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Ketamine improves the management of exaggerated postoperative pain observed in perioperative fentanyl-treated rats.
Richebe P, Rivat C, Laulin JP, Maurette P, Simonnet G.
Departement d'Anesthesie et Reanimation III, Centre Hospitalier et Universitaire, Bordeaux, France.
BACKGROUND: Although opioids are unsurpassed analgesics, experimental and clinical studies suggest that opioids activate N-methyl-d-aspartate pronociceptive systems leading to pain hypersensitivity and short-term tolerance. Because it is difficult in humans to differentiate pain from hyperalgesia during the postoperative period, the authors performed experimental studies with fentanyl using the rat incisional pain model for evaluating relations between hyperalgesia and short-term tolerance. Because N-methyl-d-aspartate receptor antagonists oppose both pain hypersensitivity and tolerance induced by opioids, the authors examined the capability of ketamine for improving exaggerated postoperative pain management. METHODS: During halothane anesthesia, a hind paw plantar incision was performed in rats receiving four fentanyl subcutaneous injections (100 microg/kg per injection, every 15 min). In some groups, three subcutaneous ketamine injections (10 mg/kg per injection, every 5 h) were performed in saline- or fentanyl-treated rats. One day after surgery, the analgesic effect of morphine (2 mg/kg subcutaneous) was tested. Analgesia, mechanical hyperalgesia, tactile allodynia, and pain score were assessed for several days using the paw pressure vocalization test, the von Frey application test, and the postural disequilibrium test. RESULTS: Fentanyl induced analgesia but also produced exaggerated postoperative pain as indicated by the enhancement of hyperalgesia, allodynia, and weight-bearing decrease after hind paw plantar incision. Ketamine pretreatment prevented such a fentanyl-induced enhancement of postoperative pain and improved its management by morphine. CONCLUSIONS: By opposing postoperative pain hypersensitivity and subsequent short-term tolerance induced by perioperative opioid use, ketamine not only improves exaggerated postoperative pain management but also provides better postoperative rehabilitation.
PMID: 15681961 [PubMed - in process]
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A randomized controlled trial to evaluate S-caine patch for reducing pain associated with vascular access in children.
Sethna NF, Verghese ST, Hannallah RS, Solodiuk JC, Zurakowski D, Berde CB.
Harvard Medical School, Department of Anesthesiology, Perioperative and Pain Medicine, Children's Hospital Boston, MA, USA. navil.sethna@childrens.harvard.edu
BACKGROUND: A randomized, double-blinded trial was performed to evaluate the efficacy and safety of the S-Caine Patch (ZARS, Inc., Salt Lake City, UT), a eutectic mixture of lidocaine and tetracaine, for pain relief during venipuncture in children. METHODS: With institutional review board approval, parental consent, and patient assent, 64 children who were scheduled for medically indicated vascular access at two centers were randomly assigned (2:1) to receive either an S-Caine Patch or a placebo patch for 20 min before venipuncture procedures. The primary outcome measure was the child's rating of pain during venipuncture using the Oucher pain scale. Additional measures of efficacy included the blinded investigator's and an independent observer's four-point categorical scores. Variables were compared between treatments using Mantel-Haenszel summary chi-square tests or Pearson chi-square tests. RESULTS: The S-Caine Patch produced significantly greater pain relief compared with placebo (median Oucher scores of 0 vs. 60; P < 0.001). Fifty-nine percent of the children in the S-Caine Patch group reported no pain compared with 20% of the children in the placebo patch group. The investigator estimated that 76% of the children in the S-Caine Patch group experienced no pain during venipuncture versus 20% in the placebo patch group (P = 0.001). Independent observer ratings also favored the S-Caine Patchtrade mark (P < 0.001). Mild skin erythema (< 38%) and edema (< 2%) occurred with similar frequencies between the groups. CONCLUSION: This study demonstrated that a 20-min application of the S-Caine Patch is effective in lessening pain associated with venipuncture procedures. Adverse events after S-Caine Patch application were mild and transient.
PMID: 15681958 [PubMed - in process]
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Continuous infusion of ropivacaine for pain relief after iliac crest bone grafting for shoulder surgery.
Blumenthal S, Dullenkopf A, Rentsch K, Borgeat A.
Department of Anesthesiology, Orthopedic University Clinic Balgrist, Zurich, Switzerland.
BACKGROUND: The aim of the study was to compare the efficacy of either ropivacaine or placebo through an iliac crest (IC) catheter after Bankart repair with IC bone grafting. METHODS: With approval of the local ethics committee and after written informed consent was obtained, 36 patients had an interscalene catheter placed preoperatively. Intraoperatively, the surgeon placed a catheter at the IC donor site. At the end of surgery, 30 ml ropivacaine, 0.5% (ropivacaine group), or 30 ml NaCl, 0.9% (placebo group), was administered. Ropivacaine, 0.2%, was started 6 h after the initial block through the interscalene catheter for 48 h (t48) in all patients. At t0, the patient received either 5 ml/h ropivacaine, 0.2% (ropivacaine group), or 5 ml/h NaCl, 0.9% (placebo group), for 48 h through the IC catheter. All patients received an intravenous morphine patient-controlled analgesia device. Pain scores at the shoulder and at the IC donor site were assessed at rest and during motion every 8 h for 48 h and after 3 months. Plasma concentrations of total and unbound ropivacaine, morphine consumption, and patient satisfaction were assessed. RESULTS: At the IC donor site, pain was significantly lower in the ropivacaine group compared with the placebo group at rest and during motion at any time. Total and unbound plasma concentrations of ropivacaine were below the toxic threshold in both groups. Morphine consumption was significantly lower in the ropivacaine group after 24 and 48 h. Patient satisfaction was significantly higher in the ropivacaine group. At 3 months, pain at the IC during motion was significantly lower in the ropivacaine group. CONCLUSIONS: Continuous application of 0.2% ropivacaine through an IC catheter after Bankart repair with IC bone grafting is an effective method for pain relief for the first 48 h, with few adverse effects and high patient satisfaction. The benefit of this technique is still present after 3 months.
PMID: 15681956 [PubMed - in process]
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Continuous peripheral nerve blocks at home for treatment of recurrent complex regional pain syndrome I in children.
Dadure C, Motais F, Ricard C, Raux O, Troncin R, Capdevila X.
