Carotid Endarterectomy Following Intravenous Thrombolysis in the UK.

OBJECTIVE: The aim of this study was to evaluate the effect of pre-operative intravenous thrombolytic therapy (ivTT) on short term outcomes after carotid endarterectomy (CEA) among patients who presented with ischaemic stroke. METHODS: A retrospective study using a large population based dataset from the National Vascular Registry in the United Kingdom (UK-NVR). The cohort included adult patients who underwent CEA for ischaemic stroke between 1 January 2014 and 31 December 2019. NVR records provided information on patient demographics, Rankin score, medication, time from onset of symptoms to surgery and whether the patient received ivTT prior to surgery. Logistic regression was used to evaluate the relationship between ivTT and rates of any stroke at 30 days after CEA and in hospital complication rates for neck haematoma. Secondary outcomes included in hospital cardiac and respiratory complications, and cranial nerve injury. RESULTS: Between 2014 and 2019, 9 030 patients presented with a stroke and underwent CEA, of whom 1 055 (11.7%) had received pre-operative ivTT. Those receiving ivTT were younger (mean 70.6 vs. 72.0 years, p < .001). The median (IQR) time from symptom to CEA was 10 days (6 - 17) for ivTT patients and 11 days (7 - 20) for CEA patients not receiving ivTT. Post-operative rates of 30 day stroke were similar between the no ivTT (2.1%) and ivTT (1.8%) cohorts (p = .48). In hospital neck haematomas were statistically significantly more common in CEA patients receiving ivTT (3.7%) vs. no ivTT (2.3%) (p = .006). There was no statistically significant association between 30 day stroke and neck haematoma complications when stratified for delays from symptom onset to CEA, but the overall cohort contained few adverse events for analysis during the very early time period. CONCLUSION: The use of ivTT before CEA in stroke patients was not associated with an increased risk of 30 day stroke, but there was an increase in the risk of neck haematoma.

Non-invasive assessment of portal hypertension using quantitative magnetic resonance imaging.

BACKGROUND & AIMS: Hepatic venous pressure gradient (HVPG) measurement is currently the only validated technique to accurately evaluate changes in portal pressure. In this study, we evaluate the use of non-contrast quantitative magnetic resonance imaging (MRI) as a surrogate measure of portal pressure. METHODS: Thirty patients undergoing HVPG measurement were prospectively recruited. MR parameters of longitudinal relaxation time (T1), perfusion of the liver and spleen (by arterial spin labelling), and blood flow in the portal, splanchnic and collateral circulation (by phase contrast MRI) were assessed. We estimated the liver stiffness measurement (LSM) and enhanced liver fibrosis (ELF) score. The correlation of all non-invasive parameters with HVPG was evaluated. RESULTS: The mean (range) HVPG of the patients was 9.8 (1-22) mmHg, and 14 patients (48%) had clinically significant portal hypertension (CSPH, HVPG ⩾10mmHg). Liver T1 relaxation time, splenic artery and superior mesenteric artery velocity correlated significantly with HVPG. Using multiple linear regression, liver T1 and splenic artery velocity remained as the two parameters in the multivariate model significantly associated with HVPG (R=0.90, p<0.001). This correlation was maintained in patients with CSPH (R=0.85, p<0.001). A validation cohort (n=10) showed this linear model provided a good prediction of HVPG. LSM and ELF score correlated significantly with HVPG in the whole population but the correlation was absent in CSPH. CONCLUSIONS: MR parameters related to both hepatic architecture and splanchnic haemodynamics correlate significantly with HVPG. This proposed model, confirmed in a validation cohort, could replace the invasive HVPG measurement. LAY SUMMARY: In patients with cirrhosis, the development and progression of portal hypertension is related to worse outcomes. However, the standard technique of assessing portal pressure is invasive and not widely used in clinical practice. Here, we have studied the use of non-invasive MRI in evaluating portal pressure. The MRI measures of liver architecture and blood flow in the splenic artery correlated well with portal pressure. Therefore, this non-invasive method can potentially be used to assess portal pressure in clinical trials and monitoring treatment in practice.

Treatment of Renal Artery Stenosis in a Solitary Kidney Using Cutting Balloon Angioplasty in a Paediatric Patient.

