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- Item2020 WSES guidelines for the detection and management of bile duct injury during cholecystectomy(BioMed Central, 2021-06-10) de Angelis, Nicola; Catena, Fausto; Memeo, Riccardo; Coccolini, Federico; Martínez-Pérez, Aleix; Romeo, Oreste M.; De Simone, Belinda; Di Saverio, Salomone; Brustia, Raffaele; Rhaiem, Rami; Piardi, Tullio; Conticchio, Maria; Marchegiani, Francesco; Beghdadi, Nassiba; Abu-Zidan, Fikri M.; Alikhanov, Ruslan; Allard, Marc-Antoine; Allievi, Niccolò; Amaddeo, Giuliana; Ansaloni, Luca; Andersson, Roland; Andolfi, Enrico; Azfar, Mohammad; Bala, Miklosh; Benkabbou, Amine; Ben-Ishay, Offir; Bianchi, Giorgio; Biffl, Walter L.; Brunetti, Francesco; Carra, Maria C.; Casanova, Daniel; Celentano, Valerio; Ceresoli, Marco; Chiara, Osvaldo; Cimbanassi, Stefania; Bini, Roberto; Coimbra, Raul; Luigi de’Angelis, Gian; Decembrino, Francesco; De Palma, Andrea; de Reuver, Philip R.; Domingo, Carlos; Cotsoglou, Christian; Ferrero, Alessandro; Fraga, Gustavo P.; Gaiani, Federica; Gheza, Federico; Gurrado, Angela; Harrison, Ewen; Henriquez, Angel; Hofmeyr, Stefan; Iadarola, Roberta; Kashuk, Jeffry L.; Kianmanesh, Reza; Kirkpatrick, Andrew W.; Kluger, Yoram; Landi, Filippo; Langella, Serena; Lapointe, Real; Le Roy, Bertrand; Luciani, Alain; Machado, Fernando; Maggi, Umberto; Maier, Ronald V.; Mefire, Alain C.; Hiramatsu, Kazuhiro; Ordoñez, Carlos; Patrizi, Franca; Planells, Manuel; Peitzman, Andrew B.; Pekolj, Juan; Perdigao, Fabiano; Pereira, Bruno M.; Pessaux, Patrick; Pisano, Michele; Puyana, Juan C.; Rizoli, Sandro; Portigliotti, Luca; Romito, Raffaele; Sakakushev, Boris; Sanei, Behnam; Scatton, Olivier; Serradilla-Martin, Mario; Schneck, Anne-Sophie; Sissoko, Mohammed L.; Sobhani, Iradj; Ten Broek, Richard P.; Testini, Mario; Valinas, Roberto; Veloudis, Giorgos; Vitali, Giulio C.; Weber, Dieter; Zorcolo, Luigi; Giuliante, Felice; Gavriilidis, Paschalis; Fuks, David; Sommacale, DanieleENGLISH ABSTRACT: Bile duct injury (BDI) is a dangerous complication of cholecystectomy, with significant postoperative sequelae for the patient in terms of morbidity, mortality, and long-term quality of life. BDIs have an estimated incidence of 0.4–1.5%, but considering the number of cholecystectomies performed worldwide, mostly by laparoscopy, surgeons must be prepared to manage this surgical challenge. Most BDIs are recognized either during the procedure or in the immediate postoperative period. However, some BDIs may be discovered later during the postoperative period, and this may translate to delayed or inappropriate treatments. Providing a specific diagnosis and a precise description of the BDI will expedite the decision-making process and increase the chance of treatment success. Subsequently, the choice and timing of the appropriate reconstructive strategy have a critical role in long-term prognosis. Currently, a wide spectrum of multidisciplinary interventions with different degrees of invasiveness is indicated for BDI management. These World Society of Emergency Surgery (WSES) guidelines have been produced following an exhaustive review of the current literature and an international expert panel discussion with the aim of providing evidence-based recommendations to facilitate and standardize the detection and management of BDIs during cholecystectomy. In particular, the 2020 WSES guidelines cover the following key aspects: (1) strategies to minimize the risk of BDI during cholecystectomy; (2) BDI rates in general surgery units and review of surgical practice; (3) how to classify, stage, and report BDI once detected; (4) how to manage an intraoperatively detected BDI; (5) indications for antibiotic treatment; (6) indications for clinical, biochemical, and imaging investigations for suspected BDI; and (7) how to manage a postoperatively detected BDI.
