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The effect of short-term epidural local anesthetic blockade on urinary levels of substance P in interstitial cystitis.
Sukiennik A, Carr DB, Bonney I, Marchand JE, Wurm H, Sant GR.
Departments of Anesthesia and Urology, Tufts-New England Medical Center, Boston, Massachusetts 02111, USA.
We investigated the effect of epidural local anesthetic blockade on urinary substance P levels in five patients suffering from painful flare-ups of interstitial cystitis. Urine was collected in 24-h intervals commencing at the onset of an epidural bolus of 0.25% bupivacaine followed by maintenance epidural infusions of 0.05% bupivacaine. Substance P was measured by radioimmunoassay. After initiation of the epidural infusion, urinary substance P levels increased and then declined in all patients. All patients reported a decrease in pain intensity. We hypothesize that acute release, followed by depletion, of substance P from bladder sensory nerve endings accounts for the transient increase of peptide levels in urine and may contribute to the decrease in pain intensity during a 3-day epidural infusion. IMPLICATIONS: Substance P levels in urine initially increased and then declined in a series of 5 patients who achieved pain control by epidural local anesthetic infusion during a flare-up of interstitial cystitis.
Publication Types:
PMID: 14980950 [PubMed - indexed for MEDLINE]
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Persistent cerebrospinal fluid leak: a complication of the combined spinal-epidural technique.
Chan BO, Paech MJ.
Department of Anaesthesia and Pain Medicine, King Edward Memorial Hospital for Women, Perth, Western Australia. sputnik5@iinet.net.au
Persistent cerebrospinal fluid (CSF) leak is an apparently rare complication of dural puncture from spinal or epidural anesthesia. Combined spinal-epidural techniques are increasingly popular but persistent CSF leak has not been reported. We describe three parturients with persistent fluid leak from the insertion site after epidural catheter removal following combined spinal-epidural anesthesia. Uncertainties related to the diagnosis, treatment, and the implications of this complication are discussed, including beta(2)-transferrin immunofixation assay as a diagnostic test for the presence of CSF in this situation. IMPLICATIONS: Combined spinal-epidural block can be complicated by persistent fluid leak from the skin insertion site. Testing for the presence of cerebrospinal fluid may be a useful aid to management.
Publication Types:
PMID: 14980946 [PubMed - indexed for MEDLINE]
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Analgesia after total knee arthroplasty: is continuous sciatic blockade needed in addition to continuous femoral blockade?
Ben-David B, Schmalenberger K, Chelly JE.
Department of Anesthesiology, University of Pittsburgh Medical Centers, Shadyside Hospital, Pittsburgh, Pennsylvania 15232, USA. bendavid@verizon.net
Continuous femoral "3-in-1" nerve blocks are commonly used for analgesia after total knee arthroplasty (TKA). There are conflicting data as to whether additional sciatic blockade is needed. Our routine use of both continuous femoral (CFI) and sciatic (CSI) peripheral nerve blocks was changed because of concerns that sciatic blockade, and its motor consequences in particular, might obscure diagnosis of perioperative sciatic nerve injury. The revised protocol includes placing single-shot blocks and perineural catheters at both sites, but infusing local anesthetic postoperatively only in the CFI. CSI is reserved for patients having poorly controlled posterior knee or calf pain. A sample group of 12 patients treated with this protocol was followed. Ten of 12 patients required use of the CSI. Within 1 h of a 5-10 mL CSI bolus of 0.2% ropivacaine and beginning an infusion of the same drug at 5 mL/h, patients' median pain by verbal analog scale decreased from 7.5 to 2.0 (mean scores from 7.3 to 2.4). It was possible to maintain this level of analgesia until the third postoperative day when catheters were discontinued. Our experience suggests that, in most patients, adequate analgesia after TKA cannot be achieved with CFI alone and that the addition of CSI renders a significant improvement in analgesia. IMPLICATIONS: A child with neurofibromatosis, scoliosis, and a chest wall deformity presenting for spinal fusion developed severe hypotension while prone. This was due to compression of the heart by the sternum, not compression of the great vessels by neurofibromas. Sternal pressure in prone patients with chest wall deformities should be avoided. Unique management included the use of transesophageal echocardiography to determine the cause of the hypotension.
Publication Types:
PMID: 14980931 [PubMed - indexed for MEDLINE]
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The influence of ambulation time on the incidence of transient neurologic symptoms after lidocaine spinal anesthesia.
