Anesth Analg 2001 Aug;93(2):514
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PMID: 11473888, UI: 21367419
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Anesth Analg 2001 Aug;93(2):472-6 , 4th contents page
Department of Anesthesiology, Hopital Ambroise Pare, 9 Avenue Charles de Gaulle, Boulogne-Billancourt, 92100, France.
The extent to which epidurally administered sufentanil acts directly on spinal opioid receptors remains controversial. We tested the hypothesis that small-dose boluses of sufentanil, given epidurally or IV, provide comparable analgesia at similar plasma sufentanil concentrations. The lipophilicity of sufentanil makes it likely to be absorbed into fat surrounding the epidural space. We therefore also tested the hypothesis that more epidural than IV sufentanil is required to produce comparable analgesia. Analgesia and plasma sufentanil concentrations were evaluated in 20 postoperative patients randomly assigned to patient-controlled epidural or IV sufentanil. Pain was evaluated with visual analog scales by blinded observers. Sufentanil doses and plasma concentrations were measured. Analgesia was similar with epidural and IV sufentanil administration. Plasma sufentanil concentrations were virtually identical in the two groups. However, significantly larger sufentanil doses were required with epidural administration: 238 +/- 50 microg vs 160 +/- 32 microg (P < 0.01). The primary mechanism by which small-dose boluses of epidurally-administered sufentanil produce analgesia seems to be systemic absorption of the drug with subsequent recirculation to the supraspinal opioid receptors. This study demonstrates that the cumulative dose of sufentanil, when administered as a small epidural bolus, is approximately 50% more than that administered IV to provide comparable analgesia. This indicates that the bioavailability of epidurally-administered sufentanil is reduced and suggests that a large proportion of the drug may be absorbed into the epidural fat. IMPLICATIONS: More epidural than IV sufentanil was required to provide comparable postoperative pain relief and similar plasma sufentanil concentrations. These data suggest that when sufentanil is administered in small-dose boluses, much of the drug is absorbed into the epidural fat and that the primary mechanism by which epidurally administered sufentanil produces analgesia is via systemic absorption.
PMID: 11473882, UI: 21367413
Anesth Analg 2001 Aug;93(2):419-23 , 4th contents page
Department of Anesthesiology, Osaka Medical College, Takatsuki, Japan.
Although intradermal injection of capsaicin produces acute pain and secondary hyperalgesia, long-term topical application of capsaicin cream has been used as a medication for pain relief in various pain conditions. We previously reported that intrathecal administration of prostaglandin (PG) E(2) and PGF(2alpha) into mice induced touch-evoked pain (allodynia) through capsaicin-sensitive and capsaicin-insensitive afferent fibers, respectively. To clarify the mechanism of an analgesic effect by capsaicin cream, here we applied it to the tail and hind paws of mice and investigated its effects on PGE(2)- and PGF(2alpha)-induced allodynia. Twenty-four-hour pretreatment of mice with 0.025% or 0.05% capsaicin cream markedly alleviated allodynia induced by PGE(2), but not by PGF(2alpha). These results suggest that the topical application of capsaicin cream modulates capsaicin-sensitive afferents and ameliorates allodynia evoked by PGE(2) at the spinal level. IMPLICATIONS: Topical application of capsaicin cream alleviates touch-evoked pain induced by the intrathecal administration of prostaglandin E(2). This study may provide a rationale for the use of capsaicin cream as a therapeutic drug for pain relief.
