Preoperative determinants of common bile duct stones during laparoscopic cholecystectomy

INTRODUCTION

The aim of this study is to determine whether there are any clinical or biochemical predictors of common bile duct (CBD) stones in patients undergoing laparoscopic cholecystectomy.

METHODS

A prospective database of nearly 1000 laparoscopic cholecystectomies performed under the care of a single surgeon with a standardised technique between 1999 and 2006, was analysed. Clinical presentation, ultrasound and immediate preoperative biochemical results as well as the operative cholangiogram findings were reviewed. Routine cholangiography was attempted in most patients and the primary outcome variable was the detection of bile duct stones. The data was analysed using chi-squared test for categorical variables. The significant variables on univariate analysis were further characterised to identify the independent predictors of bile duct stones using a logistic regression model (significance p < 0.05).

RESULTS

A total of 757 of 988 patients (77%) underwent cholangiography. Male-to-female ratio was 1 : 3 with a median age of 54 years (range: 17-93). Ten per cent of patients had bile duct stones identified on cholangiography. On univariate analysis, jaundice (p = 0.019), cholangitis (p < 0.001), alanine transaminase > 100 (p = 0.024), alkaline phosphatase (ALP) > 350 (p < 0.001) and CBD > 10 mm (p = 0.01) were significant markers for predicting bile duct stones. Bilirubin > 30 (x2 normal) was found not to be significant (p = 0.145). On a logistic regression model, ALP > 350 and/or cholangitis were found to be independent predictive factors of CBD stones (odds ratio 6.1).

CONCLUSIONS

If a policy of routine intra-operative cholangiography is not adopted, a history of cholangitis or a raised ALP immediately preoperatively should lead to a high suspicion of CBD stones.

Surgery for hilar cholangiocarcinoma: the Leeds experience

AIM

To review the experience with hilar cholangiocarcinoma and to determine the results of a radical surgical approach in a UK centre.

METHODS

A 10-year review of all patients treated surgically for proximal bile duct carcinoma at a single surgical unit was conducted. Patient demographics, disease details and histopathology reports were reviewed. From January 1993 through December 2003, 106 patients were admitted with the diagnosis of hilar cholangiocarcinoma and 61 patients received surgical exploration.

RESULTS

Tumours were staged as follows (UICC 6th edition): stage IB, n=10 IIA, n=9; IIB, n=20; III, n=8; IV, n=14. Out of 61 patients, 44 had a resection (3 bile duct resection alone, 41 liver resection with bile duct resection), 5 were considered unresectable and 12 underwent liver transplantation (LT). The caudate lobe was excised in 34 of the patients and regional lymphadenectomy was systematically carried out. Para-aortic lymphadenectomy was performed in 17 cases. Portal vein resection was needed in 17 and hepatic artery resection was performed in 4 cases. Negative histologic margins (R0) were achieved in 20 patients and microscopic margin involvement (R1) was seen in 16. In the remaining 8 resected patients, localised metastasis were found (peritoneal deposits in 2, liver metastasis in 4 and positive para-aortic lymph nodes in 2); nevertheless the resection was performed and it was considered R2. Overall survival at 3 and 5 years for patients who underwent a resection was 43% and 28% including postoperative deaths. The 1-, 3- and 5-year actuarial survival rates for patients who underwent R0 resection were 78%, 64% and 45% respectively, including the postoperative deaths (n=3). The median survival time was 41.1 months. The 1-, 3- and 5-year actuarial survival rates for R1 resection and R2 were 60%, 26%, 26% and 25% and 0% respectively, while the median survival time for these groups was 15.4 and 6.8 months respectively. The actuarial survival rate at 1, 3 and 5 years for well-differentiated tumours (G1) was 73%, 54% and 40% (median 39.7 months). The figures for G2 were 60%, 48% and 0%. The figures for G3 (poorly differentiated) were 16% and 0% at three years (p=0.03).The overall survival at 3 and 5 years for those patients who had a liver transplant was 41% and 20% including early postoperative mortality. The tumour grading (presence of poorly differentiated tumour) was found to be the only independent factor affecting the survival time producing a hazard ratio of 4.3 (p=0.0034, 95% confidence interval 0.1007-6.342).