Department of Anesthesia and Critical Care Medicine, Lapeyronie University Hospital, Montpellier, France. chdadure@yahoo.fr
BACKGROUND: Recurrent complex regional pain syndrome I is not rare in the pediatric population. The authors conducted this study to evaluate the efficacy of continuous peripheral nerve blocks with elastomeric disposable pumps associated with initial Bier blocks for the treatment of recurrent complex regional pain syndrome I in children. METHODS: After parental informed consent, 13 children who did not respond to conventional complex regional pain syndrome treatment were included (mean age, 13 yr; range, 9-16 yr). After general anesthesia, peripheral nerve block was performed using 0.5 ml/kg lidocaine, 1%, with epinephrine and 0.5% ropivacaine injected in the peripheral nerve block catheter. Then, a 20-min Bier block was performed using a tourniquet and 0.2 ml/kg lidocaine, 1%; 3 ml/kg hydroxyethyl starch 130/06; and 5 mg/kg buflomedil injected intravenously. A solution of 0.1 ml . kg . h continuous ropivacaine, 0.2%, was infused through the catheter using an elastomeric pump for 96 h. Need for rescue analgesia, occurrence of side effects, and status of motor and sensory block were recorded at hours 1, 6, 12, 24, 48, 72, and 96. Children and parents completed a satisfaction assessment. All of the children had follow-up visits after 2 months. RESULTS: Postoperative analgesia was excellent. The median pain score was 0 for each period studied. Motor blockade was minimal before 12 h (median, 1) and absent thereafter. One child needed rescue analgesia. All children were able to walk easily after the initial 24-h period (walking score, > 4). Children and parents were all satisfied. Children returned home under parental surveillance beginning in the 24th hour. Neither peripheral nerve block nor Bier block caused side effects. After 2 months, none of the children exhibited any clinical symptom of recurrent complex regional pain syndrome. CONCLUSION: Ambulatory continuous peripheral nerve block associated with an initial Bier block seems to be a significant and novel contribution to treat recurrent pediatric complex regional pain syndrome I. It allows complete pain relief, early mobilization, and rapid return home, representing a psychological advantage for these children.
PMID: 15681955 [PubMed - in process]
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Complex regional pain syndromes in children and adolescents.
Berde CB, Lebel A.
Publication Types:
PMID: 15681937 [PubMed - in process]
[Quality assurance program for pain management after obstetrical perineal injury]
[Article in French]
Urion L, Bayoumeu F, Jandard C, Fontaine B, Bouaziz H.
Service d'anesthesie-reanimation, maternite regionale de Nancy, 10, rue Heydenreich, BP 4213, 54042 Nancy cedex, France.
INTRODUCTION: A quality insurance program has been set up in order to improve the relief of pain in patients with perineal injury after childbirth. PATIENTS AND METHODS: The program has been developed according to the French standards of accreditation. After elaboration of a referential, a first study (103 patients) allowed to evaluate the ongoing practices and to appreciate the pain intensities. After analysis of the results, an action strategy has been elaborated, with a brand new therapeutic standard and a pain-monitoring program for nurses. Six months later, a second study (105 patients) measured the efficiency of the accomplished actions. The statistic analysis used chi2 and Kruskal-Wallis tests and a multivariate analyse (p <0.05). RESULTS: Several indicators led to conclude to the success of this program: analgesics prescribed systematically and earlier, best observance, larger utilisation of the NSAI, decrease of the analgesics requests, improvement of the satisfaction referred to the relief of pain. The multivariate analyse showed a risk twice as little as in the second study to have a 36th hour VAS score superior to four (p =0.03). CONCLUSION: The apply of this quality insurance program allowed to improve the analgesia after obstetric perineal injuries. A few adaptations are needed, and also more formations of the medical and paramedical staff. The durability of the accomplished actions shall be evaluated in the future.
PMID: 15581719 [PubMed - indexed for MEDLINE]
Improving patient care. My right knee.
Berwick DM.
Institute for Healthcare Improvement, Cambridge, Massachusetts 02138, USA. dberwick@ihi.org <dberwick@ihi.org>
Despite some impressive recent gains, improving the glaring deficiencies in health care quality is proving to be very hard. Improvement is local, rather than system-wide, and is sustained with difficulty, rather than becoming an intrinsic feature of care. My right knee will probably need to be replaced soon. This has given me the opportunity to define, in very personal terms, 5 specific dimensions of "total quality" that I will require from the medical institution that does my surgery and that every patient has the right to require of their encounters with the health care system. Don't kill me (no needless deaths). Do help me, and don't hurt me (no needless pain). Don't make me feel helpless. Don't keep me waiting. And don't waste resources, mine or anyone else's. Given my requirements, it is not clear that any health care institution in the United States will want to take me on as a patient. Although at this point individual institutions can meet some of these requirements, no single institution can deliver on all of them. Generating the energy, insight, and courage we need to get to "total quality" may require those of us who work in health care to get much better at seeing images of ourselves in the people we help. As Gandhi said, "You must be the change you wish to see in the world."
PMID: 15657160 [PubMed - indexed for MEDLINE]
Reproduction of chest pain by palpation: diagnostic accuracy in suspected pulmonary embolism.
Gal GL, Testuz A, Righini M, Bounameaux H, Perrier A.
Equipe d'accueil 3878 (GETBO), Brest University Hospital, 29609 Brest, France.
PMID: 15684025 [PubMed - as supplied by publisher]
Randomised controlled trial of intravenous antibiotic treatment for cellulitis at home compared with hospital.
Corwin P, Toop L, McGeoch G, Than M, Wynn-Thomas S, Wells JE, Dawson R, Abernethy P, Pithie A, Chambers S, Fletcher L, Richards D.
Department of Public Health and General Practice, Christchurch School of Medicine and Health Sciences, PO Box 4345, Christchurch, New Zealand. paul.corwin@chmeds.ac.nz
OBJECTIVES: To compare the efficacy, safety, and acceptability of treatment with intravenous antibiotics for cellulitis at home and in hospital. DESIGN: Prospective randomised controlled trial. SETTING: Christchurch, New Zealand. PARTICIPANTS: 200 patients presenting or referred to the only emergency department in Christchurch who were thought to require intravenous antibiotic treatment for cellulitis and who did not have any contraindications to home care were randomly assigned to receive treatment either at home or in hospital. MAIN OUTCOME MEASURES: Days to no advancement of cellulitis was the primary outcome measure. Days on intravenous and oral antibiotics, days in hospital or in the home care programme, complications, degree of functioning and pain, and satisfaction with site of care were also recorded. RESULTS: The two treatment groups did not differ significantly for the primary outcome of days to no advancement of cellulitis, with a mean of 1.50 days (SD 0.11) for the group receiving treatment at home and 1.49 days (SD 0.10) for the group receiving treatment in hospital (mean difference 0.01 days, 95% confidence interval -0.3 to 0.28). None of the other outcome measures differed significantly except for patients' satisfaction, which was greater in patients treated at home. CONCLUSIONS: Treatment of cellulitis requiring intravenous antibiotics can be safely delivered at home. Patients prefer home treatment, but in this study only about one third of patients presenting at hospital for intravenous treatment of cellulitis were considered suitable for home treatment.
Publication Types:
- Clinical Trial
- Randomized Controlled Trial
PMID: 15604157 [PubMed - indexed for MEDLINE]
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Painful stimulation of the temple during optokinetic stimulation triggers migraine-like attacks in migraine sufferers.
Granston A, Drummond P.
School of Psychology, Murdoch University, Western Australia.
