Anesth Analg 2002 May;94(5):1372; discussion 1372
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PMID: 11973231, UI: 21969048
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Anesth Analg 2002 May;94(5):1369
PMID: 11973227, UI: 21969044
Anesth Analg 2002 May;94(5):1263-9, table of contents
Universite Bordeaux 1, France.
Perioperative opioids increase postoperative pain and morphine requirement, suggesting acute opioid tolerance. Furthermore, opioids elicit N-methyl-D-aspartate (NMDA)-dependent pain hypersensitivity. We investigated postfentanyl morphine analgesic effects and the consequences of NMDA-receptor antagonist (ketamine) pretreatment. The rat nociceptive threshold was measured by the paw-pressure vocalization test. Four fentanyl boluses (every 15 min) elicited a dose-dependent (a) increase followed by an immediate decrease of the nociceptive threshold and (b) reduction of the analgesic effect of a subsequent morphine administration (5 mg/kg): -15.8%, -46.6%, -85.1% (4 x 20, 4 x 60, 4 x 100 microg/kg of fentanyl, respectively). Ketamine pretreatment (10 mg/kg) increased the fentanyl analgesic effect (4 x 60 microg/kg), suppressed the immediate hyperalgesic phase, and restored the full effect of a subsequent morphine injection. Fentanyl also elicited a delayed dose-dependent long-lasting decrease of the nociceptive threshold (days) that was prevented by a single ketamine pretreatment before fentanyl. However, a morphine administration at the end of the fentanyl effects restored the long-lasting hyperalgesia. Repeated ketamine administrations were required to obtain a complete preventive effect. Although ketamine had no analgesic effect per se at the dose used herein, our results indicate that sustained NMDA-receptor blocking could be a fruitful therapy for improving postoperative morphine effectiveness. IMPLICATIONS: Fentanyl-induced analgesia is followed by early hyperalgesia (hours), acute tolerance to the analgesic effects of morphine, and long-lasting hyperalgesia (days). All these phenomena are totally prevented by repeated administrations of the NMDA-receptor antagonist, ketamine, simultaneously with fentanyl and morphine administration.
PMID: 11973202, UI: 21969019
Anesth Analg 2002 May;94(5):1178-81, table of contents
Department of Anesthesiology, Children's National Medical Center, Washington, DC 20010, USA. icohen@cnmc.org
Desflurane and sevoflurane anesthesia are associated with emergence agitation in children. In this study, we examined the effect of a single intraoperative dose of fentanyl on emergence characteristics in children undergoing adenoidectomy. One hundred children, 2-7 yr old, were randomly assigned to receive desflurane or sevoflurane for maintenance of general anesthesia after an inhaled induction with sevoflurane and a 2.5 microg/kg dose of fentanyl. An observer blind-ed to the anesthetic technique assessed the times to achieve emergence, extubation and recovery criteria, as well as emergence behaviors. The results showed a similar incidence of severe emergence agitation after general anesthesia with desflurane (24%) and sevoflurane (18%). Times to achieve extubation and postanesthesia care unit discharge criteria were shorter with desflurane than with sevoflurane. With this technique, desflurane allows for a more rapid emergence and recovery than sevoflurane. In children receiving desflurane or sevoflurane, the concurrent use of fentanyl in a dose of 2.5 microg/kg results in a small incidence of emergence agitation. IMPLICATIONS: The concurrent use of fentanyl in a dose of 2.5 microg/kg in children receiving desflurane or sevoflurane results in a low incidence of emergence agitation. Desflurane allows for a more rapid emergence and recovery than sevoflurane.
PMID: 11973185, UI: 21969002
Anesth Analg 2002 May;94(5):1161-4, table of contents
Department of Anesthesiology, Children's National Medical Center, Washington, DC 20010, USA. sverghes@cnmc.org
In this study, we examined the effectiveness of caudal blocks and correlated it with the laxity of the patients' anal sphincter before emergence from anesthesia in 178 children undergoing inguinal and/or penile surgery. Bupivacaine 0.25% in a volume of 0.6-1.25 mL/kg was used in all patients. The presence of a lax anal sphincter at the end of surgery correlated significantly with the reduced administration of narcotics intraoperatively and in the postanesthesia care unit (P < 0.001). The sensitivity of the sphincter tone test was 98.1% with a 95% confidence interval (CI) ranging from 94.3% to 99.6%. The specificity of the test was 94.4% with a 95% CI of 72.0%-100%. The positive predictive value of this test in predicting adequate caudal block was excellent (99.4%) with a 95% CI of 96.1%-100%. The negative predictive value was better than average (85%) with a 95% CI of 62.9%-95.4%. We conclude that a lax anal sphincter can predict the effectiveness of analgesia after pediatric caudal blockade. A tight sphincter may suggest the need to repeat the block before the child awakens, or consider alternate methods of postoperative analgesia. IMPLICATIONS: A lax anal sphincter in children undergoing inguinal and/or penile surgery can predict the effectiveness of analgesia after pediatric caudal blockade.
