Vitamins and Minerals for Blood Pressure Reduction in the General, Normotensive Population: A Systematic Review and Meta-Analysis of Six Supplements.

Hypertension is the leading preventable risk factor for cardiovascular disease and all-cause mortality worldwide. However, studies have shown increased risk of mortality from heart disease and stroke even within the normal blood pressure (BP) range, starting at BPs above 110-115/70-75 mm Hg. Nutraceuticals, such as vitamins and minerals, have been studied extensively for their efficacy in lowering BP and may be of benefit to the general, normotensive population in achieving optimal BP. Our study investigated the effects of six nutraceuticals (Vitamins: C, D, E; Minerals: Calcium, Magnesium, Potassium) on both systolic blood pressure (SBP) and diastolic blood pressure (DBP) in this population. We performed a systematic review and pairwise meta-analysis for all six supplements versus placebo. Calcium and magnesium achieved significant reductions in both SBP and DBP of -1.37/-1.63 mm Hg and -2.79/-1.56 mm Hg, respectively. Vitamin E and potassium only yielded significant reductions in SBP with values of -1.76 mm Hg and -2.10 mm Hg, respectively. Vitamins C and D were not found to significantly lower either SBP or DBP. Future studies should determine optimal dosage and treatment length for these supplements in the general, normotensive population.

Teaching the management of trauma patients through virtual reality.

INTRODUCTION: Virtual reality (VR) fully immersive interactive video teaching (VR FIIT) allows learners to develop through observing and interacting with complex realistic environments, developing technical and nontechnical skills. One such complex clinical environment is managing a trauma patient. Despite the significant developments in managing these patients, foundation doctors are frequently highly anxious due to their limited knowledge and experience. The aim of this project was twofold; to improve foundation doctor performance of managing trauma patients and to reduce their associated anxiety, through the use of VR teaching. METHODS: A total of 14 foundation doctors were divided into two groups. One group underwent departmental teaching. The second group underwent departmental teaching and VR FIIT. We assessed the doctors via two methods. First, time taken to complete tasks correctly in trauma simulations was compared. Second, the doctors completed a self-reported level-based assessment questionnaire regarding anxiety and stress around trauma calls. RESULTS: The VR FIIT intervention group were able to complete each task on average 118s faster than the standard group. The standard group missed essential tasks such as C-spine immobilisation. The VR FIIT group self-reported significantly lower levels of anxiety related to trauma calls. CONCLUSION: VR teaching improves foundation doctor performance at managing simulated major trauma patients and decreases foundation doctor anxiety towards management and exposure of these clinical situations.

Should the rectal defect be sutured following TEMS/TAMIS carried out for neoplastic rectal lesions? A meta-analysis.

INTRODUCTION: Management of the rectal defect following transanal endoscopic microsurgery (TEMS) or minimally invasive surgery (TAMIS) carried out for excision of neoplasm in the lower rectum is controversial. We aimed to extract evidence by carrying out a meta-analysis to compare the peri- and postoperative outcomes following rectal neoplasm excision carried out by TEMS and/or TAMIS, whereby the defect is either sutured or left open. METHODS: A literature search of Ovid MEDLINE and EMBASE was performed. Full-text comparative studies published until November 2019, in English and of adult patients, whereby TEMS or TAMIS was undertaken for rectal neoplasms were included. The main outcome measures were postoperative bleeding, infection, operative time and hospital stay. FINDINGS: Three studies (one randomised controlled trial and two comparative case series) yielded 555 cases (283 in the sutured group and 272 in the open group). The incidence of postoperative bleeding was higher and statistically significant (p = 0.006) where the rectal defect was left open following excision of the neoplasm (19/272, 6.99% vs 6/283, 2.12%). There was no statistical difference between the sutured and open groups regarding infection (p = 0.27; (10/283, 3.53% vs 5/272, 1.84%, respectively), operative time (p = 0.15) or length of stay (p = 0.67). CONCLUSION: Suturing the rectal defect following excision of rectal neoplasm by TEMS/TAMIS reduces the incidence of postoperative bleeding in comparison to leaving the defect open. However, suturing makes the procedure slightly longer but there was no statistical difference between both groups when postoperative infection and length of hospital stay were compared.