Granston A & Drummond PD. Painful stimulation of the temple during optokinetic stimulation triggers migraine-like attacks in migraine sufferers. Cephalalgia 2004. London. ISSN 0333-1024To determine whether motion sickness induced by optokinetic stimulation would trigger migraine-like attacks, 27 migraine sufferers and 23 controls attended the laboratory up to three times at intervals of at least 3 weeks. On one occasion subjects experienced up to 15 min of optokinetic stimulation, followed by three 30-s applications of ice to the temple at 4-min intervals. On another occasion, the ice applications preceded and accompanied optokinetic stimulation. On a third occasion, one hand was immersed in ice water for 30 s, three times at 4-min intervals before and during optokinetic stimulation. Subjects recorded headache activity in a diary over the course of the study. None of the controls experienced a migraine-like attack at any stage of the experiment. In migraine sufferers, the incidence of migraine-like attacks was greater than the expected daily incidence of 8% after sessions that involved painful stimulation of the temple during or after optokinetic stimulation (44% and 28% of the group, respectively) (P < 0.001). In contrast, migraine-like attacks developed in only 13% of migraine sufferers after the session that involved immersing the hand in ice water during optokinetic stimulation (not significant). The development of nausea and headache during optokinetic stimulation increased the likelihood of migraine-like attacks afterwards. These findings indicate that motion sickness and head pain increase susceptibility to migrainous attacks in migraine sufferers, and suggest that the symptoms of migraine build upon each other in a vicious circle. Thus, targeting multiple symptoms should be more effective than targeting individual symptoms, both for preventing and treating attacks of migraine.
PMID: 15689198 [PubMed - in process]
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Prospective PC-interactive pressure algesimetry of post-traumatic neck pain after whiplash injury.
Nebel K, Stude P, Ludecke C, Wiese H, Diener HC, Keidel M.
Department of Neurology, University of Essen, Essen, Germany.
Nebel K, Stude P, Ludecke C, Wiese H, Diener H-C & Keidel M. Prospective PC-interactive pressure algesimetry of post-traumatic neck pain after whiplash injury. Cephalalgia 2004. London. ISSN 0333-1024Cervical pain is a prominent symptom in both acute whiplash injury and late whiplash syndrome. However, no systematic analysis of post-traumatic pain development covering several weeks has yet been performed in whiplash patients. It was the aim of the present study to analyse the duration and course of post-traumatic muscle pain due to whiplash injury in a prospective follow-up examination with short investigation intervals. A recovery of initially increased muscle pain after whiplash injury within 1 month was hypothesized. Pressure pain of the splenius and trapezius muscles was recorded using PC-interactive pressure algesimetry. Whiplash patients were investigated during the acute injury stage and after 3, 4, and 6 weeks and compared with matched controls. We found significantly increased pressure pain of the splenius and trapezius muscles in the acute stage of whiplash injury. After 4 weeks patients' scores of pain parameters were comparable to those of healthy control subjects. Within the patient group the first changes of pressure pain were observed within 3 (splenius) and 4 weeks (trapezius). For most patients the recovery dynamics lasted 4-6 weeks. A minority of patients did not show any improvement after 6 weeks. The present study shows that the dynamics of pressure pain due to whiplash injury can be quantified by means of PC-interactive pressure algesimetry. Our results confirm the clinical experience that the acute post-traumatic cervical syndrome normally subsides within weeks.
PMID: 15689196 [PubMed - in process]
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Biceps tendinitis caused by an osteochondroma in the bicipital groove: a rare cause of shoulder pain in a baseball player.
Onga T, Yamamoto T, Akisue T, Marui T, Kurosaka M.
From the Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan.
Tendinitis of the long head of the biceps brachii muscle is commonly seen in athletes who do repetitive overhead motions. Common causes of biceps tendinitis include impingement syndrome, subluxation of the biceps tendon, and attrition tendinitis, whereas biceps tendinitis secondary to a bone neoplasm is rare. A case of biceps tendinitis caused by an osteochondroma arising in the left humeral bicipital groove in a 25-year-old male baseball player is reported. The tumor was hook-shaped, originated from the inferomedial portion of the humeral lesser tubercle, and surrounded the biceps tendon. Symptoms of increasing pain and inability to throw resulted from direct irritation of the biceps tendon by the tumor. Total excision of the tumor relieved the symptoms within 3 weeks. To our knowledge, there have been no reported cases in the English-language literature of biceps tendinitis caused by an osteochondroma.
PMID: 15685083 [PubMed - in process]
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The Causes of Pain in Benign Solitary Enchondromas of the Proximal Humerus.
Levy JC, Temple HT, Mollabashy A, Sanders J, Kransdorf M.
From the *Department of Orthopaedics and Rehabilitation, University of Miami School of Medicine, Miami, FL; and the daggerDiagnostic Radiology, Mayo Medical Center, Jacksonville, FL.
Patients with benign solitary enchondromas of the proximal humerus frequently present to the diagnosing physician with shoulder pain. Once the lesion is considered benign, emphasis can be placed on identifying the etiology for the pain. We reviewed our experience with these patients to identify the cause of the presenting pain. A retrospective review of clinical records and radiographic studies (radiographs, magnetic resonance images, and bone scans) was done for all patients presenting to an orthopaedic oncology unit with solitary enchondroma of the proximal humerus. Attention was focused on diagnostic evidence of additional disease in the shoulder. Fifty-seven patients (mean age, 53.6 years) met the criteria of the study and were included for evaluation. Of patients presenting with pain, 82% (47 of 57 patients) had findings seen on magnetic resonance imaging scans that correlated with the initial clinical diagnostic impression, suggesting that other disease was present that could explain the pain. Solitary enchondromas of the proximal humerus often are found incidentally during the initial evaluation of patients with shoulder pain. This study showed that additional treatable disease usually is present in patients with enchondromas of the proximal humerus.Level of Evidence: Diagnostic study, Level III-1 (study of nonconsecutive patients-no consistently applied reference "gold" standard).
PMID: 15685073 [PubMed - as supplied by publisher]
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Soft tissue and intra-articular injection of bupivacaine, epinephrine, and morphine has a beneficial effect after total knee arthroplasty.
Lombardi AV Jr, Berend KR, Mallory TH, Dodds KL, Adams JB.
Joint Implant Surgeons, Inc, Columbus, OH 43215, USA. LombardiAV@joint-surgeons.com
The purpose of this study was to determine if an intraoperative intraarticular and soft-tissue injection of local anaesthetic, epinephrine, and morphine has a beneficial effect for total knee arthroplasty. A control group of 138 patients (181 knees) received no intraoperative injection. The study group of 171 patients (197 knees) received intraoperative injection of 0.25% bupivacaine with epinephrine and morphine with 2/3 injected into the soft tissues and 1/3 injected into the joint. Patients having bilateral simultaneous procedures received a divided dose. The pain treatment protocol otherwise was identical. Pain, sedation, rescue narcotic usage, narcotic reversal and blood loss were examined. Pain levels during the immediate postoperative period, blood loss, and bleeding indices were reduced with injection. Considerably more control patients required rescue doses of narcotics. Preemptive analgesia with soft tissue and intra-articular injection of long-acting local anesthetic with epinephrine and morphine provides better pain control in the immediate postoperative period, decreases blood loss, and decreases the need for rescue narcotics and reversal agents. This simple, inexpensive method provides an effective adjunct to a multimodal approach in improving the postoperative course of primary total knee arthroplasty.
PMID: 15534532 [PubMed - indexed for MEDLINE]
Evaluation of tamoxifen and anastrozole in the prevention of gynecomastia and breast pain induced by bicalutamide monotherapy of prostate cancer.
Boccardo F, Rubagotti A, Battaglia M, Di Tonno P, Selvaggi FP, Conti G, Comeri G, Bertaccini A, Martorana G, Galassi P, Zattoni F, Macchiarella A, Siragusa A, Muscas G, Durand F, Potenzoni D, Manganelli A, Ferraris V, Montefiore F.
