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Defining the outcomes of risk stratification studies of ED patients with chest pain: the marginal value of adding revascularization to the composite end point.
Chen EH, Sites F, Shofer FS, Hollander JE.
Department of Emergency Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA 19104-4283, USA.
OBJECTIVES: Cardiovascular risk stratification studies use various end points, sometimes including revascularization. We assessed whether adding revascularization to a strictly defined composite end point of death, acute myocardial infarction (AMI), and unstable angina (UA) impacts the likelihood of patients attaining the composite end point. METHODS: We conducted a secondary analysis of a prospectively collected data set of emergency department patients who received an electrocardiogram for chest pain. Patients were followed daily; discharged patients had 30-day telephone follow-up. The main outcome was a 30-day composite end point of death, AMI, and UA compared with death, AMI, UA, and revascularization. RESULTS: There were 4492 patients enrolled (mean age, 52 +/- 16 years; men, 41%; African American, 68%). One hundred seventy patients were revascularized (158 had AMI or UA). Overall, the incidence of death/AMI/UA was 20.1% (95% confidence interval, 18.9%-21.2%). With revascularization included, the incidence of the composite end point was 20.3% (95% confidence interval, 19.1%-21.5%). CONCLUSION: When both AMI and UA are strictly defined, there appears to be a limited role for adding revascularization to a composite end point of death, AMI, and UA because most revascularized patients have a diagnosis of AMI or UA.
PMID: 16291439 [PubMed - in process]
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The minimum clinically significant difference in patient-assigned numeric scores for pain.
Kendrick DB, Strout TD.
Department of Emergency Medicine, Maine Medical Center, Portland, ME 04102, USA.
OBJECTIVE: To determine the minimum clinically significant difference (MCSD) in patient-assigned, 11-point numeric rating scale (NRS-11) scores for pain and to determine if the MCSD varied with demographic characteristics. METHODS: Eligible emergency department patients presenting with pain were asked to rate their pain on the NRS-11 every 20 minutes. Subjects compared pain intensity by choosing from the following verbal descriptor responses: "a lot more," "a little more," "about the same," "a little less," or "a lot less" pain. The MCSD was defined as the difference between scores rated "a little more" or "a little less" severe. RESULTS: Three hundred fifty-four subjects were enrolled. The MCSD was 1.39 +/- 1.05 (95% confidence interval, 1.27-1.51). No statistically significant difference based on sex or pain etiology was noted. CONCLUSIONS: Findings suggest that a change of 1.39 +/- 1.05 (95% confidence interval, 1.27-1.51) on the NRS-11 is clinically significant when measuring pain.
PMID: 16291435 [PubMed - in process]
Shoulder pain: diagnosis and management in primary care.
Mitchell C, Adebajo A, Hay E, Carr A.
Institute of General Practice and Primary Care, School of Health and Related Research (ScHARR), University of Sheffield, Northern General Hospital, Sheffield S5 7AU. c.mitchell@sheffield.ac.uk
Publication Types:
PMID: 16282408 [PubMed - in process]
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Researchers investigate potential use of plant as a pain killer.
Marwick C.
Publication Types:
PMID: 16282403 [PubMed - in process]
Adjuncts to caudal block in children--Quo vadis?
Lonnqvist PA.
Publication Types:
PMID: 16155039 [PubMed - indexed for MEDLINE]
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A comparison of the postoperative analgesic efficacy of single-dose epidural tramadol versus morphine in children.
Demiraran Y, Kocaman B, Akman RY.
Department of Anesthesiology, Duzce School of Medicine, Abant Izzet Baysal University, Turkey. demiryvz@yahoo.com
BACKGROUND: The aim of this study was to compare epidural administration of single-dose tramadol with morphine in children undergoing urological surgery with respect to preoperative haemodynamic effects, postoperative analgesia and side-effects. METHODS: Eighty children aged between 7 and 14 undergoing urological surgery were included in the study. After intubation, in the lateral decubitus position, a single dose of morphine 0.1 mg kg(-1) in isotonic saline 0.2 ml kg(-1) (morphine group) and tramadol 2 mg kg(-1) in isotonic saline 0.2 ml kg(-1) (tramadol group) was administered epidurally. During the 24-h postoperative period, heart rate, systolic blood pressure, respiration rate, pain score and sedation level of the patients were monitored. A modified objective pain score of 3 or lower was accepted as an indicator of inadequate analgesia and these patients were given 20 acetaminophen mg kg(-1) rectally or orally. Time to first analgesia was noted. Sedation level was evaluated with a four-point sedation scale. RESULTS: In the postoperative period, pain scores and the average time for analgesic requirement were similar in the two groups. However, the incidences of allergic rash, itching, sedation and respiratory depression and sedation score were greater in the morphine group than in the tramadol group. CONCLUSION: Greater epidural use of tramadol may be preferred to morphine for postoperative analgesia under these circumstances.
Publication Types:
PMID: 16100237 [PubMed - indexed for MEDLINE]
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Halothane and propofol differentially affect electroencephalographic responses to noxious stimulation.
Orth M, Barter L, Dominguez C, Atherley R, Carstens E, Antognini JF.
Department of Anesthesiology and Pain Medicine, University of California, Davis, 95616, USA.