Percutaneous caecostomy for the management of closed loop large bowel obstruction: A delayed complication of severe gallstone pancreatitis.

Colonic complications following pancreatitis are unusual events ranging from 1% to 15%. In a patient with a hostile abdomen and multiple previous laparotomies, surgical management of a closed-loop large-bowel obstruction risks significant morbidity and mortality for the patient, necessitating other strategies for management. Caecostomy in the management of large bowel obstruction is an often forgotten weapon in the general surgeons' armoury.

Organ Preservation Using Contact Radiotherapy for Early Rectal Cancer: Outcomes of Patients Treated at a Single Centre in the UK.

AIMS: Contact radiotherapy for early rectal cancer uses 50 kV X-rays to treat rectal cancers under direct vision. We present data of a series of patients treated at a single centre with prospective follow-up and functional assessment. MATERIALS AND METHODS: All patients were treated at the Queen's Centre for Oncology, Hull, UK between September 2011 and October 2015. Patients received a biopsy, magnetic resonance imaging (MRI) of the liver/pelvis, computed tomography of the chest and endorectal ultrasound. Patients were deemed to be either unfit for radical surgery or refused it due to the need for a permanent stoma. Follow-up consisted of 3 monthly flexible sigmoidoscopy and MRI of the liver/pelvis and 12 monthly computed tomography of the chest. RESULTS: In total, 42 patients were treated with contact radiotherapy ± external beam chemo/radiotherapy without any primary surgical excision. The median age was 78 years (range 50-94 years). Local recurrence-free survival was 88%, disease-free survival was 86% and overall survival was 88% with a median follow-up of 24 months (range 5-54 months). The median time to recurrence was 12 months (range 4-14 months). The estimated 30 day surgical mortality for this cohort with radical surgery was 12%. Mortality from the contact radiotherapy procedure was 0%. Functional outcomes as investigated by the Low Anterior Resection Syndrome (LARS) score were good, with 65% having no LARS. CONCLUSIONS: Contact radiotherapy for early rectal cancer is a safe, well-tolerated outpatient procedure, allowing organ preservation, with excellent oncological and functional outcomes. For elderly co-morbid patients with suitable rectal cancers this should be considered as a standard of care.

Retention of laryngoscopy skills in medical students: a randomised, cross-over study of the Macintosh, A.P. Advance(™) , C-MAC(®) and Airtraq(®) laryngoscopes.

In addition to being effective and easy to learn how to use, the ideal laryngoscope should be associated with minimal reduction in skill performance during gaps in practice over time. We compared the time taken to intubate the trachea of a manikin by novice medical students immediately after training, and then after 1 month, with no intervening practice. We designed a two-period, four-group, randomised, cross-over trial to compare the Macintosh, Venner(™) A.P. Advance(™) with difficult airway blade, C-MAC(®) with D-Blade and Airtraq(®) with wireless video-viewer. A bougie was used to aid intubation with the Macintosh and the C-MAC. After training, there was no significant difference in median (IQR [range]) intubation time using the videolaryngoscopes compared with the Macintosh, which took 30 (26.5-35 [12-118])s. One month later, the intubation time was longer using the C-MAC (41 (29.5-52 [20-119])s; p = 0.002) and A.P. Advance (40 (28.5-57.5 [21-107])s; p = 0.0003)m compared with the Macintosh (27 (21-29 [16-90])s); there was no difference using the Airtraq (27 (20.5-32.5 [15-94])s; p = 0.258) compared with the Macintosh. While skill acquisition after a brief period of learning and practice was equal for each laryngoscope, performance levels differed after 1 month without practice. In particular, the consistency of performance using the C-MAC and A.P. Advance was worse compared with the Macintosh and the Airtraq. While the clinical significance of this is doubtful, we believe that reliable and consistent performance at laryngoscopy is desirable; for the devices that we tested, this requires regular practice.

