Nasopharyngeal malignant melanoma masquerading in the gallbladder: the importance of histological assessment

Metastatic melanoma of the gallbladder is a rare entity that is often diagnosed late, leading to a poor prognosis. The disease may present insidiously as acute cholecystitis or remain asymptomatic. Optimal management remains unclear but surgical resection is considered the mainstay of treatment for this condition. We report the case of a 47-year-old man who suffered a protracted course of generalised abdominal symptoms eventually culminating in a diagnosis of acute cholecystitis. Following an emergency laparoscopic cholecystectomy, the histology revealed a melanoma with an unknown primary. Subsequently this was traced to the nasopharynx. Because of the presence of concurrent liver metastasis, systemic immunotherapy with palliative intent was commenced following a multidisciplinary team discussion. This case highlights the importance of sending clinical specimens for histological analysis. We argue against selectively choosing which specimens to send for histology because radiological and/or intraoperative macroscopic inspection of resected tissue alone can result in a missed diagnosis.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Open Abdominal Aortic Aneurysm Replacement in the Awake Patient

Nonintubated aortic surgery using various techniques has been reported, but despite publication of favorable outcomes in select patient groups, awake aortic surgery remains unpopular. Our patient had an abdominal aortic aneurysm that was unsuitable for endovascular repair. Because of the significant respiratory disease, general anesthesia represented an unacceptably high risk. As a result, he underwent open AAA repair via a retroperitoneal approach with the aid of epidural anesthesia. Here, we highlight the benefits of the procedure which offer a select cohort of patients the chance of life-saving surgery.

Systematic review and meta-analysis of outcomes following emergency surgery for Clostridium difficile colitis

BACKGROUND

Only a small proportion of patients with severe Clostridium difficile infection (CDI) undergo emergency surgery, the timing and nature of which is unclear. The aim of this study was to describe the operations performed and to identify factors predictive of death following emergency surgery for CDI.

METHODS

A systematic review of published literature was performed for studies comparing survivors and non-survivors of emergency surgery for CDI. Meta-analysis was carried out for 30-day and in-hospital mortality.

RESULTS

Overall 31 studies were included, which presented data on a total of 1433 patients undergoing emergency surgery for CDI. Some 1·1 per cent of all patients with CDI and 29·9 per cent with severe CDI underwent emergency surgery, although rates varied between studies (0·2-7·6 and 2·2-86 per cent respectively). The most commonly performed operation was total colectomy with end ileostomy (89·0 per cent, 1247 of 1401 detailed surgical procedures). When total colectomy with end ileostomy was not performed, reoperation to resect further bowel was needed in 15·9 per cent (20 of 126). Where described, the 30-day mortality rate was 41·3 per cent (160 of 387). Meta-analysis of high-quality studies revealed that the strongest predictors of postoperative death were those relating to preoperative physiological status: preoperative intubation, acute renal failure, multiple organ failure and shock requiring vasopressors.

CONCLUSION

This systematic review supports total colectomy with end ileostomy as the primary surgical treatment for patients with severe CDI; other surgical procedures are associated with high rates of reoperation and mortality. Less extensive surgery may have a role in selected patients with earlier-stage disease.

Pneumonyssoides species infestation in two Pekingese dogs in the UK

Two male, neutered, Pekingese dogs aged four years and 12 years were presented for acute-onset nasal pruritus and sneezing following a visit to a beach in northern Scotland. Routine nasal investigations revealed the presence of the canine nasal mite Pneumonyssoides both by direct visualisation and histopathologically. Resolution of clinical signs was observed following selamectin treatment. To the authors' knowledge, this report describes the first cases of Pneumonyssoides infestation in non-travelled UK dogs.

A prospective randomised controlled trial of nutritional supplementation in malnourished elderly in the community: clinical and health economic outcomes

BACKGROUND & AIMS

Malnutrition is common in sick elderly people on admission to hospital and in the community. We conducted a randomised controlled trial to determine if nutritional supplementation after discharge from hospital improved nutritional status and functional outcomes, or reduced health-care costs.

METHODS

Elderly malnourished subjects were randomised to 8 weeks of supplementation or no supplementation post discharge, and followed up for 24 weeks. Weight, body mass index, anthropometrics, handgrip strength, quality of life and requirements for health-care professionals' services and social services were measured throughout the study.

RESULTS

Nutritional status improved significantly from baseline to week 24 in the intervention group (P<0.05), but not in the control group. There was no significant difference in nutritional status between groups at week 24. Handgrip strength improved significantly in the intervention group during supplementation, and was significantly different from that of the control group at week 8, but decreased thereafter. There was no significant difference in quality of life or health economic outcomes between groups at week 24.

CONCLUSIONS

In already malnourished elderly subjects, it may be too late to expect to improve function or quality of life or to reduce health-care costs simply by providing nutritional supplements after hospitalisation. Prevention is key. All elderly patients should be nutritionally assessed as part of their routine care, and appropriate intervention initiated early.

Dietary vitamin K influences intra-individual variability in anticoagulant response to warfarin

The relationship between dietary intake of vitamin K, fat, plasma vitamin K concentrations and anticoagulation response to warfarin within individuals, as well as the contribution of dietary vitamin K to differences in warfarin dose requirements between individuals were investigated in 53 patients on warfarin therapy who had stably controlled anticoagulation. Each patient completed a dietary record of all foods consumed on a daily basis for 4 weeks. Each week a blood sample was taken for measurement of the international normalized ratio (INR), plasma vitamin K, triglycerides and warfarin enantiomer concentrations. The patients' genotype for CYP2C9 was also determined. Regression analysis of the data showed that, for each increase of 100 microg in the daily dietary intake of vitamin K averaged over 4 d, the INR was reduced by 0.2. There was no correlation between warfarin daily dose and average daily dietary vitamin K intake when calculated over 28 d. The regression model for warfarin dose showed that, while dietary vitamin K had no effect, CYP2C9 genotype (P = 2%) and age (P < 1%) significantly contributed to inter-patient variability in warfarin dose requirements. A consistent intake of vitamin K could reduce intrapatient variability in anticoagulation response and thus improve the safety of warfarin therapy.

