Role of succinyl substituents in the mannose-capping of lipoarabinomannan and control of inflammation in Mycobacterium tuberculosis infection.

The covalent modification of bacterial (lipo)polysaccharides with discrete substituents may impact their biosynthesis, export and/or biological activity. Whether mycobacteria use a similar strategy to control the biogenesis of its cell envelope polysaccharides and modulate their interaction with the host during infection is unknown despite the report of a number of tailoring substituents modifying the structure of these glycans. Here, we show that discrete succinyl substituents strategically positioned on Mycobacterium tuberculosis (Mtb) lipoarabinomannan govern the mannose-capping of this lipoglycan and, thus, much of the biological activity of the entire molecule. We further show that the absence of succinyl substituents on the two main cell envelope glycans of Mtb, arabinogalactan and lipoarabinomannan, leads to a significant increase of pro-inflammatory cytokines and chemokines in infected murine and human macrophages. Collectively, our results validate polysaccharide succinylation as a critical mechanism by which Mtb controls inflammation.

The shape of cancer relapse: Topological data analysis predicts recurrence in paediatric acute lymphoblastic leukaemia.

Although children and adolescents with acute lymphoblastic leukaemia (ALL) have high survival rates, approximately 15-20% of patients relapse. Risk of relapse is routinely estimated at diagnosis by biological factors, including flow cytometry data. This high-dimensional data is typically manually assessed by projecting it onto a subset of biomarkers. Cell density and "empty spaces" in 2D projections of the data, i.e. regions devoid of cells, are then used for qualitative assessment. Here, we use topological data analysis (TDA), which quantifies shapes, including empty spaces, in data, to analyse pre-treatment ALL datasets with known patient outcomes. We combine these fully unsupervised analyses with Machine Learning (ML) to identify significant shape characteristics and demonstrate that they accurately predict risk of relapse, particularly for patients previously classified as 'low risk'. We independently confirm the predictive power of CD10, CD20, CD38, and CD45 as biomarkers for ALL diagnosis. Based on our analyses, we propose three increasingly detailed prognostic pipelines for analysing flow cytometry data from ALL patients depending on technical and technological availability: 1. Visual inspection of specific biological features in biparametric projections of the data; 2. Computation of quantitative topological descriptors of such projections; 3. A combined analysis, using TDA and ML, in the four-parameter space defined by CD10, CD20, CD38 and CD45. Our analyses readily extend to other haematological malignancies.

Multiple Myeloma with Aberrant CD3 Expression in a Red-Lored Amazon Parrot (Amazona autumnalis).

A 20-year-old, female, red-lored Amazon parrot (Amazona autumnalis) was presented for a 2-week history of weakness. On physical examination, the bird was quiet, fluffed, weak, and had a distended coelom. Radiographic and ultrasound imaging revealed coelomic distention, increased pulmonary parenchymal opacity, renomegaly, dilated intestines, and a thickened ventricular wall. The results of a complete blood cell count indicated the patient was anemic (28%) and had intermediate to large lymphocytes with immature chromatin that were suspected to be neoplastic. Immunocytochemistry on peripheral blood determined that the suspected circulating neoplastic cells were cluster of differentiation (CD) 3+ and occasionally expressed multiple myeloma oncogene 1 (MUM1). Abnormalities from a plasma biochemistry panel were moderate hyperphosphatemia (6.8 mg/dL), marked hyperproteinemia (13.6 g/L), analbuminemia (0 g/dL), and marked hyperglobulinemia (13.6 g/dL). Agarose gel plasma protein electrophoresis documented the presence of albumin (1.2 g/dL) and monoclonal bands which, on reduced lithium dodecyl sulfate polyacrylamide gel electrophoresis, resolved as 60-kd and ∼25-kd bands consistent with immunoglobulin Y heavy and light chains. On the basis of these findings, multiple myeloma was diagnosed. Because of a poor prognosis, the bird was euthanized for postmortem examination. Bone marrow cytology from samples collected during the postmortem examination revealed 17.4% plasma cells and 24% large immature cells with occasional plasmacytoid features. Histopathologic findings included aggregates of neoplastic plasma cells in the bone marrow, spleen, kidney, liver, gastrointestinal tract, muscle, ovary, and brain. The neoplastic cells were strongly immunoreactive for MUM1 and cluster of differentiation 3 (CD3), but negative for CD79a, paired box protein 5, and CD20. This confirmed the clinical diagnosis of multiple myeloma. This report describes an avian immunoglobulin Y-secreting multiple myeloma with aberrant CD3 expression and pseudoanalbuminemia. Aberrant CD3 expression by avian multiple myeloma may explain previously published cases of birds with a monoclonal gammopathy and apparent T-cell lymphoma diagnosed by CD3 immunoreactivity.

