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An introduction to the basic principles of health economics for those involved in the development and delivery of headache care.
Kernick D.
St Thomas Health Centre, Exeter, UK. su1838@eclipse.co.uk
Against a background of increasing demands on limited resources, health economics is gaining an increasing impact on decision making and a basic understanding of the subject is important for all those involved in headache research and service delivery at whatever level. This paper is not intended as a review of the literature in the area of headache economics but discusses some general principles of health economics from the perspective of headache, with a focus on cost of illness studies and economic evaluation.
Publication Types:
PMID: 16109053 [PubMed - indexed for MEDLINE]
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Greater occipital nerve block is ineffective in chronic tension type headache.
Leinisch-Dahlke E, Jurgens T, Bogdahn U, Jakob W, May A.
Department of Neurology, University of Regensburg, Regensburg, Germany.
Patients with primary headache syndromes often describe a pain distribution, that does not respect the trigeminal innervation of the head. In addition to pain in frontal areas, innervated by the first (ophthalmic) division of the trigeminal nerve, the pain often occurs in occipital parts of the head, innervated by the greater occipital nerve, a branch of the C2 spinal nerve root. Anatomical and neurophysiological studies in animals suggest a convergence of cervical and trigeminal input in the trigeminal nucleus caudalis. Modulation of this pathway has been discussed to be of potential benefit in headache disorders. We investigated in an open pilot study the effect of bilateral block of the greater occipital nerve with 50 mg prilocaine and 4 mg dexamethasone in patients with chronic tension type headache. From 15 patients, only one patient described a headache relief after initial exacerbation of headache for 2 days. Headache intensity was unchanged in 11 patients. In further three patients, the headache worsened in the first hours or days after injection. No serious adverse events were observed. One patient showed a bradycardia (36/min) after the first injection during palpation of the muscles of the neck. Three patients suffered pain on the injection site for a few days. Our results indicate that block of the greater occipital nerve is not effective in the treatment of chronic tension type headache. If at all, rather a 'pro-nociceptive' effect was observed.
Publication Types:
PMID: 16109052 [PubMed - indexed for MEDLINE]
Computed Tomography-Guided Anterior Approach to the Superior Hypogastric Plexus for Noncancer Pelvic Pain: A Report of Two Cases.
Michalek P, Dutka J.
From the *Department of Cardiovascular Anesthesia and Intensive Care, Na Homolce Hospital, Prague, Czech Republic; and the daggerDepartment of Radiology, Thomayer Teaching Hospital, Prague, Czech Republic.
The objective of this study was to evaluate the possibility and describe the methodology of a computed tomography-guided anterior approach to superior hypogastric plexus block for noncancer pain. A computed tomography-guided anterior approach to the superior hypogastric plexus was used in 2 patients with pelvic pain and anatomic disturbance of the lumbar spine, which was a contraindication to the conventional dorsal approach. The first case was a 43-year-old patient suffering from burning pain of the urethra. Pain relief using analgesics and antidepressants was insufficient. The posterior approach was excluded due to coexisting irritation of the L5 nerve root. The second case was a 68-year-old man suffering from chronic burning and itching pain of the urethra and glans penis. Conservative therapy (anti-inflammatory drugs, tramadol, spasmolytics) failed to provide satisfactory pain relief. The posterior approach was contraindicated because of laterally prominent L5 vertebral body osteophytes. Both patients received a prognostic block to the superior hypogastric plexus via the anterior approach guided by computed tomography. Visual analog scale scores prior to the block were 6 to 7 and 5 to 6, respectively. The visual analog scale scores 24 hours after the block were 1 and 0, respectively. The second patient received a permanent neurolytic block via the anterior approach to provide long-term pain relief. In conclusion, the authors describe the computed tomography-guided anterior approach to the superior hypogastric plexus for chronic pelvic pain. The technique is simple to perform, and the analgesic effect is satisfactory. More extensive studies are necessary to evaluate the safety of this approach.
PMID: 16215342 [PubMed - as supplied by publisher]
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Effectiveness of pamidronate for treating intractable chronic neuropathic pain: case report of two adolescents.
Brown SC, Jeavons M, Stinson J.
From the Department of Anaesthesia, The Hospital for Sick Children, and The University of Toronto, Toronto, Ontario, Canada.
The objective of this study is to evaluate the effectiveness of pamidronate for the treatment of chronic neuropathic pain refractory to previous management. Intravenous pamidronate (60 mg/day for 3 days) was administered to 2 adolescents with neuropathic pain refractory to previous multidisciplinary treatments. Pain intensity, functional improvement, and adverse effects were evaluated. There were no significant reductions in pain intensity or improvements in function initially or at follow-up at 1 week, 1 month and 4 months. Minor side effects included myalgia and skeletal pain that were relieved by acetaminophen. There was no long-term morbidity. In contrast to recent positive reports in adults, pamidronate was not effective in decreasing pain or improving function in 2 adolescents with chronic neuropathic pain. Pamidronate may be effective only when pain is accompanied by abnormal bone density. Future trials should include scans to document bone density pretherapy and posttherapy.
