Ultimo Aggiornamento: Gennaio 2004

1: Am J Emerg Med. 2004 Jan;22(1):51-7.

Pain management in the ED.

Wilsey B, Fishman S, Rose JS, Papazian J.

Recent regulatory and legal scrutiny has raised concerns about the over- and
undertreatment of pain in the hospital. This debate stems from either the overly
aggressive approach to the management of pain with opioids or, alternatively, to
the barriers preventing the appropriate prescribing of these medications. The
media attention on diversion of controlled substances for illicit purposes has
intensified this debate, highlighting the possible overuse of these medications
in the treatment of nonmalignant pain. Because pain is a highly common
presenting complaint in the ED, EPs are pivotal players in these controversies.
Accordingly, they must apprise themselves of pain management skills and continue
to help those in need of appropriate medications while thwarting inappropriate
prescribing. This review offers a synopsis of the pitfalls associated with ED
pain management and provides recommendations for selected conditions.

PMID: 14724879 [PubMed - in process]

2: BMJ. 2004 Jan 31;328(7434):254. Epub 2004 Jan 14.

Randomised controlled trial and economic evaluation of a chest pain observation
unit compared with routine care.

Goodacre S, Nicholl J, Dixon S, Cross E, Angelini K, Arnold J, Revill S, Locker
T, Capewell SJ, Quinney D, Campbell S, Morris F.

School of Health and Related Research, University of Sheffield, Sheffield S1
4DA. s.goodacre@sheffield.ac.uk

OBJECTIVES: To measure the effectiveness and cost effectiveness of providing
care in a chest pain observation unit compared with routine care for patients
with acute, undifferentiated chest pain. DESIGN: Cluster randomised controlled
trial, with 442 days randomised to the chest pain observation unit or routine
care, and cost effectiveness analysis from a health service costing perspective.
SETTING: The emergency department at the Northern General Hospital, Sheffield,
United Kingdom. PARTICIPANTS: 972 patients with acute, undifferentiated chest
pain (479 attending on days when care was delivered in the chest pain
observation unit, 493 on days of routine care) followed up until six months
after initial attendance. MAIN OUTCOME MEASURES: The proportion of participants
admitted to hospital, the proportion with acute coronary syndrome sent home
inappropriately, major adverse cardiac events over six months, health utility,
hospital reattendance and readmission, and costs per patient to the health
service. RESULTS: Use of a chest pain observation unit reduced the proportion of
patients admitted from 54% to 37% (difference 17%, odds ratio 0.50, 95%
confidence interval 0.39 to 0.65, P < 0.001) and the proportion discharged with
acute coronary syndrome from 14% to 6% (8%, -7% to 23%, P = 0.264). Rates of
cardiac event were unchanged. Care in the chest pain observation unit was
associated with improved health utility during follow up (0.0137 quality
adjusted life years gained, 95% confidence interval 0.0030 to 0.0254, P = 0.022)
and a saving of pound 78 per patient (- pound 56 to pound 210, P = 0.252).
CONCLUSIONS: Care in a chest pain observation unit can improve outcomes and may
reduce costs to the health service. It seems to be more effective and more cost
effective than routine care.

PMID: 14724129 [PubMed - in process]

3: Br J Anaesth. 2004 Feb;92(2):296.

Sub-Tenon's infiltration using bupivacaine 0.5% decreases acute postoperative
pain.

Celaschi DA, Ruschen H, Calenda E.

London, UK Rouen, France.

PMID: 14722192 [PubMed - in process]

4: Br J Anaesth. 2004 Feb;92(2):235-7.

Pain on medical wards in a district general hospital.

Dix P, Sandhar B, Murdoch J, MacIntyre PA.

Royal Devon and Exeter Hospital, Barrack Rd, Exeter, EX2 5DW, UK.

