Evaluation of preincisional mexiletine administration to alleviate postoperative pain

Mexiletine, an antiarrhythmic agent, was preincisionally administered intravenously for the purpose of reducing postoperative pain. Twenty-eight female patients for mastectomy were studied. The patients were divided into three groups. Group 1 received no mexiletine. Group 2 received bolus administration of mexiletine 1 mg.kg-1 with additional continuous administration of 1 mg.kg-1.hr-1 for 75 minutes. Group 3 received bolus administration of mexiletine 2 mg.kg-1. The requirement of butorphanol as a postoperative analgesic within 1 hour after mastectomy in Group 3 was significantly lower than that in Group 1 (P < 0.05), but butorphanol requirement in Group 2 was not significantly lower than that in Group 1. Plasma mexiletine concentration was slightly higher in Group 3 (1.7 micrograms.ml-1) than that in Group 2 (1.0 microgram.ml-1) immediately after the intravenous mexiletine administration, although there was no significant difference. The results indicate that mexiletine 2 mg.kg-1 as preoperative bolus administration maintains its plasma concentration above 1.7 micrograms.ml-1, and is clinically effective for reducing the postoperative pain after mastectomy.     

Aprotinin and recombinant human erythropoietin reduce the need for homologous blood transfusion in cardiac surgery

The effects of low dose aprotinin (Trasylol) and preoperative administration of recombinant human erythropoietin (EPO) were evaluated in 144 patients undergoing cardiopulmonary bypass divided into four groups. Group I (n = 43) received a subcutaneous administration of EPO (18,000 U) one week before operation and intraoperative administration of low-dose aprotinin (mean; 1.38 +/- 0.26 x 10(6) kallikrein inactivator units; KIU) from extracorporeal circulation, group II (n = 39) received only preoperative administration of EPO, group III (n = 28) received only intraoperative administration of low-dose aprotinin (mean; 1.46 +/- 0.25 x 10(6) KIU), and group IV (n = 34) were not administered either drug. Compared with group IV, the intraoperative blood loss was significantly lower in group I (p < 0.01), and in group II or III (p < 0.05). The postoperative drainage in 24 hours was significantly lower in groups I and III receiving aprotinin than in the other groups. The mean volume of total homologous blood transfusion and the percentage of cases not requiring a homologous blood transfusion in each group was, respectively, 74 +/- 235 ml and 88.4% in group I, 282 +/- 1289 ml and 87.2% in group II, 414 +/- 584 ml and 60.7% in group III, and 976 +/- 1931 ml and 44.1% in group IV. Significant differences were recognized between group I and group IV (p < 0.05). These findings indicate that when used in combination, both drugs reduce blood loss and the need for a homologous blood transfusion more effectively than either drug alone.     

A double-blind, randomized study of naproxen sodium, ibuprofen, and placebo in postoperative dental pain

In a double-blind, parallel, placebo-controlled study, 203 patients with post-operative dental pain following the extraction of one or two bony impacted third molars were randomized to receive a single dose of naproxen sodium 220 mg, ibuprofen 200 mg or placebo. Pain intensity and pain relief were assessed at intervals for 12 hours postdose. Both active drugs demonstrated superior analgesic efficacy over placebo. Naproxen sodium and ibuprofen were comparable both in onset of analgesic action and in pain relief. From 1 to 12 hours postdose, naproxen sodium showed a trend for superior analgesic efficacy compared with ibuprofen; this trend reached statistical significance at the 12-hour time point. Both drugs were well-tolerated and effective analgesics for postoperative dental pain.     

