Evaluation of a fast-track programme for patients undergoing liver resection.

BACKGROUND: Recent developments in perioperative pathophysiology and care have documented evidence-based, multimodal rehabilitation (fast-track) to hasten recovery and to decrease morbidity and hospital stay for several major surgical procedures. The aim of this study was to investigate the effect of introducing fast-track principles for perioperative care in unselected patients undergoing open or laparoscopic liver resection. METHODS: This was a prospective study involving the first 100 consecutive patients who followed fast-track principles for liver resection. Catheters and drains were systematically removed early, and patients were mobilized and started eating and drinking from the day of surgery. An opioid-sparing multimodal pain treatment was given for the first week. Discharge criteria were: pain sufficiently controlled by oral analgesics alone, patient comfortable with discharge and no untreated complications. RESULTS: Median length of stay (LOS) for all patients was 5 days, with 2 days after laparoscopic versus 5 days following open resection (P < 0·001). Median LOS after minor open resections (fewer than 3 segments) was 5 days versus 6 days for major resections (3 or more segments) (P < 0·001). Simple right or left hemihepatectomies had a median LOS of 5 days. The readmission rate was 6·0 per cent and 30-day mortality was zero. CONCLUSION: Fast-track principles for perioperative care were introduced successfully and are safe after liver resection. Routine discharge 2 days after laparoscopic resection and 4-5 days after open liver resection may be feasible.

Preoperative high-dose glucocorticoids for early recovery after liver resection: randomized double-blinded trial.

BACKGROUND: Glucocorticoids modulate the surgical stress response. Previous studies showed that high-dose preoperative glucocorticoids reduce levels of postoperative inflammatory markers and specific biomarkers of liver damage compared with placebo, and suggested a reduced complication rate and shorter hospital stay after liver surgery. However, there are no studies with a clinical primary outcome or of early recovery outcomes. The aim of this study was to investigate whether a single high dose of preoperative glucocorticoid reduces complications in the immediate postoperative phase after liver surgery. METHODS: This was a single-centre, double-blinded, parallel-group RCT investigating preoperative methylprednisolone 10 mg/kg (high dose) versus dexamethasone 8 mg (standard-dose postoperative nausea prophylaxis) in patients scheduled for open liver resection. The primary outcome was number of patients with a complication in the postanaesthesia care unit; secondary outcomes included duration of hospital stay, pain and nausea during admission, and 30-day morbidity. RESULTS: A total of 174 patients (88 in high-dose group, 86 in standard-dose group) were randomized and analysed (mean(s.d.) age 65(12) years, 67.2 per cent men); 31.6 per cent had no serious co-morbidities and 25.3 per cent underwent major liver resection. Complications occurred in the postanaesthesia care unit in 51 patients (58 per cent) in the high-dose group and 58 (67 per cent) in the standard-dose group (risk ratio 0.86, 95 per cent c.i. 0.68 to 1.08; P = 0.213). Median duration of hospital stay was 4 days in both groups (P = 0.160). Thirty-day morbidity and mortality rates were similar in the two groups. CONCLUSION: A high dose of preoperative glucocorticoids did not reduce acute postoperative complications after open liver resection compared with a standard dose. Registration number: NCT03403517 (http://www.clinicaltrials.gov); EudraCT 2017-002652-81 (https://eudract.ema.europa.eu/).

Field examination of ground water quality as an indicator of microbiological activity at gasoline contaminated sites.

Various portable electrodes and an on-line colorimetric test kit were used in the field to examine ground water quality as an indicator of natural bioremediation across two sites in Connecticut having subsurface gasoline contamination. The parameters examined included dissolved oxygen, dissolved carbon dioxide, direct redox potential (Eh), nitrate, ammonia and pH. These parameters permitted delineating regions of aerobic and anaerobic microbiological activity. Variations in these parameters over an eighteen month period along with gas chromatographic analyses of certain gasoline components in the ground water indicated that in-situ bioremediation was effective at containing the petroleum contamination at both sites. It was found that a new on-line colorimetric test kit for the determination of oxygen was more accurate than a commonly used dissolved oxygen electrode.

