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Derivation of a clinical guideline for the assessment of nonspecific abdominal pain: the Guideline for Abdominal Pain in the ED Setting (GAPEDS) Phase 1 Study.
Gerhardt RT, Nelson BK, Keenan S, Kernan L, Mackersie A, Lane MS.
Department of Emergency Medicine, Brooke Army Medical Center/San Antonio Uniformed Services Health Education Consortium, Fort Sam Houston, TX 78234, USA; Department of Emergency Medicine, Texas Tech University Health Sciences Center, El Paso, TX, USA.
OBJECTIVE: The purpose of this study was to identify a clinical guideline for the evaluation of nonspecific abdominal pain (NSAP) using history, physical examination, laboratory analysis, acute abdominal series (AAS) radiographs, and nonenhanced helical computed tomography (NHCT) clinical predictor variables (CPVs). SETTING: The setting of this study was at an urban emergency department (ED) with 70000 yearly visits. METHODS: This is an institutional review board-approved, prospective, observational study. The primary outcome variable was urgent intervention (UI), defined as a diagnosis requiring surgical or medical treatment to prevent death or major morbidity. Subjects underwent prompted history, physical, laboratory studies, AAS, and NHCT and were followed up to 6 months for ultimate diagnosis and outcome. CPVs were subjected to classification and regression tree analysis. RESULTS: One hundred sixty-five subjects were analyzed. Thirteen percent of subjects required UI within 24 hours of presentation; an additional 34% underwent elective interventions that mitigated morbidity or mortality. Four guideline models were generated. Model 1 consisted of history and physical, with a sensitivity of 25%, a specificity of 92%, a positive likelihood ratio of 3.17, and a negative likelihood ratio of 0.81. Model 2 consisted of model 1 with laboratory, with a sensitivity of 39%, a specificity of 88%, a positive likelihood ratio of 3.25, and a negative likelihood ratio of 0.69. Model 3 consisted of model 2 with AAS, with a sensitivity of 56%, a specificity of 81%, a positive likelihood ratio of 2.94, and a negative likelihood ratio of 0.54. Model 4 comprised all inputs, including NHCT, with a sensitivity of 92%, a specificity of 90%, a positive likelihood ratio of 9.2, and a negative likelihood ratio of 0.089. NHCT was the single most accurate CPV for UI. CONCLUSIONS: No clinical guideline was identified exclusive of NHCT that possessed adequate sensitivity for exclusion of UI. NHCT is a rational choice for decision support in the evaluation of NSAP and is likely the single most useful diagnostic adjunct available to augment the clinical evaluation.
PMID: 16182976 [PubMed - in process]
Comment on:
Remifentanil for labor pain: is the drug or the method the problem?
Lacassie HJ, Olufolabi AJ.
Publication Types:
PMID: 16192558 [PubMed - indexed for MEDLINE]
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Evaluating the efficacy of the valsalva maneuver on venous cannulation pain: a prospective, randomized study.
Agarwal A, Sinha PK, Tandon M, Dhiraaj S, Singh U.
Department of Anesthesia, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India. aagarwal@sgpgi.ac.in
Pain associated with venous cannula is a distressing symptom. We evaluated the efficacy of the Valsalva maneuver on pain associated with venous cannulation. Seventy-five adults, ASA physical status I and II, either sex, undergoing elective surgery, were included in this study. Patients were randomized into 3 groups of 25 each. Group I (C): control; Group II (V): blew into sphygmomanometer tubing and raised the mercury column up to 30 mm Hg for 20 s; Group III (B): pressed a rubber ball. Twenty seconds later, peripheral venous cannulation was performed. Venous cannulation pain was graded using a 4-point scale: 0-3, where 0 = no pain, 1 = mild pain, 2 = moderate pain, and 3 = severe pain, and visual analog scale of 0-10, where 0 = no pain and 10 = worst imaginable pain. A significant reduction in the incidence of pain was observed in the Valsalva group: 18 of 25 (72%) patients, whereas 25 of 25 (100%) experienced pain in the other two groups (P < 0.001). A significant reduction in the severity of pain, number of patients in whom one needed to make the vein prominent before cannulation, and the time taken for the same were observed in the Valsalva group (P < 0.001). IMPLICATIONS: Venous cannulation is a necessary step for safe anesthesia administration; however, the pain associated with it is sometimes very distressing. We observed that the Valsalva maneuver performed at the time of venous cannulation greatly decreases this pain.
Publication Types:
PMID: 16192551 [PubMed - indexed for MEDLINE]
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Using stimulating catheters for continuous sciatic nerve block shortens onset time of surgical block and minimizes postoperative consumption of pain medication after halux valgus repair as compared with conventional nonstimulating catheters.
Casati A, Fanelli G, Koscielniak-Nielsen Z, Cappelleri G, Aldegheri G, Danelli G, Fuzier R, Singelyn F.
Department of Anesthesiology and Pain Therapy, Azienda Ospedaliera di Parma, Via Gramsci 14-43100 Parma, Italy. acasati@ao.pr.it
We prospectively tested the hypothesis that the use of a stimulating catheter improves the efficacy of continuous posterior popliteal sciatic nerve block in 100 randomized patients scheduled for elective orthopedic foot surgery. After eliciting a sciatic mediated muscular twitch at < or = 0.5 mA nerve stimulation output, the perineural catheter was advanced 2-4 cm beyond the tip of the introducer either blindly (Group C; n = 50) or stimulating via the catheter (Group S; n = 50). A bolus dose of 25 mL of 1.5% mepivacaine was followed by a postoperative patient-controlled infusion of 0.2% ropivacaine (basal infusion: 3 mL/h; incremental dose: 5 mL; lockout time: 30 min). Propacetamol 2 g IV was administered every 8 h, and opioid rescue analgesia was available if required. Catheter placement required 7 +/- 2 min in Group S and 5 +/- 2 min in Group C (P = 0.056). A significantly shorter onset time of both sensory and motor blocks was noted in Group S. No difference in quality of pain relief at rest and during motion was reported between the groups. Median (range) local anesthetic consumption during the first 48 h after surgery was 239 mL (175-519 mL) and 322 mL (184-508 mL) in Groups S and C, respectively (P = 0.002). Rescue opioid analgesia was required by 12 (25%) and 28 (58%) patients in Groups S and C, respectively (P = 0.002). We conclude that the use of a stimulating catheter results in shorter onset time of posterior popliteal sciatic nerve block, similar pain relief with reduced postoperative consumption of local anesthetic solution, and less rescue opioid consumption. IMPLICATIONS: This prospective, randomized, blind investigation demonstrated that the use of a stimulating catheter for continuous posterior popliteal sciatic nerve block resulted in shorter onset time of sensory and motor blocks and less local anesthetic consumption and need for rescue pain medication after elective orthopedic foot surgery compared with blind catheter advancement.
Publication Types:
PMID: 16192543 [PubMed - indexed for MEDLINE]
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Disappearance of phantom limb pain during cauda equina compression by spinal meningioma and gradual reactivation after decompression.
Aydin MD, Cesur M, Aydin N, Alici HA.
Department of Neurosurgery, Ataturk University, School of Medicine, Erzurum, Turkey.