Professorial Unit of Medical Oncology (Medical Oncology B), University and National Cancer Research Institute, Largo R. Benzi 10, 16132 Genoa, Italy; e-mail: f.boccardo@unige.it.
PURPOSE To determine whether tamoxifen or anastrozole prevents gynecomastia and breast pain caused by bicalutamide (150 mg) without compromising efficacy, safety, or sexual functioning. PATIENTS AND METHODS A double-blind, placebo-controlled trial was performed in patients with localized, locally advanced, or biochemically recurrent prostate cancer. Patients (N = 114) were randomly assigned to either bicalutamide (150 mg/d) plus placebo or in combination with tamoxifen (20 mg/d) or anastrozole (1 mg/d) for 48 weeks. Gynecomastia, breast pain, prostate-specific antigen (PSA), sexual functioning, and serum levels of hormones were assessed. Results Gynecomastia developed in 73% of patients in the bicalutamide group, 10% of patients in the bicalutamide-tamoxifen group, and 51% of patients in the bicalutamide-anastrozole group (P < .001); breast pain developed in 39%, 6%, and 27% of patients, respectively (P = .006). Baseline PSA level decreased by >/= 50% in 97%, 97%, and 83% of patients in the bicalutamide, bicalutamide-tamoxifen, and bicalutamide-anastrozole groups, respectively (P = .07); and adverse events were reported in 37%, 35%, and 69% of patients, respectively (P = .004). There were no major differences among treatments in sexual functioning parameters from baseline to month 6. Elevated testosterone levels occurred in each group; however, free testosterone levels remained unchanged in the bicalutamide-tamoxifen group because of increased sex hormone-binding globulin levels. CONCLUSION Anastrozole did not significantly reduce the incidence of bicalutamide-induced gynecomastia and breast pain. In contrast, tamoxifen was effective, without increasing adverse events, at least in the short-term follow-up. These data support the need for a larger study to determine any effect on mortality.
PMID: 15681525 [PubMed - in process]
Angina with "normal" coronary arteries: a changing philosophy.
Bugiardini R, Bairey Merz CN.
Department of Internal Medicine, Cardio-Angiology and Hepatology, University of Bologna, Bologna, Italy. raffaele.bugiardini@unibo.it
CONTEXT: Many women with angina are told that they have no significant heart disease following demonstration of normal or near-normal coronary arteries and are offered no specific treatment beyond reassurance. EVIDENCE ACQUISITION: MEDLINE and the Cochrane Database of Systematic Reviews were searched from their start dates until June 2004 for analysis using specific key words including diagnosis and therapy of angina with normal angiography and angina with normal coronary arteries. Reference lists of published articles and data of meeting presentations were also consulted. EVIDENCE SYNTHESIS: Normal or nonobstructive coronary disease at angiography is not uncommon and occurs in 10% of women presenting with ST-segment elevation myocardial infarction compared with 6% in men. Patients with evidence of myocardial ischemia or myocardial infarction and nonobstructive atherosclerotic disease of the coronary arteries are more likely to be women and nonwhite. Symptoms are often indistinguishable from those with obstructive coronary artery disease. The prognosis of patients with unstable angina and nonobstructive atherosclerotic coronary artery disease is not benign and includes a 2% risk of death or myocardial infarction at 30 days of follow-up. Recent work has shown that at least 20% of women with normal or nonobstructive angiography have myocardial ischemia, likely due to atherosclerosis-related endothelial dysfunction, which itself is associated with an increased risk of later adverse cardiac events and development of frank future obstructive disease. Randomized placebo-controlled studies have demonstrated that tricyclic antidepressants, beta-blockers, angiotensin-converting enzyme inhibitors, L-arginine, statins, and exercise may relieve symptoms, vascular dysfunction, or both; however, longer-term studies evaluating cardiac event rates need to be performed. CONCLUSIONS: Patients with chest pain and normal or nonobstructive coronary angiograms are predominantly women, and many have a prognosis that is not as benign as commonly thought. Assessment of endothelial function may help identify patients at risk for future cardiac events. Therapy should be directed at symptom relief with tricyclic agents and beta-blockers, and aggressive antiatherosclerotic therapy with statins, angiotensin-converting enzyme inhibitors, or both should be applied when risk factors are present or prognostic risk is high. Large-scale randomized trials need to be conducted to determine optimal ways of preventing clinical events.
Publication Types:
PMID: 15671433 [PubMed - indexed for MEDLINE]
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A simplified approach to the management of non-ST-segment elevation acute coronary syndromes.
Gluckman TJ, Sachdev M, Schulman SP, Blumenthal RS.
Division of Cardiology, the Johns Hopkins Hospital, Baltimore, Md, USA.
CONTEXT: While current practice guidelines provide an evidence-based approach to management of acute coronary syndromes (ACS), application of the evidence by individual physicians has been suboptimal. OBJECTIVE: To assess and synthesize the evidence regarding optimal management of non-ST-segment elevation ACS (NSTE-ACS). DATA SOURCES: Systematic searches of peer-reviewed publications were performed in MEDLINE and the Cochrane Database from January 1990 through November 2004, with consultation by content experts. Search terms included antiplatelet therapy, antithrombotic therapy, angiotensin-converting enzyme inhibition, angiotensin receptor blockade, beta-blockade, hypertension, hyperlipidemia, cigarette smoking, diet, diabetes mellitus, exercise, myocardial ischemia, and coronary artery disease. STUDY SELECTION AND DATA EXTRACTION: Criteria for selection of studies included controlled study design, English language, and clinical pertinence. Data quality was based on the publishing journal and relevance to clinical management of NSTE-ACS. DATA SYNTHESIS: While outcomes of controlled studies support a comprehensive approach in the management of patients with NSTE-ACS, many physicians perceive existing guidelines as lengthy and complex. After risk stratification to identify those patients most likely to benefit from an early invasive vs early conservative strategy, a comprehensive management plan can be assembled through an "ABCDE" approach. The elements of this include "A" for antiplatelet therapy, anticoagulation, angiotensin-converting enzyme inhibition, and angiotensin receptor blockade; "B" for beta-blockade and blood pressure control; "C" for cholesterol treatment and cigarette smoking cessation; "D" for diabetes management and diet; and "E" for exercise. CONCLUSION: An "ABCDE" approach for the management of NSTE-ACS provides a practical and systematic means to implement evidence-based medicine into clinical practice.
Publication Types:
PMID: 15657328 [PubMed - indexed for MEDLINE]
Erratum in:
- Pain. 2004 Nov;112(1-2):222.
Corrected and republished in:
- Pain. 2004 Nov;112(1-2):223-4.
Comment on:
Can pain be more or less neuropathic?
Attal N, Bouhassira D.
Publication Types:
PMID: 15690577 [PubMed - indexed for MEDLINE]
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Intracerebroventricular injection of phospholipases A2 inhibitors modulates allodynia after facial carrageenan injection in mice.
Yeo JF, Ong WY, Ling SF, Farooqui AA.
Department of Oral and Maxillofacial Surgery, National University of Singapore, Lower Kent Ridge Road, Singapore, Singapore 119260.
