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All: 46 
Review: 3 
Items 1 - 46 of 46
One page.
1: Am J Emerg Med. 2006 Jan;24(1):87-112. Related Articles, Links
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Body surface mapping in the ED evaluation of the patient with chest pain: use of the 80-lead electrocardiogram system.

Self WH, Mattu A, Martin M, Holstege C, Preuss J, Brady WJ.

Department of Emergency Medicine, Box 800699, University of Virginia Health Sciences Center, Charlottesville, VA 22908, USA.

Body surface mapping (BSM) is an electrocardiographic (ECG) technique that uses numerous leads on a patient's anterior and posterior chest, enabling more complete visualization of cardiac electrical activity. The rationale behind BSM is an extension of additional lead ECG. Output from BSM is displayed in a 12-lead ECG format, an 80-lead ECG format, and on color contour maps. The color contour maps can be displayed on a torso image or as a flat map.

PMID: 16338516 [PubMed - in process]

2: Am J Emerg Med. 2006 Jan;24(1):62-7. Related Articles, Links
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ALARMED: Adverse events in Low-risk patients with chest pain Receiving continuous electrocardiographic Monitoring in the Emergency Department. A pilot study.

Atzema C, Schull MJ, Borgundvaag B, Slaughter GR, Lee CK.

Division of Emergency Medicine, Sunnybrook and Women's College Health Sciences Centre, Toronto, ON, Canada M4N 3M5.

OBJECTIVES: Current guidelines suggest that most patients who present to an emergency department (ED) with chest pain should be placed on a continuous electrocardiographic monitoring (CEM) device. We evaluated the utility of CEM in ED patients with chest pain. METHODS: We enrolled stable patients who presented to a single ED with chest pain suspected to be ischemic in origin and who were placed on CEM. Patients were classified according to risk of poor outcome using 3 published stratification tools. Trained observers prospectively recorded number of monitored hours, alarms, changes in management, and monitor-detected adverse events (AEs). The primary outcome measure was the rate of AEs detected by CEM. Secondary outcome measures were the rate of alarms that resulted in a change in management and number of false alarms. RESULTS: We enrolled 72 patients, 56% of whom were categorized as very low-risk by Goldman risk criteria. During 371 monitored hours, we recorded 1762 alarms or 4.7 alarms per monitored hour. There were 11 AEs (0.68%; 95% CI, 0.35%-1.2%), 3 of which resulted in a change in management (0.2%; 95% CI, 0.04%-0.5%). Seven AEs were bradydysrhythmias with a heart rate of 45 or higher; the eighth patient had no change in symptoms and was given atropine for a heart rate of 32. The other 3 AEs were an untreated supraventricular tachycardia, a brief sinus pause that triggered a rate change in intravenous nitroglycerin by the patient's nurse, and a run of premature ventricular contractions after which heparin was administered. None of the 3 patients with a change in management was categorized as the lowest-risk. CONCLUSIONS: Routine CEM in low-risk ED patients with chest pain results in an excessive number of alarms, most of which require no change in management. In these patients, the benefit of CEM may be limited, and given that 99.4% of alarms were false, current CEM technology needs to be improved.

PMID: 16338512 [PubMed - in process]

3: Am J Emerg Med. 2006 Jan;24(1):1-7. Related Articles, Links
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Door-to-ECG time in patients with chest pain presenting to the ED.

Diercks DB, Kirk JD, Lindsell CJ, Pollack CV Jr, Hoekstra JW, Gibler WB, Hollander JE.

Division of Emergency Medicine, University of California, Davis Medical Center, Sacramento, CA 95817, USA.

OBJECTIVE: To describe time to electrocardiogram (ECG) acquisition, identify factors associated with timely acquisition, and evaluate the influence of time to ECG on adverse clinical outcomes. METHODS: We measured the door-to-ECG time for emergency department patients enrolled in prospective chest pain registry. Clinical outcomes were defined as occurrence of myocardial infarction or death within 30 days of the visit. RESULTS: Among patients with acute coronary syndrome (ACS), 34% and 40.9% of patients with non-ST-elevation ACS and ST-elevation myocardial infarction (STEMI), respectively, had an ECG performed within 10 minutes of arrival. A delay in ECG acquisition was only associated with an increase risk of clinical outcomes in patients with STEMI at 30 days (odds ratio, 3.95; 95% confidence interval, 1.06-14.72; P = .04). CONCLUSION: Approximately one third of patients with ACS received an ECG within 10 minutes. A prolonged door-to-ECG time was associated with an increased risk of clinical outcomes only in patients with STEMI.

PMID: 16338501 [PubMed - in process]

4: Anesth Analg. 2005 Nov;101(5 Suppl):S30-43. Related Articles, Links
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The role of intrathecal drugs in the treatment of acute pain.

Rathmell JP, Lair TR, Nauman B.

Department of Anesthesiology, University of Vermont College of Medicine, Burlington, Vermont, USA. james.rathmell@vtmednet.org

Intrathecal opioids are widely used as useful adjuncts in the treatment of acute and chronic pain, and a number of non-opioid drugs show promise as analgesic drugs with spinal selectivity. In this review we examine the historical development and current use of intrathecal opioids and other drugs that show promise for treating pain in the perioperative period. The pharmacology and clinical use of intrathecal morphine and other opioids is reviewed in detail, including dosing guidelines for specific surgical procedures and the incidence and treatment of side effects associated with these drugs. Available data on the use of non-opioid drugs that have been tested intrathecally for use as analgesics are also reviewed. Evidence-based guidelines for dosing of intrathecal drugs for specific surgical procedures and for the treatment of the most common side effects associated with these drugs are presented.

Publication Types:
PMID: 16334491 [PubMed - indexed for MEDLINE]

5: Anesth Analg. 2005 Nov;101(5 Suppl):S23-9. Related Articles, Links
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Emerging techniques in the management of acute pain: epidural analgesia.

Viscusi ER.

Department of Anesthesiology, Jefferson Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania 19107-5092, USA. eugene.viscusi@jefferson.edu

Epidural analgesia, often using opioids intraoperatively and postoperatively, is widely accepted as a valuable modality for perioperative pain management. In this review I present data from meta-analyses and recently published trials that evaluate the perioperative use of opioids administered epidurally or parenterally (as-needed or by patient-controlled analgesia) and their effect on outcome. Published effects of perioperative epidural techniques on cardiac and pulmonary function are reviewed. Clinical and practical issues associated with epidural anesthesia and analgesia include the existence of analgesic gaps (often related to technical difficulties with the pump or use of an indwelling catheter), the occurrence of hypotension, and compatibility with anticoagulation therapy. A new treatment option, a single epidural injection of morphine for continuous perioperative analgesia (DepoDur; Endo Pharmaceuticals Inc, Chadds Ford, PA), may reduce some of these problems. Data from recent clinical studies are presented.

Publication Types:
PMID: 16334490 [PubMed - indexed for MEDLINE]

6: Anesth Analg. 2005 Nov;101(5 Suppl):S5-22. Related Articles, Links
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The changing role of non-opioid analgesic techniques in the management of postoperative pain.

White PF.

Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas 75390-9068, USA. paul.white@utsouthwestern.edu

Given the expanding role of ambulatory surgery and the need to facilitate an earlier hospital discharge, improving postoperative pain control has become an increasingly important issue for all anesthesiologists. As a result of the shift from inpatient to outpatient surgery, the use of IV patient-controlled analgesia and continuous epidural infusions has steadily declined. To manage the pain associated with increasingly complex surgical procedures on an ambulatory or short-stay basis, anesthesiologists and surgeons should prescribe multimodal analgesic regimens that use non-opioid analgesics (e.g., local anesthetics, nonsteroidal antiinflammatory drugs, cyclooxygenase inhibitors, acetaminophen, ketamine, alpha 2-agonists) to supplement opioid analgesics. The opioid-sparing effects of these compounds may lead to reduced nausea, vomiting, constipation, urinary retention, respiratory depression and sedation. Therefore, use of non-opioid analgesic techniques can lead to an improved quality of recovery for surgical patients.

Publication Types:
PMID: 16334489 [PubMed - indexed for MEDLINE]

7: Anesth Analg. 2005 Nov;101(5 Suppl):S1-4. Related Articles, Links
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Postoperative pain: to diversify is to satisfy.

Rowlingson JC.

Publication Types:
PMID: 16334488 [PubMed - indexed for MEDLINE]

8: Anesth Analg. 2005 Nov;101(5):1560-1; author reply 1561. Related Articles, Links
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Comment on:
Short-lasting effect of perineural resiniferatoxin on mechanical hyperalgesia.

Banik RK.

Publication Types:
PMID: 16244036 [PubMed - indexed for MEDLINE]

9: Anesth Analg. 2005 Nov;101(5):1556-7. Related Articles, Links
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Report of the 13th annual meeting of the International Society for Anaesthetic Pharmacology.