PMID: 11973180, UI: 21968997
BMJ 2002 May 11;324(7346):1162
[Medline record in process]
PMID: 12008731, UI: 22000663
Eur J Pharmacol 2002 Apr 19;441(1-2):57-65
Department of Pharmacology, Faculty of Medicine of Ribeirao Preto-USP, Av. Bandeirantes 3900, CEP 14049-900, Ribeirao Preto, Sao Paolo, Brazil
[Record supplied by publisher]
The effects of local application of a cream containing nitric oxide (NO) donors, S-nitroso-N-acetylpenicillamine (SNAP) or isosorbide dinitrate were studied in a rat model of incision pain. An incision was made in the plantar aspect of a hind paw and the cream was applied inside the surgical wound. SNAP (1-10%) or isosorbide (2.5-5%) reduced the incision allodynia as measured with von Frey filaments. Higher concentrations produced a smaller or no effect, but SNAP (30%) intensified the allodynia. Allodynia was also intensified by SNAP (5% or 30%) in rats pretreated with intraplantar 1H-[1,2,4]oxadiazolo[4,3-alpha]quinoxalin-1-one (ODQ, 4 &mgr;g), a guanylate cyclase inhibitor. The effect of isosorbide (5%) was prevented by ODQ. The cream containing SNAP released 10- to 20-fold more nitrite than did isosorbide from a macrophage culture. We conclude that local application of drugs generating a low NO concentration reduces incision pain through activation of guanylate cyclase. Drugs generating high NO concentrations, however, intensify pain via a guanylate cyclase-independent mechanism.
PMID: 12007920
Eur J Pharmacol 2002 Apr 19;441(1-2):47-55
NeuroPsychoPharmacologie Moleculaire, Cellulaire et Fonctionnelle, INSERM U 288, Faculte de Medecine Pitie-Salpetriere, 91 Boulevard de l'Hopital, 75634 Cedex 13, Paris, France
Although it is well established that adenosine exerts antinociceptive effects at the spinal level in various species including human, the mechanisms responsible for such effects are still a matter of debate. We presently investigated whether adenosine-induced antinociception might possibly be related to an inhibitory influence of this neuromodulator on the spinal release of neuropeptides implicated in the transfer and/or control of nociceptive signals. For this purpose, the K(+)-evoked overflow of substance P-, calcitonin gene-related peptide (CGRP)- and cholecystokinin-like materials was measured from slices of the dorsal half of the rat lumbar enlargement superfused with an artificial cerebrospinal fluid supplemented with increasing concentrations of various adenosine receptor ligands. The data showed that stimulation of adenosine A(1) and (possibly) A(3) receptors, but not A(2A) receptors, exerted an inhibitory influence on the spinal release of CGRP-like material. In contrast, none of the adenosine A(1), A(2A) and A(3) receptor agonists tested within relevant ranges of concentrations significantly affected the release of substance P- and cholecystokinin-like materials. These results support the idea that adenosine-induced antinociception at the spinal level might possibly be caused, at least partly, by the stimulation of inhibitory adenosine A(1) receptors located presynaptically on primary afferent fibres containing CGRP but not substance P.
PMID: 12007919, UI: 22003596
J Pain Symptom Manage 2002 May;23(5):442-7
Oncology Symptom Control & Research, Community Cancer Care, Indianapolis, IN, USA
We performed a pilot open-label, crossover trial of mirtazapine (15 and 30 mg at night) in advanced cancer patients with pain and other distressing symptoms. Twenty patients completed the trial and sixteen dropped out. Following a baseline assessment, patients completed a one-week observation period and were then randomized to a starting dose of either 15 mg or 30 mg of mirtazapine given at bedtime. After three weeks, subjects were switched to the alternate dose and followed by an additional three-week period, completing the treatment. The average age of the completers was 60.2 years and consisted of 7 women and 13 men. The majority were Caucasian (n = 18, 90%) and married (n = 18, 90%). The drop-out group did not significantly differ from the completers based on age, gender, race, marital status, or tumor type. We examined the impact of mirtazapine therapy on patients' levels of depression, pain intensity, appetite, insomnia, weight, and overall quality of life. A series of repeated measures ANOVAs were conducted to compare the completers' status at Weeks 1, 4, and 7 compared to baseline and to examine the interaction with starting dose and baseline observations. Scores on the Zung self-rating Depression Scale (F = 8.20, P < 0.05) and the Functional Assessment of Cancer Therapy - General Measure (F = 5.73, P < 0.05) were significantly improved at study end (Week 7) and were not dependent on mirtazapine dosage. Patients' weights were significantly higher at both Week 4 and Week 7, independent of dosage. Trend level differences were found on Memorial Pain Assessment Card items for pain, pain relief, and mood and on numeric rating scales measuring nausea, anxiety, insomnia, and appetite. This open-label pilot study suggests that mirtazapine may be effective for improving multiple symptoms, depression and quality of life in patients with advanced cancer. A controlled trial of this drug would be valuable.