The present study was carried out, using inhibitors to secretory phospholipase A2 (sPLA2, 12-epi-scalaradial), cytosolic phospholipase A2 (cPLA2, AACOCF3), or calcium-independent phospholipase A2 (iPLA2, bromoenol lactone), to compare possible contributions of central nervous PLA2 isoforms to the development of allodynia after facial carrageenan injection in mice. C57BL/6J (B6) mice showed increased responses to facial stimulation using a von Frey hair (1 g force), at 8 h, 1 day, and 3 days after facial carrageenan injection. On the other hand, BALB/c mice did not show increased responses at any of the time points. In both B6 and BALB/c mice, intracerebroventricular injection of inhibitors to each of the three PLA2 isoforms significantly reduced responses to von Frey hair stimulation at 8 h and 1 day after facial carrageenan injection, but at 3 days after injection, only the sPLA2 inhibitor had an effect. Since BALB/c mice did not show increased responses after facial carrageenan injection, the reduction in responses actually indicates that there is loss of normal sensitivity to von Frey hair stimulation after intracerebroventricular injection of each of these inhibitors, in this strain of mice. The effects of PLA2 inhibitors are unlikely to be due simply to inhibition of arachidonic acid generation, since intracerebroventricular injection of arachidonic acid also had an anti-nociceptive effect. The above results support an important role of central nervous PLA2s in neurotransmission and pain transmission.
PMID: 15494195 [PubMed - indexed for MEDLINE]
Pain reactivity in 2-month-old infants after prenatal and postnatal serotonin reuptake inhibitor medication exposure.
Oberlander TF, Grunau RE, Fitzgerald C, Papsdorf M, Rurak D, Riggs W.
Department of Pediatrics, Biobehavioral Research Unit, Centre for Community Child Health Research, Room L408, 4480 Oak St, Vancouver, BC, Canada. toberlander@cw.bc.ca
OBJECTIVE: In this prospective study, we examined biobehavioral responses to acute procedural pain at 2 months of age in infants with prenatal and postnatal selective serotonin reuptake inhibitor (SSRI) medication exposure. Based on previous findings showing reduced pain responses in newborns after prenatal exposure, we hypothesized that altered pain reactivity would also be found at 2 months of age. METHODS: Facial action (Neonatal Facial Coding System) and cardiac autonomic reactivity derived from the respiratory activity and heart rate variability (HRV) responses to a painful event (heel-lance) were compared between 3 groups of infants: (1) infants with prenatal SSRI exposure alone (n = 11; fluoxetine, n = 2; paroxetine, n = 9); (2) infants with prenatal and postnatal SSRI (via breast milk) exposure (total n = 30; fluoxetine, n = 6; paroxetine, n = 20; sertraline, n = 4); and (3) control infants (n = 22; nonexposed) during baseline, lance, and recovery periods. Measures of maternal mood and drug levels were also obtained, and Bayley Scales of Infant Development-II were administered at ages 2 and 8 months. RESULTS: Facial action increased in all groups immediately after the lance but was significantly lower in the pSE group during the lance period. HR among infants in the pSE and ppSE groups was significantly lower during recovery. Using measures of HRV and the transfer relationship between heart rate and respiration, exposed infants had a greater return of parasympathetic cardiac modulation in the recovery period, whereas a sustained sympathetic response continued in control infants. Although postnatal exposure via breast milk was extremely low when infant drug levels could be detected in ppSE infants, changes in HR and HRV from lance to recovery were greater compared among infants with levels too low to be quantified. Neither maternal mood nor the presence of clonazepam influenced pain responses. CONCLUSIONS: Blunted facial-action responses were observed among infants with prenatal SSRI exposure alone, whereas both prenatal and postnatal exposure was associated with reduced parasympathetic withdrawal and increased parasympathetic cardiac modulation during recovery after an acute noxious event. These findings are consistent with patterns of pain reactivity observed in the newborn period in the same cohort. Given that postnatal exposure via breast milk was extremely low and altered biobehavioral pain reactivity was not associated with levels of maternal reports of depression, these data suggest possible sustained neurobehavioral outcomes beyond the newborn period. This is the first study of pain reactivity in infants with prenatal and postnatal SSRI exposure, and our findings were limited by the lack of a depressed nonmedicated control group, small sample size, and understanding of infant behaviors associated with pain reactivity that could have also have been influenced by prenatal SSRI exposure. The developmental and clinical implications of our findings remain unclear, and the mechanisms that may have altered 5-hydroxytryptamine-mediated pain modulation in infants after SSRI exposure remain to be studied. Treating maternal depression with antidepressants during and after pregnancy and promoting breastfeeding in this setting should remain a key goal for all clinicians. Additional study is needed to understand the long-term effects of prenatal and early postnatal SSRI exposure.
PMID: 15687451 [PubMed - in process]
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Development of a multidimensional measure for recurrent abdominal pain in children: population-based studies in three settings.
Malaty HM, Abudayyeh S, O'Malley KJ, Wilsey MJ, Fraley K, Gilger MA, Hollier D, Graham DY, Rabeneck L.
Department of Medicine, Baylor College of Medicine, Houston, Texas, USA. hmalaty@bcm.tmc.edu
OBJECTIVE: Recurrent abdominal pain (RAP) is a common problem in children and adolescents. Evaluation and treatment of children with RAP continue to challenge physicians because of the lack of a psychometrically sound measure for RAP. A major obstacle to progress in research on RAP has been the lack of a biological marker for RAP and the lack of a reliable and valid clinical measure for RAP. The objectives of this study were (1) to develop and test a multidimensional measure for RAP (MM-RAP) in children to serve as a primary outcome measure for clinical trials, (2) to evaluate the reliability of the measure and compare its responses across different populations, and (3) to examine the reliabilities of the measure scales in relation to the demographic variables of the studied population. METHODS: We conducted 3 cross-sectional studies. Two studies were clinic-based studies that enrolled children with RAP from 1 pediatric gastroenterology clinic and 6 primary care clinics. The third study was a community-based study in which children from 1 elementary and 2 middle schools were screened for frequent episodes of abdominal pain. The 3 studies were conducted in Houston, Texas. Inclusion criteria for the clinic-based studies were (1) age of 4 to 18 years; (2) abdominal pain that had persisted for 3 or more months; (3) abdominal pain that was moderate to severe and interfered with some or all regular activities; (4) abdominal pain that may or may not be accompanied by upper-gastrointestinal symptoms; and (5) children were accompanied by a parent or guardian who was capable of giving informed consent, and children over the age of 10 years were capable of giving informed assent. The community-based study used standardized questionnaires that were offered to 1080 children/parents from the 3 participating schools; 700 completed and returned the questionnaires (65% response rate). The questionnaire was designed to elicit data concerning the history of abdominal pain or discomfort. A total of 160 children met Apley's criteria and were classified as having RAP. Inclusion criteria were identical to those criteria for the clinic-based studies. Participating children in the 3 studies received a standardized questionnaire that asked about socioeconomic variables, abdominal pain (intensity; frequency; duration; nature of abdominal pain, if present, and possible relationships with school activities; and other upper gastrointestinal symptoms). We used 4 scales for the MM-RAP: pain intensity scale (3 items), nonpain symptoms scale (12 items), disability scale (3 items), and satisfaction scale (2 items). Age 7 was used as a cutoff point for the analysis as the 7-year-olds have been shown to exhibit more sophisticated knowledge of illness than younger children. RESULTS: A total of 295 children who were aged 4 to 18 years participated in the study: 155 children from the pediatric gastroenterology clinics, 82 from the primary care clinics, and 58 from the schools. The interitem consistency (Cronbach's coefficient alpha) for the pain intensity items, nonpain symptoms items, disability items, and satisfaction items were 0.75, 0.81, 0.80, and 0.78, respectively, demonstrating good reliability of the measure. The internal consistencies of the 4 scales did not significantly differ between younger (< or =7 years) and older (>7 years) children. There was also no significant variation in the coefficient alpha of each of the 4 scales in relation to gender or the level of the parent's education. Reliability was identical for the pain-intensity items (0.74) among children who sought medical attention from primary care or pediatric gastroenterology clinics. The intercorrelations of factor scores among the 4 scales showed a strong relationship among the factors but not high enough that correlations would be expected to be measuring the same items. The results of the factor analysis identified 5 components instead of 4 components representing the 4 scales. The 12 items of the nonpain symptoms scale were classified into 2 components; 1 component included heartburn, burping, passing gas, bloating, problem with ingestion of milk, bad breath, and sour taste (nonpain symptoms I), and the other included nausea/vomiting, diarrhea, and constipation (nonpain symptoms II). The program ordered the 5 components on the basis of the percentage of the total variance explained by each component and consequently by the