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Remifentanil: a novel systemic analgesic for labor pain.
Evron S, Glezerman M, Sadan O, Boaz M, Ezri T.
Department of Anesthesia, Wolfson Medical Center, Holon, Israel.
In a double-blind, randomized, controlled clinical trial, we compared the analgesic effect of remifentanil in patient-controlled IV analgesia (PCIA) during labor and delivery with the effect of an IV infusion of meperidine. Eighty-eight healthy term parturients who requested IV analgesia for labor pain were enrolled in the study and were randomly assigned to receive either increasing doses (0.27-0.93 microg/kg per bolus) of PCIA remifentanil (n=43) or an IV infusion of meperidine 150 mg (range, 75-200 mg) per patient (n=45). Remifentanil by the PCIA device was more effective and reliable analgesia for labor and delivery than IV infusion of meperidine. The visual analog score was lower (35.8 +/- 10.2 versus 58.8 +/- 12.8; P <0.001) and the patient satisfaction score higher (3.9 +/- 0.6 versus 1.9 +/- 0.4; P <0.001), with less of a sedative effect (1.2 +/- 0.1 versus 2.9 +/- 0.1; P <0.001) and less hemoglobin desaturation (97.5% +/- 1.0 versus 94.2% +/- 1.5; P <0.007). The percentage of analgesia failure (the rate of crossover from opiate to epidural analgesia) was less for remifentanil compared with meperidine (10.8% versus 38.8%; P <0.007). There were no significant differences between groups in the mode of delivery or neonatal outcome. There were fewer nonreassuring abnormal fetal heart rate patterns, i.e., higher variability and reactivity with fewer decelerations, under remifentanil therapy as compared with meperidine (P <0.001). In conclusion, an intermittent incremental regimen with repeated small-dose PCIA boluses of remifentanil provided effective and reliable analgesia during labor and delivery.
Publication Types:
- Clinical Trial
- Randomized Controlled Trial
PMID: 15616083 [PubMed - indexed for MEDLINE]
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The impact of the joint commission for accreditation of healthcare organizations pain initiative on perioperative opiate consumption and recovery room length of stay.
Frasco PE, Sprung J, Trentman TL.
Department of Anesthesiology, Mayo Clinic, 13400 East Shea Boulevard, Scottsdale AZ, 85259, USA. frasco.peter@mayo.edu
The enhanced organizational emphasis on the management of pain in hospitalized patients mandated by the Joint Commission for Accreditation of Health Care Organizations (JCAHO) pain initiative precipitated a number of changes by the perioperative services at our facility. In October 2002, a numeric pain scale became mandatory in our postanesthesia care unit (PACU). Response to analgesia in the PACU was recorded using this scale. In addition, an acceptable pain score was required for discharge from the PACU. We evaluated the effects of these changes in the pain management of 1082 patients undergoing general, orthopedic, neurosurgical, urologic, and gynecologic surgeries. We detected an overall increase in the average consumption of opiates (morphine equivalents) in 2002 compared with 2000 (46.6 +/- 20.4 mg versus 40.4 +/- 13.2 mg, P <0.001). This increase was most significant in the PACU (10.5 +/- 10.4 mg versus 6.5 +/- 7.3 mg, P <0.001 between the 2 periods, respectively). This increase in opiate use was not associated with an increased length of stay, an increase in the requirement for naloxone, or an increase in treatment for postoperative nausea and vomiting. We conclude that the increase in opiate use, which could be explained by compliance with the JCAHO pain initiative, was not associated with additional opiate-induced morbidity in the immediate postoperative period.
PMID: 15616072 [PubMed - indexed for MEDLINE]
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Parasternal block and local anesthetic infiltration with levobupivacaine after cardiac surgery with desflurane: the effect on postoperative pain, pulmonary function, and tracheal extubation times.
McDonald SB, Jacobsohn E, Kopacz DJ, Desphande S, Helman JD, Salinas F, Hall RA.
