record_id,pubmedID,title,authors,abstract,year,label_included,label_abstract_screening
1,10021952,Bupivacaine 0.125% produces motor block and weakness with fentanyl epidural analgesia in children.,A S Carr; D W Fear; N Sikich; B Bissonnette,"Epidural infusions of fentanyl (2 micrograms.ml-1) alone or combined with bupivacaine 0.125% were compared for perioperative analgesia, motor block and other side-effects in children who underwent urological surgery. In a prospective, double-blind study, 42 children, ASA I-II, 1-16 yr, were randomly allocated to receive either epidural F (fentanyl bolus 2 micrograms.kg-1 in 0.5 ml.kg-1 saline followed by 2 micrograms.ml-1 fentanyl infusion) or epidural F-B (fentanyl bolus 2 micrograms.kg-1 in 0.5 ml.kg-1 bupivacaine 0.25% followed by 2 micrograms.ml-1 fentanyl infusion in bupivacaine 0.125%) after induction of general anaesthesia. Adequacy of analgesia, lower limb motor block and side-effects were assessed four hourly postoperatively. Both infusion regimens provided excellent analgesia (median objective pain scores = 0). Epidural infusion rates were similar in the F (0.29 +/- 0.07 ml.kg-1.hr-1) and F-B (0.26 +/- 0.05 ml.kg-1.hr-1) groups. Three children in the F group and all children in the F-B group developed lower limb weakness. (P < 0.05) Bromage scores were different in the F group (median 0, range 0-0.66) compared with the F-B group (median 0.33, range 0-1) (P < 0.001). Other side-effects did not differ. Postoperative epidural fentanyl infusion provides equipotent analgesia to administration of a solution including both fentanyl and bupivacaine 0.125% and causes less lower limb weakness. No reduction in the fentanyl requirement resulted from the addition of bupivacaine 0.125%.",1999.0,0,0
2,10025691,Chronic pain after spinal cord injury: a survey of practice in UK spinal injury units.,A Ravenscroft; Y S Ahmed; I G Burnside,"To determine current practice regarding assessment and management of patients with chronic pain after spinal cord injury (SCI) in the UK. A postal questionnaire sent to the medical directors of the 12 spinal injury units in the UK. A response was received from nine of the 12 units. Chronic pain was felt to be a significant problem amongst patients with SCI, with inconsistent opinion between respondents regarding prevalence, aetiology and classification of chronic pain after spinal cord injury. Only one unit had established protocols for the investigation and management of pain, and most units felt that guidelines would be useful. Most felt that there was a need for further information on the subject. Our survey has demonstrated the uncertainty that exists amongst specialists dealing with pain after SCI, and emphasised the need for more research into the problem.",1999.0,0,0
3,10027027,Postoperative nausea and vomiting in children using patient-controlled analgesia: the effect of prophylactic intravenous dixyrazine.,E Kokinsky; E Thornberg; K Nilsson; L E Larsson,"Although patient-controlled analgesia (PCA) with morphine provides a high degree of satisfactory postoperative analgesia in children, it is often associated with a high incidence of postoperative nausea and vomiting (PONV). Our aim in this study was to evaluate the prophylactic effect of dixyrazine, a phenothiazine with proven anti-emetic properties. The incidence of nausea and vomiting was studied in 60 children using PCA after major surgery. The patients were randomised to receive either dixyrazine 0.25 mg kg-1 or placebo on the induction of anaesthesia in a double-blind, placebo-controlled design. The anaesthetic technique was standardised. The PCA pump was programmed to deliver bolus doses of morphine of 20 micrograms kg-1 with a continuous background infusion of 8-10 micrograms kg-1 h-1. Nausea, vomiting, sedation and pain scores were noted every 3 h for a period of 24 h. The morphine consumption of morphine was the same in both groups. During the stay in the recovery room the incidence of vomiting was 3% in the dixyrazine group compared to 30% in the placebo group (P < 0.05). On the ward, 57% versus 83% of the children vomited (P < 0.05). Rescue antiemetics were significantly lower, 30%, in the dixyrazine group compared to 60% in the placebo group (P < 0.05). Higher sedation scores were recorded for the dixyrazine group in the recovery room. No other adverse effects were found. A significant number of children using PCA with morphine after major surgery experience PONV. Although prophylactic dixyrazine reduces the incidence and severity of vomiting, the incidence still remains high.",1999.0,0,0
4,10027033,Lack of pre-emptive analgesic effect of (R)-ketamine in laparoscopic cholecystectomy.,L C Mathisen; V Aasbø; J Raeder,"This study evaluated the pre-emptive analgesic effect of intravenous (i.v.) (R)-ketamine in laparoscopic cholecystectomy. (R)-ketamine was used due to the lower incidence of side-effects. Sixty patients who underwent surgery under general anesthesia were randomly allocated to 3 groups and studied in a double-blind manner. Two i.v. injections were administered: one after induction of anesthesia, approximately 3 min before surgery, and one after surgery. The placebo group (PLA, n = 20) received saline in both injections. The preoperative group (PRE, n = 20) received (R)-ketamine 1 mg/kg and then saline. The postoperative group (POST, n = 20) received saline and then (R)-ketamine 1 mg/kg. Postoperatively, the patients used a patient-controlled analgesia (PCA) pump. Pain was evaluated with a visual analog scale (VAS) at 30 min and every hour for 4 h and with a verbal rating scale (VRS) at 24 h and after 7 days. There were no occurrence of side-effects from (R)-ketamine. VAS and VRS at 1, 2, 3, and 4 h postoperatively showed no statistical differences. In the POST group, extubation was delayed and pain score (VAS) at 30 min postoperatively was significantly lower (P < 0.05) than the two other groups. There were no statistical differences in meperidine consumption during the first 4 h postoperatively and no differences in consumption of analgesics at 24 h and 7 days. In this study a 1 mg/kg dose of (R)-ketamine given at the end of surgery exerted a short-lasting hypnotic and analgesic effect. The same dose given preoperatively did not show postoperative analgesic effect or pre-emptive effect.",1999.0,0,0
5,10028307,The management of a person with haemophilia who has a fixed flexed hip and intractable pain.,M Heim; D Varon; S Strauss; U Martinowitz,"The clinical picture of a fixed flexed hip associated with pain in a person with haemophilia is suggestive of a haemorrhage in that area. Sonography facilitates differentiation between a haemarthrosis, intraperitoneal haemorrhage, subperiosteal bleed, a bleed into the soft tissue around the hip joint or a psoas haematoma. All these aforementioned causes may result in the same clinical presentation. Two cases are described in which coxhaemarthrosis resulted in a flexion contracture of the joint associated with severe intractable pain. Narcotic drugs failed to alleviate the severe pain. Joint aspiration produced dramatic pain relief and early joint rehabilitation.",1999.0,0,0
6,10030776,Use of transdermal amitriptyline gel in a patient with chronic pain and depression.,M A Scott; K J Letrent; K L Hager; J L Burch,A man with severe inflammatory bowel disease suffered from chronic abdominal pain and depression. A transdermal amitriptyline gel preparation was compounded since he was unable to take drugs orally Serum concentrations of amitriptyline and its active metabolite nortriptyline were measured over 24 hours. Symptoms of depression were monitored before starting transdermal therapy and at the end of 6 weeks. Pain symptoms and amitriptyline adverse drug events were monitored daily Steady-state serum concentrations of drug and metabolite were within the therapeutic range over 24 hours. The patient reported that his mood was improved but his abdominal pain remained unchanged. Transdermal amitriptyline gel was well tolerated and is an alternative delivery system in patients unable to take drugs orally.,1999.0,0,0
7,10051763,Inducing placebo respiratory depressant responses in humans via opioid receptors.,F Benedetti; M Amanzio; S Baldi; C Casadio; G Maggi,"Several lines of evidence indicate that placebos produce analgesia through the activation of endogenous opioid systems. Recently, we showed that placebos may also produce respiratory depressant responses, a typical side-effect of narcotics, when a subject had a prior experience of respiratory depression in the course of narcotic treatment. In the present study, we report that the placebo respiratory depression can be induced after repeated administrations of the partial opioid agonist buprenorphine. The placebo respiratory depressant effect that resulted from the buprenorphine conditioning was completely blocked by a dose of 10 mg of naloxone, indicating that it was mediated by endogenous opioids. These findings show that placebos act, via the activation of opioid receptors, not only on pain mechanisms but on the respiratory centres as well, thus mimicking a typical side-effect of narcotics. In addition, the experimental procedure we used did not produce any expectation of respiratory depression and, similarly, the subjects did not notice any sign of respiratory discomfort. Thus, the placebo respiratory depression elicited in the present study cannot be explained on the basis of cognitive or motivational mechanisms. Rather, it appears to be a sequence effect due to learning, thus suggesting a conditioning mechanism mediated by endogenous opioids.",1999.0,0,0
8,10051933,The effectiveness of clonidine as an analgesic in paediatric adenotonsillectomy.,E J Reimer; G S Dunn; C J Montgomery; P M Sanderson; L D Scheepers; P M Merrick,"To compare the analgesic effects of preoperative oral clonidine with intraoperative intravenous fentanyl in children undergoing tonsillectomy or adenotonsillectomy. This randomized, controlled, double-blind study of 36 ASA I-II children, age 7-12 yr undergoing adenotonsillectomy was conducted at a tertiary care paediatric teaching hospital. Either 4 micrograms.kg-1 clonidine po was given 60-90 min preoperatively or 3 micrograms.kg-1 fentanyl i.v. was given intraoperatively. Postoperatively visual analog pain scores (VAS) were recorded at rest and on swallowing every 10 min for the first 30 min and then every 15 min for two hours. Morphine 0.05 mg.kg-1 i.v. was given for VAS > or = 5. If > 3 doses were required, 1.5 mg.kg-1 codeine po and 20 mg.kg-1 acetaminophen po were given. Sedation and anxiety scores were recorded preoperatively. Haemodynamic changes, blood loss, recovery scores, and the incidence of vomiting, hypotension, and airway obstruction were recorded. Children who received clonidine had a higher incidence of preoperative sedation (63%) than those receiving fentanyl (6%). Preinduction mean arterial pressure was lower in the clonidine group but required no intervention. VAS scores were similar throughout the observation period. There was no difference either in the number of morphine or codeine rescue doses administered or in the incidence of side effects. Oral clonidine is an effective analgesic and sedative for children undergoing tonsillectomy or adenotonsillectomy.",1999.0,0,0
9,10051934,"Perioperative antinociceptive effects of tramadol. A prospective, randomized, double-blind comparison with morphine.",M Naguib; M Seraj; M Attia; A H Samarkandi; M Seet; R Jaroudi,"To compare the efficacy of tramadol and morphine for intra- and postoperative analgesia in patients undergoing laparoscopic cholecystectomy. In a prospective, randomized, double-blind study 100 patients were allocated randomly into two groups. Ten minutes before induction of anaesthesia, patients in group 1 received 100 mg tramadol and those in group 2 received 10 mg morphine i.v. Anaesthesia was induced with 5 mg.kg-1 thiopental and was maintained with O2, N2O plus isoflurane with additional doses of tramadol or morphine as decided by the attending anaesthetist. Postoperatively, patients in group 1 and group 2 received tramadol and morphine, respectively, from a patient-controlled analgesia (PCA) device. Pain, analgesic consumption, vital signs and side effects were recorded postoperatively for 24 hr. Intraoperative consumption of tramadol and morphine were 137 +/- 37 and 12.2 +/- 3 mg, respectively. Compared with morphine, patients receiving tramadol had higher blood pressures and required greater mean ETisQ to control haemodynamic variables (P < 0.05). Postoperatively, there were no differences in observer pain score or visual analogue pain score during the first 24 hr between groups except at 30, 45, and 90 min where patients in the tramadol group reported higher pain scores (P < 0.05). The cumulative, 24 hr PCA consumption was 111 +/- 93 and 7.5 +/- 6.6 mg of tramadol and morphine, respectively. There was no difference between the use of tramadol and morphine to treat pain after laparoscopic cholecystectomy from 90 min after the end of surgery. Morphine was more effective than tramadol as an intraoperative analgesic.",1999.0,0,0
10,10068176,Oral transmucosal fentanyl citrate (OTFC) for the treatment of breakthrough pain in cancer patients: a controlled dose titration study.,R K Portenoy; R Payne; P Coluzzi; J W Raschko; A Lyss; M A Busch; V Frigerio; J Ingham; D B Loseth; E Nordbrock; M Rhiner,"Oral transmucosal fentanyl citrate (OTFC) is a novel opioid formulation in which the potent synthetic mu-agonist fentanyl is embedded in a sweetened matrix that is dissolved in the mouth. It is undergoing investigation as a treatment for cancer-related breakthrough pain, a prevalent phenomenon defined as a transitory flare of moderate to severe pain that interrupts otherwise controlled persistent pain. There have been no controlled trials of other treatments for this condition. To evaluate the safety and efficacy of ascending doses of OTFC, a novel controlled dose titration methodology was developed that applied blinding and randomization procedures to the evaluation of recurrent pains in the home environment. The study was a multicenter, randomized, double-blind dose titration study in ambulatory cancer patients. The sample comprised adult patients receiving a scheduled oral opioid regimen equivalent to 60-1000 mg oral morphine per day, who were experiencing at least one episode per day of breakthrough pain and had achieved at least partial relief of this pain by use of an oral opioid rescue dose. After collection of 2 days of baseline data concerning the efficacy of the usual rescue drug, patients were randomly treated with either 200 or 400 microg OTFC unit doses in double-blind fashion. Up to two breakthrough pains each day could be treated with up to four OTFC unit doses per pain. OTFC in unit doses containing 200, 400, 600, 800, 1200 or 1600 microg of fentanyl citrate were available for the study. The unit dose was titrated upward in steps until the patient had 2 consecutive days on which breakthrough pain could be treated with the single unit dose, titration was ineffective at a 1600 microg unit dose, or 20 days elapsed. To maintain the double-blind, orders to titrate up were ignored one-third of the time according to a pre-defined randomization schedule accessible only to an unblinded study pharmacist. Main outcome measures included, numeric or categorical measures of pain intensity, pain relief, and global assessment of drug performance. Dose response relationships were found suggesting that the methodology was sensitive to opioid effects. Seventy-four percent of patients were successfully titrated. There was no relationship between the total daily dose of the fixed schedule opioid regimen and the dose of OTFC required to manage the breakthrough pain. Although the study was not designed to provide a definitive comparison between OTFC and the usual rescue drug, exploratory analyses found that OTFC provided significantly greater analgesic effect at 15, 30 and 60 min, and a more rapid onset of effect, than the usual rescue drug. Adverse effects of the OTFC were typically opioid-related, specifically somnolence, nausea and dizziness. Very few adverse events were severe or serious. This study demonstrated the feasibility of controlled trial methodology in studies of breakthrough pain. OTFC appears to be a safe and effective therapy for breakthrough pain, and dose titration can usually identify a unit dose capable of providing adequate analgesia. If the lack of a relationship between the effective OTFC dose and fixed schedule opioid regimen is confirmed, dose titration may be needed in the clinical use of this formulation. Further investigation of OTFC as a specific treatment for breakthrough pain is warranted.",1999.0,0,0
11,10071701,Pain assessment and management in critically ill postoperative and trauma patients: a multisite study.,K C Carroll; P J Atkins; G R Herold; C A Mlcek; M Shively; P Clopton; D N Glaser,"Pain in critically ill patients is undertreated. To examine patients' perceptions of pain and acute pain management practices in a large metropolitan area to provide direction for improvements in pain relief. In a descriptive, correlational study, data were collected from 213 patients in 13 hospitals. Interviews with patients, chart reviews, and interviews with nurse leaders were used to examine institutional and individual approaches to pain management. Twenty-eight percent of patients did not recall an explanation of a pain management plan, and 64% were often in moderate to severe pain while in the intensive care unit. High pain intensity correlated with wait for an analgesic (P < .001), expectations of less pain (P < .001), and longer stay in the intensive care unit (P < .001). Low satisfaction correlated with expectations of less pain (P < .001), often being in moderate to severe pain (P < .001), and long wait for an analgesic (P < .001). In the first 24 hours postoperatively, only 54% of patients had a numerical pain rating documented; 91% had a pain description. The amount of opioid given on postoperative day 1 was influenced by pain intensity (P < .001), the patient's age (P = .03), type of surgery (P = .002), and route of analgesic (P < .001). Only 33% of patients had nonpharmacological pain interventions documented. Despite moderate to severe pain, patients are generally satisfied with their pain relief. Measuring patients' satisfaction alone is not a reliable outcome for determining the effectiveness of pain management. Realistic expectations of patients about their pain may enhance coping, increase satisfaction, and decrease pain intensity after surgery.",1999.0,0,0
12,10078674,Transdermal nitroglycerine enhances spinal sufentanil postoperative analgesia following orthopedic surgery.,G R Lauretti; R de Oliveira; M P Reis; A L Mattos; N L Pereira,"Sufentanil is a potent but short-acting spinal analgesic used to manage perioperative pain. This study evaluated the influence of transdermal nitroglycerine on the analgesic action of spinal sufentanil in patients undergoing orthopedic surgery. Fifty-six patients were randomized to one of four groups. Patients were premedicated with 0.05-0.1 mg/kg intravenous midazolam and received 15 mg bupivacaine plus 2 ml of the test drug intrathecally (saline or 10 microg sufentanil). Twenty to 30 min after the spinal puncture, a transdermal patch of either 5 mg nitroglycerin or placebo was applied. The control group received spinal saline and transdermal placebo. The sufentanil group received spinal sufentanil and transdermal placebo. The nitroglycerin group received spinal saline and transdermal nitroglycerine patch. Finally, the sufentanil-nitroglycerin group received spinal sufentanil and transdermal nitroglycerine. Pain and adverse effects were evaluated using a 10-cm visual analog scale. The time to first rescue analgesic medication was longer for the sufentanil-nitroglycerin group (785+/-483 min) compared with the other groups (P<0.005). The time to first rescue analgesics was also longer for the sufentanil group compared with the control group (P<0.05). The sufentanil-nitroglycerin group group required less rescue analgesics in 24 h compared with the other groups (P<0.02) and had lesser 24-h pain visual analog scale scores compared with the control group (P<0.005), although these scores were similar to the sufentanil and nitroglycerin groups (P>0.05). The incidence of perioperative adverse effects was similar among groups (P>0.05). Transdermal nitroglycerine alone (5 mg/day), a nitric oxide generator, did not result in postoperative analgesia itself, but it prolonged the analgesic effect of spinal sufentanil (10 microg) and provided 13 h of effective postoperative analgesia after knee surgery.",1999.0,0,0
13,10081516,A comparison of metoprolol and morphine in the treatment of chest pain in patients with suspected acute myocardial infarction--the MEMO study.,B Everts; B Karlson; N J Abdon; J Herlitz; T Hedner,"To compare the analgesic effect of metoprolol and morphine in patients with chest pain due to suspected or definite acute myocardial infarction after initial treatment with intravenous metoprolol. All patients, regardless of age, admitted to the coronary care unit at Uddevalla Central Hospital due to suspected acute myocardial infarction were evaluated for inclusion in the MEMO study (metoprolol-morphine). The effects on chest pain and side-effects of the two treatments were followed during 24 h. Pain was assessed by a numerical rating scale. A total of 265 patients were randomized in this prospective double-blind study and 59% developed a confirmed acute myocardial infarction. In both treatment groups, there were rapid reductions of pain intensity. However, in the patient group treated with morphine, there was a more pronounced pain relief during the first 80 min after start of double-blind treatment. The side-effects were few and were those expected from each therapeutic regimen. During the first 24 h, nausea requiring anti-emetics was more common in the morphine-treated patients. In suspected acute myocardial infarction, if chest pain persists after intravenous beta-adrenergic blockade treatment, standard doses of an opioid analgesic such as morphine will offer better pain relief than increased dosages of metoprolol.",1999.0,0,0
14,10081529,Intra-articular morphine for pain relief after knee arthroscopy.,L A Rosseland; A Stubhaug; A Skoglund; H Breivik,"Peripheral opioid analgesia is well documented. But the clinical usefulness of intra-articular morphine after surgery is uncertain. The aim of the present study was to evaluate the analgesic effects of intra-articular morphine after knee arthroscopy. In this parallel-group, double-blind study, 90 patients were randomised to receive either morphine 1 mg, morphine 2 mg or placebo in 5 ml saline intra-articularly at the end of arthroscopic knee surgery. Anaesthetic technique was local infiltration and intra-articular injection of lidocaine. Analgesic efficacy was evaluated by a global pain score, pain intensity (visual analogue scale), and analgesic requirements (paracetamol) during the first 48 h postoperatively. No significant differences between the groups were found for any of the efficacy variables. A majority of the patients had mild pain throughout the study, thus possibly compromising study sensitivity. In a subgroup with more intense pain early after arthroscopy, intra-articular morphine 2 mg reduced pain intensity (P < 0.05) and analgesic requirements (P < 0.05) compared with placebo. Postoperative analgesic effect of intra-articular morphine was found only in a subgroup of patients with higher pain intensity in the immediate postanaesthetic period. Possible reasons for our overall negative findings include low study sensitivity due to weak pain stimulus, lack of inflammation that may be a prerequisite for peripheral opioid analgesia, and the local anaesthetic, which impedes local inflammatory reaction and expression of peripheral opioid receptors. These factors may also explain the conflicting results in other studies.",1999.0,0,0
