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BACKGROUND AND OBJECTIVES: The aim of this study was to compare the efficacy and safety of continuous axillary brachial plexus block by infusion and by intermittent injection of bupivacaine 0.25% in the management of postoperative pain. METHODS: Two methods of continuous axillary brachial plexus block for pain management were compared in a prospective randomized trial. Twenty 16- to 62-year-old male patients (ASA I and II), undergoing microsurgery, received 0.25% bupivacaine following surgery, by either continuous infusion (group C, n = 10), or intermittent hourly bolus (group B, n = 10), via an axillary brachial plexus catheter inserted prior to operation. Efficacy assessments and analysis of plasma bupivacaine levels were performed for up to 38 hours postsurgery. RESULTS: There was no difference between groups with respect to pain scores, degree of motor block, or supplemental narcotic requirements. Plasma bupivacaine levels were higher in group C, with the difference reaching significance after 26 hours (means +/- SEM: C = 1.03 +/- 0.10 micrograms/mL, B = 0.73 +/- 0.08 microgram/mL, P < .05). There were no significant differences in cumulative bupivacaine doses or infusion rates between the groups. Complications included one case of axillary artery puncture at insertion, two unplanned premature catheter removals, and a self-limited grand mal convulsion in a known epileptic. CONCLUSIONS: Overall, both techniques provided safe and effective postoperative analgesia. As compared with continuous infusion, intermittent bolus administration resulted in lower plasma bupivacaine levels despite similar infusion rates.

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We studied 151 patients undergoing total hip or knee arthroplasty, or cruciate ligament reconstruction in a multicentre study in Australia and New Zealand. Patients were openly allocated randomly to one of five treatment groups or to a control group. General anaesthesia was induced after introduction of extradural block with 0.5% ropivacaine. After surgery, patients received an extradural infusion of 0.2% ropivacaine at 6, 8, 10, 12 or 14 ml h-1 or received no postoperative extradural infusion (control group). All patients had access to i.v. PCA morphine for supplementary analgesia. Morphine consumption was lower in all treatment groups compared with the control group, decreasing with increasing ropivacaine infusion rate. Median VAS scores were lower in all ropivacaine infusion groups compared with the control group for the first 10 h of the study; however by the end of the study, VAS scores were similar in all groups. The higher ropivacaine infusion rates caused a slower convergence of spread of the initial sensory block and a higher degree of motor block. The overall incidence of side effects was similar, with the exception of a higher incidence of urinary retention and hypotension in the groups receiving the higher rates of ropivacaine. The quality of treatment scores were similar for all treatment groups (Br. J. Anaesth. 1996; 76: 606-610).

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Little information is available regarding the level of immunity to Bordetella pertussis among adolescents. We measured serum antibodies in 156 healthy adolescents to the following pertussis antigens: pertussis toxin, filamentous hemagglutinin, and 69-kd outer membrane protein. In an attempt to identify intercurrent pertussis infections, we also obtained a total of 43 repeated samples during the following 5 years. Using a 50% or greater rise in IgG enzyme-linked immunosorbent assay titers to define seroconversion, we found an annual incidence of 6.1%; by alternative definitions of seropositivity, the predicted annual incidence of infection ranged from 1.2% to 8.2%. These data suggest that infection with B pertussis is common in the adolescent population.

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OBJECTIVE: To evaluate the safety and immunogenicity in adults of several different concentrations of an acellular pertussis vaccine. DESIGN: Double-blind, randomized, placebo-controlled trial. SETTING: Medical center immunization clinic. PARTICIPANTS: One hundred eighteen healthy adult volunteers. INTERVENTIONS: Participants received standard adult tetanus-diphtheria vaccine alone or combined with full-strength, half-strength, or quarter-strength concentrations of a currently licensed acellular pertussis vaccine used for booster doses in young children. Full-strength vaccine contained 40 micrograms of pertussis proteins, consisting of 86% filamentous hemagglutinin, 8% pertussis toxin, 4% 69-kd outer-membrane protein, and 2% agglutinogens. MAIN OUTCOME MEASURES: Local and systemic reactions were assessed for 14 days after vaccination. Serum samples for antibody assay were obtained before, 1 month after, and 1 year after immunization. RESULTS: Adverse reactions were few and minor and did not differ in frequency or severity among the four study groups. The groups receiving acellular pertussis vaccine showed strong antibody responses to pertussis antigens, which did not significantly differ by concentration of vaccine. After 1 year, levels of antibody to pertussis had declined by approximately 50% but remained substantially higher than preimmunization levels. The four groups did not differ in antibody responses to tetanus or diphtheria toxoids. CONCLUSIONS: Routine reimmunization of adults with a vaccine containing acellular pertussis antigens in addition to diphtheria and tetanus toxoids can substantially enhance pertussis antibody levels without an increase in adverse reactions or diminution in response to the diphtheria and tetanus components. Such a program might materially reduce respiratory illness among both adults and children.

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Healthy 17- to 24-month-old children, previously immunized with three doses of whole-cell diphtheria-tetanus-pertussis (DTP) vaccine, were enrolled in a multi-center double-blind, randomized study comparing a DTP vaccine with an acellular pertussis-component (APDT) and a conventional whole-cell pertussis-component DTP vaccine. Thirty-eight children received APDT vaccine, and 37 children received DTP vaccine. APDT vaccine recipients had significantly less local pain and warmth than DTP vaccine recipients. Antibody responses to lymphocytosis-promoting factor were similar in the two groups. The APDT vaccine recipients had a higher IgG antibody response to filamentous hemagglutinin than the DTP vaccinees had. Equivalent agglutinin responses were seen in the two groups. The APDT vaccine recipients had a significantly better antibody re-enzyme-linked immunosorbent assay, than DTP vaccinees had 1 month and 1 year after immunization. This APDT vaccine was immunogenic and caused fewer local reactions than conventional DTP vaccine when administered as a fourth dose to 17- to 24-month-old children.

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The ability of human monocytes to phagocytize and kill nonpiliated opaque (T3) and transparent (T4) gonococci was investigated in a tumbling tube suspension assay. A serum-sensitive strain, F62, and a serum-resistant strain, FA19, were studied. CFU remaining after incubation with monocytes were used to assess the extent of killing. The data show that 50% of T3 and T4 gonococci of both strains were killed by monocytes over a 2-h period. Serum was necessary for the killing of transparent gonococci of both strains as well as for FA19 T3. Concentrations of serum ranging from 0.5 to 10% were equally effective, and heat-labile components were required. Killing of F62 T3, however, occurred in the absence of serum. An increased ratio of bacteria to monocytes decreased the rate of killing. A 30-min preopsonization of gonococci in 10% serum resulted in an enhanced rate of killing. Monocytes were able to kill plate-grown, but not log-phase, organisms. Disruption of the monocytes by sonication to release internalized bacteria did not increase the number of viable organisms. The addition of 10 micrograms of cytochalasin B per ml completely inhibited the reduction in colony numbers over time. These data indicate that freshly isolated human monocytes are capable of phagocytizing and killing nonpiliated gonococci.

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