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Comment on:
Cost-effectiveness of clopidogrel plus aspirin versus aspirin alone.
Rothberg M.
Publication Types:
PMID: 16172448 [PubMed - indexed for MEDLINE]
Comment on:
Cost-effectiveness of clopidogrel plus aspirin versus aspirin alone.
Eriksson P.
Publication Types:
PMID: 16172447 [PubMed - indexed for MEDLINE]
Tolerability of acute postoperative pain management: nausea, vomiting, sedation, pruritis, and urinary retention. Evidence from published data.
Dolin SJ, Cashman JN.
Pain Clinic, St Richard's Hospital, Chichester PO19 6SE, UK.
This review examines the evidence from published data concerning the tolerability (indicated by the incidence of nausea, vomiting, sedation, pruritis, and urinary retention), of three analgesic techniques after major surgery; intramuscular analgesia (i.m.), patient-controlled analgesia (PCA), and epidural analgesia. A MEDLINE search of publications concerned with the management of postoperative pain and these indicators identified over 800 original papers and reviews. Of these, data were extracted from 183 studies relating to postoperative nausea and vomiting, 89 relating to sedation, 166 relating to pruritis, and 94 relating to urinary retention, giving pooled data which represent a total of more than 100 000 patients. The overall mean (95% CI) incidence of nausea was 25.2 (19.3-32.1)% and of emesis was 20.2 (17.5-23.2)% for all three analgesic techniques. PCA was associated with the highest incidence of nausea but the emesis was unaffected by analgesic technique. There was considerable variability in the criteria used for defining sedation. The overall mean for mild sedation was 23.9 (23-24.8)% and for excessive sedation was 2.6 (2.3-2.8)% for all three analgesic techniques (significantly lower with epidural analgesia). The overall mean incidence of pruritus was 14.7 (11.9-18.1)% for all three analgesic techniques (lowest with i.m. analgesia). Urinary retention occurred in 23.0 (17.3-29.9)% of patients (highest with epidural analgesia). The incidence of nausea and excessive sedation decreased over the period 1980-99, but the incidence of vomiting, pruritis, and urinary retention did not. From these published data it is possible to set standards of care after major surgery for nausea 25%, vomiting 20%, minor sedation 24%, excessive sedation 2.6%, pruritis 14.7%, and urinary retention requiring catheterization 23%. Acute Pain Services should aim for incidences less than this standard of care.
PMID: 16169893 [PubMed - in process]
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Pharmacokinetic mass of fentanyl for postoperative analgesia in lean and obese patients.
Shibutani K, Inchiosa MA Jr, Sawada K, Bairamian M.
Department of Anesthesiology, New York Medical College, Valhalla, New York, USA.
BACKGROUND: We previously proposed dosing weights for fentanyl, termed 'pharmacokinetic mass', that span the total body weight (TBW) range from 40 to 210 kg. In this study, we examined the relationships among fentanyl doses needed to achieve postoperative analgesia, corresponding plasma fentanyl concentrations, and pharmacokinetic mass in lean and obese patients undergoing abdominal surgery. METHODS: A total of 69 patients were studied, with TBW ranging from 48 to 181 kg. Fentanyl infusion was used during surgery. After surgery, fentanyl infusion rates were titrated to achieve analgesia without significant respiratory depression. Plasma fentanyl concentrations were measured when an apparent steady analgesic state was obtained. Comparisons were made for dosing requirements and effective plasma concentrations for 37 lean patients (body mass index < 30, TBW < 85 kg) and 33 obese patients (body mass index > 30, TBW > or = 85 kg). RESULTS: The average fentanyl dose (microg h(-1)) required to achieve and maintain analgesia over the 4 h postoperative period had a non-linear relationship to TBW; in comparison, fentanyl dose had a strong linear relationship to pharmacokinetic mass: dose (microg h(-1)) = 1.22 x pharmacokinetic mass - 7.5; r = 0.741, P < 0.001. Based on results from our earlier study, the corresponding values of TBW and pharmacokinetic mass are: 52 kg--52 kg; 70 kg--65 kg; 100 kg--83 kg; 120 kg--93 kg; 140 kg--99 kg; 160 kg--104 kg; 180 kg--107 kg; 200 kg--109 kg. In the group comparisons, there was no statistically significant difference in the postoperative fentanyl dose per unit of pharmacokinetic mass between lean and obese patients. The plasma concentration of fentanyl required for analgesia was approximately 1.5 ng ml(-1), and was similar in the two groups. CONCLUSION: The relationship between dose and pharmacokinetic mass, compared with that of dose vs TBW, may provide confidence for the use of pharmacokinetic mass as a dosing approximation for fentanyl. Fentanyl dose based on TBW may cause overdosing in obese patients.
