Intravenous iron versus blood transfusion for postpartum anemia: a systematic review and meta-analysis.

BACKGROUND: Intravenous iron (IV-iron) is used as an alternative to, or alongside, red blood cell transfusion (RBC-T) to treat more severe postpartum anemia (PPA), although optimal treatment options remain unclear. No previous systematic reviews have examined IV-iron and RBC-T, including patient-reported outcomes and hematological responses. METHODS: A systematic review and meta-analysis of randomized trials comparing IV-iron and RBC-T with each other, oral iron, no treatment, and placebo for the treatment of PPA. Key inclusion criteria were PPA (hemoglobin < 12 g/dL) and IV-iron or RBC-T as interventions. Key exclusion criteria were antenatal IV-iron or RBC-T. Fatigue was the primary outcome. Secondary outcomes included hemoglobin and ferritin concentrations, and adverse events. From 27th August 2020 to 26th September 2022, databases, registries, and hand searches identified studies. A fixed-effect meta-analysis was undertaken using RevMan (5.4) software. The quality of the studies and the evidence was assessed using the Cochrane Risk of Bias table, and Grading of Recommendations, Assessment, Development, and Evaluation. This review is registered with the Prospective Register of Systematic Reviews (CRD42020201115). RESULTS: Twenty studies and 4196 participants were included: 1834 assigned IV-iron, 1771 assigned oral iron, 330 assigned RBC-T, and 261 assigned non-intervention. Six studies reported the primary outcome of fatigue (1251 participants). Only studies of IV-iron vs. oral iron (15 studies) were available for meta-analysis. Of these, three reported on fatigue using different scales; two were available for meta-analysis. There was a significant reduction in fatigue with IV-iron compared to oral iron (standardized mean difference - 0.40, 95% confidence interval (CI) - 0.62, - 0.18, I2 = 0%). The direction of effect also favored IV-iron for hemoglobin (mean difference (MD) 0.54 g/dL, 95% confidence interval (CI) 0.47, 0.61, I2 = 91%), ferritin, (MD 58.07 mcg/L, 95% CI 55.74, 60.41, I2 = 99%), and total adverse events (risk-ratio 0.63, 95% CI 0.52, 0.77, I2 = 84%). The overall quality of the evidence was low-moderate. DISCUSSION: For all outcomes, the evidence for RBC-T, compared to IV-iron, non-intervention, or dose effects of RBC-T is very limited. Further research is needed to determine whether RBC-T or IV-iron for the treatment of PPA is superior for fatigue and hematological outcomes.

PreciSSIon: a collaborative initiative to reduce surgical site infections after elective colorectal surgery.

BACKGROUND: Surgical site infections (SSIs) are common after colorectal surgery, but most hospitals do not know their SSI rates. Approximately half of SSIs occur after discharge, and postdischarge surveillance is needed for accurate measurement. Perioperative care bundles are known to reduce SSI rates. PreciSSion is a collaboration between seven hospitals in the West of England. AIMS: To establish reliable SSI measurement after elective colorectal surgery using 30-day patient-reported outcome measures, and to implement an evidence-based four-point care bundle that had already demonstrated a reduction in the SSI rate in a local hospital. The bundle included: 2% chlorhexidine skin preparation, a second dose of antibiotic after 4 h, use of a dual-ring wound protector, and use of antibacterial sutures for abdominal wall closure. METHODS: The 30-day patient-reported SSI rate was determined using the Public Health England questionnaire, and response rates were recorded. The baseline SSI rate was measured from November 2019 to May 2020, and continued after implementation of the care bundle until March 2021. Bundle compliance was also measured. FINDINGS: The average questionnaire response rate was 81%, and average compliance was 92%, 96%, 79% and 85% for each element of the bundle. The baseline SSI rate was 8-30%. Six of seven hospitals reduced their SSI rate, and the regional average SSI rate almost halved from 18% (1447 patients) to 9.5% (1247 patients). CONCLUSION: A care bundle developed in a single hospital can be adopted in other hospitals, and a 50% reduction in SSI rate after elective colorectal surgery can be replicated in other hospitals within 18 months.

