Comparison of postoperative pain outcomes after vertical or Pfannenstiel incision for major gynecologic surgery

OBJECTIVE

The Pfannenstiel incision is commonly used for gynecologic surgery. It is not known if this incision is associated with less postoperative pain compared to a vertical midline incision. Therefore, as part of a study to evaluate the postoperative analgesic effects and dose response of intravenous adenosine in patients undergoing open abdominal gynecologic surgery, this manuscript compares postoperative pain and analgesic consumption in patients who had a midline vertical incision or a Pfannenstiel incision.

RESEARCH DESIGN AND METHODS

This is a secondary analysis of data from a primary study investigating the dose response of IV adenosine for postoperative analgesia. Women scheduled for elective major gynecologic surgery under general anesthesia were enrolled and randomly assigned to receive one of four doses of intraoperative adenosine infusion (25, 50, 100, or 200 microg/kg/min) or matching placebo (normal saline). The anesthetic technique was standardized and adjusted based on hemodynamic and depth of anesthesia (bispectral index) values. Postoperative analgesia was provided with a standardized morphine patient controlled analgesia protocol which included rescue ketorolac, as needed. Comparative outcome analysis of the midline and Pfannenstiel skin incisions with regards to analgesic consumption and pain scores was performed and presented in this manuscript.

RESULTS

A total of 165 patients were identified; 105 women had a Pfannenstiel incision and 60 had the lower midline abdominal incision. There were no differences between the midline and Pfannenstiel groups with respect to intraoperative fentanyl, postoperative pain scores [worst pain scores 0-24 h (mean +/- SD) 8.2 +/- 2.1 vs. 8.2 +/- 1.9), p = 0.352], cumulative opioid consumption [0-24 h morphine equivalents (mean +/- SD) 63 +/- 27 vs. 72 +/- 43 mg, p = 0.496], or need for rescue ketorolac. While the duration of surgery was longer in patients who had a vertical incision (p = 0.02), there was no difference between the groups in the duration of postanesthesia care unit (44 +/- 53 vs. 30 +/- 45 min, p = 0.093) or hospital stays (74 +/- 27 vs. 67 +/- 20 h, p = 0.254).

CONCLUSIONS

There was no significant difference in postoperative pain and opioid consumption in patients undergoing major abdominal gynecologic surgery performed with either a midline or Pfannenstiel incision. However, it is important to note that since this a secondary analysis of data from a primary study investigating the dose response of IV adenosine, the patients were not prospectively randomized into the two incision types.

Association of chromosome 2q36.1-36.3 and autosomal dominant transmission in ankylosing spondylitis: results of genetic studies across generations of Han Chinese families

Background:

Ankylosing spondylitis (AS) is a chronic, potentially crippling, spondyloarthropathy with strong genetic components affecting approximately 0.3% of the population. Its exact genetic mechanism and mode of transmission, however, remains obscure.

Methods and results:

The authors conducted a genome wide scan on 75 individuals across multiple generations of three Han Chinese families affected with AS. Segregation analysis and pedigree investigation suggested an autosomal dominant inheritance. Pairwise logarithm of odds (LOD) scores were calculated using LINKAGE package for the obtained genotypes. High resolution mapping was then performed based on markers with significant LOD scores. To minimise the number of crossovers in each family, haplotype were constructed and assigned. Two of the pedigrees shared one candidate region for AS on 2q36.1–2q36.3 spanning 6-cM (maximum heterogeneity LOD score of 12.41 at marker D2S2228), while the other showed strong linkage to the HLA-B region.

Conclusions:

This is the first report which proposes one of the new genetic models of autosomal dominant transmission in AS. The breakthrough in the identification of linkage to chromosome 2q36.1–2q36.3 and the HLA-B region highlights the future potential of more comprehensive genetic studies of determinants of disease risk.