15,10081530,Continuous interscalene brachial plexus block for postoperative analgesia following shoulder surgery.,S Lehtipalo; L O Koskinen; G Johansson; J Kolmodin; B Biber,"Severe postoperative pain is a well-known problem following shoulder surgery. This study evaluates the clinical efficacy of continuous interscalene brachial plexus block, patient-controlled analgesia, and morphine (i.v. and i.m.) for postoperative analgesia in this setting. Thirty patients, scheduled for acromioplasty during general anesthesia, were randomly allocated to one of three different postoperative pain management groups. Group MO received morphine (5 mg i.m. and 2 mg i.v.) when visual analogue pain score (VAS) > 3, group PL received a continuous interscalene brachial plexus block with bupivacaine (1.25 mg kg-1 + 0.25 mg kg-1 h-1) and group PCA received patient-controlled analgesia with morphine (bolus 1 mg). Postoperative pain relief was assessed (24 h) by VAS, circulatory and respiratory stress parameters (heart rate, systemic arterial pressure and respiratory rate) and stress metabolites (glucose, lactate, glycerol by abdominal subcutaneous microdialysis). Pain relief in the PL group was effective (VAS < 3) and significantly more potent than in groups MO and PCA, except at 16 and 20 h. Lactate was significantly increased in the PL group, glucose was significantly increased in all groups, while glycerol showed a variable pattern. There were no significant stress metabolite differences among groups. VAS showed no statistical correlation with microdialysate, respiratory or circulatory data. Successful continuous interscalene brachial plexus block provides very good pain relief following shoulder surgery and is superior to the other methods studied. However, we were unable to demonstrate a correlation between VAS pain scores and stress indicators in metabolic, circulatory and respiratory parameters.",1999.0,0,0
16,10081531,Comparative effects of intravenous ketorolac and pethidine on perioperative analgesia and postoperative nausea and vomiting (PONV) for paediatric strabismus surgery.,D Shende; K Das,"Corrective strabismus surgery is associated with moderate pain and a very high incidence of postoperative nausea and vomiting (PONV). Ketorolac tromethamine, a nonsteroidal anti-inflammatory drug, is a popular analgesic in adults. There are only limited published data on the use of intravenous ketorolac for paediatric analgesia perioperatively. This study evaluated and compared the emetic and analgesic effect of ketorolac with pethidine and its suitability for this kind of surgery. Following institutional ethics committee approval and parental consent, 52 ASA class I children of age 2.5 to 15 yr were randomised to receive either ketorolac 0.9 mg kg-1 or pethidine 0.5 mg kg-1 given intravenously (i.v.). A blinded observer assessed recovery by Steward's method immediately after arrival at the post anaesthesia care unit (PACU), pain by validated Objective Pain Score (OPS) at 0 h, 1/2 h and 1 h after arrival at the PACU and PONV by Numeric Rank Score at specified time intervals. There were no differences in demographic data, anaesthesia time or surgery duration. Recovery scores, OPS and postoperative analgesic requirement were similar in both groups. PONV at various time intervals for the first 24 h, occurred more frequently in the pethidine group as compared to the ketorolac group (P < 0.001) There were no side effects observed with either drug. Ketorolac in a dose of 0.9 mg kg-1 i.v. at the induction of anaesthesia is as effective as pethidine 0.5 mg kg-1 i.v. as an analgesic and is associated with significantly less PONV.",1999.0,0,0
17,10083964,Aggressive pharmacologic treatment of pain.,M Pappagallo,"In this article, the author outlines the pharmacology of nociception and discusses the two major classes of drugs used for pain control: opioids and nonopioid analgesics. In order to provide satisfactory pain relief and prevent the possible sequelae of untreated pain, physicians must possess both knowledge and expertise in the use of opioid and nonopioid analgesics. Opioid analgesics have been underused in the management of pain. Opioids have a higher analgesic potency and wider range of indications than any of the other currently available medications for pain control. The second class of drugs, the nonopioid analgesics and adjuvants, has recently expanded to include new and potentially beneficial medications. This article furthers the understanding on how to use analgesics for a prompt, safe, and effective pharmacologic treatment of acute and chronic pain.",1999.0,0,0
18,10084100,,,,,0,0
19,10090435,"Sumatriptan treatment for migraine in a health maintenance organization: economic, humanistic, and clinical outcomes.",J A Cohen; D Beall; A Beck; J Rawlings; D W Miller; B Clements; D G Pait; A Batenhorst,"This study was undertaken to assess the impact of 12 months of sumatriptan therapy (6 mg subcutaneously) for migraine on health care use, health-related quality of life, productivity, patient satisfaction with the medication, and clinical efficacy in a health maintenance organization (HMO). One hundred forty-eight patients received open-label sumatriptan for 12 months for the treatment of migraine. Medical records were reviewed to obtain information on the frequency of migraine-related health care use during the 12 months before and during sumatriptan treatment. Patients completed questionnaires on their productivity at work, health-related quality of life, and satisfaction with medication at baseline and after 3, 6, and 12 months of sumatriptan treatment. For each migraine, patients recorded pain severity scores before and after taking sumatriptan and the time between dosing and onset of meaningful relief. Sumatriptan was associated with significant reductions in migraine-related use of general outpatient services, telephone calls, urgent care services, and emergency department visits (P < 0.05); a significant increase in the use of pharmacy services (P < 0.05); and significant and sustained improvements in health-related quality-of-life scores compared with baseline (P < 0.001). Patients lost significantly less time from work and were significantly more satisfied with sumatriptan compared with their usual therapy (P < 0.05). Two hours after dosing, 81% of patients experienced reduction of moderate or severe pain to mild or no pain, and 90% of all patients experienced meaningful relief of pain. The use of sumatriptan for 12 months in an HMO was associated with reductions in health care use and improved health-related quality of life, productivity, and patient satisfaction with medication.",1999.0,0,0
20,10101626,Responders and non-responders to post-operative pain treatment: the loading dose predicts analgesic needs.,U M Stamer; S Grond; C Maier,"The study compares responders and non-responders to post-operative patient-controlled analgesia (PCA) and evaluates factors that might differ between these two groups in order to identify non-responders during the early post-operative period. A prospective, randomized, double-blinded study design was used. Patients recovering from abdominal surgery were assigned to one of three treatment groups for a study period of 48 h. After titration of an individual loading dose, patients could self-administer 1 mL bolus doses (2 mg of morphine, 20 mg of tramadol or placebo) using a PCA device. Patients responding or not responding to the treatment were identified. In non-responders the escape medication was morphine. There were 96 responders and 65 non-responders. All responders showed similar pain scores, irrespective of the drug they received. Drug consumption of placebo responders was twice as high as that of opioid responders. Pain scores and analgesic consumption of non-responders were significantly higher compared with responders, although those patients received morphine. The loading dose correlated with subsequent analgesic consumption. Altogether, 89.2% of the non-responders were identified after the loading dose. Size of loading dose and pain scores during the first 30 min are useful for assessing the overall response to post-operative pain management. These factors may be valuable for predicting individual pain management.",1999.0,0,0
21,10101629,"Effectiveness of Harpagophytum extract WS 1531 in the treatment of exacerbation of low back pain: a randomized, placebo-controlled, double-blind study.",S Chrubasik; H Junck; H Breitschwerdt; C Conradt; H Zappe,"Two daily doses of oral Harpagophytum extract WS 1531 (600 and 1200, respectively, containing 50 and 100 mg of the marker harpagoside) were compared with placebo over 4 weeks in a randomized, double-blind study in 197 patients with chronic susceptibility to back pain and current exacerbations that were producing pain worse than 5 on a 0-10 visual analogue scale. The principal outcome measure, based on pilot studies, was the number of patients who were pain free without the permitted rescue medication (tramadol) for 5 days out of the last week. The treatment and placebo groups were well matched in physical characteristics, in the severity of pain, duration, nature and accompaniments of their pain, the Arhus low back pain index and in laboratory indices of organ system function. A total of 183 patients completed the study. The numbers of pain-free patients were three, six and 10 in the placebo group (P), the Harpagophytum 600 group (H600) and the Harpagophytum 1200 group (H1200) respectively (P = 0.027, one-tailed Cochrane-Armitage test). The majority of responders' were patients who had suffered less than 42 days of pain, and subgroup analyses suggested that the effect was confined to patients with more severe and radiating pain accompanied by neurological deficit. However, subsidiary analyses, concentrating on the current pain component of the Arhus index, painted a slightly different picture, with the benefits seeming, if anything, to be greatest in the H600 group and in patients without more severe pain, radiation or neurological deficit. Patients with more pain tended to use more tramadol, but even severe and unbearable pain would not guarantee that tramadol would be used at all, and certainly not to the maximum permitted dose. There was no evidence for Harpagophytum-related side-effects, except possibly for mild and infrequent gastrointestinal symptoms.",1999.0,0,0
22,10141133,Opioids for chronic pain of non-malignant origin--coercion or consent?,M A Somerville,,1995.0,0,0
23,10141140,Opioids for chronic pain of non-malignant origin--caring or crippling.,R G Large; S A Schug,"Pain management has improved in the past few decades. Opioid analgesics have become the mainstay in the treatment of cancer pain whilst inter-disciplinary pain management programmes are the generally accepted approach to chronic pain of non-malignant origin. Recently some pain specialists have advocated the use of opioids in the long-term management of non-cancer pain. This has raised some fundamental questions about the purpose of pain management. Is it best to opt for maximum pain relief and comfort, or should one emphasise function and activity as higher priorities? Will the use of opioids create more autonomy for pain sufferers or will this add handicaps to lives which are already limited? Until more clinical outcome data are available we advocate caution in the use of opioid analgesia. Such caution can, and does, raise questions about the rights of the patient and the rights of the prescriber in a context where the facts do not point to a clear course of action.",1995.0,0,0
24,10153644,Narcotics are safe for acute and chronic pain.,,,1994.0,0,0
25,10156211,Patient autonomy as the prerequisite for care: opioids for chronic pain of non-malignant origin.,S C Tourigny,,1995.0,0,0
26,10163578,Pharmacoeconomics of chronic nonmalignant pain.,M J Zagari; P D Mazonson; W C Longton,"Pain is one of the most common reasons for patients to seek medical care. In most settings, the model of acute pain treatment, with its emphasis on pharmacological therapy, is used for acute and chronic pain alike. Persistent chronic pain, however, often leads to complex social and psychological maladaptations, as well as substantial direct and indirect costs. Thus, the proper treatment of chronic pain usually involves pharmacological, behavioural and psychological interventions. Pain is a subjective sensation, but persistent chronic pain often results in long term neurophysiological and psychological changes that might be more appropriately considered disease manifestations. Unfortunately, the subjectivity of pain has meant that the assessment of the epidemiology, pharmacotherapy and economic costs of chronic pain has been difficult. As a result, many of the techniques for chronic pain management are unfamiliar to practising physicians. Even those healthcare professionals who are familiar with the special techniques for the management of chronic pain may be unable to identify the subpopulations for which they might be most effective. The clinician must evaluate patients for the appropriateness of a number of alternative drug delivery methods, novel analgesic agents, neuromodulatory techniques and multidisciplinary behavioural and psychological treatment programmes. The most effective treatment will often involve a combination of these techniques, as determined by the unique features of the patient's pain condition as well as individual patient characteristics. The costs and outcomes of various treatment strategies vary considerably and there is a need for comparative studies. Increasing emphasis on diagnosis and treatment in the primary care setting will place more importance on knowing the relative efficacies and appropriate use of a widening array of choices for chronic pain treatment. The management of chronic pain is remarkably complex and resource-intensive, and there is clearly a need for more intensive pharmacoeconomic studies, especially those comparing the many alternative strategies for management.",1996.0,0,0
27,10175652,Managing the persistent patient with chronic pain. How can we help a patient with a psychiatric illness who persistently demands medical appointments?,D E Hoffmann,,1997.0,0,0
28,10183392,Tramadol: new preparation. Capsules: central analgesic; step 2 on the WHO scale.,,"The clinical assessment file on tramadol is of low quality.  In acute postoperative pain and chronic pain there is no proof that tramadol has a better risk-benefit ratio than the paracetamol + codeine combination or other step 2 analgesics in the World Health Organisation classification.  Like all other central analgesics, tramadol can have neuropsychological adverse effects, especially a risk of dependence and misuse.",1998.0,0,0
29,10186467,Cost analysis of palliative care for terminally ill cancer patients in the UK after switching from weak to strong opioids. Palliative Care Advisory Committee.,J F Guest; W M Hart; R F Cookson,"We constructed a UK-based decision model of palliative care for terminally ill cancer patients who were switched from a weak to a strong opioid so that the expected direct healthcare costs in the UK could be estimated from the time a patient commenced a strong opioid until death. Decision analysis techniques were used to estimate the expected total direct healthcare cost per patient, stratified according to the first choice of strong opioid. The model was based on prescription data on 1975 terminally ill cancer patients who were on the Intercontinental Medical Statistics database, Mediplus (IMS Ltd, Middlesex, England). Resource-use data were obtained from published literature, a Delphi Panel and an advisory panel with expertise in palliative care. The expected cost of managing terminally ill cancer patients after they switched from a weak to a strong opioid ranged from 2391 pounds sterling (Pounds) to 3701 Pounds at 1995/1996 prices, depending primarily on the patient's duration of survival. Sensitivity analyses showed that the cost could be as low as 1500 Pounds or as high as 6000 Pounds, depending on resource use (at 1995/1996 prices). The key cost drivers were: hospice care, hospitalisation, general practitioner (GP) consultations and specialist nurse visits. In contrast, neither the choice of opioid nor managing constipation impacted substantially on the expected cost. Approximately two-thirds of the expected total cost was incurred by the UK National Health Service (NHS), with the remainder incurred by voluntary and charitable sectors. Hospice care and hospitalisation collectively accounted for between 50 and 80% of the expected costs. Management of patients in the community by the primary healthcare team accounted for between 10 and 40% of the costs. The acquisition cost of opioids accounted for between 2 and 8% of the expected cost and discounting the cost of these drugs sold to hospitals did not impact substantially on the total expected costs. The use of other resources such as antiemetics, NSAIDS, antidepressants and gastrointestinal drugs accounted for up to 3% of the expected cost. The expected cost of palliative care in the UK healthcare setting ranged from approximately 2500 Pounds to 4000 Pounds (1500 Pounds to 6000 Pounds in the sensitivity analysis) depending on the length of survival after patients switch from weak to strong opioids. Since opioids account for only 2 to 8% of expected costs, factors other than economic issues, such as tolerability profile, patient preference and convenience of use, should form the basis of clinical decision-making between opioids with similar analgesic efficacy.",1998.0,0,0
30,10189654,Comparison of morphine sulphate and codeine phosphate in children undergoing adenotonsillectomy.,D Semple; S Russell; E Doyle; L M Aldridge,"We undertook a double-blind study to evaluate equianalgesic doses of intramuscular morphine sulphate (0.15 mg.kg-1) and codeine phosphate (1.5 mg.kg-1) in 40 healthy children undergoing adenotonsillectomy. There were no significant differences in pain scores, analgesic requirements or sedation scores between the two groups over the following 24 h. More children vomited in the morphine group (60%) than the codeine group (30%) between one and six h after the procedure (P < 0.05). Codeine phosphate is associated with less postoperative vomiting than morphine sulphate while providing comparable postoperative analgesia for adenotonsillectomy.",1999.0,0,0
31,10193215,Side-effects of epidural infusions of opioid bupivacaine mixtures.,J A Gedney; E H Liu,"The incidence of side-effects occurring with epidural diamorphine (0.05 mg.ml-1), fentanyl (2.0 micrograms.ml-1), methadone (0.1 mg.ml-1), morphine (0.05 mg.ml-1) and pethidine (1.0 mg.ml-1) used by infusion in combination with bupivacaine has been compared. One hundred and sixty patients were studied, 32 receiving each opioid. The incidence of nausea and vomiting was significantly greater with morphine than fentanyl (p = 0.0097) and pethidine (p = 0.0021). The incidence of pruritus was significantly greater with morphine and diamorphine than with methadone (p = 0.012) and pethidine (p = 0.027). Morphine was also associated with a significantly greater incidence of urinary retention than pethidine (p = 0.012) and methadone (p = 0.025).",1999.0,0,0
32,10193280,Effect of i.v. ketamine in combination with epidural bupivacaine or epidural morphine on postoperative pain and wound tenderness after renal surgery.,S Ilkjaer; L Nikolajsen; T M Hansen; M Wernberg; J Brennum; J B Dahl,"We studied 60 patients undergoing operation on the kidney with combined general and epidural anaesthesia, in a double-blind, randomized, controlled study. Patients were allocated to receive a preoperative bolus dose of ketamine 10 mg i.v., followed by an i.v. infusion of ketamine 10 mg h-1 for 48 h after operation, or placebo. During the first 24 h after surgery, all patients received 4 ml h-1 of epidural bupivacaine 2.5 mg ml-1. From 24 to 48 h after operation, patients received epidural morphine 0.2 mg h-1 preceded by a bolus dose of 2 mg. In addition, patient-controlled analgesia (PCA) with i.v. morphine (2.5 mg, lockout time 15 min) was offered from 0 to 48 h after operation. Patients who received ketamine felt significantly more sedated at 0-24 h, but not at 24-48 h after operation, compared with patients who received placebo (P = 0.002 and P = 0.127, respectively). There were no significant differences in pain (VAS) at rest, during mobilization or cough, PCA morphine consumption, sensory block to pinprick, pressure pain detection threshold assessed with an algometer, touch and pain detection thresholds assessed with von Frey hairs, peak flow or side effects other than sedation. The power of detecting a reduction in VAS scores of 20 mm in our study was 80% at the 5% significance level. We conclude that we were unable to demonstrate an (additive) analgesic or opioid sparing effect of ketamine 10 mg h-1 i.v. combined with epidural bupivacaine at 0-24 h, or epidural morphine at 24-48 h after renal surgery.",1999.0,0,0
33,10193284,"Balanced pre-emptive analgesia: does it work? A double-blind, controlled study in bilaterally symmetrical oral surgery.",W I Campbell; R W Kendrick; J P Fee,"We studied 32 patients undergoing bilateral symmetrical lower third molar surgery under general anaesthesia to determine if the combined effects of pre-emptive local anaesthetic block using 0.5% bupivacaine, together with i.v. tenoxicam and alfentanil had any benefits over postoperative administration. Patients acted as their own controls and were allocated randomly to have surgery start on one side, the second side always being the pre-emptive side. Difference in pain intensity between the two sides was determined using visual analogue scales completed by each individual at 6 h, and at 1, 3 and 6 days after operation. A long-form McGill pain questionnaire was also used to assess difference in pain intensity between the two sides on the morning after surgery. There was no significant difference in pain intensity at any time after surgery. Our findings indicate that the combined use of pre-emptive analgesia from 0.5% bupivacaine, tenoxicam and alfentanil did not reduce postoperative pain intensity in patients undergoing molar exodontia.",1999.0,0,0
34,10193285,Dextromethorphan and pain after total abdominal hysterectomy.,P M McConaghy; P McSorley; W McCaughey; W I Campbell,"Dextromethorphan is an N-methyl-D-aspartate (NMDA) receptor antagonist which has been shown to inhibit the development of cutaneous secondary hyperalgesia after tissue trauma. We studied 60 ASA I-II patients undergoing total abdominal hysterectomy in a randomized, double-blind, placebo-controlled study. Patients received either dextromethorphan 27 mg capsules, two doses before operation and three doses in the first 24 h after operation, or placebo. Visual analogue pain scores (VAS) at 24 and 48 h were assessed at rest, on coughing and on sitting up, and were not significantly different between groups. Morphine consumption from a patient-controlled analgesia (PCA) device was also not significantly different between groups. Evidence of secondary hyperalgesia was assessed with von Frey hairs 10 cm above the Pfannenstiel incision. Both groups of patients exhibited evidence of secondary hyperalgesia after 24 and 48 h but there were no significant differences between groups. There was also no difference between groups in VAS scores at 1 month.",1999.0,0,0