- ItemAbdominoperineal resection in the prone position: early outcomes at a tertiary institution in the Western Cape, South Africa(Medpharm, 2020-09) Stevenson, N.; Lambrechts, A. V. V.; Forgan, T.BACKGROUND: Extra-levator abdominoperineal resection (ELAPE) performed in the prone jack-knife position is a new technique in the developing world. Literature on the outcomes of ELAPE in a developing country context is scarce. The objective was to assess early outcomes after ELAPE in the prone jack-knife position, and to compare outcomes of patients who underwent the abdominal part of the procedure performed laparoscopically with an open group, at a tertiary institution in Cape Town. METHODS: Records of patients who underwent ELAPE for rectal adenocarcinoma from February 2011 to February 2017 at Tygerberg Hospital were retrospectively reviewed. Variables of interest included staging, rate of circumferential resection margin involvement (CRMI), intraoperative tumour perforation (IOP), perineal wound complications, early postoperative morbidity, length of intensive care unit (ICU) stay, duration of postoperative hospital stay and 30-day mortality rate. RESULTS: 52 patients (median age: 59 years) were included in the analysis. CRMI was evident in 16% (8/49) of patients and IOP in 6% (3/52). Perineal wound complications occurred in 32% (16/50) of patients. Median length of ICU and postoperative hospital stay was 3 days and 7 days, respectively. Overall morbidity was 47% (24/51) and the 30-day mortality rate was 3% (2/52). A significant difference in length of hospital stay was evident between the open and laparoscopic groups (11.5 days vs 6 days CONCLUSION: Prone abdominoperineal resection (APR), ELAPE, and laparoscopic ELAPE are acceptable and feasible procedures for patients with rectal cancer in the developing world, with outcomes being comparable to those determined in the developed world.
- ItemAbnormal serum lipoprotein levels as a risk factor for the development of human lenticular opacities(Clinics Cardiv Publishing, 2003-04) Meyer, D.; Parkin, D.; Maritz, F. J.; Liebenberg, P. H.Aim: To determine whether an association exists between the different plasma lipoprotein constituents and the prevalence of lenticular opacities in dyslipidaemic subjects. Methods: Adult patients (n = 115) of both genders were included if their fasting total serum cholesterol concentrations exceeded the 95th percentile of normal or their serum low-density lipoprotein (LDL) : high-density lipoprotein (HDL) ratios exceeded 5. Patients were excluded if they suffered from any condition known to cause, or predispose them to, elevated lipoprotein levels or lenticular opacification. Lenticular changes were assessed by means of a slit-lamp through the fully dilated pupil. Results: An extremely strong association (p < 0.0001) was found to exist between HDL cholesterol levels and the development of lens opacities. Below an HDL-C level of 1.5 mmol/l subjects had a seven-fold higher calculated probability of falling in the lens opacity subgroup than those with HDL-C levels above 1.5 mmol/l [odds ratio = 7.33 (95% CI = 2.06–26.10; p = 0.001)]. An equally strong association was found between high (>5) LDL:HDL ratios and the development of lens opacities (p < 0.0003). The risk of falling into the cataract subgroup if the individual’s LDL:HDL ratio exceeded 5 was 2.35 (95% CI = 1.09–5.04; p = 0.014). Conclusions: This study strongly suggests that an association exists between low levels of HDL cholesterol and high LDL:HDL ratios on one hand and the development of adult lens opacification on the other.
- ItemAcute abdomen in a patient with situs inversus : a case report(Health and Medical Publishing Group -- HMPG, 1986-02) Du Toit, D. F.; Greeff, M.The case of a man with situs inversus who presented with acute abdomen is reported. Acute left-sided appendicitis was considered before operation, but at laparotomy an omental abscess of unknown aetiology was drained. The appendix, localized in the left iliac fossa, was removed but was normal on histological examination.
