The safety of telemedicine clinics as an alternative to in-person preoperative assessment for elective laparoscopic cholecystectomy in patients with benign gallbladder disease: a retrospective cohort study.

BACKGROUND: The telemedicine clinic for follow up after minor surgical procedures in general surgery is now ubiquitously considered a standard of care. However, this method of consultation is not the mainstay for preoperative assessment and counselling of patients for common surgical procedures such as laparoscopic cholecystectomy. The aim of this study was to evaluate the safety of assessing and counselling patients in the telemedicine clinic without a physical encounter for laparoscopic cholecystectomy. METHODS: We conducted a retrospective analysis of patients who were booked for laparoscopic cholecystectomy for benign gallbladder disease via general surgery telemedicine clinics from March 2020 to November 2021. The primary outcome was the cancellation rate on the day of surgery. The secondary outcomes were complication and readmission rates, with Clavein-Dindo grade III or greater deemed clinically significant. We performed a subgroup analysis on the cases cancelled on the day of surgery in an attempt to identify key reasons for cancellation following virtual clinic assessment. RESULTS: We identified 206 cases booked for laparoscopic cholecystectomy from telemedicine clinics. 7% of patients had a cancellation on the day of surgery. Only one such cancellation was deemed avoidable as it may have been prevented by a face-to-face assessment. Severe postoperative adverse events (equal to or greater than Clavien-Dindo grade III) were observed in 1% of patients, and required re-intervention. 30-day readmission rate was 11%. CONCLUSIONS: Our series showed that it is safe and feasible to assess and counsel patients for laparoscopic cholecystectomy remotely with a minimal cancellation rate on the day of operation. Further work is needed to understand the effect of remote consultations on patient satisfaction, its environmental impact, and possible benefits to healthcare economics to support its routine use in general surgery.

Autologous blood transfusion reduces the requirement for perioperative allogenic blood transfusion in patients undergoing major hepatopancreatobiliary surgery: a retrospective cohort study.

INTRODUCTION: Major hepatopancreatobiliary surgery is associated with a risk of major blood loss. The authors aimed to assess whether autologous transfusion of blood salvaged intraoperatively reduces the requirement for postoperative allogenic transfusion in this patient cohort. MATERIALS AND METHODS: In this single centre study, information from a prospective database of 501 patients undergoing major hepatopancreatobiliary resection (2015-2022) was analysed. Patients who received cell salvage ( n =264) were compared with those who did not ( n =237). Nonautologous (allogenic) transfusion was assessed from the time of surgery to 5 days postsurgery, and blood loss tolerance was calculated using the Lemmens-Bernstein-Brodosky formula. Multivariate analysis was used to identify factors associated with allogenic blood transfusion avoidance. RESULTS: 32% of the lost blood volume was replaced through autologous transfusion in patients receiving cell salvage. Although the cell salvage group experienced significantly higher intraoperative blood loss compared with the noncell salvage group (1360 ml vs. 971 ml, P =0.0005), they received significantly less allogenic red blood cell units (1.5 vs. 0.92 units/patient, P =0.03). Correction of blood loss tolerance in patients who underwent cell salvage was independently associated with avoidance of allogenic transfusion (Odds ratio 0.05 (0.006-0.38) P =0.005). In a subgroup analysis, cell salvage use was associated with a significant reduction in 30-day mortality in patients undergoing major hepatectomy (6 vs. 1%, P =0.04). CONCLUSION: Cell salvage use was associated with a reduction in allogenic blood transfusion and a reduction in 30-day mortality in patients undergoing major hepatectomy. Prospective trials are warranted to understand whether the use of cell salvage should be routinely utilised for major hepatectomy.

Access to medicines through global health diplomacy.

