Pain management after total knee arthroplasty: A prospective randomized study

INTRODUCTION

Total knee arthroplasty (TKA) is a common procedure for improving mobility and quality of life in patients with osteoarthritis. Postoperative pain control management after TKA is still a concern as it relates to patients satisfaction and functional recovery.Many anesthetic regimens and techniques have been explored to decrease postoperative pain and enhance the fast recovery after TKA. The aim of this study was to evaluate the best anesthetic treatment in pain control after TKA.

METHODS

51 patients were included in a randomized prospective study and distributed in three groups. The first group (CG) in which no analgesic protocol was implemented (control group). The second group (LIA group) received an intraoperative local infiltration anesthesia (LIA) (60 ml mixture of two ropivacaine 75mg/10 mL + adrenaline 100μg/10 mL + physiological solution). The third group (FNB group) had only a femoral nerve block (FNB). Continuous outcomes including visual analogue scale (VAS) at 5,24,48 h and at 1 week, morphine consumption and range of motion (ROM) at 1,2,7 days.

RESULTS

There was significant difference between all groups (p < 0,001) in terms of the VAS score: at 5h after surgery (4.55,2.15,1.82); at 24h (4.15,2.65,3.36); at 48h (3.85,2.45,2.73); at 1 week (2.95,1.80, 1.64), respectively for groups CG, LIA, FNB.ROM was better in LIA and FNB groups than CG: at 1 die after surgery (44°,50°,54°); at 3 dies (69°,70°,71°); at 7 dies (91°,98°,98°), respectively for groups CG, LIA, FNB (p < 0,001).

DISCUSSION

LIA and FNB groups both showed a significant reduction at VAS score, better range of motion and less morphine consumption than CG (control group). LIA group has obtained a constant pain control in the postoperative days; FNB group had a good pain control in the hours after surgery, with a decrease in efficacy in the following days.

CONCLUSION

Further studies are still needed in order to define LIA as the reference pain management in TKA.

Arthroscopy in osteochondral pathology of the elbow: indications, treatment and complications

The arthroscopic technique has revolutionized orthopaedic surgery in the last forty years, due to the improvement in surgical technique and innovations in technologies. Actually, knee and shoulder arthroscopy are commonly used to treat the most frequent pathologies with mini-invasive approaches demonstrate recovery of function and outcomes. Not the same thing can be said for other joints such as ankle, elbow and hip, where the narrowness of the space makes the technique more challenging. In this study, a brief review of the literature and the history of elbow arthroscopy are described. Indications, surgical technique, risks and complication, tip and tricks, advices and notes to avoid complications are reported. Elbow arthroscopic surgery is a difficult technique that requires a long learning curve, but in an experienced surgeon's hands, it is a safe and successful methodology when applied with correct indications and cautions.

Continuous intraarticular and periarticular levobupivacaine for management of pain relief after total knee arthroplasty: A prospective randomized, double-blind pilot study

BACKGROUND

Total knee arthroplasty (TKA) can result in major postoperative pain which can impact the recovery and rehabilitation of patients and for this reason the use of a pain-control infusion pumps (PCIP) enhances analgesia for TKA.

PURPOSE

To investigate whether a PCIP of levobupivacaine would reduce pain in patients following TKA.

METHODS

This was a prospective, randomized, controlled study conducted in 55 patients. Criteria for participation were unilateral TKA for osteoarthritis and no allergies to levobupivacaine. The primary outcomes measured were postoperative pain intensity on Visual Analogue Scale (VAS) score measured at 24 h and 48 h. Other measures included amount of narcotics, presence of adverse events, and length of hospital stay.

RESULTS

PCIP-treated patients (n = 28) showed significant reductions in VAS score at any time versus control (p < 0.01). Amount of narcotics, presence of adverse events, and length of hospital stay were significantly less with the PCIP versus control (each p < 0.01).

CONCLUSION

The use of a mix of levobupivacaina, ketoral-trometamina, and adrenalin provides a safe and effective means in post-operative pain relief in patients undergoing TKA.

LEVEL OF EVIDENCE

Level II therapeutic study.

First 100 early endometrial cancer cases treated with laparoendoscopic single-site surgery: a multicentric retrospective study

OBJECTIVE

We sought to assess feasibility and perioperative outcomes for laparoendoscopic single-site surgery (LESS) in early endometrial cancer.

