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The Nuffield Department of Surgical Sciences is the academic department of surgery at the University of Oxford, and hosts a multidisciplinary team of senior clinical academic surgeons, senior scientists, junior clinicians and scientists in training.
Primary carcinoma of the appendix.
Primary adenocarcinoma of the appendix is a rare tumor. Fewer than 200 cases are on record. Correct preoperative diagnosis is virtually nonexistent. Two patients with adenocarcinoma of the appendix are described. Although appendectomy appears to be adequate treatment for carcinoid, right hemicolectomy is, in our opinion, the treatment of choice for mucinous cystadenocarcinoma, while it is mandatory in cases of adenocarcinoma of the colonic type.
Distinct Cytokine Responses in Central and Systemic Compartments after Subarachnoid Haemorrhage.
INTRODUCTION: Neuroinflammation may contribute to outcomes following subarachnoid haemorrhage (SAH). Human cerebrospinal fluid (CSF) cytokine data is limited and its relationship with systemic inflammation is unknown. This study compares the inflammatory responses in CSF and plasma compartments, and their associations with outcome. METHODS: Ten cytokines were measured in CSF and plasma from 98 SAH patients and 18 control patients. Outcome was assessed with the modified Rankin scale (mRS) and Subarachnoid Haemorrhage Outcome Tool (SAHOT) at days 7, 28, 90 and 180. Regression analyses and principal component analysis (PCA) were performed. RESULTS: Median levels of all CSF cytokines and plasma IL-6 were higher in SAH patients than controls (p
Radiofrequency thalamotomy for tremor outcomes correlate with dentorubrothalamic tract distance.
BACKGROUND: Thalamotomy was the main surgical treatment for medically refractory tremor before deep brain stimulation (DBS). While DBS is now preferred, it has drawbacks such as hardware failure, infection risk, frequent battery replacements, and multiple programming adjustments. Radiofrequency (RF) thalamotomy avoids these issues, can be performed under local anaesthesia, and suits patients in poor health. This study examines long-term outcomes of RF thalamotomy. METHODS: We reviewed 14 consecutive RF thalamotomies performed in Oxford from 2016 to 2021. Three patients died from unrelated causes, leaving eight for long-term assessment. We recorded Bain and Findlay (BF) tremor scores, Clinical Global Impression of Severity (CGI-S), Clinical Global Impression of Change (CGI-C), Patient's Global Impression of Change (PGI-C), and Efficacy Index (EI). The median follow-up was 39 months (range 12-126). Post-operative tractography was correlated with clinical outcomes. RESULTS: Six patients had essential tremor and eight had Parkinson's disease. Reasons for choosing thalamotomy over DBS included medical comorbidities, patient preference, age, and previous DBS failure. Ten patients (71%) reported significant tremor improvement, with relapse in two after six months. The mean BF tremor score decreased from 16.1 preoperatively to 8.5 postoperatively (p = 0.0043). Adverse events occurred in seven patients (50%), resolving completely in three, partially in three, and persisting in one. Sustained outcomes correlated with a wider distance of residual dentrorubrothalamic tract (DRTT) fibres from the lesion. CONCLUSIONS: RF thalamotomy is an effective long-term treatment for medication-refractory tremor and should be considered for select patients needing unilateral tremor control.
Clinical neurocardiology: defining the value of neuroscience-based cardiovascular therapeutics - 2024 update.
The intricate role of the autonomic nervous system (ANS) in regulating cardiac physiology has long been recognized. Aberrant function of the ANS is central to the pathophysiology of cardiovascular diseases. It stands to reason, therefore, that neuroscience-based cardiovascular therapeutics hold great promise in the treatment of cardiovascular diseases in humans. A decade after the inaugural edition, this White Paper reviews the current state of understanding of human cardiac neuroanatomy, neurophysiology and pathophysiology in specific disease conditions, autonomic testing, risk stratification, and neuromodulatory strategies to mitigate the progression of cardiovascular diseases.
Global clubfoot treatment in 2023: an overview of advances and outcomes.
