This review article aims to provide an overview of image-guided ablation of renal cell carcinoma (RCC) since it was first introduced in 1998. This will cover the background and rationale behind its ...development; an overview of the evidence for current thermal technology, such as heat-based, e.g., radiofrequency ablation (RFA), microwave ablation (MWA), and cold-based energies, e.g., cryoablation used; and summarise the published evidence regarding its treatment efficacy and oncological outcome. In addition, it aims to provide an insight into the potential role of the new non-thermal ablative technology, e.g., irreversible electroporation (IRE)/Nanoknife in image-guided ablation of RCC, as well as areas of challenge that will require further research and clinical evaluation to ensure delivery of a quality patient-centred interventional oncology (IO) service in image-guided ablation of RCC.
To characterise training for, and conduct of, image-guided liver tumour ablation amongst UK interventional radiologists.
A web-based survey of British Society of Interventional Radiology members was ...carried out between 31 August to 1 October 2022. Twenty-eight questions were designed, covering four domains: (1) respondent background, (2) training, (3) current practice, and (4) operator technique.
One hundred and six responses were received, with an 87% completion rate and an approximate response rate of 13% of society members. All UK regions were represented, with the majority from London (22/105, 21%). Seventy-two out of 98 (73%) were either extremely or very interested in learning about liver ablation during training, although levels of exposure varied widely, and 37/103 (36%) had no exposure. Performed numbers of cases also varied widely, between 1–10 cases and >100 cases per operator annually. All (53/53) used microwave energy, and most routinely used general anaesthesia (47/53, 89%). Most 33/53 (62%) did not have stereotactic navigation system, and 25/51(49%) always, 18/51 (35%) never, and 8/51(16%) sometimes gave contrast medium (mean 40, SD 32%) after procedures. Fusion software to judge ablation completeness was never used by 86% (43/55), sometimes used by 9% (5/55), and always used by 13% (7/55) of respondents.
Although there are high levels of interest in image-guided liver ablation amongst UK interventional radiologists, training arrangements, operator experience, and procedural technique vary widely. As image-guided liver ablation evolves, there is a growing need to standardise training and techniques, and develop the evidence base to ensure high-quality oncological outcomes.
•Most UK Interventional Radiologists are interested in learning liver ablation.•Training, operator experience and procedural technique vary widely.•Training and techniques should be standardised for improved outcomes.
BACKGROUNDNosocomial outbreaks of Candida auris, a multidrug-resistant fungus, are increasingly reported worldwide; the mode of transmission has usually been reported to be via direct contact. Some ...studies previously suggested potential short-distance air dispersal during high-turbulence activities, but evidence on long-range air dispersal remains scarce.AIMTo describe a C. auris nosocomial outbreak involving two wards (H7, 5E) in two local hospitals.METHODSSamples were taken from patients, ward surfaces (frequently touched items and non-reachable surfaces) while settle plates were used for passive air sampling to investigate possible contributions by direct contact and air dispersal. Epidemiological and phylogenetic analyses were also performed on the C. auris isolates from this outbreak.FINDINGSEighteen patients were confirmed to have asymptomatic C. auris skin colonization. C. auris was expectedly identified in samplings from frequently touched ward items but was also isolated in two samples from ceiling supply air grilles which were 2.4 m high and inaccessible by patients. Moreover, one sample from a corridor return air grille as far as 9.8 m away from the C. auris cohort area was also positive. Two passive air samplings were positive, including one from a cubicle with no confirmed cases for four days, suggesting possible air dispersal of C. auris. Whole-genome sequencing confirmed clonality of air, environment, and patients' isolates.CONCLUSIONThis is the first study to demonstrate potential long-range air dispersal of C. auris in an open-cubicle ward setting. Ventilation precautions and decontamination of out-of-reach high-level surfaces should be considered in C. auris outbreak management.
To gauge current final year medical students' exposure to interventional radiology (IR)and assess their perceptions of IR as a prospective career option.
An online questionnaire comprising of ...questions that gauge final-year medical students' understanding of and exposure to IR based on the recommendations set out by the British Society of Interventional Radiology (BSIR), was sent out to final-year students across 34 UK medical schools.
