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Pain management after discharge from the ED.
McIntosh SE, Leffler S.
Pain is an important but understudied and often overlooked aspect of emergency medical care. This study examined the management of pain after discharged of patients from the emergency department (ED). We hypothesized that pain management after discharge would be adequate, and that patients would use their medications as prescribed. We surveyed 144 patients by telephone after they had been treated in the ED for common orthopedic complaints. We used a standardized questionnaire to assess prescription-filling practices, side effects of medications, interventions by other health-care professionals, and adequacy of pain relief. Most patients discharged from the ED with a prescription for medication were satisfied with their pain relief (77%). Of those who did not fill their prescription, only 67% were satisfied. Although 26% of the patients reported side effects, most were minor. Thirteen percent of patients with prescribed medications did not fill their prescriptions. Of patients for whom narcotic analgesics were prescribed, 7% drove vehicles while taking these medications. The patients in the study were quite satisfied with their pain control. Most filled their prescriptions and did so in a timely manner. Those who did not fill prescriptions for medications reported the least satisfaction with pain control.
PMID: 15011222 [PubMed - in process]
Patient preferences for acute pain treatment{dagger}
Gan TJ, Lubarsky DA, Flood EM, Thanh T, Mauskopf J, Mayne T, Chen C.
Department of Anesthesiology, Duke University Medical Center, Box 3094, Durham, NC 27710, USA.
BACKGROUND: Optimal treatment for acute pain is a function of an individual's willingness to make trade-offs between treatment side effects and pain control. The objective was to investigate the degree to which patients are willing to make these trade-offs. METHODS: Fifty patients undergoing major abdominal surgery were enrolled and completed interviews before and after surgery. Measures included an experience with pain questionnaire and an adaptive conjoint analysis (ACA) interview. RESULTS: Percentage of pain relief obtained post-surgery was between 70 and 80%. Eight-two per cent reported at least one moderate or severe side effect. ACA results demonstrated that pain efficacy and side effect type/severity have almost equal 'importance' scores. Patients varied in their willingness to trade-off pain efficacy for different or milder side effects. CONCLUSIONS: We conclude that people have different relative preferences for different side effects and are willing to trade-off pain relief for less upsetting and/or less severe side effects but to different degrees. Thus, physicians should consider offering pain medications with fewer side effects than narcotics as a first choice. Our study indicates the need to balance analgesia and side effects in order for patients to achieve optimal pain control.
PMID: 15003986 [PubMed - as supplied by publisher]
Symptomatic hypogonadism in male survivors of cancer with chronic exposure to opioids.
Rajagopal A, Vassilopoulou-Sellin R, Palmer JL, Kaur G, Bruera E.
Section of Cancer Pain Management, Department of Anesthesiology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas 77030, USA. arajagop@mdanderson.org
BACKGROUND: Profound hypogonadism has been noted in patients receiving intrathecal opioids. The purpose of the current study was to determine whether chronic consumption of oral opioids by male survivors of cancer also would lead to central hypogonadism and whether this hypogonadism was associated with symptoms of sexual dysfunction, fatigue, anxiety, and depression. METHODS: A case-control study was conducted at The University of Texas M. D. Anderson Cancer Center (Houston, TX), in which 20 patients who were chronically consuming opioids were compared with 20 matched controls. Patients completed the Sexual Desire Inventory (SDI), the Hospital Anxiety and Depression Scale (HADS), the Functional Assessment of Chronic Illness Therapy with general and fatigue subscales (FACT-G/FACIT-F), and the Edmonton Symptom Assessment System (ESAS) questionnaires. Serum samples were collected for testosterone, follicle-stimulating hormone (FSH), and luteinizing hormone (LH). RESULTS: Comparing the opioid group with the control group, 18 of the 20 patients (90%; 95% confidence interval [CI], 65-98%) exhibited hypogonadism, compared with 8 of the 20 control patients (40%; 95% CI, 19-64%). The median testosterone level was 145 ng/dL versus 399.5 ng/dL (5.0 nmol/L vs. 13.9 nmol/L; P < 0.0001), the median FSH level was 2.85 milli-International Units (mIU)/mL versus 5.3 mIU/mL (P = 0.08), the median LH level was 1.8 mIU/mL versus 4.2 mIU/mL (P = 0.0014), the median SDI-dyadic score was 18.5 versus 40 (P = 0.01), the median SDI-solitary score was 0 versus 5 (P = 0.007), the HADS (anxiety) score was 8.5 versus 5.5 (P = 0.053), the HADS (depression) score was 7.5 versus 1.5 (P = 0.0002), the FACT-G score was 64 versus 96.3 (P = 0.0001), and the FACIT-F score was 24 versus 46 (P = 0.0003). CONCLUSIONS: Survivors of cancer who chronically consumed opioids experienced symptomatic hypogonadism with significantly higher levels of depression, fatigue, and sexual dysfunction. With the increasing use of opioids among patients with cancer, further research in improving quality-of-life outcomes is warranted. Copyright 2004 American Cancer Society.