35,10193286,Tramadol or morphine administered during operation: a study of immediate postoperative effects after abdominal hysterectomy.,J F Coetzee; H van Loggerenberg,"Tramadol may cause awareness and EEG activation during anaesthesia. We compared tramadol with morphine, administered during wound-closure, surmising that tramadol may cause earlier awakening, more rapid recovery, less respiratory depression and equivalent pain relief. Forty patients received nitrous oxide-enflurane for abdominal surgery. At wound closure, patients received tramadol 3 mg kg-1 or morphine 0.2 mg kg-1 and end-tidal enflurane concentrations were maintained at 0.5 kPa until skin closure, whereupon anaesthesia was discontinued. Times to spontaneous respiration, awakening and orientation were similar in the two groups, as were blood-gas tensions, ventilatory frequency, pain scores and incidence of nausea. Half of each group required supplementary analgesia during their 90-min stay in the recovery room. P-deletion counts improved more rapidly in the tramadol group. This study confirms previous reports that tramadol did not antagonize the hypnotic effects of volatile anaesthetics. Tramadol, administered during operation, was as effective as morphine in providing postoperative analgesia while permitting more rapid psychomotor recovery.",1999.0,0,0
36,10195718,Pain after primary inguinal herniorrhaphy: influence of surgical technique.,T Callesen; K Bech; J Andersen; R Nielsen; O Roikjaer; H Kehlet,"Pain is an important problem after ambulatory hernia repair. To assess the influence of the surgical technique on postoperative pain, two separate randomized, patient-blinded, controlled trials were performed in men with an indirect inguinal hernia. In study A, 48 patients with an internal inguinal ring smaller than 1.5 cm were randomly allocated to either simple extirpation of the hernial sac or extirpation plus annulorrhaphy. In study B, 84 patients with an internal inguinal ring wider than 1.5 cm were randomly allocated to extirpation plus annulorrhaphy or extirpation plus Lichtenstein mesh repair (modified). All operations were performed under unmonitored local anesthesia with standardized perioperative analgesia using methadone and tenoxicam. Pain was scored daily for the first postoperative week and after 4 weeks on a four-point verbal-rank scale (no, light, moderate, or severe pain) during rest, while coughing, and during mobilization (rising to the sitting position). Use of supplementary analgesics (paracetamol) was recorded. Cumulative daily pain scores for the first postoperative week and the number of patients who used supplementary analgesics were the main outcome measures. There were no significant differences in cumulative pain scores or use of supplementary analgesics between the treatment groups in either study. Cumulative pain scores were significantly higher during coughing and mobilization than during rest in both studies. Choice of surgical technique for open repair of a primary indirect inguinal hernia has no influence on postoperative pain.",1999.0,0,0
37,10199350,Spinal-cord stimulation in critical limb ischaemia: a randomised trial. ESES Study Group.,H M Klomp; G H Spincemaille; E W Steyerberg; J D Habbema; H van Urk,"For patients with critical limb ischaemia, spinal-cord stimulation has been advocated for the treatment of ischaemic pain and the prevention of amputation. We compared the efficacy of the addition of spinal-cord stimulation to best medical treatment in a randomised controlled trial. 120 patients with critical limb ischaemia not suitable for vascular reconstruction were randomly assigned either spinal-cord stimulation in addition to best medical treatment or best medical treatment alone. Primary outcomes were mortality and amputation. The primary endpoint was limb survival at 2 years. The mean (SD) age of the patients was 72.6 years (10.3). Median (IQR) follow-up was 605 days (244-1171). 40 (67%) of 60 patients in the spinal-cord-stimulator group and 41 (68%) of 60 patients in the standard group were alive at the end of the study, (p=0.96). There were 25 major amputations in the spinal-cord-stimulator group and 29 in the standard group, (p=0.47). The hazard ratio for survival at 2 years without major amputation in the spinal-cord stimulation group compared with the standard group was 0.96 (95% CI 0.61-1.51). Spinal-cord-stimulation in addition to best medical care does not prevent amputation in patients with critical limb ischaemia.",1999.0,0,0
38,10199880,Effect of butorphanol tartrate on shock-related discomfort during internal atrial defibrillation.,C Timmermans; L M Rodriguez; G M Ayers; H Lambert; J L Smeets; J W Vlaeyen; A Albert; H J Wellens,"In patients with atrial fibrillation, intracardiac atrial defibrillation causes discomfort. An easily applicable, short-acting analgesic and anxiolytic drug would increase acceptability of this new treatment mode. In a double-blind, placebo-controlled manner, the effect of intranasal butorphanol, an opioid, was evaluated in 47 patients with the use of a step-up internal atrial defibrillation protocol (stage I). On request, additional butorphanol was administered and the step-up protocol continued (stage II). Thereafter, if necessary, patients were intravenously sedated (stage III). After each shock, the McGill Pain Questionnaire was used to obtain a sensory (S), affective (A), evaluative (E), and total (T) pain rating index (PRI) and a visual analogue scale analyzing pain (VAS-P) and fear (VAS-F). For every patient, the slope of each pain or fear parameter against the shock number was calculated and individual slopes were averaged for the placebo and butorphanol group. All patients were cardioverted at a mean threshold of 4.4+/-3.3 J. Comparing both patient groups for stage II, the mean slopes for PRI-T (P=0.0099), PRI-S (P=0.019), and PRI-E (P=0.015) became significantly lower in the butorphanol group than in the placebo group. Comparing patients who received the same shock intensity ending stage I and going to stage II, in those patients randomized to placebo the mean VAS-P (P=0.023), PRI-T (P=0. 029), PRI-S (P=0.030), and PRI-E (P=0.023) became significantly lower after butorphanol administration. During a step-up internal atrial defibrillation protocol, intranasal butorphanol decreased or stabilized the value of several pain variables and did not affect fear. Of the 3 qualitative components of pain, only the affective component was not influenced by butorphanol. The PRI evaluated pain more accurately than the VAS.",1999.0,0,0
39,10201671,Effects of prophylactic nalmefene on the incidence of morphine-related side effects in patients receiving intravenous patient-controlled analgesia.,G P Joshi; L Duffy; J Chehade; J Wesevich; N Gajraj; E R Johnson,"Opioid-related side effects associated with intravenous patient-controlled analgesia can be reduced by a low-dose naloxone infusion. The influence of nalmefene, a pure opioid antagonist with a longer duration of action, on opioid-related side effects has not been evaluated. This study was designed to determine the dose-response relation for nalmefene for the prevention of morphine-related side effects in patients receiving intravenous patient-controlled analgesia. One hundred twenty women undergoing lower abdominal surgery were enrolled in the study. General anesthesia was induced using thiopental and rocuronium and maintained with desflurane, nitrous oxide, and fentanyl or sufentanil. All patients received neostigmine and glycopyrrolate to reverse residual neuromuscular blockade. No prophylactic antiemetics were administered. At the end of surgery, patients were randomized to receive saline, 15 microg nalmefene, or 25 microg nalmefene intravenously. The need for antiemetic and antipruritic drugs and the total consumption of morphine during the 24-h study were recorded. The incidences of postoperative nausea, vomiting, pruritus, and pain were recorded 30 min after patients were admitted to the postanesthesia care unit. In addition, patient remembrance of these side effects was noted at 24 h after operation. The need for antiemetic and antipruritic medications during the 24-h study period was significantly lower in the patients receiving nahmefene compared with those receiving placebo. However, the need to treat side effects was similar in the two nahmefene groups. Prophylactic administration of nalmefene reduced the patients remembrance of nausea and itching as assessed 24 h after operation. Although the total consumption of morphine during the 24-h study period was similar in the three groups, retrospectively patients who received nalmefene characterized their pain as less severe in the previous 24 h. Compared with placebo, prophylactic administration of nalmefene significantly decreased the need for antiemetics and antipruritic medications in patients receiving intravenous patient-controlled analgesia with morphine.",1999.0,0,0
40,10201714,Analgesia and sedation in preterm neonates who require ventilatory support: results from the NOPAIN trial. Neonatal Outcome and Prolonged Analgesia in Neonates.,K J Anand; B A Barton; N McIntosh; H Lagercrantz; E Pelausa; T E Young; R Vasa,"Preterm neonates are exposed to multiple painful procedures after birth and exhibit acute physiological responses to pain. Occurrence of early intraventricular hemorrhage within 24 to 72 hours after birth suggests a role of pain and stress in the multifactorial causation of severe intraventricular hemorrhage and periventricular leukomalacia. We proposed that such neurologic outcomes in preterm neonates who require ventilatory support may be reduced by morphine analgesia or midazolam sedation compared with a placebo. To define the incidence of clinical outcomes in the target study population, to estimate the effect size and adverse effects associated with analgesia and sedation, and to calculate the sample size for a definitive test of this hypothesis. Sixty-seven preterm neonates were randomized in a pilot clinical trial from 9 centers. Neonates of 24 to 32 weeks gestation were eligible if they had been intubated and required ventilatory support for less than 8 hours and if they were enrolled within 72 hours after birth. Exclusion criteria included major congenital anomalies, severe intrapartum asphyxia, and participation in other research studies. Severity of illness was assessed by the Clinical Risk Index for Babies, and neonates were randomized to receive continuous infusions of morphine sulfate, midazolam hydrochloride, or 10% dextrose (placebo). Masked study medications were continued as long as clinically necessary, then weaned and stopped according to predefined criteria. Levels of sedation (COMFORT scores) and responses to pain (Premature Infant Pain Profile scores) were measured before, during, and 12 hours after discontinuation of drug infusion. Cranial ultrasound examinations were performed as part of routine practice, and poor neurologic outcomes were defined as neonatal death, severe intraventricular hemorrhage (grade III or IV), or periventricular leukomalacia. No significant differences occurred in the demographic, clinical, and socioeconomic variables related to mothers and neonates in the 3 groups or in the severity of illness at birth as measured by Clinical Risk Index for Babies scores. Two neonates in the placebo group and 1 neonate in the midazolam group died; no deaths occurred in the morphine group. Poor neurologic outcomes occurred in 24% of neonates in the placebo group, 32% in the midazolam group, and 4% in the morphine group (likelihood ratio chi2 = 7.04, P = .03). Secondary clinical outcomes and neurobehavioral outcomes at 36 weeks' postconceptional age were similar in the 3 groups. Responses elicited by endotracheal tube suction (Premature Infant Pain Profile scores) were significantly reduced during the morphine (P<.001) and midazolam (P = .002) infusions compared with the placebo group. This pilot trial suggests that preemptive analgesia given by continuous low-dose morphine infusion may reduce the incidence of poor neurologic outcomes in preterm neonates who require ventilatory support. Limitations in the sample size of this pilot study suggest that these results should be confirmed in a large multicenter randomized trial.",1999.0,0,0
41,10204735,"A comparison of 50, 100 and 200 mg of intra-articular pethidine during knee joint surgery, a controlled study with evidence for local demethylation to norpethidine.",A Söderlund; L O Boreus; L Westman; B Engström; A Valentin; A Ekblom,"Pethidine (meperidine) is a compound with both local anaesthetic and opioid agonist properties. We have in a recent study demonstrated that pethidine could be an interesting alternative to prilocaine in arthroscopy with local anaesthetic technique. Therefore, we investigated, in a controlled randomized double-blind study, the effect of three doses of pethidine compared with a standard local anaesthetic, in patients subjected to arthroscopic knee joint surgery. Ten patients in each group received 50 mg (P50), 100 mg (P100), 200 mg (P200) of pethidine or prilocaine (5 mg/ml) + adrenaline (4 mg/ml) (PC), injected intra-articularly (i.a.) before surgery. We measured pain intensity and discomfort during arthroscopy and pain intensity at rest and at movement, nausea and tiredness for 3 days post-operatively at regular intervals using the VAS-technique. We also measured the concentration of pethidine and its demethylated metabolite, norpethidine, in plasma by collecting blood samples at 20, 40, 60, 80, 140 and 200 min following injection, and in synovial fluid which was collected through the arthroscope at the start and the end of the surgery. It was found that significantly more patients in the P50 group (n = 6) needed general anaesthesia due to intense pain than those in the P100 group (n = 1), P200 group (n = 0) or the PC group (n = 1). The PC group required significantly more analgesics and had a significantly higher calculated total sum of pain scores at movement post-operatively, than the other three groups. The P200 group more often reported tiredness post-operatively than the other three groups. We conclude that 100 or 200 mg pethidine i.a. produces satisfactory anaesthesia for surgery. There was a rapid transfer of pethidine from synovial fluid to plasma, resulting in plasma levels earlier reported to produce centrally mediated effects, such as analgesia and tiredness. We found much higher concentrations of norpethidine in the synovial fluid than in plasma, suggesting a local demethylation in the knee joint tissues. This site of drug oxidation has not earlier been demonstrated neither in vitro nor in vivo. The results suggest that pethidine given i.a. in the dose range of 50 to 200 mg results in analgesia due to both peripheral and central mechanisms. The significant systemic uptake of pethidine can cause unwanted side-effects.",1999.0,0,0
42,10204760,Successful treatment of whiplash-type injury induced severe pain syndrome with epidural stimulation: a case report.,O A Kirvelä; E Kotilainen,"Chronic severe cervico-facial pain syndrome associated with a whiplash-type injury was successfully treated with epidural spinal cord stimulation. The patient had been in pain for 9 years, responding temporarily only to stellate ganglion blocks. The patient has now been painless for 18 months. We have been unable to find a similar case reported in the literature to date.",1999.0,0,0
43,10207461,Acute appendicitis: influence of early pain relief on the accuracy of clinical and US findings in the decision to operate--a randomized trial.,B Vermeulen; A Morabia; P F Unger; C Goehring; C Grangier; I Skljarov; F Terrier,"To determine the influence of early pain relief on the diagnostic performance of ultrasonography (US) and on the appropriateness of the surgical decision. A prospective randomized, double-blind placebo-controlled trial with morphine was conducted. A visual analog scale was used to evaluate pain in 340 patients aged 16 years or older. US was performed with a standardized protocol. Diagnosis was confirmed at histologic analysis or, in the patients released without surgery, at follow-up. One hundred seventy-five patients were injected with morphine, and 165 were injected with the placebo. Pain relief was stronger in the morphine group. In the morphine group, US had lower (71.1%) sensitivity (difference, -9.5%; 95% CI, -18.5%, -0.5%) and higher (65.2%) specificity (difference, 11.4%; 95% CI, 1.0%, 21.8%). This group had also a higher positive predictive value (64.6%) and a lower negative predictive value (71.4%), but the differences between this group and the placebo group were not statistically significant. Among female patients, the decision to operate was appropriate more often in the morphine group (75.8%), but the difference between this group and the placebo group was not statistically significant (5.1%; 95% CI, -7.4%, 17.6%). In male patients and overall, opiate analgesia did not influence the appropriateness of the decision. The appropriateness to discharge patients without surgery was 100% in all groups. Morphine does not improve US-based diagnosis of appendicitis.",1999.0,0,0
44,10209375,The effect of intravenous tenoxicam on pruritus in patients receiving epidural fentanyl.,S Colbert; D M O'Hanlon; F Chambers; D C Moriarty,"In this prospective randomised study, pruritus and pain were evaluated in patients undergoing abdominal surgery during which epidural fentanyl was administered. All patients had an epidural catheter inserted at the time of surgery. Epidural fentanyl 100 micrograms was administered intra-operatively and infused at a concentration of 2 micrograms.ml-1 for 48 h postoperatively. All patients received a standard anaesthetic and, in addition, the study group had a 20 mg bolus of tenoxicam intravenously, intra-operatively. Patients receiving tenoxicam demonstrated significantly lower pruritus and pain scores at 30 min, 2, 4, 8 and 24 h postoperatively as well as reduced pethidine requirements for breakthrough pain in the first 24 h. In conclusion, tenoxicam 20 mg significantly reduces the incidence and severity of postoperative pruritus in patients who received peri-operative epidural fentanyl. In addition, it significantly reduces pain and further analgesic requirements postoperatively.",1999.0,0,0
45,10211014,Continuous epidural infusion of ropivacaine for postoperative analgesia after major abdominal surgery: comparative study with i.v. PCA morphine.,C Jayr; M Beaussier; U Gustafsson; Y Leteurnier; N Nathan; B Plaud; G Tran; C Varlet; J Marty,"We have compared the quality of three regimens of postoperative analgesia (continuous epidural administration of ropivacaine (Ropi. group), epidural ropivacaine and patient-controlled analgesia (PCA) with i.v. morphine (Ropi. + PCA group) and PCA morphine alone (PCA group)) during the first postoperative 24 h in a multicentre, randomized, prospective study. Postoperative analgesia was studied in 130 patients after major abdominal surgery performed under general anaesthesia. The ropivacaine groups received 20 ml of epidural bolus ropivacaine 2 mg ml-1 via the epidural route at the end of surgery, followed by continuous infusion of 10 ml h-1 for 24 h. The Ropi. + PCA group also had access to i.v. PCA morphine 1 mg, with a 5-min lockout. The PCA group received morphine as the sole postoperative pain treatment. The two ropivacaine groups had lower pain scores (P < 0.01) than the PCA group. Morphine consumption was higher in the PCA group (P < 0.05) than in the two ropivacaine groups. The quality of pain relief was rated as good or excellent in 79-85% of patients in the three groups. The percentage of patients without motor block increased between 4 and 24 h from 61% to 89% in the Ropi. group, and from 51% to 71% in the Ropi. + PCA group.",1999.0,0,0
46,10213849,Patient-controlled analgesia: An efficient therapeutic tool in the postoperative setting.,K A Lehmann,"Patient-controlled analgesia (PCA) is one of the newer techniques for pain management. It was developed in reaction to the large number of unsatisfied postoperative patients suffering from moderate to severe pain despite the availability of potent analgesic drugs. With PCA, patients are allowed to self-administer small analgesic doses into a running intravenous infusion, intramuscularly, subcutaneously or even into the spinal space. Clinical experience soon demonstrated that individual variability in pain intensity and analgesic needs was extremely large. Psychological factors seem to be as important as the surgical trauma. Opioid consumption is usually higher than with conventional regimens, but without serious side effects. Although patients generally prefer self-control, pain relief is not necessarily better than with well-conducted conventional techniques. In addition to routine clinical pain management, PCA has proven its importance in research, e.g. for pain measurement, to determine predictors of postoperative pain, to evaluate drug interactions and the concept of pre-emptive analgesia, or for pharmacokinetic designs. PCA has been extremely important in order to change the mind of physicians and nursing staff with respect to individual pain management strategies.",2000.0,0,0
47,10214482,Postoperative pain after lumbar disc surgery: a comparison between parenteral ketorolac and narcotics.,P D Le Roux; S Samudrala,"Lumbar discectomy is a common elective surgical procedure but many patients still experience postoperative back pain which may delay hospital discharge. We therefore evaluated the efficacy of a parenteral non-steroidal antiinflammatory agent, ketorolac, for the management of post-surgical pain. Fifty three patients undergoing lumbar discectomy at a Medical School affiliated Veterans Administration hospital were randomly assigned to receive either: 1) 30 mg intramuscular ketorolac upon surgical closure and every 6 hours for 36 hours and narcotic analgesics as needed (PRN); or 2) only narcotic analgesics as needed. A blinded observer recorded the average, minimum and maximum postoperative pain intensity using a Numeric Pain Intensity Scale; total postoperative narcotic consumption, complications, length of hospitalization (from surgery to discharge) and outcome at 6 weeks. The patients who received ketorolac reported significantly lower average (p < 0.001), minimum (p < 0.001), and maximum (p < 0.001) pain scores than patients receiving only narcotic analgesics. Cumulative narcotic doses (standardized to parenteral morphine) were significantly lower in the ketorolac group (p < 0.001). There was no significant difference between groups in the frequency of side effects, and no complication specifically associated with ketorolac use was observed. Mean length of hospitalization was significantly shorter (p = 0.05) in patients receiving ketorolac than in patients receiving only narcotics. Six weeks after surgery 5 (19.2%) patients who received only narcotics were troubled by persistent back pain. By contrast, all patients who received ketorolac were free of back pain at follow-up (p = 0.03). These results suggest that ketorolac, when used with PRN narcotics, is more effective than PRN narcotics alone for postoperative pain following lumbar disc surgery. In addition, this strategy also may contribute to early discharge from hospital after lumbar disc surgery.",1999.0,0,0
