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Anesth Analg 2003 Feb;96(2):631
Department of Anesthesia, Okazaki City Hospital, Okazaki, Japan. Department of Anesthesiology and Resuscitology, Nagoya City University Medical School, Nagoya, Japan.
[Medline record in process]
PMID: 12538232, UI: 22425395
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Anesth Analg 2003 Feb;96(2):498-506, table of contents
Department of Anesthesia and General Intensive Care, University of Vienna, Austria.
We tested the hypothesis that the risk or discomfort associated with a clinical trial influence patients' decisions to participate. Simultaneously, we evaluated factors likely to influence patients' decisions such as understanding of the risk and discomfort associated with the study, patient age, educational level, and psychological status. With IRB approval, participants, who believed they were being asked to participate in a real trial, were presented one of three sham protocols: no risk or pain (Control, n = 48), pain but no risk (Pain, n = 51), or risk but no pain (Risk, n = 51). Patients were debriefed at the end of the interview. Our major outcome measures were (a) understanding risk or pain associated with the proposed studies, (b) the extent to which patients felt pressured to participate, and (c) willingness to participate. Whereas understanding was similar in all groups (Control, 68%; Pain, 67%; and Risk, 72%), willingness to participate differed significantly (Control, 64%; Pain, 35%; Risk, 26%; P < 0.001). Patients who understood the level of risk or pain associated with the protocols were twice as likely to participate than those who did not (49% versus 24%; P = 0.003). Nine percent agreed to participate in the risky or painful protocols without understanding the risks involved. Patients who felt pressured did not agree to participate. Thus, the consent process protected patients, although for unexpected reasons. Understanding was poor, but patients who did not understand the risks or pain involved or who felt pressured rarely consented. Consequently, relatively few patients unknowingly agreed to participate in risky or painful studies.
PMID: 12538203, UI: 22425366
Anesth Analg 2003 Feb;96(2):493-7
Outcomes Research Institute and Department of Anesthesiology, University of Louisville, Louisville, Kentucky. Ludwig Boltzmann Institute, University of Vienna, Vienna, Austria.
Minute sphere acupressure has been used for more than 2000 yr and remains popular in Japan. The points most relevant to abdominal surgery are those associated with meridian flows crossing or originating in the abdomen. We tested the hypothesis that minute sphere therapy reduces pain and analgesic requirements after open abdominal surgery. Participating patients were given standardized desflurane and fentanyl anesthetic. On completion of surgery, they were randomly assigned to untreated control or minute sphere acupressure at the Neiguan, Zusanli, Sanyinjiao, and Gongsun points. Each site was covered with bulky gauze dressings so that patients could not determine their assignments. Postoperative pain was treated with IV morphine via a patient-controlled analgesia pump. Our primary a priori end-points were pain and opioid consumption on the first postoperative morning. Data are reported as median (25th percentile, 75th percentile). Fifty-three patients (30 controls and 23 minute spheres) completed the study. Morphine requirements (47 mg [27, 58] vs 41 mg [25, 69]) and pain scores (29.5 mm [16, 59] vs 40 mm [22, 58]) were similar in the control and acupressure groups. These data provide an 80% power for detecting a 50% difference in morphine consumption at an alpha of 0.05. Minute sphere treatment at the Neiguan, Zusanli, Sanyinjiao, and Gongsun points thus failed to provide analgesia after abdominal surgery. Minute sphere therapy is a form of acupuncture. We tested whether minute spheres placed on three acupressure points relevant to abdominal surgery reduced pain and morphine requirements after abdominal surgery. Treatment and control patients received a similar covering. Neither pain nor morphine requirements were different between the groups.
PMID: 12538202, UI: 22425365
Anesth Analg 2003 Feb;96(2):481-6
Department of Anaesthesiology and Intensive Care Medicine, Institute of Medical Informatics, and. Rudolf-Buchheim-Institute for Pharmacology, Justus-Liebig-University, Giessen, Germany.
The function of beta-endorphin immunoreactive material (IRM) released under perioperative conditions remains to be clarified. In 17 patients undergoing orthopedic surgery, we determined beta-endorphin IRM in venous blood plasma and in cerebrospinal fluid (CSF) before surgery (t(A)); after termination of surgery and general anesthesia, but still under spinal anesthesia (t(B)); on occurrence of postoperative pain (t(C)); and 1 day after the operation (t(D)). Pain severity was rated by the patients by using a visual analog scale. Patients felt postoperative pain (t(C)), but they felt no pain at times t(A), t(B), and t(D). beta-Endorphin IRM plasma levels before surgery (t(A)) or with postoperative pain (t(C)) proved to be significantly higher than levels determined just after surgery, but still under spinal anesthesia (t(B)), or those determined 1 day after the operation (t(D)); beta-endorphin IRM plasma levels at times t(A) and t(C) correlated positively with postoperative pain severity (t(C)). beta-Endorphin IRM CSF levels after surgery, but still under spinal anesthesia (t(B)), were significantly higher than levels determined at times t(A), t(C), or t(D). No correlation was found between beta-endorphin IRM CSF levels and pain severity. In conclusion, postoperative pain severity appears to be related to beta-endorphin IRM levels in plasma before surgery as well as with postoperative pain; the analgesic significance of this material remains to be elucidated. IMPLICATIONS: beta-Endorphin immunoreactive material has been determined in plasma and cerebrospinal fluid under perioperative conditions. Its release into the cardiovascular compartment is related to postoperative pain severity, although its analgesic significance remains to be elucidated.