Intranasal mast cell tumors: Clinical, immunohistochemical, and molecular features in 20 dogs.

Mast cell tumors (MCTs) are an uncommon primary neoplasm of the nasal cavity in dogs for which there is a paucity of existing literature regarding their clinical behavior and molecular features. The objectives of this retrospective study were to examine the clinical findings, histopathologic and immunohistochemical features, and c-KIT mutation status of primary intranasal MCTs in dogs and identify potential prognostic factors. Canine biopsies submitted to a diagnostic laboratory in Colorado between 2010 and 2019 with intranasal neoplasms diagnosed as MCTs and no history of cutaneous or oral MCT were considered. Immunohistochemistry for CD117 and Ki67 and polymerase chain reaction (PCR) for internal tandem duplications at exons 8 and 11 of the c-KIT gene were performed. Twenty out of 1849 (1%) primary intranasal neoplasms were MCTs. Metastases were reported in 11/20 cases (55%), with the mandibular lymph node representing the most common site. One case had distant metastases to abdominal viscera. Of the cases with available outcome data, 6/14 (43%) died or were euthanized from MCT-related disease within 1 year of the onset of clinical signs. Only one case had a c-KIT mutation at exon 11. In our study, intranasal MCTs were prone to metastasize and had a generally poor prognosis, resembling the behavior of MCTs arising in other mucosal locations. While dogs with metastatic disease and survival times of <1 year tended to have atypical KIT localization, moderate to high Ki67 indices, and mitotic counts ≥8, definitive prognosticators could not be identified due to the limited number of cases with favorable clinical outcomes.

Digital Image Analysis of Heterogeneous Tuberculosis Pulmonary Pathology in Non-Clinical Animal Models using Deep Convolutional Neural Networks.

Efforts to develop effective and safe drugs for treatment of tuberculosis require preclinical evaluation in animal models. Alongside efficacy testing of novel therapies, effects on pulmonary pathology and disease progression are monitored by using histopathology images from these infected animals. To compare the severity of disease across treatment cohorts, pathologists have historically assigned a semi-quantitative histopathology score that may be subjective in terms of their training, experience, and personal bias. Manual histopathology therefore has limitations regarding reproducibility between studies and pathologists, potentially masking successful treatments. This report describes a pathologist-assistive software tool that reduces these user limitations, while providing a rapid, quantitative scoring system for digital histopathology image analysis. The software, called 'Lesion Image Recognition and Analysis' (LIRA), employs convolutional neural networks to classify seven different pathology features, including three different lesion types from pulmonary tissues of the C3HeB/FeJ tuberculosis mouse model. LIRA was developed to improve the efficiency of histopathology analysis for mouse tuberculosis infection models, this approach has also broader applications to other disease models and tissues. The full source code and documentation is available from https://Github.com/TB-imaging/LIRA.

Usefulness of sputum gram stain for etiologic diagnosis in community-acquired pneumonia: a systematic review and meta-analysis.

BACKGROUND: Implementation of sputum Gram stain in the initial assessment of community-acquired pneumonia (CAP) patients is still controversial. We performed a systematic review and meta-analysis to investigate the usefulness of sputum Gram stain for defining the etiologic diagnosis of CAP in adult patients. METHODS: We systematically searched the Medline, Embase, Science Direct, Scopus and LILACS databases for full-text articles. Relevant studies were reviewed by at least three investigators who extracted the data, pooled them using a random effects model, and carried out quality assessment. For each bacterium (Streptococcus pneumoniae, Haemophilus influenzae, Staphylococcus aureus, and Gram-negative bacilli), pooled sensitivity, specificity, positive and negative likelihood ratios were reported. RESULTS: After a review of 3539 abstracts, 20 articles were included in the present meta-analysis. The studies included yielded 5619 patients with CAP. Pooled sensitivity and pooled specificity of sputum Gram stain were 0.59 (95% CI, 0.56-0.62) and 0.87 (95% CI, 0.86-0.89) respectively for S. pneumoniae, 0.78 (95% CI, 0.72-0.84) and 0.96 (95% CI, 0.94-0.97) for H. influenzae, 0.72 (95% CI, 0.53-0.87) and 0.97 (95% CI, 0.95-0.99) for S. aureus, and 0.64 (95% CI, 0.49-0.77) and 0.99 (95% CI, 0.97-0.99) for Gram-negative bacilli. CONCLUSION: Sputum Gram stain test is sensitive and highly specific for identifying the main causative pathogens in adult patients with CAP. TRIAL REGISTRATION: This study has been registered at PROSPERO International prospective register of systematic reviews under registration no. CRD42015015337 .

