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The efficacy of continuous fascia iliaca compartment block for pain management in burn patients undergoing skin grafting procedures.
Cuignet O, Pirson J, Boughrouph J, Duville D.
Burn Center, Queen Astrid Military Hospital, Military Medical Research Program and Development Committee, Brussels, Belgium, and the. Department of Anesthesiology, Cliniques Universitaires Saint Luc, Universite Catholique de Louvain, Brussels, Belgium.
Postoperative pain from split skin donor sites is often more intense than the pain at the grafted site. In this prospective, randomized, double-blind study we assessed the efficacy of a continuous fascia iliaca compartment block (FICB) in reducing the pain at the thigh donor site. Twenty patients, with a total burn surface area of 16% +/- 13% (mean +/- SD) were randomized 1:1 to receive either ropivacaine 0.2% or saline 0.9%. All patients received a general anesthesic followed by preincision continuous FICB with 40 mL of the randomized solution, then an infusion of 10 mL/h of either ropivacaine or saline until the first dressing change (72 h later). Postoperative analgesia consisted of propacetamol 2g/6h, IV patient-controlled analgesia of morphine chlorhydrate (2 mg/mL), and morphine hydrochlorate 0.5 mg/kg PO once 60 min before first dressing change. The visual analog scale (VAS) scores were compared using the Mann-Whitney U-test preoperatively, 24 and 48 h postoperatively, and during the first dressing change. The cumulative morphine consumption was compared with repeated-measures analysis of variance followed by Scheffe's method if indicated. Patients with continuous FICB had significantly reduced postoperative morphine consumption at all time points (23 +/- 20 versus 88 +/- 29 mg after 72 h, study versus control groups, respectively; P < 0.05). In both groups, VAS scores remained low but were only significantly lower for patients with continuous FICB during the first dressing change (3 [1] versus 7 [3]; median [interquartile range]; P < 0.05). We conclude that continuous FICB is an efficient method for diminishing pain at the thigh donor site. (250 words) IMPLICATIONS:Postoperative pain at the split skin donor sites is often more intense than the pain at the grafted site. This prospective, randomized, double-blind study assessed the efficacy of a continuous fascia iliaca compartment block in reducing the pain at the thigh donor site.
PMID: 15041602 [PubMed - in process]
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Intrathecal clonidine and bupivacaine have synergistic analgesia for acute thermally or inflammatory-induced pain in rats.
Nishiyama T, Hanaoka K.
Department of Anesthesiology, The University of Tokyo, Faculty of Medicine, Tokyo, Japan.
We investigated the interaction between spinally administered bupivacaine and clonidine using an animal model of acute and inflammatory pain. Rats implanted with lumbar intrathecal catheters were injected intrathecally with saline (control), bupivacaine (1 to 100 micro g), or clonidine (0.1 to 3 micro g) and tested for their responses to thermal stimulation to the tail (tail flick test) and subcutaneous formalin injection into the hindpaw (formalin test). The effects of the combination of bupivacaine and clonidine on both stimuli were tested by isobolographic analysis. General behavior and motor function were examined as side effects. The 50% effective doses of bupivacaine and clonidine were significantly smaller when combined compared with each single drug in both the tail flick test (2.82 and 0.11 micro g versus 7.1 and 0.29 micro g, respectively) and phase 1 (0.24 and 0.009 micro g versus 5.7 and 0.15 micro g) and phase 2 (0.31 and 0.012 micro g versus 3.2 and 0.16 micro g) of the formalin test. Side effects were decreased by the combination. These results suggest a favorable combination of intrathecal bupivacaine and clonidine in the management of acute and inflammatory pain. IMPLICATIONS: The analgesic interaction between intrathecally administered bupivacaine and clonidine was examined during acute thermal and inflammatory-induced pain in rats. The analgesia produced by the combination of these two drugs was synergistic in both acute thermal and inflammatory induced pain, with a decrease in behavioral side effects.
PMID: 15041598 [PubMed - in process]
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Perioperative intravenous lidocaine has preventive effects on postoperative pain and morphine consumption after major abdominal surgery.
Koppert W, Weigand M, Neumann F, Sittl R, Schuettler J, Schmelz M, Hering W.
Department of Anesthesiology, University of Erlangen, Erlangen, Germany. Department of Anesthesiology Mannheim, University of Heidelberg, Mannheim, Germany. Department of Anesthesiology, St. Marien Hospital Siegen, Siegen, Germany.