PMID: 14770444 [PubMed - indexed for MEDLINE]
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Trazodone hydrochloride attenuates thermal hyperalgesia in a chronic constriction injury rat model.
Okuda K, Takanishi T, Yoshimoto K, Ueda S.
Dokkyo University School of Medicine, Department of Anaesthesiology, Mibu, Tochigi, Japan. y-okuda@dokkyomed.ac.jp
BACKGROUND AND OBJECTIVE: Trazodone hydrochloride is used in the treatment of neuropathic pain. However, the analgesic effects of trazodone on neuropathic pain are controversial. The study was undertaken to determine the analgesic effect of trazodone on a chronic constriction injury model. METHODS: We tested the effect of trazodone on thermal hyperalgesia due to a chronic constriction injury of the sciatic nerve in rats and examined the effects of lesions in the descending and ascending serotonergic system induced by 5,7-dihydroxytriptamine (5,7-DHT). RESULTS: The analgesic effects of trazodone showed a clear dose dependency. Furthermore, the analgesic effect of trazodone was observed in rats injected with 5,7-DHT into the dorsal raphe nucleus and medial raphe nucleus. CONCLUSIONS: The results suggest that a mainly serotonergic descending pain control pathway mediates the analgesic effects of trazodone.
PMID: 12790215 [PubMed - indexed for MEDLINE]
Parenteral vs epidural analgesia for postoperative pain.
Jankowski CJ, Warner DO.
Publication Types:
PMID: 15010438 [PubMed - in process]
Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 8-2004. A 28-year-old man with abdominal pain, fever, and a mass in the region of the pancreas.
Brugge WR, Mueller PR, Misdraji J.
Gastroenterology Unit, Department of Medicine, Massachusetts General Hospital, USA.
Publication Types:
PMID: 15014187 [PubMed - in process]
Evaluation and treatment of central pain syndromes.
Nicholson BD.
Department of Anesthesia, Pennsylvania State University School of Medicine, Lehigh Valley Hospital and Health Network, Allentown, PA 18105, USA.
Central pain syndromes represent a form of neuropathic pain that is associated with lesions of the brain or the spinal cord after a stroke or other traumatic injury. Although spinal cord injury (SCI) pain and central post-stroke pain (CPSP) are both classified as central pain syndromes, they may have differing etiologies. The pathophysiology of SCI pain and CPSP has yet to be completely elucidated, but both spinal and supraspinal pathways may be involved. Pain resulting from an injury to the CNS may be vague or difficult to classify or characterize, and patients may describe painful sensations that are poorly localized or that change over time. Pharmacologic interventions that have demonstrated efficacy in central pain syndromes include iv lidocaine and opioids as well as the tricyclic antidepressant amitriptyline and the AEDs gabapentin and lamotrigine. Nonpharmacologic interventions have also demonstrated benefit in some patients who are refractory to pharmacologic treatments. Additional studies are needed to further evaluate the efficacy and safety of both pharmacologic and nonpharmacologic treatments for central pain syndromes.
PMID: 15007162 [PubMed - in process]
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Joint pain and hyperalgesia due to pyridostigmine bromide in a patient with myasthenia gravis.
Rostedt A, Stalberg E.
Department of Clinical Neurophysiology, University Hospital, Uppsala, Sweden. anna.rostedt@swipnet.se
PMID: 15007152 [PubMed - in process]
Comment on:
Are nonstimulating catheters really inappropriate for continuous nerve block techniques?
Chelly JE, Casati A.
Publication Types:
PMID: 14556143 [PubMed - indexed for MEDLINE]
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Memories of the early years of regional anesthesia for childbirth.
