Outcome analysis of pancreaticoduodenectomy at a community hospital

There is an ongoing debate about the proposed regionalization of pancreaticoduodenectomies. The purpose of our study is to demonstrate that good outcomes can be achieved in a well-managed low-volume community hospital. We retrospectively analyzed pathologic findings, morbidity, mortality, and one-year survival in 32 patients who underwent pancreaticoduodenectomy at Providence Hospital over a 10-year period and compared these results with data collected at Johns Hopkins, and the Mayo Clinic. The patients had a mean age of 68.5 +/- 2.96 years; 56.3 per cent were female and 71.9 per cent were white. Overall in our series 90.6 per cent of specimens were found to be malignant, which is statistically higher than the 68 per cent at Johns Hopkins (P = 0.013) and not significantly different from Mayo Clinic (76%). The 30-day mortality rate at Providence Hospital was 3.1 per cent, which is not statistically different from Johns Hopkins (1.3%) and Mayo Clinic (3.6%). One-year survival rate at Providence Hospital was 59.4 per cent, which is significantly different from 79 per cent at Johns Hopkins (P = 0.016). The one-year survival rate at Providence Hospital is higher than an approximately 50 per cent average reported nationally. The postoperative complication rate was 62.5 per cent; the most common complication was delayed early gastric emptying (28.1%). A statistical difference in morbidity exists between Providence Hospital and Johns Hopkins (P = 0.027) but not between Providence Hospital and Mayo Clinic (46%). The higher rate of malignant disease treated in the population at Providence Hospital may contribute to a higher complication rate and lower one-year survival rate than the reported rates at Johns Hopkins because of the poorer health of cancer patients. However, statistical analysis of mortality rates for pancreaticoduodenectomy at Providence Hospital show no difference from mortality rates at Johns Hopkins and Mayo Clinic. Therefore in low-volume community hospitals pancreaticoduodenectomy can be performed safely as evidenced by a comparable low mortality rate and a high one-year survival rate.     

Survival and prognostic factors of different sites of head and neck cancer: an analysis from Thailand

Background: Head and neck cancers are prevalent in Thailand, in particular in the southern region of the country. However, survival with a large data set has not been reported. The purpose of the present study was to evaluate the survival figures and the prognostic factors in a cohort of patients treated in a university hospital located in the south of Thailand. Patients and Methods: Consecutive new cases of primary carcinoma of the oral cavity, oropharyx, hypopharynx and larynx, treated at Songklanagarind Hospital during 2002 to 2004, were analyzed. The 5-year overall survival rates were obtained by the Kaplan-Meier method. Prognostic factors were identified through multivariate Cox regression analysis. Results: A total 1,186 cases were analyzed. Two-thirds (66.6%) of the cases were at advanced stage (stage III & IV) at presentation. The five-year overall survivals for the whole cohort, oral cavity, oropharynx, hypopharynx and larynx were 24.1%, 25.91%, 19.2%, 13.4%, 38.0% respectively. Stage and treatment type were strong prognostic factors for all sites. An age ≥ 80 years was associated with poor survival in oral cavity and larynx cancer. Conclusions: The results revealed remarkably poor outcomes of the patients in the series, indicating a strong need to increase the proportion of early stage presentations and maximize the treatment efficacy to improving outcomes. Very old patients are of particular concern for treatment care of oral cavity and larynx cancer.     

A Rapid Stability Indicating HPLC Method for Determination of Quetiapine Fumarate in Tablets and Extemporaneous Formulations

Pharmaceutical Chemistry Journal - Quetiapine fumarate is an atypical antipsychotic drug, which is clinically used for the treatment of depression and bipolar disorders. A stability indicating...     

Review of third and fourth re-excision for narrow or positive margins of invasive and intraductal carcinoma

The trend in breast surgery has shifted toward breast conservation. We reviewed our third and fourth breast re-excision cases, with an analysis of various factors used in making this decision. A retrospective analysis identified 585 patients who underwent re-excision surgery for positive or close margins of invasive carcinoma or ductal carcinoma in situ (DCIS). Of these patients 75 (13%) and 17 (3%) underwent third and fourth re-excisions, respectively. The indication for a third re-excision was the presence of positive and/or close (< or = 1 mm) margins for invasive carcinoma or DCIS in 72/75 patients. A third re-excision was done 31 days (range 8-123 days) after the second re-excision. Re-excision of margins was done in 45 (60%) patients, whereas 30 (40%) patients underwent mastectomy. Residual tumor mandated a fourth re-excision in 17 patients, which was done 45 days (range 14-87 days) after the third surgery. Re-excision of margins was done in 6 patients, whereas 11 patients underwent mastectomy. Involved or close margins with DCIS were the most common indication for re-excision, accounting for 61/75 (82%) of third and 16/17 (94%) of fourth re-excisions. Histopathology revealed that 28/75 (37%) of third and 7/17 (41%) of fourth re-excision patients had no residual tumor. In conclusion, the majority of re-excisions was done for margins < 1 mm. Lower rates of re-excision were noted in well-differentiated invasive carcinomas. A close or involved DCIS margin was more likely to lead to a third and even a fourth re-excision. The absence of residual tumors in 40% of patients undergoing third and fourth re-excisions calls for a review of margin guidelines for breast re-excision.     