Sodium channel blockers are approved for IV administration in the treatment of neuropathic pain states. Preclinical studies have suggested antihyperalgesic effects on the peripheral and central nervous system. Our objective in this study was to determine the time course of the analgesic and antihyperalgesic mechanisms of perioperative lidocaine administration. Forty patients undergoing major abdominal surgery participated in this randomized and double-blinded study. Twenty patients received lidocaine 2% (bolus injection of 1.5 mg/kg in 10 min followed by an IV infusion of 1.5 mg. kg(-1). h(-1)), and 20 patients received saline placebo. The infusion started 30 min before skin incision and was stopped 1 h after the end of surgery. Lidocaine blood concentrations were measured. Postoperative pain ratings (numeric rating scale of 0-10) and morphine consumption (patient-controlled analgesia) were assessed up to 72 h after surgery. Mean lidocaine levels during surgery were 1.9 +/- 0.7 micro g/mL. Patient-controlled analgesia with morphine produced good postoperative analgesia (numeric rating scale at rest, </=3; 90%-95%; no group differences). Patients who received lidocaine reported less pain during movement and needed less morphine during the first 72 h after surgery (103.1 +/- 72.0 mg versus 159.0 +/- 73.3 mg; Student's t-test; P < 0.05). Because this opioid-sparing effect was most pronounced on the third postoperative day, IV lidocaine may have a true preventive analgesic activity, most likely by preventing the induction of central hyperalgesia in a clinically relevant manner. IMPLICATIONS: The perioperative administration of systemic small-dose lidocaine reduces pain during surgery associated with the development of pronounced central hyperalgesia, presumably by affecting mechanoinsensitive nociceptors, because these have been linked to the induction of central sensitization and were shown to be particularly sensitive to small-dose lidocaine.
PMID: 15041597 [PubMed - in process]
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Preoperative oral rofecoxib reduces postoperative pain and tramadol consumption in patients after abdominal hysterectomy.
Karamanlioglu B, Turan A, Memis D, Ture M.
Department of Anesthesiology and. Biostatistics, Trakya University, Medical Faculty, Edirne, Turkey.
We designed this study to determine whether the administration of a preoperative dose of rofecoxib to patients undergoing abdominal hysterectomy would decrease patient-controlled analgesia (PCA) tramadol use or enhance analgesia. Sixty patients were randomized to receive either oral placebo or rofecoxib 50 mg 1 h before surgery. All patients received a standard anesthetic protocol. Intraoperative blood loss was determined. At the end of surgery, all patients received tramadol IV via a PCA-device. Pain scores, sedation scores, mean arterial blood pressure, heart rate, and peripheral oxygen saturation were assessed at 1, 2, 4, 6, 8, 12, and 24 h after surgery. Total and incremental tramadol consumption at the same times was recorded from the PCA-device. Antiemetic requirements and adverse effects were noted during the first postoperative 24 h. Duration of hospital stay was also recorded. The pain scores were significantly lower in the rofecoxib group compared with the placebo group at 6 times during the first 12 postoperative h (P < 0.05). The total consumption of tramadol (627 +/- 69 mg versus 535 +/- 45 mg; P < 0.05) and the incremental doses at 1, 2, 4, 6, 8, and 12 h after surgery were significantly more in the placebo group than in the rofecoxib group. There were no differences between groups in intraoperative blood loss, sedation scores, hemodynamic variables, peripheral oxygen saturation, antiemetic requirements, or adverse effects after surgery. The length of hospital stay was also similar in the groups. We conclude that the preoperative administration of oral rofecoxib provided a significant analgesic benefit and decreased the opioid requirements in patients undergoing abdominal hysterectomy. IMPLICATIONS: This study was designed to determine whether the administration of a preoperative dose of rofecoxib to patients undergoing abdominal hysterectomy would decrease patient-controlled analgesia tramadol use or enhance analgesia. We conclude that the preoperative administration of oral rofecoxib provided a significant analgesic benefit and decreased the opioid requirements in patients undergoing abdominal hysterectomy.
PMID: 15041595 [PubMed - in process]
Systematic review of topical capsaicin for the treatment of chronic pain.
Mason L, Moore RA, Derry S, Edwards JE, McQuay HJ.
Pain Research and Nuffield Department of Anaesthetics, University of Oxford, Oxford Radcliffe Hospital, Headington, Oxford OX3 7LJ.
OBJECTIVE: To determine the efficacy and safety of topically applied capsaicin for chronic pain from neuropathic or musculoskeletal disorders. DATA SOURCES: Cochrane Library, Medline, Embase, PubMed, an in-house database, and contact with manufacturers of topical capsaicin. STUDY SELECTION: Randomised controlled trials comparing topically applied capsaicin with placebo or another treatment in adults with chronic pain. DATA EXTRACTION: Primary outcome was dichotomous information for the number of patients with about a 50% reduction in pain. Outcomes were extracted at four weeks for musculoskeletal conditions and eight weeks for neuropathic conditions. Secondary outcomes were adverse events and withdrawals due to adverse events. DATA SYNTHESIS: Six double blind placebo controlled trials (656 patients) were pooled for analysis of neuropathic conditions. The relative benefit from topical capsaicin 0.075% compared with placebo was 1.4 (95% confidence interval 1.2 to 1.7) and the number needed to treat was 5.7 (4.0 to 10.0). Three double blind placebo controlled trials (368 patients) were pooled for analysis of musculoskeletal conditions. The relative benefit from topical capsaicin 0.025% or plaster compared with placebo was 1.5 (1.1 to 2.0) and the number needed to treat was 8.1 (4.6 to 34). Around one third of patients experienced local adverse events with capsaicin, which would not have been the case with placebo. CONCLUSIONS: Although topically applied capsaicin has moderate to poor efficacy in the treatment of chronic musculoskeletal or neuropathic pain, it may be useful as an adjunct or sole therapy for a small number of patients who are unresponsive to, or intolerant of, other treatments.
