World First: Surgeons Restored A Man’s Sight By Operating a Robot Inside His Eye


Doctors from Oxford have performed an eye operation using remote controlled robots. The use of the Preceyes surgical robot inside the eye opens the door for more precision operations using robots.

ROBOT SURGEON

The field of miniature robotics is revolutionizing the way we do surgeries. What was once done by huge machines or the trembling hands of a surgeon can now be done by the precise movements of robots.

That is exactly what happened to the field of eye surgery with this new development. Doctors from Oxford’s John Radcliffe Hospital have performed the first ever eye surgery using tiny robots that operated inside the eye.

While robot-assisted surgery is nothing new, these are often confined to large organs. This is because they lack the minute precision required in delicate environments such as the eye. Despite this, it was a robot who was operating on Revd Dr William Beaver, 70, an Associate Priest at St Mary the Virgin, Iffley, Oxford, who had a membrane 100th of a millimeter thick blocking his retina. He is the first patient ever to undergo this experimental procedure.

DELICATE PROCEDURES

The Preceyes surgical robot, developed by a Dutch medical robotics firm, was specifically designed for this sort of procedure. It is able to move precisely and adjust for the trembling of the surgeon’s hands controlling the robot. Preceyes is controlled using a joystick and touch-screen, and is monitored using microscope. In this particular surgery, it was controlled by Robert MacLaren, Professor of Ophthalmology, who was assisted by Dr Thomas Edwards, Nuffield Medical Fellow.

The robot features seven independent computer-controlled motors, which act like a mechanical hand that moves with a precision of 1000th of a millimeter in scale. Large movements of the joystick result in small movements of the robot, and has a “freezing” function that stops the robot when grip is lost on the joystick or when preparing for drug delivery. With the successful operation on Beaver, the field may open up to more robot assisted eye surgeries. But the ultimate goal is performing operations impossible with human operators.

“We can certainly improve on current operations, but I hope the robot will allow us to do new more complex and delicate operations that are impossible with the human hand,” says Prof Robert MacLaren, who led the procedure, to the BBC.

The Dangers of Science: Population Explosion, Antibiotic Resistance, and Medicine.


Many argue that science and technology are bringing us closer and closer to perfection. Of course there are a number of issues with pollutants and sustainability, but speaking specifically about modern medicine, few will deny how few we have come.  In fact, there are many scientists who predict that humans could be living to be 150 years old in the near future, some even assert that the first person who will live to be 150 has already been born.

Information via USDA report, which can be found here

And it’s all thanks to science.

Modern drugs that help us combat the flu, malaria, and a host of other health issues have drastically increased the lives of many around the world. Thanks to new drugs and medicine, each year the average life expectancy increases…even in the most depressing areas on Earth. However, is this truly a triumph? Or is it cause for some concern?

One issue associated with modern medicine is the increase in population. Although vast tracks of the planet are still uninhabited, humanity’s agriculture alone takes up a landmass equal to South America. As we continue to improve our medicine, the population of the planet is only going to increase…and so will our demand for natural resources. However, population isn’t the only thing that we need to be concerned about. One of the biggest concerns? We might not be able to use antibiotics for much longer. Yes, you read that right.

Oxford researchers recently conducted a study on antibiotic resistance and noted that, “Antibiotic resistance is subject to frequent press comment, with fears expressed that we shall soon ‘run out’ of antibiotics and that classical infections will regain their status as major sources of mortality. It is suggested, too, that a swathe of modern medical procedures—from transplants to immunosuppressive cancer management—may collapse, as each depends crucially on our ability to treat infection.” When interrogating the accuracy of these fears, the researchers found that, although the resistance landscape is not as bleak as it is sometimes painted, there is a cause for serious concern.

So, how did we get here?

One was is the introduction of antibiotics to livestock. Ultimately, bacteria are becoming more resilient to existing antibiotics because many farmers do not properly regulate the intake of what their animals receive. Instead, all animals are given the same drugs, regardless of whether this is actually necessary. This leads vast swaths of antibiotic resistant bacteria, which no longer have to compete with non-resistant bacteria. As such, the resistant bacteria flourish. This, in turn, leads to the antibiotic becoming ineffective when used in humans. This new epidemic is already becoming apparent in many situations, and many hospitals are struggling to cope with the rise in the number of infections that patients obtain, post operation, due to ineffective antibiotics.