INTRODUCTION: Approximately 200 000 children are born each year with clubfoot, the majority of whom live in low-income and middle-income countries (LMICs). If untreated, clubfoot causes pain and reduced mobility, leading to activity limitations and disability. The Ponseti method is a highly effective and minimally invasive treatment. This observational study aims to quantify the countries providing clubfoot services and the children receiving treatment in 2023 and compares progress since data were first collected in 2005. METHODS: In January and February 2024, data on clubfoot treatment in 2023 were collected from 70 countries. Informants completed a survey about new cases enrolled, treatment outcomes and health system integration. Data were analysed using descriptive statistics, with adjustments made for duplicates, and included clinic locations, the number and ages of children starting treatment, types of support available and Ministry of Health involvement. We compared coverage trends over time and used a cartogram to visualise the extent of clubfoot programme coverage across countries. RESULTS: Responding countries accounted for 83% of all expected cases in LMICs. There was an increase in enrolment numbers, to 40 382, in 2023. Despite this progress, treatment coverage remained low at approximately 22% across respondent countries. While integration of clubfoot services into national healthcare systems varied widely, strong public-private partnerships in many countries suggest a foundation for sustainable, long-term treatment programmes. However, quality care remained a challenge, with only 67% of children receiving their first foot abduction brace, indicating gaps in ensuring comprehensive treatment necessary for successful clubfoot management. Lingering effects of COVID-19 restrictions include a higher percentage of cases enrolled after 1 year of age. CONCLUSIONS: A larger proportion of children in LMICs received Ponseti treatment in 2023 compared with 2005. However, more work is needed to expand national programmes, build sustainable, high-quality treatment capacity and ensure all children get the care they need to avoid lifelong disability.
Optimising laser lithotripsy
Urinary stone disease is a major and growing medical field, with significant impact on patients’ quality of life and health. It is most commonly treated using lasers to destroy stones, and the technology has evolved rapidly over the last 30 years. This research examines lasers representing the two most commonly used technologies (Ho:YAG and thulium fibre lasers) in a bench environment, to investigate how the properties of these lasers correlate to performance outcomes. These outcomes include ablation rate (how quickly stone is destroyed), retropulsion (how much and what kind of unintended stone motion is caused) and particle size (the fragments remaining after stone destruction). This research also aims to establish robust, repeatable experimental frameworks by which other lasers can be assessed and compared.
Urological stone disease: a 5-year update of stone management using Hospital Episode Statistics.
OBJECTIVE: To reassess the trends in upper urinary tract (UUT) stone disease burden and management in the UK during the last 5 years. METHODS: The present paper is our third quinquennial analysis of trends in the management of renal stones in England. Data were collected using the Hospital Episode Statistics database for the years 2015-2020 inclusive. These were then analysed, summarized and presented. RESULTS: The number of UUT stone episodes increased by 2.2% from 86 742 in 2014-2015 to 88 632 in 2019-2020 but annual prevalence remained static at 0.14%. The number of UUT stone episodes in those of working age has remained static but increased by 9% for patients aged > 60 years (from 27 329 to 29 842). The number of shockwave lithotripsy (SWL) treatments decreased by 6.8%. There was a further increase in the use of ureteroscopy (URS) between 2015 and 2020 of 18.9%. Within this subgroup, flexible URS had the most rapid increase in use, with a rise of 20.4% from 7108 to 8558 recorded cases. Over the 20-year period from 2000 to 2020 there was a remarkable 257% increase in URS cases. There was a further decline in open surgery for UUT stone disease by 40%. Stone surgery day-case numbers have increased by 14.7% (from 31 014 to 35 566), with a corresponding decline in the number of bed days of 14.3%. Emergency cases increased by 40%, while elective cases saw a slight increase of 1.9%. CONCLUSION: The present study shows a plateauing in the prevalence of UUT stone disease in England in the last 5 years, with a move towards day-case procedures and an increase in the proportion of emergency work. For the first time in England, URS has overtaken SWL as the most common procedure for treating UUT stone disease, which might reflect patients' or physicians' preference for a more effective definitive treatment.
