Same-day discharge for left atrial appendage occlusion procedure: A systematic review and meta-analysis.

INTRODUCTION: Most patients undergoing a left atrial appendage occlusion (LAAO) procedure are admitted for overnight observation. A same-day discharge strategy offers the opportunity to improve resource utilization without compromising patient safety. We compared the patient safety outcomes and post-discharge complications between same-day discharge versus hospital admission (HA) (>1 day) in patients undergoing LAAO procedure. METHODS: A systematic search of MEDLINE and Embase was conducted. Outcomes of interest included peri-procedural complications, re-admissions, discharge complications including major bleeding and vascular complications, ischemic stroke, all-cause mortality, and peri-device leak >5 mm. Mantel-Haenszel risk ratios (RRs) with 95% CIs were calculated. RESULTS: A total of seven observational studies met the inclusion criteria. There was no statistically significant difference between same-day discharge versus HA regarding readmission (RR: 0.61; 95% confidence interval [CI]: [0.29-1.31]; p = .21), ischemic stroke after discharge (RR: 1.16; 95% CI: [0.49-2.73]), peri-device leak >5 mm (RR: 1.27; 95% CI: [0.42-3.85], and all-cause mortality (RR: 0.60; 95% CI: [0.36-1.02]). The same-day discharge study group had significantly lower major bleeding or vascular complications (RR: 0.71; 95% CI: [0.54-0.94]). CONCLUSIONS: This meta-analysis of seven observational studies showed no significant difference in patient safety outcomes and post-discharge complications between same-day discharge versus HA. These findings provide a solid basis to perform a randomized control trial to eliminate any potential confounders.

Intrameningioma Metastases - A Wolf among the Sheep.

Systemic metastases to primary tumors involving the brain are uncommon. Tumor-to-tumor metastasis involving meningioma from carcinoma breast is very rare. Neuroimaging may suggest the diagnosis-these are neither sensitive nor specific. Thus, the only way to diagnose it is through tissue biopsy.

Comparing jurisdiction-specific pharmaco-economic evaluations using medical purchasing power parities.

OBJECTIVES: To demonstrate how medical purchasing power parities (mPPP) may harmonize economic evaluations from different jurisdictions and enable comparisons across jurisdictions. METHODS: We describe the use of mPPPs and illustrate this with an example of economic evaluations of nab-paclitaxel with gemcitabine (Nab-P + Gem) versus gemcitabine monotherapy in the setting of metastatic pancreatic cancer. Following a literature search, we extracted data from cost-effectiveness studies on these treatments performed in various countries. mPPPs from the Organization for Economic Co-operation and Development were used to convert reported costs in the jurisdiction of origins to US dollars for the most current year using two possible pathways: (1) reported costs first adjusted by mPPP then adjusted by exchange index; and (2) reported costs first adjusted by exchange index then adjusted by mPPP. RESULTS: Despite many of the pharmaco-economic evaluations sharing similar assumptions and inputs, even after mPPP conversion, residual heterogeneity was attributable to perspectives, discount rate, outcomes, and costs, among others; including in studies conducted in the same jurisdiction. CONCLUSION: Despite the methodological challenges and heterogeneity within and across jurisdictions, we demonstrated that mPPP offers a way to compare economic evaluations across jurisdictions.

An Unusual Posterior Mediastinal Mass - Ectopic Thyroid within the Oesophagus.

Presence of ectopic thyroid tissue in unusual locations is a rare phenomenon. Herein we present the case of a 55 year old lady, who on evaluation of dyspnoea was detected to have a mediastinal mass. Initial radiological evaluation showed the presence of a mass arising from the wall of the oesophagus which was presumed most likely to be leiomyosarcoma. She underwent surgical resection of the mass, but on histopathological examination, it turned out to be a nodular goiter which was lying within the smooth muscle layer of the oesophageal wall.

Different dimensions of religiousness/spirituality are associated with health behaviors in breast cancer survivors.