Plasma levels of mid-regional pro-adrenomedullin in sepsis are associated with risk of death.

BACKGROUND: Identifying Intensive Care Unit (ICU) patients with sepsis and predicting the risk of death are unmet clinical needs. METHODS: Prospective observational single-center study of 120 consecutive ICU patients with suspected severe sepsis at Jerez Hospital. Epidemiological, clinical, laboratory data and MR-proADM, Procalcitonin (PCT) and C-reactive protein (CRP) levels were recorded at ICU admission and follow-up. RESULTS: At ICU discharge, 104 patients were diagnosed with severe sepsis and 39 died. Plasma MR-proADM was highly indicative of sepsis: 4.05 nmol/L vs. of 0.309 nmol/L (P<0.001), with area under the ROC curve (AUC-ROC) was 0.947. At 48 hours following admission, the median MR-proADM levels in surviving sepsis patients fell to 1.65 nmol/L but remained higher in the non-survivors (2.475 nmol/L) (P=0.04). On day 5 the levels fell to 1.36 nmol/L in surviving sepsis patients vs. 3.42 nmol/L in the non-survivors (P<0.001). On day 5 the survivors showed greater MR-proADM clearance (62.7% vs. 21.2%). The AUC-ROC on day 5 was 0.825, PCT 0.725 and CRP 0.700. The AUC-ROC to MR-proADM clearance on day 5 was 0.734. In a multivariable model, MR-proADM levels at 48 hours and on day 5 and clearance on day 5 following admission were statistically significant predictive factors of mortality. CONCLUSIONS: In clinical practice, in ICU patients admitted with SIRS and organ dysfunction, an MR-proADM cut-off point of 1.425 nmol/L helps to identify those with sepsis. An MR-proADM value above 5.626 nmol/L 48 hours after admission was associated with a high risk of death.

Primary central nervous system neoplasms in African hedgehogs.

In this retrospective study, we describe the clinicopathologic and immunohistochemical findings in a series of primary central nervous system (CNS) neoplasms in African hedgehogs ( Atelerix albiventris). Twelve CNS neoplasms were found among 762 African hedgehog submissions (1.6%) to a private diagnostic laboratory in an 18-y period. The median age of affected hedgehogs was 3.5 y. No sex predilection was found. Hindlimb paresis, weakness, and ataxia were the most commonly reported clinical signs. Gangliogliomas ( n = 6) and astrocytomas ( n = 5) were the most commonly observed neoplasms; one oligodendroglioma was found. Gangliogliomas were found in the cerebellar white matter (2 of 6), brainstem (4 of 6), cervical spinal cord (1 of 6), and frontal lobe (1 of 6); one metastasized to the tongue. Gangliogliomas were immunoreactive for neurofilament protein (NFP), glial fibrillary acidic protein (GFAP), S100, and CD34. All astrocytomas were gemistocytic, located in the cerebrum, and none of these neoplasms metastasized. Astrocytomas were positive for GFAP, S100, and CD34, but negative for NFP. The oligodendroglioma was located in the cerebrum, and was positive for S100, but negative for GFAP and NFP.

Infectious keratoconjunctivitis in free-ranging mule deer in Wyoming: a retrospective study and identification of a novel alphaherpesvirus.

