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Laparoscopic Adjustable Gastric Banding is one of the cardinal bariatric interventions and due to its early safety profile, became the mainstay. Major long-term complications of gastric banding include pouch-herniation-dilation and gastric erosion. A 59-year-old female presented to the emergency department with a 2-week history of progressive central abdominal pain and distention on a background history of a laparoscopic adjustable band insertion 11 years previously. Subsequent computed tomography demonstrated an intragastric band erosion. An exploratory laparotomy demonstrated a gastric band eroded through the stomach sealed by a biofilm. Secondary findings included small bowel ischemia and portal vein thrombosis. The gastric band was extracted, and the stomach was repaired. The ischemic small bowel was resected with primary anastomosis. The patient recovered uneventfully. Gastric band erosion should be considered in all patients presenting with abdominal pain and previous weight loss surgery. Prompt recognition may avoid fatal consequences.

Successive reports have put childcare costs in Ireland at among the highest in the OECD. In this paper we investigate the usage and cost of childcare in Ireland, profiling those experiencing high childcare costs by income quintile, family type and number and age of children. We show how the National Childcare Scheme is likely to improve the affordability of childcare in Ireland while pointing out features of the scheme that may disincentivise work. Lastly, we simulate a number of reforms to the National Childcare Scheme, showing how affordability and incentives to work are likely to be affected by the alteration of specific parameters of the subsidy.

Recent diving with the JAMSTEC Shinkai 6500 manned submersible in the Mariana fore arc southeast of Guam has discovered that MORB‐like tholeiitic basalts crop out over large areas. These “fore‐arc basalts” (FAB) underlie boninites and overlie diabasic and gabbroic rocks. Potential origins include eruption at a spreading center before subduction began or eruption during near‐trench spreading after subduction began. FAB trace element patterns are similar to those of MORB and most Izu‐Bonin‐Mariana (IBM) back‐arc lavas. However, Ti/V and Yb/V ratios are lower in FAB reflecting a stronger prior depletion of their mantle source compared to the source of basalts from mid‐ocean ridges and back‐arc basins. Some FAB also have higher concentrations of fluid‐soluble elements than do spreading center lavas. Thus, the most likely origin of FAB is that they were the first lavas to erupt when the Pacific Plate began sinking beneath the Philippine Plate at about 51 Ma. The magmas were generated by mantle decompression during near‐trench spreading with little or no mass transfer from the subducting plate. Boninites were generated later when the residual, highly depleted mantle melted at shallow levels after fluxing by a water‐rich fluid derived from the sinking Pacific Plate. This magmatic stratigraphy of FAB overlain by transitional lavas and boninites is similar to that found in many ophiolites, suggesting that ophiolitic assemblages might commonly originate from near‐trench volcanism caused by subduction initiation. Indeed, the widely dispersed Jurassic and Cretaceous Tethyan ophiolites could represent two such significant subduction initiation events.

Introduction Gastrointestinal bleeding results in significant morbidity, cost and mortality. TXA, an antifibrinolytic agent, has been proposed to reduce mortality; however, many studies report conflicting results. Methods The aim of the study was to perform the first systematic review and meta-analysis of RCTs to evaluate the efficacy TXA for both upper and lower gastrointestinal bleeding. This was performed per PRISMA guidelines. PubMed, EMBASE, Cochrane and Scopus databases were searched for RCTs. Dichotomous variables were pooled as risk ratios (RR) with 95% confidence intervals (CI) using the MH method with random effects modelling. Results Fourteen RCTs were identified with 14,338 patients and mean age of 58.4 years. 34.9% ( n  = 5008) were female and 65.1% ( n  = 9330) male. There was no significant difference in mortality between TXA and placebo (RR 0.86 95% CI (0.74 to 1.00), P : 0.05). The secondary outcomes, similarly, did not yield significant results. These included rebleeding, need for surgical intervention (RR: 0.75 95% CI (0.53, 1.07)), endoscopic intervention (RR: 0.92 95% CI (0.70, 1.22)), transfusion requirement (RR: 1.01 95% CI (0.94, 10.7)) and length of stay (RR: 0.03 95% CI (− 0.03, 0.08)). There was no increased risk of VTE, RR: 1.29 95% CI (0.53, 3.16). One trial ( n  = 12,009) reported an increased risk of seizure in the TXA group, RR: 1.73 95% CI (1.03–2.93). Conclusion TXA does not reduce mortality in patients with acute upper or lower gastrointestinal bleeding and may confer an increased risk of seizures. The authors do not recommend the use of TXA in acute gastrointestinal bleeding.