The World Health Organisation (WHO) emphasizes that equitable access to safe and affordable medicines is vital to attaining the highest possible standard of health by all. Ensuring equitable access to medicines (ATM) is also a key narrative of the Sustainable Development Goals (SDGs), as SDG 3.8 specifies "access to safe, effective, quality and affordable essential medicines and vaccines for all" as a central component of universal health coverage (UHC). The SDG 3.b emphasizes the need to develop medicines to address persistent treatment gaps. However, around 2 billion people globally have no access to essential medicines, particularly in lower- and middle-income countries. The states' recognition of health as a human right obligates them to ensure access to timely, acceptable, affordable health care. While ATM is inherent in minimizing the treatment gaps, global health diplomacy (GHD) contributes to addressing these gaps and fulfilling the state's embracement of health as a human right.

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.

A Multicenter, Randomized, Double-Blinded, Clinical Trial Comparing Cattell-Warren and Blumgart Anastomoses Following Partial Pancreatoduodenectomy: PANasta Trial.

Whether a Blumgart anastomosis (BA) is superior to Cattell-Warren anastomosis (CWA) in terms of postoperative pancreatic fistula (POPF) following pancreatoduodenectomy. Importance: Complications driven by POPF following pancreatic cancer resection may hinder adjuvant therapy, shortening survival. BA may reduce complications compared to CWA, improving the use of adjuvant therapy and prolonging survival. Methods: A multicenter double-blind, controlled trial of patients undergoing resection for suspected pancreatic head cancer, randomized during surgery to a BA or CWA, stratified by pancreatic consistency and duct diameter. The primary end point was POPF, and secondary outcome measures were adjuvant therapy use, specified surgical complications, quality of life, and survival from the date of randomization. For a 10% POPF reduction, 416 patients were required, 208 per arm (two-sided α = 0·05; power = 80%). Results: Z-score at planned interim analysis was 0.474 so recruitment was held to 238 patients; 236 patients were analyzed (112 BA and 124 CWA). No significant differences in POPF were observed between BA and CWA, odds ratio (95% confidence interval [CI]) 1·04 (0.58-1.88), P = 0.887, nor in serious adverse events. Adjuvant therapy was delivered to 98 (62%) of 159 eligible patients with any malignancy; statistically unrelated to arm or postoperative complications. Twelve-month overall survival, hazard ratio (95% CI), did not differ between anastomoses; BA 0.787 (0.713-0.868) and CWA 0.854 (0.792-0.921), P = 0.266, nor for the 58 patients with complications, median (IQR), 0.83 (0.74-0.91) compared to 101 patients without complications 0.82 (0.76-0.89) (P = 0.977). Conclusions: PANasta represents the most robust analysis of BA versus CWA to date.

Oral health status and self- assessment of oral health risk factors among South Indian diabetic patients.

BACKGROUND: The disease profile of the world is changing at an astonishingly fast rate. It is essential that the impending nature of chronic disease is recognized and acted on urgently. India leads the world with the largest number of diabetics earning the dubious distinction of being termed the "diabetic capital" of the world. AIM: To assess and compare the oral health status and related oral health risk factors among diabetic patients in Hyderabad and Secunderabad. SETTINGS: A cross sectional study was carried out in various diagnostic centers among 801 patients aged 30 years and above. METHODS AND MATERIALS: Oral health status and self-assessed data on related oral risk factors were measured using modified World Health Organization (WHO) assessment form and oral health questionnaire for adults 2013. STATISTICAL ANALYSIS: Comparison of mean scores of the variables based on gender was assessed using ANOVA. Statistical significance was set at p < 0.05. RESULTS: Females had higher proportion of untreated caries (362; 85%) and DMFT (Decayed, Missing and Filled Teeth; 375; 88%) compared to males. On the basis of loss of attachment, the mean number of sextants with no loss of attachment was mostly noted among female subjects. CONCLUSION: In the present study, though gingivitis was seen in higher percentage (82%), the presence of periodontal disease was relatively low (68.3%). It can be concluded that diabetic subjects may have poor oral health.

Cell-free DNA TAPS provides multimodal information for early cancer detection.