PMID: 12538200, UI: 22425363
Anesth Analg 2003 Feb;96(2):475-80
Departments of Anesthesiology and. Surgery, Universitat de Barcelona, Hospital Clinic, Barcelona, Spain.
In cirrhotic patients undergoing hepatic surgery, postoperative analgesia remains a challenge. In this study, we evaluated the efficacy of a single dose of morphine combined with small-dose ketamine given epidurally for postoperative pain relief. One-hundred-four classification "Child A" cirrhotic patients were randomly assigned to two groups: 1) (MKG, n = 54): epidural morphine (3.5-5 mg) plus ketamine (20/30 mg); and 2) epidural morphine (3.5/5 mg) (MG, n = 50). The level of analgesia, side effects, psychomimetic and neurological disorders, additional analgesic needs, and overall quality of the analgesia were recorded. The mean duration of analgesia was longer in the MKG group (27.2 +/- 8 h versus 16.4 +/- 10 h; P < 0.05). In the MKG group, the visual analog scale (VAS) score began to be significantly lower from 14 h at rest and 12 h on coughing until the end of the study. The need for additional analgesia was also smaller in the MKG group (P < 0.05): at 24 h, only 10% of patients in the MKG group needed complementary analgesia, whereas in the MG group it was 100% (P = 0.003). Side effects were similar in both groups. Psychomimetic side effects and neurological disorders were not detected. These results suggest that postoperative analgesia provided by a single dose of epidural morphine with small-dose ketamine is effective in cirrhotic Child's A patients having major upper abdominal surgery. IMPLICATIONS: This is a clinical prospective and randomized trial. The study shows the efficacy and safety of a single-dose administration of epidural morphine plus small-dose ketamine given as the only treatment for postoperative pain relief in cirrhotic patients having liver resection.
PMID: 12538199, UI: 22425362
Anesth Analg 2003 Feb;96(2):469-74
Tufts University School of Medicine and Tufts-New England Medical Center, Boston, Massachusetts.
We compared pain intensity, analgesic consumption, patient satisfaction, and length of stay in 114 patients undergoing gastric bypass surgery under general anesthesia. Patients were randomized to incisional local anesthetic infiltration plus postoperative patient-controlled analgesia (Group A), epidural anesthesia and analgesia (Group B), or postoperative patient-controlled analgesia (Group C). All received perioperative nonsteroidal antiinflammatory drugs. Age, sex, body mass index, length of stay, and patient satisfaction were equivalent in all groups. Pain at time 0 and 36 h was the smallest in Group B, greater in Group A, and greatest in Group C. Pain scores in a subset of Group A were lower at all times than in Groups B and C, but this difference was significant only at 0, 12, and 36 h. In responders, infiltration analgesia as part of a multimodal regimen offers a simple, safe, and inexpensive alternative to epidural pain control. IMPLICATIONS: We compared pain intensity, analgesic consumption, length of stay, and patient satisfaction in patients undergoing gastric bypass surgery randomized to one of three treatment groups. In responders, infiltration analgesia as part of a multimodal postoperative pain management regimen offered a simple, safe, and inexpensive alternative to epidural pain control.