PMID: 12007762, UI: 22004020
J Pain Symptom Manage 2002 May;23(5):433-41
Department of Plastic Surgery, Free University Hospital, Amsterdam, The Netherlands
To study what happens in a family where one member suffers from chronic pain, we quantitatively assessed the effect of chronic pain resulting from complex regional pain syndrome type 1 (CRPS) on 1) employment status, 2) time allocation, 3) additional domestic help, and 4) out-of-pocket expenses of Dutch patients (n = 50) and their spouses (n = 43). This study is the first to measure the effect of chronic pain on time allocation by means of a diary assessment technique. The results were compared with normative values for the Dutch population overall. In households containing a male patient, the total employment full time equivalent (FTE) decreased by 47% (P = 0.05), with the result that the mean household income decreased by $4,000 (P = 0.01). In those with a female patient, there was a reduction in FTE of 29% (P < 0.05), causing a decrease of the mean household income by $2,000 (p < 0.001). As compared with controls, patients were found to spend less time on paid employment, and to invest more time in household maintenance and housekeeping. Of 50 patients, 35 received a mean of 4.5 hours per week of domestic help. The mean out-of-pocket expenses related to CRPS amounted $1,350 per patient per year. Spouses were forced to invest more time on housekeeping and household maintenance, which resulted in less time for personal needs and leisure activities. There were only small differences in time allocation between cases where the sufferer was male or female and, similarly, only minor variation between hand-affected or foot-affected patients. Households with either male or hand-affected patients did prove to have higher out-of-pocket expenses as compared with households containing female or foot-affected patients. Those containing female or hand-affected patients required more domestic help than households either with male or foot-affected patients. The present study demonstrates that chronic pain due to CRPS has a profound impact on many aspects of the lives of both patients and their spouses.
PMID: 12007761, UI: 22004019
J Pain Symptom Manage 2002 May;23(5):417-23
Psycho-Oncology Division, National Cancer Center Research Institute East, Chiba, Japan
This study aimed to compare the impact of dyspnea, pain, and fatigue on daily life activities in ambulatory patients with advanced lung cancer. One hundred seventy-one outpatients with advanced lung cancer completed a questionnaire about symptom severity and whether symptoms interfered with daily life activities (normal work, walking, sleep, mood, relation with other people, enjoyment of life, and general activities). The results indicated that 1) dyspnea and fatigue interfered with at least one daily life activity in more than half the patients, and pain in about 40%, 2) dyspnea and fatigue interfered predominantly with physical activities, such as walking and work, whereas pain interfered with all activities almost equally, and 3) symptoms rated as low severity (1 to 3 on a 0-10-point numerical scale) were severe enough to interfere with at least one daily life activity. To recognize the impact of symptoms may contribute to provide better management.
PMID: 12007759, UI: 22004017
J Pain Symptom Manage 2002 May;23(5):393-405
School of Nursing, Queensland University of Technology, Brisbane, Australia
The purpose of this study was to examine attitudinal barriers to effective pain management in a consecutively recruited cohort of 114 cancer patients from four Australian hospitals. When surveyed, 48% of this sample reported experiencing pain within the previous 24 hours. Of these, 56% reported this pain to be "distressing, horrible or excruciating," with large proportions indicating that this pain had affected their movement, sleep and emotional well-being. Three factors were identified as potentially impacting on patients' responses to pain-poor levels of patient knowledge about pain, low perceived control over pain, and a deficit in communication about pain. A trend for older patients to experience more severe pain was also identified. These older patients reported being more willing to tolerate pain and perceive less control over their pain. Suggestions are made for developing patient education programs and further research using concepts drawn from broader social and behavioral models.