48,10215712,Radicular acute pain after epidural anaesthesia with the technique of loss of resistance with normal saline solution.,J Gracia; C Gomar; V Riambau; C Cardenal,"Epidural anaesthesia using the loss of resistance to saline technique, without air, was successfully performed in a 65-year-old man scheduled for elective vascular surgery of the right leg. Epidural catheterisation was uneventful. Fifteen minutes after the initial dose of plain 0.5% bupivacaine, the patient experienced severe pain in his lower abdomen and legs which coincided with a supplementary injection of 2 ml bupivacaine and 50 microgram fentanyl, and a change from the lateral to the supine position. General anaesthesia was induced and CT and MRI scans were performed showing trapped air in the epidural space at the L4 level causing compression of the thecal sac. After excluding other causes, the spontaneous entry of air through the Tuohy needle was thought to be the most likely explanation for this complication. The patient recovered uneventfully.",1999.0,0,0
49,10216434,[Update on the pharmacologic approach to pain].,L Brasseur; P Desgieux; F Guirimand,"Acute pain can be managed favourably by the use of paracetamol, non steroidal anti-inflammatory drugs, opioids and local anaesthetics, solely or in combination. Sophisticated methods of administration such as nerve blocks or patient-controlled analgesia will improve results. Chronic pain, on the other hand, presents a more complex situation and the pharmacological approach is only one aspect of bio-psycho-social management programmes. The role of opioids in the treatment of chronic non-cancer pain has still not been clarified. Adjuvant drugs are often required.",1999.0,0,0
50,10216436,,,,,0,0
51,10217341,The influence of the route of administration: a comparative study at steady state of oral sustained release morphine and morphine sulfate suppositories.,X Du; G Skopp; R Aderjan,"Steady state pharmacokinetics of morphine (M), morphine-3-glucuronide (M3G) and morphine-6-glucuronide (M6G) were investigated in 6 patients with intractable cancer pain administered orally with MST (Mundipharma, Limburg, Germany) and, subsequently, rectally with MSR to make a judgment whether orally administered morphine can be replaced by rectally administered morphine. The parent drug and glucuronide metabolites were measured simultaneously using high-performance liquid chromatography (HPLC) and native fluorescence detection. The mean morphine area under the curve (AUC) value (0-8 h) was smaller (434.3 +/- 170.2 nmolL(-1)h) in the oral administration than in the rectal administration (574.8 +/- 285.0 nmolL(-1)h) (p < 0.05). The rectal administration resulted in less production of M3G and M6G. There were no significant differences in the mean steady state concentrations (C(ss)) of morphine, M3G, and M6G between the oral and rectal administrations (p > 0.05). The median AUC ratio--M3G/M and M6G/M, 12.58 and 1.85--following MSR rectal administration was smaller than following MST oral administration in 6 patients (19.97 and 2.59; p < 0.05), whereas the median AUC ratio M3G/M6G in the rectal dosing was 6.24 (range 5.2-7.6) was almost the same as the median ratio M3G/M6G in the oral dosing was 6.49 (range 5.8-8.5; p > 0.1). Four of the 6 patients had a greater Cmax of M3G and M6G after oral administration than after rectal administration. The same 4 had lower fluctuation rates for morphine, M3G (p < 0.05), and M6G (p < 0.05) after rectal administration. Therefore, during chronic morphine treatment, it still seems difficult to decide whether oral administration can be replaced by rectal administration.",1999.0,0,0
52,10220630,Effect of intravenous metoprolol before hospital admission on chest pain in suspected acute myocardial infarction.,M Gardtman; M Dellborg; C Brunnhage; J Lindkvist; L Waagstein; J Herlitz,"The aim of this study was to describe the effect of intravenous metoprolol on the intensity of chest pain before hospital admission in patients with suspected acute myocardial infarction AMI). Two hundred sixty-two patients with acute chest pain and suspected AMI were randomly assigned before hospital admission to either 5 mg morphine plus metoprolol 5 mg x 3 intravenously or 5 mg morphine plus intravenous placebo. Chest pain was evaluated on a 10-grade scale before and for 60 minutes after intravenous injection. One hundred thirty-four patients were randomly assigned to metoprolol and 128 to placebo. Among all patients randomized to metoprolol, the mean chest pain score was reduced by 3.0 +/- 1.9 arbitrary units AU) from before to after intravenous injection compared with 2.6 +/- 2.1 AU for placebo not significant). Among patients with an initially confirmed or strong suspicion of AMI, the corresponding figures were 3.1 +/- 1.8 AU for metoprolol and 2.2 +/- 1.6 AU for placebo P =.02). Among patients with only a vague or moderate suspicion of AMI, there was no difference. The treatment was well tolerated. When all patients were included in the analyses, there was no significant difference with regard to reduction of chest pain in the patients randomly assigned to metoprolol compared with placebo. A retrospective subgroup analysis indicated a beneficial effect of metoprolol among patients with an initially strong suspicion of or confirmed AMI. Further investigations are warranted to confirm this finding.",1999.0,0,0
53,10221469,Emerging concepts in the neurobiology of chronic pain: evidence of abnormal sensory processing in fibromyalgia.,R M Bennett,"Chronic pain often differs from acute pain. The correlation between tissue pathology and the perceived severity of the chronic pain experience is poor or even absent. Furthermore, the sharp spatial localization of acute pain is not a feature of chronic pain; chronic pain is more diffuse and often spreads to areas beyond the original site. Of importance, chronic pain seldom responds to the therapeutic measures that are successful in treating acute pain. Physicians who are unaware of these differences may label the patient with chronic pain as being neurotic or even a malingerer. During the past decade, an exponential growth has occurred in the scientific underpinnings of chronic pain states. In particular, the concept of nonnociceptive pain has been refined at a physiologic, structural, and molecular level. This review focuses on this new body of knowledge, with particular reference to the chronic pain state termed ""fibromyalgia.""",1999.0,0,0
54,10225069,Focus on mobilisation after lower abdominal surgery. A double-blind randomised comparison of epidural bupivacaine with morphine vs. lidocaine with morphine for postoperative analgesia.,T Rygnestad; K Zahlsen; O Bergslien; O Dale,"Epidural infusion of morphine, usually with bupivacaine, for postoperative pain relief has proved to be safe and effective. Lidocaine with its short duration of action and low toxicity may be an alternative to bupivacaine. The clinical importance of the choice of local anaesthetic drug on mobilisation after lower abdominal surgery has not been studied previously. A total of 52 patients was randomised to epidural infusion of morphine (1.6-4.4 micrograms.kg-1.h-1) with either lidocaine (0.44-0.98 mg.kg-1.h-1) or bupivacaine (0.10-0.28 mg.kg-1.h-1) in a double-blind fashion. The time to mobilisation, degree of pain relief, blood pressure, respiration and motor function were recorded at regular intervals postoperatively for 40 h. Serum concentrations of lidocaine, its main metabolite monoethylglycinexylidide (MEGX) and bupivacaine were measured at 3, 15 and 40 h. There were no significant differences in the clinical characteristics between the two patient groups. There were no significant differences in the time from the end of surgery to the time the patients were able to stand without support (bupivacaine: median 24 h (interquartile range (IQR): 22-31), lidocaine: median 28 h (IQR 23-40), P = 0.15) or were able to walk without support (bupivacaine: median 46 h (IQR 28-62), lidocaine: median 48 h (IQR 35-54), P = 0.78). No significant differences between the groups were recorded with respect to pain relief, blood pressure, respiration, sedation score and motor function. The plasma concentration of lidocaine and bupivacaine increased significantly during the treatment period (P < 0.01 for both drugs), but not the concentration of MEGX. The highest venous lidocaine concentration was 17.5 mumol/l and the highest bupivacaine concentration was 18.8 mumol/l. There was a significant correlation between the concentration of both lidocaine and bupivacaine and the concentration of alpha 1-acid glycoprotein (AAG) (lidocaine: r = 0.77, P < 0.001, bupivacaine: r = 0.60, P < 0.001), suggesting that the free fraction of the drugs did not increase. No patients showed serious signs of toxicity. The epidural infusion rates remained stable in both groups during the study period. There were no clinically or statistically significant differences in the postoperative course after lower abdominal surgery in patients who received an epidural infusion of morphine combined with bupivacaine as compared to patients who received morphine with lidocaine. Further clinical studies to establish the place of lidocaine in postoperative epidural analgesia should be performed.",1999.0,0,0
55,10225070,Lumbar versus thoracic epidural buprenorphine for postoperative analgesia following coronary artery bypass graft surgery.,Y Mehta; R Juneja; H Madhok; N Trehan,"Thoracic epidural analgesia (TEA) is reported to provide effective analgesia following cardiac surgery. We compared the effect of buprenorphine (BN) through the lumbar and thoracic epidural routes for postoperative analgesia following coronary artery bypass graft surgery (CABG). Forty patients with normal left ventricular ejection fraction scheduled for CABG were randomly divided into two groups, the TEA group (n = 19) and the lumbar epidural analgesia (LEA) group (n = 20). For postoperative pain relief they received epidural BN 0.15 mg at the first demand for pain relief following extubation. A top-up dose of BN 0.15 mg was administered in cases where visual analogue scale (VAS) score was > 3 at 1 h after first dose. Subsequent breakthrough pain was treated with 30 mg intramuscular ketorolac tromethamine (ketorolac). Pain assessed by VAS score on a 0-10 scale, respiratory rate, FEV1, FVC, mean arterial blood pressure, cardiac index, PaO2 and PaCO2 were measured at frequent intervals. Side effects of epidural opioids were noted. Both groups were comparable in demographic characteristics, had similar VAS scores from 1 to 24 h postoperatively, required similar amounts of intramuscular ketorolac for break-through pain and had comparable pulmonary functions and side effects. This study shows that BN by the lumbar epidural route for analgesia after CABG compares favourably with the same drug through the thoracic route in terms of quality of analgesia and incidence of side effects.",1999.0,0,0
56,10225168,Tramadol or fentanyl analgesia for ambulatory knee arthroscopy.,B Cagney; O Williams; L Jennings; D Buggy,"In a double-blind, randomized, controlled study, 61 patients who received a standardized anaesthetic for day case arthroscopic knee surgery were studied. Group T (n = 31) received tramadol 1.5 mg kg-1, and group F (n = 30) received fentanyl 1.5 micrograms kg-1 at the induction of anaesthesia. All patients also received 20 mL of intra-articular bupivacaine 0.5% at the end of surgery. Assessments were made of pain at rest and on movement, analgesic requirements and side-effects at hourly intervals up to 6 h and by means of a postal questionnaire at 24 h and 48 h post-operatively. Group F had higher pain scores than group T at 4 h only [VAS 3.3 (1.6-5.5) vs. 2.4 (1-4), P = 0.039, respectively; median (interquartile range)]. There were no other significant differences between the groups in terms of pain scores, supplemental analgesic requirements or incidence of side-effects. We conclude that tramadol offers little benefit clinically compared with fentanyl when used at induction of anaesthesia for day case arthroscopic knee surgery. Further studies are indicated in patients with more severe pain to determine the role of tramadol in post-operative analgesia.",1999.0,0,0
57,10225169,"Analgesia for adenotonsillectomy in children and young adults: a comparison of tramadol, pethidine and nalbuphine.",A A van den Berg; L F Montoya-Pelaez; E M Halliday; I Hassan; M S Baloch,"A prospective, double-blind, randomized, controlled study was undertaken to compare the perioperative analgesic and recovery characteristics of equipotent doses of tramadol, pethidine and nalbuphine (3.0 mg kg-1, 1.5 mg kg-1 and 0.3 mg kg-1 respectively) with placebo (saline 0.02 ml kg-1) given at induction of anaesthesia in 152 ASA 1 children and young adults undergoing tonsillo-adenoidectomy. Premedication (temazepam and diclofenac), induction and maintenance of anaesthesia (thiopentone, atracurium, nitrous oxide and isoflurane), with controlled ventilation, were standardized. Variables monitored were heart rate (HR) and systolic arterial pressure (SAP) during surgery, time to recovery of spontaneous respiration at the termination of anaesthesia and restlessness, time to awakening, sedation and emesis in the recovery unit. Increases in HR or SAP > 33% of baseline during surgery were treated with esmolol 2.0 mg kg-1 intravenously (i.v.) and restlessness during recovery was treated with the same opioid i.v. given with an aesthesia, or pethidine i.v. in the placebo group. With placebo, there was a high requirement for esmolol during surgery and for pethidine in the recovery ward. Tramadol did not reduce the rate of intra-operative treatment with esmolol, but reduced the tramadol requirement during recovery (P < 0.05). Pethidine and nalbuphine reduced the intra-operative esmolol requirement more significantly (P < 0.025 and P < 0.005 respectively) and the need for treatment during recovery with opioids (P < 0.005 each). The time to recovery of spontaneous respiration at the end of anaesthesia was only delayed by pethidine. Other recovery variables were similar, except that restlessness-pain scores were reduced by tramadol (P < 0.02), pethidine (P < 0.005) and nalbuphine (P < 0.005). These results suggest that pethidine 1.5 mg kg-1 and nalbuphine 0.3 mg kg-1 given with induction of anaesthesia provide better analgesia during and after tonsillo-adenoidectomy than does tramadol 3.0 mg kg-1. The delay to recovery of spontaneous respiration with pethidine suggests a greater safety profile of nalbuphine and tramadol.",1999.0,0,0
58,10228251,Patients willing to try colonoscopy without sedation: associated clinical factors and results of a randomized controlled trial.,D K Rex; T F Imperiale; V Portish,"Sedation causes most of the complications of colonoscopy. Sedation is used selectively in some countries but is routine in the United States. Cross-sectional survey and randomized controlled trial were used to identify patient factors associated with willingness to try colonoscopy without sedation and to compare pain and satisfaction scores and willingness to return to the same physician in patients randomized to receive routine sedation versus as needed sedation. A single colonoscopist invited 250 consecutive eligible outpatients to be randomized to routine sedation versus as needed sedation. Seventeen who preferred no sedation and 163 who preferred sedation refused. Seventy accepted and were randomized. Male gender (odds ratio 4.33; 95% CI [2.27, 8.26]), increasing age (odds ratio for 10-year increase 1.28; 95% CI [1.01, 1.06]), and absence of abdominal pain (odds ratio 5.13; 95% CI [1.68, 15.63]) were associated with willingness to be randomized. Total colonoscopy was achieved without sedation in 94% of those who received sedation only as needed. Pain scores were higher in the sedation as needed arm. All 35 patients in the routine sedation arm were ""very satisfied"". In the sedation as needed arm, 31 of the 34 were ""very satisfied"" and 3 were ""somewhat satisfied"". All randomized patients said they would return to the same colonoscopist. Patients in the sedation as needed arm had less decline in blood pressure, less hypoxemia, and lower charges than those in the routine sedation arm. Experienced colonoscopists should consider offering colonoscopy without sedation to selected patients.",1999.0,0,0
59,10229408,"Treatment of osteoarthritis pain with controlled release oxycodone or fixed combination oxycodone plus acetaminophen added to nonsteroidal antiinflammatory drugs: a double blind, randomized, multicenter, placebo controlled trial.",J R Caldwell; M E Hale; R E Boyd; J M Hague; T Iwan; M Shi; P G Lacouture,"To compare the efficacy and safety of controlled release oxycodone given every 12 h around the clock with immediate release oxycodone-acetaminophen (APAP) given 4 times daily for osteoarthritis (OA) pain. Adults (n=167) with moderate to severe OA pain despite regular use of nonsteroidal antiinflammatory drugs (NSAID) entered open label titration for 30 days with immediate release oxycodone qid; 107 qualified for randomization to double blind, parallel group treatment for 30 days with placebo, controlled release oxycodone, or immediate release oxycodone-APAP. Following titration with immediate release oxycodone, mean (SE) pain intensity (0, none to 3, severe) decreased from 2.44 (0.04) to 1.38 (0.05) (p=0.0001), and quality of sleep (1, very poor; 5, excellent) improved from 2.58 (0.08) to 3.57 (0.07) (p=0.0001). Mean dose was about 40 mg/day. Pain intensity and quality of sleep were significantly improved in both active groups compared with the placebo group (p< or =0.05) during the double blind trial. Pain intensity and sleep scores were comparable in both active groups during double blind treatment. Nausea (p=0.03) and dry mouth (p=0.09) were less common with controlled release oxycodone than immediate release oxycodone-APAP. Controlled release oxycodone q12h and immediate release oxycodone-APAP qid, added to NSAID, were superior to placebo for reducing OA pain and improving quality of sleep. The active treatments provided comparable pain control and sleep quality. Controlled release oxycodone was associated with a lower incidence of some side effects.",1999.0,1,1
60,10232715,Adding low dose meperidine to spinal lidocaine prolongs postoperative analgesia.,K Murto; A C Lui; N Cicutti,"To investigate the effects of the addition of low dose meperidine to spinal lidocaine on the sensory and motor blockade profile, and the quality and duration of postoperative analgesia. In a randomized double blind prospective dose finding study 40 patients undergoing transurethral prostatectomy with spinal anesthetic were allocated to receive 75 mg lidocaine 5% intrathecally as the sole agent (group A), or co-administered with 0.15 mg x kg(-1) meperidine (group B) or 0.30 mg x kg(-1) meperidine (group C). Sensory and motor blockade profiles were documented. Postoperatively, the amount of analgesics required, time to first analgesic, visual analogue scores and adverse events were recorded. Sensory blocks at or above T10 was maintained for 128, 156 and 145 minutes in groups A, B and C respectively. There was no difference in the latency or duration of the motor block among the three groups. Patients in group C had lower visual analogue pain scores (VAPS) over time than did those in groups A and B (P < 0.05). Time to first analgesia was longer (429 +/- 197 minutes) in group C than in group A (254 +/- 157 minutes) (P < 0.05). Fewer patients in group C required parenteral opioid postoperatively than in group A (P < 0.05). The incidence of bradycardia was higher in the groups receiving meperidine. No symptoms of transient radicular irritation (TRI) were reported in the groups receiving meperidine. The addition of 0.3 mg x kg(-1) of meperidine to spinal lidocaine prolongs postoperative analgesia without delaying discharge from post anesthetic care unit (Table II) and reduces the requirement for parenteral analgesics (Table III).",1999.0,0,0
61,10234493,A randomized controlled trial of continuous extra-pleural analgesia post-thoracotomy: efficacy and choice of local anaesthetic.,D J Barron; M J Tolan; R E Lea,"Controversy persists over the efficacy of intercostal nerve block administered through a tunnelled extrapleural catheter. We have undertaken a randomized, prospective double-blind trial of two different local anaesthetic regimes to evaluate the effect of this technique on post-thoracotomy pain relief and pulmonary function. Sixty-eight patients were randomized to receive bupivacaine 0.25% (n = 22), lignocaine 1% (n = 21) or 0.9% NaCl (saline) (n = 20) via an extrapleural catheter, inserted peroperatively. All patients underwent a standard posterolateral thoracotomy. Pain was assessed using a visual analogue pain score and by the requirement for opiate analgesia. Pulmonary function was measured using bedside spirometry. Pain scores were lower in the local anaesthetic groups at 24, 32 and 72 h compared with placebo (P < 0.05) and the total amount of opiate required was less than placebo for both lignocaine and bupivicaine (P < 0.05). Pulmonary function was better in the local anaesthetic groups throughout the post-operative period and was most pronounced at 24 h with a mean improvement of 30% for forced expiratory volume (FEV1), 24% for forced vital capacity (FVC) and 19% for peak expiratory flow rate (PEFR) compared with placebo. There was no significant difference between pain scores, opiate requirement or pulmonary function between lignocaine and bupivicaine. CT scanning demonstrated containment of the local anaesthetic in an extra-pleural tunnel. Extra-pleural infusion of local anaesthetics is a simple technique, with low risk of complications and provides effective pain relief as well as an improvement in post-operative pulmonary function. Lignocaine is equally as effective as bupivacaine and its use would result in some cost-saving.",1999.0,0,0
