Does an enhanced recovery programme add value to laparoscopic colorectal resections?

PURPOSE: Enhanced recovery programmes (ERP) are now becoming integral to the management of patients undergoing colorectal resection. The benefits of ERP in patients undergoing open colorectal resections have been well recognized; however, the value of ERP in patients undergoing laparoscopic resections is still uncertain. This study was undertaken to assess the impact of ERP in our unit where nearly 90 % of elective colorectal resections are performed laparoscopically. METHODS: A prospectively maintained database of all patients undergoing colorectal resections between Jan 2008 to December 2012 was analysed. The ERP programme was introduced in Aug 2010. The primary outcome measure was post-operative length of stay. Secondary outcome measures were post-operative morbidity and mortality. RESULTS: A total of 506 patients underwent major colorectal resections in the study period (282 patients since introduction of ERP). There were no demographic differences between the pre-ERP and post-ERP groups of patients. The median length of stay prior to the introduction of ERP was 6 days (right-sided resections = 6, left-sided resections = 7.5 and rectal resections = 5.5). For post-ERP, the median length of stay was 5 days (right = 5.5, left = 5 and rectal = 4). Patients who had their laparoscopic procedure converted to open had a course similar to open resections. The morbidity and mortality was lesser in the ERP group but did not reach statistical significance. CONCLUSION: The introduction of an ERP adds additional value in laparoscopic colorectal resections, with further reductions in morbidity and length of stay.

Audit of accuracy of clinical coding in oral surgery.

We aimed to study the accuracy of clinical coding within oral surgery and to identify ways in which it can be improved. We undertook did a multidisciplinary audit of a sample of 646 day case patients who had had oral surgery procedures between 2011 and 2012. We compared the codes given with their case notes and amended any discrepancies. The accuracy of coding was assessed for primary and secondary diagnoses and procedures, and for health resource groupings (HRGs). The financial impact of coding Subjectivity, Variability and Error (SVE) was assessed by reference to national tariffs. The audit resulted in 122 (19%) changes to primary diagnoses. The codes for primary procedures changed in 224 (35%) cases; 310 (48%) morbidities and complications had been missed, and 266 (41%) secondary procedures had been missed or were incorrect. This led to at least one change of coding in 496 (77%) patients, and to the HRG changes in 348 (54%) patients. The financial impact of this was £114 in lost revenue per patient. There is a high incidence of coding errors in oral surgery because of the large number of day cases, a lack of awareness by clinicians of coding issues, and because clinical coders are not always familiar with the large number of highly specialised abbreviations used. Accuracy of coding can be improved through the use of a well-designed proforma, and standards can be maintained by the use of an ongoing data quality assurance programme.

Novel nanoparticles for pulmonary drug administration.

A novel one-step, low energy method, which avoids harsh processing conditions including potentially toxic and chemically reactive cross-linking agents, for the production of hydrophilic drug nanoparticles suitable for dispersion in the hydrofluoroalkane propellants was investigated. Reverse-phase microemulsions were used as the template for the production of nanoparticles. Two microemulsion systems were investigated: water/sodium bis(2-ethylhexyl) sulphosuccinate (AOT)/iso-octane and water/lecithin/propan-2-ol/iso-octane. Nanoparticles were captured by snap freezing with subsequent freeze-drying. Nanoparticles were dispersed in 1,1,1,2,3,3,3-heptafluoropropane (HFA-227) and the aerosol performance of the pressurised metered dose inhaler (pMDI) assessed by cascade impaction. Spherical nanoparticles less than 300 nm in size were produced. Nanoparticles produced using AOT as the surfactant could not be dispersed in HFA-227. However lecithin based nanoparticles could be dispersed in co-solvent modified HFA-227 and produced fine aerosols (Mass Median Aerodynamic Diameter < or = 1.5 microns, fine particle fraction > 58%). This data suggests that a high fraction of the nanoparticles would be deposited (targeted) within the lung with the deposition being mainly alveolar. That is the ideal deposition profile for the systemic delivery of drugs via the lungs.

Optimised separation of endogenous urinary components using cyclodextrin-modified micellar electrokinetic capillary chromatography.