The development, validation and application of a multi-detector CT (MDCT) scanner model for assessing organ doses to the pregnant patient and the fetus using Monte Carlo simulations

The latest multiple-detector technologies have further increased the popularity of x-ray CT as a diagnostic imaging modality. There is a continuing need to assess the potential radiation risk associated with such rapidly evolving multi-detector CT (MDCT) modalities and scanning protocols. This need can be met by the use of CT source models that are integrated with patient computational phantoms for organ dose calculations. Based on this purpose, this work developed and validated an MDCT scanner using the Monte Carlo method, and meanwhile the pregnant patient phantoms were integrated into the MDCT scanner model for assessment of the dose to the fetus as well as doses to the organs or tissues of the pregnant patient phantom. A Monte Carlo code, MCNPX, was used to simulate the x-ray source including the energy spectrum, filter and scan trajectory. Detailed CT scanner components were specified using an iterative trial-and-error procedure for a GE LightSpeed CT scanner. The scanner model was validated by comparing simulated results against measured CTDI values and dose profiles reported in the literature. The source movement along the helical trajectory was simulated using the pitch of 0.9375 and 1.375, respectively. The validated scanner model was then integrated with phantoms of a pregnant patient in three different gestational periods to calculate organ doses. It was found that the dose to the fetus of the 3 month pregnant patient phantom was 0.13 mGy/100 mAs and 0.57 mGy/100 mAs from the chest and kidney scan, respectively. For the chest scan of the 6 month patient phantom and the 9 month patient phantom, the fetal doses were 0.21 mGy/100 mAs and 0.26 mGy/100 mAs, respectively. The paper also discusses how these fetal dose values can be used to evaluate imaging procedures and to assess risk using recommendations of the report from AAPM Task Group 36. This work demonstrates the ability of modeling and validating an MDCT scanner by the Monte Carlo method, as well as assessing fetal and organ doses by combining the MDCT scanner model and the pregnant patient phantom.

The development of Assessment of SpondyloArthritis international Society classification criteria for axial spondyloarthritis (part II): validation and final selection

OBJECTIVE

To validate and refine two sets of candidate criteria for the classification/diagnosis of axial spondyloarthritis (SpA).

METHODS

All Assessment of SpondyloArthritis international Society (ASAS) members were invited to include consecutively new patients with chronic (> or =3 months) back pain of unknown origin that began before 45 years of age. The candidate criteria were first tested in the entire cohort of 649 patients from 25 centres, and then refined in a random selection of 40% of cases and thereafter validated in the remaining 60%.

RESULTS

Upon diagnostic work-up, axial SpA was diagnosed in 60.2% of the cohort. Of these, 70% did not fulfil modified New York criteria and, therefore, were classified as having "non-radiographic" axial SpA. Refinement of the candidate criteria resulted in new ASAS classification criteria that are defined as: the presence of sacroiliitis by radiography or by magnetic resonance imaging (MRI) plus at least one SpA feature ("imaging arm") or the presence of HLA-B27 plus at least two SpA features ("clinical arm"). The sensitivity and specificity of the entire set of the new criteria were 82.9% and 84.4%, and for the imaging arm alone 66.2% and 97.3%, respectively. The specificity of the new criteria was much better than that of the European Spondylarthropathy Study Group criteria modified for MRI (sensitivity 85.1%, specificity 65.1%) and slightly better than that of the modified Amor criteria (sensitivity 82.9, specificity 77.5%).

CONCLUSION

The new ASAS classification criteria for axial SpA can reliably classify patients for clinical studies and may help rheumatologists in clinical practice in diagnosing axial SpA in those with chronic back pain.

TRIAL REGISTRATION NUMBER

NCT00328068.

Comparison of carcinoembryonic antigen prognostic value in serum and tumour tissue of patients with colorectal cancer

OBJECTIVE

Carcinoembryonic antigen (CEA) in the serum and the tumour tissue of colorectal cancer (CRC) patients is the most commonly used tumour marker for the diagnosis and evaluation of prognosis or recurrence after treatment, but the role remains controversial. The objective of this study was to compare the prognostic value of CEA both in serum and tumour tissue in CRC.

METHOD

A total of 173 patients with CRC in stages I-III were retrospectively assessed with the endpoint of recurrence or metastasis after curative operation. CEA was assessed both in serum and tumour tissue.