STUDY DESIGN

This was a retrospective multicentric study of 100 early endometrial cancer cases undergoing LESS from July 2009 through July 2011.

RESULTS

All patients underwent total hysterectomy and bilateral salpingo-oophorectomy by LESS. Pelvic and paraaortic lymphadenectomy were performed in 48 and 27 patients, respectively. A median of 16 pelvic lymph nodes (range, 1-33) and 7 paraaortic lymph nodes (range, 2-28) were retrieved. Both median operative time (129 minutes; range, 45-321) and estimated blood loss (70 mL; range, 10-500) were greater when staging lymphadenectomy was performed (P values = .001). Four intraoperative and 4 postoperative complications were observed. Conversion to standard laparoscopy and laparotomy was necessary for completion of 1 case each. Patients responded positively regarding cosmetic result and minimal postoperative pain control.

CONCLUSION

LESS further minimizes the invasive nature of surgery and is feasible for treatment of early-stage endometrial cancer.

Phase II study of the combination carboplatin plus celecoxib in heavily pre-treated recurrent ovarian cancer patients

Background

Cyclooxygenase-2 overexpression is associated with poor outcome and resistance to platinum-based chemotherapy in ovarian cancer. We evaluated the antitumor activity and safety of the combination carboplatin plus the COX-2 inhibitor celecoxib in recurrent heavily-treated OC patients.

Methods

Patients were administered oral celecoxib (400 mg/day) in combination with intravenous carboplatin (AUC5, q28). A Simon's two-stage design was employed.

Results

45 patients were enrolled: 23 (51.1%) presented platinum-resistance, and 27 (60%) had received at least 3 prior regimens for recurrence. The response rate was 28.9% with 3 complete and 10 partial responses (median duration of response = 6 months). Only one (0.4%) G4 non-febrile neutropenia was observed; G3 neutropenia, anemia, or thrombocytopenia, were observed in 2.5%, 1.7%, and 1.7% of the cycles, respectively. G3-4 vomiting was reported in only 1.7%, and 0.4% of the cycles were associated with G3 dyspepsia or diarrhea or constipation. Only one patient experienced G3 hypertension associated to G2 hypersensitivity reaction. No differences in baseline versus post-treatment Quality of Life scores were observed. Median progression free survival and overall survival were 5 and 13 months, respectively.

Conclusions

Celecoxib combined with carboplatin showed promising activity and it is well tolerated in heavily-treated recurrent ovarian cancer patients.

Trial registration number

NCT01124435 (ClinicalTrials.gov Identifier) and 935/03 (study ID numbers).

Symptomatic vaginal bleeding in a postmenopausal woman revealing colon adenocarcinoma metastasizing exclusively to the vagina

Vaginal carcinomas are rare entities, accounting for 2% of all malignant cancers of the female genital tract, and the vast majority are metastatic. Adenocarcinoma of the colon metastasizing to the vagina is extremely rare, only 5 cases have been reported. We present the case of a woman who experienced vaginal bleeding as an isolated symptom of vaginal metastasis of colorectal adenocarcinoma. Vaginal localization of metastasis from colorectal cancer significantly worsens the survival prognosis, and a standard treatment has not yet been proposed. Potential mechanisms of spread of colorectal cancer to the vagina and therapeutic approaches are discussed. In this case, treatment included surgery and chemotherapy.