PMID: 16215341 [PubMed - in process]
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Consistent Management of Repeated Procedural Pain With Sucrose in Preterm Neonates: Is It Effective and Safe for Repeated Use Over Time?
Stevens B, Yamada J, Beyene J, Gibbins S, Petryshen P, Stinson J, Narciso J.
From the *Faculties of Nursing and Medicine, University of Toronto, Toronto, Ontario, Canada, and daggerThe Hospital for Sick Children Toronto, Ontario, Canada, double daggerDepartment of Biostatistics, University of Toronto, and the Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada, section signSunnybrook & Women's College Health Sciences Centre, Toronto, Ontario, Canada, parallelFaculty of Nursing, University of Toronto, Toronto, Ontario, Canada, and paragraph signSt Michael's Hospital, Toronto, Ontario, Canada, and #Department of Nursing, Mount Sinai Hospital Toronto, Ontario, Canada.
OBJECTIVE:: Preterm neonates undergo numerous painful procedures in the neonatal intensive care unit (NICU). Sucrose, with and without pacifiers, is effective and safe for relieving pain from single painful events. However, repeated use of sucrose for multiple painful procedures has not been adequately evaluated. The study objectives were to: 1) determine the efficacy and safety of consistent management of repeated procedural pain with sucrose; and 2) explore the impact of consistent pain management on clinical outcomes and neurobiological risk status. METHODS:: Sixty-six preterm infants were randomized to receive standard care (positioning and swaddling; n = 21), sterile water plus pacifier (n = 23), or 24% sucrose plus pacifier (n = 22) prior to all painful procedures in the NICU during the first 28 days of life. Also, at a routine heel lance at 7, 14, 21, and 28 days of life, data were collected to determine efficacy and immediate and long-term adverse events. Data on clinical outcomes and neurobiological risk status were collected at 28 days or NICU discharge. RESULTS:: There was no intervention by time interaction (P = 0.60). There was a significant main effect of intervention (P = 0.03) between the sucrose plus pacifier group, and the standard care group (P = 0.01), but there was no main effect of time (P = 0.72). No group differences existed for adverse events, clinical outcomes, or neurobiological risk status. DISCUSSION:: Consistent management of painful procedures with sucrose plus pacifier was effective and safe for preterm neonates during their stay in the NICU. Further exploration of consistent pain management with sucrose on clinical, developmental, and neurobiological outcomes is required.
PMID: 16215340 [PubMed - as supplied by publisher]
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The Efficacy of Preoperative Versus Postoperative Rofecoxib for Preventing Acute Postoperative Dental Pain: A Prospective Randomized Crossover Study Using Bilateral Symmetrical Oral Surgery.
Ong KS, Seymour RA, Yeo JF, Ho KH, Lirk P.
From the *Faculty of Dentistry, Department of Oral & Maxillofacial Surgery, National University of Singapore, Singapore; daggerSchool of Dental Studies, Department of Restorative Dentistry, University of Newcastle upon Tyne, Newcastle upon Tyne, United Kingdom; and double daggerDepartment of Anesthesiology & Critical Care Medicine, Medical College of Wisconsin, Milwaukee, WI.
BACKGROUND:: Previous data have demonstrated that rofecoxib has good analgesic efficacy for acute postoperative dental pain. However, up to half of these patients require rescue analgesics within the first 24 hours. As the timing of analgesic interventions may be an important factor in pain control, the present study tested the hypothesis that rofecoxib administered preoperatively would improve the analgesic efficacy and reduce rescue analgesic requirements within the first 24 hours compared with postoperative administration. METHODS:: This was a double-blind, randomized, crossover study where 45 patients had each of their identical impacted mandibular third molars removed under local anesthesia on 2 separate occasions. Patients acted as their own control; one side was pretreated with rofecoxib 50 mg, 2 hours before surgery, followed by placebo 15 minutes after surgery, and the contralateral side was pretreated with placebo 2 hours before surgery and posttreated with rofecoxib 50 mg 15 minutes after surgery. The difference in postoperative pain between 2 sides was assessed by 4 primary end-points: pain intensity as measured by a 100-mm visual analogue scale hourly for 12 hours, time to rescue analgesic, postoperative analgesic consumption, and patient's global assessment. RESULTS:: Patients reported significantly lower pain scores (P = 0.04), longer time to rescue analgesic (P = 0.02), lesser postoperative analgesic consumption (P = 0.008), and better global assessment (P = 0.01) in the pretreated compared with the posttreated sides. There were significantly more patients in the pretreated group who did not required rescue analgesic within the first 24 hours (80% vs. 58%, P = 0.01), and the pain scores were extremely low in both groups during the 12 hours postoperative period (9.8 +/- 5.0 mm vs. 14.3 +/- 7.4 mm). CONCLUSION:: Rofecoxib is an excellent analgesic for preventing postoperative dental pain and when given 2 hours preoperatively rendered most patients relatively pain free, requiring no rescue analgesics on the first postoperative day.