BACKGROUND: Anaesthetics blunt neuronal responses to noxious stimulation, including effects on electroencephalographic (EEG) responses. It is unclear how anaesthetics differ in their ability to modulate noxious stimulation-evoked EEG activation. We investigated the actions of propofol and halothane on EEG responses to noxious stimuli, including repetitive electrical C-fibre stimulation, which normally evokes neuronal wind-up. METHODS: Rats were anaesthetized with halothane (n=8) or propofol (n=8), at 0.8x or 1.2x the amount required to produce immobility in response to tail clamping [minimum alveolar concentration (MAC) for halothane and median effective dose (ED(50)) for propofol]. We recorded EEG responses to repetitive electrical stimulus trains (delivered to the tail at 0.1, 1 and 3 Hz) as well as supramaximal noxious tail stimulation (clamp; 50 Hz electrical stimulus, each for 30 s). RESULTS: Under halothane anaesthesia, noxious stimuli evoked an EEG activation response manifested by increased spectral edge frequency (SEF) and median edge frequency (MEF). At 0.8 MAC halothane, the tail clamp increased the MEF from approximately 6 to approximately 8.5 Hz, and the SEF from approximately 25.5 to approximately 27 Hz. At both 0.8 and 1.2 MAC halothane, similar patterns of EEG activation were observed with the 1 Hz, 3 Hz and tetanic stimulus trains, but not with 0.1 Hz stimulation, which does not evoke wind-up. Under propofol anaesthesia, noxious stimuli were generally ineffective in causing EEG activation. At 0.8 ED(50) propofol, only the tail clamp and 1 Hz stimuli increased MEF ( approximately 8 to approximately 10-10.5 Hz). At the higher propofol infusion rate (1.2 ED(50)) the repetitive electrical stimuli did not evoke an EEG response, but the tetanic stimulus and the tail clamp paradoxically decreased SEF (from approximately 23 to approximately 21.5 Hz). CONCLUSIONS: Propofol has a more significant blunting effect on EEG responses to noxious stimulation compared with halothane.
PMID: 16051650 [PubMed - indexed for MEDLINE]
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An unusual complication of interscalene brachial plexus catheterization: delayed catheter migration.
Jenkins CR, Karmakar MK.
Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories. carolinejenkins@cuhk.edu.hk
This case report describes the delayed migration of an interscalene brachial plexus catheter that was inserted for postoperative analgesia and to facilitate physiotherapy after shoulder surgery. Approximately 18 h after surgery the catheter was found to have migrated into the interpleural space, which could have resulted in a serious complication, namely a pneumothorax.
Publication Types:
PMID: 16051648 [PubMed - indexed for MEDLINE]
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Clinical actions of subarachnoid sevoflurane administration in vivo: a study in dogs.
Garcia-Fernandez J, Parodi E, Garcia P, Matute E, A-Gomez-de-Segura I, Cediel R, Gilsanz F.
Department of Paediatric Anaesthesia, University Hospital La Paz, Madrid, Spain. ventilacionpediatrica@hotmail.com
BACKGROUND: Halogenated ethers produce clinical effects at spinal sites. Nevertheless, in vitro and in vivo studies have not determined whether the immobilizing effect in the spinal cord is due to inhibition of nociceptive or motor transmission or both. Our goal was to characterize the clinical effects of direct spinal sevoflurane administration. METHODS: Five adult beagle dogs completed the study. In a randomized and blinded manner each animal received placebo (saline 0.1 ml kg(-1)) and three concentrations of pure sevoflurane administered intrathecally (0.05, 0.075 and 0.1 ml kg(-1)) by means of a permanent spinal catheter. Sensory and motor block and state of consciousness were determined at baseline and at predetermined regular intervals until at least 2 h after total recovery. RESULTS: None of the dogs presented a decrease in consciousness with either 0.05 or 0.075 ml kg(-1) of sevoflurane. Administration of 0.1 ml kg(-1) produced light sedation (2 on a four-point sedation scale) in three of the five dogs. A comparison of the duration of the sensory and motor blocks among the three sevoflurane dosages shows a significant dose-dependent increase that is greater in all cases than that for the saline solution. CONCLUSIONS: Spinal administration of pure sevoflurane resulted in a dose-related and totally reversible motor and sensory regional block without any signs of clinical neurotoxicity or significant decrease in consciousness. Therefore the model allows us to comment on the analgesic effects at the spinal level in addition to the direct immobilizing effects of sevoflurane.
PMID: 16040635 [PubMed - indexed for MEDLINE]
Transdermal fentanyl in the management of children with chronic severe pain.
Finkel JC, Finley A, Greco C, Weisman SJ, Zeltzer L.
Department of Anesthesiology, George Washington University, Washington, DC.
BACKGROUND: The current study was conducted to assess the safety and tolerability of a transdermal fentanyl delivery system for the relief of chronic pain in a pediatric population, and also to validate titration recommendations and conversion to transdermal fentanyl from oral opioid therapy. METHODS: This 15-day (with 3-month extension), single-arm, open-label trial was conducted at 66 sites in 10 countries. A total of 199 pediatric patients (ages 2-16 years) with both malignant and nonmalignant conditions who were receiving oral or parenteral opioids for moderate to severe chronic pain were enrolled. Transdermal fentanyl doses were titrated upward according to the rescue medication consumed during the previous application period. Degree of pain was assessed by patients and parents/guardians using visual and numeric scales. Level of play and quality of life were assessed using the Play Performance Scale (PPS) and the Child Health Questionnaire (CHQ). Adverse events were monitored on Days 1-15. Hypoventilation and sedation were monitored every 4 hours during the first 72 hours of the study. RESULTS: A total of 173 patients completed the primary treatment period and 130 entered the extension phase. The average daily pain intensity scores were reported to have decreased by Day 16 and improvements in the mean PPS scores were observed to the end of the extension period. The CHQ scores demonstrated improvements in 11 of 12 domains after Month 1 of the extension period. CONCLUSIONS: Transdermal fentanyl was found to be a safe and well tolerated alternative to oral opioid treatment for children ages 2-16 years who were previously exposed to opioid therapy. Cancer 2005. (c) 2005 American Cancer Society.