PMID: 11473873, UI: 21367404
Anesthesiology 2001 Aug;95(2):500-8
Klinik fur Anaesthesiologie und operative Intensivmedizin, Universitatsklinikum Benjamin Franklin, Freie Universitat Berlin, Germany. rittner@medizin.fu-berlin.de
BACKGROUND: Inflammatory pain can be effectively controlled by an interaction of opioid receptors on peripheral sensory nerve terminals with opioid peptides released from immune cells upon stressful stimulation. To define the source of opioid peptide production, we sought to identify and quantify populations of opioid-containing cells during the course of Freund's complete adjuvant-induced hind paw inflammation in the rat. In parallel, we examined the development of stress-induced local analgesia in the paw. METHODS: At 2, 6, and 96 h after Freund's complete adjuvant inoculation, cells were characterized by flow cytometry using a monoclonal pan-opioid antibody (3E7) and antibodies against cell surface antigens and by immunohistochemistry using a polyclonal antibody to beta-endorphin. After magnetic cell sorting, the beta-endorphin content was quantified by radioimmunoassay. Pain responses before and after cold water swim stress were evaluated by paw pressure thresholds. RESULTS: In early inflammation, 66% of opioid peptide-producing (3E7+) leukocytes were HIS48+ granulocytes. In contrast, at later stages (96 h), the majority of 3E7+ immune cells were ED1+ monocytes or macrophages (73%). During the 4 days after Freund's complete adjuvant inoculation, the number of 3E7+ cells increased 5.6-fold (P < 0.001, Kruskal-Wallis test) and the beta-endorphin content in the paw multiplied 3.9-fold (P < 0.05, Kruskal-Wallis test). In parallel, cold water swim stress-induced analgesia increased by 160% (P < 0.01, analysis of variance). CONCLUSIONS: The degree of endogenous pain inhibition is proportional to the number of opioid peptide-producing cells, and distinct leukocyte lineages contribute to this function at different stages of inflammation. These mechanisms may be important for understanding pain in immunosuppressed states such as cancer, diabetes, or AIDS and for the design of novel therapeutic strategies in inflammatory diseases.
PMID: 11506126, UI: 21396926
Anesthesiology 2001 Aug;95(2):421-7
Department of Anesthesia, Great Ormond Street Hospital for Children NHS Trust and the Institute of Child Health, London, United Kingdom. r.howard@ich.ucl.ac.uk
BACKGROUND: Low doses of local anesthetics applied to the young rat spinal cord in vitro have been shown to inhibit C-fiber-evoked responses. The aim of this work was to investigate whether such low doses applied epidurally selectively reduce nociceptive responses in vivo and to investigate the influence of postnatal development on such local anesthetic actions. METHODS: Three groups of rat pups aged 3, 10, and 21 days were studied. The threshold of the flexion withdrawal reflex to mechanical stimulation was determined in the hind limb at each age. Inflammatory pain was induced in the right hind limb with 2% carrageenan, causing a reduction in the sensory threshold on that side. The difference in threshold between the two sides represents inflammatory hypersensitivity. The effect of low-dose epidural bupivacaine on sensory thresholds and thus the induced hypersensitivity was also determined for each age group. RESULTS: Inflammatory hypersensitivity was selectively attenuated by very low doses of bupivacaine (concentration range. 0.004-0.0625%), which did not affect the sensory threshold in the contralateral uninflamed limb. This effect was also age-related, with younger rats being more sensitive than older rats. CONCLUSIONS: The effects of epidural bupivacaine in the infant rat are developmentally regulated. Lower doses have a selective analgesic effect that decreases with increasing postnatal age.
PMID: 11506116, UI: 21396916
Anesthesiology 2001 Aug;95(2):395-402
Department of Anesthesiology, University of Erlangen-Nuremberg, Germany. koppert@kfa.imed.uni-erlangen.de
BACKGROUND: The authors used the analgesics alfentanil, S(+)-ketamine, and systemic lidocaine to examine a new human model of experimental pain and hyperalgesia. METHODS: Transcutaneous electrical stimulation at a high current density (5 Hz, 67.5+/-6.6 mA) was used to provoke acute pain (numeric rating scale, 5 of 10), stable areas of secondary mechanical hyperalgesia to pin prick (43.6+/-32.1 cm2), and light touch (27.5+/-16.2 cm2) for 2 h. Alfentanil, S(+)-ketamine, and lidocaine were applied for 20 min in a double-blind, placebo-controlled, crossover design in 12 subjects using target controlled infusions. RESULTS: In the placebo session, pain ratings and areas of hyperalgesia were stable during the stimulation period, which facilitated the assessment of analgesic effects. Alfentanil effectively inhibited electrically evoked pain and reduced pin prick hyperalgesia and allodynia during its infusion. S(+)-ketamine-induced inhibition of secondary hyperalgesia was more pronounced and lasted for the whole experimental protocol. Therapeutic levels of systemic lidocaine showed only marginal analgesic effects, but lasting antihyperalgesic effects. CONCLUSIONS: A new model of electrically induced pain and hyperalgesia was established, which enabled assessment of the time course of analgesic and antihyperalgesic effects with high temporal resolution and minimum tissue damage and which was further validated by use of common intravenous anesthetics.
