Locally administered ketorolac and bupivacaine for control of postoperative pain in breast augmentation patients

With recent developments in the field of analgesia, the question arises whether there is a role for placing local anesthetics, nonsteroidal anti-inflammatory drugs, or both into the breast implant pocket. The objective of this study was to test the effectiveness of locally administered intraoperative ketorolac and bupivacaine with epinephrine at reducing pain in the postoperative period. The study was a prospective, randomized, double-blind clinical trial. One hundred consecutive retropectoral breast augmentation patients were enrolled, and informed consent was obtained. A standard anesthetic protocol and surgical procedure were followed. Normal saline, ketorolac alone (30 mg), bupivacaine alone (150 mg), or ketorolac and bupivacaine (30 mg and 150 mg respectively) were placed into the implant pocket before implant insertion. All patients completed the study. The power of this study to detect a 20 percent difference with respect to the primary outcome was 0.90 and confidence intervals of 95 percent were used to determine significance. The primary outcome was pain as measured by the visual analogue pain scale. The secondary outcome was time spent in the recovery room. Intraoperative placement of ketorolac combined with bupivacaine reduced pain in the postoperative period. It did not appear that anesthesiologist, anesthesia time, surgeon, operating room time, difficulty of dissection, breast incision, or implant size had a significant effect on postoperative pain. There was a trend that the ketorolac and bupivacaine patients spent less time in the recovery room and used fewer analgesics postoperatively than the other patients. There were no hematomas requiring reoperation and no complications. Locally administered intraoperative ketorolac and bupivacaine with epinephrine significantly reduced pain in the postoperative period.     

Efficacité comparée de l'antibioprophylaxie par la céfoxitine en une ou trois doses dans la césarienne.

To compare the effectiveness of three doses and of a single dose of cefoxitin, a second-generation cephalosporin, in preventing infection after nonelective cesarean section, we carried out a prospective study in 255 women who underwent the procedure between March 1983 and February 1985. The rate of postoperative infection was 7% in the group that received three doses and 8% in the one-dose group. The sensitivity and specificity of perioperative cultures were low. The rate of asymptomatic bacteriuria was high, at 20%, but few symptomatic urinary tract infections were found. Routine antibiotic prophylaxis with a single dose is suggested for all nonelective cesarean sections.     

Cefepime in the treatment of infection in neutropenic patients]

Cefepime, a fourth-generation cephalosporin, was used in the treatment of 11 febrile episodes in 8 patients with profound neutropenia. The patients were neutropenic because of high-dose chemotherapy with stem-cell rescue or second-line salvage chemotherapy for malignant lymphomas (5 patients) or solid tumors (3 patients). The median duration of grade-IV neutropenia (according to the WHO classification) was 11 days (7 to 14). Cefepime was used as the monotherapy in a dose of 2 g thrice daily. Disappearance of the infection signs was recorded in 8 episodes (73 per cent). In 3 episodes (23 per cent) cefepime was replaced by another drug. The tolerability of cefepime was good and no adverse events were observed with the exception of 1 event of an allergic reaction.     

Mouse models of short- and long-term foreign body in the urinary bladder: analogies to the bladder segment of urinary catheters.

Catheter-associated bacteriuria is the most common infection occurring in hospitals, where urethral catheters are generally in place for a few days, and in nursing homes, where catheters may be in place for months or years. We developed murine models with intrabladder urinary catheters for studying complications of bacteriuria in short- and long-term catheterization. In the short-term model, a catheter segment was inserted transurethrally and lay free within the bladder lumen. Half of the animals expelled segments during a 2-to-7-day period, durations similar to catheterizations in hospitalized patients. For studies of long-term catheter use, the catheter segment was secured within the bladder by a single suture for up to 12 months. Antibiotics administered for 7 days after catheter placement and housing mice in cages with wire screen floors reduced spontaneous bacteriuria to an acceptably low incidence rate of only 7%. Proteus mirabilis bacteriuria of high concentration provoked the same complications that are common in patients with long-term catheters: acute pyelonephritis, chronic renal inflammation, and struvite stone formation. These models allow inoculation of the bacteria of interest and are suitable for studies of short- and long-term foreign body-associated bacteriuria and its complications.     