- ItemAfrican KhoeSan ancestry linked to high-risk prostate cancer(BMC (part of Springer Nature), 2019-06-04) Petersen, Desiree C.; Jaratlerdsiri, Weerachai; Van Wyk, Abraham; Chan, Eva K. F.; Fernandez, Pedro; Lyons, Ruth J.; Mutambirw, Shingai B. A.; Van der Merwe, Andre; Venter, Philip A.; Bates, William; Bornman, M. S. R.; Hayes, Vanessa M.Backgrounds: Genetic diversity is greatest within Africa, in particular the KhoeSan click-speaking peoples of southern Africa. South African populations represent admixture fractions including differing degrees of African, African-KhoeSan and non-African genetic ancestries. Within the United States, African ancestry has been linked to prostate cancer presentation and mortality. Together with environmental contributions, genetics is a significant risk factor for high-risk prostate cancer, defined by a pathological Gleason score ≥ 8. Methods: Using genotype array data merged with ancestry informative reference data, we investigate the contribution of African ancestral fractions to high-risk prostate cancer. Our study includes 152 South African men of African (Black) or African-admixed (Coloured) ancestries, in which 40% showed high-risk prostate cancer. Results: Genetic fractions were determined for averaging an equal African to non-African genetic ancestral contribution in the Coloured; we found African ancestry to be linked to high-risk prostate cancer (P-value = 0.0477). Adjusting for age, the associated African ancestral fraction was driven by a significant KhoeSan over Bantu contribution, defined by Gleason score ≥ 8 (P-value = 0.02329) or prostate specific antigen levels ≥20 ng/ml (Pvalue = 0.03713). Additionally, we observed the mean overall KhoeSan contribution to be increased in Black patients with high-risk (11.8%) over low-risk (10.9%) disease. Linking for the first time KhoeSan ancestry to a common modern disease, namely high-risk prostate cancer, we tested in this small study the validity of using KhoeSan ancestry as a surrogate for identifying potential high-risk prostate cancer risk loci. As such, we identified four loci within chromosomal regions 2p11.2, 3p14, 8q23 and 22q13.2 (P-value = all age-adjusted < 0.01), two of which have previously been associated with high-risk prostate cancer. Conclusions: Our study suggests that ancient KhoeSan ancestry may be linked to common modern diseases, specifically those of late onset and therefore unlikely to have undergone exclusive selective pressure. As such we show within a uniquely admixed South African population a link between KhoeSan ancestry and high-risk prostate cancer, which may explain the 2-fold increase in presentation in Black South Africans compared with African Americans.
- ItemAfrican multi-site 2-year neuropsychological study of school-age children perinatally infected, exposed, and unexposed to human immunodeficiency virus(Oxford University Press, 2020-10) Boivin, Michael J.; Chernoff, Miriam; Fairlie, Lee; Laughton, Barbara; Zimmer, Bonnie; Joyce, Celeste; Barlow-Mosha, Linda; Bwakura-Dangarembizi, Mutsawashe; Vhembo, Tichaona; Ratswana, Mmule; Kamthunzi, Portia; McCarthy, Katie; Familiar-Lopez, Itziar; Jean-Philippe, Patrick; Coetzee, Joan; Abrahams, Nasreen; Gous, Hermien; Violari, Avy; Cotton, Mark F.; Palumbo, Paul E.Background Children living with human immunodeficiency virus (HIV) are at neuropsychological risk for cognitive and motor dysfunction. However, few prospective, multi-site studies have evaluated neuropsychological outcomes longitudinally among perinatally infected African children who received early antiretroviral treatment (ART). Methods We enrolled 611 children aged 5 to 11 years at 6 sites (South Africa [3], Zimbabwe, Malawi, Uganda). Of these, there were 246 children living with HIV (HIV+) who were initiated on ART before 3 years of age in a prior clinical trial comparing nevirapine to lopinavir/ritonavir (International Maternal Pediatric Adolescent Acquired Immunodeficiency Syndrome Clinical Trials [IMPAACT] P1060); 183 age-matched, exposed but uninfected (HEU) children; and 182 unexposed and uninfected (HUU) children. They were compared across 3 assessment time points (Weeks 0, 48, and 96) on cognitive ability (Kaufman Assessment Battery for Children, second edition [KABC-II]), attention/impulsivity (Tests of Variables of Attention [TOVA]), motor proficiency (Bruininks-Oseretsky Test, second edition [BOT-2]), and on the Behavior Rating Inventory of Executive Function (BRIEF). The cohorts were compared using linear mixed models, adjusting for site, child’s age and sex, and selected personal/family control variables. Results The HIV+ cohort performed significantly worse than the HEU and HUU cohorts for all KABC-II, TOVA, and BOT-2 performance outcomes across all 3 time points (P values < .001). The HUU and HEU cohorts were comparable. For the KABC-II planning/reasoning subtests, the HIV+ children showed less improvement over time than the HUU and HEU groups. The groups did not differ significantly on the BRIEF. Conclusions Despite initiation of ART in early childhood and good viral suppression at the time of enrollment, the HIV+ group had poorer neuropsychological performance over time, with the gap progressively worsening in planning/reasoning. This can be debilitating for self-management in adolescence.