PMID: 16215339 [PubMed - as supplied by publisher]
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Treatment of Persistent Pain Associated With Osteoarthritis With Controlled-Release Oxycodone Tablets in a Randomized Controlled Clinical Trial.
Markenson JA, Croft J, Zhang PG, Richards P.
From the *Hospital for Special Surgery, New York, NY; daggerArthritis Center, P.C., Chevy Chase, MD; and double daggerPurdue Pharma L.P., Stamford, CT.
OBJECTIVE:: This study, lasting up to 90 days, was undertaken in patients with osteoarthritis with persistent moderate to severe pain uncontrolled by standard therapy (nonsteroidal anti-inflammatory drugs, acetaminophen, and/or short-acting opioids) to evaluate functional outcomes, as well as efficacy and safety, of controlled-release oxycodone versus placebo. METHODS:: One hundred seven patients received either controlled-release oxycodone or placebo every 12 hours in this double blind, randomized, placebo-controlled, parallel-group study. Stable previous regimens of acetaminophen or nonsteroidal anti-inflammatory agents were allowed to continue. Primary efficacy variables included Brief Pain Inventory average pain intensity scores at completion of initial titration, Western Ontario and McMaster Universities Osteoarthritis Index scores at days 30 and 60, and the percentage of patients discontinuing due to inadequate pain control. RESULTS:: Controlled-release oxycodone was significantly superior to placebo in decreasing average pain intensity and in reducing pain-induced interference with general activity, walking ability (except at day 30), and normal work, as well as mood, sleep, relations with people (at days 60 and 90), and enjoyment in life. Daily functioning, as measured by the Western Ontario and McMaster Universities Osteoarthritis Index, was also significantly improved in the controlled-release oxycodone group. In the placebo group, a significantly greater percentage of patients discontinued due to inadequate pain control. Adverse events were consistent with opioid adverse events, and no safety concerns were noted. DISCUSSION:: Treatment with controlled-release oxycodone of patients with osteoarthritis with persistent moderate to severe pain uncontrolled by standard therapy resulted in significant pain control and improvements in physical functioning.
PMID: 16215338 [PubMed - as supplied by publisher]
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Age and the Experience of Chronic Pain: Differences in Health and Quality of Life Among Younger, Middle-Aged, and Older Adults.
Rustoen T, Wahl AK, Hanestad BR, Lerdal A, Paul S, Miaskowski C.
From *Faculty of Nursing, Oslo University College, Oslo, Norway; daggerDepartment of Public Health and Primary Health Care, University of Bergen, Bergen, Norway; double daggerBuskerud University College, Drammen, and Department of Behavioral Science in Medicine, University of Oslo, Oslo, Norway; and section signDepartment of Physiological Nursing, School of Nursing, University of California, San Francisco, CA.
OBJECTIVES:: To describe age differences in chronic pain and to evaluate for differences in demographic and health-related variables among younger (18-39 years), middle-aged (40-59 years), and older adults (60-81 years) who reported chronic pain. METHODS:: A total of 4000 Norwegian citizens were mailed a questionnaire that measured pain, quality of life, mood, and demographic and health-related variables. RESULTS:: Of the total sample (n = 1912), 19.2% of the younger age group, 27.5% of the middle-aged group, and 31.2% of the older group reported chronic pain (ie, >3 months duration). A total of 58.9% of the participants in chronic pain reported having a chronic disease, with the most common being musculoskeletal problems, chronic pain disorder, and osteoarthritis. Participants in the older age group reported pain of longer duration and more comorbidities and received pain treatment more often. They had higher total quality of life scores, were more satisfied with their material comforts and social life, and reported better mood. The middle-aged group reported the largest number of pain locations, reported having fibromyalgia more frequently, and reported that the cause of their pain was not known. They were less satisfied with their social life than the older age group. The younger age group reported the highest rates of injury and accidents as the cause of their pain, and almost 43% of this age group was not receiving any treatment of their chronic pain. CONCLUSION:: This study found that the prevalence rates for chronic pain do vary with age and that the middle-aged group may be a high-risk group of patients with chronic pain.
PMID: 16215337 [PubMed - as supplied by publisher]
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Oral Methadone for Chronic Noncancer Pain: A Systematic Literature Review of Reasons for Administration, Prescription Patterns, Effectiveness, and Side Effects.
Sandoval JA, Furlan AD, Mailis-Gagnon A.
From the *Comprehensive Pain Program, Toronto Western Hospital, Toronto, Ontario, Canada; daggerUniversity of Toronto Centre for the Study of Pain, Toronto, Ontario, Canada; double daggerInstitute for Work & Health, Toronto, Ontario, Canada; section signHealth Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; and parallelKrembil Neuroscience Center, Toronto Western Hospital, Toronto, Ontario, Canada.
