First Report With Medium-term Follow-up of Intestinal Transplantation for Advanced and Recurrent Nonresectable Pseudomyxoma Peritonei.

OBJECTIVE: To report our experience with the combination of radical surgical excision and intestinal transplantation in patients with recurrent pseudomyxoma peritonei (PMP) not amenable to further cytoreductive surgery (CRS). BACKGROUND: CRS and heated intraoperative peritoneal chemotherapy are effective treatments for many patients with PMP. In patients with extensive small bowel involvement or nonresectable recurrence, disease progression results in small bowel obstruction, nutritional failure, and fistulation, with resulting abdominal wall failure. METHODS: Between 2013 and 2022, patients with PMP who had a nutritional failure and were not suitable for further CRS underwent radical debulking and intestinal transplantation at our centre. RESULTS: Fifteen patients underwent radical exenteration of affected intra-abdominal organs and transplantation adapted according to the individual case. Eight patients had isolated small bowel transplantation and 7 patients underwent modified multivisceral transplantation. In addition, in 7 patients with significant abdominal wall tumor involvement, a full-thickness vascularized abdominal wall transplant was performed. Two of the 15 patients died within 90 days due to surgically related complications. Actuarial 1-year and 5-year patient survivals were 79% and 55%, respectively. The majority of the patients had significant improvement in quality of life after transplantation. Progression/recurrence of disease was detected in 91% of patients followed up for more than 6 months. CONCLUSION: Intestinal/multivisceral transplantation enables a more radical approach to the management of PMP than can be achieved with conventional surgical methods and is suitable for patients for whom there is no conventional surgical option. This complex surgical intervention requires the combined skills of both peritoneal malignancy and transplant teams.

An analysis of the association between older recipient age and outcomes after whole-organ pancreas transplantation - a single-centre, retrospective study.

Older people are increasingly being referred for consideration for pancreas transplantation (PT). We investigated the outcomes after PT in our older recipient cohort. A prospectively maintained database was interrogated. The cohort was analysed for associations between outcome and older recipient age. A total of 444 transplants were performed in patients aged 23-54 years and 83 transplants in patients aged 55-67 years. There was no difference in death-censored pancreas or kidney graft survival between the groups. Patient death was associated with older recipient age (HR 1.63 per 10-year increase). In multivariate Cox regression, risk of mortality was also associated with post-transplant myocardial infarction (HR 7.25, P = 0.006), pancreas failure (HR 1.91, P = 0.003) and kidney failure (HR 3.55, P < 0.001). About 40% of recipients who died in the first year post-transplant suffered early graft loss. Those alive at a year post-transplant had inferior survival if they had lost their kidney graft (P < 0.001). Mortality is higher in older patients and is strongly associated with pancreas and kidney graft failure. This suggests that pancreas transplantation is feasible in older recipients, and careful selection of donor organs is important to optimize survival.

Findings from the 2017 HIV estimation round & trend analysis of key indicators 2010-2017: Evidence for prioritising HIV/AIDS programme in India.

Background & objectives: The National AIDS Control Organisation (NACO) and the ICMR-National Institute of Medical Statistics, the nodal agency for conducting HIV estimations in India, have been generating HIV estimates regularly since 2003. The objective of this study was to describe India's biennial HIV estimation 2017 process, data inputs, tool, methodology and epidemiological assumptions used to generate the HIV estimates and trends of key indicators for 2010-2017 at national and State/Union Territory levels. Methods: Demographic Projection (DemProj) and AIDS Impact Modules (AIM) of Spectrum 5.63 software recommended by the United Nations Programme on HIV and AIDS Global Reference Group on HIV Estimates, Modelling and Projections, were used for generating HIV estimations on key indicators. HIV sentinel surveillance, epidemiological and programme data were entered into Estimation Projection Package (EPP), and curve fitting was done using EPP classic model. Finally, calibration was done using the State HIV prevalence of two rounds of National Family Health Survey (NFHS) -3 and -4 and Integrated Biological and Behavioural Surveillance (IBBS), 2014-2015. Results: The national adult prevalence of HIV was estimated to be 0.22 per cent in 2017. Mizoram, Manipur and Nagaland had the highest prevalence over one per cent. An estimated 2.1 million people were living with HIV in 2017, with Maharashtra estimated to have the highest number. Of the 88 thousand annual new HIV infections estimated nationally in 2017, Telangana accounted for the largest share. HIV incidence was found to be higher among key population groups, especially people who inject drugs. The annual AIDS-related deaths were estimated to be 69 thousand nationally. For all indicators, geographic variation in levels and trends between States existed. Interpretation & conclusions: With a slow decline in annual new HIV infections by only 27 per cent from 2010 to 2017 against the national target of 75 per cent by 2020, the national target to end AIDS by 2030 may be missed; although at the sub-national level some States have made better progress to reduce new HIV infection. It calls for reinforcement of HIV prevention, diagnosis and treatment efforts by geographical regions and population groups.

