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Cancer 2001 Dec 15;92(12):3056-61
Pain and Palliative Care Service, Department of Neurology, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA.
BACKGROUND: Therapeutic fentanyl blood levels are reached approximately 12-16 hours after the initial application of transdermal fentanyl patches. For this reason, fentanyl patches should not be used to treat acute exacerbations of cancer pain. Acute cancer-related pain can be treated with fentanyl administered by continuous intravenous infusion (CII) in combination with patient-controlled analgesia (PCA). Patients then can be switched from intravenous (IV) to transdermal fentanyl once stable pain relief has been achieved. The objective of the current case series was to evaluate and describe the safety and effectiveness of a method for converting hospitalized patients with cancer-related pain from IV to transdermal fentanyl. METHODS: The authors prospectively evaluated 15 consecutive cancer patients during the conversion from IV to transdermal fentanyl. In all patients, a transdermal patch delivering fentanyl at a rate equivalent to that of the final continuous IV infusion was applied. The CII rate was decreased by 50% 6 hours after application of the fentanyl patch and then discontinued after another 6 hours. Demand boluses of IV fentanyl equivalent in dosage to 50-100% of the final CII rate remained available via PCA during the 24 hours after patch application. Pain intensity (on a scale of 0-10), sedation (on a scale of 0-3), and hourly PCA administration (microg/hr) were assessed and recorded immediately prior to application of the fentanyl patch and 6, 12, 18, and 24 hours thereafter. RESULTS: Pain intensity, sedation, and hourly PCA administration appeared to remain stable throughout the transition from IV to transdermal fentanyl. CONCLUSIONS: The results of the current study demonstrate that the conversion from IV to transdermal fentanyl can be accomplished safely and effectively using a 1:1 (IV:transdermal) conversion ratio and a two-step taper of the CII over 12 hours. Copyright 2001 American Cancer Society.
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PMID: 11753984, UI: 21621846
Eur J Pharmacol 2002 Jan 18;435(1):43-57
Department of General Pharmacology, Novo Nordisk A/S, 2760 Maaloev, Denmark
[Medline record in process]
The tricyclic compound (R)-1-(3-(10,11-dihydro-5H-dibenzo[a,d]cyclohepten-5-ylidene)-1-propyl)-3-piperidine carboxylic acid (ReN 1869) is a novel, selective histamine H(1) receptor antagonist. It is orally available, well tolerated, easily enters the central nervous system (CNS) but no adverse effects are seen in mice at 300 mg/kg. ReN 1869 at 0.01-10 mg/kg is antinociceptive in tests of chemical nociception in rodents (formalin, capsaicin, phenyl quinone writhing) but not in thermal tests (hot plate and tail flick). ReN 1869 amplifies the analgesic action of morphine but does not show tolerance after chronic dosing. Moreover, the compound is effective against inflammation of neurogenic origin (antidromic nerve stimulation, histamine-evoked edema) but not in carrageenan-induced inflammation. We suggest that ReN 1869, via H(1) blockade, counteracts the effect of histamine liberated from activated mast cells and inhibits pain transmission in the dorsal spinal cord. ReN 1869 represents a new class of antihistamines with pain-relieving properties that probably is mediated centrally through histamine H(1) receptors but alternative mechanisms of action cannot be excluded.
PMID: 11790377, UI: 21650524
Eur J Pharmacol 2001 Nov 2;430(2-3):219-27
Department of Biology, GlaxoSmithKline S.p.A., Medicines Research Centre, Via Fleming 4, 37135, Verona, Italy. mq7886@gsk.com
The effects of the N-methyl-D-aspartate (NMDA) receptor/glycine site antagonist, GV196771A (E-4,6-dichloro-3-(2-oxo-1-phenyl-pyrrolidin-3-ylidenemethyl)-1H-indole-2-carboxylic acid sodium salt), on mechanical allodynia and on tolerance to the antinociceptive effects induced by morphine were evaluated. Its antiallodynic properties were studied in a model of chronic constriction injury applied to rat sciatic nerve. GV196771A (0.3-10 mg/kg, p.o.) dose-dependently inhibited established mechanical allodynia when tested 14 or 21 days after nerve ligation. In the formalin test in mice, GV196771A (10 or 20 mg/kg, p.o.), administered for 8 days together with morphine 10 mg/kg, i.p. inhibited morphine tolerance development in both early and late phases of the test. This finding reinforces the key role of the NMDA receptors in the plastic event, such as allodynia, which develops in some conditions of painful neuropathy. Moreover, the capability to strongly reduce morphine-induced tolerance suggests that GV196771A could be an alternative agent for the treatment of difficult pain states not only when given alone, but also in combination, in order to prolong the analgesic effects of the opiates.
