Robotic assisted laparoscopic radical prostatectomy versus retropubic radical prostatectomy: a prospective assessment of postoperative pain

PURPOSE: Laparoscopic prostatectomy, whether or not coupled with robotic assistance, is often considered less invasive than open radical retropubic prostatectomy (RRP). Minimal postoperative pain has been reported following robot assisted laparoscopic prostatectomy (RALP) but there have been few comparative studies with RRP. We compared perioperative narcotic use and patient reported pain in a prospective patient series. MATERIALS AND METHODS: Between June 2003 and May 2004, 314 patients underwent radical prostatectomy at our institution, including RALP in 159, RRP in 154 and conversion in 1. All patients were treated on a postoperative clinical pathway that included 30 mg ketorolac intravenously immediately postoperatively, followed by 15 mg intravenously every 6 hours. No regional anesthesia (epidural/spinal) narcotics or patient controlled analgesic pumps were used. All narcotic use was converted to morphine sulfate equivalents for purpose of analysis. A Likert scale of 0 to 10 was used to assess pain on the day of surgery, and on postoperative days 1 and 14. RESULTS: The total mean morphine sulfate equivalent +/- SD in patients in the RALP and RRP groups was low and, when corrected for length of stay, it was not statistically different (22.41 +/- 1.13 vs 23.01 +/- 1.16 mg, p = 0.72). Mean Likert pain perception scores were low at all time points in the RALP and RRP groups but statistically lower on the day of surgery in the RALP cohort (2.05 +/- 1.99 vs 2.60 +/- 2.25, p = 0.027). Patient reported mean pain scores were almost identical for RALP vs RRP on postoperative days 1 (1.76 +/- 1.87 vs 1.73 +/- 1.77, p = 0.880) and 14 (2.51 +/- 1.91 vs 2.42 +/- 1.84, p = 0.722). CONCLUSIONS: Perioperative narcotic use and patient reported pain are low regardless of the surgical approach used for radical prostatectomy. RALP did not provide a clinically meaningful decrease in pain compared with RRP, primarily because of the low pain scores reported in each group. Outcomes other than pain will ultimately determine the role of laparoscopic radical prostatectomy and RALP.     

Organochlorine pesticides and mercury in cottonmouths (Agkistrodon piscivorus) from northeastern Texas, USA

Despite their ecological importance and global decline, snakes remain poorly studied in ecotoxicology. In this study, we examined organochlorine (OC) pesticide and mercury accumulation in cottonmouths (Agkistrodon piscivorus) living on a contaminated site in northeastern Texas (USA). Mercury and p,p'-dichlorodiphenyldichloroethylene (p,p'-DDE) were detected in all snakes examined. Other OCs, including p,p'-dichlorodiphenyltrichloroethane (p,p'-DDT), methoxychlor, aldrin, and heptachlor, also were detected, but less frequently. Concentrations of p,p'-DDE were higher in fat than in liver, while mercury concentrations were highest in liver, followed by kidney and tail clips. One animal contained the highest mercury concentration yet reported for a snake (8,610 ng/g). Mercury concentrations in liver and kidney were higher in males than females, while no intersex differences in p,p'-DDE concentrations were observed. Concentrations of p,p'-DDE in fat were correlated positively with body size in male cottonmouths but not females, suggesting a slower rate of accumulation in females. Body size strongly predicted mercury concentrations in liver, kidney, and tail clips of both sexes. Tail clips were strong predictors of mercury in liver and kidney in males but not females, suggesting possible sex-dependent differences in mercury toxicokinetics. Both long-term field studies and controlled laboratory investigations are needed to adequately assess the response of cottonmouths to chronic contaminant exposure.     

Increasing prevalence of cardiovascular risk factors among American Indians in Montana

BACKGROUND: Cardiovascular disease (CVD) is the leading cause of death among American Indians. The objective of this study was to assess trends in CVD and CVD risk factors among American Indians in Montana. METHODS: In 1999 and 2003, 1000 American Indian adults aged > or =18 years living on or near the seven reservations in Montana were interviewed each year using an adapted Behavior Risk Factor Surveillance System survey. RESULTS: During the 5-year period from 1999 to 2003, the prevalence of CVD risk factors increased significantly: diabetes (12% to 16%), high blood pressure (26% to 34%), high cholesterol (23% to 30%), and obesity (34% to 39%). The percentage reporting current smoking was stable and remained high (38% to 36%). After adjusting for age and gender, the increases in high blood pressure, high cholesterol, and obesity remained significant. The percentage reporting two or more CVD risk factors increased significantly overall, among men and women, and among older and younger respondents during the 5-year time period. CONCLUSIONS: The prevalence of CVD risk factors among American Indian adults in Montana is high, and for many of the risk factors, has increased significantly over a 5-year period.     