Department of Anesthesiology, Virginia Mason Medical Center, 1100 Ninth Ave., PO Box 900, Mailstop B2-AN, Seattle, WA 98111, USA. anesbm@vmmc.org
Early tracheal extubation has become common after cardiac surgery. Anesthetic techniques designed to achieve this goal can make immediate postoperative analgesia challenging. We conducted this randomized, placebo-controlled, double-blind study to investigate the effect of a parasternal block on postoperative analgesia, respiratory function, and extubation times. We enrolled 20 patients having cardiac surgery via median sternotomy; 17 patients completed the study. A de-sflurane-based, small-dose opioid anesthetic was used. Before sternal wire placement, the surgeons performed the parasternal block and local anesthetic infiltration of sternotomy and tube sites with either 54 mL of saline placebo or 54 mL of 0.25% levobupivacaine with 1:400,000 epinephrine. Effects on pain and respiratory function were studied over 24 h. Patients in the levobupivacaine group used significantly less morphine in the first 4 h after surgery (20.8 +/- 6.2 mg versus 33.2 +/- 10.9 mg in the placebo group; P=0.013); they also had better oxygenation at the time of extubation. Four of nine in the placebo group needed rescue pain medication, versus none of eight in the levobupivacaine group (P=0.08). Peak serum levobupivacaine concentrations were below potentially toxic levels in all patients (0.64 +/- 0.43 microg/mL; range, 0.24-1.64 microg/mL). Parasternal block and local anesthetic infiltration of the sternotomy wound and mediastinal tube sites with levobupivacaine can be a useful analgesic adjunct for patients who are expected to undergo early tracheal extubation after cardiac surgery.
Publication Types:
- Clinical Trial
- Randomized Controlled Trial
PMID: 15616047 [PubMed - indexed for MEDLINE]
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Postoperative analgesia and recovery after open and laparoscopic prostatectomy.
Atallah F, Khedis M, Seguin P, Fourcade O, Samii K.
Publication Types:
PMID: 15562103 [PubMed - indexed for MEDLINE]
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Single-injection paravertebral block before general anesthesia enhances analgesia after breast cancer surgery with and without associated lymph node biopsy.
Kairaluoma PM, Bachmann MS, Korpinen AK, Rosenberg PH, Pere PJ.
Department of Anesthesia and Intensive Care Medicine, Helsinki University Hospital, PO Box 580, Helsinki, FIN-00029 HUS, Finland. pekka.kairaluoma@hus.fi
Paravertebral block (PVB) seems to decrease postoperative pain and postoperative nausea and vomiting (PONV) after breast surgery, but the studies have not been placebo controlled. We studied 60 patients scheduled for breast cancer surgery randomly given single-injection PVB at T3 with bupivacaine 5 mg/mL (1.5 mg/kg) or saline before general anesthesia. The patient and attending investigators were blinded; the PVB or the sham block was performed behind a curtain by an anesthesiologist not involved in the study. The patients given PVB with bupivacaine needed 40% less IV opioid medication (primary outcome variable) in the postanesthesia care unit, had a longer latency to the first opioid dose, and had less pain at rest after 24 h than the control patients (P < 0.01). They also had less PONV in the postanesthesia care unit (P < 0.05), were less sedated until 90 min (P < 0.05), and performed better in the digit symbol substitution test at 90 min and the ocular coordination test 60-120 min after surgery (P < 0.05). The average peak bupivacaine plasma concentration was 750 ng/mL. One patient had bilateral convulsions immediately after bupivacaine injection. We conclude that PVB before general anesthesia for breast cancer surgery reduced postoperative pain, opioid consumption, and occurrence of PONV and improved recovery from anesthesia.
Publication Types:
- Clinical Trial
- Randomized Controlled Trial
PMID: 15562083 [PubMed - indexed for MEDLINE]
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Epidural blood patch and acute varicella.
Martin DP, Bergman BD, Berger IH.
Department of Anesthesiology, Mayo Clinic, 200 First St. S.W., Rochester, MN 55905, USA. martin.david@mayo.edu
We present the case of a 38-yr-old woman who required an epidural blood patch in the context of acute varicella (chickenpox). The unique risks in this case include the possible triggering of central nervous system complications after the introduction of viremic blood into the epidural or intrathecal space. However, the risk was believed to be acceptable because the patient was receiving antiviral coverage. She enjoyed complete relief of her headache but experienced transient back and leg pain. Leptomeningeal irritation caused by acute varicella infection may put patients at increased risk for pain after epidural blood patch.
Publication Types:
PMID: 15562067 [PubMed - indexed for MEDLINE]
Sonographic localization of an implanted infusion pump injection port: another useful application of ultrasound in pain medicine.
Greher M, Eichenberger U, Gustorff B.
Publication Types:
PMID: 15618822 [PubMed - indexed for MEDLINE]
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Ketamine for perioperative pain management.
Himmelseher S, Durieux ME.
Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia 22908-0710, USA.
Publication Types:
PMID: 15618805 [PubMed - indexed for MEDLINE]
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Gabapentin normalizes spinal neuronal responses that correlate with behavior in a rat model of cancer-induced bone pain.
Donovan-Rodriguez T, Dickenson AH, Urch CE.
Department of Pharmacology, University College London, London, United Kingdom.