PMID: 11711034, UI: 21567905
N Engl J Med 2001 Nov 22;345(21):1574; discussion 1574-5
PMID: 11794230, UI: 21553863
N Engl J Med 2001 Nov 22;345(21):1573-4; discussion 1574-5
PMID: 11794228, UI: 21553862
N Engl J Med 2001 Nov 15;345(20):1503
PMID: 11794213, UI: 21544524
N Engl J Med 2001 Nov 15;345(20):1502-3
PMID: 11794212, UI: 21544523
N Engl J Med 2001 Nov 1;345(18):1340-2
PMID: 11794155, UI: 21517338
N Engl J Med 2001 Nov 1;345(18):1312-7
Institute for Health Policy, Division of General Internal Medicine, Massachusetts General Hospital-Partners Health Care System and Harvard Medical School, Boston, USA.
BACKGROUND: Gatekeeping refers to the prior approval of referrals to specialists by a primary care physician. Although many health plans view gatekeeping as an essential tool for controlling costs and coordinating care, many patients and physicians object to it. METHODS: On April 1, 1998, Harvard Vanguard Medical Associates, a large, multispecialty, capitated group practice previously known as Harvard Community Health Plan, eliminated a gatekeeping system that had been in place for over 25 years. We determined the effects of opening access to specialists on visits to primary care physicians and specialists by adults. In randomly selected cohorts of 10,000 members each, we analyzed visits during 6-month periods for the 3 years before and 18 months after gatekeeping was eliminated. RESULTS: Adults visited a primary care physician an average of 1.21 times and 1.19 times per six-month period before and after the elimination of gatekeeping, respectively (P=0.05); the average number of visits to a specialist was 0.78 per six-month period both before and after its elimination (P=0.35). There was little change in the percentage of visits to specialists included in the analysis as a proportion of all visits (39.1 percent before the elimination of gatekeeping and 39.5 percent afterward). The percentage of first visits to specialists as a proportion of all visits to specialists included in the analysis increased from 24.7 to 28.2 percent (P<0.001). There were small increases in the numbers of visits to orthopedists and physical or occupational therapists. The proportion of visits to specialists for low back pain that were new consultations increased from 26.6 to 32.9 percent (P=0.01). CONCLUSIONS: In a capitated, multispecialty group practice, we found little evidence of substantial changes in the use of specialty services by adults in the first 18 months after the elimination of gatekeeping.
PMID: 11794151, UI: 21517334
Pain 2002 Jan;95(1-2):175-86
Departments of Preventive Sciences, Neuroscience, Psychiatry, and Cancer Center, University of Minnesota, 18-208 Moos Tower, 515 Delaware Street SE, 55455, Minneapolis, MN, USA
Although pains arising from the craniofacial complex can be severe and debilitating, relatively little is known about the peripheral and central mechanisms that generate and maintain orofacial pain. To better understand the neurons in the trigeminal complex and spinal cord that are activated following nociceptive stimuli to the orofacial complex, we examined substance P (SP) induced internalization of substance P receptors (SPR) in neurons following dental extraction in the rat.Unilateral gingival reflection or surgical extraction of a rat maxillary incisor or molar was performed and tissues harvested at various time points post-extraction. Immunohistochemical analysis of brainstem and cervical spinal cord sections was performed using an anti-SPR antibody and confocal imaging. Both the number and location of neurons showing SPR internalization was dependent on the location and extent of tissue injury. Whereas extraction of the incisor induced internalization of SPR in neurons bilaterally in nucleus caudalis and the spinal cord, extraction of the molar induced strictly unilateral internalization of SPR-expressing neurons in the same brain structures. Minor tissue injury (retraction of the gingiva) activated SPR neurons located in lamina I whereas more extensive and severe tissue injury (incisor or molar extraction) induced extensive SPR internalization in neurons located in both laminae I and III-V. The rostrocaudal extent of the SPR internalization was also correlated with the extent of tissue injury. Thus, following relatively minor tissue injury (gingival reflection) neurons showing SPR internalization were confined to the nucleus caudalis while procedures which cause greater tissue injury (incisor or molar extraction), neurons showing SPR internalization extended from the interpolaris/caudalis transition zone through the C7 spinal level. Defining the population of neurons activated in orofacial pain and whether analgesics modify the activation of these neurons should provide insight into the mechanisms that generate and maintain acute and chronic orofacial pain.
