Outcome after pancreaticoduodenectomy for T3 adenocarcinoma: A multivariable analysis from the UK Vascular Resection for Pancreatic Cancer Study Group

BACKGROUND

Most resectable pancreatic cancers are classified as T3, including those involving the porto-mesenteric vein. Survival and perioperative morbidity for venous resection have been found to be comparable to standard resection. We investigate factors associated with short and long term outcomes in pancreaticoduodenectomy with (PDVR) and without (PD) venous resection exclusively for T3 adenocarcinoma of the head of the pancreas.

METHODS

This is a UK multicenter retrospective cohort study assessing outcomes in patients undergoing PD and PDVR. All consecutive patients with T3 only adenocarcinoma of the head of the pancreas undergoing surgery between December 1998 and June 2011 were included. Multivariable logistic and proportional hazards regression analyses were performed to determine the association between the surgical groups and in-hospital mortality (IHM) and overall survival (OS).

RESULTS

1070 patients were included of whom 840 (78.5%) had PD and 230 (21.5%) had PDVR. Factors independently associated with IHM were a high creatinine (aHR 1.14, p = 0.02), post-operative bleeding (aHR 2.86, p = 0.04) and a re-laparotomy (aHR 8.42, p = 0.0001). For OS, multivariable analyses identified R1 resection margin status (aHR 1.22, p = 0.01), N1 nodal status (aHR 1.92, p = 0.0001), perineural invasion (aHR 1.37, p = 0.002), tumour size >20mm (aHR 0.63, p = 0.0001) and a relaparotomy (aHR 1.84, p = 0.0001) to be independently associated with overall mortality.

CONCLUSION

This study on T3 adenocarcinoma of the head of the pancreas suggests that IHM is strongly associated with perioperative complications whilst OS is affected by histological parameters. Detailed pre-operative disease evaluation and advances in oncological treatment have the potential to improve OS.

Audit of preoperative localisation of tumor with tattoo for patients undergoing laparoscopic colorectal surgery

BACKGROUND

Preoperative localisation of tumour is an essential requirement in laparoscopic colorectal surgery. Since the introduction of laparoscopic colorectal resections in NGH in February 2010, the difficulties of tumour localisation at the time of surgery without tattoo have been highlighted. Furthermore, endoscopic documentation of site of tattoo with respect to the tumour can be inconsistent and at times misleading or difficult to interpret. Tattooing guidelines should be simple to follow and consistent for all lesions irrespective of the location of the tumour. The recommendations were to place at least three spots of tattoo one mucosal fold distal to the lesion and clearly document site of tattoo with respect to tumour in the endoscopy report.

METHOD

We identified 100 patients undergoing elective laparoscopic colorectal cancer resections over a two-year period. Data were collected regarding presence of tattoo preoperatively as documented in the colonoscopy report and subsequently the visibility of the tattoo at time of laparoscopy and its accuracy in relation to the tumour. Abdominoperineal resections and emergency colorectal operations were excluded.

RESULTS

Only 59% of the patients had a visible and accurate tattoo. In 17% of the patients, the tattoo was not visible at all, although it was documented in the endoscopy report that it had been administered. In 4% of patients, it was visible but inaccurately placed. In 20% of the patients, there were no tattoos at all, necessitating on table endoscopy and intraoperative specimen analysis to confirm that the tumour/lesion was within the resection specimen.

DISCUSSION

Preoperative tumour localisation is extremely important to correctly identify the site of tumour or lesion at laparoscopy. A standardised departmental protocol should be implemented by all endoscopists to place three spots of tattoo one mucosal fold distal to any significant lesions found. Failure to tattoo lesions/cancers preoperatively can lead to intraoperative delays and potential harm to patients from on-table endoscopy.

Is estimated intra-operative blood loss a reliable predictor of surgical outcomes in laparoscopic colorectal cancer surgery?

BACKGROUND

Studies have shown that laparoscopic surgery for colorectal cancer is often associated with significantly reduced intra-operative blood loss compared to the corresponding open procedures. Increased intra-operative blood loss can be associated with increased risk of post-operative morbidity and mortality. We sought to determine whether estimated intra-operative blood loss was a reliable predictor of post-operative surgical outcomes.

METHOD

Prospective data were collected for patients undergoing elective laparoscopic colorectal cancer resections from July 2011 to November 2013. Weighing swabs and measuring blood volume in suction devices calculated the estimated intra-operative blood loss. The operative outcome data including post-operative 30 day morbidity and mortality, length of hospital stay, re-admission and re-operation within 30 days were collected. The operative blood loss was grouped into Group 1 (less than 50 ml, Group 2 (50-150 ml) and Group 3 (over 150 ml). Patients who underwent open operations and laparoscopic conversions were excluded.