- ItemAgeing with Cerebral Palsy after being treated with Orthopaedic Interval Surgery Approach during childhood(Stellenbosch : Stellenbosch University., 2020-03) Du Toit, Jacques; Lamberts, Robert P.; Langerak, Nelleke G.; Stellenbosch University. Faculty of Health Sciences. Dept. of Surgical Sciences: Orthopaedic Surgery.ENGLISH ABSTRACT: No abstract available.
- ItemAlan Blyth - my halfeeu op Ladismith(Health and Medical Publishing Group -- HMPG, 1983-06) Van Zyl, J. J. W.No abstract available
- ItemAlcohol levels in trauma victims(Health and Medical Publishing Group -- HMPG, 1986-11) Muller, R.; Van Rensburg, L. C. J.A group of 142 patients injured in motor vehicle accidents or assaults was investigated to ascertain patterns of alcohol usage and blood alcohol levels; 77% were positive for blood alcohol (range 0,01 0,492 g/dl; mean 0,212 g/dl). A correlation between alcohol levels and injury severity was found. In assaults. multiple injuries were associated with high alcohol levels because of less effective selfdefence. Injured young pedestrians as well as injured occupants of motor vehicles showed alarmingly high alcohol levels. The increasing load placed on trauma services and the resultant burden to the taxpayer necessitates an urgent programme of public education designed to alter attitudes towards alcohol consumption.
- ItemAlternative modalities being promoted for breast screening(Health & Medical Publishing Group, 2018) Edge, Jenny; Roodt, LianaENGLISH ABSTRACT: is a political issue as much as a medical one, and although there is an enormous amount of literature looking at the benefits of the standard modalities, there is no consensus about the efficacy of screening. South Africa (SA) does not have a national mammographic breast screening programme. There are both economic and logistical reasons for this. The absence of a policy has resulted in alternative modalities being promoted as plausible substitutes. If a new modality is to be used for screening/symptomatic evaluation of the breasts, it should be compared with any of the established and well-researched existing modalities. This editorial serves to highlight some of the problems with the three commonest modalities being promoted in this country at present.
- ItemAnaesthesia for microsurgery(Health and Medical Publishing Group -- HMPG, 1985-04) Jakubowski, M.; Lamont, A.; Murray, W. B.; De Wit, S. L.The data from a retrospective study of 32 anaesthetics administered for free-flap tissue operations are analysed. We suggest balanced analgesic-dominated general anaesthesia, supported wherever possible by continuous regional block. Special attention is paid to full control over the cardiovascular system and the haemodynamics, including the microcirculation and optimal rheological properties of the blood, as well as metabolic ability. Our results suggest that factors such as adequate infusion therapy guided by central venous pressure and urinary output and strict body temperature control, supplementary use of regional blocks and peri-operative use of dextran 40 (Rheomacrodex) can contribute significantly towards the overall success of free-flap surgery.
