, energy, productivity and depressive symptomatology.

Liver resection under total vascular exclusion with or without preceding Pringle manoeuvre.

BACKGROUND: Adequate control of bleeding is crucial during liver resection. This study analysed the safety and efficacy of hepatectomy under total hepatic vascular exclusion (THVE) in patients with tumours encroaching or infiltrating the hepatic veins and/or the inferior vena cava (IVC). METHODS: All patients undergoing liver resection with THVE between January 2000 and July 2006 were identified from a prospectively collected database containing 2400 patients. Data on patient demographics, surgical procedure and outcome were collected. RESULTS: A total of 87 patients scheduled for liver resection under THVE were identified, 77 with malignant tumours and ten with benign disease. THVE could not be used in two patients (2 per cent) owing to haemodynamic intolerance during trial clamping. Seventeen patients received simultaneous clamping of the portal triad and vena cava, and 68 had portal triad clamping followed by concomitant portal and vena cava clamping. The mean(s.d.) duration of THVE was 28.3(7.5) and 18.7(5.2) min respectively. Overall postoperative complication and operative mortality rates were 53 and 2 per cent respectively. Mean(s.d.) hospital stay was 16.8(4.7) days. CONCLUSION: Major hepatic resection for tumours encroaching on the hepatic veins or IVC can be carried out under THVE with reasonable morbidity and mortality.

An investigation of two interventions for micrographia in individuals with Parkinson's disease.

OBJECTIVE: This pilot study was designed to compare a change in micrographia between using grid lines and parallel horizontal lines as visual cues in individuals with Parkinson's disease. DESIGN: Single group pre- and post-test. SETTING: Research lab. PARTICIPANTS: Eleven males with Parkinson's disease. INTERVENTIONS: Practice writing words with parallel and grid lines. The sequence of practising was randomized. MAIN OUTCOME MEASURES: Length of words. RESULTS: The length of the words after practising with parallel lines was longer than in the initial free writing condition (17.83 ± 3.93 cm vs. 23.36 ± 5.82 cm, P =0.008). The length of the words after practising with grid lines was also longer than during free writing (17.83 ± 3.93 cm vs. 22.65 ± 4.04 cm, P =0.003). The length of the words after practising with parallel lines was not different from that after practising with grid lines. CONCLUSION: Improvements in letter size after practising with horizontal parallel lines and grid lines were not different. The addition of vertical lines to form a grid did not appear to improve the writing more than horizontal lines alone in persons with Parkinson's disease who experienced micrographia.

Immunoglobulin G4-associated sclerosing cholangitis mimicking cholangiocarcinoma.

Immunoglobulin G4-related lymphoplasmacytic sclerosing disease is an emerging disease. Recently, it has been shown to be responsible for autoimmune pancreatitis-induced strictures of the bile duct mimicking cholangiocarcinoma. Making a diagnosis of immunoglobulin G4-associated sclerosing cholangitis requires a high index of suspicion. The differential diagnoses include primary sclerosing cholangitis, cholangiocarcinoma, and pancreatic cancer. The preoperative diagnosis is likely to be missed due to the lack of specific symptoms; a clinical presentation that may mimic other disorders, especially malignant biliary strictures; and the lack of specific imaging features. This article reports on a 51-year-old man with immunoglobulin G4-associated sclerosing cholangitis without autoimmune pancreatitis. He underwent resection of his extrahepatic bile duct with a hepaticojejunostomy. The diagnosis was confirmed after a histopathological examination. This case highlights the obstacles to making a preoperative diagnosis of immunoglobulin G4-associated sclerosing cholangitis.