Meta‐analysis of standard,restrictive and supplemental fluid administration in colorectal surgery

Background:

Optimal fluid therapy for colorectal surgery remains uncertain.

Methods:

A simple model was applied to define standard, restrictive and supplemental fluid administration. These definitions enabled pooling of data from different trials. Randomized controlled trials on fluid amount (standard versus restrictive or supplemental amount) and on guidance for fluid administration (goal‐directed fluid therapy by oesophageal Doppler‐derived variables versus conventional haemodynamic variables) in patients with colorectal resection were eligible for inclusion. The primary outcome measure was postoperative morbidity. Secondary endpoints were mortality, cardiopulmonary morbidity, wound infection, anastomotic failure, recovery of bowel function and hospital stay. A random‐effects model was applied.

Results:

Nine randomized controlled trials were included. Restrictive fluid amount (odds ratio (OR) 0·41 (95 per cent confidence interval (c.i.) 0·22 to 0·77); P = 0·005) and goal‐directed fluid therapy by means of oesophageal Doppler‐derived variables (OR 0·43 (95 per cent c.i. 0·26 to 0·71); P = 0·001) significantly reduced overall morbidity. There were no significant differences in the secondary endpoints analysed.

Conclusion:

Using standardized definitions, this meta‐analysis suggests that restrictive rather than standard fluid amount according to current textbook opinion, and goal‐directed fluid therapy rather than fluid therapy guided by conventional haemodynamic variables, reduce morbidity after colorectal resection. Copyright © 2009 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.     

Meta-Analysis of the Clamp-Crushing Technique for Transection of the Parenchyma in Elective Hepatic Resection: Back to Where We Started?

Background  After introduction of the clamp-crushing technique in the 1970s, various devices have been developed for transection of the liver with the aim of further reducing blood loss and improving the outcome of patients who undergo hepatic resection. We performed a meta-analysis to quantitatively compare the clamp-crushing technique to any subsequently introduced transection technique with respect to patients’ perioperative outcome. Methods  A systematic literature search was conducted to identify randomized controlled trials comparing the clamp-crushing technique to any alternative method of hepatic transection. Relative risks (RR) were calculated for each outcome and reported along with their 95% confidence intervals (95% CI). Meta-analyses were stratified for the various types of transection techniques compared with the clamp-crushing technique and were carried out by a random effects model. Results  Seven randomized controlled trials with a total of 554 patients were included in final analyses. Analyses of overall morbidity (RR .89; 95% CI, .63–1.25), biliary leakage (RR 1.03; 95% CI, .50–2.13), transfusion rates (RR .69; 95% CI, .31–1.51), and mortality RR (.20; 95% CI, .02–1.65) revealed no difference between the clamp-crushing and alternative transection techniques. None of the identified studies demonstrated a clinically important benefit of an alternative transection method in terms of blood loss, parenchymal injury, transection time, and hospital stay. Conclusions  This meta-analysis does not indicate a benefit of any alternative transection technique on patients’ perioperative outcome compared with the clamp-crushing technique. The clamp-crushing technique remains the reference technique for transection of the parenchyma in elective hepatic resection. Nuh N. Rahbari, Moritz Koch authors contributed equally to this article.     

Validation of Prognostic Scoring Systems for Patients Undergoing Resection of Colorectal Cancer Liver Metastases

Background  

Several prognostic scoring systems have been established for patients undergoing resection of colorectal cancer (CRC) liver metastases; however, comparative analyses of their prognostic relevance is still lacking in the literature. The aim of the present study was to assess the predictive value of five published scoring systems in an independent patient cohort for the purpose of external validation.     

Invasion front-specific expression and prognostic significance of microRNA in colorectal liver metastases

The tumor edge of colorectal cancer and its adjacent peritumoral tissue is characterized by an invasion front-specific expression of genes that contribute to angiogenesis or epithelial-to-mesenchymal transition. Dysregulation of these genes has a strong impact on the invasion behavior of tumor cells. However, the invasion front-specific expression of microRNA (miRNA) still remains unclear. Therefore, the aim of the present study was to investigate miRNA expression patterns at the invasion front of colorectal liver metastases. Laser microdissection of colorectal liver metastases was performed to obtain separate tissue compartments from the tumor center, tumor invasion front, liver invasion front and pure liver parenchyma. Microarray expression analysis revealed 23 miRNA downregulated in samples from the tumor invasion front with respect to the same miRNA in the liver, the liver invasion front or the tumor center. By comparing samples from the liver invasion front with samples from pure liver parenchyma, the tumor invasion front and the tumor center, 13 miRNA were downregulated. By quantitative RT-PCR, we validated the liver invasion front-specific downregulation of miR-19b, miR-194, let-7b and miR-1275 and the tumor invasion front-specific downregulation of miR-143, miR- 145, let-7b and miR-638. Univariate analysis demonstrated that enhanced expression of miR-19b and miR-194 at the liver invasion front, and decreased expression of let-7 at the tumor invasion front, is an adverse prognostic marker of tumor recurrence and overall survival. In conclusion, the present study suggests that invasion front-specific downregulation of miRNA in colorectal liver metastases plays a pivotal role in tumor progression.     