OBJECTIVE:: To assess the indications, prescription patterns, effectiveness, and side effects of oral methadone for the treatment of chronic noncancer pain. METHODS:: We conducted searches of several electronic databases, textbooks and reference lists for controlled or uncontrolled studies in humans. Effectiveness was assessed using a dichotomous classification of "meaningful" versus "nonmeaningful" outcomes. RESULTS:: Twenty-one papers (1 small randomized trial, 13 case reports, and 7 case series) involving 545 patients with multiple noncancer pain conditions were included. In half of the patients, no specific diagnosis was reported. Methadone was administered primarily when previous opioid treatment was ineffective or produced intolerable side effects. Starting dose ranged from 0.2 to 80 mg/day and maximum dose ranged from 20 to 930 mg/day. Pain outcomes were meaningful in 59% of the patients in the uncontrolled studies. The randomized trial demonstrated a statistically significant improvement in pain for methadone (20 mg/day) compared to placebo. Side effects were considered minor. DISCUSSION:: Oral methadone is used for various noncancer pain syndromes, at different settings and with no prescription pattern that could be identifiable. Starting, maintenance, and maximum doses showed great variability. The figure of 59% effectiveness of methadone should be interpreted very cautiously, as it seems overrated due to the poor quality of the uncontrolled studies and their tendency to report positive results. The utilization of oral methadone for noncancer pain is based on primarily uncontrolled literature. Well-designed controlled trials may provide more accurate information on the drug's efficiency in pain syndromes and in particular neuropathic pain.
PMID: 16215336 [PubMed - as supplied by publisher]
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"Ow!": Spontaneous Verbal Pain Expression Among Young Children During Immunization.
Stanford EA, Chambers CT, Craig KD, McGrath PJ, Cassidy KL.
From the *Department of Psychology, University of British Columbia, and daggerCentre for Community Child Health Research, B.C. Research Institute for Children's and Women's Health, Vancouver, British Columbia, Canada; double daggerDepartments of Psychology, Pediatrics and Psychiatry, IWK Health Centre and Dalhousie University, Halifax, Nova Scotia, Canada; and section signDepartment of Psychiatry, Dalhousie University, Halifax, Nova Scotia, Canada.
OBJECTIVES:: Although self-reports are a commonly used means of assessing pain in clinical settings, little is understood about the nature of children's spontaneous verbal expressions of pain. The purpose of this study was to describe verbalizations of pain among children receiving a preschool immunization and to examine how pain verbalizations correspond to children's facial expressions and self-reports of pain intensity. METHODS:: Fifty-eight children between the ages of 4 years 8 months and 6 years 3 months (67% female) were videotaped while receiving their routine preschool immunization. Global ratings of facial expression and detailed transcription and coding of pain verbalizations were undertaken. Children provided self-reports of pain using a 7-point faces pain scale. RESULTS:: Fifty-three percent of children used verbalizations spontaneously to express their pain. The modal verbalization was the interjection "Ow!," which expressed negative affect and was specific to the experience of pain. Older children were less likely to use verbalizations to express their pain. Children who used verbalizations to express pain displayed greater facial reactions to pain and rated their pain experience as being more intense than children who did not use words to express their pain. DISCUSSION:: Results indicate that many young children do not spontaneously use verbalizations to express pain from immunization. When 5-year-olds use verbalizations to express pain, the verbalizations are most often brief statements that express negative affect and directly pertain to pain. Knowledge of how children verbalize pain may lead to an improved ability to assess and manage pediatric pain.
PMID: 16215335 [PubMed - as supplied by publisher]
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Body Movements: An Important Additional Factor in Discriminating Pain From Stress in Preterm Infants.
Holsti L, Grunau RE, Oberlander TF, Whitfield MF, Weinberg J.
From the *Centre for Community Child Health Research, British Columbia Research Institute for Children's and Women's Health, Vancouver, British Columbia, Canada; daggerDepartment of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada; double daggerChildren's and Women's Health Centre of British Columbia, Vancouver, British Columbia, Canada; and the section signDepartment of Anatomy and Cell Biology, University of British Columbia, Vancouver, British Columbia, Canada.
OBJECTIVES:: To describe developmentally appropriate, specific body movements and other biobehavioral responses of preterm infants to a group of routine care giving tasks (Clustered Care), and to compare responses to acute pain with those of Clustered Care. METHODS:: In a randomized design, 54 preterm infants were assessed at 32 weeks gestational age during 3 phases of blood collection (Baseline, Lance/squeeze, Recovery) and of diaper changing, measuring abdominal girth and axillary temperature, and mouth care (Baseline, Clustered Care, Recovery) in a neonatal intensive care unit. The Newborn Individualized Developmental Care and Assessment Program and 1 facial action from the Neonatal Facial Coding System, Brow Bulge, were coded from separate continuous bedside video recordings. Heart rate and oxygen saturation were also acquired continuously. RESULTS:: Brow Bulge, heart rate, and a subset of 9 Newborn Individualized Developmental Care and Assessment Program movements increased and oxygen saturation decreased significantly to Lance/squeeze compared to Baseline. Similar facial and physiological changes occurred during Clustered Care, but with less intensity. However, infants showed greater frequencies and variety of Newborn Individualized Developmental Care and Assessment Program stress cues during Clustered Care than during Lance/squeeze. Stress cues persisted after Clustered Care, whereas the infants returned to Baseline following Lance/squeeze. DISCUSSION:: Changes in facial activity and heart rate remain the most sensitive markers of pain in preterm infants. Tactile procedures, such as diaper changing, produce lower intensity facial and physiological responses than pain procedures, but greater body reactions. Also, the effects from tactile procedures appear to last longer. Adding observations of a small number of specific body movements to the assessment of pain and stress provides complementary information particularly for those infants who may show dampened facial reactivity as a result of repeated pain exposure.