We describe a 65-yr-old woman, whose right lower limb had been amputated at the mid-femoral level because of complicated femur fracture sustained at the age of 5 yr. After amputation, she experienced phantom limb pain (PLP), which gradually decreased in intensity but persisted for 60 yr. At this point the pain diminished progressively, in parallel with the evolution of cauda equina compression caused by an intraspinal tumor. The PLP gradually reappeared over 3 mo after surgical removal of the tumor. IMPLICATIONS: We present a case in which phantom limb pain (PLP) in an amputated leg disappeared during cauda equina compression by meningioma and reactivated after surgical decompression. This case suggests that complete compression or blockade of nerves, a nerve plexus, the cauda equina, or the medullary cord may result in suppression of PLP, and decompression of or recovery from the block may cause reactivation.
Publication Types:
PMID: 16192532 [PubMed - indexed for MEDLINE]
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The effects of perioperative pain management techniques on food consumption and body weight after laparotomy in rats.
Shavit Y, Fish G, Wolf G, Mayburd E, Meerson Y, Yirmiya R, Beilin B.
Department of Psychology, The Hebrew University, Mount Scopus, Jerusalem 91905, Israel. Udi.Shavit@huji.ac.il
We examined the effects of two perioperative pain management techniques on recovery after laparotomy, as assessed by body weight (BW) and food consumption (FC). All rats received a preoperative intrathecal mixture of morphine plus bupivacaine combined with one of two treatments: (a) injection of slow-release morphine at the end of the surgery or (b) an antiinflammatory drug, interleukin-1 receptor antagonist (IL-1ra), combined with the preoperative mixture. Laparotomy significantly decreased FC and BW. Both analgesic treatments resulted in a faster recovery of FC and BW. This beneficial effect was more pronounced in the group receiving preoperative analgesics combined with IL-1ra. IMPLICATIONS: Effective perioperative pain management can improve postoperative recovery. We studied the effects of two preoperative pain management techniques on recovery after laparotomy in rats. Both analgesic treatments resulted in a faster recovery, especially preoperative analgesics combined with interleukin-1 receptor antagonist.
PMID: 16192530 [PubMed - indexed for MEDLINE]
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Presentation, diagnoses, mechanisms of injury, and treatment of soldiers injured in Operation Iraqi Freedom: an epidemiological study conducted at two military pain management centers.
Cohen SP, Griffith S, Larkin TM, Villena F, Larkin R.
Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions, 550 North Broadway, Suite 301, Baltimore, Maryland 21205, USA. scohen40@jhmi.edu
In recent military conflicts the major source of soldier attrition has not been battle injuries but more mundane causes similar to those encountered in civilian life. In an effort to determine the pain conditions affecting soldiers during wartime, we conducted an observational study among 162 soldiers medically evacuated from Operation Iraqi Freedom who were referred to 2 large pain treatment centers located outside the theaters of combat. Fifty-three percent of soldiers presented with either radicular (n = 49) or axial (n = 37) low back pain, with lumbar herniated disk being the most frequently diagnosed condition (24%). The two most implicated etiologies were exacerbation of a previous pain condition treated with surgery (15%) and motor vehicle accidents(12%). Only 17% of patients were injured during battle. Seventy-two percent of soldiers received at least one nerve block/injection, the most common of which was lumbar epidural steroid administration (22%). Nonsteroidal antiinflammatory drugs were prescribed to 56% of patients, opioids to 49%, and some form of alternative therapy to 17%. Among the 49 patients in whom data were available, only 2% returned to combat duty in Iraq. With the exception of battle-related injuries, the pain conditions suffered during modern warfare seem to be similar to those encountered in civilian pain clinics. To improve the return-to-duty rate, better preventive measures and more aggressive treatment conducted in forward-deployed medical units are recommended. IMPLICATIONS: We conducted an observational study at two large military pain treatment centers among soldiers injured in Operation Iraqi Freedom. Fifty-three percent of soldiers presented with low back pain, with lumbar herniated disk being the most common diagnosis. Only 2% of patients returned to combat duty in Iraq. To improve the return-to-duty rate, better preventive measures and more aggressive treatment in forward-deployed medical units are recommended.
PMID: 16192528 [PubMed - indexed for MEDLINE]
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Pain on injection of lipid-free propofol and propofol emulsion containing medium-chain triglyceride: a comparative study.
Dubey PK, Kumar A.
Department of Anesthesiology & Critical Care Medicine, Indira Gandhi Institute of Medical Sciences, Patna, India. pkdubey@hotmail.com
Pain on injection of propofol continues to be a problem for anesthesiologists. A lipid-free formulation of propofol and a propofol emulsion containing medium-chain triglyceride have become available in the Indian market. We performed this study to assess the pain on injection of propofol emulsion containing medium-chain triglyceride as the lipid carrier and lipid-free propofol formulation. One-hundred-thirty adult patients were randomly assigned to one of two groups: Group I received propofol emulsion containing medium-chain triglyceride and Group II received lipid-free propofol. One fourth of the total calculated induction dose was injected over 5 s in the largest vein on the dorsum of a hand. Pain was assessed using verbal response and behavioral signs. Both formulations caused pain on injection. However, the lipid-free propofol solution produced frequent (89%) and severe pain on injection compared with the emulsion containing medium-chain triglyceride (40%). IMPLICATIONS: Pain on injection of two formulations of propofol was compared. A lipid-free formulation produced more pain on injection as compared with the emulsion containing medium-chain triglyceride.
Publication Types:
PMID: 16192520 [PubMed - indexed for MEDLINE]
Comment on:
Efficacy of the NSAIDs depends on multiple factors.
Huang J.
Publication Types:
PMID: 16116024 [PubMed - indexed for MEDLINE]
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Transient global amnesia after general anesthesia.
Bortolon RJ, Weglinski MR, Sprung J.
Department of Anesthesiology, Mayo Clinic College of Medicine, Mary Brigh 2-752, 200 First Street SW, Rochester, MN 55905, USA.
Transient global amnesia (TGA) is an amnestic syndrome, clinically dramatic but benign in nature. The hallmark of TGA is brief inability to form new memories and recall past memories despite otherwise normal neurological function. In a significant number of patients with TGA a stressful precipitating factor can be identified. We report two cases of TGA after uneventful general anesthesia. Anesthesia per se does not appear to be a direct trigger of TGA, as our first patient had a second anesthetic the next day without recurrence of TGA. Because the presentation of TGA can be dramatic and may mimic an acute cerebral ischemic event, a thorough neurologic evaluation should be pursued.
Publication Types:
PMID: 16116014 [PubMed - indexed for MEDLINE]
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Continuous intra- and postoperative thoracic epidural analgesia attenuates brain natriuretic peptide release after major abdominal surgery.
Suttner S, Lang K, Piper SN, Schultz H, Rohm KD, Boldt J.