Keltner JR, Flood P; International Society for Anaesthetic Pharmacology.

Department of Anesthesia University of California, San Francisco, Box 1654, 2255 Post Street, MZ Bldg N PAIN, San Francisco, CA 94143-1654, USA. keltnerj@anesthesia.ucsf.edu

PMID: 16244032 [PubMed - indexed for MEDLINE]

10: Anesth Analg. 2005 Nov;101(5):1319-22. Related Articles, Links
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Total shoulder arthroplasty as an outpatient procedure using ambulatory perineural local anesthetic infusion: a pilot feasibility study.

Ilfeld BM, Wright TW, Enneking FK, Mace JA, Shuster JJ, Spadoni EH, Chmielewski TL, Vandenborne K.

Department of Anesthesiology, P.O. Box 100254, 1600 SW Archer Rd., Gainesville, FL 32610-0254, USA. bilfeld@ufl.edu

We investigated the feasibility of converting total shoulder arthroplasty (TSA) into an outpatient procedure using ambulatory interscalene perineural ropivacaine infusion. Of the patients of the first phase (n = 8) who were required to remain hospitalized for at least 1 postoperative night, 5 met discharge criteria in the recovery room. Of the subsequent patients of the second phase (n = 6), all met discharge criteria in the recovery room after surgery, and 5 were discharged directly home. For all patients, postoperative pain was well controlled, oral opioid requirements and sleep disturbances were minimal, range-of-motion consistently reached or exceeded the surgeon's expectations, and patient satisfaction was high. These results suggest that TSA may be performed on an outpatient basis using perineural local anesthetic infusion. Additional research is required to define the appropriate subset of patients and assess the incidence of complications associated with this practice before its mainstream use.

PMID: 16243987 [PubMed - indexed for MEDLINE]

11: Anesth Analg. 2005 Nov;101(5):1304-10. Related Articles, Links
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Intraarticular bupivacaine-clonidine-morphine versus femoral-sciatic nerve block in pediatric patients undergoing anterior cruciate ligament reconstruction.

Tran KM, Ganley TJ, Wells L, Ganesh A, Minger KI, Cucchiaro G.

Children's Hospital of Philadelphia, Room, 9th Floor, 34th St. and Civic Center Blvd., Philadelphia, PA 19104, USA.

We hypothesized that combined femoral-sciatic nerve block (FSNB) offers better analgesia with fewer side effects than intraarticular infiltration (IA) in children undergoing anterior cruciate ligament (ACL) reconstruction. Thirty-six children undergoing ACL reconstruction were randomized to FSNB or IA. FSNB patients had FSNB with bupivacaine (0.125%)-clonidine (2 microg/kg), whereas IA patients received bupivacaine (0.25%)-clonidine (1 microg/kg)-morphine (5 mg). Postoperatively, analgesia was provided with patient-controlled analgesia and rescue morphine. Patient demographics were similar. FSNB patients required less intraoperative fentanyl (50 +/- 40 microg versus 80 +/- 50 microg; P = 0.04). Visual analog scale score for FSNB was smaller than IA in the recovery room (1.8 +/- 3 versus 5.4 +/- 3; P = 0.0002) and during the first 24 h (1.6 +/- 1 versus 2.9 +/- 2; P = 0.01)). FSNB morphine use in the first 18 h was less (7 +/- 13 mg versus 21 +/- 21 mg; P = 0.03). Fewer FSNB patients vomited (11% versus 50%; P = 0.03). IA patients required morphine patient-controlled analgesia sooner. After ACL reconstruction in children, FSNB with bupivacaine-clonidine provides better analgesia with fewer side effects than IA with bupivacaine-clonidine-morphine.

Publication Types:
PMID: 16243985 [PubMed - indexed for MEDLINE]

12: Anesthesiology. 2005 Oct;103(4):900-1; author reply 901. Related Articles, Links
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Comment on:
Iliac crest bone harvest: should we really use continuous infusion of ropivacaine?

Geffroy A, Cook F, Juvin P, Mantz J.

Publication Types:
PMID: 16192786 [PubMed - indexed for MEDLINE]

13: Anesthesiology. 2005 Oct;103(4):813-20. Related Articles, Links
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Comment in:
Intraoperative epidural analgesia combined with ketamine provides effective preventive analgesia in patients undergoing major digestive surgery.

Lavand'homme P, De Kock M, Waterloos H.

Department of Anesthesiology, St. Luc Hospital, Universite Catholique de Louvain, Brussels, Belgium. lavandhomme@anes.ucl.ac.be

BACKGROUND: As a broader definition of preemptive analgesia, preventive analgesia aims to prevent the sensitization of central nervous system, hence the development of pathologic pain after tissular injury. To demonstrate benefits from preventive treatment, objective measurement of postoperative pain such as wound hyperalgesia and persistent pain should be evaluated. The current study assessed the role and timing of epidural analgesia in this context. METHODS: In a randomized, double-blinded trial, 85 patients scheduled to undergo neoplastic colonic resection were included. All the patients received a thoracic epidural catheter, systemic ketamine at a antihyperalgesic dose, and general anesthesia. Continuous infusion of analgesics belonging to the same class was administered by either intravenous or epidural route before incision until 72 h after surgery. Patients were allocated to four groups to receive intraoperative intravenous lidocaine-sufentanil-clonidine or epidural bupivacaine-sufentanil-clonidine followed postoperatively by either intravenous (lidocaine-morphine-clonidine) or epidural (bupivacaine-sufentanil-clonidine) patient-controlled analgesia. Postoperative pain scores (visual analog scale), analgesic consumption, wound area of punctuate hyperalgesia, residual pain, and analgesics needed from 2 weeks until 12 months were recorded. RESULTS: Analgesic requirements, visual analog scale scores, and area of hyperalgesia were significantly higher in the intravenous treatment group (intravenous-intravenous), and more patients reported residual pain from 2 weeks until 1 yr (28%). Although postoperative pain measurements did not differ, postoperative epidural treatment (intravenous-epidural) was less effective to prevent residual pain at 1 yr (11%; P = 0.2 with intravenous-intravenous group) than intraoperative one (epidural-epidural and epidural-intravenous groups) (0%; P = 0.01 with intravenous-intravenous group). CONCLUSION: Combined with an antihyperalgesic dose of ketamine, intraoperative epidural analgesia provides effective preventive analgesia after major digestive surgery.

Publication Types:
PMID: 16192774 [PubMed - indexed for MEDLINE]

14: Br J Anaesth. 2006 Jan;96(1):1-4. Related Articles, Links
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Acute pain management: scientific evidence revisited.

Macintyre PE, Walker S, Power I, Schug SA.

Publication Types:
PMID: 16357114 [PubMed - in process]

15: Br J Anaesth. 2005 Nov;95(5):685-91. Epub 2005 Sep 23. Related Articles, Links
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Comparison of three different epidural solutions in off-pump cardiac surgery: pilot study.

Olivier JF, Le N, Choiniere JL, Prieto I, Basile F, Hemmerling T.

Perioperative Cardiac Research Group, Department of Anesthesiology, Hotel-Dieu, Centre Hospitalier de l'Universite de Montreal, Montreal, Quebec, Canada.

BACKGROUND: Immediate extubation using thoracic epidural analgesia (TEA) has become more popular after off-pump coronary artery bypass grafting (OPCAB). In this randomized prospective double-blind study, we present the first comparison of preoperative and postoperative haemodynamics during different regimens of TEA for immediate extubation after cardiac surgery. METHODS: Sixty patients undergoing OPCAB were enrolled in this study. TEA was installed >1 h before application of heparin at levels T2-T4. Analgesia was provided by bupivacaine 0.25%, 8 ml, 15 min before surgery and extubation, and at 10 ml h(-1) during surgery and up to 72 h afterwards using one of the following regimens: bupivacaine 0.125% alone, bupivacaine 0.125% with fentanyl 3 microg ml(-1) or bupivacaine 0.125% with clonidine 0.6 microg ml(-1). Patients were block-randomized for one of the three treatments. Pain scores and infusion rates of TEA were assessed up to 48 h after surgery. Respiratory function was assessed by Pa(o2) and Pa(o2) immediately after surgery, and haemodynamic stability was recorded in the form of heart rate and diastolic and systolic blood pressure. RESULTS: Patient characteristics, respiratory function and haemodynamic stability did not vary between the three groups. Pain control was very good and was not significantly different between the groups using similar infusion rates after surgery. Paraesthesia in dermatomes T1 or C8 occurred equally in all three groups. There was no neurological complication related to TEA in this study. CONCLUSIONS: We conclude that immediate extubation after OPCAB using TEA is feasible with different TEA regimens. Respiratory function, haemodynamic stability and pain control are not different between TEA with bupivacaine alone, bupivacaine with fentanyl or bupivacaine with clonidine.