PMID: 11506112, UI: 21396912
Anesthesiology 2001 Aug;95(2):349-56
Department of Anesthesiology, University of Hirosaki School of Medicine, Japan. nao@cc.hirosaki-u.ac.jp
BACKGROUND: In a controlled and double-blind study, the authors tested the hypothesis that preoperative insertion of intradermal needles at acupoints 2.5 cm from the spinal vertebrae (bladder meridian) provide satisfactory postoperative analgesia. METHODS: The authors enrolled patients scheduled for elective upper and lower abdominal surgery. Before anesthesia, patients undergoing each type of surgery were randomly assigned to one of two groups: acupuncture (n = 50 and n = 39 for upper and lower abdominal surgery, respectively) or control (n = 48 and n = 38 for upper and lower abdominal surgery, respectively). In the acupuncture group, intradermal needles were inserted to the left and right of bladder meridian 18-24 and 20-26 in upper and lower abdominal surgery before induction of anesthesia, respectively. Postoperative analgesia was maintained with epidural morphine and bolus doses of intravenous morphine. Consumption of intravenous morphine was recorded. Incisional pain at rest and during coughing and deep visceral pain were recorded during recovery and for 4 days thereafter on a four-point verbal rating scale. We also evaluated time-dependent changes in plasma concentrations of cortisol and catecholamines. RESULTS: Starting from the recovery room, intradermal acupuncture increased the fraction of patients with good pain relief as compared with the control (P < 0.05). Consumption of supplemental intravenous morphine was reduced 50%, and the incidence of postoperative nausea was reduced 20-30% in the acupuncture patients who had undergone either upper or lower abdominal surgery (P < 0.01). Plasma cortisol and epinephrine concentrations were reduced 30-50% in the acupuncture group during recovery and on the first postoperative day (P < 0.01). CONCLUSION: Preoperative insertion of intradermal needles reduces postoperative pain, the analgesic requirement, and opioid-related side effects after both upper and lower abdominal surgery. Acupuncture analgesia also reduces the activation of the sympathoadrenal system that normally accompanies surgery.
PMID: 11506105, UI: 21396905
Br J Anaesth 2001 Sep;87(3):400-5
Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok 10700, ThailandCorresponding author.
[Medline record in process]
This study was designed to cross-validate a composite measure of the pain scales CHEOPS (Children's Hospital of Eastern Ontario Pain Scale), OPS (Objective Pain Scale, simplified for parent use by replacing blood pressure measurement with observation of body language or posture), TPPPS (Toddler Preschool Postoperative Pain Scale) and FLACC (Face, Legs, Activity, Cry, Consolability) in 167 Thai children aged 1-5.5 yr. The pain scales were translated and tested for content, construct and concurrent validity, including inter-rater and intra-rater reliabilities. Discriminative validity in immediate and persistent pain for the age groups </=3 and >3 yr were also studied. The children's behaviour was videotaped before and after surgery, before analgesia had been given in the post-anaesthesia care unit (PACU), and on the ward. Four observers then rated pain behaviour from rearranged videotapes. The decision to treat pain was based on routine practice and was made by a researcher unaware of the rating procedure. All tools had acceptable content validity and excellent inter-rater and intra-rater reliabilities (intraclass correlation >0.9 and >0.8 respectively). Construct validity was determined by the ability to differentiate the group with no pain before surgery and a high pain level after surgery, before analgesia (P<0.001). The positive correlations among all scales in the PACU and on the ward (r=0.621-0.827, P<0.0001) supported concurrent validity. Use of the kappa statistic indicated that CHEOPS yielded the best agreement with the routine decision to treat pain. The younger and older age groups both yielded very good agreement in the PACU but only moderate agreement on the ward. On the basis of data from this study, we recommend CHEOPS as a valid, reliable and practical tool. Br J Anaesth 2001; 87: 400-5
PMID: 11517123, UI: 21407605
J Pain Symptom Manage 2001 Jul;22(1):622-6
Department of Anesthesia-Section Pain Clinic, Ghent University Hospital, Ghent, Belgium
A patient with mycosis fungoides illustrates the problem of pain management during wound care and suggests the utility of a novel treatment, gabapentin. Skin lesions, be they induced through necrosis of tumor, therapy (e.g., radiotherapy), or by pressure ulceration, are often the cause of continuous pain or acute wound dressing pain. Optimizing the analgesic treatment in those patients is thus of major importance. Anti-inflammatory drugs and opioids are the cornerstones in the treatment of cancer pain but are rarely sufficient to control wound pain. Different adjuvant techniques can be used, including topical analgesics, psychological distraction techniques, anxiolytics, and co-analgesics. There is growing evidence that anticonvulsants, and sodium channel blockers in particular, are effective not only in neuropathic but also in inflammatory pain. Gabapentin, a voltage sensitive sodium and calcium channel blocker, was used as a co-analgesic to supplement morphine in this case of cancer wound dressing pain.