Silvanto M, Tarkkila P, Makela ML, Rosenberg PH.
Research Institute of Military Medicine, Central Military Hospital, Helsinki, Finland.
The cause of transient neurologic symptoms (TNSs) after lidocaine spinal anesthesia remains unclear. It has been proposed that early ambulation after spinal anesthesia contributes to the development of TNSs. We evaluated the influence of ambulation time on the occurrence of TNSs after spinal anesthesia with 50 mg of 2% plain lidocaine for knee arthroscopy. One-hundred-twenty patients undergoing knee arthroscopy (ASA physical status 1-2) were randomized into 3 groups, i.e., early (Group E), 6-h (Group 6-h), or late ambulation (Group L) groups. In Group E, ambulation was allowed as early as possible after regression of spinal block (on average 229 +/- 21 min; range, 135-247 min). In Group 6-h, the patients remained in bed for approximately 6 h after the block and in Group L until the next morning. The patient groups were comparable with respect to demographic, anesthetic, and surgical variables. The overall incidence of TNSs was 16%. TNSs occurred in 3 patients of Group E (7.5%), in 11 patients of Group 6-h (28%), and in 5 patients of Group L (13%). No significant differences were detected between the patients with and without TNSs. Early ambulation was not found to be a risk factor for TNSs after spinal anesthesia with 50 mg of 2% lidocaine. IMPLICATIONS: This study shows that early ambulation time does not increase the incidence of transient neurologic symptoms after spinal anesthesia with 50 mg of 2% lidocaine for elective knee arthroscopy.
Publication Types:
- Clinical Trial
- Randomized Controlled Trial
PMID: 14980912 [PubMed - indexed for MEDLINE]
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Continuous psoas compartment blocks after major orthopedic surgery in children: a prospective computed tomographic scan and clinical studies.
Dadure C, Raux O, Gaudard P, Sagintaah M, Troncin R, Rochette A, Capdevila X.
Departments of Anesthesia and Critical Care Medicine, Lapeyronie University Hospital, Montpellier, France. c-dadure@chu-montpellier.fr
Femoral shaft or hip surgeries are very painful for children. We conducted both computed tomographic (CT) and clinical prospective studies to define new landmarks in children and to evaluate the effectiveness of continuous psoas compartment blocks (CPCBs) using disposable elastomeric pumps. In a preliminary CT scan study of 20 patients, the plexus depth was correlated to patient age and the optimal point of puncture for CPCB was three-quarters of the distance from the spinous process of L4 to a line parallel to the spinal column passing through the posterior superior iliac spine. In a subsequent prospective series, a CPCB was administered before surgery to 15 children for pain relief after femoral and hip osteotomies. After general anesthesia, a 0.5 mL/kg bolus of a mixture of 1% lidocaine with epinephrine (1/200.000) and 0.5% ropivacaine was injected through the CPCB catheter. After contrast media assessment of the catheter location, a disposable pump (Infusor LV); Baxter, Paris, France) with 0.2% ropivacaine was connected and pump flow was adjusted to the patient's weight (0.2 mg x kg(-1) x h(-1)). Postoperative pain was evaluated using a visual analog scale or the Children and Infants Postoperative Pain Score at hour H1, H6, H12, H18, H24, H36, and H48, and in terms of rescue analgesia, adverse events, and motor blocks. All blocks were effective during surgery. Postoperative analgesia was excellent. The median pain scores were 1 for H1 and 0 beginning H6. The motor blockade was minimal before 24 h and absent thereafter. No major adverse event was noted. Parents of 93% of the children were satisfied. We conclude that postoperative analgesia with CPCB is a very effective technique in children after major proximal lower limb orthopedic surgery. The CT scan landmarks described in this study were more medial than the conventional landmarks used in the literature. IMPLICATIONS: Continuous psoas compartment blocks provide optimal pain relief in children after major orthopedic surgery without major adverse events. The landmarks used, defined in a preliminary computed tomographic scan study, were more medial than conventional landmarks.
Publication Types:
PMID: 14980909 [PubMed - indexed for MEDLINE]
The painful total hip replacement.
Bozic KJ, Rubash HE.