Adapting the chronic care model to treat chronic illness at a free medical clinic

This pilot project was designed to determine the feasibility and effectiveness of an adaptation of the chronic care model applied to uninsured patients in a free medical clinic staffed by volunteer physicians. Of the 149 enrolled patients, 117 had hypertension, 91 had diabetes, and 51 had hyperlipidemia. Patients were enrolled in a chronic disease registry from March 1, 2001 through September 30, 2002 at the Salvation Army Free Clinic (SAFC). Two part-time registered nurses served as care managers providing disease-specific management using evidence-based guidelines. Consistent specialty consultation was available via phone, e-mail, or physician visit. Patient self-management was encouraged through collaborative goal setting. There were 40 patients lost to follow-up; 109 completed the study. A clinically significant improvement was obtained in at least one chronic disease for 79 patients. The chronic care model was a useful template for the delivery of effective chronic disease care to a group of uninsured patients at a free medical clinic.     

Proposal of a modified, treatment-oriented classification of odontoid fractures.

BACKGROUND CONTEXT: The classification scheme of odontoid fractures described by Anderson and D'Alonzo is the one most commonly used. However, uncertainty exists in the distinction between Type II and "shallow" Type III fractures. Moreover, fractures at the base of the odontoid (Anderson and D'Alonzo Type II) include a spectrum of injury patterns. PURPOSE: To modify the Anderson and D'Alonzo classification of odontoid fractures based on current clinical treatment options. STUDY DESIGN: Proposal of a modified classification system for odontoid fractures. METHODS: A more precise distinction between Type II and III fractures based on the presence/absence of C1-C2 facet involvement is proposed. A modified classification of Type II fractures based on fracture line obliquity, displacement and comminution is then proposed, because these are factors deemed to influence management. To evaluate the reproducibility of this classification, 52 odontoid fractures were reviewed and classified by four attending spine surgeons and three spine fellows. RESULTS: There was substantial agreement (at least five of seven respondents) in 70% of cases. The overall kappa value for the modified classification system was 0.48, indicating moderate agreement, and there were no differences in kappa values between attending spine surgeons and fellows. CONCLUSIONS: The reproducibility of this system was demonstrated by the moderate agreement observed when applied to odontoid fractures at our institution. The proposed utility of this system is its ability to guide clinical decision making in the treatment of odontoid fractures. Prospective application of this modified classification system and suggested treatment options is now required.     

Evaluation of the efficacy of the electrosurgical bipolar vessel sealer (LigaSure) devices in sealing lymphatic vessels

Various sources of ultrasonic and thermal energy have been developed to facilitate blood vessel ligation. However, their efficacy in sealing lymphatics has not been clearly established to date. We hypothesized that the electrosurgical bipolar vessel sealer (EBVS) produces reliable and durable sealing of large lymphatic vessels in a porcine model. Thoracic ducts from 4 adult pigs were explanted and sealed at multiple levels by using 3 different EBVS devices: LigaSure Atlas, XTD, and V. Fifteen seals (5 per group) were analyzed for sealing time and visual quality. Seal burst strength was measured by using a graduated pressure saline injection system. Twelve intact seals also underwent a histologic analysis. The mean overall burst strength of the seals was 271+/-78 mm Hg (127 to 360 mm Hg). The burst pressures in the 3 groups were not statistically different. The overall mean time to achieve a seal was 5.1+/-2.2 seconds (3 to 10 seconds). Seals were achieved significantly faster in the V group (4.1+/-0.6 seconds) compared with the Atlas (6.3+/-2.3 seconds) and XTD (6.4+/-2.6 seconds) groups. Qualitative seal assessment revealed minimal sticking and charring, a favorable degree of seal tissue clarity, and desiccation in the 3 groups. Histologic analysis demonstrated a fusion of lymphovascular channels with a complete obliteration of the lumens. We demonstrated that the use of EBVS results in a fast and effective sealing of large porcine lymphatic vessels. The seals created by all 3 devices burst at markedly supraphysiologic intraluminal pressures. Ongoing randomized human trials may prove the clinical benefits of the routine use of EBVS devices for various tissue dissections.