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Sacral postherpetic neuralgia and successful treatment using a paramedial approach to the ganglion impar.
McAllister RK, Carpentier BW, Malkuch G.
Department of Anesthesiology, Scott and White Memorial Hospital and Clinic, Temple, Texas, USA. mcallister@swmail.sw.org
Publication Types:
PMID: 15564959 [PubMed - indexed for MEDLINE]
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Efficacy of a prophylactic epidural blood patch in preventing post dural puncture headache in parturients after inadvertent dural puncture.
Scavone BM, Wong CA, Sullivan JT, Yaghmour E, Sherwani SS, McCarthy RJ.
Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, USA. bscavone@nmff.org
BACKGROUND: Postdural puncture headache (PDPH) occurs in up to 80% of parturients who experience inadvertent dural puncture during epidural catheter placement. The authors performed a randomized double blind study to assess the effect of prophylactic epidural blood patch on the incidence of PDPH and the need for therapeutic epidural blood patch. METHODS: Sixty-four parturients who incurred inadvertent dural puncture were randomized to receive a prophylactic epidural blood patch with 20 ml autologous blood (prophylactic epidural blood patch group) or a sham patch (sham group). Subjects were evaluated daily for development of PDPH for a minimum of 5 days after dural puncture. Those who developed a PDPH were followed daily for a minimum of 3 days after resolution of the headache. Subjects with moderate headaches who reported difficulties performing childcare activities and all those with severe headaches were advised to receive a therapeutic epidural blood patch. RESULTS: Eighteen of 32 subjects in each group (56%) developed PDPH. Therapeutic blood patch was recommended in similar numbers of patients in each group. The groups had similar onset time of PDPH, median peak pain scores, and number of days spent unable to perform childcare activities as a result of postural headache. The median duration of PDPH, however, was shorter in the prophylactic epidural blood patch group. CONCLUSIONS: A decrease in the incidence of PDPH or the need for criteria-directed therapeutic epidural patch was not detected when a prophylactic epidural blood patch was administered to parturients after inadvertent dural puncture. However, prophylactic epidural blood patch did shorten the duration of PDPH symptoms.
Publication Types:
- Clinical Trial
- Randomized Controlled Trial
PMID: 15564951 [PubMed - indexed for MEDLINE]
Comment in:
Combinations of bupivacaine, fentanyl, and clonidine for lumbar epidural postoperative analgesia: a novel optimization procedure.
Sveticic G, Gentilini A, Eichenberger U, Zanderigo E, Sartori V, Luginbuhl M, Curatolo M.
Division of Pain Therapy, Department of Anesthesiology, Inselspital, Bern, Switzerland. gorazd.sveticic@insel.ch
BACKGROUND: The authors developed and applied a method to optimize the combination of bupivacaine, fentanyl, and clonidine for continuous postoperative lumbar epidural analgesia. METHODS: One hundred eighteen patients undergoing knee or hip surgery participated in the study. Postoperative epidural analgesia during 48 h after surgery was optimized under restrictions dictated by side effects. Initially, eight combinations of bupivacaine, fentanyl, and clonidine (expressed as drug concentration in the solution administered) were empirically chosen and investigated. To determine subsequent combinations, an optimization model was applied until three consecutive steps showed no decrease in pain score. For the first time in a clinical investigation, a regression model was applied when the optimization procedure led to combinations associated with unacceptable side effects. RESULTS: The authors analyzed 12 combinations with an allowed bupivacaine concentration range of 0-2.5 mg/ml, a fentanyl concentration range of 0-5 microg/ml, and a clonidine concentration range of 0-5 microg/ml. The best combinations of bupivacaine, fentanyl, and clonidine concentrations were 1.0 mg/ml-1.4 microg/ml-0.5 microg/ml, 0.9 mg/ml-3.0 microg/ml-0.3 microg/ml, 0.6 mg/ml-2.5 microg/ml-0.8 microg/ml, and 1.0 mg/ml-2.4 microg/ml-1.0 microg/ml, respectively, all producing a similarly low pain score. The incidence of side effects was low. The application of the regression model to combinations associated with high incidence of motor block successfully directed the optimization procedure to combinations within the therapeutic range. CONCLUSIONS: The results support further study of the combinations of bupivacaine, fentanyl, and clonidine mentioned above for postoperative analgesia after knee and hip surgery. This novel optimization method may be useful in clinical research.
