Pain management in ambulatory surgery.

Successful ambulatory surgery is dependent on analgesia that is effective, has minimal adverse effects, and can be safely managed by the patient at home after discharge. A number of studies have identified that the provision of effective postoperative analgesia is inadequate for a significant proportion of patients. The following discussion details the current available analgesic options for ambulatory surgery patients and the rationale for their use. Preemptive analgesia should be given to all patients unless there are specific contraindications. Consideration should be given to the use of long-acting oral COX-2 selective nonsteroidal anti-inflammatory drugs (NSAIDs) and long-acting oral opioids to treat postoperative pain. A standardized multimodal postdischarge analgesic regimen tailored to the patient's expected postoperative pain levels should be prescribed. Patient follow-up by telephone questionnaire will confirm those surgical procedures that result in mild or moderate-to-severe postoperative pain and the effectiveness of treatment plans.     

Accuracy of single-time, multilevel registration in image-guided spinal surgery.

BACKGROUND CONTEXT: Computerized frameless stereotactic image-guidance has been used in recent years to improve the accuracy and safety of pedicle screw placement during spine surgery. Because the possibility of intervertebral motion exists, and because the patient is usually in a different position when preoperative imaging is performed compared with the operative position, it has been suggested that the imaging model of the complete lumbar spine and the surgically exposed lumbar spine may be significantly discordant. Consequently, current protocols suggest registering each spinal level (single-level registration) separately before pedicle screw placement at that level, a time-consuming process. PURPOSE: To assess the accuracy of single-time multilevel registration for multilevel pedicle screw placement during image-guided, computer-assisted spine surgery, in the setting of degenerative disorders of the lumbar spine. STUDY DESIGN/SETTING: This is a prospective clinical and radiological study of 45 patients with degenerative disorders of the lumbar spine who underwent instrumented fusion with the use of single-time multilevel registration computer-assisted, image-guided tomography. The accuracy of the pedicle screws placement was confirmed on the basis of a protocol that included intraoperative spontaneous electromyographic (EMG) recordings, direct pedicle visualization, and computer tomography (CT) scans when clinically indicated during the follow-up period. PATIENT SAMPLE: Forty-five consecutive patients who fulfilled the criteria of computer-assisted, image-guided tomography pedicle screw placement for degenerative lumbar spine disease without overt instability. OUTCOME MEASURES: The principal outcome measure was the accuracy of pedicle screw placement with single-time multilevel registration for multilevel pedicle screw placement during image-guided, computer-assisted spine surgery; postoperative CT performed for clinical indications during the follow-up course was used for the assessment of pedicle screw placement. METHODS: Patients were assessed clinically before and after the operation. Data from 45 consecutive cases of image-guided, computer-assisted lumbar spinal fusion were statistically analyzed to determine the relationship between the number of levels registered during single-time registry and the mean registration error (MRE). Intraoperative spontaneous EMG, direct visualization, and postoperative CT scans were used to assess the accuracy of pedicle screw insertion. RESULTS: None of the patients involved in this study experienced clinical sequelae of improper pedicle screw placement. MREs after surface mapping and after point merge were small (less than 1.00 mm and less than 3.00 mm, respectively). During the intraoperative assessment of the pedicle screws placement, no significant spontaneous EMG activity was recorded and the pedicular walls were found intact in direct visualization. The postoperative CT scans showed in 10 patients accurate placement in 55 of the 57 pedicle screws with expansion of the medial wall in two screws. CONCLUSIONS: Single-time, multilevel registration may decrease operative time relative to repeated, single-level registrations, without compromising the increased accuracy of pedicle screw placement afforded by this technique in the setting of degenerative disorders of the lumbar spine. Despite the advantages in computer-guided image surgery, cautious application in the individual patient is recommended until more comprehensive data can be gathered in specific degenerative pathology with overt instability; thus the knowledge of the anatomy remains crucial.     

Prognostic importance of human papillomavirus type 16 DNA in cervical cancer.

Human papillomavirus (HPV) type 16 DNA is frequent in invasive cervical cancers. Among 43 patients with invasive cervical cancer, HPV-16-positive tumors spread to the parametrial and pelvic lymph nodes significantly more often than did HPV-16-negative tumors (P less than 0.05). Demonstration of HPV-16 DNA in invasive cervical cancers may be an additional prognostic factor for this disease.     