- ItemAn analysis of adverse events and human error associated with the imaging of patients at a major trauma centre in South Africa(Health & Medical Publishing Group, 2019) Bashir, A. A.; Kong, V. Y.; Buitendag, J. J. P.; Manchev, V.; Bekker, W.; Bruce, J. L.; Laing, G. L.; Brysiewicz, P.; Clarke, D. L.Background. There is growing realisation that human error contributes significantly to morbidity and mortality in modern healthcare. A number of taxonomies and classification systems have been developed in an attempt to categorise errors and quantify their impact. Objectives. To record and identify adverse events and errors as they impacted on acute trauma patients undergoing a computed tomography (CT) scan, and then quantify the effect this had on the individual patients. It is hoped that these data will provide evidence to develop error prevention programmes designed to reduce the incidence of human error. Methods. The trauma database was interrogated for the period December 2012 - April 2017. All patients aged >18 years who underwent a CT scan for blunt trauma were included. All recorded morbidity for these patients was reviewed. Results. During the period under review, a total of 1 566 patients required a CT scan at our institution following blunt trauma. Of these, 192 (12.3%, 134 male and 58 female) experienced an error related to the process of undergoing a CT scan. Of 755 patients who underwent a CT scan with intravenous contrast, detailed results were available for 312, and of these 46 (14.7%) had an acute deterioration in renal function. According to Chang’s taxonomy, physical harm occurred as follows: grade I n=6, grade II n=62, grade III n=45, grade IV n=11, grade V n=27, grade VI n=21, grade VII n=15, grade VIII n=3 and grade IX n=2. Adverse events were performing an unnecessary scan (n=24), omitting an indicated scan (n=23), performing the scan incorrectly (n=8), scanning the wrong body part (n=7), equipment failure (n=18), omitting treatment following the scan (n=6), incorrect interpretation of the scan (n=65), deterioration during the scan (n=6) and others (n=35). The setting for the error was the ward (n=19), the radiology suite (n=126), the emergency department (n=45) and the operating theatre (n=2). The staff responsible for the adverse events were medical (n=155), nursing (n=4) and radiology staff (n=15). There were 67 errors of commission and 125 errors of omission. The primary cause was a planning problem in 78 cases and an execution problem in 114. Conclusions. Errors and adverse events related to obtaining a CT scan following blunt polytrauma are not uncommon and may impact significantly on the patient. Communication is essential to eliminate errors related to performing the wrong type of scan. The commonest errors relate to misinterpretation of the scan.
- ItemAnatomy of the clavicle and its medullary canal - a computer tomography study(Stellenbosch Univeristy, 2014-12) King, Paul Reginald; Ikram, Ajmal; Lamberts, Robert Patrick; Stellenbosch University. Faculty of Health Sciences. Dept. of Surgical Sciences: Orthopaedic Surgery.ENGLISH ABSTRACT: Background With recent literature indicating certain clavicle shaft fracture types are best treated surgically; there is renewed interest in the anatomy of the clavicle. lntramedullary fixation of clavicle shaft fractures requires an adequate medullary canal to accommodate the fixation device used. This computer tomography anatomical study of the clavicle and its medullary canal describes its general anatomy and determines the suitability of its medullary canal to intramedullary fixation. Description of methods Four hundred and eighteen clavicles in 209 patients were examined using computer tomography imaging. The length and curvatures as well as the height and width of the clavicle and its canal at various pre-determined points were measured. ln addition the start and end of the medullary canal from the sternal and acromial ends of the clavicle were determined. The data was grouped according to age, gender and lateralization. Summary of results The average length of the clavicle was 151.15 mm with the average stemal and acromial curvature being 146 and 133 respectively. The medullary canal starts on average 6.59 mm from the sternal end and ends 19.56 mm from the acromial end with the average height and width of the canal at the middle third being 5.61 mm and 6.63 mm respectively. Conclusion The medullary canal of the clavicle is large enough to accommodate commonly used intramedullary devices in the nraprity of cases. The medullary canal extends far enough medially and laterally for an intramedullary device to adequatet'y bridge most middte third clavicle fractures. An alternative surgical option should be avalable in theatre when treating females as the medullary canal is too small to pass an intranedullary device past the fracture site on rare occasions.
- ItemAneurysm of a peripheral pulmonary artery : case report and brief review of the literature(Health and Medical Publishing Group (HMPG), 1975-08) Janson, P. M. C.; Barnard, P. M.; Weich, H. F. H.; MacMahon, A. G.A patient is presented in whom a solitary aneurysm of a peripheral pulmonary artery was treated by left lower lobectomy. This is the eighth reported successful resection of such an aneurysm. A brief review of the literature is also presented and the importance of pulmonary arteriography in the diagnosis of this condition is mentioned.
- ItemAnti-allergic ophthalmic drugs in general practice : which, why and when?(Medpharm Publications, 2013) Mohamed, N.; Smit, D. P.Ocular allergies present in many different guises. They may vary from self-limiting episodes of acute allergic conjunctivitis, to potentially sight-threatening chronic conditions, such as vernal keratoconjunctivitis. This article provides a brief description of the different ocular allergic conditions to aid accurate diagnosis. It also focuses on the different types of anti-allergic ophthalmic preparations and how to employ them in a logical, stepwise management strategy to obtain optimal results, while minimising exposure to potent drugs with potentially serious side-effects.