The Effects of a Transition to Minimalist Shoe Running on Intrinsic Foot Muscle Size.

A proposed benefit of minimalist shoe running is an increase in intrinsic foot muscle strength. This study examined change in intrinsic foot muscle size in runners transitioning to Vibram FiveFingers™ minimalist shoes compared to a control group running in traditional running shoes. We compare pre-transition size between runners who developed bone marrow edema to those who did not. 37 runners were randomly assigned to the Vibram FiveFingers™ group (n=18) or control group (n=19). Runners' bone marrow edema and intrinsic foot muscle size were measured at baseline and after 10 weeks. Total running volume was maintained by all runners. A significant increase in abductor hallucis cross-sectional area of 10.6% occurred in the Vibram FiveFingers™ group compared to the control group (p=0.01). There was no significant change in any of the other muscles examined (p>0.05). 8 of the Vibram FiveFingers™ runners, and 1 control runner developed bone marrow edema. Those who developed bone marrow edema, primarily women, had significantly smaller size in all assessed muscles (p≤0.05). Size of intrinsic foot muscles appears to be important in safely transitioning to minimalist shoe running. Perhaps intrinsic foot muscle strengthening may benefit runners wanting to transition to minimalist shoes.

Total plasma proANP increases with atrial dilatation in horses.

Equine atrial natriuretic peptide (ANP) plasma concentrations are correlated with left atrial size. However, species-specific assays are lacking and the results from human assays are poorly reproducible. A new methodology called processing independent analysis (PIA) that measures the total proANP product in plasma has proven to be successful in human medicine, but has never been used in horses. The aims were to establish an equine proANP reference interval by measurement of the total proANP product using PIA and to examine the proANP concentrations in horses with atrial dilatation. Sample stability was studied by comparison of storage at -80°C and -20°C. Plasma samples were obtained from 23 healthy horses, 12 horses with moderate or severe valvular regurgitation without atrial dilatation and 42 horses with valvular regurgitation and atrial dilatation. The proANP concentration was significantly (P<0.001) higher in horses with atrial dilatation (761.4 (442.1-1859.1) pmol/l) than in healthy horses (491.6 (429.5-765.9) pmol/l; P<0.001) or horses with cardiac disease but without atrial dilatation (544.4 (457.0-677.6) pmol/l). A cut-off value (573.8 pmol/l) for detection of atrial dilatation was calculated. Sample storage at -80°C did not differ from sample storage at -20°C. The measurement of total proANP in plasma detects atrial dilatation in horses and may be useful for clinical evaluation in equine medicine.

Perineal hernia formation following extralevator abdominoperineal excision.

AIM: Extralevator abdominoperineal excision (ELAPE) has become increasingly used because of some evidence of improved oncological outcome. It is, however, thought to be associated with a higher incidence of perineal hernia formation, although the exact incidence is not known. The aim of this study was to identify the incidence of perineal hernia after ELAPE. METHOD: The case notes of patients over a 54-month period were reviewed. The perineal closure technique, perineal complications and management plan were recorded. RESULTS: During the study period, 56 patients underwent ELAPE, of whom 24 (44%) developed a perineal wound complication. Primary perineal closure was performed with (eight patients) and without (32 patients) insertion of a biological mesh or myocutaneous flap. Perineal hernia was the commonest complication (26%) and occurred in nine (45%) of 20 patients who had a laparoscopic ELAPE. CONCLUSION: Perineal hernia formation was the commonest perineal complication of ELAPE and occurred in nearly half of patients having a laparoscopic ELAPE.

Jet injection of a monoclonal antibody: A preliminary study.