BACKGROUND: Cancer-induced bone pain is a major clinical problem for which current treatments lack full efficacy. Gabapentin is licensed for use in neuropathic pain yet is also effective against inflammatory stimuli in animals. METHODS: A rat model of cancer-induced bone pain using the MRMT-1 cell line injected into the tibia was established to investigate the efficacy of acute (10, 30, 100 mg/kg) and chronic (30 mg/kg) systemic gabapentin on electrophysiological superficial dorsal horn neuronal responses to natural and noxious electrical stimuli, as well as on pain-related behavior. RESULTS: In electrophysiological studies gabapentin worked both acutely (100 mg/kg) and chronically (30 mg/kg) to normalize the hyperexcitable superficial dorsal horn neuronal response, significantly reducing electrical-evoked and mechanical-evoked but not thermal-evoked responses. The behavioral study showed that chronic gabapentin (30 mg/kg) significantly attenuated pain behavior in MRMT-1 rats, restoring responses to preoperative baseline degrees, and that this attenuation was accompanied by a reversion to normal (non-MRMT-1) wide-dynamic-range: nociceptive specific superficial dorsal horn neuronal profiles. CONCLUSIONS: Pain-related behavior in this rat model of cancer-induced bone pain is strongly linked to hyperexcitability of a population of superficial dorsal horn neurones. Gabapentin normalizes the cancer-induced bone pain induced dorsal horn neuronal changes and attenuates pain behavior. It may therefore provide a novel clinical treatment for cancer-induced bone pain.
PMID: 15618797 [PubMed - indexed for MEDLINE]
Comment on:
Placebos in medicine: pain that is relieved by placebo is not therefore unreal.
Moore ND.
Publication Types:
PMID: 15626815 [PubMed - indexed for MEDLINE]
Daily scheduled opioids for intractable head pain: long-term observations of a treatment program.
Lockwood AH.
Publication Types:
PMID: 15623742 [PubMed - in process]
Letter to the Editor of PAIN.
Thompson EN.
Anaesthesia and Pain Management, 1196 Beaverwood Road, Manotick, Ont., Canada K4M 1A5.
Publication Types:
PMID: 15621390 [PubMed - in process]
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Beyond dualism: the role of life stress in chronic pain.
Van Houdenhove B, Luyten P.
Department of Liaison Psychiatry, University Hospital Gasthuisberg, B-3000 Leuven, Belgium.
Publication Types:
PMID: 15621385 [PubMed - in process]
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Thalamic thermo-algesic transmission: ventral posterior (VP) complex versus VMpo in the light of a thalamic infarct with central pain.
Montes C, Magnin M, Maarrawi J, Frot M, Convers P, Mauguiere F, Garcia-Larrea L.
Dept Fisiologia, Universidad de Malaga, Campus de Teatinos s/n, 29080 Malaga, Spain.
The respective roles of the ventral posterior complex (VP) and of the more recently described VMpo (posterior part of the ventral medial nucleus) as thalamic relays for pain and temperature pathways have recently been the subject of controversy. Data we obtained in one patient after a limited left thalamic infarct bring some new insights into this debate. This patient presented sudden right-sided hypesthesia for both lemniscal (touch, vibration, joint position) and spinothalamic (pain and temperature) modalities. He subsequently developed right-sided central pain with allodynia. Projection of 3D magnetic resonance images onto a human thalamic atlas revealed a lesion involving the anterior two thirds of the ventral posterior lateral nucleus (VPL) and, to a lesser extent, the ventral posterior medial (VPM) and inferior (VPI) nuclei. Conversely, the lesion did not extend posterior and ventral enough to concern the putative location of the spinothalamic-afferented nucleus VMpo. Neurophysiological studies showed a marked reduction (67%) of cortical responses depending on dorsal column-lemniscal transmission, while spinothalamic-specific, CO2-laser induced cortical responses were only moderately attenuated (33%). Our results show that the VP is definitely involved in thermo-algesic transmission in man, and that its selective lesion can lead to central pain. However, results also suggest that much of the spino-thalamo-cortical volley elicited by painful heat stimuli does not transit through VP, supporting the hypothesis that a non-VP locus lying more posteriorly in the human thalamus is important for thermo-algesic transmission.
PMID: 15621383 [PubMed - in process]
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mGluR1 and mGluR5 antagonists in the amygdala inhibit different components of audible and ultrasonic vocalizations in a model of arthritic pain.
Han JS, Neugebauer V.
Department of Neuroscience and Cell Biology, The University of Texas Medical Branch, 301 University Blvd. RT 1069, Galveston, TX 77555-1069, USA.