PMID: 16284992 [PubMed - as supplied by publisher]
Persistent back pain - why do physical therapy clinicians continue treatment? A mixed methods study of chiropractors, osteopaths and physiotherapists.
Pincus T, Vogel S, Breen A, Foster N, Underwood M.
Department of Psychology, Royal Holloway, University of London, Egham, Surrey TW20 0EX, UK.
AIMS: (a) To investigate how widespread is the use of long term treatment without improvement amongst clinicians treating individuals with low back pain. (b) To study the beliefs behind the reasons why chiropractors, osteopaths and physiotherapists continue to treat people whose low back pain appears not to be improving. METHODS: A mixed methods study, including a questionnaire survey and qualitative analysis of semi-structured interviews. Questionnaire survey; 354/600 (59%) clinicians equally distributed between chiropractic, osteopathy and physiotherapy professions. Interview study; a purposive sample of fourteen clinicians from each profession identified from the survey responses. Methodological techniques ranged from grounded theory analysis to sorting of categories by both the research team and the subjects themselves. RESULTS: At least 10% of each of the professions reported that they continued to treat patients with low back pain who showed almost no improvement for over three months. There is some indication that this is an underestimate. reasons for continuing unsuccessful management of low back pain were not found to be primarily monetary in nature; rather it appears to have much more to do with the scope of care that extends beyond issues addressed in the current physical therapy guidelines. The interview data showed that clinicians viewed their role as including health education and counselling rather than a 'cure or refer' approach. Additionally, participants raised concerns that discharging patients from their care meant sending them to into a therapeutic void. CONCLUSION: Long-term treatment of patients with low back pain without objective signs of improvement is an established practice in a minority of clinicians studied. This approach contrasts with clinical guidelines that encourage self-management, reassurance, re-activation, and involvement of multidisciplinary teams for patients who do not recover. Some of the rationale provided makes a strong case for ongoing contact. However, the practice is also maintained through poor communication with other professions and mistrust of the healthcare system.
PMID: 16291300 [PubMed - in process]
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Fear of pain associated with medical procedures and illnesses.
Munoz Sastre MT, Albaret MC, Maria Raich Escursell R, Mullet E.
Universite du Mirail, Toulouse, France.
The study was aimed at determining the dimensions of fear of pain associated with medical procedures and the dimensions of fear of pain associated with illnesses and accidents on a sample composed of young, middle-aged and elderly persons. The participants were 573 adults (aged 26-94 years). They were presented with (a) the French adaptation of the ten medical fear items from the original FPQ plus 19 additional items, (b) the French adaptation of the 6 illness items from the original FPQ plus 49 additional items, and (c) an Exposure to Painful Situations Questionnaire. As regards the fear of medical procedures, a four-factor structure was identified: Examination and Care, Shots, Dental care, and Invasive procedures. Older participants, and less educated participants tended to show more fear of invasive procedures than younger participants, and more educated participants. As regards the fear of pain associated with illnesses, an eight-factor solution was found: Minor ailments, cramps, infections and abscesses, inflamed joints, colics, breaks, lesion of organs, and cancer and terminal illness. Older participants tended to show more fear of pain associated with minor ailments, inflamed joints, breaks, colic, and cramps than younger participants did. Previous exposure to pain resulted in a clear decrease in fear of pain associated with most of medical procedures, especially invasive procedures and shots.
PMID: 16291299 [PubMed - in process]
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Evaluation of noncardiac chest pain: diagnostic approach, coping strategies and quality of life.
Husser D, Bollmann A, Kuhne C, Molling J, Klein HU.
Department of Cardiology, University Hospital Magdeburg, Leipziger Str. 44, 39120 Magdeburg, Germany.
BACKGROUND: Approximately 30% of coronary angiograms are negative for significant coronary artery disease and patients are classified as having noncardiac chest pain (NCCP). So far, no systematic diagnostic approach to patients with NCCP investigating for possible esophageal, psychiatric and musculoskeletal abnormalities exists. Furthermore, coping strategies and quality of life are poorly characterized in NCCP patients. METHODS AND RESULTS: A simple diagnostic approach was applied to 37 consecutive patients (21 female, age 61+/-12 years) with angina-like chest pain and normal coronary angiograms. Twenty-one patients were found to suffer from psychiatric disorders (combined anxiety (A) and depression (D): n=10, D: n=5, panic disorder (P): n=3, somatization (S): n=3) based on their Symptom Check List 90 scores and according to DSM IV-R criteria. Sixteen patients had an improvement of their chest pain after oral esomeprazole (40mg for 7 days) and were therefore diagnosed with gastroesophageal reflux disease (GERD). Musculoskeletal abnormalities including chostochondritis (n=4), thoracic spondylodynia (n=1), and fibromyalgia (n=1) were found in six patients. Multiple diagnoses were confirmed in six patients with GERD (additional D n=3, additional musculoskeletal disorders n=3). Patients with psychiatric disorders showed a diminished quality of life (MOS-SF 36), more frequent chest pain, less treatment satisfaction (Seattle Angina Questionnaire) and more rumination (Trier Coping Scales) compared to GERD patients. CONCLUSIONS: Immediate combined psychiatric and orthopedic evaluation as well as esomeprazole administration following exclusion of coronary artery disease may confirm the causes of noncardiac chest pain. Identification of psychiatric disorders seems especially warranted since these patients experience a reduced quality of life and exhibit pathologic coping strategies.
PMID: 16291298 [PubMed - in process]
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Further support for the pain stages of change model: Suggestions for improved measurement.
Maurischat C, Harter M, Kerns RD, Bengel J.