Department of Anesthesiology and Intensive Care Medicine, Klinikum der Stadt Ludwigshafen, Bremserstrasse 79, D-67063 Ludwigshafen, Germany. suttner@gmx.de
We investigated whether blocking afferent nociceptive inputs by continuous intra- and postoperative thoracic epidural analgesia (TEA) would decrease plasma concentrations of brain natriuretic peptide (BNP) in patients who were at risk for, or had, coronary artery disease. Twenty-eight patients undergoing major abdominal surgery received either general anesthesia supplemented with a continuous thoracic epidural infusion of 1.25 mg/mL bupivacaine and 1 microg/mL sufentanil (n = 14; TEA) or general anesthesia followed by IV patient-controlled analgesia (n = 14; IV PCA). Visual analog scale pain scores, hemodynamics, plasma catecholamines, cardiac troponin T, atrial natriuretic peptide (ANP), and BNP were serially measured preoperatively, 90 min after skin incision, at arrival in the intensive care unit, and in the morning of the first, second, and third postoperative day. Dynamic visual analog scale scores were significantly less in the TEA group. TEA reduced the postoperative heart rate without affecting other hemodynamic variables. Plasma epinephrine increased perioperatively in both groups but was significantly lower in the TEA group. Baseline ANP and BNP concentrations were similar between groups (TEA 3.4 +/- 1.8 and 27.0 +/- 12.3 pg/mL; IV PCA 3.1 +/- 2.0 and 25.9 +/- 13.0 pg/mL, respectively). ANP and BNP increased perioperatively in both groups, with significantly lower postoperative BNP levels in TEA patients (TEA 92.1 +/- 31.9 pg/mL; IV PCA 161.2 +/- 44.7 pg/mL). No such difference was observed in plasma ANP concentrations. Plasma cardiac troponin T concentrations were within normal limits in both groups at all times. We conclude that continuous perioperative TEA using local anesthetics and opioids attenuated the release of BNP in patients undergoing major abdominal surgery who were at risk for, or had, coronary artery disease.
PMID: 16116011 [PubMed - indexed for MEDLINE]
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The effects of femoral nerve blockade in conjunction with epidural analgesia after total knee arthroplasty.
YaDeau JT, Cahill JB, Zawadsky MW, Sharrock NE, Bottner F, Morelli CM, Kahn RL, Sculco TP.
Hospital for Special Surgery, Weill Medical College of Cornell University, 535 E. 70th Street, New York, NY 10021, USA. yadeauj@hss.edu
Either epidural analgesia or femoral nerve blockade improves analgesia and rehabilitation after total knee arthroplasty. No study has evaluated the combination of femoral nerve blockade and epidural analgesia. In this prospective, randomized, blinded study we investigated combining femoral nerve blockade with epidural analgesia. Forty-one patients received a single-injection femoral nerve block with 0.375% bupivacaine and 5 microg/mL epinephrine; 39 patients served as controls. All patients received combined spinal-epidural anesthesia and patient-controlled epidural analgesia with 0.06% bupivacaine and 10 microg/mL hydromorphone. Average duration of epidural analgesia was 2 days. All patients received the same standardized physical therapy intervention. Median visual analog scale (VAS) scores with physical therapy were significantly lower for 2 days among patients who received a femoral nerve block versus controls: 3 versus 4 (day 1), 2.5 versus 4 (day 2); P < 0.05. Median VAS pain scores at rest were 0 in both groups on days 1 and 2. Flexion range of motion was improved on postoperative day 2 (70 degrees versus 63 degrees ; P < 0.05). No peripheral neuropathies occurred. We conclude that the addition of femoral nerve blockade to epidural analgesia significantly improved analgesia for the first 2 days after total knee arthroplasty.
Publication Types:
PMID: 16116010 [PubMed - indexed for MEDLINE]
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Ultrasound-guided infraclavicular versus supraclavicular block.
Arcand G, Williams SR, Chouinard P, Boudreault D, Harris P, Ruel M, Girard F.
Department of Anesthesiology, CHUM, Hopital Notre-Dame, 1560 Sherbrooke east, Montreal, Quebec, Canada H2L 4M1.
In this prospective study we compared ultrasound-guided (USG) infraclavicular and supraclavicular blocks for performance time and quality of block. We hypothesized that the infraclavicular approach would result in shorter performance times with a quality of block similar to that of the supraclavicular approach. Eighty patients were randomized into two equal groups: Group I (infraclavicular) and Group S (supraclavicular). All blocks were performed using ultrasound visualization with a 7.5-MHz linear probe and neurostimulation. The anesthetic mixture consisted of 0.5 mL/kg of bupivacaine 0.5% and lidocaine hydrocarbonate 2% (1:3 vol.) with epinephrine 1:200,000. Sensory block, motor block, and supplementation rates were evaluated for the musculocutaneous, median, radial, and ulnar nerves. Surgical anesthesia without supplementation was achieved in 80% of patients in group I compared with 87% in Group S (P = 0.39). Supplementation rates were significantly different only for the radial territory: 18% in Group I versus 0% in group S (P = 0.006). Block performance times were not different between groups (4.0 min in Group I versus 4.65 min in Group S; P = 0.43). Technique-related pain scores were not different between groups (I: 2.0; S: 2.0; P = 1.00). We conclude that USG infraclavicular block is at least as rapidly executed as USG supraclavicular block and produces a similar degree of surgical anesthesia without supplementation.
Publication Types:
PMID: 16116009 [PubMed - indexed for MEDLINE]
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Epidural injection of lidocaine reduces the response to dural puncture accompanying spinal needle insertion when performing combined spinal-epidural anesthesia.
van den Berg AA, Sadek M, Swanson S, Ghatge S.
The University of Texas Medical School at Houston, 6431 Fannin, MSB 5.020, Houston, TX 77030-1503, USA. antonvdb2000@yahoo.com
During placement of needles for combined spinal-epidural anesthesia (CSEA), patients may experience pain, pressure, paresthesia, or discomfort during skin and deeper injection of local anesthetic, needle impingement on periosteum, dural puncture by the spinal needle, and insertion of the epidural catheter. We investigated the incidence of perception of and spontaneous verbal and motor responses to insertion of a spinal needle through the dura mater and pia mater and the effect of injecting lidocaine into the epidural space through the epidural needle before inserting the spinal needle through the meninges. Forty-three patients presenting for elective cesarean delivery under CSEA were studied. After localization of the epidural space using loss of resistance to air using a 17-gauge Tuohy needle, either 3 mL preservative free normal saline or 3 mL lidocaine 2% plus epinephrine 1:200,000 was injected through the Tuohy needle. "Needle through needle" dural puncture was performed 1 min later using a 27-gauge Whitacre pencil-point needle. At the moment of dural puncture, 2 (9%) parturients given lidocaine and 17 (81%) parturients given saline (P < 0.005) responded to dural puncture by spontaneously moving (33%), spontaneously vocalizing (62%), or, in response to direct questioning, by acknowledging (76%) having perceived sensation during thecal penetration. This study reveals that dural puncture by a Whitacre 27-gauge pencil-point needle inserted through a Tuohy epidural needle sited using loss of resistance to air causes involuntary movement, spontaneous vocalization, or is perceived by the majority of patients presenting for cesarean delivery under CSEA and that lidocaine injected into the epidural space before dural puncture largely eliminates these responses and sensations.
Publication Types:
PMID: 16116008 [PubMed - indexed for MEDLINE]
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Postoperative epidural morphine for postpartum tubal ligation analgesia.
Marcus RJ, Wong CA, Lehor A, McCarthy RJ, Yaghmour E, Yilmaz M.