Double-blind Trial to Compare Ampicillin,Cephalexin, Co-trimoxazole,and Trimethoprim in Treatment of Urinary Infection

In order to test their value in urinary infection a double-blind trial was carried out using ampicillin, cephalexin, trimethoprim-sulphamethoxazole (co-trimoxazole), and trimethoprim. Eighty-three courses of treatment were given to hospital patients, 149 to pregnant women, and 107 to patients with dysuria and frequency seen in domiciliary practice. Thus infections of varying severity in defined groups of patients caused by organisms with different antibiotic sensitivities were treated.Analysis of the overall results (339 courses) was compared with those from the individual groups and considerable variation in response was found. In domiciliary infections and bacteriuria in pregnancy trimethoprim alone proved to be at least as effective as the other three compounds and caused fewer than half the number of side effects. In the hospital patients co-trimoxazole was superior to trimethoprim.The overall results for ampicillin and cephalexin were similar although cephalexin proved to be inferior in treating symptomatic domiciliary infections.     

Point-of-care versus central testing of hemoglobin during large volume blood transfusion

Hypoxic preconditioning (HPC) may protect multiple organs from various injuries. We hypothesized that HPC would reduce lung injury in patients undergoing thoracoscopic lobectomy. In a prospective randomized controlled trial, 70 patients undergoing elective thoracoscopic lobectomy were randomly allocated to the HPC group or the control group. Three cycles of 5-min hypoxia and 3-min ventilation applied to the nondependent lung served as the HPC intervention. The primary outcome was the PaO2/FiO2 ratio. Secondary outcomes included postoperative pulmonary complications, pulmonary function, and duration of hospital stay. HPC significantly increased the PaO2/FiO2 ratio compared with the control at 30 min after one-lung ventilation and 7 days after operation. Compared with the control, it also significantly improved postoperative pulmonary function and markedly reduced the postoperative hospital stay duration. No significant differences between groups were observed in the incidence of pulmonary complications or overall postoperative morbidity. HPC improves postoperative oxygenation, enhances the recovery of pulmonary function, and reduces the duration of hospital stay in patients undergoing thoracoscopic lobectomy. This study was registered in the Chinese Clinical Trial Registry (ChiCTR-IPR-17011249) on April 27, 2017.     

Randomised trial of safety and efficacy of immediate postoperative enteral feeding in patients undergoing gastrointestinal resection.

OBJECTIVES: To assess whether immediate post-operative enteral feeding in patients who have undergone gastrointestinal resection is safe and effective. DESIGN: Randomised trial of immediate post-operative enteral feeding through a nasojejunal tube v conventional postoperative intravenous fluids until the reintroduction of normal diet. SETTING: Teaching hospitals in London. SUBJECTS: 30 patients under the care of the participating consultant surgeon who were undergoing elective laparotomies with a view to gastrointestinal resection for quiescent, chronic gastrointestinal disease. Two patients did not proceed to resection. MAIN OUTCOME MEASURES: Nutritional state, nutritional intake and nitrogen balance, gut mucosal permeability measured by lactulose-mannitol differential sugar absorption test, complications, and outcome. RESULTS: Successful immediate enteral feeding was established in all 14 patients with a mean (SD) daily intake of 6.78 (1.57)MJ (1622 (375) kcal before reintroduction of oral diet compared with 1.58 (0.14) MJ (377 (34) kcal) for those on intravenous fluids (P < 0.0001). Urinary nitrogen balance on the first postoperative day was negative in those on intravenous fluids but positive in all 14 enterally fed patients (mean (SD) - 13.2 (11.6) g v 5.3 (2.7) g; P < 0.005). There was no difference by day 5. There was no change in gut mucosal permeability in the enterally fed group but a significant increase from the test ratios seen before the operation in those on intravenous fluids (0.11(0.06) v 0.15 (0.12); P < 0.005). There were also fewer postoperative complications in the enterally fed group (P < 0.005). CONCLUSIONS: Immediate postoperative enteral feeding in patients undergoing intestinal resection seems to be safe, prevents an increase in gut mucosal permeability, and produces a positive nitrogen balance.     

Phenacetin Nephropathy

Four patients who had ingested large amounts of phenacetin-salicylate medications were studied during a 12-month period. Renal failure had progressed slowly over a number of years. All patients took the drug because of psychogenic headache. Considerable skill was required to elicit the history of drug habituation. The major features of the nephropathy were multiple episodes of metabolic acidosis, minimal proteinuria, pyuria but no bacteriuria, and polyuria and polydipsia early in the course of drug ingestion. Papillary necrosis was not a prominent clinical feature of this series. Discontinuation of drug ingestion by one patient was associated with recovery of a considerable degree of renal function. Preliminary experimental evidence obtained in the dog suggests that salicylate impaired the efficiency of the counter-current multiplier by decreasing sodium transport in the ascending limb of Henle, and decreased the permeability to water of the distal convoluted and collecting tubule; phenacetin had no such effect.     