strength of each components in the following order: nonpain symptoms I, pain intensity, pain disability, satisfaction, and nonpain symptoms II. Of the 20 items that composed the MM-RAP, 17 met the inclusion criteria of having a correlation of > or =0.40 on the primary factor analyses. The 3 items that assessed pain intensity met the inclusion criteria as well as the 2 items that assessed satisfaction. Two of the 3 items that assessed disability met the inclusion criteria; however, the missed school item did not. The sleep problem and the loss of appetite items in the nonpain items also did not meet the inclusion criteria in both components of the nonpain symptoms scale. However, the loss of appetite item met the inclusion criteria in the disability scale with a correlation of 0.6. The 2 items that did not meet the inclusion criteria (missed school days and sour taste) will be eliminated in the revised measure for RAP. CONCLUSION: The MM-RAP demonstrated good reliability evidence in population samples. Children who have RAP and are seen at pediatric gastroenterology or primary care pediatric clinics have similar responses, showing that the measure performed well across several populations. Age did not affect the reliability of responses. The MM-RAP included 4 dimensions, each with several items that may identify disease-specific dimensions. In addition, dividing the nonpain symptoms scale into 2 components instead of 1 component could assist in creating a disease-specific measure. The present study focused exclusively on developing the multidimensional measure for RAP in children that could assist physicians in evaluating the efficacy of RAP treatment independent of psychological evaluations. In addition, the measure was designed for use in clinical trials that evaluate the efficacy of RAP treatment and to allow comparison between intervention studies. In conclusion, we were able to identify 4 dimensions of RAP in children (pain intensity, nonpain symptoms, pain disability, and satisfaction with health). We demonstrated that these dimensions can be measured in a reliable manner that is applicable to children who experience RAP in various settings.
PMID: 15687428 [PubMed - in process]
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Pain among children and adolescents: restrictions in daily living and triggering factors.
Roth-Isigkeit A, Thyen U, Stoven H, Schwarzenberger J, Schmucker P.
Department of Anesthesiology, University of Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, D-23538 Luebeck, Germany. isigkeit@uni-luebeck.de
OBJECTIVES: Pain among children and adolescents has been identified as an important public health problem. Most studies evaluating recurrent or chronic pain conditions among children have been limited to descriptions of pain intensity and duration. The effects of pain states and their impact on daily living have rarely been studied. The objective of this study was to investigate the impact of perceived pain on the daily lives and activities of children and adolescents. In addition, we sought to delineate self-perceived triggers of pain among children and adolescents. In this study, we (1) document the 3-month prevalence of painful conditions among children and adolescents, (2) delineate their features (location, intensity, frequency, and duration), (3) describe their consequences (restrictions and health care utilization), and (4) elucidate factors that contribute to the occurrence of pain episodes among young subjects. METHODS: The study was conducted in 1 elementary school and 2 secondary schools in the district of Ostholstein, Germany. Children and adolescents, as well as their parents/guardians, were contacted through their school administrators. The teachers distributed an information leaflet, explaining the conduct and aim of the study, to the parents a few days before the official enrollment of the youths in the study. Parents of children in grades 1 to 4 of elementary school were asked to complete the pain questionnaire for their children at home, whereas children from grade 5 upward completed the questionnaire on their own during class, under the supervision of their teachers. The response rate was 80.3%. As previously stated, chronic pain was defined as any prolonged pain that lasted a minimum of 3 months or any pain that recurred throughout a minimal period of 3 months. The children and adolescents were surveyed with the Luebeck Pain-Screening Questionnaire, which was specifically designed for an epidemiologic study of the characteristics and consequences of pain among children and adolescents. The questionnaire evaluates the prevalence of pain in the preceding 3 months. The body area, frequency, intensity, and duration of pain are addressed by the questionnaire. In addition, the questionnaire inquires about the private and public consequences of pain among young subjects. Specifically, the questionnaire aims to delineate the self-perceived factors for the development and maintenance of pain and the impact of these conditions on daily life. RESULTS: Of the 749 children and adolescents, 622 (83%) had experienced pain during the preceding 3 months. A total of 30.8% of the children and adolescents stated that the pain had been present for >6 months. Headache (60.5%), abdominal pain (43.3%), limb pain (33.6%), and back pain (30.2) were the most prevalent pain types among the respondents. Children and adolescents with pain reported that their pain caused the following sequelae: sleep problems (53.6%), inability to pursue hobbies (53.3%), eating problems (51.1%), school absence (48.8%), and inability to meet friends (46.7%). The prevalence of restrictions in daily living attributable to pain increased with age. A total of 50.9% of children and adolescents with pain sought professional help for their conditions, and 51.5% reported the use of pain medications. The prevalence of doctor visits and medication use increased with age. Weather conditions (33%), illness (30.7%), and physical exertion (21.9%) were the most frequent self-perceived triggers for pain noted by the respondents. A total of 30.4% of study participants registered headache as the most bothersome pain, whereas 12.3% cited abdominal pain, 10.7% pain in the extremities, 8.9% back pain, and 3.9% sore throat as being most bothersome. A total of 35.2% of children and adolescents reported pain episodes occurring > or =1 time per week or even more often. Health care utilization because of pain differed among children and adolescents according to the location of pain. Children and adolescents with back pain (56.7%), limb pain (55.0%), and abdominal pain (53.3%) visited a doctor more often than did those with headache (32.5%). In contrast, children and adolescents with headache (59.2%) reported taking medication because of pain more often than did those with back pain (16.4%), limb pain (22.5%), and abdominal pain (38.0%). The prevalence of self-reported medication use and doctor visits because of pain increased significantly with age (chi2 test). The prevalence of self-reported medication use was significantly higher among girls than among boys of the same age, except between the ages of 4 and 9 years (chi2 test). The prevalence of restrictions in daily activities varied among children and adolescents with different pain locations; 51.1% of children and adolescents with abdominal pain and 43.0% with headache but only 19.4% with back pain reported having been absent from school because of pain. The prevalence of restrictions attributable to pain was significantly higher among girls than among boys of the same age, except between the ages of 4 and 9 years (chi2 test). The self-reported triggers for pain varied between girls and boys. Girls stated more often than boys that their pain was triggered by weather conditions (39% vs 25%), illness (eg, common cold or injury) (35.9% vs 23.9%), anger/disputes (20.9% vs 11.9%), family conditions (12.1% vs 5.2%), and sadness (11.9% vs 3.4%). In contrast, boys stated more often than girls that their pain was triggered by physical exertion (28% vs 17.2%). We used a logistic regression model to predict the likelihood of a child paying a visit to the doctor and/or using pain medication. Health care utilization was predicted by increasing age, greater intensity of pain, and longer duration of pain but not by the frequency of pain. We used a logistic regression model to predict restrictions in daily activities. Only the intensity of pain was predictive of the degree of restrictions in daily life attributable to pain; the duration of pain and the frequency of pain episodes had no bearing on the degree to which the daily lives of the children were restricted because of pain. CONCLUSIONS: More than two thirds of the respondents reported restrictions in daily living activities attributable to pain. However, 30 to 40% of children and adolescents with pain reported moderate effects of their pain on school attendance, participation in hobbies, maintenance of social contacts, appetite, and sleep, as well as increased utilization of health services because of their pain. Restrictions in daily activities in general and health care utilization because of pain increased with age. Girls > or =10 years of age reported more restrictions in daily living and used more medications for their pain than did boys of the same age. We found gender-specific differences in self-perceived triggers for pain. Pain intensity was the most robust variable for predicting functional impairment in > or =1 areas of daily life. Increasing age of the child and increasing intensity and duration of pain had effects in predicting health care utilization (visiting a doctor and/or taking medication), whereas restrictions in daily activities were predicted only by the intensity of pain. Our results underscore the relevance of pediatric pain for public health policy. Additional studies are necessary and may enhance our knowledge about pediatric pain, to enable parents, teachers, and health care professionals to assist young people with pain management, allowing the young people to intervene positively in their conditions before they become recurrent or persistent.