Publication Types:
PMID: 16183682 [PubMed - indexed for MEDLINE]

16: Br J Anaesth. 2005 Nov;95(5):669-73. Epub 2005 Sep 9. Related Articles, Links
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Effects of stellate ganglion block on cerebral haemodynamics as assessed by transcranial Doppler ultrasonography.

Gupta MM, Bithal PK, Dash HH, Chaturvedi A, Mahajan RP.

Department of Neuroanaesthesiology, All India Institute of Medical Sciences, New Delhi, India.

BACKGROUND: Stellate ganglion block (SGB) causes vasodilatation in the skin of the head and neck because of regional sympathetic block. Its effects on cerebral haemodynamics, in health or in disease, are not clear. We evaluated the effects of SGB on ipsilateral middle cerebral artery flow velocity (MCAFV), estimated cerebral perfusion pressure (eCPP), zero flow pressure (ZFP), carbon dioxide reactivity (CO2R) and cerebral autoregulation using transcranial Doppler ultrasonography (TCD). METHODS: Twenty male patients, with pre-existing brachial plexus injury, and undergoing SGB for the treatment of complex regional pain syndrome of the upper limb, were studied. For SGB, 10 ml of plain lidocaine 2% was used and the onset of block was confirmed by presence of ipsilateral Horner's syndrome. The MCAFV, eCPP, ZFP, CO2R, and cerebral autoregulation were assessed before and after SGB using established TCD methods. The changes in these variables were analysed using Wilcoxon's signed rank test. RESULTS: The block caused a significant decrease in MCAFV from median (inter-quartile range) value of 61 (53, 67) to 55 (46, 60) cm s(-1), a significant increase in eCPP from 59 (51, 67) to 70 (60, 78) mm Hg, and a significant decrease in ZFP from 32 (26, 39) to 25 (16, 30) mm Hg. There were no significant changes in CO2R or cerebral autoregulation. CONCLUSION: The increase in eCPP, decrease in ZFP, and no changes in CO2R or cerebral autoregulation suggest that the SGB decreases cerebral vascular tone without affecting the capacity of the vessels to autoregulate. These effects may be of therapeutic advantage in relieving cerebral vasospasm in certain clinical settings.

PMID: 16155036 [PubMed - indexed for MEDLINE]

17: Br J Anaesth. 2005 Nov;95(5):611-5. Epub 2005 Sep 9. Related Articles, Links
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Remifentanil infusion in association with fentanyl-propofol anaesthesia in patients undergoing cardiac surgery: effects on morphine requirement and postoperative analgesia.

Rauf K, Vohra A, Fernandez-Jimenez P, O'Keeffe N, Forrest M.

Central Manchester and Manchester Children's University Hospitals NHS Trust, Department of Anaesthesia, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK.

BACKGROUND: We have prospectively assessed the effects of remifentanil on morphine requirement in the first hour after emerging from general anaesthesia after elective coronary artery bypass surgery and in the first 12 h postoperatively, and pain and agitation scores in the first hour after emerging from general anaesthesia. METHODS: Twenty patients undergoing off-pump coronary artery bypass surgery, receiving standardized propofol-fentanyl-based anaesthesia, randomly received infusions of either remifentanil 0.1 microg kg(-1) min(-1) (Group R, n=10) or saline (Group S, n=10), each infused at 0.12 ml kg(-1) h(-1). Propofol and trial drug infusion were continued into the postoperative period until the patients were ready to be woken up. Postoperative analgesia was provided with morphine infusion commenced immediately after operation, and was additionally nurse controlled on the basis of a visual analogue scale (VAS) score (0-10). Agitation score was recorded using a VAS of 0-3. RESULTS: In the first hour after discontinuing propofol and trial infusion, morphine requirements were significantly higher in the remifentanil group (8.15 (sd 3.59) mg) compared with the saline group (3.29 (2.36) mg) (P<0.01). There was no difference in the total morphine given during the period after stopping propofol or in the total requirement in the first 12 h postoperatively. There was no significant difference in either pain scores or agitation scores between the two groups. CONCLUSION: Use of remifentanil is associated with increased opioid requirement in the first hour after it has been discontinued.

Publication Types:
PMID: 16155034 [PubMed - indexed for MEDLINE]

18: Cancer. 2005 Nov 1;104(9):1894-900. Related Articles, Links
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A phase II trial of palliative radiotherapy for metastatic renal cell carcinoma.

Lee J, Hodgson D, Chow E, Bezjak A, Catton P, Tsuji D, O'Brien M, Danjoux C, Hayter C, Warde P, Gospodarowicz MK.

Department of Radiation Oncology, Princess Margaret Hospital, University of Toronto, Toronto, Ontario, Canada.

BACKGROUND: Renal cell carcinoma (RCC) has previously been described as being less responsive to radiotherapy (RT) than other tumor types. The authors conducted a prospective study to assess the effect of RT on symptoms and quality of life (QOL) in patients with metastatic RCC. METHODS: Between 1996 and 2002, patients with symptomatic metastatic RCC were entered into a prospective study in two cancer centers. Symptomatic sites of disease were treated with 30 grays (Gy) in 10 fractions. Patients reported pain, analgesic use, symptoms, and QOL using validated questionnaires before RT, 1 month and 3 months after treatment, and every 3 months to 1 year thereafter. RESULTS: Thirty-one patients (19 males and 12 females) were entered into the trial. The median age of the patients was 61 years (range, 35-81 yrs). The most common indication for RT was bone pain (n = 24). The median duration of follow-up was 4.3 months (range, 1-15 mos). Of 23 evaluable patients treated for pain, 83% (n = 19) experienced site-specific pain relief after RT, and 48% (n = 11) did not have an associated increase in analgesic medication use. The median duration of site-specific pain response was 3 months (range, 1-15 mos). The global pain response rate was only 15% (n = 3) because many patients developed other painful metastases. Global QOL was found to improve in 33% (n = 8) of the evaluable patients. CONCLUSIONS: A palliative radiotherapy dose of 30 Gy in 10 fractions can result in a significant response rate and the relief of local symptoms in patients with bone metastases from RCC. Improvements in global pain and QOL appear to be limited by the effects of progressive systemic disease. (c) 2005 American Cancer Society.

Publication Types:
PMID: 16177996 [PubMed - indexed for MEDLINE]

19: Clin J Pain. 2006 Jan-Feb;22(1 Suppl):S9-S13. Related Articles, Links
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Using pain quality assessment measures for selecting analgesic agents.

Jensen MP.

From the Department of Rehabilitation Medicine, University of Washington School of Medicine, and Multidisciplinary Pain Center, University of Washington Medical Center, Seattle, WA.

Although those in the field of pain management have long recognized the multidimensional character of pain, global pain intensity remains the most frequently assessed domain measured in clinical trials of pain treatments. However, a number of specific pain qualities have been shown to be associated with neuropathic versus nociceptive pain and, as such, can be used for diagnostic purposes. In addition, preliminary evidence suggests that pain quality measures may be helpful for measuring outcomes in clinical trials. A number of such measures are currently available, each with its strengths and weaknesses. These measures are reviewed, and potential future uses of these tools are discussed.

PMID: 16344610 [PubMed - in process]

20: Clin J Pain. 2006 Jan-Feb;22(1 Suppl):S2-8. Related Articles, Links
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Management of Neuropathic Pain: Translating Mechanistic Advances and Evidence-based Research Into Clinical Practice.

Gallagher RM.

From the Veterans Affairs Medical Center and Departments of Psychiatry and Anesthesiology, University of Pennsylvania, Philadelphia, PA.

The concept of rational polypharmacy is now well established in the field of pain management. This concept has evolved in concert with progress in understanding the pathophysiologic mechanisms of pain diseases and disorders and how medications affect these processes. Other clinical factors must be considered in formulating the pain management strategy most likely to succeed in both controlling pain and improving function in a given patient. This article will review how pain diagnosis, pain mechanisms, pain phenomenology, medication efficacy, and risk profile influence medication selection in pain medicine practice, with a selective focus on the treatment of neuropathic pain. In addition, the role of psychosocial factors as they affect pain management will be discussed.

PMID: 16344609 [PubMed - in process]

21: Clin J Pain. 2006 Jan-Feb;22(1 Suppl):S1. Related Articles, Links
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Analgesic Selection in the Management of Chronic Pain: Linking Mechanisms & Evidence-based Research to Clinical Practice.

Gallagher RM.

From the Veterans Affairs Medical Center and Departments of Psychiatry and Anesthesiology, University of Pennsylvania, Philadelphia, PA.

PMID: 16344608 [PubMed - in process]

22: Clin J Pain. 2006 Jan;22(1):109-110. Related Articles, Links
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Basal Blood Flow in Complex Regional Pain Syndrome Does Not Necessarily Indicate Vasoconstrictor Nerve Activity.

