Chesterfield Royal Hospital NHS Foundation Trust

To report real-world outcomes for high-risk non-muscle-invasive bladder cancer (HRNMIBC), including bacillus Calmette-Guérin (BCG) and radical cystectomy (RC), as randomised comparisons of these have not been possible. We detail consecutive participants screened for the BRAVO randomised controlled trial comparing RC with BCG (International Standard Randomised Controlled Trial Number [ISRCTN]12509361). Patients were prospectively registered and case-note review used for outcomes. The primary outcome was overall survival. Secondary outcomes included recurrence, progression, metastasis, and bladder cancer-specific survival. A total of 193 patients were screened, including 106 (54.9%) who received BCG, 43 (22.3%) primary RC, 37 (19.2%) 'other' treatment and seven (3.6%) hyperthermic intravesical mitomycin C. All-cause death occurred in 55 (28.5%) patients at median (interquartile range [IQR]) of 29.0 (19.5-42.0) months. In multivariable analysis, overall mortality was more common in older patients (hazard ratio [HR] 2.63, 95% confidence interval [CI] 1.35-5.13; Cox P = 0.004 for age >70 years), those recruited from district hospitals (HR 0.53, 95% CI 0.3-0.95; P = 0.032) and those who did not undergo RC as their first treatment (HR 2.16, 95% CI 1.17-3.99; P = 0.014). In all, 17 (8.8%) patients died from bladder cancer (BC) at median (IQR) of 22.5 (19-36.25) months. In multivariable analysis, BC-specific mortality was more common in older patients (HR 4.87, 95% CI 1.1-21.6; P = 0.037) and those with Tis/T1 disease (HR 2.26, 95% CI 1.23-4.16; P = 0.008) but did not vary with initial treatment. Patients with HRNMIBC are at high-risk of mortality. Those choosing RC as their initial treatment have lower risks of mortality than others, although this may reflect fitness and selection.

Prevention of acute kidney injury (AKI) in the intensive care unit (ICU) is a management strategy with a multidisciplinary approach. Sepsis being the most common cause requires immediate treatment with antimicrobials. Other causes such as cardiogenic shock, postoperative cause, and drug-induced injury are not infrequent in diabetic patients. Control of blood sugar and accompanying electrolyte abnormalities requires expertise. Contrast use is necessary in ICU patients which adds insult to the injury. A point-of-care ultrasound is a mandatory imaging for evaluation of the kidneys and to assess for inferior vena cava collapsibility. Nutrition plays an important component of the therapy, and fluid replacement and the use of vasopressors are necessary. Cardiac support with an intra-aortic balloon pump and extracorporeal membrane oxygenation with the ventricular-assisted device is necessary in maintaining hemodynamic status. Artificial intelligence and a new technological approach with a multidisciplinary team comprising a nephrologist, intensivist, cardiologist, hepatologist, infectious disease specialist, and nutritionist work as a team in preventing AKI in People with diabetes in the ICU.