Moore DC.
Department of Anasthesiology, Virginia Mason Medical Center, Seattle, WA 98101, USA. Sue.Stewart@vmmc.org
Publication Types:
PMID: 14556139 [PubMed - indexed for MEDLINE]
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Ambulatory perineural infusion: the patients' perspective.
Ilfeld BM, Esener DE, Morey TE, Enneking FK.
Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL 32610, USA. bjilfeld@hotmail.com
BACKGROUND AND OBJECTIVES: Ambulatory perineural local anesthetic infusion is a relatively new method for providing postoperative analgesia, and many aspects of this technique remain in the domain of conjecture and speculation. This retrospective chart review and survey was undertaken to investigate patients' opinions on various aspects of their ambulatory perineural infusion experience. METHODS: Patients who had received an ambulatory perineural infusion from the University of Florida were identified via pharmacy records. Patients were contacted by phone and were asked various questions regarding their experiences and preferences during and after their perineural infusion. RESULTS: Of 217 patients identified, 215 charts were located and retrieved. Of these, 137 (64%) were successfully contacted and 131 (61%) consented to take part in the survey. More than 97% of patients reported that they felt "safe" during home infusion, that one physician telephone call each night was optimal contact, and that they were comfortable removing the catheter with instructions given over the phone. Only 4% would have preferred to return for catheter removal, and 43% felt that they would have been comfortable with only written instructions for catheter removal. CONCLUSION: This investigation suggests that perineural local anesthetic infusion is generally well tolerated by ambulatory patients.
PMID: 14556132 [PubMed - indexed for MEDLINE]
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Early experience with continuous cervical paravertebral block using a stimulating catheter.
Boezaart AP, De Beer JF, Nell ML.
Department of Anesthesia, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA. andre-boezaart@uiowa.edu
Background and Objectives: This study reports our early experience with continuous cervical paravertebral block (CCPVB) using a stimulating catheter for the management of acute pain after shoulder surgery. METHODS: This prospective observational study presents 256 CCPVB for pain relief after 14 different shoulder operations. Surgery was performed under general anesthesia and blocks were placed prior to induction of general anesthesia (n = 81 [32%]), after induction of general anesthesia (n = 116 [45%]), or postoperatively in the recovery room (n = 59 [23%]). A bolus dose of 30 mL of 0.5% ropivacaine was followed by an infusion of 0.1 mL/kg/h of 0.2% ropivacaine. Patient- or nurse-initiated bolus doses of 10 mL of the same drug were used for breakthrough pain and rescue analgesics were available. Postoperative pain, patient satisfaction, and motor function in different parts of the upper limb were evaluated immediately after surgery (time 0), and then 6, 12, 24, 48, 60 hours, and 14 days postoperatively. RESULTS: An average of 2 (range 1-7) attempts were needed to advance the catheter while still stimulating the nerve. Average postoperative pain ranged from 0.27 +/- 1.04 cm to 0.78 +/- 1.56 cm (mean +/- SD) on a visual analog scale (VAS) (0-10 cm) for the first 48 hours and 3.8 +/- 2.1 cm and 3.5 +/- 2.4 cm at 60 hours and 14 days, respectively. Patient satisfaction on a VAS of 0 to 5 was 4.19 +/- 1.1, 4.28 +/- 1.01, and 4.69 +/- 1.05 at times 0, 6 hours, and 14 days, respectively. Motor function returned to normal in the fingers within 24 hours and in the shoulder within 60 hours. Complications included Horner's syndrome (40%), dyspnea (8%), superficial skin infection (5%), posterior neck pain (22%), subclavian artery puncture (1%), contralateral epidural spread (4%), and 8% of the patients complained of an unpleasant "dead feeling" of the arm. Ninety-one percent of patients would request CCPVB again for future shoulder surgery. There was no evidence of nerve damage.
Publication Types:
PMID: 14556130 [PubMed - indexed for MEDLINE]
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A comparison of levobupivacaine 0.5% and racemic bupivacaine 0.5% for extradural anesthesia for caesarean section.
Faccenda KA, Simpson AM, Henderson DJ, Smith D, McGrady EM, Morrison LM.