Surgical site infection prevention bundle in elective colorectal surgery.

OBJECTIVE: Surgical Site Infections (SSIs) are responsible for a significant economic burden as well as intangible costs suffered by the patient, with up to 60% deemed preventable. Colorectal patients are disproportionally affected by SSI due the risk of wound contamination with bowel content. We aimed to reduce the rate of superficial SSI after elective colorectal surgery using a bundle of evidence-based interventions. METHODS: An SSI prevention bundle was implemented in elective colorectal surgery, comprised of triclosan-coated sutures, 2% chlorhexidine skin preparation and use of warmed carbon dioxide (CO2) during laparoscopic procedures. The SSI reduction strategy was prospectively implemented and compared with historical controls. Our primary outcome measure was the overall rate of superficial SSI. Centres for Disease Control and Prevention criteria, which use microbiological evidence in conjunction with clinical features were used as the definition of SSI. RESULTS: The overall SSI rate was 27.4% in the pre-bundle group (N = 208) and 12.5% in the patients who received the SSI prevention bundle (N = 184) (adjusted odds ratio 0.38; confidence interval 0.21-0.67; P<0.001). The median time to SSI diagnosis was postoperative day 8. Overall patient length of stay (LOS) was unchanged from six days at baseline following implementation of the bundle. CONCLUSIONS: We have shown successful implementation of an SSI prevention bundle which has reduced superficial SSI rate. We recommend this SSI prevention bundle becomes standard practice in elective colorectal surgery and plan to extend the bundle to emergency general surgery.

A Multicentre UK Study of Outcomes for Locally Advanced Sinonasal Squamous Cell Carcinoma Treated with Adjuvant or Definitive Intensity-modulated Radiotherapy.

AIMS: Sinonasal malignancies are rare; the most common histological subtype is squamous cell carcinoma (SCC). No randomised trial data exist to guide treatment decisions, with options including surgery, radiotherapy and chemotherapy. The role and sequence of a primary non-surgical approach in this disease remains uncertain. The aim of this study was to present treatment outcomes for a multicentre population of patients with locally advanced, stage IVa/b sinonasal SCC treated with radical-intent intensity-modulated radiotherapy, either definitively or postoperatively. MATERIALS AND METHODS: Consecutively treated patients with locally advanced, stage IVa/b sinonasal SCC at four UK oncology centres between January 2012 and December 2017 were retrospectively identified. Descriptive statistics and survival analyses were carried out. Univariable Cox regression analysis was carried out to evaluate the relationship between patient, disease and treatment factors and survival outcomes. RESULTS: In total, 56 patients with sinonasal SCC were included (70% maxillary sinus, 21% nasal cavity, 9% ethmoid/frontal sinus). Forty-one patients (73%) were treated by surgery/adjuvant (chemo)radiotherapy and 15 (27%) by definitive (chemo)radiotherapy. The median duration of follow-up was 3.8 years (interquartile range 2.0-4.7 years). Estimates for 5-year overall survival and progression-free survival were 30.2% and 24.2%, respectively. Local, regional and distant treatment failures were seen in 33%, 33% and 16% of patients, respectively. Univariable analysis revealed inferior progression-free survival for patients treated with neck dissection (hazard ratio 2.6, 95% confidence interval 1.2-6.1, P = 0.022) but no other significant association between the studied factors and survival outcomes. CONCLUSION: We show poor survival outcomes and high rates of locoregional treatment failure for patients with locally advanced stage IVa/b sinonasal SCC. There is a need to investigate improved treatments for this group of patients.

Imaging pitfalls in paediatric posterior fossa neoplastic and non-neoplastic lesions.

Paediatric posterior fossa lesions can have much overlap in their clinical and radiological presentation. There are, however, a number of key imaging features that can help the reading radiologist to distinguish tumours from important tumour mimics which are often inflammatory or metabolic entities. This pictorial review provides a number of important cases that proved challenging on imaging and illustrates some common pitfalls when interpreting lesions in the posterior fossa in children. Not everything that is abnormal will be a tumour, but often other causes are overlooked and misinterpreted as tumours, leading to great morbidity for that child. This article highlights some lesions that were mistaken as tumours and will introduce the reader to less commonly seen pathologies which are important to consider on a differential list for this location.