PMID: 12538198, UI: 22425361
Anesth Analg 2003 Jan;96(1):263-72
Department of Anesthesiology, Virginia Mason Medical Center, Seattle, Washington 98111, USA. anessl@vmmc.org
Publication Types:
PMID: 12505964, UI: 22392438
Anesth Analg 2003 Jan;96(1):253-9, table of contents
Department of Anesthesiology and Orthopedic Surgery, Vita-Salute University of Milano, IRCCS H. San Raffaele, Italy. casati.andrea@hsr.it
We compared the onset time and quality of interscalene brachial plexus block produced with levobupivacaine and ropivacaine in 50 patients undergoing open shoulder surgery randomly allocated to receive 30 mL of 0.5% levobupivacaine (n = 25) or 0.5% ropivacaine (n = 25) injected through a 20-gauge catheter placed into the interscalene sheath using a 18-gauge insulated and stimulating Tuohy introducer. The block was also prolonged after surgery using a patient-controlled interscalene analgesia with 0.125% levobupivacaine or 0.2% ropivacaine, respectively (basal infusion rate, 6 mL/h; bolus, 2 mL; lockout period, 15 min; maximum boluses per hour, three). Three patients (two with levobupivacaine [8%] and one with ropivacaine [4%]) failed to achieve surgical block within 45 min after the injection and were excluded. The onset time of surgical block was 20 min (10-40 min) with levobupivacaine and 20 min (5-45 min) with ropivacaine (P = 0.53). Rescue intraoperative analgesia (0.1 mg of fentanyl IV) was required in eight patients in each group (34%) (P = 0.99). Forty-two patients completed the 24-h postoperative infusion (22 with levobupivacaine and 20 with ropivacaine). Postoperative analgesia was similarly effective in both groups. Total consumption of local anesthetic infused during the first 24 h was 147 mL (144-196 mL) with levobupivacaine and 162 mL (144-248 mL) with ropivacaine (P = 0.019), with a ratio between boluses received and requested of 0.8 (0.4-1.0) and 0.7 (0.4-1.0), respectively (P = 0.004). The degree of motor block of the operated limb was deeper with levobupivacaine than ropivacaine when starting postoperative analgesia; however, no further differences in degree of motor function were observed between the two groups. We conclude that 30 mL of levobupivacaine 0.5% induces an interscalene brachial plexus anesthesia of similar onset and intensity as the one produced by the same volume and concentration of ropivacaine. Postoperative interscalene analgesia with 0.125% levobupivacaine results in similar pain relief and recovery of motor function with less volume of local anesthetic than with 0.2% ropivacaine. IMPLICATIONS: This prospective, randomized, double-blinded study demonstrates that 30 mL of 0.5% levobupivacaine produces an interscalene brachial plexus block of similar onset and quality as the one produced by the same volume of 0.5% ropivacaine. When prolonging the block after surgery, 0.125% levobupivacaine provides adequate pain relief and recovery of motor function after open shoulder surgery, with less volume infused during the first 24 h after surgery than 0.2% ropivacaine.
PMID: 12505962, UI: 22392436
Anesth Analg 2003 Jan;96(1):247-52, table of contents
Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota 55905, USA.
Continuous axillary brachial plexus block may theoretically increase the risk of neurologic complications because of catheter-induced mechanical trauma or local anesthetic toxicity. In this study, we retrospectively reviewed the frequency of complications using current techniques and applications. There were 405 continuous axillary catheters in 368 patients. A preexisting neurologic condition was present in 41 (10.1%) patients, including 30 patients with a preoperative ulnar neuropathy. In 305 (75.3%) cases, the axillary catheter was placed to facilitate rehabilitation after major elbow surgery. Catheters were typically placed postoperatively, after documentation of the patient's normal neurologic examination. The local anesthetic infusion contained bupivacaine in 355 (88.7%) patients and mepivacaine in 45 (11.1%) patients. The mean infusion rate was 10 +/- 2 mL/h. Catheters remained indwelling for 55 +/- 32 h. In 31 patients, the axillary catheter was replaced because of technical problems or inadequate analgesia. There were 9 complications in 8 patients for an overall frequency of 2.2%. Complications included one each of the following: localized infection (treated with catheter removal and antibiotics), axillary hematoma, and retained catheter fragment requiring surgical excision. In addition, two patients reported signs and symptoms of systemic (preseizure) local anesthetic toxicity. Four (1.0%) patients reported new neurologic deficits postoperatively. In two patients, the neural dysfunction was non-anesthesia related. All four had continuous catheters placed after major elbow surgery. We conclude that the risk of neurologic complications associated with continuous axillary blockade is similar to that of single-dose techniques. IMPLICATIONS: We evaluated the risk of neurologic complications in 368 patients undergoing 405 consecutive continuous axillary blocks. New neurologic deficits were reported in four patients. This series suggests that the risk of neurologic complications associated with continuous axillary block is similar to that of single-dose techniques.
PMID: 12505961, UI: 22392435
Anesth Analg 2003 Jan;96(1):186-90, table of contents
Foothills Regional Pain Center and Mountainview Medical Imaging, Seneca, South Carolina, USA. marionmc@worldnet.att.net
A cohort of seven patients receiving intrathecal analgesic drug therapy for chronic intractable pain underwent radiocontrast myelography and computed tomography (CT) scanning to screen for catheter-associated intrathecal masses. Three of seven patients examined had intraspinal masses associated with the tip of the drug infusion catheter after a total of 118 mo of therapy. The index case presented with exacerbation of neuropathic pain and paralysis of the left lower extremity. The two additional cases detected by CT myelography were asymptomatic at the time the catheter-associated mass was assessed. The mean duration of therapy before diagnosis of the catheter-associated mass was 19.6 mo, with a range of 16-25 mo. An intergroup comparison of demographic and treatment variables between patients, with and without catheter-associated masses, demonstrated that patients with masses were younger and were receiving a larger morphine dose than patients without masses. The differences were statistically significant (P = 0.05). In one patient with an asymptomatic catheter-associated intrathecal mass, regression of the mass was observed after cessation of therapy. In a second asymptomatic patient, the mass remained stable over 1 yr of continued treatment after substitution of hydromorphone for morphine without interruption of therapy. Neither asymptomatic patient has subsequently developed additional neurologic findings or injury after detection of occult catheter-associated intrathecal masses and clinical intervention. We suggest that all patients receiving long-term intrathecal analgesia should undergo periodic radiographic surveillance to further define their risk of developing occult catheter-associated masses and to allow intervention before neurologic injury can develop. IMPLICATIONS: Catheter-associated intrathecal masses were detected in three of seven patients receiving long-term intrathecal analgesia. In the two asymptomatic patients, timely clinical intervention was associated with the avoidance of subsequent neurologic injury and spontaneous resolution of one of the occult masses.