PMID: 11790480, UI: 21650979
Pain 2002 Jan;95(1-2):165-73
EMI INSERM 9904, EA 1741, Laboratoire de Pharmacologie Medicale, Faculte de Medecine, B.P. 38, 63001 Cedex, Clermont-Ferrand, France
Most pain tests used for the assessment of drug analgesic activity in animal chronic pain models are based on the measurement of the response to an external acute stimulation (thermal, mechanical or electrical). But these stimuli are not related to the chronic pain experienced by the animal. Quantitative analysis of the spontaneous behaviour induced by the chronic pain state is needed. Several authors have suggested that ultrasonic vocalisations (USVs) emitted by rats in painful situations might reflect expression of affective pain. In a first study, we recorded spontaneous USVs in sub-chronic and chronic pain models: inflammation induced by carrageenan, arthritis induced by Freund's adjuvant and diabetes induced by streptozotocin. The USVs were analysed when naive Sprague-Dawley rats were alone and during non-agonistic interaction with a conspecific. When the rats were alone they did not emit any USV. During social interaction, no difference in either the frequency or the duration was observed between the emissions of healthy rats and rats in pain. In a third study, the influence of three parameters, degree of confrontation between the rats, age of the conspecific and housing conditions (isolated or collective) was studied in the arthritic rat model. Arthritic rats did not emit more USVs than controls in any of our experimental conditions. A fourth study showed that Aspirin (200 mg/kg) had no effect on the USVs, this data confirms the lack of direct relationship between USVs and experimental chronic pain in rats in our conditions.
PMID: 11790479, UI: 21650978
Pain 2002 Jan;95(1-2):143-52
Department of Pharmacology, University of Arizona Health Sciences Center, 85724, Tucson, AZ, USA
Neuropathic pain is a debilitating chronic syndrome that often arises from injuries to peripheral nerves. Such pain has been hypothesized to be the result of an aberrant expression and function of sodium channels at the site of injury. Here, we show that intrathecal administration of specific antisense oligodeoxynucleotides (ODN) to the peripheral tetrodotoxin (TTX)-resistant sodium channel, NaV1.8, resulted in a time-dependent uptake of the ODN by dorsal root ganglion (DRG) neurons, a selective 'knock-down' of the expression of NaV1.8, and a reduction in the slow-inactivating, TTX-resistant sodium current in the DRG cells. The ODN treatment also reversed neuropathic pain induced by spinal nerve injury, without affecting non-noxious sensation or response to acute pain. These data provide direct evidence linking NaV1.8 to neuropathic pain. As NaV1.8 expression is restricted to sensory neurons, this channel offers a highly specific and effective molecular target for the treatment of neuropathic pain.
PMID: 11790477, UI: 21650976
Pain 2002 Jan;95(1-2):133-42
Department of Rehabilitation Medicine, Box 356490, University of Washington School of Medicine, 98195-6490, Seattle, WA, USA
Biopsychosocial models of chronic pain hypothesize a role for psychological and environmental factors in adjustment to chronic pain. To test the utility of such models for understanding phantom limb pain, 61 persons with recent amputations were administered measures of average phantom limb pain intensity, pain interference, depression, pain coping use, pain cognitions and appraisals, and social environmental variables 1 month post-amputation, and the measures of pain intensity, pain interference, and depression again 5 months later. Multiple regression analyses showed that the psychosocial predictors made a statistically significant contribution to the concurrent prediction of average phantom limb pain, pain interference, and depression at the initial assessment, and a significant contribution to the prediction of subsequent change in pain interference and depression over the course of 5 months. The results support the utility of studying phantom limb pain from a biopsychosocial perspective, and identify specific biopsychosocial factors (e.g., catastrophizing cognitions, social support, solicitous responses from family members, and resting as a coping response) that may play an important role in adjustment to phantom limb pain.