62,10235527,"Prospective, randomized comparison of epidural versus parenteral opioid analgesia in thoracic trauma.",M R Moon; F A Luchette; S W Gibson; J Crews; G Sudarshan; J M Hurst; K Davis; J A Johannigman; S B Frame; J E Fischer,"To evaluate systemic versus epidural opioid administration for analgesia in patients sustaining thoracic trauma. The authors have previously shown that epidural analgesia significantly reduces the pain associated with significant chest wall injury. Recent studies report that epidural analgesia is associated with a lower catecholamine and cytokine response in patients undergoing elective thoracotomy compared with patient-controlled analgesia (PCA). This study compares the effect of epidural analgesia and PCA on pain relief, pulmonary function, cathechol release, and immune response in patients sustaining significant thoracic trauma. Patients (ages 18 to 60 years) sustaining thoracic injury were prospectively randomized to receive epidural analgesia or PCA during an 18-month period. Levels of serum interleukin (IL)-1beta, IL-2, IL-6, IL-8, and tumor necrosis factor-alpha (TNF-alpha) were measured every 12 hours for 3 days by enzyme-linked immunosorbent assay. Urinary catecholamine levels were measured every 24 hours. Independent observers assessed pulmonary function using standard techniques and analgesia using a verbal rating score. Twenty-four patients of the 34 enrolled completed the study. Age, injury severity score, thoracic abbreviated injury score, and length of hospital stay did not differ between the two groups. There was no significant difference in plasma levels of IL-1beta, IL-2, IL-6, or TNF-alpha or urinary catecholamines between the two groups at any time point. Epidural analgesia was associated with significantly reduced plasma levels of IL-8 at days 2 and 3, verbal rating score of pain on days 1 and 3, and maximal inspiratory force and tidal volume on day 3 versus PCA. Epidural analgesia significantly reduced pain with chest wall excursion compared with PCA. The route of analgesia did not affect the catecholamine response. However, serum levels of IL-8, a proinflammatory chemoattractant that has been implicated in acute lung injury, were significantly reduced in patients receiving epidural analgesia on days 2 and 3. This may have important clinical implications because lower levels of IL-8 may reduce infectious or inflammatory complications in the trauma patient. Also, tidal volume and maximal inspiratory force were improved with epidural analgesia by day 3. These results demonstrate that epidural analgesia is superior to PCA in providing analgesia, improving pulmonary function, and modifying the immune response in patients with severe chest injury.",2001.0,0,0
63,10320603,Patient controlled analgesia in children and adolescents: a randomized controlled trial.,J W Peters; I E Bandell Hoekstra; H Huijer Abu-Saad; J Bouwmeester; A E Meursing; D Tibboel,"In children, patient controlled analgesia (PCA) and continuous infusion (CI) of morphine are well established methods of relieving postoperative pain. This study was designed to assess the efficacy of PCA plus background infusion (BI) (15 microg x kg(-1) x h(-1) and bolus doses of 15 microg x kg(-1) with a lock-out interval of 10 min) with CI (20 to 40 microg x kg(-1) x h(-1)) in terms of analgesia, morphine needs and side-effects. A stratified randomized controlled trial was carried out. 47 children aged 5-18 years undergoing major elective lower/upper abdominal or spinal surgery were allocated. The magnitude of surgery was assessed by the Severity of Surgical Stress scoring (SSS) system. Pain was assessed by self-report every three h. Side-effects compatible with morphine as well as morphine consumption were recorded. Morphine consumption was significantly increased in the PCA group compared with the CI group. Moreover, morphine consumption was associated with SSS, independent of the technique of administration. There were no significant differences between groups in pain scores or in the incidence of side-effects.",1999.0,0,0
64,10321417,"Treatment of menstruation-associated migraine with the nonprescription combination of acetaminophen, aspirin, and caffeine: results from three randomized, placebo-controlled studies.",S D Silberstein; J J Armellino; H D Hoffman; J P Battikha; S W Hamelsky; W F Stewart; R B Lipton,"This retrospective study sought to examine the benefits of the nonprescription combination of acetaminophen, aspirin, and caffeine (AAC; Excedrin Migraine, Bristol-Myers Squibb Company, New York, New York) for the treatment of menstruation-associated migraine compared with migraine not associated with menses. Data were derived from 3 double-masked, randomized, placebo-controlled, single-dose trials enrolling subjects who met the International Headache Society's diagnostic criteria for migraine with or without aura. Subjects with incapacitating disability (attacks requiring bed rest >50% of the time) and those who usually experienced vomiting > or =20% of the time were excluded. Retrospective analysis of the 1220 subjects included in the efficacy-evaluable data set indicated that 185 women treated menstruation-associated migraine, 781 women treated migraine not associated with menses, and 1 woman provided no information regarding menstrual status. At baseline and at 0.5, 1, 2, 3, 4, and 6 hours postdose, subjects assessed the intensity of headache pain, functional disability, nausea, photophobia, and phonophobia. Pain intensity, nausea, photophobia, and phonophobia were rated on a 4-point scale ranging from 0 = none to 3 = severe; functional disability was rated on a 5-point scale ranging from 0 = none to 4 = incapacitating. For both menstruation-associated migraine and migraine not associated with menses, the proportion of subjects with pain intensity reduced to mild or none (responders) was significantly greater with AAC than with placebo at all postdose time points from 0.5 through 6 hours (P< or =0.05), with no statistically significant difference in treatment effect between menstruation-associated migraine and migraine not associated with menses at any postdose time point. Migraine characteristics such as photophobia, phonophobia, and functional disability were significantly improved in AAC-treated subjects at all time points from 1 through 6 hours (P< or =0.01) in both the menstruating and nonmenstruating groups. Significant relief from nausea was experienced in both menstruation-associated migraine and migraine not associated with menses, but relief appeared earlier in the AAC nonmenstruating subjects (2 hours postdose, P< or =0.01) than in the menstruating subjects (6 hours postdose, P< or =0.05). Beginning at 3 hours postdose, significantly fewer subjects treated with AAC required rescue medication (P< or =0.05) for menstruation-associated migraine (AAC 6%, placebo 15%) and migraine not associated with menses (AAC 7%, placebo 14%). The most commonly used rescue medications in both the menstruating and nonmenstruating groups were nonsteroidal anti-inflammatory drugs, prescription combination analgesics/narcotics, and prescription migraine preparations. AAC was well tolerated in both menstruation-associated migraine and migraine not associated with menses; in general, adverse experiences were similar in both groups. The proportion of subjects who had 1 or more adverse experiences was significantly higher among those receiving AAC than among those receiving placebo (menstruation-associated migraine: AAC 26.4%, placebo 12.6%, P = 0.025; nonmenstruation-associated migraine: AAC 18.6%, placebo 11.4%, P = 0.005). Adverse experiences were similar in type and severity to those previously associated with single doses of acetaminophen, aspirin, or caffeine. Thus the nonprescription combination of AAC was highly effective in treating the pain, disability, and associated symptoms of both menstruation-associated migraine and migraine not associated with menses.",1999.0,0,0
65,10323113,Effectiveness of preoperative analgesics on postoperative dental pain: a study.,M Zacharias; K M Hunter; A B Baker,"Patients undergoing extractions of third molar teeth under general anesthesia were given a placebo, diclofenac (a nonsteroidal anti-inflammatory drug) 100 mg, or methadone (an opiate) 10 mg 60 to 90 min prior to surgery, and their pain scores and postoperative medication requirements were measured for 3 days. All patients received local anesthetic blocks and analgesic drugs during the perioperative period. There were no significant differences between the three groups in the pain scores and medication requirements during the period of study. It was concluded that preoperative use of nonsteroidal anti-inflammatory drugs and opiates may not offer a preemptive analgesic effect in patients who have had adequate analgesia during the surgery. Continued use of analgesic drugs during the postoperative period is perhaps more useful for this purpose. There appears to be a higher incidence of vomiting following opiates (methadone), precluding its clinical use in day-care patients.",1999.0,0,0
66,10325836,Influence of bolus size on efficacy of postoperative patient-controlled analgesia with piritramide.,B Morlion; E Ebner; A Weber; W Finke; C Puchstein,"We have examined the influence of bolus size on efficacy, opioid consumption, side effects and patient satisfaction during i.v. patient-controlled analgesia (PCA) in 60 patients (ASA I-II, aged 32-82 yr) after abdominal surgery. Patients were allocated randomly, in a double-blind manner, to receive PCA with a bolus dose of either piritramide 0.75 mg or 1.5 mg (lockout 5 min) for postoperative pain control. Mean 24 h piritramide consumption differed significantly between groups (11.4 (SD 5.8) mg vs 22.5 (18.3) mg; P = 0.001). There were no significant differences in the number of applied bolus doses, pain scores, pain relief (VAS), sedation, nausea, pruritus and patient satisfaction. We conclude that a PCA regimen with a bolus dose of piritramide 0.75 mg and a lockout time of 5 min was effective in the treatment of postoperative pain, but did not reduce the occurrence of side effects.",1999.0,0,0
67,10326986,Chronic pain conditions in women.,J G Meisler,"There are inconsistent data on the age/sex prevalence pattern of back pain and on chest pain. However, it is possible that for chest pain, the rates are higher in younger women and older men. Neck pain, joint pain, and fibromyalgia all appear to increase with age in both genders, whereas abdominal pain and tension-type headaches decrease with age, and migraine headache and TMD appear to peak in the reproductive years. A concluding example illustrates how epidemiologic data can be used to enhance our understanding of the causes of pain. A higher prevalence in women and a peak prevalence during the reproductive years as seen in TMD suggest that either biologic or psychosocial factors unique to women in this period of life could increase the risk of developing or maintaining this pain. As female reproductive hormones can play a role in migraine, at least for some women, it would be interesting to examine whether hormones play a role in TMD. The situation that occurs when menopause is followed by hormone replacement therapy (HRT) provides a natural experiment similar to a laboratory experiment in which female animals are deprived of the natural sources of hormones and then hormones are replaced exogenously. In women, of course, the decision to receive HRT may be associated with a number of psychosocial variables that might also influence pain. Recognizing these limitations, data from records of a large health maintenance organization were examined to ascertain whether use of estrogen or progestin (or both) in postmenopausal women might be associated with the occurrence of TMD pain and, thus, whether the hormone hypothesis might be worthy of further investigation. More women with TMD than controls used estrogen replacement therapy, and slightly more patients than controls used progestin. The use of estrogen significantly increased the odds of having TMD. Progestin use showed a weaker association, which did not hold up after other factors were controlled. However, the risk of TMD appears to increase with increasing doses of estrogen. A review of the epidemiologic literature indicates that there are definite age and sex differences in the prevalence of many chronic pain conditions. There is little basic information about the source of these differences, such as different onset rates, different probabilities of recurrence, or different durations of pain, or combinations of these in women and men. Nevertheless, a systematic examination of the existing epidemiologic data may be an important step in helping pain researchers to generate hypotheses in the search for a better understanding of chronic pain in both sexes.",1999.0,0,0
68,10332431,Indinavir urolithiasis: an emerging cause of renal colic in patients with human immunodeficiency virus.,A D Kohan; N A Armenakas; J A Fracchia,"We evaluate the clinical, diagnostic and radiographic findings in patients on indinavir therapy who presented with renal colic, and propose appropriate treatment options for indinavir urolithiasis. A total of 16 patients positive for human immunodeficiency virus on indinavir were evaluated for 18 episodes of severe renal colic requiring hospitalization. Laboratory evaluation was performed in all patients followed by an imaging study. Conservative treatment included intravenous hydration, narcotic analgesics and temporary cessation of indinavir. Intervention was elected only in patients with persistent fever or intractable pain. A month after hospital discharge an excretory urogram and metabolic stone evaluation were performed. Mean followup was 9.3 months and 2 patients had recurrent symptoms. All patients presented with nausea or vomiting and hematuria. Imaging studies confirmed obstruction in all patients with 13 radiolucent (indinavir) and 3 radiopaque (calcium oxalate) stones. Patients with radiolucent and radiopaque stones demonstrated significant differences in urinary pH (p = 0.002) and serum creatinine (p = 0.03). Conservative therapy was successful in 11 patients (68.8%) within 48 hours and 4 patients (25%) with radiolucent calculi required endoscopic stenting for persistent fever. Metabolic stone evaluation demonstrated significant hypocitruria (less than 50 mg./24 hours) in all patients with radiolucent calculi. The urologist should be familiar with this growing cause of renal colic in patients on indinavir therapy. Pure indinavir stones are radiolucent and have a soft, gelatinous endoscopic appearance. Conservative treatment is successful in most patients and if intervention is deemed medically necessary, endoscopic stent placement should be the procedure of choice.",1999.0,0,0
69,10335806,Management of cancer pain.,R K Portenoy; P Lesage,"Patients with cancer have diverse symptoms, impairments in physical and psychological functioning, and other difficulties that can undermine their quality of life. If inadequately controlled, pain can have a profoundly adverse impact on the patient and his or her family. The critical importance of pain management as part of routine cancer care has been forcefully advanced by WHO, international and national professional organisations, and governmental agencies. The prevalence of chronic pain is about 30-50% among patients with cancer who are undergoing active treatment for a solid tumour and 70-90% among those with advanced disease. Prospective surveys indicate that as many as 90% of patients could attain adequate relief with simple drug therapies, but this success rate is not achieved in routine practice. Inadequate management of pain is the result of various issues that include: undertreatment by clinicians with insufficient knowledge of pain assessment and therapy; inappropriate concerns about opioid side-effects and addiction; a tendency to give lower priority to symptom control than to disease management; patients under-reporting of pain and non-compliance with therapy; and impediments to optimum analgesic therapy in the healthcare system. To improve the management of cancer pain, every practitioner involved in the care of these patients must ensure that his or her medical information is current and that patients receive appropriate education.",1999.0,0,0
70,10340954,How should we manage fibromyalgia?,P A Reilly,,1999.0,0,0
71,10342006,Chronic pain after thoracic surgery: a follow-up study.,K Perttunen; T Tasmuth; E Kalso,"The incidence of long-term post-thoracotomy pain is reported to be up to 67%. A relationship between the severity of acute postoperative pain and the development of chronic post-thoracotomy pain has been suggested. Patients scheduled for elective thoracotomy were interviewed before and one week after surgery to find out if they had pain before surgery and how much pain they experienced postoperatively. The amount of analgesics the patients were given were registered during the first 5 postoperative days. The patients were interviewed by letter 3, 6 and 12 months after surgery to find out if they still had pain due to surgery and to what extent this pain interfered with their daily activities. One hundred and ten patients entered the study. Information about the complete study period was obtained from 67 patients. The incidence of chronic post-thoracotomy pain was 80% at 3 months, 75% at 6 months and 61% one year after surgery. The incidence of severe pain was 3-5%. Chronic post-thoracotomy pain interfered with the patient's normal daily life in more than half of the patients. High consumption of analgesics during the first postoperative week was associated with a higher risk of chronic post-thoracotomy pain. A significant proportion of patients undergoing thoracotomies will suffer from chronic pain. Surgeons and anaesthetists should be aware of this fact and they should look for effective means of preventing and treating this pain syndrome.",2000.0,0,0
72,10342407,Are opioids effective in relieving neuropathic pain?,P Dellemijn,"The purpose of this review is to identify important issues and to review the data that underlie the controversial effectiveness of opioids in relieving neuropathic pain. This controversy seems related to the use of multiple definitions of neuropathic pain together with its distinct mechanisms in both experimental animal models and human neuropathic pain syndromes, methodological shortcomings in available randomized controlled clinical trials, different methods of pain assessment, the inappropriate use of terms like efficacy and responsiveness, differential responses in spontaneous versus evoked pains, interindividual differences to specific opioids and opioid doses, and duration of follow-up. New randomized controlled clinical trials with opioids in neuropathic pain are still needed. These studies should include larger patient samples with rigorously defined homogeneous neuropathic pain syndromes. Active placebo's mimicking side-effects should be included in the double-blind design, and control of unmasking should be performed. Individual titration of the opioid dose and active management of side-effects in long-term follow-up studies need to measure both pain relief and quality of life.",1999.0,0,0
73,10342415,Epidemiology of complex regional pain syndrome: a retrospective chart review of 134 patients.,G Allen; B S Galer; L Schwartz,"Complex regional pain syndrome (CRPS) remains a poorly understood chronic pain disorder. Little data has been published assessing the epidemiology of CRPS (and reflex sympathetic dystrophy, RSD). This study assessed epidemiological variables in 134 CRPS patients evaluated at a tertiary chronic pain clinic in the US, including demographic, health care utilization and legal/workman's compensation measures. In addition, the frequency of physician-imposed immobilization of the CRPS limb was assessed, as was physical examination evidence of myofascial dysfunction. This study found that these patients had seen on average 4.8 different physicians before referral to the pain center and had received an average of five different kinds of treatments both prior to and during pain clinic treatment. The mean duration of CRPS symptoms prior to pain center evaluation was 30 months. Seventeen percent had a lawsuit and 54% had a worker compensation claim related to the CRPS. Fifty-one patients received a bone scan, but only 53% of which were interpreted as consistent with the diagnosis of RSD/CRPS. Forty-seven percent had a history of physician-imposed immobilization, and 56% had a myofascial component present at evaluation. The duration of CRPS symptoms and the involvement of the upper extremity was significantly associated with the presence of myofascial dysfunction. Thus, this study found that most CRPS patients are referred to a pain specialty clinic after several years of symptoms and many failed therapies. The data also suggest the lack of utility of a diagnostic bone scan and highlight the prominence of myofascial dysfunction in a majority of CRPS patients.",1999.0,0,0
74,10342416,"Intra-subject variability in post-operative patient-controlled analgesia (PCA): is the patient equally satisfied with morphine, pethidine and fentanyl?",A Woodhouse; M E Ward; L E Mather,"Our previous study suggested that when compared between patients, morphine, pethidine and fentanyl were equally satisfactory for use in patient-controlled analgesia (PCA), although quantitative differences in their side-effect profiles were detectable. The present study evaluated whether individual patients could detect differences or express preferences for individual opioids when treated by PCA with all three in random sequence finishing with the first administered opioid. The main side effects were pruritus, nausea and vomiting. There were few differences in patients' responses to morphine, pethidine and fentanyl, or of satisfaction with these drugs, across patients, but individual patients' responses to the opioids could be highly variable. Some patients were able to tolerate all three opioids investigated, some were intolerant to all and some patients appeared to be sensitive to one or two of the opioids but show a preference for the remainder. These findings support the clinical practice of changing from one opioid to another (with good effect) in post-operative patients experiencing intolerable side-effects. The reasons for a patient responding differently to different opioids and even to the same opioid on separate occasions are not clear and appear inexplicable on the grounds of currently postulated receptor affinities or of physicochemical properties of the opioids studied. A plethora of factors will influence how an individual patient will respond to surgery and how he/she will recover. The physiological response to opioids is one variable which appears to be influenced by this complex set of factors and in turn will affect them. The findings of this study, like that of its predecessor, suggest that morphine, pethidine and fentanyl can be used successfully in PCA and that for some patients who are responding poorly, changing the opioid may be beneficial.",1999.0,0,0
75,10352657,Epidural and spinal agents for postoperative analgesia.,N Rawal,"The discovery of opioid receptors and the subsequent development of the technique of epidural and intrathecal opioid administration are undoubtedly two of the most significant advances in pain management in recent decades. The use of spinal opioids is widespread and increasing. The technique is used widely to treat intraoperative, postoperative, traumatic, obstetric, chronic, and cancer pain. Newer developments include the increasing use of combined local anesthetics and opioids or nonopioids and also PCEA, particularly in the obstetric population. Meta-analysis of controlled trials has demonstrated improved pulmonary outcome in patients receiving epidural postoperative analgesia. Although rare, respiratory depression continues to be a major problem of the technique. None of the currently available opioids is completely safe; however, extensive international experience has shown that patients receiving spinal opioids for postoperative analgesia can be safely nursed on regular wards, provided that trained personnel and appropriate guidelines are available. The importance of a good acute pain service to provide the safe and effective use of spinal opioids cannot be overemphasized.",1999.0,0,0