Factors predicting ablation site recurrence following percutaneous microwave ablation of colorectal hepatic metastases.

BACKGROUND: Microwave ablation (MWA) is a recognised treatment option for liver metastases. The size of the tumour is a well-established factor that influences the success of MWA. However, the effect of "heat sink" on the success of MWA for hepatic metastases is unclear. The aim of this study was to determine whether heat sink effect is a factor that contributes to ablation site recurrence (ASR). METHODS: A prospectively maintained database of patients who underwent percutaneous MWA for treatment of colorectal liver metastases was analysed. Imaging and demographic characteristics were compared between metastases that recurred following ablation and those that did not. Proximity to a large hepatic vein was defined as <10 mm. RESULTS: 126 ablations in 87 patients met the inclusion criteria and were studied over a median follow-up period of 28 (12-75) months. ASR was detected in 43 ablations (34%) and was associated with clinical risk score (CRS) ≥2 (OR 2.2 95% CI 1.3-3.3, p = 0.029), metastasis size (OR 0.953 95% CI (0.929-0.978), p < 0.001) and proximity to a large hepatic vein (OR 7.5 95%CI 2.4-22.8, p < 0.001). Proximity to a large hepatic vein was not associated with reduced overall survival (OS) but was associated with liver-specific recurrence (HR 4.7 95%CI 1.7-12.5, p = 0.004). CONCLUSIONS: In addition to tumour size proximity to large hepatic venous structures is an independent predictor of ASR and liver-specific recurrence following MWA. However, this was not associated with overall survival.

De novo donor-specific HLA antibodies after combined intestinal and vascularized composite allotransplantation - a retrospective study.

Combining vascularized composite allotransplantation (VCA) with intestinal transplantation to achieve primary abdominal closure has become a feasible procedure. Besides facilitating closure, the abdominal wall can be used to monitor intestinal rejection. As the inclusion of a VCA raises the possibility of an enhanced alloimmune response, we investigated the incidence and clinical effect of de novo donor-specific HLA antibodies (dnDSA) in a cohort of patients receiving an intestinal transplant with or without a VCA. The sequential clinical study includes 32 recipients of deceased donor intestinal and VCA transplants performed between 2008 and 2015; eight (25%) modified multivisceral transplants and 24 (75%) isolated small bowel transplants. A VCA was used in 18 (56.3%) cases. There were no episodes of intestinal rejection without VCA rejection. Fourteen patients (14 of 29; 48.3%) developed dnDSA. In the VCA group, fewer patients developed dnDSA; six of 16 (37.5%) VCA vs. eight of 13 (61.5%) non-VCA. There was no statistically significant difference in one- and 3-year overall graft survival stratified for the presence of dnDSA; P = 0.286. In the study, there is no evidence that the addition of a VCA increases the incidence of dnDSA formation compared to transplantation of the intestine alone.

The financial sustainability of the World Health Organization and the political economy of global health governance: a review of funding proposals.