Toda K, Muneshige H, Asou T, Harada T, Okazaki M, Tachiki N, Horie N, Cheng W, Nakamura S.

From the *Department of Rehabilitation, Hiroshima University Hospital, Hiroshima, Japan; and daggerThird Department of Internal Medicine, Hiroshima University School of Medicine, Hiroshima, Japan.

OBJECTIVES:: To quantitatively investigate simultaneous skin blood flow and sweating in a patient with complex regional pain syndrome. METHOD:: Using one probe, skin blood flow and sweating were measured on the affected and non-affected sides at baseline and after activation of sympathetic system in a 47-year-old woman with complex regional pain syndrome type I of the left hand. RESULTS:: Basal sweating, sympathetic sweat response, basal blood flow, sympathetic flow response, and attrition rate of blood flow (the ratio of sympathetic flow response to basal blood flow) of the affected side were greater than those on the non-affected side. CONCLUSIONS:: Although sympathetic nerve activity (sympathetic flow response) appeared greater on one side, basal blood flow was also greater on that side. These contradictory results suggest that some factor or factors increase basal blood flow despite a higher sympathetic nerve tone on the side. Comparing basal blood flow on one side to the contralateral side does not necessarily indicate lesser vasoconstrictor nerve activity on that side. Advantages of simultaneous measurement of skin blood flow and sweating with a single probe may make the method useful.

PMID: 16340600 [PubMed - as supplied by publisher]

23: Clin J Pain. 2006 Jan;22(1):97-103. Related Articles, Links
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The Validity of the Neuropathic Pain Scale for Assessing Diabetic Neuropathic Pain in a Clinical Trial.

Jensen MP, Friedman M, Bonzo D, Richards P.

From the *Department of Rehabilitation Medicine, University of Washington School of Medicine and Multidisciplinary Pain Center, Seattle, WA; and daggerPurdue Pharma L.P., Stamford, CT.

OBJECTIVES:: In controlled trials of analgesics for the treatment of neuropathic pain, the primary outcome variable is most often a measure of global pain intensity. However, because neuropathic pain is associated with a variety of pain sensations, the effects of analgesic treatments on different sensations could go undetected if specific pain qualities are not assessed. This study sought to evaluate the utility of assessing the multiple components of neuropathic pain in an analgesic clinical trial. METHODS:: One hundred fifty-nine subjects with diabetes-related foot pain were randomly assigned to receive an active analgesic (controlled-release oxycodone) or matching placebo for 6 weeks. A multidimensional measure of neuropathic pain, the Neuropathic Pain Scale (NPS), was administered before, during, and after study treatment. RESULTS:: Relative to placebo, the opioid analgesic produced statistically significantly greater decreases in global pain intensity, pain unpleasantness, and sharp, dull, and deep pain sensations. Responder analyses indicated a higher rate of responding to the opioid condition, relative to placebo, for intense, unpleasant, deep, and surface pain. The opioid analgesic did not significantly reduce hot, cold, itchy, or sensitive pain sensations compared with placebo in either analysis. CONCLUSIONS:: These findings support the utility of the NPS for characterizing the multidimensional nature of the neuropathic pain experience and for detecting changes in neuropathic pain with treatment.

PMID: 16340598 [PubMed - as supplied by publisher]

24: Clin J Pain. 2006 Jan;22(1):90-96. Related Articles, Links
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The Effect of Small Doses of Botulinum Toxin A on Neck-Shoulder Myofascial Pain Syndrome: A Double-Blind, Randomized, and Controlled Crossover Trial.

Ojala T, Arokoski JP, Partanen J.

From the *Department of Clinical Neurophysiology, Kuopio University Hospital, Kuopio, Finland, and daggerDepartment of Physical and Rehabilitation Medicine, Kuopio University Hospital, Kuopio, Finland.

OBJECTIVES:: Myofascial pain syndrome is a common cause of muscular pain in the shoulder-neck region. Injections of large amounts of botulinum toxin A have been found to be beneficial for the alleviation of myofascial pain, but large doses of this toxin may cause paresis of the muscle and other adverse events. The aim of this work was to determine the effect of small doses (5 U) of botulinum toxin A (BTA) injected directly into the painful trigger points of the muscles, using a double-blind crossover technique. METHODS:: On the basis of the empirical criteria proposed for diagnosis of myofascial pain syndrome, 31 patients suffering from myofascial pain in the neck-shoulder region were studied. The patients received either botulinum toxin A or physiological saline injections on 2 occasions 4 weeks apart. The total dose varied from 15 to 35 U of botulinum toxin A [28 +/- 6 U (mean +/- SD)]. The follow-up measurements were carried out at 4 weeks after each treatment. Neck pain and result of treatment were assessed with questionnaires. The pressure pain threshold was determined using a dolorimeter. RESULTS:: Neck pain values decreased from 4.3 +/- 2.4 to 3.3 +/- 2.0 after saline injections and from 4.1 +/- 2.1 to 3.3 +/- 2.2 after botulinum toxin A. The pressure pain threshold values increased from 5.2 +/- 1.6 to 5.9 +/- 1.5 and from 5.7 +/- 1.6 to 5.9 +/- 1.6 after injections with saline and botulinum toxin A, respectively. No statistically significant changes in the neck pain and pressure pain threshold values occurred between the botulinum toxin A and saline groups. After the first injections, the subjective result of treatment was significantly (P = 0.008) in favor of botulinum toxin A, and after the second injections, the subjective result was better for saline, but the difference was not statistically significant (P = 0.098). There was no significant difference in the prevalence of side effects between saline and botulinum toxin A. CONCLUSIONS:: Our study shows that there was no difference between the effect of small doses of botulinum toxin A and those of physiological saline in the treatment of myofascial pain syndrome.

PMID: 16340597 [PubMed - as supplied by publisher]

25: Clin J Pain. 2006 Jan;22(1):82-89. Related Articles, Links
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Tunneled Epidural Catheter Infections in Noncancer Pain: Increased Risk in Patients With Neuropathic Pain/Complex Regional Pain Syndrome.

Hayek SM, Paige B, Girgis G, Kapural L, Fattouh M, Xu M, Stanton-Hicks M, Mekhail NA.

From the *Department of Pain Management, The Cleveland Clinic Foundation, Cleveland, OH, and the daggerDepartment of Biostatistics, The Cleveland Clinic Foundation, Cleveland, OH.

BACKGROUND AND OBJECTIVE:: Tunneled epidural catheters are often used to control pain and facilitate rehabilitation in patients with regional pain syndromes. A cohort retrospective study design was undertaken to evaluate the risk of catheter-related infection in patients who underwent a TEC placement to manage their chronic noncancer regional pain over a 5-year period. METHODS:: There were 260 tunneled epidural catheters placed in 218 patients accounting for a total of 10,985 catheter-days. Of these, 230 catheters were placed in patients with neuropathic pain (90% of whom had complex regional pain syndrome) and 30 catheters in patients with somatic pain. RESULTS:: There were 24 epidural space infections in symptomatic patients, 23 of whom were in the neuropathic pain group-22 had complex regional pain syndrome. Additionally, tunneled epidural catheters had to be discontinued in 34 patients because of superficial infection or suspicion of infection; 33 of these were in the neuropathic pain group. The differences in the infection rates were significantly higher in the neuropathic pain group compared to the somatic group. When analyzed to an infection index per 1000 catheter-days, the rate of infection rate was 5.51 for the patients with neuropathic pain and 2.43 for the patients with somatic pain. The rates for deep and superficial infections were 2.26 and 3.25, respectively, per 1000 catheter-days for the neuropathic pain group compared to 1.22 for both deep and superficial infections in the patients with somatic pain. There were 6 frank epidural abscesses upon contrast-enhanced magnetic resonance imaging examinations of the spine, 1 epidural phlegmon and 2 patients displayed mild or questionable epidural enhancement on magnetic resonance imaging, suggestive of epidural inflammation. All these magnetic resonance imaging abnormalities were detected in patients with complex regional pain syndrome. Two of the patients with epidural abscesses underwent surgical exploration and drainage of the epidural abscess, though no neurologic deficits were observed in any of the patients. CONCLUSIONS:: The higher risk of tunneled epidural catheter infection observed in patients with neuropathic pain (particularly complex regional pain syndrome) warrants further study.

PMID: 16340596 [PubMed - as supplied by publisher]

26: Clin J Pain. 2006 Jan;22(1):67-81. Related Articles, Links
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Electronic Momentary Assessment in Chronic Pain II: Pain and Psychological Pain Responses as Predictors of Pain Disability.

Sorbi MJ, Peters ML, Kruise DA, Maas CJ, Kerssens JJ, Verhaak PF, Bensing JM.

