University Hospital Coventry is a large National Health Service (NHS) hospital situated in the Walsgrave on Sowe area of Coventry, West Midlands, England, 4 miles (6 km) north-east of the city centre. It is part of the University Hospitals Coventry and Warwickshire NHS Trust, and works in partnership with the University of Warwick's Warwick Medical School. It has a large, progressive accident & emergency department providing a trauma service to Coventry and Warwickshire.
Objectives Primary objective: to determine whether prostate gland partial ablation (PA) has non‐inferior oncological treatment success vs radical treatment (RT) of localised intermediate‐risk prostate cancer (irPCa). Secondary objectives: to compare (i) participant‐reported urinary and sexual dysfunction side effects, (ii) short/medium term serious adverse events, (iii) health‐related quality of life (HRQoL), (iv) cost‐effectiveness; and to report (v) the need for repeat PA, (vi) accuracy of magnetic resonance imaging and biopsy protocols in determining suitability for PA, (vii) disease progression, local spread and metastases, (viii) medium‐term disease‐specific and overall mortality. Participants and Methods The ‘Partial prostate Ablation versus Radical Treatment’ (PART; International Standard Randomised Controlled Trial Number ISRCTN17249875) is a UK‐wide, multicentre, pragmatic, randomised controlled trial investigating whether PA (high‐intensity focused ultrasound [HIFU] or irreversible electroporation [IRE]) is non‐inferior to RT (radical prostatectomy, radical radiotherapy, or low‐dose‐rate brachytherapy [LDR‐B]) in treating localised irPCa. A Qualitative Research Integrated within Trials (QuinteT) Recruitment Intervention is included to optimise recruitment and informed consent. Primary outcome treatment success for PA will be determined by prostate biopsies and imaging, and for RT using standard definitions. Participants will receive treatment according to their randomised allocation, with HIFU or IRE for PA depending on lesion location, and radical prostatectomy, radical radiotherapy, or LDR‐B according to patient and physician preference for RT. Based on 95% and 85% oncological treatment success for RT and PA, respectively, with a non‐inferiority margin of 20%, at median 3 years of follow‐up, PART requires 275 recruited men (137 per group, randomised on a 1:1 basis), for 80% power, with a one‐sided alpha of 0.025. Allowing for a 10% total withdrawal or dropout rate, PART requires 306 recruited and randomised participants. Conclusions The PART trial will provide robust prospective data and high‐level randomised evidence to determine oncological treatment effectiveness of PA vs RT for localised irPCa, along with comparative side effect, HRQoL, and health economics evaluations, to inform clinical decision‐making.
Background More intensive systolic blood pressure (BP) targets have been proposed to improve cardiovascular outcomes, but the balance of benefit and risk remains uncertain. Methods MEDLINE, Embase, and the Cochrane Central Register were searched for trials comparing intensive (systolic BP <130 mmHg) versus less intensive (≥130 mmHg) targets. The primary outcome was a composite of major cardiovascular events (major adverse cardiovascular events [MACEs]). Pooled relative risks (RRs) with 95% confidence intervals (CIs) were calculated using a random-effects model. Results Ten trials were included. Intensive BP lowering reduced the risk of MACEs compared with a less intensive strategy (RR: 0.77; 95% CI: 0.70–0.85). A lower BP target decreased the risk of cardiovascular death (RR: 0.73; 95% CI: 0.65–0.82), all-cause mortality (RR: 0.88; 95% CI, 0.82–0.95), stroke (RR: 0.76; 95% CI, 0.69–0.84), myocardial infarction (RR: 0.82; 95% CI, 0.73–0.92) and heart failure (RR: 0.71; 95% CI, 0.60–0.84). The results were largely consistent across the subpopulations of hypertension, diabetes, and stroke patients. There was no significant difference in the risk of acute coronary syndrome and revascularization between the two strategies. Conclusions Intensive treatment increased the incidence of hypotension and syncope but did not raise serious adverse event rates. Targeting systolic BP to <130 mmHg significantly reduces major cardiovascular events and mortality compared with higher BP targets, although this strategy was associated with increased risks of acute kidney injury, hypotension, syncope, and electrolyte abnormalities.
Catheter ablation remains a cornerstone in the treatment of ventricular tachycardia (VT) in structural heart disease. Part 1 of this review focused on the principles and technical aspects of radiofrequency (RF) ablation. Part 2 explores alternative strategies designed to overcome the limitations of conventional RF, in particular, achieving transmurality in complex or deep intramuscular substrates. We critically evaluate the mechanisms, evidence and clinical applications of bipolar RF ablation, pulsed-field ablation (PFA), ultra-low-temperature cryoablation (ULTC) and venous ethanol and needle ablation. Despite the rapid expansion of the technological armamentarium, current clinical evidence remains limited. The data supporting long-term safety and durability are predominantly based on preclinical and small observational studies. We advocate for continued investigation into these specialised techniques to provide a more tailored, patient-specific approach to VT management.
This case report discusses a middle-aged patient with metastatic pleuro-pulmonary Ewing sarcoma, with the rare initial presentation of spontaneous haemothorax. The patient had a prior history of Ewing sarcoma of the pelvis in young age, which had been treated with chemoradiotherapy with remission. There was a 2-week history of right sided chest pain and shortness of breath, and a chest x-ray showed complete opacification of the right hemithorax, with subsequent CT arising suspicion of a heterogeneous soft tissue pleural lesion with fluid in the pleural cavity. While awaiting further treatment including biopsy, the patient deteriorated rapidly and was eventually started on end-of-life care. Postmortem examination showed large right pleural haemorrhage with lung collapse, and histological examination of pleural lesions confirmed a diagnosis of recurrent Ewing's sarcoma. Extraskeletal presentations of Ewing's sarcoma, particularly with spontaneous haemothorax as the initial presentation have been rarely reported in the literature in adult patients. Diagnosing pleural Ewing's sarcoma requires a multimodal approach, utilising investigations such as contrast-enhanced CT imaging, pleural fluid analysis, thoracoscopy, and PET-CT to evaluate for disease spread. Treating pleural Ewing's sarcoma can be challenging; early diagnosis and management of complications such as haemothorax is essential with thoracocentesis or thoracotomy. Ongoing treatment can include multimodal therapies including chemotherapy and radiotherapy with or without surgery, depending on disease extent.
