bluuebunny/crossref_metadata_2025 huggingface dataset:
210 Assessing the Quality of Guidelines for the Management of Gastro-Intestinal Stromal Tumour
Authors: Askari A , Ebrahim S , Al Habsha O , Zuberi S , Raja H , Jambulingam P , Rashid F
Published: August 2024

Introduction

Gastro Intestinal Stromal Tumours (GISTs) are tumours of the gastro-intestinal tract that arise from connective tissue and they have potential for malignancy. A number of guidelines exist in their management. The aim of this study is to assess the quality of these guidelines.

Method

A search of the literature was undertaken for appropriate guidelines pertaining to the diagnosis and management of GISTs. The AGREE II checklist was used to assess the current GIST guidelines.

Results

A total of nine guidelines were included in this study. The overall median score across all guidelines was 68% (lowest; 50%, highest 89%). Guidelines tended to score highly in Domain IV (Clarity of Presentation, median score 76%) as well as Domain VI (Editorial Independence, 67%) and Domain I (Scope and Purpose, 61%). However, lower scores were noted in the Domain V (Applicability, 39%), Domain III (Rigor of Development, 52%) and Domain II (Stakeholder Involvement, 56%). None of the guidelines scored a unanimous ‘Yes’ vote for clinical usage, and all needed some level of modifying.

Conclusions

Whilst some of the current guidelines for the management of GISTs is of a high quality, there is a need for improvement with regards to the quality of the methodology used to formulate the guidelines and how they can be implemented in daily clinical use.
872 Does Endoscopic Management Play a Role for Chronic Radiation Proctitis: A Systematic Review and a Meta-Analysis
Authors: Yan Naing C L , Gittens J , Fok M , Fowler H , Clifford R , Vimalachandran D
Published: August 2024

Background

Chronic radiation proctitis (CRP) as side effect of radiotherapy poses a challenge in clinical management, necessitating effective and standardized therapeutic approaches. This review addresses the dynamic progress of endoscopic interventions, specifically argon plasma coagulation (APC) and formalin application.

Aim

The primary objective is to evaluate the role of endoscopic therapy in CRP, emphasizing its potential to standardize treatment protocols. The study aims to assess the safety and efficacy of APC and formalin, comparing their clinical response rates, complications, and highlighting the need for standardized management strategies.

Methods

Conducting a systematic literature search from 2000 until March 2023 across databases, the review includes 81 papers, including 11 randomized control trials, 20 systematic reviews, 1 cohort study, and 49 case series. Methodological quality assessment was performed, and data on cohort size, therapy types, treatment sessions, clinical responses, and complications were extracted. Bias for studies was assessed and a meta-analysis, utilizing a random-effects model, was conducted.

Results

The meta-analysis of 81 papers reveals a robust 89% pooled response rate for both APC and formalin therapies, emphasising their efficacy in addressing CRP. While adverse effects were generally minimal, the review highlights variations in treatment protocols and definitions of adverse events across studies.

Conclusions

Endoscopic therapies, particularly APC and formalin, exhibit commendable clinical response rates in CRP management. However, the lack of standardized treatment protocols highlights the need for larger prospective studies. Clear guidelines, informed by defined outcomes and quality-of-life assessments, are imperative for enhancing patient outcomes and minimizing morbidity associated with CRP.
927 Can Active Shape Modelling Be Used to Distinguish Those at Risk of Femoral Fracture in Osteoporosis?
Authors: Elwes C
Published: August 2024

The prevention of fractures is the primary treatment goal for osteoporosis patients (Klibanski et al., 2001), therefore the early identification of individuals who are at high risk of hip fracture is crucial and could delay incidence of fracture and the often-crippling consequences that accompany it. The analysis of the shape of the proximal femur has been previously identified as a useful tool in the prediction of hip fracture.

The aim of this systematic review was to evaluate published literature which investigated the accuracy of the application of active shape modelling (ASM) on radiographs of the femur and hip joint in patients with osteoporosis in the prediction of hip fracture compared to controls.

This review compiles data from studies applying ASM on hip radiographs taken from patients with osteoporosis and control groups. Initial literature search produced 120 papers but due to exclusion criteria and where full text was not available, only two papers were included in the final analysis.

Both studies used a 29-point model for ASM of the femoral head. Statistical significance was found between fracture and control groups for femoral neck and trochanter in both studies when applying ASM. It was shown that combining BMD and ASM improved the accuracy of the correct identification of fracture group to 90% compared to Pshape (74%) and BMD (66%) alone. No statistical significance was found between fracture and control groups for physiological factors on bone structure.

It was concluded that incorporating ASM into analysis of hip radiographs in osteoporotic patients would aid in fracture prediction.
139 A Survey of the Estimated Cost of Surgical Consumable Items Amongst Trauma and Orthopaedic Surgeons
Authors: Divekar O , Pandya K , Kanegaonkar R
Published: August 2024

Aim

The current economic climate is placing greater strain on the NHS leading to scrutiny of high expenditure areas, including the use of consumable items. Studies indicate that clinician’s knowledge surrounding health economics is limited, we hence conducted this survey to assess cost-awareness of Trauma and Orthopaedic (T&O) departmental staff.