Improved survival prediction for oropharyngeal cancer beyond TNMv8.

PURPOSE: For oropharynx squamous cell carcinoma (OPSCC) this study aimed to: (i) compare 5-year overall survival (OS) stratification by AJCC/UICC TNM versions 7 (TNMv7) and 8 (TNMv8), (ii) determine whether changes to T and N stage groupings improve prognostication and (iii) develop and validate a model incorporating additional clinical characteristics to improve 5-year OS prediction. MATERIAL AND METHODS: All OPSCC treated with curative-intent at our institution between 2011 and 2017 were included. The primary endpoint was 5-year OS. Survival curves were produced for TNMv7 and TNMv8. A three-way interaction between T, N stage and p16 status was evaluated for improved prognostication. Cox proportional hazards modelling was used to derive a new predictive model. RESULTS: Of 750 OPSCC cases, 574 (77%) were p16-positive. TNMv8 was more prognostic than TNMv7 (concordance probability estimate [CPE] ±â€¯SE = 0.72 ±â€¯0.02 vs 0.53 ±â€¯0.02). For p16-positive disease, TNMv8 discriminated stages II vs I (HR 2.32, 95% CI 1.47-3.67) and III vs II (HR 1.75, 95% CI 1.13-2.72). For p16-negative disease, TNMv7 and TNMv8 demonstrated poor hazard discrimination. Different T, N stage and p16-status combinations did not improve prognostication after adjusting for other factors (CPE = 0.79 vs 0.79, p = 0.998). A model for p16-positive and p16-negative OPSCC including additional clinical characteristics improved 5-year OS prediction beyond TNMv8 (c-index 0.76 ±â€¯0.02). CONCLUSIONS: TNMv8 is superior to TNMv7 for p16-positive OPSCC, but both performed poorly for p16-negative disease. A novel model incorporating additional clinical characteristics improved 5-year OS prediction for both p16-positive and p16-negative disease.

A Multicentre UK Study of Outcomes of Nasopharyngeal Carcinoma Treated With Intensity-Modulated Radiotherapy ± Chemotherapy.

AIMS: To report the outcomes of nasopharyngeal carcinoma in adults across three large centres in a non-endemic region in the era of intensity-modulated radiotherapy (IMRT). MATERIALS AND METHODS: Adult patients with nasopharyngeal carcinoma treated in three large cancer centres with IMRT ± chemotherapy with curative intent between 2009 and 2016 were identified from institutional databases. Radiotherapy was delivered with 70 Gy in 33-35 daily fractions. A univariable analysis was carried out to evaluate the relationship of patient, tumour and treatment factors with progression-free survival (PFS) and overall survival. RESULTS: In total, 151 patients were identified with a median follow-up of 5.2 years. The median age was 52 years (range 18-85). Seventy-five per cent were of Caucasian origin; 75% had non-keratinising tumours; Epstein Barr virus status was only available in 23% of patients; 74% of patients had stage III or IV disease; 54% of patients received induction chemotherapy; 86% of patients received concurrent chemotherapy. Five-year overall survival, PFS, local disease-free survival, regional disease-free survival and distant disease-free survival were 70%, 65%, 91%, 94% and 82%, respectively. Keratinising squamous cell carcinoma, older age, worse performance status, smoking and alcohol intake were associated with inferior overall survival and PFS. CONCLUSIONS: Local, regional and distant disease control are relatively high following IMRT ± chemotherapy in a non-endemic population. There was considerable heterogeneity in terms of radiotherapy treatment and the use of chemotherapy, encouraging the development of treatment protocols and expert peer review in non-endemic regions.

African swine fever virus evasion of host defences.

