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Am J Emerg Med 2002 Oct;20(6):562-6
Department of Emergency Medicine, Akron General Medical Center, Akron, OH.
[Medline record in process]
To evaluate patients' perceptions and preferences concerning pain control during intravenous (IV) catheterization, a sample of 50 adult patients received subcutaneous lidocaine (0.2 mL 1%) by jet injector, or no anesthetic with a sham injection before IV catheterization. Visual analog scale (VAS), pain intensity score (PIS), and adverse reactions were recorded. A significant difference existed in the scores of patients who received lidocaine versus those who did not VAS (P <.001) PIS (P <.004). Patients' receiving lidocaine via jet-injector experienced more minor and potentially preventable adverse effects such as mild bruising and trauma to the veins. Patients in both groups (84% overall) preferred local anesthesia based on this experience. Using the jet-injector to provide local anesthesia before IV catheterization in the ED is effective, fast, and does not require sharps disposal and handling precautions. (Am J Emerg Med 2002;20:562-566. Copyright 2002, Elsevier Science (USA). All rights reserved.)
PMID: 12369033, UI: 22252336
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Am J Emerg Med 2002 Oct;20(6):510-2
Division of Emergency Medicine and the dagger Division of Cardiovascular Medicine, Department of Internal Medicine, University of California, Davis, School of Medicine, Sacramento, CA.
To evaluate the prevalence of dyslipidemia in patients who are evaluated in a chest pain evaluation unit (CPEU) a prospective study of all patients admitted to our CPEU from January 1 to December 31, 1999 was conducted. Serum total cholesterol (TC) and high density lipoprotein (HDL) levels were obtained unless prior levels were known or at the discretion of the attending physician. Both TC and HDL were tested in 606 (59%) patients. Abnormal lipid levels were reported in 306 (50%) patients. Of these, 86 had both abnormal TC and HDL. Isolated low HDL levels were found in 60 of the patients and TC alone was abnormal in 160. Of the 246 patients with abnormal TC, 169 (69%) had borderline high levels (200-239 mg/dL) and 77 (31%) had high levels (>/=240 mg/dL). Our study shows a high prevalence of abnormal lipid levels in patients, as identified by a screening protocol in our CPEU. (Am J Emerg Med 2002;20:510-512. Copyright 2002, Elsevier Science (USA). All rights reserved.)
PMID: 12369022, UI: 22252325
Am J Emerg Med 2002 Oct;20(6):502-5
Department of Emergency Medicine, William Beaumont Hospital, A Wayne State University Affiliated Program, Royal Oak, MI.
Our primary objective was to compare use of analgesia for patients with and without fracture as a result of isolated lower extremity trauma, in the emergency department (ED). Our secondary objective was to compare the analgesic practices of emergency physicians (EPs) with that of physician assistants (PAs). We performed a prospective, blinded cohort study with the presence of fracture as the risk factor and provision of any pain medication while in the ED as the primary outcome. Included in the study were all patients who presented to a 90,000 visit suburban teaching hospital with an isolated lower extremity injury who received a radiograph of the foot or ankle over a 9-week period. We excluded patients without trauma, with multiple trauma, admitted, or seen by one of the investigators. Patients admitted and those with multiple trauma were excluded because these patients had contacts with multiple physicians and it is unlikely they would be able to differentiate which physician prescribed medication and if they were emergency personnel. We defined analgesia as any pain medication at any dose. One investigator preformed follow-up interviews using a standardized questionnaire 3 days after the visit. Patients expressed their recollection of their degree of pain using a verbal analog scale of 1 to 10. We report crude and adjusted odds ratios (OR). Of 516 consecutive patients, 111 met exclusion criteria and 3 had incomplete data. Of the remaining 405, we contacted 384 (95%) in an average of 3 +/- 1 days. Patients with and without fractures recalled their initial degree of pain similarly, with the mean initial pain scores on the verbal analog scale of 6.6 +/- 2.5 versus 6.8 +/- 2.1 respectively. Patients with a fracture were more likely to receive pain medication while in the ED (23% v 15% P =.047, OR 1.75 (CI 95% 1.02, 2.99). EPs gave some form of ED analgesia to 29% of patients, as compared with 10% of patients seen by PAs (OR = 3.58 CI 95% 2.05, 6.24). EPs provided a prescription to 44% of patients versus 21% of patients seen by PAs (OR = 2.91 CI 95% 1.85, 4.57). Our estimated adjusted ORs for providing analgesia in the ED were: fracture = 2.0 (CI 95% 1.13, 3.58); EP: 3.52 (CI 95% 1.98, 2.99); and for every additional point on the verbal pain scale: 1.28 (CI 95% 1.11, 1.48). Patients with fracture were more likely to receive pain, despite reporting identical degree of pain. EPs were more likely to provide analgesia than PAs. (Am J Emerg Med 2002;20:502-505. Copyright 2002, Elsevier Science (USA). All rights reserved.)
