Preoperative serum C-reactive protein levels and post-operative lymph node ratio are important predictors of survival after pancreaticoduodenectomy for pancreatic ductal adenocarcinoma.

CONTEXT: There is paucity of data on the prognostic value of pre-operative inflammatory response and post-operative lymph node ratio on patient survival after pancreatic-head resection for pancreatic ductal adenocarcinoma. OBJECTIVES: To evaluate the role of the preoperative inflammatory response and postoperative pathology criteria to identify predictive and/or prognostic variables for pancreatic ductal adenocarcinoma. DESIGN: All patients who underwent pancreaticoduodenectomy for pancreatic ductal adenocarcinoma between 2002 and 2008 were reviewed retrospectively. The following impacts on patient survival were assessed: i) preoperative serum CRP levels, white cell count, neutrophil count, neutrophil/lymphocyte ratio, lymphocyte count, platelet/lymphocyte ratio; and ii) post-operative pathology criteria including lymph node status and lymph node ratio. RESULTS: Fifty-one patients underwent potentially curative resection for pancreatic ductal adenocarcinoma during the study period. An elevated preoperative CRP level (greater than 3 mg/L) was found to be a significant adverse prognostic factor (P=0.015) predicting a poor survival, whereas white cell count (P=0.278), neutrophil count (P=0.850), neutrophil/lymphocyte ratio (P=0.272), platelet/lymphocyte ratio (P=0.532) and lymphocyte count (P=0.721) were not significant prognosticators at univariate analysis. Presence of metastatic lymph nodes did not adversely affect survival (P=0.050), however a raised lymph node ratio predicted poor survival at univariate analysis (P<0.001). The preoperative serum CRP level retained significance at multivariate analysis (P=0.011), together with lymph node ratio (P<0.001) and tumour size (greater than 2 cm; P=0.008). CONCLUSION: A pre-operative elevated serum CRP level and raised post-operative lymph node ratio represent significant independent prognostic factors that predict poor prognosis in patients undergoing curative resection for pancreatic ductal adenocarcinoma. There is potential for future neo-adjuvant and adjuvant treatment strategies in pancreatic cancer to be tailored based on preoperative and postoperative factors that predict a poor survival.

Lichtenstein hernia repair under different anaesthetic techniques with special emphasis on outcomes in older people.

BACKGROUND: This study compared local (LA) and general anaesthesia (GA) for elective inguinal hernia repair with specific reference to older people (≥70 years). METHODS: A total of 470 inguinal hernia repairs were compared for demographics, operating time, day case rates and complications. Subgroup analysis was performed to evaluate outcomes in <70 and >70 years. RESULTS: A total of 288 LA and 182 GA repairs were performed. One hundred and forty-four (30.6%) patients were older than 70 years of which 80 (55%) were ASA (American Society of Anaesthesiologists) grades 3 and 4. Older (≥70 years) ASA grade 3 and 4 patients are more likely to undergo surgery under LA than GA (63% LA, 35% GA, P = 0.005) with higher day case rates of 81% LA, 33% GA, P = 0.0001). No significant difference in early complications, satisfaction rate and long-term recurrence rates were noted between the two groups. CONCLUSIONS: LA inguinal hernia repair has significant short-term advantages and facilitates day surgery in older patients. LA should be the preferred option in the older patients.

Compliance to recommended liver function monitoring in patients on statin therapy.

Product information and national guidelines consistently recommend the estimation of serum alanine aminotranferase (ALT) before and after approximately 3 months as part of risk management following initiation of statin therapy. The aim of this study was to determine compliance to the recommendations for monitoring ALT in patients initiated on statin therapy. The prevalence of abnormal serum ALT levels was also evaluated and compared with current data. We performed a retrospective observational audit of the Medicine's Monitoring Unit (MEMO) prescribing record-linkage database, which includes evidence of prescribing and biochemistry results of all patients in Tayside, Scotland. We examined patients with first-time statin prescriptions and evaluated all laboratory liver function tests recorded before and after prescriptions from 1st January 2002 to 31st December 2002. Of the 5717 patients identified, 54% were male and the subjects had a mean age of 62 +/- 14 standard deviation (SD) years. The prescriptions yielded five types of statin and included the start date, dose, and number of tablets. In total, 1455 (25%) patients had no biochemistry data at all from the year 2002, and despite the 75% of patients who had an ALT measurement, over 90% of patients did not follow the current recommendations. The prevalence of elevated transaminases was consistent with published data in that significant elevation occurred in 1.9% of subjects. Adherence to the recommended laboratory monitoring for patients first prescribed with statin therapy is low in Tayside. Adverse drug reactions need to be more closely monitored by all healthcare professionals involved in prescribing. Monitoring can highlight abnormalities and therefore reduce potentially damaging effects.