PMID: 12505950, UI: 22392424
Anesth Analg 2003 Jan;96(1):68-77, table of contents
Department of Anesthesiology and Intensive Care Medicine, Herlev University Hospital, Copenhagen, Denmark. moiniche@dadlnet.dk
The use of nonsteroidal antiinflammatory drugs (NSAIDs) for analgesia after tonsillectomy is controversial because NSAIDS, through platelet inhibition, may increase the risk of perioperative bleeding. We systematically searched for randomized, controlled trials that reported on the incidence of perioperative bleeding attributable to the use of NSAIDs in patients undergoing tonsillectomy. As secondary outcome measures, we analyzed the quality of pain relief and the incidence of postoperative nausea and vomiting. Twenty-five studies with data from 970 patients receiving a NSAID and 883 receiving a non-NSAID treatment or a placebo were analyzed. Data were combined using a fixed-effect model. Of four bleeding end points (intraoperative blood loss, postoperative bleeding, hospital admission, and reoperation because of bleeding), only reoperation happened significantly more often with NSAIDs: Peto-odds ratio, 2.33 (95% confidence interval [CI], 1.12-4.83) and number-needed-to-treat, 60 (95% CI, 34-277). Compared with opioids, NSAIDs were equianalgesic, and the risk of emesis was significantly decreased (relative risk, 0.73; 95% CI, 0.63-0.85; numbers-needed-to-treat, 9; 95% CI, 5-19). IMPLICATIONS: The evidence for nonsteroidal antiinflammatory drugs to increase the risk of bleeding after tonsillectomy is equivocal, and the risk-benefit ratio is not straightforward. There is some evidence for an increased likelihood of reoperation because of bleeding. The agenda must be one of further research rather than of clinical recommendations.
PMID: 12505926, UI: 22392400
Anesth Analg 2003 Jan;96(1):33-8, table of contents
Department of Anesthesiology, Pitie-Salpetriere Hospital, Paris, France.
Remifentanil is a potent ultra-short-acting opioid, which permits rapid emergence. However, remifentanil is expensive and may have detrimental effects on hemodynamics in case of overdose. Target-controlled infusion (TCI) permits adapting infusion to pharmacokinetic models. In this prospective randomized study, we compared intra- and postoperative hemodynamics, remifentanil requirement during anesthesia, and postoperative morphine requirement in patients scheduled for carotid surgery, and receiving either continuous IV weight-adjusted infusion of remifentanil (RIVA) or TCI for remifentanil (TCIR). Forty-six patients were enrolled in this study: all were anesthetized by using TCI for propofol. Twenty-three received RIVA (0.5 micro g. kg(-1) x min(-1)) for the induction of anesthesia and endotracheal intubation, with the infusion rate decreased to 0.25 micro g x kg(-1) x min(-1) after intubation, then adapted by step of 0.05 micro g x kg(-1) x min(-1) according to hemodynamics. Twenty-three patients received TCIR (Minto model, Rugloop), with an effect-site concentration at 4 ng/mL during induction, then adapted by step of 1 ng/mL according to hemodynamics. All patients received atracurium and a 50% mixture of N(2)O/O(2). Hemodynamic variables were recorded each minute. The number and duration of hemodynamic events were collected, and total doses of anesthetics (remifentanil and propofol) and vasoactive drugs were noted in both groups of patients. Data were analyzed by using unpaired t-tests. RIVA was significantly associated with more frequent episodes of intraoperative hypotension (16 versus 6, P < 0.001) and more frequent episodes of postoperative hypertension and/or tachycardia requiring more frequent administration of beta-adrenergic blockers (16 vs 10, P < 0.04) in comparison with TCIR. The need for morphine titration was not significantly different between groups. TCIR led to a significantly smaller requirement of remifentanil (700 +/- 290 versus 1390 +/- 555 micro g, P < 0.001) without difference in propofol requirement. This prospective randomized study demonstrated that, during carotid endarterectomy, in comparison with patients receiving remifentanil using continuous RIVA, TCI results in less hypotensive episodes during the induction of anesthesia, in fewer episodes of tachycardia and/or hypertension and a smaller beta-adrenergic blocker requirement during recovery, and a decrease in remifentanil requirement. Recommendations to prefer TCI for remifentanil administration during carotid endarterectomy may be justified. IMPLICATIONS: Remifentanil for intraoperative analgesia in carotid artery surgery is associated with a better stability in perioperative hemodynamics when administered in target-controlled infusion compared with continuous weight-adjusted infusion. This may be related to a smaller requirement of this drug when using target-controlled infusion, as well as a smooth mode of administration.