PMID: 16024584 [PubMed - indexed for MEDLINE]
Case reports: ossified mass of the rotator cuff tendon in the subacromial bursa.
Matsumoto I, Ito Y, Tomo H, Nakao Y, Takaoka K.
Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Japan.
Unlike calcification, ossification is infrequent in the rotator cuff. We describe the clinical, radiographic, and pathologic findings in 64-year-old man with an ossified mass arising from a calcified portion of the rotator cuff tendon within the subacromial bursa. Mechanical stress and ischemic events are possible causes of cartilage formation followed by endochondral ossification, producing a mass causing outlet impingement.
Publication Types:
PMID: 16056056 [PubMed - indexed for MEDLINE]
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Function after resection of humeral metastases: analysis of 59 consecutive patients.
Bickels J, Kollender Y, Wittig JC, Meller I, Malawer MM.
The National Unit of Orthopedic Oncology, Tel-Aviv Sourasky Medical Center, Tel-Aviv University, Israel. jbickels@012.net.il
Metastatic bone disease of the humerus may require surgery for treatment of an impending or existing pathologic fracture or for alleviating disabling pain. Prompt restoration of function is a main goal of surgery, although published results do not reveal if that goal is being met. We retrospectively reviewed range of motion and function of 59 patients operated on from 1986-2003 for those indications. After resection, tumors around the humeral head and condyles (n = 20) were reconstructed with a prosthesis, and tumors at the humeral diaphysis (n = 39) were reconstructed with cemented nailing. Each patient's range of motion was recorded, and functional outcome was evaluated according to the American Musculoskeletal Tumor Society system. Patients who had cemented nailing had better shoulder motion, hand positioning, lifting ability, and emotional acceptance than patients who had endoprosthetic reconstruction. Pain alleviation and dexterity were comparable in both groups. All patients had a stable extremity, and the overall function of 56 patients (95%) was greater than 68% of normal upper extremity function. An aggressive surgical approach in patients with humeral metastases who met the criteria for surgical intervention was associated with good function. LEVEL OF EVIDENCE: Therapeutic study, Level IV (case series--no, or historical control group). See the Guidelines for Authors for a complete description of levels of evidence.
PMID: 16056050 [PubMed - indexed for MEDLINE]
Atlas of Uncommon Pain Syndromes: S. D. Waldman (ed.). Saunders, Elsevier: Philadelphia, USA, 2003, 256 pp; indexed, colour illustrations by C. H. Duckwall ISBN: 0-7216-9372-5; Price pound74.99.
Hester J.
London, UK.
PMID: 16174326 [PubMed - in process]
Nausea and vomiting after cataract surgery: does neostigmine have an emetic effect?
Frizelle HP, Curran E, Twomey C, MacAdoo J, Shorten G.
Publication Types:
PMID: 16045147 [PubMed - indexed for MEDLINE]
The persisting analgesic effect of low-dose intravenous ketamine after spinal anaesthesia for caesarean section.
Sen S, Ozmert G, Aydin ON, Baran N, Caliskan E.
Adnan Menderes University, Department of Anaesthesiology and Reanimation, Aydin, Turkey. drseldasen@yahoo.com
BACKGROUND AND OBJECTIVES: To compare the analgesic effects of intrathecal fentanyl and low-dose intravenous ketamine as adjuvants to intrathecal bupivacaine for Caesarean section. METHODS: Ninety elective Caesarean section patients were randomized into three groups. Spinal anaesthesia was performed with 15 mg hyperbaric bupivacaine in all groups. Ketamine (0.15 mg kg(-1)) or an equal volume of normal saline was given intravenously immediately after initiating spinal anaesthesia in the ketamine and control group, respectively. In the fentanyl group, 10 microg fentanyl was added to the intrathecal bupivacaine. Arterial pressures, heart rate values, adverse effects, the time of first request for postoperative analgesia, visual analogue pain scores, total analgesic consumptions at 24 and 48 h were recorded in all patients. RESULTS: The time to first request for analgesia was significantly longer in the ketamine (197 min) and fentanyl (165 min) groups compared to the control group (144 min). Postoperative pain scores were significantly lower in the ketamine group than in both other groups. Although the analgesic requirements during first 24 h were significantly lower in the ketamine group, there was no significant difference between the groups during the following 24 h. CONCLUSION: Intravenous low-dose ketamine combined with intrathecal bupivacaine for Caesarean section provides longer postoperative analgesia and lower postoperative analgesic consumption than bupivacaine alone suggesting a pre-emptive effect.
