Enhanced recovery after surgery (ERAS) reduces postoperative length of hospital stay and patient stress response to liver surgery. The aim of the present study was to evaluate the efficacy and ...feasibility of an ERAS programme for liver resection.
A multidisciplinary ERAS protocol was implemented for both open and laparoscopic liver resection in a tertiary hospital in Hong Kong. The clinical outcomes of patients who underwent liver resection and underwent the ERAS perioperative programme were compared with those who received a conventional perioperative programme between September 2015 and July 2016. Propensity score matching analysis was used to minimise background differences.
A total of 20 patients who underwent liver resection were recruited to the ERAS programme. Their clinical outcomes were compared with another 20 patients who received hepatectomy under a conventional perioperative programme after propensity score matching. The ERAS programme was associated with a significantly shorter length of hospital stay (P=0.033) without an increase in complication rates in patients who underwent open liver resection. There was no such significant association in patients who underwent laparoscopic liver resection. No patients required readmission in this cohort.
The ERAS perioperative programme for liver resection is safe and feasible. It significantly shortened the hospital stay after open liver resection but not after laparoscopic liver resection.
Background
Postoperative nausea and vomiting (PONV) are common complications following surgery and anaesthesia. Antiemetic drugs are only partially effective in preventing PONV. An alternative ...approach is to stimulate the PC6 acupoint on the wrist. This is an update of a Cochrane review first published in 2004, updated in 2009 and now in 2015.
Objectives
To determine the effectiveness and safety of PC6 acupoint stimulation with or without antiemetic drug versus sham or antiemetic drug for the prevention of PONV in people undergoing surgery.
Search methods
We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (Cochrane Library, Issue 12, 2014), MEDLINE (January 2008 to December 2014), EMBASE (January 2008 to December 2014), ISI Web of Science (January 2008 to December 2014), World Health Organization Clinical Trials Registry, ClinicalTrials.gov, and reference lists of articles to identify additional studies. We applied no language restrictions.
Selection criteria
All randomized trials of techniques that stimulated the PC6 acupoint compared with sham treatment or drug therapy, or combined PC6 acupoint and drug therapy compared to drug therapy, for the prevention of PONV. Interventions used in these trials included acupuncture, electro‐acupuncture, transcutaneous electrical acupoint stimulation, transcutaneous nerve stimulation, laser stimulation, capsicum plaster, acu‐stimulation device, and acupressure in people undergoing surgery. Primary outcomes were the incidences of nausea and vomiting after surgery. Secondary outcomes were the need for rescue antiemetic therapy and adverse effects.
Data collection and analysis
Two review authors independently extracted the data and assessed the risk of bias domains for each trial. We used a random‐effects model and reported risk ratio (RR) with associated 95% confidence interval (95% CI). We used trial sequential analyses to help provide information on when we had reached firm evidence in cumulative meta‐analyses of the primary outcomes, based on a 30% risk ratio reduction in PONV.
Main results
We included 59 trials involving 7667 participants. We rated two trials at low risk of bias in all domains (selection, attrition, reporting, blinding and other). We rated 25 trials at high risk in one or more risk‐of‐bias domains. Compared with sham treatment, PC6 acupoint stimulation significantly reduced the incidence of nausea (RR 0.68, 95% CI 0.60 to 0.77; 40 trials, 4742 participants), vomiting (RR 0.60, 95% CI 0.51 to 0.71; 45 trials, 5147 participants) and the need for rescue antiemetics (RR 0.64, 95% CI 0.55 to 0.73; 39 trials, 4622 participants). As heterogeneity among trials was substantial and there were study limitations, we rated the quality of evidence as low. Using trial sequential analysis, the required information size and boundary for benefit were reached for both primary outcomes.
PC6 acupoint stimulation was compared with six different types of antiemetic drugs (metoclopramide, cyclizine, prochlorperazine, droperidol. ondansetron and dexamethasone). There was no difference between PC6 acupoint stimulation and antiemetic drugs in the incidence of nausea (RR 0.91, 95% CI 0.75 to 1.10; 14 trials, 1332 participants), vomiting (RR 0.93, 95% CI 0.74 to 1.17; 19 trials, 1708 participants), or the need for rescue antiemetics (RR 0.87, 95% CI 0.65 to 1.16; 9 trials, 895 participants). We rated the quality of evidence as moderate, due to the study limitations. Using trial sequential analyses, the futility boundary was crossed before the required information size was surpassed for both primary outcomes.
Compared to antiemetic drugs, the combination of PC6 acupoint stimulation and antiemetic therapy reduced the incidence of vomiting (RR 0.56, 95% CI 0.35 to 0.91; 9 trials, 687 participants) but not nausea (RR 0.79, 95% CI 0.55 to 1.13; 8 trials, 642 participants). We rated the quality of evidence as very low, due to substantial heterogeneity among trials, study limitations and imprecision. Using trial sequential analysis, none of the boundaries for benefit, harm or futility were crossed for PONV. The need for rescue antiemetic was lower in the combination PC6 acupoint stimulation and antiemetic group than the antiemetic group (RR 0.61, 95% CI 0.44 to 0.86; 5 trials, 419 participants).