African swine fever virus causes a haemorrhagic fever in domestic pigs and wild boar. The continuing spread in Africa, Europe and Asia threatens the global pig industry. The lack of a vaccine limits disease control. To underpin rational strategies for vaccine development improved knowledge is needed of how the virus interacts with and modulates the host's responses to infection. The virus long double-stranded DNA genome codes for more than 160 proteins of which many are non-essential for replication in cells but can have important roles in evading the host's defences. Here we review knowledge of the pathways targeted by ASFV and the mechanisms by which these are inhibited. The impact of deleting single or multiple ASFV genes on virus replication in cells and infection in pigs is summarised providing information on strategies for rational development of modified live vaccines.

Ninety Day Mortality After Radical Radiotherapy for Head and Neck Cancer.

AIMS: Treatment for head and neck cancers using definitive radiotherapy, with or without chemotherapy, is associated with significant acute toxicity. Our aim was to assess 90 day mortality after radical radiotherapy. A further aim was to identify patient, tumour or treatment factors associated with early death after treatment and whether these could be used to predict outcomes. MATERIALS AND METHODS: In total, 1116 patients with squamous cell pharyngeal and larynx cancer between January 2011 and December 2015 were included. Patients with T1 larynx cancer were excluded. Patients were treated using radical radiotherapy, with or without chemotherapy. Ninety day mortality was calculated using survival of less than 135 days from the planned start date for radical radiotherapy, to include early deaths during and up to 90 days after treatment. RESULTS: Overall, 90 day mortality was 4.7%. Among the subgroup of patients treated with concurrent platinum chemotherapy, the 90 day mortality rate was 0.4%. Overall survival at 1, 3 and 5 years was 84%, 62% and 53%, respectively. Factors associated with a higher risk of early death included performance status > 1, haemoglobin <100 g/l, weight < 60 kg, age > 80 years and presence of multiple comorbidities. CONCLUSION: We report excellent crude overall survival rates among our radically treated cohort of head and neck cancer patients. Several factors were associated with an increased risk of death within 90 days of completion of radical head and neck radiotherapy. Given the potential severe acute effects and the impact on patient quality of life associated with radical head and neck radiotherapy, this information is helpful to inform treatment-related discussions with patients.

Cohort study of mesenteric panniculitis and its relationship to malignancy.

BACKGROUND: Mesenteric panniculitis (MP) is a rare condition that historically has been associated with the presence of malignancy. Paraneoplastic phenomena in general regress with cure and in most cases with treatment of the cancer. This study was undertaken to determine whether MP regressed with cancer treatment and cure. METHODS: This was a retrospective review of a database of all patients with MP confirmed on CT between 2003 and August 2015 at Christchurch Hospital. Patients were categorized as having malignant or non-malignant disease, and follow-up scans were assessed for remission of MP. Patients with malignancy were further categorized as having malignancy cured or not cured. RESULTS: A total of 308 patients were identified with possible MP; 135 were excluded as radiological appearances were not typical of MP (43 patients) or there was no follow-up CT (92). Of 173 patients (131 men) included, 75 (43·4 per cent) were diagnosed with malignancy. Follow-up imaging showed that 33 patients (19·1 per cent) had remission of MP, whereas 140 (80·9 per cent) had no remission. There was no difference in the rates of MP remission in the malignancy versus no malignancy groups (P = 1·000), or between groups in which malignancy was cured or not cured (P = 0·572). Nor was there any difference in the rates of MP remission in malignancy cured versus no malignancy groups (P = 0·524). CONCLUSION: MP does not behave like a paraneoplastic phenomenon. The association with malignancy is most likely an epiphenomenon of the many CT images acquired for staging of cancer.

Salvage surgery in patients with recurrent or residual squamous cell carcinoma of the anus.

