The effect of intra-operative passive movement therapy on non-surgical site pain after breast reconstructive surgery: a preliminary study.

Pain distant to an operative site is under-reported but sometimes more severe than pain from the surgical site. Intra-operative passive movement could possibly reduce this pain. This preliminary study was designed to assess the practicalities of conducting a randomised controlled trial of this therapy in anaesthetised patients. The study design was pragmatic. Forty-two patients undergoing breast reconstruction were randomly assigned to receive either intra-operative passive movement or standard care. Twenty-four hours after surgery, median (IQR [range]) morphine consumption was 33 (11-42 [0-176]) mg in the passive movement group compared with 74 (15-118 [0-238]) mg with standard care (p = 0.126), while participants reported median (IQR [range]) visual analogue scores in areas distant from the surgical site of 0 (0-4 [0-34]) mm in the passive movement group compared with 10 (2-30 [0-57]) mm in those receiving standard care (p = 0.002). A full trial of intra-operative passive movement therapy to reduce postoperative is feasible and warranted.

Oral vs intravenous paracetamol for lower third molar extractions under general anaesthesia: is oral administration inferior?

BACKGROUND: Paracetamol formulations provide effective analgesia after surgery [Duggan ST, Scott LJ. Intravenous paracetamol (acetominophen). Drugs 2009; 69: 101-13; Toms L, McQuay HJ, Derry S, Moore RA. Single dose oral paracetamol (acetaminophen) for postoperative pain in adults. Cochrane Database Syst Rev 2008: CD004602]. I.V. paracetamol is superior to oral for pain rescue (Jarde O, Boccard E. Parenteral versus oral route increases paracetamol efficacy. Clin Drug Invest 1997; 14: 474-81). By randomized, double-blinded trial, we aimed to determine whether preoperative oral paracetamol provides inferior postoperative analgesia to preoperative i.v. paracetamol. METHODS: One hundred and thirty participants received either oral paracetamol and i.v. placebo (Group OP), or oral placebo and i.v. paracetamol (Perfalgan™) (Group IP). Oral preparations were given at least 45 min before surgery; i.v. preparations after induction of anaesthesia. Pain was assessed by a 100 mm visual analogue scale (VAS) 1 h from the end of surgery. Rescue analgesia was given on request. RESULTS: A total of 128 patients completed the study. There were no significant differences in baseline characteristics or intraoperative variables between the groups. The study was designed to reveal whether OP is inferior to IP, with an inferiority margin of 20%. The number of patients reporting satisfactory analgesia at 1 h with VAS ≤ 30 mm were 15 (OP) and 17 (IP), respectively. The secondary outcome measure of the mean (standard deviation) VAS (mm) for the whole of each group was 52 (22) for OP and 47 (22) for IP. Analysis of confidence intervals indicates that oral paracetamol is not inferior to i.v. paracetamol. The median survival (90% CI) to rescue analgesia request was 54.3 (51.2-57.4) min in Group OP and 57.3 (55.4-59.2) min in Group IP; there was no significant difference in this measure. CONCLUSIONS: In this study of lower third molar extraction, oral paracetamol is not inferior to i.v. for postoperative analgesia. ISRCTN Registration http://www.controlled-trials.com/ISRCTN77607163.

Assessment of the bone status of Nigerian women by ultrasound and biochemical markers.

Ultrasound analysis of the calcaneus and serum markers of bone turnover were used to examine the bone status of healthy Nigerian women who reside in an area of the world where dietary calcium intake is generally low and estrogen replacement therapy is not widely available. A total of 218 women (108 premenopausal and 110 postmenopausal) between the ages of 16 and 95 years were enrolled in the study. Broadband ultrasound attenuation (BUA) and speed of sound velocity (SOS) were measured and used to calculate the stiffness index (SI) of the calcaneus. In this cross-sectional study, the Nigerian women exhibited a marked age-dependent decline in SI that was defined by the regression equation SI = 105.9 - 6.62E-3 x Age2. SI was significantly correlated with age (r = -0.41, P < 0.001) and with serum NTx concentrations (r = -0.26, P < 0.001), but not with serum levels of bone-specific alkaline phosphatase (BSAP). Years since menopause was also significantly correlated with SI (r = 0.40, P < 0.001). A significant increase in serum NTx concentration occurred at least a decade before a significant decline in SI was evident. In the total study group, 24% of the women had T-scores indicative of osteopenia and 9% had T-scores indicative of osteoporosis, based on US reference data. Although the reported current incidence of fracture is low in women in sub-Saharan West Africa, these data show that after menopause Nigerian women have a decline in bone quality and increase in bone turnover similar to North American Caucasian women.

The effects of carbon dioxide pneumoperitoneum on seeding of tumor in port sites in a rat model.

OBJECTIVES: The use of laparoscopic surgical techniques for the resection of intraperitoneal malignancies has been rapidly increasing in recent years; concomitantly, tumor recurrences at trocar sites have also been reported. These reports bring into question the appropriateness of pneumoperitoneum and laparoscopic techniques for carcinoma removal. We hypothesized that the carbon dioxide pneumoperitoneum and instrumentation used during laparoscopic procedures contribute to a greater incidence of tumor implantation into the ventral peritoneal wall wound sites than seen with laparotomy. This study, which used port placement and carbon dioxide pneumoperitoneum in an animal model, was designed to determine the relative incidences of tumor implantation into wound sites of the ventral peritoneal wall for laparoscopy and laparotomy. STUDY DESIGN: Viable MAT B III rat mammary adenocarcinoma cells were injected into the lower right quadrant of the peritoneal cavity of Fisher 344 rats (1 x 10(5) cells/rat). The animals were then divided into 4 groups: 1 group (n = 9) served as a control group and received no further manipulations; another (n = 8) underwent a midline laparotomy; another (n = 8) had four 18-gauge trocars inserted into the peritoneal cavity; and the last (n = 8) underwent induction of a 7- to 8-mm Hg carbon dioxide pneumoperitoneum in addition to the insertion of four 18-gauge trocars. All animals were maintained under surgical conditions for 2 hours. Animals were killed at 7 days, and the ventral peritoneal wall was examined for macroscopic evidence of tumor formation. RESULTS: A total of 32 possible sites of tumor implantation were measured. The control group showed no significant macroscopic evidence of tumor translocation to the ventral peritoneal wall. Among the 32 measured sites the laparotomy group had an overall lower incidence of tumor implantation at the peritoneal wall wound sites (n = 5) than did the group with the trocars alone (n = 20) group (P =.003) and the group with trocars plus carbon dioxide insufflation (n = 29, P <.0001). The group with trocars alone had a lower incidence of tumor implantation than did the group with trocars plus carbon dioxide pneumoperitoneum (P =.02). CONCLUSIONS: Trocar use during laparoscopic surgical procedures led to greater translocation of free tumor cells to peritoneal wall wound sites than did laparotomy in this animal model. The addition of carbon dioxide pneumoperitoneum further increased implantation of tumor cells at trocar sites. These results provide evidence that the use of laparoscopic techniques for resection of intraperitoneal malignancy needs further long-term study.