U-shaped relationship between tissue docosahexaenoic acid and atrial fibrillation following cardiac surgery.

BACKGROUND/OBJECTIVES: Randomised controlled trials (RCTs) evaluating the effect of fish oil supplementation on postoperative atrial fibrillation (POAF) following cardiac surgery have produced mixed results. In this study, we examined relationships between levels of red blood cell (RBC) n-3 long-chain polyunsaturated fatty acids (LC-PUFAs) and the incidence of POAF. SUBJECTS/METHODS: We used combined data (n=355) from RCTs conducted in Australia and Iceland. The primary end point was defined as POAF lasting >10 min in the first 6 days following surgery. The odds ratios (ORs) for POAF were compared between quintiles of preoperative RBC n-3 LC-PUFA levels by multivariable logistic regression. RESULTS: Subjects with RBC docosahexaenoic acid (DHA) in the fourth quintile, comprising a RBC DHA range of 7.0-7.9%, had the lowest incidence of POAF. Subjects in the lowest and highest quintiles had significantly higher risk of developing POAF compared with those in the fourth quintile (OR=2.36: 95% CI; 1.07-5.24 and OR=2.45: 95% CI; 1.16-5.17, respectively). There was no association between RBC eicosapentaenoic acid levels and POAF incidence. CONCLUSIONS: The results suggest a 'U-shaped' relationship between RBC DHA levels and POAF incidence. The possibility of increased risk of POAF at high levels of DHA suggests an upper limit for n-3 LC-PUFAs in certain conditions.

Randomized trial of the effect of video feedback on the acquisition of surgical skills.

BACKGROUND: Constructive feedback provides a mechanism for reinforcing learning during the acquisition of surgical skills. Feedback is usually given verbally, and sometimes documented, after direct observation by a trained assessor. The aim was to evaluate video recording as an effective modality for enhancing feedback, in comparison with standard verbal feedback alone. METHODS: This was a prospective, blinded, randomized clinical trial comparing standard verbal feedback plus video with standard verbal feedback alone. Validated pro formas for assessment were used and quality control was performed by independent expert assessors. Trial participants were recorded on video performing the surgical skill, and returned the next day to perform the skill again following video and standard verbal feedback (group 1) or standard verbal feedback alone (group 2). RESULTS: Forty-eight participants were divided equally between the two groups. There was a significant improvement in the mean overall procedure score for group 1 of 2·875 from a maximum achievable score of 20 (P = 0·003), but not for group 2. There were significant improvements in the specific domains of instrument familiarity, needle handling, skin handling and accurate apposition, again all in group 1. The only significant improvement in group 2 was in an organized approach to the task, also observed in group 1. Knot-tying security deteriorated after feedback in group 2 but not in group 1. CONCLUSION: The addition of video feedback can improve the acquisition of surgical skills, and could be incorporated into formal surgical curricula.

Incidental focal colonic lesions found on (18)Fluorodeoxyglucose positron emission tomography/computed tomography scan: further support for a national guideline on definitive management.

AIM: (18)Fluorodeoxyglucose ((18)FDG) positron emission tomography/computed tomography (PET/CT) is an established part of staging in a wide variety of malignancies. Incidental abnormal uptake of (18)FDG of unknown significance is frequently encountered. Therefore, we investigated patients with abnormal colonic uptake of (18)FDG, determined by PET/CT images, using colonoscopy. METHOD: The radiology reports of all patients referred to a tertiary referral centre for a PET/CT scan were reviewed retrospectively. Patients with abnormal colonic uptake of (18)FDG were identified and the PET/CT findings were correlated with colonoscopic findings. RESULTS: Of 555 consecutive patients identified over a 26-month period, 53 had abnormal colonic uptake of (18)FDG, as determined by PET/CT images. Twenty-nine were not investigated following discussion in a specialist multidisciplinary (MDT) meeting, according to local protocol. Twenty out of 24 patients investigated by endoscopy had a colonic lesion correlating to the site identified on the PET/CT image: 16 patients had tubulovillous adenomas (nine of which were > 10 mm), two had invasive adenocarcinomas, two had diverticular disease and one had collagenous colitis; no colonic lesion was detected in three. These findings were incidental and not related to the primary diagnosis for which the scan was being performed. Accordingly, a positive predictive value of 83% is associated with the finding of abnormal uptake of (18)FDG on PET/CT images. CONCLUSION: Incidental abnormal colonic uptake of (18)FDG, determined by a PET/CT scan requires definitive colonic investigation in patients suitable for further treatment because significant colonic pathology is frequently identified. The benefit of this approach should be discussed in specialist MDT meetings and tailored to each patient; however, national guidelines for management are required.

Management of splenic injury.

Traumatic splenic injury is a potentially life-threatening complication of both blunt and penetrating trauma to the abdomen and thorax. The spleen is susceptible to injury in the presence or absence of damage to surrounding viscera and can lead to haemodynamic instability and hypovolaemic shock. This review examines the classification, investigation and management of this condition with both non-operative and operative techniques.

A phase II study evaluating the use of concurrent mitomycin C and capecitabine in patients with advanced unresectable pseudomyxoma peritonei.

Pseudomyxoma peritonei (PMP) is a rare neoplastic process characterised by progressive intra-abdominal dissemination of mucinous tumour, and generally considered resistant to systemic chemotherapy. A phase II study in patients with advanced unresectable PMP was undertaken to evaluate the combination of systemic concurrent mitomycin C (7 mg m(-2) i.v. on day 1) and capecitabine (1250 mg m(-2) b.d. on days 1-14) in a 3-weekly cycle (MCap). Response was determined by semiquantitative assessment of disease volume on serial computed tomographic (CT) scans and serum tumour marker (CEA, CA125, CA19-9) changes at 12 weeks. Between 2003 and 2006, 40 patients were recruited through a national centre for the treatment of peritoneal surface tumours. At baseline, 23 patients had progressive disease and 17 had stable disease. Of 39 assessable patients, 15 (38%, 95% confidence intervals (CIs): 25, 54%) benefited from chemotherapy in the form of either reductions in mucinous deposition or stabilisation of progressive pretreatment disease determined on CT scan. Notably, two patients, originally considered unresectable, following MCap and re-staging underwent potentially curative cytoreductive surgery. Grade 3/4 toxicity rates were low (6%, 95% CIs: 4, 9%). Twenty out of 29 assessed patients (69%, 95% CIs: 51, 83%) felt that their Global Health Status improved during chemotherapy. This is the first trial to demonstrate an apparent benefit of systemic chemotherapy in patients with advanced unresectable PMP.

Peristomal varices--life threatening or luminal?

Bleeding from the edge of an ileostomy site is a common problem. In those who have undergone a proctocolectomy with ileostomy formation in conjunction with a risk of chronic liver disease (even with normal liver function tests), this may be due to peristomal varices. If this is the case, significant, difficult-to-control and potentially life-threatening bleeding is likely in the future and may require transfusion. Improvements in radiological imaging techniques can give quick, sensitive and specific information to diagnose and guide management in this group. In those patients with major bleeding episodes, an initial conservative management policy should be adopted with the knowledge that, if bleeding persists, propanolol therapy, portosystemic shunt insertion or even liver transplantation may be indicated.