PMID: 15033881 [PubMed - as supplied by publisher]
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Systematic review of efficacy of topical rubefacients containing salicylates for the treatment of acute and chronic pain.
Mason L, Moore RA, Edwards JE, McQuay HJ, Derry S, Wiffen PJ.
Pain Research and Nuffield Department of Anaesthetics, University of Oxford, Oxford Radcliffe Hospital, Headington, Oxford OX3 7LJ.
OBJECTIVE: To determine the efficacy and safety of topical rubefacients containing salicylates in acute and chronic pain. DATA SOURCES: Electronic databases and manufacturers of salicylates. STUDY SELECTION: Randomised double blind trials comparing topical rubefacients with placebo or another active treatment, in adults with acute or chronic pain, and reporting dichotomous information, around a 50% reduction in pain, and analyses at one week for acute conditions and two weeks for chronic conditions. DATA EXTRACTION: Relative benefit and number needed to treat, analysis of adverse events, and withdrawals. DATA SYNTHESIS: Three double blind placebo controlled trials had information on 182 patients with acute conditions. Topical salicylate was significantly better than placebo (relative benefit 3.6, 95% confidence interval 2.4 to 5.6; number needed to treat 2.1, 1.7 to 2.8). Six double blind placebo controlled trials had information on 429 patients with chronic conditions. Topical salicylate was significantly better than placebo (relative benefit 1.5, 1.3 to 1.9; number needed to treat 5.3, 3.6 to 10.2), but larger, more valid studies were without significant effect. Local adverse events and withdrawals were generally rare in trials that reported them. CONCLUSIONS: Based on limited information, topically applied rubefacients containing salicylates may be efficacious in the treatment of acute pain. Trials of musculoskeletal and arthritic pain suggested moderate to poor efficacy. Adverse events were rare in studies of acute pain and poorly reported in those of chronic pain. Efficacy estimates for rubefacients are unreliable owing to a lack of good clinical trials.
PMID: 15033879 [PubMed - as supplied by publisher]
Rhetoric and reality on acute pain services in the UK: a national postal questionnaire survey.
Powell AE, Davies HT, Bannister J, Macrae WA.
Centre for Public Policy and Management, University of St Andrews, St Andrews KY16 9AL, UK.
BACKGROUND: The study aimed to explore the extent to which NHS acute pain services (APSs) have been established in accordance with national guidance, and to assess the degree to which clinicians in acute pain management believe that these services are fulfilling their role. METHODS: A postal questionnaire survey addressed to the head of the acute pain service was sent to 403 National Health Service hospitals each carrying out more than 1000 operative procedures a year. RESULTS: Completed questionnaires were received from 81% (325) of the hospitals, of which 83% (270) had an established acute pain service. Most of these (86%) described their service as Monday-Friday with a reduced service at other times; only 5% described their service as covering 24 hours, 7 days a week. In the majority of hospitals (68%), the on-call anaesthetist was the sole provider of out of hours services. Services were categorized by respondents as thriving (30%), struggling to manage (52%) or non-existent (17%). There was widespread agreement (>/=85%) on the principles that should underpin acute pain services, and similar agreement on the need for better organizational approaches (95%) rather than new treatments and delivery techniques (19%). CONCLUSIONS: More than a decade since the 1990 report Pain after Surgery, national coverage of comprehensive acute pain services is still far from being achieved. Despite wide consensus about the problems, concrete solutions are proving hard to implement. There is strong support for a two-fold response: securing greater political commitment to pain services and using organizational approaches to address current deficits.
PMID: 15033893 [PubMed - as supplied by publisher]
Comment in:
Anaesthesia for carotid endarterectomy: comparison of hypnotic- and opioid-based techniques.
Godet G, Reina M, Raux M, Amour J, De Castro V, Coriat P.