PMID: 11516605, UI: 21408244
J Pain Symptom Manage 2001 Jul;22(1):617-21
Marie Curie Centre, Liverpool, United Kingdom
A difficult pain occurred in a man with chronic renal failure as a result of the underlying condition of calciphylaxis. In this condition, calcification of small and medium-sized arteries occurs, which may result in ischemia and gangrene. In general, the prognosis is poor, with mortality rates ranging from 23-63%. Pain associated with this condition has been previously reported. In this report, the pain occurred in the lower limbs and penis, and was associated with local necrosis. The pain was observed to be significantly worse on dialysis. A multiprofessional approach to care ultimately resulted in good symptom control.
PMID: 11516604, UI: 21408243
J Pain Symptom Manage 2001 Jul;22(1):610-6
Department of Medicine, University of Medicine and Dentistry New Jersey/New Jersey Medical School, Newark, NJ, USA
Patients with unresectable pancreatic cancer often suffer severe pain. Various techniques are available for pain control. We present a patient with pancreatic cancer who underwent unilateral video-assisted thoracoscopic sympathectomy-splanchnicectomy and had complete pain relief. This minimally invasive procedure offers promise in carefully selected patients with severe pain from pancreatic cancer and other conditions which are not amenable to conventional interventions.
PMID: 11516603, UI: 21408242
J Pain Symptom Manage 2001 Jul;22(1):600-9
Departments of Pediatric Surgery, Netherlands Institute of Health Sciences, Erasmus University, Rotterdam, The Netherlands
To estimate the association between behavioral and physiological pain measures and to identify determinants predicting the level of association, the COMFORT 'behavior' scale, heart rate (HR), mean arterial pressure (MAP), and the variability of HR and MAP (HRV and MAPV) were assessed every 3 hours after major abdominal or thoracic surgery. Subjects were 204 infants aged 0-3 years. The within-subject correlations, using the repeated measures, were 0.37, 0.44, 0.48, and 0.49 for COMFORT 'behavior' with HRV, HR, MAP, and MAPV, respectively. Neonates had lower behavior-physiology correlations than the older infants, due to low pain scores. Pain characteristics significantly predicted the COMFORT 'behavior'-HR/MAP correlations, suggesting that the behavior-physiology correlations increase with increasing pain. The behavior-physiology correlations were not greatly affected by physical condition. These data demonstrate large interindividual differences in behavior-physiology correlations after major surgery in 0- to 3-year-old infants. These differences should be further explored in future research.