Publication Types:
- Clinical Trial
- Randomized Controlled Trial
PMID: 15564946 [PubMed - indexed for MEDLINE]
Comment on:
Physiotherapy for neck and back pain.
Harvey N, Cooper C.
Publication Types:
PMID: 15637350 [PubMed - indexed for MEDLINE]
What use is pain?
Nash TP.
Publication Types:
PMID: 15629906 [PubMed - in process]
Efficacy of spinal cord stimulation for neuropathic pain: assessment by abstinence; Monhemius R, Simpson BA, Eur J Pain 2003;7:513-9.
Simpson BA.
Department of Neurosurgery, University Hospital of Wales, Heath Park, Cardiff CF14 4XW, UK.
Publication Types:
PMID: 15629881 [PubMed - in process]
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Efficacy of spinal cord stimulation for neuropathic pain: assessment by abstinence; Monhemius R, Simpson B, Eur J Pain 2003,7;513-9.
Devulder J, Crombez E, Brusselmans G.
Department of Anesthesia and Pain Clinic, Ghent University Hospital, De Pintelaan 185, Ghent 9810, Belgium.
Publication Types:
PMID: 15629880 [PubMed - in process]
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Evidence for the involvement of endogenous ATP and P2X receptors in TMJ pain.
Oliveira MC, Parada CA, Veiga MC, Rodrigues LR, Barros SP, Tambeli CH.
Laboratory of Orofacial Pain, Department of Physiology, Faculty of Dentistry of Piracicaba, University of Campinas - UNICAMP, Limeira Av, 901 Zip Code, 13414-900, Piracicaba, SP, Brazil.
Evidence is accumulating which supports a role for ATP in the initiation of pain by acting on P2X receptors expressed on nociceptive afferent nerve terminals. To investigate whether these receptors play a role in temporomandibular (TMJ) pain, we studied the presence of functional P2X receptors in rat TMJ by examining the nociceptive behavioral response to the application of the selective P2X receptor agonist alpha,beta-methylene ATP (alpha,beta-meATP) into the TMJ region of rat. The involvement of endogenous ATP in the development of TMJ inflammatory hyperalgesia was also determined by evaluating the effect of the general P2 receptor antagonist pyridoxal-phosphate-6-azophenyl- [Formula: see text] , [Formula: see text] -disulphonic acid (PPADS) on carrageenan-induced TMJ inflammatory hyperalgesia. Application of alpha,beta-meATP into the TMJ region of rats produced significant nociceptive responses that were significantly reduced by the co-application of lidocaine N-ethyl bromide quaternary salt, QX-314, (2%) or of the P2 receptor antagonist PPADS. Co-application of PPADS with carrageenan into the TMJ significantly reduced inflammatory hyperalgesia. The results indicate that functional P2X receptors are present in the TMJ and suggest that endogenous ATP may play a role in TMJ inflammatory pain mechanisms possibly by acting primarily in these receptors.
PMID: 15629879 [PubMed - in process]
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The effect of eye orientation on slowly increasing pain.
Naveteur J, Mars F, Crombez G.
Departement de Biologie, Universite de Lille 1, SN4.1, F-596555 Villeneuve d'Ascq Cedex, France.
