Low dose intrathecal morphine effects on post-hysterectomy pain: a randomized placebo-controlled study.

BACKGROUND: Spinal anesthesia with different doses of intrathecal morphine has been shown to relieve post-operative pain. We studied in a prospective randomized, double-blind fashion the effects of morphine 0, 100, 200, or 300 µg added to intrathecal bupivacaine on first post-operative 24 h patient-controlled analgesia morphine (PCA-morphine) consumption after abdominal hysterectomy under general anesthesia. METHODS: One hundred and forty-four American Society of Anesthesiologists I-II women were assigned to receive spinal anesthesia with 12 mg of hyperbaric bupivacaine combined with 100, 200, and 300 µg morphine or saline before standardized general anesthesia was induced. Low transverse incision abdominal hysterectomy was performed. Post-operative outcome measures were recorded at 1, 2, 4, 6, 12, and 24 h. Primary outcome was 24 h PCA-morphine. Secondary outcomes were pain by visual analogue scale (0-10), nausea, pruritus, sedation, and respiratory depression. RESULTS: Intrathecal morphine reduced accumulated 24 h post-operative morphine consumption. Morphine 100 µg significantly reduced morphine consumption vs. placebo at 0-6 h, 6-12 h, and for the entire 0-24 h time interval post-operation. Morphine 200 µg further significantly reduced morphine consumption vs. morphine 100 µg at 0-6 h and for the entire 0-24 h post-operation. There was no further reduction of morphine consumption seen with morphine 300 µg. No serious side effects were seen. Emesis was similar in all groups, and pruritus was experienced only in the morphine groups. CONCLUSION: Intrathecal morphine supplementation to bupivacaine reduces first 24 h PCA-morphine consumption after abdominal hysterectomy under general anesthesia, and we found no benefit from increasing the dose over 200 µg.

Differential tissue-specific protein markers of vaginal carcinoma.

The objective was to identify proteins differentially expressed in vaginal cancer to elucidate relevant cancer-related proteins. A total of 16 fresh-frozen tissue biopsies, consisting of 5 biopsies from normal vaginal epithelium, 6 from primary vaginal carcinomas and 5 from primary cervical carcinomas, were analysed using two-dimensional gel electrophoresis (2-DE) and MALDI-TOF mass spectrometry. Of the 43 proteins identified with significant alterations in protein expression between non-tumourous and tumourous tissue, 26 were upregulated and 17 were downregulated. Some were similarly altered in vaginal and cervical carcinoma, including cytoskeletal proteins, tumour suppressor proteins, oncoproteins implicated in apoptosis and proteins in the ubiquitin-proteasome pathway. Three proteins were uniquely altered in vaginal carcinoma (DDX48, erbB3-binding protein and biliverdin reductase) and five in cervical carcinoma (peroxiredoxin 2, annexin A2, sarcomeric tropomyosin kappa, human ribonuclease inhibitor and prolyl-4-hydrolase beta). The identified proteins imply involvement of multiple different cellular pathways in the carcinogenesis of vaginal carcinoma. Similar protein alterations were found between vaginal and cervical carcinoma suggesting common tumourigenesis. However, the expression level of some of these proteins markedly differs among the three tissue specimens indicating that they might be useful molecular markers.

Protein expression patterns in primary carcinoma of the vagina.

