Post-partum ALT increases are observed in 30% of HBsAg+ mothers and are also noticed in mothers administered nucleoside analogues (NA) to prevent mother-to-child transmission (MTCT). As such flares may be injurious we have studied the utility of novel and sensitive markers of cccDNA transcriptional activity [hepatitis B core-related antigen (HBcrAg) and pre-genomic (pg)RNA] to predict post-partum ALT flares in both NA treated and untreated HBsAg+ mothers.We aimed to evaluate the role of serum levels of HBcrAg and pgRNA in pregnancy to predict post-delivery ALT flares, their severity and by inference, a preference to continue on NA. Methods Plasma samples from 642 HBsAg-positive pregnant women were collected during 3rd trimester and at 6, 12, 24, 36 and 48 weeks post-partum. 103(16%) were HBeAg +; median age 31 years. Samples were tested for HBeAg, HBV DNA (Roche; IU/ml); quantitative HBsAg (Abbott Architect; log 10 IU/ml), HBcrAg levels (CLEIA Fujirebio; log 10 U/ml) and pgRNA concentrations (PCR assay Abbott Diagnostic; log 10 U/ml). 95/642(15%) mothers with HBV DNA concentrations >200,000 IU/ml started tenofovir prophylaxis from 28 weeks of gestation to prevent HBV MTCT. The ALT flares incidence and severe flares (defined as >10xULN) was correlated with HBcrAg and pgRNA in treated and untreated mothers. Results Untreated cohort: 106/547(19%) of untreated mothers developed a post-delivery flare, but none was severe. Higher pre-delivery HBV DNA, HBcrAg and pgRNA concentrations were observed in untreated mothers with postpartum ALT flares vs. mothers without a flare. Pregnancy ALT and HBsAg concentrations were similar in flare vs. no flare patients.NA treated cohort: Higher pre-delivery HBcrAg and pgRNA concentrations were observed in NA treated mothers with a post-partum flare. 80/95(84%) treated mothers stopped NA therapy post-partum (median 4 weeks). However no difference in flares incidence was observed in mothers discontinuing treatment vs. mothers who continued NA.[56/80(70%) vs 13/15(87%)]. Seven HBeAg-negative treated patients who stopped NA developed a severe ALT flare within 12 weeks post-delivery. High pre-delivery levels of HBcrAg (>7 log 10 U/ml) and pgRNA (>4 log 10 U/ml) were exclusive in mothers with severe flare, but no flares were associated with hepatic synthetic dysfunction and resolved after re-starting NA. 13/103(13%) mothers lost HBeAg and 6 (1%) lost HBsAg spontaneously within 1 year post-delivery (all mild flares). Conclusion Post-partum ALT flares are more common in pregnant women with higher pregnancy HBcrAg and pgRNA levels, in both NA treated and untreated mothers. High predelivery levels could suggest that NA therapy should be continued post-partum to avoid severe and injurious ALT flares.
Competition for Core Surgical Training (CST) is rising, placing a strong emphasis on interview performance. Several interview courses offer to help candidates secure their chosen surgical job but at premium fees. A group of London-based CSTs started a free course offering high-quality mock interview experiences to over 90 applicants in 2022, with the aim of providing an accessible opportunity for financially disadvantaged candidates.Course candidates completed three sets of questionnaires, pre-and post-mock interview, and a final one upon job allocation. Candidates' educational background and schooling history were obtained as well as their self-assessment score, eventual rank after interview and the rank of the job they had accepted.The three sets of questionnaires were completed by 87, 73 and 45 candidates respectively. Overall, there was a statistically significant difference in self-reported confidence scores after the course (P < 0.001). There was no significant difference in the self-assessment score of the 44.2% of candidates who had attended private education in the UK, compared to publicly educated (P = 0.0525), nor was there a difference in their rank after interviews (P = 0.236). Candidates who spent £50 or more had higher self-assessment scores (P = 0.042) but they didn't rank higher in overall scores (P = 0.591).Interview preparation courses are helpful in increasing candidates' confidence, however spending more money does not translate into a better overall interview performance. Our study suggests that candidates from private education backgrounds do not have an advantage in the CST application process.
Introduction Hospital acquired venous thromboembolism (VTE) is potentially preventable yet still accounts for 60% of all VTE seen. This study aimed to establish adherence to guidelines on VTE prevention including completion of VTE risk assessment within 24 hours of admission and appropriate prescription of mechanical and pharmacological VTE prophylaxis. Methods A database of all general surgical inpatients in our hospital at any point during the 48-hour period from 21/12/2021 to 22/12/2021 was obtained. Electronic records were examined to check for the presence of 11 established risk factors for VTE and to check for adherence to VTE guidelines. Every surgical patient was reviewed to check whether they were wearing anti-embolic stockings. Standard statistical analyses were undertaken. Results There were 107 general surgical patients in hospital during the study period. Of these, 33 (31%) had 3 or more risk factors on admission for VTE. 106 (99%) patients had VTE assessments completed within 24 hours of admission. Of these 107 patients, 93 (87%) had appropriate pharmacological VTE prophylaxis or had a documented reason why this was not prescribed. 14 (13%) patients had no pharmacological VTE prophylaxis prescribed. 84 patients were assessed as requiring anti-embolic stockings. Of these, 57 (68%) of patients were prescribed stockings, and 30 (36%) were physically wearing stockings. Conclusion This study has shown that adherence to VTE guidelines among surgical patients in our hospital is substandard. We suggest having a VTE safeguard during the ward round responsible for identifying any deficits in VTE prophylaxis and ensuring recommendations are acted upon. Take-home message VTE guidelines among surgical patients is substandard. We suggest having a VTE safeguard during the ward round responsible for identifying any deficits in VTE prophylaxis and ensuring recommendations are acted upon.
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