RESULTS

37.0% (64/173) patients had a high level of CEA in serum (S-CEA) while 39.3% (68/173) had high CEA in tumour tissue (T-CEA). There were no significant differences in clinico-pathological features between the low and high S-CEA or T-CEA groups. The high S-CEA group had a worse prognosis than the low S-CEA group but the difference was not significant. The high T-CEA group had a significantly poorer prognosis than the low T-CEA group (P = 0.028) in the univariate analysis. The multivariate analysis demonstrated that the T-CEA was an independent prognosis factor in CRC. Because many factors would affect the concentration of S-CEA, there was no correlation between S-CEA and T-CEA directly.

CONCLUSION

Our study suggests that a high T-CEA concentration may be a useful and independent predictor for poor outcome after surgery in CRC patients. It may be stronger than a high preoperative serum CEA level.

MM-111: a novel bispecific antibody targeting ErbB3 with potent anti-tumor activity in ErbB2 over-expressing malignancies

Abstract #4166

ErbB3 has been identified as a preferred dimerization partner of ErbB2, critical for driving the proliferation of ErbB2 over-expressing breast tumors. We have designed a bispecific antibody, MM-111, which inhibits ligand-induced phosphorylation of ErbB3 with sub-nanomolar potency by exploiting the abundant expression of its dimerization partner, ErbB2, for specific targeting to cancer cells that express both receptors. We employed computational physicochemical modeling to guide the kinetic optimization of the monovalent binding affinities to the ErbB2 and ErbB3 receptors to increase the potency and specificity of MM-111 for tumor cells. We have demonstrated that MM-111 inhibits activation of the phosphatidylinositol 3-kinase pathway in vitro and in vivo, resulting in attenuation of tumor proliferation. Inhibition of growth by MM-111 has been observed in several murine xenograft models including BT474 and MDA-MB-361 breast tumors. While the antitumor activity of MM-111 is positively correlated with ErbB2 expression levels, MM-111's potent inhibition of ErbB3 phosphorylation and signaling downstream from this receptor differs markedly from currently available therapies targeting ErbB2 over-expressing breast tumors and thus provides a novel approach to treatment for these malignancies. In conclusion, our data demonstrate that the combination of computational biology with antibody engineering has resulted in the development of a promising, novel therapeutic, MM-111, that has potent antitumor activity in malignancies driven by the ErbB2/3 oncogenic unit.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 4166.

Distinctly different expression of cytokines and chemokines in the lungs of two H5N1 avian influenza patients

The pathogenesis of human H5N1 influenza remains poorly understood and controversial. 'Cytokine storm' has been hypothesized to be the main cause of the severity of this disease. However, the significance of this hypothesis has been called into question by a recent report, which demonstrates that inhibition of the cytokine response did not protect against lethal H5N1 influenza infection in mice. Here we showed discrepant findings in two adult H5N1 autopsies and a fetus obtained at autopsy which also raise doubt about this hypothesis. Antigens of 10 cytokines/chemokines which were found to be significantly elevated in previous H5N1-infected patients and in vitro experiments, and mRNA of eight of these, were absent from the lungs of a pregnant woman and her fetus. In contrast, antigens of seven cytokines/chemokines and mRNA of six of these were found to be increased in the lungs of a male autopsy. The cells expressing these cytokines and chemokines were identified as type II pneumocytes, bronchial epithelial cells, macrophages and vascular endothelial cells. Levels of cytokines and chemokines in the serum of the male case were also significantly higher than those of infectious (infection other than by H5N1) and non-infectious controls. In comparison with results from our previous study, it appeared that the male case had increased cytokine/chemokine expression but reduced viral load, while the pregnant female had diminished cytokine/chemokine expression but a significantly increased viral load in the lungs. These disparate findings in these two cases suggest that 'cytokine storm' alone could not be a sufficient explanation for the severe lung injury of this newly emerging disease.

Isolated intracranial Rosai-Dorfman disease mimicking suprasellar meningioma: case report with review of the literature

Rosai-Dorfman disease (RDD) is an idiopathic histiocytic proliferation affecting the lymph nodes. Isolated intracranial RDD is rare and usually appears as a well-defined, dural-based lesion without lymphadenopathy. The clinical and radiological features of intracranial RDD are similar to meningioma. Histopathology and immunohistochemistry are essential for a definitive diagnosis. This is a report of a 43-year old male with isolated intracranial RDD, which manifested as a suprasellar meningioma. The clinical, radiological and pathological aspects of the disease are discussed within the context of a review of previously reported cases.

