Ethnic Minorities Have Equal Access to Bariatric Surgery in the UK and Ireland

Under-representation of ethnic minority groups in bariatric surgery rates has been reported in the USA. Ethnic minorities form 7.9 % of the UK population, but comparable data on provision of bariatric surgery for these groups have not previously been reported in the UK. We calculated an estimate of rates of bariatric surgery amongst ethnic groups in the UK and Ireland using data from the National Bariatric Surgery Registry and census data from the UK and Ireland. The number of procedures recorded per 1,000 morbidly obese patients was 5.2 for Caucasian patients, 5.2 for Asian patients and 5.2 for Black patients. The identical rates across different ethnic groups suggest that bariatric services are provided equitably in the UK, with ethnic minority groups achieving equal access.     

Exploratory Study of Apparent Diffusion Coefficient Histogram Metrics in Assessing Pancreatic Malignancy

PurposeTo evaluate whole-lesion 3D-histogram apparent diffusion coefficient (ADC) metrics for assessment of pancreatic malignancy.MethodsForty-two pancreatic malignancies (36 pancreatic adenocarcinoma [PDAC], 6 pancreatic neuroendocrine [PanNET]) underwent abdominal magnetic resonance imaging (MRI) with diffusion-weighted imaging before endoscopic ultrasound biopsy or surgical resection. Two radiologists independently placed 3D volumes of interest to derive whole-lesion histogram ADC metrics. Mann-Whitney tests and receiver operating characteristic analyses were used to assess metrics’ diagnostic performance for lesion histology, T-stage, N-stage, and grade.ResultsWhole-lesion ADC histogram metrics lower in PDACs than PanNETs for both readers (P ≤ .026) were mean ADC (area under the curve [AUC] = 0.787-0.792), mean of the bottom 10th percentile (mean_0-10) (AUC = 0.787-0.880), mean of the 10th-25th percentile (mean_10-25) (AUC = 0.884-0.917) and mean of the 25th-50th percentile (mean_25-50) (AUC = 0.829-0.829). For mean_10-25 (metric with highest AUC for identifying PDAC), for reader 1 a threshold > 0.94 × 10^?3 mm²/s achieved sensitivity 94% and specificity 83%, and for reader 2 a threshold > 0.82 achieved sensitivity 97% and specificity 67%. Metrics lower in nodal status ≥ N₁ than N₀ for both readers (P ≤ .043) were mean_0-10 (AUC = 0.789-0.822) and mean_10-25 (AUC = 0.800-0.822). For mean_10-25 (metric with highest AUC for identifying N₀), for reader 1 a threshold <1.17 achieved sensitivity 87% and specificity 67%, and for reader 2 a threshold <1.04 achieved sensitivity 87% and specificity 83%. No metric was associated with T-stage (P > .195) or grade (P > .215).ConclusionVolumetric ADC histogram metrics may serve as non-invasive biomarkers of pancreatic malignancy. Mean_10-25 outperformed standard mean for lesion histology and nodal status, supporting the role of histogram analysis.     

Screening for subclinical subclavian artery stenosis before coronary artery bypass grafting: Should we do it?

Atherosclerotic subclavian artery disease is detected in about 5% of patients referred for coronary artery bypass (CABG) surgery. The internal mammary artery, a branch of the subclavian artery, is the most frequently utilized graft to restore coronary circulation because of its longevity. Stenosis or occlusion of the subclavian artery can cause retrograde blood flow in the ipsilateral internal mammary artery, known as “steal,” compromising coronary circulation supplied by the graft. Steal may be asymptomatic or may result in symptoms of myocardial ischemia. Symptomatic subclavian artery stenosis post bypass is referred to as coronary subclavian steal syndrome post‐CABG. The incidence is not well defined, and the benefits of screening patients referred for CABG are not known. Despite the various modalities available to detect subclavian artery stenosis, current guidelines fail to provide guidance about screening high‐risk patients for this entity. Detection of subclavian artery disease prior to CABG can reduce complications posed by post‐mammary artery graft cardiac ischemia. This review discusses the utility of preoperative subclavian artery screening prior to CABG.     