To keep up with this epidemic, pharmaceutical companies must invest heavily into finding and testing new antibiotics that can fight against the ‘Super Bug’. Since some bacteria are resistant to some antibiotics naturally, scientists and working to extract what it is that allows them to have a resistance. Moreover, scientists are looking in deep ocean ridges, that harbor millions of bacteria, which they believe may help them discover a new antidote; however, it could be sometime until they find and test a suitable new antibiotic…which then would only treat against one type of bacteria. This is problematic, as  there are millions of bacteria that can significantly harm us.

Many say that the only way to overcome this epidemic is for governments to provide sufficient funding to the companies to enable them to continue researching.

The nuclear option for insulinomas.


Although insulinomas are rare tumours, they have fascinated clinicians for many years because of the variety in clinical presentation, close association between symptoms and biochemistry, and striking response to surgical cure. In a patient who is otherwise healthy, and in the absence of a history of diabetes mellitus, intermittent hypoglycaemia is usually attributable to inappropriate insulin activity.1 If other causes can be excluded—which is not always easy if, for example, patients are knowingly injecting insulin or taking drugs that stimulate insulin release—insulinoma should be seriously considered as a diagnosis. Diagnosis can be proven by confirmed hypoglycaemia in the presence of inappropriate insulin secretion; however, threshold criteria for measurements of glucose and insulin are somewhat controversial. Recent guidelines suggest that blood glucose concentrations should be lower than 3 mmol/L to be regarded as hypoglycaemia,1 but at the Churchill Hospital in Oxford, UK, we noted that this cutoff produced too many false positives and have reverted to a stricter threshold of 2·2 mmol/L. Equally, the inappropriate level of insulin in the presence of hypoglycaemia has been set at 3 mIU/L, but because insulin assays have become more specific, this crucial concentration of insulin has decreased. Indeed, we have reported a confirmed insulinoma in a patient with an insulin concentration of 2·7 mIU/L.2 As in other areas of endocrinology, improved assays have led to more difficult diagnostic decisions. However, a C-peptide concentration of more than 200 pmol/L is a useful and potentially robust determinant of inappropriate insulin secretion.

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After the diagnosis of insulinoma has been made, localisation of the tumour is the biggest challenge. Most tumours are benign and small, with almost all less than 2 cm in maximum diameter, so identification can be problematic. Previously, surgeons would operate and trust that they could feel the tumour by direct palpation, but nowadays this technique is rarely practised (although intraoperative ultrasound is still used). CT scanning has good resolution but the difference in tissue density might not allow clear discrimination of the tumour. We reported that MRI was the most sensitive discriminatory imaging technique, identifying about 75% of tumours, and this sensitivity might be improved with diffusion-weighted imaging.3 Other groups have emphasised the role of endoscopic ultrasound.4 Intra-arterial injection of calcium with measurement of hepatic vein insulin is often used, but is invasive and only regionalises rather than localises the tumour; however, it can help confirm an anatomically identified abnormality.3—5 Thus, a need remains for precise localisation of these tumours. Nuclear medicine has been suggested to be useful in this context because it depends on functional aspects rather than simple anatomical size, but somatostatin scintigraphy and 18F-fluorodeoxyglucose (18F-FDG) PET have not proved useful for these benign tumours.

In The Lancet Diabetes & Endocrinology, Emanuel Christ and colleagues6 ingeniously speculated that because most insulin cells contain receptors for incretins—specifically the glucagon-like peptide-1 receptor (GLP-1R)—injection of radiolabelled exendin-4, a GLP-1R agonist, might identify these tumours where other techniques have failed. Following on from an initial pilot study7 showing the feasibility of this technique, the group now report on 30 patients who were referred for exendin-4 scanning in centres in Switzerland, Germany, and the UK. All patients had either no lesion or only a suspicion of one on CT or MRI scanning, to exclude patients with evidence of malignant insulinoma. Christ and colleagues were able to report on 25 patients who had histological confirmation of insulinoma after surgery; of these, 23 had both CT/MRI and 111In-DTPA-exendin-4 scanning.6 CT/MRI correctly identified 47% (95% CI 27—68) of insulinomas in this study and endoscopic ultrasound correctly diagnosed seven of nine patients assessed using this technique. 111In-DTPA-exendin-4 scanning was 95% (75—100) sensitive, and was the only modality to correctly identify the tumour in all ten instances of histologically confirmed insulinoma where the other imaging was negative, although there were four false positives. Patients had a mean fall in blood glucose concentrations of 1·3 mmol/L (IQR 0·8—2·1) during the study so glucose infusions are required with the technique. Notably, the investigators used a different chelating agent, DPTA, in this study than in previous studies,7 which might cause fewer side effects (such as nausea and hypoglycaemia).