Department of Anaesthesia, St. John's Hospital, Livingston, Scotland, UK. faccenda@ualberta.ca
BACKGROUND AND OBJECTIVES: Bupivacaine is available as a racemic mixture of its enantiomers, dextrobupivacaine and levobupivacaine. Both in vitro and in vivo studies show that dextrobupivacaine has a greater inherent central nervous system (CNS) and cardiovascular toxicity than levobupivacaine. Clinical studies show levobupivacaine to have similar local anesthetic potency to the racemate. The aim of this study was to investigate the clinical efficacy and safety of levobupivacaine compared with racemic bupivacaine for extradural anesthesia. METHODS: We studied 62 patients undergoing elective caesarean delivery who received 25 mL of either levobupivacaine 0.5% or bupivacaine 0.5%, extradurally, in a randomized, double-blind study. RESULTS: The 2 groups were similar in terms of time to block suitable for surgery, segmental spread, and duration of sensory block. However, lower-limb motor block was significantly longer in the levobupivacaine group but of significantly less intensity. CONCLUSIONS: Levobupivacaine produces an extradural block that is similar to bupivacaine, and is a suitable local anesthetic agent for caesarean delivery.
Publication Types:
- Clinical Trial
- Randomized Controlled Trial
PMID: 14556128 [PubMed - indexed for MEDLINE]
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"He said, she said, NSAIDs".
Wedel DJ, Berry D.
Department of Anesthesia, Mayo Foundation, Rochester, MN, USA.
PMID: 14556123 [PubMed - indexed for MEDLINE]
Hip strategy for balance control in quiet standing is reduced in people with low back pain.
Mok NW, Brauer SG, Hodges PW.
Department of Physiotherapy, University of Queensland, Australia.
STUDY DESIGN: Quiet stance on supporting bases with different lengths and with different visual inputs were tested in 24 study participants with chronic low back pain (LBP) and 24 matched control subjects. OBJECTIVES: To evaluate postural adjustment strategies and visual dependence associated with LBP. SUMMARY OF BACKGROUND DATA: Various studies have identified balance impairments in patients with chronic LBP, with many possible causes suggested. Recent evidence indicates that study participants with LBP have impaired trunk muscle control, which may compromise the control of trunk and hip movement during postural adjustments (e.g., hip strategy). As balance on a short base emphasizes the utilization of the hip strategy for balance control, we hypothesized that patients with LBP might have difficulties standing on short bases. METHODS: Subjects stood on either flat surface or short base with different visual inputs. A task was counted as successful if balance was maintained for 70 seconds during bilateral stance and 30 seconds during unilateral stance. The number of successful tasks, horizontal shear force, and center-of-pressure motion were evaluated. RESULTS: The hip strategy was reduced with increased visual dependence in study participants with LBP. The failure rate was more than 4 times that of the controls in the bilateral standing task on short base with eyes closed. Analysis of center-of-pressure motion also showed that they have inability to initiate and control a hip strategy. CONCLUSIONS: The inability to control a hip strategy indicates a deficit of postural control and is hypothesized to result from altered muscle control and proprioceptive impairment.
PMID: 15014284 [PubMed - in process]
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Prevalence, incidence, and recurrence of low back pain in scaffolders during a 3-year follow-up study.
Elders LA, Burdorf A.
Department of Public Health, Erasmus MC, University Medical Center Rotterdam, The Netherlands. l.elders@erasmusmc.nl
STUDY DESIGN: Prospective cohort study. OBJECTIVE: To describe the natural history of low back pain by its prevalence, incidence, and recurrence during a 3-year period and identify risk factors for cumulative incidence and recurrence of low back pain in scaffolders. SUMMARY OF BACKGROUND DATA: Although some studies have described prevalence, incidence, or recurrence of low back pain, few studies have assessed two or more of these outcome measures simultaneously. Furthermore, little is known about the association between individual, physical, psychosocial, and health-related risk factors and cumulative incidence and recurrence of low back pain in scaffolders. METHODS: Between 1998 and 2001, a cohort of 288 scaffolders (response 85%) completed a questionnaire at baseline and at three yearly follow-ups during 3 years. RESULTS: At baseline 60% of the study population had had an episode of low back pain in the past 12 months of which 22% was of chronic nature. During follow-up, the yearly incidence of low back pain varied between 20% and 28%, while yearly recurrence rates were 64% to 77%. Only few workers consistently reported the presence (20%) or absence (26%) of low back pain each year. Weak significant associations were present for the following: age 35 to 44 years, moderate general health, high strenuous arm movements, and body mass index with the cumulative incidence of low back pain. Significant associations were found between high manual handling of material and high job demand and low job control and the cumulative recurrence of low back pain, while moderate general health only showed a weak significant association with this outcome measure. CONCLUSIONS: Low back pain was a dynamic process with high rates for incidence, recurrence, and recovery. General health and work-related physical and psychosocial factors influenced both the incidence and recurrence of low back pain. The incidence and recurrence of low back pain depend strongly on the recall period of low back pain and the time-window of investigation.