PMID: 12369020, UI: 22252323
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BMJ 2002 Sep 21;325(7365):659
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PMID: 12242188, UI: 22226359
J Pain Symptom Manage 2002 Jul;24(1 Suppl):S28-37
Section of Health Services Research, Department of Biostatistics, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030-4009, USA.
The economic evaluation of health care programs is undertaken to assess health care costs and benefits. Part of the goal of cost-effectiveness analysis is to maximize health benefits given the constraint of limited health care resources. The identification of costs is critical in a cost-effectiveness analysis of clinical interventions. The recent introduction of the cyclooxygenase (COX)-2-selective inhibitors, coxibs, for treatment of rheumatoid arthritis, osteoarthritis, and acute pain gives rise to cost-effectiveness issues. These new agents provide similar efficacy with fewer gastrointestinal events compared with nonselective nonsteroidal anti-inflammatory drugs (NSAIDs), but are more expensive on a per-dose basis. However, several modeled cost analyses have suggested that COX-2 inhibitors are cost effective in subsets of patients because they are associated with fewer downstream costs, particularly medical and surgical treatment of gastrointestinal adverse effects. Three cost-effectiveness models of interventions for rheumatoid arthritis and osteoarthritis, including COX-2 inhibitors, are reviewed. Prospective clinical investigation of the potential costs and benefits of these new agents is necessary to further support these findings.
PMID: 12204485, UI: 22194590
Reg Anesth Pain Med 2002 Sep-Oct;27(5):529-32
Department of Anesthesiology, Shiga University of Medical Science, Shiga, Japan.
Background and Objectives: The aim of the present case series was to examine whether changes in regional cerebral blood flow (rCBF) induced by electroconvulsive therapy (ECT) in the thalamus are related to the efficacy of ECT. Four chronic pain patients with complex regional pain syndrome (CRPS) type-1 (age, 33 to 58 years) who had failed to respond to standard pain treatments received a course of ECT. To investigate the possible mechanisms of the analgesic effect of ECT on chronic CRPS type-1, we measured significant changes in the rCBF of the thalamus using technetium-99m ethyl cysteinate dimer single photon emission computed tomography (99mTc ECD SPECT), before and after ECT and compared these values between responders and nonresponders. RESULTS: Two of 4 (50.0%) patients responded to ECT treatment (response defined as a reduction of at least 60% on the visual analog scale [VAS]). 99mTc ECD SPECT showed that the mean contralateral thalamus-to-cerebellum ratio increased 11.5% after ECT compared with the ratio before ECT in the 2 responders, but remained unchanged in nonresponders. CONCLUSIONS: The results from the SPECT suggest that normalization of the balance of rCBF in the thalamus may be related to the analgesic efficacy of the ECT on CRPS Type-1. Reg Anesth Pain Med 2002;27:529-532.
PMID: 12373706, UI: 22260862
Reg Anesth Pain Med 2002 Sep-Oct;27(5):524-8
Departments of Orthopedic Surgery (T.U., T.T., M.K.), Anesthesiology (T.K.), and Anatomy and Cell Biology (V.S.Z), Kochi Medical School, Nankoku, Kochi, Japan.
OBJECTIVE: Ketamine hydrochloride (KET), an agent used for general anesthesia, has local anesthetic effects and N-methyl-D-aspartate (NMDA) receptor antagonist action. Because recent studies emphasized the role of peripherally distributed NMDA receptors in processing the nociceptive information, we investigated whether peripheral application of the ointment containing KET is able to attenuate the symptoms of local neuropathic pain. Case Reports: We applied ointment containing KET (0.25%-1.5%) to the affected area on limbs in 5 patients with complex regional pain syndrome type I (CRPS I) and in 2 patients with type II (CRPS II). One to 2 weeks later, we observed improvement of the report of pain intensity, measured by the visual analog scale, in 4 patients with acute early dystrophic stage of CRPS I. Swelling of the affected limbs subsided as well. No apparent changes were noticed in 1 patient with chronic atrophic stage of CRPS I and in both patients with CRPS II. CONCLUSION: Topical application of KET appears to be beneficial for the patients with acute early dystrophic stage of CRPS I because of either its local anesthetic effect or NMDA receptor antagonist action. Patients with chronic atrophic stage of CRPS I and CRPS II patients do not appear to respond to this treatment. Reg Anesth Pain Med 2002;27:524-528.