PMID: 12505919, UI: 22392393
Anesthesiology 2003 Jan;98(1):280-1; author reply 281
PMID: 12503013, UI: 22390634
Anesthesiology 2003 Jan;98(1):270-2
Department of Anesthesiology, National Taiwan University Hospital, Nationnal Taiwan University College of Medine, Taipei, Taiwan.
PMID: 12503009, UI: 22390630
Anesthesiology 2003 Jan;98(1):203-8
Pain Mechanisms Laboratory, Department of Anesthesiology and Center for the Study of Pharmacologic Plasticity, Wake Forest university School of Medicine, wisnton Salem, North Carolina 27157-1009, USA. wma@wfubmc.edu
BACKGROUND: Systemic lidocaine and other local anesthetics reduce hypersensitivity states induced by both acute inflammation and peripheral nerve injury in animals and produce analgesia in some patients with chronic pain. The mechanisms underlying the antiallodynic effect of systemic lidocaine are unclear, although most focus is on peripheral mechanisms. Central mechanisms, particularly at the spinal dorsal horn level, are less known. In this study, the authors aimed to determine whether intrathecal lidocaine has an antiallodynic effect on established mechanical allodynia in two well-characterized neuropathic pain rat models: partial sciatic nerve ligation (PSNL) and spinal nerve ligation (SNL). METHODS: Lidocaine (100-300 micro g) was intrathecally injected in PSNL and SNL rats. The withdrawal threshold of both hind paws in response to mechanical stimulation was measured using a series of calibrated von Frey filaments. RESULTS: This single injection reduced ongoing tactile allodynia in PSNL and SNL rats. The antiallodynic effect of intrathecal lidocaine lasted longer in PSNL (> 3 days) than in SNL rats (< 3 days). Intraperitoneal lidocaine (300 micro g) had no effect on tactile allodynia in PSNL rats. In SNL rats, prior intrathecal lidocaine (200 and 300 micro g) potentiated the antiallodynic effect of intrathecal ketorolac, a nonselective cyclooxygenase inhibitor. Intrathecal ketorolac alone had no antiallodynic effect on SNL rats. However, prior intrathecal lidocaine (100 micro g) failed to potentiate the antiallodynic effect of intrathecal ketorolac. CONCLUSION: The authors' data suggest that intrathecal lidocaine possibly suppressed the hyperexcitability of the dorsal horn neurons and likely interacted with eicosanoid systems in the spinal dorsal horn.
PMID: 12502998, UI: 22390619
Anesthesiology 2003 Jan;98(1):143-50
*Consultant, dagger Professor and Chief of Staff, Department of Anesthesiology, University Clinic of Zurich/Balgrist. double dagger AstraZeneca R&D, Sodertalje, Sweden.
BACKGROUND: In this open, randomized study, the pharmacokinetics, clinical efficacy, and safety of a 48-h continuous interscalene infusion of 2 mg/ml ropivacaine for postoperative pain relief were investigated in patients undergoing open major shoulder surgery. METHODS: An initial interscalene block with 30 ml ropivacaine, 7.5 mg/ml (225 mg), was performed. After completion of interscalene block, all patients (n = 24) received general anesthesia, and 6 h after interscalene block, a 48-h continuous interscalene infusion of 12 or 18 mg/h using 2 mg/ml ropivacaine was started. Total and unbound plasma concentrations of ropivacaine and 2.6-pipecoloxylidide (PPX; a major active metabolite) were determined during and up to 6 h after the interscalene infusion. Postoperative pain at rest was assessed by a visual analog scale. Supplementary analgesics and adverse events were recorded. RESULTS: Plasma concentrations of total and unbound ropivacaine were proportional to the total dose. At the end of the interscalene infusion of 9 ml/h, the mean +/- SD plasma concentrations of total and unbound ropivacaine were 1.40 +/- 0.54 and 0.03 +/- 0.01 mg/l, respectively, and of total and unbound PPX were 0.70 +/- 0.38 and 0.30 +/- 0.20 mg/l, respectively. Plasma concentrations of unbound ropivacaine and unbound PPX, added together, remained well below threshold levels for systemic central nervous system toxicity. There were no significant differences between the groups for postoperative pain (median maximum of about 20 mm on the visual analog scale in both groups), analgesic consumption, or quality of pain relief assessed by the patient. No signs or symptoms of systemic local anesthetic toxicity were observed. CONCLUSION: A 48-h continuous interscalene infusion of 6 or 9 ml/h ropivacaine, 2 mg/ml, started 6 h after an initial interscalene block of 30 ml ropivacaine, 7.5 mg/ml, provided satisfactory postoperative pain relief after major shoulder surgery and was well tolerated. Unbound plasma concentrations of ropivacaine and PPX remained well below threshold levels for systemic central nervous toxicity.