Department of Orthopaedic Surgery, University of California-San Francisco, 500 Parnassus, MU 320W, San Francisco, CA 94143-0728, USA. bozick@orthosurg.ucsf.edu
Total hip replacement is one of the most common and successful orthopaedic procedures. However, evaluation and treatment of the painful total hip replacement is one of the most difficult challenges for the arthroplasty surgeon. The differential diagnosis includes causes that are intrinsic and extrinsic to the hip. A thorough history and physical examination provide the basis for a focused, efficient workup of the painful total hip replacement. The temporal onset, duration, severity, site, and character of the pain all provide important clues in determining the cause of the painful total hip replacement. The physical examination should focus on tests and maneuvers that reproduce the patient's symptoms. Laboratory tests and radiographic evaluation are used selectively as indicated by the history and physical examination findings. With a careful and thorough evaluation, the cause of the painful total hip replacement can be determined in most patients, and the appropriate treatment can be initiated.
PMID: 15057074 [PubMed - in process]
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Organization and development of pain clinics and palliative care in developing countries.
Kumar A.
Publication Types:
PMID: 15055887 [PubMed - in process]
The cost effectiveness of spinal cord stimulation in the treatment of pain: a systematic review of the literature.
Taylor RS, Taylor RJ, Van Buyten JP, Buchser E, North R, Bayliss S.
University of Birmingham (R.S.T., R.J.T., S.B.), Birmingham, UK; Algemene Kliniek Maria Middelares (J.-P.V.B.), St. Niklaas, Belgium; Hopital De Morges (E.B.), Morges, Switzerland; and Departments of Neurosurgery, Anesthesiology and Critical Care Medicine (R.N.), Johns Hopkins University, Baltimore, Maryland, USA.
In this systematic review, we identified and evaluated studies of the cost effectiveness of spinal cord stimulation (SCS) for the treatment of chronic pain. Published reports were identified from a systematic search of a number of general medical electronic databases (Medline, CINAHL, and EMBASE), and specialist economic databases (NHS Centre for Reviews and Dissemination Economic Evaluation Database, and Health Economics Evaluation Database). Reference lists of retrieved reports were also searched, and contact was made with experts in the field. Of the 99 abstracts identified, 14 studies were considered to meet the inclusion criteria of the review. We found that across a range of medical indications, the initial healthcare acquisition costs of SCS implantation are consistently offset by a reduction in post-implant healthcare resource demand and costs. Further research is required to formally examine the cost effectiveness of SCS.
PMID: 15050665 [PubMed - as supplied by publisher]
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Safety and effectiveness of intravenous morphine for episodic (breakthrough) pain using a fixed ratio with the oral daily morphine dose.
Mercadante S, Villari P, Ferrera P, Bianchi M, Casuccio A.
Anesthesia and Intensive Care Unit, Pain Relief and Palliative Care Unit (S.M., P.V., P.F.), La Maddalena Cancer Center, Palermo; Department of Pharmacology (M.B.), University of Milan, Milan; and Department of Hygiene and Microbiology (A.C.), University of Palermo, Palermo, Italy.
Breakthrough pain is normally severe in intensity and has a rapid onset. The availability of supplemental doses of opioids (rescue medication) in addition to the continuous analgesic medication is the main treatment suggested to manage these pain flares. The intravenous (IV) route may provide analgesia fast enough, but has never been assessed in clinical studies. The aim of this open-label study was to verify the safety and effectiveness of an IV dose equal to one-fifth the calculated equianalgesic total daily dose in advanced cancer patients with episodic pain. A consecutive sample of 48 cancer patients treated with oral morphine, who reported an acceptable basal analgesia and reported episodic pains, were selected for the study. The intravenous dose of morphine was one-fifth of the oral daily dose, converted into an IV dose using an equianalgesic ratio of 1/3 (IV/oral). Written orders were given and intravenous morphine (IV-M) was administered by nurses. For each episode, pain intensity and opioid-related symptoms were recorded at the start (T0), after achieving maximum pain relief (T1), and one hour after (T2). In five patients, blood samples were taken at the time intervals described for measuring plasma concentrations of morphine and related glucuronated metabolites. One hundred seventy-one breakthrough pains were recorded during admission. In 162 episodes, a reduction of pain intensity of more than 33% was obtained within a mean of 17.7 minutes, from a mean intensity of 7.9 (on a 0-10 numeric scale) to 3. One hundred thirty-six episodes had more than a 50% pain intensity decrease after the IV-M within a mean of 16.6 minutes, from a pain intensity of 7.9 to 2.6. No differences in age, sex, pain mechanism, and time of events were found. There was a trend but no statistically significant differences between the groups receiving different basal doses and time to reach the maximum effect. Twenty episodes in ten patients required an additional dose within 2 hours. Adverse effects were uncommon and were significantly related to the basal dose, and as a consequence, with the IV-M dose. Morphine concentration significantly increased at the time of pain intensity reduction, and then decreased. These observations suggest that IV-M at a dose equivalent to 20% of the basal oral dosage is safe and effective in the majority of patients experiencing pain exacerbation. This treatment is inexpensive and can be used at little risk to patients.