AIMS: Renovascular hypertension is a rare cause of paediatric hypertension. It is however, a potentially treatable cause particularly when caused by renal artery stenosis (RAS). MATERIALS AND METHODS: We present the case of an 11-month-old girl presenting with cardiac dysfunction. She was found to be hypertensive with a systolic blood pressure >180mmHg. DMSA demonstrated a small right kidney and a divided renal function of 6% on the right and 94% on the left. Spectral analysis demonstrated abnormal waveforms suggestive of RAS of the left kidney. RESULTS: Angioplasty with a cutting balloon was successful. Blood pressure measurements, renal function and left ventricular function improved. CONCLUSION: RAS can be successfully treated with cutting balloon angioplasty after failure of convention balloon angioplasty to relieve the narrowing. In our case, there was an immediate successful angiographic result that on mid-term follow-up demonstrated significant improvement in clinical and biochemical outcomes and cessation of all anti-hypertensive medication.

Systems-centered training groups' process and outcome: a comparison with AGPA institute groups.

In this quasi-experimental study we compared the process and outcome of six experiential Systems-Centered Training (SCT) groups to those of American Group Psychotherapy Association (AGPA) Institute groups from two prior studies (MacKenzie, Dies, Coche, Rutan, & Stone, 1987; Tschuschke & Greene, 2002). The SCT training compared well overall and the results provided preliminary, indirect support for the usefulness of "functional subgrouping" - SCT's conceptual and methodological bridge between the group-as-a-whole and the individual member. However, quasi-experimental design limitations make other interpretations equally plausible. Within-group change in the process variables for the SCT groups was also explored, as well as the relative contributions of these variables to post-training learning outcomes and anxious and depressive experience. The results partly corroborated prior studies, but also suggested that SCT may alter training group dynamics, learning, and emotional experience in ways consistent with SCT theory.

Measuring How Systems-Centered® Members Connect with Group Dynamics: FSQ-2 Construct Validity.

Understanding and intervening at the connection between group dynamics and member behavior has been a long-standing challenge. Functional subgrouping (FS) is the core Systems-centered training and therapy (SCT) method and is hypothesized to solve vexing member/group dynamic problems such as scapegoating. The self-report Functional Subgrouping Questionnaire-2 (FSQ-2) was developed to measure the amount of functional subgrouping in a group. The current FSQ-2 construct validity study aims to determine whether: 1) FSQ-2 scores change across sessions; 2) level of SCT experience is related to scores; and 3) SCT experience moderates change in FSQ-2 scores over SCT training. Results from groups at various SCT training events showed higher FSQ-2 responses for those with greater SCT experience, and increased scores over time. However, change over time on most FSQ-2 items did not depend on SCT experience level. Findings provide further support for the construct validity of the FSQ-2, and thus also for the SCT model. Suggestions for future SCT/FSQ-2 research are made.

Healthcare costs of transarterial chemoembolization in the treatment of hepatocellular carcinoma.

BACKGROUND: A meta-analysis comparing drug-eluting beads transarterial chemoembolization (DEB-TACE) with conventional transarterial chemoembolization (cTACE) has recently been published. On balance, no significant differences were found in terms of objective response and overall survival. The impact on healthcare costs had been studied in small series based on a hypothetical model and was in favor of DEB-TACE. We aimed to evaluate and compare health-care costs and effectiveness of both modalities in a cohort of patients from Nottingham, UK. METHODS: Using a dedicated radiology database, we identified all patients who had undergone cTACE or DEB-TACE between 2006 and 2012 at a single tertiary referral center based in Nottingham. We collected clinical data, including treatment response, postprocedure complications and 30-day mortality. Costing models were constructed to present both our local hospital perspective as well as the national health service position. RESULTS: During our study period, 101 procedures were performed on 43 patients (76 cTACE procedures on 26 patients and 25 DEB-TACE procedures on 17 patients). Overall, 11/26 in cTACE and 5/17 in DEB-TACE group had progressive disease (p=0.52). Adverse events were seen in 6/76 cTACE compared with 7/25 DEB-TACE group (p=0.16). Based on the predetermined standard pathway there was an unadjusted average cost difference of £3770.30 (TACE =£9070.44, DEB-TACE =£5300.14) in favor of the DEB-TACE. Results from our costing models indicated a £2715.33 (95% CI £580.88-4849.77) cost difference in favor of the same procedure. CONCLUSIONS: Even when the extra costs of DEB-TACE were considered, the overall treatment costs per patient were lower in relation to cTACE.

Abciximab in patients with ruptured intracranial aneurysms.