Department of Anesthesiology, Pitie-Salpetriere Hospital, 47 bd de l'Hopital, F-75651 Paris Cedex 13, France. gilles.godet@psl.ap-hop-paris.fr
BACKGROUND: Although the synergistic interaction between hypnotics and opioids for total i.v. anaesthesia has been repeatedly demonstrated, questions about different dose combinations of hypnotics and opioids remain. The optimal combination would be based on maximal synergy, using the lowest dose of both drugs and having the lowest incidence of side-effects. METHODS: The major goal of this prospective randomized study was to compare two different dose combinations of propofol and remifentanil (both administered by target controlled infusion (TCI)) in respect of haemodynamics during surgery and recovery, and the need for cardiovascular treatment in the recovery room. A secondary goal was to compare pain scores (VAS) and morphine consumption in the recovery room. Anaesthesia was induced in both groups using TCI propofol, adjusted to obtain a bispectral index score (BIS) value between 40 and 60. TCI for remifentanil commenced at an initial effect-site concentration of 0.5 ng ml(-1), and was adjusted according to haemodynamics. Patients were divided into one of two groups during anaesthesia: (i). Group H, hypnotic anaesthesia (n=23), propofol effect-site concentration maintained at 2.4 microg x ml(-1); and (ii). Group O, opioid anaesthesia (n=23), propofol effect-site concentration maintained at 1.2 microg x ml(-1). In both groups, remifentanil effect-site concentration was adjusted according to haemodynamics and changes in BIS value. RESULTS: In Group O, more episodes of intraoperative hypotension (P<0.02) and hypertension (P<0.01), and fewer episodes of tachycardia were observed. More patients in Group O required nicardipine administration for postoperative hypertension (8 patients in Group H vs 15 patients in Group O, P<0.04). During recovery, morphine titration was necessary in approximately 50% of patients. No significant difference between groups was observed concerning pain scores or requirement for morphine titration. CONCLUSIONS: Maintenance of anaesthesia predominantly with propofol and a low dose of remifentanil, both administered using TCI, is associated with greater stability in perioperative haemodynamics than anaesthesia predominantly with remifentanil alone. Postoperative pain was identical in both groups of patients who underwent relatively short duration, and relatively painless surgery.
Publication Types:
- Clinical Trial
- Randomized Controlled Trial
PMID: 14742344 [PubMed - indexed for MEDLINE]
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Analgesia for day-case shoulder surgery.
Wilson AT, Nicholson E, Burton L, Wild C.
Department of Anaesthesia, Leeds General Infirmary, Great George St, Leeds LS1 3EX, UK. awilson@doctors.org.uk
BACKGROUND: Single-shot nerve blocks provide excellent postoperative analgesia for a limited period and are increasingly used in day-case units. They allow early patient discharge following painful operative procedures that would otherwise require overnight hospitalization. We investigated the adequacy of analgesia at home after the block had worn off. METHODS: A prospective audit by telephone 1 week after surgery of 50 consecutive patients who had had a single-shot interscalene block for day-case shoulder arthroscopic surgery. RESULTS: The mean length of adequate sensory block was 22.5 h (9-48 h) after which 20% of patients had a maximum visual analogue scale (VAS) score of 5/5. Most patients did not take analgesics as prescribed and two patients (5.4%) required additional analgesia from their family doctor or accident and emergency department. CONCLUSIONS: We conclude that analgesia at home is often inadequate after painful day-case surgical procedures if single-shot local anaesthetic blockade is used.
PMID: 14742335 [PubMed - indexed for MEDLINE]
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Double-blind randomized controlled trial of caudal versus intravenous S(+)-ketamine for supplementation of caudal analgesia in children.
Martindale SJ, Dix P, Stoddart PA.
Bristol Royal Hospital for Children, Upper Maudlin Street, Bristol BS2 8BJ, UK.
BACKGROUND: The postoperative analgesic efficacy of S(+)-ketamine after caudal or i.v. administration following sub-umbilical surgery in children was studied to investigate its principal site of analgesic action. METHODS: Sixty children undergoing caudal block during general anaesthesia for hernia repair or orchidopexy were prospectively randomized to one of three groups: the bupivicaine group received plain bupivacaine 0.25% 1 ml x kg(-1); the caudal ketamine group received caudal plain bupivacaine 0.25% 1 ml x kg(-1) with S(+)-ketamine 0.5 mg x kg(-1); the i.v. ketamine group received caudal plain bupivacaine 0.25% 1 ml x kg(-1) plus S(+)-ketamine 0.5 mg x kg(-1) i.v. Postoperative measurements included analgesic requirements and modified objective pain score for the first 24 h. RESULTS: The median time to first analgesia was significantly longer in the caudal ketamine group (10 h) than in the i.v. ketamine (4.63 h) or bupivacaine (4.75 h) groups (P=0.01). Significantly fewer doses of analgesia were required over the first postoperative 24 h by subjects in the caudal ketamine group (median 1) compared with the i.v. ketamine (median 2) or bupivacaine (median 2.5) groups (P<0.05). There was no difference between the groups in the incidence of postoperative nausea and vomiting or psychomotor reactions. CONCLUSIONS: We have demonstrated that the addition of caudal S(+)-ketamine to bupivacaine prolongs the duration of postoperative analgesia. However, the same dose of i.v. S(+)-ketamine combined with a plain bupivacaine caudal provides no better analgesia than caudal bupivacaine alone, indicating that the principal analgesic effect of caudal S(+)-ketamine results from a local neuroaxial rather than a systemic effect.