Publication Types:
PMID: 16045141 [PubMed - indexed for MEDLINE]
Comment on:
Radiotherapeutic prophylaxis of gynecomastia.
Thonnessen D, Wenz F.
Publication Types:
PMID: 16110041 [PubMed - indexed for MEDLINE]
Comment in:
A process for measuring the quality of cancer care: the Quality Oncology Practice Initiative.
Neuss MN, Desch CE, McNiff KK, Eisenberg PD, Gesme DH, Jacobson JO, Jahanzeb M, Padberg JJ, Rainey JM, Guo JJ, Simone JV.
Oncology Hematology Care, 4725 E Galbraith, Suite 320, Cincinnati, OH 45236, USA. mneuss@ohcmail.com
PURPOSE: The Quality Oncology Practice Initiative (QOPI) is a practice-based system of quality self-assessment sponsored by the participants and the American Society of Clinical Oncology (ASCO). The process of quality evaluation, development of the pilot questionnaire, and preliminary results are reported. METHODS: Physicians from seven oncology groups developed medical record abstraction measures based on practice guidelines and consensus-supported indicators of quality care. Each practice completed two rounds of records review and received practice and aggregate results. Mean frequencies of responses for each indicator were compared among practices. RESULTS: Participants universally, if informally, find QOPI helpful, and results show statistically significant variation among practices for several indicators, including assessing pain in patients close to death, documentation of informed consent for chemotherapy, and concordance with granulocytic and erythroid growth factor administration guidelines. Measures with universally high concordance include the use of serotonin antagonist antiemetics according to the ASCO guideline; the presence of a pathology report in the record; the use of chemotherapy flow sheets; and adherence to standard chemotherapy recommendations for patients with certain stages of breast, colon, and rectal cancer. Concordance with quality indicators significantly changed between survey rounds for several measures. CONCLUSION: Pilot results indicate that the QOPI process provides a rapid and objective measurement of practice quality that allows comparisons among practices and over time. It also provides a mechanism for measuring concordance with published guidelines. Most importantly, it provides a tool for practice self-examination that can promote excellence in cancer care.
PMID: 16087948 [PubMed - indexed for MEDLINE]
Comment on:
Acute coronary syndromes without ST-segment elevation--what is the role of early intervention?
Boden WE.
Publication Types:
PMID: 16162887 [PubMed - indexed for MEDLINE]
Comment in:
Early invasive versus selectively invasive management for acute coronary syndromes.
de Winter RJ, Windhausen F, Cornel JH, Dunselman PH, Janus CL, Bendermacher PE, Michels HR, Sanders GT, Tijssen JG, Verheugt FW; Invasive versus Conservative Treatment in Unstable Coronary Syndromes (ICTUS) Investigators.
Academisch Medisch Centrum, Amsterdam, Netherlands. r.j.dewinter@amc.uva.nl
BACKGROUND: Current guidelines recommend an early invasive strategy for patients who have acute coronary syndromes without ST-segment elevation and with an elevated cardiac troponin T level. However, randomized trials have not shown an overall reduction in mortality, and the reduction in the rate of myocardial infarction in previous trials has varied depending on the definition of myocardial infarction. METHODS: We randomly assigned 1200 patients with acute coronary syndrome without ST-segment elevation who had chest pain, an elevated cardiac troponin T level (> or =0.03 mug per liter), and either electrocardiographic evidence of ischemia at admission or a documented history of coronary disease to an early invasive strategy or to a more conservative (selectively invasive) strategy. Patients received aspirin daily, enoxaparin for 48 hours, and abciximab at the time of percutaneous coronary intervention. The use of clopidogrel and intensive lipid-lowering therapy was recommended. The primary end point was a composite of death, nonfatal myocardial infarction, or rehospitalization for anginal symptoms within one year after randomization. RESULTS: The estimated cumulative rate of the primary end point was 22.7 percent in the group assigned to early invasive management and 21.2 percent in the group assigned to selectively invasive management (relative risk, 1.07; 95 percent confidence interval, 0.87 to 1.33; P=0.33). The mortality rate was the same in the two groups (2.5 percent). Myocardial infarction was significantly more frequent in the group assigned to early invasive management (15.0 percent vs. 10.0 percent, P=0.005), but rehospitalization was less frequent in that group (7.4 percent vs. 10.9 percent, P=0.04). CONCLUSIONS: We could not demonstrate that, given optimized medical therapy, an early invasive strategy was superior to a selectively invasive strategy in patients with acute coronary syndromes without ST-segment elevation and with an elevated cardiac troponin T level. Copyright 2005 Massachusetts Medical Society.
Publication Types:
PMID: 16162880 [PubMed - indexed for MEDLINE]
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