Inhibition of the growth of human hepatoma cell line bothin vitro andin vivo by transducing CKI genep21 ( WAF-1 ) with GE7 targeting gene delivery system

The EGF receptor-mediated targeting gene delivery system GE7 was used to transduce exogenous genepCEP-p21 ( WAF-1 ) into human hepatocellular carcinoma cell bothin vitro andin vivo. Afterin vitro transduction of the exogenous gene, the growth of the cell lines SMMC-7721 and BEL-7402 was significantly inhibited compared with the control. On day 8 the inhibition rates of the above cell lines reached 56.0% and 66.7%, respectively. Thein vivo experiment showed that the growth of human hepatoma transplanted in nude mice injected with GE7 gene delivery system subcutaneously once a week for 3 weeks was remarkably inhibited compared with that of untransfected control. The average tumor weight of the experiment group was (0.083 +/-0.043) g, while that of the control group was (0.281 +/-0.173) g. The difference is significant (P<0.05). It was indicated that GE7 gene delivery system could efficiently transduce exogenous genepCEP-p21 ( WAF-1 ) into hepatoma cell with high EGF receptor expression, and inhibit the cell growth with high efficacy bothin vivo andin vitro.

The impact of clinical risk factors in the conversion from acute lung injury to acute respiratory distress syndrome in severe multiple trauma patients

Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) are different stages of the same disease, the aggravated stage of ALI leading to ARDS. Patients with ARDS have higher hospital mortality rates and reduced long-term pulmonary function and quality of life. It is, therefore, important to prevent ALI converting to ARDS. This study evaluated 17 risk factors potentially associated with the conversion from ALI to ARDS in severe multiple trauma. The results indicate that the impact of pulmonary contusion, APACHE II score, gastrointestinal haemorrhage and disseminated intravascular coagulation may help to predict conversion from ALI to ARDS in the early phase after multiple-trauma injury. Trauma duration, in particular, strongly impacted the short- and long-term development of ALI. Being elderly (aged > or = 65 years) and undergoing multiple blood transfusions in the early phase were independent risk factors correlated with secondary sepsis, deterioration of pulmonary function and transfusion-related acute lung injury due to early multiple fluid resuscitation.

Management of cicatricial entropion of the upper lid using acellular human dermal allograft

Cicatricial entropion with trichiasis can be a challenging problem to manage. This condition is caused by scarring of the tarsus and the inward rotation or the defect of the lid margin. A variety of biological materials have been used to reconstruct the disfigured lid margin. Tarsal wedge resection and modified grey line splitting with acellular human dermal allograft insertion by 10/0 nylon sutures passing through the eyelid margin allow for correction of the cicatricial entropion while providing a reconstructed lid margin. This technique produces satisfying cosmetic and functional results when used to treat mild to moderate cicatricial entropion with lid margin distortion.

Expression of methylation-related genes is associated with overall survival in patients with non-small cell lung cancer

The abnormality of DNA methylation is involved in tumour progression, and thus has a modulating effect on clinical outcome of cancer patients. In this study, we measured the mRNA expression levels of three methylation-regulating genes (DNMT1, DNMT3b, and MBD2) in 148 tumour samples from patients with non-small cell lung cancer (NSCLC) using quantitative real-time polymerase chain reaction and then determined their prognostic values. Our data showed that the high level of DNMT1 expression was significantly associated with an increased risk of death in all NSCLC patients (hazard ratio (HR), 1.74; 95% confidence interval (95% CI), 1.04-2.90). However, the high level of DNMT3b expression was significantly associated with poor prognosis only in young patients (<65 years). The high level of MBD2 expression had a significantly reduced risk for death only in male patients and in squamous cell lung carcinoma (SQLC) patients. All three combination groups with DNMT1 and DNMT3b, DNMT1 and MBD2 or DNMT3b and MBD2 revealed significant combined effects in male patients and SQLC patients. Our results suggest that DNMT1, DNMT3b, and MBD2 may play important roles in modulating NSCLC patient survival and thus be useful for identifying NSCLC patients who would benefit most from aggressive therapy.