Results of routine shunting and patch closure during carotid endarterectomy

BackgroundThe role of shunting and patching during carotid endarterectomy remains controversial.MethodsThis is a retrospective case series evaluating consecutive patients undergoing carotid endarterectomy with routine shunting and patching. The primary endpoints were perioperative stroke, arterial injury, and lesion recurrence by duplex.ResultsOf the 220 operations performed, 43% were for symptomatic disease. Successful shunt placement occurred in 98%, with no shunt-related injuries. There was 1 minor perioperative stroke and no major strokes. At a mean follow-up of 24 months (median = 12 months), there was 1 restenosis potentially related to shunt placement. The incidence of asymptomatic >50% stenosis in the patched segment was 8%.ConclusionsA combined policy of routine shunting and patching simplifies intraoperative decision making with results that rival or exceed those of trials in which their use was not standardized. Shunts need not be avoided because of concern of arterial injury.     

Robot-Assisted Transaxillary Thyroid Surgery in the United States: Is it Comparable to Open Thyroid Lobectomy?

Background  

The purpose of this study was to compare the outcome of robot-assisted transaxillary thyroid surgery (RATS) to the standard open technique for thyroid lobectomy in the U.S. population.     

Detection of bladder dysplasia using 5-aminolaevulinic acid-induced porphyrin fluorescence

OBJECTIVE: To report results of a clinical investigation on the detection of bladder dysplasia and in situ carcinoma by using fluorescence induced by 5-aminolaevulinic acid (ALA). PATIENTS AND METHODS: The study included 50 patients with a primary bladder lesion, who had a bladder instillation of 50 mL of 3% ALA solution >or= 1 h before transurethral resection of the tumour. Random biopsies were taken using white-light cystoscopy, then using blue light to induce fluorescence; positive zones were noted and biopsied. The primary lesion was then resected. The frequency of dysplasia detected by ALA-induced fluorescence was evaluated, as was the risk of recurrence with a follow-up of >or= 2 years. RESULTS: In all patients the tumours were positive; in 21 fluorescence distant from the tumour was detected. The pathological report of the biopsies showed 11 cases of dysplasia, six of carcinoma in situ and four of inflammatory lesions. In 29 patients there was no fluorescence and quadrant biopsies were normal in all but three with moderate dysplasia. Within the minimum follow-up patients with bladder dysplasia detected by ALA-induced fluorescence had a higher risk of recurrence. CONCLUSION: ALA-induced fluorescence of the bladder significantly enhanced the detection of dysplasia and in situ carcinoma. However, this technique requires further investigation using well-characterized instrumentation and study protocols to determine any effect on treatment choice.     

Predictive value of neutrophil-to-lymphocyte ratio in diabetic wound healing

Objective

The neutrophil-to-lymphocyte ratio (NLR) has been used as a surrogate marker of systemic inflammation. We sought to investigate the association between NLR and wound healing in diabetic wounds.

Pilot study of a novel pain management strategy: evaluating the impact on patient outcomes

Background

Our objective was to evaluate the impact of a novel multimodal pain management strategy on intraoperative opioid requirements, postoperative pain, narcotic use, and length of stay.

Methods

Consecutive patients undergoing elective laparoscopic colorectal resection were managed with an experimental protocol. The protocol uses a post-induction, pre-incision bilateral TAP block and local peritoneal infiltration at port sites with long-acting liposomal bupivacaine (20 mL long-acting liposomal bupivacaine, 30 mL 0.25 % bupivacaine, 30 mL saline). Experimental patients were matched on age, body mass index, gender, comorbidity, diagnosis, and procedure to a control group that received no block or local wound infiltration. Both groups followed a standardized enhanced recovery pathway. Demographics, perioperative, and postoperative outcomes were evaluated. The main outcome measures were intraoperative opioids, postoperative pain, opioid use, and length of stay.

Results

Fifty patients were analyzed—25 experimental and 25 controls. Patients were well matched on all demographics. In both cohorts, the main diagnosis was colorectal cancer and primary procedure performed a segmental resection. Operative times were similar (p = 0.41). Experimental patients received significantly less intraoperative fentanyl (mean 158 mcg experimental vs. 299 mcg control; p < 0.01). The experimental group had significantly lower initial (p < 0.01) and final PACU pain scores (p = 0.04) and shorter LOS (3.0 vs. 4.1 days, p = 0.04) compared to controls. Experimental patients trended toward shorter PACU times and lower opioid use and daily pain scores throughout the hospital stay. Postoperative complication and readmission rates were similar across groups. There were no reoperations or mortality.

Conclusions

Our multimodal pain management strategy reduced intraoperative opioid administration. Postoperatively, improvements in PACU time, postoperative pain and narcotic use, and lengths of stay were seen in the experimental cohort. With the favorable finding from the pilot study, further investigation is warranted to fully evaluate the impact of this pain management protocol on patient satisfaction, clinical and financial outcomes.

     

A proposed staging system for small bowel carcinoid tumors based on an analysis of 6,380 patients

Background

Little is known about the long-term prognosis of small bowel carcinoids because currently no staging system exists.