Pain has a strong emotional component. The amygdala plays a key role in emotionality and is also involved in pain processing and pain modulation. Our previous studies showed an important role of group I metabotropic glutamate receptors (mGluRs) in pain-related synaptic plasticity and sensitization of neurons in the central nucleus of the amygdala (CeA). Here we address the roles of mGluR1 and mGluR5 subtypes in the CeA in the modulation of supraspinally organized behavioral responses in a model of arthritic pain. Audible and ultrasonic (25+/-4kHz) vocalizations were measured in awake rats during and after innocuous and noxious stimulation (15s) of the knee joint. Vocalizations were recorded in the same animals before arthritis, 6h after arthritis induction and during administration of antagonists selective for mGluR1 (CPCCOEt) and mGluR5 (MPEP) into the CeA through stereotaxically implanted microdialysis probes. The duration of audible and ultrasonic vocalizations increased in the arthritic pain state. The duration of vocalizations during stimulation (VDS), which are organized at the brainstem level, was significantly reduced by CPCCOEt but not by MPEP. Vocalizations that continued after stimulation (VAS), which are organized in the limbic forebrain, particularly the amygdala, were inhibited by CPCCOEt and MPEP. These findings suggest differential roles of mGluR1 and mGluR5 in the CeA in pain-related vocalizations. Both mGluR1 and mGluR5 contribute to vocalizations generated in the amygdala whereas mGluR1, but not mGluR5, is involved in the amygdala-mediated modulation of vocalizations originating from activity in the brainstem.
PMID: 15621382 [PubMed - in process]
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A placebo-controlled randomized clinical trial of perioperative administration of gabapentin, rofecoxib and their combination for spontaneous and movement-evoked pain after abdominal hysterectomy.
Gilron I, Orr E, Tu D, Peter O'neill J, Zamora JE, Bell AC.
Departments of Anesthesiology and Pharmacology and Toxicology, Queen's University, 76 Stuart Street, Kingston, Ont., Canada ON K7L 2V7.
Current treatments for post-injury movement-evoked pain are inadequate. Non-opioids may complement opioids, which preferentially reduce spontaneous pain, but most have incomplete efficacy as single agents. This trial evaluates efficacy of a gabapentin-rofecoxib combination following hysterectomy. In addition to IV-PCA morphine, 110 patients received either placebo, gabapentin (1800mg/day), rofecoxib (50mg/day) or a gabapentin-rofecoxib combination (1800/50mg/day) starting 1h pre-operatively for 72h. Outcomes included pain at rest, evoked by sitting, peak expiration and cough, morphine consumption and peak expiratory flow (PEF). For placebo, gabapentin, rofecoxib and combination, 24h pain (100mm VAS) was: at rest-23.6 (P<0.05 vs. all treatments), 13.8, 14.4 and 12.1; during cough-50.7 (P<0.05 vs. all treatments), 41.5, 44.8 and 30.8; 48h morphine consumption (mg) was: 130.4 (P<0.05 vs. all treatments), 81.7, 75.6 and 57.2 (P<0.05 vs. gabapentin and rofecoxib) and 48h PEF (% baseline) was: 63.9 (P<0.05 vs. all treatments), 77.2, 76.7 and 87.5 (P<0.05 vs. gabapentin and rofecoxib). Adverse effects were similar in all groups except sedation which was more frequent with gabapentin. Combination and rofecoxib reduced pain interference with movement, mood and sleep (P<0.05) and combination was superior to gabapentin for all these three (P<0.05). These data suggest that a gabapentin-rofecoxib combination is superior to either single agent for postoperative pain. Other benefits include opioid sparing, reduced interference with movement, mood and sleep and increased PEF suggesting accelerated pulmonary recovery. Future research should identify optimal dose-ratios for this and other analgesic combinations.
PMID: 15621380 [PubMed - in process]
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Acute and persistent pain modulation of attention-related anterior cingulate fMRI activations.
Buffington AL, Hanlon CA, McKeown MJ.
Department of Psychiatry and Behavioral Sciences, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
The anterior cingulate cortex (ACC) has been implicated in both sustained attention (SA) and pain perception. Nonetheless, only a small body of literature has examined the relationship between SA and pain perception. This study utilized fMRI to examine activation patterns that emerged in the ACC in healthy participants and participants with chronic pain (due to osteoarthritis (OA) of the knee) while completing a sustained attention task with and without exposure to an acute painful stimulus. Independent component analysis (ICA) was used to determine groups of voxels within the ACC that covaried with performance on the SA task completed with and without exposure to a painful stimulus. In all participants, two distinct spatial patterns within the ACC were isolated that reflected (1) disrupted ACC activity when a painful stimulus was applied, or (2) emergent ACC activity when a painful stimulus was applied. In the healthy group, there were broadly distributed clusters of voxels within the ACC that were modulated by painful stimulation. But in the chronic pain group, a discrete focal region of the ACC was modulated by pain. These results demonstrate that ACC activity is modulated differently during tasks of SA and pain, and that acute pain in healthy participants and participants with chronic pain result in significantly different ACC activation patterns.