PMID: 11516602, UI: 21408241
J Pain Symptom Manage 2001 Jul;22(1):591-9
Department of Psychology, The University of Georgia, Athens, GA, USA
This study evaluated the concurrent and construct validity of the Child-Adult Medical Procedure Interaction Scale-Short Form (CAMPIS-SF), a behavior rating scale of children's acute procedural distress and coping, and the coping promoting behaviors and distress promoting behaviors of their parents and the medical personnel who were present in the medical treatment room. Sixty preschool children undergoing immunizations at a county health department served as subjects. Videotapes of the procedures were scored using three observational measures in addition to the CAMPIS-SF. Also, parent, nurse, and child report measures of child distress, fear, pain, and cooperation were obtained. Results indicated that the validity of the CAMPIS-SF codes of Child Coping, Child Distress, Parent Coping Promoting, Parent Distress Promoting, Nurse Coping Promoting, and Nurse Distress Promoting behaviors was supported by multiple significant correlations with the other measures. The interrater reliability of the 5-point CAMPIS-SF scales was good to excellent. The results emphasize that the CAMPIS-SF scales can be used to monitor not only children's acute procedural distress, but also their coping and the various adults' behaviors that significantly influence children's distress. Further, because of the CAMPIS-SF's ease of use, it is likely that the study of the effects of the social environment on children's distress and coping will be facilitated.
PMID: 11516601, UI: 21408240
J Pain Symptom Manage 2001 Jul;22(1):584-90
Departments of Psychiatry, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
Although pain is an extremely common symptom presenting to primary care physicians, it frequently is not optimally managed. The purpose of this feasibility study was to develop and pilot-test an efficient, rapid assessment and management approach for pain in busy community practices. The intervention utilized the Dartmouth COOP Clinical Improvement System (DCCIS) and a telephone-based, nurse-educator intervention. Patients from four primary care practices in rural New Hampshire and Vermont were screened by mail for the presence of persistent pain. Patients with mild to severe pain were randomized to either the usual care control group (n = 383) or the intervention group (n = 320). Patients who reported pain but no psychosocial problems received a summary of identified problems and targeted educational material via mail (DCCIS). Patients who reported pain and psychosocial problems received the DCCIS intervention and calls from a nurse-educator who provided pain self-management strategies and a problem-solving approach for psychosocial problems. Post-treatment evaluation revealed that patients in the intervention group scored significantly better on the Pain, Physical, Emotional, and Social subscales of the SF-36 and on the total score of the Functional Interference Scale, as compared to a usual care control group. Feasibility and acceptability of the approach were demonstrated; however, the conclusions based on analyses of the post-treatment outcomes were tempered by baseline imbalances across groups.
PMID: 11516600, UI: 21408239
J Pain Symptom Manage 2001 Jul;22(1):575-83
Pain and Palliative Care Service, Department of Neurology, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
This open-label study evaluated the long-term safety and tolerability of oral transmucosal fentanyl citrate (OTFC) in ambulatory cancer patients with breakthrough pain undergoing cancer care at 32 university- or community-based practices. Patients had participated in a previous short-term titration trial of OTFC, were experiencing at least one episode per day of breakthrough pain, and had achieved relief of their breakthrough pain with an opioid. Patients received OTFC units at a starting dosage strength determined in the short-term trial (200-1600 &mgr;g). Outcome measures included number of successfully treated breakthrough pains, global satisfaction rating (0 = poor through 4 = excellent), and side effects. In total, 41,766 units of OTFC were used to treat 38,595 episodes of breakthrough pain in 155 patients. Number of treatment days ranged from 1 to 423 (mean, 91 days). Patients averaged 2.9 breakthrough pain episodes per day. About 92% of episodes were successfully treated with OTFC and there was no trend toward decreased effectiveness over time. Most patients (61%) did not require dose escalation during treatment. Global satisfaction ratings were consistently above 3, indicating very good to excellent relief. Common adverse events associated with OTFC were somnolence (9%), constipation (8%), nausea (8%), dizziness (8%), and vomiting (5%). Six patients (4%) discontinued therapy due to an OTFC-related adverse event. There were no reports of abuse and no concerns about the safety of the drug raised by patients or families. OTFC was used safely and effectively during long-term treatment of breakthrough pain in cancer patients at home.
PMID: 11516599, UI: 21408238
JAMA 2001 Aug 15;286(7):788
PMID: 11497524, UI: 21389434
Lancet 2001 Aug 11;358(9280):437-8
Department of Urology, University of Texas Health Science Center, San Antonio, TX 78229-3900, USA.
