Satisfaction of orthodontic Post-CCST training: A survey of trainee perceptions.

INTRODUCTION: This survey was undertaken as a second part to 'Barriers to Post-CCST training in orthodontics: A survey of trainee perceptions'. Recruitment of Post-CCST trainees in certain areas of the country has attracted concerns as it has become increasingly difficult. This survey was undertaken to assess trainee satisfaction with Post-CCST training and to look at possible ways to improve trainee satisfaction and make Post-CCST training more desirable. METHODS: The Training Grades Group (TGG) committee of the British Orthodontic Society (BOS) produced an online survey that was sent to all TGG members and newly qualified consultants in May 2021. All Post-CCSTs who entered training between February 2017 and October 2020, were asked to complete the survey. RESULTS: There were 37 respondents, which gave a response rate of 62%. While 61% of respondents were satisfied with their Post-CCST training, 17% were 'neither satisfied or dissatisfied' and 6% were either 'dissatisfied' or 'very dissatisfied'. Of the 37 respondents, 25 (67%) would apply for Post-CCST training again, 6 (16%) would not and 6 (16%) did not answer this question. When asked for possible suggestions for improvements to Post-CCST training to encourage greater satisfaction, the responses could be grouped into the following themes: Part-time training; Teaching; Time commitment; Salary; and Experience. CONCLUSION: In general, respondents were satisfied with Post-CCST training. There was a significant range of positive and negative responses to various aspects of training including multidisciplinary team clinic preparation, support, supervision and management experience. Suggestions for improvements echo the barriers to Post-CCST training survey.

Gastric Metastasis of Primary Neuroendocrine Tumor of Skin: Rare Tumor with Rare Presentation.

Merkel cell carcinoma (MCC) is a rare primary neuroendocrine tumor of the skin. It has an aggressive biological behavior and shows early local and distant metastasis. Diagnosis of MCC is a challenge and requires confirmation by immunohistochemistry (IHC). However, metastasis of MCC to the stomach is extremely uncommon and is rarely reported in the literature. We hereby describe a patient with gastric metastasis of MCC, who presented with black tarry stool and was finally diagnosed on the basis of clinical history, histology, and IHC.

Genetic Architecture of Acute Myocarditis and the Overlap With Inherited Cardiomyopathy.

BACKGROUND: Acute myocarditis is an inflammatory condition that may herald the onset of dilated cardiomyopathy (DCM) or arrhythmogenic cardiomyopathy (ACM). We investigated the frequency and clinical consequences of DCM and ACM genetic variants in a population-based cohort of patients with acute myocarditis. METHODS: This was a population-based cohort of 336 consecutive patients with acute myocarditis enrolled in London and Maastricht. All participants underwent targeted DNA sequencing for well-characterized cardiomyopathy-associated genes with comparison to healthy controls (n=1053) sequenced on the same platform. Case ascertainment in England was assessed against national hospital admission data. The primary outcome was all-cause mortality. RESULTS: Variants that would be considered pathogenic if found in a patient with DCM or ACM were identified in 8% of myocarditis cases compared with <1% of healthy controls (P=0.0097). In the London cohort (n=230; median age, 33 years; 84% men), patients were representative of national myocarditis admissions (median age, 32 years; 71% men; 66% case ascertainment), and there was enrichment of rare truncating variants (tv) in ACM-associated genes (3.1% of cases versus 0.4% of controls; odds ratio, 8.2; P=0.001). This was driven predominantly by DSP-tv in patients with normal LV ejection fraction and ventricular arrhythmia. In Maastricht (n=106; median age, 54 years; 61% men), there was enrichment of rare truncating variants in DCM-associated genes, particularly TTN-tv, found in 7% (all with left ventricular ejection fraction <50%) compared with 1% in controls (odds ratio, 3.6; P=0.0116). Across both cohorts over a median of 5.0 years (interquartile range, 3.9-7.8 years), all-cause mortality was 5.4%. Two-thirds of deaths were cardiovascular, attributable to worsening heart failure (92%) or sudden cardiac death (8%). The 5-year mortality risk was 3.3% in genotype-negative patients versus 11.1% for genotype-positive patients (Padjusted=0.08). CONCLUSIONS: We identified DCM- or ACM-associated genetic variants in 8% of patients with acute myocarditis. This was dominated by the identification of DSP-tv in those with normal left ventricular ejection fraction and TTN-tv in those with reduced left ventricular ejection fraction. Despite differences between cohorts, these variants have clinical implications for treatment, risk stratification, and family screening. Genetic counseling and testing should be considered in patients with acute myocarditis to help reassure the majority while improving the management of those with an underlying genetic variant.