Department of Anesthesiology, Feinberg School of Medicine, Northwestern University, 251 E. Huron, F 5-704, Chicago, IL 60611, USA. r-marcus@northwestern.edu
Women undergoing postoperative postpartum tubal ligation (PPTL) often experience considerable pain. We hypothesized that epidural morphine, as part of a multi-modal analgesic regimen, would decrease postoperative pain and the need for systemic analgesia after PPTL. In a double-blinded study, patients were randomized to receive epidural saline or morphine 2 mg, 3 mg, or 4 mg after epidural anesthesia for PPTL. Postoperatively, ibuprofen 600 mg was administered every 6 h and patients could request acetaminophen 325 mg/hydrocodone 10 mg. The primary outcome variable was time to first request for supplemental analgesia. Verbal rating scores for pain and the incidence and severity of side effects were recorded for 24 h. Morphine group subjects requested supplemental analgesia later and received fewer doses compared with the saline group subjects. Peak cramping and incisional verbal rating scores for pain and the area under the verbal rating scores for pain x time curve for cramping pain were less after epidural morphine compared with saline, but there were no differences among morphine groups. Nausea, vomiting, and pruritus occurred more often in all morphine groups and subjects who received morphine 4 mg required treatment for these side effects more frequently than the saline or morphine 2 mg groups. In conclusion, epidural morphine 2 mg as part of a multi-modal analgesic regimen improved analgesia and decreased the need for supplemental analgesics after PPTL. The need to treat side effects with morphine 2 mg was not increased compared to a regimen of oral acetaminophen/opioid/nonsteroidal antiinflammatory analgesics.
Publication Types:
PMID: 16116007 [PubMed - indexed for MEDLINE]
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The antiallodynic and antihyperalgesic effects of neurotropin in mice with spinal nerve ligation.
Suzuki T, Li YH, Mashimo T.
Department of Anesthesiology, Osaka University Medical School, 2-2 Yamadaoka, Suita, Osaka, Japan 565-0871. tsuzuki@anes.med.osaka-u.ac.jp
Although Neurotropin(R) (NTP) has been used clinically as an analgesic in Japan for many years, its effect on neuropathic pain in animal models has not been examined in detail. Its main effect has been indicated to be activation of the descending monoaminergic pain inhibitory systems. To study the effect of NTP on neuropathic pain, we subjected mice to spinal nerve ligation. NTP inhibited both tactile allodynia and mechanical and thermal hyperalgesia in a dose-dependent manner. When the effect of NTP was examined after depletion of monoamines in the spinal cord by intrathecal neurotoxins, the antiallodynic and antihyperalgesic effects were still observed after serotonergic denervation, but not after noradrenergic denervation. In addition, intracerebroventricular NTP increased withdrawal threshold and latency although intrathecal or local administration of NTP did not. These results suggest that the antiallodynic and antihyperalgesic effect of NTP on neuropathic pain induced by spinal nerve ligation is mediated principally through the action at supraspinal sites and through activation of spinal noradrenergic systems, possibly via the descending inhibitory pathway.
PMID: 16115993 [PubMed - indexed for MEDLINE]
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Determining the plasma concentration of ketamine that enhances epidural bupivacaine-and-morphine-induced analgesia.
Suzuki M, Kinoshita T, Kikutani T, Yokoyama K, Inagi T, Sugimoto K, Haraguchi S, Hisayoshi T, Shimada Y.
Department of Anesthesiology, Second Hospital Nippon Medical School, Kanagawa 211-8533, Japan. manzo@nms.ac.jp
N-methyl-D-aspartate (NMDA) receptor antagonists enhance opioid-induced analgesia. The plasma concentration of ketamine, an NMDA receptor antagonist that enhances epidural morphine-and-bupivacaine-induced analgesia, is not known. We examined 24 patients with lung carcinoma or metastatic lung tumor who underwent video-assisted thoracic surgery in a placebo-controlled, double-blind manner 4 h after emergence from anesthesia. The morphine + ketamine group (n = 8) and morphine + placebo group (n = 8) received 5 mL volume of 2.5 mg morphine and 0.25% bupivacaine and the placebo + ketamine group (n = 8) received 5 mL volume of saline and 0.25% bupivacaine epidurally at the end of skin closure. Four hours after this anesthesia, in the morphine + ketamine and placebo + ketamine groups, ketamine was administered to successively maintain a stable plasma ketamine concentration of 0, 10, 20, 30, 40, and 50 ng/mL by a target-controlled infusion device, and patients assessed the levels of pain at rest, pain on coughing, somnolence (drowsiness), and nausea using a 100-mm visual analog scale (VAS). In the morphine + placebo group, a placebo (saline) was similarly administered instead of ketamine. In the morphine + ketamine group, the VAS scores for pain at rest and pain on coughing significantly decreased on ketamine administration at a plasma concentration of 20 ng/mL or larger compared with the respective baseline VAS scores (P < 0.05 each). In the placebo + ketamine group, the VAS scores for pain at rest and pain on coughing did not significantly change at any plasma concentration of ketamine as compared to the morphine + placebo group. In the morphine + ketamine group, a plasma concentration of ketamine larger than 20 ng/mL did not further reduce VAS scores for pain at rest and pain on coughing. The VAS scores for drowsiness were comparable among the three groups at any plasma concentration of ketamine. Ketamine at a plasma concentration of 20 ng/mL or larger may enhance epidural morphine-and-bupivacaine-induced analgesia. As an adjunct with epidural morphine-and-bupivacaine and considering the safety of small doses, the minimal plasma concentration of ketamine given IV may be approximately 20 ng/mL.
Publication Types:
PMID: 16115991 [PubMed - indexed for MEDLINE]
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Continuous monitoring of cerebral oxygen saturation in elderly patients undergoing major abdominal surgery minimizes brain exposure to potential hypoxia.
Casati A, Fanelli G, Pietropaoli P, Proietti R, Tufano R, Danelli G, Fierro G, De Cosmo G, Servillo G.
Department of Anesthesiology, Azienda Ospedaliera di Parma, Via Gramsci 14, 43100 Parma, Italy. acasati@ao.pr.it
Elderly patients are more prone than younger patients to develop cerebral desaturation because of the reduced physiologic reserve that accompanies aging. To evaluate whether monitoring cerebral oxygen saturation (rSO(2)) minimizes intraoperative cerebral desaturation, we prospectively monitored rSO(2) in 122 elderly patients undergoing major abdominal surgery with general anesthesia. Patients were randomly allocated to an intervention group (the monitor was visible and rSO(2) was maintained at > or =75% of preinduction values; n = 56) or a control group (the monitor was blinded and anesthesia was managed routinely; n = 66). Cerebral desaturation (rSO(2) reduction <75% of baseline) was observed in 11 patients of the treatment group (20%) and 15 patients of the control group (23%) (P = 0.82). Mean (95% confidence intervals) values of mean rSO(2) were higher (66% [64%-68%]) and the area under the curve below 75% of baseline (AUCrSO2(2)< 75% of baseline) was lower (0.4 min% [0.1-0.8 min%]) in patients of the treatment group than in patients of the control group (61% [59%-63%] and 80 min% [2-144 min%], respectively; P = 0.002 and P = 0.017). When considering only patients developing intraoperative cerebral desaturation, a lower Mini Mental State Elimination (MMSE) score was observed at the seventh postoperative day in the control group (26 [25-30]) than in the treatment group (28 [26-30]) (P = 0.02), with a significant correlation between the AUCrSO(2) < 75% of baseline and postoperative decrease in MMSE score from preoperative values (r(2)= 0.25, P = 0.01). Patients of the control group with intraoperative cerebral desaturation also experienced a longer time to postanesthesia care unit (PACU) discharge (47 min [13-56 min]) and longer hospital stay (24 days [7-53] days) compared with patients of the treatment group (25 min [15-35 min] and 10 days [7-23 days], respectively; P = 0.01 and P = 0.007). Using rSO(2) monitoring to manage anesthesia in elderly patients undergoing major abdominal surgery reduces the potential exposure of the brain to hypoxia; this might be associated with decreased effects on cognitive function and shorter PACU and hospital stay.