The World Health Organization (WHO) continues to experience immense financial stress. The precarious financial situation of the WHO has given rise to extensive dialogue and debate. This dialogue has generated diverse technical proposals to remedy the financial woes of the WHO and is intimately tied to existential questions about the future of the WHO in global health governance. In this paper, we review, categorize, and synthesize the proposals for financial reform of the WHO. It appears that less contentious issues, such as convening financing dialogue and establishing a health emergency programme, received consensus from member states. However, member states are reluctant to increase the assessed annual contributions to the WHO, which weakens the prospect for greater autonomy for the organisation. The WHO remains largely supported by earmarked voluntary contributions from states and non-state actors. We argue that while financial reform requires institutional changes to enhance transparency, accountability and efficiency, it is also deeply tied to the political economy of state sovereignty and ideas about the leadership role of the WHO in a crowded global health governance context.

Acalculous Cholecystitis: Is an Elective Interval Cholecystectomy Necessary.

BACKGROUND: Acute acalculous cholecystitis (AAC) accounts for 5-10% of cases of acute cholecystitis. The advantage of interval cholecystectomy for patients with AAC is unclear. Therefore, a retrospective analysis of patients diagnosed with AAC at our institution was performed over a 5-year period. METHODS: Patients were identified via hospital coding using the keywords "acalculous cholecystitis, cholecystostomy and gall bladder perforation." Follow-up data was obtained by performing a retrospective review of the patients' hospital records. RESULTS: A total of 33 patients with AAC were identified and followed for a median period of 18 months. The median age at presentation was 70 (10-96) and American Society of Anesthesiologists (ASA) grade was 3 (1-5). Twenty-three patients (70%) were treated with antibiotics alone, 7 patients (21%) with percutaneous cholecystostomy and 3 patients (9%) with laparoscopic cholecystectomy. The 90-day mortality rate was 30% with significant correlation to comorbid status, as all deaths occurred in ASA grade 3-5 individuals (p = 0.020). Two patients (6%) developed recurrent AAC and were managed non-operatively. CONCLUSION: Antibiotics and cholecystostomy were the mainstay of AAC management, and comorbid status influenced related mortality. Our results suggest that it appears safe to avoid interval cholecystectomy in patients who recover from AAC, as they are typically high-risk surgical candidates.

Impact of Health Locus of Control on Oral Health Status among a Cohort of IT Professionals.

PURPOSE: To assess the relationship between health locus of control and oral health status among Information Technology (IT) professionals in Hyderabad, India. MATERIALS AND METHODS: A cross-sectional questionnaire study was carried out among IT employees in Hyderabad city. The behaviour, attitude and perceptions of individuals towards health were assessed using the multidimensional health locus of control scale. Oral health status was evaluated clinically utilising the simplified oral hygiene index, community periodontal index, and loss of attachment index. Data were statistically analysed using SPSS software (v 21.0). RESULTS: A convenience sample of 989 employees (response rate of 82.4%, mean age 26.3 ± 5.0 years) completed the questionnaire. The overall highest mean domain score was recorded for 'chance locus of control' (CLOC; 9.0 ± 2.1) and lowest overall mean domain score for 'internal locus of control' (ILOC; 6.7 ± 0.9). The overall mean scores of DI-S, CI-S and OHI-S were 0.7 ± 0.4, 0.7 ± 0.5 and 1.4 ± 0.8, respectively; there was an inverse relation with age groups. The mean CPI and LOA scores observed among males, ranging from 0.4 ± 0.6 to 1.6 ± 1.1, were statistically significantly higher than those of females, ranging from 0.2 ± 0.5 to 1.3 ± 1.2 (p = 0.00). Powerful locus of control had a statistically significant negative correlation with oral hygiene indices. In contrast, a positive correlation was observed between ILOC and DI-S and OHI-S (r = 0.0672 and r = 0.0639, respectively). CONCLUSION: This study highlighted that people with a positive attitude regulate their health behaviour and maintain good oral hygiene.

Determining Caries Activity Using Oratest Among 12-to 15-year-old Children.