Enzymes of ammonia assimilation in hyphae and vesicles of Frankia sp. strain CpI1.

Frankia spp. are filamentous actinomycetes that fix N2 in culture and in actinorhizal root nodules. In combined nitrogen-depleted aerobic environments, nitrogenase is restricted to thick-walled spherical structures, Frankia vesicles, that are formed on short stalks along the vegetative hyphae. The activities of the NH4(+)-assimilating enzymes (glutamine synthetase [GS], glutamate synthase, glutamate dehydrogenase, and alanine dehydrogenase) were determined in cells grown on NH4+ and N2 and in vesicles and hyphae from N2-fixing cultures separated on sucrose gradients. The two frankial GSs, GSI and GSII, were present in vesicles at levels similar to those detected in vegetative hyphae from N2-fixing cultures as shown by enzyme assay and two-dimensional polyacrylamide gel electrophoresis. Glutamate synthase, glutamate dehydrogenase, and alanine dehydrogenase activities were restricted to the vegetative hyphae. Vesicles apparently lack a complete pathway for assimilating ammonia beyond the glutamine stage.

Developmental potential of Frankia vesicles.

The ability of nitrogenase-containing Frankia sp. strain CpI1 vesicles to regrow vegetative hyphae is demonstrated. Vesicles attached to hyphae in N2-fixing CpI1 cultures and sucrose gradient-isolated vesicles exhibited hyphal outgrowths when incubated in certain defined liquid media. Single or multiple hyphal extensions grew out from the vesicles.

Differences in fatty acid composition between vegetative cells and N(2)-fixing vesicles of Frankia sp. strain CpI1.

When growing on N(2), actinomycetes from the genus Frankia form multicellular structures that contain nitrogenase. The structures are referred to as vesicles and are indistinguishable from vesicles formed when Frankia sp. are in root-nodule symbioses. Vesicles isolated from N(2)-grown cells of Frankia sp. strain CpI1 had a significantly higher amount and different composition of fatty acids than did vegetative cells recovered from NH(4) (+)-containing medium. Lipids from vesicles, whole cells grown on N(2), and whole cells grown on NH(4) (+) were fractionated by silicic acid chromatography into neutral lipids, glycolipids, and polar lipids. The fatty acids were transesterified by methanolysis and analyzed by gas chromatography and mass spectrometry. Vesicles had considerably higher amounts of fatty acids in the neutral and glycolipid fractions but lower amounts of polar lipid fatty acids than did vegetative cells. Polar lipids from vesicles had a higher proportion of mono-unsaturated and cyclopropane fatty acids and a lower proportion of isobranched fatty acids than did polar lipids from NH(4) (+)-grown or N(2)-grown cells. The neutral lipid and glycolipid fractions contained several long-chain compounds with molecular ions at m/z 408 and 410. The proportions of these compounds were significantly higher in the lipids from vesicles than from vegetative cells. These results suggest that lipids in vesicles might be involved in the protection of nitrogenase from O(2) and suggest a parallel with the glycolipids involved in protecting nitrogenase from O(2) in the cyanobacterial heterocysts.

Relationship of age and hypertension to neuropsychological test performance.

Young adult (X- = 29) and middle aged (X- =50) hypertensive and normotensive subjects were compared with respect to seven neuropsychological test scores derived from tests on the Halstead-Reitan battery. Age main effects, with inferior performance for the middle aged subjects, were observed for the localization and time portions of the Tactile Performance Test (TPT) and for the Trail Making A test. The multivariate age effect was significant for the composite of seven scores. A multivariate blood pressure main effect was obtained and main effect blood pressure was significant for the category test; hypertensives made more errors than normotensives. A blood pressure by age interaction was observed for finger tapping scores and the TPT-Memory scores with larger differences between hypertensives and normotensives for the younger than for the middle aged group. Results were discussed in terms of previous studies of age and hypertension with the WAIS, the Primary Mental Abilities Test and serial reaction time measures. The poor prediction of hypertensive status from individual neuropsychological test scores was emphasized and readers were cautioned not to conclude that essential hypertensives, as a group, can be characterized as brain damaged.