Medicalisation of vaping in the UK? E-cigarette users' perspectives on the merging of commercial and medical routes to vaping.

BACKGROUND: In the UK, most smokers choosing e-cigarettes to quit smoking will access vaping via commercial routes. In recent years, however, a shift towards medicalisation of vaping has become apparent, with public health guidance supporting e-cigarettes for smoking cessation and increased partnership working between healthcare professionals and the vaping industry. To achieve the UK's Smokefree 2030 target, the UK Government has set out measures to use e-cigarettes in National Health Service (NHS) settings and to move towards streamlining processes to make e-cigarettes available to a million smokers. This article aims to understand acceptability of different approaches by seeking perspectives of people with lived experience of e-cigarette use for smoking cessation. METHODS: Mixed methods data collected between March 2018 and March 2019 as part of a broader study of e-cigarette use trajectories (ECtra study). Data here relate to the views of partnership working and medicalisation of vaping extracted from 136 interviews/extended surveys of people who had used e-cigarettes to try to stop smoking. Qualitative data were thematically analysed. Participant ratings of interventions were presented descriptively, and differences in participant characteristics and ratings were reported. RESULTS: Three qualitative themes were identified: pro-partnership, anti-partnership and medicalisation dissonance. Medicalisation was discussed for its potential to reassure smokers about e-cigarette harms and its potential to reach smokers from disadvantaged backgrounds. Concerns were raised about cost-effectiveness, quality of support, conflicts of interest and limiting product choice. Most participants rated interventions involving partnership working as potentially helpful in switching from smoking to vaping. There were no statistically significant associations between age, gender and socioeconomic status, and helpfulness ratings. CONCLUSION: Both commercial and medical routes to vaping offer perceived benefits to vapers and may complement and reinforce each other to support smoking cessation.

Liver resection rate following downsizing chemotherapy with cetuximab in metastatic colorectal cancer: UK retrospective observational study.

AIMS: The high objective response rate to cetuximab along with chemotherapy in patients with colorectal liver metastases makes it an effective downsizing protocol to facilitate surgery in those with initially unresectable disease. Adoption of this strategy has been variable in the UK. A retrospective observational study was conducted in 7 UK specialist liver surgical centres to describe the liver resection rate following a downsizing protocol of cetuximab and chemotherapy and to evaluate the quality and efficiency of processes by which the treatment was provided. METHODS: Data were collected in 2012 by reviewing medical records of patients with colorectal metastases confined to the liver, defined as unresectable without downsizing therapy at first review by a specialist Multi Disciplinary Team (MDT). RESULTS: Sixty patients were included; 29 (48%) underwent liver resection following cetuximab and chemotherapy. Of the 29, 17 (59% or 28% of all patients) achieved R0 resection and 7 (24% or 12% of all patients) R1 resection. All treated patients were KRAS wild-type. CONCLUSION: In specialist liver surgical centres, where patients are evaluated for liver resection, optimal management by MDT using KRAS testing, cetuximab and chemotherapy results in a 28% R0 resection rate in patients with initially unresectable colorectal cancer liver metastases.

Endoscopic ultrasonography allowing expectant management of pancreatic haemangioma.

Pancreatic haemangiomas are rare benign tumours that can affect both adults and children. They have an unknown incidence and only 15 adult cases have been reported, all from histological examination. Patients present with vague symptoms relating to tumour mass or they are detected incidentally. Cross-sectional imaging is the mainstay of investigation and may reveal arterially enhancing cystic lesions but in the case presented here, it was non-diagnostic. The use of endoscopic ultrasonography confirmed the nature of the benign lesion, allowing a conservative approach as opposed to operative resection.

Hepatobiliary cystadenomas.

INTRODUCTION: Hepatobiliary cystadenomas are rare cystic tumours that can arise from any portion of the biliary tract but most commonly develop intrahepatically. They typically cause non-specific symptoms and are often detected incidentally. Cystadenomas can be mistaken for simple hepatic cysts on radiological imaging, which leads to inadequate treatment. Hepatobiliary cystadenomas have a malignant predisposition and a high recurrence rate. Complete excision including hepatic resection is therefore generally recommended. METHODS: Three cases of hepatobiliary cystadenoma were identified at one unit over a six-month period. Their clinical details and management are reported. RESULTS: Three female patients are described aged 25, 37 and 73 years. One patient presented because of recurrent infection, one presented because of pressure related symptoms and one lesion was identified incidentally. All patients were investigated by ultrasonography and computed tomography (CT), two additionally had magnetic resonance imaging (MRI) and one had a liver biopsy. The tumours were 4-16cm in size and all lesions were excised by non-anatomical, parenchyma sparing resections. Histology revealed mixed epithelium with underlying ovarian-like stroma. CONCLUSIONS: The management of hepatic cystadenomas as well as operative and pathological findings are discussed. Preoperative ultrasonography, CT and MRI is recommended, and early referral for specialist hepatobiliary review is advised. Operative resection is also recommended and complete excision was achieved in these cases. This strategy is supported by the current literature and recurrence has been shown to be unlikely.