Department of Rehabilitation Psychology, University of Freiburg, D-79085 Freiburg, Germany; Department of Psychiatry and Psychotherapy, University Hospital of Freiburg, D-79104 Freiburg, Germany.
Recent efforts to operationalize persons' readiness to adopt a self-management approach to chronic pain have met with promising, but somewhat limited, results. The current study describes the development and psychometric evaluation of a German version of Pain Stages of Change Questionnaire (PSOCQ). A new item pool was developed to attempt to improve in particular the discriminant validity of the scales and in order to obtain a shortened measure. The items were administered to 494 chronic pain patients who were split into two independent samples. Item- and factor-analysis performed on data from one half of the sample resulted in four scales: precontemplation, preparation, action, and maintenance. The scales of the new measure, called the "Freiburg Questionnaire-Stages of Chronic Pain Management (FQ-STAPM)", showed good indices of reliability, homogeneity, and discriminant validity. Both the concurrent and divergent validity indices and the relationships between scale scores and pain related variables proved to be consistent with the transtheoretical model. Confirmatory factor analysis using LISREL performed on the second half of the sample supported the goodness-of-fit of the structure model. Implications of these findings for future research exploring the relevance of the pain stages of change model are discussed.
PMID: 16291297 [PubMed - in process]
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Upper limb activity over time in complex regional pain syndrome type 1 as objectively measured with an upper limb-activity monitor: An explorative multiple case study.
Schasfoort FC, Bussmann JB, Krijnen HJ, Stam HJ.
Department of Rehabilitation Medicine, Erasmus MC, University Medical Center Rotterdam, P.O. Box 1738, 3000DR Rotterdam, The Netherlands.
BACKGROUND: An upper limb-activity monitor (ULAM) has been developed to determine activity limitations in complex regional pain syndrome type 1 (CRPS1). The ULAM is based on 24h ambulatory monitoring of body segment accelerations and enables valid and objective quantification of mobility and upper limb activity in transversal studies. AIMS: To explore upper limb activity over time in acute upper limb CRPS1 as measured with the ULAM in a longitudinal study, and to compare this to time courses of other outcome measures for activity limitations and impairments. METHODS: Four subjects were measured four times during a treatment protocol. Several ULAM outcome measures related to upper limb usage and mobility, three questionnaires (RASQ, DASH, RAND36), and six impairment outcome indicators (VAS-momentary pain, VAS-pain resulting from effort, volume, temperature, active range of motion, strength) were used. RESULTS: Objectively measured upper limb activity frequently improved; improvements of >5% were found for 63% of the ULAM outcome measures at final assessment. The ULAM outcome measures had a time course more similar to the body-part and CRPS1 specific questionnaire RASQ than the other questionnaires. The time course of impaired temperature was most often in accordance with the ULAM, and both VAS scores showed least accordance. CONCLUSIONS: Clear changes in upper limb activity over time were frequently found as objectively measured with the ULAM, and relationships among the time courses of the ULAM and other outcome measures were largely explainable. The ULAM can validly assess upper limb activity over time in CRPS1, but between-measurement variability needs careful consideration.
PMID: 16291296 [PubMed - in process]
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A comparison of the relative utility of coping and acceptance-based measures in a sample of chronic pain sufferers.
McCracken LM, Eccleston C.
Pain Management Unit, Royal National Hospital for Rheumatic Diseases and The University of Bath, Bath BA1 1RL, UK.
Previous research suggests that to define the problem of chronic pain as a problem of coping may not be as useful as framing it as a problem of acceptance for some patients. The coping approach may encourage, or at least permit, a somewhat inflexible agenda of pain reduction or control while the acceptance approach may allow a more flexible agenda of willingness to have pain in some circumstances where that serves the goal of better life functioning. The purpose of this study was to continue to examine the relative utility of concepts of coping and acceptance of pain. Two hundred and thirty consecutive patients seeking assessment from a pain management service were the participants in the study. Patients completed the Coping Strategies Questionnaire (CSQ) and the Chronic Pain Acceptance Questionnaire (CPAQ). A revised scoring method was used for the CSQ (to correct for technical limitations noted in the past) and recently developed subscales of the CPAQ were examined. Correlation results showed that the acceptance variables were reliably stronger predictors of distress and disability compared with coping variables. Regression analyses confirmed that, compared with coping variables, acceptance accounted larger unique increments in variance in measures of patient functioning regardless of whether the coping variables were given priority in the regression equations. Increasing data support the view that the pain management field may benefit from evolving toward incorporating a less control-oriented and more accommodating view of aversive private experiences in some circumstances.
PMID: 16291295 [PubMed - in process]
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Nurses' in the multi-professional pain team: A study of attitudes, beliefs and treatment endorsements.
Brown CA, Richardson C.
Division of Occupational Therapy, School of Health Sciences, University of Liverpool, Johnston Building, Brownlow Hill, Liverpool, UK.