PMID: 15621378 [PubMed - in process]
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Social context and acceptance of chronic pain: the role of solicitous and punishing responses.
McCracken LM.
Pain Management Unit, Royal National Hospital for Rheumatic Diseases and University of Bath, Upper Borough Walls, Bath BA1 1RL, UK.
Much of the behavior of chronic pain sufferers happens in social contexts where social influences can play a role in their suffering and disability. Researchers have investigated relations of social responses with verbal and overt pain behavior and, more recently, with patient thinking, such as catastrophizing. There has not yet been a study of social influences on patient acceptance of chronic pain. The purpose of the present study was to investigate the relations between solicitous, punishing, and distracting responses, from significant others in the patient's life, with components of patient acceptance of pain. 228 consecutive patients referred to a multidisciplinary pain center provided data for this study including their responses to the Chronic Pain Acceptance Questionnaire and the Multidimensional Pain Inventory. Primary results showed that, as predicted, both solicitous and punishing responses from significant others were negatively associated with acceptance of pain. These relations remained, independent of patient age, education, pain level, and level of general support from the significant other. These results suggest that social influences can play a role in patients' engagement in activity with pain present and their willingness to have pain without trying to avoid or control it.
PMID: 15621376 [PubMed - in process]
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Gender differences in pain modulation evoked by repeated injections of glutamate into the human trapezius muscle.
Ge HY, Madeleine P, Arendt-Nielsen L.
Center for Sensory-Motor Interaction (SMI), Department of Health Science and Technology, Aalborg University, Aalborg DK-9220, Denmark.
Gender differences in pain habituation, temporal summation, and pressure hyperalgesia evoked by repeated injections of glutamate into the dominant trapezius muscle were investigated. The glutamate-evoked muscle pain intensity and pressure pain threshold (PPT) were assessed. The PPTs were measured bilaterally in the trapezius muscles (local pain area) and posterolateral neck muscles (referred pain area) after glutamate injection in healthy and age-matched males and females (each n=14). Two glutamate injections (0.4ml, 2M each) were injected with an interval of 5min. One injection of glutamate (0.4ml, 2M) served as a control. Males, but not females, rated the second injection (maximal pain intensity) significantly less painful than the first injection. The area under the visual analogue scale pain curve of the second injection was significantly larger than the first injection in females. Repeated glutamate injections, but not one-glutamate injection, significantly decreased PPTs in the local pain area, with no significant gender differences. No PPTs changes were observed either in the contralateral trapezius muscle or bilaterally in the referred pain areas in either sex. These results suggest that a less efficient pain habituation and a greater susceptibility to the development of temporal summation of muscle pain in females, but not in males, might be one of the contributing factors to the higher incidence of neck shoulder pain in females. In addition, the reduction of PPTs in the local pain area evoked by intramuscular glutamate injection may represent an early process of peripheral pressure hyperalgesia, which is most likely gender independent.
PMID: 15621373 [PubMed - in process]
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The development and preliminary validation of a brief measure of chronic pain impact for use in the general population.
Ruehlman LS, Karoly P, Newton C, Aiken LS.
Department of Psychology, Arizona State University, Box 871104, Tempe, AZ 85287, USA.
From a biopsychosocial perspective, assessing chronic pain's psychological impact should involve at minimum the measurement of pain severity, functional interference, and pain-related emotional burden. This article details the development of a brief instrument, the 15-item Profile of Chronic Pain: Screen (PCP:S), designed to address these three key elements in a national (US) sample of over 2400 individuals recruited via random digit dialing. Retest reliability, internal consistency, and preliminary validity were excellent. The scales also demonstrated minimal social desirability response bias. A series of confirmatory factor analyses on several distinct samples revealed a stable, 3-factor solution reflecting pain severity, interference, and emotional burden. Finally, national norms were developed by gender and three age groups. In view of its strong psychometric properties, the PCP:S has the potential to serve as a brief, cost-effective assessment tool for identifying individuals whose chronic pain merits more detailed psychosocial evaluation.
PMID: 15621367 [PubMed - in process]
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The differential role of pain, work characteristics and pain-related fear in explaining back pain and sick leave in occupational settings.