Central Adiposity Increases Risk of Kidney Stone Disease through Effects on Serum Calcium Concentrations.
SIGNIFICANCE STATEMENT: Kidney stone disease is a common disorder with poorly understood pathophysiology. Observational and genetic studies indicate that adiposity is associated with an increased risk of kidney stone disease. However, the relative contribution of general and central adipose depots and the mechanisms by which effects of adiposity on kidney stone disease are mediated have not been defined. Using conventional and genetic epidemiological techniques, we demonstrate that general and central adiposity are independently associated with kidney stone disease. In addition, one mechanism by which central adiposity increases risk of kidney stone disease is by increasing serum calcium concentration. Therapies targeting adipose depots may affect calcium homeostasis and help to prevent kidney stone disease. BACKGROUND: Kidney stone disease affects approximately 10% of individuals in their lifetime and is frequently recurrent. The disease is linked to obesity, but the mechanisms mediating this association are uncertain. METHODS: Associations of adiposity and incident kidney stone disease were assessed in the UK Biobank over a mean of 11.6 years/person. Genome-wide association studies and Mendelian randomization (MR) analyses were undertaken in the UK Biobank, FinnGen, and in meta-analyzed cohorts to identify factors that affect kidney stone disease risk. RESULTS: Observational analyses on UK Biobank data demonstrated that increasing central and general adiposity is independently associated with incident kidney stone formation. Multivariable MR, using meta-analyzed UK Biobank and FinnGen data, established that risk of kidney stone disease increases by approximately 21% per one standard deviation increase in body mass index (BMI, a marker of general adiposity) independent of waist-to-hip ratio (WHR, a marker of central adiposity) and approximately 24% per one standard deviation increase of WHR independent of BMI. Genetic analyses indicate that higher WHR, but not higher BMI, increases risk of kidney stone disease by elevating adjusted serum calcium concentrations (β=0.12 mmol/L); WHR mediates 12%-15% of its effect on kidney stone risk in this way. CONCLUSIONS: Our study indicates that visceral adipose depots elevate serum calcium concentrations, resulting in increased risk of kidney stone disease. These findings highlight the importance of weight loss in individuals with recurrent kidney stones and suggest that therapies targeting adipose depots may affect calcium homeostasis and contribute to prevention of kidney stone disease.
The association of pre-operative home accelerometry with cardiopulmonary exercise variables.
We investigated the association of pre-operative activity, reported by the Duke Activity Score Index, Short Form-12 and measured by an accelerometer worn at home, with five cardiopulmonary exercise variables: peak power; peak oxygen consumption; anaerobic threshold; and ventilatory equivalents for oxygen and carbon dioxide. Fifty patients scheduled for major surgery underwent a standard pre-operative cardiopulmonary exercise test and wore a chest-mounted triaxial accelerometer for a mean (SD) duration of 3.2 (0.4) days. The Duke Activity Score Index and six accelerometer variables were significantly correlated with all five cardiopulmonary exercise variables, Pearson correlation coefficients 0.5-0.7, p = 0.02 to p
CT Texture Analysis of Ex Vivo Renal Stones Predicts Ease of Fragmentation with Shockwave Lithotripsy.