Proliferative fasciitis arising from the abdominal wall: A rare tumour excised by laparoscopy.

Proliferative fasciitis (PF) is a rare pseudosarcomatous lesion arising from the subcutaneous fascia and the fibrous septa. Only few hundred cases have been reported in the literature. In the largest series of 53 patients, only two patients had PF lesion arising from the flank. The most common site of origin is extremities followed by abdomen and head and neck. Its origin from the abdominal wall layer and presentation as the fever has been rarely reported in the literature. A PF lesion larger than 5 cm dimension has been sparsely noted. We report the presence of this rare entity in a 68-year-old gentleman who presented to us with low-grade fever and the presence of large lump arising from the abdominal wall. In our patient, the lesion was arising from transervsalis fascia and was excised in toto laparoscopically without damaging the abdominal muscles. It is imperative to differentiate both these lesions from sarcoma on histopathological examination as the follow-up treatment protocols for both vary.

Safety and efficacy of laparoscopic sleeve gastrectomy in patients with portal hypertension with liver function of Childs A.

INTRODUCTION: Advanced liver disease and portal hypertension (PH) are seen as a relative contraindication for bariatric and metabolic surgery. Several studies have shown significant improvement in liver function and liver histology after bariatric surgery. There are very few studies describing bariatric surgery in patients with PH. The purpose of this retrospective study is to evaluate the feasibility and results of laparoscopic sleeve gastrectomy (SG) in patients with PH. MATERIAL AND METHODS: We present our experience of performing laparoscopic SG in 15 patients with evidence of PH. All the patients were Childs Pugh Criteria A. PH was confirmed by the presence of dilated esophageal varices on endoscopy. RESULTS: The mean operative time was 77.33 ± 15.22 min and mean blood loss was 80.67 ± 37.12 ml. The mean length of stay was 2.73 ± 0.59 days. There were no intraoperative or immediate postoperative complications. None of the patients required blood transfusion in the postoperative period. The weight, BMI, Excess body weight loss% (EBWL%), Total weight loss (TWL) and TWL% at 1 year were 86.05 ± 14.40 kg, 31.16 kg/m2 ± 3.82, 63.84% ± 15.24, 31.49 ± 9.54 kg and 26.50 ± 5.42%, respectively. Diabetes and hypertension resolution at 1 year was 80% and 72.72%, respectively. All the patients were followed up for mean 3 ± 1.5 years. There were no immediate or long-term morbidity and mortality noted. CONCLUSION: SG is a feasible and safe option for the treatment of obesity in carefully selected patients with PH with good weight loss and comorbidity resolution.

Rapid deployment aortic valve replacement through anterior right thoracotomy: Clinical outcomes and haemodynamic performance.

BACKGROUND: The ease of implantation of the rapid deployment (RD) and sutureless valves has contributed to the adoption of anterior right thoracotomy (ART) approach for aortic valve replacement (AVR). AIM OF THE STUDY: This study evaluates the safety and haemodynamic performance of minimally invasive AVR through ART using the RD valves. METHODS: This is a retrospective, single-center review of a total of 50 consecutive patients who received RD-AVR through ART. RESULTS: The median age of patients was 75 years (interquartile range [IQR]: 69-80), and median Euroscore II was 5.1 (IQR: 2.4-7.5). ART RD-AVR was successfully performed in all cases with no conversion to sternotomy, paravalvular leaks or need for valve explantation. The mean size of the implanted valve was 23.2 ± 2.3 mm. In-hospital mortality was 2%. The mean and maximum pressure gradients across the aortic prosthesis were 10 mm Hg (IQR: 9-12) and 19 mm Hg (IQR: 16-23). CONCLUSIONS: Rapid deployment aortic valve replacement can be safely performed through anterior right thoracotomy wit excellent haemodynamic performance and low postoperative complications rate.