From the *Department of Health Psychology, Utrecht University, Utrecht, The Netherlands, daggerDepartment of Medical, Clinical and Experimental Psychology, University of Maastricht, Maastricht, The Netherlands, double daggerDepartment of Methodology and Statistics, Utrecht University, Utrecht, The Netherlands, and section signNetherlands Institute of Primary Health Care, Utrecht, The Netherlands.

OBJECTIVES AND METHODS:: More than 7100 electronic diaries from 80 patients with chronic pain (mean: 89.3, range 30-115) entered multilevel analyses to establish the statistical prediction of disability by pain intensity and by psychological functioning (fear avoidance, cognitive, and spousal pain responses). We also tested the differences between prechronic, recently chronic, and persistently chronic pain in the prediction of disability (impaired physical and mental capacity, pain interference with activities, immobility due to pain). RESULTS:: Pain intensity explained 8% to 19% of the disability variance. Beyond this psychological functioning explained 7% to 16%: particularly fear-avoidance and cognitive pain responses predicted chronic pain disorder disability; spousal responses predicted immobility better than other aspects of disability. Immobility due to actual pain occurred infrequently. When it did, however, it was better predicted by avoidance behavior in the patient and by spousal discouragement of movement than by actual pain intensity. The prediction of immobility due to pain by, respectively, avoidance behavior and catastrophizing was better in chronic pain (>6 months) and that of physical impairment by catastrophizing better in persistently chronic pain (>12 months) than in pain of shorter duration. DISCUSSION:: The psychological prediction of chronic pain disorder disability was determined beyond that accounted for by pain intensity. Nonetheless, psychological functioning explained substantial variance in chronic pain disorder disability. The psychological prediction of immobility and physical impairment was stronger with longer pain duration. Patient characteristics and momentary states of disability-and in particular of immobility-should be carefully distinguished and accounted for in chronic pain disorder.

PMID: 16340595 [PubMed - as supplied by publisher]

27: Clin J Pain. 2006 Jan;22(1):55-66. Related Articles, Links
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Electronic Momentary Assessment in Chronic Pain I: Psychological Pain Responses as Predictors of Pain Intensity.

Sorbi MJ, Peters ML, Kruise DA, Maas CJ, Kerssens JJ, Verhaak PF, Bensing JM.

From the *Department of Health Psychology, Utrecht University, Utrecht, The Netherlands, daggerDepartment of Medical, Clinical and Experimental Psychology, University of Maastricht, Maastricht, The Netherlands, double daggerDepartment of Methodology and Statistics, Utrecht University, Utrecht, The Netherlands, and section signNetherlands Institute of Primary Health Care, Utrecht, The Netherlands.

OBJECTIVES AND METHODS:: Electronic momentary assessment was employed to substantiate the relevance of psychological functioning in chronic pain. More than 7100 electronic diaries from 80 patients with varying IASP classified types of chronic pain served to investigate to what extent fear-avoidance, cognitive and spousal solicitous and punishing pain responses explained fluctuations in pain intensity and whether patients with pre-chronic, recently chronic and persistently chronic pain differed in this regard. RESULTS:: Psychological pain responses explained 40% of the total variance in pain intensity: almost 24% concerned pain variance that occurred between the CPD patients and 16% pertained to pain variance due to momentary differences within these patients. Separately tested fear-avoidance and cognitive responses each explained about 28% of the total pain variance, while spousal responses explained 9%. Catastrophizing emerged as the strongest pain predictor, followed by pain-related fear and bodily vigilance. Results did not differ with the duration of chronicity. DISCUSSION:: Exaggerated negative interpretations of pain, and fear that movement will induce or increase pain strongly predicted CPD pain intensity. Spousal responses-assessed only when the spouse was with the patient who at that moment was in actual pain-may more strongly affect immobility due to pain than pain intensity per se (see part II of the study). The findings substantiate the importance of catastrophizing, fear and vigilance identified primarily in low back pain and extend this to other forms of chronic pain. The compelling evidence of momentary within-patients differences underscores that these must be accounted for in chronic pain research and practice.

PMID: 16340594 [PubMed - as supplied by publisher]

28: Clin J Pain. 2006 Jan;22(1):45-54. Related Articles, Links
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Fear-Avoidance Beliefs, Disability, and Participation in Workers and Nonworkers With Acute Low Back Pain.

Swinkels-Meewisse IE, Roelofs J, Verbeek AL, Oostendorp RA, Vlaeyen JW.

From the *Practice of Physical Therapy and Manual Therapy, Eindhoven, The Netherlands, daggerFaculty of Medicine and Pharmacology, Postgraduate Education Manual Therapy, Free University Brussels, Brussels, Belgium, double daggerDepartment of Medical, Clinical, and Experimental Psychology, University of Maastricht, Maastricht, The Netherlands, section signDepartment of Epidemiology and Biostatistics, University Medical Centre St. Radboud, Nijmegen, The Netherlands, parallelCentre for Quality of Care Research, University Medical Centre St. Radboud, Nijmegen, The Netherlands, paragraph signDutch Institute of Allied Health Care, Amersfoort, The Netherlands, and #Institute for Rehabilitation Research, Hoensbroek, The Netherlands. This research was partially supported by the Royal Dutch Physical Therapists Association. The Netherlands Organization for Health Research and Development (ZonMw) supported participation of Dr. J. Vlaeyen with grant # gou-65-ogo.

OBJECTIVES:: Fear-avoidance beliefs have been shown to be associated with disability and work status in patients with low back pain. Especially in acute low back pain, much research is needed to increase the knowledge concerning the role of fear-avoidance beliefs and its associated avoidance behavior in the influence on disability and the participation in daily and social life activities. The Fear-Avoidance Beliefs Questionnaire is developed to measure such beliefs and has become increasingly popular for use in primary care practice. The aim of the current study was: 1) to investigate the factor structure of the Fear-Avoidance Beliefs Questionnaire in a population of patients with acute low back pain by means of confirmatory factor analysis; 2) to examine the relationship between fear-avoidance beliefs and perceived disability, as well as participation in daily and social life; and 3) to investigate whether perceived disability mediates the association between pain and participation and between fear-avoidance beliefs and participation. METHODS:: The study has a cross-sectional design and was performed on a sample of 615 patients with acute low back pain in primary care settings in The Netherlands. Patients completed a visual analogue scale for pain, the Roland Disability Questionnaire, the Fear-Avoidance Beliefs Questionnaire, a sociodemographic questionnaire, and 5 participation items. RESULTS:: Confirmatory factor analysis corroborated the 2-factor structure of the Fear-Avoidance Beliefs Questionnaire as found by Waddell et al. Investigation of the association between fear-avoidance beliefs and perceived disability or participation was performed for workers and nonworkers separately. The 2 subscales of the Fear-Avoidance Beliefs Questionnaire were significantly associated with perceived disability and participation, although there were differences between the samples. Perceived disability was significantly predicted by pain intensity and fear-avoidance beliefs. Perceived disability significantly predicted participation, and finally, the mediational role of perceived disability was supported. DISCUSSION:: In the early stage of low back pain, the reduction of pain and fear-avoidance beliefs might increase the level of activity, which might foster increased participation in daily and social life activities.

PMID: 16340593 [PubMed - as supplied by publisher]

29: Clin J Pain. 2006 Jan;22(1):37-44. Related Articles, Links
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Hypoalgesia in the Referred Pain Areas After Bilateral Injections of Hypertonic Saline Into the Trapezius Muscles of Men and Women: A Potential Experimental Model of Gender-Specific Differences.

Ge HY, Madeleine P, Cairns BE, Arendt-Nielsen L.

From the *Laboratory For Experimental Pain Research, Center For Sensory-Motor Interaction (SMI), Aalborg University, Aalborg, Denmark, and daggerDepartment of Anesthesia, Harvard Medical School/Children's Hospital, John F. Enders Pediatric Research Laboratories, Boston, MA.

OBJECTIVE:: The study was to assess the local pain intensity, referred pain patterns, and changes in the pressure pain thresholds of the local and referred pain areas following bilateral injections of hypertonic saline into trapezius muscles and to delineate gender differences in pain profile and the possible modulation of pressure pain thresholds. METHODS:: Fifteen healthy men and women each participated. Pain intensity and areas were assessed after bilateral injections. The pressure pain thresholds in the trapezius and posterolateral neck muscles (referred pain areas) were measured before and 7.5 and 15 minutes postinjection. RESULTS:: The time to maximal pain intensity was significantly shorter after the second injection than after the first injection. Patients exhibited a bilaterally symmetrical distribution of pain areas that included the neck to shoulder angle and the posterolateral neck. Bilateral injections significantly elevated pressure pain thresholds in the right and left posterolateral neck muscles 7.5 and 15 minutes postinjection. In men but not women, the pressure pain thresholds measured in the posterolateral neck muscles 7.5 and 15 minutes after the second injection were higher than those after the first injection and also higher than those after the second injection in women, men tolerated more pressure than women at all time points. DISCUSSION:: These findings indicate that both excitatory and inhibitory mechanisms modulate pain response characteristics in bilateral neck-shoulder pain conditions and suggest that there may be a more potent inhibitory control mechanism in men than women. This experimental model may be potentially used to detect gender differences in descending inhibition.