Gheldof EL, Vinck J, Vlaeyen JW, Hidding A, Crombez G.
Department of Health Psychology, Limburg University Center, 3590 Diepenbeek, Belgium.
This cross-sectional questionnaire study investigated the role of pain (pain severity, radiating pain), work characteristics (physical workload, job stressors, job satisfaction), negative affect and pain-related fear in accounting for low back pain (LBP) and sick leave (SL) in 1294 employees from 10 companies in Belgium and the Netherlands. An increased risk for short-term LBP (1-30 days during the last year) was observed for workers reporting high physical workload (OR=2.39), high task exertion (OR=1.63) and high negative affect (OR=1.03). For prolonged LBP (>30 days during the last year) severe pain (OR=13.03), radiating pain (OR=2.37) and fear of work-related activities (OR=3.17) were significant risk factors. A lack of decision latitude decreased the risk of long-term LBP (OR=0.39). Short-term SL (1-30 days during the last year) was associated with severe pain (OR=2.83), high physical workload (OR=2.99) and high fear of movement/(re)injury (OR=1.88). A lack of decision latitude increased the risk of short-term SL (OR=1.92). Long-term SL (>30 days during the last year) was associated with radiating pain (OR=3.80) and high fear of movement/(re)injury (OR=6.35). A lack of co-worker support reduced the risk of long-term SL (OR=0.27). These results suggest that physical load factors are relatively more important in the process leading to short-term LBP and short-term SL, whereas job stressors, severe pain, radiation, and pain-related fear are more important in determining the further course and maintenance of the inability to work. The potential implications of these findings for primary and secondary prevention, and occupational rehabilitation are discussed.
PMID: 15621366 [PubMed - in process]
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Ketamine and postoperative pain - a quantitative systematic review of randomised trials.
Elia N, Tramer MR.
EBCAP Institute (Evidence-Based Critical care, Anaesthesia and Pain treatment), Division of Anaesthesiology, Geneva University Hospitals, 24 Rue Micheli-du-Crest, CH-1211 Geneva 14, Switzerland.
Ketamine, an N-methyl-d-aspartate receptor antagonist, is known to be analgesic and to induce psychomimetic effects. Benefits and risks of ketamine for the control of postoperative pain are not well understood. We systematically searched for randomised comparisons of ketamine with inactive controls in surgical patients, reporting on pain outcomes, opioid sparing, and adverse effects. Data were combined using a fixed effect model. Fifty-three trials (2839 patients) from 25 countries reported on a large variety of different ketamine regimens and surgical settings. Sixteen studies tested prophylactic intravenous ketamine (median dose 0.4mg/kg, range (0.1-1.6)) in 850 adults. Weighted mean difference (WMD) for postoperative pain intensity (0-10cm visual analogue scale) was -0.89cm at 6h, -0.42 at 12h, -0.35 at 24h and -0.27 at 48h. Cumulative morphine consumption at 24h was significantly decreased with ketamine (WMD -15.7mg). There was no difference in morphine-related adverse effects. The other 37 trials tested in adults or children, prophylactic or therapeutic ketamine orally, intramuscularly, subcutaneously, intra-articulary, caudally, epidurally, transdermally, peripherally or added to a PCA device; meta-analyses were deemed inappropriate. The highest risk of hallucinations was in awake or sedated patients receiving ketamine without benzodiazepine; compared with controls, the odds ratio (OR) was 2.32 (95%CI, 1.09-4.92), number-needed-to-harm (NNH) 21. In patients undergoing general anaesthesia, the incidence of hallucinations was low and independent of benzodiazepine premedication; OR 1.49 (95%CI 0.18-12.6), NNH 286. Despite many published randomised trials, the role of ketamine, as a component of perioperative analgesia, remains unclear.
PMID: 15621365 [PubMed - in process]
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The joint contribution of physical pathology, pain-related fear and catastrophizing to chronic back pain disability.
Peters ML, Vlaeyen JW, Weber WE.
Department of Medical, Clinical and Experimental Psychology, Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands.
The present study examined the contribution of physical pathology, pain-related fear and catastrophizing cognitions to pain intensity and disability in 100 patients with non-specific low back pain. Self-report instruments were completed as part of the intake procedure of patients, while physical pathology was quantified from medical charts using the MEDICS procedure. Results of the multiple regression analyses, adjusted for relevant demographic variables, pain intensity and pain duration, indicated that physical pathology was associated with pain intensity, but not with self-reported physical disability. Disability showed the strongest association with pain intensity. However, pain-related fear and catastrophizing contributed 4-10% additional explained variance to the regression models for pain intensity and disability. Thus, this study confirms the relationship between biological and psychological variables in determining the severity of low back pain complaints, and underscores the necessity for a multidisciplinary approach to diagnostics and intervention.