PMID: 11790476, UI: 21650975
Pain 2002 Jan;95(1-2):119-24
Department of Anesthesiology, Vanderbilt University School of Medicine, Vanderbilt University Medical Center, Suite 403-G MAB, 1211 Twenty-First Avenue South, 37232-1557, Nashville, TN, USA
This study tested for evidence supporting the clinical lore of three sequential stages of complex regional pain syndrome (CRPS) and examined the characteristics of possible CRPS subtypes. A series of 113 patients meeting IASP criteria for CRPS underwent standardized history and physical examinations to assess CRPS signs and symptoms in four domains identified in previous research: pain/sensory abnormalities, vasomotor dysfunction, edema/sudomotor dysfunction, and motor/trophic changes. K-Means cluster analysis was used to derive three relatively homogeneous CRPS patient subgroups based on similarity of sign/symptom patterns in these domains. The resulting CRPS subgroups did not differ significantly regarding pain duration as might be expected in a sequential staging model. However, the derived subgroups were statistically-distinct, and suggested three possible CRPS subtypes: (1) a relatively limited syndrome with vasomotor signs predominating, (2) a relatively limited syndrome with neuropathic pain/sensory abnormalities predominating, and (3) a florid CRPS syndrome similar to 'classic RSD' descriptions. Subtype 3 showed the highest levels of motor/trophic signs and possible disuse-related changes (osteopenia) on bone scan, despite having directionally the briefest pain duration of the three groups. EMG/NCV testing suggests that Subtype 2 may reflect CRPS-Type 2 (causalgia). Overall, these results are consistent with limited previous work that argues against three sequential stages of CRPS. However, several distinct CRPS subtypes are suggested, and these could ultimately have utility in targeting treatment more effectively.
PMID: 11790474, UI: 21650973
Pain 2002 Jan;95(1-2):111-8
Department of Neuropsychology at the Ruprecht-Karls-University of Heidelberg, Central Institute of Mental Health, J 5, D-68159, Mannheim, Germany
The role of operant conditioning for the development and maintenance of chronic pain was examined in 30 chronic back pain patients (CBP) and 30 matched healthy controls. Half of each group was reinforced for increased, half for decreased pain reports while EEG, EOG, heart rate, skin conductance and muscle tension levels were recorded. Both groups showed similar learning rates, however, the CBP patients displayed slower extinction of both the verbal and the cortical (N150) pain response. In addition, the CBP group displayed prolonged elevated electromyogram levels to the task. These data suggest that CBP patients are more easily influenced by operant conditioning factors than healthy controls and this susceptibility may add to the maintenance of the chronic pain problem.
PMID: 11790473, UI: 21650972
Pain 2002 Jan;95(1-2):83-91
Division of Research, Western States Chiropractic College, 2900 NE 132nd Avenue, 97230, Portland, OR, USA
Clinicians use patients' recall of pain and disability relief as indicators of therapeutic effectiveness. Recall can change over time, however, and is influenced by factors other than true relief, including current health status. We have determined the trend in the relative contribution of current pain/disability and actual relief (current-baseline score) to relief recall over the course of 1 year. Self-referred patients (n=1182) seeking treatment from primary-care medical doctors and chiropractors in community-based clinics were asked to record present pain and disability, as well as perceived relief at five follow-up time points from 2 weeks to 12 months after initial consultation for acute and chronic low back pain (LBP). Multiple regression analysis was performed at each time point and over the five follow-up time points. We found a clear logarithmic time trend of increasing dependence of pain relief recall on present pain (P<0.0001) and a concomitant pattern of decreasing dependence on actual pain relief (P<0.0001). The patterns are fairly consistent for acute and chronic patients. The principal independent predictor of perceived pain/disability relief appears to be present pain/disability with actual relief playing a smaller role at all time points (P<0.0001) except for disability relief recall at 2 weeks (P=0.103). The findings are robust in LBP sufferers. Complaint characteristics including LBP chronicity, sciatica, LBP history, and comorbidity; psychosocial variables including stress, depression, and well being; sociodemographics; and treating provider type are not important independent predictors of pain and disability relief recall in ambulatory LBP patients. Perceived relief is too weakly related to present pain and disability to be accurate enough for use as a clinical assessment tool for individual patients. Physicians may need to use objective relief data to give the patient a realistic idea of actual improvement.
PMID: 11790470, UI: 21650969
Pain 2002 Jan;95(1-2):75-82
Pain Research Group, MDAnderson Cancer Center, 1515 Holcombe Blvd., Box 221, 77030, Houston, TX, USA
This study examined the impact of pain on self-rated health status in the community-dwelling older adults using the 1993 public release data of the Asset and Health Dynamics Among the Oldest Old (AHEAD). AHEAD is a population-based household survey designed to examine the dynamic interactions between health, family, and economic variables among US older adults. Results showed that 33% of the older adults reported frequent pain and 20% reported significant pain resulting in activity limitation. Controlling for clinical health status, socio-demographic characteristics, and access to medical care, logistic regression analyses showed that those who often have pain were more than twice as likely (odds ratio (OR)=2.63; confidence interval (CI)=2.35, 2.95; P=<0.0001) to perceive their health status to be 'poor'. Other predictors (P<0.01) include functional impairment (OR=2.78), chronic diseases (OR=1.89), minority status (OR=1.88), education (OR=1.77), and physician visits (OR=1.64). This study documents the adverse impact of pain on self-rated health as well as the fact that the experience of pain and poor subjective health and well-being is greatest among the most socially disadvantaged older adults (minorities and those with the least education). The findings suggest that treating and controlling pain may significantly enhance the subjective health and well-being of community-dwelling older adults.
