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Br J Anaesth 2003 Mar;90(3):314-9
Department of Anaesthesiology and Critical Care, Groupe Hospitalier Pitie-Salpetriere, Assistance Publique-Hopitaux de Paris (AP-HP), Universite Pierre et Marie Curie, Paris, France. frederic.aubrun@psl.ap-hop-paris.fr
BACKGROUND: Propacetamol is widely used in the management of postoperative pain. It decreases morphine requirements but its effect on the incidence of morphine-related adverse effects remains unknown. METHODS: Patients (550) were randomly assigned to receive propacetamol or a placebo over the first 24 h after operation in a blinded study. Intravenous morphine titration was performed, after which morphine was administered s.c. every 4 h according to their pain score. Pain was assessed using a visual analogue scale (VAS). The primary end-point was the incidence of morphine-related adverse effects. The main secondary end-points were morphine requirements and VAS score. RESULTS: After morphine titration, the VAS score and the number of patients with pain relief did not differ between groups. Morphine requirements were decreased in the propacetamol group (21 vs 14.5 mg, P<0.001) but the incidence of morphine-related adverse effects did not differ between groups (42 vs 46%, not significant). In patients with moderate pain (n=395), morphine requirements decreased by 37% (P<0.001) and the percentage of patients requiring no morphine was greater (21 vs 8%, P=0.002) in the propacetamol group. In patients with severe pain (n=155), morphine requirements decreased by 18% (P=0.04) in the propacetamol group and the number of patients who did not require morphine (3 vs 8%) did not differ significantly. CONCLUSIONS: Although propacetamol induced a small morphine-sparing effect, it did not change the incidence of morphine-related adverse effects in the postoperative period. Moreover, no benefit could be demonstrated in patients with severe postoperative pain.
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PMID: 12594143, UI: 22482057
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Br J Anaesth 2003 Mar;90(3):300-3
Institut Arnault Tzanck, Saint Laurent du Var, Nice, France.
BACKGROUND: After cardiac surgery adequate postoperative analgesia is necessary. We assessed analgesia using intrathecal morphine and clonidine. METHODS: In a double-blind randomized study, 45 patients having coronary artery bypass graft surgery were allocated randomly to receive i.v. patient-controlled analgesia (PCA) morphine (bolus, 1 mg; lock-out interval, 7 min) (control group), either alone or combined with intrathecal morphine 4 microg kg(-1) or with both intrathecal morphine 4 microg kg(-1) and clonidine 1 microg kg(-1). Intrathecal injections were performed before the induction of general anaesthesia. Pain was measured after surgery using a visual analogue scale (VAS). We recorded i.v. PCA morphine consumption during the 24 h after operation. RESULTS: Morphine dosage [median (25th-75th percentiles)] was less in the first 24 h in the patients who were given intrathecal morphine + clonidine [7 (0-37) mg] than in other patients [40.5 (15-61.5) mg in the intrathecal morphine group and 37 (30.5-51) mg in the i.v. morphine group]. VAS scores were lower after intrathecal morphine + clonidine compared with the control group. Time to extubation was less after intrathecal morphine + clonidine compared with the i.v. morphine group [225 (195-330) vs 330 (300-360) min, P<0.05]. CONCLUSION: Intrathecal morphine and clonidine provide effective analgesia after coronary artery bypass graft surgery and allow earlier extubation.
PMID: 12594140, UI: 22482054
J Pain Symptom Manage 2003 Apr;25(4):386-90
Departments of Anesthesiology, Milwaukee, WI, USA
[Medline record in process]
A 14-year-old girl presented with Complex Regional Pain Syndrome, Type I (CRPS-1) of the left ankle after a remote history of sprain. Allodynia, pain, temperature and color changes, and swelling were successfully treated with physical therapy, transcutaneous electrical nerve stimulation (TENS), gabapentin, amitriptyline, and tramadol. Five weeks later, she presented with a continuous, involuntary, intermittent coarse tremor of the left foot causing increased pain. The electromyogram showed rhythmic discharges of 3 Hz frequency lasting 20-80 milliseconds in the left tibialis, peroneus and gastrocnemius, suggestive of either basal ganglia or spinal origin. Tremor and pain were controlled with epidural bupivacaine, but the tremor reappeared after discontinuing epidural blockade. Carbidopa/levodopa 25/100 (Sinemet((R))) was started and the tremor disappeared after two days. With continued physical therapy, pain and swelling resolved within two months and carbidopa/ levodopa was discontinued after five weeks with no recurrence of the tremor. Our success in the treatment of CRPS-associated tremor in this young girl with carbidopa/levodopa suggests that this patient may have had underlying movement disorder which was unmasked by the peripheral injury.