We describe the clinicopathologic findings, relative prevalence, and pathogens associated with infectious keratoconjunctivitis in mule deer ( Odocoileus hemionus) in Wyoming. Seventeen cases with ocular lesions were identified among 1,036 mule deer postmortem submissions (1.6%) in an ~16 y period. Sixteen cases were observed in winter and most were in male (15 cases) and juvenile (13 cases) deer. Blindness was the most commonly reported clinical sign (10 cases). A herpesvirus was detected only in the 4 cases of bilateral necrotizing bulbar conjunctivitis. Phylogenetic analysis of glycoprotein amino acid sequences consistently identified this virus as a novel alphaherpesvirus. In 2 of these herpesvirus-positive cases, Actinomyces sp. and Moraxella ovis were also identified. Trueperella pyogenes was identified in 4 cases of unilateral ulcerative keratitis, keratoconjunctivitis, and panophthalmitis. M. ovis was cultured from 3 cases of bilateral conjunctivitis and keratoconjunctivitis. In the remaining cases, isolates included Moraxella bovis (1 case), Staphylococcus sp. and Streptococcus sp. (2), Flavobacterium sp. and Pseudomonas sp. (2), Escherichia coli and Enterobacter sp. (1), and bovine viral diarrhea virus 1 (1). No pathogens were identified in 2 cases. The relative prevalence of keratoconjunctivitis in mule deer in Wyoming appears to be low, and this disease is most commonly associated with infection by a novel alphaherpesvirus, T. pyogenes, and M. ovis.

Correlation of cellular factors and differential scrapie prion permissiveness in ovine microglia.

Prion diseases are fatal neurodegenerative disorders by which the native cellular prion protein (PrPC) is misfolded into an accumulating, disease-associated isoform (PrPD). To improve the understanding of prion pathogenesis and develop effective treatments, it is essential to elucidate factors contributing to cellular permissiveness. We previously isolated five clones from an immortalized subline of ovine microglia, two of which had demonstrated differential permissiveness to a natural isolate of sheep scrapie and distinct transcriptomic profiles. To more robustly identify factors contributing to this activity, relative permissiveness, cell proliferation, selected gene transcript level, and matrix metalloproteinase 2 (MMP2) activity were compared amongst all five clones. Differences in cell proliferation were not detected between clones; however, significant correlations were identified between relative permissiveness and genes associated with cell growth (i.e., RARRES1 and PTN), protein degradation (i.e., CTSB and SQSTM1), and heparin binding (i.e., SEPP1). MMP2 activity varied amongst clones, but did not correlate with permissiveness. These associations support the contribution of cell division and protein degradation on the permissiveness of cultured ovine microglia to PrPD.

Immortalized sheep microglial cells are permissive to a diverse range of ruminant viruses.

BACKGROUND: Ruminants, including sheep and goats (small ruminants), are key agricultural animals in many parts of the world. Infectious diseases, including many viral diseases, are significant problems to efficient production of ruminants. Unfortunately, reagents tailored to viruses of ruminants, and especially small ruminants, are lacking compared to other animals more typically used for biomedical research. OBJECTIVE: The purpose of this study was to determine the permissibility of a stably immortalized, sheep microglial cell line to viruses that are reported to infect ruminants: bovine viral diarrhea virus (BVDV), bovine herpesvirus 1 (BoHV-1), small ruminant lentiviruses (SRLV), and bovine respiratory syncytial virus (BRSV). METHODS: Sublines A and H of previously isolated, immortalized, and characterized (CD14-positive) ovine microglial cells were used. Bovine turbinate cells and goat synovial membrane cells were used for comparison. Cytopathic changes were used to confirm infection of individual wells, which were then counted and used to calculate the 50% tissue culture infectious dose. Uninoculated cells served as negative controls and confirmed that the cells were not previously infected with these viruses using polymerase chain reaction (PCR). RESULTS: Inoculation of the two microglial cell sublines with laboratory and field isolates of BVDV, BoHV-1, and BRSV resulted in viral infection in a manner similar to bovine turbinate cells. Immortalized microglia cells are also permissive to SRLV, similar to goat synovial membrane cells. CONCLUSION AND CLINICAL RELEVANCE: These immortalized sheep microglial cells provide a new tool for the study of ruminant viruses in ruminant microglial cell line.

Transcriptomic Determinants of Scrapie Prion Propagation in Cultured Ovine Microglia.