PMID: 15050663 [PubMed - as supplied by publisher]
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The adequacy of the minimum data set assessment of pain in cognitively impaired nursing home residents.
Cohen-Mansfield J.
Department of Health Care Sciences and of Prevention and Community Health, George Washington University Medical Center and School of Public Health, Washington, District of Columbia, and Research Institute on Aging, Hebrew Home of Greater Washington, Rockville, Maryland USA.
This paper examines the validity of the Minimum Data Set (MDS), a comprehensive functional assessment used in most United States nursing homes, for recognizing pain in cognitively impaired nursing home residents. Eighty nursing home residents participated in the study. They were initially divided into four groups, along two dimensions: severe vs. mild/moderate cognitive impairment, and pain-medicated vs. non-medicated for pain. Three indicators of pain were derived from the MDS: pain frequency, pain intensity, and number of sites with pain. Geriatricians from outside the nursing home assessed the medical condition of the residents and their associated pain levels. Residents were asked to report on their level of pain. The three MDS indicators were highly intercorrelated. According to these indicators, 34-39% of the residents suffered from pain. Some correlations between self-report of pain and MDS ratings were significant among those with mild/moderate impairment, but not for those with severe impairment. Similarly, some correlations between MDS ratings and the geriatricians' ratings were significant for those with mild/moderate impairment but not for those with severe impairment. Persons with mild/moderate cognitive impairment were rated by the MDS as having more pain than those with severe impairment. The findings reveal that the MDS underreports pain in cognitively impaired residents. Given the centrality of the MDS in the U.S. as a tool for clinical decision-making in long-term care, there seems to be an urgent need to improve either the MDS pain assessment tools or the procedures used for completing them.
PMID: 15050662 [PubMed - as supplied by publisher]
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Equipping medical students to manage cancer pain: A comparison of three educational methods.
Sloan PA, Plymale M, LaFountain P, Johnson M, Snapp J, Sloan DA.
Departments of Anesthesiology (P.A.S.), Surgery (M.P., D.A.S.), and Behavorial Science (M.J.), University of Kentucky College of Medicine; and Hospice of the Bluegrass (P.L., J.S.), Lexington, Kentucky, USA.
A Cancer Pain Structured Clinical Instruction Module (SCIM), with skills stations incorporating actual cancer patients, has been developed to enhance cancer pain education among our medical students. The Cancer Pain SCIM has not been compared with more traditional cancer pain education, thus the purpose of this study was to assess the effectiveness and durability of three educational methods for teaching cancer pain management to medical students compared with a control group. Four consecutive rotations of 32 third-year medical students participated in one of four cancer pain educational strategies: 1) control group with no formal cancer pain education, 2) CD-ROM self-instruction module on cancer pain, 3) a 2-hour Cancer Pain SCIM plus the CD-ROM information, and 4) Cancer Pain SCIM, plus CD-ROM, plus a structured home-hospice patient visit. The effectiveness of the educational interventions was assessed at 4 months post-instruction using a 4-component Cancer Pain Objective Structured Clinical Examination (OSCE). The main findings of this educational study are that: 1) all three educational groups performed better on the Cancer Pain OSCE at 4 months than the control group (P<0.05); 2) medical students receiving structured education on cancer pain management significantly out-performed students at 4 months compared with control or traditional instructional formats; 3) students receiving the Cancer Pain SCIM plus home visit performed highest on the pain management, physical exam, and communication stations of the OSCE; and 4) the SCIM format of education shows durability as assessed at 4 months post-instruction. The Cancer Pain SCIM has a unique potential to substantially improve the quality of cancer pain education.
PMID: 15050661 [PubMed - in process]
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In their own words: seven advanced cancer patients describe their experience with pain and the use of opioid drugs.
Coyle N.