BACKGROUND AND AIM: It is widely accepted that chronic pain is best treated by a multidisciplinary team. Team approaches are best facilitated if all members understand their own and each others role. Roles and responsibilities have inherent values and beliefs which need to be understood if the team is going to function optimally. Little is known about the attitudes and beliefs of the pain team or the individual professionals within it. All members of the pain team therefore need to critically examine the values and beliefs they bring to these teams. The aim of this study was to start this process for nurses. This was done uniquely by: finding out what components of pain management nurses endorse as important; investigating their beliefs about pain management; and exploring whether nurses' beliefs differ in relation to other service providers. METHOD: Data from 103 nurses was extracted from a wider research study of the congruence between what service providers and service users believe to be important treatments for chronic pain. Nurses were surveyed regarding their opinions about which specific treatments or treatment components they would endorse for people with chronic pain. Skevington's Beliefs About Pain Control Questionnaire (BPCQ) was also included. This measured beliefs in three crucial areas; the internal or personal control of pain, beliefs that powerful others (doctors) control pain and beliefs that pain is controlled by chance events. Statistical comparisons were made between nurses who endorsed particular treatments and their belief pattern. Differences between nurses and other professionals and service users were explored. RESULTS: The study showed that nurses were high treatment endorsers. There was universal agreement to the importance of 'The nurse', 'The multidisciplinary team', 'relaxation', and 'psychological assessment' for chronic pain management'. Nurses' endorsement patterns were different to the other professionals, because they endorsed more treatments. BPCQ scores were consistently lower than the other professionals and the service users. CONCLUSIONS: The findings of this study are congruent with emerging literature highlighting the complexity of health care. The high endorsement patterns seen in this study could be taken as support that nurses are, either tacitly or overtly, aware of this need to approach pain management in an open-minded and flexible manner.
PMID: 16291294 [PubMed - in process]
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Psycho-social factors and coping strategies as predictors of chronic evolution and quality of life in patients with low back pain: A prospective study.
Koleck M, Mazaux JM, Rascle N, Bruchon-Schweitzer M.
Psychology Unit EA 3662, University Victor Segalen, Bordeaux 2, France.
Low back pain (LBP) is a major problem of public health. Chronic pain is the most difficult to treat and the most expensive. The way patients cope with their pain may influence its outcome. AIM:: To identify coping strategies of LBP patients, and their influence on LBP evolution. METHODS:: Ninety nine patients were assessed just after an acute LBP episode and one year later. Assessment tools included medical and social reports, scales of anxiety, depression, quality of life, locus of control (LOC), social support and coping strategies. RESULTS:: One year after the initial episode, 67% of patients have improved and 33% had a chronic pain. A principal components analysis showed that two main dimensions might be identified inside the outcome: functional and emotional non-adjustment. Functional non-adjustment was predicted by male gender, reduction of activity, and history of trauma over one year. Emotional non-adjustment was only predicted by trait-depression. Reactions to pain were structured in four factors: distraction-praying, helplessness-hopelessness, cognitive restructuration and perceived control. Two of these factors predicted adjustment one year later: distraction-praying had a direct effect on functional non-adjustment, and helplessness-hopelessness on emotional issue. CONCLUSIONS:: Besides somatic factors, psychosocial predictors of LBP chronic evolution may be identified. Both aspects must be taken into account in order to prevent chronic pain. Perhaps cognitive-behavior therapy may help LBP patients to cope with pain in a better way.
PMID: 16291293 [PubMed - in process]
Combination kyphoplasty and spinal radiosurgery: a new treatment paradigm for pathological fractures.
Gerszten PC, Germanwala A, Burton SA, Welch WC, Ozhasoglu C, Vogel WJ.
Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA. gersztenpc@upmc.edu
OBJECT: Patients with symptomatic pathological compression fractures require spinal stabilization surgery for mechanical back pain control and irradiation for the underlying malignant process. The authors evaluated a treatment paradigm of closed fracture reduction and fixation involving kyphoplasty and subsequent spinal radiosurgery. METHODS: Twenty-six patients (six men and 20 women, mean age 72 years) with pathological compression fractures (16 thoracic and 10 lumbar) were prospectively evaluated. Histological diagnoses included 11 lung, nine breast, four renal, one cholangiocarcioma, and one ocular melanoma. Seven lesions had received prior external-beam radiation therapy. All patients underwent kyphoplasty that involved the percutaneous transpedicular technique. Fiducial markers allowing for image guidance during CyberKnife treatment were placed, at time of the kyphoplasty, in the pedicles at adjacent levels. Patients underwent single-fraction radiosurgery (mean time after kyphoplasty 12 days) in an outpatient setting. The tumor dose was maintained at 16 to 20 Gy (mean 18 Gy) to the 80% isodose line. The treated tumor volume ranged from 12.7 to 37.1 cm3. No acute radiation-induced toxicity or new neurological deficit occurred during the follow-up period (range 11-24 months, median 16 months). Axial pain improved in 24 (92%) of 26 patients. CONCLUSIONS: The combined kyphoplasty and spinal radiosurgery treatment paradigm was found to be clinically effective in patients with pathological fractures; there was no significant spinal canal compromise. In this technique two minimally invasive surgical procedures are combined to avoid the morbidity associated with open surgery while providing both immediate fracture fixation and administering a single-fraction tumoricidal radiation dose.
Publication Types:
PMID: 16266071 [PubMed - indexed for MEDLINE]
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Hospice care in a cohort of elders with dementia and mild cognitive impairment.
Bekelman DB, Black BS, Shore AD, Kasper JD, Rabins PV.
Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland 21287, USA.
The objectives of this study were to identify the characteristics associated with hospice enrollment, to determine whether enrollment in hospice was associated with less pain and psychiatric symptoms, and to assess caregiver satisfaction with care near death in a sample of patients with dementia and mild cognitive impairment (MCI). Participants included decedents with dementia or MCI and other medical illnesses whose deaths were expected (n = 81) during a 3-year prospective, longitudinal, community-based cohort study. A total of 29.6% (n = 24) of participants received hospice care prior to death. Participants in hospice experienced less pain compared to those not in hospice, but this did not reach statistical significance (41.7% vs. 62.5%, P = 0.085). They were 65% more likely to be free of psychiatric symptoms (including restlessness, sleep problems, agitation, nervousness, and aggression toward others) during their final illness prior to death (OR = 0.35; 95% CI 0.13-0.96). In this cohort of people with dementia and MCI who died, several markers of quality of care suggest that hospice care can be beneficial for patients with dementia or MCI.