PMID: 12502990, UI: 22390611
Ann Intern Med 2003 Jan 21;138(2):160
PMID: 12529108, UI: 22417125
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BMJ 2003 Jan 4;326(7379):13
Department of Paediatrics, Poissy-Saint Germain Hospital, 78300 Poissy, France. carbajal@club-internet.fr
OBJECTIVES: To investigate whether breast feeding is effective for pain relief during venepuncture in term neonates and compare any effect with that of oral glucose combined with a pacifier. DESIGN: Randomised controlled trial. PARTICIPANTS: 180 term newborn infants undergoing venepuncture; 45 in each group. INTERVENTIONS: During venepuncture infants were either breast fed (group 1), held in their mother's arms without breast feeding (group 2), given 1 ml of sterile water as placebo (group 3), or given 1 ml of 30% glucose followed by pacifier (group 4). Video recordings of the procedure were assessed by two observers blinded to the purpose of the study. MAIN OUTCOME MEASURES: Pain related behaviours evaluated with two acute pain rating scales: the Douleur Aigue Nouveau-ne scale (range 0 to 10) and the premature infant pain profile scale (range 0 to 18). RESULTS: Median pain scores (interquartile range) for breast feeding, held in mother's arms, placebo, and 30% glucose plus pacifier groups were 1 (0-3), 10 (8.5-10), 10 (7.5-10), and 3 (0-5) with the Douleur Aigue Nouveau-ne scale and 4.5 (2.25-8), 13 (10.5-15), 12 (9-13), and 4 (1-6) with the premature infant pain profile scale. Analysis of variance showed significantly different median pain scores (P<0.0001) among the groups. There were significant reductions in both scores for the breast feeding and glucose plus pacifier groups compared with the other two groups (P<0.0001, two tailed Mann-Whitney U tests between groups). The difference in Douleur Aigue Nouveau-ne scores between breast feeding and glucose plus pacifier groups was not significant (P=0.16). CONCLUSIONS: Breast feeding effectively reduces response to pain during minor invasive procedure in term neonates.
PMID: 12511452, UI: 22399481
Cephalalgia 2003 Feb;23(1):67-8
Department of Neurology, University of Munster, Munster, and Department of Neurology, University of Regensburg, Regensburg, Germany.
PMID: 12534584, UI: 22422774
Cephalalgia 2003 Feb;23(1):2-5
Departments of Neurology at Mayo Clinic Rochester, Mayo Clinic Scottsdale and Mayo Clinic Jacksonville.
Eross EJ, Dodick DW, Swanson JW & Capobianco DJ. A review of intractable facial pain secondary to underlying lung neoplasms. Cephalalgia 2003; 23:2-5. London. ISSN 0333-1024 We describe a 63-year-old smoker who suffered from intractable facial pain secondary to an underlying lung neoplasm. Data from 30 previously reported and similar cases are also summarized. The clinical triad of a smoker suffering from periauricular pain and an elevated ESR should alert the clinician to the possibility of an occult lung mass. In these cases a computed tomography of the chest should always be obtained. Previously refractory pain typically responds to surgical resection of the mass and/or radiation therapy.
PMID: 12534572, UI: 22422762
Eur J Pharmacol 2003 Jan 26;460(1):37-41
Dipartimento di Scienze del Farmaco, Universita degli Studi di Sassari, via Muroni 23/a, 07100, Sassari, Italy
Linalool is a monoterpene compound commonly found as a major component of the essential oils of several aromatic plant species, many of which are used in traditional medical systems as analgesic and anti-inflammatory remedies. We previously reported that (-)-linalool, the natural occurring enantiomer, plays a major role in the anti-inflammatory activity displayed by different essential oils, suggesting that linalool-producing species are potentially anti-inflammatory agents. In this study, the antinociceptive activity of (-)-linalool was examined in two different pain models in mice: the acetic acid-induced writhing response, a model of inflammatory pain, and the hot plate test, a model of supraspinal analgesia. Moreover, the effect of (-)-linalool on spontaneous locomotor activity (25, 50, 75 and 100 mg/kg) was evaluated. The results show that this compound induced a significant reduction of the acid-induced writhing at doses ranging from 25 to 75 mg/kg. Such effect was completely reversed both by the opioid receptor antagonist naloxone and by the unselective muscarinic receptor antagonist atropine. In the hot plate test, only the dose of 100 mg/kg of (-)-linalool resulted in a significant effect. (-)-Linalool induced a dose dependent increase of motility effects, thus ruling out the confounding influence of a possible sedative effect. The more pronounced effect of (-)-linalool on the writhing test with respect to the hot plate test is consistent with the observation that (-)-linalool possesses anti-inflammatory activity. Finally, the activation of opioidergic and cholinergic systems appears to play a crucial role in (-)-linalool-induced antinociception.