Mucinous cystic tumour of the pancreas presenting with acute pancreatitis.

BACKGROUND: The optimal therapy for mucinous neoplasms of the pancreas is surgical resection because these tumours are either premalignant (cystadenoma) or malignant. CASE OUTLINE: A 44-year-old previously fit woman presented with sudden onset of epigastric pain. Clinical and laboratory findings were consistent with acute pancreatitis. Abdominal ultrasound scan demonstrated a mature 6-cm cyst in the tail of pancreas and no findings suggestive of cholelithiasis. These findings were confirmed by a CT scan, which also demonstrated splenic infarction and evidence of recent haemorrhage into the cyst. The patient's abdominal pain persisted after amylase levels returned to normal. RESULTS: Splenic infarction, a mature cyst in the tail of the pancreas, and peripancreatic inflammation consistent with recent pancreatitis were found at laparotomy. Enbloc distal pancreatectomy and splenectomy were performed. Histological examination of the cyst wall demonstrated a focus of mucinous cystadenoma. DISCUSSION: This case demonstrates that acute pancreatitis may be the first presentation of a cystic neoplasm.

Combined suicide and granulocyte-macrophage colony-stimulating factor gene therapy induces complete tumor regression and generates antitumor immunity.

The use of prodrug-activated ("suicide") gene therapy has been shown to be effective in inducing tumor regression when only a small proportion of tumor cells contains the suicide gene. These experiments were designed to test whether additional therapeutic benefit may be obtained by stimulating the immune response. Murine MC26 colon carcinoma cells, either untransduced or transduced with genes for herpes simplex virus-1 thymidine kinase (HSV1-TK) or human GM-CSF, were injected subcutaneously into syngeneic BALB/c mice in various combinations. Inoculation of equal numbers of untransduced and HSV1-TK-containing cells followed by ganciclovir (GCV) treatment resulted in almost complete tumor regression, but by 7 weeks, tumors had recurred in all mice. A similar initial regression was obtained using equal numbers of cells containing HSV1-TK and GM-CSF genes, but >80% of these mice remained tumor-free after 3 months. Groups of tumor-free mice that had received GM-CSF-containing cells were left for different periods of time and rechallenged with unmodified MC26 cells on the opposite flank. Of the mice rechallenged 14, 28, and 108 days later, 100%, 88%, and 57%, respectively, showed complete resistance to unmodified tumor cells. In mice that showed tumor regrowth, tumor volume was much less than in control mice. Adoptive transfer of spleen cells from resistant mice to naïve syngeneic mice resulted in partial resistance to challenge with unmodified tumor cells. Specific cytotoxicity against MC26 cells was only demonstrable in mice receiving GM-CSF- and HSV1-TK-containing tumor cells. These experiments show that the presence of cells secreting GM-CSF in HSV1-TK-containing, regressing tumor is able to induce complete or partial resistance to tumor rechallenge. This indicates the potential usefulness of GM-CSF in enhancing other antitumor therapies.

Choledocholithiasis and gallstone pancreatitis.

Gallstones are commonly found within the main bile duct (MBD) of patients undergoing cholecystectomy. Retained MBD stones are a common cause of obstructive symptoms and complications. Endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy (ES) is the recommended modality for both the detection of such stones and their extraction. Recent trials of ERCP in conjunction with laparoscopic cholecystectomy suggest that it should be reserved for use post-operatively. Gallstones within the MBD are the most common single cause of acute pancreatitis. Initial treatment is supportive, although new agents designed to suppress the systemic inflammatory response are under development and have proved beneficial in clinical trials. Severe cases should be treated with systemic antibiotics and early removal of the obstructing stones by ERCP and ES. Prophylactic cholecystectomy is recommended to prevent further attacks of gallstone pancreatitis.

Early reoperation after major vascular surgery: a four-year prospective analysis.

Between 1 January 1985 and 31 December 1988, 1176 major vascular operations were performed on 1040 patients by the Oxford Regional Vascular Service, of which 136 (12 per cent) were reoperations within 30 days of the initial procedure (110 patients). Sixty-seven (49 per cent) of the reoperations were attempted revascularizations, 43 (32 per cent) were amputations, and surgery for bleeding accounted for 18 (13 per cent). Of the first reoperations 71 (65 per cent) were successful, but among the remaining 39 patients, 17 underwent 26 further reoperations, 15 of which were reoperations for revascularization. The 30-day mortality rate for patients undergoing one reoperation was 13 per cent; this rose to 35 per cent if more than one reoperation was performed. Early reoperation after major vascular surgery is common and carries a high operative mortality. This should be borne in mind when obtaining the informed consent of the patient.