BACKGROUND: Little attention has been paid to pain on medical wards, with
publications limited to the management of surgical patients. We wanted to
establish the prevalence and severity of pain in the general medical setting,
and how this compared with other clinical specialties. METHODS: All consenting
adult in-patients were assessed daily for 5 days. Patients recorded the
occurrence and severity of pain, and whether their pain was bearable. The pain
team reviewed patients with unbearable pain. RESULTS: 1594 questionnaires were
completed, representing 54% of the target population. 887 patients reported
pain, 17% with pain scores over 6, and 10% with unbearable pain. The
distribution of pain was similar for all ward types with 52% of patients on
medical wards reporting pain. Of these, 20% reported severe pain and 12%
unbearable pain. When patients with pain scores over 6 were analysed by
consultant specialty, elderly care, general medicine, and general surgery scored
highest. In each specialty 20-25% of patients with pain reported a pain score
over 6. In patients reviewed by the pain team, reasons for poor analgesia
included inadequate information, pain assessment, analgesic prescribing, and
administration and patient reporting. CONCLUSION: Patients in all hospital
specialities experience pain. Until the issue of pain management in medical
patients is fully addressed the situation will not improve. Br J Anaesth 2004;
92: 235-7

PMID: 14722175 [PubMed - in process]

5: J Clin Oncol. 2004 Jan 15;22(2):300-6.

Percutaneous image-guided radiofrequency ablation of painful metastases
involving bone: a multicenter study.

Goetz MP, Callstrom MR, Charboneau JW, Farrell MA, Maus TP, Welch TJ, Wong GY,
Sloan JA, Novotny PJ, Petersen IA, Beres RA, Regge D, Capanna R, Saker MB,
Gronemeyer DH, Gevargez A, Ahrar K, Choti MA, de Baere TJ, Rubin J.

Department of Oncology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA.

PURPOSE: Few options are available for pain relief in patients with bone
metastases who fail standard treatments. We sought to determine the benefit of
radiofrequency ablation (RFA) in providing pain relief for patients with
refractory pain secondary to metastases involving bone. PATIENTS AND METHODS:
Thirty-one US and 12 European patients with painful osteolytic metastases
involving bone were treated with image-guided RFA using a multitip needle.
Treated patients had > or = 4/10 pain and had either failed or were poor
candidates for standard treatments such as radiation or opioid analgesics. Using
the Brief Pain Inventory-Short Form, worst pain intensity was the primary end
point, with a 2-unit drop considered clinically significant. RESULTS:
Forty-three patients were treated (median follow-up, 16 weeks). Before RFA, the
mean score for worst pain was 7.9 (range, 4/10 to 10/10). Four, 12, and 24 weeks
following treatment, worst pain decreased to 4.5 (P <.0001), 3.0 (P <.0001), and
1.4 (P =.0005), respectively. Ninety-five percent (41 of 43 patients)
experienced a decrease in pain that was considered clinically significant.
Opioid usage significantly decreased at weeks 8 and 12. Adverse events were seen
in 3 patients and included (1) a second-degree skin burn at the grounding pad
site, (2) transient bowel and bladder incontinence following treatment of a
metastasis involving the sacrum, and (3) a fracture of the acetabulum following
RFA of an acetabular lesion. CONCLUSION: RFA of painful osteolytic metastases
provides significant pain relief for cancer patients who have failed standard
treatments.

PMID: 14722039 [PubMed - in process]

6: N Engl J Med. 2004 Jan 15;350(3):267-75.

Case records of the Massachusetts General Hospital. Weekly clinicopathological
exercises. Case 2-2004. A 32-year-old man with pain and swelling of the jaw.

Dodson TB, Caruso PA, Nielsen GP.

Department of Oral and Maxillofacial Surgery, Massachusetts General Hospital,
USA.

Publication Types:
Case Reports
Clinical ConferencePMID: 14724307 [PubMed - indexed for MEDLINE]

7: Neurology. 2003 Nov 11;61(9):1303.

Intracranial hypertension following epidural blood patch.

Cestari DM, Rizzo JF 3rd.

Neuro-ophthalmology Service, Massachusetts Eye and Ear Infirmary, Boston, MA
02114, USA.

Publication Types:
Case ReportsPMID: 14610148 [PubMed - indexed for MEDLINE]

8: Neurology. 2003 Apr 22;60(8):E6-7.

Comment on:
Neurology. 2003 Apr 22;60(8):1274-83.
Neurology. 2003 Apr 22;60(8):1391-2.Patient pages. Treatment of postherpetic neuralgia.

Lovitt S.

Publication Types:
Comment
Patient Education HandoutPMID: 12707463 [PubMed - indexed for MEDLINE]

9: Neurology. 2003 Apr 22;60(8):1391-2.

Comment in:
Neurology. 2003 Apr 22;60(8):E6-7.Topical ketamine treatment of postherpetic neuralgia.

Quan D, Wellish M, Gilden DH.