Publication Types:
PMID: 16115985 [PubMed - indexed for MEDLINE]
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The incidence of transient neurologic symptoms after spinal anesthesia with mepivacaine.
YaDeau JT, Liguori GA, Zayas VM.
Department of Anesthesiology, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA. yadeauj@hss.ed
We prospectively evaluated 1273 patients who received spinal (or combined spinal-epidural [CSE]) anesthesia with 1.5% mepivacaine (plain, no glucose) for ambulatory surgery. We hypothesized that analysis of a large series of patients would confirm previous findings that isobaric 1.5% mepivacaine is not frequently associated with transient neurologic symptoms (TNS). Patients were contacted twice after the anesthetic, at days 1-4 and days 6-9. One-thousand-two-hundred-ten patients were successfully contacted postoperatively (95% follow-up rate). None of the patients had permanent neurologic sequelae from the anesthetic. None of the 372 CSE anesthetics was inadequate for surgery. Fourteen of 838 (1.7%) of the spinal anesthetics were inadequate. TNS, defined as the new onset of back pain that radiated bilaterally to buttocks or distally, occurred in 78 patients (6.4%; 95% confidence intervals 5.1%-8%). The mean age of patients who developed TNS (48 +/- 14 yr) was older than that of patients without TNS (41 +/- 16 yr) (P < 0.001). TNS was not influenced by gender or intraoperative position. The frequent success rate and infrequent rates of complications such as TNS and postdural puncture headache suggest that spinal anesthesia with mepivacaine is likely to be a safe and effective anesthetic for ambulatory patients.
Publication Types:
PMID: 16115971 [PubMed - indexed for MEDLINE]
Role for Cyclooxygenase 2 in the Development and Maintenance of Neuropathic Pain and Spinal Glial Activation.
Takeda K, Sawamura S, Tamai H, Sekiyama H, Hanaoka K.
* Ph.D. Student, Tokyo University School of Medicine. dagger Chief Anesthesiologist, Department of Anesthesia, Showa General Hospital, Kodaira, Tokyo. double dagger Assistant Professor, section sign Professor and Chairman, Department of Anesthesiology, Tokyo University Hospital.
BACKGROUND:: Lines of evidence have indicated that cyclooxygenase 2 plays a role in the pathophysiology of neuropathic pain. However, the site and mechanism of its action are still unclear. Spinal glia has also been reported to mediate pathologic pain states. The authors evaluated the effect of continuous intrathecal or systemic cyclooxygenase-2 inhibitor on the development and maintenance of neuropathic pain and glial activation in a spinal nerve ligation model of rats. METHODS:: Continuous intrathecal infusion of meloxicam (32 or 320 mug . kg . day) or saline was started immediately after L5-L6 spinal nerve ligation. Mechanical allodynia and thermal hyperalgesia were evaluated on days 4 and 7 postoperatively. Spinal astrocytic activation was evaluated with glial fibrially acidic protein immunoreactivity on day 7. In other groups of rats, continuous intrathecal meloxicam was started 7 days after spinal nerve ligation, and effects on established neuropathic pain and glial activation were evaluated. Last, effects of continuous systemic meloxicam (16 mg . kg . day) on existing neuropathic pain and glial activation were examined. RESULTS:: Intrathecal meloxicam prevented the development of mechanical allodynia and thermal hyperalgesia induced by spinal nerve ligation. It also inhibited spinal glial activation responses. In contrast, when started 7 days after the nerve ligation, intrathecal meloxicam did not reverse established neuropathic pain and glial activation. Systemic meloxicam started 7 days after ligation partially reversed neuropathic behaviors but not glial activation. CONCLUSIONS:: Spinal cyclooxygenase 2 mediates the development but not the maintenance of neuropathic pain and glial activation in rats. Peripheral cyclooxygenase 2 plays a part in the maintenance of neuropathic pain.
PMID: 16192777 [PubMed - as supplied by publisher]
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Somatotopy in Human Primary Somatosensory Cortex in Pain System.
Ogino Y, Nemoto H, Goto F.
* Anesthetist Instructor, dagger Assistant Professor, double dagger Professor.
BACKGROUND:: Compared with somatotopical organization (somatotopy) in the postcentral gyrus in the tactile system, somatotopy in the pain system is not well understood. The aim of this study is to elucidate whether there is somatotopy in the human pain system. METHODS:: To elucidate the somatotopy of nociceptive neurons in the postcentral gyrus, the authors recorded pain-evoked cortical responses to noxious intraepidermal electrical stimulation applied to the left hand and left foot in 11 male subjects, using magnetoencephalography. RESULTS:: Brief painful stimuli evoked sustained cortical activity in the primary somatosensory cortex (SI) in the hemisphere contralateral to the stimulated side and in the secondary somatosensory cortex in both hemispheres. In SI, representations of the hand and foot were distinctly separated, with a more medial and posterior location for the foot, whereas no significant difference was found in the locations for the secondary somatosensory cortex dipole. The SI arrangement along the central sulcus was compatible with the homunculus revealed by Penfield using direct cortical stimulation during surgery. CONCLUSIONS:: The human pain system contains a somatotopical representation in SI but with less somatotopical organization in the secondary somatosensory cortex. The current results provide supporting evidence of SI involvement in human pain perception and suggest that human SI subserves the localization of the stimulated site in nociceptive processing.
PMID: 16192775 [PubMed - as supplied by publisher]
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Preventive Analgesia to Reduce Wound Hyperalgesia and Persistent Postsurgical Pain: Not an Easy Path.
Brennan TJ, Kehlet H.
*Departments of Anesthesia and Pharmacology, The University of Iowa, Iowa City, Iowa. daggerSection for Surgical Pathophysiology, The Juliane Marie Centre, Rigshospitalet, Copenhagen, Denmark. henrik.kehlet@rh.dk.
PMID: 16192759 [PubMed - as supplied by publisher]
Effect of neutropenia on the impact of a cognitive-behavioral intervention for symptom management.
Given BA, Given CW, Jeon S, Sikorskii A.
College of Nursing, Michigan State University, East Lansing, MI 48824, USA. bgiven@msu.edu
BACKGROUND: Trials of cognitive-behavioral interventions (CBI) designed to reduce symptom severity or improve dimensions of quality of life seldom consider how the side effects of treatment or the complications imposed by the disease or treatment may moderate the impact of the trial on the designated outcome. To address this issue, the moderating effect of neutropenia on the impact of a CBI for reducing symptom severity was evaluated among patients with cancer undergoing chemotherapy. METHODS: The authors described the impact of a randomized trial of a 10-contact, 20-week CBI on symptom severity, as well as the moderating effect of a neutropenic episode on symptom severity at 20 weeks. Severity scores were based on sum scores (0-10) for 15 symptoms. RESULTS: There was an effect for age (younger) and group on severity at 20 weeks and an interaction between neutropenia and group. Among patients with no evidence of neutropenia, those in the experimental arm had a 9-point lower severity score at 20 weeks. Among patients who experienced neutropenia, differences in symptom severity by arm of the trial were < 3 points. Further, fatigue, fever, and pain were more prevalent among patients with neutropenia. CONCLUSIONS: Patients who experienced neutropenia did not benefit from a CBI to lower symptoms. The overall effect of this intervention came almost exclusively from patients without neutropenia.