Expression of CD133-1 and CD133-2 in ovarian cancer

Cancer stem cells have been isolated from several solid tumors including prostate, colon, liver, breast, and ovarian cancer. Stem cells isolated from nervous system and prostate express CD133 antigen, which is widely used to isolate hematopoietic stem and progenitor cells. The aims of this study were to investigate the expression of the CD133-1 and CD133-2 epitopes in primary ovarian tumors and to biologically characterize CD133(+) ovarian cancer cells, also according to clinicopathologic parameters. Tissue specimens were obtained at primary surgery from 41 ovarian carcinomas; eight normal ovaries and five benign ovarian tumors were also collected. Flow cytometry with monoclonal antibodies against CD133-1 and CD133-2 epitopes was employed. FACS (fluorescence activated cell sorting) analysis enabled the selection of CD133(+) cells, whose epithelial origin was confirmed by immunofluorescence analysis with monoclonal anti-cytokeratin 7. CD133(+) cells gave rise to a 4.7 +/- 0.9-fold larger number of colonies than that documented in CD133(-) population (P < 0.001). Moreover, CD133(+) cells showed an enhanced proliferative potential compared to CD133(-) cells. The percentages of CD133-1- and CD133-2-expressing cells were significantly lower in normal ovaries/benign tumors with respect to those in ovarian carcinoma. Both the percentages of CD133-1- and CD133-2-expressing cells were significantly lower in omental metastases than in primary ovarian cancer (P = 0.009 and 0.007 for CD133-1- and CD133-2-expressing cells, respectively). There seems not to be any difference in the distribution of the percentage of CD133-1- and CD133-2-expressing cells according to clinicopathologic parameters and response to primary chemotherapy. CD133-1 and CD133-2 may be useful in order to select and enrich the population of CD133(+) ovarian tumor cells, which are characterized by a higher clonogenic efficiency and proliferative potential.

Expression of class III beta tubulin in cervical cancer patients administered preoperative radiochemotherapy: correlation with response to treatment and clinical outcome

OBJECTIVES

Alterations of the beta subunit of tubulin have been reported to be predictive of resistance to radiation and antitubulin agents in several solid tumors. The aim of the study was to investigate the clinical role of beta III tubulin expression as prognostic factor for survival and as a predictive parameter of response to preoperative radiochemotherapy in a single institutional series of locally advanced cervical cancer (LACC) patients.

METHODS

The study included 98 LACC patients admitted to the Gynecologic Oncology Unit, Catholic University of Rome and Campobasso between January 1998 and January 2005. Immunohistochemistry was performed by using the polyclonal rabbit anti-beta III tubulin antibody (Covance, Princeton, NJ, USA). The value of 10% immunostained tumor cells was arbitrarily chosen as cut-off value to distinguish cases with high versus low beta III tubulin content.

RESULTS

In the whole series, beta III tubulin immunoreaction was detectable in 66/98 cases (67.3%), and the percentage of positively stained cells ranged from 0 to 100% (median=10%). The percentages of cases with high beta III tubulin expression were shown not to be differently distributed according to clinico-pathological characteristics. There was no statistically significant difference in the distribution of cases with high beta III tubulin expression according to clinical and pathological response to treatment. During the follow-up period, recurrence and death of disease occurred in 15 and 13 cases, respectively. There was no difference in disease-free and overall survival in cases with high versus low beta III tubulin expression.

CONCLUSIONS

The assessment of class III beta tubulin status seems of little usefulness in order to identify LACC patients with poor chance of response to concomitant radiochemotherapy and unfavorable prognosis.

Impact of pattern of recurrence on clinical outcome of ovarian cancer patients: Clinical considerations

Recurrence of disease represents a clinical challenge in ovarian cancer patients. The aim of this study was to analyse the distribution and pattern of recurrence and their association with clinical outcome in a large series of ovarian cancer patients. This study was conducted on 328 primary untreated ovarian cancer patients. For each relapse, information on date of clinical/instrumental recurrence, and pattern of disease presentation were retrieved. In stage III-IV cases (n = 270), diffuse abdominal carcinomatosis occurred in 62.1% of cases, while recurrences presented as a single lesion or multiple nodules occurred in 9.9% and 26.7% of cases, respectively. Pattern of recurrence as carcinomatosis was shown to be associated with unfavourable outcome even when stratified according to platinum free interval (PFI) duration. In multivariate analysis, pattern of recurrence and PFI duration retained an independent prognostic role for post-relapse survival. Duration of PFI and type of recurrence may independently influence post-relapse survival in ovarian cancer patients.

Class III beta-tubulin overexpression is a marker of poor clinical outcome in advanced ovarian cancer patients

PURPOSE

Overexpression of beta III tubulin has been involved in paclitaxel resistance in several experimental models. We investigated the role of beta III tubulin as predictor of clinical outcome in ovarian cancer patients given platinum/paclitaxel treatment. We also investigated whether beta III tubulin expression could be modified after the selective pressure represented by chemotherapy in vivo.