PMID: 15687423 [PubMed - in process]
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Pain management in every hospital.
Peronnet D, Angeli C, Rivoire B.
PMID: 15690280 [PubMed - in process]
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Annual fall pain meeting & workshops.
[No authors listed]
PMID: 15690276 [PubMed - as supplied by publisher]
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Reliability of Retrospective Clinical Data to Evaluate the Effectiveness of Lumbar Fusion in Chronic Low Back Pain.
Pellise F, Vidal X, Hernandez A, Cedraschi C, Bago J, Villanueva C.
From the *Unitat de Cirurgia del Raquis, Hospital Vall d'Hebron, Barcelona, Spain, daggerServei de Farmacologia Clinica, Hospital Vall d'Hebron, Barcelona, Spain, and double daggerMultidisciplinary Pain Center, Division of Clinical Pharmacology and Toxicology, and Clinic of Internal Medicine for Rehabilitation, University Hospital, Geneva, Switzerland.
STUDY DESIGN.: Patients in whom a posterior spinal fusion instrumentation had been performed to treat low back pain were asked to recall their preoperative clinical status by retrospectively filling out the same 3 self-evaluation scales they had completed before surgery in a prospective fashion. OBJECTIVES.: To evaluate the impact of recollection error and compare outcomes using retrospective versus prospective methodologies among a cohort of patients treated with posterior spinal fusion instrumentation. SUMMARY OF BACKGROUND DATA.: Literature on spine surgery from 1990 to 2000 shows a greater increase in retrospective studies as compared to randomized controlled trials and other prospective studies. Cross-sectional studies evaluate therapeutic effectiveness by comparing the current condition with the recalled (retrospectively recorded) pretreatment condition. There are no studies analyzing the characteristics of recalled data in a cohort of patients with chronic low back pain treated with posterior spinal fusion instrumentation. METHODS.: The preoperative clinical status of 58 patients, 33 women and 25 men, with a mean age of 48.3 years (22-84 years) was assessed prospectively with 3 self evaluation questionnaires and retrospectively at a mean of 37.5 months (2-58 months) after surgery using the same questionnaires. The Wilcoxon test was used to compare prospective and retrospective preoperative data and to compare prospective outcomes with outcomes determined from cross-sectional data. Agreement between prospective and retrospective measures was estimated with intraclass correlation coefficients for absolute agreement and consistency. RESULTS.: Comparisons between prospective and recalled data showed significant differences, demonstrating a worse preoperative situation when using retrospective data. Assessment of treatment effectiveness showed that cross-sectional evaluation significantly improved the real surgical outcome. Both absolute agreement and consistency intraclass correlation coefficients showed poor agreement between prospective and cross-sectional data, revealing no systematic bias. Follow-up, age, and gender did not modify agreement and cross-sectional overestimation. CONCLUSIONS.: Relying on a patient's recall of preoperative clinical status is not an accurate method to evaluate surgical outcome after posterior spinal fusion instrumentation. Cross-sectional studies may overestimate the effectiveness of surgery.
PMID: 15682021 [PubMed - as supplied by publisher]
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Differences in the Work-Up and Treatment of Conditions Associated With Low Back Pain by Patient Gender and Ethnic Background.
Taylor BA, Casas-Ganem J, Vaccaro AR, Hilibrand AS, Hanscom BS, Albert TJ.
From the *Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, Missouri, daggerDepartment of Orthopaedic Surgery, University of Texas Health Science Center San Antonio, San Antonio, Texas, double daggerRothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, and section signSpine Center at Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
STUDY DESIGN.: Retrospective review comparing physician workup of degenerative lumbosacral pathologies between different genders and ethnic groups. OBJECTIVES.: To investigate whether patient ethnicity and gender influence the workup and treatment of degenerative spinal pathologies. SUMMARY OF BACKGROUND DATA.: Data from numerous studies suggest that patient gender and ethnicity play a role in medical decision-making, with white males receiving more frequent interventions than women and minorities. METHODS.: Patients enrolled for an "initial visit" in the National Spine Network database with lumbosacral level degenerative diagnosis were reviewed. Variables included patient gender, ethnicity, age, duration of symptoms, patient-graded severity of symptoms, radicular symptom pattern, and work status. RESULTS.: We identified 5690 patients with degenerative lumbosacral pathologies. Although females were more likely than males to have imaging tests ordered, male (18.5%) patients were significantly more likely to have surgery recommended than female (16.3%) patients (P < 0.031). Nonwhite females were 52% less likely to have surgery offered at initial visit, as compared to white males (P < 0.005). More imaging tests were ordered or reviewed among whites (76.6%) than among any other ethnic group (P = 0.162). White (18.3%) and Asian (22.5%) patients were significantly more likely to have surgery recommended or prescribed than black (11.1%) and Hispanic (14.5) patients (P < 0.0001). CONCLUSIONS.: This study suggests that ethnicity and gender affect the workup and surgical management of degenerative spinal disorders. However, it should be noted that there are a number of confounding factors not identified in the database, including managed care and insurance status and cultural differences, which may affect both test ordering and treatment recommendations. Further study of bias in clinical decision-making is indicated to assure equal delivery of quality care.
PMID: 15682020 [PubMed - as supplied by publisher]
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Low Back Pain on Passive Straight Leg Raising: The Anterior Theca as a Source of Pain.
Summers B, Malhan K, Cassar-Pullicino V.