PMID: 11790469, UI: 21650968
Pain 2002 Jan;95(1-2):49-63
The Outpatient Spine Clinic, Haukeland University Hospital, Bergen, Norway
In general, randomized controlled studies concerning return to work have failed to demonstrate significant treatment effects for long-lasting musculoskeletal pain, and most treatments examined have not been economically beneficial. Individuals (n=654) sick-listed for at least 8 weeks with musculoskeletal pain, selected from the Norwegian mandatory sickness insurance system and volunteering to participate, were categorized into three groups differing in a prognosis score (good, medium, poor) for return to work, based on a brief, standardized screening of psychological and physiotherapy findings. They were then randomly assigned to three outpatient treatments with three different levels of intensity (ordinary treatment, light multidisciplinary, and extensive multidisciplinary treatment). The evaluation was based on 14 months follow-up data on return to work collected from social security records. The patients with good prognosis for return to work do equally well with ordinary treatment as with the two more intensive treatments. The patients with medium prognosis benefit equally from the two multidisciplinary treatments. The patients with poor prognosis receiving extensive multidisciplinary treatment returned to work at a higher rate than patients with poor prognosis receiving ordinary treatment, 55 vs. 37% (P<0.05) at 14 months. Multidisciplinary treatment is effective concerning return to work, when given to patients who are most likely to benefit from that treatment. Measures of pain or quality of life are not included in this study. The cost-benefit analysis of the economic returns of the light multidisciplinary and the extensive multidisciplinary treatment programs yields a positive net present social value of the treatment. A simple, standardized, screening instrument including only psychological and physiotherapeutic observations may be a useful clinical tool for allocating patients with musculoskeletal pain to the right level of treatment.
PMID: 11790467, UI: 21650966
Pain 2002 Jan;95(1-2):31-40
Neurology Research Laboratories, University of Michigan, 48105, Ann Arbor, MI, USA
We identified long-term (up to 12 weeks), bilateral changes in spontaneous and evoked pain behavior and baseline forebrain activity following a chronic constriction injury (CCI) of the sciatic nerve. The long-term changes in basal forebrain activation following CCI were region-specific and can be divided into forebrain structures that showed either: (1) no change, (2) an increase, or (3) a decrease in activity with regard to the short-term (2 weeks) changes we previously reported. All the rats showed spontaneous pain behaviors that persisted throughout the 12-week observation period, resembling the pattern of change found in four limbic system structures: the anterior dorsal thalamus, habenular complex, and the cingulate and retrosplenial cortices. In contrast, heat hyperalgesia was delayed in onset until 4 weeks following CCI, but then persisted, showing a nearly constant level of increased responsiveness. The forebrain activation that resembles this behavioral pattern of change is found in somatosensory cortex, and in the hypothalamic paraventricular nucleus and the basolateral amygdala. Finally, mechanical allodynia, which was maximal during the first 2 weeks following nerve injury and gradually recovered by the seventh post-operative week uniquely matches the time course of changes in ventrolateral and ventroposterolateral thalamic activity. Our results indicate that peripheral nerve damage results in persistent changes in behavior and resting forebrain systems that modulate pain perception. The persistent abnormalities in the somatosensory cortex and thalamus suggest that the sensory thalamocortical axis is functionally deranged in certain chronic pain states.