EXPERIMENTAL DESIGN

The study was designed to include a series of consecutive ovarian cancer patients with unresectable disease at time of first surgery, who underwent interval debulking surgery with pathologic assessment of response to treatment with platinum/paclitaxel chemotherapy. Immunostaining was done on formalin-fixed, paraffin-embedded tissue sections from pretreatment and posttreatment tissue biopsies by using the polyclonal rabbit anti-class III beta-tubulin antibody.

RESULTS

beta III Tubulin immunoreaction was observed in 51 of 62 (82.2%) cases. beta III Tubulin positivity was neither associated with clinicopathologic variables nor with pathologic response to chemotherapy. Significantly lower percentages of beta III tubulin positivity were observed in posttreatment (range, 5-80%; median, 20%) versus pretreatment (range 10-100%; median, 40%) tissue biopsies (P = 0.0011). Cases with high beta III tubulin expression showed a worse overall survival with respect to cases with low beta III tubulin expression (median overall survival, 25 versus 46 months; P = 0.002). Multivariate analysis showed that high content of beta III tubulin remains independently associated with a worse prognosis.

CONCLUSIONS

Assessment of beta III tubulin could be useful to identify poor prognosis ovarian cancer patients candidates to more aggressive and/or targeted therapy.

Cyclo-oxygenase-2 (Cox-2) expression and resistance to platinum versus platinum/paclitaxel containing chemotherapy in advanced ovarian cancer

Background

Cyclo-oxygenase-2 (COX-2), the key enzyme in the conversion of arachidonic acid to prostaglandins, is involved in critical steps of tumor onset and progression, and is a strong predictor of chemotherapy resistance and poor outcome in advanced ovarian cancer. To our knowledge, no data has been reported until now about the association between COX-2 status and response to different chemotherapy regimens.

Methods

A retrospective study was performed to investigate the association of COX-2 with outcome and response to platinum versus platinum/paclitaxel in 68 primary ovarian cancer. COX-2 immunoreaction was performed on paraffin-embedded sections by using rabbit polyclonal antiserum against COX-2.

Results

In the overall series, COX-2 positivity was found in a statistically significant higher percentage of not responding cases than in patients responding to chemotherapy (n = 15/21; 71.4% versus n = 17/47; 36.1%; p value = 0.0072). A higher percentage of COX-2 positivity was found in patients unresponsive (n = 11/13; 84.6%) versus patients responsive to platinum-based chemotherapy (n = 9/26; 34.6%). In cases administered platinum/paclitaxel, COX-2 positivity was found in 4 out of 8 (50%) of un responsive versus 8 out of 21 (38.1%) of responsive cases. Logistic regression analysis of parameters likely to affect response to treatment resulted in a p value = 0.17 for the interaction COX-2/type of treatment.

Conclusion

Although these findings need to be confirmed in a larger series, our study suggests a possible indication that there is a difference in the influence of COX-2 on response depending on treatment regimen.

Phase II study on the combination carboplatin-celecoxib in heavily pre-treated recurrent ovarian carcinoma patients

15009

Background: Cyclooxygenase-2 (COX-2) has been shown to be involved in several steps of ovarian onset and progression and its overepression is associated with a poor chance of response to chemotherapy and poor prognosis in ovarian cancer. Celecoxib, an orally active selective COX-2 inhibitor, has been tested for its ability to potentiate the activity of carboplatin in treatment of heavily pretreated recurrent ovarian cancer patients. Methods: A phase II study was planned, considering the regimen active if at least 12 responses were observed among the 43 enrolled patients. Celecoxib (400 mg/die), and carboplatin (5 AUC) q28 were administered, until progression or unacceptable toxicity. Response was assessed by RECIST and also by Rustin criteria. Results: 34 pts (median age: 60 yrs, range 28–74) and an ECOG performance status (0/1/2) of (21/12/1), were enrolled. 58.8% of patients were platinum resistant (progressing during or < 6 months from primary treatment). Median number of previous chemotherapy regimens was 3 (range 2–6). Currently 27 patients are evaluable for response. The overall response rate (CR and PR) was 25.9% (2 CR, 5 PR) with stabilization of disease in 8 patients (29.6%). Four responses occurred in platinum sensitive and 3 in platinum resistant group Median time to response was 11 weeks (range 9–19) and median duration of response was 23 weeks (range 12–39). According to Rustin criteria 10 patients out of 25 (40%) were considered responsive to treatment (return of CA125 levels to normal level or >50% reduction). Overall, 143 cycles were administered with a median value of 3 cycles (range = 1–10). Moderate/severe toxicities were as follows: G3 anemia occurred in 2.3% cycles, G3 neutropenia in 4.6% cycles, G3 thrombocytopenia in 1.5% cycles, G3/4 gastrointestinal toxicity occurred in 4.6% cycles. Cutaneous diffuse erithema was observed in 2 patients, in both cases recovered with a short period of antihistaminic treatment; 2 cases of hypertension were documented, G2 hypersensitivity reactions during carboplatin infusion were observed in 4 cases. Conclusions: Celecoxib combined with carboplatin is well tolerated and has promising activity as salvage treatment in heavily pretreated recurrent ovarian cancer patients.