Publication Types:
PMID: 16183004 [PubMed - indexed for MEDLINE]
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High doses of topically applied lidocaine in a cancer patient.
Likar R.
Publication Types:
PMID: 16183001 [PubMed - indexed for MEDLINE]
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Facing others in pain: the effects of empathy.
Goubert L, Craig KD, Vervoort T, Morley S, Sullivan MJ, Williams AC, Cano A, Crombez G.
Department of Experimental-Clinical and Health Psychology, Ghent University, Ghent, Belgium; Research Institute for Psychology & Health, Utrecht, The Netherlands.
PMID: 16289804 [PubMed - as supplied by publisher]
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Pain-related emotions modulate experimental pain perception and autonomic responses.
Rainville P, Bao QV, Chretien P.
Departement de Stomatologie, Faculte de medecine dentaire, Universite de Montreal, CP. 6128, Succ. Centre-ville, Montreal, Que., Canada H3C 1J7.
The effect of emotions on pain perception is generally recognized but the underlying mechanisms remain unclear. Here, emotions related to pain were induced in healthy volunteers using hypnosis, during 1-min immersions of the hand in painfully hot water. In Experiment 1, hypnotic suggestions were designed to induce various positive or negative emotions. Compared to a control condition with hypnotic-relaxation, negative emotions produced robust increases in pain. In Experiment 2, induction of pain-related anger and sadness were found to increase pain. Pain increases were associated with increases in self-rated desire for relief and decreases in expectation of relief, and with increases in arousal, negative affective valence and decreases in perceived control. In Experiment 3, hypnotic suggestions specifically designed to increase and decrease the desire for relief produced increases and decreases in pain, respectively. In all three experiments, emotion-induced changes in pain were most consistently found on ratings of pain unpleasantness compared to pain intensity. Changes in pain-evoked cardiac responses (R-R interval decrease), measured in experiments 2 and 3, were consistent with changes in pain unpleasantness. Correlation and multiple regression analyses suggest that negative emotions and desire for relief influence primarily pain affect and that pain-evoked autonomic responses are strongly associated with pain affect. These results confirm the hypothesized influence of the desire for relief on pain perception, and particularly on pain affect, and support the functional relation between pain affect and autonomic nociceptive responses. This study provides further experimental confirmation that pain-related emotions influence pain perception and pain-related physiological responses.
PMID: 16289802 [PubMed - as supplied by publisher]
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Cortical representation of experimental tooth pain in humans.
Jantsch HH, Kemppainen P, Ringler R, Handwerker HO, Forster C.
Department of Physiology and Pathophysiology, University of Erlangen-Nuernberg, Universitaetsstrasse 17, D-91054 Erlangen, Germany.
Cortical processing of electrically induced pain from the tooth pulp was studied in healthy volunteers with fMRI. In a first experiment, cortical representation of tooth pain was compared with that of painful mechanical stimulation to the hand. The contralateral S1 cortex was activated during painful mechanical stimulation of the hand, whereas tooth pain lead to bilateral activation of S1. The S2 and insular region were bilaterally activated by both stimuli. In S2, the center of gravity of the activation during painful mechanical stimulation was more medial/posterior compared to tooth pain. In the insular region, tooth pain induced a stronger activation of the anterior and medial parts. The posterior part of the anterior cingulate gyrus was more strongly activated by painful stimulation of the hand. Differential activations were also found in motor and frontal areas including the orbital frontal cortex where tooth pain lead to greater activations. In a second experiment, we compared the effect of weak with strong tooth pain. A significantly greater activation by more painful tooth stimuli was found in most of those areas in which tooth pain had induced more activation than hand pain. In the medial frontal and right superior frontal gyri, we found an inverse relationship between pain intensity and BOLD contrast. We concluded that tooth pain activates a cortical network which is in several respects different from that activated by painful mechanical stimulation of the hand, not only in the somatotopically organized somatosensory areas but also in parts of the 'medial' pain projection system.
PMID: 16289801 [PubMed - as supplied by publisher]
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Activation of CB(1) and CB(2) receptors attenuates the induction and maintenance of inflammatory pain in the rat.
Elmes SJ, Winyard LA, Medhurst SJ, Clayton NM, Wilson AW, Kendall DA, Chapman V.
Institute of Neuroscience, School of Biomedical Sciences, E Floor, Medical School, Queen's Medical Centre, University of Nottingham, Nottingham NG7 2UH, UK.
The aim of the present study was to investigate the effects of cannabinoid agonists on established inflammatory hyperalgesia. We have compared the effects of pre-administration versus post-administration of a potent non-selective cannabinoid agonist HU210 and a selective CB(2) receptor agonist JWH-133 on hindpaw weight bearing and paw oedema in the carrageenan model of inflammatory hyperalgesia. For comparative purposes we also determined the effects of the mu-opioid receptor agonist morphine and the COX2 inhibitor rofecoxib in this model. At 3h following intraplantar injection of carrageenan (2%, 100mul) there was a significant (P<0.001) reduction in weight bearing on the ipsilateral hindpaw, compared to vehicle treated rats and a concomitant increase in ipsilateral hindpaw volume (P<0.001), compared to vehicle treated rats. Systemic administration of HU210 (10mug/kg) and JWH-133 (10mg/kg) at 3h following injection of carrageenan, significantly attenuated decreases in ipsilateral hindpaw weight bearing (P<0.05 for both) and paw volume (P<0.001 for both). Pre-administration of HU210 and JWH-133 had similar effects on weight bearing in this model. Pre-administered HU210 also significantly decreased carrageenan-induced changes in paw volume (P<0.001), this was not the case for JWH-133. Effects of post-administered HU210 and JWH-133 on ipsilateral hindpaw weight bearing and paw volume were comparable to the effect of systemic post-administration of morphine and rofecoxib (3mg/kg for both). In summary, both HU210 and JWH-133 attenuated established inflammatory hypersensitivity and swelling, suggesting that cannabinoid-based drugs have clinical potential for the treatment of established inflammatory pain responses.