PMID: 11790465, UI: 21650964
Pain 2002 Jan;95(1-2):23-30
Department of Psychology, University of Northern British Columbia, 3333 University Way, British Columbia, V2L 4Z9, Prince George, Canada
The development of procedures for assessing factors that contribute to pain and disability is crucial for clinical and epidemiologic studies. The present paper describes a system for in vivo, real-time assessment of pain behaviors integrated with a standardized physical examination for low back pain patients. The principles for measuring five categories of pain behavior - guarding, touching/rubbing, words, sounds and facial expressions and for parsing the physical examination are described. The system was learned by five observers who then applied it during the physical examinations of 176 patients classified as suffering from sub-acute or chronic pain. The system was also applied to 77 patients in a test-retest consistency study. Measures of guarding, words, sounds and facial expression showed adequate psychometric properties. The test-retest consistency of guarding, sounds and facial expression was moderate-to-good, suggesting that these behaviors were consistent over the test-retest interval and promising for future study. The advantages and limitations of the technique are discussed and ways of modifying it to simplify coding and enhance the accuracy and reliability of its application are suggested. Overall, the technique shows promise for clinical and epidemiologic research.
PMID: 11790464, UI: 21650963
Pain 2002 Jan;95(1-2):1-5
Cognitive Neurophysiology Research Group R2-01, Department of Clinical Neuroscience, Karolinska Institute, 171 76, Stockholm, Sweden
PMID: 11790461, UI: 21650960
Reg Anesth Pain Med 2002 Jan-Feb;27(1):90-3
Department of Anesthesiology and Critical Care Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico.
BACKGROUND AND OBJECTIVES: We present 2 case reports that illustrate that chronic intrathecal (IT) baclofen administration may be efficacious in treating patients with long-standing complex regional pain syndrome, type I (CRPS I) who have failed treatment with multiple drugs and procedures. Case Reports: Both cases presented were women who developed CRPS I following multiple lower extremity surgeries. One patient had had symptoms for 5 years and had continued symptoms despite multiple sympathetic blocks, sympathectomy, spinal cord stimulation, and various medication trials. The other patient had had chronic lower extremity pain for 30 years and symptoms of CRPS for about 5 years. Her symptoms continued despite multiple sympathetic blocks, sympathectomy, and many medications. Neither patient had motor dysfunction (dystonia, tremors, spasticity) associated with their painful disorder. One patient experienced good control of pain, allodynia, and autonomic dysfunction with a combination of IT baclofen and clonidine after failing treatment with IT morphine. Baclofen alone produced intolerable side effects at the doses required to produce adequate analgesia. The other patient experienced long-term control of pain, allodynia, and autonomic symptoms with IT baclofen alone. CONCLUSIONS: IT baclofen appears to be an option for patients with intractable CRPS who have failed other modalities, including IT morphine. Reg Anesth Pain Med 2002;27:90-93.
PMID: 11799510, UI: 21657648
Reg Anesth Pain Med 2002 Jan-Feb;27(1):68-71
Department of Anesthesiology and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
PMID: 11799507, UI: 21657645
Reg Anesth Pain Med 2002 Jan-Feb;27(1):43-6
Anesthetic Department and Pain Clinic, Tenon Hospital, Assistance Publique Hopitaux de Paris, Paris, France.
BACKGROUND AND OBJECTIVES: Hypnosis has been reported to induce analgesia and to facilitate anesthesia. To date, hypnotic-induced analgesia has had little explanation and it has even been questioned. The current study was thus designed to investigate the effect of hypnotic suggestion on thermal-detection thresholds, heat pain, and heat-pain tolerance thresholds. METHODS: In 15 healthy volunteers, enrolled in a randomized cross-over study, thermal thresholds were investigated in 2 sequences of measurements, under waking and hypnotic states, using a thermal stimulator. RESULTS: Heat detection and heat-pain thresholds were increased under hypnosis (from 34.3 +/-.9 degrees C to 36.0 +/- 2.9 degrees C and 45.0 +/- 3.7 degrees C to 46.7 +/- 2.7 degrees C, respectively, P <.05), whereas heat-pain tolerance and cold-detection thresholds were not statistically changed. CONCLUSION: These results indicate that hypnosis may partly impair the detection of Adelta and C fibers stimulation, potentially explaining its analgesic effect. Reg Anesth Pain Med 2002;27:43-46.
PMID: 11799504, UI: 21657642
Reg Anesth Pain Med 2002 Jan-Feb;27(1):9-14
Department of Anesthesiology, Virginia Mason Medical Center, Seattle, Washington.