CONCLUSIONS

Radical surgical resection is the best treatment for hilar cholangiocarcinoma. R0 resection provides acceptable 5-year survival, but R1 resection may also provide acceptable palliation. In our experience TNM stage and tumour grade were the main determinants of long-term survival.

Surgery for hilar cholangiocarcinoma: the Leeds experience

AIM

To review the experience with hilar cholangiocarcinoma and to determine the results of a radical surgical approach in a UK centre.

METHODS

A 10-year review of all patients treated surgically for proximal bile duct carcinoma at a single surgical unit was conducted. Patient demographics, disease details and histopathology reports were reviewed. From January 1993 through December 2003, 106 patients were admitted with the diagnosis of hilar cholangiocarcinoma and 61 patients received surgical exploration.

RESULTS

Tumours were staged as follows (UICC 6th edition): stage IB, n=10 IIA, n=9; IIB, n=20; III, n=8; IV, n=14. Out of 61 patients, 44 had a resection (3 bile duct resection alone, 41 liver resection with bile duct resection), 5 were considered unresectable and 12 underwent liver transplantation (LT). The caudate lobe was excised in 34 of the patients and regional lymphadenectomy was systematically carried out. Para-aortic lymphadenectomy was performed in 17 cases. Portal vein resection was needed in 17 and hepatic artery resection was performed in 4 cases. Negative histologic margins (R0) were achieved in 20 patients and microscopic margin involvement (R1) was seen in 16. In the remaining 8 resected patients, localised metastasis were found (peritoneal deposits in 2, liver metastasis in 4 and positive para-aortic lymph nodes in 2); nevertheless the resection was performed and it was considered R2. Overall survival at 3 and 5 years for patients who underwent a resection was 43% and 28% including postoperative deaths. The 1-, 3- and 5-year actuarial survival rates for patients who underwent R0 resection were 78%, 64% and 45% respectively, including the postoperative deaths (n=3). The median survival time was 41.1 months. The 1-, 3- and 5-year actuarial survival rates for R1 resection and R2 were 60%, 26%, 26% and 25% and 0% respectively, while the median survival time for these groups was 15.4 and 6.8 months respectively. The actuarial survival rate at 1, 3 and 5 years for well-differentiated tumours (G1) was 73%, 54% and 40% (median 39.7 months). The figures for G2 were 60%, 48% and 0%. The figures for G3 (poorly differentiated) were 16% and 0% at three years (p=0.03).The overall survival at 3 and 5 years for those patients who had a liver transplant was 41% and 20% including early postoperative mortality. The tumour grading (presence of poorly differentiated tumour) was found to be the only independent factor affecting the survival time producing a hazard ratio of 4.3 (p=0.0034, 95% confidence interval 0.1007-6.342).

CONCLUSIONS

Radical surgical resection is the best treatment for hilar cholangiocarcinoma. R0 resection provides acceptable 5-year survival, but R1 resection may also provide acceptable palliation. In our experience TNM stage and tumour grade were the main determinants of long-term survival.

Plasma amyloid beta protein is elevated in late-onset Alzheimer disease families

OBJECTIVE

Plasma A beta levels are elevated in early-onset Alzheimer disease (AD) caused by autosomal dominant mutations. Our objective was to determine whether similar genetic elevations exist in late-onset AD (LOAD).

METHODS

We measured plasma A beta in first-degree relatives of patients with LOAD in a cross-sectional series and in extended LOAD families. We screened these subjects for pathogenic mutations in early-onset AD genes and determined their ApoE genotypes.

RESULTS

Plasma A beta is significantly elevated in the LOAD first-degree relatives in comparison to unrelated controls and married-in spouses. These elevations are not due to ApoE epsilon 4 or pathogenic coding mutations in the known early-onset AD genes.

CONCLUSIONS

The findings provide strong evidence for the existence of novel, as yet unknown genetic factors that affect late-onset Alzheimer disease by increasing A beta.