Publication Types:
- Clinical Trial
- Randomized Controlled Trial
PMID: 14742331 [PubMed - indexed for MEDLINE]
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Periods of cluster headache induced by nitrate therapy and spontaneous remission of angina pectoris during active clusters.
Ekbom K, Sjostrand C, Svensson DA, Waldenlind E.
Department of Neurology, Division of Neurology, Karolinska Institutet, Huddinge University Hospital, Stockholm, Sweden.
Glyceryl trinitrate (GTN) is known to induce single extra attacks of cluster headache (CH) during active cluster periods, most probably via actions of nitric oxide (NO). Induction of whole periods of CH by organic nitrates has, however, attracted little attention in the literature. We report on eight patients with episodic CH and coexistent effort-induced angina pectoris. Cases 1-6 had been free of their headaches for many years but got recurrence of CH within a few weeks after the administration of long-acting organic nitrates (isosorbide-dinitrate, isosorbide-5-mononitrate or slow-release GTN) aimed at treating their chest pains. These nitrate-induced headache periods were more severe and had a longer duration than the previous spontaneous ones. Furthermore, one of the subjects and two additional cases experienced a marked reduction of their anginal attacks during successive CH periods. Exercise time to effort-induced angina was increased in all three patients and one of them revealed a markedly elevated threshold for eliciting ischaemic cardiac symptoms by standardized physical exercise on a cycle ergometer. We hypothesize whether extra CH periods elicited by sustained nitrate therapy and remission of angina pectoris during active clusters are caused by central mechanisms involving inhibition of sympathetic tone and effects on both cranial vessels and cardiac functions.
Publication Types:
PMID: 14728704 [PubMed - indexed for MEDLINE]
Lower leg pain in a 17-year-old boy.
Lou J, Erol B, States L, Pawel BR, Dormans JP.
Division of Orthopaedic Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA 19104-4399, USA.
Publication Types:
PMID: 15043131 [PubMed - in process]
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The young adult with hip pain: diagnosis and medical treatment, circa 2004.
Troum OM, Crues JV 3rd.
Division of Rheumatology, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA. Otroum@yahoo.com
Hip pain in young adults (18-35 years old) often is characterized by nonspecific symptoms, normal imaging studies, and vague findings from the history and physical examination. In younger patients, pain is more likely to be caused by congenital hip dysplasia, athletic injuries, trauma, spondyloarthropathy, and by conditions that first appear during this stage of life, such as rheumatoid arthritis, osteoarthritis, intravenous drug use, alcoholism, or corticosteroid use. The history and physical examination may narrow the diagnosis to intraarticular, extraarticular, or referred sources of pain. Plain radiography and magnetic resonance imaging are the preferred initial imaging procedures. Analyses of the blood, urine, and synovial fluid can be helpful in diagnosing inflammation, infection, and systematic rheumatic disease. Fractures, infection, and ischemic necrosis should be ruled out early because they require immediate treatment to prevent damage to the joint. Hip trauma at a young age increases the risk of osteoarthritis with advancing age, and, unlike most older adults, young adults receiving total hip replacement can expect revision surgery. Medical treatment often involves patient education, physical therapy, and pharmacotherapy. Acetaminophen, nonsteroidal anti-inflammatory drugs, and opioids for pain and antibiotics for infection are the most often prescribed drugs for this population.
PMID: 15043086 [PubMed - in process]
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Papules with minimal perilesional erythema. Intermittently painful, yellow-white "bumps" drain chalky substance.
Levine N.
University of Arizona Health Sciences Center, Tucson, USA.
PMID: 15035577 [PubMed - in process]
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Efficacy of transdermal nitroglycerin combined with etodolac for the treatment of chronic post-thoracotomy pain: an open-label prospective clinical trial.
Glantz L, Godovic G, Lekar M, Kramer M, Eidelman LA.
Department of Anesthesiology, Rabin Medical Center, Beilinson Campus, Petah Tikva, Israel.
Chronic post-thoracotomy pain (CPP) is associated with surgical intercostal nerve injury. Like other forms of neuropathic pain, there is no ideal treatment. Nitroglycerin (NTG) has been found efficacious in acute pain, but has not been tested for chronic pain with neuropathic characteristics. The present study investigated the efficacy of NTG combined with the nonsteroidal anti-inflammatory drug etodolac for the treatment of CPP. Thirty of 129 patients who underwent thoracotomy within an 18-month period had moderate to severe pain that did not respond to etodolac. NTG, 5 mg/day, was added to the treatment. A significant reduction in VAS was observed on day 14 of treatment (from 66.7 +/- 11 to 42.1 +/- 5, P< 0.05). Similar changes were noted in breakthrough pain intensity and and sleep efficiency. The only side effect was mild headache, which was self-limited to the first few days of NTG administration. We conclude that NTG added to etodolac appears to be effective for the treatment of CPP, with minimal side effects. Further randomized blinded studies are required.