PMID: 16215334 [PubMed - as supplied by publisher]
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Stressful Experiences in Childhood and Chronic Back Pain in the General Population.
Kopec JA, Sayre EC.
From the *Department of Health Care and Epidemiology, University of British Columbia, Vancouver, British Columbia, Canada, and daggerArthritis Research Centre of Canada, Vancouver, British Columbia, Canada.
OBJECTIVES:: To determine if stressful experiences in childhood are associated with an increased risk of chronic back problems later in life. METHODS:: We conducted a prospective cohort study in the Canadian household population. Study participants were respondents to the first 3 cycles of the National Population Health Survey in Canada who were 18 years of age or older at baseline (n = 9552). Cases of chronic back pain during a 4-year follow-up period were ascertained with an interviewer-administered questionnaire. Stressful experiences in childhood were measured by an index consisting of 7 questions. RESULTS:: In multivariate analyses, the risk of back pain was 1.17 (95% confidence interval 0.97-1.41) for 1 stressful event and 1.49 (95% confidence interval 1.21-1.84) for 2 or more events. The effect was consistent across subgroups defined by gender, socioeconomic status, and health status. Specific events associated with an increased risk included fearful experiences, prolonged hospitalization, and parental unemployment. DISCUSSION:: Our study shows that persons reporting multiple stressful experiences in childhood are at increased risk of developing chronic back problems.
PMID: 16215332 [PubMed - as supplied by publisher]
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Impact of Controlled-Release Oxycodone on Efficacy Beliefs and Coping Efforts Among Osteoarthritis Patients With Moderate to Severe Pain.
Zautra AJ, Smith BW.
From the *Department of Psychology, Arizona State University, Tempe, AZ, and daggerDepartment of Psychology, University of New Mexico, Albuquerque, NM.
OBJECTIVES:: This study examines the impact of controlled-release oxycodone (OxyContin(R)) on cognitive-behavioral indicators of efficacy beliefs and coping efforts in patients with osteoarthritis who experience persistent pain. METHODS:: This was a double-blind, placebo-controlled study of 104 male and female patients with osteoarthritis who experienced moderate to severe pain. Pain assessment, arthritis helplessness, and coping efforts were assessed before and after for treatment and placebo control groups. RESULTS:: Examination of differences between treatment and control groups after 2 weeks revealed significant reductions in reported pain, improvements in coping efficacy, and reductions in helplessness and passive coping in response to controlled-release oxycodone treatment compared to placebo. Changes in pain partially mediated the effects on coping in subsequent assessments. DISCUSSION:: The findings indicate that controlled-release oxyco- done treatment accounted for improvements in coping with pain beyond that of placebo controls. This medication may be most beneficial to osteoarthritis patients when incorporated as part of a multidisciplinary approach to pain management.
PMID: 16215331 [PubMed - as supplied by publisher]
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A Randomized, Controlled Trial of Manual Therapy and Specific Adjuvant Exercise for Chronic Low Back Pain.
Geisser ME, Wiggert EA, Haig AJ, Colwell MO.
From *The Spine Program, Department of Physical Medicine and Rehabilitation, University of Michigan Health System, Ann Arbor, MI, and daggerDepartment of Surgery, University of Michigan Health System, Ann Arbor, MI.
OBJECTIVE:: This article examines the effectiveness of manual therapy with specific adjuvant exercise for treating chronic low back pain and disability. METHODS:: A single blind, randomized, controlled trial was employed. Patients were prescribed an exercise program that was tailored to treat their musculoskeletal dysfunctions or given a nonspecific program of general stretching and aerobic conditioning. In addition, patients received manual therapy or sham manual therapy. Participants were seen for 6 weekly sessions and were asked to perform their exercise program twice daily. RESULTS:: Seventy-two out of 100 patients completed the study. Multivariate tests conducted for measures of pain and disability revealed a significant group by time interaction (P = 0.04 and P = 0.05, respectively), indicating differential change in these measures pretreatment to posttreatment as a function of the treatment received. When controlling for pretreatment scores, patients receiving manual therapy with specific adjuvant exercise reported significant reductions in pain. No change in perceived disability was observed, with the exception that patients receiving sham manual therapy with specific adjuvant exercise reported significantly greater disability at posttreatment. DISCUSSION:: Manual therapy with specific adjuvant exercise appears to be beneficial in treating chronic low back pain. Despite changes in pain, perceived function did not improve. It is possible that impacting chronic low back pain alone does not address psychosocial or other factors that may contribute to disability. Further studies are needed to examine the long-term effects of these interventions and to address what adjuncts are beneficial in improving function in this population.