Wisconsin Comorbidity Assessment Scale (WCAS): A novel, comprehensive, performance-based assessment scale of geriatric syndromes and medical comorbidities in older cancer patients

19619

Background: Elderly patients with cancer have potential for multiple geriatric syndromes that influence treatment and outcomes. No single clinical assessment tool has targeted all the major geriatric syndromes and their interaction on cancer management and outcomes. We developed WCAS to evaluate cognitive and physical function, risk of falls and gait disorders, polypharmacy, and medical comorbidities. Methods: Eighteen newly diagnosed patients with breast cancer (age 55–82), were enrolled prior to cancer treatment. Cognitive function was evaluated with a comprehensive battery of neuropsychological tests targeting the domains of memory, executive function, attention, language, and praxis. Physical function skills were assessed with novel performance-based tasks (e.g., bed-making) and computerized assessments of balance, gait and risk of falls. Cancer treatment included surgery in all patients with variable use of adjuvant radiation and medical therapy. WCAS was administered at baseline and at month 6. Results: Ten subjects have completed both baseline and month 6 visits. Surgical treatment occurred at a mean of ten days after baseline assessment (SD 6.7). The mean (SD) of the age, years of education and baseline Mini Mental Status Exam (MMSE) was 66 years (7.3), 15.2 years (3.7) and 29.3 (1.1). From baseline to month six assessment performance on the WAIS Digit Symbol test, a measure of working memory and processing speed, declined (mean change −11.7, p<0.01). Likewise, the performance on the WAIS letter number sequence test (mean change −1.3, p=0.09) and the MMSE (mean change −1.1, p=0.12) declined. Interestingly, four subjects with pre-existing hypothyroidism on replacement treatment showed a greater decline (p<0.01) in memory than those without this common condition. Conclusions: Findings indicate that breast cancer diagnosis and therapy can be associated with significant decline in aspects of cognition in older adults with cancer. These changes can last at least 6 months and are more pronounced in those with hypothyroidism. Larger, longer term prospective studies utilizing WCAS are necessary to confirm our preliminary findings.

No significant financial relationships to disclose.

Should Cardiac Troponins be Used as a Risk Stratification Tool for Patients with Chronic Critical Limb Ischaemia?

OBJECTIVES

Cardiovascular mortality in patients with chronic critical lower limb ischaemia (CCLI) is high and early risk stratification in these patients may aid clinical management improving outcomes. Cardiac troponin I (cTnI) has prognostic significance in patients with unstable angina. The aim of this study was to evaluate the prognostic significance of cardiac troponins in CCLI patients who had no clinical evidence of unstable coronary heart disease.

METHODS

Patients (n=152) admitted with CCLI to a single vascular unit over a two-year period were included prospectively in this study. Patients with clinical evidence of unstable coronary disease were excluded from the study. Patient demographics, clinical history, co-morbidity and risk factors for peripheral vascular disease were documented. Admission cTnI levels were recorded using a threshold, 0.1 ng/ml. The primary endpoint was mortality.

RESULTS

Fifty-two patients (34.2%) had an elevated cTnI, whilst 100 (65.8%) had cTnI <0.1 ng/ml. Sixty-two patients died during the follow-up period, 38 with an elevated admission cTnI. Death rate in patients with cTnI >0.1 ng/nl was 73% compared with 24% in those with levels below the threshold (p<0.0001). Patients with elevated cTnI were significantly older than those with normal level (median age 76 years vs 71 years, p<0.001). An elevated cTnI was found to independently predict disease-specific mortality on Cox regression analysis (Hazard Ratio 4.2; 95% Confidence Interval 1.3-12.7).

CONCLUSION

In this series of patients with CCLI the measurement of cTnI on admission was a significant independent predictor of survival. cTnI has potential as a prognostic test to stratify patients with a high cardiovascular risk and may enable further optimisation of these high-risk patients.

Hormone effects on fMRI and cognitive measures of encoding: importance of hormone preparation

We compared fMRI and cognitive data from nine hormone therapy (HT)-naive women with data from women exposed to either opposed conjugated equine estrogens (CEE) (n = 10) or opposed estradiol (n = 4). Exposure to either form of HT was associated with healthier fMRI response; however, CEE-exposed women exhibited poorer memory performance than either HT-naive or estradiol-exposed subjects. These preliminary findings emphasize the need to characterize differential neural effects of various HTs.