The side effects associated with PC6 acupoint stimulation were minor, transient and self‐limiting (e.g. skin irritation, blistering, redness and pain) in 14 trials. Publication bias was not apparent in the contour‐enhanced funnel plots.
Authors' conclusions
There is low‐quality evidence supporting the use of PC6 acupoint stimulation over sham. Compared to the last update in 2009, no further sham comparison trials are needed. We found that there is moderate‐quality evidence showing no difference between PC6 acupoint stimulation and antiemetic drugs to prevent PONV. Further PC6 acupoint stimulation versus antiemetic trials are futile in showing a significant difference, which is a new finding in this update. There is inconclusive evidence supporting the use of a combined strategy of PC6 acupoint stimulation and antiemetic drug over drug prophylaxis, and further high‐quality trials are needed.
To examine the feasibility and potential efficacy of 5% lidocaine medicated plaster for acute postoperative pain in a parallel, blinded, randomized controlled pilot trial.
Twenty-eight women ...undergoing elective gynecological surgery with midline incisions were randomly allocated 5% lidocaine medicated patch (Lignopad) or placebo plasters. Postoperative pain at rest and on movement at 24 hours were the primary study endpoints, with secondary endpoints of postoperative pain within the first 48 hours, cumulative morphine consumption (mg), predicted peak flow rate (PFR) (%) and adverse effects. We assessed pain scores at rest and on movement using the visual analogue scale (0-100).
The lidocaine patch group had lower postoperative pain scores at rest at 24 hours (mean difference MD -15.1, 95% confidence interval 95% CI -28.3 to -2.0; P = .024) but not on movement at 24 hours (MD -6.4, 95% CI -22.7 to 9.9; P = .445). Compared to placebo, lidocaine may slightly lower cumulative morphine consumption (mg) over time (MD -3.4, 95% CI -6.9 to 0.2; group*time interaction P = .065). The difference in improvement in the PFR over time after surgery between groups appeared small (group*time P = .0980). No adverse effects occurred.
Lidocaine patch may provide a clinically important reduction in postoperative pain intensity. A larger trial to confirm the efficacy and safety of lidocaine patch is feasible after modifying the inclusion criteria and collecting patient-centered outcomes, such as quality of recovery and patient satisfaction.
The tail of the logarithmic degree distribution of networks decays linearly with respect to the logarithmic degree is known as the power law and is ubiquitous in daily lives. A commonly used ...technique in modeling the power law is preferential attachment (PA), which sequentially joins each new node to the existing nodes according to the conditional probability law proportional to a linear function of their degrees. Although effective, it is tricky to apply PA to real networks because the number of nodes and that of edges have to satisfy a linear constraint. This paper enables real application of PA by making each new node as an isolated node that attaches to other nodes according to PA scheme in some later epochs. This simple and novel strategy provides an additional degree of freedom to relax the aforementioned constraint to the observed data and uses the PA scheme to compute the implied proportion of the unobserved zero-degree nodes. By using martingale convergence theory, the degree distribution of the proposed model is shown to follow the power law and its asymptotic variance is proved to be the solution of a Sylvester matrix equation, a class of equations frequently found in the control theory (see Hansen and Sargent (2008, 2014)). These results give a strongly consistent estimator for the power-law parameter and its asymptotic normality. Note that this statistical inference procedure is non-iterative and is particularly applicable for big networks such as the World Wide Web presented in Section 6. Moreover, the proposed model offers a theoretically coherent framework that can be used to study other network features, such as clustering and connectedness, as given in Cheung (2016).
Renal dysfunction and CABG Ho, Anthony MH; Chan, Simon KC
Current opinion in pharmacology,
04/2012, Letnik:
12, Številka:
2
Journal Article
Recenzirano
Highlights ► Renal dysfunction after CABG is associated with higher morbidity and mortality. ► Very few interventions have been shown to mitigate renal dysfunction after CABG. ► Fenoldopam infusion ...and avoidance of recent contrast injection may be beneficial. ► Excessively low intraoperative haemaglobin may harm the kidneys. ► Adherence to basic principles of organ perfusion remain the best strategy.
To evaluate the attitude and perception of surgeons about postoperative pain management, and an anaesthesiologist-based acute pain service.
Questionnaire survey.
Tertiary university teaching ...hospital, Hong Kong.
All surgical staff members (specialists and trainees) of the Departments of Surgery, Orthopaedics and Traumatology, and Obstetrics and Gynaecology.
Opinions on postoperative pain management, different pain management modalities, and services provided by the acute pain service.
Of the 147 questionnaires, 104 (71%) were returned. The majority (97%) agreed that effective pain control improves patient recovery and 88% believed that anaesthetists should be involved in postoperative pain management. Overall, 85% of the respondents were satisfied with the acute pain service. However, about one third of them wanted to maintain an active role in postoperative pain management and only 54% thought that the acute pain service has a significant impact on patient outcomes. In addition, only 10% of surgeons agreed that patients receiving acute pain service intervention would be discharged earlier. The respondents also thought that, compared to intravenous patient-controlled analgesia, epidural analgesia required more nursing care and was less cost-effective. Areas of the acute pain service warranting improvement included: education of surgeons on postoperative pain and its management (92%), communication (74%), and referral systems (80%).