The radiotracer technique seems to be less effective for malignant tumours than benign tumours (radiolabelled octreotide might be more useful) and is not yet commercially available.8 However, it might allow for the identification of tumours not otherwise readily visualised, and should decrease the number of blind laparotomies, decreasing surgical morbidity, and could also allow for an increased rate of laparoscopic removal. Furthermore, some 5—10% of these tumours are a manifestation of multiple endocrine neoplasia type 1 (MEN1), in which multiple lesions frequently occur in the pancreas and identification of insulinomas is difficult. In Christ and colleagues’ study, two patients had MEN1 and their insulinomas were identified and successfully removed after 111In-DTPA-exendin-4 scanning.

A few points warrant emphasis. All patients in the study were selected for inclusion and had uncertain imaging, and at some point a direct comparison against optimum MRI and possibly endoscopic ultrasound and calcium-stimulated venous catheterisation should be done. At the moment, the new radiotracer technique is probably best reserved for those cases in which conventional localisation techniques have not worked. In time, PET isotopes might become available that are more sensitive and can reduce scan times (although whether this would work well for the pancreas is unknown). Endocrinologists should nevertheless regard the nuclear technique as offering great potential benefit to our patients in the future.

Source: Lancet

Effect of thrombolysis with alteplase within 6 h of acute ischaemic stroke on long-term outcomes (the third International Stroke Trial [IST-3]): 18-month follow-up of a randomised controlled trial.


Background

Few data are available from randomised trials about the effect of thrombolysis with alteplase on long-term functional outcome in patients who have had acute ischaemic stroke and no trial has reported effects on health-related quality of life. A secondary objective of the third International Stroke Trial (IST-3) was to assess the effect of thrombolysis on such outcomes at 18 months.

Methods

In this open-label, international, multicentre, randomised, controlled trial, 3035 patients with ischaemic stroke from 12 countries were randomly allocated within 6 h of onset via a secure central system to either intravenous alteplase (0·9 mg/kg; n=1515) plus standard care or standard care alone (control; n=1520). 2348 patients were scheduled for 18-month follow-up. For our main analysis, survivors were assessed at 18 months with the Oxford handicap scale (OHS; the primary outcome was the adjusted odds of OHS score 0—2). We also used the EuroQoL (EQ) instrument and asked questions about overall functioning and living circumstances. We analysed the OHS and the five EQ domains by ordinal logistic regression and calculated the mean difference between treatment groups in EQ utility index and visual analogue scale score. Analyses were adjusted for key baseline prognostic factors. This study is registered with controlled-trials.com, number ISRCTN25765518.

Findings

At 18 months, 408 (34·9%) of 1169 patients in the alteplase group versus 414 (35·1%) of 1179 in the control group had died (p=0·85). 391 (35·0%) of 1117 patients versus 352 (31·4%) of 1122 had an OHS score of 0—2 (adjusted odds ratio [OR] 1·28, 95% CI 1·03—1·57; p=0·024). Treatment was associated with a favourable shift in the distribution of OHS grades (adjusted common OR 1·30, 95% CI 1·10—1·55; p=0·002). Alteplase treatment was associated with significantly higher overall self-reported health (adjusted mean difference in EQ utility index 0·060; p=0·019). The differences between the groups in visual analogue scale score and the proportion living at home were not significant.

Interpretation

IST-3 provides evidence that thrombolysis with intravenous alteplase for acute ischaemic stroke does not affect survival, but does lead to statistically significant, clinically relevant improvements in functional outcome and health-related quality of life that are sustained for at least 18 months.

Source: Lancet

 

 

HPS2-THRIVE: Niacin therapy not beneficial for vascular disease.


Niacin, in combination with laropiprant, appears to provide no benefit and may have harmful effects in patients with vascular disease, researchers reported.

