Survey of postoperative analgesia following ambulatory surgery

Background: The quality of pain relief during the first 48 hours following ambulatory surgery has been poorly documented. This questionnaire study was performed to evaluate the nature and severity of pain after the patient leaves the hospital. Methods: 1100 patients in the age group 5–88 years who underwent ambulatory surgery during a period of 6months were asked to complete a questionnaire 48 h after the end of the operation. In thecase of children, parents were asked to complete a similar questionnaire. The questions were related to pain experienced during the first 48 h after surgery and to the nature andseverity of postoperative complications. Results: A total of 1035 out of the 1100 patients returned the questionnaire, 94.1%. Overall the majority (65%) of patients had only mild pain at home; however, patients undergoing certain types of surgery had moderate-to-severe pain: inguinal hernia surgery (62% patients), orthopaedic surgery (41%), hand surgery (37%) and varicose vein surgery (36%). In these patients the severity of pain did not decrease during the 2-day study period. About 10% patients had more severe pain than they had anticipated, and 20% had difficulty in sleeping at night due to severe pain. Despite this, over 95% of patients were satisfied with man-agement of postoperative pain. Nausea (20%), tiredness (20%) and vomiting (8%) were the commonest complications reported during the first 48 h. A significant association was found between the administration of a general anaesthetic and the incidence of nausea postoperatively. A large number of patients were alone at home after the operation (28.4%); some (3.8%) had no access to a relative or friend in case of need. Conclusion: Our results show that about 35% of day-surgery patients experience moderate-to-severe pain at home in spite of analgesic medication. About 20% of patients had sleep problems due to severe pain. However, only 5% of patients were dissatisfied. Better analgesic techniques are necessary for patients undergoing certain types of surgery. Patient information and follow-up routines need to be improved.     

Biomodulation of transcriptional factor NF-kappa B by ionizing radiation]

NF-kappaB (Nuclear Factor-kappaB) was described for the first time in 1986 as a nuclear protein binding to the kappa immunoglobulin-light chain enhancer. Since then, NF-kappaB has emerged as an ubiquitous factor involved in the regulation of numerous important processes as diverse as immune and inflammatory responses, apoptosis and cell proliferation. These last two properties explain the implication of NF-kappaB in the tumorigenic process as well as the promise of a targeted therapeutic intervention. This review focuses on the current knowledge on NF-kappaB regulation and discusses the therapeutic potential of targeting NF-kappaB in cancer in particular during radiotherapy.     

Osteointegration of hydroxyapatite-titanium implants coated with nonglycosylated recombinant human bone morphogenetic protein-2 (BMP-2) in aged sheep

Osteointegration of metal implants into aged organisms can be severely compromised due to reduced healing capacity of bone, lack of precursor cells for new bone formation, or osteoporosis. Here, we report on successful implant healing in a novel model of aged sheep in the presence of nonglycosylated bone morphogenetic protein 2 (BMP-2). Ewes of 8 to 12 years with significant radiologic and histologic signs of osteoporosis and adipocytic bone marrow received a cylindrical hydroxyapatite-titanium implant of 12 x 10 mm. BMP-2 has been produced as a bacterial recombinant fusion protein with maltose-binding protein and in vitro generation of mature BMP-2 by renaturation and proteolytic cleavage. A BMP-2 inhibition ELISA was developed to measure the in vitro release kinetics of bioactive human BMP-2 from immersed solid implant materials by using Escherichia coli expressed and biotinylated recombinant human BMP-2 receptor IA extracellular domain (ALK-3 ECD). The implants were placed laterally below both tibial plateaus, with the left leg implant carrying 380 microg BMP-2. Both implant types became integrated within the following 20 weeks. The control implant only integrated at the cortical bone, and little new bone formation was found within the pre-existing trabecular bone or the marrow cavity. Marrow fat tissue was partially replaced by unspecific connective tissue. In contrast, BMP-2-coated implants initiated significant new bone formation, initially in trabecular arrangements to be replaced by cortical-like bone after 20 weeks. The new bone was oriented towards the cylinder. Highly viable bone marrow appeared and filled the lacunar structures of the new bone. In mechanical tests, the BMP-2-coated implants displayed in average 50% higher stability. This animal model provided first evidence that application of nonglycosylated BMP-2 coated on solid implants may foster bone healing and regeneration even in aged-compromised individuals.     

Discovery of a dsRNA virus infecting the marine photosynthetic protist Micromonas pusilla

We report the isolation of the first double-stranded (ds) RNA virus in the family Reoviridae that infects a protist (microalga Micromonas pusilla, Prasinophyceae). The dsRNA genome was composed of 11 segments ranging between 0.8 and 5.8 kb, with a total size of approximately 25.5 kb. The virus (MpRNAV-01B) could not be assigned to the genus level because host type, genome size, and number of segments smaller than 2 kb did not correspond to either of the two existing 11-segmented dsRNA genera Rotavirus and Aquareovirus. MpRNAV-01B has a particle size of 65-80 nm, a narrow host range, a latent period of 36 h, and contains five major proteins (120, 95, 67, 53, and 32 kDa). MpRNAV-01B was stable to freeze-thawing, resistant to chloroform, ether, nonionic detergents, chelating and reducing agents. The virus was inactivated at temperatures above 35 degrees C and by ionic detergent, ethanol, acetone, and acidic conditions (pH 2-5).     

Decision-making in the delivery room: a survey of neonatologists.