76,10353500,Breakthrough pain: characteristics and impact in patients with cancer pain.,R K Portenoy; D Payne; P Jacobsen,"Few surveys have been performed to define the characteristics and impact of breakthrough pain in the cancer population. In this cross-sectional survey of inpatients with cancer, patients responded to a structured interview (the Breakthrough Pain Questionnaire) designed to characterize breakthrough pain, and also completed measures of pain and mood (Memorial Pain Assessment Card (MPAC)), pain-related interference in function (Brief Pain Inventory (BPI)), depressed mood (Beck Depression Inventory (BDI)), and anxiety (Beck Anxiety Inventory (BAI)). Of 178 eligible patients, 164 (92.2%) met the criteria for controlled background pain. The median age was 50.6 years (range 26 to 77 years), 52% were men, and 80.6% were Caucasian. Tumor diagnoses were mixed, 75% had metastatic disease, 65% had pain caused directly by the neoplasm, and a majority had mixed nociceptive-neuropathic pain. The median Karnofsky Performance Status score was 60 (range 40 to 90). Eighty-four (51.2%) patients had experienced breakthrough pain during the previous day. The median number of episodes was six (range 1 to 60) and the median interval from onset to peak was 3 min (range 1 s to 30 min). Although almost two-thirds (61.7%) could identify precipitants (movement 20.4%; end-of-dose failure 13.2%), pain was unpredictable in a large majority (78.2%). Patients with breakthrough pain had more intense (P < 0.001) and more frequent (P < 0.01) background pain than patients without breakthrough pain. Breakthrough pain was also associated with greater pain-related functional impairment (difference in mean BPI. P < 0.001), worse mood (mood VAS, P < 0.05; BDI, P < 0.001), and more anxiety (BAI, P < 0.001). Multivariate analysis confirmed that breakthrough pain independently contributed to impaired functioning and psychological distress. These data confirm that cancer-related breakthrough pain is a prevalent and heterogeneous phenomenon. The presence of breakthrough pain is a marker of a generally more severe pain syndrome, and is associated with both pain-related functional impairment and psychological distress. The findings suggest the need for further studies of breakthrough pain and more effective therapeutic strategies.",1999.0,0,0
77,10357424,Outcome and complications of epidural analgesia in patients with chronic cancer pain.,S Mercadante,,2000.0,0,0
78,10358691,Lower body osteoarticular pain and dose of analgesic medications in older disabled women: the Women's Health and Aging Study.,M Pahor; J M Guralnik; J Y Wan; L Ferrucci; B W Penninx; A Lyles; S Ling; L P Fried,"This study assessed use and dosage of analgesic medications in relation to severity of osteoarticular pain. The type and dose of analgesic medication and the severity of pain in the lower back, hips, knees, or feet of 1002 older disabled women were assessed. Severe pain and the use of analgesic medications were reported by 48.5% and 78.8% of women, respectively. Among those who had severe pain, 41.2% were using less than 20% of the maximum analgesic dose. Overall, 6.6% of women were using more than 100% of the maximum dose. Severe pain is common. Additional, more effective, and safe analgesic treatments are needed for controlling pain in older persons.",1999.0,0,1
79,10359427,Management of chronic pain.,M A Ashburn; P S Staats,"Chronic pain is a common condition for which patients seek care from various health-care providers. This type of pain causes much suffering and disability and is frequently mistreated or undertreated. Patients who present for evaluation for chronic pain should undergo a careful assessment before therapy. Patients with chronic pain commonly experience depression, sleep disturbance, fatigue, and decreased overall physical and mental functioning. They frequently require an interdisciplinary model of care to allow care givers to address the multiple components of the patient's pain experience. After a careful evaluation, therapy may include medication, nerve blocks, active physical therapy, behavioural interventions, and assistance with vocational evaluation and training. Less frequently therapy may include placement of implantable devices to alter the pain experience. These patients suffer from a chronic condition and often require long-term care, with frequent reassessment and adjustment of therapy. Although cure is possible, it is also infrequent. Therefore, therapy is provided with the aim of decreasing pain and suffering while improving physical and mental functioning.",1999.0,0,0
80,10360847,Oral ketamine and transdermal nitroglycerin as analgesic adjuvants to oral morphine therapy for cancer pain management.,G R Lauretti; I C Lima; M P Reis; W A Prado; N L Pereira,"Guidelines for cancer pain management include nonsteroidal antiinflammatory drugs with opioids administered in a time-contingent manner. This study was designed to evaluate the role of oral ketamine or transdermal nitroglycerin polymer, a nitric oxide donor, as coadjuvants to oral morphine in cancer pain therapy. After institutional approval and informed patient consent were obtained, 60 patients with cancer pain were randomized to one of four groups (n = 15) and studied prospectively to evaluate analgesia and any adverse effects. A visual analog scale that consisted of a 10-cm line with 0 representing ""no pain at all"" and 10 representing ""the worst possible pain"" was introduced. All patients were regularly taking oral amitriptyline 50 mg at bedtime. The morphine regimen was adjusted individually to a maximal oral dose of 80-90 mg/day to keep the visual analog scale score less than 4. When patients reported pain (visual analog scale of 4 or more), despite taking 80-90 mg oral morphine daily, the test drug was added as follows: the control group (CG) received an additional 20 mg oral morphine (10 mg at 12-h intervals); the nitroglycerin group (NG) received a 5-mg nitroglycerin patch daily; the ketamine group (KG) received 0.5 mg/kg oral ketamine at 12-h intervals; and the dipyrone group (DG) received 500 mg oral dipyrone at 6-h intervals. Patients were free to manipulate their daily morphine consumption when the test drug was introduced to keep their visual analog scale score less than 4. The groups were similar with respect to demographic data and visual analog scale pain scores before treatment. The visual analog scale scores after the test drug was introduced were similar among the groups. The daily consumption of oral morphine was as follows: on day 15: CG = DG = NG (P > 0.05), CG > KG (P = 0.036); on day 20: CG > NG = KG (P < 0.02) (CG > KG, P < 0.005; CG > NG, P < 0.02), DG > KG (P < 0.05); on day 30: CG = DG > KG = NG (P < 0.05). Patients in the CG and DG groups reported somnolence, but patients in the NG and KG groups did not. Low-dose ketamine and transdermal nitroglycerin were effective coadjuvant analgesics. In conjunction with their opioid tolerance-sparing function, joint delivery of ketamine or nitric oxide donors with opiates may be of significant benefit in cancer pain management.",1999.0,0,0
81,10361663,Intrathecal morphine. Double-blind evaluation of optimal dosage for analgesia after major lumbar spinal surgery.,A P Boezaart; J A Eksteen; G V Spuy; P Rossouw; M Knipe,"A prospective, randomized, double-blind study. To evaluate the efficacy and safety of three different dosages of intrathecal morphine sulfate for postoperative analgesia after lumbar spinal fusion. Analgesia and respiratory depression after intrathecal morphine sulfate injection are dose related. The optimal dose to use for major spinal surgery is not known. Sixty patients undergoing posterolateral lumbar fusion with or without decompression were divided randomly into 3 groups of 20 patients each. Anesthesia, monitoring, and surgery were similar for all patients. Just before closing of the wound, morphine sulfate was injected into the dural sack under direct visualization. Patients in groups 1-3 received 0.2 mg, 0.3 mg, and 0.4 mg morphine, respectively. Routine analgesia, consisting of diclofenac, was prescribed to use if necessary. Measurements were made and compared between the groups at zero hours (on admission to the Intensive Care Unit), 6 hours, 12 hours, 18 hours, and 24 hours after surgery. At zero hours and at 12 hours after surgery, pain levels were similar in groups 2 and 3, but were significantly higher in group 1 (P < 0.05). The respiratory rate was significantly lower in group 3 than in the other two groups (P < 0.05), and the arterial CO2 tension (PaCO2) was consistently higher in group 3. PaCO2 decreased in all three groups over the first 24 hours. Pruritus and nausea did not differ among the three groups. For adult patients undergoing posterolateral lumbar fusion, 0.3 mg (0.004 mg/kg) is probably the optimal dose of intrathecal morphine to manage pain.",1999.0,0,0
82,10364869,,,,,0,0
83,10364998,I.v. diclofenac and ketorolac for pain after thoracoscopic surgery.,K Perttunen; E Nilsson; E Kalso,"We studied intensity of pain, cumulative morphine consumption, ventilatory and renal function, and haemostasis in patients undergoing video-assisted thoracoscopic surgery and receiving a 2-day i.v. infusion of diclofenac, ketorolac or saline. Plasma concentrations of the two NSAID were also measured. The study was randomized, double-blind and placebo-controlled, with 10 patients in each group. Patients experienced mainly moderate pain. Mean consumption of i.v. morphine during the first day after operation was 57 (SEM 11) mg in the placebo group. Diclofenac and ketorolac were equally effective in reducing total morphine consumption (61% and 52%, respectively). Adverse events were similar and minor. Greater variability in plasma concentrations of ketorolac were detected compared with diclofenac.",1999.0,0,0
84,10369590,Use of an orbital epidural catheter to control pain after orbital implant surgery.,J P Fezza; K A Klippenstein; R E Wesley,"The surgical placement of orbital implants for eviscerations, enucleations, and secondary implantations can cause severe postoperative pain that may not be relieved with high doses of narcotics. We analyzed the effectiveness of a method for postoperative pain control in orbital implant surgery using an orbital epidural pain catheter connected to a patient-controlled analgesia bupivacaine hydrochloride pump. One hundred nineteen patients undergoing orbital hydroxyapatite implant surgery received placement of an orbital epidural catheter for the infusion of local anesthetics at the conclusion of their surgery. Patients were asked to gauge their level of comfort into the following 3 categories: total, some, or no pain relief in the first week after surgery. A separate numerical grading scale was used to further quantitate pain. Blood samples were collected in 4 patients to assess the systemic levels of bupivacaine. Most patients (88.2%) responded with total or some pain relief, with only 11.8% suffering severe pain. The mean numerical pain score was 2.8, within a range of 0 (no pain) to 10 (severe pain). The average plasma bupivacaine level in the 4 patients in whom this was measured was 0.38 microg/mL, which is well below the toxic level of 4.0 microg/mL. Furthermore, there were only 5 minor complications caused by the catheters, ie, 1 retrobulbar hemorrhage and 4 catheters that did not work. No permanent problems arose from any of the complications. The orbital epidural pain catheter is an effective means to achieve postoperative pain control after orbital implant surgery. The simple technique of insertion and management of the catheters was well tolerated in our patient population.",1999.0,0,0
85,10382920,Pain and somatosensory dysfunction in acute herpes zoster.,M Haanpää; P Laippala; T Nurmikko,"To determine the nature of sensory change and its association with pain and allodynia in acute herpes zoster. Prospective clinical study. One hundred thirteen immunocompetent patients with acute herpes zoster. Onset, intensity, and quality of pain and severity of rash were recorded. Quantitative somatosensory testing for tactile and thermal thresholds, qualitative pinprick testing, and testing of dynamic and static allodynia were performed within the affected dermatome, its mirror-image dermatome, and in an adjacent dermatome bilaterally. Acute pain was reported as severe in 50%, moderate in 29%, mild in 12%, and absent in 9% of patients. Preherpetic pain (median = 4 days, range = 1-60 days) was experienced by 71%. Mechanical allodynia, dynamic, static, or both, was found in 37% of patients and was noted to extend one or more dermatomes outside the rash in 12%. In the affected dermatomes, thresholds were elevated for warmth and cold, lowered for heat pain, and unchanged for touch when compared with the contralateral side. Logistic regression analyses showed that compression-evoked allodynia, brush-evoked allodynia, and the history of preherpetic pain were more frequently encountered in patients with severe pain. Sensory threshold changes were not associated with the severity of pain or rash or with the presence of allodynia. Pain, allodynia, and altered sensation are common features of acute herpes zoster. They are likely to result primarily from widespread neural inflammation within the affected afferent system. The sensory changes found in acute herpes zoster are different from those reported in published studies on postherpetic neuralgia and suggest sensitization phenomena and preservation of tactile functions rather than major neural damage. The exact mechanisms for acute herpes zoster pain, however, remain speculative.",1999.0,0,0
86,10382926,Disease-specific and generic health outcomes: a model for the evaluation of long-term intrathecal opioid therapy in noncancer low back pain patients.,J Brown; J Klapow; D Doleys; D Lowery; U Tutak,"The present study provided comprehensive characterization of the long-term outcomes of intrathecal opioid administration via a drug administration system (DAS) in chronic pain patients with predominantly low back pain. A conceptual framework based on multidimensional outcomes is proposed using both disease-specific and generic measures. Pre-post longitudinal data were collected in a retrospective fashion on 38 patients receiving intraspinal opioid therapy for a minimum of 36 months (average = 50 months). Disease-specific measures included magnitude of infused opioid, side effects/complications, pain ratings, McGill Pain Questionnaire, Beck Depression Inventory, Oswestry Disability Questionnaire, and patient estimated improvement in pain (0-100%). Generic measures of health included the Quality of Well-Being Scale, Medical Outcomes Study (MOS) Short Form 36 (SF-36), return to work, patient estimated improvement in functioning, overall patient satisfaction, and family opinion of patient improvement. Disease-specific outcomes. Patients receiving long-term intrathecal opioid administration showed a sixfold increase in morphine equivalents infusion rates across time. DAS patients showed a small but significant decrease in pain ratings from pre-treatment levels. Following 3 years or more of intrathecal opioid infusion, patients endorsed high pain levels on the McGill Pain Questionnaire, severe levels of disability via the Oswestry Disability Questionnaire, mild levels of depression based on the Beck Depression Inventory, and multiple side effects associated with the intrathecal opioids and complications related to the infusion system. On retrospective questioning, patients receiving long-term intrathecal opioid administration reported an average of 64% improvement in their pain and 48% improvement in functioning. Family members of patients reported that they observed on average a 61% improvement in patient's pain. Generic outcome measures. On the Quality of Well-Being Scale, patients reported significantly lower health-related quality of life than health maintenance organization enrollees with no known chronic condition and patients with rheumatoid arthritis (p < 0.001). On the MOS SF-36, patients reported significantly lower physical functioning than the U.S. general population, patients with uncomplicated medical conditions, diabetes-type II patients, and congestive heart failure patients. Mental functioning was comparable to the U.S. general population (p > 0.001). Fourteen percent of patients were working following implantation. Eighty-nine percent of patients reported good to excellent satisfaction with the long-term intrathecal opioid therapy. Results from this study revealed differences in findings across the outcome measures, highlighting the complexity of intrathecal opioid therapy. Generally, patients after 3 years or more of intrathecal opioid therapy can be characterized as hav ing substantially impaired physical functioning with a high prevalence of side effects. Despite poor physical functioning, patients endorsed relatively good mental health status with only mild depressive symptoms. Longitudinal pain ratings showed a modest decrease from pretreatment levels. On retrospective evaluation, patients and their family endorsed high levels of pain relief secondary to intrathecal therapy. Overall, findings support that intrathecal opioid therapy provides some therapeutic benefit although substantial physical impairment continues to cause debilitation in the patient population.",1999.0,0,0
87,10383545,Management of postoperative pain in abdominal surgery in Spain. A multicentre drug utilization study.,A Vallano; C Aguilera; J M Arnau; J E Baños; J R Laporte,"Postoperative pain is common in hospital-admitted patients. Its management is determined by different therapeutic traditions and by the attitudes of health professionals in each hospital. The aim of this study was to describe the patterns of prescription and administration of analgesic drugs used for postoperative pain after abdominal surgery in Spanish hospitals, to know the prevalence and the severity of postoperative pain, and to determine the extent of variability in the management of postoperative pain among the participating centres. The study was a multicentre descriptive cross-sectional drug utilization study in 12 Spanish hospitals. The subjects were an unselected sample of consecutive patients undergoing abdominal surgery, admitted between October 1994 and January 1995. For each patient, information about the surgical procedure and the use of analgesics was prospectively collected. The severity of postoperative pain was assessed during the first day after surgery by means of a six-category (none, mild, moderate, severe, very severe, and unbearable) rating scale and a visual analogue scale (VAS). Nine hundred and ninety-three patients (547 men) were included. The most common surgical procedures were inguinal hernia repair (315, 32%), cholecystectomy (268, 27%), appendectomy (140, 14%), bowel resection (137, 14%), and gastric surgery (58, 6%). Fifty-nine percent of patients (587) received nonopioid analgesics only, 9% (89) received opioid analgesics only, and 27% (263) received both opioid and nonopioid analgesics. The most frequently administered drugs were metamizole (667 patients) and pethidine (213 patients). Although in the majority of medical orders the administration of analgesics was scheduled at regular time intervals, the majority of actual doses were given 'as-needed'. The average administered daily doses of all analgesics were lower than those prescribed. Thirty-eight percent (371/967) of patients rated their maximum pain on the first day as severe to unbearable. Wide interhospital variability was recorded in the surgical procedures which had been performed, in the analgesics used, and also in the pain scores referred by patients. The percentage of patients in each centre who suffered severe to unbearable pain varied from 22 to 67%. In Spain many patients still suffer severe pain after abdominal surgery, and this seems to be due to an inadequate use of analgesics. Wide interhospital variability in the management of postoperative pain and in its prevalence was also recorded.",1999.0,0,0
88,10386115,Primary care and pain medicine. A community solution to the public health problem of chronic pain.,R M Gallagher,"The author emphasizes that pain is an important public health problem that demands attention. He discusses ineffective management and its causes, administrative and socioeconomic problems perpetuating poor care, problems in technology transfer, organizational models, specialists and subspecialists, and other topics.",1999.0,0,0
89,10386120,Headache disorders.,J R Saper,"Head, neck, and facial pain disorders possess characteristic features that, in some ways, distinguish them from other painful disorders. Generally speaking, the headache disorders can be reconciled within the same model of assessment as that of other painful conditions.",1999.0,0,0
90,10386121,"Medically unexplained chronic orofacial pain. Temporomandibular pain and dysfunction syndrome, orofacial phantom pain, burning mouth syndrome, and trigeminal neuralgia.",J J Marbach,"Orofacial pain syndromes pose a dilemma for physicians. Even when the patient is referred, quality medical care requires that the physician be acquainted with current evidence-based practice. Such practice may be radically different from the traditional view. This article reviews the differential diagnosis and treatment of the most common medically unexplained orofacial syndromes.",1999.0,0,0
91,10386123,Approaches to treatment decisions for psychiatric comorbidity in the management of the chronic pain patient.,D A Fishbain,A number of different types of comorbidities have been described within psychiatric patients. These comorbidity types are reviewed and their application to the chronic pain population is discussed. These various types of comorbidities are then utilized to generate an approach for treatment decisions in the management of the chronic pain patient.,1999.0,0,0
92,10386124,Opioid use in the management of chronic pain.,S R Savage,"Opioids are a necessary and effective component of the management of chronic non-cancer-related pain in some patients. Careful structuring, monitoring, and documentation of care are important, but the therapeutic use of opioids is uncomplicated in the majority of patients using opioids and is gratifying for both the patient and the treating physician when it results in significant reduction in pain, improvement in level of function, and a higher quality of life. Opioid therapy is most often successful when combined with other pharmacologic and nonpharmacologic interventions as indicated by the type of pain and the context in which it occurs.",1999.0,0,0
93,10386127,"Treatment planning in pain medicine. Integrating medical, physical, and behavioral therapies.",R M Gallagher,This article addresses a systematic approach to the treatment of chronic pain. The first section presents a biopsychosocial model of pain. The second section presents an application of the biopsychosocial approach to the clinical assessment and management of clinical cases with chronic pain.,1999.0,0,0