PMID: 16215330 [PubMed - as supplied by publisher]
A randomized, placebo-controlled study of rofecoxib with paracetamol in early post-tonsillectomy pain in adults.
Naesh O, Niles LA, Gilbert JG, Ammar MM, Phibbs PW, Phillips AM, Khrapov AV, Robert AJ, McClintock A.
Timaru Hospital, Department of Anaesthesia, New Zealand. onaesh@timhosp.co.nz
BACKGROUND AND OBJECTIVE: Effective and early treatment of postoperative pain and nausea have become pivotal for the early discharge of patients after tonsillectomy. Opioid-based analgesia is standard practice but the use of non-steroidal anti-inflammatory drugs is discouraged due to their platelet inhibiting properties. The cyclo-oxygenase-2 selective non-steroidal anti-inflammatory drugs are effective analgesics and do not affect platelet function. We hypothesized that premedication with cyclo-oxygenase-2 selective non-steroidal anti-inflammatory drug in addition to paracetamol would provide effective analgesia and decrease opioid consumption during early recovery from tonsillectomy. METHODS: In a randomized, placebo-controlled study of adult tonsillectomy patients (n=40) one group (R-group; n=20) was premedicated with paracetamol 1.5 g and rofecoxib 50 mg and a control group (P-group; n=20) was premedicated with paracetamol 1.5 g and placebo. Morphine was used as rescue medication. Postoperative (24 h) pain scores (0--10), morphine consumption as well as intraoperative blood loss were recorded. RESULTS: We found no overall difference in pain scores between the groups but significantly more patients in the placebo group had pain scores >5 within the first 8 h. The rofecoxib group consumed less morphine during the first 12 h. A lower intraoperative blood loss was observed in the rofecoxib group. CONCLUSION: Our results suggest an early although clinically minor analgesic benefit of the addition of a cyclo-oxygenase-2 selective non-steroidal anti-inflammatory drug to paracetamol as premedication for adult tonsillectomy.
PMID: 16211736 [PubMed - in process]
Pain studies illuminate the placebo effect.
Kuehn BM.
Publication Types:
PMID: 16219873 [PubMed - indexed for MEDLINE]
Adolescent siblings with thigh pain at the same age.
Shirado O, Nomoto T, Kuwazawa Y, Kim YT, Oda H, Hirose T.
Department of Orthopaedic Surgery, Saitama Medical School, Moroyama, Iruma-Gun, Saitama 350-0495, Japan. oshirado@m4.dion.ne.jp
Publication Types:
PMID: 16214605 [PubMed - indexed for MEDLINE]
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5-year outcome of an interventional strategy in non-ST-elevation acute coronary syndrome: the British Heart Foundation RITA 3 randomised trial.
Fox KA, Poole-Wilson P, Clayton TC, Henderson RA, Shaw TR, Wheatley DJ, Knight R, Pocock SJ.
Centre for Cardiovascular Science, Department of Medical and Radiological Sciences, University of Edinburgh, Edinburgh EH16 4SB, UK. k.a.a.fox@ed.ac.uk
BACKGROUND: The long-term outcome of an interventional strategy in patients with non-ST-elevation acute coronary syndrome is unknown. We tested whether an interventional strategy (routine angiography followed by revascularisation) was better than a conservative strategy (ischaemia-driven or symptom-driven angiography) over 5 years' follow-up. METHODS: In a multicentre randomised trial, 1810 patients (from 45 hospitals in England and Scotland, UK) with non-ST-elevation acute coronary syndrome were randomly assigned to receive an early intervention (n=895) or a conservative strategy (n=915) within 48 h of the index episode of cardiac pain. In each group, the aim was to provide the best medical treatment, and also to undertake coronary arteriography within 72 h in the interventional strategy with subsequent management guided by the angiographic findings. Analysis was by intention to treat and the primary outcome (composite of death or non-fatal myocardial infarction) had masked independent adjudication. RITA 3 has been assigned the International Standard Randomised Control Trial Number ISRCTN07752711. FINDINGS: At 1-year follow-up, rates of death or non-fatal myocardial infarction were similar. However, at a median of 5 years' follow-up (IQR 4.6-5.0), 142 (16.6%) patients with intervention treatment and 178 (20.0%) with conservative treatment died or had non-fatal myocardial infarction (odds ratio 0.78, 95% CI 0.61-0.99, p=0.044), with a similar benefit for cardiovascular death or myocardial infarction (0.74, 0.56-0.97, p=0.030). 234 (102 [12%] intervention, 132 [15%] conservative) patients died during follow-up (0.76, 0.58-1.00, p=0.054). The benefits of an intervention strategy were mainly seen in patients at high risk of death or myocardial infarction (p=0.004), and for the highest risk group, the odds ratio of death or non-fatal myocardial infarction was 0.44 (0.25-0.76). INTERPRETATION: In patients with non-ST-elevation acute coronary syndrome, a routine invasive strategy leads to long-term reduction in risk of death or non-fatal myocardial infarction, and this benefit is mainly in high-risk patients. The findings provide support for national and international guidelines in the need for more robust risk stratification in acute coronary syndrome.