Multimodal, genome-wide characterization of epigenetic and genetic information in circulating cell-free DNA (cfDNA) could enable more sensitive early cancer detection, but it is technologically challenging. Recently, we developed TET-assisted pyridine borane sequencing (TAPS), which is a mild, bisulfite-free method for base-resolution direct DNA methylation sequencing. Here, we optimized TAPS for cfDNA (cfTAPS) to provide high-quality and high-depth whole-genome cell-free methylomes. We applied cfTAPS to 85 cfDNA samples from patients with hepatocellular carcinoma (HCC) or pancreatic ductal adenocarcinoma (PDAC) and noncancer controls. From only 10 ng of cfDNA (1 to 3 ml of plasma), we generated the most comprehensive cfDNA methylome to date. We demonstrated that cfTAPS provides multimodal information about cfDNA characteristics, including DNA methylation, tissue of origin, and DNA fragmentation. Integrated analysis of these epigenetic and genetic features enables accurate identification of early HCC and PDAC.

Does lumbar spine fusion predispose patients to future total hip replacement?

OBJECTIVE: Hip-spine syndrome has been well studied since it was first described by Offierski and MacNab in 1983. Today, strong evidence links symptoms of hip and spine pathology to postsurgical outcomes. Recent studies have reported increased rates of hip dislocation in patients previously treated with total hip arthroplasty (THA) who had undergone lumbar fusion procedures. However, the effect of this link on native hip-joint degeneration remains an area of ongoing research. The purpose of this study was to characterize the relationship between use of lumbar fusion procedures and acceleration of hip pathology by analyzing the rate of future THA in patients with preexisting hip osteoarthritis. METHODS: This population-level, retrospective cohort study was conducted by using the PearlDiver research program. The initial patient cohort was defined by the presence of diagnosis codes for hip osteoarthritis. Patients were categorized according to use of lumbar fusion after diagnosis of hip pathology. Survival curves with respect to THA were generated by comparison of the no lumbar fusion cohort with the lumbar fusion cohort. To assess the impact of fusion construct length, the lumbar fusion cohort was then stratified according to the number of levels treated (1-2, 3-7, or ≥ 8 levels). Hazard ratios (HRs) were then calculated for the risk factors of number of levels treated, patient age, and sex. RESULTS: A total of 2,275,683 patients matched the authors' inclusion criteria. Log-rank analysis showed no significant difference in the rates of THA over time between the no lumbar fusion cohort (2,239,946 patients) and lumbar fusion cohort (35,737 patients; p = 0.40). When patients were stratified according to number of levels treated, again no differences in the incidence rates of THA over the study period were determined (p = 0.30). Patients aged 70-74 years (HR 0.871, p < 0.001), 75-79 years (HR 0.733, p < 0.001), 80-84 years (HR 0.557, p < 0.001), and ≥ 85 years (HR = 0.275, p < 0.001) were less likely to undergo THA relative to the reference group (patients aged 65-69 years). CONCLUSIONS: Although lumbar fusion was initially hypothesized to have a significant effect on rate of THA, lumbar fusion was not associated with increased need for future THA in patients with preexisting hip osteoarthritis. Additionally, there was no relationship between fusion construct length and rate of THA. Although lumbar fusion reportedly increases the risk of hip dislocation in patients with prior THA, these data suggest that lumbar fusion may not clinically accelerate native hip degeneration.

Activated Regulatory T-Cells, Dysfunctional and Senescent T-Cells Hinder the Immunity in Pancreatic Cancer.

Pancreatic cancer has one of the worst prognoses of any human malignancy and leukocyte infiltration is a major prognostic marker of the disease. As current immunotherapies confer negligible survival benefits, there is a need to better characterise leukocytes in pancreatic cancer to identify better therapeutic strategies. In this study, we analysed 32 human pancreatic cancer patients from two independent cohorts. A multi-parameter mass-cytometry analysis was performed on 32,000 T-cells from eight patients. Single-cell RNA sequencing dataset analysis was performed on a cohort of 24 patients. Multiplex immunohistochemistry imaging and spatial analysis were performed to map immune infiltration into the tumour microenvironment. Regulatory T-cell populations demonstrated highly immunosuppressive states with high TIGIT, ICOS and CD39 expression. CD8+ T-cells were found to be either in senescence or an exhausted state. The exhausted CD8 T-cells had low PD-1 expression but high TIGIT and CD39 expression. These findings were corroborated in an independent pancreatic cancer single-cell RNA dataset. These data suggest that T-cells are major players in the suppressive microenvironment of pancreatic cancer. Our work identifies multiple novel therapeutic targets that should form the basis for rational design of a new generation of clinical trials in pancreatic ductal adenocarcinoma.