Method

A questionnaire was digitally distributed to T&O staff in the East Kent Hospitals Trust requiring respondents to include demographic data and make cost estimations for 10 T&0 consumables. The mean, median and interquartile range of the estimated prices was compared to the item's actual cost. An estimate was deemed 'correct' if it was within 20% of the actual cost of the item.

Results

7.1% of all estimates were ‘correct’. No correlation was seen between years of staff experience and the accuracy of estimates. The ‘Kenalog 1ml ampoule' had the highest accuracy of cost estimation (13%), while the ‘kirchner wires’ and ‘3.2 drill bit’ had the lowest accuracy. The cost of the ‘velcro wrist splint’ was the most overestimated (median estimate/actual cost = 1.57). The most underestimated item cost was the ‘tourniquet cuffs’ (median estimate/actual cost = 0.16).

Conclusions

There is a paucity of knowledge surrounding the cost of specialist T&O consumable items. Limitations included the sample size (98 respondents) and geographical area (East Kent Hospitals Trust). This study shows that there is need for further research and education surrounding this topic, with long term outcomes which may be beneficial both economically and environmentally.
277 AI vs. the Spinal Surgeons: A Comparative Analysis of the Management of 18 Common Controversial Spinal Scenarios
Authors: Mehmet S , McCarthy M , Elmarawany M N , James S , Grevitt M P , Jayasuriya R , Jones A , Bowey A , Chan D , Bayley E , Harding I , Tomlinson J , Andrews J , Srinivas S
Published: August 2024

Aim

Can Large Language Models (LLMs) provide the answers to common controversial spinal surgery scenarios and answer the dilemmas that we can’t?

Method

54 highly detailed questions were developed on 18 scenarios, for example, ‘Management of Painless Foot Drop’. 9 Consultant Spinal Surgeons answered the questions on 2 separate occasions. The questions were submitted to 4 LLMs and the answers regenerated 5 times for each. Response reproducibility and consistency was compared, and a thematic analysis of the AI answers was undertaken.

Results

Bing Chat was excluded from the study. ChatGPT3.5 refused to give a definitive answer in 14% of its answers, ChatGPT4 in 29% and Bard in 11%. ChatGPT3.5 suggested the user seek medical advice in 60% of its answers, ChatGPT4 99% and Bard 45%. Surgeons stated they were confident in their answers in 96%. AI answers were deemed decisive: ChatGPT3.5 71%, ChatGPT4 24% and Bard 92%.

Reproducibility of Consultants answers averaged 63%, and 64% for AI overall. Agreement between the Consultants for each question averaged 66%, and 64% between AI.

Thematic analysis of the AI answers revealed themes including surgical and conservative management, individualised approach, risks and benefits, consideration of severity and duration of symptoms, and decision-making processes.

Conclusions

ChatGPT and Bard provide detailed answers to common controversial spinal surgery scenarios, however, they are not as decisive as consultants, and agreed on fewer management plans. Many of these scenarios remained unanswered.
175 Beyond Human Capabilities: The Potential of AI in Robotic Urology
Authors: Shaker G
Published: August 2024

Introduction

The growing influence of artificial intelligence (AI) in medicine has extended to the field of robotic urology, holding the promise of enhancing diagnostic precision, patient safety, and overall efficiency in surgical procedures. This study aims to explore the current state of AI in robotic urology and its potential applications.

Method

A systematic review was conducted on AI utilization in robotic urology, encompassing relevant articles published from 2015 to 2022. Databases including PubMed, Scopus, and Web of Science were searched for studies focusing on AI's role in procedures like prostatectomy, nephrectomy, and cystectomy.

Results

The review revealed significant strides in integrating AI within robotic urology across three key domains:Image Guidance: AI enhances tumour identification and targeting during robot-assisted surgeries, minimizing errors and improving surgical outcomes.Surgical Planning: AI aids in creating 3D patient anatomical models, facilitating pre-surgery planning, and reducing operation time.Skill Assessment: AI algorithms provide real-time feedback on surgeons' techniques, contributing to improved training and consistent surgical outcomes.

Conclusions

This review highlights the substantial potential of AI in elevating the quality of robotic urological procedures. Its implementation may lead to more accurate diagnoses, streamlined surgeries, reduced complications, improved patient outcomes, and potential cost savings. Future research should concentrate on refining adaptable AI technologies that seamlessly integrate with existing robotic systems and provide real-time surgeon feedback. Nevertheless, comprehensive research, validation, and ethical considerations are essential before AI can be integrated into routine clinical practice.
726 Are Disposable Flexible Cystoscopies Beneficial for Patients and Financially Feasible?
Authors: Huq S , Godil F , Khan I , Waqas M , Ali M , Chaudry A , Shahid J , Fazili Z , Raheem R , Tassadaq T
Published: August 2024

Aim

This QIP aims to outline the reason why the introduction of disposable flexible cystoscopies is beneficial to patient care and financially beneficial for the trust. This equipment also allows a cheaper alternative to how the current management of acute urinary retention takes place.

Method

Retrospective data over a period of 6 months was taken collecting the indication of the use of the disposable cystoscopies. A total of 22 cases were identified.

Results

12 uses of the scope were for patients with haematuria who required evaluating the cause of haematuria. 8 uses were for difficult catheterizations which would have otherwise required a slot in the emergency theatre.1 was for stent removal and 1 was for insertion of a suprapubic catheter under vision. Patients requiring emergency catheterization had intervention much earlier due to the easy access to disposable scopes at the bedside. Each disposable scope costs 136 pounds. The alternative of taking the patient to theatre for catheterization would have cost the trust 1200 pounds on average.

