Prognosis of Resected Ampullary Adenocarcinoma by Preoperative Serum CA19-9 Levels and Platelet-Lymphocyte Ratio

Background  The objective of this study was to evaluate whether preoperative CA19-9 levels and the platelet–lymphocyte ratio (PLR) might reflect prognostic indices for resected ampullary adenocarcinoma. Materials and Methods  Data were collected prospectively over a 10-year period for consecutive patients undergoing pancreatoduodenectomy for malignancy. Results  Both preoperative PLR and CA19-9 results were available in 52 cases of resected ampullary adenocarcinoma. Preoperative CA19-9 levels of ≤150 kU/l (or ≤300 kU/l in the presence of bilirubin levels >35 μmol/l) and a PLR of ≤160 were found to represent the optimal cut-off values to risk stratify patients. If both levels were elevated (n = 8), patients had a median overall survival of 10.1 months. If either CA19-9 or PLR were elevated individually (n = 23), patients had a median survival of 25.2 months. For cases where both levels were less than the cut-off values (n = 21), the median overall survival time was not reached but was greater than 60 months (log rank, p < 0.001). This preoperative risk stratification was found to remain a significant independent predictor of survival on multivariate analysis (Cox, p = 0.001) alongside resection margin status (p = 0.002) and tumor size (p = 0.051). Conclusions  Preoperative CA19-9 and PLR both merit further evaluation as prognostic indices in resected ampullary adenocarcinoma.     

Role of Prophylactic Antibiotics in Laparoscopic Cholecystectomy: A Meta-Analysis

Background   The role of prophylactic antibiotics in laparoscopic cholecystectomy in low-risk patients is controversial. We conducted a meta-analysis to evaluate the efficacy of prophylactic antibiotics in low-risk patients (those without cholelithiasis or cholangitis) undergoing laparoscopic cholecystectomy. Methods   Multiple databases and abstracts were searched. Randomized controlled trials (RCTs) comparing prophylactic antibiotics to placebo or no antibiotics in low-risk laparoscopic cholecystectomy were included. The effects of prophylactic antibiotics were analyzed by calculating pooled estimates of overall infections, superficial wound infections, major infections, distant infections, and length of hospital stay. Separate analyses were performed for each outcome by using odds ratio or weighted mean difference. Both random and fixed effects models were used. Publication bias was assessed by funnel plot. Heterogeneity among studies was assessed by calculating I ² measure of inconsistency. Results   Nine RCTs (N = 1,437) met the inclusion criteria. No statistically significant reduction was noted for those receiving prophylactic antibiotics and those who did not for overall infectious complications (p = 0.20), superficial wound infections (p = 0.36), major infections (p = 0.97), distant infections (p = 0.28), or length of hospital stay (p = 0.77). No statistically significant publication bias or heterogeneity were noted. Conclusions   Prophylactic antibiotics do not prevent infections in low-risk patients undergoing laparoscopic cholecystectomy. Scientific Meeting: Data presented at Digestive Disease Week on 19 May 2008 at San Diego, CA.     

Comparative effects of desflurane and isoflurane on recovery after long lasting anaesthesia

Purpose  Increasing the duration of exposure could lead to amplification of the pharmacokinetic differences between halogenated anaesthetic agents. The aim of our study was to compare anaesthesia recovery after desflurane and isoflurane, administered for more than three hours. Methods  After informed consent, patients were randomly assigned to either desflurane (n = 15) or isoflurane (n = 15) groups. At the end of surgery, halogenated agents were discontinued and fresh gas flow was increased to 6 l · min⁻¹ oxygen 100%. Results  Mean anaesthesia duration was 292 ± 63 and 304 ± 91 min in the desflurane and isoflurane groups respectively. After desflurane and isoflurane discontinuation, the time to opening eyes was 12 ± 7 and 24 ± 11 min respectively (P < 0.001); to squeeze fingers at command was 17 ± 11 and 35 ± 19 min (P < 0.001); to extubation was 16 ± 6 and 33 ± 13 min (P < 0.001); to give their name was 22 ± 12 and 43 ± 21 min (P < 0.001); to achieve a Steward score of 6 was 28 ± 16 and 57 ± 33 min (P < 0.001), to be fit for discharge from the recovery room was 46 ± 19 and 81 ± 37 min (P < 0.003). Ranges of times to reappearance of recovery variables in the desflurane group were less than those after isoflurane (P < 0.05). Conclusion  After long duration anaesthesia lasting up to three hours, desflurane allowed recovery and extubation in approximately half the time required by isoflurane. Less variability in results suggests better predictability of recovery with desflurane.