Purpose Use of neoadjuvant chemotherapy (NAC) for locally advanced colon cancer (LACC) remains controversial. An integrated analysis of data from high-quality studies may inform the long-term safety of NAC for this cohort. Our aim was to perform a systematic review and meta-analysis of randomised clinical trials (RCTs) and propensity-matched studies to assess the oncological safety of NAC in patients with LACC. Methods A systematic review was performed as per preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. Survival was expressed as hazard ratios using time-to-effect generic inverse variance methodology, while surgical outcomes were expressed as odds ratios (ORs) using the Mantel-Haenszel method. Data analysis was performed using Review Manager version 5.4. Results Eight studies (4 RCTs and 4 retrospective studies) including 31,047 patients with LACC were included. Mean age was 61.0 years (range: 19–93 years) and mean follow-up was 47.6 months (range: 2–133 months). Of those receiving NAC, 4.6% achieved a pathological complete response and 90.6% achieved R0 resection (versus 85.9%, P  < 0.001). At 3 years, patients receiving NAC had improved disease-free survival (DFS) (OR: 1.28, 95% confidence interval (CI): 1.02–1.60, P  = 0.030) and overall survival (OS) (OR: 1.76, 95% CI: 1.10–2.81, P  = 0.020). When using time-to-effect modelling, a non-significant difference was observed for DFS (HR: 0.79, 95% CI: 0.57–1.09, P  = 0.150) while a significant difference in favour of NAC was observed for OS (HR: 0.75, 95% CI: 0.58–0.98, P  = 0.030). Conclusion This study highlights the oncological safety of NAC for patients being treated with curative intent for LACC using RCT and propensity-matched studies only. These results refute current management guidelines which do not advocate for NAC to improve surgical and oncological outcomes in patients with LACC. Trial registration International Prospective Register of Systematic Review (PROSPERO) registration: CRD4202341723.

Introduction The 12-gene recurrence score (RS) is a clinically validated assay which predicts recurrence risk in patients with stage II/III colon cancer. Decisions regarding adjuvant chemotherapy may be guided using this assay or based on the judgement of tumour board. Aims To assess the concordance between the RS and MDT decisions regarding adjuvant chemotherapy in colon cancer. Methods A systematic review was performed in accordance with PRISMA guidelines. Meta-analyses were performed using the Mantel–Haenszel method using the Review Manager version 5.4 software. Results Four studies including 855 patients with a mean age of 68 years (range: 25–90 years) met inclusion criteria. Overall, 79.2% had stage II disease (677/855) and 20.8% had stage III disease (178/855). For the entire cohort, concordant results between the 12-gene assay and MDT were more likely than discordant (odds ratio (OR): 0.38, 95% confidence interval (CI): 0.25–0.56, P  < 0.001). Patients were more likely to have chemotherapy omitted than escalated when using the RS (OR: 9.76, 95% CI: 6.72–14.18, P  < 0.001). For those with stage II disease, concordant results between the 12-gene assay and MDT were more likely than discordant (OR: 0.30, 95% CI: 0.17–0.53, P  < 0.001). In stage II disease, patients were more likely to have chemotherapy omitted than escalated when using the RS (OR: 7.39, 95% CI: 4.85–11.26, P  < 0.001). Conclusions The use of the 12-gene signature refutes the decision of tumour board in 25% of cases, with 75% of discordant decisions resulting in omission of adjuvant chemotherapy. Therefore, it is possible that a proportion of such patients are being overtreated when relying on tumour board decisions alone.

Purpose Colorectal cancer (CRC) is a clinically diverse disease whose molecular etiology remains poorly understood. The purpose of this study was to identify miRNA expression patterns predictive of CRC tumor status and to investigate associations between microRNA (miRNA) expression and clinicopathological parameters. Methods Expression profiling of 380 miRNAs was performed on 20 paired stage II tumor and normal tissues. Artificial neural network (ANN) analysis was applied to identify miRNAs predictive of tumor status. The validation of specific miRNAs was performed on 102 tissue specimens of varying stages. Results Thirty-three miRNAs were identified as differentially expressed in tumor versus normal tissues. ANN analysis identified three miRNAs ( miR-139-5p , miR-31 , and miR-17-92 cluster) predictive of tumor status in stage II disease. Elevated expression of miR-31 ( p  = 0.004) and miR-139-5p ( p  < 0.001) and reduced expression of miR-143 ( p  = 0.016) were associated with aggressive mucinous phenotype. Increased expression of miR-10b was also associated with mucinous tumors ( p  = 0.004). Furthermore, progressively increasing levels of miR-10b expression were observed from T1 to T4 lesions and from stage I to IV disease. Conclusion Association of specific miRNAs with clinicopathological features indicates their biological relevance and highlights the power of ANN to reliably predict clinically relevant miRNA biomarkers, which it is hoped will better stratify patients to guide adjuvant therapy.