Monoclonal antibodies (mAbs) represent a major group of biotherapeutics. The high concentration and volume of drug administered together with a shift to administration via the subcutaneous route have generated interest in alternative delivery technologies. The feasibility of using a novel, highly controllable jet injection technology to deliver a mAb is presented. The effect of delivery parameters on protein structure were evaluated and compared with delivery using a conventional needle and syringe. Injection of mAb into a rat model showed that jet injection using the device resulted in more rapid absorption and longer duration of exposure.

Outcomes of asymptomatic anastomotic leaks found on routine postoperative water-soluble enema following anterior resection for cancer.

BACKGROUND: The incidence and consequence of an anastomotic leak associated with low anterior resection for cancer mandates covering stoma in most cases. A water-soluble enema is often performed to assess anastomotic integrity prior to stoma reversal. The functional outcome following reversal in patients with occult radiologically detected leaks is poorly defined. The goal of the present study was to determine the functional outcome in patients with a radiologically detected anastomotic leak who subsequently underwent stoma reversal. METHODS: This case control study used patients with and without radiologically detected occult anastomotic leak having undergone reversal of covering stomata. The study group was matched with controls for age, gender, procedure, tumor stage, and adjuvant/neoadjuvant therapy. Validated fecal incontinence quality of life (FIQL), Cleveland Clinic Fecal Incontinence Score (CCFIS), and the Memorial Sloan-Kettering Cancer Center (MSKCC) Bowel Function Index (BFI) were used. Patient satisfaction, medication use, and ancillary procedures prior to closure were also recorded. RESULTS: Thirteen patients with radiologically detected occult anastomotic leaks and 13 matched controls were identified from a prospectively maintained database. The FIQL, CCFIS, and MSKCC BFI scores were significantly reduced in those with occult leaks. The mean number of radiological and surgical interventions was significantly greater in the patients with occult leaks. Antidiarrheal and bulking agent use, as well as patient satisfaction, were the same for both groups. Only one patient in the occult leak group would not undergo stoma reversal again. CONCLUSIONS: Reversal of a defunctioning ileostomy in the presence of an occult radiological leak can be associated with poorer functional outcomes, but patient satisfaction is undiminished.

Balloon dilatation of benign rectal anastomotic strictures -- a review.

BACKGROUND: The occurrence of anastomotic stricture at the level of the rectum gives rise to three broad therapeutic options, namely major pelvic and abdominal revisional surgery, faecal diversion (stoma), or local revision by transanal approaches (including endoscopic and fluoroscopic). This article updates the current evidence and focuses on the results of the balloon dilatation technique. METHODS: A Medline search was carried out using the search terms (dilatation OR dilatation) AND (stricture OR strictures OR stenosis OR stenotic) AND (rectum OR rectal). In an effort to lessen publication bias, articles included at least 10 patients who were consecutively referred for treatment. RESULTS/CONCLUSION: This review would suggest that probably relatively short strictures have been chosen for balloon dilatation and that the results have had a very low major morbidity (0.45%) and mortality (0%) rate.

Whole body vibration as an adjunct to static stretching.

This study was a randomized control trial. The purpose of this study was twofold: 1) to determine if stretching the hamstrings during whole-body-vibration (WBV) is more effective than static stretching alone; and 2) to monitor retention of flexibility changes. The main outcome measure was hamstring flexibility as measured in degrees using a passive knee extension test. Thirty-four recreationally active college-age subjects (23.4+/-1.7 yrs) completed this study (22 males, 12 females, avg. ht.=175.6+/-6.4 cm, avg. wt.=74.9+/-11.8 kg). Subjects were assigned to a control group (C), a static stretch group (SS), or a vibration + static stretch group (V). Subjects stretched 5 days/wk for 4-weeks and were followed for 3-weeks after cessation to monitor retention. Analysis showed a significant difference between treatment groups (p<0.0001), time (p<0.0001), gender (p=0.0002) and in treatment*time (p=0.0119), with 14%+/-3.86% (SEM) and 22%+/-3.86% (SEM) increases in flexibility after 4-weeks of stretching for the SS and V groups respectively. Three-week follow-up showed SS returning to baseline with V group still 6.4 degrees (11%+/-3.88% (SEM)) more flexible than at baseline. Stretching concurrently with vibration on a WBV platform appears to be a good adjunct to static stretching with the potential to enhance retention of flexibility gains.