Hyperhomocysteinaemia is associated with the rate of abdominal aortic aneurysm expansion

OBJECTIVES

Previous literature has suggested an association between AAA and the presence of elevated plasma homocysteine levels (HCY). Homocysteine can stimulate elastolysis in the arterial media via activation of elastase and matrix metalloproteinases. No evidence in the literature exists correlating aneurysm expansion and HCY. The study objective is to identify whether the rate of AAA expansion is related to HCY.

METHODS

108 patients undergoing surveillance for AAA were identified at our vascular surgical unit. AAA size and growth rate were assessed by serial ultrasonographic measurements. Fasting total HCY levels were measured using fluorescence polarisation immunoassays. Demographic details and atherosclerotic risk factors were noted all AAA patients. A multivariate analysis was performed for growth rate vs. HCY, hypertension and hypercholesterolaemia. The correlation between AAA growth rate, AAA size and HCY levels were calculated.

RESULTS

60% of patients with AAA had some degree of hyperhomocysteinaemia (> 15 micromol/l). Multivariate analysis showed HCY to be the only significant factor affecting AAA growth rate. A positive correlation was demonstrated between HCY levels and AAA growth rate using a linear regression model (R=0.28, p=0.003). Median growth rate among patients with hyperHCY was double that of patients with normal HCY (0.5 mm/month vs. 0.25 mm/month, p=0.003). A growth rate of > 10 mm/year was seen in 25% of hyper HCY patients and in only 2% of patients with normal HCY. In addition patients with hyper HCY and larger AAAs (> 4 cm) had a growth rate twice as fast as patients with hyper HCY and AAAs < 4 cm.

CONCLUSIONS

A correlation between HCY and growth rate exists, although this is weak due to the multifactorial aetiology of AAAs. HyperHCY patients have faster expansion rates than patients with normal HCY, with significant numbers demonstrating rapid expansion (> 10 mm/year) and therefore an increased risk of rupture.

Differential modulation of plasma -amyloid by insulin in patients with Alzheimer disease

BACKGROUND

Hyperinsulinemia and insulin resistance are risk factors for memory impairment and Alzheimer disease (AD). Insulin regulates levels of the amyloid beta-peptide (Abeta) in vitro in neuronal cultures and in vivo in the CSF of normal older adults.

OBJECTIVE

To determine whether insulin affected plasma Abeta levels and whether such effects differed for patients with AD compared with normal older adults.

METHODS

Fifty-nine patients with AD and 50 healthy older adults each received infusions of saline and of insulin (1.0 mU.kg(-1).min(-1)) with accompanying dextrose to maintain euglycemia. A subset of participants (19 AD, 12 normal) received two additional conditions, in which insulin was infused at a lower (0.33 mU.kg(-1).min(-1)) and higher (1.67 mU.kg(-1).min(-1)) rate. Plasma insulin and Abeta were measured after 120 minutes of infusion.

RESULTS

Adults with AD had higher plasma insulin vs normal adults at the two higher infusion rates, despite receiving comparable amounts of insulin. For normal adults, insulin reduced plasma Abeta levels at the middle (1.0 mU.kg(-1).min(-1)) dose, with attenuated effects at lower and higher doses. In contrast, for patients with AD, insulin raised plasma Abeta levels at the two higher doses (1.0 and 1.67 mU.kg(-1).min(-1)).

CONCLUSIONS

These results suggest that patients with Alzheimer disease (AD) have reduced insulin clearance and insulin-provoked plasma amyloid beta-peptide (Abeta) elevation. Abnormal regulation of peripheral Abeta by insulin may contribute to AD risk.

Triangular and self-triangulating cavocavostomy for orthotopic liver transplantation without posterior suture lines: a modified surgical technique

A modified caval preservation technique with the potential for decreased incidence of venous outflow obstruction and haemorrhage.

Testosterone improves spatial memory in men with Alzheimer disease and mild cognitive impairment

OBJECTIVE

To determine the efficacy of testosterone (T) supplementation on cognition in a sample of men with Alzheimer disease (AD) or mild cognitive impairment (MCI).

