Preoperative tests: an Irish perspective.

INTRODUCTION: We sought to investigate whether hospital doctors in Ireland order too many expensive, unnecessary tests and analyse their motives for so doing. METHODS: A series of test patients modelled along guidelines as outlined by the National Institute for Clinical Excellence were presented to doctors in two university teaching hospitals. For each case, they were asked to identify the appropriate investigations. RESULTS: Fifty-three interns on a surgical rotation completed the questionnaires. Forty-four percent (n = 50) of interns ordered the tests based on influences from the consultant leading their team, with only 24% citing their medical training as the critical reason for ordering a preoperative investigation. No intern considered cost to have any influence on their decision to book preoperative tests. DISCUSSION: This study demonstrates that the previously well-documented international practice of overuse and unexplained variation in preoperative testing is also the norm in Ireland.

Inhibition of the stress response to breast cancer surgery by regional anesthesia and analgesia does not affect vascular endothelial growth factor and prostaglandin E2.

Angiogenesis is essential for breast cancer metastases formation and is mediated by vascular endothelial growth factor (VEGF) and prostaglandin E2 (PGE2). We hypothesized that serum levels of VEGF and PGE2 are increased by the stress response to breast cancer surgery and attenuated by paravertebral anesthesia and analgesia (PVAA). Thirty women undergoing mastectomy were enrolled in this prospective, randomized study, to receive general anesthesia (GA) and postoperative opioid analgesia (morphine 0.1 mg/kg bolus and patient-controlled infusion) or GA and PVAA (72-h infusion). All patients received rectal diclofenac. Venous blood samples were taken preoperatively and at 4 and 24 h postoperatively for serum glucose, cortisol, C-reactive protein, VEGF, and PGE2. PVAA inhibited the surgical stress response, as indicated by significantly less plasma glucose, cortisol, and C-reactive protein. VEGF and PGE2 values did not differ significantly between the groups. Mean (SD) percentage change in VEGF at 4 and 24 h respectively were 3% +/- 44% versus 9% +/- 80%, P=0.29 and 5% +/- 43% versus -10% +/- 63%, P=0.41 for patients with combined general and PVAA and GA alone, respectively. Mean percentage change in postoperative PGE2 at 4 and 24 h respectively was 10% +/- 17% versus 11% +/- 69%, P=0.29 and 34% +/- 19% versus 47% +/- 18%, P=0.15. We conclude that despite inhibiting the surgical stress response, PVAA had no effect on serum levels of putative breast cancer angiogenic factors, VEGF and PGE2.