Publication Types:
PMID: 16154018 [PubMed - indexed for MEDLINE]
Comment on:
Chronic stable angina.
Aguiar-Souto P, Silva-Melchor L, Ortigosa-Aso FJ.
Publication Types:
PMID: 16207859 [PubMed - indexed for MEDLINE]
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Motor cortex stimulation for refractory neuropathic pain: Four year outcome and predictors of efficacy.
Nuti C, Peyron R, Garcia-Larrea L, Brunon J, Laurent B, Sindou M, Mertens P.
Department of Neurosurgery, CHU Saint-Etienne, Bd Pasteur, 42055 Saint-Etienne cedex 2, France; INSERM EMI 0342, UCBLyon1 & UJM Saint-Etienne, France.
Thirty-one patients with medically refractory neuropathic pain were included in a prospective evaluation of motor cortex stimulation. The long-term outcome was evaluated using five variables: (a) rate (percentage) of pain relief, (b) pain scores as assessed on VAS, (c) postoperative decrease in VAS scores, (d) reduction in analgesic drug intake, (e) a dichotomic (yes/no) response to the question whether the patient would accept, under similar circumstances, to be operated on again. Pain relief was rated as excellent (>70 % pain relief) in 10 % of cases, good (40-69 %) in 42 %, poor (10-39 %) in 35 % and negligible (0-9 %) in 13 %. Intake of analgesic drugs was decreased in 52 % of patients and unchanged in 45 % (unavailable data in 3 %), with complete withdrawal of analgesic drugs in 36 % of patients. Twenty-one patients (70 %) declared themselves favourable to re-intervention if the same beneficial outcome could be guaranteed. Neither preoperative motor status, pain characteristics, type or localisation of lesions, quantitative sensory testing, Somatosensory Evoked Potentials, nor the interval between pain and surgery were found to predict the efficacy of MCS. The level of pain relief, as evaluated in the first month following implantation was a strong predictor of long-term relief (regression analysis, R=0.744; p<0.0001). These results confirm that MCS can be a satisfactory and durable alternative to medical treatments in patients with refractory pain, and suggest that the efficacy of MCS may be predicted in the first month of therapy.
PMID: 16214292 [PubMed - as supplied by publisher]
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Algorithm for neuropathic pain treatment: An evidence based proposal.
Finnerup NB, Otto M, McQuay HJ, Jensen TS, Sindrup SH.
Department of Neurology, Danish Pain Research Centre, Aarhus University Hospital, Aarhus Sygehus, Noerrebrogade 44, Aarhus 8000, Denmark.
New studies of the treatment of neuropathic pain have increased the need for an updated review of randomized, double-blind, placebo-controlled trials to support an evidence based algorithm to treat neuropathic pain conditions. Available studies were identified using a MEDLINE and EMBASE search. One hundred and five studies were included. Numbers needed to treat (NNT) and numbers needed to harm (NNH) were used to compare efficacy and safety of the treatments in different neuropathic pain syndromes. The quality of each trial was assessed. Tricyclic antidepressants and the anticonvulsants gabapentin and pregabalin were the most frequently studied drug classes. In peripheral neuropathic pain, the lowest NNT was for tricyclic antidepressants, followed by opioids and the anticonvulsants gabapentin and pregabalin. For central neuropathic pain there is limited data. NNT and NNH are currently the best way to assess relative efficacy and safety, but the need for dichotomous data, which may have to be estimated retrospectively for old trials, and the methodological complexity of pooling data from small cross-over and large parallel group trials, remain as limitations.
PMID: 16213659 [PubMed - as supplied by publisher]
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Heart rate mediation of sex differences in pain tolerance in children.
Lu Q, Zeltzer LK, Tsao JC, Kim SC, Turk N, Naliboff BD.
Pediatric Pain Program, Department of Pediatrics, David Geffen School of Medicine at UCLA, and Veterans Administration Greater Los Angeles Healthcare System, Bldg. 115, Rm. 223 11301 Wilshire Boulevard, Los Angeles, CA 90073, USA.
Despite evidence supporting the existence of important sex-related differences in pain, the mechanisms underpinning such differences are not well understood. The aim of this study is to examine the relationship between sex and pubertal differences in autonomic arousal and pain tolerance to laboratory pain stimuli in healthy children. We tested the following specific hypotheses: (1) females would have greater autonomic arousal and less pain tolerance than males, and (2) this sex difference in pain tolerance would be mediated by autonomic arousal. Participants were 244 healthy children (50.8% female, mean age 12.73+/-2.98 years, range 8-18 years). Separate 4-trial blocks of cutaneous pressure and thermal pain stimuli were presented in counterbalanced order. Heart rate (HR) was recorded during 2-3min periods preceding each block and a 1-min period between trials. Results indicated lower tolerance in females for cutaneous pressure, but not thermal pain, compared to males. In addition, pre-trial HR was greater for females than males. Mediation analyses suggested that sex differences in pressure pain tolerance were accounted for by sex differences in pre-trial HR. There were also significant effects for puberty, but these did not vary by sex. Overall, early pubertal children had greater pre-trial HR and less pain tolerance than those in late puberty for both cutaneous pressure and thermal pain across sex. These results suggest that autonomic arousal may be a mediator of sex-related differences in pain responses in children.