The present study investigated the influence of eye orientation upon the experience of pain. Quasi continuous electrocutaneous stimuli which slowly increased in intensity were delivered to 32 healthy females volunteers. Participants were instructed to direct the eyes at locations that were ipsilateral or contralateral to the stimulated hand. Unpleasantness threshold and pain threshold were significantly higher when the eyes were oriented ipsilateral towards the stimulated hand. In a second experiment phase, the pain intensity increased until tolerance. There was no effect of eye orientation upon pain threshold and tolerance. Results of the first experimental part are in line with the counterintuitive idea that selective monitoring reduces pain distress. The lack of significant results in the second experiment phase is discussed in terms of statistical power and a change in coping induced by the expectation of high intensity pain.
PMID: 15629878 [PubMed - in process]
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Prevalence and treatment of pain in adults admitted to Italian hospitals.
Visentin M, Zanolin E, Trentin L, Sartori S, de Marco R.
Department of Oncology, Pain Therapy and Palliative Care Unit, S. Bortolo Hospital, Via Rodolfi 37, 36100 Vicenza, Italy.
Background: Very few studies have been conducted on the presence and control of pain in Italian hospitals. Aims: The present study estimates pain prevalence and therapy in Italian hospitalised patients. Methods: In the autumn of 2000, a survey was taken on 4523 inpatients throughout Italy. All eligible patients were given a questionnaire with two Numerical Rating Scales (NRS) concerning their pain intensity at interview and over the previous 24 h. Nurses were given a second questionnaire asking for information on analgesic treatment and another NRS about the pain they supposed the patient felt. Results: At interview, 91.2% (95%CI: 90.3-92.1%) of the patients reported pain; 46.6% reported severe pain. The prevalence of severe pain was significantly lower in women and was double in general medicine wards compared to surgical wards. The degree of agreement between the pain reported by the patient and the pain scores given by the nurse was poor (Cohen [Formula: see text] ). Only 28.5% of the inpatients had taken analgesics in the past 24 h and the probability of receiving analgesic treatment was higher for women (adjusted OR=1.33, 95%CI: 1.14-1.54) and lower for general medicine compared to surgical wards (adjusted OR=0.55, 95%CI: 0.45-0.64), while it was unrelated both to the patient's self-reported pain and to level of pain assessed by the nurse. Conclusions: Pain affects an impressively high percentage of inpatients and is largely untreated and unrecognised in Italian wards. Educational intervention is required to improve the knowledge and attitudes of health professionals towards the approach and handling of patients in pain.
PMID: 15629876 [PubMed - in process]
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Survey of assessment criteria prior to implantation of spinal cord stimulators in United Kingdom pain management centres.
Ackroyd R, Bush DJ, Graves J, McVey J, Horton S.
Leeds Pain Management Service, St James Hospital NHS Trust, Leeds, UK.
Spinal cord stimulation (SCS) is a useful option in selected patients with chronic neuropathic pain. The aim of this questionnaire-based survey was to determine what assessment methods are used for patients being considered for SCS in pain management centres in the United Kingdom. This was in relation to the recommendations produced by the Task Force of the European Federation of IASP chapters (1998) on neuromodulation. Questionnaires were sent out to previously identified individual SCS implanters. The response rate was 64% ( [Formula: see text] ). The results of the survey were generally encouraging. Just over half of respondents use some form of guideline to assess patients for SCS, most trying opioid and co-analgesia before proceeding to SCS insertion. There was significant variation concerning absolute contraindications. The majority of respondents worked in a multi-disciplinary team and 61% stated their patients received a psychological assessment but although 96% of individuals worked with a specialist nurse only 25% reported that the nurse had an active role in the pre-assessment of patients for SCS. The development of national guidelines may provide a more standardised approach but further research into the role of the specialist nurse and the benefits of psychological assessment would also be useful.
PMID: 15629875 [PubMed - in process]
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Predictive value of symptom level measurements for complex regional pain syndrome type I.
Perez RS, Keijzer C, Bezemer PD, Zuurmond WW, de Lange JJ.