PMID: 16289798 [PubMed - as supplied by publisher]
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Why is a treatment aimed at psychosocial factors not effective in patients with (sub)acute low back pain?
Jellema P, van der Windt DA, van der Horst HE, Blankenstein AH, Bouter LM, Stalman WA.
Department of General Practice, VU University Medical Center, Amsterdam, The Netherlands; Institute for Research in Extramural Medicine (EMGO Institute), VU University Medical Center, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands.
Psychosocial factors have been shown to play an important role in the development of chronic low back pain (LBP). In our recently completed cluster-randomized trial we found, however, no evidence of an effect of our minimal intervention strategy (MIS) aimed at psychosocial factors, over usual care (UC) in patients with (sub)acute LBP. To explore the reasons why, this paper presents an evaluation of the processes presumably underlying the effectiveness of MIS. General practitioner (GP) attitude was evaluated by the Pain Attitudes and Beliefs Scale and two additional questions. GP behaviour was evaluated by analysing treatment registration forms and patients' responses to items regarding treatment content. Patients also scored items on satisfaction and compliance. Modification of psychosocial measures was evaluated by analysing changes after 6 and 52 weeks on the Fear Avoidance and Beliefs Questionnaire, the Coping Strategies Questionnaire and the 4-Dimensional Symptom Questionnaire. A total of 60 GPs and 314 patients participated in the study. GPs in the MIS-group adopted a less biomedical orientated attitude than in the UC-group, but were only moderately successful in identification of psychosocial factors. Treatment contents as perceived by the patient and patient satisfaction differed significantly between both groups. Changes on psychosocial measures, however, did not differ between groups. The suboptimal identification of psychosocial factors in the MIS-group and the absence of a relevant impact on psychosocial factors may explain why MIS was not more effective than UC.
PMID: 16289797 [PubMed - as supplied by publisher]
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The development and preliminary validation of the Profile of Chronic Pain: Extended Assessment Battery.
Ruehlman LS, Karoly P, Newton C, Aiken LS.
Consultants in Behavioral Research, Research and Development, 8621 S. Maple Ave., 85284 Tempe, AZ, USA.
The aim of the present research was the development and validation of a set of instruments, collectively called the Profile of Chronic Pain: Extended Assessment Battery (PCP:EA), designed to be administered to adults (between the ages of 25 to 80) after establishing the existence of a chronic pain problem. The final 86-item version of the PCP:EA consisted of 33 single items assessing: pain location and severity, pain characteristics (e.g. worst daily pain), medication use, health care status, the identity of the most important person in the patient's life, and functional limitations in 10 areas of daily living. In addition, the PCP:EA includes 13 multi-item subscales addressing aspects of coping (guarding, ignoring, task persistence, and positive self-talk), catastrophizing, pain attitudes and beliefs (including disability beliefs, belief in a medical cure for pain, belief in pain control, and pain-induced fear), and positive (tangible and emotional) and negative (insensitivity and impatience) social responses. Data were obtained from two national samples which were recruited and screened via a random-digit dialing telephone interview procedure. Stratified sampling was employed to assure equal gender and age group representation across three age groupings (25-44; 45-64; 65-80). Two survey studies provided strong evidence for the hypothesized factor structure, internal consistency, independence from response bias, and validity of the PCP:EA. Moreover, the presence of normative data enhance the diagnostic and prescriptive utility of the instrument.
PMID: 16289796 [PubMed - as supplied by publisher]
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Multilevel analysis of couple congruence on pain, interference, and disability.
Cano A, Johansen AB, Franz A.
Department of Psychology, Wayne State University, 5057 Woodward Avenue, Detroit, MI 48202, USA.
Couple congruence on ratings of pain severity and disability were examined using hierarchical linear modeling. Older community Individuals with Chronic Pain (ICPs) and their spouses completed the Multidimensional Pain Inventory (pain severity, interference, negative spouse responses to pain), Sickness Impact Profile (physical disability, psychosocial disability), and the Mood and Anxiety Symptom Questionnaire (psychological distress). Both spouses reported on ICPs' pain and disability as well as their own psychological distress. Spousal incongruence was observed on interference and physical disability such that ICPs reported greater disability than their spouses reported for them. No significant incongruence was observed in pain severity or psychosocial disability. Predictors of couples' mean ratings of pain and disability were identified. Specifically, couples in which the ICP was female reported higher couples' ratings of pain severity and interference. ICP distress was related to higher couples' ratings of all pain and disability variables whereas spouse distress was related to higher psychosocial disability ratings. ICPs' perceptions of negative spouse responses were also positively associated with couples' ratings of physical and psychosocial disability. In terms of congruence, ICP distress was associated with incongruence on interference, physical disability, and psychosocial disability whereas spouse distress predicted incongruence on pain severity, and interference. This study suggests that understanding couples' pain outcome ratings involves an awareness of factors that might influence their perceptions and behaviors.
PMID: 16289795 [PubMed - as supplied by publisher]
Spinal neuropeptide responses in persistent and transient pain following cervical nerve root injury.
Rothman SM, Kreider RA, Winkelstein BA.
Department of Bioengineering, University of Pennsylvania, Philadelphia, Pennsylvania 19104-6392, USA.