BACKGROUND AND PURPOSE: Experience with intravenous abciximab to manage thromboembolism during treatment of ruptured intracranial aneurysms is limited. We present our experience in 13 patients. METHODS: We retrospectively reviewed all patients with thromboembolic complications during endovascular management of ruptured intracranial aneurysms. Thromboembolic complications were treated with intravenous abciximab. We recorded patient and aneurysm demographics, aneurysm occlusion, drug therapy, complications, and outcomes. RESULTS: World Federation of Neurological Surgeons Grades were 1 or 2 in 11 patients (85%). Median time from diagnostic angiography to treatment was 1 day. Ten (77%) aneurysms involved the anterior or posterior communicating artery, and one each occurred in the posterior inferior cerebellar artery, middle cerebral artery, and basilar regions. Eleven aneurysms were <10 mm. Five were incompletely occluded (0%-90% treated) at the time of the complication. Thromboembolic complications were at the coil-ball/parent-artery interface in nine patients (69%). Two were associated with coil-loop prolapse; one was prophylactically treated without evidence of thromboembolism. Five patients (38%) had distal complications; one also had a proximal thrombus. All patients received an intravenous bolus of abciximab (5-10 mg in 92%) without infusion. Postprocedural recanalization was complete in eight (62%) and partial in four (31%). Eleven patients (85%) had a Glasgow Outcome Scale score of 1 at 3 months. One had a poor outcome (GOS4). One died following additional coiling after abciximab administration, though this intervention was uneventful in three others. CONCLUSION: Abciximab completely or partially treated thromboembolic complications arising during coiling of ruptured aneurysms. Further coiling should be performed with extreme caution and needs to be decided on a patient-by-patient basis.

The issue of moral distress in community pharmacy practice: background and research agenda.

OBJECTIVES: Moral distress arises from situations in which the individual identifies the morally right action required, but feels unable to act accordingly due to organisational constraints within the work place. Research into this phenomenon has focused predominately on the experience of those in the nursing profession, due to its perceived moral grounding and its traditionally subordinate role. As the conceptual boundaries of moral distress have developed, so too has the research interest in the experiences of other professional groups. Here, we seek to determine if there is scope to study moral distress in pharmacists. METHODS: A review of the literature on moral distress in healthcare professions was undertaken. KEY FINDINGS: Pharmacists working in the UK operate within a highly-regulated occupational sphere, and are bound by strict legal frameworks and codes of professional conduct. This regulatory environment, when combined with the emerging recognition that pharmacy is a value-based profession with a strong ethical grounding, creates the potential for moral distress to occur due to the limitations placed on acting in congruence with ethical judgements. Studies concerning moral distress in nurses have identified significant negative consequences for both the practitioner and for the quality of patient care. CONCLUSIONS: To date, the incidence of moral distress among UK-based community pharmacists remains unexamined. Research must be undertaken to determine what situations cause the highest instances of moral distress for community pharmacists, and the extent to which these pharmacists experience moral distress in their working lives.

Economic modelling of early transjugular intrahepatic portosystemic shunt insertion for acute variceal haemorrhage.

INTRODUCTION: Early insertion of transjugular intrahepatic portosystemic shunt (TIPS) in high-risk patients with acute variceal haemorrhage reduces rebleeding and mortality. However, the economic benefit of utilizing this approach remains unclear. We evaluated the economic implications of introducing early TIPS into routine algorithms for the management of variceal bleeding. METHODS: Consecutive patients admitted in 2009 with variceal haemorrhage to two liver units and eligible for early TIPS insertion were identified retrospectively. The costs of a 12-month follow-up from index bleeding admission were calculated--the actual cost of follow-up and rebleeding in this cohort was compared with the theoretical 12-month follow-up costs of instead inserting an early TIPS at index admission. Our findings were subjected to a sensitivity analysis to assess the cost effectiveness of early TIPS insertion compared with standard care. RESULTS: In 2009, 78 patients were admitted to our units with variceal haemorrhage; 27 patients (35%) were eligible for early TIPS insertion. The actual cost of a 12-month follow-up was £138 473.50. Early TIPS insertion, assuming a 3.2% rebleeding rate, would save £534.70 per patient per year (P<0.0001). On sensitivity analysis, early TIPS dominated standard care up to an early TIPS rebleeding rate of 6% and remained cost-effective up to a rebleeding rate of 12%. CONCLUSION: Early TIPS insertion for high-risk patients with acute variceal bleeding is a cost-efficient intervention. This has important implications for the introduction of early TIPS as standard care and the organization of interventional radiology services.

Borderline tumors of the ovary: CT and MRI features and tumor markers in differentiation from stage I disease.

OBJECTIVE: We sought to describe MDCT and MRI features and tumor marker levels that differentiate borderline ovarian tumors from stage I ovarian tumors. CONCLUSION: Borderline ovarian tumors are complex masses with imaging features similar to stage I tumors. The thickness of septations and the size of solid components are significantly larger in stage I tumors, and these features may be helpful for predicting likelihood of invasive tumors. However, neither feature allows confident differentiation of borderline tumors from stage I disease.