PMID: 11513904, UI: 21405922
N Engl J Med 2001 Aug 9;345(6):469
PMID: 11496869, UI: 21364563
Pain 2001 Sep;93(3):317-25
Primary Care Sciences Research Centre, University of Keele, Staffordshire ST5 5BG, Stoke-on-Trent, UK
The objective of the study was to examine the 1-year cumulative incidence of episodic neck pain and to explore its associations with individual risk factors, including a history of previous neck injury. A baseline cross-sectional survey of an adult general population sample made up of all 7669 adults aged 18-75 years, registered with two family practices in South Manchester, United Kingdom, identified the study population of adults with no current neck pain. This study population was surveyed again 12 months later to identify all those who had experienced neck pain during the follow-up period. At follow-up, cumulative 1-year episode incidence of neck pain was estimated at 17.9% (95% confidence interval 16.0-19.7%). Incidence was independent of age, but was more common in women. A history of previous neck injury at baseline was a significant risk factor for subsequent neck pain in the follow-up year (risk ratio 1.7, 95% confidence interval 1.2-2.5), independent of gender and psychological status. Other independent baseline risk factors for subsequent neck pain included number of children, poor self-assessed health, poor psychological status and a past history of low back pain. We have carried out a prospective study in a general population sample and demonstrated that established risk factors for chronic pain predict future episodes of neck pain, and shown that in addition a history of neck injury is an independent and distinct risk factor. This finding may have major public health and medicolegal implications.
PMID: 11514090, UI: 21406106
Pain 2001 Sep;93(3):279-93
Department of Clinical Neurology, Ruhr-University, Bochum, Germany
Based on bed-side neurological testing, it has recently been shown that 33% of chronic complex regional pain syndrome (CRPS) type I patients exhibit sensory impairments, which extend past the painful area of the affected limb in a hemisensory distribution (Pain, 80 (1999) 95). In the present study, the clinically observed changes in touch and temperature sensations on the side of the body ipsilateral to the affected limb were investigated quantitatively. Neurophysiological and psychological examinations were conducted to detect changes in the peripheral and central nervous system as well as psychopathological abnormalities.In 40 patients with CRPS, a bed-side neurological examination was performed. Quantitative sensory testing was conducted at five locations on each side of the body. The evaluation of touch thresholds was performed using von Frey filaments (n=40). To measure cool, warm and heat pain thresholds quantitatively, a thermal stimulator using a Peltier-element was used (n=28). With respect to clinical findings, the initiating trauma and severity of abnormalities on nerve conduction testing, three patients were diagnosed as having a reliable CRPS II (causalgia) and five patients a possible CRPS II. Thirty-two patients were diagnosed as having a CRPS I.On clinical examination, 15 patients revealed generalized sensory deficits on the side of the body ipsilateral to the affected limb (hemisensory deficit, n=12; sensory impairment in the upper quadrant of the body, n=3). Patients with these generalized sensory deficits had a significantly longer illness duration (P<0.05) and a significantly higher percentage of mechanical allodynia/hyperalgesia than patients with spatially restricted sensory deficits (n=25) (P<0.05). In patients with generalized sensory impairment, thresholds for touch, warm and cold sensations, and for heat pain were significantly increased at all five locations tested ipsilaterally compared with the contralateral body side, except for the cool threshold on the chest and the heat pain threshold distally on the affected limb. In patients with sensory deficits limited to the affected limb, the touch threshold was significantly higher only in the distal part of the affected limb when compared with the contralateral limb. In these patients, thermal testing revealed almost no differences in cool, warm and heat pain thresholds when comparing both sides. Repeated thermal testing conducted in five patients with generalized sensory impairment reproduced the significant differences between both sides for cool, warm and heat pain thresholds. However, the correlation between the results obtained in the first and second examinations was poor.Neurophysiological recordings revealed pathological results in 46% for nerve conduction studies, 24% for somatosensory evoked potentials and 39% for sympathetic skin response. For all methods applied, there was no statistically significant difference in the incidence of pathological results between patients with generalized and patients with spatially restricted sensory abnormalities. Psychological examination using the structured clinical interview on DSM-IV (SKID) demonstrated a high frequency of affective and anxiety disorders, however, without significant differences between both groups.We conclude that hemisensory impairment in patients with CRPS Type I is probably related to functional disturbances in processing of noxious events in the thalamus and may be a clinical correlate of subcortical brain plasticity in chronic pain.