No significant financial relationships to disclose.

Anemia in patients with locally advanced cervical carcinoma administered preoperative radiochemotherapy: association with pathological response to treatment and clinical outcome

OBJECTIVE

The aim of this study was to investigate the role of anemia at presentation (basal HB) and during treatment (nadir HB) as predictor of pathological response, as well as disease-free (DFS) and overall survival (OS) in LACC patients undergoing chemoradiation followed by radical surgery.

METHODS

114 consecutive LACC patients were accrued at the Gynecologic Oncology Unit, Catholic University, Rome and at the Department of Oncology, Catholic University of Campobasso, Italy. Neoadjuvant treatment included chemotherapy with cisplatin (20 mg/m2) and 5-fluorouracil (1000 mg/m2, 24-h infusion) (both on days 1-4 and 27-30) and external radiotherapy to the whole pelvic region (22 fractions, 1.8 Gy/day, totaling 39.6 Gy). Clinical responders underwent radical surgery. Hemoglobin levels were recorded and expressed in gram per literx10(-2) (g/dl). The value of 10 g/dl was arbitrarily chosen as cut-off value.

RESULTS

In cases showing high basal HB status, the percentage of pathological response was significantly higher than in patients showing low HB status (76.3% versus 46.7%) (P value=0.027). When logistic regression was applied, only advanced stage remained associated with a poor chance of response to treatment. Cases with low basal HB status had a shorter DFS and OS than cases with a high HB status (P value=0.0001 and 0.0022, respectively). Similar results were obtained when analyzing nadir HB status. In multivariate analysis, high basal HB status, and advanced stage, retained an independent negative prognostic role for DFS and OS.

CONCLUSIONS

Anemia identifies LACC patients administered preoperative radiochemotherapy, who are at higher risk of recurrence and death of disease.

Celecoxib Up-Regulates the Expression of the ζ Chain of T Cell Receptor Complex in Tumor-Infiltrating Lymphocytes in Human Cervical Cancer

PURPOSE

We evaluated the effects of celecoxib treatment on tumor-infiltrating lymphocyte (TIL) subsets [CD3(+), CD4(+),CD8(+), CD25(+), and T cell receptor (TCR)-zeta-expressing cells] and tryptase-positive mast cells in cervical tumors. Circulating levels of cytokines [interleukin (IL)-1beta, IL-10, tumor necrosis factor-alpha, IL-6, and IL-12] and angiogenesis-modulating factors (vascular endothelial growth factor and endostatin) have also been analyzed.

EXPERIMENTAL DESIGN

Cervical tumor biopsies and blood samples were obtained at the time of diagnosis and after 10 days of celecoxib treatment (400 mg b.i.d., at 8:00 a.m. and 8:00 p.m.) in 27 cases. Immunohistochemistry and ELISA assays were used to assess the expression of biological factors in tumor tissue and circulating levels of cytokines and angiogenic molecules.

RESULTS

We showed a statistically significant increase in the percentage of TIL expressing the TCR-zeta chain after celecoxib treatment: indeed, in cases exposed to celecoxib, the percentage of TCR-zeta(+) cells ranged from 5.0 to 50.0 (median, 22.5) with respect to baseline expression (range, 3.0-50.0; median, 10.0; P = 0.0016). There was no significant treatment-related difference in the percentage of CD3(+), CD4(+), CD8(+), and CD25(+) TIL as well as in tryptase-positive cells. IL-12 levels were significantly reduced in posttreatment samples with respect to baseline levels (P = 0.002). We also found a reduction in the circulating levels of vascular endothelial growth factor, and a statistically significant increase of serum endostatin levels (P = 0.035).