INTRODUCTION: Anal squamous cell cancers are uncommon, and primary treatment is radical chemoradiotherapy. The role of radical surgery is in salvage of patients with residual and recurrent disease. The primary aim of the study is to determine how often such salvage surgery is required, while the secondary aim is to determine which features indicate salvage surgery may be required and to determine the outcome of salvage surgery. METHODS: A prospective database was analysed of all patients with anal cancer over an 18 year period (Dec 1996-Jan 2015). The records of patients requiring salvage surgery were reviewed. RESULTS: 203 Patients were identified with anal cancers, of which 180 had squamous cell anal carcinoma. 112 Female (median age 59.4, range 33-92) 68 male (median age 63.8 range 36-87). Of these 27 patients (15%) required salvage surgery. 23 Patients had a R0 resection. 18 Patients had an extended resection (16 R0) while 9 had a routine APR (7 R0). The 30-day post-operative mortality rate was 0%. The overall 5 year survival was 78%, not significantly different from those not requiring salvage surgery (p = 0.23). Age, gender, AJCC stage, T stage, radiation therapy alone, were not predicators of the need for salvage surgery. CONCLUSIONS: Salvage surgery is uncommonly required. Extended surgery beyond routine APR is often required to obtain an R0 resection. Excellent patient survival can be achieved in highly selected cases. There were no identifiable clinical predictors of those needing salvage surgery, and consideration should be given to explore molecular and genetic factors.

Comparison of children's food and beverage intakes with national recommendations in New York City child-care centres.

OBJECTIVE: The present study compared foods and beverages provided to and consumed by children at child-care centres in New York City (NYC) with national nutrition recommendations. DESIGN: The study used survey, observational and centre record data collected from child-care centres. Food and beverage intakes from two days of observation and amounts of energy and nutrients were estimated using the US National Cancer Institute's Automated Self-Administered 24 h Recall system. SETTING: Meal and snack time at 108 child-care centres in low-income communities in NYC. SUBJECTS: Children aged 3-4 years old in classrooms selected by the directors of the participating child-care centres. RESULTS: Foods and beverages provided to and consumed by children (n 630) met >50 % of the Dietary Reference Intake (DRI) for most nutrients. Intakes of fibre and vitamins D and E were 50 % of the recommended average daily intake amounts for total grains, fruits and fruit juices, and dairy, but <50 % of the recommended amounts for whole grains, protein foods and vegetables. Intake of oils was below the allowance for energy levels, but foods and beverages with solid fats and added sugars exceeded the limits by 68 %. CONCLUSIONS: Providing more whole grains, vegetables and low-fat dairy and fewer foods with solid fats and added sugars may improve children's diet quality when at child-care centres. Centre staff may need training, resources and strategies in order to meet the nutrition recommendations.

Progress in the management of retrorectal tumours.

AIM: Tumours in the retrorectal space are rare and pathologically heterogeneous. The roles of imaging and preoperative biopsy, nonoperative management and the indications for surgical resection are controversial. This study investigated a series of retrorectal tumours treated in a single institution with the aim of producing a modern improved management algorithm. METHOD: A retrospective analysis was conducted of the management of all retrorectal lesions identified between 1998 and 2013 from a radiology database search. Patient demographics, presenting symptoms, imaging, biopsy, management and the results were recorded. Descriptive statistics were used and Kaplan-Meier survival analysis was performed. RESULTS: Sixty-nine patients with a confirmed retrorectal tumour were identified. The median age was 50 (36-67 interquartile range) and 42 (56%) were female. Twenty (29%) of the tumours were malignant: 4 of 41 cystic lesions were malignant (12.9%) vs. 16 of 28 solid (or heterogeneous) lesions (57.1%) (P < 0.0001). Imaging demonstrated a 95% sensitivity and 64% specificity for differentiating benign from malignant tumours. Magnetic resonance imaging (MRI) was significantly better at distinguishing between benign and malignant tumours than computed tomography (94% vs. 64%, P = 0.03). Percutaneous biopsy was performed in 16 patients and only 27 underwent resection. There was no evidence of local recurrence associated with biopsy. Solid lesions were associated with a nonsignificant decreased overall survival (P = 0.348). CONCLUSION: This study demonstrated that MRI should be the investigation of choice for retrorectal lesions. Biopsy of solid lesions is safe and useful for guiding neoadjuvant and surgical therapy. Cystic lesions without suspicious radiological features can be followed by serial imaging without resection.