---

Résumé Objectif  Les différences pharmacodynamiques entre les agents halogènes sont amplifiées par la durée d’administration. Ce travail compare les paramètres de réveil après une anesthésie supérieure à trois heures avec de l’iso-flurane ou du desflurane. Méthode  Après consentement éclairé, les patients ont été répartis par tirage au sort pour recevoir de l’isoflurane (n = 15) ou du desflurane (n = 15). Au dernier point de suture cutanée, l’administration d’agent halogène était stoppée et le débit de gaz frais porté à 6 l · min⁻¹ d’oxygène. Résultats  La durée d’anesthésie a été de 292 ± 63 et 304 ± 91 min pour le desflurane et l’isoflurane respectivement. Le délai pour l’ouverture des yeux a été de 12 ± 7 et 24 ± 11 min (P < 0.001); pour serrer les mains à la demande de 17 ± 11 et 35 ± 19 min (P < 0.001); pour l’extubation de 16 ± 6 et 33 ± 13 min (P < 0.001); pour donner son nom de 22 ± 12 et 43 ± 21 min (P < 0.001); pour récupérer un score de Steward à 6 de 28 ± 16 et 57 ± 33 min (P < 0.001); pour avoir l’autorisation de sortie de salle de réveil de 46 ± 19 et 81 ±37 min (P < 0.003) pour le desflurane et l’isoflurane respectivement. Conclusion  Après une anesthésie supérieure à trois heures, le desflurane permet un réveil et une extubation approximativement deux fois plus rapide que l’isoflurane. La plus faible variabilité des valeurs suggère une meilleure prédictibilité des paramètres de réveil avec le desflurane.

---

---

Supported by a grant from Pharmacia France, St Quentin-Yvelyne, France.     

Anaemia in cardiac surgery – a retrospective review of a centre's experience with a pre-operative intravenous iron clinic

Pre-operative anaemia is associated with higher rates of transfusion and worse outcomes, including prolonged hospital stay, morbidity and mortality. Iron deficiency is associated with significantly lower haemoglobin levels throughout the peri-operative period and more frequent blood transfusion. Correction of iron stores before surgery forms part of the first pillar of patient blood management. We established a pre-operative anaemia clinic to aid identification and treatment of patients with iron deficiency anaemia scheduled for elective cardiac surgery. We present a retrospective observational review of our experience from January 2017 to December 2019. One-hundred and ninety patients received treatment with intravenous iron, a median of 21 days before cardiac surgery. Of these, 179 had a formal laboratory haemoglobin level measured before surgery, demonstrating a median rise in haemoglobin of 8.0 g.l^-1. Patients treated with i.v. iron demonstrated a significantly higher incidence of transfusion (60%) compared with the non-anaemic cohort (22%) during the same time period, p < 0.001. Significantly higher rates of new requirement for renal replacement therapy (6.7% vs. 0.6%, p < 0.001) and of stroke (3.7% vs. 1.2%, p = 0.010) were also seen in this group compared with those without anaemia, although there was no significant difference in in-hospital mortality (1.6% vs. 0.8%, p = 0.230). In patients where the presenting haemoglobin was less than 130 g.l^-1, but there was no intervention or treatment, there was no difference in rates of transfusion or of complications compared with the anaemic group treated with iron. In patients with proven iron deficiency anaemia, supplementation with intravenous iron showed only a modest effect on haemoglobin and this group still had a significantly higher transfusion requirement than the non-anaemic cohort. Supplementation with intravenous iron did not improve outcomes compared with patients with anaemia who did not receive intravenous iron and did not reduce peri-operative risk to non-anaemic levels. Questions remain regarding identification of patients who will receive most benefit, the use of concomitant treatment with other agents, and the optimum time frames for treatment in order to produce benefit in the real-world setting.     

CA 19-9 Velocity Predicts Disease-Free Survival and Overall Survival After Pancreatectomy of Curative Intent

Introduction  This study was undertaken to correlate serum CA 19-9 levels and CA 19-9 velocity with disease-free and overall survival after pancreatectomy for adenocarcinoma. Methods  From 1997 to 2002, 96 patients underwent pancreatectomy without adjuvant chemotherapy as the control arm of a large randomized prospective adjuvant therapy trial. After resection, CA 19-9 levels were drawn at baseline, 4 weeks, and 12-week intervals thereafter. CA 19-9 velocity denotes rate of change in CA 19-9 levels over a 4-week period. Postoperative baseline CA 19-9 levels and CA 19-9 velocity were correlated with disease-free and overall survival. Data are presented as median (mean ± SD). Results  Disease-free survival was 7 months (14 ± 13.7), and overall survival was 12 months (19 ± 14.3) with 24 (25%) patients alive at 41 months (39 ± 7.8). Baseline CA 19-9 levels and CA 19-9 velocity predicted disease-free (p < 0.01) and overall survival (p < 0.01). CA 19-9 velocity was a better predictor of overall survival than baseline CA 19-9 (p < 0.001). CA 19-9 velocity at disease progression was 131 U/ml/4-weeks (1,684 ± 4,474.8) vs. 1 U/ml/4-weeks (1 ± 3.8) at 22 months for patients without disease progression (p < 0.001). Conclusions  CA 19-9 velocity predicts imminent disease progression after resection of pancreatic adenocarcinoma and is a better predictor of overall survival than baseline CA 19-9 levels. CA 19-9 velocity is a reliable and relatively inexpensive means of monitoring patients after resection of pancreatic cancer and should be considered in all patients enrolled in clinical trials as well as patients receiving adjuvant therapy.     