Protein patterns in six samples from primary vaginal cancers, in five from normal vaginal tissue and in five primary cervical cancers, were analysed using two-dimensional polyacrylamide gel electrophoresis (2-DE). Protein expression profile was evaluated by computer-assisted image analysis (PDQUEST) and proteins were subsequently identified using matrix-assisted laser desorption/ionisation mass spectrometry. The aim was to analyse the protein expression profiles using the hierarchical clustering method in vaginal carcinoma and to compare them with the protein pattern in cervical carcinoma in order to find a helpful tool for correct classification and for increased biomedical knowledge. Protein expression data of a distinct set of 33 protein spots were differentially expressed. These differences were statistically significant (Mann-Whitney signed-Ranked Test, P<0.05) between normal tissue, vaginal and cervical cancer. Furthermore, protein profiles of pairs of primary vaginal and cervical cancers were found to be very similar. Some of the protein spots that have so far been identified include Tropomyosin 1, cytokeratin 5, 15 and 17, Apolipoprotein A1, Annexin V, Glutathione-S-transferase. Others are the stress-related proteins, calreticulin, HSP 27 and HSP 70. We conclude that cluster analysis of proteomics data allows accurate discrimination between normal vaginal mucosa, primary vaginal and primary cervical cancer. However, vaginal and cervical carcinomas also appear to be relatively homogeneous in their gene expression, indicating similar carcinogenic pathways. There might, further, be a possibility to identify tumour-specific markers among the proteins that are differentially expressed. The results from this study have to be confirmed by more comprehensive studies in the future.

Value of diagnostic laparoscopy in fertile women with suspected appendicitis.

OBJECTIVE: To assess the value of diagnostic laparoscopy in women of child-bearing age with suspected appendicitis. DESIGN: Prospective, non-randomised study. SETTING: University hospital, Sweden. SUBJECTS: 94 women aged between 15 and 40 years with suspected appendicitis. INTERVENTION: Diagnostic laparoscopy. If necessary, the appendix was removed either laparoscopically or by open operation. The outcomes were compared with those during 1994, during which all appendicectomies were done through a laparotomy. MAIN OUTCOME MEASURES: Rates of unnecessary appendicectomy, operating time, and length of hospital stay. RESULTS: 77 had diagnostic laparoscopy, and 17 primary open appendicectomy. 73 appendixes were removed; 53 open and 20 laparoscopically. 12 appendicectomies (13%) were unnecessary compared with 27/80 (34%) during the year 1994. The duration of the open operation was significantly shorter (mean (SD) 35 (14) minutes) than the laparoscopic one (78 (18) minutes) (p<0.001), and there were no differences in duration of postoperative hospital stay. No patients developed complications. CONCLUSIONS: Diagnostic laparoscopy is safe and helpful in suspected cases of appendicitis and could substantially reduce the rate of unnecessary appendicectomies. However, the data suggest that laparoscopic appendicectomy offers no advantages over primary open appendicectomy in terms of postoperative course.

Phenotypic analysis of ovarian carcinoma: polypeptide expression in benign, borderline and malignant tumors.

Studies of multiple markers in tumors are required for adequate biological characterization. We have characterized the expression of multiple proteins in human ovarian tumors using the technique of 2-dimensional gel electrophoresis (2-DE/PDQUEST). Tumor cells were prepared from the tissue of 22 ovarian tumors. Large variations were observed between tumors in the expression of various polypeptides, indicating heterogeneity in gene expression. An increase in the spot density of 2 cell-cycle-related proteins, PCNA and OP18/stathmin, was observed in carcinomas. Borderline tumors expressed low levels of these proteins. Significant increases in the levels of nm23, GST-pi, elongation factor 2 and triose phosphate isomerase were recorded in ovarian carcinomas. Furthermore, decreases in the levels of tropomyosin-2 and lamin C were observed in malignant as compared with benign tumors. The pattern of expression of 9 protein markers was examined in individual tumors. All malignant tumors showed simultaneous alterations in the expression of 5 or more of these proteins, whereas no benign tumor showed alterations in the expression of more than 3 polypeptides. Borderline tumors showed alterations in 0 to 6 markers. We conclude that the simultaneous analysis of multiple polypeptides, which can be achieved by 2-DE, is useful for characterization of gene expression and diagnostic studies in ovarian tumors.

Infections after hysterectomy. A prospective nation-wide Swedish study. The Study Group on Infectious Diseases in Obstetrics and Gynecology within the Swedish Society of Obstetrics and Gynecology.