Malignancy and mesenteric panniculitis.

AIM: Mesenteric panniculitis (MP) is a chronic inflammatory process of the small bowel mesentery that has been reported in conjunction with malignancy. The objectives of the present study were to identify the frequency and type of cancers that may coexist with MP and whether these can be seen on the initial diagnostic computerised tomography (CT). METHOD: A prospective database was kept of patients diagnosed with MP in the Canterbury region of New Zealand between 1 January 2003 and 31 December 2014. CT scans were independently reviewed. Clinical records were reviewed and family doctors were contacted for additional information. RESULTS: There were 302 patients with possible MP identified and 259 in whom it was confirmed on review. Seventy-eight patients had a diagnosis of malignancy, with 54 having a current cancer (59 total cancers), 33 a past cancer and nine both. Of the 59 current cancers the most common primary sites were colorectum (19), lymph nodes (17), kidney (six) and prostate (four). Fifty-four were at sites included on an abdominal CT scan. At all sites [except prostate (0/4)] there were high rates of detection on CT with 44/54 cancers visible including 20/23 gastrointestinal tract, 14/17 lymphomas and 9/9 non-prostate urogenital tract malignancies. Six people were subsequently diagnosed with cancer after the index CT. CONCLUSION: When MP occurs in association with malignancy, the commonest primary sites are large bowel, the lymph nodes and the urogenital tract. In those with MP on imaging, any cancer except prostate can usually be seen on the index CT. Further extensive investigation in asymptomatic patients is therefore likely to be of low yield.

Does Bowel Preparation for Colonoscopy Affect Cognitive Function?

Colonoscopy is a common procedure used in the diagnosis and treatment of a range of bowel disorders. Prior preparation involving potent laxatives is a necessary stage to ensure adequate visualization of the bowel wall. It is known that the sedatives given to most patients during the colonoscopy cause a temporary impairment in cognitive function; however, the potential for bowel preparation to affect cognitive function has not previously been investigated. To assess the effect of bowel preparation for colonoscopy on cognitive function. This was a prospective, nonrandomized controlled study of cognitive function in patients who had bowel preparation for colonoscopy compared with those having gastroscopy and therefore no bowel preparation. Cognitive function was assessed using the Modified Mini Mental State Examination (MMMSE) and selected tests from the Cambridge Neuropsychological Test Automated Battery. Individual test scores and changes between initial and subsequent tests were compared between the groups. Age, gender, and weight were also compared. Forty-three colonoscopy and 25 gastroscopy patients were recruited. The 2 groups were similar for age and gender; however, patients having gastroscopy were heavier. MMMSE scores for colonoscopy and gastroscopy groups, respectively, were 28.6 and 29.5 (P = 0.24) at baseline, 28.7 and 29.8 (P = 0.32) at test 2, 28.1 and 28.5 (P = 0.76) at test 3. Motor screening scores for colonoscopy and gastroscopy groups, respectively, were 349.3 and 354.1 (P = 0.97) at baseline, 307.5 and 199.7 (P = 0.06) at test 2, 212.0 and 183.2 (P = 0.33) at test 3. Spatial working memory scores for colonoscopy and gastroscopy groups, respectively, were 14.4 and 6.7 (P = 0.29) at baseline, 9.7 and 4.3 (P = 0.27) at test 2, 10 and 4.5 (P = 0.33) at test 3. Digit Symbol Substitution Test scores for colonoscopy and gastroscopy groups, respectively, were 36.3 and 37.8 (P = 0.84) at baseline, 36.4 and 40.0 (P = 0.59) at test 2, 38.6 and 40.8 (P = 0.76) at test 3.This study did not find evidence of cognitive impairment resulting from administration of bowel preparation before colonoscopy.

Impact of obesity on the cost of major colorectal surgery.