The majority of surgeons were satisfied with the acute pain service and agreed that anaesthetists should be involved in postoperative pain management. However, a proportion wanted to maintain an active role in postoperative pain management.
Background and Study Aims: PCS is increasingly used in day-case surgery. Its use seems ideal for colonoscopy as an outpatient procedure. In theory PCS leads to faster recovery and earlier discharge. ...Patients and Methods: Between July 1999 and October 1999 patients undergoing colonoscopy as an outpatient procedure were randomized to receive intravenous injection of diazemuls 0.1mg/Kg and pethidine 0.5mg/Kg or a mixture of propofol 400mg and alfentanil 1 mg delivered via a Graseby 3300 PCA pump in bolus of 2mg/ml (lockout period of 3 minutes). Patients' pulse rate and oxygen saturation were monitored continuously and blood pressure taken every 5 minutes. Outcome parameters included procedure time, recovery time, pain score (un-scaled 10cm visual analogue score), desaturation (oxygen saturation < 90%) and hypotension (systolic blood pressure < 90mmHg). Results: 110 patients were recruited (55 in each group). The two groups were comparable in age, body weight and sex ratio. The mean procedure time was significantly longer in the PCS group (25 ± 13 vs. 17.6 ± 8 minutes). Desaturation occurred in 2 patients from the PCS group and 4 from the diazemul group (P=0.68). Fourteen from the PCS group and 16 from the diazemul group developed hypotension (P=0.67). The mean pain score was comparable in either group (5.4 vs. 4.6, P=0.49). A tendency towards shorter median recovery time was noted in the PCS group (20 vs. 30 mintues, P=0.08). Conclusions: PCS in outpatient colonoscopy led to slightly shorter recovery time at the expense of significantly longer procedure time.
Cell-free DNA (cfDNA) in human plasma is a class of biomarkers with many current and potential future diagnostic applications. Recent studies have shown that cfDNA molecules are not randomly ...fragmented and possess information related to their tissues of origin. Pathologies causing death of cells from particular tissues result in perturbations in the relative distribution of DNA from the affected tissues. Such tissue-of-origin analysis is particularly useful in the development of liquid biopsies for cancer. It is therefore of value to accurately determine the relative contributions of the tissues to the plasma DNA pool in a simultaneous manner. In this work, we report that in open chromatin regions, cfDNA molecules show characteristic fragmentation patterns reflected by sequencing coverage imbalance and differentially phased fragment end signals. The latter refers to differences in the read densities of sequences corresponding to the orientation of the upstream and downstream ends of cfDNA molecules in relation to the reference genome. Such cfDNA fragmentation patterns preferentially occur in tissue-specific open chromatin regions where the corresponding tissues contributed DNA into the plasma. Quantitative analyses of such signals allow measurement of the relative contributions of various tissues toward the plasma DNA pool. These findings were validated by plasma DNA sequencing data obtained from pregnant women, organ transplantation recipients, and cancer patients. Orientation-aware plasma DNA fragmentation analysis therefore has potential diagnostic applications in noninvasive prenatal testing, organ transplantation monitoring, and cancer liquid biopsy.
Background
: Pegylated recombinant human arginase (PEG-BCT-100) is an arginine depleting drug. Preclinical studies showed that HCC is reliant on exogenous arginine for growth due to the ...under-expression of the arginine regenerating enzymes argininosuccinate synthetase (ASS) and ornithine transcarbamylase (OTC).
Methods
: This is a single arm open-label Phase II trial to assess the potential clinical efficacy of PEG-BCT-100 in chemo naïve sorafenib-failure HCC patients. Pre-treatment tumour biopsy was mandated for ASS and OTC expression by immunohistochemistry (IHC). Weekly intravenous PEG-BCT-100 at 2.7 mg/kg was given. Primary endpoint was time to progression (TTP); secondary endpoints included radiological response as per RECIST1.1, progression free survival (PFS) and overall survival (OS). Treatment outcomes were correlated with tumour immunohistochemical expressions of ASS and OTC.
Results
: In total 27 patients were recruited. The median TTP and PFS were both 6 weeks (95% CI, 5.9–6.0 weeks). The disease control rate (DCR) was 21.7% (5 stable disease). The drug was well tolerated. Post hoc analysis showed that duration of arginine depletion correlated with OS. For patients with available IHC results, 10 patients with ASS-negative tumour had OS of 35 weeks (95% CI: 8.3–78.0 weeks) vs. 15.14 weeks (95% CI: 13.4–15.1 weeks) in 3 with ASS-positive tumour; expression of OTC did not correlate with treatment outcomes.
Conclusions
: PEG-BCT-100 in chemo naïve post-sorafenib HCC is well tolerated with moderate DCR. ASS-negative confers OS advantage over ASS-positive HCC. ASS-negativity is a potential biomarker for OS in HCC and possibly for other ASS-negative arginine auxotrophic cancers. Trial registration number: NCT01092091. Date of registration: March 23, 2010.
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