Costs and quality of life associated with acute upper gastrointestinal bleeding in the UK: cohort analysis of patients in a cluster randomised trial.

OBJECTIVES: Data on costs associated with acute upper gastrointestinal bleeding (AUGIB) are scarce. We provide estimates of UK healthcare costs, indirect costs and health-related quality of life (HRQoL) for patients presenting to hospital with AUGIB. SETTING: Six UK university hospitals with >20 AUGIB admissions per month, >400 adult beds, 24 h endoscopy, and on-site access to intensive care and surgery. PARTICIPANTS: 936 patients aged ≥18 years, admitted with AUGIB, and enrolled between August 2012 and March 2013 in the TRIGGER trial of AUGIB comparing restrictive versus liberal red blood cell (RBC) transfusion thresholds. PRIMARY AND SECONDARY OUTCOME MEASURES: Healthcare resource use during hospitalisation and postdischarge up to 28  days, unpaid informal care, time away from paid employment and HRQoL using the EuroQol EQ-5D at 28  days were measured prospectively. National unit costs were used to value resource use. Initial in-hospital treatment costs were upscaled to a UK level. RESULTS: Mean initial in-hospital costs were £2458 (SE=£216) per patient. Inpatient bed days, endoscopy and RBC transfusions were key cost drivers. Postdischarge healthcare costs were £391 (£44) per patient. One-third of patients received unpaid informal care and the quarter in paid employment required time away from work. Mean HRQoL for survivors was 0.74. Annual initial inhospital treatment cost for all AUGIB cases in the UK was estimated to be £155.5 million, with exploratory analyses of the incremental costs of treating hospitalised patients developing AUGIB generating figures of between £143 million and £168 million. CONCLUSIONS: AUGIB is a large burden for UK hospitals with inpatient stay, endoscopy and RBC transfusions as the main cost drivers. It is anticipated that this work will enable quantification of the impact of cost reduction strategies in AUGIB and will inform economic analyses of novel or existing interventions for AUGIB. TRIAL REGISTRATION NUMBER: ISRCTN85757829 and NCT02105532.

Strengthening the argument for rapid brain MR imaging: estimation of reduction in lifetime attributable risk of developing fatal cancer in children with shunted hydrocephalus by instituting a rapid brain MR imaging protocol in lieu of Head CT.

BACKGROUND AND PURPOSE: Children with shunted hydrocephalus have been undergoing surveillance neuroimaging, generally in the form of head CT, for evaluation of ventricular size. As the life expectancy of these children has improved due to better shunt technology and medical care, risks related to the ionizing radiation incurred during multiple head CT examinations that they are expected to undergo throughout their lifetime have become a concern. The purpose of this study is to estimate the LAR of developing fatal cancer due to head CT for ventricular size assessment in children with shunted hydrocephalus and to assess the impact of instituting a rapid brain MR imaging protocol in reducing radiation exposure. MATERIALS AND METHODS: Retrospective review of medical records yielded 182 patients who underwent neuroimaging for assessment of ventricular size. Available neuroimaging studies (head CT and rapid brain MR) were counted and annual neuroimaging frequency was calculated. It was assumed that these patients undergo a similar number of neuroimaging studies annually through 20 years of age. A risk estimate was calculated based on the BEIR VII report and effective doses obtained using the International Commission on Radiologic Protection Report 103 organ weighting factors. RESULTS: The mean annual neuroimaging study frequency was 2.1. Based on the average age of 1.89 years, it was assumed neuroimaging surveillance commences in the second year of life. LAR was calculated assuming that a patient undergoes neuroimaging in the form of head CT at this frequency (2/year) through 20 years of age. Assuming 2 scans are performed per year and the low-dose head CT protocol is used, approximately 1 excess lifetime fatal cancer would be generated per 230 patients; with standard head CT, there would be 1 excess lifetime fatal cancer per 97 patients. CONCLUSIONS: Children with shunted hydrocephalus are at increased risk of developing fatal cancer if they are to undergo surveillance using head CT. Implementation of a rapid brain MR imaging protocol with no radiation detriment will reduce this risk.

The suction pseudopolyp technique: a novel method for the removal of small flat nonpolypoid lesions of the colon and rectum.

BACKGROUND AND STUDY AIMS: Small flat nonpolypoid lesions of the colorectum can be technically difficult to target and completely remove; techniques such as hot biopsy forceps electrocauterization are associated with serositis, delayed bleeding, and perforation. This study aimed to describe a novel technique for the removal of such lesions and demonstrate its safety and efficacy. PATIENTS AND METHODS: Patients aged 18 - 80 years with flat nonpolypoid lesions (Paris-Japanese classification 0-IIa and 0-IIb, measuring less than 10 mm) identified at colonoscopy were included in this prospective study. The lesions were removed by the suction pseudopolyp technique (SPT): the lesion is aspirated into the suction channel of the colonoscope and continuous suction applied for 5 seconds whilst the colonoscope is gently retracted. On release of the suction, the resulting pseudopolyp containing the lesion and a margin of normal tissue is easily ensnared and resected. The primary outcomes were endoscopic completeness of polyp resection and complication rate. RESULTS: Over a 12-month period, 1231 polyps were removed during 2656 colonoscopies; 126 polyps (in 101 patients) met inclusion criteria. Complete endoscopic resection was achieved in 100 % of the polyps, without immediate or delayed complication. Of the resected lesions, 57 % had malignant potential (adenomas 47 % and sessile serrated lesions 10 %); a higher proportion of lesions removed from the right colon had malignant potential compared with those from the left colon (75 % vs. 41 %, P = 0.0066). CONCLUSIONS: Diminutive flat lesions of the colorectum are predominantly adenomas and sessile serrated lesions. SPT is a safe, effective, and reproducible therapy for removal of these lesions.