PMID: 16340592 [PubMed - as supplied by publisher]

30: Clin J Pain. 2006 Jan;22(1):25-31. Related Articles, Links
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Clinically Significant Change in Pain Intensity Ratings in Persons With Spinal Cord Injury or Amputation.

Hanley MA, Jensen MP, Ehde DM, Robinson LR, Cardenas DD, Turner JA, Smith DG.

From the *Department of Rehabilitation Medicine, University of Washington School of Medicine, Seattle, WA, daggerMultidisciplinary Pain Center, University of Washington Medical Center-Roosevelt, Seattle, WA, double daggerDepartment Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, and section signOrthopaedic Surgery and Sports Medicine, University of Washington School of Medicine, Seattle, WA.

OBJECTIVE:: To examine the clinical significance of changes in chronic pain in 2 disability groups: spinal cord injury and lower limb amputation. METHODS:: A reanalysis of 2 controlled clinical trials for pain in persons with disabilities. Eighty-two persons with spinal cord injuries and 34 persons with amputations provided pretreatment and posttreatment ratings of pain intensity on 0 to 10 numerical rating scales. After treatment, participants also rated the meaningfulness of any changes in pain they experienced. RESULTS:: An average decrease of 1.80 points on the 0 to 10 numerical rating scales and percent decreases of about 36% corresponded to reports of a meaningful change in pain. There was no significant difference between samples, and also no differences due to gender or treatment condition. Age and pretreatment pain, however, were associated with the amount of pain decrease rated as meaningful. The change in pain intensity rated as meaningful was greater for older participants and participants with higher levels of pretreatment pain. Consistent with previous research, percent change scores were less biased by pretreatment pain than were absolute change scores. DISCUSSION:: These findings are generally consistent with similar findings in other pain populations, and, in light of previous research, support an approximate 33% decrease in pain as a reasonable standard for meaningful change across chronic pain conditions. Percent change scores may be more useful for comparing the effects of pain treatments across samples or conditions because they are less biased by pretreatment pain level.

PMID: 16340590 [PubMed - as supplied by publisher]

31: Clin J Pain. 2006 Jan;22(1):19-24. Related Articles, Links
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Men With Pelvic Pain: Perceived Helpfulness of Medical and Self-Management Strategies.

Turner JA, Ciol MA, Korff MV, Liu YW, Berger R.

From the *Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, daggerDepartment of Rehabilitation Medicine, University of Washington School of Medicine, Seattle, WA, double daggerCenter for Health Studies, Group Health Cooperative of Puget Sound, Seattle, WA, and section signDepartment of Urology, University of Washington School of Medicine, Seattle, WA.

OBJECTIVE:: To assess the frequency of use of different treatments and pain management strategies and their perceived helpfulness in male patients with pelvic pain. METHODS:: Approximately 1 month after a health maintenance oganization visit for pelvic pain, 286 men (mean age 46.7 years) completed telephone interviews about their symptoms and treatments and pain management strategies used in the past year. Participants rated the helpfulness of each treatment and strategy used on 0 to 10 scales. RESULTS:: Even though men with identified bacterial etiology were excluded from the study, antibiotic medication was the most commonly reported treatment (67% of patients) and rated as the second most helpful treatment [mean (SD) = 6.3 (3.6)]. Opiates were rated as the most helpful treatment on average [mean (SD) = 7.9 (2.1)], but were used by only 12% of patients. Substantial minorities of patients reported several behaviors as helpful, including urinating (reported as helpful by 26%), taking warm baths (23%), and drinking water (23%), although patterns of effects differed for men with versus without urinary symptoms. Activities most commonly reported as worsening symptoms were sitting (42%), walking/jogging (27%), and sexual activity (25%). DISCUSSION:: Patients with male pelvic pain syndrome are commonly prescribed antibiotics, which they perceive as moderately helpful, despite the lack of scientific evidence of efficacy. Clinicians may find it useful to support patient use of safe, inexpensive, self-management approaches, especially warm baths, increased water intake, and avoidance of prolonged sitting.

PMID: 16340589 [PubMed - as supplied by publisher]

32: Clin J Pain. 2006 Jan;22(1):10-18. Related Articles, Links
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Personality and Pain-Related Beliefs/Coping Strategies: A Prospective Study.

Asghari A, Nicholas MK.

From the *Department of Psychology, University of Shahed, Tehran, Iran; and daggerPain Management and Research Centre, University of Sydney, Royal North Shore Hospital, St. Leonards, Australia.

The ways in which people adjust to chronic pain has been partly attributed to pre-existing personality traits, but most evidence to date is from cross-sectional studies and mainly with arthritis groups. The present study examined the effects of 5 personality dimensions on measures of pain-related beliefs and catastrophizing assessed 9 months apart with a heterogeneous chronic pain sample. METHOD:: One hundred forty-five patients with chronic pain presenting to a hospital pain center completed the NEO-Personality Inventory-Revised, 3 measures of pain related beliefs, the Catastrophizing scale of the Coping Strategy Questionnaire, and a 0 to 10 pain scale. Nine months from the initial assessment, patients completed the same measures, apart from the NEO-Personality Inventory-Revised. RESULTS:: Of the 5 personality dimensions studied, only neuroticism was related to the pain-related variables. Multiple hierarchical regression analyses revealed that neuroticism was a significant predictor of residualized change in pain self-efficacy beliefs and pain control appraisals over the time of the study, after controlling for initial values of both constructs. However, the effects were small, suggesting that other factors play a role in the determination of such beliefs, in addition to neuroticism. In contrast, neuroticism was not a significant predictor of residualized change in catastrophizing responses over the same period. The findings provide partial support for the hypothesis that pre-existing personality traits place some patients at risk for poor adjustment to chronic pain.

PMID: 16340588 [PubMed - as supplied by publisher]

33: Clin J Pain. 2006 Jan;22(1):1-9. Related Articles, Links
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Psychometric Properties of the Mood and Anxiety Symptom Questionnaire in Patients With Chronic Pain.

Geisser ME, Cano A, Foran H.

From *The Spine Program, Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI; daggerDepartment of Psychology, Wayne State University, Detroit, MI; and double daggerDepartment of Psychology, Eastern Michigan University, Ypsilanti, MI.

OBJECTIVE:: Previous studies have demonstrated that the Mood and Anxiety Symptom Questionnaire is able to discriminate between depressive and anxious symptoms. Factor analysis of the scale has revealed 3 factors: general distress, positive affect, and physiological hyperarousal. However, the properties of the Mood and Anxiety Symptom Questionnaire have not been extensively examined in medical populations, in which the measurement of depressive and anxious symptoms is complicated by the presence of comorbid physical symptoms such as pain. Therefore, the purpose of the present study was to evaluate the psychometric properties of the Mood and Anxiety Symptom Questionnaire in patients with chronic pain. MATERIALS AND METHODS:: A total of 230 persons with chronic musculoskeletal pain were recruited from a multidisciplinary pain clinic (n = 110) and a large urban community (n = 120). Participants completed the Mood and Anxiety Symptom Questionnaire and were interviewed for the presence of depressive disorders using the Structured Clinical Interview for the DSM-IV. Factor analyses, scale reliability analyses, and discriminative function analyses were performed on the data. RESULTS:: Utilizing principal factor analysis and orthogonal rotation, the factor structure of the Mood and Anxiety Symptom Questionnaire in both chronic pain samples was similar to previously reported factor analyses. Three factors emerged: positive affect, general distress, and physiological hyperarousal. Coefficients of congruence calculated from the factor structures of each subsample of persons with chronic pain suggested that the factors were highly similar (0.83-0.93). Given that the factor structures were comparable in both populations, a final analysis was conducted on the entire sample. Again, this analysis revealed a 3-factor solution. Examination of the factor loadings and item-to-total correlations revealed that some of the original scale items failed to load on or correlate with a specific factor, or correlated highly with 2 or more factors (thus lacking discriminatory power). A revised scale, eliminating items with low factors loadings and/or high cross loadings, was examined. Reliabilities for the subscales were high, and the subscales demonstrated the ability to predict clinical diagnoses of depression in a hypothesized fashion. DISCUSSION:: The results support the utility of the Mood and Anxiety Symptom Questionnaire with samples of patients with chronic pain and provide further support for the tripartite model of anxiety and depression.