PMID: 12691691, UI: 22578662
J Pain Symptom Manage 2003 Apr;25(4):376-85
College of Nursing, Taipei Medical University, Taipei, Taiwan
The purpose of the study was to develop and preliminarily test the feasibility, validity, reliability, and factor structures of the Pain Opioid Analgesics Beliefs Scale-Cancer (POABS-CA) in hospitalized adults diagnosed with cancer in Taiwan. This scale was developed in three phases. In Phase I, item development was based on qualitative analysis as well as a review of the literature. Face validity, content validity, and feasibility were also evaluated. In Phase II, internal consistency reliability was further tested in 42 subjects with pain. In Phase III, test-retest reliability, internal consistency, and essential construct validity were further assessed in a sample of 361 hospitalized cancer patients with pain. The POABS-CA evolved from testing as a 10-item 5-point Likert-type instrument. Higher scores indicated more negative beliefs regarding opioids and their use in managing pain. Satisfactory face validity and content validity were found. The POABS-CA was also shown to be a reliable and stable pain belief scale, with Cronbach's alpha and test-retest reliability of 0.70 and 0.94, respectively. Two factors, namely pain endurance beliefs and negative effect beliefs, were extracted from the principal component factor analysis to support the construct validity. In conclusion, preliminary evidence indicates the POABS-CA is a reliable, stable, valid and easily applied scale for assessing beliefs regarding opioid use for cancer pain. Further studies should test this scale in different populations to increase its applications in cancer pain management.
PMID: 12691690, UI: 22578661
J Pain Symptom Manage 2003 Apr;25(4):344-56
Vanderbilt University Medical Center, Nashville, TN, USA
The purpose of this study was to determine if continued access to information following a baseline pain education program would increase knowledge and positive beliefs about cancer pain management, thus resulting in improved pain control during a 6-month follow-up period. Patients with cancer-related pain and their primary caregivers received a brief pain education program, and were then randomized into one of three information groups: a) usual care, b) pain hot line, and c) weekly provider-initiated follow-up calls for 1 month post-education. Sixty-four patients and their primary caregivers were recruited. Both patients and caregivers showed an improvement in knowledge and beliefs after the baseline pain education program. Continued access to pain information with either the pain hot line or provider-initiated weekly follow-up calls did not affect long-term outcomes of pain intensity, interference because of pain, adequacy of analgesics used, or pain relief. In addition, long-term outcomes did not differ between patients who had improvement and those who showed decline in knowledge and beliefs pre-post education. These findings suggest that a brief pain education program can improve knowledge and beliefs of both patient and primary caregiver. Continued access to pain related information using either a patient- or provider-initiated format did not affect long-term pain outcomes.
PMID: 12691686, UI: 22578657
J Pain Symptom Manage 2003 Apr;25(4):334-43
West Clinic, Memphis, TN, USA
The Zero Acceptance of Pain (ZAP) Quality Improvement Project was a multi-site effort to improve the lives of outpatients with cancer pain by enhancing the clinical practice of pain assessment and management. Independent samples of patients completed self-report measures of severity of pain, pain interference, global quality of life, pain treatment satisfaction, general medical treatment satisfaction, pain attitudes, and pain-related medical costs before and after the implementation of ZAP. Results suggested that ZAP decreased the severity of recent pain, decreased interference of pain on daily functioning, and improved satisfaction with pain treatment and attitudes about addiction to opioid medication. Direct medical costs consisting of pain-related hospitalizations, emergency department visits, and physician office visits were greatly reduced. In summary, the findings of this study support the idea that clinic-based efforts to improve the practice of pain management are effective in improving the lives of cancer patients who are experiencing pain.
PMID: 12691685, UI: 22578656
J Pain Symptom Manage 2003 Apr;25(4):302-5
La Maddalena Cancer Center, Palermo, Italy
PMID: 12691680, UI: 22578651
J Pain Symptom Manage 2003 Apr;25(4):299-302
MGH Pain Center Department of Anesthesia and Critical Care Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
PMID: 12691679, UI: 22578650
J Pain Symptom Manage 2003 Apr;25(4):297-9
Department of Medicine, Chattanooga Unit University of Tennessee College of Medicine, Chattanooga, TN, USA
PMID: 12691678, UI: 22578649
J Pain Symptom Manage 2003 Mar;25(3):276-83
University of Utah College of Pharmacy and School of Medicine, Salt Lake City, UT, USA.