Equipment needed Equipment needed are McGill forceps, lubrication jelly, 2x60 cc syringes with a luer lock, one large bladder irrigation syringe, a sphygmomanometer or any other hand-held device for measuring pressure, and contrast with water for insertion into the gastric balloon. Other options occasionally favoured in the USA include securing the SB tube to the rim of a helmet. 3 However, several users have described this as cumbersome in terms of nursing care. Learning points The combination of this traction method and ensuring a relatively low pressure is maintained in the oesophageal balloon has resulted in few/no pressure-related complications.

Abstract Background Healthcare-associated wastewater and asymptomatic patient reservoirs colonized by carbapenemase-producing Enterobacterales (CPE) contribute to nosocomial CPE dissemination, but the characteristics and dynamics of this remain unclear. Methods We systematically sampled wastewater sites (n = 4488 samples; 349 sites) and patients (n = 1247) across six wards over 6–12 months to understand blaKPC-associated CPE (KPC-E) diversity within these reservoirs and transmission in a healthcare setting. Up to five KPC-E-positive isolates per sample were sequenced (Illumina). Recombination-adjusted phylogenies were used to define genetically related strains; assembly and mapping-based approaches were used to characterize antimicrobial resistance genes, insertion sequences (ISs) and Tn4401 types/target site sequences. The accessory genome was evaluated in some of the largest clusters, and those crossing reservoirs. Results Wastewater site KPC-E-positivity was substantial [101/349 sites (28.9%); 228/5601 (4.1%) patients cultured]. Thirteen KPC-E species and 109 strains were identified using genomics, and 24% of wastewater and 26% of patient KPC-E-positive samples harboured one or more strains. Most diversity was explained by the individual niche, suggesting localized factors are important in selection and spread. Tn4401 + flanking target site sequence diversity was greater in wastewater sites (P < 0.001), which might favour Tn4401-associated transposition/evolution. Shower/bath- and sluice/mop-associated sites were more likely to be KPC-E-positive (adjusted OR = 2.69; 95% CI: 1.44–5.01; P = 0.0019; and adjusted OR = 2.60; 95% CI: 1.04–6.52; P = 0.0410, respectively). Different strains had different blaKPC dissemination dynamics. Conclusions We identified substantial and diverse KPC-E colonization of wastewater sites and patients in this hospital setting. Reservoir and niche-specific factors (e.g. microbial interactions, selection pressures), and different strains and mobile genetic elements likely affect transmission dynamics. This should be considered in surveillance and control strategies.

Healthcare-associated wastewater and asymptomatic patient reservoirs colonized by carbapenemase-producing Enterobacterales (CPE) contribute to nosocomial CPE dissemination, but the characteristics and dynamics of this remain unclear. We systematically sampled wastewater sites (  = 4488 samples; 349 sites) and patients (  = 1247) across six wards over 6-12 months to understand bla -associated CPE (KPC-E) diversity within these reservoirs and transmission in a healthcare setting. Up to five KPC-E-positive isolates per sample were sequenced (Illumina). Recombination-adjusted phylogenies were used to define genetically related strains; assembly and mapping-based approaches were used to characterize antimicrobial resistance genes, insertion sequences (ISs) and Tn types/target site sequences. The accessory genome was evaluated in some of the largest clusters, and those crossing reservoirs. Wastewater site KPC-E-positivity was substantial [101/349 sites (28.9%); 228/5601 (4.1%) patients cultured]. Thirteen KPC-E species and 109 strains were identified using genomics, and 24% of wastewater and 26% of patient KPC-E-positive samples harboured one or more strains. Most diversity was explained by the individual niche, suggesting localized factors are important in selection and spread. Tn + flanking target site sequence diversity was greater in wastewater sites (  < 0.001), which might favour Tn -associated transposition/evolution. Shower/bath- and sluice/mop-associated sites were more likely to be KPC-E-positive (adjusted OR = 2.69; 95% CI: 1.44-5.01;  = 0.0019; and adjusted OR = 2.60; 95% CI: 1.04-6.52;  = 0.0410, respectively). Different strains had different bla dissemination dynamics. We identified substantial and diverse KPC-E colonization of wastewater sites and patients in this hospital setting. Reservoir and niche-specific factors (e.g. microbial interactions, selection pressures), and different strains and mobile genetic elements likely affect transmission dynamics. This should be considered in surveillance and control strategies.