Management of penile cancer patients during the COVID-19 pandemic: An eUROGEN accelerated Delphi consensus study

ObjectivesTo develop an international consensus on managing penile cancer patients during the COVID-19 acute waves. A major concern for patients with penile cancer during the coronavirus disease 2019 (COVID-19) pandemic is how the enforced safety measures will affect their disease management. Delays in diagnosis and treatment initiation may have an impact on the extent of the primary lesion as well as the cancer-specific survival because of the development and progression of inguinal lymph node metastases.Materials and methodsA review of the COVID-19 literature was conducted in conjunction with analysis of current international guidelines on the management of penile cancer. Results were presented to an international panel of experts on penile cancer and infection control by a virtual accelerated Delphi process using 4 survey rounds. Consensus opinion was defined as an agreement of ≥80%, which was used to reconfigure management pathways for penile cancer.ResultsLimited evidence is available for delaying penile cancer management. The consensus rate of agreement was 100% that penile cancer pathways should be reconfigured, and measures should be developed to prevent perioperative nosocomial transmission of COVID-19. The panel also reached a consensus on several statements aimed at reconfiguring the management of penile cancer patients during the COVID-19 pandemic.ConclusionsThe international consensus panel proposed a framework for the diagnostic and invasive therapeutic procedures for penile cancer within a low-risk environment for COVID-19.     

A Narrative Review of Common Uses of Ophthalmic Ultrasound in Emergency Medicine

BackgroundThe timely evaluation of ocular conditions in the emergency department (ED) can be difficult due to a general lack of specialized equipment, trained personnel, and the time-sensitive nature of emergent ocular conditions. Recently, the use of ocular point-of-care ultrasound (POCUS) has been shown to be particularly useful in the ED. POCUS can be used to promptly diagnose various ocular pathologies, which include ocular trauma, vitreous hemorrhage, central retinal artery occlusion, and retinal detachment.ObjectivesThis narrative review seeks to inform the reader of current literature regarding the use of POCUS for the assessment of various ocular emergencies in the ED. The goal of this review is to provide the emergency physician with succinct and up-to-date information and instruction regarding the current uses of POCUS for patients presenting with particular ocular emergencies. Ocular pathologies that are common (ocular trauma) or for which ultrasound is particularly useful (such as retinal detachment) are discussed. Other ocular pathologies are also briefly discussed, such as central retinal artery occlusion, which is a promising new application for ultrasound evaluation.DiscussionThere have been many studies that provide evidence for the utility of POCUS in the evaluation of trauma and other ocular pathologies, including vitreous hemorrhage, retinal detachment, and central retinal artery occlusion.ConclusionsOcular POCUS is a useful modality in the evaluation of acute ocular complaints in the ED. Emergency physicians should be aware of these findings and feel confident in the utility of ocular POCUS in the ED.     

Future Directions for Early Childhood Prevention of Mental Disorders: A Road Map to Mental Health,Earlier

Mental disorders are the predominant chronic diseases of youth, with substantial life span morbidity and mortality. A wealth of evidence demonstrates that the neurodevelopmental roots of common mental health problems are present in early childhood. Unfortunately, this has not been translated to systematic strategies for improving population-level mental health at this most malleable neurodevelopmental period. We lay out a translational Mental Health, Earlier road map as a key future direction for prevention of mental disorder. This paradigm shift aims to reduce population attributable risk of mental disorder emanating from early life, by preventing, attenuating, or delaying onset/course of chronic psychopathology via the promotion of self-regulation in early childhood within large-scale health care delivery systems. The Earlier Pillar rests on a “science of when to worry” that (a) optimizes clinical assessment methods for characterizing probabilistic clinical risk beginning in infancy via deliberate incorporation of neurodevelopmental heterogeneity, and (b) universal primary-care-based screening targeting patterns of dysregulated irritability as a robust transdiagnostic marker of vulnerability to life span mental health problems. The core of the Healthier Pillar is provision of low-intensity selective intervention promoting self-regulation for young children with developmentally atypical patterns of irritability within an implementation science framework in pediatric primary care to ensure highest population impact and sustainability. These Mental Health, Earlier strategies hold much promise for transforming clinical outlooks and ensuring young children’s mental health and well-being in a manner that reverberates throughout the life span.