Publication Types:
PMID: 15971198 [PubMed - indexed for MEDLINE]
Remifentanil compared with morphine for postoperative patient-controlled analgesia after major abdominal surgery: a randomized controlled trial.
Kucukemre F, Kunt N, Kaygusuz K, Kiliccioglu F, Gurelik B, Cetin A.
Eskisehir State Hospital, Department of Anaesthesiology, Eskisehir, Turkey.
BACKGROUND AND OBJECTIVE: This randomized, double-blinded clinical study was designed to compare the efficacy and safety of remifentanil and morphine administered using intravenous (i.v.) patient-controlled analgesia (PCA) for postoperative analgesia after major abdominal surgery during the first 24 postoperative hours. METHODS: Sixty-nine patients were randomly allocated into two groups, each receiving remifentanil or morphine. The first group received i.v. remifentanil PCA with a loading dose of 45 microg, a maintenance dose of 1 microg min(-1), a bolus dose of 15 microg and a lockout interval of 10 min during the first 24 postoperative hours. The second group received i.v. morphine PCA with a loading dose of 5 mg, a maintenance dose of 0.3 mg h(-1), a bolus dose of 1 mg and a lockout interval of 15 min. Age, weight, sex, history of general anaesthesia, duration of surgery and time spent in the post-anaesthesia care unit were recorded. Preoperative pulse rate, systolic and diastolic blood pressures (BP), respiration rate and arterial blood gases were collected. Pulmonary function was tested before induction of anaesthesia, as well as at 4 and 26 h after operation. Pulse rate, systolic and diastolic BP, respiration rate, arterial blood gases, sedation and visual analogue scores, and presence of side-effects in the recovery room and on the ward for 24 h were recorded at 0, 1, 2, 4, 6, 12, 18 and 24 h after operation. Total drug use, number of boluses delivered, number of boluses demanded and delivery/demand ratio were collected. RESULTS: Sixty patients were evaluated. The groups did not differ in age, weight, sex, history of general anaesthesia, duration of surgery or time spent in the recovery unit. There were also no clinically relevant differences between the groups with regard to haemodynamic and respiratory parameters as well as sedation and visual analogue scores (P > 0.05). More bolus doses were demanded and delivered and the delivery/demand ratio was significantly higher in the remifentanil group (P < 0.05). There was no finding suggesting acute opioid tolerance during remifentanil or morphine PCA. CONCLUSION: The i.v. remifentanil PCA with the chosen dosage regimen after abdominal surgery produces postoperative analgesia and has cardiovascular side-effects similar to those achieved with i.v. morphine. Special attention must be given to respiratory depression during establishment of PCA with remifentanil.
Publication Types:
PMID: 15918388 [PubMed - indexed for MEDLINE]
Propacetamol and ketoprofen after thyroidectomy.
Fourcade O, Sanchez P, Kern D, Mazoit JX, Minville V, Samii K.
University of Toulouse, Purpan Hospital, Anaesthesia Department, France. fourcade.o@chu-toulouse.fr
BACKGROUND AND OBJECTIVE: The combination of non-opioid analgesic drugs, though widely used, has been rarely evaluated. The aim of this study was to compare the efficacy of propacetamol and the non-steroidal analgesic drug ketoprofen, alone or in combination, on pain relief after thyroid surgery performed using remifentanil. METHODS: Ninety-seven patients were randomly allocated to one of the three groups: propacetamol 2 g (32), ketoprofen 100 mg (33) and propacetamol 2 g + ketoprofen 100 mg (32). Each regimen was administered intravenously (i.v.) 30 min before the end of surgery and then every 6 h. If pain was not relieved, patients received an i.v. bolus of tramadol 100 mg. Tramadol consumption and pain intensity using a visual analogue scale was recorded at 1, 2, 8 and 14 h after the end of surgery. RESULTS: Pain scores were significantly higher with propacetamol compared with ketoprofen 2 h after surgery (35 +/- 3.7, 21 +/- 2.6, respectively; P < 0.01). The number of patients receiving tramadol was higher with propacetamol alone compared with the two other groups, 1 h (14/32, 4/33, 2/32, respectively; P > 0.01) and 2 h (24/32, 6/33, 8/32, respectively; P < 0.01) after surgery. There was no difference between ketoprofen alone and ketoprofen plus propacetamol, and there was no difference between the three groups from the 8th hour onward. CONCLUSIONS: In the immediate postoperative period after thyroid surgery performed using remifentanil, the concomitant use of propacetamol and ketoprofen does not improve analgesia compared with ketoprofen alone.
Publication Types:
PMID: 15918387 [PubMed - indexed for MEDLINE]
Comment in:
Post-craniotomy analgesia: current practices in British neurosurgical centres--a survey of post-craniotomy analgesic practices.
Roberts GC.
University Hospital of Wales, B4 Neurosurgery, Cardiff, Wales, UK. Gemma.Roberts@bromor-tr.wales.nhs.uk
BACKGROUND AND OBJECTIVE: An evaluation of post-craniotomy analgesia within the University Hospital of Wales Neurosurgical Unit, Cardiff, found that many patients were experiencing moderate to severe pain post-craniotomy. It was therefore decided to undertake a nationwide survey of analgesic practices in order to establish best practice guidelines and benchmark with other units. METHOD: A postal questionnaire was sent to the senior nurse of every Neurosurgical Directorate within the UK inquiring about the current, standard analgesic practices for post-craniotomy patients in their unit. RESULTS: Completed replies were received from 23 of the 33 centres (70%). Intramuscular (i.m.) codeine phosphate was found to be the principal first-line analgesic used post-craniotomy. Only three centres used morphine as the first-line analgesic and only one centre used patient controlled analgesia routinely. The majority of centres (82%) used balanced analgesia. Pain assessments were only carried out in 57% of centres and no centre used a validated pain assessment tool specifically for dysphasic patients. CONCLUSIONS: Codeine phosphate continues to be the mainstay of post-craniotomy analgesia, however, it is proposed that patient controlled analgesia with morphine is an efficacious and safe alternative.
PMID: 15918378 [PubMed - indexed for MEDLINE]
Heterotopic ischemic pain attenuates somatosensory evoked potentials induced by electrical tooth stimulation: Diffuse noxious inhibitory controls in the trigeminal nerve territory.
Fujii K, Motohashi K, Umino M.
Anesthesiology and Clinical Physiology, Department of Oral Restitution, Division of Oral Health Sciences, Graduate School, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo 113-8549, Japan.
The purpose of this study was to determine whether the late component of somatosensory evoked potentials (SEP) induced by electrical tooth stimulation and pain intensity are inhibited by heterotopic ischemic stimulation. The tourniquet pressure with 50mmHg greater than the individual's systolic pressure was applied to the left upper arm for 10min as ischemic conditioning stimulation. The late component of SEP and visual analogue scale (VAS) were recorded at 4 times and both were significantly decreased when ischemic conditioning stimulation was applied. The maximum reductions in SEP amplitude and the VAS value were 26.1% and 21.2%, respectively, during ischemic conditioning stimulation. After-effect was observed 5min after removal of the conditioning stimulation. The present study revealed that heterotopic ischemic stimulation attenuated the late component of SEP induced by electrical tooth stimulation, triggering diffuse noxious inhibitory controls (DNIC) and after-effects in the trigeminal nerve territory. It was also suggested that the DNIC effect differs, depending on the intensity, kind, and quality of the test and conditioning stimuli.