STUDY DESIGN: Behavioral and immunohistochemical analysis in rat models of persistent and transient allodynia. OBJECTIVES: To examine separate cervical nerve root injuries (compression, transection) for producing behavioral hypersensitivity and investigate spinal neuropeptides to understand relationships to pain symptoms. SUMMARY OF BACKGROUND DATA: Mechanical cervical nerve root injury can be a source of neck pain. Painful lumbar radiculopathy models show that different nerve root ligation intensities produce differential allodynia responses. Spinal neuropeptides can mediate pain responses. Yet, little is known about their contributions to pain in the cervical spine. METHODS: Rats underwent separate procedures on the right C7 nerve roots: transection (n = 12), 10-gf compression for 15 minutes (n = 11), or sham (n = 5). Ipsilateral forepaw mechanical allodynia was measured after surgery for 7 days. C7 spinal cord tissue was analyzed by immunohistochemistry for substance P and calcitonin gene-related peptide (CGRP) expression on days 1 and 7 for each injury; densitometry quantified immunoreactivity in lamina I of the ipsilateral dorsal horn. RESULTS: Both injuries immediately produced significant increases in allodynia. Sensitivity was sustained following root compression, and at day 7, was not different from day 1. By day 7 after transection, allodynia had returned to baseline and sham levels, significantly decreasing from day 1 (P = 0.0012). Spinal substance P and CGRP were increased over normal at day 1 for both injuries and decreased with time for CGRP after transection, which paralleled behaviors. For individual rats, substance P was significantly (P < 0.001) correlated with CGRP expression for both injuries. CONCLUSIONS: Compression and transection of the cervical nerve root produce different forepaw allodynia responses, with persistent and transient sensitivity, respectively. Spinal neuropeptide expression in these models parallels this sensitivity, suggesting their potential role in pain symptoms.
PMID: 16284585 [PubMed - in process]
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Transdermal fentanyl versus sustained release oral morphine in strong-opioid naive patients with chronic low back pain.
Allan L, Richarz U, Simpson K, Slappendel R.
Northwick Park & St. Marks NHS Trust, Harrow, Middlesex, UK. laurie.allan@datacam.net
STUDY DESIGN: Open, randomized, parallel group multicenter study. OBJECTIVES: To compare the efficacy and safety of transdermal fentanyl (TDF) and sustained release morphine (SRM) in strong-opioid naive patients with chronic low back pain (CLBP). SUMMARY OF BACKGROUND DATA: Most studies of TDF and SRM have involved patients already receiving strong opioids. This is the first large-scale study focusing on strong-opioid naive patients with CLBP. METHODS: Adults with CLBP requiring regular strong opioid therapy received either TDF or SRM for 13 months. Starting doses were 25 microg/hr fentanyl patches every 72 hours or 30 mg oral morphine every 12 hours. Doses were adjusted according to response. Participants assessed pain relief and bowel function using weekly diaries. Other assessments, including quality of life, disease progression, and side effects, were made by patients and investigators. RESULTS: Data from 680 patients showed that TDF and SRM provided similar levels of pain relief, but TDF was associated with significantly less constipation than SRM, indicating a greater likelihood of satisfactory pain relief without unmanageable constipation for patients receiving TDF. Other ratings were similar for TDF and SRM, but TDF provided greater relief of pain at rest and at night. CONCLUSIONS: TDF and SRM provided equivalent levels of pain relief, but TDF was associated with less constipation. This study indicates that sustained-release strong opioids can safely be used in strong-opioid naive patients.
PMID: 16284584 [PubMed - in process]
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The influence of fear avoidance beliefs on disability and quality of life is sparse in Spanish low back pain patients.
Kovacs FM, Muriel A, Abriaira V, Medina JM, Castillo Sanchez MD, Olabe J; Spanish Back Pain Research Network.
Departamento Cientifico, Fundacion Kovacs, Palma de Mallorca, Spain. kovacs@kovacs.org
STUDY DESIGN: Correlation between previously validated questionnaires. OBJECTIVES: To assess the influence of fear avoidance beliefs (FAB) on disability and quality of life in Spanish low back pain (LBP) patients. SUMMARY OF BACKGROUND DATA: FAB has shown to be a major determinant of disability in LBP patients in Northern European and Anglo-Saxon cultural environments. There are no data on its influence on Latin-Mediterranean patients. METHODS: The study was done in 12 primary care and 9 hospital services from seven different regions of Spain, with 209 patients who were in a potentially active working situation and visited the National Health Service for LBP. None was excluded and the sample was balanced for acute, subacute, and chronic patients. On their first visit and 14 days later, patients were given two independent Visual Analogue Scales (VAS) for LBP and leg pain, as well as the validated Spanish versions of the Fear Avoidance Beliefs (FABQ), Roland-Morris (RMQ), and SF-12 questionnaires. RESULTS: Correlations between LBP, leg pain, FABQ, disability, and quality of life were moderate on day 1 (r = 0.320-0.564) and stronger on day 15 (r = 0.457-0.637).All of them were statistically highly significant (P = 0.000). Regression models showed that LBP severity explains 33% of disability on day 1 and 20% on day 15, while FAB only explains 6% on day 1 and 2% on day 15. FAB does not explain mental quality of life. It explains only 5% of physical quality of life on day 1 and 4% on day 15. There was no interaction between FAB and chronicity, and FABQ values on day 1 did not predict disability or quality of life at day 15. CONCLUSIONS: As opposed to what has been shown in other cultural settings, FAB have virtually no clinical relevance in Spanish LBP patients who are treated in the National Health Service and who are in a potentially active working situation. The influence of FAB on disability is minimal and much less than that of pain severity, and their contribution to the patient's quality of life is irrelevant. Further studies should explore the potential value of FAB in other Latin-Mediterranean countries.
PMID: 16284579 [PubMed - in process]
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