Neurological Manifestations Do not Affect Cumulative Survival in Indian Patients with Antineutrophil Cytoplasmic Antibody Associated Vasculitis.

BACKGROUND: Neurological manifestations are an important cause of morbidity in antineutrophil cytoplasmic antibody (ANCA) associated vasculitis (AAV). It is not clear whether or not they are indicative of a severe disease course with multiple organ involvement and shortened survival. AIMS AND OBJECTIVES: To characterize the neurological manifestations of AAV and analyze their relationship with other organ system and cumulative survival. METHODS: This was a retrospective single-center cohort study of AAV patients at a tertiary care hospital in North India. Data was collected from medical records regarding clinical history, neurological examination, Birmingham Vasculitis Activity Score (BVAS), serology, electrophysiology, imaging, and histopathological examination findings of patients. RESULTS: Ninety-two patients of systemic vasculitis were identified, 67 with granulomatosis with polyangiitis (GPA), 14 with microscopic polyangiitis, 8 with Churg-Strauss syndrome (CSS), and 3 with undifferentiated AAV. The median BVAS at presentation was 18.0 (interquartile range (IQR): 12.0). The median duration of follow-up was 31.3 months (IQR: 40.5). A total of 45.7% patients had neurological manifestations among which 23.8% presented with neurological complaints. Peripheral neuropathy was the most common manifestation noted in 23.9% of the patients. Among patients with GPA, 40.3% had neurological involvement (seen in 33.3% patients at presentation). Patients with nervous system disease were more likely to have associated musculoskeletal manifestations (P = 0.046) and less likely to have renal involvement (P = 0.017). The estimated cumulative survival of the subgroup with neurological involvement was 95.1 months from the time of diagnosis, which was not significantly different from the cohort without neurological involvement (113.8 months, P = 0.631). CONCLUSION: Neurological morbidity commonly accompanies systemic vasculitis. Nervous system disease does not affect the survival significantly in these patients.

Efficacy of ultrasound-guided transversus abdominis plane (TAP) block for postoperative analgesia in laparoscopic gastric sleeve resection: a randomized single blinded case control study.

BACKGROUND: Pain following bariatric surgery can be quite troublesome and prolongs recovery. Transversus abdominis plane (TAP) block is a new regional anesthetic technique to reduce postoperative pain and is an important part of current analgesic regimen for many abdominal surgeries. The primary objective of our study was to assess the efficacy of the TAP block in controlling postoperative pain in laparoscopic sleeve gastrectomy. Secondary outcomes assessed in this study were postoperative nausea and vomiting (PONV), time to ambulate, readiness for discharge, and whether it leads to improved patient satisfaction. METHODS: This is a prospective single blind randomized controlled study. A total of 60 patients were included in the study. Patients were allocated in two groups, using a computer generated randomization sequence using http://www.randomization.com . Test group included 30 patients who received Ultrasound-guided transversus abdominis plane (USG-TAP) block along with systemic analgesia and the Control group included 30 patients who received only systemic analgesia. Postoperatively patients were evaluated for pain and satisfaction using VAS scores and 'Capuzzo' satisfaction score, respectively. RESULTS: Sixty patients were enrolled in the study after fulfilling the eligibility criteria. No patient was lost to follow-up. The difference of VAS scores between test (TAP) and control (Non-TAP) was statistically significant both at rest and on movement. The patient satisfaction score in TAP group was higher than the control group (p value < 0.001). The patients who received TAP block showed earlier readiness for discharge, early ambulation, early resumption of bowel activity, and decreased incidence of PONV as compared to the non-TAP group. CONCLUSION: USG-guided TAP block is a feasible, minimally invasive technique and can be a part of an effective multimodal analgesia in morbidly obese patients undergoing bariatric surgery. Limitations of this study would be the small sample size and the study being Single-blinded.

Alimentary Limb Ischemia During Roux-en-Y Gastric Bypass and its Management.

