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Background Biliary leaks and anastomotic strictures are common early anastomotic biliary complications (EABCs) following liver transplantation. However, there are no large multicentre studies investigating their clinical impact or risk factors. This study aimed to define the incidence, risk factors and impact of EABC. Methods The NHS registry on adult liver transplantation between 2006 and 2017 was reviewed retrospectively. Adjusted regression models were used to assess predictors of EABC, and their impact on outcomes. Results Analyses included 8304 liver transplant recipients. Patients with EABC (9·6 per cent) had prolonged hospitalization (23 versus 15 days; P, Early anastomotic biliary complications are common following liver transplantation. In this national registry analysis we show that these complications have a significant, independent, impact on graft loss and mortality following transplantation. We also identify a number of key risk factors for development of early anastomotic biliary complications.

Background Asthma is a highly prevalent chronic disease among Ontario children; however, the extent to which rural status and distance are associated with unplanned emergency department (ED) use by this population is largely unknown. Objective To explore the impact of rurality and geographical distance to primary and specialist care services on healthcare utilization by analyzing the use of unplanned ED services. Methods A population level retrospective cohort study of Ontario children ages 5–14 with newly diagnosed asthma was conducted using health administrative data from Institute for Clinical Evaluative Sciences (ICES). Adjusted logistic regression models were used to analyze the association between unplanned ED use with rural status and distance to general practitioner/family physician (GP/FP) and specialist healthcare services, while controlling for confounders. Results In total, 19,732 individuals met the inclusion criteria. Individuals who lived in rural locations (OR 2.00, 95% CI 1.64–2.44) and travelled >50 km to a GP/FP (OR 1.25, 95% CI 1.06–1.48) or specialist (OR 1.20, 95% CI 1.05–1.38) were more likely to utilize an ED. Conclusion Children with asthma utilize healthcare services differently based on rural status and distance to services. To ensure equitable access to care, there is a need to accommodate for these factors in the planning and provision of asthma healthcare services.

Previous Mendelian randomization (MR) studies on 25-hydroxyvitamin D (25(OH)D) and cancer have typically adopted a handful of variants and found no relationship between 25(OH)D and cancer; however, issues of horizontal pleiotropy cannot be reliably addressed. Using a larger set of variants associated with 25(OH)D (74 SNPs, up from 6 previously), we perform a unified MR analysis to re-evaluate the relationship between 25(OH)D and ten cancers. Our findings are broadly consistent with previous MR studies indicating no relationship, apart from ovarian cancers (OR 0.89; 95% C.I: 0.82 to 0.96 per 1 SD change in 25(OH)D concentration) and basal cell carcinoma (OR 1.16; 95% C.I.: 1.04 to 1.28). However, after adjustment for pigmentation related variables in a multivariable MR framework, the BCC findings were attenuated. Here we report that lower 25(OH)D is unlikely to be a causal risk factor for most cancers, with our study providing more precise confidence intervals than previously possible., Studies of the genetic association between vitamin D and cancer risk have typically been underpowered. Here the authors analyse this using Mendelian Randomisation with more than 70 vitamin D variants obtained from the UK Biobank and large-scale data from various consortia, confirming null associations between vitamin D and most cancers.

Restructuring of institutional long-term care was undertaken using predictions of future bed need with assumptions made on incidence rates of clients defined by type of disability, survival, and demographic changes. Recent substantial increase in the population rate of clients seeking placement across all degrees of disability, coincident with new facilities for those with modest disability, occurred. Consequently, more appropriate housing and supervised care beds, and more limited downsizing of nursing homes will be required.

Major urological complications (MUCs) after kidney transplantation contribute to patient morbidity and compromise graft function. The majority arise from the vesico-ureteric anastomosis and present early after transplantation. Ureteric stents have been successfully used to treat such complications. A number of centres have adopted a policy of universal prophylactic stenting, at the time of graft implantation, to reduce the incidence of urine leaks and ureteric stenosis. Stents are associated with specific complications and some centres advocate a policy of only stenting selected anastomoses.To examine the benefits and harms of routine ureteric stenting to prevent urological complications in kidney transplant recipients.We searched the Cochrane Central Register of Controlled Trials (CENTRAL in The Cochrane Library), MEDLINE, EMBASE, reference lists of articles, books and abstracts and contacted companies, authors and experts to identify relevant randomised controlled trials (RCTs).All RCTs and quasi-RCTs were included in our meta-analysis.Four reviewers assessed the trials for quality against four criteria (allocation concealment, blinding, intention-to-treat and completeness of follow-up). The primary outcome was the incidence of MUCs. Further outcomes of interest were graft and patient survival and the incidence of adverse events (urinary tract infection (UTI), haematuria, irritative symptoms, pain and stent migration). Statistical analyses were performed using the random effects model and the results expressed as relative risk (RR) with 95% confidence intervals (CI).Seven RCTs (1154 patients) of low or moderate quality were identified. The incidence of MUCs was significantly reduced (RR 0.24, 95% CI 0.07 to 0.77, P = 0.02, NNT 13) by universal prophylactic stenting. This was dependent on whether the same surgeon performed, or was in attendance, during the operations. Two patients lost their grafts to infective urinary tract complications in the stented group. UTIs, in general, were more common in stented patients (RR 1.49, 95% CI 1.04 to 2.15) unless the patients were prescribed cotrimoxazole 480 mg/d: in which case the incidence was equivalent (RR 0.97, 95% CI 0.71 to 1.33). Stents appeared generally well tolerated, although trials using longer stents (/= 20 cm) for longer periods (6 weeks) had more problems with encrustation and migration.Routine prophylactic stenting reduces the incidence of MUCs. Trials comparing selective stenting and universal prophylactic stenting, whilst difficult to design and analyse, would address the unresolved quality of life and economic issues.