Department of Anesthesiology, VU University medical center, P.O. Box 7057, 1007 MB, Amsterdam, The Netherlands.
The validity with respect to presence or absence of CRPS I according to Veldman's criteria was assessed for measured pain, temperature, volume differences and limitations in range of motion. Evaluated were 155 assessments of 66 outpatients, initially diagnosed with CRPS I, but many of them not so on follow up visits. Pain was measured with VAS and McGill, temperature by infrared thermometry, volume differences by water displacement volumeters and limitations in range of motion by universal goniometers. Sensitivity, specificity, positive and negative predictive value of the measurement instruments at different cut-off points was calculated. Combined symptom scores were evaluated in a similar fashion. High sensitivity was found for the VAS, McGill, and range of motion. The specificity was overall lower, but highest values were obtained for volume differences. The positive predictive value was good for all measurement instruments. Negative predictive value was lower, especially for measurement of temperature and volume asymmetries. If sensitivity and specificity are equally important, VAS [Formula: see text] 3 cm, McGill [Formula: see text] 6 words, temperature difference 0.4 degrees C, volume difference [Formula: see text] 6.5% and ROM limitation [Formula: see text] 15% provide the best results. Using these cut off values, the highest value of sensitivity and of sensitivity and specificity combined, was found for a combination of VAS, McGill and ROM. The highest value of specificity was found for different combinations of 3, 4 and 5 instruments, all containing the VAS. We conclude that the measured pain, temperature, volume and range of motion can be used as diagnostic indicators for establishing presence or absence of CRPS I.
PMID: 15629874 [PubMed - in process]
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Deep pain thresholds in the distal limbs of healthy human subjects.
Rolke R, Andrews Campbell K, Magerl W, Treede RD.
Institute of Physiology and Pathophysiology, Johannes Gutenberg University, Saarstr. 21, D-55099 Mainz, Germany.
Pressure pain thresholds (PPTs) in distal limbs have been under-investigated despite their potential clinical importance. Therefore, we compared PPTs over nail bed, bony prominences, and muscle in distal parts of upper and lower limbs. We investigated 12 healthy subjects using three handheld devices: a spring-loaded, analogue pressure threshold meter (PTM) with two operating ranges, and an electronic Algometer. PPTs were determined with three series of ascending stimulus intensities with a ramp of about 50 kPa/s. PPTs were normally distributed in logarithmic space. PPTs over different tissues varied significantly (ANOVA, [Formula: see text] ): mean thresholds and 95% confidence intervals were 615 kPa (266-1424 kPa) over the nail bed, 581 kPa (271-1245 kPa) over bony prominences, and 520 kPa (246-1100 kPa) over muscles. PPTs on the foot were higher than on the hand (ANOVA, [Formula: see text] ), except over muscles. PPTs were significantly lower with the Algometer than with PTMs (ANOVA, [Formula: see text] ); again these differences were least when testing over muscle. There was no significant right-left difference (ANOVA, [Formula: see text] ). In spite of considerable variability across subjects, reproducibility within subjects was high (correlation coefficients [Formula: see text] 0.90). For within-subject comparisons, threshold elevations beyond 33-43% would be abnormal (95% confidence intervals), whereas only deviations from the group mean by at least a factor of two would be abnormal with respect to absolute normative values. PPTs over distal muscles were comparable to published values on proximal limb and trunk muscles. These findings suggest that pressure pain testing over distal muscles may be a sensitive test for deep pain sensitivity and that the simple and less expensive devices are sufficient for testing this tissue type. Intra-individual site-to-site comparisons will be more sensitive than absolute normative values.
PMID: 15629873 [PubMed - in process]
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Randomized double-blind comparison of serotonergic (Citalopram) versus noradrenergic (Reboxetine) reuptake inhibitors in outpatients with somatoform, DSM-IV-TR pain disorder.
Aragona M, Bancheri L, Perinelli D, Tarsitani L, Pizzimenti A, Conte A, Inghilleri M.