Expression of cyclin D2 is an independent predictor of the development of hepatic metastasis in colorectal cancer.

INTRODUCTION: Cyclin D1 has been implicated in the progression of several cancers by virtue of its influence on progression of the G1/S phase of the cell cycle. However, little is known about the possible roles of cyclin D2 and D3 in colorectal cancers (CRCs). METHOD: We investigated the expression levels of cyclin D2 and D3 in 84 CRC specimens. Antigen expression was determined by immunohistochemical analysis of cyclin D1, D2, D3, p16INK4A and Ki67 on tissue microarrays constructed using core samples from tumour centres and margins. RESULTS: For the whole cohort, expression of cyclin D2 at the margin was associated with vascular invasion (P = 0.039), lymph node metastasis (P = 0.020) and liver metastasis (P < 0.001). In patients with stage I and II tumours (n = 84), elevated cyclin D2 and D3 were associated with vascular invasion (P = 0.014 and 0.028 respectively), liver metastasis (P = 0.001 and 0.007 respectively) and reduced disease specific survival (Cyclin D2, P < 0.022). No association was noted between the proliferative marker Ki-67 and the D-type cyclins. CONCLUSION: These findings suggest that cyclin D2 expression at the invasive margin of CRCs is associated with liver metastasis and may serve as a useful prognostic marker and indicator of the need for adjuvant therapy.

Exaggerated adrenarche in a cohort of Scottish children: clinical features and biochemistry.

OBJECTIVE: To investigate the reported association between exaggerated adrenarche (EA) and reduced foetal growth and to identify possible risk factors for future morbidity in Scottish children with clinical features of EA. DESIGN: Three-year prospective study. MEASUREMENTS: Auxology, blood pressure (BP), biochemical analysis of blood and urine, pelvic ultrasound in girls. RESULTS: Fifty-two patients were recruited of whom one girl had nonclassical congenital adrenal hyperplasia (17-OHP 17 nmol/l) and one had insufficient blood for analysis. The final cohort comprised 42 girls of mean (SD) age 7.7 (0.99) and eight boys of 8.8 (0.67) years. Mean (SD) birth weight was 3.27 (0.49) and 3.10 (0.76) kg in girls and boys respectively. Height/weight SDS were 1.13/1.69 in girls and 1.69/1.88 in boys. Mean systolic/diastolic BP was 107.8/60.4 (50th-75th centile) in girls and 115.5/63.9 (75th-91st centile) in boys. Uterine and ovarian development was prepubertal. Median serum dehydroepiandrosterone sulphate (DHEAS) was 2.1 and 4.1 mumol/l, androstenedione 3.1 and 3.8 nmol/l in girls and boys respectively, with DHEAS within the reference range/undetectable in 18/2 and androstenedione in 12/6 patients. Fasting insulin was 9.0 and 15.0 mU/l in girls and boys respectively, with concomitant low normal SHBG. Anti-Mullerian hormone (AMH) was 15.7 pmol/l in 27 girls, compared with 5.0 pmol/l in normal girls aged 5-8 years. CONCLUSIONS: Our Scottish EA cohort showed female predominance, no evidence of reduced foetal growth, a tendency to overweight with commensurate mild hyperinsulinaemia and modest elevation of serum androgens in some patients. We have found raised AMH levels in the girls, indicating advanced ovarian follicular development.

Audit of anticoagulation after embolectomy for acute ischaemia.