Methods

A search of the Surveillance, Epidemiology and End Results (SEER) database identified 6,380 patients with small bowel carcinoid tumors from 1977 to 2004. Patients were analyzed according to various clinicopathologic factors and a tumor (T1, T2, T3), lymph node (N0, N1), and metastasis (M0, M1) staging system was created according to these parameters.

Results

Among the 6,380 patients, 2,985 women and 3,395 men, with a median age of 66 years (range 14-98), the median tumor size was 1.9 cm (range .1-30 cm). Multivariate analysis demonstrated that age, size of the primary tumor, and depth of invasion were significant factors. Four stages were created according to statistically significant prognostic factors: 13% of patients were classified into stage I, 31% into stage II, 16% into stage III, and 40% into stage IV. Five-year survival rates were 96%, 87%, 74%, and 43% for stages I through IV, respectively.

Conclusions

The newly developed TNM staging system accurately discriminates prognosis for small bowel carcinoid tumors.     

单核细胞向巨噬细胞分化过程中CD44mRNA表达和黏附功能的变化

目的探讨单核细胞向巨噬细胞分化过程中CD44 mRNA表达和黏附功能的变化。方法应用豆蔻佛波醇乙酯(PMA)诱导单核细胞系U937向巨噬细胞分化;应用RT-PCR分析U937细胞CD44 mRNA表达变化,并以β-actin作为内参进行半定量评价,并对主要条带进行测序;应用荧光染料BCECF/AM作为探针,测定黏附于激活的内皮细胞上的U937细胞数目。结果与对照组比较,PMA诱导的U937细胞CD44 mRNA总体表达显著增加(P=0.01037),异构体/标准CD44比例显著上升(P=0.0005551),测序结果显示PMA刺激后显著增加的是947 bp(V8 V9 V10)和1208 bp(V7 V8 V9 V10)CD44异构体。同时,PMA刺激后U937细胞黏附功能显著增加(P=0.0029)。结论单核细胞向巨噬细胞分化过程中CD44 mRNA,特别是947bp(V8 V9 V10)和1208 bp(V7 V8 V9 V10)CD44异构体的表达显著增加,可能与细胞黏附功能的增强相关。     

RNA Synthesis in Cultures of Normal Human Peripheral Blood

RNA and DNA synthesis were measured in cultures of normal human peripheral blood using tritiated cytidine and thymidine and autoradiographictechnics. RNA synthesis preceded DNA synthesis by 24 hours. RNA synthesisoccurred predominantly in the large and medium-sized "blast-like" cells, butdid occur, to a lesser extent, in the small lymphocytes. RNA synthesis did notoccur in the absence of phytohemagglutinin, nor did DNA synthesis. Mechanisms of action of phytohemagglutinin are discussed with particular referenceto its possible antigenic nature.

Submitted on August 12, 1963 Accepted on January 6, 1964     

PRETREATMENT WITH PARACETAMOL INHIBITS METABOLISM OF ENFLURANE IN RATS

We studied the interaction between paracetamol (acetaminophenU.S.P.) and enflurane. Sixteen rats were assigned to four groups(n=4) to receive: paracetamol 7.5 mg/100 g body weight; paracetamolplus 1% enflurane; 1% enflurane alone, or no treatment (controls).Animals were killed 6 h later. A second series of 16 were treatedidentically, but were killed after 24 h. Measurements were madeof fluoride concentrations in serum, liver and urine (indicatorsof biotransformation of enflurane), paracetamol concentrationsin urine, pathological changes in liver samples, and concentrationsof the enzymes aspartate aminotransferase (AST) and alanineaminotransferase (ALT) in serum. Pretreatment with paracetamolsignificantly decreased urinary fluoride at 6 and 24 h afterexposure to enflurane, but decreased fluoride concentrationsin serum and liver only at 6 h after exposure to enflurane.Paracetamol concentrations in urine did not change after exposureto enflurane. Exposure to paracetamol alone increased AST andALT. At 24 h after exposure to enflurane, serum concentrationsof enzymes in rats pretreated with paracetamol were similarto those of control rats. Pretreatment with paracetamol maytherefore inhibit metabolism of enflurane. Although no hepaticdamage was observed, the increased in AST and AL T suggestedsubclinical liver damage in rats given only paracetamol.     

Postoperative radiation therapy in the management of lung cancer

Postoperative radiation therapy for lung cancer is still controversial. In a 9-year period, 69 patients with non-oat-cell carcinoma of the lung (16% stage I, 26% stage II, and 58% stage III) received such therapy. The radiation dose was less than 5,000 cGy in 42 patients, 5,000-5,900 cGy in 16, and 6,000 cGy or more in 11; follow-up ranged from 24 to 64 months. Actuarial survival at 2 and 4 years was 50% and 16%, respectively, for squamous cell carcinoma, and 40% and 26% for adenocarcinoma. The 5-year survival for stages I, II, and III cancer was 29%, 17%, and 19%, respectively. Histologic findings and type of surgery did not affect survival, but the radiation dose apparently did. The 3-year survival for patients who received less than 6,000 cGy was 35%, compared with 73% for patients who received higher doses. In eight patients, treatment failed within the irradiated volume: all had received doses of less than 6,000 cGy, and the volume in three was judged to be inadequate.