Five hundred and ten responses were collected from 33 out of 34 eligible medical schools. Sixty-four per cent of respondents rated their own IR knowledge as inadequate. On average, only 50% of all subtopics proposed in the BSIR undergraduate curriculum was covered during medical school and 32.7% of respondents were not exposed to any fundamental IR principles and techniques recommended by the BSIR during medical school. Regarding careers, 2.7% of respondents reported a definite interest in pursuing a career in IR. Most respondents (89.8%) felt that there was insufficient undergraduate teaching on IR and that they lacked information to consider pursuing a career in IR (87.5%).
Insufficient exposure and teaching on IR throughout medical schools have led to a lack of awareness and consideration of IR as a future career choice amongst UK medical students. The re-evaluation of IR teaching in the medical school curricula is needed. In the long-term, such recommendations could provide the much-needed solution to the workforce shortages seen in IR.
•64% of medical students rated their own IR knowledge as inadequate.•Only 50% of the BSIR undergraduate curriculum was covered in medical schools.•Most medical students felt that undergraduate teaching on IR is insufficient.•64.5% of medical students were less likely to consider a career in IR.•Medical students lacked information and resources on IR's career pathway.
The objective of our study is to determine the positive rate for urolithiasis in male and female patients, and evaluate whether there has been any change at our institution in the use and outcome of ...unenhanced multidetector CT (CT KUB) performed in the emergency department (ER) for patients presenting with suspected acute renal colic.
A retrospective review of all 1357 consecutive cases between August 2007 and August 2009 admitted to the ER and investigated with CT KUB.
The positive rate for urolithiasis was 47.5% and the rate of other significant findings was 10%. Female patients had a significantly lower positive rate than male patients (26.8% vs 61.6%, p<0.001). Urological intervention was required in 37% and these patients had a larger average stone size. In young female patients with a significantly sized ureteric calculus (>4 mm), the presence of hydronephrosis vs no hydronephrosis was 83% vs 17%, respectively. Among them, only three patients required ureteroscopy for stone removal.
Contrary to other studies there has been no "indication creep" in the use of CT KUB at our institution. However, the young female patient presenting with suspected urolithiasis presents a particular diagnostic problem, and the significant percentage of negative examinations in females implies that an improvement in current practice is needed. The indiscriminate use of CT KUB in all female patients with flank pain should be avoided, and it is suggested that they should be initially evaluated with ultrasound to detect the presence of hydronephrosis.
Over recent years a number of novel therapies have shown promise in advanced renal cell carcinoma (RCC). Internationally the standard of care of first-line therapy is sunitinib™, after a clear ...survival benefit was demonstrated over interferon-α. Convention dictates that sunitinib is continued until evidence of disease progression, assuming tolerability, although there is no evidence that this approach is superior to intermittent periods of treatment. The purpose of the STAR trial is to compare the standard treatment strategy (conventional continuation strategy, CCS) with a novel drug free interval strategy (DFIS) which includes planned treatment breaks.
The STAR trial is an NIHR HTA-funded UK pragmatic randomised phase II/III clinical trial in the first-line treatment of advanced RCC. Participants will be randomised (1:1) to either a sunitinib CCS or a DFIS. The overall aim of the trial is to determine whether a DFIS is non-inferior, in terms of 2-year overall survival (OS) and quality adjusted life years (QALY) (averaged over treatment and follow up), compared to a CCS. The QALY primary endpoint was selected to assess whether any detriment in terms of OS could be balanced with improvements in quality of life (QoL). This is a complex trial with a number of design challenges, and to address these issues a feasibility stage is incorporated into the trial design. Predetermined recruitment (stage A) and efficacy (stage B) intermediary endpoints must be met to allow continuation to the overall phase III trial (stage C). An integral qualitative patient preference and understanding study will occur alongside the feasibility stage to investigate patients' feelings regarding participation or non-participation in the trial.
The optimal duration of continuing sunitinib in advanced RCC is unknown. Novel targeted therapies do not always have the same constraints to treatment duration as standard chemotherapeutic agents and currently there are no randomised data comparing different treatment durations. Incorporating planned treatment breaks has the potential to improve QoL and cost effectiveness, hopefully without significant detriment on OS, as has been demonstrated in other cancer types with other treatments.
Controlled-trials.com ISRCTN 06473203.