Conclusions

The introduction of disposable flexible cystoscopies has provided safe patient care, improved quality of care, eliminated reprocessing costs and diagnosed the cause of haematuria and is financially beneficial to the trust.
1121 High Grade Bladder Cancer in A 28-Year-Old Male: The Burden Of Recurrence
Authors: Adefehinti M
Published: August 2024

Bladder cancer is the seventh commonest cancer worldwide to affect men. The known risk factors for bladder cancer are smoking, occupational exposure to chemicals, male sex.

We report a case of non-muscle invasive bladder cancer in a 28–year–old male smoker who works as a hotel manager. No exposure to occupational dyes and other risk factors. Bladder cancer can occur at any age, however data on bladder cancer in the young like in this patient is uncommon in the literature.

He presented with painless gross hematuria and had a flexible cystoscopy done which revealed a 2-3cm papillary growth just lateral to the right ureteric orifice with a narrow stalk and ultrasound of the urinary tract showed no abnormal finding. Urgent transurethral resection of the tumour was done. The tumor was completely resected, and biopsy confirmed a high grade non muscle invasive G3pTa transitional cell carcinoma. Computed tomography scan of the chest showed no evidence of metastasis. MRI of the bladder confirmed tumor grading to be T2aN0M0.The patient had intravesical mitomycin post operatively. Repeat flexible cystoscopy showed a suspicious recurrence and he underwent a rigid cystoscopy and biopsy which confirmed a low grade G2pTa transitional cell carcinoma recurrence.

Currently, he is being considered for regular surveillance cystoscopies versus intravesical Bacillus Calmette-Guerin therapy. There are slightly conflicting recommendations from NICE and EAU.

The goal of this paper is to recount our experience and review the literature on the management of recurrent high grade, non-muscle invasive bladder cancer.
1173 A Case of Unilateral Renal Agenesis and Blind Ureter and Ectopic Ureterocoele Causing Hematuria
Authors: Patil S , Kumar A , Shetty S
Published: August 2024

Introduction

Urogenital anomalies involving kidneys are common entities discovered antenatally . However, we report a case in a male in 60s with complaints of Hematuria.

Case Report

A 68-year-old male was referred to Urology team for evaluation of visible hematuria . Focused history did not reveal any risk factors for associated symptoms. He underwent imaging study in the form of CT scan which evaluated Right renal agenesis with blind ending ureter with Ectopic Ureterocoele. Cystoscopy was performed which confirmed Ureterocoele without any sinister pathology in bladder. Patient’s symptoms were managed conservatively with regular follow up.

Discussion

It is rare to have undiagnosed Urological congenital anomalies due to antenatal check-up. Solitary Renal agenesis is common in males with more inclination towards left side. Presence of Blind ending ureter with Ureterocoele is an uncommon variant . As a clinician it is important to be aware of such rare instances while managing patients with red flag symptoms . Published Literature does not put light on possible management of symptoms such abdominal pain , urinary symptoms ; However, we discussed option of excision of Ureter along with ureterocele possibly responsible for hematuria. Patient underwent routine follow up with routine examinations and imaging A decision was taken to manage things conservatively in view of symptoms being controlled.

Conclusions

It is important to be aware of such presentations with possible options of surgical interventions.
128 Frozen Elephant Trunk: An Overview of Hybrid Prostheses
Authors: Hammad A , Hussain M , Abubacker I , Bashir M
Published: August 2024

Background

Thoracic aortic pathologies are usually managed with different surgical and hybrid procedures, with total aortic arch replacement (TAR) being the main treatment for the disease implicating the aortic arch and the descending thoracic aorta (DTA). This can be performed in a single-procedure hybrid fashion using the frozen elephant trunk technique which utilises a hybrid aortic prosthesis (HP). This narrative review aims to provide an overview of the four major FET HPs, highlighting their design features, mechanical properties, configurations, and variants, and evaluating their clinical outcomes in the literature.

Methods

A comprehensive literature search was conducted using multiple electronic databases to identify and extract relevant data and information.

Results

Four FET devices were identified that can be considered the main option on the global market; Thoraflex Hybrid Plexus (THP), E-Vita, Cronus and Frozenix J Graft. Each hybrid prosthesis (HP) features unique design and features resulting in varying clinical outcomes. THP and E-Vita are the most widely used and investigated HPs, however, THP’s innovative design has translated to superior clinical outcomes. The use of Cronus and Frozenix is geographically confined to mainly manufacturers’ countries and therefore have not been thoroughly studied.

Conclusion

The FET technique for TAR can be considered an evolutionary step in the field of aortovascular surgery, allowing optimal treatment for complex aortic arch pathologies with favourable clinical outcomes. However, of the four main FET HPs on the global market, THP can be considered the primary choice due to its unique innovative design which has translated to superior clinical outcomes.
414 A Real-World Diagnostic Algorithm for Identifying Carotid Artery Stenosis
Authors: Khosravi S , Elkorety M , Naseer A , Sarin S , Rosenfeld K
Published: August 2024

Aim

Eighty-five percent of ischaemic strokes are caused by extracranial atheromatous lesions involving a narrowing of the Internal Carotid Artery so accurate and timely diagnosis is vital for management. The aim of this study was to correlate CT angiogram (CTA) and ultrasound doppler (US) derived measurements of carotid artery stenosis (CAS), with a view to identify those cases where second modality is required to reduce potential errors.

