Randomized controlled trial of intra-articular ketorolac on pain and inflammation after minor arthroscopic knee surgery.

BACKGROUND: Ketorolac is an effective non-steroidal anti-inflammatory drug, commonly used with local anaesthetics as part of local infiltration analgesia protocols following orthopaedic surgery. However, systemic uptake and drug action may be the major mechanism after local infiltration. The aims of this project were to study the effects of a small, systemically ineffective dose of ketorolac given intra-articularly for post-operative pain and also to study synovial inflammatory biomarkers. We investigated whether ketorolac affects pro-inflammatory biomarkers in an in vitro model, as well. METHODS: In this placebo-controlled, blind, randomized study, we analysed intra-articular ketorolac (5 mg) in ambulatory minor knee surgery patients with moderate or severe pain (n = 44). We assessed post-operative pain intensity (n = 44) and analysed microdialysis samples taken from knee synovial tissue every 20 min (n = 34). We also tested cyclooxygenase-independent effects of ketorolac in synovial cells stimulated by prostaglandin E2 and chondroitin sulphate in vitro. RESULTS: Intra-articular ketorolac (5 mg) administration did not reduce pain or synovial pro-inflammatory cytokines CXCL1, IL-8, and MCP-1, 0-120 min after knee arthroscopy. Female gender was a risk factor for moderate or severe pain (relative risk 1.45, 95% confidence interval 1.04-2.01). Paradoxically, ketorolac increased the release of CXCL1 and IL-8 in prostaglandin E2 and chondroitin sulphate-stimulated synovial cells in vitro. CONCLUSION: Ketorolac prescribed at a low dose intra-articularly does not produce any detectable analgesic effect after minor knee surgery.

Pain and disability 1 year after knee arthroscopic procedures.

BACKGROUND: Persistent chronic pain after surgery is a major health care problem. Its prevalence after knee arthroscopy is unknown. We conducted a follow-up of knee arthroscopy patients. The aims were to estimate the prevalence of pain at rest and during activity 1 year after knee arthroscopy. METHODS: One hundred patients with moderate or severe acute pain after knee arthroscopy were included in one of two randomized-controlled pain trials. A questionnaire was mailed to all the patients 1 year after inclusion. RESULTS: The prevalence of pain at rest 1 year after surgery [numeric rating scale (NRS) 0-10 grade >/=1] was 30% (95% CI 17-47) in women and 29% (95% CI 17-46) in men. Four of 33 female (10%) and three of 34 male patients (9%) experienced pain intensities at rest of NRS>4, and the number of patients who had experienced NRS>4 during activities were 7 (21%) and 4 (11%), respectively. Age above 50 years was positively correlated to persistent pain. The number of patients who reported a reduced activity of daily living (ADL) due to pain (NRS>4) was 14 of 33 (42%, 95% CI 28-56%) in female and five of 34 (15%, 95% CI 5-25%) in male patients (P=0.03). Age above 50 years was positively correlated to impaired ADL function due to knee pain. CONCLUSIONS: Persistent pain after knee arthroscopy may be a significant health care problem. Age and female gender are independent risk factors for pain and disability 1 year after surgery.

Spread of methicillin-resistant Staphylococcus aureus in a neonatal intensive unit associated with understaffing, overcrowding and mixing of patients.

Over the period May-June 1999, an outbreak of methicillin-resistant Staphylococcus aureus (MRSA) was registered in eight newborns in a neonatal intensive care unit (NICU) at the Department of Pediatrics, Ullevål University Hospital (UUH) in Oslo. Seven were infected or colonized with an indistinguishable strain, detected at the NICU, and one patient with a slightly different PFGE type (i.e. a subtype) was registered at the outpatient clinic. The MRSA strains resembled the sensitive, inbred 'Norwegian type' described four years earlier at UUH, showing a relatively low and heterogenic methicillin resistance (MIC 12-96 mg/L), and susceptibility to most other anti-staphylococcal agents. Before and during the outbreak, there was high activity, understaffing, overcrowding and a mix of patients; 42% of the staff were relatively untrained, and up to 62% (during weekends) were extra nursing staff, partly from other Scandinavian countries. All cases were isolated (air and contact isolation), and all other patients and personnel were treated as being exposed to MRSA (isolated from other departments) until the last patient had been identified, disinfection of all rooms was complete, and all screening samples from staff and other patients were negative. The NICU and the delivery suite were closed for one week for disinfection and screening. The outbreak ended after 34 days. Since then, two years later, no further cases have been detected in the NICU or the delivery suite.

A three-year survey of nosocomial and community-acquired infections, antibiotic treatment and re-hospitalization in a Norwegian health region.