PMID: 16340587 [PubMed - as supplied by publisher]

34: Curr Treat Options Neurol. 2006 Jan;8(1):69-79. Related Articles, Links
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Treatment of chronic facial pain.

Lincoff NS.

Jacobs Neurologic Institute, 100 High Street, Buffalo, NY 14203, USA. lincoff@acsu.buffalo.edu.

Facial pain occurs because of damage to the fifth cranial nerve anywhere along its course from its terminal subcutaneous craniofacial branches to the brainstem. Although topical agents may be effective in relieving pain caused by subcutaneous branch damage, systemic oral agents are usually needed to alter or correct deeper trigeminal nociceptive pain caused by damage to the trigeminal nerve further along its course. Antidepressive agents with anti-nociceptive properties, anticonvulsants, and anti-inflammatory agents are most commonly used. Newer agents are beginning to replace the commonly used first-line medications. Combination therapy is popular because it maximizes the effect of each drug while reducing the side effects seen in higher-dose monotherapy. Treatment of secondary clinical depression is very important in the management of patients with facial pain, explaining the beneficial dual role of antidepressants in this condition. Alternative and holistic approaches are also popular, but most are not confirmed by controlled studies at the present time.

PMID: 16343362 [PubMed - in process]

35: Eur J Anaesthesiol. 2005 Oct;22(10):804-5. Related Articles, Links

Comment on:
Intraperitoneal tramadol and buvacaine in total abdominal hysterectomy.

Memis D, Turan A, Karamanlioglu B.

Publication Types:
PMID: 16211788 [PubMed - indexed for MEDLINE]

36: Eur J Anaesthesiol. 2005 Oct;22(10):802-4. Related Articles, Links

Comment on:
General anaesthesia for a super obese patient.

Leykin Y, Pellis T, Albano G, Zannier G.

Publication Types:
PMID: 16211787 [PubMed - indexed for MEDLINE]

37: Eur J Pain. 2005 Dec 7; [Epub ahead of print] Related Articles, Links
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On the relation between sensory deafferentation, pain and thalamic activity in Wallenberg's syndrome: A PET-scan study before and after motor cortex stimulation.

Garcia-Larrea L, Maarrawi J, Peyron R, Costes N, Mertens P, Magnin M, Laurent B.

INSERM E342, Central Integration of Human Pain, Hopital Neurologique, 59 Bd Pinel, 69003 Lyon, France; Universite Claude Bernard Lyon1, France.

Decrease of thalamic blood flow contralateral to neuropathic pain has been described by several groups, but its relation with sensory deafferentation remains unclear. Here we report one instance where the thalamic effects of sensory deafferentation could be dissociated from those of neuropathic pain. A 50-year-old patient underwent a left medullary infarct leading to right-sided thermal and pain hypaesthesia up to the third right trigeminal division, as well as in the left face. During the following months the patient developed neuropathic pain limited to the left side of the face. Although the territory with sensory loss was much wider in the right (non painful) than in the left (painful) side of the body, PET-scan demonstrated significant reduction of blood flow in the right thalamus (contralateral to the small painful area) relative to its homologous region. After 3 months of right motor cortex stimulation the patient reported 60% relief of his left facial pain, and a new PET-scan showed correction of the thalamic asymmetry. We conclude that thalamic PET-scan hypoactivity contralateral to neuropathic pain does not merely reflect deafferentation, but appears related to the pain pathophysiology, and may be normalized in parallel with pain relief. The possible mechanisms linking thalamic hypoactivity and pain are discussed in relation with findings in epileptic patients, possible compensation phenomena and bursting thalamic discharges described in animals and humans. Restoration of thalamic activity in neuropathic pain might represent one important condition to obtain successful relief by analgesic procedures, including cortical neurostimulation.

PMID: 16338151 [PubMed - as supplied by publisher]

38: Eur J Pain. 2005 Dec 3; [Epub ahead of print] Related Articles, Links
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Efficacy of mu-opioid agonists in the treatment of evoked neuropathic pain: Systematic review of randomized controlled trials.

Eisenberg E, McNicol ED, Carr DB.

Pain Relief Unit, Rambam Medical Center, Haifa Pain Research Group, the Technion-Israel Institute of Technology, P.O. Box 9602, Haifa 31096, Israel.

Several reviews of randomized controlled trials (RCTs) have shown the efficacy of mu-opioids in reducing spontaneous neuropathic pain (NP). However, relatively little is known about their specific efficacy for evoked pain, which is a significant problem for many patients with NP. The present systematic review assesses the efficacy of opioid agonists for the treatment of evoked NP based upon published RCTs. We searched articles in any language using the MEDLINE database (1966 to December 2004), the Cochrane Central Register of Controlled Trials (4th quarter, 2004) and the reference lists of retrieved papers, employing search terms for RCTs, opioids and NP. Only RCTs in which opioid agonists were given to treat NP of any etiology, and evoked pain was assessed were included. Data were extracted by two independent investigators. Nine articles met inclusion criteria and were classified as short-term (less than 24h; n=7) or intermediate-term trials (4 weeks; n=2). Although the scarcity of retrieved data precluded formal meta-analysis of short-term trials, we found that the intensity of dynamic mechanical allodynia was significantly attenuated by opioids relative to placebo in all studies. In contrast, no consistent effects on the magnitude of static allodynia, the threshold for mechanical allodynia or the threshold or magnitude of heat allodynia were found. The threshold and magnitude of cold-induced allodynia generally responded positively to opioid treatments in patients with peripheral pain syndromes, but not central pain syndromes. Evoked pain was studied in only two intermediate-term trials, in both of which oxycodone was significantly superior to placebo. The results of the two trials were combinable for a meta-analysis that showed an overall 24 points difference in endpoint pain intensities between patients given opioids and those treated with placebo (95% CI -33 to -15; p<0.00001). In conclusion: short-term studies show that opioids can reduce the intensity of dynamic mechanical allodynia and perhaps of cold allodynia in peripheral NP. Insufficient evidence precludes drawing conclusions regarding the effect of opioids on other forms of evoked NP. A meta-analysis of intermediate-term studies demonstrates the efficacy of opioids over placebo for evoked NP. These findings are clinically relevant because dynamic mechanical allodynia and cold allodynia are the most prevalent types of evoked pain in NP.

PMID: 16337151 [PubMed - as supplied by publisher]

39: Eur J Pain. 2005 Dec 3; [Epub ahead of print] Related Articles, Links
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Repeatability of autonomic responses to pain anticipation and pain stimulation.

Colloca L, Benedetti F, Pollo A.

Department of Neuroscience, Clinical and Applied Physiology Program, University of Turin Medical School, Corso Raffaello 30, 10125 Turin, Italy.

In this study we address the problem of the repeatability of autonomic responses in the experimental setting. In healthy volunteers, we measured the heart rate (HR) response to pain anticipation and to pain elicited with galvanic stimulation. After evaluation of pain threshold (T), all subjects underwent the same experimental protocol, whereby a painful stimulus at 1.5T was delivered on the forehead following a warning, while the ECG was continuously recorded. The procedure was repeated three times across a three-week period. The parameters recorded included pain threshold, pain rating, HR response to pain anticipation and HR response to pain. We found a high correlation among the three sessions for all parameters, indicating that, as occurs for pain threshold and pain rating, individual differences in autonomic responses can be reliably reproduced as well, even though significant habituation develops.

PMID: 16337150 [PubMed - as supplied by publisher]

40: Eur J Pain. 2005 Oct;9(5):599-611. Related Articles, Links
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Interaction of mu-opioid receptor agonists and antagonists with the analgesic effect of buprenorphine in mice.

Kogel B, Christoph T, Strassburger W, Friderichs E.

Department of Pharmacology, Biomedical Research, Grunenthal GmbH, Zieglerstr. 6, 52099 Aachen, Germany.

Buprenorphine is a potent opioid analgesic with partial agonistic properties at mu-opioid receptors. This study investigated the interaction potential with several full mu-agonists in the tail-flick test in mice. We further examined the reversibility of buprenorphine antinociception by different mu-opioid receptor antagonists. Combination of buprenorphine with morphine, oxycodone, hydromorphone and fentanyl in the analgesic dose range resulted in additive or synergistic effects. When given after the decline of the acute buprenorphine effect, both morphine and fentanyl also showed full efficacy. A moderate antagonistic effect according to the partial mu-agonistic properties of buprenorphine was only seen when high doses exceeding the therapeutic dose ranges were combined. Under these conditions antinociception of morphine was reduced to the effect of buprenorphine alone. Prophylactic administration of naloxone (10 mg/kg i.v.), naltrexone (1 mg/kg i.v.) and clocinnamox (5 mg/kg s.c.) fully and persistently blocked the antinociception of a high dose of buprenorphine. An established effect of buprenorphine was less sensitive, although repeated administration of naloxone induced complete antagonism, as did the irreversible antagonist clocinnamox under prophylactic and curative treatment conditions. Our results suggest that the antinociceptive effect of buprenorphine is mainly, if not exclusively, mediated by activation of mu-opioid receptors. They confirm clinical experience that in the analgesic dose range a switch between buprenorphine and full mu-agonists is possible without loss of analgesic efficacy and without a refractory period between the termination of buprenorphine analgesia and the onset of action of the new mu-opioid treatment. Antinociception of buprenorphine is sensitive towards mu-opioid receptor antagonists and incomplete inhibition can be improved by increasing the dose or repetitive dosing.