BACKGROUND AND OBJECTIVES: A survey of anesthesiology training programs in 1980 reported the use of a regional anesthetic technique in 21.3% of cases. A similar survey of anesthesiology training programs in 1990 reported that the use of regional anesthetic techniques had increased to 29.8%. Over the ensuing 10 years, additional changes have occurred in the field of anesthesiology and its United States residency training programs. This manuscript reports the impact these changes have had on the use of regional anesthesia techniques in residency training programs in the year 2000. METHODS: Blinded cumulative data about regional anesthetic techniques performed by anesthesiology residents were obtained from all annual training report forms submitted to the Residency Review Committee for Anesthesiology. Exposure to obstetric (OB) anesthesia, pain management, and a resident's year-in-training were analyzed as independent factors expected to influence the use of regional anesthesia. RESULTS: Anesthesiology trainees used a regional anesthesia technique in 30.2% of cases in the year 2000. This represents an insignificant change from 1990 and a marked slowing in the growth of regional anesthesia techniques compared with the 1980 to 1990 period. The use of regional anesthesia remains strongly correlated with a resident's exposure to OB anesthesia and pain consultations. Variability in exposure to regional anesthesia techniques among individual residents has decreased. CONCLUSIONS: Anesthesiology training programs now appear to provide a satisfactory exposure to regional anesthesia for a majority of resident trainees, although 40% of residents may still be deficient in nerve block anesthesia. The growth in the use of regional anesthesia during residency has plateaued over the past decade, but the discrepancy between individual resident experience has improved. Reg Anesth Pain Med 2002;27:9-14.
PMID: 11799499, UI: 21657637
Spine 2001 Oct 1;26(19):2112-8
Department of Orthopaedic Surgery, School of Medicine, Keio University, Tokyo, Japan. kchiba@sc.itc.keio.ac.jp
STUDY DESIGN: A retrospective case study of patients with intraspinal cyst having a distinct connection with the corresponding intervertebral disc. OBJECTIVES: To propose a new clinical entity, "discal cyst," by clarifying the clinical, radiographic, and histologic aspects of the disease. SUMMARY OF BACKGROUND DATA: Several types of intraspinal cysts with different pathogenesis, causing symptoms indistinguishable from those of lumbar disc herniation, have been reported, such as perineural cysts, synovial cysts, and ganglion cysts. However, to the authors' knowledge, no detailed analysis has been made of cysts that have a distinct connection with the corresponding intervertebral disc. METHODS: Clinical pictures, radiographic findings, and surgical and histologic findings in eight surgically treated patients with intraspinal cyst having a distinct connection with the intervertebral disc were reviewed. Possible pathogenesis and a proposal for nomenclature were also discussed. RESULTS: This disease can be characterized by (1) clinical symptoms indistinguishable from those of typical disc herniation, manifesting as a unilateral single nerve root lesion; (2) incidence at slightly younger age and at upper intervertebral levels than with typical disc herniation; (3) T1 low signal and T2 high signal intensity, round to oval mass lesion on magnetic resonance imaging, compatible with a liquid-containing cyst; (4) minimal degeneration of the involved disc, either on discography/computed tomographic discography or magnetic resonance imaging; (5) a connection between the cyst and the corresponding intervertebral discs on discograms with severe radiating pain in the affected leg at the time of injection; (6) immediate relief of symptoms after simple removal of the cyst; (7) cyst wall consisting of dense fibrous connective tissue containing bloody to clear serous discharge; and (8) absence of disc materials and a specific lining cell layer on histologic examination. Although the exact cause is unknown, underlying minor disc injury may serve as a basis for cyst formation. CONCLUSION: Eight cases of intraspinal cysts communicating with the intervertebral disc presenting symptoms identical to those of disc herniation are presented. Because all cysts were connected to the corresponding disc and the development of the cyst was assumed to be related to underlying disc injury, it is proposed to name this clinical entity discal cyst.
PMID: 11698889, UI: 21555761
Spine 2001 Oct 15;26(20):E479-83; discussion E484
Department of Physical Medicine, Hotel-Dieu University Hospital, Paris, France. jy.maigne@htd.ap-hop-paris.fr
STUDY DESIGN: A prospective pilot study with independent assessment and a 2-year follow-up period was conducted. OBJECTIVES: To compare and assess the efficacy of three manual coccydynia treatments, and to identify factors predictive of a good outcome. SUMMARY OF BACKGROUND DATA: Various manual medicine treatments have been described in the literature. In an open study, the addition of manipulation to injection treatment produced a 25% increase in satisfactory results. Dynamic radiographs of the coccyx allow breakdown of coccydynia into four etiologic groups based on coccygeal mobility: luxation, hypermobility, immobility, and normal mobility. These groups may respond differently to manual treatments. METHODS: The patients were randomized into three groups, each of which received three to four sessions of a different treatment: levator anus massage, joint mobilization, or mild levator stretch. Assessment with a visual analog scale was performed by an independent observer at 7 days, 30 days, 6 months, and 2 years. RESULTS: The results of the manual treatments were satisfactory for 25.7% of the cases at 6 months, and for 24.3% of the cases at 2 years. The results varied with the cause of the coccydynia. The patients with an immobile coccyx had the poorest results, whereas those with a normally mobile coccyx fared the best. The patients with luxation or hypermobility had results somewhere between these two rates. Levator anus massage and stretch were more effective than joint mobilization, which worked only for patients with a normally mobile coccyx. Pain when patients stood up from sitting and excessive levator tone were associated with a good outcome. However, none of the results was significant because of the low success rate associated with manual treatment. CONCLUSIONS: There is a need for a placebo-controlled study to establish conclusively whether manual treatments are effective. This placebo must be an external treatment. A sample size of 190 patients would be required for 80% confidence in detecting a difference.