Susceptibility to infection by prions is highly dependent on the amino acid sequence and host expression of the cellular prion protein (PrPC); however, cellular expression of a genetically susceptible PrPC is insufficient. As an example, it has been shown in cultured cells that permissive and resistant sublines derived from the same parental population often have similar expression levels of PrPC. Thus, additional cellular factors must influence susceptibility to prion infection. The aim of this study was to elucidate the factors associated with relative permissiveness and resistance to scrapie prions in cultured cells derived from a naturally affected species. Two closely related ovine microglia clones with different prion susceptibility, but no detectable differences in PrPC expression levels, were inoculated with either scrapie-positive or scrapie-negative sheep brainstem homogenates. Five passages post-inoculation, the transcriptional profiles of mock and infected clones were sequenced using Illumina technology. Comparative transcriptional analyses identified twenty-two differentially transcribed genes, most of which were upregulated in poorly permissive microglia. This included genes encoding for selenoprotein P, endolysosomal proteases, and proteins involved in extracellular matrix remodeling. Furthermore, in highly permissive microglia, transforming growth factor ß-induced, retinoic acid receptor response 1, and phosphoserine aminotranspherase 1 gene transcripts were upregulated. Gene Set Enrichment Analysis identified proteolysis, translation, and mitosis as the most affected pathways and supported the upregulation trend of several genes encoding for intracellular proteases and ribosomal proteins in poorly permissive microglia. This study identifies new genes potentially involved in scrapie prion propagation, corroborates results from other studies, and extends those results into another cell culture model.

Comparison of Outside Versus Inside Brachial Plexus Sheath Injection for Ultrasound-Guided Interscalene Nerve Blocks.

OBJECTIVES: Ultrasound-guided interscalene brachial plexus blocks are commonly used to provide anesthesia for the shoulder and proximal upper extremity. Some reviews identify a sheath that envelops the brachial plexus as a potential tissue plane target, and current editorials in the literature highlight the need to establish precise and reproducible injection targets under ultrasound guidance. We hypothesize that an injection of a local anesthetic inside the brachial plexus sheath during ultrasound-guided interscalene nerve blocks will result in enhanced procedure success and provide a consistent tissue plane target for this approach with a reproducible and characteristic local anesthetic spread pattern. METHODS: Sixty patients scheduled for shoulder surgery with a preoperative interscalene block for postoperative pain management were enrolled in this prospective randomized observer-blinded study. Each patient was randomly assigned to receive a single-shot interscalene block either inside or outside the brachial plexus sheath. RESULTS: The rate of complete motor and sensory blocks of the axillary nerve territory 10 minutes after local anesthetic injection for the inside group was 70% versus 37% for the outside group (P < .05). At all measurement intervals beyond 10 minutes, however, neither group showed a statistically significant difference in complete sensory blockade. The incidence rates of transient paresthesia during needle passage were 6.7% for the outside group and 96.7% for the inside group (P < .05). CONCLUSIONS: Except for faster onset, this prospective randomized trial did not find any advantages to performing an interscalene block inside the brachial plexus sheath. There was a higher incidence of transient paresthesia when injections were performed inside compared to outside the sheath.

hTERT-immortalized ovine microglia propagate natural scrapie isolates.

Ex vivo propagation of natural prion isolates (i.e., propagated solely in the natural host) is crucial for the characterization and study of transmissible spongiform encephalopathies (TSEs). Several well-established, prion-permissive cell culture systems are available; however, only a few cell lines are permissive to natural prion isolates and these cells are not pathophysiologically relevant (e.g., renal epithelium and fibroblast-like cells). Therefore, a pathophysiologically relevant cell line derived from a natural TSE host could be used for propagation of natural prion isolates. In this study, ovine brain macrophages (microglia) were immortalized by transfection with the human telomerase reverse transcriptase (hTERT) gene to identify cell lines (hTERT-microglia) permissive to natural scrapie prion isolates. Following transfection, hTERT-microglia were passaged up to 100 times and their lifespan was significantly longer compared to parental cells (Fisher's exact test, P<0.001). Multiple sublines were permissive to cell culture-adapted prions; two sublines were also permissive to natural scrapie isolates (i.e., derived from brain homogenates of sheep infected with scrapie). Prion infectivity and partial protease resistance of the prion protein were maintained in hTERT-microglia. Comparisons between scrapie-permissive and non-permissive hTERT-microglia sublines revealed that overall quantity of the normal cellular prion protein was not associated with prion permissiveness. The use of hTERT-microglia in future TSE studies may be more germane to the characterization of the cellular and subcellular pathophysiology of natural scrapie prion isolates and to investigate host-specific factors involved in prion replication.