PMID: 16188472 [PubMed - as supplied by publisher]
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Switching from reservoir to matrix systems for the transdermal delivery of fentanyl: a prospective, multicenter pilot study in outpatients with chronic pain.
Freynhagen R, von Giesen HJ, Busche P, Sabatowski R, Konrad C, Grond S.
Departments of Anesthesiology, University of Dusseldorf, Dusseldorf, Germany.
Matrix systems for transdermal fentanyl will replace the reservoir systems in Europe. In an industry-independent, prospective, multicenter pilot study, 46 outpatients with chronic pain were asked to assess pain intensity, sleep interference, adverse events, and multiple secondary parameters during administration of the last reservoir and the first two matrix patches. There was no difference in pain intensity, sleep interference, and the rate of adverse events between both systems. Self assessment on a 6-step numeric rating scale (1 = very good, 6 = insufficient) comparing the two systems (reservoir vs. matrix) showed that skin compatibility (2.6 vs. 1.5), adhesive properties (3.2 vs. 1.8), wearability/comfort (2.8 vs. 1.5), and general satisfaction (2.5 vs. 1.8) improved significantly with the new matrix technology. At study endpoint, 91% of patients preferred the matrix system for future use. The new fentanyl matrix system is characterized by a high level of general satisfaction, ease of use, patient acceptance, and improved skin compatibility. Reservoir and matrix systems appear to have comparable efficacy and safety so that outpatients can be switched directly from the reservoir to the matrix system without difficulties and new dose titration.
PMID: 16183013 [PubMed - in process]
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An item response theory-based pain item bank can enhance measurement precision.
Lai JS, Dineen K, Reeve BB, Von Roenn J, Shervin D, McGuire M, Bode RK, Paice J, Cella D.
Center on Outcomes Research and Education, Evanston Northwestern Healthcare and Northwestern University, Evanston, Illinois 60201, USA.
Cancer-related pain is often under-recognized and undertreated. This is partly due to the lack of appropriate assessments, which need to be comprehensive and precise yet easily integrated into clinics. Computerized adaptive testing (CAT) can enable precise-yet-brief assessments by only selecting the most informative items from a calibrated item bank. The purpose of this study was to create such a bank. The sample included 400 cancer patients who were asked to complete 61 pain-related items. Data were analyzed using factor analysis and the Rasch model. The final bank consisted of 43 items which satisfied the measurement requirement of factor analysis and the Rasch model, demonstrated high internal consistency and reasonable item-total correlations, and discriminated patients with differing degrees of pain. We conclude that this bank demonstrates good psychometric properties, is sensitive to pain reported by patients, and can be used as the foundation for a CAT pain-testing platform for use in clinical practice.
PMID: 16183012 [PubMed - in process]
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Using quality improvement to address pain management practices in nursing homes.
Horner JK, Hanson LC, Wood D, Silver AG, Reynolds KS.
Medical Review of North Carolina, Inc., Cary, North Carolina, USA.
The objective of this study was to test whether a quality improvement intervention can improve pain management in nursing homes. Experts in quality improvement and clinical pain management provided nursing home staff leaders with feedback on pain quality indicator data, education in pain management, and technical assistance to apply the Plan-Do-Study-Act model of quality improvement. Trained abstractors completed structured chart audits at baseline and five months to capture quality indicator data related to pain assessment and treatment. Residents in pain who underwent pain assessments increased from 8% to 29% (P < 0.001). Residents receiving non-pharmacological pain treatments increased from 31% to 42% (P = 0.010), but pain medication use did not change. Among residents with daily moderate or excruciating pain, complete pain assessment was associated with increased probability of pain medication use. Quality improvement is a promising method to improve pain management in nursing homes.
PMID: 16183011 [PubMed - in process]
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The cancer pain experience of Israeli and American patients 65 years and older.
Cohen MZ, Musgrave CF, Munsell MF, Mendoza TR, Gips M.
School of Nursing, The University of Texas Health Science Center at Houston, Houston, Texas 77030, USA.
With the aging of the world's population, cancer pain will become an increasingly important health issue. The purpose of this study was to describe the cancer pain experience of Americans (n = 60) and Israelis (n = 39) 65 years and older. Outpatients in teaching hospitals in the U.S. and in Israel completed study questionnaires. Thirty percent of the total variance of worst pain was explained by age, symptom severity, and cancer stage, and 40% of the total variance of pain interference was explained by whether they were American or Israeli, symptom severity, and sense of coherence. Israeli patients had significantly higher scores on worst pain and pain interference, and significantly lower pain management index (PMI) and knowledge and attitudes toward pain and pain control scores. Studies with larger samples and across different cultures are needed to confirm these findings in order to develop culturally appropriate interventions.
PMID: 16183009 [PubMed - in process]
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Predictors of quality of life in oncology outpatients with pain from bone metastasis.
Rustoen T, Moum T, Padilla G, Paul S, Miaskowski C.
Faculty of Nursing, Oslo University College, Oslo, Norway.
The relationship between pain and quality of life (QOL) in cancer patients is complex due to the number and the diversity of factors that can influence pain and QOL. The aims of this study of oncology outpatients with pain from bone metastasis were: 1) to determine the extent to which pain characteristics (i.e., severity, duration, meaning of pain, and perceived availability and efficacy of pain relief), psychological distress (i.e., depression), physical functioning, social functioning and QOL are intercorrelated, and 2) to determine which of these variables are important predictors of QOL. A total of 157 oncology outpatients completed questionnaires that evaluated pain, QOL, depression, physical functioning, and social functioning at the time of enrollment into a randomized clinical trial that evaluated the effectiveness of a psychoeducational intervention to improve cancer pain management. Pearson product moment correlation coefficients were calculated to examine the relationships among the study variables. A blockwise, hierarchical multiple regression analysis was performed to determine which variables were the most important predictors of QOL. Meaning of pain was significantly correlated with all the other variables, in particular pain intensity and duration. The most important factors that predicted QOL were depression, social functioning, and physical functioning. Depression proved to be the most important predictor of QOL.
PMID: 16183007 [PubMed - in process]
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The use of Lactobacillus GG in irritable bowel syndrome in children: a double-blind randomized control trial.
Bausserman M, Michail S.
Department of Pediatrics, Wright State University School of Medicine and The Children's Medical Center, Dayton, Ohio 45404, USA.
OBJECTIVE: To determine whether oral administration of the probiotic Lactobacillus GG under randomized, double-blinded, placebo-controlled conditions would improve symptoms of irritable bowel syndrome (IBS) in children. STUDY DESIGN: Fifty children fulfilling the Rome II criteria for IBS were given Lactobacillus GG or placebo for 6 weeks. Response to therapy was recorded and collected on a weekly basis using the Gastrointestinal Symptom Rating Scale (GSRS). RESULTS: Lactobacillus GG was not superior to placebo in relieving abdominal pain (40.0% response rate in the placebo group vs 44.0% in the Lactobacillus GG group; P=.774). There was no difference in the other gastrointestinal symptoms, except for a lower incidence of perceived abdominal distention (P=.02 favoring Lactobacillus GG). CONCLUSIONS: Lactobacillus GG was not superior to placebo in the treatment of abdominal pain in children with IBS but may help relieve such symptoms as perceived abdominal distention.
Publication Types:
PMID: 16126049 [PubMed - indexed for MEDLINE]
Beta2-adrenergic receptor genotype and survival among patients receiving beta-blocker therapy after an acute coronary syndrome.
Lanfear DE, Jones PG, Marsh S, Cresci S, McLeod HL, Spertus JA.
