Postoperative pain relief after total hip arthroplasty: a randomized, double-blind comparison between intrathecal morphine and local infiltration analgesia.

BACKGROUND: Postoperative pain after total hip arthroplasty (THA) can delay mobilization. This was assessed after intrathecal morphine (ITM) compared with local infiltration analgesia (LIA) using a non-inferiority design. METHODS: Eighty patients were recruited in this randomized, double-blind study. ITM 0.1 mg (Group ITM) or periarticular local anaesthetic (ropivacaine 300 mg)+ketorolac 30 mg+ epinephrine 0.5 mg (total volume 151.5 ml) (Group LIA) were compared. After 24 h, 22 ml of saline (Group ITM) or ropivacaine (150 mg)+ketorolac (30 mg)+epinephrine (0.1 mg) (Group LIA) were injected via a catheter. After operation, rescue analgesic consumption, pain intensity, and home-readiness were measured. RESULTS: Morphine consumption was equivalent, median difference 0 mg (95% confidence interval -4 to 4.5) between the groups at 0-24 h. During 24-48 h, it was lower in Group LIA (3 mg, 0-60 mg, median, range) compared with Group ITM (10 mg, 0-81 mg) (P=0.01). Lower pain scores were recorded at rest at 8 h in Group ITM (P<0.01), but in Group LIA on standing and mobilization, at 24-48 h (P<0.01). Paracetamol and tramadol consumption was lower in Group LIA (P=0.05 and 0.05, respectively) as was pruritus, nausea, and vomiting (P<0.05). CONCLUSION: Lower pain intensity was recorded early after surgery in ITM group but later, analgesic consumption, pain intensity on mobilization, and side-effects were lower in patients receiving LIA. LIA is a good alternative to ITM in patients undergoing THA.

Improved analgesia with clonidine when added to local anesthetic during combined spinal-epidural anesthesia for hip arthroplasty: a double-blind, randomized and placebo-controlled study.

BACKGROUND: The perioperative effects of intrathecal and epidural clonidine combined with local anesthetic were evaluated in 60 patients undergoing hip arthroplasty. METHODS: This was a double-blinded study and the patients were randomized into three groups, with 20 patients in each group. All patients received spinal anesthesia with 17.5 mg of plain bupivacaine with 15 microg of clonidine (Group BC-RC) or without clonidine (Groups B-R and B-RC). Postoperatively, epidural infusion was administered in the following way: Group B-R-ropivacaine 4 mg h(-1); Groups B-RC and BC-RC: ropivacaine 4 mg h(-1) and clonidine 40 microg h(-1). Sensory block was assessed with light touch, pinprick, transcutaneous electrical stimulation at T12 and L2 dermatomes, and perception of thermal stimuli. RESULTS: The maximal upper level of sensory block measured by pin-prick (T6-T7) did not differ between the groups while the partial sensory block for cold and warmth were increased two dermatomes above pin-prick level in the group with intrathecal clonidine compared to the other two groups (P < 0.05). Duration of anesthesia, analgesia and motor block were longer in Group BC-RC compared to Groups B-R and B-RC (P < 0.02). Postoperatively, both VAS score on movement and PCA-morphine consumption were higher in Group B-R than in Groups B-RC and BC-RC (P < 0.01). The arterial pressure and heart rate in Groups B-RC and BC-RC were significantly lower than in Group B-R at 10-24 and 15-24 h, respectively, after spinal injection. CONCLUSION: Low-dose intrathecal clonidine provided a better quality of anesthesia and longer-lasting analgesia. Epidural clonidine-ropivacaine infusion resulted in improved postoperative analgesia but was associated with a moderate decrease in blood pressure.

Lack of evidence for association between endothelial nitric oxide synthase gene polymorphisms and coronary artery disease in the Australian Caucasian population.