94,10389953,Effect of ketorolac in pediatric sickle cell vaso-occlusive pain crisis.,W E Hardwick; T G Givens; K W Monroe; W D King; D Lawley,"Ketorolac is a parenteral, nonsteroidal analgesic that does not have a narcotic's risks of respiratory depression, hypotension, or dependence. Its usefulness in providing pain relief in pediatric patients with acute vaso-occlusive crisis of sickle cell disease has not been studied to date. Twenty-nine patients with sickle cell disease between the ages of 5 and 18 years who presented to The Children's Hospital of Alabama emergency department (ED) with 41 distinct episodes of acute vaso-occlusive pain crisis were enrolled prospectively and randomized to receive either 0.9 mg/kg intravenous (IV) ketorolac or placebo in a double-blind fashion. All patients also received IV fluids and an initial 0.1 mg/kg of IV morphine. Subsequent standardized doses of morphine were given every 2 hours over a 6-hour observation period based upon severity of pain as scored by a 10-cm linear visual analog scale (VAS). Vital signs and pain severity were recorded initially and assessed hourly. Disposition was made at the end of the observation period. Patients receiving ketorolac and those receiving placebo were of similar age, weight, gender, number of prior ED visits, number of prior hospital admissions, duration of pain prior to presentation, and initial pain score. The total dose of morphine received, reduction in severity of pain as measured by VAS, rate of hospital admission, and rate of return to the ED for discharged patients did not differ significantly between the two groups. We were unable to demonstrate a synergistic analgesic effect for ketorolac in the treatment of pain from acute vaso-occlusive crisis in pediatric sickle cell disease. Further investigations involving larger samples of sickle cell patients may be needed to further define a role for ketorolac in the acute management of sickle cell vaso-occlusive pain.",2001.0,0,0
95,10391814,,,,,0,0
96,10393001,Opioids in pain management.,H McQuay,"Opioids are our most powerful analgesics, but politics, prejudice, and our continuing ignorance still impede optimum prescribing. Just over 100 years ago, opium poppies were still grown on the Cambridgeshire fens in the UK to provide oblivion for the working man and his family, but the brewing lobby argued on thin evidence that their potions were less dangerous. The restriction of opioid availability to protect society and the individual continues in many countries. In this review I focus on chronic and cancer pain, but many of the principles apply in acute pain. The justification for this focus is that patients with chronic pain may suffer longer and unnecessarily if we prescribe and legislate badly.",1999.0,0,0
97,10395414,Comparison of ketorolac-chlorpromazine with meperidine-promethazine for treatment of exacerbations of chronic pain.,L E Mehl-Madrona,"The aim was to compare the efficacy and safety of a combination of intramuscular ketorolac and chlorpromazine for the treatment of acute exacerbations of chronic pain with the more commonly used regimen of intramuscular meperidine and promethazine. Use-effective case series were drawn from a real-life, rural emergency department practice, in which 200 consecutive patients coming to a rural emergency department with acute exacerbations of chronic pain syndromes were assigned on an every-other basis in a single-blind fashion to one of the two treatment conditions. Patients were given intramuscular doses of either 60 mg of ketorolac plus 50 mg of chlorpromazine (75 mg of chlorpromazine for patients weighing more than 100 kg), or 50 mg of meperidine plus 25 mg of promethazine (50 mg of promethazine for patients weighing more than 75 kg); patients weighing more than 100 kg were given 1.5 doses. Patients older than 65 years or whose blood pressure at the time of injection was less than 110/70 mmHg were given half-doses. Patients could receive one additional half-dose injection if they had no results within 30 to 60 minutes after the first injection. Patients were assessed on self-report and on a verbal and visual analog scale of pain rating. Temperature, blood pressure, heart rate, and respirations were monitored every 15 minutes. Both regimens performed well, with more than 90 percent of patients reporting good or excellent improvement on acute exacerbations of chronic pain. Ketorolac-chlorpromazine offered significant advantages compared with meperidine-promethazine when patients rated their pain on a visual analog pain scale (P < 0.05) but not on a verbal scale. Adverse reactions were minimal and consisted of more respiratory tract depression with meperidine and more vertigo or dizziness with chlorpromazine. There was no difference in incidence of hypotension between the two groups. The combination of ketorolac and chlorpromazine is a safe and efficacious alternative to meperidine plus promethazine for the treatment of exacerbations of chronic pain in the rural emergency department setting.",1999.0,0,0
98,10396713,Comparison of the analgesic effects of intrabursal oxycodone and bupivacaine after acromioplasty.,P A Muittari; O Nelimarkka; T Seppälä; J H Kanto; O A Kirvelä,"To compare the peripheral analgesic effect of oxycodone, an opioid agonist, to the effect of bupivacaine infiltration and parenteral oxycodone administration in conjunction with shoulder surgery. Prospective, randomized, double-blind study. University teaching hospital. 42 ASA physical status I and II patients scheduled for shoulder surgery with general anesthesia. Patients were randomized to three study groups: at the end of the surgery patients received either 10 ml of 0.5% bupivacaine (group BIB) or 5 mg of oxycodone in 10 ml of saline (group OIB) in the subacromial bursa; or 5 mg of oxycodone intramuscularly (group OIM). Postoperative analgesia was provided by patient-controlled analgesia (PCA). The fentanyl requirements were recorded for the 24-hour postoperative period and the total perioperative period. Postoperative pain was assessed by visual analog scale for pain (VASP). Plasma oxycodone concentrations were measured in groups OIB and OIM. The total perioperative fentanyl consumption was significantly lower in groups BIB (0.97 +/- 0.09 mg) and OIB (1.23 +/- 0.12 mg) than in group OIM (1.61 +/- 0.12 mg) (p = 0.01 and 0.048, respectively). Groups BIB and OIB were similar (p = 0.34). The absorption of oxycodone was significantly lower after subacromial than after intramuscular administration. Intrabursal oxycodone and intrabursal bupivacaine reduced perioperative analgesic requirements similarly. Intrabursal oxycodone may offer an effective, simple, and safe method for postoperative analgesia after shoulder surgery.",1999.0,0,0
99,10408823,Clinical experience using intrathecal (IT) bupivacaine infusion in three patients with complex regional pain syndrome type I (CRPS-I).,C Lundborg; P Dahm; P Nitescu; L Appelgren; I Curelaru,"To date, there is no reliable method for treating the severe pain and for modifying the natural evolution of CRPS-I. Therefore, we explored the effect of long-term IT bupivacaine infusion (with or without buprenorphine) on this syndrome. (a) two women and one man, 25, 31 and 42 years old, with CRPS-I of the lower (n=2) or upper (n=1) extremity lasting for 4 and 5 months, and 14 years. (b) insertion of externalized IT catheters; IT infusion of buprenorphine 0.015 mg/ml and bupivacaine 4.75 mg/ml (n=1), or only bupivacaine 5 mg/ml (n=2) from external electronic pumps. The IT treatment lasted for 172, 282 and 668 days. The mean/maximal daily doses of the IT bupivacaine were 39/66, 55/80 and 69/125 mg, respectively. The pain intensity decreased from VASmean =7+/-1 to VASmean =2+/-2. None of the patients had regression of allodynia, edema, and trophic disturbances in the affected extremities. In 2 patients, the IT treatment did not prevent spread of the disease to the opposite extremity or the occurrence of phantom pain and stump allodynia after amputation. The IT catheters were withdrawn as being no longer needed: in 2 patients 56 and 458 days after amputation of the involved extremity, and in another one before replacement of the IT bupivacaine infusion with epidural dorsal column stimulation (EDCS). After termination of the IT treatment, the patients were observed for 1437, 1575, and 2689 days (until September 1, 1998). At that date, all the patients were alive, and still affected by their CRPS-I, either in the amputation stump (n=2), and/or in the opposite or remote extremities (n=2); further, two were unemployed and one worked for 75% of the time. One of them was taking up to 1500 mg of slow-release morphine to cope with pain. The IT pain treatment with bupivacaine (with or without buprenorphine) alleviated the ""refractory"" pain, but affected neither the associated symptoms and signs of the CRPS-I, nor its natural evolution. Thus, the IT treatment cannot be recommended in preference to other pain treatment regimens for CRPS-I.",1999.0,0,0
100,10411767,A comparison of two concentrations of bupivacaine and adrenaline with and without fentanyl in paediatric inguinal herniorrhaphy.,W Joshi; N R Connelly; M Dwyer; D Schwartz; P R Kilaru; S S Reuben,"This study was designed to determine whether administration of caudal bupivacaine with fentanyl would have any effect on analgesia in paediatric patients undergoing inguinal herniorrhaphy repair. Fifty-six outpatient paediatric patients undergoing inguinal hernia repair were evaluated. Patients received, in a randomized manner, 1 ml.kg-1 of either bupivacaine 0.25% or 0.125% with or without fentanyl 1 microg.kg-1. There was no difference in pain scores in the hospital, the night of surgery, or 24 h postoperatively nor was there a difference in the oral analgesics administered between any of the groups. There was a higher incidence of vomiting at home in both 0.25% bupivacaine groups irrespective of the use of fentanyl. The 0.125% bupivacaine group had significantly more patients who received intravenous fentanyl in the PACU than did the other three groups (P<0.001). Increasing the concentration of bupivacaine from 0. 125% to 0.25% increased the incidence of postoperative vomiting. We recommend that clinicians utilize bupivacaine 0.125% with 1 microg. kg-1 fentanyl as the caudal injectate in paediatric patients undergoing inguinal hernia repair.",1999.0,0,0
101,10414471,Treatment of chronic pain with antiepileptic drugs: a new era.,H C Hansen,"Shortcomings of traditional pain relief agents have led physicians to investigate other alternatives, such as antiepileptic drugs. Safe, effective, nonhabituating agents are currently available to enhance pain treatment strategies. In this article, various pharmacologic options and their mechanisms of action are reviewed briefly, with a focus on treatment of chronic pain with antiepileptic drugs (AEDs). Antiepileptic drugs have been widely studied and prescribed for the relief of acute and chronic pain. Similarities in the neurophysiology of pain and epilepsy suggest that AEDs may be a suitable adjunct in the management of chronic pain. Of the newer AEDs, gabapentin shows the greatest potential and appears to be well tolerated by patients. Treatment of chronic pain remains a challenge for physicians and patients. Further research is required to identify the role of various agents and their effect on patient return to function and quality of life.",1999.0,0,0
102,10417452,Randomised double-blind comparison of morphine vs. a morphine-alfentanil combination for patient-controlled analgesia.,W D Ngan Kee; K S Khaw; E L Wong,"In a randomised, double-blind study, we compared a combination of morphine and alfentanil with morphine alone for patient-controlled analgesia (PCA) after Caesarean section under spinal anaesthesia. After surgery, patients were randomly allocated to receive PCA with a bolus dose of either morphine 0.75 mg plus alfentanil 0.125 mg (Group MA, n = 40) or morphine 1.5 mg alone (Group M, n = 37) with a lockout interval of 8 min and no hourly dose limit. Clinical assessments were made in the first 24 h, after which patients completed a written questionnaire. There were no differences between groups in PCA usage or visual analogue scale pain scores measured at 2, 4, 6 and 24 h. There was a low incidence of side-effects in both groups. In the questionnaire, patients in Group MA scored higher compared with Group M when asked to grade speed of onset and effectiveness of analgesia after a PCA bolus; there were no differences in grading for duration of analgesia or overall patient satisfaction. Addition of alfentanil to morphine may have advantages for PCA.",1999.0,0,0
103,10417454,Thoracic epidural infusions for post-thoracotomy pain: a comparison of fentanyl-bupivacaine mixtures vs. fentanyl alone.,S V Mahon; P D Berry; M Jackson; G N Russell; S H Pennefather,"A randomised double-blind clinical trial was conducted on 106 patients scheduled for pulmonary resection. Patients received an epidural infusion containing 0.1%, 0.2% bupivacaine or saline in combination with fentanyl 10 microgram.ml -1. Adequacy of analgesia was assessed at rest and during movement over 24 h. Analgesic efficacy was assessed using visual analogue scores and an observer/verbal ranking scale. Pain scores were higher in the fentanyl-only group at the 2 h assessment (p < 0.05). Otherwise, there were no between-group differences in pain scores or in the total amounts of epidural solution used. All patients received continuous haemodynamic monitoring. There were no between-group differences in the number of episodes of hypotension or in the number of interventions for hypotension. However, the use of intra-operative vasopressor and the incidence of temporary neurological complications was higher in the 0.2% bupivacaine group (p < 0.05). We conclude that, in the early postoperative period, the addition of bupivacaine 0.1% improves fentanyl epidural analgesia in patients undergoing lung resection and is not associated with the disadvantages seen with the addition of bupivacaine 0.2%.",1999.0,0,0
104,10417506,Serum concentrations of tramadol enantiomers during patient-controlled analgesia.,S Grond; T Meuser; H Uragg; H J Stahlberg; K A Lehmann,"Tramadol, a centrally acting analgesic, is used as a racemate containing 50% of a (+)- and 50% of a (-)-enantiomer. This paper presents the pharmacokinetic results of postoperative patient-controlled analgesia using (+)-tramadol, (-)-tramadol or the racemate. Ninety-eight patients recovering from major gynaecological surgery were treated in a randomised, double-blind study with (+)-tramadol, (-)-tramadol or the racemate. Following an i.v. bolus up to a maximum of 200 mg, patient-controlled analgesia with demand doses of 20 mg was made available for 24 h. Prior to each demand, the serum concentrations of the enantiomers of tramadol and its metabolite M1 were measured in 92 patients. The mean concentrations of tramadol during the postsurgery phase were 470+/-323 ng ml-1, 590+/-410 ng ml-1 and 771+/-451 ng ml-1 in the (+)-, racemate- and (-)-group, respectively ((+) vs (-), P<0.05); the mean concentrations of the metabolite M1 were 57+/-18 ng ml-1, 84+/-34 ng ml-1 and 96+/-41 ng ml-1 in the (+)-, racemate- and (-)-group, respectively ((+) vs (-) and (+) vs racemate, P<0.05). The mean concentrations of (+)-tramadol and (+)-M1 were lower in the racemate- than in the (+)-group (P<0.05), those of (-)-tramadol and (-)-M1 were lower in the racemate than in the (-)-group (P<0.05). In the racemate group, the mean serum concentrations of (+)-tramadol were higher than those of (-)-tramadol (P<0.05), whereas the mean serum concentrations of (-)-M1 were higher than those of (+)-M1 (P<0. 05). The therapeutic serum concentration of tramadol and M1 showed a great variability. The lowest mean concentrations were measured in the (+)-group and the highest in (-)-group. This is in agreement with the clinical finding that (+)-tramadol is a more potent analgesic than (-)-tramadol.",1999.0,0,0
105,10417863,Long-term intraspinal infusions of opioids with a new implantable medication pump.,R Likar; M C Spendel; W Amberger; B Kepplinger; S Supanz; A Sadjak,"Experiences with long-term intraspinal infusion of opioid drugs using the new implantable medication pump VIP 30 in patients with chronic non-malignant pain are reported. During a 19-month period 10 patients with chronic pain--mainly mixed nociceptive-neuropathic pain--underwent implantation of the medication pump for long-term treatment. The mean follow-up period was 9.5 months. Pain relief was classified as very good in 22.2%, good in 44.4%, moderate in 22.2% and poor in 11.1%. In 88.9% of the cases the patients stated they would undergo the same procedure again. Technical problems (catheter dislocation) developed in 1/10 patients could be surgically corrected. One pump including catheter was explanted because of an infected seroma within the pocket area. Long-term intrathecal application of opioids with the VIP 30 pumps is an effective and safe treatment in patients with chronic non-malignant pain.",1999.0,0,0
106,10418644,"The analgesic effect of preoperative administration of propacetamol, tenoxicam or a mixture of both in arthroscopic, outpatient knee surgery.",P Van Lancker; B Vandekerckhove; F Cooman,"A prospective, randomized, double-blind, placebo-controlled, comparative study was undertaken to assess the efficacy of the preemptive use of propacetamol, tenoxicam or the combination of both in arthroscopic, outpatient surgery of the knee. One hundred patients aged 18 to 65 years, ASA 1-2, scheduled for arthroscopy were randomized to receive propacetamol 30 mg/kg i.v. (repeated after 6 hours), tenoxicam 0.5 mg/kg i.v. (max. 40 mg), the combination of both or placebo one hour prior to a standard anesthetic. There were no differences with regard to total dose opioid consumption, sedation scores and side effects in the four groups.",1999.0,0,0
107,10422664,What are the qualities of dilemmas experienced when prescribing opioids in general practice?,P Bendtsen; G Hensing; C Ebeling; A Schedin,"The decision process preceding prescribing analgesics is complex and the physician is often struggling to balance several disparate considerations in order to work out what is rational. Several factors--medical, intellectual, emotional and logistic--influence the decision whether or not to prescribe, and the decision itself influences how the physicians feel about themselves. In this study the 'critical incident technique' was used for exploring the qualities of dilemmas among general physicians prior to prescribing analgesics to patients in primary health care. The study displayed two main types of problems in connection with prescription of opioids. The first main problem was a concern about abuse and addiction with no proper indication for the drug. The second main type of problem was related to the appropriateness of the drug, although the indication as such might be correct, i.e. acute or chronic pain. An important consequence of the dilemmas experienced influenced the physicians' self-esteem negatively, including failures in the patient-physician relationship. This results in emotional strain and is often experienced as a personal defeat. Only a few physicians denied prescription despite the experience of a dilemma, which might indicate an ambivalence or lack of knowledge among physicians with regard to proper indications for opioid prescription. However, it may also suggest that physicians need more training in saying no, or skills in deciding proper indications for opioids, which needs to be addressed during educational programmes.",1999.0,0,0
108,10422923,Effects of perioperative analgesic technique on the surgical outcome and duration of rehabilitation after major knee surgery.,X Capdevila; Y Barthelet; P Biboulet; Y Ryckwaert; J Rubenovitch; F d'Athis,"Continuous passive motion after major knee surgery optimizes the functional prognosis but causes severe pain. The authors tested the hypothesis that postoperative analgesic techniques influence surgical outcome and the duration of convalescence. Before standardized general anesthesia, 56 adult scheduled for major knee surgery were randomly assigned to one of three groups, each to receive a different postoperative analgesic technique for 72 h: continuous epidural infusion, continuous femoral block, or intravenous patient-controlled morphine (dose, 1 mg; lockout interval, 7 min; maximum dose, 30 mg/4 h). The first two techniques were performed using a solution of 1% lidocaine, 0.03 mg/ml morphine, and 2 microg/ml clonidine administered at 0.1 ml x kg(-1) x h(-1). Pain was assessed at rest and during continuous passive motion using a visual analog scale. The early postoperative maximal amplitude of knee flexion was measured during continuous passive motion at 24 h and 48 h and compared with the target levels prescribed by the surgeon. To evaluate functional outcome, the maximal amplitudes were measured again on postoperative day 5, at hospital discharge (day 7), and at 1- and 3-month follow-up examinations. When the patients left the surgical ward, they were admitted to a rehabilitation center, where their length of stay depended on prospectively determined discharge criteria The continuous epidural infusion and continuous femoral block groups showed significantly lower visual analog scale scores at rest and during continuous passive motion compared with the patient-controlled morphine group. The early postoperative knee mobilization levels in both continuous epidural infusion and continuous femoral block groups were significantly closer to the target levels prescribed by the surgeon than in the patient-controlled morphine group. On postoperative day 7, these values were 90 degrees (60-100 degrees)(median and 25th-75th percentiles) in the continuous epidural infusion group, 90 degrees (60-100 degrees) in the continuous femoral block group, and 80 degrees (60-100 degrees) in the patient-controlled morphine group (P < 0.05). The durations of stay in the rehabilitation center were significantly shorter: 37 days (range, 30-45 days) in the continuous epidural infusion group, 40 days (range, 31-60 days) in the continuous femoral block group, and 50 days (range, 30-80 days) in the patient-controlled morphine group (P < 0.05). Side effects were encountered more frequently in the continuous epidural infusion group. Regional analgesic techniques improve early rehabilitation after major knee surgery by effectively controlling pain during continuous passive motion, thereby hastening convalescence.",1999.0,0,0
109,10422926,The relationship between the visual analog pain intensity and pain relief scale changes during analgesic drug studies in chronic pain patients.,M S Angst; W G Brose; J B Dyck,"Most analgesic drug studies in humans quantify drug action based on verbal reports of pain intensity and pain relief. Although measures of pain intensity and pain relief show a good overall correlation, it is not known if they relate to each other consistently over time Such consistency is necessary if both measures are used to depict analgesic drug action versus time. This study examined in chronic pain patients if the relationship between visual analog pain intensity and pain relief scores was consistent during two analgesic drug studies. Data from two independently performed analgesic drug studies were analyzed using linear regression. Data were split into pain intensity and pain relief scores recorded before and after patients' experience of maximum analgesia (>90% of maximum pain relief). The slopes of the linear regression line depicting pain intensity versus pain relief scores before and after maximum analgesia were statistically compared. The slope of the linear regression line before and after maximum analgesia was significantly different in both drug studies (nonoverlapping 95% confidence intervals), -2.16+/-0.57 versus -1.05+/-0.10 and -1.47+/-0.26 versus -1.09+/-0.07, respectively. These results are compatible with the observation that patients indicating the same pain intensity before and after maximum analgesia reported a different magnitude of pain relief. The relationship between visual analog pain intensity and pain relief scores changed systematically during both analgesic drug studies. The authors hypothesize that patients' interpretation of the pain relief scale had changed during the studies and therefore suggest using the pain intensity scale to quantify analgesic drug action over time.",1999.0,0,0