Postoperative analgesia in herniated disk surgery. Comparative study of diclofenac , lysine acetylsalicylate, and ketorolac

INTRODUCTION: Nonsteroidal anti-inflammatory drugs (NSAIDs) are effective in treating musculoskeletal pain and are theoretically ideal for treating postoperative pain of the lumbar column. OBJECTIVES: To compare the analgesic efficacy and side effects of treatment with 3 NSAIDs (lysine acetylsalicylate, ketorolac and diclofenac) in the treatment of pain after surgery for lumbar disc hernia. PATIENTS AND METHODS: We enrolled 75 ASA I-II patients undergoing discectomy because of lumbar disc hernia; balanced general anesthesia was used in all cases. The patients were randomly distributed in 3 groups based on type of analgesia given in the immediate postoperative period. Group A received lysine acetylsalicylate (1800 mg), group B received ketorolac (30 mg) and group C received diclofenac (75 mg). The analgesics were diluted in 100 mg of saline solution and administered through a peripheral vein over 10 min. We evaluated the analgesia attained on a visual analog scale (VAS) and the physiological response to pain was assessed by monitoring changes in arterial pressure, heart rate and breathing frequency. If analgesia was insufficient 30 min after administration of the drug, 200 mg of lysine cloximate was given as a top-up. The side effects of each drug were also recorded. RESULTS: VAS evaluation showed significant reductions in pain 60 min after administration in groups A and B and after 120 min in group C. Nine patients in each group required lysine cloximate. There were no significant differences in physiological response among the 3 groups. No patient suffered major side effects. Mild side effects were reported most often in group B. CONCLUSIONS: The NSAIDs studied were inadequately for treating pain after surgery for lumbar disc hernia. Ketorolac was no better than the other analgesics studied but was associated with a higher number of mild side effects.     

Treatment of hypercholesterolemia in patients undergoing multiple coronary angioplasties

BACKGROUND: Hypercholesterolemia is a known risk factor for coronary artery disease (CAD). Multiple studies have shown that its treatment will reduce the rate of progression of coronary atherosclerosis and lead to regression of the atherosclerotic process. Recent studies have also shown impact on mortality. Angioplasty (PTCA) is a well established revascularization procedure for many of these patients. In this study we investigated whether or not therapy for hypercholesterolemia in patients undergoing elective PTCA had been instituted and, if so, whether desirable cholesterol levels had been achieved. METHODS: We reviewed the charts of 129 patients (pts) who were consecutively admitted for elective PTCA between September 1993 and August 1994. All pts. had at least one PTCA in the past and all of them had the diagnosis of hypercholesterolemia. The list was made using a computer search of all pts. meeting the previous two diagnoses. Pts on whom PTCA was performed in the setting of acute ischemic events were excluded as well as pts with no known history of hypercholesterolemia. RESULTS: In 13 out of 129 pts., it was not possible to find cholesterol levels. The 116 pts in whom cholesterol levels were available were divided in two groups. Group I (54 pts.-46.5%) included pts. not being treated with any lipid lowering agent and group II (62 pts.-53.5%) included pts being treated with at least one of those drugs. Both groups were further subdivided into "A" and "B", depending on whether the PTCA was being performed because of a "new" lesion or because of "restenosis", respectively. Group IA had a total of 31 pts, IB 23 pts, IIA 29 pts and IIB, 33 pts. Group I pts had an average of 3.40 PTCA's and a mean cholesterol level of 227 mg/dl. Group II pts had an average number of PTCA's of 3.34 and a mean cholesterol level of 228 mg/dl. Group IA had an average number of PTCA's of 3.65 and a mean cholesterol level of 221 mg/dl; for group IIA these values were, respectively, 3.17 and 221 mg/dl. Group IB had an average number of procedures of 3.09 while for group IIB this number was 3.49; the mean cholesterol levels were, respectively, 235 mg/dl and 234 mg/dl. None of these differences is statistically significant. Group I had 14 pts (26%) with cholesterol levels below 200 mg/dl while group II had 16 pts. with cholesterol levels below 200 mg/dl (26%). In group I, 8 pts (14%) had lipid profiles documented. Only 1 pt. had an LDL level below 100 mg/dl and only 3 pts had an LDL level below 130 mg mg/dl. In group II, 15 pts (24%) had a lipid profile documented. Of these, no pt. had an LDL level below 100 mg/dl and only 4 pts had an LDL level below 130 mg/dl. CONCLUSIONS: A significant percentage of pts. undergoing multiple PTCA's are not being treated or monitored adequately for hypercholesterolemia despite aggressive invasive management.     