Structural relationships of stemona alkaloids: assessment of species-specific accumulation trends for exploiting their biological activities

On the basis of a comparison of 42 Stemona samples, representing eight different species collected and cultivated in Thailand, species-specific accumulation trends of Stemona alkaloids were analyzed. An overview was achieved by comparative HPLC analyses of methanolic crude extracts of underground parts coupled with diode array or evaporative light scattering detectors. All major compounds were isolated and their structures elucidated by NMR and MS analyses. Protostemonine- and stichoneurine-type derivatives dominated, from which the latter characterize S. tuberosa and S. phyllantha accumulating species-specific isomers of tuberostemonine (3). The widespread S. curtisii and S. collinsiae clearly deviate by protostemonine-type derivatives dominated by stemofoline (10) and/or didehydrostemofoline (11). Further diversification within this structural type results from a mutual accumulation of derivatives with a pyrrolo- or pyridoazepine nucleus, leading to chemical variability in S. curtisii and S. aphylla.     

Isolation of manumycin-type derivatives and genome characterization of a marine Streptomyces sp. C1-2

A marine actinomycete strain C1-2 was taxonomically characterized as the genus Streptomyces, based on whole-genome sequence analysis. The highest average nucleotide identity (ANI) value (98.96%) and digital DNA–DNA hybridization (DDH) value (90.4%) were observed between Streptomyces sp. C1-2 and Streptomyces griseoaurantiacus. Thus, Streptomyces sp. C1-2 could be identified as S. griseoaurantiacus. Genome analysis revealed that Streptomyces sp. C1-2 contained 22 biosynthetic gene clusters (BGCs) for secondary metabolites, where among them, 54% have low similarities with known BGCs. The chemical investigation led to the isolation of three new manumycin-type derivatives and two known analog antibiotics named SW-B and cornifronin B. All compounds showed antioxidant activity with the half-maximal inhibitory concentration (IC₅₀) values in a range of 50.82 ± 0.8–112.04 ± 1.0 μg/mL with no cytotoxicity against Vero cells. This is the first report of the antioxidant property of manumycin-type derivatives. Moreover, two known compounds exhibited antifungal activity against Phytophthora capsici, Fusarium oxysporum f. sp. cucumerinum, and Magnaporthe grisea, with the minimum inhibitory concentration (MIC) values in a range of 125–500 μg/mL.     

Receptor changes in metachronous breast tumors--our experience of 10 years

IntroductionPatients with primary breast cancer (PBC) are at 2 to 6 times higher risk for developing synchronous and metachronous breast cancer (MBC). The pathology and behavior of MBC still remains unclear.MethodsWe reviewed the charts of 108 women with MBC at our hospital over the past 10 years. Profile patterns of the estrogen receptor (ER), the progesterone receptor (PR), and Her2/neu receptors were explored.ResultsOf 33 patients with ER⁺/PR⁺ in the primary tumor, 23 (70%) retained the status in MBC. Forty-five (92%) of 49 patients with ER^?/PR^? in the primary tumor remained the same in MBC. Most Her2^? tumors (22/31, 71%) remained negative, but 50% (8/16) of Her2⁺ tumors became negative.ConclusionsMost MBC retained the ER/PR expression patterns irrespective of the treatment for the primary tumor, thus suggesting a common origin. Because MBCs tend to be triple negative and thus more aggressive, early detection and close surveillance techniques must be devised.     

Corneal Phaeohyphomycosis Caused by Bipolaris hawaiiensis

PurposeTo report a rare case of keratitis infected by Bipolaris hawaiiensis.MethodsA patient who was diagnosed as fungal keratitis caused by B. hawaiiensis was retrospectively reviewed for history, clinical characteristics, risk factors, laboratory findings, treatments, and outcomes.ResultsA 63-year-old man with a history of trauma and saw dust in the left eye presented with a corneal ulcer. Eye examination revealed whitish infiltration with a feathery edge and small brownish deposits in the anterior stroma of the left cornea. Numerous septate hyphal fragments were detected in a corneal specimen, and nucleotide sequence analysis identified B. hawaiiensis. Treatment was started with 5% natamycin eyedrops and oral itraconazole. Subsequently, a corneal plaque developed which did not respond to medication and debridement. The patient underwent therapeutic penetrating keratoplasty.ConclusionsB. hawaiiensis is a rare cause of corneal phaeohyphomycosis. A brownish pigmented infiltration is an important diagnostic clue, however microbiologic studies are required to obtain a definite diagnosis. Although antifungal medication and debridement are the mainstay of most corneal fungal infection, therapeutic penetrating keratoplasty can prevent morbidity related to this fungal infection.Key Words: Bipolaris hawaiiensis, Phaeohyphomycosis, Keratitis, Dematiaceous fungus     

Prolonged (longer than 3 hours) laparoscopic cholecystectomy: reasons and results

For the experienced surgeon, the average operative time for a laparoscopic cholecystectomy is less than 1 hour. There has been no study documenting the causes and results of prolonged (longer than 3 hours) surgery. A retrospective study was done of patients who underwent cholecystectomy between January 2003 and December 2007. A total of 3126 cholecystectomies were done. After excluding patients who had a planned open cholecystectomy and patients who had additional laparoscopic surgeries, we identified 70 patients who had a planned laparoscopic cholecystectomy with operative time exceeding 3 hours. Multivariate stepwise logistic regression was performed analyzing the various factors leading to prolonged surgery. Of the 70 patients, ranging in age from 21 to 92 years (mean, 57 years), most (n = 53) were female. Operative time ranged from 3 hours to 6 hours 40 minutes (mean, 3 hours 37 minutes). Emergency:elective admission ratio was 9:5 and acute cholecystitis (n = 40) was the most common indication. Common characteristics were obesity (n = 44, P = 0.031), intra-abdominal adhesions (n = 43, P = 0.004), and previous abdominal surgeries (n = 40, P = 0.002). Intraoperative complications included spillage of stones (n = 6), bile duct injury (n = 3), and bleeding (n = 3). The possibility of prolonged laparoscopic cholecystectomy should be anticipated in patients with obesity and previous abdominal operations. Prolonged surgery increases the risk of complications (bile duct injury, bleeding) and prolongs the postoperative hospital stay.