Method

All consecutive carotid US and CTA examinations performed in 2021 and 2022 were included for comparison in this retrospective cohort study. Collected data was then reviewed and evaluated by a multidisciplinary team. North American Symptomatic Carotid Endarterectomy Trial (NASCET) and St Mary’s criteria were used to narrow down the percentage stenosis.

Results

There were fifty-one patients (102 carotid arteries) over this period who had both studies performed. Twenty-nine males and twenty-three females with a median age of seventy-three. Initial data analysis showed no discrepancy in ninety-one (90%) carotid arteries between both modalities. After MDT review, there were eight (7.1%) false positive results and three (2.9%) true positive (2 symptomatic & 1 asymptomatic). In three (2.9%) cases quantification was significantly inaccurate in the initial imaging modality because of heavily calcified vessels.

Conclusions

This study supports the use of US or CTA as a single modality in grading CAS. Heavily calcified vessels on the first test should be a ‘red flag’ for triggering further alternative imaging to reduce the risk of error. Persistent discrepancies even after the second modality will require a further modality e.g., enhanced magnetic resonance angiography.
784 Safety and Efficiency of Trainee-Led Radiofrequency Ablation of Varicose Veins: A Single-Centre Retrospective Analysis
Authors: Haidar O , Jaques A , Guest M , Metcalfe M , Sadat U , Selvakumar S , Shaikh F
Published: August 2024

Aim

Day-case procedures such as Radiofrequency Ablation (RFA) of varicose veins provide excellent opportunities for surgical trainees to improve skills and develop core competencies in Vascular Surgery. We aim to evaluate the comparative safety and efficiency of trainee led RFA procedures for symptomatic varicose veins. Findings are used to plan service provision and facilitate training opportunities for Vascular Registrars to meet Intercollegiate Surgical Curriculum Programme requirements for the management of superficial venous disease.

Method

Between July 2022and October 2023, Retrospective analysis of postoperative outcomes following 120 RFA procedures performed in a UK District General Hospital between July 2022 and October 2023. We assessed operative notes, postoperative outcomes, and re-attendances to Accident & Emergency.

Results

90/120 (75%) were led by Consultant Vascular Surgeons and 30/120 (25) by Vascular Trainees with Consultant supervision. We found no significant difference in length of admission (7.35 ± 5.56 vs 6.56 ± 4.61, p=0.93), post operative VTE or Emergency Department attendance within 30 days of operation (3 vs 6, p=0.17) between the two groups. Findings were consistent when controlling for age, sex, ASA grade, anaesthetic type (local or general anaesthetic) or disease severity, as per Clinical, Etiology, Anatomy & Pathophysiology (CEAP) scoring.

Conclusions

Our analysis found that Vascular Trainee-led Radiofrequency Ablations showed non-inferiority to consultant-led procedures with no significant difference in length of admission, postoperative VTE or ED attendance within 30-days. Moving forward vascular departments should promote trainee-led operating lists as a means to maximise training opportunities with the reassurance of no detrimental impact on patient safety or experience.
1027 Smoking Is Associated with Reduced Long-Term Survival Following Fenestrated Endovascular Aneurysm Repair, Whereas Taking Angiotensin-Converting Enzyme Inhibitors or Angiotensin Receptor Blockers Pre-Operatively Can Improve Long-Term Outcomes
Authors: Suszko K , Premnath S , Paice B , Pintar D , Bungay P , Rowlands T , Kuhan G
Published: August 2024

Introduction

Fenestrated Endovascular Aneurysm Repair (FEVAR) allows for minimally invasive and tailored treatment of Juxta-renal Aortic Aneurysms while avoiding the anaesthetic physiological burden compared to open repair.

Aim

To study patient factors that affect long-term outcomes following FEVAR for Juxta-renal Abdominal Aortic Aneurysm.

Method

Data was collected of all patients that have undergone FEVAR at a single centre between 2011–2022 . Patient demographics, past medical history, drug history, smoking status and long-term outcomes were recorded and analysed from digital records. Kaplan-Meier survival analysis was performed to determine long term overall survival, reintervention free survival and major adverse cardiovascular event (MACE) free survival. Predictors were determined using the log-rank test and Cox regression analysis.

Results

119 patients were recorded with a mean age of 74 years. 110 (92%) were male and 33 (27.7%) were current smokers. Seventy-four (62.2%) patients had a past medical history of hypertension and 54 (45.4%) patients were taking Angiotensin-Converting Enzyme inhibitors (ACEi) or Angiotensin receptor blockers (ARB) pre-operatively. The mean overall survival, reintervention-free survival and MACE-free survival were 83.4, 67.1 and 76.6 months respectively.

On log-rank test and Cox regression analysis, current smoking was significantly associated with poorer overall long-term survival (p value – 0.017). Patients on preoperative ACEi/ARBs were found to have significantly better MACE free survival (p value– 0.048).