Pain and Palliative Care Service, Department of Neurology, Memorial Sloan-Kettering Cancer Center, New York, New York, USA.
Seven individuals living with advanced cancer, who were followed by a pain and palliative care service at an urban cancer center and had at least once expressed a desire for hastened death, describe how both pain and the use of opioid drugs affected their quality of life. Their description is part of a broader phenomenological inquiry on the experience of living with advanced cancer and how that experience affected attitudes towards life and death. Serial, "in-depth semi-structured" interviews were conducted (mean=3 interviews/patient). Themes that emerged in relation to pain and opioid use reflect struggle-with self, with God, and with desire to live and/or readiness to die. Recognizing the appraisal process that patients undertake regarding the cost/benefit of reporting pain and accepting opioids, as well as the impact on severe pain on desire for death, from the patients' own word, gives a framework for the clinician to intervene.
PMID: 15050657 [PubMed - in process]
Raynaud's phenomenon of the nipple: a treatable cause of painful breastfeeding.
Anderson JE, Held N, Wright K.
Department of Pediatrics, University of California, San Francisco, California 94115, USA. jane.anderson@ucsfmedctr.org
Maurice Raynaud first described the vasospasm of arterioles in 1862, and Raynaud's phenomenon is now felt to be common, affecting up to 20% of women of childbearing age. Raynaud's phenomenon has been reported to affect the nipples of breastfeeding mothers and is recognized by many lactation experts as a treatable cause of painful breastfeeding. In 1997, Lawlor-Smith and Lawlor-Smith reported 5 women with Raynaud's phenomenon associated with breastfeeding, but there are few other case reports, and none report the possible relationship between Raynaud's phenomenon of the nipple and previous breast surgery. We report 12 women who breastfed 14 infants, all of whom were seen in 1 pediatric practice and 1 lactation consultation center in San Francisco, California, within the past 3 years. Of the 12 women, 11 were seen between June 2002 and May 2003. All women suffered from extremely painful breastfeeding, with symptoms precipitated by cold temperatures and associated with blanching of the nipple followed by cyanosis and/or erythema. Poor positioning and poor attachment or latch may cause blanching of the nipple and pain during breastfeeding, but 10 of the 12 mothers were evaluated by experienced lactation consultations, who were sure that inappropriate breastfeeding techniques were not contributing factors. Because the breast pain associated with Raynaud's phenomenon is so severe and throbbing, it is often mistaken for Candida albicans infection. It is not unusual for mothers who have Raynaud's phenomenon of the nipple to be treated inappropriately and often repeatedly for C albicans infections with topical or systemic antifungal agents. Eight of our 12 mothers and their infants received multiple courses of antifungal therapy without relief before the diagnosis was made. To diagnose Raynaud's phenomenon accurately, additional symptoms such as precipitation by cold stimulus, occurrence of symptoms during pregnancy or when not breastfeeding, and biphasic or triphasic color changes must be present. All our mothers experienced precipitation of symptoms by cold stimuli and demonstrated biphasic or triphasic color changes, and 6 of the 12 experienced symptoms during pregnancy. Interestingly 3 of 12 mothers also reported a history of breast surgery, including 1 mother who had a fibroadenoma removed and 2 who had breast-reduction surgery. The association between breast surgery/implants and autoimmune disease, including Raynaud's phenomenon, has been discussed extensively, but the association of Raynaud's phenomenon of the nipple during breastfeeding has not been reported previously. Given the small numbers in the study, it is uncertain as to whether this may be a precipitating factor in developing Raynaud's phenomenon. Treatment options include methods to prevent or decrease cold exposure, avoidance of vasoconstrictive drugs/nicotine that could precipitate symptoms, and pharmacologic measures. There are reports in the lay press of the use of herbal medicines, aerobic exercise, and dietary supplements, but because most women with painful breastfeeding require immediate relief of the pain to continue breastfeeding successfully, it is important to offer a treatment plan that will alleviate the pain quickly. Nifedipine, a calcium channel blocker, has been used to treat Raynaud's phenomenon because of its vasodilatory effects. Very little of the medication can be demonstrated in breast milk and thus is safe to use in breastfeeding mothers. Of the 12 mothers in our series, 6 chose to use nifedipine, and all had prompt relief of pain. Only 1 mother developed side effects from nifedipine. Pediatricians and lactation consultants should be aware of this treatable cause of painful breastfeeding and should specifically question their patients, because most mothers will not provide this information to the breastfeeding consultant. Prompt treatment will allow mothers to continue to breastfeed pain free while avoiding unnecessary antifungal therapy.