BACKGROUND: Genetic polymorphism in the gene for endothelial nitric oxide synthase (eNOS) has been identified as a potential risk factor for the development of premature coronary artery disease (CAD). We determined whether the eNOS 4ab, G894T, and T-786C polymorphisms are associated with premature coronary artery disease. DESIGN: A case-control study. METHODS: PCR-based assays were used to compare the frequency of eNOS gene polymorphisms in 573 Caucasian subjects aged under 50 years presenting with symptomatic CAD and documented by coronary angiography, with or without myocardial infarction, to that of 624 similarly aged community controls without a history of symptomatic CAD. RESULTS: We found no difference in the frequency of 4ab genotypes between cases and controls: in the CAD subjects, the 4aa, 4ab, and 4bb genotype frequencies were 1.9%, 24.3% and 73.8% respectively, compared to 2.2%, 25.5% and 72.3% respectively for the controls. There was also no significant difference between cases and controls in the frequency of any allele (4a/4b, 894G/894T, -786C/-786T), or genotype for any of the polymorphisms. Similarly, logistic regression analysis showed no evidence for an association of the polymorphisms with premature CAD or myocardial infarction or any indication of an interaction between the polymorphisms and other CAD risk factors, including smoking. CONCLUSIONS: In a large case-control study, and in contrast to some earlier positive findings by others, we have found no evidence for an association between several eNOS gene polymorphisms and premature CAD in an Australian Caucasian population.

Teaching colposcopy and androscopy in family practice residencies.

Addressing the widespread human papillomavirus and genital epithelial dysplasia epidemic requires mastery of colposcopy, androscopy, and cryotherapy. Implementing a family medicine residency training program for these skills requires identifying a faculty facilitator to consider the issues of time, cost, caseload, reimbursement, specialist support, personal training, and office impact related to this training. Experience with teaching these skills in a community-based family practice residency indicates that startup costs range from $10,000 to $20,000. Residents will initially require from 30 to 60 minutes to provide a complete examination. All procedures require precepting by trained faculty and adherence to established protocol. The most frequent indications for these procedures include evaluating the abnormal Papanicolaou smear, visible cervical abnormalities, or evidence of clinical papillomavirus infection in either sex. Experience suggests that over 90% of cervical dysplasia can be managed entirely in the residency outpatient setting. These procedures have become the most common outpatient procedures performed, surpassing all others combined. Referrals to the residency for these procedures are readily available. Strategies for developing curriculum, literature review, learning materials, and training workshops are presented. Colposcopy, androscopy, and cryotherapy are appropriate additions to the training curriculum of family practice residencies.

A comparative investigation of reactivity to tuberculin using a multiple-puncture technique (the Monotest) and the Mantoux test.

A percutaneous, multiple-puncture method for the testing of tuberculin reactivity called Monotest (Mérieux) was compared with the conventional, intracutaneous, Mantoux test in 182 schoolchildren (14 years of age) and 338 adults. Correspondence of reactivity was observed in 84 and 85% respectively. These results indicate that the Monotest could be used to select schoolchildren for BCG-vaccination in Sweden.

A comparative study of Danish (Statens Seruminstitut), Glaxo and Behringwerke vaccines--revaccination of schoolchildren.

Three BCG vaccines were studied for their capacity to evoke tuberculin reactivity and local reactions at revaccination. The vaccines were produced by Statens Seruminstitut in Denmark (vaccine based on the Danish strain 1331), by the Glaxo Laboratories in England (vaccine based on the British strain 1077) and by the Behringwerke in the Federal Republic of Germany (vaccine based on the Danish strain 1331). The study comprised three independent trials (in Gothenburg, Umeå-Skellefteå and Stockholm) in children aged 14-15 years who had been vaccinated with BCG at birth. A total of 2997 children were vaccinated. In the Gothenburg areas tuberculin tests (2 TU PPD RT23) were performed 6-7 weeks after vaccination. Of the children vaccinated with the Danish vaccine 98% developed a tuberculin induration of greater than 6 mm. The mean size of induration was 11.4 mm. The corresponding figures for the Glaxo vaccine were 98% and 13.4 mm, and for the Behringwerke vaccine 76% and 8.0 mm. Open lesions 6-7 weeks after vaccination were reported in 4% of the children vaccinated with Danish vaccine (mean diameter of lesion 4.0 mm) and in 8% vaccinated with the Glaxo vaccine (mean diameter of lesion 4.6 mm) while none vaccinated with the Behringwerke vaccine showed open lesions. On the basis of the results obtained in our investigation as well as in other studies reported in the BCG literature, the authors concluded that the Danish and the Glaxo vaccines at present appear suitable vaccines for use in Sweden.