In this study both native and chemically modified cyclodextrins (CDs) were investigated as buffer additives to improve the micellar electrokinetic capillary chromatography (MEKC) separation of endogenous bioanalytes in human urine. The following CDs were investigated: alpha, beta, gamma-CDs; hydroxypropyl-alpha-CD, hydroxypropyl-beta-CD, methylated beta-CD, sulphated beta-CD, sulphobutyl ether-beta-CD and hydroxypropyl-gamma-CD. The separations were compared to MEKC without additives. The best improvement in peak resolution and separation of urine components was observed with the sulphated beta-CD. A four-factor three-level full factorial design study was conducted on voltage, temperature, pH and sulphated beta-CD molarity. The optimum conditions were 25 mM sodium tetraborate, pH 9.5, 75 mM sodium dodecyl sulphate (SDS) and 6.25 mM sulphated beta-CD and were able to resolve 70 peaks from a urine pool in 12 min. These optimum conditions have been successfully applied to a number of clinical samples.

Determination of allantoin in biofluids using micellar electrokinetic capillary chromatography.

A micellar electrokinetic chromatographic method is described for the determination and quantitation of allantoin, an end-product of purine metabolism in mammals that is applicable to biofluids of different mammal species and man. The method was optimised following a study on the effect of pH and sample preparation procedure. Final conditions were 30 mM sodium tetraborate, pH 9.5, 75 mM sodium dodecyl sulphate, 20 kV and 20 degrees C. Allantoin was well resolved from endogenous compounds and could be determined in horse, dog, mouse and rabbit urine. No allantoin could be found in man. No complicated sample treatment was necessary, thus the developed method was rapid (< 5 min), sensitive (5 microM) and simple. Results from this work will permit the determination of allantoin in man as a measure of free radical generation reactions as well as its presence in the plasma and other biofluids with modification of the sample preparation procedures.

Pattern recognition analysis of 1H NMR spectra from perchloric acid extracts of human brain tumor biopsies.

Pattern recognition techniques (factor analysis and neural networks) were used to investigate and classify human brain tumors based on the 1H NMR spectra of chemically extracted biopsies (n = 118). After removing information from lactate (because of variable ischemia times), unsupervised learning suggested that the spectra separated naturally into two groups: meningiomas and other tumors. Principal component analysis reduced the dimensionality of the data. A back-propagation neural network using the first 30 principal components gave 85% correct classification of meningiomas and nonmeningiomas. Simplification by vector rotation gave vectors that could be assigned to various metabolites, making it possible to use or to reject their information for neural network classification. Using scores calculated from the four rotated vectors due to creatine and glutamine gave the best classification into meningiomas and nonmeningiomas (89% correct). Classification of gliomas (n = 47) gave 62% correct within one grade. Only inositol showed a significant correlation with glioma grade.

Micellar electrokinetic capillary chromatography (MECC) of UV-absorbing constituents in normal urine: a chemometric optimisation of the separation.

A micellar electrokinetic capillary chromatography (MECC) method when compared to free solution capillary electrophoresis (CZE) was shown to offer improved selectivity and resolution for the separation of UV-absorbing components of human urine. Some of the factors affecting MECC separation e.g. methanol concentration, sodium dodecyl sulphate (SDS) concentration, beta-cyclodextrin (beta-CD) concentration, voltage, pH, temperature and electrolyte additives (urea, beta-CD and Brij 35) were optimised using chemometric techniques. Three-level three-factor (3(3)) factorial designs and simplex optimisation were used to achieve optimised conditions with the goal of obtaining the maximum number of peaks in the shortest possible analysis time. Using a TSP CE2000 instrument with detection from 195-300 nm and fitted with a 75 microns x 44 cm (37 cm effective length) fused silica capillary the final optimum conditions were found to be, an electrolyte consisting of 30 mM sodium tetraborate, pH 10, containing 75 mM SDS and 10 mM beta-CD, 15 degrees C, 20 kV, 4 s hydrodynamic injection of filtered urine. These conditions were capable of separating 70 peaks from a normal human urine pool in less than 12 min. The separation of components in urine using the optimised MECC was simpler, more reproducible, faster and gave better resolution than gradient reversed-phase high performance liquid chromatography.