Effects of amino acids and gastric inhibitory polypeptide on insulin release in dogs

Insulin release following intravenous administration of an amino acid solution with and without a simultaneous infusion of varying amounts of porcine gastric inhibitory polypeptide (GIP) was studied in dogs. Group I received a 10-amino acid mixture (300 mosmol/kg iv) at 16.6 ml/min for 1 h; group II, amino acid mixture plus 0.5 micrograms.kg-1.h-1 porcine GIP; group III, amino acid mixture plus 1.0 micrograms.kg-1.h-1 of GIP; group IV (a and b) received either 0.5 or 1.0 micrograms.kg-1.h-1 of GIP alone. Compared to group I, groups II and III had a greater insulin response during the first 30 min of the infusion. Group] IV (a and b) showed no insulin release. Glucose concentrations showed no significant change in all groups. From these results, it is concluded that insulin release after intravenous infusion of an amino acid mixture plus GIP is greater than after amino acids or GIP alone. It appears that this effect is more pronounced in the early phase of insulin release.     

Comparison of caudal block using bupivacaine and ketamine with ilioinguinal nerve block for orchidopexy in children

Forty boys weighing less than 25 kg undergoing unilateral orchidopexy were randomly allocated to receive one of two analgesic regimens. Group C received a caudal epidural block with 0.25% bupivacaine 1 ml.kg-1 and preservative-free ketamine 0.5 mg.kg-1; Group L received an ilioinguinal nerve block with 0.25% bupivacaine 0.5 ml.kg-1 and infiltration of the wound with 0.25% bupivacaine 0.5 ml.kg-1. All subjects received diclofenac sodium 1-2 mg.kg-1 as a rectal suppository. Postoperative pain was assessed by means of a modified Objective Pain Score and analgesia was administered if this exceeded a value of 4. The median duration of analgesia was 10 h (range 2.6 to > 24 h) in Group C and 2.9 h (range 0.7 to > 24 h) in Group L (p < 0.05). There were no differences between groups in the incidence of motor block, urinary retention, postoperative vomiting or postoperative sedation. Subjects in Group L required significantly more doses of postoperative analgesia than those in Group C (p < 0.05).     

Resection hip arthroplasty for malignant pelvic tumor. Outcome in 5 patients followed more than 2 years

BACKGROUND: Vasoactive intestinal peptide (VIP) has been reported to have some properties that provide protection from lung injury. Furthermore, its protective effect in cold storage of donor lungs has been confirmed. We examined its effect and the timing of administration in an in vivo rat lung transplantation model. METHODS: All lungs were flushed with low-potassium dextran-1% glucose solution, and orthotopic left lung transplantations were performed. Rats were divided into four groups (n = 6). Group I received no preservation or storage. Groups II, III, and IV grafts were stored for 18 hours at 4 degrees C. Group II received no VIP. Group III received VIP (0.1 g/ml) via the flush solution. Group IV recipients received VIP (3 microg/kg) intravenously just after reperfusion. Twenty-four hours after transplantation, the right main pulmonary artery and right main bronchus were ligated, and the rats were ventilated with 100% O2 for 5 minutes. Mean pulmonary arterial pressure, peak airway pressure, blood gas analysis, serum lipid peroxide level, tissue myeloperoxidase activity, and wet-dry weight ratio were measured. RESULTS: The partial O2 tension values of groups III and IV were better than group II (groups II, III, and IV: 147.4 +/- 71.4, 402.1 +/- 64.8, 373.4 +/- 81.0 mm Hg; p < 0.05). Peak airway pressure was lower in groups III and IV than in group II (groups II, III, and IV: 19.7 +/- 0.8, 16.7 +/- 0.9. and 16.3 +/- 1.0 mm Hg; p < 0.05). Mean pulmonary arterial pressure in group III was lower than group II (groups II and III: 36.3 +/- 3.0 and 22.1 +/- 2.2 mm Hg; p < 0.01). Wet-dry weight ratio in group III was lower than in groups II and IV (group II, III, and IV: 5.2 +/- 0.2, 4.4 +/- 0.2, and 5.2 +/- 0.3; II vs III; p < 0.05, III vs IV; p < 0.01). Serum lipid peroxide levels in groups III and IV were significantly lower (groups II, III, and IV: 2.643 +/- 0.913, 0.455 +/- 0.147, and 0.325 +/- 0.124 nmol/ml; p < 0.01). CONCLUSION: VIP ameliorates reperfusion injury in an in vivo rat lung transplantation model. Either administration of VIP via the flush solution or systemically just after reperfusion was associated with improved pulmonary function.     

