A procedure-specific systematic review and consensus recommendations for postoperative analgesia following laparoscopic cholecystectomy.

BACKGROUND: Laparoscopic cholecystectomy has advantages over the open procedure for postoperative pain. However, a systematic review of postoperative pain management in this procedure has not been conducted. METHODS: A systematic review was conducted according to the guidelines of the Cochrane Collaboration. Randomized studies examining the effect of medical or surgical interventions on linear pain scores in patients undergoing laparoscopic cholecystectomy were included. Qualitative and quantitative analyses were performed. Recommendations for patient care were derived from review of these data, evidence from other relevant procedures, and clinical practice observations collated by the Delphi method among the authors. RESULTS: Sixty-nine randomized trials were included and 77 reports were excluded. Recommendations are provided for preoperative analgesia, anesthetic and operative techniques, and intraoperative and postoperative analgesia. CONCLUSIONS: A step-up approach to the management of postoperative pain following laparoscopic cholecystectomy is recommended. This approach has been designed to provide adequate analgesia while minimizing exposure to adverse events.

Comparison of the efficacy of three commercial bacterins in preventing canine leptospirosis.

Twenty-four specific pathogen-free beagles were randomly allocated into four groups (three vaccinated groups and one control group) and inoculated at nine and 12 weeks of age with one of three commercial inactivated Leptospira vaccines: A (Vanguard 7; Pfizer Santé Animale), B (Dohyvac 7L; Fort Dodge), and C (Nobivac DHPPi + Lepto; Intervet International); the control group received Nobivac DHPPi (Intervet International). Seven weeks after the second vaccination all the dogs were challenged with Leptospira interrogans serogroup canicola. All the vaccinated dogs developed a mild serological response (microscopic agglutination titres) after the booster vaccination. A significant serological response after the challenge was observed, particularly in the controls. The challenge induced fever and clinical disorders in the control group, whereas in the vaccinated groups the clinical signs were mild. Blood cultures became positive in all control dogs, and in one of six dogs vaccinated with vaccine A and two of four dogs vaccinated with vaccine B; none of the six dogs vaccinated with vaccine C was leptospiraemic at any stage of the experiment. Urine cultures were positive in all the control dogs two weeks after the challenge. One of six dogs vaccinated with vaccine A and two of four dogs vaccinated with vaccine B shed bacteria in their urine after the challenge, but none of the dogs vaccinated with vaccine C shed bacteria in their urine at any time during the experiment.

Localisation and activity of cathepsins K and B in equine osteoclasts.

Cathepsin K and cathepsin B were immunolocalised in equine osteoclasts (OC s) present in ex vivo cartilage/subchondral bone samples. Samples were obtained post mortem from the lateral trochlear ridge (LTR) of six horses and ponies aged between 303 days gestation to 8 months. Strong expression of cathepsin K was detected in OC s, particularly those located at the osteochondral junction, apparently involved in the resorption of calcified cartilage. Cathepsin K expression was also detected in hypertrophic chondrocytes and in the endothelial cells of some blood vessels penetrating the hypertrophic zone of cartilage. By contrast, cathepsin B was either absent or present at very low levels in OC s.Osteoclast-like cells (OCL s) were generated in vitro from bone marrow (BM), obtained from the femurs of one horse and two ponies. High levels of cathepsin K activity but only very low levels of cathepsin B activity were demonstrated in OCL s using fluorogenic substrates for these enzymes. The cathepsin K activity could be blocked by the general cysteine proteinase inhibitor, E-64, but not by the cathepsin B inhibitor, CA-074Me. The cathepsin B activity was completely blocked by both CA-074Me and E-64. Taken together, these results suggest that cathepsin K is more important than cathepsin B in the osteoclastic resorption of bone and calcified cartilage of developing equine long bones. Given the apparent importance of cathepsin K in equine endochondral ossification further investigation into the possibility that abnormal expression of this enzyme is involved in the pathogenesis of equine developmental orthopaedic disease is warranted.

Generation and activity of equine osteoclasts in vitro: effects of the bisphosphonate pamidronate (APD).

Equine osteoclast-like cells (OCLs) were generated from the bone marrow (BM) of two ponies and one horse in the presence of RANKL, the receptor activator of NF kappa B ligand and macrophage colony-stimulating factor (M-CSF). The phenotype of these cells was confirmed by demonstration of characteristics typical of osteoclasts (OCs) including: the expression of tartrate-resistant acid phosphatase (TRAP), the vitronectin receptor (VNR) and the calcitonin receptor (CTR), the demonstration of responsiveness to calcitonin (CT) and the ability to form resorption lacunae on ivory slices and calcium phosphate films. The bisphosphonate pamidronate (APD) dose-dependently inhibited resorption of calcium phosphate films by equine OCLs with an IC(50) of 5.8 x 10(-7) M in one horse. APD also dose-dependently inhibited the number of OCLs present in BM cultures after 7 days. However, this effect is most likely attributable to increased OCL death rather than decreased OCL formation. Paradoxically, ADP appeared to cause an early, transient, increase in OCL formation in BM cultures, however, this effect was reversed after 7 days. These preliminary in vitro data support the potential use of APD in clinical conditions characterised by increased bone turnover such as osteomyelitis, osteitis, septic osteoarthritis, navicular disease, cystic bone lesions and immobilisation-induced osteoporosis and provide useful information for future pharmacokinetic studies and clinical trials in vivo.