CONCLUSIONS

We reported the first evidence in humans that celecoxib restores zeta expression by TIL in primary cervical tumors, suggesting that a positive modulation of immune function may serve as an additional mechanism supporting the antitumor effect of this class of drugs.

Attachment security: a meta-analysis of maternal mental health correlates

This meta-analysis addresses the association between attachment security and each of three maternal mental health correlates. The meta-analysis is based on 35 studies, 39 samples, and 2,064 mother-child pairs. Social-marital support (r = .14; based on 16 studies involving 17 samples and 902 dyads), stress (r = .19; 13 studies, 14 samples, and 768 dyads), and depression (r = .18; 15 studies, 19 samples, and 953 dyads) each proved significantly related to attachment security. All constructs showed substantial variance in effect size. Ecological factors and approach to measuring support may explain the heterogeneity of effect sizes within the social-marital support literature. Effect sizes for stress varied according to the time between assessment of stress and assessment of attachment security. Among studies of depression, clinical samples yielded significantly larger effect sizes than community samples. We discuss these results in terms of measurement issues (specifically, overreliance on self-report inventories) and in terms of the need to study the correlates of change in attachment security, rather than just the correlates of attachment security per se.

Nonmedical drug use among adolescent students: highlights from the 1999 Ontario Student Drug Use Survey

BACKGROUND

During the 1990s, rates of nonmedical drug use among adolescents escalated. We assessed data from 5 cycles of the Ontario Student Drug Use Survey for overall trends in the proportion of students reporting illegal drug use between 1991 and 1999.

METHODS

The survey is a repeated, cross-sectional, 2-stage cluster-design survey of students enrolled in grades 7, 9, 11 and 13. Outcome measures were prevalence of use of 17 drugs, including alcohol and tobacco, over the 12 months preceding the survey.

RESULTS

The rates of drug use increased between 1993 and 1999. The 95% confidence intervals (CIs) for the differences in proportions between 1997 and 1999 indicated significant increases in the overall use of 6 drugs: alcohol (95% CIdiff 6.1, 1.9-10.3), cannabis (95% CIdiff 46.3, 0.2-8.4), glue (95% CIdiff 2.3, 1.3-3.3), other solvents (95% CIdiff 5.0, 3.1-6.3), barbiturates (95% CIdiff 1.9, 0.4-3.4) and hallucinogens such as mescaline and psilocybin (95% CIdiff 3.5, 0.8-6.9). Fewer grade 7 students in 1999 than in earlier cohorts reported using alcohol or cigarettes by age 9.

INTERPRETATION

The public health implications of the findings are mixed. On the positive side, there is no evidence of increases in early onset of drug use. On the negative side, the overall proportion of students reporting illegal drug use has continued to rise.

Alcohol and aggression: general population views about causation and responsibility

The purpose of this paper is to explore the public's perceptions about alcohol as a causal agent in aggressive behavior, and to assess how these beliefs are associated with notions of responsibility and the excuse-function of alcohol. In a 1995 probability survey, 994 adults across Ontario (50.3% female; mean age = 41.5, SD = 5.9) were asked questions about: alcohol-aggression expectancies; alcohol as an excuse; responsibility; personal drinking behavior; alcohol-aggression victimization; and demographics. Descriptive and regression analyses were conducted. Over three-quarters of respondents believed that alcohol is associated with aggression, with females, older respondents, those with less education, and those who do not drink heavily more likely to hold this view. A majority (92%) believed that an intoxicated person is responsible for any behavior, with very little subgroup variation. Analyses showed that the perception of alcohol as a causal agent was not associated with decreased personal responsibility attributions. In fact, the stronger the belief in the alcohol-aggression link, the more likely one was to hold the view that an intoxicated person is responsible for behavior. Beliefs that alcohol causes violence do not translate into the acceptance of intoxication as an excuse. Reasons as to why intoxication does not alleviate responsibility for the drunken actor--a result inconsistent with attribution theory--are discussed. The consistency of these results with the "New Temperance" movement in the United States is also discussed.