Atrial fibrillation and coronary disease

OBJECTIVE: To study the incidence of atrial fibrillation in patients (pts) with angiographic coronary artery disease and its relation with clinical and angiographic parameters. DESIGN: Retrospective study. SETTING: Six hundreds consecutive pts, submitted to diagnostic coronary angiography, performed in Hemodynamic Laboratory of Santa Marta Hospital (from 88/04/03 to 90/05/04). MATERIAL AND METHODS: From six hundreds pts were excluded 43 because they had also valvular heart disease and/or minimal coronary artery lesions. Two groups were considered: Group I-pts with atrial fibrillation (n = 7) and Group II-pts in sinus rhythm (n = 549). We evaluated the following parameters: age, sex, clinical history, basal ECG, cardiac enlargement in chest X-ray, angiographic score of LVF, left ventricular diastolic pressure (LVDP), ventricular aneurysm, mitral regurgitation and number of vessels disease. RESULTS: We only found significant statistically differences between the two groups concerning the following parameters: a) age-mean age was superior in group I (Group I-64.2 +/- 8.2 versus 56.3 +/- 9.6), the number of pts older than 60 years in group I was 75% vs 33.8% in group II (p < 0.02); b) heart failure-the incidence was superior in group I, 37.5% vs 9% in group II (p < 0.03); c) cardiac enlargement in chest X-ray-75% pts of group I vs 22% of group II (p < 0.002); d) moderate to severe mitral regurgitation-25% of pts in group I vs 5% of pts of group II (p < 0.05). CONCLUSIONS: Atrial fibrillation is an unusual rhythm in pts with angiographic coronary artery disease. Its presence is related with age, clinical evidence of heart failure, cardiac enlargement and moderate to severe mitral regurgitation.     

Measurement of pulmonary status and surfactant protein levels during dexamethasone treatment of neonatal respiratory distress syndrome

PURPOSE: To study the effect of epidural buprenorphine on minimum alveolar concentration (MAC) of volatile anaesthetics, duration of analgesia and respiratory function in the perioperative period. METHODS: One hundred and twenty patients, ASA I-II undergoing gynaecological surgery were randomly divided into three studies. The forty patients in each study were randomly divided into four groups depending on the dosage; Group I (control), Group II (80 micrograms. kg-1 morphine), Group III (4 micrograms. kg-1 buprenorphine), Group IV (8 micrograms. kg-1 buprenorphine). The MAC of halothane was measured following epidural administration of the agents in each group. The duration of analgesia was assessed by the first request for pentazocine. Postoperative analgesic effects were assessed by the total dosage of pentazocine required for the 48 hr after surgery. Respiratory rate (RR), minute volume (MV), and PaCO2 were measured during surgery and the postoperative period. The MAC of halothane was reduced in Group IV (P < 0.01). The duration of analgesia was 10.0 +/- 5.1 hr (Mean +/- SE) in Group I, 37.7 +/- 4.7 hr in Group II, 27.1 +/- 7.1 hr in Group III, and 44.4 +/- 4.1 hr in Group IV. Total dosage of pentazocine was lower in Group IV (P < 0.05) than in the other groups. The decrease of RR, MV and the increase of PaCO2 were observed within 60 min in Group III and IV dose dependently. CONCLUSION: Epidural buprenorphine administered in a dose of 4 or 8 micrograms. kg-1 provides postoperative analgesia that is no less effective than that of morphine.     