Department of Psychiatry, University of Rome "La Sapienza", V.le Universita 30 00185 Rome, Italy.
Objectives: Whether the effect of tricyclic antidepressants on Pain Disorder arises from their noradrenergic or serotonergic actions or both remains unclear. We compared the selective serotonin reuptake inhibitor (SSRI) citalopram and the noradrenergic reuptake inhibitor (NARI) reboxetine in outpatients with Pain Disorder. We also distinguished the drugs' analgesic and antidepressant effects. Methods: In this 8-week, randomized double-blind study, 35 patients with a DSM-IV-TR diagnosis of Pain Disorder were randomly assigned to receive either citalopram 40 mg/day ( [Formula: see text] patients) or reboxetine 8 mg/day ( [Formula: see text] ). The Present Pain Intensity (PPI) scale and the Total Pain Rating Index (tPRI) of the McGill Pain Questionnaire were used to measure the effect on pain symptoms. Changes in the Zung Self-Rating Depression Scale (Zung-D) scores were evaluated to monitor a possible antidepressant effect. For all patients who had at least one assessment, an intent-to-treat analysis was performed. Results: No significant differences were found in the demographic variables or clinical characteristics of the two treatment groups. In the citalopram group, PPI and tPRI scores measured at baseline decreased after treatment (tPRI: 41.9 vs. 30.0, [Formula: see text] ; PPI: 3.5 vs. 2.8, [Formula: see text] ) whereas in the reboxetine group differences were not statistically significant (tPRI: 35.2 vs. 31.5; PPI: 3.7 vs. 3.1). The Zung-D showed no significant changes between baseline and endpoint assessment in either group. Conclusions: Our study suggests that the SSRI citalopram may have a moderate analgesic effect in patients with Pain Disorder, and that this analgesic activity appears to be not correlated to changes in depressive scores. If confirmed in a larger sample, this evidence suggests that patients who are intolerant or resistant to tricyclic antidepressants, may be treated with SSRIs.
PMID: 15629872 [PubMed - in process]
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Quality of life in chronic pain is more associated with beliefs about pain, than with pain intensity.
Lame IE, Peters ML, Vlaeyen JW, Kleef MV, Patijn J.
Pain Management and Research Centre, University Hospital Maastricht, P.O. Box 5800, 6202 AZ Maastricht, The Netherlands.
Objectives. The objectives of this study were to investigate pain cognitions and quality of life of chronic pain patients referred to a multi-disciplinary university pain management clinic and to search for predictors of quality of life. Methods. A heterogeneous group of 1208 chronic pain patients referred to the Maastricht university hospital pain clinic participated in this cross-sectional study. At the initial assessment, all patients completed a set of questionnaires on demographic variables, cause, location, pain intensity (McGill pain questionnaire, MPQ), pain coping and beliefs (pain coping and cognition list, PCCL), pain catastrophising (pain catastrophising scale, PCS) and eight dimensions of quality of life (Rand-36). Results. The results showed that the present sample of heterogeneous pain patients reported low quality of life on each domain and significantly lower scores than has been found in previous studies with other Dutch chronic pain populations. Patients with low back pain and multiple pain localisations experienced most functional limitations. Women reported more pain, more catastrophising thoughts about pain, more disability and lower vitality and general health. When tested in a multiple regression analysis, pain catastrophising turned out to be the single most important predictor of quality of life. Especially social functioning, vitality, mental health and general health are significantly associated with pain catastrophising. Conclusions. Patients from a multi-disciplinary university pain clinic experience strikingly low quality of life, whereby low back pain patients and patients with multiple pain localisations have the lowest quality of life. Pain catastrophising showed the strongest association with quality of life, and stronger than pain intensity.
PMID: 15629870 [PubMed - in process]
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Opioids in renal failure and dialysis patients.
Dean M.