OBJECTIVE: To examine influences on neonatologists' decision-making regarding resuscitation of extremely premature infants. STUDY DESIGN: A mailed survey of Illinois neonatologists evaluated influences on resuscitation. Personal and parentally opposed (that is, acting against parental wishes) gray zones of resuscitation were defined, with the lower limit (LL) the gestational age at or below which resuscitation would be consistently withheld and the upper limit (UL) above which resuscitation was mandatory. RESULT: Among the 85 respondents, LL and UL of the personal and parentally opposed gray zones were median 22 and 25 weeks, respectively. Neonatologists with an UL personal gray zone <25 completed weeks were significantly more fearful of litigation, more likely to have received didactic/continuing medical education teaching, and less likely to always consider parents' opinions in resuscitation decisions. Neonatologists with an UL parentally opposed gray zone <25 completed weeks were more fearful of litigation. CONCLUSION: Neonatologists perceive a 'gray zone' of resuscitative practices and should understand that external influences may affect their delivery room resuscitation practices.     

Subclinical hypothyroidism is a risk factor for nephropathy and cardiovascular diseases in Type 2 diabetic patients.

AIMS: The purpose of this study was to determine the relationship between subclinical hypothyroidism and prevalence of retinopathy and nephropathy, incident cardiovascular disease, and mortality in Type 2 diabetic patients without taking thyroid medication. METHODS: Serum thyrotropin and free thyroxine concentrations were measured in 588 Type 2 diabetic subjects in Taipei Veterans General Hospital, Taiwan. In a cross-sectional study, we examined the prevalence of retinopathy and nephropathy. In a longitudinal study, we examined the risk of cardiovascular disease events, cardiovascular mortality and total mortality in the 4-year follow-up. RESULTS: In the cross-sectional analysis, subclinical hypothyroidism was associated with a greater prevalence of diabetic nephropathy (odds ratio, 3.15 [95% CI, 1.48-6.69]) and did not show a high prevalence of diabetic retinopathy (odds ratio, 1.15 [95% CI, 0.59-2.26]) compare to euthyroid diabetics. During the 44.0 +/- 7.4 months of follow-up, 51 participants had cardiovascular events. The risk of cardiovascular events was significantly increased in Type 2 diabetics with subclinical hypothyroidism after adjustment for age, sex, A1C, other standard cardiovascular risk factors and medication (hazard ratio, 2.93; 95% CI, 1.15-7.48; P = 0.024), but it became nonsignificant after additional adjustment for urinary albumin-to-creatinine ratio (hazard ratio, 2.06; 95% CI, 0.67-6.36; P = 0.211). The rates of cardiovascular-related and total mortality did not significantly differ by thyroid status. CONCLUSIONS: Type 2 diabetic patients with subclinical hypothyroidism are associated with an increased risk of nephropathy and cardiovascular events, but not with retinopathy. Our data suggest that the higher cardiovascular events in subclinical hypothyroidism with Type 2 diabetes may be mediated with nephropathy.     

Aortoesophageal fistula due to caustic ingestion.

PURPOSE: Caustic agent ingestion may produce corrosive lesions that can extend beyond adjacent organs. We report three cases of aortoesophageal fistulas (AEF) after caustic ingestion that were diagnosed by autopsy. RESULTS: AEF is a fatal complication that should be suspected in any patient with caustic ingestion who presents with gastrointestinal bleeding. A high index of suspicion, early recognition by gastrointestinal endoscopy, computed tomography scan, and aortography are important to improve the outcome.     

PAK1 hyperactivation is sufficient for mammary gland tumor formation

Emerging data suggest that p21-activated kinase 1 (Pak1), a downstream signaling molecule of the small GTPases, growth factors, and lipid signaling, is upregulated or hyperactivated in human breast cancer. Until now, however, no direct causative role had been found for Pak1 in mammary tumor formation. We therefore sought to identify the role that Pak1 plays in mammary gland tumorigenesis. Our results showed that in a transgenic mouse model, overexpression of catalytically active Pak1 leads to the development of malignant mammary tumors and to a variety of other breast lesions, including focal solid nodules, ductal hyperplasia, and mini-intraductal neoplasm and adenoma. We also found that Pak1 hyperactivation increases the stimulation of downstream proliferative signaling effectors MEK1/2 and p38-MAPK in mammary tumor epithelial cells. Moreover, in our study, we detected expression of estrogen receptor-alpha expression and progesterone receptor expression during early stages of the lesions, but their expression was lost during the cells' transition to malignant invasive tumors. Finally, we found that consistent with a role in breast tumor progression, Pak1 expression and its nuclear accumulation was increased progressively during the transition from ductal hyperplasia to ductal carcinoma in situ to adenocarcinoma in widely used multistep polyoma-middle T-antigen transgenic mice. Together, these findings provide the first direct evidence that Pak1 deregulation may be sufficient for the formation of mammary gland tumors.     

Surgical approach to vascular complications of intravenous drug abuse.

OBJECTIVE: To assess the complications related to intravenous drug abuse. DESIGN: Prospective study. METHODS: Intravenous drug abusers (IVDAs) with vascular complications were assessed. RESULTS: Sixty-two patients presented with swelling and tenderness in the groin, and 3 patients with similar lesions in the cubital fossa. Infected pseudoaneurysms and deep vein thrombosis (DVTs) were diagnosed in 41 and 31 patients respectively (27 patients had both lesions). In patients with infected pseudoaneurysms, 9 patients underwent excision with early revascularization and 32 patients underwent ligation without revascularization. For all patients with femoral vein thrombosis ligation and excision was performed. 4 patients with pure DVTs were managed conservatively. Disabling claudication occurred in 6 patients. Four of them underwent late revascularization with an acceptable outcome. CONCLUSIONS: Ligation without revascularization is the appropriate treatment of infected pseudoaneurysms in IVDAs. Late revascularization is of great importance in patients with disabling claudication after treatment of addiction. Pure septic DVTs can be managed conservatively.