Opioids have demonstrated efficacy and often are drugs of choice in the management of postoperative pain. However, their use is often limited by adverse drug events (ADEs). The objective of this study was to determine the ADE rate in adult surgical patients who received opioids and the impact of opioid ADEs on length of stay (LOS), costs, and mortality. A hospital-based computerized system detected potential ADEs. Adult patients were selected if they received at least one dose of opioid medication during a surgical hospitalization between 1 January 1990 and 31 December 1999. Control patients were matched based on matching length of stay ([LOS] at least as long as time to ADE), age (within 10 years), sex, admission year, major disease category (MDC), and without an ADE. Linear regression models were used to determine the predictors of increased LOS, total hospital costs, and log-transformed total hospital costs. 60,722 patients received opioid medication during their surgical hospitalization and 2.7% experienced an opioid-related ADE. The most common clinical manifestations were nausea and vomiting (67%), and rash, hives, or itching (33.5%). No statistically significant difference was seen in mortality between ADE/non-ADE patients. ADE patients had statistically significant increases in LOS (0.53 days) and in log-transformed cost (16%). The estimated log cost difference of 16%, if applied to the median cost patient in the non-ADE group, averaged US$ 840. Opioid-related ADEs are common in hospitalized patients and increase LOS and total hospital costs.
PMID: 12614962, UI: 22503229
Lancet 2003 Mar 8;361(9360):809-13
Division of Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA. cercek@cshs.org
BACKGROUND: There is serological and epidemiological evidence of an association between Chlamydia pneumoniae infection and coronary artery disease. Results of previous smaller studies have indicated a reduction of recurrent ischaemic events in patients with acute coronary syndrome when given macrolide antibiotics. We aimed to assess whether short-term treatment with the macrolide antibiotic azithromycin reduces recurrent ischaemic events in patients admitted for unstable angina or myocardial infarction. METHODS: We assessed the effect of azithromycin in a multicentre, double-blind randomised trial in 1439 patients with unstable angina or acute myocardial infarction. Patients were randomly allocated to receive 500 mg azithromycin on the first day after randomisation, followed by 250 mg daily for 4 days or placebo. Patients were followed up for 6 months. The primary endpoints were death, recurrent myocardial infarction, or recurrent ischaemia necessitating revascularisation. Analysis was done by intention to treat. FINDINGS: Treatment with azithromycin did not result in reduction of either individual endpoints or any of the primary endpoints. Of the 716 patients in the azithromycin group, 23 (3%) died, 17 (2%) developed myocardial infarction, 65 (9%) had recurrent ischaemia needing revascularisation, and 100 (14%) had one or more of these endpoints. In the placebo group (n=723) the corresponding numbers of patients were 24 (4%), 22 (3%), 59 (8%), and 106 (15%), respectively (p=0.664, 95% CI 0.72-1.24). 62 (9%) of patients in the azithromycin group and 59 (8%) in the placebo group reached the secondary endpoint of ischaemia or congestive heart failure necessitating admission (difference 0.5%, 95% CI 0.75-1.53; p=0.707). We recorded few side-effects. INTERPRETATION: Short-term treatment with azithromycin does not reduce development of recurrent events in patients with acute coronary syndrome.
PMID: 12642046, UI: 22529462
Neurology 2003 Apr 8;60(7):1214
Department of Neurology, University of New Mexico School of Medicine, Albuquerque, USA. jshih@salud.unm.edu
PMID: 12682343, UI: 22569121
Pain 2003 Feb;101(3):237-50
Department of Physiology, Institute of Biomedicine, University of Turku, Kiinamyllynkatu 10, FIN-20520 Turku, Finland. Antti.Pertovaara@utu.fi
The efficacy of spinally versus supraspinally administered morphine was studied in rats with a spinal nerve ligation-induced neuropathy. Behavioural assessment indicated that the effect of intrathecally administered morphine on pain-related responses was attenuated when compared with unoperated controls. The decreased efficacy of spinal morphine was associated with neuropathic symptoms, since sham ligation or nerve ligation without accompanying tactile allodynia did not lead to spinal inefficacy of morphine. In contrast, the pain attenuating effect of morphine in the periaqueductal gray (PAG) was enhanced in neuropathic animals. The effect of systemically administered morphine on pain-related behavior of neuropathic rats was in the same range as in controls or decreased, depending on the test. Coadministration of lidocaine or MK-801, a N-methyl-D-aspartate (NMDA) receptor antagonist, into the rostroventromedial medulla enhanced the tactile antiallodynic but not the thermal antinociceptive effect of intrathecally administered morphine in neuropathic animals. Supraspinal administration of MK-801 or lidocaine did not influence efficacy of spinal morphine in sham-operated animals. Electrophysiological recordings of nociceptive wide-dynamic range (WDR) neurons in the deep spinal dorsal horn of pentobarbitone-anesthetized animals corresponded to a large extent with behavioral results. The inhibitory effect of spinally and systemically administered morphine on WDR neuron responses was attenuated whereas that induced by morphine in the PAG was enhanced in neuropathic animals. The results indicate that in spinal nerve ligation-induced neuropathy the efficacy of spinal morphine is decreased whereas that of supraspinal morphine is increased. Descending influence from brainstem-spinal pathways, involving NMDA receptors in the rostroventromedial medulla, may contribute to the selective reduction in tactile antiallodynic efficacy of spinal morphine.