Hypothermic machine perfusion preservation has been shown to improve the outcome of renal grafts from non-heartbeating donors. We have noticed that organs gain a variable amount of weight during perfusion.All grafts, whether used or discarded, were assessed with respect to their weight gain. Primary outcome measures were the results of viability testing. Secondary outcomes were early transplant variables including incidence and duration of delayed graft function and histological examination of protocol graft biopsies.Weight increase data was available on 97 grafts. There were no significant differences in weight gain between kidneys used and discarded (17% vs 20%). 14 patients received grafts which gained over 30% of their initial retrieval weight. There were no significant differences in secondary outcome measures between this group of recipients and patients who had received less "waterlogged" kidneys. Histological changes including endothelial inflammation and oedema were observed.Kidney grafts which have gained over 30% of weight on hypothermic machine perfusion preservation can be transplanted successfully. Complex interactions between the period of warm ischaemia, in situ flushing, perfusion pressures and perfusate probably lead to the phenomenon of excessive graft weight gain.

Transplantation using non-heart beating donors (NHBD) is one way of reducing the global kidney shortage. Unfortunately the large warm ischaemic insult sustained by the graft leads to a high rate of delayed graft function (DGF). We have investigated the use of a regimen utilising an II-2r blocker (DZB) in place of Tacrolimus for the initial post-operative immunosupression with the aim of reducing the incidence of DGF.Prospective randomised controlled trial based in two NHBD UK centres (Leicester and Newcastle). 51 patients were enrolled over two years and randomised into two treatment arms: 1. DZB/MMF/Steroids (Tacrolimus started when creatinine dropped below 350 micromol/l) 2. Tacro/MMF/Steroids.There was one death, during the study period, in a patient who had had a non-functioning graft removed. The overall incidence of immediate function (IF) was higher than expected (28%), no significant difference was found in the incidence of immediate graft function between the two groups (35% group 1 and 22% group 2). Sub-group analysis however has shown a significant advantage for the delayed introduction of Tacrolimus for machine perfused grafts (IF: 53% vs 13%, chi2 p=0.015). There was no difference in the rate of rejection.The delayed introduction of Tacrolimus reduces the incidence of DGF in machine-perfused NHBD kidney transplantation.

A young female with cerebral and left arm symptoms from the congenital subclavian steal syndrome is presented. Surgical correction was performed using an axillary-axillary bypass. Pre-operative noninvasive vascular evaluation demonstrated reversal of flow in the left carotid artery which was corrected postoperatively. There was complete relief of symptoms and equal upper extremity blood pressure. This report represents the first instance in which this extremely rare congenital disorder was fully evaluated with noninvasive vascular techniques, and the first to be treated with an extra-anatomical surgical approach.

Ibuprofen is a nonsteroidal drug with analgesic, antipyretic, and anti-inflammatory properties that was recently introduced for use in antiarthritis therapy in the United States. In a year-long double-blind multiclinic trial in 885 patients with rheumatoid arthritis, ibuprofen was at least as satisfactory as aspirin, considering both efficacy and tolerance. In the majority of patients, daily doses ranged from 800 to 1,600 mg of ibuprofen and 3 to 6 gm of aspirin. The drugs did not differ greatly in providing relief from arthritis symptoms, but ibuprofen was definitely better tolerated, especially in regard to gastrointestinal complaints. Seven percent of the ibuprofen group dropped out of the study because of adverse reactions, as compared with 16% of the aspirin group; 17% of the ibuprofen group and 31% of the aspirin group had gastrointestinal symptoms.

SUPPURATIVE arthritis remains a relatively frequent form of joint disease despite the introduction of antibacterial agents. Chartier et al 1 of the Mayo Clinic covered the period from 1939 to 1957 and reported 77 cases of suppurative arthritis. Ward et al 2 from the Massachusetts General Hospital concentrated on the ten-year period from 1954 to 1964, reporting a total of 24 cases. Our interest in suppurative arthritis began in January 1960, and from then until 1964 we have observed 42 cases of infectious arthritis at the three universityaffiliated hospitals in the Buffalo area. Case Material Cases of infectious arthritis due to gonococcus, meningococcus, fungi, or tuberculosis were excluded on the basis that these represented specific diseases. Also, cases of pyogenic joint infection from osteomyelitis, penetrating wounds, or by extension were excluded. These were considered different problems from ordinary septic arthritis because of the nature of the cause. As a result