Birmingham General Hospital

BackgroundBariatric surgery is an effective treatment for obesity and type 2 diabetes mellitus (T2DM). Sleeve Gastrectomy (SG) and Roux-en-Y Gastric Bypass (RYGB) are the two most common procedures, but their outcomes in Middle Eastern populations are less well studied.ObjectiveTo describe and compare the three-year outcomes of T2DM remission after SG and RYGB in patients with BMI ≥35.MethodsThis was a retrospective cohort study of 162 patients with T2DM who underwent laparoscopic SG (n=84) or RYGB (n=78) at the Cleveland Clinic Abu Dhabi between 2017 and 2018. Patients were followed for at least three years. The main outcome was diabetes remission, defined as HbA1c <6.5% without glucose-lowering medication. We also examined changes in medication use and differences between males and females.ResultsThe age range of patients was 39-74 years for the SG group and 41-72 years for the RYGB group, with no significant difference between them. At three years, 39.3% of patients who had SG and 52.6% of those who had RYGB achieved remission. Among patients on insulin at baseline, 30.0% (SG) and 37.9% (RYGB) went into remission. About half of the insulin users in each group were able to switch to oral medications only, and fewer remained on insulin after RYGB (13.8%) compared with SG (20.0%). In patients using only oral agents before surgery, remission was more frequent after RYGB (61.2%) than SG (44.4%). Remission rates were similar between men and women, indicating that gender did not significantly influence outcomes.ConclusionBoth SG and RYGB were associated with remission of T2DM at three years in patients with BMI ≥35, with a higher proportion of remission observed after RYGB. Gender did not appear to affect outcomes.

Abortion is a common pregnancy outcome; in the UK 1 in 3 women will have an abortion by the age of 45. Despite women making up 11.7% of the UK Armed Forces (AF) there have been countless reports of their gender-specific health needs not being addressed by the UKAF. There is a worldwide absence of literature and policy on abortion-care in the AF, including rates and experiences. This survey addresses the paucity of data on abortion experiences in UK servicewomen to ensure the UKAF is providing the best possible care. A REDCap survey was circulated among UK servicewomen via social media networks, and snowball distribution was encouraged to widen participation. Quantitative data was used for descriptive statistics and qualitative data was analysed iteratively by authors, with regular meetings to agree on themes. 427 servicewomen responded: 29% declared they previously had an abortion, with 78.5% of those being during military service and 11% required while on deployment. Four key themes emerged: 'Trust in information holders', 'Influencers, barriers and access', 'Systemic lack of awareness' and 'Life in the military'. This is the first study to collect data on UK Servicewomen's experience around abortion-care and highlights a complex interplay of factors which may influence abortion-care decisions. Stigma and judgement were pervasive threads running through all themes, negatively impacting UKAF women. Evidence-based policies and information on abortion are recommended for both servicepeople and healthcare professionals to facilitate access to abortion and begin to destigmatise it in the AF.

Introduction. The succenturiate lobe is a morphological variation of the placenta that usually appears as a separate lobe from the main placental disc and can be single or multiple. This incidence increases when there is a history of pelvic infection, infertility, twin pregnancies, or preeclampsia. As for the product, it can present prematurity, growth disorder, and surgical resolution of pregnancy. Clinical case. Female, 30 years old, with the following obstetric history, menarche 15 years, rhythm 28X5 days, dysmenorrhea, IVSA: 15 years-old, Pregnancies 3, births one, 5 years-old, abortion one in the first trimester, cesarean section one. Emergency with detects blood pressure 154/90 mmhg, second take 166/93 mmhg. The diagnosis of pregnancy of 29.4 weeks of gestation by first-trimester ultrasound, preeclampsia is integrated. Among the surgical findings, a violaceous uterus is observed on the anterior and anterior sides, with clinical data of hematic infiltration secondary to placental abruption grade 1, Placenta with a succenturiate lobe Discussion. Placental anomalies are rare because they have a low incidence and in most cases, their diagnosis is made after delivery, however, they can cause problems in the third stage of labor such as placental retention or postpartum hemorrhage, the latter because the accessory vessels can rupture and compromise the viability of the product or during delivery, the accessory lobe can be retained causing hemorrhage and compromising the life of the mother. Conclusions: The antenatal diagnosis of placental anomalies is important because it allows these patients to be classified and considered as high-risk pregnancies.