PMID: 11514087, UI: 21406103
Pain 2001 Sep;93(3):247-57
Klinik fur Anaesthesiologie und Operative Intensivmedizin, Universitat zu Koln, 50924, Koln, Germany
Most patients with advanced cancer develop diverse symptoms that can limit the efficacy of pain treatment and undermine their quality of life. The present study surveys symptom prevalence, etiology and severity in 593 cancer patients treated by a pain service. Non-opioid analgesics, opioids and adjuvants were administered following the WHO-guidelines for cancer pain relief. Other symptoms were systematically treated by appropriate adjuvant drugs. Pain and symptom severity was measured daily by patient self-assessment; the physicians of the pain service assessed symptom etiology and the severity of confusion, coma and gastrointestinal obstruction at each visit. The patients were treated for an average period of 51 days. Efficacy of pain treatment was good in 70%, satisfactory in 16% and inadequate in 14% of patients. The initial treatment caused a significant reduction in the average number of symptoms from four to three. Prevalence and severity of anorexia, impaired activity, confusion, mood changes, insomnia, constipation, dyspepsia, dyspnoea, coughing, dysphagia and urinary symptoms were significantly reduced, those of sedation, other neuropsychiatric symptoms and dry mouth were significantly increased and those of coma, vertigo, diarrhea, nausea, vomiting, intestinal obstruction, erythema, pruritus and sweating remained unchanged. The most frequent symptoms were impaired activity (74% of days), mood changes (22%), constipation (23%), nausea (23%) and dry mouth (20%). The highest severity scores were associated with impaired activity, sedation, coma, intestinal obstruction, dysphagia and urinary symptoms. Of all 23 symptoms, only constipation, erythema and dry mouth were assessed as being most frequently caused by the analgesic regimen. In conclusion, the high prevalence and severity of many symptoms in far advanced cancer can be reduced, if pain treatment is combined with systematic symptom control. Nevertheless, general, neuropsychiatric and gastrointestinal symptoms are experienced during a major part of treatment time and pain relief was inadequate in 14% of patients. Cancer pain management has to be embedded in a frame of palliative care, taking all the possibilities of symptom management into consideration.
PMID: 11514084, UI: 21406100
Pain 2001 Sep;93(3):229-37
Section for Personal Injury Prevention, Karolinska Institute, Box 127 18, S-112 94, Stockholm, Sweden
A better knowledge of differential treatment outcomes for subgroups of chronic spinal pain patients may, for instance, help clinicians in treatment planning or pain researchers in treatment outcome research. The purpose of this prospective study was to evaluate the predictive validity of a subgroup classification based on the Swedish version of the (West Haven Yale) Multidimensional Pain Inventory, the MPI-S. Patients referred to a vocational rehabilitation program were classified into one of three groups, labeled 'adaptive copers', 'dysfunctional' patients, and 'interpersonally distressed' patients, and followed over an 18-month follow-up period. The outcome variables were absence from work (defined as sick listing plus early retirement), general health status, and utilization of health care resources. To our knowledge, the predictive validity of the MPI subgroups has not been evaluated regarding sick listing and early retirement after rehabilitation. As hypothesized, the results showed that the 'dysfunctional' patient group had significantly more registered absences from work and reported higher utilization of health care, over the follow-up period compared to the 'adaptive copers'. Furthermore, as hypothesized, the 'interpersonally distressed' and 'dysfunctional' patient groups report a poorer general health status than the 'adaptive copers' over the whole follow-up period. However, contrary to our hypothesis, the proportion of improved patients did not differ significantly between the subgroups. Altogether, the predictive validity of the MPI-S subgroup classification was mainly confirmed. The clinical implications of this study suggest that the matching of treatment to patient needs may enhance treatment outcome, reduce pain and suffering among chronic spinal pain patients and facilitate a better health economic allocation of treatment resources.
PMID: 11514082, UI: 21406098
Pain 2001 Sep;93(3):201-5
Department of Psychology and the Center for Neurosciences, University of Colorado at Boulder, 80309-0345, Boulder, CO, USA
PMID: 11514078, UI: 21406094
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