OBJECTIVE: Religiousness/spirituality (R/S) may influence cancer survivors' health through multiple pathways. We aimed to examine one potentially key pathway that has seldom been examined: relationships between survivors' R/S and their health behaviors. METHODS: The present study investigated links between four core dimensions of R/S (beliefs, behaviors, identity, and coping) and three health behaviors (fruit/vegetable consumption, physical activity, and maintenance of a healthy weight) in 172 breast cancer survivors. RESULTS: Both spiritual identity and use of religious coping were positively related to fruit and vegetable intake, while private prayer was marginally positively related. Both service attendance and religious identity (marginally) were related to engaging in less physical activity, while private prayer was positively related. Afterlife beliefs and private prayer were positively associated with BMI. CONCLUSIONS: R/S has complex but meaningful associations with health behaviors in breast cancer survivors. More research is needed to understand these relationships and to determine whether different dimensions of R/S may play useful roles in lifestyle change interventions.

Training the Trainers of Tomorrow Today - driving excellence in medical education.

Training the Trainers of Tomorrow Today (T4) is a new way to deliver "Training for Trainers". Responding to local dissatisfaction with existing arrangements, T4 builds on 3 essential requirements for a future shape of training: 1. Clinical Leadership and a Collaborative Approach 2. Cross-Specialty Design and Participation 3. Local Delivery and Governance Networks Design principles also included: 3 levels of training to reflect differing needs of clinical supervisors, educational supervisors and medical education leader, mapping to GMC requirements and the London Deanery's Professional Development Framework; alignment of service, educational theory and research; recognition of challenges in delivering and ensuring attendance in busy acute and mental health settings, and the development of a faculty network. The delivery plan took into account census of professional development uptake and GMC Trainee Surveys. Strong engagement and uptake from the 11 Trusts in NW London has been achieved, with powerful penetration into all specialties. Attendance has exceeded expectations. Against an initial 12 month target of 350 attendances, 693 were achieved in the first 8 months. Evaluation of content demonstrates modules are pitched appropriately to attendees needs, with positive feedback from trainers new to the role. Delivery style has attracted high ratings of satisfaction: 87% attendees rating delivery as "good\excellent". External evaluation of impact demonstrated improved training experiences through changes in supervision, the learning environment and understanding of learning styles. We have addressed sustainability of the programme by advertising and recruiting Local Faculty Development Trainers. Volunteer consultants and higher trainees are trained to deliver the programme on a cascade model, supported by the Specialty Tutors, individual coaching and educational bursaries. The Trainers are local champions for excellence in training, provide a communication between the programme and local providers, are a repository of expertise in their service, and trouble shoot local barriers to engagement.

Effect of simulated astigmatic refractive error on reading performance in the young.

PURPOSE: Few studies have specifically investigated the functional effects of uncorrected astigmatism on measures of reading fluency. This information is important to provide evidence for the development of clinical guidelines for the correction of astigmatism. METHODS: Participants included 30 visually normal, young adults (mean age, 21.7 ± 3.4 years). Distance and near visual acuity and reading fluency were assessed with optimal spectacle correction (baseline) and for two levels of astigmatism, 1.00 diopter cylinder (DC) and 2.00 DC, at two axes (90 and 180°) to induce both against-the-rule (ATR) and with-the-rule (WTR) astigmatism. Reading and eye movement fluency were assessed using standardized clinical measures including the test of Discrete Reading Rate (DRR), the Developmental Eye Movement test (DEM), and by recording eye movement patterns with the Visagraph (III) during reading for comprehension. RESULTS: Both distance and near acuity were significantly decreased compared with baseline for all the astigmatic lens conditions (p < 0.001). Reading speed with the DRR for N16 print size was significantly reduced for the 2.00 DC ATR condition (a reduction of 10%), whereas for smaller text sizes, reading speed was reduced by up to 24% for the 1.00 DC ATR and 2.00 DC condition in both axis directions (p < 0.05). For the DEM, subtest completion speeds were significantly impaired, with the 2.00 DC condition affecting both vertical and horizontal times and the 1.00 DC ATR condition affecting only horizontal times (p < 0.05). Visagraph reading eye movements were not significantly affected by the induced astigmatism. CONCLUSIONS: Induced astigmatism impaired performance on selected tests of reading fluency, with ATR astigmatism having significantly greater effects on performance than did WTR, even for relatively small amounts of astigmatic blur of 1.00 DC. These findings have implications for the minimal prescribing criteria for astigmatic refractive errors.