Near infrared autofluorescence (NIRAF) is a novel intraoperative technology that has shown promising results in the localisation of parathyroid glands (PGs) over the last decade. This study aimed to assess the potential utility of NIRAF in first time surgery for primary hyperparathyroidism (PHPT). An observational study over a period of 3 years in patients who underwent surgery for PHPT was designed. Data on the use of NIRAF and fluorescent patterns in different organs (thyroid and parathyroid) and parathyroid pathology (single versus multi-gland disease) were explored. In addition, cure rates and operating times were compared between the NIRAF and no-NIRAF groups to determine the potential value of NIRAF in this cohort. In 230 patients undergoing first time surgery for PHPT, NIRAF was used in 50 patients. Of these 50 patients, NIRAF was considered to aid parathyroid identification in 9 patients (18%). The overall cure rate at 6 months of follow-up was 96.5% (98% in NIRAF and 96.1% without NIRAF; p=1.0). The median (interquartile range) operating time was longer in the NIRAF arm at 102 minutes (74-120 minutes) compared to the no-NIRAF arm at 75 minutes (75-109 minutes); however, this difference was not statistically significant (p=0.542). Although the median parathyroid to thyroid (P/T) auto-fluorescence (AF) ratio was similar between single gland and multi gland disease (2.5 vs to 2.76; p=1.0), the P/T AF ratio correlated negatively with increasing gland weight (p=0.038). The use of NIRAF resulted in some potential "surgeon-perceived" benefit but did not lead to improvements in cure rates. The negative correlation between fluorescent intensity and gland weight suggests loss of fluorescence with pathology, which needs further investigation. Further studies on larger cohorts of patients, in depth analysis of fluorescence patterns between normal, adenomatous, and hyperplastic glands and evaluation of user experience are needed. Primary hyperparathyroidism, hyperparathyroidism, autofluorescence, near-infrared fluorescence, parathyroid glands, endocrine, surgery.

Background Falls among the adult population are a major global health concern with severe repercussions for individuals and healthcare systems. The purpose of this study was to investigate the prevalence and associated risk factors of falls in hospitalized patients in order to improve hospital care for elderly adults. Materials and methods The research was conducted at two institutions of tertiary care in Abbottabad, Pakistan. After extensive screening and obtaining informed consent, a total of 210 participants aged 50 and older were enrolled in the study. Mental status, history of falls, ambulation/elimination status, vision, gait/balance, systolic blood pressure, medication use, and predisposing diseases were evaluated using the Long Term Care Fall Risk Assessment Form. Additionally, the Dynamic Gait Index was utilized to evaluate various aspects of gait. Results 58.6% of participants reported a history of falls in the previous year, according to the findings. BMI, imbalance, vertigo, and fear of falling were significantly associated with an increased risk of falls in older individuals. The Long-Term Care Fall Risk Assessment, the Montreal Cognitive Assessment (MoCA), the Dynamic Gait Index (DGI), and the Mini-BESTest scores revealed that patients with a history of falls had inferior functional and cognitive outcomes. Falls were more common among individuals with a robust BMI, especially men. Conclusions The study results highlight the multifactorial nature of falls in the adult population and the need for targeted interventions to address modifiable risk factors. To enhance hospital care for high-risk patients, proactive fall prevention strategies, including regular risk assessments and individualized interventions, should be implemented. This study provides important insights into the prevalence and causes of accidents among hospitalized patients, particularly in developing nations such as Pakistan. ​​​​​​.