PMID: 12535857, UI: 22423192
JAMA 2003 Jan 15;289(3):331-42
TIMI Study Group, Brigham and Women's Hospital, Boston, Mass 02115, USA.
CONTEXT: Low-molecular-weight heparins (LMWHs) possess several potential pharmacological advantages over unfractionated heparin as an antithrombotic agent. OBJECTIVE: To systematically summarize the clinical data on the efficacy and safety of LMWHs compared with unfractionated heparin across the spectrum of acute coronary syndromes (ACSs), and as an adjunct to percutaneous coronary intervention (PCI). DATA SOURCES: We searched MEDLINE for articles from 1990 to 2002 using the index terms heparin, enoxaparin, dalteparin, nadroparin, tinzaparin, low molecular weight heparin, myocardial infarction, unstable angina, coronary angiography, coronary angioplasty, thrombolytic therapy, reperfusion, and drug therapy, combination. Additional data sources included bibliographies of articles identified on MEDLINE, inquiry of experts and pharmaceutical companies, and data presented at recent national and international cardiology conferences. STUDY SELECTION: We selected for review randomized trials comparing LMWHs against either unfractionated heparin or placebo for treatment of ACS, as well as trials and registries examining clinical outcomes, pharmacokinetics, and/or phamacodynamics of LMWHs in the setting of PCI. Of 39 studies identified, 31 fulfilled criteria for analysis. DATA EXTRACTION: Data quality was determined by publication in the peer-reviewed literature or presentation at an official cardiology society-sponsored meeting. DATA SYNTHESIS: The LMWHs are recommended by the American Heart Association and the American College of Cardiology for treatment of unstable angina/non-ST-elevation myocardial infarction. Clinical trials have demonstrated similar safety with LMWHs compared with unfractionated heparin in the setting of PCI and in conjunction with glycoprotein IIb/IIIa inhibitors. Finally, LMWHs show promise as an antithrombotic agent for the treatment of ST-elevation myocardial infarction. CONCLUSIONS: The LMWHs could potentially replace unfractionated heparin as the antithrombotic agent of choice across the spectrum of ACSs. In addition, they show promise as a safe and efficacious antithrombotic agent for PCI. However, further study is warranted to define the benefit of LMWHs in certain high-risk subgroups before their use can be universally recommended.
PMID: 12525234, UI: 22413771
Spine 2003 Jan 15;28(2):177-9
Department of Medicine, Riyadh Armed Forces Hospital, Riyadh, Saudi Arabia. alfaraj@yahoo.com
STUDY DESIGN: Initial assessment involved 360 patients (90% women and 10% men) attending spinal and internal medicine clinics over a 6-year period who had experienced low back pain that had no obvious cause for more than 6 months. The patients ranged in age from 15 to 52 years. OBJECTIVES: To investigate the contribution of vitamin D deficiency as a cause for idiopathic chronic low back pain, to find a simple and sensitive test for screening patients with low back pain for vitamin D deficiency, and to determine the correlation between the vitamin deficiency and pain. METHODS: A biochemical assay of serum calcium, phosphate, alkaline phosphatase, and 25-hydroxy vitamin D level was performed before and after treatment with vitamin D supplements. RESULTS: Findings showed that 83% of the study patients (n = 299) had an abnormally low level of vitamin D before treatment with vitamin D supplements. After treatment, clinical improvement in symptoms was seen in all the groups that had a low level of vitamin D, and in 95% of all the patients (n = 341). CONCLUSIONS: Vitamin D deficiency is a major contributor to chronic low back pain in areas where vitamin D deficiency is endemic. Screening for vitamin D deficiency and treatment with supplements should be mandatory in this setting. Measurement of serum 25-OH cholecalciferol is sensitive and specific for detection of vitamin D deficiency, and hence for presumed osteomalacia in patients with chronic low back pain.
PMID: 12544936, UI: 22433045
Spine 2003 Jan 15;28(2):161-6
CentraState Medical Center, Spine Center, Freehold, New Jersey 07728, USA. mwerneke@juno.com
STUDY DESIGN: Secondary analysis of a previously described cohort of prospective, consecutive patients with acute neck or low back pain referred to outpatient rehabilitation was performed. OBJECTIVE: To estimate discriminant validity and relative precision of two classification procedures (first visit vs multiple visit) in discriminating short-term pain intensity and perceived disability outcomes. SUMMARY OF BACKGROUND DATA: Centralization and noncentralization are pain responses used to classify patients and predict outcomes. Different time frames have been proposed for operationally defining these responses, which are problematic for comparing outcomes across clinical trials. Classifying patients according to pain response observed from initial examination (first visit) and over time (multiple visits) influences prevalence within categories and interpretation of classification usefulness, which merits further investigation. METHODS: Patients with acute onset of nonspecific neck or low back pain referred to two outpatient physical therapy clinics completed body pain diagrams, pain intensity ratings, and disability questionnaires at initial evaluation, during each visit, and at discharge. Therapists collected data enabling patient classification on initial examination and throughout treatment. Differences in pain and disability from intake to discharge from rehabilitation across classification categories were used to assess discriminant validity. Relative precision was estimated by determining ratios of analysis of covariance F values between classification procedures for pain and disability. RESULTS: Both classification procedures discriminated categories for change in pain and disability. The multiple-visit classification procedure was more precise for discriminating outcomes than the first-visit classification procedure. CONCLUSION: Multiple-visit classification of patients into specific pain pattern subgroups is recommended when pain intensity and disability outcomes are of interest.