Conclusions

Smoking is associated with reduced long-term survival following Fenestrated Endovascular Aneurysm Repair, whereas taking Angiotensin-Converting Enzyme Inhibitors or Angiotensin Receptor Blockers pre-operatively can improve long-term outcomes.
Epidemiology of cardiogenic shock using the Shock Academic Research Consortium (SHARC) consensus definitions
Authors: Berg David D , Bohula Erin A , Patel Siddharth M , Alfonso Carlos E , Alviar Carlos L , Baird-Zars Vivian M , Barnett Christopher F , Barsness Gregory W , Bennett Courtney E , Chaudhry Sunit-Preet , Fordyce Christopher B , Ghafghazi Shahab , Gidwani Umesh K , Goldfarb Michael J , Katz Jason N , Menon Venu , Miller P Elliott , Newby L Kristin , Papolos Alexander I , Park Jeong-Gun , Pierce Matthew J , Proudfoot Alastair G , Sinha Shashank S , Sridharan Lakshmi , Thompson Andrea D , van Diepen Sean , Morrow David A
Published: August 2024

Aims

The Shock Academic Research Consortium (SHARC) recently proposed pragmatic consensus definitions to standardize classification of cardiogenic shock (CS) in registries and clinical trials. We aimed to describe contemporary CS epidemiology using the SHARC definitions in a cardiac intensive care unit (CICU) population.

Methods and results

The Critical Care Cardiology Trials Network (CCCTN) is a multinational research network of advanced CICUs coordinated by the TIMI Study Group (Boston, MA). Cardiogenic shock was defined as a cardiac disorder resulting in SBP < 90 mmHg for ≥30 min [or the need for vasopressors, inotropes, or mechanical circulatory support (MCS) to maintain SBP ≥ 90 mmHg] with evidence of hypoperfusion. Primary aetiologic categories included acute myocardial infarction-related CS (AMI-CS), heart failure-related CS (HF-CS), and non-myocardial (secondary) CS. Post-cardiotomy CS was not included. Heart failure-related CS was further subcategorized as de novo vs. acute-on-chronic HF-CS. Patients with both cardiogenic and non-cardiogenic components of shock were classified separately as mixed CS. Of 8974 patients meeting shock criteria (2017–23), 65% had isolated CS and 17% had mixed shock. Among patients with CS (n = 5869), 27% had AMI-CS (65% STEMI), 59% HF-CS (72% acute-on-chronic, 28% de novo), and 14% secondary CS. Patients with AMI-CS and de novo HF-CS were most likely to have had concomitant cardiac arrest (P < 0.001). Patients with AMI-CS and mixed CS were most likely to present in more severe shock stages (SCAI D or E; P < 0.001). Temporary MCS use was highest in AMI-CS (59%). In-hospital mortality was highest in mixed CS (48%), followed by AMI-CS (41%), similar in de novo HF-CS (31%) and secondary CS (31%), and lowest in acute-on-chronic HF-CS (25%; P < 0.001).

Conclusion

SHARC consensus definitions for CS classification can be pragmatically applied in contemporary registries and reveal discrete subpopulations of CS with distinct phenotypes and outcomes that may be relevant to clinical practice and future research.
A suitable and efficient optimization system for the culture of Chlamydia trachomatis in adult inclusion conjunctivitis
Authors: Wei Yuan , Xu Xizhan , Wang Leying , Chen Qiankun , Li Jinsong , Liu Xiafei , Wei Zhenyu , Pang Jinding , Peng Yan , Guo Xiaoyan , Cheng Zhen , Wang Zhiqun , Zhang Yang , Chen Kexin , Lu Xinxin , Liang Qingfeng
Published: August 2024

The prevalence of Chlamydia trachomatis infection in the genitourinary tract is increasing, with an annual rise of 9 million cases. Individuals afflicted with these infections are at a heightened risk of developing adult inclusive conjunctivitis (AIC), which is commonly recognized as the ocular manifestation of this sexually transmitted infection. Despite its significant clinical implications, the lack of distinctive symptoms and the overlap with other ocular conditions often lead to underdiagnosis or misdiagnosis of AIC associated with C. trachomatis infection. Here, we established six distinct C. trachomatis culture cell lines, specifically highlighting the MA104 N*V cell line that exhibited diminished expression of interferon regulatory factor 3 (IRF3) and signal transducer and activator of transcription 1 (STAT1), resulting in reduced interferons. Infected MA104 N*V cells displayed the highest count of intracytoplasmic inclusions detected through immunofluorescence staining, peaking at 48 h postinfection. Subsequently, MA104 N*V cells were employed for clinical screening in adult patients diagnosed with AIC. Among the evaluated cohort of 20 patients, quantitative PCR (qPCR) testing revealed positive results in seven individuals, indicating the presence of C. trachomatis infection. Furthermore, the MA104 N*V cell cultures derived from these infected patients demonstrated successful cultivation and replication of the pathogen, confirming its viability and infectivity. Molecular genotyping identified four distinct urogenital serovars, with serovar D being the most prevalent (4/7), followed by E (1/7), F (1/7), and Ia (1/7). This novel cellular model contributes to studies on C. trachomatis pathogenesis, molecular mechanisms, and host–pathogen interactions both in vitro and in vivo. It also aids in acquiring clinically relevant strains critical for advancing diagnostics, treatments, and vaccines against C. trachomatis.
Black soldier fly (Diptera: Stratiomyidae) larvae reduce cyathostomin (Nematoda: Strongylidae) eggs but develop poorly on horse manure
Authors: Mann Destiny N , Hobert Kasey T , Biddle Amy S , Crossley Michael S
Published: August 2024