PMID: 16139189 [PubMed - indexed for MEDLINE]

41: Eur J Pain. 2005 Oct;9(5):571-9. Epub 2005 Jan 20. Related Articles, Links
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Opioid switch in palliative care, opioid choice by clinical need and opioid availability.

Muller-Busch HC, Lindena G, Tietze K, Woskanjan S.

PalliativZentrum Berlin-Brandenburg, D-10557 Berlin, Germany. muebu@havelhoehe.de

Availability of different WHO-step 3 opioids has encouraged the discussion on their value and led to the concepts of opioid rotation. Rotation is suggested, when other measures fail to achieve optimal analgesia and tolerability in cancer pain treatment. Opioid use was assessed in a prospective cohort study of 412 palliative care patients from 14 inpatient and outpatient palliative care facilities in Germany. The most frequently used opioids at baseline were morphine and fentanyl. The most frequent changes in medication (N=106) occurred from oral to parenteral morphine. Only in 49 cases true switches to other long acting opioids were recorded. This is far less than expected from other reports. True switches and adverse side effects were found to occur more frequently in inpatients, while efficacy problems were more frequently recorded in outpatients. There was no correlation between the opioid used at baseline and switch frequency, but numbers of cases receiving other opioids than fentanyl or morphine were low. Reasons for and frequencies of changes in medication were found to be largely shaped by the setting reflecting patients' needs and clinical necessities. Recommendation of first line therapy and availability of opioid formulations define the frequency of opioid use. This impedes evaluation of specific differences between the opioids.

PMID: 16139186 [PubMed - indexed for MEDLINE]

42: Eur J Pain. 2005 Oct;9(5):555-60. Related Articles, Links
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Postoperative analgesia in children--current practice in Germany.

Stamer UM, Mpasios N, Maier C, Stuber F.

Department of Anaesthesiology and Intensive Care Medicine, University of Bonn, Sigmund-Freud-Strasse 25, D-53105 Bonn, Germany. ukrike.stamer@ukb.uni-bonn.de

German departments of anaesthesia were surveyed to determine current practice of postoperative pain management in children. The response rate of the survey was 58.6%: Questionnaires of 383 departments in which paediatric surgery was performed could be analyzed. 37.3% operated an acute pain service (APS). In 58.8% of the hospitals, postoperative pain management in children was mainly performed by surgeons or pediatricians. Anaesthesiologists or an APS were in charge for pain management in children in 38.6% of the institutions. Non-opioid analgesics were the drugs most widely used (93.4%), whereas i.v. opioids were never used in 20.9% of the hospitals and used less than once a week in 28.7%. The intramuscular route was chosen at least occasionally by 27.7% of the respondents. Peripheral and central regional techniques were performed in most of the departments, however, frequency of use varied considerably between hospitals running or not running an APS. The majority performed the techniques of regional anaesthesia less than once a week. The basic primary quality criterion of pain therapy, a regular measurement and documentation of pain scores, was performed in only 4% of the institutions. Paediatric pain management does not meet quality criteria and standards of care already established in adults. In the future, additional education of the medical staff considering analgesic techniques and measurement of pain scores has to be emphasized.

PMID: 16139184 [PubMed - indexed for MEDLINE]

43: Geriatrics. 2005 Dec;60(12):17. Related Articles, Links

Scaly red plaques on dorsal part of hand. Patient notes morning stiffness and pain.

Levine N.

University of Arizona Health Sciences Center, Tucson, USA.

Publication Types:
PMID: 16343031 [PubMed - indexed for MEDLINE]

44: J Neurosurg Spine. 2005 Nov;3(5):355-63. Related Articles, Links

Surgical treatment of thoracic outlet syndrome: a randomized trial comparing two operations.

Sheth RN, Campbell JN.

Department of Neurosurgery, School of Medicine, The Johns Hopkins University, Baltimore, Maryland 21287, USA.

OBJECT: Various surgical approaches have been proposed for the treatment of thoracic outlet syndrome (TOS). The authors of this study focused on the differences in outcome after supraclavicular neuroplasty of brachial plexus (SNBP [no rib resection]) and transaxillary first rib resection (TFRR) in patients in whom the dominant clinical problem was pain. METHODS: Fifty-five patients were randomized to undergo TFRR or SNBP. Patients with an anomalous cervical rib, intrinsic weakness, and primarily vascular findings were excluded from the study. Preoperatively, the following findings were typically observed: provocation of symptoms by certain postures (the so-called spear-throwing position as well as downward tugging of the shoulder) and marked tenderness in the supraclavicular fossa. The intergroup severity of the symptoms was comparable. Eight patients were lost to follow up. There were 24 TFRRs (in two cases the procedure was bilateral) and 25 SNBPs. The mean follow-up interval was 37 months. In both groups pain decreased significantly after surgery. By all measures the TFRR operation conferred superior results. Patients reported significantly less pain (39 +/- 7 compared with 61 +/- 7; score range 0-100 on a visual analog scale), greater percentage of pain relief (52 +/- 8% compared with 30 +/- 7%), and less pain (3.7 +/- 0.4 compared with 5.1 +/- 0.5) on an affective scale (all p < 0.05) in the TFRR and SNBP groups, respectively). In the TFRR group, 75% of patients reported good or excellent outcomes compared with 48% in the SNBP group (p < 0.05). CONCLUSIONS: Transaxillary first rib resection provided better relief of symptoms than SNBP. The major compressive element in patients with TOS-associated pain appeared to be the first rib.

Publication Types:
PMID: 16302629 [PubMed - indexed for MEDLINE]

45: J Pain Symptom Manage. 2005 Aug;30(2):192-9. Related Articles, Links
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Stability of tramadol and haloperidol for continuous subcutaneous infusion at home.

Negro S, Martin A, Azuara ML, Sanchez Y, Barcia E.

Departamento de Farmacia y Tecnologia Farmaceutica, Facultad de Farmacia, Universidad Complutense de Madrid, Madrid, Spain.

Terminally ill cancer patients commonly suffer from several symptoms at the same time, such as pain, nausea, anxiety, cognitive failure, bowel obstruction, and fatigue. To obtain optimal symptom control, the simultaneous administration of more than one drug by continuous subcutaneous (SC) infusion is often required. Tramadol is considered an effective step II agent of the World Health Organization's analgesic ladder for the control of chronic pain conditions, including neuropathic pain, and also exhibits a good safety profile. Haloperidol has been found to be very efficient in controlling agitation with or without pain, nausea and/or vomiting of central origin, intestinal obstruction, and delirium. Although the combination of tramadol and haloperidol in the same solution for SC infusion may be desirable, the physicochemical stability of this combination has not yet been documented. Therefore, our aim was to study the physicochemical stability of drug admixtures composed of tramadol hydrochloride and haloperidol lactate, which have been stored in polypropylene syringes at 4 degrees C and 25 degrees C, and assayed at 0, 5, 7, and 15 days after preparation.

PMID: 16125035 [PubMed - indexed for MEDLINE]

46: J Pain Symptom Manage. 2005 Aug;30(2):183-91. Related Articles, Links
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Temporary sympathectomy in the treatment of chronic refractory angina.

Moore R, Groves D, Hammond C, Leach A, Chester MR.

The Cardiothoracic Center, NHS Trust, Liverpool, United Kingdom.

The aim of this study was to investigate the safety and efficacy of the two most commonly practiced temporary sympathectomy techniques in the treatment of chronic refractory angina. Fifty-nine consecutive refractory angina patients commencing outpatient temporary sympathectomy from November 1, 2000 to November 1, 2002, were prospectively audited for duration of pain relief and procedural complications over a two-year period. A total of 227 stellate ganglion blockades (SGB) and 100 paravertebral blockades (PVB) were performed on 59 chronic refractory angina (CRA) patients naive to sympathectomy. The mean period of pain relief obtained following SGB was 3.48 weeks (SD 3.38) and the mean relief following PVB was 2.80 weeks (SD 2.00). Mild, fully reversible complications occurred in 3% of SGB and 3% of PVB procedures, with one patient requiring overnight hospitalization. This study demonstrates that temporary sympathectomy may provide a safe and effective outpatient procedure in refractory angina patients when applied as part of holistic care.

PMID: 16125034 [PubMed - indexed for MEDLINE]

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