Tabletop scenarios for realism in bioterrorism and threat preparedness.

Five realistic tabletop scenarios were designed to facilitate threat preparedness training of Medical, Public Health, Nursing, Emergency Services, Mental Health, Allied Health, and Pharmacy personnel. Training scenarios were (1) student contaminates lettuce (Act) in a state university with Shigella sonnei (Agent), (2) dismissed athlete contaminates ice (Act) at the basketball tournament with Escherichia coli (Agent), (3) workers fail to report abandoned backpacks (Act) at a state fair that contain smallpox virus (Agent), (4) terrorists expose county residents (Act) to Pneumonic plague bacterium (Agent), and (5) infected birds expose field-trip participants (Act) to Avian influenza virus (Agent). Evaluation of the tabletops yielded positive ratings of educational outcomes in these domains: well-structured, organized, plausible, realistic, engaging, on-target, useful, and multidisciplinary. Attendees with previous blended-learning courses on bioterrorism and threat preparedness enhanced performance in the tabletop exercises. Evaluative data indicated a new level of competence and self-confidence about being part of a coordinated, local-level, interdisciplinary response.

Primary pigmented nodular adrenocortical disease.

Primary pigmented nodular adrenocortical disease (PPNAD) is a rare cause of ACTH-independent Cushing's syndrome and has characteristic gross and microscopic pathologic findings. We report a case of PPNAD in a 15-year-old boy, which was not associated with Carney's complex. Bilateral adrenalectomy is the treatment of choice.

Clinicopathological features and genotype distribution in patients with hepatitis C virus chronic liver disease.

BACKGROUND AND OBJECTIVE: Hepatitis C virus (HCV) genotype influences the severity of disease and response to therapy. This retrospective study examined the clinical and histological features and the genotype distribution in biopsied patients with HCV related chronic liver disease. METHODS: Of 105 biopsies from patients with HCV infection, 96 from patients with chronic liver disease were reviewed. The Ishak scoring system was used for histological analysis. RESULTS: Genotype 3 was most common accounting for 77.1%, and genotype 1 for 9.4% of cases. There was no significant association of transaminase levels, viral load or necro-inflammatory activity score with genotype. A severe degree of fibrosis was seen in 77.8% cases of genotype 1 and in 63.5% of genotype 3 (p=0.76). Variable degrees of steatosis were noted in 68.8% of cases. However, severe steatosis was noted only in genotype 3 (7 cases). Serum transaminase levels did not correlate with either histological activity (p=0.43) or degree of fibrosis (p=0.72). Severe fibrosis / cirrhosis was seen in 74.24% of patients above 40 years of age as compared to 33.3% of patients below 40 years (p=0.001). The frequency of Mallory hyaline was significantly different between genotypes 1 and 3 infection (P<0.001). CONCLUSIONS: This study confirms the preponderance of genotype 3 in Indian patients with HCV related chronic liver disease. Severe steatosis was seen only in genotype 3 and Mallory hyaline was very common in genotype 1. The small numbers of patients in non genotype 3 could be a reason for the apparent lack of histological differences between different HCV genotypes. Severe fibrosis seen in older age groups confirms that HCV infection is progressive and major acceleration of the disease process occurs after 40 years of age.

Cancer health disparities among Indian and Pakistani immigrants in the United States: a Surveillance, Epidemiology, and End Results-based study from 1988 to 2003.