PMID: 15038339 [PubMed - in process]
Urine drug testing in pain medicine.
Heit HA, Gourlay DL.
Department of Medicine, Georgetown University School of Medicine, Washington, D.C., USA.
The use of urine drug testing (UDT) has increased over recent years. UDT results have traditionally been used in legal proceedings under supervision of a medical review officer (MRO). In this context, testing has been required by statute or regulation and so is typically not in the "donor's" interest. Physicians, however, can use UDT to assist in monitoring their patient's treatment plan. By using UDT in a patient-centered fashion, both patient and physician interests are maintained. The MRO-based model of testing in the clinical setting can lead to mistrust and a deterioration of the doctor-patient relationship. Clinical testing can enhance the doctor-patient relationship when the results are used to improve communication. A patient-centered model of UDT should be used to improve quality of care. This article discusses why urine is the biological specimen of choice for drug testing; who, when and why to test; testing methods; and, most importantly, interpretation of results.
PMID: 15010104 [PubMed - in process]
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Self-discrepancy in chronic low back pain: relation to pain, depression, and psychological distress.
Waters SJ, Keefe FJ, Strauman TJ.
Pain Prevention and Treatment Program, Duke University Medical Center, DUMC 3159, Durham, NC 27710, USA.
Self-discrepancies occur when patients' evaluations of their actual self differ from their views of who they ideally would like to be (ideal self) or feel they ought to be (ought self), or from patients' perceptions of how significant others wish they could be (ideal-other self) or ought to be (ought-other self). These self-discrepancies may be related to psychological functioning and adjustment to pain. This study sought to: 1) determine the reliability of self-discrepancy assessments in patients; 2) determine whether each of the four types of self-discrepancies (actual self vs. ideal self, actual self vs. ought self, actual self vs. ideal-other self and actual self vs. ought-other self) measure a distinct type of self-discrepancy; and, 3) examine the relationship of self-discrepancies to pain intensity, depression, and psychological distress in 93 chronic low back pain patients. A semi-structured questionnaire assessed self-discrepancies. Standardized measures were used to assess pain intensity, depression, and psychological distress. Results showed that self-discrepancies can be reliably assessed in patients with persistent pain. Furthermore, data analyses showed that patients who had large ought-other self-discrepancies reported more severe pain and higher levels of psychological distress. Patients who had large ideal self-discrepancies reported higher levels of depression and psychological distress. Taken together, these findings suggest that self-discrepancy can be reliably assessed in patients with persistent pain and demonstrate that self-discrepancies are related in meaningful ways to measures of pain, depression, and psychological distress in chronic low back pain patients.
PMID: 15010103 [PubMed - in process]
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Existential pain--an entity, a provocation, or a challenge?
Strang P, Strang S, Hultborn R, Arner S.
Department of Oncology and Pathology, Karolinska Institutet, SSH, Mariebergsg 22, 112-35 Stockholm, Sweden.
"Existential pain" is a widely used but ill-defined concept. Therefore the aim of this study was to let hospital chaplains (n=173), physicians in palliative care (n=115), and pain specialists (n=113) respond to the question: "How would you define the concept existential pain?" A combined qualitative and quantitative content analysis of the answers was conducted. In many cases, existential pain was described as suffering with no clear connection to physical pain. Chaplains stressed significantly more often the guilt issues, as well as various religious questions (P<0.001). Palliative physicians (actually seeing dying persons) stressed more often existential pain as being related to annihilation and impending separation (P<0.01), while pain specialists (seeing chronic patients) more often emphasized that "living is painful" (P<0.01). Thirty-two percent (32%) of the physicians stated that existential suffering can be expressed as physical pain and provided many case histories. Thus, "existential pain" is mostly used as a metaphor for suffering, but also is seen as a clinically important factor that may reinforce existing physical pain or even be the primary cause of pain, in good agreement with the current definition of pain disorder or somatization disorder.
PMID: 15010102 [PubMed - in process]
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Coping with long-term pain after a stroke.
Widar M, Ek AC, Ahlstrom G.
Department of Medicine and Care, Division of Nursing Science, Faculty of Health Sciences, Linkoping University, Linkoping, Sweden.
The aim of this qualitative study was to describe pain, coping strategies, and experienced outcome of coping with long-term pain conditions after a stroke. Forty-three participants were interviewed: 15 with central post-stroke pain (CPSP), 18 with nociceptive pain, and 10 with tension-type headache. Analysis of the data was by content analysis. Pain-related problems described were incomprehensibility regarding the pain, disturbed sleep, fatigue, diminished capacity, mood changes, and stress in relationships. Different coping strategies were used; the most common were making the pain comprehensible, planning of activities, taking medications, communicating, and distractions. Changing body position, making comparison, and enduring the pain were common in central or nociceptive pain, rest and relaxation in tension-type headache. Communicating their pain gave a feeling of perplexity and resignation. Satisfaction was reported in the cases of consideration shown by others. Pain after a stroke requires specialized knowledge in order to understand the patient's experiences and to enhance coping.