A prospective study of the workload of a newly formed PEG advice team

BACKGROUND

A multidisciplinary advice team may be the optimal way of providing the long-term nutritional and percutaneous endoscopic gastrostomy (PEG)-related care for patients dependent on PEG feeding but the workload involved is unknown.

AIM

To study prospectively the workload of a proactive, multidisciplinary PEG advice team over a 2-year period.

METHODS

Separate documentation from main case notes of each episode of the team's contact with PEG or potential PEG patients, including assessment, advice and therapy given, from the time of its establishment, for four consecutive 6-monthly periods.

RESULTS

During the audit, 89 patients were referred to the team for consideration of PEG insertion and PEGs were placed in 74. Eighty-nine additional patients were referred for follow up having had a PEG placed elsewhere. During the four audit periods the rate of new PEG insertions increased by 53%, the rate of PEG replacements by 315%, and the number of patients under the team increased from 16 to 70, an increase of 337%. Numbers of inpatient and outpatient consultations, and visits to other institutions by members of the team increased commensurately.

CONCLUSIONS

The rapidly increasing workload of the team suggests it is playing a valued role but there are significant resource implications.

A study of nutritional deficits of long-stay geriatric patients

Current information suggests that dietary intake of nutrients declines with age and that undernutrition in elderly long-stay hospital patients may be under-recognized. We undertook to describe the daily dietary intakes of a group of elderly long-stay hospital patients (n = 92) (group A), using 7-day weighed dietary records. The aim of the study was to determine the adequacy of the diet and investigate whether any differences existed in the intakes of the hospital patients. An assessment of nutritional status was carried out by anthropometry, haematology and biochemistry and was validated by comparison with two further groups: fit young subjects (n = 41) (group B) and fit community elderly subjects (n = 92) (group C). Men in group B had the highest mean values for mid-arm circumference, arm-muscle circumference, corrected arm-muscle area and arm-fat area while women in group A had the lowest mean values for all measured anthropometric indices. There were significant correlations between daily energy intake and anthropometry for men in groups B and C. In group A 68% had intakes < 2/3 recommended daily allowance for energy, 100% for vitamin D, E, B6, folic acid; 98% for magnesium and zinc; and 90% for retinol. Serum calcium and serum alkaline phosphatase were correlated with vitamin D intake in men in group A. There was no biochemical or haematological evidence of undernutrition in the three groups. Elderly long-stay hospital patients were grossly undernourished and their dietary intake did not satisfy basal metabolic demands, based on recommended daily allowances.

Hyponatremia and hyperkalemia associated with idiopathic or experimentally induced chylothorax in four dogs

Two dogs with idiopathic chylothorax and 2 dogs with experimentally induced (ie, ligation of the cranial vena cava) chylothorax were treated by intermittent thoracic drainage. Of these 4 dogs, 3 that did not have evidence of renal failure had normal or near-normal serum sodium and potassium concentrations before thoracic drainage began, and all 3 developed repeatedly marked hyponatremia and hyperkalemia during thoracic drainage. Another dog became weak and depressed, ostensibly because of hyperkalemia. Serum sodium and potassium concentrations in 1 dog with spontaneous chylothorax returned to normal after chylothorax resolved and thoracic drainage was stopped. The other 3 dogs died or were euthanatized, and the effect of stopping thoracic drainage could not be evaluated. In 3 dogs in which it was measured, normal-to-high plasma cortisol concentration was observed before and after adrenocorticotropin administration, and 2 dogs also had hyperaldosteronemia. Hyponatremia was hypothesized to be caused by sodium loss via thoracic drainage whereas hyperkalemia may have been multifactorial in origin, but probably was attributable, at least, in part to decreased renal potassium clearance.

Effect of humidity on calcium sulphate hemihydrate

The conversion of calcium sulphate hemihydrate powders to dihydrate by reaction with atmospheric water vapour has been re-examined gravimetrically. Storage is usually said to be safe at less than '70 per cent RH', but this is shown to be an inadequate criterion (water vapour pressure being more useful in the context) and based on an inappropriate experiment. At 23 degrees C, greater than about 2.3 kPa water vapour pressure caused rapid reaction, and this may be taken as a more reliable critical value.

Nutritional state of patients with lung cancer undergoing thoracotomy

Preoperative nutritional assessment was carried out on 39 consecutive patients with bronchial carcinoma who underwent thoracotomy. For 18 patients the body mass index and triceps and subscapular skinfold thickness fell below the 25th centile. In 23 patients the creatinine height index was less than 80% of the predicted value. The mean (SEM) serum albumin concentration was 40.3 (0.57) g/l (reference range 35-50 g/l) and mean (SEM) serum transferrin 1.77 (0.1) g/l (reference range 2.0-3.0 g/l). Although only three patients were hypoalbuminaemic, transferrin concentrations were depressed in 26 patients. There was a significant fall in the serum concentrations of both prealbumin and transferrin in the first postoperative week. Nutritional insufficiency was particularly severe in the four patients who developed an early bronchopleural fistula. It is concluded that protein-energy malnutrition is common in patients with operable bronchial carcinoma and that routine postoperative feeding does not prevent further depletion of circulating proteins. A larger prospective study is needed to examine the relation between preoperative nutritional state and outcome.