Cyathostomins are common digestive tract parasites of grazing horses that spread through contact with horse feces. Horse feces are colonized by a variety of organisms, some of which could serve to reduce parasite loads in horse pastures. Black soldier fly (Hermetia illucens L.; Diptera: Stratiomyidae) larvae (BSFL) could be an ideal candidate for biological control of cyathostomins, due to their near-global distribution, low risk of pathogen transmission, ability to develop on a variety of nutrient-poor substrates (including horse manure), and dramatic effect on microbial communities that cyathostomins depend on. Here, using controlled feeding bioassays, we evaluated the effect of BSFL on cyathostomin egg densities in horse manure while also tracking BSFL performance on manure relative to standard grain-based diets. We found that BSFL consumed less substrate, were slower to reach the prepupal stage, and ultimately yielded less biomass when reared on horse manure compared to grain-based diets. However, BSFL reduced average cyathostomin egg densities in horse manure by over 3-fold. Overall, our results suggest that despite horse manure being a poor substrate for BSFL growth, BSFL effectively reduce cyathostomin egg loads in infected horse manure, though the mechanisms by which they do this are uncertain. While BSFL are known to transform the microbial communities within a diversity of rearing substrates, their effect on larger, parasitic organisms in animal manures may be underappreciated. Promoting the decomposition of infected horse manure with BSFL might be a promising approach to managing parasite populations among grazing horses.
Cyclical drought and herbivore threats are potential causes of leaf variegation dimorphism in Cypripedium forrestii
Authors: Lin Lie-Wen , Huang Hua , Liu Wei-Wei , Sun Wei-Bang
Published: August 2024

Leaf variegation, the mosaic of colors on the leaf surface, can be developed by certain plant species without external influence. Although it may be associated with a variety of functions, the stable existence of different leaf color morphs within a plant species has not been fully explained by previous studies. This study focuses on the two leaf morphs of Cypripedium forrestii, an endangered lady slipper orchid, and compares their micromorphological structure, photosynthetic potential, differentially expressed genes (DEGs), and ecological features to gain a comprehensive understanding of the underlying leaf variegation polymorphism. Our findings demonstrate that leaf variegation is not pathological and does not affect photosynthetic potential. Additionally, it significantly reduces herbivory damage. We found that the probability of herbivory and leaf area loss for variegated leaves was notably higher under drought conditions. Therefore, variegated individuals may be more adaptive under such conditions, while non-variegated ones may be more cost-effective in normal years. These results suggest that different leaf color morphs may be favored by varying environmental conditions, and leaf polymorphism may be a legacy of ancient climate and herbivore fluctuations.
The intra-abdominal zebra, paraduodenal hernias resulting in small bowel obstructions: a case series
Authors: Anklowitz Andrew , Livezey Jonathan , Hoppe Samuel W , Mangieri Christopher W , Faler Byron
Published: August 2024

Paraduodenal hernias are a rare but important clinical entity, as their presentation can be life-threatening if not properly diagnosed and managed appropriately. Additionally, this entity is defined by a unique and complex congenital anatomical abnormality which dictates a specific treatment algorithm. Here we present the cases of three patients from our clinical experience who all presented with either acute or chronic small bowel obstructions secondary to paraduodenal hernias. Two were left-sided paraduoenal hernias and one was right-sided. All three patients were successfully managed with surgical intervention. An appreciation of paraduodenal hernias, including the defining anatomy and methods of surgical management, is important for the general surgeon.
Placing two inferior vena cava filters for the bail-out management of opening failure of an inferior vena cava filter
Authors: Kawatani Yohei , Yoshiyama Azusa , Hori Takaki
Published: August 2024

A 93-year-old man with a femoral fracture was admitted to the emergency department. The patient presented with severe hypoxemia and shock. Enhanced computed tomography confirmed deep venous thrombosis in the left leg and pulmonary embolism. Subsequently, an inferior vena cava filter (IVCF) was implanted. Although the IVCF was completely unsheathed for deployment, it remained fully folded and did not open; it was not deployed or retrieved. A new IVCF was successfully placed in the same position. Acute treatment for the deep venous thrombosis and further pulmonary embolism was achieved.
Hepatic artery aneurysm post remote pancreaticoduodenectomy
Authors: Djalal Fakim , Landau John , Dubois Luc
Published: August 2024

We present a case of a 4.2-cm hepatic artery aneurysm following remote pancreaticoduodenectomy, which extended to the first division of the right hepatic artery. Given the absence of collateral flow from the superior mesenteric artery (SMA) and the inability to place a covered stent, we treated the patient with a saphenous vein graft to the right hepatic artery bifurcation. A CT scan at 1-year demonstrated a patent bypass to the right hepatic artery. We would advise caution when considering hepatic embolization following pancreaticoduodenectomy due to loss of SMA-based collaterals. Techniques that preserve arterial flow should be favored in this situation.
Pigmented basal cell carcinoma of the anus: a rare entity with diagnostic challenges
Authors: Fuentes-Calvo Kevin Joseph , Silva-Ramos Cielo Scarlet , Arechavala-López Sara Fernanda , Aguilar-Ruiz Fernando , Arias-Ruiz Luis Felipe , Trejo-Ávila Mario
Published: August 2024