Evaluation of intravenous tenoxicam for postoperative cesarean delivery pain relief. Preliminary report

BACKGROUND AND OBJECTIVES: To assess safety and efficacy of tenoxicam for postoperative pain relief after cesarean delivery. METHODS: Postoperative pain relief, supplemental analgesic requirements, and adverse side effects were evaluated in 80 patients undergoing cesarean delivery. Forty patients received a slow intravenous injection of tenoxicam at a fixed dose of 20 mg (2 mL), immediately before induction of spinal anesthesia with 15 mg (3 mL) of 0.5% hyperbaric bupivacaine. The other 40 patients received 2 mL of saline solution. Newborns were evaluated by means of Apgar score and umbilical cord blood gases. RESULTS: There was a significant prolongation of analgesia in the tenoxicam group (365 +/- 91.1 minutes versus 305 +/- 53.2 minutes in control group, P < .001). Supplementary analgesic requirements were significantly decreased by intravenous tenoxicam (1.55 +/- 0.70 versus 2.25 +/- 0.68). Adverse side effects did not differ between groups and few complaints of phlebitis were noted. Apgar scores and blood gas analyses were similar in neonates from both groups. CONCLUSIONS: Intravenous tenoxicam is safe and slightly increases the length of postoperative analgesia provided by the local anesthetic. It is effective in decreasing analgesic consumption in cesarean delivery patients.     

Phosphatidylcholine-associated aspirin accelerates healing of gastric ulcers in rats

In this double-blind study, we administered lumbar epidural bupivacaine or bupivacaine plus verapamil to investigate the possible role of the calcium channel blocker, verapamil, in postoperative pain. One hundred patients (ASA physical class I or II) scheduled for lower abdominal surgery were randomly assigned to one of four groups. Group 1 received 10 mL of 0.5% epidural bupivacaine injected 15 min before incision, followed by 10 mL of epidural normal saline 30 min after incision. Group 2 received 10 mL of epidural normal saline injected before incision, followed by 10 mL of 0.5% epidural bupivacaine 30 min after incision. Group 3 received 10 mL of 0.5% epidural bupivacaine plus 5 mg of verapamil injected before incision, followed by 10 mL of epidural normal saline 30 min after incision. Group 4 received the same drugs as Group 3, in the reverse order. Pain and mood numeric rating scores, sedation scores, Prince Henry scores, patient-controlled cumulative postoperative analgesic consumption, and the incidence of side effects were assessed 2, 6, 12, 24, and 48 h after the operation in each group. Cumulative postoperative analgesic consumption in Groups 3 and 4 was significantly lower (P < 0.05) than that in Groups 1 and 2 24 and 48 h after surgery. There were no differences in the pain, mood, and sedation scores and the incidence of side effects among the four groups. We conclude that epidural verapamil decreases postoperative pain, possibly by interfering with normal sensory processing and by preventing the establishment of central sensitization. Implications: Calcium plays an important role in pain physiology at the spinal cord level. We examined the effect of bupivacaine plus verapamil (calcium channel blocker) and of bupivacaine alone. We demonstrated that the combination, administered epidurally, resulted in less postoperative analgesic consumption than bupivacaine alone.     