PMID: 12007757, UI: 22004015
J Pain Symptom Manage 2002 May;23(5):383-92
Health Services Research Group, General Practice and Primary Care Research Unit, Institute of Public Health, Cambridge, United Kingdom
During recent years, the national policy of the United Kingdom has increasingly recognized the central place of general practitioners (GPs) in the care of cancer patients, from screening and early diagnosis through to palliative care and bereavement. There are, however, continuing reports of poor control of pain and other symptoms in the community. To investigate general practitioners' prescribing habits and knowledge of some key pain control issues in advanced cancer, a postal questionnaire surveyed a random sample of 450 East Anglian GPs. The response rate was 73.3%. Most respondents were familiar with the modern management of cancer pain, including the World Health Organization approach, the use of oral opioids, and the management of bone pain. There was less awareness of the drug options available for more uncommon situations, especially the dose conversion of oral morphine to subcutaneous diamorphine and drugs that may be used in syringe drivers. GPs in the UK are familiar with the management of the more common pain control problems. However, it is not appropriate to expect GPs to know the details of management of more unusual cancer pain problems. Specialist clinicians need to make themselves readily available to advise their generalist colleagues. The educational implications for GPs are discussed.
PMID: 12007756, UI: 22004014
J Pain Symptom Manage 2002 May;23(5):369-82
School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
The purpose of this study was to describe the difficulties with pain management that patients and family caregivers bring to a nurse's attention during a teaching and coaching intervention. Data were obtained from audiotaped and transcribed interactions between intervention nurses and patients (n = 52) and their family caregivers (n = 33) who were participating in a randomized clinical trial of a nursing intervention called the PRO-SELF Copyright Pain Control Program. Using qualitative content analysis, we found that patients had difficulty in seven areas when they attempted to put a pain management regimen into practice, namely: obtaining the prescribed medication(s), accessing information, tailoring prescribed regimens to meet individual needs, managing side effects, cognitively processing information, managing new or unusual pain, and managing multiple symptoms simultaneously. The findings from this study suggest that the provision of information about cancer pain management to patients and their family caregivers is not sufficient to improve pain control in the home care setting. Patients and their family caregivers require ongoing assistance with problem-solving to optimize their pain management regimen.
PMID: 12007755, UI: 22004013
J Pain Symptom Manage 2002 May;23(5):355-68
Abbott Laboratories, Parsippany, NJ, USA
The objective of this open-label, repeated-dose, single-treatment, multicenter study was to evaluate the outcomes associated with a standardized conversion from prior opioid therapy to a novel, once-daily, OROS((R)) osmotic technology, extended-release (ER) hydromorphone formulation in an outpatient population with chronic malignant or nonmalignant pain. The study period was divided into 3 phases: the prior opioid stabilization phase (>/=3 days), the conversion and titration phase (3-21 days), and the maintenance phase (14 days). Patients were evaluated at 5 visits during the study period. Analgesic efficacy was measured using the Brief Pain Inventory (BPI). At baseline, patients were required to have daily oral morphine equivalent requirements of >/=45 mg. Prior oral or transdermal opioid therapy was converted to single daily doses of ER hydromorphone (8, 16, 32, and 64 mg tablets) at a 5:1 (morphine equivalent to hydromorphone) ratio. Immediate-release (IR) hydromorphone was given as rescue medication for breakthrough pain. Among the 445 patients who enrolled, 404 received the study medication. Of these, 73 (18.1%) had chronic malignant pain and 331 (81.9%) had chronic nonmalignant pain. Dose stabilization (defined as a 3-day period during which the total daily dose of ER hydromorphone remained unchanged and </=3 doses of IR hydromorphone per day were required) was attained by 73.8% of patients (298/404), of whom 70.1% (209/298) were stabilized with </=2 titration steps. The mean +/- standard deviation (SD) time to dose stabilization was 12.1 +/- 5.7 days (range of 3 to 33 days). The mean +/- SD final daily dose of ER hydromorphone was 63.4 +/- 129.2 mg. The mean +/- SD final daily dose of IR hydromorphone was 11.5 +/- 36.4 mg, and the mean +/- SD final number of daily doses of IR hydromorphone was 1.7 +/- 1.3. Intent-to-treat and completer analysis demonstrated significant improvements in BPI ratings from prior opioid therapy to the end of ER hydromorphone therapy (P < 0.01 for all pairwise comparisons). Adverse events were consistent with those expected of an opioid agonist in such a patient group, affecting primarily the gastrointestinal and central nervous systems. This uncontrolled study delineates a regimen by which patients with chronic malignant or nonmalignant pain can be readily converted from prior opioid therapy and titrated to an appropriate maintenance dose of ER hydromorphone. Controlled longitudinal studies are required to further evaluate the use of ER hydromorphone in patients with discrete chronic malignant or nonmalignant pain conditions.
PMID: 12007754, UI: 22004012
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