The 4-year HPS2-THRIVE study tested a combination of extended-release niacin 2 g plus laropiprant 40 mg (Tredaptive, Merck) compared with placebo in 25,673 patients at risk for CV events. In addition, all patients received simvastatin (Zocor, Merck), with or without ezetimibe (Zetia, Merck).

According to results presented at a late-breaking clinical trials session, the study did not meet the primary endpoint of reducing risk for a major vascular event, defined as a composite of nonfatal MI or CV-related death, stroke, or need for angioplasty or bypass surgery. Patients assigned extended-release niacin/laropiprant had a similar number of major vascular events compared with patients assigned placebo (13.2% vs. 13.7%; P=.29).

The extended-release niacin/laropiprant had increased rates of excess bleeding (2.5% vs. 1.9%) and infections (8% vs. 6.6%). In addition, serious adverse events were more prevalent with combination therapy, including new-onset diabetes (9.1% vs. 7.3%), diabetic complications (11.1% vs. 7.5%), indigestion and diarrhea (4.8% vs. 3.8%) and rashes (0.7% vs. 0.4%).

Data by the HPS2-THRIVE Collaborative Group published in European Heart Journal in early March revealed that by the end of the study 25% of patients assigned combination therapy had stopped treatment compared with 17% of patients assigned placebo.

“A striking finding from the study was a significant excess [in adverse events] among people who were allocated the niacin preparation. The excess represents a 3% absolute excess, which means 30 patients for every 1,000 treated patients had at least one side effect,” Jane Armitage, FFPH, FRCP,professor at the University of Oxford, United Kingdom, said at a press conference.

“It was a disappointing result but, nevertheless, these are clear and reliable results from a large study.”

 

PERSPECTIVE

 

Christie M. Ballantyne

  • We confirmed that using niacin in well-treated patients on statins with low LDL does not have a benefit. That was a very common use for this medicine. The other important point this study nails down is that the adverse effects of niacin in extended release were considerable. If we are going to use the drug in patients with high LDL, we have to think about the modest benefits and risks.
  • Christie M. Ballantyne, MD
  • Professor of Medicine
    Baylor College of Medicine

    • Source: Endocrine Today.

 

Moderate drinking in pregnancy ‘harms IQ’.


Current government advice is to avoid drinking alcohol during pregnancy

Drinking one or two glasses of wine a week during pregnancy can have an impact on a child’s IQ, a study says.

Researchers from Oxford and Bristol universities looked at the IQ scores of 4,000 children as well as recording the alcohol intake of their mothers.

They found “moderate” alcohol intake of one to six units a week during pregnancy affected IQ.

Experts said the effect was small, but reinforced the need to avoid alcohol in pregnancy.

Previous studies have produced inconsistent and confusing evidence on whether low to moderate levels of alcohol are harmful in pregnancy, largely because it is difficult to separate out other factors that may have an effect such as the mother’s age and education.

But this research, published in the PLOS One journal, ruled that out by looking at changes in the genes that are not connected to social or lifestyle effects.

‘Why take the risk?’

The study found that four genetic variants in alcohol-metabolising genes in children and their mothers were strongly related to lower IQ at age eight.

On average, the child’s IQ was almost two points lower per genetic modification they possessed.

But this effect was only seen among the children of women who drank between one and six drinks a week during pregnancy and not among women who abstained when they were pregnant.

The researchers said although a causal effect could not be proven, the way they had done the study strongly suggested that it was exposure to alcohol in the womb that was responsible for the differences in child IQ.

Dr Ron Gray, from Oxford University, who led the research added that although the differences appeared small, they may well be significant and that lower IQ had been shown to be associated with being socially disadvantaged, having poorer health and even dying younger.

“It is for individual women to decide whether or not to drink during pregnancy, we just want to provide the evidence.

“But I would recommend avoiding alcohol. Why take the risk?”

A Department of Health spokesman said that since 2007 their advice had been that women who are trying to conceive or are pregnant should avoid alcohol.

But Dr Clare Tower, consultant in obstetrics and fetal maternal medicine, at St Mary’s Hospital, Manchester, stressed that women who have had the occasional alcoholic drink in pregnancy should not be overly alarmed by the findings.

“Current UK advice is that the safest course of action is abstinence during pregnancy.

“The finding of this study would concur that this is undoubtedly the safest advice.”

But she pointed out that another recent study had found no effect on IQ at five years.

“It is likely therefore, that any impact is likely small and not seen in all women.”

Source: BBC