Anal cancer is uncommon, comprising 2.2% of gastrointestinal cancers. Squamous cell carcinoma (SCC) is the most common; while perianal basal cell carcinoma (BCC) is rare, representing only 0.2% of anorectal malignancies. BCC, associated with sun exposure and immunosuppression, often resembles benign conditions and manifests as perianal ulcers or masses. Histologically, BCC exhibits basaloid tumor cells with distinct patterns. Despite its rarity, accurate diagnosis is crucial. We expose a case study of a 59-year-old male, previously healthy, that presented with hematochezia and perianal pain, leading to a diagnosis of lower gastrointestinal bleeding. Colonoscopy was needed, and a biopsy revealed an ulcerated, indurated lesion involving the left lateral hemorrhoidal bundle, diagnosed as pigmented basaloid carcinoma. Microscopic examination showed malignant nests of cells with peripheral nuclear palisading, melanocytes, and melanin pigment. Immunohistochemistry confirmed positivity for p63, CK5/6, and BCL2. Respect the treatment, due to the involvement of the anal sphincteric muscle, radiotherapy was chosen.
Abdominal endovascular aneurysm repair using an aorto-uni-iliac device resulting in resting lower extremity pain: a case report and discussion on patient selection
Authors: Ekblad John R , Hupp Colleen
Published: August 2024

Abdominal aortic aneurysms that meet criteria for repair are often managed with endovascular aneurysm repair using a bifurcated two-piece or bifurcated single-body stent. Patients with difficult anatomy, extensive calcifications, complete occlusion of common or external iliac artery, tortuous vessels, or small vessels may require placement of an Aorto-Uni-Iliac (AUI) stent graft. Placement of an AUI stent graft is typically combined with a femorofemoral crossover bypass to ensure adequate perfusion to the contralateral limb. In the elective setting, some literature now supports that select patients with unilateral occlusive common or external iliac disease may be treated with an AUI stent graft alone without femorofemoral crossover bypass. Here, we present a case of a 79-year-old female with an abdominal aortic aneurysms with unilateral occlusive iliac disease managed with an AUI stent graft who subsequently developed rest pain requiring a femorofemoral crossover bypass.
Patient Best Interest
Authors: Veatch Robert M.
Published: August 2024

Classical healthcare ethics generated by the health professions centers on the maxim that the health professional should do what will benefit the patient according to the professional’s ability and judgment. In the modern healthcare ethics of the 20th century, this faced four problems: basing patient benefit on the individual clinician’s judgment; excluding the interests of others; giving benefits and harms priority over moral rights; and assuming that the health professional can be expected to know the patient’s interests. Late in the 20th century, this maxim was first challenged by the occasional ethically exotic case such as abortion in which the patient’s moral perspective was recognized. By the end of the century, however, a more radical challenge had emerged: the realization that literally every clinical decision requires that some value perspective be superimposed on the basic medical and nursing facts and that there is no reason to assume that the clinician is an expert on which value perspective is relevant. This presents new challenges in nursing ethics.
Conceptions of Vulnerability Within the Context of Clinical Research
Authors: Deem Michael J. , Erlen Judith A.
Published: August 2024

Clinical research aims to produce new knowledge, understanding, and therapeutics to advance the care and treatment of patients. Sometimes achieving these goals involves recruitment of patients who are labeled as “vulnerable” by researchers, clinicians, and international ethics bodies. Despite the near ubiquity of the term vulnerable populations in discourse about nursing education, care, and research, it is not clear that such discourse consistently picks out the same referent when using the term. This chapter aims to clarify the term vulnerable as it is utilized in the context of clinical research. After mapping some of the conceptual terrain of vulnerability in clinical research contexts, the chapter provides a narrative ethical account of one author’s own research experience with two different study populations. Finally, the chapter examines the ethical and practical insights gained from combining these conceptual and narrative approaches to vulnerability and argues that while vulnerability is more appropriately recognized in individuals rather than populations, the label “vulnerable population” can be useful when researchers bear in mind certain qualifications regarding to what and to whom the term vulnerable refers.
Empowering Parents for Better Decision-Making
Authors: Salter Erica K.
Published: August 2024

Being a parent of an ill child, especially an acutely ill child, is a disorienting and bewildering experience. Studies examining parental coping during a child’s hospitalization demonstrate that a primary contributor to a parental stress response was the “loss of parenting role” experienced by parents. Pediatric clinical ethics tends to focus on conflicts in isolated treatment decisions, but in so doing can neglect the important reality that because of the disorienting nature of parenting an ill child, parents often engage (or disengage) in the decision-making process from a position of disempowerment, insecurity, and fear because their role as parent has been disrupted. The result can be disastrous: communication deteriorates, parents withdraw or become “difficult,” clinicians become frustrated, and nurses, in particular, are left feeling like surrogate parents. This chapter argues that pediatric clinical ethics should recognize the centrality of the parenting role and the practices of parenting to good clinical decision-making and invest in the empowerment of parents in reclaiming and reformulating their role as parent. The chapter argues that by returning attention to the practices and goods of parenting, parents of ill children are better equipped to engage in treatment decision-making. The chapter concludes with practical suggestions for how to engage, empower, and equip the parents of ill children as they reclaim their role as parents in the wilderness of significant childhood illness. Special attention is paid to the role nurses play in this process as they are uniquely positioned to help parents reimagine and reclaim their role.
Consent and My Chronically Ill Child
Authors: Largent Emily A.
Published: August 2024