Coronavirus disease 2019 (COVID-19 - severe acute respiratory syndrome coronavirus 2 {SARS-CoV-2}) infection has been associated with thromboembolic events and coagulopathy, leading to a surge in the use of anticoagulants. The dose and duration of therapy differ according to the followed protocol. Several case reports documented fatal bleeding as an adverse effect of anticoagulation.We report a case of nearly fatal retroperitoneal bleed in an otherwise healthy 60-year-old man who developed severe COVID-19 requiring ICU stay and mechanical ventilation. The development of retroperitoneal bleed led to a 50% drop in his hemoglobin. The patient happens to be a Jehovah's Witness, and the family refused blood transfusion, which added to the complexity of the situation.Anticoagulation is associated with a potential risk of fatal bleed in critically ill COVID-19 patients. There are different protocols of anticoagulation in the management of SARS-CoV-2. The risk of bleeding vs thrombosis should be weighed on a case-by-case basis. A high degree of suspicion, early intervention, and knowledge of alternatives to blood transfusion can improve outcomes.

BackgroundAmong patients with non–small-cell lung cancer (NSCLC), data on intratumor heterogeneity and cancer genome evolution have been limited to small retrospective cohorts. We wanted to prospectively investigate intratumor heterogeneity in relation to clinical outcome and to determine the clonal nature of driver events and evolutionary processes in early-stage NSCLC.MethodsIn this prospective cohort study, we performed multiregion whole-exome sequencing on 100 early-stage NSCLC tumors that had been resected before systemic therapy. We sequenced and analyzed 327 tumor regions to define evolutionary histories, obtain a census of clonal and subclonal events, and assess the relationship between intratumor heterogeneity and recurrence-free survival.ResultsWe observed widespread intratumor heterogeneity for both somatic copy-number alterations and mutations. Driver mutations in EGFR, MET, BRAF, and TP53 were almost always clonal. However, heterogeneous driver alterations that occurred later in evolution were found in more than 75% of the tumors and were common in PIK3CA and NF1 and in genes that are involved in chromatin modification and DNA damage response and repair. Genome doubling and ongoing dynamic chromosomal instability were associated with intratumor heterogeneity and resulted in parallel evolution of driver somatic copy-number alterations, including amplifications in CDK4, FOXA1, and BCL11A. Elevated copy-number heterogeneity was associated with an increased risk of recurrence or death (hazard ratio, 4.9; P=4.4×10−4), which remained significant in multivariate analysis.ConclusionsIntratumor heterogeneity mediated through chromosome instability was associated with an increased risk of recurrence or death, a finding that supports the potential value of chromosome instability as a prognostic predictor. (Funded by Cancer Research UK and others; TRACERx ClinicalTrials.gov number, NCT01888601.)

A 61-year-old woman attended the breast clinic with unresolving mastitis and an associated mass, following failed treatment with antibiotics. Triple assessment confirmed idiopathic granulomatous mastitis. Unresponsive to further conservative management and steroid therapy, she underwent surgical excision and made uneventful recovery. No evidence of recurrence was detected at 18 months follow-up.

Minor reactions to streptokinase are not uncommon, although the etiology is unknown. It is widely presumed, however, that these, like the more serious immune reactions, are antibody-mediated. We measured specific anti-streptokinase IgG, subclasses IgG1, IgG2, IgG3, IgG4 and IgE by ELISAs, haemagglutination, indirect Coombs' test and immunoblotting in six patients who developed reactions to streptokinase. Evidence of complement activation by streptokinase was sought by a haemolytic complement assay and by measurement of C3, C4 and C3d. The patients who reacted to streptokinase presented with low titres of anti-streptokinase IgG (median = 5; range 0-32) and IgG1 (median = 3; range 0-14). No evidence of any other IgG subclass was found, nor of specific anti-streptokinase IgE. Anti-streptokinase IgG1 was found to fix complement; patients who reacted to streptokinase were found to have low levels of total complement 1 year post reaction. Probable aggregates and fragments of human albumin (added stabilizer) were found in the streptokinase preparation and proved to be antigenic in some patients, but were not found to be related to the development of reactions. The findings suggest that patients who develop reactions to streptokinase cannot be predicted on the basis of antibody titres at presentation. Minor reactions to streptokinase would not appear to be antibody-mediated, although complement activation may be involved.