INTRODUCTION: Ischemia of the tip of the alimentary limb involving the gastrojejunostomy (GJ) is an unusual complication during Roux-en-Y gastric bypass (RYGB). Revision of the GJ may be needed to manage this complication. OBJECTIVES: We present a case of inadvertent perforation of the jejunum by a gastric calibration tube, which was recognized on the table and appropriate measures are then taken. Repair of this enterotomy however then led to ischemia of the tip of alimentary limb extending to a portion of the GJ anastomosis. We present its subsequent management. METHODS: Our patient is a morbidly obese female patient with a BMI value of 44.6 kg/msq undergoing RYGB. We performed an antecolic, antegastric linear-stapled gastrojejunostomy of 2.5 cm. After hand-sewn closure of the common enterotomy, we tried passing a 38-F Bougie through the anastomosis into the Roux limb. During this maneuver, the Bougie inadvertently perforated the Roux limb at the mesenteric border. Following the repair of this jejunal rent, the distal part of the Roux limb became dusky and involved a portion of the gastrojejunal anastomosis. The gastrojejunostomy was therefore completely revised. Intraoperatively, methylene blue dye test was done which showed no leak. RESULTS: Post-operative gastrografin study revealed no leak and liquids were started on POD1. CONCLUSION: Inadvertent injury by a Bougie is a rare but known complication in laparoscopic RYGB. Intraoperative recognition of the complication is essential to prompt the necessary repair. Revision of the gastrojejunostomy is necessary if the Roux limb or the anastomosis itself is ischemic and can be accomplished with good results.

A cross-sectional survey of cardiovascular health and lifestyle habits of hospital staff in the UK: Do we look after ourselves?

Background A high prevalence of stress-related disorders is well known among healthcare professionals. We set out to assess the prevalence of cardiovascular risk factors and compliance with national dietary and physical activity recommendations in NHS staff in the UK with comparison between clinical and non-clinical staff, and national surveys. Design A multi-centre cross-sectional study. Methods A web-based questionnaire was developed to include anonymised data on demographics, job role, cardiovascular risk factors and diseases, dietary habits, physical activity and barriers towards healthy lifestyle. This was distributed to staff in four NHS hospitals via emails. Results A total of 1158 staff completed the survey (response rate 13%) with equal distribution between the clinical and non-clinical groups. Most staff were aged 26-60 years and 79% were women. Half of the staff were either overweight or obese (51%) with no difference between the groups ( P = 0.176), but there was a lower prevalence of cardiovascular risk factors compared to the general population. The survey revealed a low compliance (17%) with the recommended intake of five-a-day portions of fruit and vegetables, and that of moderate or vigorous physical activity (56%), with no difference between the clinical and non-clinical staff ( P = 0.6). However, more clinical staff were exceeding the alcohol recommendations ( P = 0.02). Lack of fitness facilities and managerial support, coupled with long working hours, were the main reported barriers to a healthy lifestyle. Conclusions In this survey of UK NHS staff, half were found to be overweight or obese with a lower prevalence of cardiovascular risk factors compared to the general population. There was a low compliance with the five-a-day fruit and vegetables recommendation and physical activity guidelines, with no difference between the clinical and non-clinical staff.

Prevalence of obstructive coronary artery disease and prognosis in patients with stable symptoms and a zero-coronary calcium score.

AIMS: CT calcium scoring (CTCS) and CT cardiac angiography (CTCA) are widely used in patients with stable chest pain to exclude significant coronary artery disease (CAD). We aimed to resolve uncertainty about the prevalence of obstructive coronary artery disease and long-term outcomes in patients with a zero-calcium score (ZCS). METHODS AND RESULTS: Consecutive patients with stable cardiac symptoms referred for CTCS or CTCS and CTCA from chest pain clinics to a tertiary cardiothoracic centre were prospectively enrolled. In those with a ZCS, the prevalence of obstructive CAD on CTCA was determined. A follow-up for all-cause mortality was obtained from the NHS tracer service. A total of 3914 patients underwent CTCS of whom 2730 (69.7%) also had a CTCA. Half of the patients were men (50.3%) with a mean age of 56.9 years. Among patients who had both procedures, a ZCS was present in 52.2%, with a negative predictive value of 99.5% for excluding ≥70% stenosis on CTCA. During a mean follow-up of 5.2 years, the annual event rate was 0.3% for those with ZCS compared with 1.2% for CS ≥1. The presence of non-calcified atheroma on CTCA in patients with ZCS did not affect the prognostic value (P = 0.98). CONCLUSION: In patients with stable symptoms and a ZCS, obstructive CAD is rare, and prognosis over the long-term is excellent, regardless of whether non-calcified atheroma is identified. A ZCS could reliably be used as a 'gatekeeper' in this patient cohort, obviating the need for further more expensive tests.