BackgroundIn health, women have a lower haemoglobin than men and their prevalence of both anaemia and iron deficiency may be higher, especially if they have heart failure. The erythropoietic response to iron might also differ between the sexes. We used data from a randomised trial (IRONMAN) of intravenous (IV) ferric derisomaltose (FDI) to investigate these issues.MethodsPatients with a diagnosis of heart failure, a left ventricular ejection fraction ≤45%, and either a TSAT <20% or serum ferritin <100 µg/L were included. Haemoglobin for women had to be in the range of 9-13 g/dL and for men 9-14g/dL. Patients were randomised to receive IV ferric derisomaltose (FDI) or not. Neither the patient nor investigator was blinded. The main endpoints of interest were changes in haemoglobin at 4 months and 12 months and the primary endpoint of the trial (the rate of the composite outcome of heart failure hospitalisations or cardiovascular death expressed as events per 100 patient-years). Analyses were conducted by intention to treat, stratified by sex. A further analysis was conducted for patients with a TSAT <20%.ResultsOf 1,137 patients randomised, 300 were women. Women and men were of similar age (73 vs 74 years), predominantly in NYHA class II, with similar values for NT-proBNP, LVEF, eGFR, ferritin and TSAT. However, haemoglobin was lower in women (11.8 [11.0 to 12.4] g/dL] compared to men (12.3 [11.3 to 13.0] g/dL).The increases in haemoglobin with FDI compared to control was similar for women at 4 months (+0.8 [+0.5 to +1.2] g/dL) and 12 months (+0.8 [+0.4 to +1.3] g/dL) compared to men ((+0.5 [+0.3 to +0.7] g/dL) and (+0.5 [+0.3 to +0.8] g/dL) respectively.The hazard ratio for the primary endpoint for men was 0.81 (0.63 to 1.03) and for women 0.77 (0.42 to 1.42), the wider confidence intervals reflecting the smaller population and fewer events. The results were similar when restricted to patients with a TSAT <20%.ConclusionsThe increase in haemoglobin with IV FDI and its effect on the primary endpoint rate are similar for men and women. 144 Table 1Prevalence of iron deficiency and response to IV iron according to sex in a randomised trial of intravenous iron (IRONMAN)malefemaleBaselineN= 837300Age74 (67,80)72 (65,78)NYHA II (%)479 (57)169 (56)CADNT-proBNP1785(936,3788)N=4231414(780,2659)N=142BNP414 (212,715)N=152285 (188,598)N=45TSAT 16 (11,20)15 (10,19)Ferritin52 (31,87)42 (27,79)LVEF33 (25, 37)35 (27,39)eGFR51 (38,69)51 (39,68)Haemoglobin Baseline12.3(11.3,13.0)11.8(11.0,12.4)Follow-upUCFDIDiff/RRUCFDIDiff/RRHaemoglobin month 412.4(1.5)12.9(1.4)0.5(0.3,0.7)11.7(1.1)12.6(1.3)0.9(0.6,1.2)Haemoglobin month 1212.6 (1.7)13.1 (1.4)0.6 (0.3,0.8)11.7(1.1)12.4 (1.4)0.7(0.3,1.1)Delta haemoglobin month 40.2 (1.3)0.8(1.3)0.5(0.3,0.7)0.1(1.0)0.9(1.5)0.8(0.5,1.2)Delta haemoglobin month 120.3 (1.6)0.9 (1.4)0.5 (0.3,0.8)-0.0 (1.2)0.8 (1.5)0.8 (0.4,1.3)Primary Endpoint recurrent events, rate (per 100 patient years) and rate ratio. All314 (29.8)257 (23.5)0.81 (0.63,1.03)148 (21.3)129 (17.4)0.77 (0.42,1.42)TSAT <20%TSAT <20% onlymalefemaleBaselineN= 629238Age74 (67,79)73 (65,78)NYHA II (%)336 (53)129 (54)CADNT-proBNP1986(1001,4241)N=2941492(802,2954)N=107BNP440 (220,726)N=121302(194,608) n-36TSAT 13(9,17)13(9,16)Ferritin51 (29,104)39 (24,81)LVEF31 (25,36)35(27,39)eGFR51(37,68)51(39,68)Haemoglobin Baseline12.1(11.1,12.9)11.7(10.8,12.3)Follow-upUCFDIDiff/RRUCFDIDiff/RRHaemoglobin month 412.3(1.5)12.9(1.5)0.6 (0.3,0.9)11.7(1.1)12.7(1.4)0.9(0.6,1.3)Haemoglobin month 1212.6 (1.8)13.1(1.4)0.6(0.2,0.9)11.7(1.2)12.4(1.5)0.7(0.3,1.2)Delta haemoglobin month 40.3(1.3)1.0(1.4)0.7(0.4,0.9)0.2(1.0)1.2(1.6)1.0(0.6,1.4)Delta haemoglobin month 120.5(1.8)1.1(1.4)0.6(0.2,0.9)0.1(1.2)1.0(1.6)1.0(0.5,1.5)Primary Endpoint recurrent events, rate (per 100 patient years) and rate ratio.240(32.6)191(24.1)0.75(0.57,1.00)84(23.1)63(22.5)0.94(0.55,1.63)Conflict of InterestNone