Palliative Care Department, Western Memorial Regional Hospital, Corner Brook, Newfoundland and Labrador, Canada.
This article reviews the literature pertaining to the metabolism of several of the commonly used opioids, and the known activity of their metabolites. The effect of renal failure on the pharmacokinetics of these drugs and metabolites is then reviewed. Finally, the effect of renal dialysis on opioid drugs and metabolites is reviewed. Based on the review, it is recommended that morphine and codeine are avoided in renal failure/dialysis patients; hydromorphone or oxycodone are used with caution and close monitoring; and that methadone and fentanyl/sufentanil appear to be safe to use. Note is made that the "safe" drugs in renal failure are also the least dialyzable.
Publication Types:
PMID: 15504625 [PubMed - indexed for MEDLINE]
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Dr. George Crile--early contributions to the theoretic basis for twenty-first century pain medicine.
Tetzlaff JE, Lautsenheiser F, Estafanous FG.
Center for Anesthesiology Education, Division of Critical Centre, E30, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA. tetzlaj@ccf.org
PMID: 15635520 [PubMed - in process]
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Management of perioperative pain in patients chronically consuming opioids.
Carroll IR, Angst MS, Clark JD.
Veterans Affairs, Palo Alto Health Care System, and Stanford University Department of Anesthesiology, 3801 Miranda Ave., Palo Alto, CA 94304, USA.
BACKGROUND: The prevalence of licit and illicit opioid use is growing, and a greater percentage of chronically opioid-consuming patients are presenting for surgery. These patients can be expected to experience increased postoperative pain, greater postoperative opioid consumption, and prolonged use of healthcare resources for managing their pain. METHODS: Achieving adequate pain control in these patients can be challenging because commonly used strategies for alleviating postoperative pain may have diminished effectiveness. We explore the prevalence and characteristics of opioid use in the United States and discuss its impact on the perioperative management of pain. We examine mechanistically why adequate perioperative pain control in chronically opioid-consuming patients may be difficult. CONCLUSIONS: We present strategies for providing adequate analgesia to these patients that include the optimal use of opioids, adjuvant medications, and regional anesthetic techniques.
PMID: 15635517 [PubMed - in process]
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Clinical hypnosis modulates functional magnetic resonance imaging signal intensities and pain perception in a thermal stimulation paradigm.
Schulz-Stubner S, Krings T, Meister IG, Rex S, Thron A, Rossaint R.
Department of Anesthesia, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, 6 JCP, Iowa City, IA 52242-1079, USA. Sebastian-schulz-stubner@uiowa.edu
OBJECTIVE: This study was designed to describe regional changes in blood oxygenation level dependent signals in functional magnetic resonance images (fMRI) elicited by thermal pain in hypnotized subjects. These signals approximately identify the neural correlates of the applied stimulation to identify neuroanatomic structures involved in the putative effects of clinical hypnosis on pain perception. METHODS: After determination of the heat pain threshold of 12 healthy volunteers, fMRI scans were performed at 1.5 Tesla by using echoplanar imaging technique during repeated painful heat stimuli. Activation of brain regions in response to thermal pain during hypnosis (using a fixation and command technique of hypnosis) was compared with responses without hypnosis. RESULTS: With hypnosis, less activation in the primary sensory cortex, the middle cingulate gyrus, precuneus, and the visual cortex was found. An increased activation was seen in the anterior basal ganglia and the left anterior cingulate cortex. There was no difference in activation within the right anterior cingulate gyrus in our fMRI studies. No activation was seen within the brainstem and thalamus under either condition. CONCLUSION: Our observations indicate that clinical hypnosis may prevent nociceptive inputs from reaching the higher cortical structures responsible for pain perception. Whether the effects of hypnosis can be explained by increased activation of the left anterior cingulate cortex and the basal ganglia as part of a possible inhibitory pathway on pain perception remains speculative given the limitations of our study design.
PMID: 15635514 [PubMed - in process]
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