Congenital absence of the common bile duct: A rare anomaly of extrahepatic biliary tract.

Congenital absence of the common bile duct (CBD) is an extremely rare developmental anomaly with right and left hepatic ducts draining directly into the gallbladder (GB). Other synonyms for this clinical condition are "cholecystohepatic ducts", "transverse lie of the GB" or "interposition of the GB". The potential for iatrogenic injury is high, because of either inadvertent division or ligation of the ducts. Diagnosis is mostly made intraoperatively, and needs some form of biliary reconstruction. Herein, we are reporting a case of congenital absence of the CBD in a 36-year-old lady that was detected intraoperatively.

Impact of renal involvement on survival in ANCA-associated vasculitis.

BACKGROUND: Renal involvement is a serious complication of anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV). We describe the pattern of renal involvement and its correlation with outcomes. PATIENTS AND METHODS: Medical records of 92 patients seen in rheumatology clinic and diagnosed as AAV between January 2007 and June 2014 were analysed. Patients were classified as granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), eosinophilic granulomatosis with polyangiitis (EGPA) and undifferentiated AAV. Overall and renal outcomes were analysed. Patients were classified as advanced renal failure (creatinine >5.7 mg/dl or requiring dialysis), deranged RFT not qualifying the above parameters, and normal renal function. RESULTS: Sixty-seven (72.8 %) patients had GPA, 14 (15.2 %) had MPA, 8 (8.7 %) had EGPA, and 3 (3.3 %) had undifferentiated AAV. Renal involvement was seen in 51 (55.4 %) patients (46.3 % of GPA patients, 78.6 % of MPA, 37.5 % of EGPA and 33.3 % of unclassifiable AAV patients). Renal involvement was more common in males (p = 0.008). Patients with renal involvement had higher mean BVAS scores as compared to patients without renal involvement (p < 0.01). Thirteen patients (25.5 %) presented with advanced renal failure (creatinine >5.7 mg/dl or requiring dialysis), 21 (41.2 %) had deranged renal functions but did not require dialysis, and the rest had proteinuria and active sediments with normal serum creatinine. Twenty-four patients (47.1 %) had good renal outcome with normal creatinine, 12 (23.5 %) had persistent renal insufficiency, 12 (23.5 %) died, and one (2 %) remained dialysis dependent. Mean survival and mortality did not differ in patients with and without renal involvement (p = 0.454, p = 0.388). CONCLUSIONS: Renal involvement was more common in males. BVAS was higher in patients with renal involvement. The mean survival and mortality were similar in patients with or without renal involvement.

Classification of Aortic Stenosis by Flow and Gradient Patterns Provides Insights into the Pathophysiology of Disease.

Different patterns of flow and valve gradients can lead to diagnostic uncertainty about the severity of aortic stenosis (AS). Consecutive patients with severe AS (valve area <1 cm(2)) underwent echocardiography and computed tomography. Patients were classified into 4 groups (high-gradient/normal flow [HGNF], high-gradient/low flow [HGLF], low-gradient/normal flow [LGNF], and low-gradient/low flow [LGLF]). Low flow was defined as stroke volume index <35 mL/m(2) and low gradient as a mean aortic gradient <40 mm Hg. Aortic valve calcification (AVC) was calculated using the Agatston score. Of 181 patients, 56, 30, 46, and 49 had HGNF, HGLF, LGNF and LGLF with median AVC of 2048, 2015, 1366, and 1178 AU/m(2) (P < .0001) and valvuloarterial impedance of 4.5, 6.4, 4.2, and 5.9, respectively (P < .0001). Among those with LGLF, AVC was lower in patients with preserved compared to reduced left ventricular ejection fraction (1018 vs 2550 AU/m(2); P < .0001), but valvuloarterial impedance was similar (P = .33). The LGLF AS with preserved ejection fraction is associated with lower AVC and may identify patients with less severe AS in association with an adaptive ventricular response to high afterload.