PMID: 15060268 [PubMed - in process]
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Recurrent abdominal pain, anxiety, and depression in primary care.
Campo JV, Bridge J, Ehmann M, Altman S, Lucas A, Birmaher B, Di Lorenzo C, Iyengar S, Brent DA.
Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA. campojv@msx.upmc.edu
OBJECTIVE: The prevalence of psychiatric disorder in children and adolescents with functional recurrent abdominal pain (RAP) is unknown. Our aim was to determine whether RAP is associated with psychiatric symptoms and disorders, anxious temperament, and functional impairment in pediatric primary care. METHODS: Children and adolescents who were 8 to 15 years of age, inclusive, and presented with RAP (N = 42) or for routine care in the absence of recurrent pain (N = 38) were identified by a screening procedure in pediatric primary care office waiting rooms and recruited to participate in a case-control study. Outcome measures were psychiatric diagnoses generated by standardized psychiatric interview administered blind to subject status and self, parent, and clinician ratings of child psychiatric symptoms, temperamental traits, and functional status. RESULTS: RAP patients were significantly more likely to receive a diagnosis of a psychiatric disorder, with a categorical anxiety disorder in 33 (79%) and a depressive disorder in 18 patients (43%), and higher levels of anxiety and depressive symptoms, temperamental harm avoidance, and functional impairment than control subjects. Anxiety disorders (mean age of onset: 6.25 [standard deviation: 2.17] years) were significantly more likely to precede RAP (mean age of onset: 9.17 [standard deviation: 2.75] years) in patients with associated anxiety. CONCLUSIONS: Youths who present with RAP in primary care deserve careful assessment for anxiety and depressive disorders. Future studies should examine treatments that are proved to be efficacious for pediatric anxiety and/or depressive disorders as potential interventions for RAP. Longitudinal, family, and psychobiological studies are needed to illuminate the nature of observed associations among RAP, anxiety, and depression.
PMID: 15060233 [PubMed - in process]
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Lateral approach to the sciatic nerve in the popliteal fossa: a comparison between 1.5% mepivacaine and 0.75% ropivacaine.
Taboada M, Cortes J, Rodriguez J, Ulloa B, Alvarez J, Atanassoff PG.
Department of Anesthesiology, Hospital Clinico Universitario de Santiago, Santiago de Compostela, Spain. manutabo@mixmail.com
BACKGROUND AND OBJECTIVES: Ropivacaine and mepivacaine are commonly used local anesthetics for peripheral nerve blockade. The purpose of the present study was to compare onset time, quality of anesthesia, and duration of analgesia with ropivacaine 0.75% and mepivacaine 1.5% for lateral popliteal nerve block. METHODS: Fifty American Society of Anesthesiologists (ASA) physical status I or II patients scheduled for foot and ankle surgery with calf tourniquet under lateral popliteal sciatic nerve block were randomly assigned to receive 30 mL of either ropivacaine 0.75% or mepivacaine 1.5%. Time required for onset of sensory and motor block, resolution of motor blockade, onset of postsurgical pain, and time of first analgesic medication were recorded. RESULTS: The 2 groups were similar with regard to demographic variables and duration of surgery. Onset of sensory and motor block was significantly shorter in the mepivacaine group (9.9 +/- 3.3 min and 14.7 +/- 3.6 min, respectively) than in the ropivacaine group (18.1 +/- 6.1 min and 23.6 +/- 5.5 min, respectively) (P < 0.001). Resolution of motor block occurred later in the ropivacaine group than in the mepivacaine group (P < 0.001), and duration of postoperative analgesia was significantly longer in the ropivacaine group (19 +/- 3.4 h) compared with the mepivacaine group (5.9 +/- 1.1 h) (P < 0.001). Analgesic requirements were higher in mepivacaine group than in the ropivacaine group (P < 0.001). There were 2 failed blocks, one in each group. CONCLUSIONS: Both ropivacaine and mepivacaine provided effective sciatic nerve blockade. Mepivacaine 1.5% displayed a significantly shorter onset time than ropivacaine 0.75%. Postoperatively, ropivacaine 0.75% resulted in longer-lasting analgesia and less need for oral pain medication.