PMID: 12373705, UI: 22260861
Reg Anesth Pain Med 2002 Sep-Oct;27(5):514-6
Department of Anesthesia and Intensive Care, University of Muenster, Muenster, Germany; and the University of Iowa, Iowa City, Iowa.
PMID: 12373702, UI: 22260858
Reg Anesth Pain Med 2002 Sep-Oct;27(5):481-6
Departments of Anaesthesia and Pain Management (M.B.) and Neurology (P.C.), University Hospitals of Leicester NHS Trust, Leicester General Hosptial, Leicester, UK; and the Mater Misericordiae Hospital, Dublin, Ireland.
Background and Objectives: Severe phantom limb pain after surgical amputation affects 50% to 67% of patients and is difficult to treat. Gabapentin is effective in several syndromes of neuropathic pain. Therefore, we evaluated its analgesic efficacy in phantom limb pain. METHODS: Patients attending a multidisciplinary pain clinic with phantom limb pain were enrolled into this randomized, double-blind, placebo-controlled, cross-over study. Other anticonvulsant therapy was discontinued. Each treatment was 6 weeks separated by a 1-week washout period. Codeine/paracetamol was allowed as rescue analgesia. The daily dose of gabapentin was titrated in increments of 300 mg to 2,400 mg or the maximum tolerated dose. Patients were assessed at weekly intervals. The primary outcome measure was visual analog scale (VAS) pain intensity difference (PID) compared with baseline at the end of each treatment. Secondary measures were indices of sleep interference, depression (Hospital Anxiety and Depression [HAD] scale), and activities of daily living (Bartel Index). RESULTS: Nineteen eligible patients (mean age, 56 years; range, 24 to 68 years; 16 men) were randomized, of whom 14 completed both arms of the study. Both placebo and gabapentin treatments resulted in reduced VAS scores compared with baseline. PID was significantly greater than placebo for gabapentin therapy at the end of the treatment (3.2 +/- 2.1 v 1.6 +/- 0.7, P =.03). There were no significant differences between placebo and gabapentin therapy in terms of the number of tablets of rescue medication required, sleep interference, HAD scale, or Bartel Index. The medication was well tolerated with few reports of adverse effects. CONCLUSIONS: After 6 weeks, gabapentin monotherapy was better than placebo in relieving postamputation phantom limb pain. There were no significant differences in mood, sleep interference, or activities of daily living, but a type II error cannot be excluded for these variables. Reg Anesth Pain Med 2002;27:481-486.
PMID: 12373695, UI: 22260851
Reg Anesth Pain Med 2002 Sep-Oct;27(5):451-455
Department of Anesthesiology, Rush Medical College at Rush-Presbyterian-St. Luke's Medical Center, Chicago, IL.
[Record supplied by publisher]
Background and Objectives: After peripheral inflammatory stimuli, spinal cord cyclooyxgenase-2 (COX-2) mRNA and protein levels increase, whereas COX-1 is unchanged. In animal models of inflammatory pain, intrathecal COX-2 selective inhibitors suppress hyperalgesia. However, the role of spinal COX-2 inhibition in postoperative pain is not well elucidated. This study investigates whether a water-soluble COX-2 selective inhibitor, L-745,337, can modify allodynic responses in a rat model of postoperative pain. METHODS: Allodynia was induced in the left plantar hindpaw by surgical incision. Animals then received intrathecal (0-80 &mgr;g) or subcutaneous (0-30 mg/kg) L-745,337 coadministered with intrathecal morphine (0-2 nmol). Reduction of mechanical allodynia (increased withdrawal threshold) was quantified with calibrated von Frey hairs. RESULTS: L-745,337 alone, whether intrathecal or systemic, had no effect on withdrawal threshold. When intrathecal L-745,337 at doses of 40 to 80 &mgr;g was combined with a subthreshold dose (0.5 nmol) of morphine, withdrawal thresholds were increased in a dose-dependent manner. Adding 80 &mgr;g L-745,337 to 1 nmol morphine produced an antiallodynic effect greater than that of morphine at twice the dose. Subcutaneous L-745,337, up to 30 mg/kg combined with intrathecal morphine resulted in the same antiallodynic response as morphine alone. CONCLUSION: These results suggest a spinal interaction of COX-2 inhibition with opiate analgesia may allow a reduction of postoperative pain with lower doses of opiate. Reg Anesth Pain Med 2002;27:451-455.
PMID: 12373690
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