In Norway, hospital-acquired infections (HAI) were analysed by repeated point prevalence studies (four each year) performed simultaneously at 14 hospitals in a health region (860,000 inhabitants) during the period 1996-1998. The study included 3200 beds and 121,000 discharged patients each year, and was initiated by and co-ordinated from the regional university hospital; Ullevål University Hospital (UHH). An overall prevalence rate of HAI of 6.5% (interhospital variation 1.4-11.7%) was found for the 32,248 patients studied. The rate of HAI was reduced from 7.7% in 1996 to 5. 9% in 1998. Smaller hospitals (<200 beds) generally had lower rates of HAI, community acquired infections (CAI), postoperative infections and use of antibacterial agents, than the large regional hospital (1200 beds). HAI was reduced in non-operated patients from 5.8% in 1996 to 4.4% in 1998 and in operated patients from 13.2% in 1996 to 10.5% in 1998. The risk of developing HAI was twice as high after surgery. From 1996 to 1998 there was a reduction in: urinary tract infections from 2.4% to 1.7%, lower respiratory tract infections from 1.5% to 0.8% and postoperative wound infections from 5.7% to 4.3%, while septicaemia (from 0.5% to 0.4%) remained unchanged. Re-hospitalization because of HAI was registered in 0.6% (interhospital variation 0.3-1.1%) of patients. The CAI rate in hospitals increased from 8.3% in 1996 to 10.8% in 1998. Approximately 16% (variation:14.4-20.6%) of the patients had an infection. The total use of antibacterial agents was 19.2% in 1996, 16.6% in 1997 and 17.8% in 1998 (variation: 14.9-23%).

[Floor cleaning methods of patients' room. Effect on bacteria, dirt and particles]. / Gulvrengjøring av pasientrom. Effekt på bakterier, smuss og partikler.

The effect of floor cleaning on bacteria, organic materials and particles in the patients' rooms was studied at Ullevål University Hospital, Oslo, Norway. Four cleaning methods were compared; dust-adhesive (dry), humified, wet mopping, and regular wet washing (RWW) without a mop. The following tests were taken from the floor before and after cleaning: bacterial counts (colony forming units = CFU) and ATP (presence of organic materials), and from the air: CFU/m3 air, and particle counts/m3 air. Humified mopping and dry mopping reduced the bacterial counts from the floor by 75% and 55% respectively (p = 0.005 and p = 0.014, using contact medium). The wet mopping had no statistically significant effect, while the wet washing even increased the CFU on the floor by 35-50% (p = 0.017 with contact medium, and p = 0.028 with petrifilm). The two wet methods were the most effective, however, in removing organic materials from the floor; 65% to 70% reduction (p = 0.051 and p =0.008). The CFU/m3 air was low both before (50-130 CFU/m3) and after (70-110 CFU/m3) cleaning. A slight increase in airborne particles was measured after dry mopping. Combined use of humified mopping and wet mopping is recommended, but is dependent on a well prepared and finished floor surface.

[Air quality and microbiologic contamination in operating theatres]. / Luftkvalitet og mikrobiologisk kontaminering i operasjonsstuer.

The present study concerns the air quality and microbiological contamination in two newly built operating theatres; one with laminar air flow (LAF) equipment for cardio-thoracic operations, and one with conventional ventilation for urological operations. Both theatres had an identical number of air exchanges (17/h), identical microclimatic conditions and they employed the same cleaning procedures. In the LAF-ventilated operating theatre bacterial contamination of the air was effectively reduced to less than 10 colony-forming units (CFU)/m3 in all 125 samples (1 m3 per sample) tested. In most samples, 118/125, the bacterial count was less than 5 CFU/m3, despite the presence of ten persons. The conventionally ventilated theatre reached values up to 120 CFU/m3 during the most active period of the day when approximately seven persons were present. The LAF ventilation reduced both the content of particles in the air and contamination by bacteria on the floor. In both theatres cleaning procedures had only a low impact on CFU in the air and on the floor. The use of diathermia markedly increased the level of small particles in the air, and this may influence the air quality in the operating theatres.

[Methicillin resistant yellow staphylococci]. / Meticillinresistente gule stafylokokker.

The incidence of methicillin-resistant Staphylococcus aureus in Norway is extremely low. Isolation of such strains is nearly always associated with import. From December 1993 to January 1997 at the Ullevål University Hospital Department of Medical Microbiology, methicillin-resistant Staphylococcus aureus was isolated from 22 persons in Oslo (17 patients and five healthy carriers). A cluster of ten infected persons was detected (five patients and five carriers (nurses)) who were infected with strains showing an unusual antibiotic resistance pattern. All of the cluster strains except for beta-lactams were resistant to fucidic acid and sensitive to other antistaphylococcal agents. The cluster was associated with two hospitals. The five patients were all admitted to the same intensive care unit during the period May to July 1995. Four of the five patients (one died) were referred to the same department in a long-term care hospital for rehabilitation and training. Problems concerning epidemiological investigation and control are discussed.