The effect of low-dose aspirin and dipyridamole upon atherosclerosis in the rabbit

To examine the effect of antiplatelet therapy upon atherosclerosis in an animal model, aspirin and dipyridamole were administered to female New Zealand rabbits while they were fed a 2% cholesterol diet. Four experimental groups of 15 animals were established: Group I (Control), no medication; Group II, aspirin, 40 mg orally five days a week; Group III, dipyridamole, 25 mg orally five days a week; Group IV, aspirin and dipyridamole. After seven weeks, the animals were sacrificed and their aortas were removed and stained. Group means of the percentage of total aortic lumenal surface occupied by gross atheromata were calculated and statistically compared with the control group mean: Group I - 49%, Group II 36%, p = NS, Group III - 47%, Group IV - 25%, p less than .01. Histologic sections of each aorta confirmed the stained areas to be atheromata of varying complexity. The lesions in animals treated with dipyridamole alone exhibited a distinct increase in smooth muscle cell proliferation. For animals receiving a combination of aspirin and dipyridamole the lesions were smaller and less advanced than those in the control group. These findings indicate that experimental atherosclerosis in rabbits is modified by the administration of anti-platelet agents and that atheroma formation is significantly inhibited when aspirin and dipyridamole are given in combination.     

Selenite and selenium yeast as feed supplements for dairy cows

The availability of inorganic and organic forms of selenium to dairy cows was studied by giving 25 cows supplementary selenium for 9 months either as sodium selenite or as a selenium-containing yeast product. Group I (eight cows) received 3.0 mg selenium as sodium selenite daily, group II (nine cows) received 3.0 mg selenium as the selenium yeast product, and group III (eight cows) received 0.75 mg selenium as the selenium yeast product. The total selenium contents of the ration were 0.26-0.32 mg/kg feed dry matter for groups I and II, and 0.16-0.18 mg/kg for group III. The supplement of 0.75 mg selenium daily from the yeast product maintained the selenium concentrations of whole blood and milk at the same levels as 3.0 mg selenium as sodium selenite, and 3.0 mg selenium from the yeast product increased the selenium concentration of whole blood by approximately equal to 40% and that of milk by approximately equal to 100%. The activity of glutathione peroxidase in erythrocytes of the group given selenite was not significantly different from that in either of the groups given the yeast product. The concentrations of selenium in the tissues of two cows from each group were marginal to adequate, and there was a trend for the concentrations to be higher in the tissues of the cows supplemented with the yeast product.     

Effect of percutaneous ethanol injection for postoperative recurrence of hepatocellular carcinoma in combination with transcatheter arterial embolization

BACKGROUND/AIMS: This study was conducted to clarify the effect of percutaneous ethanol injection (PEI) in combination with transcatheter arterial embolization (TAE) on prolonging the survival time of patients with postoperative recurrence of hepatocellular carcinoma (HCC). MATERIALS AND METHODS: The subjects were 97 consecutive patients (pts) treated for postoperative recurrent HCC between February 1987 and March 1993. Of these, 25 pts received both TAE and PEI and 72 pts received TAE alone. In the TAE & PEI group, treatment was selected according to the indications: 15 pts received TAE for multiple recurrences following PEI, and the other 10 pts received PEI for a new or residual lesion following TAE. Fourteen demographic, pathological, and clinical variables were evaluated to estimate the relative risk of pts treated with TAE & PEI or with TAE alone. RESULTS: The 1-, 3- and 5- year survival rates in the TAE & PEI group were 100%, 73.2% and 27.2%, respectively, and those in the TAE alone group were 88.9%, 30.2% and 5.5%, respectively. Based on multi-variate Cox regression analysis, the relative risk of cancer death in the TAE & PEI group was 0.32 (95% confidence interval, 0.15 to 0.67). CONCLUSION: The combination of TAE and PEI had a positive palliative effect and increased survival time of patients with postoperative recurrent HCC, compared to results obtained by TAE alone.     