RESULTS

The median age, length of hospital stay, male to female ratio and body mass index were similar in the three groups. There was no 30-day mortality in any of the groups. The number of re-admissions within 30 days was similar in all groups. The re-operation rates within 30 days were higher in Groups 2 and 3 at 11% and 8.6%, respectively. The post-operative complications were 12.5%, 16.7%, and 26% in groups 1, 2 and 3, respectively. There were no anastomotic leaks requiring re-operation noted in Group 3.

DISCUSSION

This study has shown that intra-operative blood loss was not associated with increased median length of stay nor did it increase the 30 day re-admission rate. However, increased intra-operative blood loss was associated with increased incidence of post-operative morbidity and risk of reoperation within 30 days.

What can be learned from the types of community benefit programs that hospitals already have in place?

After implementation of the Patient Protection and Affordable Care Act (ACA) how will tax-exempt hospitals adjust their community benefit programs to maintain their non-profit status? This literature review categorized existing hospital-based community benefit programs by reviewing published articles that met the following inclusion criteria: affiliated or funded by a hospital; described the program design; focused on community benefit or outreach; evaluated program outcomes; located within the United States. Of 4,917 original citations, we reviewed 265 full-text articles. One hundred and six (106) programs met all inclusion criteria and were used to develop a hospital-based community benefit program taxonomy. Results indicate that programs to enhance patient care, clinic-based programs and programs with a community partner make up the majority of community benefit programs (25%, 28% and 31%, respectively). Few programs were rigorously evaluated or provide evidence of program impact. Hospitals should work with public health professionals to design, implement, and evaluate their community benefit programs.

Search for patterns by combining cosmic-ray energy and arrival directions at the Pierre Auger Observatory

Energy-dependent patterns in the arrival directions of cosmic rays are searched for using data of the Pierre Auger Observatory. We investigate local regions around the highest-energy cosmic rays with [Formula: see text] eV by analyzing cosmic rays with energies above [Formula: see text] eV arriving within an angular separation of approximately 15[Formula: see text]. We characterize the energy distributions inside these regions by two independent methods, one searching for angular dependence of energy-energy correlations and one searching for collimation of energy along the local system of principal axes of the energy distribution. No significant patterns are found with this analysis. The comparison of these measurements with astrophysical scenarios can therefore be used to obtain constraints on related model parameters such as strength of cosmic-ray deflection and density of point sources.

Normal values for transbulbar sonography and magnetic resonance imaging of the optic nerve sheath diameter (ONSD) in children and adolescents

PURPOSE

To establish normal values of the optic nerve sheath diameter (ONSD) in children and adolescents for transbulbar sonography and magnetic resonance imaging.

MATERIALS AND METHODS

In 99 children and adolescents (age: 5.6 - 18.6 years, mean: 12 years) without neurologic or ophthalmologic disease, measurements of the ONSD with transbulbar sonography were performed. For comparison 59 children and adolescents (age: 5.1 - 17.4 years, mean 12.3 years) with a normal MR examination of the brain had measurements of the ONSD on a T2-weighted thin section sequence of the orbit. Besides establishing modality-related normal values, age dependency, accuracy and reproducibility of measurements were assessed.

RESULTS

Overall the mean ONSD was 5.75 ± 0.52 mm for transbulbar sonography and 5.69 ± 0.31 mm for MRI. There was no statistical significance between the 95 % percentiles and age for both transbulbar sonography (p = 0.332) and MRI (p = 0.336). As a parameter for the reproducibility of measurements, the repeatability coefficient (RC) was between 0.34 mm and 0.46 mm. The concordance correlation coefficient (CCC) values revealed a high agreement between readers both for transbulbar sonography (0.868) and MRI (0.796).

CONCLUSION

Normal values for ONSD in children and adolescents found in this study are significantly higher than assumed. The values found for transbulbar sonography are confirmed by comparable results for MR measurements. A precise sonographic measurement technique and the consideration of normal values found hereby are essential for correct interpretation of ONSD measurements in children and adolescents.

Frailty and technology: a systematic review of gait analysis in those with frailty

BACKGROUND

New technologies for gait assessment are emerging and have provided new avenues for accurately measuring gait characteristics in home and clinic. However, potential meaningful clinical gait parameters beyond speed have received little attention in frailty research.

OBJECTIVE

To study gait characteristics in different frailty status groups for identifying the most useful parameters and assessment protocols for frailty diagnosis.

METHODS

We searched PubMed, Embase, PsycINFO, CINAHL, Web of Science, Cochrane Library, and Age Line. Articles were selected according to the following criteria: (1) population: individuals defined as frail, prefrail, or transitioning to frail, and (2) outcome measures: quantitative gait variables as obtained by biomechanical analysis. Effect sizes (d) were calculated for the ability of parameters to discriminate between different frailty status groups.