PMID: 15014283 [PubMed - in process]
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Children at risk: risk factors for low back pain in the elementary school environment.
Limon S, Valinsky LJ, Ben-Shalom Y.
Petach Tikva Area Ministry of Health, Petach Tikva, Israel. limonfamily@hotmail.com
STUDY DESIGN: A prevalence survey of 101 randomly selected elementary schools in the Israel Central District. OBJECTIVES: To identify and describe risk factors for low back pain that exist in the elementary school environment. SUMMARY OF BACKGROUND DATA: Recent surveys report a high prevalence of low back pain in children and adolescents that increases with age, with a correlation between low back pain in adolescence and that experienced in adulthood. Environmental risk factors have been associated with the development of low back pain in children. Because of the significant amount of time children spend in their school environment, risk factors need to be identified in this environment. METHODS: A questionnaire, completed by school nurses, measured risk factors among 10,000 children in elementary schools in Israel. These included backpack and student weight, the availability of storage facilities, the appropriateness of chair and desk height to student height, seating arrangements during frontal lessons, and physical activity at recess. RESULTS: Between 30% and 54% of students carried >15% of their body weight. Nearly 15% of the first graders and 20% of sixth graders had inappropriate chairs. In 74% of the classes, students sat with their side facing the teacher and in 35% students sat with their backs. In 6% of schools, no physical activity is offered at recess. CONCLUSIONS: Shortcomings were found in all areas investigated. There is an urgent need for health promotion programs to increase awareness and reduce risks in the school environment.
PMID: 15014281 [PubMed - in process]
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Chronic low back pain-associated paraspinal muscle dysfunction is not the result of a constitutionally determined "adverse" fiber-type composition.
Crossman K, Mahon M, Watson PJ, Oldham JA, Cooper RG.
Musculoskeletal Research Group, University of Manchester, United Kingdom.
STUDY DESIGN: Investigative case control study. OBJECTIVES: To determine whether excessive paraspinal muscle fatigue in chronic low back pain results from a paucity of muscle type I fiber content. SUMMARY OF BACKGROUND DATA: Paraspinal muscle function is vital for spinal protection. Prospective studies suggest that excessive paraspinal muscle fatigability may increase risk of first-time low back pain. As contractile performance of the paraspinal muscles is governed by their constitutionally determined fiber composition, the question arises whether a constitutionally determined "adverse" composition could predispose to low back pain through impaired spinal protection. METHODS: Thirty-five male patients with chronic low back pain were compared with 32 male control patients of similar age and anthropometry. During Sorensen and 60% of maximum voluntary isometric contraction fatigue tests, median frequency declines in the paraspinal muscle surface electromyograph signal were monitored and correlated with muscle histomorphometry. RESULTS: Patients were weaker than controls during maximum voluntary isometric contractions (84.47 [28.44]vs. 98.74 [18.11] kg, respectively; P = 0.02) and more fatigable during their Sorensen tests (endurance time 105.29 [28.53]vs. 137.50 [40.38] sec, respectively; P < 0.01). There were no between-group differences in median frequency declines during the Sorensen (-0.37 [0.16]vs. -0.36 [0.12]%.sec) or 60% maximum voluntary isometric contraction (-0.42 [0.31]vs. -0.51 [0.29]%.sec) tests, for patients and controls, respectively. There were no between-group differences in the percent number of paraspinal muscle type I fibers (64 [11]vs. 64 [9]%) or the percent area occupied by type I fibers (67 [11]vs. 69 [9]%), for patients and controls, respectively. Type I and II muscle fiber narrow diameters were similar for both groups. CONCLUSION: In the patients with chronic low back pain tested, their associated paraspinal muscle dysfunction was not the result of a constitutionally determined "adverse" fiber type composition.
PMID: 15014272 [PubMed - in process]
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