A study on the pathogenesis of hyporeninemia in diabetics

Hyporeninemic hypoaldosteronism has mainly been described in patients with diabetes mellitus. In order to elucidate the mechanisms of hyporeninemia in diabetic patients, the author studied the response of active renin concentration (ARC) and inactive renin concentration (IRC) to the administration of captopril or sodium depletion in patients with diabetes mellitus and glomerulonephritis and in normal subjects. The diabetic patients were separated into four groups: Group 0, diabetic patients without neuropathy or nephropathy; Group I, those with neuropathy without nephropathy; Group II, those without neuropathy with nephropathy; Group III, those with neuropathy and nephropathy. Diabetic patients with some complications had slightly lower plasma active renin levels than those without complications. The mean increase in plasma active renin after captopril (delta ARC) and sodium depletion was lower in group I than in group 0, and there was no difference between group II and group 0. There was no correlation between delta ARC and creatinine clearance (Ccr) in diabetes mellitus. Plasma prorenin was higher in group I than in group 0, and there was no difference between group II and group 0. No significant change of prorenin after captopril was observed in all groups, but the mean increase in plasma inactive renin after sodium depletion was slightly higher in groups I and III than in groups 0 and II. ARC/IRC was significantly lower in group I than in group 0, and there was no difference between group II and group 0. There was no correlation between ARC/IRC and Ccr in diabetes mellitus, but significant correlation between ARC/IRC and postural change in systolic blood pressure. In three diabetic patients with hyporeninemic hypoaldosteronism, the postural fall in systolic blood pressure was significant, and ARC/IRC was significantly low, but IRC was not high. These results suggest that autonomic dysfunction is a major factor in an impairment of the processing of prorenin to active renin in diabetic patients, and severe autonomic dysfunction may impair the biosynthesis of prorenin in patients with hyporeninemic hypoaldosteronism.     

Does the preoperative administration of ketorolac improve postoperative analgesia

AIM OF THE STUDY: 1) To verify the usefulness of ketorolac administration (30 mg i.v.) before a surgical operation in terms of postoperative analgesia improvement; 2) To evaluate the impact of preoperative ketorolac administration on perioperative renal function and on intraoperative water balance; 3) to evaluate the presence of adverse effect due to preoperative NSAID use. DESIGN: Prospective randomized trial. SETTING: University surgical department. PATIENTS AND METHODS: Forty adult patients undergoing major abdominal surgery, randomized in 2 groups: in group 1 ketorolac (30 mg i.v.) was administered immediately after the induction and, for postoperative analgesia, ketorolac (30 mg i.v.) was administered beginning at the time of skin closure; in group 2 no ketorolac was administered before the operation and postoperative treatment was the same. Buprenorphine (0.3 mg i.m.) was administered in case of unsatisfactory analgesia. Fluids infused and diuresis were measured intraoperatively. One, 6 and 24 hours after the end of operation pain was evaluated using pain intensity score and VAS. The day after the operation serum creatinine and urea were measured. RESULTS: No statistically significant differences were found between groups regarding fluids infused, intraoperative diuresis, postoperative pain, adverse effects and number of bleeding episodes. More than 50% of patients, in either groups, required opioids administration. CONCLUSIONS: Ketorolac (30 mg i.v.) administration before a major abdominal operation does not improve postoperative analgesia nor determines significant alterations in renal function or increase in the frequency of abnormal bleedings. Opiate administration is necessary in more than 50% of the patients to achieve adequate analgesia.     

Dose-response effect of adjuvant cyclophosphamide, methotrexate, 5-fluorouracil (CMF) in node-positive breast cancer. International Breast Cancer Study Group