Human intestinal tissue-resident memory T cells comprise transcriptionally and functionally distinct subsets.

Tissue-resident memory T (TRM) cells provide key adaptive immune responses in infection, cancer, and autoimmunity. However, transcriptional heterogeneity of human intestinal TRM cells remains undefined. Here, we investigate transcriptional and functional heterogeneity of human TRM cells through study of donor-derived TRM cells from intestinal transplant recipients. Single-cell transcriptional profiling identifies two transcriptional states of CD8+ TRM cells, delineated by ITGAE and ITGB2 expression. We define a transcriptional signature discriminating these populations, including differential expression of cytotoxicity- and residency-associated genes. Flow cytometry of recipient-derived cells infiltrating the graft, and lymphocytes from healthy gut, confirm these CD8+ TRM phenotypes. CD8+ CD69+CD103+ TRM cells produce interleukin-2 (IL-2) and demonstrate greater polyfunctional cytokine production, whereas ß2-integrin+CD69+CD103- TRM cells have higher granzyme expression. Analysis of intestinal CD4+ T cells identifies several parallels, including a ß2-integrin+ population. Together, these results describe the transcriptional, phenotypic, and functional heterogeneity of human intestinal CD4+ and CD8+ TRM cells.

The Diagnostic Accuracy of Mutant KRAS Detection from Pancreatic Secretions for the Diagnosis of Pancreatic Cancer: A Meta-Analysis.

This meta-analysis aims to identify the diagnostic accuracy of mutations in the Kirsten Rat Sarcoma (KRAS) oncogene in the diagnosis of pancreatic ductal adenocarcinoma (PDAC). The survival of PDAC remains poor often due to the fact that disease is advanced at diagnosis. We analysed 22 studies, with a total of 2156 patients, to identify if the detection of KRAS mutations from pancreatic exocrine secretions yields sufficient specificity and sensitivity to detect patients with PDAC amongst healthy individuals. The majority of the studies were retrospective, samples were obtained endoscopically or surgically, and included comparator populations of patients with chronic pancreatitis and pre-malignant pancreatic lesions (PanIN) as well as healthy controls. We performed several analyses to identify the diagnostic accuracy for PDAC among these patient populations. Our results highlighted that the diagnostic accuracy of KRAS mutation for PDAC was of variable sensitivity and specificity when compared with PanINs and chronic pancreatitis, but had a higher specificity among healthy individuals. The sensitivity of this test must be improved to prevent missing early PDAC or PanINs. This could be achieved with rigorous prospective cohort studies, in which high-risk patients with normal cross-sectional imaging undergo surveillance following KRAS mutation testing.

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.

Chronic Opioid Use Is Associated With Surgical Site Infection After Lumbar Fusion.

STUDY DESIGN: Retrospective, database review. OBJECTIVE: The purpose of this study was to explore the association between preoperative opioid use and postoperative infection requiring operative wound washout in elective lumbar fusion patients. SUMMARY OF BACKGROUND DATA: Numerous peer-reviewed publications have conducted multivariate analyses of risk factors for surgical site infection. However, few have explored preoperative opioid use. Opioids have been widely prescribed preoperatively for pain management, but their effect on postsurgical infection is currently inconclusive. METHODS: We retrospectively queried the PearlDiver national insurance claims database and included patients from 2007 to 2017 with a history of lumbar fusion. Any interbody fusion history designated exclusion. We stratified patients by single or multilevel procedures and conducted univariate analyses of previously documented infection risk factors, as well as our variable of interest, chronic preoperative opioid use. Variables associated (P < 0.100) with the outcome measure of 90-day postoperative infection treated with operative irrigation and wound debridement were included in a multivariate analysis. RESULTS: A total of 12,519 patients matched our inclusion criteria. Among the single-level cohort, only diabetes was observed to be associated with infection requiring operative wound washout and thus no subsequent regression was performed. For the cohort of patients who underwent multilevel fusion, chronic opioid use, diabetes, congestive heart failure, chronic obstructive pulmonary disease, and hypertension trended toward significance in the univariate analysis and were included in a logistic regression model. In the multivariate analysis, chronic opioid use (odds ratio [OR] = 1.435, P = 0.025), diabetes (OR = 1.591 P = 0.003), and congestive heart failure (OR = 1.929, P = 0.003) were identified as independent risk factors for infection requiring operative wound washout. CONCLUSION: In this analysis, preoperative opioid use was significantly associated with infection requiring operative wound washout in multilevel lumbar fusion patients. Limiting opioid consumption may have the benefit of reducing the risk of infection following spine surgery. LEVEL OF EVIDENCE: 3.