PURPOSE: Dental caries is the primary pathological cause of early tooth loss in children, which may lead to malnutrition and other health problems. Identification of patients with active carious lesions and at high risk for caries can help to dramatically decrease the disease prevalence. Thus, recognising the importance of early diagnosis of caries, the present study was carried out to correlate caries with oral microflora using Oratest among 12- to 15-year-old schoolchildren. MATERIALS AND METHODS: A total of 100 children were divided into control and test groups (n = 50) according to their DMFT scores. The test group was further divided into subgroup 1 (DMFT = 1-3) and subgroup 2 (DMFT > 3). Oratest, a caries activity test, was performed on all the children. Comparison among the variables was done using ANOVA and the independent sample t-test. RESULTS: Boys had lower DMFT values (1.35 ± 0.2) than did girls (1.67 ± 0.2) (p = 0.38), and the Oratest time was higher among boys (132.8 ± 0.5 min) than girls (126.4 ± 0.5 min) (p = 0.53). The control group had the highest mean Oratest time (172.7 ± 0.3 min), followed by subgroup 1 (97.8 ± 0.2 min), and subgroup 2 had the lowest Oratest time (68.5 ± 14.8 min). A statistically significant negative correlation (r = -0.893) was found between the mean DMFT and the Oratest time (p < 0.001), ie, they were inversely related to each other. CONCLUSION: An inverse relationship exists between Oratest and DMFT score.

A meta-analysis of CXCL12 expression for cancer prognosis.

BACKGROUND: CXCL12 (SDF1) is reported to promote cancer progression in several preclinical models and this is corroborated by the analysis of human tissue specimens. However, the relationship between CXCL12 expression and cancer survival has not been systematically assessed. METHODS: We conducted a systematic review and meta-analysis of studies that evaluated the association between CXCL12 expression and cancer survival. RESULTS: Thirty-eight studies inclusive of 5807 patients were included in the analysis of overall, recurrence-free or cancer-specific survival, the majority of which were retrospective. The pooled hazard ratios (HRs) for overall and recurrence-free survival in patients with high CXCL12 expression were 1.39 (95% CI: 1.17-1.65, P=0.0002) and 1.12 (95% CI: 0.82-1.53, P=0.48) respectively, but with significant heterogeneity between studies. On subgroup analysis by cancer type, high CXCL12 expression was associated with reduced overall survival in patients with oesophagogastric (HR 2.08; 95% CI: 1.31-3.33, P=0.002), pancreatic (HR 1.54; 95% CI: 1.21-1.97, P=0.0005) and lung cancer (HR 1.37; 95% CI: 1.08-1.75, P=0.01), whereas in breast cancer patients high CXCL12 expression conferred an overall survival advantage (HR 0.5; 95% CI: 0.38-0.66, P<0.00001). CONCLUSIONS: Determination of CXCL12 expression has the potential to be of use as a cancer biomarker and adds prognostic information in various cancer types. Prospective or prospective-retrospective analyses of CXCL12 expression in clearly defined cancer cohorts are now required to advance our understanding of the relationship between CXCL12 expression and cancer outcome.

Intestinal transplantation: a review.

PURPOSE OF REVIEW: The purpose of this article is to review the existing literature on the current indications, surgical techniques, immunosuppressive therapy and outcomes following intestinal transplantation (ITx). RECENT FINDINGS: Over recent years, ITx has become a more common operation with approximately 2500 procedures carried out worldwide by 2014. It is reserved for patients with intestinal failure and who have developed complications of home parenteral nutrition or who have a high risk of dying from their underlying disease. Recent advances such as the improvement in survival rates, not only for isolated small bowel transplants but also following inclusion of a liver graft in combined liver-small bowel transplant, and the utility of citrulline as a noninvasive biomarker to appreciate acute rejection herald an exciting shift in the field of ITx. SUMMARY: With advancements in immunosuppressive drugs, induction regimens, standardization of surgical techniques and improved postoperative care, survival is increasing. In due course, it will most likely become as good as remaining on home parenteral nutrition and as such could become a viable first-line option.

Skype clinics after intestinal transplantation - follow-up beyond post codes.