PMID: 12544933, UI: 22433042
Spine 2003 Jan 15;28(2):143-50
University of Florida College of Dentistry and North Florida South Georgia VA Health System, Gainesville 32610, USA. rfillingim@dental.ufl.edu
STUDY DESIGN: A cross-sectional analysis of data derived from patients with chronic spinal pain undergoing evaluation at a multidisciplinary pain treatment center was conducted. OBJECTIVE: To determine whether pain severity, psychological status, and physical disability differed as a function of gender and opioid use, and whether the clinical correlates of opioid use differed in women and men with chronic back pain. SUMMARY OF BACKGROUND DATA: Gender differences in the experience of pain have been widely reported. For example, in the general population, several chronic pain conditions are more prevalent among women than among men, and many experimental studies demonstrate lower pain thresholds and tolerances among women. In addition, recent evidence from studies of experimental and acute clinical pain suggests that responses to analgesic medications may differ in women and men. METHODS: The sample consisted of 240 patients (35% women) with low back, upper back, or neck pain undergoing evaluation for treatment at a multidisciplinary pain center. The patients were classified as opioid or nonopioid users on the basis of self-report and medical record review. All the patients completed a battery of clinical assessments, including measures of pain severity, psychological adjustment, self-reported disability, functional tasks, and pain tolerance. Analyses were conducted to examine clinical variables as a function of gender and opioid use. RESULTS: The results indicated that opioid use was associated with greater self-reported disability and poorer function in both women and men. However, the association of opioid use with affective distress differed between women and men. The women using opioids showed lower affective distress, whereas the opioid-using men reported greater affective distress. Opioid use was not associated with pain severity, although the women reported greater pain than men. CONCLUSIONS: These findings indicate that both opioid use and gender are significant predictors of clinical status of patients with chronic spinal pain. More interesting, these two variables interact because opioid use was associated with increased affective distress among the men, but the reverse was true for the women. In addition, the women reported greater pain severity, which is consistent with some previous findings. Potential explanations for these findings are presented, and the practical implications are discussed.
PMID: 12544931, UI: 22433040
Spine 2003 Jan 15;28(2):129-33
Canadian Memorial Chiropractic College, Toronto, Ontario, Canada. cpeterson@cmcc.ca
STUDY DESIGN: A prospective cross-sectional study was conducted. OBJECTIVE: To determine the relation between degeneration of all the joints in the cervical spine, and to identify the effects of litigation on pain and disability levels in trauma and nontrauma patients. SUMMARY OF BACKGROUND DATA: The link between spinal degeneration and patient symptoms remains controversial. Two recent similar studies present conflicting results concerning the association between spinal degeneration and symptomatology. These two studies, performed in different countries, did not consider the impact of impending litigation on self-reported pain and disability levels. The role of the uncovertebral and facet articulations has hitherto not been investigated. METHODS: Radiographic and questionnaire data from 180 consecutive patients with neck pain were collected. Neck pain severity was measured using two time-dependent scales. All patients completed the Neck Disability Index (NDI) and questions about chronicity, etiology, and associated litigation. The radiographs were evaluated for the number of levels of degeneration and the severity of degeneration in the discs as well as the uncovertebral and facet articulations. RESULTS: In this study, 71 patients (40.57%) reported neck pain as a result of injury. However, only 5.1% had associated litigation. There was no statistically significant difference in pain severity or disability levels between the patients with and those without cervical degeneration. According to the findings, the number of levels of cervical degeneration and the severity of degeneration in the discs, facets, and uncovertebral joints are not related to the levels of pain and disability. Patients reporting neck pain caused by injury had a tendency (P = 0.055) to more pain during the preceding week and significantly more disability (P < 0.001). Significant differences included pain intensity (P < 0.025), reading (P < 0.001), headaches (P < 0.025), ability to drive (P < 0.01), and concentration (P < 0.01). Women reported significantly more pain (P < 0.01) and disability (P < 0.001) than men, but did not have more degeneration in any of the joints. CONCLUSIONS: In patients with neck pain, there is no difference in reported pain and disability levels between those with and those without evidence of cervical spine degeneration. Patients whose neck pain is the result of trauma report significantly more pain and disability than nontrauma patients. This is not because of more spinal degeneration or overriding litigation issues.
PMID: 12544928, UI: 22433037