A comparative histological analysis of human pulp following direct pulp capping with Propolis, mineral trioxide aggregate and Dycal

Background:  Permanent teeth pulp exposures have traditionally been treated with calcium hydroxide pulp capping. The aim of this study was to investigate the response of human pulp tissue which were mechanically exposed to a new material, Propolis and compare it with two existing and commonly used pulp capping agents (mineral trioxide aggregate and Dycal).
Methods:  Thirty-six intact human premolars were mechanically exposed. Teeth were divided into six groups of 6 teeth each and were capped with Propolis, mineral trioxide aggregate and Dycal. Final restoration was done with posterior composite resin using light cured glass ionomer cement as a liner. The teeth were then extracted on the 15th or the 45th day and processed for histological evaluation.
Results:  Differences in inflammatory response and dentine bridge formation of the exposed pulp to the three different materials were statistically calculated using chi-square test and were found to be non-significant. There was more pulp inflammation in teeth treated with Dycal than with Propolis and MTA on the 15th as well as on the 45th day. Propolis and MTA showed bridge formation in more teeth, and the bridges were in closer proximity to pulp capping material than teeth treated with Dycal on the 45th day.
Conclusions:  The response of pulps to Propolis as a pulp capping agent was comparable to MTA and Dycal.     

Allogeneic Blood Transfusion Does Not Affect Outcome After Curative Resection for Advanced Cholangiocarcinoma

Purpose

To assess the impact of perioperative blood transfusion on overall and disease-free survival in patients undergoing curative resection for cholangiocarcinoma.

Methods

In a single-center study, 128 patients undergoing curative resection for cholangiocarcinoma between 2001 and 2010 were assessed. The median follow-up period was 19 months. Transfused and nontransfused patients were compared by Cox regression and propensity score analyses.

Results

Overall, 38 patients (29.7 %) received blood transfusions. The patient characteristics were highly biased with respect to receiving transfusions (propensity score 0.69 ± 0.22 vs. 0.11 ± 0.16, p < 0.001). In the unadjusted analysis, blood transfusion was associated with a 105 % increased risk of mortality [hazard ratio (HR) 2.05, 95 % CI 1.19–3.51, p = 0.010]. In the multivariate (HR 1.14, 95 % CI 0.52–2.48, p = 0.745) and the propensity score-adjusted Cox regression (HR 1.02, 95 % CI 0.39–2.62, p = 0.974), blood transfusion had no influence on overall survival. Similarly, in the propensity score-adjusted Cox regression (HR 0.62, 95 % CI 0.24–1.58, p = 0.295), no relevant effect of blood transfusion on disease-free survival was observed.

Conclusions

To our knowledge, this is the first propensity score-based analysis providing compelling evidence that the worse oncological outcome after curative resection for advanced cholangiocarcinoma in patients receiving perioperative blood transfusions is caused by the clinical circumstances requiring the transfusions, not by the blood transfusions themselves.     

Assessment of physicians knowledge in transfusion medicine, Iran, 2007

Knowledge of physicians has an important role in optimal use of blood products. This study was carried out to assess Iranian physicians' knowledge in transfusion medicine. In this cross-sectional study, 1242 physicians were selected through multistage sampling method in March 2007. Physicians' knowledge was assessed by the questionnaire comprising of 50 questions addressing basic knowledge, clinical aspects of blood use and transfusion reactions. One point was awarded for each correct answer. Approximately 22%, 37%, and 40% of the questions referring to basic knowledge, clinical aspects of blood use and transfusion reactions, respectively, were replied correctly. Thirty three percent came out to be the average figure for the questions receiving correct answers. Knowledge score of the specialists who were more frequently involved in blood use was not significantly different from other specialists (radiologists or psychiatrics) and general practitioners. Knowledge score decreased with increasing years in practice ( P < 0.001). Ninety nine percent of physicians under the study believed that they required special education to raise their transfusion medicine knowledge. Knowledge of physicians was about one-third lower than the expected level. Therefore, educational materials concerning transfusion medicine should be provided for medical students, residents and fellows. For practicing physicians, continuous medical education programmes should be offered so that the level of transfusion medicine knowledge can be improved.     

Enabling a person with multiple disabilities and minimal motor behaviour to control environmental stimulation with chin movements

Purpose: To assess whether a young man with multiple disabilities and minimal motor behaviour would learn to control environmental stimulation using chin movements and a mechanical microswitch. Method: The study was carried out according to an ABAB design in which A represented baseline and B intervention phases. The chin movements controlled the stimulation only during the intervention phases. A 2-month post-intervention check was conducted. Results: The man increased the frequency of his chin movements, thus increasing the level of environmental stimulation, during the intervention phases. This performance was maintained at the post-intervention check. Conclusion: The use of chin movements is a practical strategy for enabling individuals with minimal motor movements to control environmental stimulation. Future research should examine whether similar types of movements may enable some individuals to control voice-output communication devices.     

Primary report on distribution of tick fauna in Iran

A tick survey was carried out in four different geographical areas of Iran, where the majority of the domestic ruminants in Iran exist. About 1,500 sheep, 1,200 goats and 500 cattle of 12 herds in different provinces lying in the corresponding zones were inspected for tick infestation. The occurrence of ticks on cattle, sheep and goats were 62, 55 and 57%, respectively, with no differences between the zones. The mean number of ticks on each animal was low (10-20 ticks per animal). Ixodid ticks were found throughout the year, whereas the soft tick Ornithodoros sp., which occurred in mountainous area with a significant difference in abundance, showed a clear pattern of seasonality, being generally present from November to March. The largest numbers of adult ixodid ticks were generally present from April to August. Rhipicephalus, Haemaphysalis and Dermacentor ticks occurred in the mountainous area, whereas Boophilus and Ixodes ticks were only present in the Caspian region. Hyalomma were very abundant in each zone but especially in the mountainous area, whereas Ixodes ticks were the minor genus.