PMID: 15621363 [PubMed - in process]
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Categorizing the severity of cancer pain: further exploration of the establishment of cutpoints.
Paul SM, Zelman DC, Smith M, Miaskowski C.
Department of Physiological Nursing, University of California, 2 Koret Way-N631Y, San Francisco, CA 94143-0610, USA.
Previous work by Serlin and colleagues established cutpoints for mild, moderate, and severe cancer pain based on the pain's level of interference with function. Recent work found differences in cutpoints for pain severity for different pain-related conditions. Reasons for these discrepancies may relate to the methods used to determine the cutpoints or to differences based on the type or the cause of the pain. The purposes of this study were to determine the optimal cutpoints for mild, moderate, and severe pain based on patients' ratings of average and worst pain severity, using a larger range of potential cutpoints, and to determine if those cutpoints distinguished among the three pain severity groups on several outcome measures. Results from a homogenous sample of oncology outpatients with pain from bone metastasis confirm a non-linear relationship between cancer pain severity and interference with function and also confirm that the boundary between a mild and a moderate level of cancer pain is at 4 on a 0-10 numeric rating scale. However, this analysis did not confirm the boundary between moderate and severe cancer pain previously described by Serlin and colleagues . In addition, these results were not consistent with the cutpoints that were found for back pain, phantom limb pain, pain 'in general', or osteoarthritis pain reported by Jensen and colleagues and Zelman and colleagues . Possible explanations for these differences are discussed, as well as implications for future research.
PMID: 15621362 [PubMed - in process]
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Ethnic differences in responses to multiple experimental pain stimuli.
Campbell CM, Edwards RR, Fillingim RB.
College of Clinical and Health Psychology, University of Florida, Gainesville, FL, USA.
A growing body of literature suggests that the experience of clinical pain differs across ethnocultural groups. Additionally, some evidence indicates greater sensitivity to experimentally induced pain among African Americans; however, most studies have included only one pain modality. This study examined ethnic differences in responses to multiple experimental pain stimuli, including heat pain, cold pressor pain, and ischemic pain. Heat pain threshold and tolerance, ratings of repetitive suprathreshold heat, and ischemic and cold pressor pain threshold and tolerance were assessed in 120 (62 African American, 58 white) healthy young adults. Also, several psychological instruments were administered. No ethnic group differences emerged for threshold measures, but African Americans had lower tolerances for heat pain, cold pressor pain and ischemic pain compared to whites. Ratings of intensity and unpleasantness for suprathreshold heat stimuli were significantly higher among African Americans. African Americans reported greater use of passive pain coping strategies and higher levels of hypervigilance. Controlling for passive pain coping did not account for group differences in pain responses, while controlling for hypervigilance rendered group differences in heat pain tolerance and ischemic pain tolerance non-significant. These findings demonstrate differences in laboratory pain responses between African Americans and whites across multiple stimulus modalities, and effect sizes for these differences in pain tolerance were moderate to large for suprathreshold measures. Hypervigilance partly accounted for group differences. Additional research to determine the mechanisms underlying these effects is warranted.
PMID: 15621360 [PubMed - in process]
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Core outcome measures for chronic pain clinical trials: IMMPACT recommendations.
Dworkin RH, Turk DC, Farrar JT, Haythornthwaite JA, Jensen MP, Katz NP, Kerns RD, Stucki G, Allen RR, Bellamy N, Carr DB, Chandler J, Cowan P, Dionne R, Galer BS, Hertz S, Jadad AR, Kramer LD, Manning DC, Martin S, McCormick CG, McDermott MP, McGrath P, Quessy S, Rappaport BA, Robbins W, Robinson JP, Rothman M, Royal MA, Simon L, Stauffer JW, Stein W, Tollett J, Wernicke J, Witter J.
Department of Anesthesiology, University of Rocheser School of Medicine and Dentistry, Rochester, NY 14642, USA.
PMID: 15621359 [PubMed - in process]
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Attention and pain: merging behavioural and neuroscience investigations.
Eccleston C, Crombez G.
Pain Management Unit, Level 7, Wessex House, The University of Bath, Bath BA2 7AY, UK.
Publication Types:
PMID: 15621358 [PubMed - in process]
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Role of cutpoints: why grade pain intensity?
Anderson KO.
Division of Internal Medicine, Department of Symptom Research, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 221, Houston, TX 77030, USA.
Publication Types:
PMID: 15621357 [PubMed - in process]
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The need for ecological validity in studies of pain and ethnicity.