PMID: 16213093 [PubMed - as supplied by publisher]
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Relationship of pain and symptoms to pubertal development in adolescents.
Leresche L, Mancl LA, Drangsholt MT, Saunders K, Korff MV.
Department of Oral Medicine, University of Washington, P.O. Box 356370, Seattle, WA 98195-6370, USA.
Temporomandibular disorder (TMD) pain, abdominal pain, migraine and tension-type headache are more prevalent in women than in men. This study assessed the relationship of back pain, headache, abdominal pain, TMD pain, and the presence of multiple pain conditions to gender and pubertal development in a cross-sectional, population-based survey of adolescents. We also examined the association between pubertal development and depressive and somatic symptoms, factors often associated with pain in adults. We hypothesized that prevalence of all pain conditions, as well as rates of other symptoms, would increase as puberty progresses in females, but not males. Subjects (3101 boys and girls, 11-17 years old, selected from an HMO population) reported on the presence of each pain condition in the prior 3 months and completed scales assessing pubertal development, and depressive and somatic symptoms. Data were analyzed using descriptive statistics and multivariate logistic regression. Prevalence rates were weighted for factors affecting response. Prevalence of back pain, headache and TMD pain increased significantly (odds ratios, OR=1.4-2.0, P<0.001) and stomach pain increased marginally with increasing pubertal development in girls. Rates of somatization, depression and probability of experiencing multiple pains also increased with pubertal development in girls (P<0.0001). For boys, prevalence of back (OR=1.9, P<0.0001) and facial pain (OR=1.5, P<0.01) increased, stomach pain decreased somewhat and headache prevalence was virtually unchanged with increasing maturity. For both sexes, pubertal development was a better predictor of pain than was age. Thus it appears that pain, other somatic symptoms and depression increase systematically with pubertal development in girls.
PMID: 16213087 [PubMed - as supplied by publisher]
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Neuropathic pain associated with non-surgical treatment of breast cancer.
Jung BF, Herrmann D, Griggs J, Oaklander AL, Dworkin RH.
Department of Anesthesiology, University of Rochester School of Medicine and Dentistry, 601 Elmwood Avenue, Box 604, Rochester, NY 14642, USA.
PMID: 16213086 [PubMed - as supplied by publisher]
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TRPV4 mediates pain-related behavior induced by mild hypertonic stimuli in the presence of inflammatory mediator.
Alessandri-Haber N, Joseph E, Dina OA, Liedtke W, Levine JD.
Division of Neurosciences, University of California, 521 Parnassus Avenue, Room C-522, Box 0440, San Francisco, CA 94143-0440, USA.
The ligand-gated ion channel, TRPV4, functions as a transducer of hypotonic stimuli in primary afferent nociceptive neurons and contributes to inflammatory and neuropathic pain. Hypertonic saline also stimulates primary afferent nociceptors and the injection of mild hypertonic saline (2-5%) is widely used as an experimental model of pain in humans. Therefore, we tested whether TRPV4 participates in the transduction of hypertonic stimuli. Intradermal injection of 2% (607mOsm) or 10% (3250mOsm) saline solution in the hind paw of rats induced a concentration-dependent pain-related behavior, flinching. Sensitization with prostaglandin E(2) (PGE(2)) caused a 7-fold increase in the number of flinches induced by 2% saline but failed to increase those caused by 10% saline. Spinal administration of antisense oligodeoxynucleotides to TRPV4 caused a 46% decrease in the number of flinches induced by 2% saline, but there was no change in flinching induced by 10% saline. Similarly, only the nociceptive behavior caused by 2% saline was reduced in TRPV4(-/-) knockout mice. The TRPV4-mediated nociceptive behaviors induced by hyper- and hypotonic stimuli were dependent on Src tyrosine kinase. We suggest TRPV4 is a transducer in primary afferents that mediates nociceptive behavior induced by small increases or decreases in osmolarity. Such changes in osmolarity might contribute to pain in inflammatory and neuropathic states.
PMID: 16213085 [PubMed - as supplied by publisher]
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Is morphine-3-glucuronide of therapeutic relevance?
Skarke C, Geisslinger G, Lotsch J.
Institute of Clinical Pharmacology, Johann Wolfgang Goethe-University, pharmazentrum frankfurt/ZAFES, Theodor Stern-Kai 7, 60590 Frankfurt am Main, Germany. skarke@em.uni-frankfurt.de
Publication Types:
PMID: 15982815 [PubMed - indexed for MEDLINE]
Comment on:
Primum non nocere--first do no harm.
Butler SH.
Publication Types:
PMID: 15982811 [PubMed - indexed for MEDLINE]
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