Experience with maxipime in neurosurgical clinic]

Cefepime (Maxipime, Bristol-Myers Squibb), a 4th generation cephalosporin was used in the postoperative treatment of 121 patients of Anesthesiology and Intensive Care Unit of Neurosurgical Clinics. The patients were divided into groups by the risk factor of pyoseptic complications. The results were estimated by the number and nature of the complications such as increasing liquor neutrophilic cytosis, systemic inflammations and others. The findings (increasing liquor neutrophilic cytosis only in 2 patients and endobronchitis in 4 patients) and good tolerance of cefepime (Maxipime) were in favour of its use in a dose of 1 g administered intravenously dropwise during initial narcosis and in 12 hours as an efficient agent for perioperative prophylaxis in neurosurgical patients.     

Efficacy of levofloxacin (Tavanic) in the treatment of children with chronic pulmonary diseases]

The efficacy of the fluoroquinolone levofloxacin in the treatment of 35 children with bronchopulmonary disease exacerbation was practically the same as that of amoxycillin/clavulanate, cefotaxime or ceftriaxone. The clinical and bacteriological results were favourable. The eradication of the pathogens responsible for the bronchopulmonary inflammations in 86% of the patients was stated. There is no doubt that fluoroquinolones should not be widely used in pediatrics. They should be considered as reserve drugs for the treatment of severe cases when the routine agents fail. Their use is justified when the situation is risky and the data on the pathogen susceptibility to the drugs are available. Still, levofloxacin is the most safe fluoroquinolone with low hepatotoxicity and lower effect on the central nervous system. The episodes of its negative cardiovascular action are less frequent. Moreover, the most frequent side effects of fluoroquinolones such as nausea, diarrhea or vomiting are less frequent with the use of levofloxacin. No signs of arthropathy in the patients treated with levofloxacin were observed in our trial.     

Enhancing the antibiotic antibacterial effect by sub lethal tellurite concentrations: tellurite and cefotaxime act synergistically in Escherichia coli

The emergence of antibiotic-resistant pathogenic bacteria during the last decades has become a public health concern worldwide. Aiming to explore new alternatives to treat antibiotic-resistant bacteria and given that the tellurium oxyanion tellurite is highly toxic for most microorganisms, we evaluated the ability of sub lethal tellurite concentrations to strengthen the effect of several antibiotics. Tellurite, at nM or μM concentrations, increased importantly the toxicity of defined antibacterials. This was observed with both gram negative and gram positive bacteria, irrespective of the antibiotic or tellurite tolerance of the particular microorganism. The tellurite-mediated antibiotic-potentiating effect occurs in laboratory and clinical, uropathogenic Escherichia coli, especially with antibiotics disturbing the cell wall (ampicillin, cefotaxime) or protein synthesis (tetracycline, chloramphenicol, gentamicin). In particular, the effect of tellurite on the activity of the clinically-relevant, third-generation cephalosporin (cefotaxime), was evaluated. Cell viability assays showed that tellurite and cefotaxime act synergistically against E. coli. In conclusion, using tellurite like an adjuvant could be of great help to cope with several multi-resistant pathogens.     

Cefotaxime stimulates callus growth,embryogenesis and regeneration in hexaploid bread wheat (Triticum aestivum L em. thell)

The tissue culture responses of wheat are known to be affected by the type and concentration of growth regulator in the medium and the genotype of the tissues in culture. In this report the effects of the cephalosporin antibiotics, carbenicillin and cefotaxime, on the growth, organogenesis, embryogenesis and regeneration of wheat calli in culture are described. Cefotaxime significantly improved the performance of wheat in culture as measured by these characters. The potential uses of cefotaxime for stimulating regeneration and inducing embryogenesis are discussed.     

Single dose cefotaxime plus metronidazole versus three dose cefuroxime plus metronidazole as prophylaxis against wound infection in colorectal surgery: multicentre prospective randomised study.