- ItemAnti-infective ophthalmic preparations in general practice(Medpharm Publications, 2012) Smit, DerrickOcular infections may be bacterial, viral, fungal or parasitic in aetiology. Pharmacological preparations are available to treat infections that are caused by these groups of organisms. The majority of these preparations are intended for topical administration, although some systemically administered agents may be needed to treat or prevent specific ocular infections. This article discusses the different anti-infective options that are available to general practitioners to treat infections caused by each aetiological group. It also discusses the role that is played by povidone-iodine and antibiotic-steroid combinations to manage eye infections. A summary of all these drugs is provided in table form for easy reference.
- ItemAntibiogram profiles and efficacy of antibiotic regimens of bacterial isolates from chronic osteomyelitis of the appendicular skeleton: A developing-world perspective(Health & Medical Publishing Group, 2021-06-30) Ferreira, N.; Reddy, K.; Venter, R. G.; Centner, C. M.; Laubscher, M.ENGLISH ABSTRACT: Chronic osteomyelitis is notoriously difficult to eradicate, and high treatment failure rates have been reported in the literature.[1,2] Although no evidence-based treatment guidelines exist for the management of chronic osteomyelitis, the ideal treatment strategy can be outlined as judicious resection of all necrotic tissue, dead-space management, and neovascularisation of the debridement site followed by soft-tissue and bony reconstruction as required.[3-7] Antibiotic therapy is empirically initiated as an adjunct to surgical management, and then continued as prolonged culture-specific (targeted) therapy.[3]In the absence of non-invasive sampling methods to ascertain the microbiological profile of osteomyelitis, the choice of empirical antibiotic therapy to initiate is often aimed at the most probable infecting organism, in conjunction with current international reports.[8] As the organism and antibiotic susceptibility profiles conceivably differ between geographical regions, empirical antibiotic strategies should ideally be based on local microbiological antibiograms. There are limited data available on the local pathogen profiles and antibiograms in developing countries, including South Africa (SA).
- ItemApplication of irradiation as an immunosuppressive agent(Health & Medical Publishing Group, 1987-04) Du Toit, D. F.; Heydenrych, J. J.ENGLISH ABSTRACT: The concept of using total lymphoid irradiation (TLI) for immunosuppression is based on the prolonged and profound immunosuppressive effects observed after TLI in the treatment of patients with Hodgkin's disease. Pre-operative TLI of allograft recipients has been shown to be immunosuppressive when used alone or together with chemical immunosuppression. Fractionated TLI and allogeneic bone marrow injections produce stable chimaerism without graft-versus-host disease in inbred mice, rats and mongrel dogs and transplantation tolerance of skin and cardiac grafts in rats. In the primate, TLI and bone marrow injection result in significant tolerance of liver and kidney allografts. In 1959 sublethal whole-body irradiation was used as an immunosuppressive agent for the first successful related-human renal allografts between non-identical twins. Despite the dangers of myelosuppression, recent clinical experience has shown TLI to be a useful immunosuppressant for organ transplantation, allowing decreased dosage of concomitant immunosuppressive drugs.