Studies of the efficacy of a novel intranasal vaccine against feline bordetellosis.

A novel intranasal vaccine against disease caused by Bordetella bronchiseptica in cats was tested in a series of three experiments. In the first experiment a vaccinated group and an unvaccinated control group of kittens were challenged by the aerosol route with virulent B bronchiseptica three weeks after they had been vaccinated. The control kittens developed upper respiratory tract signs typical of feline B bronchiseptica infection, including rhinitis, a serous ocular and nasal discharge, fever, sneezing and coughing. The mean (sd) clinical score for the cats in the unvaccinated control group was 19.5 (5.4) compared with 1.53 (1.9) for the vaccinated group. In the second experiment vaccinated kittens were challenged with virulent B bronchiseptica 72 hours after they were vaccinated. Their mean clinical score was 2.76 (2.62) compared with 13.4 (3.33) for the control group. In the final experiment, vaccinated and unvaccinated control cats were challenged after six or 12 months. After six months the mean clinical scores were 13.9 (4.7) for the control group, compared with 1.33 (1.56) for the vaccinated group, and after 12 months the scores were 9.92 (5.79) for the control group compared with 0.92 (0.89) for the vaccinated group.

Intraluminal brachytherapy for malignant endobronchial tumors: an update on low-dose rate versus high-dose rate radiation therapy.

Although the evolution from low-dose rate (LDR) to high-dose rate (HDR) brachytherapy for malignant endobronchial tumors was presumably based on economy, patient convenience, and radiation protection, our experience with both modalities permits assessment of the pros and cons of each technique. In November 1991, our HDR remote afterloading brachytherapy unit became operational. By that time, we had treated 110 patients (group 1) with malignant endobronchial obstruction with LDR brachytherapy. Since then, all patients have been treated with HDR brachytherapy. The outcome of our first 110 patients (group 2) treated with HDR brachytherapy is presented in this communication, using group 1 as the historic control group. In group 1, patients were treated with 1 or 2 sessions of 30-60 Gy, each calculated at a 1-cm radius. In group 2, patients received 3 or 4 weekly treatments of 7 Gy, each calculated at a 1-cm radius. The majority of patients in each group had previously received a full course of external beam irradiation, and a history of laser bronchoscopy was also similar for the 2 groups. Differences in bronchoscopic response rate (82% vs. 96%, respectively) and complications (3.6% vs. 2.7%, respectively) were statistically insignificant between the LDR group and the HDR group. We believe HDR brachytherapy is the state-of-the-art modality in intraluminal therapy for endobronchial malignancies.

Equine osteoclast-like cells generated in vitro demonstrate similar characteristics to directly isolated mature osteoclasts.

We report on novel methods to isolate osteoclasts (OC s) and generate osteoclast-like cells (OCL s) from the bone and bone marrow of the equine femur. OC s were successfully isolated from bone scrapings taken from the endosteal surface of the femurs of three horses. OCL s were generated from bone marrow cells taken from the same animals. The validity of using the formation of OCL s as a method for studying OC differentiation and activity was confirmed by the similar characteristics of these two cells. In particular, they both were multinuclear, expressed the enzyme tartrate resistant acid phosphatase and the vitronectin receptor. Most importantly, both were able to resorb bone as demonstrated by the formation of extensive resorption pits when cultured on dentine slices. The generation of OCL s from bone marrow obtained from the equine femur can therefore be used to study equine OC differentiation and for studies requiring the generation of large numbers of these cells. OC s isolated directly from the same bones may be used to examine the effect of a variety of factors on bone resorption in vitro and to continually reaffirm the validity of using OCL s for large-scale studies on OC biology. Such research is essential for improved understanding of bone turnover and endochondral ossification in the horse.

In vitro generation of equine osteoclasts from bone marrow cells using a novel culture system.