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.

The impact of intestinal transplantation on quality of life.

INTRODUCTION: Intestinal failure (IF) and intestinal transplant (ITx) are associated with poor quality of life (QoL). Disease-specific assessment of QoL for IF and ITx is challenging, owing to the different problems encountered. We have sought to compare QoL pre-ITx with post-ITx and have compared generic QoL with a stable IF population. METHODS: Two prospectively maintained databases of patients referred for and undergoing ITx and a chronic (Type 2 & 3) IF cohort were interrogated. QoL instruments used were generic (EQ-5D-5L and SF-36) and disease-specific (HPN-QOL and ITx-QOL). Analysis used Student's t-test and one-way ANOVA with Bonferroni correction for multiple comparisons. Data were collected pre- and post-ITx at 3, 6, 12-months and yearly thereafter. RESULTS: All QoL instruments improved following ITx to levels comparable with a cohort of stable IF patients not requiring ITx. Both the visual analogue score component (EQ-5D-5L) and the effect of underlying illness on QoL (HPN-QOL/ITx-QOL) were higher following ITx than either pre-ITx or when compared with the IF cohort. Effects on general health, ability to eat and drink, to holiday and travel were improved as early as 3 months post-ITx. Other components did not before 6-12 months following ITx, but were maintained to at least 24 months. Patient personal financial pressures are greater following ITx, even in a publicly funded healthcare system. CONCLUSION: ITx has beneficial effects on QoL compared to those assessed for or awaiting ITx. QoL following ITx is similar to patients with IF not requiring ITx. A QoL instrument that covers the journey of patients from IF through ITx would assist longitudinal analysis of the value and timing of ITx at an individual level.

Effect of motivation on oral hygiene and caries status among young adults in Hyderabad City.

BACKGROUND: Motivation is a theoretical construct used to explain behavior, it gives the reasons for people's action, desires, and needs, and it drives an individual to a certain action and determines human behavior. AIM: To determine the effect of motivation on oral hygiene and caries status among young adults in Hyderabad city. SETTINGS AND DESIGN: A cross-sectional study was carried out among 18-20-year-old engineering college students of Nagole Institute of Technology and Sciences. MATERIALS AND METHODS: Intrinsic motivation was evaluated using a self-reported 12-item dental intrinsic motivation scale (DIM-S). The oral examination included simplified oral hygiene index (OHI-S) and decayed, missing, filled teeth index (DMFT index). STATISTICAL ANALYSIS USED: : Mann-Whitney U-test and ANOVA test were used for comparison among the variables included in the study. Spearman's correlation was used to correlate DIM-S with oral parameters. RESULTS: A total of 393 students participated in the study with majority of them being male (61.8%). It was observed that 69% of the students were extrinsically motivated and only 31% of them were intrinsically motivated. However, intrinsically motivated females had a higher significant score for calculus index-simplified and OHI-S scores. All oral parameters showed a negative correlation, except decayed component and the overall DMFT. However, no statistical significance was noticed among the variables. CONCLUSION: The present study revealed that to motivate people successfully, one not only has to give them information but also has to pay attention to the individual reasons which restrict their behavior.

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.

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.