Lipid metabolite peaks in pattern recognition analysis of tumour in vivo MR spectra.

The ability to classify spectra of tumours according to their stage and type will be essential if magnetic resonance spectroscopy (MRS) is to be used as an aid in the diagnosis of cancer. MRS data are normally classified on the basis of selected peak measurements but these may be difficult to extract automatically. We present two alternative methods of feature extraction which we used to discriminate between spectra from tumours and normal tissues. Discrimination could be achieved either using features from the whole spectrum, or from a selected region containing the peaks from the phospholipid precursors in the phosphomonoester region.

Pattern recognition of 31P magnetic resonance spectroscopy tumour spectra obtained in vivo.

Pattern recognition has been applied to the analysis of in vivo 31P NMR spectra. Using four different classes of tumour and three types of normal tissue, cluster analysis and artificial neural networks were successful in separating and classifying the majority of samples analysed. Although the phosphomonoester and P(i) regions appeared to be the most important spectral features, data representing the entire 31P spectrum were required for best separation of the tumour and tissue classes.

An investigation of tumor 1H nuclear magnetic resonance spectra by the application of chemometric techniques.

1H nuclear magnetic resonance (NMR) spectra of tumors and normal tissue include signals from all hydrogen-containing metabolites and can therefore be considered multicomponent multivariate mixtures. We have obtained 1H spectra from perchloric acid extracts of three normal tissues (liver, kidney, and spleen) and five rat tumors (GH3 prolactinoma, Morris hepatomas 7777 and 9618a, LBDS1 fibrosarcoma, and Walker 256 carcinosarcoma). We have applied several different chemometric methods to analyze the data. First, we used principal component analysis, cluster analysis, and an optimized artificial neural network to develop a classification rule from a training set of samples of known origin or class. The classification rule was then assessed using a set of unknown samples. We were able to successfully determine the class of each unknown sample. Second, we used the chemometric techniques of factor analysis followed by target testing to investigate the underlying biochemical differences that are detected between the classes of samples.

Classification of tumour 1H NMR spectra by pattern recognition.

1H spectra of tumours or normal tissues, which include signals from all hydrogen-containing metabolites, are too complex for the human eye to interpret. We have studied 58 1H spectra from perchloric acid extracts of three normal tissues (liver, kidney and spleen) and five rat tumours (GH3 pituitary, fibrosarcoma, Morris Hepatomas 7777 and 9618a and Walker carcinosarcoma). Instead of editing them or quantifying individual metabolites, we have used statistical pattern recognition techniques to classify them into groups. This automatic, objective method differentiated spectra from normal and malignant rat tissue biopsies, and from different types of cancer. It seems likely that this technique can be applied to human tissues and thus used for cancer diagnosis.

Extraction and STM Imaging of Spherical Giant Fullerenes.

High-temperature, high-pressure extracts of soot produced by the Krätschmer-Huffman technique (KH carbon) were characterized by mass spectrometry and imaging with scanning tunneling microscopes (STMs). The mass spectra of these samples are similar to those of ambient-pressure, high-boiling-point solvent extractions, supporting the idea that solvent temperature and possibly pressure are key parameters in extraction of the giant fuilerenes. The STM images show that the giant fullerenes in these samples are roughly spherical in shape and range in diameter from approximately 1 to 2 nanometers, corresponding to fullerenes containing 60 to 330 atoms. No evidence of bucky tubes was found.

Hyperprolactinaemia, amenorrhoea and galactorrhoea due to a pituitary thyrotroph adenoma.

A case of hyperprolactinaemia/amenorrhoea-galactorrhoea syndrome is described. A prolactinoma was diagnosed, but histology of the excised tumour revealed it to be a thyrotoph adenoma. alpha-subunit and beta-TSH levels were lowered after the operation. The significance of this tumour is discussed.

New hospitals from old stock.

With careful planning, existing hospital buildings can be adapted to meet current needs effectively and relatively cheaply. Author describes how one small hospital has been redeveloped and what lessions can be learned from 'the Nelson project'.