- ItemAspects on advanced procedures during endoscopic retrograde cholangiopancreatography (ERCP) for complex hepatobiliary disorders(Stellenbosch : Stellenbosch University, 2021-03) Lubbe, Jeanne Adele; Moore, Samuel; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Surgical Sciences.Background: The rapid development in endoscopic technology and associated skills has led to an increase in more advanced procedures being performed during endoscopic retrograde cholangiopancreatography (ERCP). Knowledge is limited regarding clinical value, integration, and outcomes for single operator cholangiopancreatoscopy (SOCP) and endoscopic intervention in the different Bismuth-Corlette (B-C) locations in the hepatic hilum. Objectives: To determine the clinical value of SOCP in the diagnosis and treatment of complex hepatobiliary and pancreatic disease. To describe the nationwide integration of SOCP and the extent to which adverse events are influenced when SOCP is added to ERCP. To compare adverse events and reintervention rates after endoscopic stenting for malignant obstruction in the distal and hilar locations of the biliary tree. To compare outcomes after endoscopic transpapillary (ETP) and percutaneous transhepatic (PTH) stenting in the palliation of malignant hilar obstruction (MHO). Methods: In study I all SOCP procedures performed between March 2007-December 2014 at a tertiary highvolume endoscopy unit were separately graded according to a predefined 4-graded scale estimating therapeutic value and diagnostic yield. Study II was a nationwide case-control study nested within the cohort of ERCP procedures, with- or without SOCP, and registered in the Swedish Registry for Gallstone Surgery and ERCP (GallRiks) between 2007-2012. To assess risk factors for adverse events, multivariate logistic regression was performed, and odds ratios (OR) calculated. The GallRiks registry was also utilised in study III where all patients undergoing endoscopic stenting for malignant biliary obstruction between 2010-2017 (based on International Classification of Diseases (ICD) coding), were included. Kaplan-Meier analysis was employed to calculate stent patency and Cox proportional hazard models to calculate the risk for recurrent biliary obstruction after single metal stent placement. To compare ETP and PTH drainage approaches, a retrospective deconstructed analysis of palliative stenting procedures for MHO at two specialised referral centres over a 5-year period was performed. Within-group analyses were performed to explore outcomes for different B-C types and Kaplan-Meier and restricted mean survival time analyses were performed to calculate and compare duration of therapeutic success. Results: In 365 SOCP procedures, SOCP was found be of pivotal importance in 19% of patients, of great clinical significance in 44%, and did not affect clinical decision-making or alter clinical course in 37% of patients. In study II a learning curve was observed after first introduction of 408 SOCP procedures, and postprocedural adverse events (19.1% vs. 14.0%), pancreatitis (7.4% vs. 3.9%) and cholangitis (4.4% vs. 2.7%) were more prevalent when SOCP was added to ERCP. After multivariate analysis, the risk for postprocedural adverse events remained (OR 1.35, 95% CI [1.04 - 1.74]). In 4623 ERCP procedures performed for stenting of malignant strictures (1364 hilar), adverse events and 6-month reintervention rates were increased after hilar stenting compared to distal stenting (17.2% vs. 12.0%, 73.4% vs. 55.9%). On multivariate analysis the risk for reintervention was three times higher after single metal stent placement in the hilum compared to the distal biliary tree (HR 3.47, 95% CI [2.01-6.00], p<0.001). In 293 patients undergoing palliative stenting for MHO (52.2% ETP, 47.8% PTH), access and bridging success in the ETP and PTH groups were 83.5% vs. 97.2% and 90.2% vs. 84.5%, respectively. Technical and therapeutic success were equivalent between the two groups, but duration of therapeutic success was longer after ETP drainage, with a 3-month gain in duration of therapeutic success after adjustment for B-C type (95% CI [26-160], p=0.006). Cholangitis rates were equivalent (21.4% vs. 24.7%), while pancreatitis was more common in the ETP group and deaths more common in the PTH group. Conclusions: When added to ERCP, SOCP contributes significant clinical value in 64% of cases. However, there is an increased risk of intra- and postprocedural adverse events which, together with a learning curve, suggests that it should likely be performed in specialised high-volume centres. Regarding endoscopic intervention for MHO, stenting in the hepatic hilum compared to the distal biliary tree is associated with more adverse events and decreased stent patency. When comparing palliative ETP with PTH stenting for MHO, both approaches have similar technical and therapeutic success, with ETP drainage being more durable. Future studies should explore the complimentary role of both approaches in specific B-C types.
- ItemAssessment and management of shoulder pain at primary care level(AOSIS, 2021-03) Kauta, Ntambue; De Vries, Elma; Du Plessis, Jean-Pierre; Grey, Ben; Anley, Cameron; Vrettos, Basil; Dachs, Robert; Roche, StephenMost patients with shoulder pain will initially visit their community health centre, private general practitioner or family physician, with various levels of experience in the assessment and management of shoulder conditions. Shoulder conditions will range from early, simple ailments that can be treated in the primary care setting, to post-traumatic injuries and complex pathologies requiring the expertise of an orthopaedic surgeon or a fellowship-trained shoulder surgeon. Correct assessment of the patient’s shoulder condition at the index consultation is a prerequisite for appropriate management. This article sets out straightforward guidelines to help general practitioners confidently identify the patient’s source of shoulder pain and initiate an appropriate management plan at primary care level. Criteria for urgent and elective referral for specialist care are also outlined.