Departments of Medicine, Genetics, and Molecular Biology and Pharmacology, Washington University School of Medicine, St Louis, Mo;
CONTEXT: Previous data support an association between polymorphisms of the beta1- and beta2-adrenergic receptors (ADRB1 and ADRB2) and surrogate end points of response to beta-adrenergic blocker therapy. However, no associations between these polymorphisms and mortality have been demonstrated. OBJECTIVE: To evaluate the effect of ADRB1 Arg389Gly (1165 CG), Ser49Gly (145 AG), and ADRB2 Gly16Arg (46 GA), Gln27Glu (79 CG) genotypes on survival among patients discharged with prescribed beta-blockers after an acute coronary syndrome (ACS). DESIGN, SETTING, AND PATIENTS: Prospective cohort study of 735 ACS patients admitted to 2 Kansas City, Mo, medical centers between March 2001 and October 2002; 597 patients were discharged with beta-blocker therapy. MAIN OUTCOME MEASURE: Multivariable-adjusted time to all-cause 3-year mortality. RESULTS: There were 84 deaths during follow-up. There was a significant association between ADRB2 genotype and 3-year mortality among patients prescribed beta-blocker therapy. For the 79 CG polymorphism, Kaplan-Meier 3-year mortality rates were 16% (35 deaths), 11% (27 deaths), and 6% (4 deaths) for the CC, CG, and GG genotypes, respectively (P = .03; adjusted hazard ratios [AHRs], 0.51 [95% confidence interval {CI}, 0.30-0.87] for CG vs CC and 0.24 (95% CI, 0.09-0.68) for GG vs CC, P = .004). For the ADRB2 46 GA polymorphism, 3-year Kaplan-Meier mortality estimates were 10% (17 deaths), 10% (28 deaths), and 20% (20 deaths) for the GG, GA, and AA genotypes, respectively (P = .005; AHRs, 0.48 [95% CI, 0.27-0.86] for GA vs AA and 0.44 [95% CI, 0.22-0.85] for GG vs AA, P = .02). No mortality difference between genotypes was found among patients not discharged with beta-blocker therapy for either the 79 CG or 46 GA polymorphisms (P = .98 and P = .49, respectively). The ADRB2 diplotype and compound genotypes were predictive of survival in patients treated with beta-blockers (P = .04 and P = .002; AHRs, 5.36 [95% CI, 1.83-15.69] and 2.41 [95% CI, 0.86-6.74] for 46 A homozygous and composite heterozygous vs 79 G homozygous, respectively). No association of the ADRB1 variants with mortality was observed in either the beta-blocker or no beta-blocker groups. CONCLUSIONS: Patients prescribed beta-blocker therapy after an ACS have differential survival associated with their ADRB2 genotypes. Further assessment of the benefits of beta-blocker therapy in high-risk genotype groups may be warranted.
PMID: 16189366 [PubMed - indexed for MEDLINE]
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A 21-year-old girl with recurrent abdominal pain after a robbery.
Selva-O'Callaghan A, Gomez-Acha J, Munne P, Vilardell-Tarres M.
Department of Internal Medicine, Vall d'Hebron Hospital, Passeig Vall d'Hebron, 119-129 08035 Barcelona, Spain. aselva@vhebron.net
Publication Types:
PMID: 16182903 [PubMed - indexed for MEDLINE]
Comment on:
Medical mystery: abdominal pain--the answer.
Kim KM, Kopelman RI.
Publication Types:
PMID: 16192498 [PubMed - indexed for MEDLINE]
Painful small-fiber neuropathy in Sjogren syndrome.
Chai J, Herrmann DN, Stanton M, Barbano RL, Logigian EL.
Department of Neurology, University of Rochester, Rochester, NY, USA.
Of 20 consecutive patients with Sjogren neuropathy, 16 (80%) presented with burning feet and 12 (60%) with non-length-dependent sensory symptoms. Leg and thigh skin biopsies, performed in 13 patients, including 7 with normal electrophysiology, showed either reduced epidermal nerve fiber (ENF) density or abnormal morphology. ENF loss was frequently non length dependent, suggesting that patients with this disorder commonly have a small-fiber sensory neuronopathy rather than a "dying-back" axonopathy.
PMID: 16186536 [PubMed - in process]
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Randomized, controlled trial of cannabis-based medicine in central pain in multiple sclerosis.
Rog DJ, Nurmikko TJ, Friede T, Young CA.
Walton Centre for Neurology and Neurosurgery, University of Liverpool, Liverpool, United Kingdom. djrdjr@doctors.org.uk
BACKGROUND: Central pain in multiple sclerosis (MS) is common and often refractory to treatment. METHODS: We conducted a single-center, 5-week (1-week run-in, 4-week treatment), randomized, double-blind, placebo-controlled, parallel-group trial in 66 patients with MS and central pain states (59 dysesthetic, seven painful spasms) of a whole-plant cannabis-based medicine (CBM), containing delta-9-tetrahydrocannabinol:cannabidiol (THC:CBD) delivered via an oromucosal spray, as adjunctive analgesic treatment. Each spray delivered 2.7 mg of THC and 2.5 of CBD, and patients could gradually self-titrate to a maximum of 48 sprays in 24 hours. RESULTS: Sixty-four patients (97%) completed the trial, 34 received CBM. In week 4, the mean number of daily sprays taken of CBM (n = 32) was 9.6 (range 2 to 25, SD = 6.0) and of placebo (n = 31) was 19.1 (range 1 to 47, SD = 12.9). Pain and sleep disturbance were recorded daily on an 11-point numerical rating scale. CBM was superior to placebo in reducing the mean intensity of pain (CBM mean change -2.7, 95% CI: -3.4 to -2.0, placebo -1.4 95% CI: -2.0 to -0.8, comparison between groups, p = 0.005) and sleep disturbance (CBM mean change -2.5, 95% CI: -3.4 to -1.7, placebo -0.8, 95% CI: -1.5 to -0.1, comparison between groups, p = 0.003). CBM was generally well tolerated, although more patients on CBM than placebo reported dizziness, dry mouth, and somnolence. Cognitive side effects were limited to long-term memory storage. CONCLUSIONS: Cannabis-based medicine is effective in reducing pain and sleep disturbance in patients with multiple sclerosis related central neuropathic pain and is mostly well tolerated.
PMID: 16186518 [PubMed - in process]
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Arachnoid cysts cause cognitive deficits that improve after surgery.
Raeder MB, Helland CA, Hugdahl K, Wester K.
Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway.
The authors investigated cognition in patients with arachnoid cysts by assessing 55 patients and 32 control subjects on four different cognitive tests preoperatively and 3 months postoperatively. The patients improved their performance from preoperative to postoperative testing, whereas the control subjects did not show a similar improvement.
PMID: 15642927 [PubMed - indexed for MEDLINE]
Comment on:
Thoughts on the American Academy of Pediatrics/American Academy of Family Physicians clinical practice guideline on acute otitis media: a different perspective.
Pellman H.
Publication Types:
PMID: 15867069 [PubMed - indexed for MEDLINE]
Comment on:
Morphine, hypotension, and intraventricular hemorrhage in the ventilated premature infant.
Perlman JM.
Department of Pediatrics, Weill Cornell Medical Center, New York, NY 10021, USA. jmp2007@med.cornell.edu
Publication Types:
PMID: 15867057 [PubMed - indexed for MEDLINE]
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