RESULTS

Eleven publications met inclusion criteria. Frailty definitions, gait protocols and parameters were inconsistent, which made comparison of outcomes difficult. Effect sizes were calculated only for the three studies which compared at least two different frailty status groups. Gait speed shows the highest effect size to discriminate between frailty subgroups, in particular during habitual walking (d = 0.76-6.17). Gait variability also discriminates between different frailty status groups in particular during fast walking. Prominent parameters related to prefrailty are reduced cadence (d = 1.43) and increased step width variability (d = 0.64), whereas frailty (vs. prefrail status) is characterized by reduced step length during habitual walking (d = 1.32) and increased double support during fast walking (d = 0.78). Interestingly, one study suggested that dual-task walking speed can be used to predict prospective frailty development.

CONCLUSION

Gait characteristics in people with frailty are insufficiently analyzed in the literature and represent a major area for innovation. Despite the paucity of work, current results suggest that parameters beyond speed could be helpful in identifying different categories of frailty. Increased gait variability might reflect a multisystem reduction and may be useful in identifying frailty. In addition, a demanding task such as fast walking or adding a cognitive distractor might enhance the sensitivity and specificity of frailty risk prediction and classification, and is recommended for frailty assessment using gait analysis.

Coumarin and salicylic acid activate resistance to Macrophomina phaseolina in Helianthus annuus

The induction of resistance to charcoal rot disease caused by Macrophomina phaseolina (Tassi) Goidanich in sunflower (Helianthus annuus L.) was studied after seed treatments with coumarin (COU) and salicylic acid (SA) at three different levels (0.3, 1.0 and 3.0 mM). The priming of sunflower seeds with 0.3 mM COU or 1.0 mM SA resulted in decreased disease severity and offered about 50% protection and more than 80% reduction in the length of stem lesions under greenhouse conditions. Both COU and SA treatments induced the accumulation of soluble sugars and phytoalexins, as well as stimulating the activity of β-1,3-glucanase and chitinase.

Normalization of NF-κB activity in dorsal root ganglia neurons cultured from diabetic rats reverses neuropathy-linked markers of cellular pathology

AIMS/HYPOTHESIS

Dorsal root ganglia (DRG) sensory neurons cultured from 3 to 5 month streptozotocin (STZ)-induced diabetic rats exhibit structural and biochemical changes seen in peripheral nerve fibers in vivo, including axonal swellings, oxidative damage, reduced axonal sprouting, and decreased NF-κB activity. NF-κB is a transcription factor required by DRG neurons for survival and plasticity, and regulates transcription of antioxidant proteins (e.g. MnSOD). We hypothesized that the diabetes-induced decrease in NF-κB activity in DRG contributes to pathological phenomena observed in cultured DRG neurons from diabetic rats.

METHODS

NF-κB localization was assessed in intact DRG and neuron cultures using immunostaining. NF-κB activity was manipulated in sensory neuron cultures derived from age-matched normal or 3-5 month STZ-diabetic rats using pharmacological means and lentiviral expression of shRNA. The impact of diabetes and altered NF-κB activity on neuronal phenotype involved analysis of neurite outgrowth, neurite morphology, oxidative stress (lipid peroxidation) and expression of MnSOD.

RESULTS

STZ-induced diabetes caused a significant decrease in nuclear localization of NF-κB subunits p50 and c-rel, but no change in p65 in intact DRG. Inhibition of NF-κB in normal neuron cultures significantly increased axonal swellings and oxidative stress, and reduced both neurite outgrowth and expression of MnSOD. These phenomena mimicked markers of pathology in cultured DRG neurons from diabetic rats. Enhancement of NF-κB activity in cultured diabetic DRG neurons ameliorated the sub-optimal neurite outgrowth and MnSOD levels triggered by diabetes. Exogenous insulin enhanced nuclear localization of p50 and c-rel but not p65 in diabetic neuronal cultures.

CONCLUSION/INTERPRETATION

The diabetes-induced decrease of nuclear localization of NF-κB subunits p50 and c-rel in DRG contributes to development of in vitro markers of peripheral neuropathy, possibly through impaired mitochondrial ROS scavenging by deficient MnSOD.

Strategy of surgical treatment of giant presacral tumor - a case report

Presacral tumors are uncommon lesions that can be difficult to diagnose because of their nonspecific presenting signs and symptoms. Surgery is the mainstay of treatment as it establishes the diagnosis and prevents the adverse consequences associated with malignant degeneration and secondary bacterial infection. Large, highly vascularised pelvic tumors may pose intraoperative difficulties as bleeding and intraoperative tumor perforation. Cross-sectional imaging is essential in evaluating these lesions to determine the optimal surgical approach and the extent of resection. We emphasize a multidisciplinary expert individualized approach. We report a case of a presacral giant gastrointestinal tumor initially considered as unresectable but further on successfully managed by preoperative vascular embolization followed by resection via abdomino-perineal approach.