Accuracy and consistency of modern elastomeric pumps.

Continuous peripheral nerve blockade has become a popular method of achieving postoperative analgesia for many surgical procedures. The safety and reliability of infusion pumps are dependent on their flow rate accuracy and consistency. Knowledge of pump rate profiles can help physicians determine which infusion pump is best suited for their clinical applications and specific patient population. Several studies have investigated the accuracy of portable infusion pumps. Using methodology similar to that used by Ilfeld et al, we investigated the accuracy and consistency of several current elastomeric pumps.

Anti-inflammatory activity of a honey flavonoid extract on lipopolysaccharide-activated N13 microglial cells.

Neuroinflammation is an important contributor to pathogenesis of age-related neurodegenerative disorders such as Alzheimer's or Parkinson's disease. Accumulating evidence indicates that inhibition of microglia-mediated neuroinflammation may become a reliable protective strategy for neurodegenerative processes. Flavonoids, widely distributed in the vegetable kingdom and in foods such as honey, have been suggested as novel therapeutic agents for the reduction of the deleterious effects of neuroinflammation. The present study investigated the potential protective effect of a honey flavonoid extract (HFE) on the production of pro-inflammatory mediators by lipopolysaccharide-stimulated N13 microglia. The results show that HFE significantly inhibited the release of pro-inflammatory cytokines such as TNF-α and IL-1ß. The expressions of iNOS and the production of reactive oxygen intermediates (ROS) were also significantly inhibited. Accordingly, the present study demonstrates that HFE is a potent inhibitor of microglial activation and thus a potential preventive-therapeutic agent for neurodegenerative diseases involving neuroinflammation.

Septic tularemia in 2 cottontop tamarins(Sanguinus oedipus).

Two captive cottontop tamarins (Sanguinus oedipus) died within 5 d of each other from systemic infection by Francisella tularensis (tularemia). One tamarin experienced mild clinical signs, including malaise, anorexia, and a mucoid nasal discharge for 4 d before death, whereas the other experienced a more rapid progression of disease that lasted less than 24 h. Differential diagnoses included gram-negative septicemia by an organism such as Escherichia coli, Salmonella, or Yersinia; protozoal infection such as Toxoplasma gondii or an acute viral infection such as lymphocytic choriomeningitis. F. tularensis infection was identified by F. tularensis-specific PCR in both primates. Possible sources of infection include aerosol, biting arthropod vectors, and transmission via a rodent reservoir. This case report highlights the importance of tularemia as a differential diagnosis in acute febrile illness in captive nonhuman primates.

The effect of pre-incisional infiltration of tonsils with bupivacaine on the pain following tonsillectomy under general anesthesia.

The aim of the present study was to test the hypothesis that blockade of nociceptive input with bupivacaine during tonsillectomy can decrease pain beyond the immediate postoperative period. Fourteen patients between the ages of 6 and 18 years scheduled for tonsillectomy (with or without adenoidectomy) were randomly divided into two groups. The patients of both groups received 0.006 mg/kg atropine and anesthesia was induced by inhalation of halothane. Atracurium 0.5 mg/kg was used for myorelaxation. After oral intubation anesthesia was maintained with isoflurane plus nitrous oxide 67% in oxygen. In the bupivacaine group, 5 min before incision the tonsillar fossae were infiltrated with 0.25% bupivacaine with epinephrine (1 : 200,000). In the control group, the tonsillar fossae were infiltrated with normal saline with epinephrine (1 : 200,000). All patients received morphine 0.07 mg/kg (in the recovery room) and oral elixir with codeine 0.05 mg/kg plus acetaminophen 5 mg/kg every 4 h. Pain assessments were made using the visual analog (100 mm scale) self-rating method. Two types of pain were assessed: constant incisional pain and pain caused by drinking 100 ml of water. In the bupivacaine group, the constant pain score on the second day after surgery was 19 +/- 6 compared to 74 +/- 8 in the saline group (P less than 0.0002). By the 4-5th day after surgery almost no constant pain occurred in the bupivacaine group, but the pain score remained at the 40-60 level in the saline group. The difference in pain intensity on swallowing between the bupivacaine and saline groups was present even on the 10th postoperative day (1 +/- 1 vs. 14 +/- 5, P less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)