OBJECTIVE--To establish whether a single preoperative dose of cefotaxime plus metronidazole was as effective as a standard three dose regimen of cefuroxime plus metronidazole in preventing wound infection after colorectal surgery. DESIGN--Prospective randomised allocation to one of two prophylactic antibiotic regimens in a parallel group trial. Group sequential analyses of each 250 patients were performed. SETTING--14 District general and teaching hospitals. PATIENTS--1018 Adults having colorectal operations were randomised, of whom 943 were evaluated. Demographic features, conditions requiring surgery, and operative procedures were similar in the two groups. Most patients had surgery for carcinoma of the colon or rectum. INTERVENTIONS--Group 1 received cefotaxime 1 g intravenously plus metronidazole 500 mg intravenously preoperatively. Group 2 received cefuroxime 1.5 g intravenously plus metronidazole 500 mg intravenously preoperatively, followed by cefuroxime 750 mg intravenously plus metronidazole 500 mg intravenously eight hours and 16 hours postoperatively. MAIN OUTCOME MEASURES--Development of surgical wound infection (as evidenced by the presence of pus), death, or discharge from hospital. RESULTS--Wound condition was scored on a five point scale on alternate days until discharge or for up to 20 days postoperatively. Wound infection rates were: group 1, 32/453 (7.1%; 95% confidence interval 4.7% to 9.4%); group 2, 33/454 (7.3%; 95% confidence interval 4.9% to 9.6%). Death rates (group 1: 26/470 (5.5%); group 2: 31/471 (6.6%], the incidence of postoperative complications, the median duration of hospital stay (12 days), and antibiotic tolerance were all similar in the two groups. Pooled data from groups 1 and 2 showed that wound infections were more frequent when minor faecal contamination had occurred at operation and when the duration of operation exceeded 90 minutes (greater than 90 min 11.2% of cases; less than 90 min 4.8%) and were associated with an extended hospital stay. CONCLUSIONS--A single preoperative dose of cefotaxime plus metronidazole is an efficacious as a three dose regimen of cefuroxime plus metronidazole in preventing wound infection after colorectal surgery and has practical advantages in eliminating the need for postoperative antibiotics.     

Dextran and intermittent pneumatic compression in prevention of postoperative deep vein thrombosis: multiunit trial.

Seven general surgical units co-operated in a clinical trial of dextran 70 and pneumatic calf compression alone and in combination in the preventing of 125I-fibrinogen-detectable deep vein thrombosis in 305 patients. Both dextran regimens were significantly more effective than pneumatic compression alone. Pulmonary embolism was diagnosed in 14 patients, but there was no significant difference in incidence among the three treatment groups. In patients receiving dextran there was no greater median operative blood loss but there was a significantly greater incidence of postoperative bleeding complications.     

Co-trimoxazole in prevention of bacteriuria after prostatectomy.

In a prospective, double-blind trial prophylactic cotrimoxazole produced a highly significant reduction in the incidence of bacteriuria after prostatectomy. Only two out of 38 patients who received the drug developed bacteriuria compared with 19 out of 36 patients on placebo. Klebsiella-Enterobacter spp and coagulase-negative staphylococci were responsible for most infections. Although co-trimoxazole prophylaxis is obviously effective, widespread use might increase the incidence of bacterial resistance.     

Kinetics of turnover of cefotaxime by the Enterobacter cloacae P99 and GCl beta-lactamases: two free enzyme forms of the P99 beta-lactamase detected by a combination of pre- and post-steady state kinetics

Third-generation cephalosporins bearing oximino side chains are resistant to hydrolysis by class C beta-lactamases such as that from Enterobacter cloacae P99. For example, steady state parameters for hydrolysis of cefotaxime by this enzyme are as follows: k(cat) = 0.41 s(-1), K(m) = 17.2 microM, and k(cat)/K(m) = 2.3 x 10(4) s(-1) M(-1). On the other hand, however, the K(i) value for cefotaxime as an inhibitor of cephalothin hydrolysis is 27 nM. The discrepancy between K(m) and K(i) indicated that a real steady state had not been achieved in at least one of these experiments. Analysis indicated that only two to three cefotaxime turnovers occurred during the K(i) determination. This suggested that the first few turnovers of cefotaxime by the P99 beta-lactamase may be different from those in the subsequent steady state. A direct pre-steady state experiment confirmed this hypothesis. The simplest reaction scheme that fitted the data involved replacement of the initial enzyme form, E, which bound cefotaxime tightly, with a second more weakly binding form, E', by partitioning of the acyl-enzyme intermediate during the first few turnovers. Steady state turnover of cefotaxime then largely involved E' as the free enzyme form. E' slowly reverted to E in the post-steady state regime. Further evidence for this scheme included quantitative analysis of the post-steady state and observation of a difference in the catalytic activity of E and E' in 2 M ammonium sulfate. The kinetics of P99 beta-lactamase-catalyzed hydrolysis of an acyclic depsipeptide substrate bearing a third-generation cephalosporin side chain showed that the side chain is necessary but not sufficient for production of resistance to beta-lactamase; a combination of the side chain and the dihydrothiazine ring of a cephalosporin is required. The beta-lactamase of E. cloacae GC1, an extended spectrum mutant of the P99 enzyme, rapidly hydrolyzes third-generation cephalosporins, without the structural transition described above. The flexibility of the extended Omega loop of the GC1 enzyme probably leads to this situation. Conformational restriction of the loop in the P99 enzyme is probably responsible for the long-lived acyl-enzyme intermediate and the transition to E' induced by cefotaxime.     