INTRODUCTION: Understanding the factors affecting success of extracorporeal shockwave lithotripsy (SWL) would improve informed decision-making on the most appropriate treatment modality for an individual patient. Although stone size and skin-to-stone distance do correlate with fragmentation efficacy, it has been shown that stone composition and architecture, as reflected by structural heterogeneity on CT, are also important factors. This study aims to determine if CT texture analysis (CTTA), a novel, nondestructive, and objective tool that generates statistical metrics reflecting stone heterogeneity, could have utility in predicting likelihood of SWL success. MATERIALS AND METHODS: Seven spontaneously passed, intact renal tract stones, were scanned ex vivo using standard CT KUB and micro-CT. The stones were then fragmented in vitro using a clinical lithotripter, after which, chemical composition analysis was performed. CTTA was used to generate a number of metrics that were correlated to the number of shocks needed to fragment the stone. RESULTS: CTTA metrics reflected stone characteristics and composition, and predicted ease of SWL fragmentation. The strongest correlation with number of shocks required to fragment the stone was mean Hounsfield unit (HU) density (r = 0.806, p = 0.028) and a CTTA metric measuring the entropy of the pixel distribution of the stone image (r = 0.804, p = 0.039). Using multiple linear regression analysis, the best model showed that CTTA metrics of entropy and kurtosis could predict 92% of the outcome of number of shocks needed to fragment the stone. This was superior to using stone volume or density. CONCLUSIONS: CTTA metrics entropy and kurtosis have been shown in this experimental ex vivo setting to strongly predict fragmentation by SWL. This warrants further investigation in a larger clinical study for the contribution of CT textural metrics as a measure of stone heterogeneity, along with other known clinical factors, to predict likelihood of SWL success.
The Preoperative Assessment and Optimization of Patients Undergoing Major Urological Surgery.
PURPOSE OF REVIEW: Improving patient outcomes from major urological surgery requires not only advancement in surgical technique and technology, but also the practice of patient-centered, multidisciplinary, and integrated medical care of these patients from the moment of contemplation of surgery until full recovery. This review examines the evidence for recent developments in preoperative assessment and optimization that is of relevance to major urological surgery. RECENT FINDINGS: Current perioperative medicine recommendations aim to improve the short-term safety and long-term effectiveness of surgical treatments by the delivery of multidisciplinary integrated medical care. New strategies to deliver this aim include preoperative risk stratification using a frailty index and cardiopulmonary exercise testing for patients undergoing intra-abdominal surgery (including radical cystectomy), preoperative management of iron deficiency and anemia, and preoperative exercise intervention. Proof of the utility and validity for improving surgical outcomes through advances in preoperative care is still evolving. Evidence-based developments in this field are likely to benefit patients undergoing major urological surgery, but further research targeted at high-risk patients undergoing specific urological operations is required.
Routine Antibiotic Prophylaxis Is Not Required for Patients Undergoing Shockwave Lithotripsy: Outcomes from a National Shockwave Lithotripsy Database in New Zealand.
PURPOSE: To assess the effectiveness of routine prophylactic antibiotics in the prevention of urinary tract infection (UTI) after extracorporeal shockwave lithotripsy (SWL) and identify predictors of UTI development in a multicenter series of over 10,000 stone cases treated in New Zealand over a 20-year period. MATERIALS AND METHODS: Patients treated with SWL on the Mobile Medical Technology vehicle between June 19, 1995 and December 1, 2014 were identified. Data collection was undertaken prospectively for patient, stone and treatment characteristics, and, retrospectively, for treatment outcomes. The primary outcome was clinical UTI, defined as development of UTI symptoms requiring antibiotic therapy. Secondary outcomes included urinary sepsis, need for hospital admission due to infectious complications, and length of hospital stay. Multivariate analysis was undertaken to identify factors independently associated with the development of post-SWL UTI. RESULTS: Antibiotic prophylaxis was used in 62.1% (n = 6710) of cases. On comparing patients who received prophylactic antibiotics to those in whom antibiotics were withheld, no significant differences were observed in terms of post-SWL UTI (1.1% vs 1.3%, p = 0.335) or urinary sepsis (0.04% vs 0.15%, p = 0.075). The use of prophylactic antibiotics was not independently associated with post-SWL UTI (OR: 1.269, 95% CI: 0.886-1.818, p = 0.194). Female gender, larger stone size, and higher number of delivered shocks were predictive of UTI development, but antibiotic prophylaxis did not appear to offer any benefit in this subgroup. CONCLUSIONS: Routine antibiotic prophylaxis was not associated with a reduction in clinical UTI after SWL in this cohort of over 10,000 stone cases in New Zealand.