Rollman GB.
Department of Psychology and Interdisciplinary Pain Program, University of Western Ontario, Social Science Centre, London, Ont., Canada N6A 5C2.
Publication Types:
PMID: 15621356 [PubMed - in process]
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Consensus on outcome measures for chronic pain trials.
McQuay H.
Department of Pain Relief, University of Oxford, Churchill Hospital, Oxford OX3 7LJ, UK.
Publication Types:
PMID: 15621355 [PubMed - in process]
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Spinal cord stimulation for chronic back and leg pain and failed back surgery syndrome: a systematic review and analysis of prognostic factors.
Taylor RS, Van Buyten JP, Buchser E.
University of Birmingham, Birmingham, United Kingdom. r.s.taylor@bham.ac.uk
STUDY DESIGN: Systematic review. OBJECTIVES: To assess efficacy and safety of spinal cord stimulation in patients with chronic leg and back pain and failed back surgery syndrome and to examine prognostic factors that predict spinal cord stimulation outcome. SUMMARY OF BACKGROUND DATA: A previous systematic review of spinal cord stimulation in patients with chronic back and leg pain and failed back surgery syndrome by Turner et al in 1995 identified 39 case studies and no controlled studies. METHODS: A number of electronic databases were searched through January 2002. Citation searching of included papers was undertaken, and gray literature was sought through contact with clinical experts. No language restrictions were applied. All controlled and noncontrolled study designs were included. Study selection was carried out independently by two reviewers. Prognostic factors (age, sex, duration of pain, time post surgery, follow-up duration, publication year, data collection year, indication, data collection country, study setting, and quality score) responsible for pain relief outcome across case series were examined using univariate and multivariate metaregression. RESULTS: One randomized controlled trial, one cohort study, and 72 case studies were included. The randomized controlled trial reported a significant benefit (P = 0.047) in the proportion of patients with failed back surgery syndrome reporting 50% or more pain relief with spinal cord stimulation (37.5%) compared with patients undergoing back reoperation (11.5%). There was evidence of substantial statistical heterogeneity (P < 0.0001) in the level of pain relief following spinal cord stimulation reported across case series studies. The four principal prognostic factors found to be predictive of increased level of pain relief with spinal cord stimulation were poor study quality score, short follow-up duration, multicenter (versus single center) studies, and the inclusion of patients with failed back surgery syndrome (versus chronic back and leg pain). Overall, 43% of patients with chronic back and leg pain/failed back surgery syndrome experienced one or more complications following a spinal cord stimulation implant, although no major adverse events were reported. CONCLUSIONS: Despite an increase in the number of studies over the last 10 years, the level of evidence for the efficacy of spinal cord stimulation in chronic back and leg pain/failed back surgery syndrome remains "moderate." Prognostic factors found to be predictive of the level of pain relief following spinal cord stimulation were study quality, follow-up duration, study setting, and patient indication.
PMID: 15626996 [PubMed - in process]
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A randomized controlled trial on the efficacy of exercise for patients with chronic neck pain.
Chiu TT, Lam TH, Hedley AJ.
Department of Rehabilitation Sciences, Hong Kong Polytechnic University, Hung Hom, Hong Kong. rstchiu@polyu.edu.hk
STUDY DESIGN: A randomized controlled trial with single-blind outcome assessments. OBJECTIVE: To evaluate the efficacy of a neck exercise program in patients with chronic neck pain. SUMMARY OF BACKGROUND DATA: The effect of exercise for patients with chronic neck pain has been investigated in a number of studies. The efficacy is, however, questionable. METHODS: A total of 145 patients were randomly allocated into an exercise (n = 67) and a nonexercise (control) group (n = 78). Patients in the control group were given infrared irradiation and neck care advice. In addition to infrared irradiation and advice, patients in the exercise group had undergone an exercise program with activation of the deep neck muscles and dynamic strengthening of the neck muscles for 6 weeks. Subjective pain and disability and isometric neck muscle strength were measured at baseline, 6 weeks, and 6 months. Analysis was by intention-to-treat. RESULTS: At week 6, the exercise group had a significantly better improvement in disability score (P = 0.03), subjective report of pain (P = 0.01), and in isometric neck muscle strength (P = 0.57-0.00) in most of the directions than the control group. However, significant differences between the two groups were found only in the subjective report of pain and patient satisfaction at the 6-month follow-up. CONCLUSIONS: At week 6, patients with chronic neck pain can benefit from the neck exercise program with significant improvement in disability, pain, and isometric neck muscle strength in different directions. However, the effect of exercise was less favorable at 6 months.
PMID: 15626966 [PubMed - in process]
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