PMID: 12583866, UI: 22472570
Reg Anesth Pain Med 2003 Mar-Apr;28(2):156-161
[Record supplied by publisher]
PMID: 12677637
Reg Anesth Pain Med 2003 Mar-Apr;28(2):120-3
Department of Anesthesia Intensive Care and Pain Clinic (University of Rennes 1), University Hospital of Rennes, France, and the Centre Medico-Chirurgical Saint-Vincent, Saint-Gregoire, France.
Background and Objectives: Tourniquet pain often limits the use of intravenous regional anesthesia (IVRA). Intravenous (IV) lidocaine has been shown to be effective in the management of acute and neuropathic pains. We tested the hypothesis that a priming IV injection of lidocaine might have an analgesic effect on tourniquet pain during IVRA. METHODS: A prospective, randomized, double- blind study was conducted on 40 patients scheduled for carpal tunnel decompression. No sedation was given. Each patient received either 1 mg/kg of IV lidocaine (group L) or 0.1 mL/kg of IV isotonic saline (group control = C) 5 minutes before IVRA. Thereafter, they received 3 mg/kg of plain 0.5 % lidocaine into the isolated and exsanguinated arm. A double-cuffed tourniquet was used. Pain at the tourniquet and the surgical sites was assessed every 5 minutes using a linear visual analog scale (VAS) and a verbal rating scale (VRS) during the surgical procedure and the immediate postoperative period (60 minutes). RESULTS: Demographic data and duration of proximal and distal tourniquet were similar in each group. Significant differences in the pain scales were observed for the distal tourniquet at tourniquet inflation time and 15 minutes after (P =.03 and.005, respectively) in the group L. For the proximal tourniquet, only the VRS was significantly improved (P =.03). No analgesic benefit was observed in the immediate postoperative period. CONCLUSIONS: Priming IV lidocaine when compared with isotonic saline is effective in reducing tourniquet pain in IVRA. Reg Anesth Pain Med 2003;28:120-123.
PMID: 12677622, UI: 22564137
Reg Anesth Pain Med 2003 Mar-Apr;28(2):113-9
Pain Management Center, Departments of Anesthesiology, Walter Reed Army Medical Center, Washington, D.C., USA. Steven.Cohen@med.nyu.edu
BACKGROUND AND OBJECTIVES: Pain arising from the sacroiliac (SI) joint is a common cause of low back pain for which there is no universally accepted, long-term treatment. Previous studies have shown radiofrequency (RF) procedures to be an effective treatment for other types of spinal pain. The purpose of this study was to determine the efficacy of reducing SI joint pain by percutaneous RF lesioning of the nerves innervating the SI joint. METHODS: Eighteen patients with confirmed SI joint pain underwent nerve blocks of the L4-5 primary dorsal rami and S1-3 lateral branches innervating the affected joint. Those who obtained 50% or greater pain relief from these blocks proceeded to undergo RF denervation of the nerves. RESULTS: Thirteen of 18 patients who underwent L4-5 dorsal rami and S1-3 lateral branch blocks (LBB) obtained significant pain relief, with 2 patients reporting prolonged benefit. At their next visit, 9 patients who experienced >50% pain relief underwent RF lesioning of the nerves. Eight of 9 patients (89%) obtained >/=50% pain relief from this procedure that persisted at their 9-month follow-up. CONCLUSIONS: In patients with SI joint pain who respond to L4-5 dorsal rami and S1-3 LBB, RF denervation of these nerves appears to be an effective treatment. Randomized, controlled trials are needed to further evaluate this procedure.
PMID: 12677621, UI: 22564136