From the *Princess Royal Hospital, Telford, Shropshire, United Kingdom; and the daggerRobert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry, Shropshire, United Kingdom.
STUDY DESIGN.: A prospective clinical and radiologic investigation of two groups of patients presenting with either acute back pain only or acute leg pain only, yet similar restriction in straight leg raising (SLR). OBJECTIVES.: To highlight a group of patients presenting with acute low back pain only, yet a restricted SLR normally associated with leg pain (sciatica) caused by a posterolateral disc prolapse. To determine the anatomic source of the pain in the low back pain only group. SUMMARY OF BACKGROUND DATA.: A restricted SLR is commonly associated with leg pain (sciatica) due to compression of a nerve root by an intervertebral disc prolapse. Previous studies investigating pain patterns on SLR have suggested that central disc prolapses tend to induce back pain whereas the more lateral prolapses induce leg pain. Such research work has involved patients presenting with typical sciatic pain investigated by myelography and undergoing decompressive surgery. There are no studies specifically investigating patients presenting with low back pain only and reduced SLR. METHODS.: Two groups of patients, one with acute low back pain only and one with acute leg pain only, yet showing similar restriction in SLR underwent MR imaging. The scans were reviewed "blind" by an experienced spinal radiologist and imaging features recorded according to a detailed protocol. The MR findings were then compared. RESULTS.: Significant disc prolapses were seen equally in both groups. The disc prolapses in the back pain only group were more likely to be central, smaller, to compress the theca only, and to be at a higher lumbar level as compared with the leg pain only group. CONCLUSIONS.: Acute low back pain associated with significant restriction in SLR is likely to be caused by a disc prolapse compressing the anterior theca.
PMID: 15682017 [PubMed - as supplied by publisher]
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A Controlled Randomized Study of the Effect of Training With Orthoses on the Incidence of Weight Bearing Induced Back Pain Among Infantry Recruits.
Milgrom C, Finestone A, Lubovsky O, Zin D, Lahad A.
From the *Department of Orthopaedics, Hadassah University Hospital, Jerusalem, Israel, daggerIsrael Defense Forces Medical Corp, Central Orthopaedic Clinic, Zerifin, Israel, and double daggerDepartment of Family Medicine, Hadassah University Hospital, Jerusalem, Israel.
STUDY DESIGN.: Randomized controlled trial. OBJECTIVES.: To determine if the use of custom shoe orthoses can lessen the incidence of weight bearing-induced back pain. SUMMARY OF BACKGROUND DATA.: The scientific basis for the use of orthoses to prevent back pain is based principally on studies that show that shoe orthoses can attenuate the shock wave generated at heel strike. The repetitive impulsive loading that occurs because of this shock wave can cause wear of the mechanical structures of the back. Previous randomized studies showed mixed results in preventing back pain, were not blinded, and used orthoses for only short periods of time. METHODS.: A total of 404 eligible new infantry recruits without a history of prior back pain were randomly assigned to received either custom soft, semirigid biomechanical, or simple shoe inserts without supportive or shock absorbing qualities. Recruits were reviewed biweekly by an orthopaedist for back signs and symptoms during the course of 14 weeks of basic training RESULTS.: The overall incidence of back pain was 14%. By intention-to treat and per-protocol analyses, there was no statistically significant difference between the incidence of either subjective or objective back pain among the 3 treatment groups. Significantly more recruits who received soft custom orthoses finished training in their assigned orthoses (67.5%) than those who received semirigid biomechanical orthoses (45.5%) or simple shoe inserts (48.6%), P = 0.001. CONCLUSIONS.: The results of this study do not support the use of orthoses, either custom soft or semirigid biomechanical, as prophylactic treatment for weight bearing-induced back pain. Custom soft orthoses had a higher utilization rate than the semirigid biomechanical or simple shoe inserts. The pretraining physical fitness and sports participation of recruits were not related to the incidence of weight bearing-induced back pain.
PMID: 15682005 [PubMed - as supplied by publisher]
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Proprioception and Rotation Range Sensitization Associated With Subclinical Neck Pain.
Lee H, Nicholson LL, Adams RD, Bae SS.
From the *School of Physiotherapy, Faculty of Health Sciences, University of Sydney, Sydney, Australia; and the daggerDepartment of Physical Therapy, College of Rehabilitation Science, Daegu University, Gyeongbuk, Korea.
STUDY DESIGN.: Cross-sectional study. OBJECTIVE.: To investigate neck proprioception, range of motion, muscle endurance, and self report of pain and disability in patients with subclinical neck pain. SUMMARY OF BACKGROUND DATA.: Untreated (i.e., subclinical) neck pain represents a category intermediate between "no pain" and "treated (i.e., clinical) pain." Therefore, the features that characterize it may be targeted for early management to prevent progression. METHODS.: Eighty-one healthy Korean university student volunteers, aged between 18 and 30 years (mean age, 23.2 years), were measured for proprioceptive sensitivity to differences in the extent of midrange neck retraction and rotation movements using a device that was not attached to the head; neck range of motion (twice) using the cervical range of motion device; and neck muscle endurance using a modified Biering-Sorensen test. Finally, patients were asked about any recurrent neck pain and completed Korean translations of four commonly used neck pain and disability questionnaires. RESULTS.: Patients were categorized into three frequency of neck pain groups: never/infrequent, monthly, or weekly. There were significant differences between these groups on the four self-report questionnaires. Neck muscle endurance was significantly lower for the groups reporting monthly and weekly pain compared with the never/infrequent group. At the second range of motion test, increased range was obtained for patients with infrequent or no neck pain, but left rotation range of motion was less on the second test (sensitization) for patients reporting monthly and weekly pain. Movement extent discrimination was best for the group with the greatest pain frequency. CONCLUSIONS.: A history of subclinical neck pain is associated with lower neck muscle endurance capacity and with less rotation range of motion on second testing but when frequent (occurring weekly or more often) is associated with greater sensitivity in judging neck movement extent. Improving strength and rotation range should therefore be investigated as targets of treatment for subclinical neck pain.
PMID: 15681998 [PubMed - as supplied by publisher]
Management of opioid-induced bowel dysfunction in cancer patients.
Tamayo AC, Diaz-Zuluaga PA.
Pain and Palliative Medicine Unit, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Vasco de Quiroga 15, Colonia Seccion XVI, Delegacion Tlalpan, CP 14000 Mexico, DF, Mexico. ancetaval@yahoo.com.mx
The gastrointestinal (GI) effects of morphine and other opioids may result in opioid-induced bowel dysfunction (OBD) and the need for treatment. Although OBD is very common in morphine-treated patients, it is usually under-diagnosed. Opioids deliver their GI effect through central and peripheral mechanisms. Laxatives are the pharmaceuticals prescribed most in this area. Prokinetics as well as cholinergic agonists have been used satisfactorily. One-third of patients with OBD have to be treated rectally. The use of opioid antagonists has been favored, but the bioavailability of oral forms is poor. Opioid antagonists with a quaternary structure have a high affinity for peripheral opioid receptors and therefore do not interfere with the analgesia, nor do they generate alkaloid withdrawal syndrome. Opioid rotation is another strategy for maintaining or improving analgesic quality directed toward decreasing the effects of previous opiates on the GI tract.
Publication Types:
PMID: 15221581 [PubMed - indexed for MEDLINE]
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