Informed consent has roots in both ethical theory and in law. The underpinning for consent is respect for autonomy, which is typically understood as independence and self-rule or self-determination. A challenge arises in pediatrics because children generally lack the ability to act independently, either because they are minors and not considered legally capable of medical decision-making, or because developmentally they have limited or no decision-making capacity. Therefore, modifications to the informed consent framework are necessary in pediatrics: a child’s parents or guardians provide informed permission, while the child gives assent, or affirmative agreement, if appropriate. In this chapter, the author considers consent—not for care but for a child’s involvement in research and clinician training activities—through a personal lens. Such decisions are difficult because, whereas care is intended solely for the child’s benefit, research and training are intended to benefit future patients—by producing generalizable knowledge or better doctors.
Relational Autonomy
Authors: Larkin Philip J.
Published: August 2024

As people make the complex transitions from living to dying, issues of autonomy become critical in how and why decisions are made, who makes them, and why. Western cultural thought would support the right of individual self-determination, a model prevalent in literature. However, taking a European lens, there are opposing arguments, rejecting individualism in favor of a family- or community-oriented decision-making system.

This chapter considers the debate on autonomy in the context of palliative and end-of-life care from the perspective of relational ethics. Using the framework proposed by Bergum and Dossetor (2005) around a series of clinical end-of-life care scenarios, the argument will be made that more compassionate, respectful, and clinically safe decisions can be made if taking a relational perspective that values how people can make decisions in “communitas” rather than only at an individual level.
Help Wanted
Authors: Chapple Helen Stanton , Gillen Megan
Published: August 2024

Being a nurse in the intensive care unit (ICU) is difficult work. It is physically, emotionally, intellectually, ethically, and spiritually taxing. This chapter explores the connection between the nurse and the machines used in the ICU as an unrecognized factor in the stress that ICU nurses undergo. The authors portray these machines and their management as part of the rescue project designed to alleviate society’s terror of human finitude. Using a case interview, they show that ICU nurses shoulder a burden that society disdains: negotiating the transition to dying while making it meaningful. Such an endeavor requires multilevel social support. But the solidarity that could enable success in this task on society’s behalf is intermittent, inconsistent, and inadequate. Without it, clinicians suffer, risk errors, and ultimately leave the bedside. Nurses use emotional labor to negotiate everyone’s detachment from the technology that is the lifeblood of the ICU environment. They need help.
Inhaled Nitric Oxide in Full-Term and Nearly Full-Term Infants With Hypoxic Respiratory Failure
Authors: Bassler Dirk
Published: August 2024

Inhaled nitric oxide was evaluated in several small studies with inconsistent results. The NINOS Trial investigated whether inhaled nitric oxide would reduce mortality or the need for extracorporeal membrane oxygenation (ECMO) in infants born at or near term who had hypoxic respiratory failure that was unresponsive to aggressive conventional therapy. Two hundred thirty-five infants were enrolled in this prospective randomized trial. Sixty-four percent of the control group and 46% of the nitric oxide group died within 120 days or were treated with ECMO (p = 0.006). The main benefit of nitric oxide was reduced use of ECMO, with little apparent effect on mortality.
Outcome at Two Years of Age of Infants From the DART Study
Authors: Onland Wes , van Kaam Anton H.
Published: August 2024

At the time of this trial, the various tradeoffs of dexamethasone—in particular that between ease of extubation and long-term neurodevelopmental outcomes—were quite uncertain. The DART study investigated the efficacy and safety of a low-dose dexamethasone regimen initiated after the first week of life. The study’s target sample size was 814, but enrollment had to be abandoned after 2 years of recruitment because of increasing lack of clinician equipoise and difficulty with recruitment following various professional and Academy statements. Ultimately, 70 ventilator-dependent extremely preterm infants were randomized to a dexamethasone regimen (0.89 mg/kg total, via a 10-day tapering course) or saline placebo, showing in the initial short-term publication that dexamethasone facilitates extubation. This follow-up study showed that there was no difference in the primary outcome of death or major disability at 2 years of age (45.7% versus 42.9%; RR 1.07, 95% CI 0.63 to 1.80).
Neurodevelopmental Outcome at 5 Years of Age After General Anesthesia or Awake-Regional Anesthesia in Infancy
Authors: DeMauro Sara B.
Published: August 2024

GAS was the first RCT to assess the effect of general anesthesia in infancy on childhood neurocognitive outcomes. This randomized, controlled, equivalence trial compared regional versus general anesthesia for infants undergoing inguinal hernia repair. The primary outcome was full-scale intelligence quotient (IQ) at 5 years. The investigators demonstrated equivalence of the 2 approaches—both IQ and multiple secondary neurodevelopmental and behavioral outcomes were similar in the 2 study arms at 5 years. Based on these results, clinicians and parents can be reassured that a single short exposure to general anesthesia during infancy should not have adverse developmental consequences during childhood.