BACKGROUND: An increased use of prophylactic antibiotics to avoid postoperative infections in women undergoing hysterectomy has been observed in Sweden. This investigation was performed a) to study the infection rate to enable future evaluation of the effect of prophylactic antibiotic regimens and b) to identify subgroups suitable for intervention. METHOD: A prospective study comprising all women undergoing pelvic surgery with hysterectomy during a two month period at forty-two Departments of Obstetrics and Gynecology in Sweden. Relevant information regarding the surgical procedure and the postoperative course was included in a standardized form at discharge from hospital and at a follow-up visit 4 to 6 weeks after surgery. RESULTS: Of the 1060 women included in the study, 23% developed postoperative infections: 9.4% had wound-, cuff-, and/or deep infections, 13% urinary tract infections, and 4% other infections unrelated to the surgical site. Only half of the wound/cuff-/deep infections were diagnosed before discharge from the hospital. Wertheim-Meigs procedures, bleedings per-operatively exceeding 1000 ml, and presence of bacterial vaginosis (BV) were associated with an increased risk of postoperative infections. Among women undergoing abdominal hysterectomy for benign reasons, (n = 159), wound-cuff/deep infection was significantly associated with preoperative BV, i.e. 7 of 28 (25%) vs. 11 of 131 (8%), respectively (relative risk = 3.0, p = 0.01). Infection was associated with prolonged postoperative hospital stay. Antibiotics were given pre- or postoperatively to 236 (22%) of the 1060 women. Reduction in the postoperative infection rate was seen among women undergoing vaginal hysterectomy who were given pre- or postoperative antibiotics. CONCLUSION: The postoperative infection rate after hysterectomy was clinically significant in this population. Wertheim-Meigs procedures, peroperative bleeding > 1000 ml and BV were identified as risk factors for postoperative infections after hysterectomy.

Serum levels of scc, cea, ca-125 and tpa in the management of cervical-carcinoma.

Serum levels of squamous cell carcinoma antigen (SCC), carcinoembryonic antigen (CEA), CA 125 and tissue polypeptide antigen (TPA) were serially determined in 116 patients with cervical carcinoma. Serum levels of SCC or TPA levels were elevated in the 12 patients with residual tumour after primary therapy. In patients who were clinically in complete remission, SCC and TPA levels were elevated in 7/69 and 5/70 patients, respectively. Three of the 7 with positive SCC and 4 of the 5 patients with positive TPA levels had a recurrence during follow-up. Elevated levels of SCC or CA 125 or TPA preceded the clinical detection of recurrence in 13 of 18 patients (median time was 7 months for SCC and 6 months for CA 125 and TPA).

Use of cefuroxime in preventing postcesarean infection in high-risk patients.

Prophylactic antibiotic therapy is accepted for prevention of postceasarean infection in certain risk groups. Of the antibiotic regimens presented none appears superior. Patients having a cesarean section (CS) more than 6 h after membrane rupture were given three doses of cefuroxime (1.5 g every 8th hour) in a prospective study. This prophylaxis was as efficacious as a 7-day treatment with cefuroxime and cefadroxil. The infection rate was 21% which should be compared to approximately 50% when no prophylaxis was given. Patients with membrane rupture of less than 6 h and having a most urgent CS received the same 24-hour prophylaxis. No postoperative infection was recorded. Women having a CS with an ongoing uterine infection were treated with cefuroxime alone or combined with metronidazole. All but one (91%) had an uneventful recovery.

Prevention of postoperative infection in cesarean section after rupture of the membranes.

Patients having a cesarean section more than 6 h after rupture of the membranes constitute a high risk group for postoperative infections. Two such groups were studied. Patients were given either cefuroxime 1.5 g every 8th hour for 24 h followed by cefadroxil 0.5 g twice daily for 6 days or received no medication. The infection rate was significantly reduced in the treatment group as compared to the control group (15% vs. 48%). Non-infected patients had a significantly shorter stay in hospital (8 days vs. 12 days). Combined use of these drugs for prevention of post-cesarean infection has not previously been reported. No side effects of the antibiotic prophylaxis were reported.