Molecular characterization of equine infectious anaemia virus from a major outbreak in southeastern France

In 2009, a major outbreak of equine infectious anaemia (EIA ) was reported in the south‐east of France. This outbreak affected three premises located in the Var region where the index case, a 10‐year‐old mare that exhibited clinical signs consistent with EIA , occurred at a riding school. Overall, more than 250 horses were tested for EIAV (equine infectious anaemia virus) antibodies, using agar gel immunodiffusion test, and 16 horses were positive in three different holdings. Epidemiological survey confirmed that the three premises were related through the purchase/sale of horses and the use of shared or nearby pastures. Molecular characterization of viruses was performed by sequencing the full gag gene sequence (1,400 bp) of the proviral DNA s retrieved from the spleen of infected animals collected post‐mortem . Phylogenetic analysis confirmed epidemiological data from the field, as viruses isolated from the three premises were clustering together suggesting a common origin whereas some premises were 50 km apart. Moreover, viruses characterized during this outbreak are different from European strains described so far, underlying the high genetic diversity of EIAV in Europe.     

Work stress and workload of full-time anesthesiologists in acute care hospitals in Japan

Purpose  The number of anesthesiologists per population in Japan is small compared with that in Europe and North America. While there is a growing concern that hard work causes anesthesiologists’ fatigue and may compromise patient safety, the workload and physical stress, as well as the impact of staff support on physicians’ stress have not been assessed in detail. The goal of this study was to evaluate the working environment, anesthesia workload, and occupational stress of anesthesiologists in Japan. Methods  A questionnaire survey was performed targeting 1010 members of the Japanese Society of Anesthesiologists working as anesthesiologists affiliated with acute care hospitals in Japan. Data on background information, working environment, operation anesthesia duties, and stress were collected, and the relationship of work stress with background, environment, and anesthesia duties was evaluated by linear regression analysis. Results  Responses were obtained from 383 full-time anesthesiologists (response rate, 43.9%). The total anesthesia time per week was 23.6 h on average. The work stress score was 114.3 ± 30.2 (mean ± SD) when the average workers’ work stress score in Japan was 100. The work stress score was significantly associated with “years of experience” (with experience < 10 years considered as the reference; 10–19 years: β = −0.18, P = 0.02, ≥20 years: β = −0.15, P = 0.04), “hospital with ≥500 beds” (with a hospital with ≤ 299 beds considered as the reference; β = 0.15, P = 0.04), “total time of anesthesia per week” (β = 0.18, P.02), “estimated annual cases managed by an anesthesiologist” (β = 0.12, P = 0.04) and “no-support stress” (β = 0.21, P < 0.01) on linear regression analysis (R² = 0.12). Conclusion  Our results provide a quantitative assessment of the duties of anesthesiologists and show that work stress among anesthesiologists is related to workload and other factors. Summaries of this study were presented at the 53rd and 54th General Meetings of the Japanese Society of Anesthesiologists (JSA) at Kobe (2006) and Sapporo (2007).     

Increased red cell 2,3-diphosphoglycerate levels in haemodialysis patients treated with erythropoietin

The efficacy of recombinant human erythropoietin (rHuEpo) forthe treatment of renal anaemia is well established. To assessthe effect of rHuEpo treatment on physical performance we evaluatedphysical working capacity, oxygen uptake and red cell 2,3diphosphoglycerate(DPG) values at rest and during and after exercise on a bicyclespiroergometer in eight chronically haemodialysed patients.Follow-up examination was carried out after a mean of 14 weeks(range 9–19 weeks), when mean haemoglobin had increasedfrom 7.8 to a stable value of 13.0 g/dl in response to rHuEpotreatment (P<0.001). Physical working capacity and oxygenuptake at the anaerobic threshold (4 rnrnol/l blood lactateconcentration) increased from 68±12 to 80±16 wattsand 0.95±0.14 to 1.10±0.20 l/min, respectively(P<0.01). DPG, which determines oxygen affinity to haemoglobinin red cells, increased by 13% from 13.7±1.5 to 15.5±2.2pmol/g Hb (P<0.05 ). With maximal exercise mean DPG valuessignificantly decreased to a much lower level without rHuEpotreatment than after correction of anaemia. Therefore rHuEpotreatment results both in better oxygen transport capacity andreduced intraerythrocytic oxygen affinity, which is followedby improved oxygen delivery to tissues per unit of haemoglobin.These effects may explain the improvement of exercise capacityobserved in dialysis patients after rHuEpo treatment.