International multicentre review of perioperative management and outcome for catecholamine-producing tumours

BACKGROUND

Surgery for catecholamine-producing tumours can be complicated by intraoperative and postoperative haemodynamic instability. Several perioperative management strategies have emerged but none has been evaluated in randomized trials. To assess this issue, contemporary perioperative management and outcome data from 21 centres were collected.

METHODS

Twenty-one centres contributed outcome data from patients who had surgery for phaeochromocytoma and paraganglioma between 2000 and 2017. The data included the number of patients with and without α-receptor blockade, surgical and anaesthetic techniques, complications and perioperative mortality.

RESULTS

Across all centres, data were reported on 1860 patients with phaeochromocytoma or paraganglioma, of whom 343 underwent surgery without α-receptor blockade. The majority of operations (78·9 per cent) were performed using minimally invasive techniques, including 16·1 per cent adrenal cortex-sparing procedures. The cardiovascular complication rate was 5·0 per cent overall: 5·9 per cent (90 of 1517) in patients with preoperative α-receptor blockade and 0·9 per cent (3 of 343) among patients without α-receptor blockade. The mortality rate was 0·5 per cent overall (9 of 1860): 0·5 per cent (8 of 517) in pretreated and 0·3 per cent (1 of 343) in non-pretreated patients.

CONCLUSION

There is substantial variability in the perioperative management of catecholamine-producing tumours, yet the overall complication rate is low. Further studies are needed to better define the optimal management approach, and reappraisal of international perioperative guidelines appears desirable.

RoxyBot-06: Stochastic Prediction and Optimization in TAC Travel

In this paper, we describe our autonomous bidding agent, RoxyBot, who emerged victorious in the travel division of the 2006 Trading Agent Competition in a photo finish. At a high level, the design of many successful trading agents can be summarized as follows: (i) price prediction: build a model of market prices; and (ii) optimization: solve for an approximately optimal set of bids, given this model. To predict, RoxyBot builds a stochastic model of market prices by simulating simultaneous ascending auctions. To optimize, RoxyBot relies on the sample average approximation method, a stochastic optimization technique.

Endoscopic ACL Reconstruction - Mitek Anchor Surgical Technique

Techniques for the repair and reconstruction of the anterior cruciate ligament (ACL) have advanced rapidly in the last decade. The procedure for ACL reconstruction and its equipment have become progressively sophisticated from what was once an open surgery requiring dislocation of the patella to the point where ACL reconstruction surgery can now be performed endoscopically through one small incision. By avoiding a superior / lateral incision through the quadriceps muscle, the endoscopic technique provides the advantages of reduced soft tissue morbidity, reduced pain and improved cosmetic appearance for the patient, and reduced costs due to the fact that the procedure can be performed on an outpatient basis. However, the success of the procedure in restoring normal stability and function to the knee is still based on the variables of graft type, placement, tension, and fixation, as well as postoperative rehabilitation. Numerous studies have provided valuable information regarding advancements in the surgical technique and rehabilitation for ACL reconstruction surgery. Regardless, variable success rates continue to be reported. For failures occurring within the first six months after surgery, graft fixation failure has been shown to be the major cause.

Pharmacokinetic observations of phenytoin disposition in the newborn and young infant

The pharmacokinetic profile of phenytoin (DPH) was studied in 30 infants aged 2 days to 96 weeks. The plasma DPH half-life during the first week of life in term infants was prolonged and very variable (20-7 +/- 11-6 h, mean +/-SD). Thereafter the plasma half-life was much shorter (7-6 +/- 3-5 h). In preterm infants the half-life was much longer (75-4 +/- 64-5 h) and more variable. The mean apparent volume of distribution was similar in these groups of infants: preterm newborn 0-80 +/- 0-22 l/kg, term infants during the first week of life 0-80 +/- 0-26 l/kg, and term infants greater than 2 weeks of age 0-73 +/- 0-18 l/kg. Predictions of steady-state plasma DPH concentrations, based on these kinetic parameters, were confirmed. Very low "trough" plasma DPH concentrations were observed after the 14th postnatal day in 19 infants receiving 8 mg/kg per 24 h orally. On the other hand, infants of less than one week of age receiving the same dose, especially if preterm, frequently showed drug accumulation to toxic plasma DPH concentrations. The impaired binding of DPH to newborn plasma protein was confirmed but "normal adult values" were approached by the age of 3 months. An intravenous loading dose of 8 mg/kg (sodium phenytoin) can be expected to generate a mean plasma DPH concentration of 10 mg/l (40 micronmol/l) in the newborn. Loading doses of up to 12 mg/kg were given without untoward effects. During the first week or so of life plasma Dph half-life is so variable that no fixed dosage regimen can be derived from the available data. Beyond the second week of life, however, a dose of 8 mg/kg per 24 h is probably inadequate for most infants.