The follow-up after intestinal transplantation (ITX) is complex and limited to specialized centers. ITX recipients often travel all over the country to be seen in the outpatient clinic of specialized centers which is costly and time-consuming. Videoconferences through Skype have been implemented to eliminate travel time, costs, and to improve patient compliance without jeopardizing safety. Eighteen of 19 patients followed up after ITX or modified multivisceral transplantation (MMVTX) in conventional outpatient clinics in Oxford agreed to attend additional Skype clinics. All patients who were followed up through Skype clinics after ITX/MMVTX received a questionnaire to measure their satisfaction with methods and technical aspects of videoconferencing as well as time/mode of traveling, travel expenses/costs, waiting time in outpatient clinic and patients' satisfaction. Mean travel distance to Oxford was 236 ± 168 miles, mean travel time was 277 ± 175 min, and mean travel cost was 200 ± 56 Great Britain Pounds. A total of 56% had to take time off work and/or find child/family care for the time spent in travel. These patients reported a satisfaction score of 4.38 ± 0.77 of 5 points as opposed to 2.88 ± 0.90 for attending the conventional outpatient clinic. Skype clinics have been proven successful and feasible in highly specialized fields like ITX in eligible patients.

Current state of abdominal wall transplantation.

PURPOSE OF REVIEW: Primary closure of the abdominal wall remains one of the early challenges of intestinal transplantation. Our aim is to review the role of abdominal wall transplantation in achieving tension-free closure of the abdomen. RECENT FINDINGS: In total, 38 full-thickness vascularized abdominal wall transplants, six partial-thickness vascularized and 17 partial-thickness nonvascularized rectus facia grafts have been reported worldwide. Different techniques have been described. The most popular choice seems to be the full-thickness vascularized abdominal wall allograft, where the anastomosis is performed either in a micro- or macrovascular fashion. Temporary 'remote' revascularisation of the allograft has been performed in some cases onto the recipient's forearm vessels when there is a long anticipated cold ischaemia time (>5 h). Preliminary data suggest that the abdominal wall skin rejection might be an early predictor of intestinal rejection. Vascularized and nonvascularized rectus fascia may be effective when there is inadequate healthy muscle/fascia but sufficient skin cover. SUMMARY: Several centres have already proved the technical and immunologic feasibility of partial or full-thickness abdominal wall transplantation. It is an effective option to achieve primary abdominal closure following intestinal transplantation and in its full-thickness form, it may be useful for monitoring rejection in visceral organs.

Solitary pancreas transplantation: a review of the UK experience over a period of 10 yr.

BACKGROUND: The aim of this study was to see whether lessons could be learned from the prospectively maintained nationwide database on solitary pancreas transplantation (SPTx) performed in the UK. METHODS: Two hundred and forty-five SPTx were utilized from the 2004-2013 period (113 pancreas transplant alone and 132 pancreas after kidney). The statistical analysis included donor, recipient, transplant variables, and the effect of a rejection episode on graft survival. RESULTS: Cold ischemia time (CIT), CIT > 12 h, donor body mass index (BMI) > 30, and non-lymphocyte-depleting induction immunosuppression achieved p-value <0.05 in the unadjusted univariate hazard model analysis. In a multivariate analysis, variables that persisted in demonstrating increased independent risk included CIT > 12 h (hazard ratio [HR] 1.94, p = 0.035) and the use of non-depleting induction immunosuppression (HR 1.95, p = 0.002). Factors such as bladder-drained grafts and donor variables including age, BMI, and donation after cardiac death (DCD) vs. donation after brain-stem death did not attain significance. Rejection reduces the overall graft survival by approximately 1000 d (1841 ± 114 d vs. 915 ± 119 d, p = 0.001). CONCLUSIONS: Cold ischemia time <12 h and the use of depleting antibodies as induction immunosuppression have a positive effect on pancreas allograft survival. Other factors such as bladder-drained grafts and donor variables such as age, BMI, and DCD status did not attain significance in a multivariate analysis.

Validation of the Pancreas Donor Risk Index for use in a UK population.

Pancreas graft failure rates remain substantial. The PDRI can be used at the time of organ offering, to predict one-year graft survival. This study aimed to validate the PDRI for a UK population. Data for 1021 pancreas transplants were retrieved from a national database for all pancreas transplants. Cases were categorized by PDRI quartile and compared for death-censored graft survival. Significant differences were observed between the UK and US cohorts. The PDRI accurately discriminated graft survival for SPK and was associated with a hazard ratio of 1.52 (P = 0.009) in this group. However, in the PTA and PAK groups, no association between PDRI quartile and graft survival was observed. This is the largest study to validate the PDRI in a European cohort and has shown for the first time that the PDRI can be used as a tool to predict graft survival in SPK transplantation, but not PTA or PAK transplantation.