METHODS

Fifteen patients with AD and 17 patients with MCI aged 63 to 85 years completed a randomized, double-blind, placebo-controlled study. Nineteen participants received weekly intramuscular (IM) injections of 100 mg T enanthate and 13 participants received weekly injections of placebo (saline) for 6 weeks. Cognitive evaluations using a battery of neuropsychological tests were conducted at baseline, week 3, and week 6 of treatment and again after 6 weeks of washout.

RESULTS

Peak serum total T levels were raised from baseline an average of 295% in the active treatment group. Improvements in spatial memory (p < 0.05) and constructional abilities (p < 0.05) and verbal memory were evident in the T group. No changes were noted for selective and divided attention or language. Prostate specific antigen did not significantly change during this brief treatment.

CONCLUSION

Testosterone supplementation may benefit selective cognitive functions in men with Alzheimer disease and mild cognitive impairment.

Activation of brain regions vulnerable to Alzheimer's disease: the effect of mild cognitive impairment

This study examined the functionality of the medial temporal lobe (MTL) and posterior cingulate (PC) in mild cognitive impairment amnestic type (MCI), a syndrome that puts patients at greater risk for developing Alzheimer disease (AD). Functional MRI (fMRI) was used to identify regions normally active during encoding of novel items and recognition of previously learned items in a reference group of 77 healthy young and middle-aged adults. The pattern of activation in this group guided further comparisons between 14 MCI subjects and 14 age-matched controls. The MCI patients exhibited less activity in the PC during recognition of previously learned items, and in the right hippocampus during encoding of novel items, despite comparable task performance to the controls. Reduced fMRI signal change in the MTL supports prior studies implicating the hippocampus for encoding new information. Reduced signal change in the PC converges with recent research on its role in recognition in normal adults as well as metabolic decline in people with genetic or cognitive risk for AD. Our results suggest that a change in function in the PC may account, in part, for memory recollection failure in AD.

Alzheimer?s disease: the impact of age-related changes in reproductive hormones

Recent findings from the Women's Health Initiative (WHI) have raised considerable concern over prolonged use of opposed and unopposed oral conjugated equine estrogen (CEE), given the increased risk of serious adverse effects, including stroke and venous thromboembolic complications. Furthermore, results from the WHI Memory Study (WHIMS) indicated that over 5 years of therapy with Prempro impaired performance on global cognitive tests and nearly doubled the risk of dementia. These surprising findings were contradictory to cumulative evidence from basic science, epidemiological and some intervention studies suggesting hormone therapy was cardioprotective and could potentially reduce the risk of dementia. This review paper focuses on the neurobiology of estrogen, summarizing the clinical evidence for neuroprotective and cognition-enhancing efficacy of estrogen. Further, the paper briefly discusses variables that may account for the unexpected findings of WHIMS, and offers suggestions for future research.

The demographic and social class basis of inequality in self reported morbidity: an exploration using the Health Survey for England

STUDY OBJECTIVES

To assess the relative contribution of age and social class to variations in the prevalence of a selection of self reported health problems. To examine the implications of observed variations for research on health inequalities.

DESIGN

Secondary analysis of the Health Survey for England (1991-1997) using morbidities that are particularly prone to class effects. A statistical measure of the "relative class effect" is introduced to compare the effects of adjusting for social class and age.

MAIN RESULTS

There is substantial variation in the relative importance of the age and class distributions of different diseases. Age effects often overshadow those of class even for conditions where an apparently strong social gradient exists. Only for self reported mental health among women does the social gradient exceed the age gradient. Within the context of a dominating age gradient, social gradients are relatively high for mental health and general health for both sexes. Variation in the relative strengths of the social gradients between the sexes are observed for angina symptoms.

CONCLUSIONS

Given variations in the "relative class effect", analysis recognising the distinct contributions of age, sex, and social class to specific morbidities is advocated as a transparent and robust approach to the assessment of morbidity based inequality.