We report on preliminary results of a novel in vitro culture system designed to generate equine osteoclasts in large numbers. Osteoclast generation, as determined by the expression of tartrate resistant acid phosphatase (TRAP) and ability to resorb bone, was enhanced in equine bone marrow cultures supplemented with fibroblastic cell (L929) conditioned medium (L929-CM). Bone marrow was collected from a total of 12 horses and ponies and TRAP-positive cells with bone resorbing ability were generated in significant numbers in the last seven. TRAP-positive mononuclear cells appeared after three days in culture and steadily increased in number and size up to seven days when multinuclear TRAP-positive cells started to appear. L929-CM caused a significant increase in the number of TRAP-positive mononuclear cells generated after four and seven days, after which time the number of TRAP-positive cells decreased. The development of this in vitro system provides a reproducible means of generating large numbers of equine osteoclasts necessary for the study of bone remodelling and endochondral ossification in the horse.

Low dose rate versus high dose rate intraluminal brachytherapy for malignant endobronchial tumors.

Although the evolution from low dose rate to high dose rate brachytherapy for malignant endobronchial malignancies was primarily based on economy, patient convenience, and radiation protection, the difference in therapeutic index, if any, between these two modalities must be kept in mind. Our experience with both methods permits assessment of the feasibility of replacing low dose rate brachytherapy with high dose rate brachytherapy. Results with our first 110 patients (group 1) treated with low dose rate brachytherapy (133 procedures) were compared with results with our initial 59 consecutive patients (group 2) treated with high dose rate brachytherapy (161 procedures). In group 1, patients were treated with one or two sessions of 30-60 Gy each calculated at a 1 cm radius. In patients in group 2, we aimed at three weekly sessions of 7 Gy each calculated at a 1 cm radius. External beam irradiation therapy had previously been given to 88% of patients in group 1 and to 85% of patients in group 2. Laser bronchoscopy was performed in 36% of patients in group 1 and in 24% of patients in group 2 before brachytherapy. Clinical or bronchoscopic improvement was noted in 72% of patients in group 1 and in 85% of patients in group 2 (p > 0.05). Complication rates were low and comparable. Survival was similar in both groups (median < 6 months). Although both low dose rate and high dose rate brachytherapy appear equally effective in palliation for malignant endobronchial obstruction, we are now practicing the latter exclusively.

Replacement of entire aorta from aortic valve to bifurcation during one operation.

A 68-year-old patient presented with an extensive aortic aneurysm extending from the aortic valve to the aortic bifurcation associated with severe continuous pain, dysphagia, and hoarseness. Because of the risk of impending rupture and an "elephant trunk" procedure not being an option, the entire aorta from the aortic valve to the aortic bifurcation was replaced during one operation using deep hypothermia with circulatory arrest and retrograde perfusion of the brain through the jugular veins. Seven months after the operation the patient walks more than 3 km a day and lives a normal life. The operative repair is presented.

Efficacy of short term versus long term tube thoracostomy drainage before tetracycline pleurodesis in the treatment of malignant pleural effusions.

BACKGROUND: A study was undertaken to compare the efficacy of short term tube thoracostomy drainage with standard tube thoracostomy drainage before instillation of tetracycline for sclerotherapy of malignant pleural effusions. METHODS: The study consisted of a randomised clinical trial in a sequential sample of 25 patients with malignant pleural effusions documented cytopathologically. Fifteen patients were randomly assigned to group 1 (standard protocol) and 10 to group 2 (short term protocol). Patients in group 1 had tube thoracostomy suction drainage until radiological evidence of lung re-expansion was obtained and the amount of fluid drained was < 150 ml/day, before tetracycline (1.5 g) was instilled. The chest tube was removed when the amount of fluid drained after instillation was < 150 ml/day. Patients in group 2 also had suction drainage, but the tetracycline (1.5 g) was instilled when the chest radiograph showed the lung to be re-expanded and the effusion drained, which was usually within 24 hours. The chest tube was removed the next day. RESULTS: The response to tetracycline sclerotherapy in the two groups was the same (80%) but the duration of chest tube drainage was significantly shorter for patients in group 2 (median two days) than for those in group 1 (median seven days). CONCLUSIONS: The duration of chest tube drainage before sclerotherapy for malignant pleural effusions need not be influenced by the amount of fluid drained daily but by radiographic evidence of fluid evacuation and lung re-expansion. Shorter duration of drainage will reduce the length of hospital stay without sacrificing the efficacy of pleurodesis.

The failure of a prostaglandin F2 alpha analogue, cloprostenol, to initiate lactation in cattle.

An experiment was designed to determine if the analogue of prostaglandin F2 alpha, cloprostenol, at a dose sufficient to cause luteolysis, was lactogenic in cattle. The mammary glands of eight Friesian heifers were developed by treatment with progesterone plus oestrogen. Lactation was then initiated by administration of cloprostenol and subsequent milk production was compared to that of heifers lactating after a normal pregnancy. Injection of cloprostenol failed to initiate lactation. The level of prolactin but not cortisol in blood was substantially elevated following treatment. The results cast further doubt on the importance of prolactin in the lactogenic process but indicate the likely involvement of glucocorticoids.