BACKGROUND: The incidence of obesity is increasing in New Zealand. The aim of the study was to determine whether obesity impacts on the cost of treating patients undergoing major colorectal surgery. METHODS: Between 1 February 2008 and 31 July 2009, consecutive patients undergoing major colorectal surgery at Christchurch Hospital, New Zealand, were enrolled in the study. Body mass index (BMI) and waist-to-hip ratios were assessed using standardized techniques. Patients with a high surgical risk were identified using established criteria and all patients were assessed using the Portsmouth modification of the Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (P-POSSUM). Cost analysis was performed using a structured query language database. Patients were analysed using accepted groupings for BMI, waist circumference and waist-to-hip ratio. RESULTS: A total of 372 patients were enrolled in the study, of whom 345 were included in the analysis. The incidence of diabetes was significantly higher with increased BMI (P = 0·002), whereas all other co-morbidities, and P-POSSUM values, did not differ between BMI groups. The groups were similar in terms of case mix. Treatment of obese patients (BMI at least 30 kg/m(2)) was significantly more expensive than that of normal weight patients (BMI 20-24·9 kg/m(2)): €10,036 versus €7390 (P = 0·005). Treatment costs for patients with a BMI of 25-29·9 kg/m(2) were next highest (€9048) followed by those for patients whose BMI was less than 20 kg/m(2) (€8884). Patients with a waist circumference above recognized standards for men and women also cost significantly more to treat (€10,063 versus €7836; P = 0·014). CONCLUSION: Excess body fat was associated with higher costs of major colorectal surgery.

Laceration of anterior mitral leaflet postpercutaneous balloon mitral valvuloplasty for rheumatic mitral stenosis.

A 37-year-old Caucasian female with known rheumatic mitral stenosis was admitted for Balloon mitral valvuloplasty which was complicated with a laceration of anterior mitral leaflet (A2 scallop) resulting in severe mitral regurgitation. Intra-aortic balloon pump (IABP) was instituted and the patient was referred for emergency mitral surgery. During surgery anterior mitral leaflet was excised. Most of the posterior leaflet was preserved. Mitral valve was replaced with St Jude mitral mechanical valve. Operation was uneventful and patient's recovery was uncomplicated. Complications associated with mitral valvuloplasty include ventricular perforation, leaflet laceration, rupture of chordae, sepsis, cardiac tamponade and premature ventricular contractions. Torrential mitral regurgitation postvalvuloplasty is a serious, life-threatening complication. Considering the risk of serious complication associated with percutaneous mitral balloon valvuloplasty (PMBV), this procedure should be performed in qualified cardiac catheterisation labs with a backup facility of cardiac surgery to deal with any potential life-threatening complications.

The process and outcomes of a nurse-led colorectal cancer follow-up clinic.

AIM: Evidence suggests that follow-up after colorectal cancer improves survival. Colorectal cancer is so common that patient follow-up can overwhelm a service, affecting the ability to see new referrals and reassess patients seen previously who have new symptoms. In order to cope with this demand a nurse-led follow-up service was started in 2004. We aimed to review the results of a nurse-led colorectal cancer follow-up clinic. METHOD: Between 1 December 2004 and 31 January 2011, patients who underwent resection for colorectal cancer were followed up by a nurse specialist according to a protocol determined by the colorectal surgeons in the unit. All patient details were recorded prospectively in a purpose designed database. RESULTS: Nine hundred and fifty patients were followed up over 7 years. Some 368 patients were discharged from the follow-up programme, 474 patients remain actively involved in the programme and 108 patients died. Of the patients discharged from the follow-up scheme 269 (73%) were discharged to their general practitioner free of disease after 5 years. Of the 108 who patients died, 98 were as a result of colorectal cancer. Twenty patients (2.1%) were identified with local (peri-anastomotic) disease recurrence and 93 patients (9.8%) were found to have developed distant metastatic disease. Of these, 65 patients (6.8%) were referred for palliative care and 28 (2.9%) had surgery for focal metastatic disease of whom 18 were still alive at the time of this analysis. CONCLUSION: This paper shows that a nurse-led clinic for colorectal cancer follow-up can achieve satisfactory results with detection rates of recurrent or metastatic disease comparable to consultant follow-up. A nurse-led clinic provides the benefits of follow-up without overwhelming the consultant colorectal surgical clinic practice.