Department of Neurology, University of Colorado Health Sciences Center, Denver
80262, USA.

Publication Types:
Review
Review, MulticasePMID: 12707455 [PubMed - indexed for MEDLINE]

10: Neurology. 2003 Apr 22;60(8):1274-83.

Comment in:
Neurology. 2003 Apr 22;60(8):E6-7.Pregabalin for the treatment of postherpetic neuralgia: a randomized,
placebo-controlled trial.

Dworkin RH, Corbin AE, Young JP Jr, Sharma U, LaMoreaux L, Bockbrader H,
Garofalo EA, Poole RM.

University of Rochester School of Medicine and Dentistry, Rochester, NY 14642,
USA. robert_dworkin@urmc.rochester.edu

OBJECTIVE: To evaluate the efficacy and safety of pregabalin in the treatment of
postherpetic neuralgia (PHN). METHODS: The authors conducted a multicenter,
parallel-group, double-blind, placebo-controlled, 8-week, randomized clinical
trial in PHN, defined as pain for 3 or more months following herpes zoster rash
healing. Patients (n = 173) were randomized to treatment with pregabalin or
placebo. Patients randomized to pregabalin received either 600 mg/day
(creatinine clearance > 60 mL/min) or 300 mg/day (creatinine clearance 30 to 60
mL/min). The primary efficacy measure was the mean of the last seven daily pain
ratings. Secondary endpoints included additional pain ratings, sleep
interference, quality of life, mood, and patient and clinician ratings of global
improvement. RESULTS: Pregabalin-treated patients had greater decreases in pain
than patients treated with placebo (endpoint mean scores 3.60 vs 5.29, p =
0.0001). Pain was significantly reduced in the pregabalin-treated patients after
the first full day of treatment and throughout the study, and significant
improvement on the McGill Pain Questionnaire total, sensory, and affective pain
scores was also found. The proportions of patients with >or=30% and >or=50%
decreases in mean pain scores were greater in the pregabalin than in the placebo
group (63% vs 25% and 50% vs 20%, p = 0.001). Sleep also improved in patients
treated with pregabalin compared to placebo (p = 0.0001). Both patients and
clinicians were more likely to report global improvement with pregabalin than
placebo (p = 0.001). Given the maximal dosage studied, pregabalin had acceptable
tolerability compared to placebo despite a greater incidence of side effects,
which were generally mild to moderate in intensity. CONCLUSIONS: Treatment of
PHN with pregabalin is safe, efficacious in relieving pain and sleep
interference, and associated with greater global improvement than treatment with
placebo.

Publication Types:
Clinical Trial
Multicenter Study
Randomized Controlled TrialPMID: 12707429 [PubMed - indexed for MEDLINE]

11: Neurology. 2003 Mar 25;60(6):1052-3; author reply 1052-3.

Comment on:
Neurology. 2002 Oct 8;59(7):1015-21.Opioids versus antidepressants in postherpetic neuralgia: a randomized,
placebo-controlled trial.

Manfredi PL.

Publication Types:
Comment
LetterPMID: 12654988 [PubMed - indexed for MEDLINE]

12: Pain. 2004 Jan;107(1-2):194-5.

Further results about pain rating by patients and physicians: reply to Chibnall
and Tait.

Marquie L, Raufaste E, Lauque D, Marine C, Ecoiffier M, Sorum P.

Universite Toulouse-II, 31058 cedex 9, Toulouse, France

PMID: 14715408 [PubMed - in process]

13: Pain. 2004 Jan;107(1-2):193.

Comment on Marquie L. et al. Pain rating by patients and physicians: evidence of
systematic pain miscalibration (Pain 2003;102:289-96).

Chibnall JT, Tait RC.

Department of Psychiatry, Saint Louis University School of Medicine, 1221 South
Grand Blvd, 63104, St Louis, MO, USA

PMID: 14715407 [PubMed - in process]

14: Pain. 2004 Jan;107(1-2):192.

Reply to Dr Walker's comments on Tassain et al. Long term effects of oral
sustained release morphine on neuropsychological performance in patients with
chronic non-cancer pain (Pain 2003;104:389-400).

Bouhassira D, Attal N, Tassain V.

Centre d'Evaluation et de Traitement de la Douleur, Hopital Ambroise Pare,
AP-HP, 9 Avenue Charles de Gaulle, 92 100, Boulogne-Billancourt, France

PMID: 14715406 [PubMed - in process]