Acyl-intermediate structures of the extended-spectrum class A beta-lactamase,Toho-1, in complex with cefotaxime,cephalothin, and benzylpenicillin

Bacterial resistance to beta-lactam antibiotics is a serious problem limiting current clinical therapy. The most common form of resistance is the production of beta-lactamases that inactivate beta-lactam antibiotics. Toho-1 is an extended-spectrum beta-lactamase that has acquired efficient activity not only to penicillins but also to cephalosporins including the expanded-spectrum cephalosporins that were developed to be stable in former beta-lactamases. We present the acyl-intermediate structures of Toho-1 in complex with cefotaxime (expanded-spectrum cephalosporin), cephalothin (non-expanded-spectrum cephalosporin), and benzylpenicillin at 1.8-, 2.0-, and 2.1-A resolutions, respectively. These structures reveal distinct features that can explain the ability of Toho-1 to hydrolyze expanded-spectrum cephalosporins. First, the Omega-loop of Toho-1 is displaced to avoid the steric contacts with the bulky side chain of cefotaxime. Second, the conserved residues Asn(104) and Asp(240) form unique interactions with the bulky side chain of cefotaxime to fix it tightly. Finally, the unique interaction between the conserved Ser(237) and cephalosporins probably helps to bring the beta-lactam carbonyl group to the suitable position in the oxyanion hole, thus increasing the cephalosporinase activity.     

Utilisation des céphalosporines comme antibioprophylaxie lors de césariennes.

Cefoxitin, a second-generation cephalosporin, was compared with cefazolin, a first-generation cephalosporin, and a placebo in a prospective, double-blind study of antibiotic prophylaxis in women undergoing nonelective cesarean section. In the groups that received cefazolin or the placebo there eas no statistically significant change in colonization of the cervix by aerobic bacteria by the fourth day after the operation, but there was a statistically significant increase in colonization by anaerobes. Cefoxitin had the opposite effect. Of the 14 postoperative infections in 11 patients, significantly more were in patients who had received the placebo; the numbers were too small to show a difference in effectiveness between the two antibiotics. Of the microorganisms implicated as the infectious agents, group B Streptococcus was the most frequent aerobe, and Peptostreptococcus and Bacteroides bivius were the most frequent anaerobes. Among the 15 patients for whom at least one perioperative specimen yielded positive culture results, a postoperative infection developed in 5 of the 6 who received the placebo, 2 of the 4 who received cefazolin and 1 of the 5 who received cefoxitin.     

Antibacterial Activity of a New Cephalosporin, Cefotaxime

The antibacterial activity of a new cephalosporin derivative, cefotaxime (HR 756), was determined. The antibiotic was active at low concentrations against R⁺ and R^- strains of Gram negative bacteria, including two out of three strains of Serratia marcescens. In general higher concentrations were needed to inhibit growth of Pseudomonas aeruginosa. Low concentrations induced elongation of cells in circumstances conducive to active growth; higher concentrations caused lysis in some strains. Cefotaxime was more stable than cephaloridine, cephalothin, cephalexin, cefoxitin and cefuroxime to various β-lactamases.     

The effect of cefotaxime on the growth and regeneration of callus from four varieties of barley (Hordeum vulgare L.)

Recently it has been reported that the cephalosporin antibiotic cefotaxime increases growth, regeneration and embryogenesis in wheat calli. We investigated the effect of cefotaxime on callus initiated from immature embryos of four barley (Hordeum vulgare L.) varieties. In calli cultured in the presence of antibiotic callus growth was up to 45% greater than in controls and the frequency of regenerating calli was increased by up to 80%. There was an apparent interaction of the antibiotic with genotype and the 2,4-D in the medium.