PMID: 15010100 [PubMed - in process]
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A comparison of five pain assessment scales for nursing home residents with varying degrees of cognitive impairment.
Closs SJ, Barr B, Briggs M, Cash K, Seers K.
School of Healthcare Studies, Baines Wing, University of Leeds, Leeds LS2 9UT, United Kingdom.
The aim of the study was to compare five different pain assessment scales for use with people with different levels of cognitive impairment who resided in nursing homes. The verbal rating scale, horizontal numeric rating scale, Faces pictorial scale, color analogue scale and mechanical visual analogue scale were presented in random order to 113 residents. Cognitive impairment was assessed using the Mini-Mental State Examination. The use of the verbal rating scale was the most successful with this group, completed by 80.5% overall, and 36% of those with severe cognitive impairment. Repeated explanation improved completion rates for all the scales. Consistency between scores on the five scales was good for those with none to moderate cognitive impairment and poor for those severely impaired. This study showed no difference in pain scores according to cognitive status.
PMID: 15010098 [PubMed - in process]
Comment in:
Study and treatment of post Lyme disease (STOP-LD): a randomized double masked clinical trial.
Krupp LB, Hyman LG, Grimson R, Coyle PK, Melville P, Ahnn S, Dattwyler R, Chandler B.
Department of Neurology, Stony Brook University Medical Center, Stony Brook, NY 11794-8121, USA. lkrupp@notes.cc.sunysb.edu
OBJECTIVE: To determine whether post Lyme syndrome (PLS) is antibiotic responsive. METHODS: The authors conducted a single-center randomized double-masked placebo-controlled trial on 55 patients with Lyme disease with persistent severe fatigue at least 6 or more months after antibiotic therapy. Patients were randomly assigned to receive 28 days of IV ceftriaxone or placebo. The primary clinical outcomes were improvement in fatigue, defined by a change of 0.7 points or more on an 11-item fatigue questionnaire, and improvement in cognitive function (mental speed), defined by a change of 25% or more on a test of reaction time. The primary laboratory outcome was an experimental measure of CSF infection, outer surface protein A (OspA). Outcome data were collected at the 6-month visit. RESULTS: Patients assigned to ceftriaxone showed improvement in disabling fatigue compared to the placebo group (rate ratio, 3.5; 95% CI, 1.50 to 8.03; p = 0.001). No beneficial treatment effect was observed for cognitive function or the laboratory measure of persistent infection. Four patients, three of whom were on placebo, had adverse events associated with treatment, which required hospitalization. CONCLUSIONS: Ceftriaxone therapy in patients with PLS with severe fatigue was associated with an improvement in fatigue but not with cognitive function or an experimental laboratory measure of infection in this study. Because fatigue (a nonspecific symptom) was the only outcome that improved and because treatment was associated with adverse events, this study does not support the use of additional antibiotic therapy with parenteral ceftriaxone in post-treatment, persistently fatigued patients with PLS.
Publication Types:
- Clinical Trial
- Randomized Controlled Trial
PMID: 12821734 [PubMed - indexed for MEDLINE]
Comment in:
Cognitive function in post-treatment Lyme disease: do additional antibiotics help?
Kaplan RF, Trevino RP, Johnson GM, Levy L, Dornbush R, Hu LT, Evans J, Weinstein A, Schmid CH, Klempner MS.
University of Connecticut School of Medicine, Farmington, USA. kaplan@psychiatry.uchc.edu
BACKGROUND: It is controversial whether additional antibiotic treatment will improve cognitive function in patients with post-treatment chronic Lyme disease (PTCLD). OBJECTIVE: To determine whether antibiotic therapy improves cognitive function in two randomized double-blind placebo-controlled studies of patients with PTCLD. METHODS: A total of 129 patients with a physician-documented history of Lyme disease from three study sites in the northeast United States were studied. Seventy-eight were seropositive for IgG antibodies against Borrelia burgdorferi, and 51 were seronegative. Patients in each group were randomly assigned to receive IV ceftriaxone 2 g daily for 30 days followed by oral doxycycline 200 mg daily for 60 days or matching IV and oral placebos. Assessments were made at 90 and 180 days after treatment. Symptom severity was measured from the cognitive functioning, pain, and role functioning scales of the Medical Outcomes Study (MOS). Memory, attention, and executive functioning were assessed using objective tests. Mood was assessed using the Beck Depression Inventory and Minnesota Multiphasic Personality Inventory. RESULTS: There were no significant baseline differences between seropositive and seronegative groups. Both groups reported a high frequency of MOS symptoms, depression, and somatic complaints but had normal baseline neuropsychological test scores. The combined groups showed significant decreases in MOS symptoms, higher objective test scores, and improved mood between baseline and 90 days. However, there were no significant differences between those receiving antibiotics and placebo. CONCLUSION: Patients with post-treatment chronic Lyme disease who have symptoms but show no evidence of persisting Borrelia infection do not show objective evidence of cognitive impairment. Additional antibiotic therapy was not more beneficial than administering placebo.