Unenhanced helical CT for kidney, ureter and bladder (CT KUB) has become the standard investigation for renal colic. This study aims to determine the sensitivity of scout radiographs in detecting ...ureteric calculi using CT KUB as a standard reference.
A retrospective review of consecutive patients who presented with acute flank pain and were investigated using CT KUB. 201 patients with positive ureteric calculi were included. Two radiologists independently reviewed the scout radiographs with access to CT KUB images. Each observer recorded the presence or absence of calculi, location, size and mean Hounsfield units of each calculus.
203 ureteric calculi were analysed from 201 patients. The overall sensitivity of scout radiographs for Observer A was 42.3% and for Observer B 52.2%, with an interobserver reliability κ-value of 0.78. The significance of mean Hounsfield units and size between two groups of patients with visible stones and those not visible were tested; the p-value for both variables was <0.0001, which is statistically significant. The study found that calculi in the upper ureter and larger than 4 mm are more likely to be seen on the scout radiograph.
Usage of CT scout radiography should be encouraged and reported routinely in conjunction with CT KUB as a baseline for treatment follow-up.
Aim To establish whether non-contrast enhanced computed tomography (NCCT) renders the kidneys–ureters–bladder (KUB) radiograph redundant as the initial imaging investigation for suspected acute ...ureteric colic. Materials and methods The imaging investigations for 120 patients consecutively admitted to an emergency department-led clinical decisions unit (CDU) with suspected acute ureteric colic were retrospectively reviewed. A multidisciplinary meeting reviewed the findings and recommended that KUB radiographs should not be routinely performed prior to NCCT. Prospective assessment of 116 consecutive patients admitted over a comparable period was then undertaken. Results In the retrospective group, 61 (50.8%) patients had calculi to account for symptoms (positive NCCT) and 59 (49.2%) patients did not have stone disease (negative NCCT). Ninety (75%) patients had a KUB radiograph prior to NCCT. However, in 46 (38% of total) of these patients the NCCT was negative for stones, and therefore, they had been subjected to an unnecessary radiographic examination. These results prompted a change in practice. In the subsequent and prospectively studied group, preliminary KUB radiographs were performed in only 6% of the patients, with no significant change in the positive NCCT rate (50.8 versus 51.7%) or the total number of examinations performed (120 versus 116). Conclusion NCCT should be the initial imaging examination for acute ureteric colic. Up to 50% of patients with clinical suspicion do not have stone disease, and therefore, preliminary KUB radiographs with attendant radiation and cost implications are unjustified. Preliminary KUB radiographs can be omitted from the imaging pathway with no resultant indication creep or increase in demand for NCCT examinations.
Disgust is considered to be a fundamental affective state associated with triggering the behavioral avoidance of infection and parasite/pathogen threat. In humans, and other vertebrates, disgust ...affects how individuals interact with, and respond to, parasites, pathogens and potentially infected conspecifics and their sensory cues. Here we show that the land snail, Cepaea nemoralis, displays a similar “disgust-like” state eliciting behavioral avoidance responses to the mucus associated cues of infected and potentially infected snails. Brief exposure to the mucus of snails treated with the Gram-negative bacterial endotoxin, lipopolysaccharide (LPS), elicited dose-related behavioral avoidance, including acute antinociceptive responses, similar to those expressed by mammals. In addition, exposure to the mucus cues of LPS treated snails led to a subsequent avoidance of unfamiliar individuals, paralleling the recognition of and avoidance responses exhibited by vertebrates exposed to potential pathogen risk. Further, the avoidance of, and antinociceptive responses to, the mucus of LPS treated snails were attenuated in a dose-related manner by the oxytocin (OT) receptor antagonist, L-368,899. This supports the involvement of OT and OT receptor homologs in the expression of infection avoidance, and consistent with the roles of OT in the modulation of responses to salient social and infection threats by rodents and other vertebrates. These findings with land snails are indicative of evolutionarily conserved disgust-like states associated with OT/OT receptor homolog modulated behavioral avoidance responses to infection and pathogen threat.
•The gastrop Snails displays aversive and avoidance responses to the mucus of snails treated with LPS.•These “disgust-like” responses to infection threat are attenuated by an oxytocin antagonist.•Exposure to the mucus of LPS treated snails leads to the avoidance of unfamiliar snails.
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