Comparison of LCx with other current viral load assays for detecting and quantifying human immunodeficiency virus type 1 RNA in patients infected with the circulating recombinant form A/G (CRF02)

LCx was compared to other assays in measuring human immunodeficiency virus type 1 (HIV-1) CRF02 viremia. LCx showed significant but low correlation with the other methods. Values of <2.60 log(10) cp/ml were observed in 29.6% of specimens with LCx and in only 14.8% with bDNA and PCR, suggesting suboptimal performance of LCx with CRF02.     

Selected RD1 Peptides for Active Tuberculosis Diagnosis: Comparison of a Gamma Interferon Whole-Blood Enzyme-Linked Immunosorbent Assay and an Enzyme-Linked Immunospot Assay

We recently set up a gamma interferon (IFN-γ) enzyme-linked immunospot assay (ELISPOT), using selected early secreted antigenic target 6 (ESAT-6) peptides, that appears specific for active tuberculosis (A-TB). However, ELISPOT is difficult to automate. Thus, the objective of this study was to determine if the same selected peptides may be used in a technique more suitable for routine work in clinical laboratories, such as whole-blood enzyme-linked immunosorbent assay (WBE). For this purpose, 27 patients with A-TB and 41 control patients were enrolled. Our WBE, using the already described selected peptides from ESAT-6 plus three new ones from culture filtrate protein 10, was performed, and data were compared with those obtained by ELISPOT. Using our selected peptides, IFN-γ production, evaluated by both WBE and ELISPOT, was significantly higher in patients with A-TB than in controls (P < 0.0001). Statistical analysis showed a good correlation between the results obtained by WBE and ELISPOT (r = 0.80, P < 0.001). To substantiate our data, we compared our WBE results with those obtained by QuantiFERON-TB Gold, a whole-blood assay based on region of difference 1 (RD1) overlapping peptides approved for TB infection diagnosis. We observed a slightly higher sensitivity with QuantiFERON-TB Gold than with our WBE (89% versus 81%); however, our test provided a better specificity result (90% versus 68%). In conclusion, results obtained by WBE based on selected RD1 peptides significantly correlate with those generated by ELISPOT. Moreover, our assay appears more specific for A-TB diagnosis than QuantiFERON-TB Gold, and thus it may represent a complementary tool for A-TB diagnosis for routine use in clinical laboratories.     

Importance of plasmapheresis in the treatment of paraneoplastic cerebellar degeneration

Paraneoplastic neurologic syndromes are disorders of the nervous system function caused by cancer but not due to metastatic disease, vascular or metabolic deficits, infections, nutritive deficiency, nor side effects of antineoplastic drugs or irradiation. Immunologic factors probably play the crucial role in the pathogenesis of paraneoplastic neurologic syndromes, but nonimmunologic mechanisms that include metabolic abnormalities and competition for substrate are also involved. Paraneoplastic cerebellar degeneration most commonly occurs in the setting of gynecologic cancers, but it accompanies the small-cell lung cancer too. Other tumors are infrequently associated with cerebellar degeneration. Several paraneoplastic antibodies have been identified in patients with paraneoplastic cerebellar degeneration. Their association with particular cancers may help identify an occult lesion. Anti-Yo antibodies are directed against Purkinje cell antigens and occur in patients with cerebellar degeneration who have breast cancer or gynecologic tumors. A target antigen of anti-Yo antibody is CDR2 protein that is normally expressed only in the brain and testis. Patients with paraneoplastic cerebellar degeneration present with dizziness, nausea and vomiting followed by gait instability, diplopia, gait and appendicular ataxia, dysarthria and dysphagia. Therapeutic options include tumor excision, chemotherapy and/or irradiation, and adjuvant therapy with glucocorticoids, immunoglobulins and plasmapheresis. The role of plasmapheresis in the treatment of paraneoplastic cerebellar degeneration is still uncertain. Reports of its efficacy are anecdotal. We present patient with paraneoplastic cerebellar degeneration with positive anti-Yo antibodies and tumor of the ovaries whose neurologic status significantly improved after four daily plasmaphereses, which was accompanied by a fourfold decrease in the anti-Yo antibodies titer. Further investigations are needed to define a protocol for plasmapheresis in the treatment of patients with paraneoplastic syndromes.