Publication Types:
- Clinical Trial
- Multicenter Study
- Randomized Controlled Trial
PMID: 12821733 [PubMed - indexed for MEDLINE]
Comment on:
Treating post Lyme disease: trying to solve one equation with too many unknowns.
Steiner I.
Publication Types:
PMID: 12821728 [PubMed - indexed for MEDLINE]
Comment on:
Comment on 'Pulsed radiofrequency treatment of the gasserian ganglion in patients with idiopathic trigeminal neuralgia'.
Devulder J, Crombez E, Brusselmans G.
Publication Types:
PMID: 14715409 [PubMed - indexed for MEDLINE]
Comment on:
Comment on: Tassain V, Attal N, Fletcher C, Brasseur L, Degieux P, Chauvin M, Bouhassira D. Long term effects of oral sustained release morphine on neuropsychological performance in patients with chronic non-malignant pain. Pain 104: 389-400.
Walker J.
Publication Types:
PMID: 14715405 [PubMed - indexed for MEDLINE]
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Addition of ultralow dose naloxone to postoperative morphine PCA: unchanged analgesia and opioid requirement but decreased incidence of opioid side effects.
Cepeda MS, Alvarez H, Morales O, Carr DB.
Department of Anesthesia, San Ignacio Hospital, Javeriana University School of Medicine, Bogota, Colombia.
Ultralow doses of naloxone (0.001-0.1 microg/kg) produce analgesia in animal models. However, no clinical study has evaluated the combination of ultralow dose naloxone and morphine using patient-controlled analgesia (PCA). This randomized, double blind controlled study sought to determine if the combination of ultralow dose naloxone and morphine in PCA solutions affects opioid requirements, analgesia, and side effects. Two-hundred and sixty-five patients (18-65 years old) undergoing operations were randomized to receive PCA morphine 1 mg/ml (n=129) or PCA morphine 1 mg/ml plus naloxone 0.6 microg/ml (n=136). We evaluated the numbers of supplemental rescue doses, the cumulative dose of each PCA solution, pain intensity, pain relief, and opioid side effects during the first 24 h after surgery. We found that opioid requirements did not differ significantly between groups. The morphine+naloxone group on average required 0.07 mg more morphine (95% CI -1.1 to 1.3) during the 24 h than the morphine group. Pain intensity levels were also similar in both groups. The morphine+naloxone group had 0.06 units lower (95% CI -0.5 to 0.4) pain intensity levels than the morphine group. The morphine+naloxone group had a lower incidence of nausea and pruritus than the morphine group (P=0.01 for both symptoms). However, the incidence of vomiting, time to tolerate fluids, sedation, and urinary retention were similar between groups (all P values >0.1). The combination of ultralow dose naloxone and morphine in PCA does not affect analgesia or opioid requirements, but it decreases the incidence of nausea and pruritus.
Publication Types:
- Clinical Trial
- Randomized Controlled Trial
PMID: 14715387 [PubMed - indexed for MEDLINE]
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Oral morphine and respiratory function amongst hospice inpatients with advanced cancer.
Walsh TD, Rivera NI, Kaiko R.
The Harry R. Horvitz Center for Palliative Medicine, Cleveland Clinic Taussig Cancer Center, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA. walsht@ccf.org
BACKGROUND: Respiratory depression is the opioid adverse effect feared most by physicians. This may hinder adequate dosing in cancer pain. The study was conducted to examine the respiratory function of patients with advanced cancer receiving significant doses (>100 mg/24 h) of oral morphine. PATIENTS AND METHODS: Consecutive pain-free hospice inpatients with advanced cancer receiving high-dose immediate-release oral morphine were evaluated. A single assessment of respiratory rate (RR), arterial blood gas (ABG), and peak flow rate (PFR) was made at assumed morphine steady state. Venous blood was drawn for a trough morphine plasma level. RESULTS: Of 31 patients who consented to examination, 20 completed the study assessment; 12 had chronic bronchitis. The median morphine dose was 30 mg 4-hourly (range 20 to 90 mg). Only one patient had evidence of ventilatory impairment. CONCLUSIONS: Morphine does not commonly cause chronic ventilatory impairment when given in this way in this population even in the presence of pre-existing or concurrent respiratory disease. Oral morphine given repeatedly in individualized dosage is a safe and efficacious analgesic in the majority of those with advanced cancer.
PMID: 14577019 [PubMed - indexed for MEDLINE]
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