There is evidence in the literature of a relationship between dose and response to adjuvant chemotherapy for breast cancer, although published results are conflicting. We therefore retrospectively analysed the role of dose response in patients included in four adjuvant trials of the International Breast Cancer Study Group (IBCSG, formerly the Ludwig Breast Cancer Study Group (trials I, II, III and V), all using 'classical' cyclophosphamide, methotrexate, and 5-fluorouracil (CMF). A total of 1385 node-positive patients were treated with oral cyclophosphamide, and intravenous methotrexate plus 5-fluorouracil (CMF) for at least six 4 week courses. 1350 of these were included in 6 month landmark treatment outcome analyses. A total of 1029 patients were premenopausal, 321 were postmenopausal; 800 had one to three and 550 more than three involved axillary nodes at surgery. The median follow-up ranged from 12 years for trial V to 15 years for trials I-III. Patients were grouped according to three prospectively defined dose levels based on the percentage of the protocol prescribed dose that was actually administered (level I > or = 85%, level II 65-84%, level III < 65%). Patients who received dose level II had a higher disease-free (P = 0.07) and overall survival (P = 0.03) than those who received a higher (level I) or lower (level III) percentage. The 10 year overall survival was 60% for dose level II, 56% for dose level I, 51% for dose level III. The results were generally consistent within trial, menopausal status, and oestrogen receptor status groups. The results within nodal groups showed a large difference among the dose levels for the group with one to three positive nodes (P = 0.02), but no difference for the group with four or more positive nodes. Our results indicate that the dose-response effect remains a crucial factor in adjuvant chemotherapy of breast cancer. Reductions larger than 35% in the dose administered of oral CMF adversely influenced the outcome of breast cancer patients and should be avoided. The better outcome of the intermediate dose group indicates the need to investigate other aspects involved in the cytotoxicity of adjuvant CMF chemotherapy.     

Comparison of propacetamol and morphine in postoperative analgesia]

To compare the analgesic efficacy and tolerance of propacetamol and morphine, 80 patients in good clinical condition were included in a prospective, parallel, randomized double blind trial after elective surgery expected to elicit light to moderate postoperative pain. At the end of general anesthesia, 40 patients received 30 mg/kg propacetamol and 40 0.2 mg/kg morphine, as a 15-min intravenous infusion. The groups were similar for age, weight and duration of anesthesia. Supplemental analgesia had to be given in 7 cases from the propacetamol group vs. 2 cases from the morphine group. The postoperative pain, evaluated 7 times during 4 h from the end of infusion with a visual analog scale, revealed a modest advantage for morphine at 0.5 and 4 h (p = 0.05). The respiratory rate was slightly lower after morphine (p = 0.02). No significant differences were observed in blood oxygen saturation, blood pressure, heart rate, body temperature and vigilance evaluated by the trailmaking test. Nausea was present in 4 cases under propacetamol and 3 under morphine, and pruritus in 2 and 7 cases, respectively. In conclusion, propacetamol may represent an alternative to morphine for pain prevention after mildly to moderately painful surgery in situations where the use of opioids is unsuitable.     

Autoimmune thyroiditis complicated with reversible changes of thyroid function

The purpose of this study was to determine whether warm ischemia (WIT) and cold storage preservation (CSP) impair endothelium-dependent vascular relaxation in the kidney. Twenty-four canine kidneys were harvested, preserved with CSP for 24 or 48 hours, and then perfused with canine blood at 37 C for the determination of glomerular filtration rate (GFR), perfusion flow rate, and renal vascular resistance (RVR). There were four experimental groups: Group I--no WIT followed by 24 hours CSP, Group II--30 minutes WIT followed by 24 hours CSP, Group III--no WIT followed by 48 hours CSP, Group IV--30 minutes WIT followed by 48 hours CSP. Endothelial function in each group was evaluated using acetylcholine (ACh, 1 mg. bolus) as an endothelial dependent vasodilator, and sodium nitroprusside (NP, 10 mg. bolus) as an endothelial independent vasodilator. Glomerular filtration rate was significantly less (P < .05) and RVR was significantly greater (P < .05) for kidneys from Groups II, III and IV compared to group I. The highest RVR was observed in kidneys from Groups II and IV. Nitroprusside administration caused an equivalent reduction in RVR among all four study groups. ACh administration caused a similar reduction in RVR in Groups I and III; however, the change in RVR was significantly less in Groups II and IV (P < .05). We hypothesize that the more severe ischemic insult in the latter groups led to vascular endothelial damage with a consequent loss of ability to secrete endothelium-derived relaxing factor in response to ACh administration.