A prospective randomized trial of cannulation technique in ERCP: effects on technical success and post-ERCP pancreatitis.

BACKGROUND AND STUDY AIMS: Inadvertent injection of contrast agent into the pancreatic duct is believed to be an important contributor to pancreatitis occurring after endoscopic retrograde cholangiopancreatography (post-ERCP pancreatitis, PEP). Our aim was to examine whether primary deep biliary cannulation with a guide wire is associated with a lower rate of PEP than conventional contrast-assisted cannulation. PATIENTS AND METHODS: From August 2003 to April 2006 all patients with an intact papilla who were referred for ERCP were eligible. Patients with pancreatic or ampullary cancer were excluded. Patients were randomized to undergo sphincterotomy biliary cannulation using either contrast injection or a guide wire. The ERCP fellow attempted initially for 5 minutes. If unsuccessful, the consultant attempted for 5 minutes using the same technique, followed by crossover to the other technique in the same sequence and then needle-knife sphincterotomy where appropriate. Patients were assessed clinically after the procedure, then followed up with telephone interviews after 24 hours and 30 days, and serum amylase and lipase tests after 24 hours. RESULTS: Out of 1654 patients undergoing ERCP, 413 were included in the study. PEP occurred in 29/413 (7.0 %): 16 in the guide-wire arm, 13 in the contrast arm ( P = 0.48). The overall cannulation success rate was 97.3 %. Cannulation was successful without crossover in 323/413 patients (78.2 %): 167/202 (81.4 %) in the guide-wire arm and 156/211 (73.9 %) in the contrast arm ( P = 0.03). Multivariate analysis demonstrated female sex (OR = 2.7, P = 0.04), suspected sphincter of Oddi dysfunction (OR = 5.5, P = 0.01), and complete filling of the pancreatic duct with contrast agent (OR = 3.5, P = 0.02) to be independently associated with PEP. The risk of PEP increased incrementally with each attempt at the papilla (OR 1.4 per attempt, P = 0.04) to greater than 10 % after four or more attempts. CONCLUSIONS: The guide-wire technique improves the primary success rate for biliary cannulation during ERCP but does not reduce the incidence of PEP compared to the conventional contrast technique. The incidence of PEP increases incrementally with each attempt at the papilla.

Digit ratio (2D:4D) and behavioral differences between inbred mouse strains.

Digit ratio (2D:4D) is a trait, which is sexually differentiated in a variety of species. In humans, males typically have shorter second digits (2Ds) (index fingers) compared to fourth digits (4Ds) (ring fingers) whereas females' fingers are more equal in length. Smaller, more masculine, digit ratios are thought to be associated with higher prenatal testosterone levels, greater sensitivity to prenatal androgens or both. Men with more masculine digit ratios have shown increased ability, achievement and speed in sports and tend to report that they are more physically aggressive. Previous research has shown the same sexually differentiated pattern in the hind paws of laboratory mice as in human hands, males have lower 2D:4D than females. We measured hind paw digit ratio in mice of eight inbred strains. These measurements were made while blind to strain, sex and whether the paw was from the left or right side. We found large differences in digit ratio between the strains and suggest that inbred mice are a promising system for investigating the correlation between digit ratio and behavioral traits.

A prospective comparison of two regimens of prophylactic antibiotics in abdominal trauma: cefoxitin versus triple drug.

To determine the best antibiotic regimen to employ in patients undergoing laparotomy for trauma, a randomized prospective study was designed comparing cefoxitin alone with a triple-drug regime of an aminoglycoside, ampicillin, and clindamycin. One hundred nineteen consecutive patients sustaining abdominal trauma (97 penetrating; 22 blunt) were divided by date of admission to a 24-hour course of antibiotics. The overall infection rate was 16.0%, with 14.5% of the cefoxitin-treated patients, and 18.0% of the triple-drug-treated patients developing an infectious complication. Excluding remote site infections, the abdominal wound and intraperitoneal infection rates were 13.0% for cefoxitin-treated patients, and 12.0% for triple-drug-treated patients. There was one instance of oliguric renal failure questionably related to an aminoglycoside. It is concluded that a 24-hour course of cefoxitin is a safe and effective prophylactic antibiotic regime in patients undergoing laparotomy for trauma.

Determinants of blood amino acid concentration after hemorrhage.

Many mechanisms, including alterations in muscle metabolism, cellular damage, decreased blood volume, and hepatic disfunction, are influential in producing the observed progressive rise in the concentration of amino acids in arterial and venous blood during persisting hypovolemic shock. The rapid rise of venous and arterial concentrations of amino acids and the increase in venoarterial concentration difference suggest that hypovolemia causes a net release from muscle of a potential substrate for energy metabolism. The blood flow through peripheral tissues, however, is reduced to such an extent during hypovolemic shock that the net rate of release of amino acids is not greater than preshock release and may be less. Therefore, the homeostatic advantages served by the alteration in protein metabolism during the more chronic stresses of starvation or after injury may not obtain during acute hypovolemia.