PMID: 11598528, UI: 21482844
Spine 2001 Oct 15;26(20):2198-207
Department of Orthopaedic Surgery, University of California at San Francisco, 94143-0514, USA.
STUDY DESIGN: Human cadaver lumbar spines were used to assess the acute effects of intradiscal electrothermal therapy in vitro. OBJECTIVE: To determine whether intradiscal electrothermal therapy produces acute changes in disc histology and motion segment stability. SUMMARY OF BACKGROUND DATA: Intradiscal electrothermal therapy has been introduced as an alternative for the treatment of discogenic low back pain. Several hypothesized mechanisms for the effect of intradiscal electrothermal therapy have been suggested including shrinkage of the nucleus or sealing of the anulus fibrosus by contraction of collagen fibers, and thermal ablation of sensitive nerve fibers in the outer anulus. METHODS: Intradiscal electrothermal therapy was performed with the Spinecath by Oratec on 19 fresh, frozen human lumbar cadaver specimens. In a separate study, eight specimens were tested biomechanically and instrumented to map the thermal distribution, whereas five specimens were tested only biomechanically, both before and after intradiscal electrothermal therapy. Six additional specimens were heated with intradiscal electrothermal therapy, and the resulting canal was backfilled with a silicone rubber compound to allow colocalization of the catheter and anular architecture. RESULTS: A consistent pattern of increased motion and decreased stiffness was observed. For the specimens in which only biomechanical measurements were taken, a 10% increase in the motion, on the average, at 5 Nm torque was observed after intradiscal electrothermal therapy. No apparent alteration of the anular architecture was observed around the catheter site in the intradiscal electrothermal therapy-treated discs. CONCLUSION: The data from this study suggest that the temperatures developed during intradiscal electrothermal therapy are insufficient to alter collagen architecture or stiffen the treated motion segment acutely.
PMID: 11598508, UI: 21482824
Spine 2001 Oct 15;26(20):2179
PMID: 11598502, UI: 21482818
Support Care Cancer 2001 Sep;9(6):467-8
Anaesthesia and Intensive Care Unit, La Maddalena Clinic for Cancer, Palermo, Italy. sebast.merc@tiscalinet.it
Pruritus is prevalent in 5-12% of palliative care patients. Rifampicin has been shown to be useful both as initial treatment and as salvage treatment after failure of other agents to control the pruritus associated with the cholestatic jaundice of malignancy. We report the case of a 65-year-old woman who complained of severe pruritus after morphine treatment. The use of rifampicin 300 mg twice a day by the i.v. route was successful, and after opioid switching it was no longer necessary to maintain rifampicin in the therapeutic regimen. Controlled clinical trials are warranted to confirm this preliminary observation.
PMID: 11585275, UI: 21469022
Support Care Cancer 2001 Sep;9(6):403-7
Palliative Medicine of East Tennessee, Blount Memorial Hospital, Maryville 37804-5016, USA.
This paper reviews the reported use of nonopioid medications for terminal sedation. To provide a summary of the available literature, an electronic database search was performed. Thirteen series and 1 4 case reports were identified. Various symptoms, including agitation, pain, and confusion, required terminal sedation. Eleven drugs were used in 342 patients. Most patients were also treated with concurrent opioids and received terminal sedation in an inpatient hospice unit. Midazolam was the most common sedative employed. A good response--defined as adequate sedation--ranged between 75% and 100%. The median time to death following the introduction of terminal sedation was greater than 1 day. No agent appears to have superior efficacy or limiting toxicity.
PMID: 11585266, UI: 21469013
Support Care Cancer 2001 Sep;9(6):401-2
PMID: 11585265, UI: 21469012
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