BACKGROUND: Immigrants from India and Pakistan comprise about 1.5% of the total United States population. To the author' knowledge, this is the first study analyzing epidemiologic data on Indian and Pakistani patients with newly diagnosed cancer. METHODS: The Surveillance, Epidemiology, and End Results (SEER) database has reported cancer incidence from 1973 to 2003. Since 1988, the Indian and Pakistani population has been reported separately under race and ethnicity. Frequency and survival analyses with SEER data were performed, and descriptive parameters were calculated along with overall survival in common cancers. RESULTS: In total, 6889 cases were reported between 1988 and 2003, and those cases included 51% men and 49% women (P = .821). Among men, 30% of cases were prostate cancers, 10% of cases were lung cancers, and 9% of cases were colorectal cancers. Among women, 38% of cases were breast cancers, 15% of cases were genital cancers, and 7% of cases were colorectal cancers. When overall survival with common cancer was compared between immigrants and non-Hispanic whites in the United States, it was better among Indian and Pakistani immigrants. CONCLUSIONS: In a United States-based Indian and Pakistani population, prostate and breast cancers were the most common malignancies in men and women, respectively. This differed from the incidence in India and Pakistan, where oral cavity cancer in men and breast and cervical cancers in women were the most common. These immigrant cancer patients also had better survival. This change in demographics may be attributed to multiple factors, and the current data have implications on cancer screening and intervention.

Barriers to effective uptake of cancer screening among Black and minority ethnic groups.

AIM: To describe some of the factors that act as barriers to effective uptake of breast and cervical cancer screening services among black minority ethnic (BME) groups living in Brent and Harrow in the UK. DESIGN: A series of focus groups among African Caribbean, African, Gujarati, Pakistani, Greek and Arabic groups were held to discover their perceptions of cancer screening, the barriers to effective uptake and some strategies for intervention. SAMPLE: This consisted of 135 participants: 85 women and 50 men. RESULTS: Analysis of focus group data has revealed poor knowledge, underlying health and cultural beliefs, attitudes, language and unhelpful attitudes of health professionals to be important barriers. In terms of strategies for effective intervention, the most popular strategy for improving uptake of screening services was community-based cancer awareness education that is sensitive to religious and cultural needs. CONCLUSION: There is a need to provide community-based education to increase the uptake of screening services among BME groups. It is essential to plan concurrently to educate GPs and other health professionals in cultural beliefs and customs, language needs, racial awareness and communication skills.

Increasing mineral density after menopause in individual lumbar vertebrae as a marker for incident degenerative disease: a pilot study for the effects of body composition and diet.

OBJECTIVE: To investigate the potential utility of dual x-ray absorptiometry (DXA) in incidence studies of lumbar spinal spondyloarthropathy. METHODS: Fifty-eight women recruited after menopause to a study of spinal bone loss were measured every 2 years for over a decade. Five developed scan image evidence of patchy calcification and 10 developed statistically significant (p < 0.05) nonparallelism of their bone loss (or gain) in L2, L3, and L4. The number of years since menopause at which these abnormal calcification trends (ACT) occurred was made the outcome in Cox proportional hazard modeling. At baseline, diet was assessed twice using 3-day weighed intakes. Nutrients estimated included carbohydrate, fat, protein, fiber, calcium and other minerals, and 6 vitamins. Measurements at baseline of fat mass and other anthropometric variables were made. RESULTS: The best single explanatory variable for developing ACT was whole body fat mass. Dietary fat was also predictive (p = 0.05) and adding dietary vitamin D (obtained substantially from oily fish) as a second predictor improved the diet model further (to p = 0.006 for model). These 2 dietary variables remained significantly predictive when fat mass was adjusted for (p = 0.0003 for model). CONCLUSION: Serial DXA measurements of the lumbar spine have the potential to provide a new, low radiation-dose approach to early identification of localized abnormal spinal calcification in epidemiology and trials. Alongside body fat, dietary fat intake and its components may warrant further investigation as risk factors for incident degenerative disease of the spine.