Knowledge, Attitude and Practice Regarding Tobacco Cessation Among Indian Dentists.

PURPOSE: To assess the knowledge, attitude and practice regarding tobacco cessation among dentists in Hyderabad city, India. MATERIALS AND METHODS: A cross-sectional questionnaire study was conducted among 264 dentists registered in the local Indian Dental Association branch, Hyderabad, Andhra Pradesh, India. The questionnaire comprised of 35 items and used a five-point Likert scale to assess tobacco use prevention and cessation counseling. RESULTS: The majority of the study participants were females (55.7%) with a mean age of 29.9 ± 7.5 years. No significant gender difference was observed for any of the mean domain scores. A statistically significant difference was noted between age groups in the 'Knowledge' domain, 'professional role and identity' item (P = 0.03) vs the 'Practice' domain, 'social influences' item (P = 0.05) with 40+ years having a higher mean score (6.5 ± 1.5). In terms of the education, those possessing Bachelor's of Dental Science had a significantly higher mean score (10.8 ± 2.2) for the 'Attitude' question 'belief about consequences' (P = 0.05) than did those with a Master's degree. The reported barriers were insufficient reimbursement (48.1%), lack of tobacco-related self-help material/pamphlets for patients (46.5%) and lack of patient motivation to receive tobacco cessation counseling (43.6%). CONCLUSION: In the present study, although dentists possessed knowledge about tobacco cessation, it was not adequate. Dental professionals play an important role in educating patients regarding the oral health risks of tobacco use and motivating them to quit.

Markers of malnutrition after intestinal transplantation: the role of IGF-1 and calprotectin.

The objective of this study is to valuate two biomarkers that may guide nutritional assessment during follow up after intestinal transplantation. We performed a retrospective study on prospectively collected data of insulin-like growth factor-1 (IGF-1) and effluent calprotectin in patients undergoing intestinal transplantation. Optimal nutritional status (ONS) was defined by using the Malnutrition Universal Screening Tool (MUST). IGF-1 and calprotectin were correlated with ONS by Pearson correlation. Eighteen cadaveric intestinal transplants were performed over 1,650 days (median follow up 425 days, range 29-1,650 days). Mean IGF-1 and calprotectin were significantly associated with independent nutrition. Seven patients became malnourished on one or more occasions. During malnutrition the mean IGF-1 was 22 ± 14 ng/ml and calprotectin 1,597 ± 1,055 mcg/g. Mean weight during episodes of malnutrition changed from 64.77 ± 8.76 kg to 59.05 ± 8.5 kg (-8.9 ± 1.25%). Both IGF-1 and calprotectin negatively correlated with ONS (Pearson's r, -0.612, p = 0.014). Patients broadly aligned with three groups: nutritionally replete (normal IGF-1 and normal calprotectin), nutritionally equivocal (normal or low normal IGF-1 and high calprotectin), and malnourished (low IGF-1 and high calprotectin). Patients with low IGF-1 and high calprotectin may have a benign clinical presentation. However it is in their interests to have parenteral nutrition restarted pending further investigation.

Treating Dehiscence During Implant Placement and Loading on Angled Abutment in Maxillary Lateral Incisor Region: A Case Report.

The primary factor causing recession is the morphology and anatomy of the dentition. The facial bony plate overlying the root is usually very thin. The complete absence of bone over the facial root surface is referred to as dehiscence. Such buccal bone defects in case of implant dentistry threaten the survival of dental implant. Many surgical techniques are introduced to enhance alveolar bone volume for placing the dental implants. Guided bone regeneration (GBR) is one such established surgical technique for correcting buccal dehiscence defects, along with the use of various barrier membranes for the same. This case report describes an implant placement in the maxillary left lateral incisor region showing dehiscence on the labial cortical plate, along with bone graft and GTR membrane.