Prevalence and risk factors for development of lymphedema following breast cancer treatment

BACKGROUND

Early detection and multimodality therapy has resulted in an overall improvement of survival among breast cancer patients. Despite a significant shift in the treatment approach from radical mastectomy to breast conservation a significant number of patients develop lymphedema. This study was conducted to evaluate the prevalence and risk factors for development of lymphedema.

SETTINGS AND DESIGN

Retrospective analysis for prevalence of lymphedema in a tertiary care regional cancer centre.

MATERIAL AND METHODS

Three hundred treated breast cancer patients with a minimum follow up of one year were evaluated for the prevalence and risk factors for lymphedema. Lymphedema was assessed using a serial circumferential measurement method. More than 3 cm difference in circumference is considered as clinical significant lymphedema. Univariate and multivariate analysis were performed for evaluating the risk factors by using the Chi square test and Cox logistic regression analysis.

RESULTS

The prevalence of clinically significant lymphedema was 33.5 % and 17.2 % had severe lymphedema. The prevalence of lymphedema was 13.4 % in patients treated with surgery only where as the prevalence was 42.4% in patients treated with surgery and radiotherapy. Stage of the disease, body surface area > 1. 5 m2, presence of co-morbid conditions, post operative radiotherapy and anthracycline based chemotherapy were significant risk factors in univariate analysis where as axillary irradiation and presence of co-morbid conditions have emerged as independent risk factors in multivariate analysis (P < 0.001).

CONCLUSION

Post treatment lymphedema continues to be a significant problem following breast cancer therapy. Presence of co-morbid conditions and axillary radiation significantly increases the risk of lymphedema. A combination of axillary dissection and axillary radiation should be avoided whenever feasible to avoid lymphedema.

Relationship between testosterone supplementation and insulin-like growth factor-I levels and cognition in healthy older men

BACKGROUND

Our laboratory has previously reported that testosterone (T) administration to older men significantly improves cognitive function. This study examined potential changes in insulin-like growth factor (IGF) IGF-I, IGF-II and IGF-related binding proteins in response to T administration in older men and their relationship to cognitive functioning.

METHODS

Twenty-five healthy community dwelling volunteers, ranging in age from 50-80 years were randomized to receive weekly intra-muscular (i.m.) injections of either 100 mg T enanthate or placebo (saline) for 6 weeks. Serum hormone levels and cognitive functioning was assessed at baseline and twice during treatment.

RESULTS

Significant positive associations between IGF-I and IGF-II and spatial memory, spatial reasoning, and verbal fluency were observed after 6 weeks of T administration. Increased serum T levels from treatment were positively associated with improvement in spatial reasoning performance, whereas estradiol was associated with a decline in divided attention performance. Serum IGF-I, IGF-II and IGFBPs did not change in response to T treatment.

CONCLUSIONS

Our results suggest that T, estradiol and IGF-I may have independent and selective effects on cognitive functioning. Positive associations between T levels and cognition are consistent with an effect of androgen treatment, whereas positive associations between IGF-I levels and cognition are reflective of a relationship between endogenous IGF-I levels and cognition.

Insulin increases CSF Abeta42 levels in normal older adults

BACKGROUND

Abnormal insulin metabolism may contribute to the clinical symptoms and pathophysiology of AD. In vitro studies show that insulin enhances the release of beta-amyloid protein (Abeta) or inhibits its degradation, either of which might increase amyloid burden.

METHODS

On separate mornings, 16 healthy older adults (10 women, 6 men; mean age 68.7 years, SD 8.6 years) each underwent two infusions consisting of either saline (placebo) or insulin (1.0 mU x kg(-1) x min(-1)) plus dextrose to maintain euglycemia. After 120 minutes of infusion, blood, CSF, and cognitive measures were acquired.

RESULTS

As expected, insulin infusion produced an increase in CSF insulin concentration. Insulin infusion also led to an increase in CSF Abeta42 levels, most notably in older subjects. As has been observed previously, insulin infusion facilitated declarative memory, but such facilitation was attenuated in the subjects with the greatest increase in CSF Abeta42 levels.

CONCLUSIONS

These findings are consistent with recent in vitro studies of insulin effects on Abeta and support the notion that insulin may modulate Abeta42 levels acutely in humans.