Publication Types:
- Clinical Trial
- Randomized Controlled Trial
PMID: 14634941 [PubMed - indexed for MEDLINE]
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Subarachnoid catheter placement after wet tap for analgesia in labor: influence on the risk of headache in obstetric patients.
Ayad S, Demian Y, Narouze SN, Tetzlaff JE.
Department of Anesthesiology, Fairview Hospital, Cleveland Clinic Health System, Cleveland, OH 44195, USA.
BACKGROUND AND OBJECTIVES: The incidence of postdural puncture headache (PDPH) after epidural wet tap for obstetric patients may be as high as 75%. We have studied how subsequent placement of a subarachnoid catheter immediately after confirmation of a wet tap, and leaving the catheter in place for 24 hours affects the incidence of PDPH. METHODS: Over a 5-year interval, 115 consecutive patients who had unintentional dural puncture were divided into 3 groups by consecutive assignment. Group A had an epidural catheter placed at another interspace. Group B had a subarachnoid catheter placed for labor analgesia that was removed immediately after delivery. Group C had a subarachnoid catheter that was left in place for 24 hours after delivery. Data were collected retrospectively. The incidence of PDPH and blood patch was compared between groups. RESULTS: The overall incidence of PDPH was 46.9% and need for blood patch 36.5%, significantly less in both subarachnoid catheter groups, 31% in B and 3% in group C, compared with group A (PDPH 81%) (P <.001). CONCLUSION: Subarachnoid catheter placement after wet tap in obstetric patients reduces the PDPH rate and does so to a greater extent if left in place for 24 hours after delivery.
PMID: 14634940 [PubMed - indexed for MEDLINE]
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The Maine-Seattle back questionnaire: a 12-item disability questionnaire for evaluating patients with lumbar sciatica or stenosis: results of a derivation and validation cohort analysis.
Atlas SJ, Deyo RA, van den Ancker M, Singer DE, Keller RB, Patrick DL.
General Medicine Division and the Clinical Epidemiology Unit, Medical Services, Massachusetts General Hospital, Harvard Medical School, Boston 02114, USA. satlas@partners.org
STUDY DESIGN: Analysis of health-related quality of life data obtained from a prospective cohort study of patients with sciatica due to an intervertebral disc herniation or lumbar spinal stenosis. OBJECTIVE: To derive and validate a shortened version of a previously validated 23-item modification of the Roland-Morris Disability Questionnaire. SUMMARY OF BACKGROUND DATA: For patients with low back pain, improving health-related quality of life is often the main goal of therapy. The Roland-Morris Disability Questionnaire is one of the best validated and most frequently used back-specific functional status measures. A shortened version may permit more widespread use in clinical and research settings. METHODS: Data from 507 patients with sciatica enrolled in the Maine Lumbar Spine Study were used to derive a shortened version of a 23-item modification of the original Roland-Morris Disability Questionnaire using qualitative and cluster analysis techniques. The internal consistency, construct validity, reproducibility, and responsiveness in detecting change over a 3-month period for a new 12-item scale was compared to the original 23-item scale. The 12-item scale was then validated in an independent cohort of 148 patients with lumbar spinal stenosis. RESULTS: Internal consistency was very good but modestly lower for the 12-item instrument compared to the 23-item original scale. Reproducibility over a 3-month interval was good and did not differ between the 12-item and original scale. Findings from the validation cohort were similar or better than the derivation cohort. A high degree of construct validity with patient-reported symptoms was demonstrated for the 12-item and original scales. The responsiveness and interpretability of the 12-item scale over 3 months was excellent and comparable to the original scale. Responsiveness assessed in patients with lumbar spinal stenosis in the independent validation cohort showed consistent findings compared to patients with a disc herniation in the derivation cohort. CONCLUSIONS: This short, simple, self-administered 12-item back-specific functional status questionnaire performed extremely well in comparison with the original 23-item scale. If validated in additional study populations, this new questionnaire may be useful in the clinical setting as a way for providers to prospectively compare their outcomes of care to other patient populations, and to study treatment effectiveness.
PMID: 12923478 [PubMed - indexed for MEDLINE]
Comment on:
A randomized trial of medical care with and without physical therapy and chiropractic care with and without physical modalities for patients with low back pain: 6-month follow-up outcomes from the UCLA low back pain study.
Conijn FJ.
Publication Types:
PMID: 12865859 [PubMed - indexed for MEDLINE]
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