INTRODUCTION: Intravenous unfractionated heparin (UFH) is routinely used in patients after arterial embolectomy. Achieving and maintaining therapeutic levels requires a co-ordinated approach which may be difficult for busy junior doctors and laboratories. There is no current evidence regarding the use of subcutaneous low molecular weight heparin (LMWH) as an alternative. PATIENTS AND METHODS: The study retrospectively examined all patients who had undergone any form of embolectomy during 2006 and 2007 by review of their medical records, an electronic laboratory database, and the patients' drug charts. RESULTS: Overall, 45 patients were studied. A total of 389 activated partial thromboplastin time (APTT) tests were performed of which 146 (37.6%) were in the therapeutic range (50-90 s), 40.4% were < 50 s and 22.1% were > 90 s. Five patients (11.1%) had further surgical procedures. Significant bleeding occurred in two patients. CONCLUSIONS: The results indicate that many patients are not appropriately anticoagulated. Whilst a new UFH protocol is being developed by our hospital trust, the authors believe the use of LMWH could provide a more effective and user-friendly alternative to UFH.

Magnetic resonance imaging accuracy in assessing tumour down-staging following chemoradiation in rectal cancer.

OBJECTIVE: Magnetic resonance imaging (MRI) is increasingly accepted as the radiological modality of choice staging rectal cancer but is subject to error. Neoadjuvant therapy is increasingly used in rectal cancer and MRI is used to stage response and occasionally plan surgery. We aim to assess the staging accuracy of MRI following chemoradiotherapy in rectal cancer. METHOD: Retrospective analysis of 86 patients with MRI stage pre- and postlong-course chemoradiotherapy and comparison with pathological assessment. RESULTS: Fourty-nine patients (34 men, 15 women) with median age 68 years (60-74) were analysed. The median time from completion of CRT to MRI was 32 days (16-37). Chemoradiotherapy led to significant down-staging (P < 0.001). MRI-staging accuracy was 43% (21/49) with over- and under-staging in 43% (21/49) and 14% (7/49) respectively. T-stage accuracy was 45% (22/49) with over-staging in 33% (16/49) and under-staging in 22% (11/49). MRI stage correlated poorly with pathological assessment for International Union Against Cancer (kappa = 0.255) and T stages (kappa = 0.112). MRI nodal assessment was 71% (35/49) accurate, with 82% (9/11) sensitivity, 68% (26/38) specificity and positive predictive value (PPV) of 43% (9/21) and negative predictive value of 93% (26/28). There was a significant difference in node positivity between MRI and pathological staging (P = 0.005, Fisher's exact). Complete radiological response was observed in 4% (2/49). Complete pathological response was observed in 10% (5/49), which were staged 0(1), I(1), II(2) and III(1) postchemoradiotherapy by MRI. CONCLUSION: MRI staging following chemoradiation is poor. Over-staging occurs three times more commonly than under-staging. Over-staging is due to poor PPV of nodal assessment.

Whole body vibration does not potentiate the stretch reflex.

Whole body vibration (WBV) is theorized to enhance neural potentiation of the stretch reflex. The purpose of this study was to determine if WBV affects the quadriceps reflex from a patellar tendon tap. Subjects were 22 volunteers (age 23 +/- 2 yrs, ht 172.8 +/- 10.8 cm, body mass 68.6 +/- 12.3 kg). The stretch reflex was elicited from the dominant leg pre, post, and 30-min post WBV treatment. A matched control group repeated the procedure without WBV. WBV treatment consisted of 5, 1-min bouts at 26 Hz with a 1-min rest period between bouts while maintaining a standardized squatting position. Two-way ANOVAs were used to detect differences between groups over time for vastus medialis (VM) and vastus lateralis (VL) latency, EMG amplitude, electromechanical delay (EMD), and force output. No group x time interactions were detected for latency (VM; F ((2,40)) = 1.20, p = .313: VL; F ((2,40)) = 0.617, p = .544), EMG mean amplitude (VM; F ((2,40)) = 0.169, p = .845: VL; F ((2,40)) = 0.944, p = .398), EMD (VM; F ((2,40)) = 0.715, p = .495: VL; F ((2,40)) = 1.24, p = .301), or quadriceps force (F ((2,40)) = 1.11, p = .341) A single session WBV treatment does not affect the quadriceps stretch reflex in terms of timing or amplitude.