110,10422932,Bupivacaine augments intrathecal fentanyl for labor analgesia.,C M Palmer; G Van Maren; W M Nogami; D Alves,"fentanyl has been shown to be an effective analgesic for labor; this study investigated the analgesic effect of low-dose bpivacaine added to intrathecal fentanyl for labor analgesia Ninety parturients in active labor who requested regional analgesia were randomized to receive an intrathecal injection of either fentanyl, 25 microg; bupivacaine, 1.25 mg, with fentanyl, 25 microg; or bupivacaine, 2.5 mg, with fentanyl, 25 microg, as part of a combined spinal-epidural technique. Visual analog pain scores were recorded before and at intervals after injection until the patient requested further analgesia. Maternal blood pressure and fetal heart rate were recorded before and at intervals after injection. Lower-extremity muscle strength was tested before and 30 min after injection; anesthetic level to cold sensation and the presence and severity of pruritus were recorded. Duration of analgesia was longer in the group receiving bupivacaine, 2.5 mg, and fentanyl, 25 microg, than the group receiving plain fentanyl (108 vs. 92 min; P < 0.05). Onset of analgesia was faster in both groups receiving bupivacaine compared with plain fentanyl (P < 0.05). No differences in muscle strength after injection were found in any group, although anesthetic levels to cold were documented in all patients in the bupivacaine groups, and 21 of 30 in the plain fentanyl group. Baseline fetal heart rates did not change after injection in any group, and maternal blood pressure was unchanged. The addition of 2.5 mg isobaric bupivacaine to 25 microg fentanyl for intrathecal labor analgesia modestly increases duration and speeds onset of analgesia compared with plain intrathecal fentanyl.",1999.0,0,0
111,10423055,Twice-daily versus once-daily morphine sulphate controlled-release suppositories for the treatment of cancer pain. A randomized controlled trial.,E Bruera; M Belzile; C M Neumann; I Ford; Z Harsanyi; A Darke,"We evaluated the safety and efficacy of controlled-release morphine sulphate suppositories administered 12-hourly and once daily in patients with chronic cancer in a randomized double-blind crossover trial. Pain was assessed using a 100-mm VAS pain scale and a five-point ordinal pain scale. The VAS pain intensity score was 17.5+/-17.2 after suppositories every 12 h, versus 16.2+/-13.4 after suppositories every 24 h (difference not significant). The difference between the mean VAS pain scores with 12-hourly and once-daily dosing was 1.3 mm (not significant). The mean ordinal pain scores were 1.0+/-0.7 versus 1.0+/-0.6 for 12-hourly and once-a-day dosing, respectively (not significant). A retrospective power analysis indicated that a difference of 5.9 mm was detectable, even with only 6 patients. Adverse events noted were constipation, nausea, anorexia, and dry mouth. The use of once-a-day controlled-release morphine suppository is a more convenient and equally effective alternative to twice a day dosing.",1999.0,0,0
112,10425951,A comparison of ketorolac tromethamine and acetaminophen codeine in the management of acute apical periodontitis.,A Sadeghein; N Shahidi; A R Dehpour,"Effective management of severe endodontic pain is often a major problem. The analgesic effect of ketorolac tromethamine (Toradol, 10 mg p.o.) was compared with acetaminophen codeine (325 mg/15 mg p.o.) in patients with severe pain due to acute apical periodontitis in a double-blind clinical study. A total of 66 patients presenting with severe pain (defined as 7 cm and more using a visual analog scale) were randomly assigned to receive either ketorolac tromethamine or acetaminophen codeine (33 patients in each group), and recorded their pain score once every 10 min for 90 min after administration. Results indicate that patients in the ketorolac group had significantly less pain than those who received acetaminophen codeine (p = 0.005).",1999.0,0,0
113,10427455,[Pain therapy after thoracoscopic interventions. Do regional analgesia techniques (intercostal block or interpleural analgesia) have advantages over intravenous patient-controlled opioid analgesia (PCA)?].,R Leger; A Ohlmer; U Scheiderer; P Dohrmann; A Böhle; H Wulf,"Systemic opioids and thoracic epidural analgesia are common techniques used to provide post-operative analgesia following thoracoscopy (video-assisted thoracic surgery). The aim of the present prospective randomised study was to evaluate the efficacy of two less invasive analgesic techniques, intercostal blocks (ICB) and interpleural analgesia (IPA). After approval from the ethics committee and informed consent from the patients, 36 patients scheduled for thoracoscopic surgery were randomly assigned to a group for postoperative pain management: group ICB: intercostal blocks of the segments involved with 5 ml 0.5% bupivacaine at the end of surgery and 6 h later; group IPA: interpleural analgesia with 20 ml 0.25% bupivacaine applied every 4 h using a catheter placed during surgery near the apex of the interpleural space; control group: IV-opiod-PCA with piritamide. Patients in the ICB and IPA groups had access to pain relief by PCA with piritramide as well. Additional medication for all groups if the analgesia was insufficient consisted of metamizol. There were no significant differences in piritramide consumption between the two regional analgesia groups and the control group up to the 3rd and 7th postoperative day. Up to the 7th day piritramide consumption in group ICB was 78 mg, in group IPA 75 mg and 80 mg in the control group. Patients in group ICB showed significantly less pain at rest measured by the visual analogue scale (VAS) on the 1st postoperative day (U-test, P < 0.05), but otherwise there were no statistical differences regarding pain scores. Respiratory parameters such as forced vital capacity, forced expiratory volume, peak flow and the Tiffeneau test (FVC, FEV1, PF, FEV1/FVC) were reduced significantly after thoracoscopy and showed a slow recovery in all three groups without significant intergroup differences. Thoracoscopic surgery causes less and shorter lasting pain in comparison to thoracotomy. Nevertheless, effective pain management is necessary. We could not demonstrate a significant reduction in piritramide consumption for the techniques of regional analgesia tested here (ICB, IPA). We conclude that the use of these techniques is not complementary after thoracoscopy, since an opioid (PCA with piritramide) combined with a non-opioid (metamizol) resulted in satisfactory analgesia.",1999.0,0,0
114,10427881,[Intramuscular ketorolac compared to subcutaneous tramadol in the initial emergency treatment of renal colic].,J A Nicolás Torralba; M Rigabert Montiel; V Bañón Pérez; P Valdelvira Nadal; M Pérez Albacete,"To compare the efficacy and safety of two analgesics (tramadol and ketorolac) for initial emergency treatment of renal colic. A prospective study on 48 patients randomly assigned to treatment with ketorolac 30 mg i.m. and tramadol 1 mg/kg s.c. Pain intensity was evaluated by a simple analogic scale ranging from 0-4 (0 = no pain, 1 = mild, 2 = moderate, 3 = severe and 4 = very severe pain). Statistical analyses were performed with Student's test and the chi square test for numerical and qualitative data, respectively. No significant differences were found for the overall efficacy (> 80%) or side effects in both groups. However, a difference was found between both groups for pain score 15 minutes post-injection, which showed i.m. ketorolac to be more effective. Both ketorolac (30 mg i.m.) and tramadol (1 mg/kg s.c.) are effective in the initial treatment of renal colic. Both drugs have an efficacy greater than 80% when used separately and almost 100% when used in combination. The analgesic effect of ketorolac is observed earlier than that of tramadol.",1999.0,0,0
115,10429417,[Chronic pain during dialysis. Pharmacologic therapy and its costs].,F Fortina; S Agllata; E Ragazzoni; A Sacco; V Cardillo; S Travaglini; P Brini; A Cavagnino,"There is very little research into the problem of chronic pain in dialysed patients, despite the fact that pain is a widely diffused phenomena amongst these patients. This work proposes to evaluate the intensity of pain, supply a scale of levels of intervention, with an indication of the consumption and relative costs of pharmacological therapies. 37 out of 100 patients undergoing haemodialysis suffer chronic pain. Aetiological research has shown that osteoarticular pain (24 cases), is the most common, peripheral vascular pain (3 cases), is subjectively and indirectly considered to be the most serious form. Nine cases have presented pain of a neuromuscular origin, whilst one case of a neoplastic origin. The degree of personal invalidism shows serious invalidism in 11 cases. The therapeutic file that forsaw four levels of pharmacological intervention (1st levels: FANS, 2nd level: Codeine+paracetamol, 3rd level: Buprenorphine, 4th level: Morphine for os), accompanied by instrumental and pharmacological support intervention, has proved to be indispensable in confronting the problem. Through pharmacy data, we have noticed a progressive increase over the year in the use of analgesic medicines, of which we can confirm the effectiveness, tolerability, low level of side-effects, at low costs. In our opinion chronic pain in dialysed patients should not be neglected. The perfection of diagnostic techniques, the discovery of pain-killers with reduced side-effects, the multidisciplinary approach, and reduced costs of treatment, are all valid arguments in favour of an intervention that improves the quality of life of these patients, already so compromised by the nature of the illness itself.",1999.0,0,0
116,10431306,[Posttraumatic pain. Causes and therapeutic possibilities].,R Dertwinkel; M Zenz; B Donner; A Wiebalck; M Strumpf,"Each patient has the right of a dedicated pain therapy according to the state of the art. However an efficient pain therapy is not possible without knowing the cause of pain. In most posttraumatic pain situations peripheral nociceptors are activated and normal afferences are conducted via an intact nociceptive system. In contrast, neuropathic pain pain is caused by lesions of the nervous system itself. Mechanisms of central sensibilization and involvement of the sympathetic nervous system may lead to chronification of such pain conditions. The therapeutic regime of nociceptive and neuropathic pain is demonstrated by algorithms of treatment modalities. Apart from classic non-opioid analgesics, co-analgesics and opioids have an important status in chronic pain management as well. Prescription of these substances has to follow strictly defined standards of pain therapy. Blockades with local anaesthetics as mono-therapy of chronic pain are obsolete. In posttraumatic pain, however, a certain number of adjuvant blockades or infiltrations of triggerpoints may be helpful. The exceptional place of sympathetic blockades are in diagnosis and therapy of sympathetic maintained pain (SMP).",1999.0,0,0
117,10434236,,,,,0,0
118,10434817,Patient-controlled analgesia: epidural fentanyl and i.v. morphine compared after caesarean section.,D W Cooper; U Saleh; M Taylor; S Whyte; D Ryall; M S Kokri; W R Desira; H Day; E McArthur,"We have compared patient-controlled epidural fentanyl (PCEF) and patient-controlled i.v. morphine (PCIM) after Caesarean section in 84 patients, in a randomized, double-blind study. All patients had an epidural and an i.v. patient-controlled analgesia (PCA) device, one of which delivered normal saline. Group PCEF received epidural fentanyl 20 micrograms with a 10-min lockout. Group PCIM received i.v. morphine 1 mg with a 5-min lockout. PCA use was lower for PCEF patients (P = 0.0007). The highest pain score recorded at rest for PCEF patients was median 20 (interquartile range 10-33) mm compared with 32 (14-52) mm for PCIM patients (P = 0.02). The highest pain score recorded on coughing was 31 (21-41) mm with PCEF compared with 56 (30-71) mm for PCIM (P = 0.001). There was less nausea (P = 0.02) and drowsiness (P = 0.0003) with PCEF. There was no difference in the overall incidence and severity of pruritus (P = 0.77). However, pruritus started earlier with PCEF.",1999.0,0,0
119,10434819,Patients' vs nurses' assessments of postoperative pain and anxiety during patient- or nurse-controlled analgesia.,I Rundshagen; K Schnabel; T Standl; J Schulte am Esch,"We have compared patients' and nurses' assessments of postoperative pain and anxiety after different analgesic treatments. Sixty orthopaedic patients were allocated randomly to receive i.v. piritramide (either nurse-controlled or patient-controlled) or subarachnoid bupivacaine (nurse-controlled or patient-controlled). Patients and nurses assessed pain and anxiety using a visual analogue scale (VAS; 1-100 mm). Pain and anxiety ratings of patients and nurses were significantly correlated (Spearman's r > or = 0.69; P < 0.001). In general, patients' pain scores were higher than nurses' scores (patients' median VAS = 34 (range 1-76) mm; nurses VAS 21 (1-59) mm) and for all groups except the patient-controlled subarachnoid bupivacaine group, where they were significantly higher (P < 0.01). Discrepancy in pain estimates between patients and nurses increased with the level of pain. The relationship between patients' and nurses' anxiety scores was less clearly defined and did not depend on the level of anxiety.",1999.0,0,0
120,10436837,Pain management of pancreatic cancer.,A Andrén-Sandberg; A Viste; A Horn; D Hoem; H Gislason,"Quality of life is receiving increasing attention as a criterion for the assessment of treatment, not least for surgery, in pancreatic cancer. In exocrine pancreatic cancer there are three main symptoms that must be dealt with: pain, loss of weight and jaundice. All of them seriously impair quality of life, but most often pain is the most feared by the patients. Despite this, the intensity and the quality of the pain is all too often only scantly described. In 85 consecutive patients with newly diagnosed pancreatic cancer we have prospectively registered the quality and quantity of their pain and correlated it to tumor and patient characteristics. It was found that about one fourth of the patients were totally pain free and half of all suffered a pain described by two or less on a Visual Analogue Scale. Only one in ten had severe pain. Although more and more patients were treated with morphine, it was still about one third of all patients that had no or only little pain in the last part of their life. Pain had a strong correlation to survival. This may be due to secondary effects like depressing the mood of the patient and reducing the food intake, but is probably more often a reflection of that generalized cancer induces more pain. Analgesic drugs are the cornerstone of the pharmacologic management of pain due to pancreatic cancer. A significant part of the patients do well with only paracetamol and nonsteroidal antiinflammatory agents. Combining these agents with narcotic analgesics can enhance pain control while lessening the dose of narcotics. A wide range of narcotics are available as well as different modes for delivery: regular pills, slow release forms, injections, subcutaneous injections, epidural etc. Each patient's pain management should be individualized, based on the intensity of pain, the type of pain and the side effects. It is essential not only to describe the medication, but also to follow-up the development of the pain and the patient's total experience of the situation. As an alternative to narcotics, plexus celiac blocks have been used with somewhat different result; in the hands of the experts the percutaneous approach is usually sufficient, but in the hands of other also poor results are reported. During the last years thoracoscopic splanchnicectomy has been tried as a complement giving long-standing pain relief with little or no side effects in the majority of patients. With this approach the sympathetic fibers lead by the symphathetic chain and further by the nervus splanchnicus major, minor and minors are divided. The denervation is easily done and can be performed bilateraly in one seance. This method will probably be used more often as the technique is now well described.",1999.0,0,0
121,10440466,Characteristics of dependent and nondependent regular users of codeine.,B A Sproule; U E Busto; G Somer; M K Romach; E M Sellers,"Although codeine is a widely used medication, the problems of codeine abuse and dependence have not been well-studied. This study characterized regular codeine users (using at least 3 days per week for 6 months, excluding those using codeine for the treatment of cancer pain) through a self-completed questionnaire. Recruitment through newspaper advertisements resulted in a total of 339 eligible questionnaires. Thirty-seven percent of subjects met DSM-IV criteria for codeine dependence. Dependent subjects (mean age, 40 +/- 10 years) were using an average of 179 (+/-171) mg of codeine per day. Codeine was predominantly used in the form of combination products with acetaminophen. Dependent subjects identified specific problems causally related to their codeine use such as depression (23%), anxiety (21%), and gastrointestinal disturbances (13%). The dependent subjects reported problems with other drugs more than did nondependent users (alcohol, 57% vs. 26%; cannabis, 23% vs. 5%; sedative/hypnotics, 33% vs. 12%; and heroin, 11% vs. 2%, respectively). Most were taking codeine primarily for a chronic pain problem (81%), although the dependent subjects currently found codeine less effective for treating pain than did the nondependent subjects and were more likely to use codeine for pleasurable effects, to relax, or to prevent withdrawal symptoms. This study showed that dependence is associated with the regular use of codeine. Pain is a key issue with these users; however, they are probably not receiving optimal treatment. There is a need to identify individuals experiencing problems with their codeine use and to develop optimal prevention and treatment strategies.",1999.0,0,0
122,10443608,Morphine-sparing effect of acetaminophen in pediatric day-case surgery.,R Korpela; P Korvenoja; O A Meretoja,"Postoperative pain is a major problem in day-case surgery in children. Nonsteroidal antiinflammatory drugs have gained popularity in management of pediatric surgical patients to reduce the need for opioids. The aim of this study was to evaluate the efficacy of different doses of rectal acetaminophen in day-case surgery in children. A randomized, double-blinded, placebo-controlled study design was used. Patients (n = 120) were randomized to receive a single dose of 0, 20, 40, or 60 mg/kg of rectal acetaminophen after induction of anesthesia. General anesthesia was induced by mask ventilation with sevoflurane (7%) in nitrous oxide and oxygen and maintained with 2.5-4.0% end-tidal sevoflurane. Opioids or local anesthetics were not used. Postoperative pain was evaluated by behavioral assessment and physiologic measurements every 10 min after arrival at the postanesthesia care unit. The pain intensity was scored using a 0-100 visual analog scale used in the authors' clinic. The need for rescue medication, intravenous morphine 0.1 mg/kg, was decided by the nurse, who was unaware of the rectal acetaminophen dose. The parents were interviewed by phone after 24 h regarding pain and its treatment, nausea, and vomiting. Rescue analgesia at home was rectal ibuprofen, 10 mg/kg. In the postanesthesia care unit pain scores were significantly lower in the 40- and 60-mg/kg groups compared with placebo and 20-mg/kg groups. Acetaminophen resulted in a dose-related reduction in the number of children who required postoperative rescue opioid, with significance reached with 40 or 60 mg/kg doses. Calculated dose of acetaminophen at which 50% of the children not requiring a rescue opioid was 35 mg/kg. The need for rescue analgesia at home during the first 24 h after surgery was also significantly less in patients in the 40- or 60-mg/kg groups than in the 0- or 20-mg/kg groups (20-17 vs. 80-63%). Thirty-three percent of patients receiving placebo had postoperative nausea and vomiting, compared with 0-3% in groups receiving 40 or 60 mg/kg acetaminophen. A single dose of 40 or 60 mg/kg of rectal acetaminophen has a clear morphine-sparing effect in day-case surgery in children if administered at the induction of anesthesia. Moreover, children with adequate analgesia with acetaminophen have less postoperative nausea and vomiting.",1999.0,0,0
123,10447905,"Comparison of epidural morphine, hydromorphone and fentanyl for postoperative pain control in children undergoing orthopaedic surgery.",M Goodarzi,"The safety and side-effects profile of epidural administration of a hydrophilic (morphine), highly lipophilic (fentanyl) and a drug with intermediate hydrophilic and lipophilic activity (hydromorphone) were compared in 90 children undergoing orthopaedic procedures. Ninety patients were randomly assigned (30 in each group) to receive epidural morphine, hydromorphone, or fentanyl for postoperative analgesia. Respiratory effects, nausea, somnolence, urinary retention, pruritus and visual pain scales were evaluated and compared during a 30-h period following surgery. In the morphine group, 25% showed respiratory depression with oxygen saturation below 90% but there was no incidence of respiratory depression in the fentanyl or hydromorphone groups. Somnolence was prominent in some of the patients in all the groups, but was more prolonged in the morphine group. Statistically, there was no significant difference in nausea between the groups, but pruritus was more severe and frequent in the morphine group. The incidence of urinary retention in the morphine group was higher compared with the fentanyl and hydromorphone groups. In conclusion, epidural hydromorphone, demonstrating less side-effects, is preferable to morphine and fentanyl for epidural analgesia in children.",1999.0,0,0
124,10451130,Rectal indomethacin reduces postoperative pain and morphine use after cardiac surgery.,T Rapanos; P Murphy; J P Szalai; L Burlacoff; J Lam-McCulloch; J Kay,"To evaluate the combination of rectal indomethacin with patient controlled intravenous morphine analgesia (PCA) on postoperative pain relief and opioid use after cardiac surgery. With institutional ethics approval, 57 consenting adults undergoing elective aortocoronary bypass surgery were randomly assigned preoperatively in a double-blind fashion to receive either placebo (n = 26) or indomethacin 100 mg suppositories (n = 31), 2-3 hr postoperatively, and 12 hr later. Both groups utilized PCA morphine. Pain scores in the two treatment groups were assessed on a 10-cm visual analogue scale (VAS) (at rest and with cough) at 4, 6, 12, 18 and 24 hr after initial dosing, and were analyzed through a 2 x 5 repeated measures of variance. The 24 hr analgesic consumption, 12 and 24 hr chest tube blood loss, and time to tracheal extubation were also recorded, and compared for the two treatment arms through Student's t test on independent samples. Postoperative morphine consumption in the first 24 hr was 38% less in the indomethacin group (22.40 +/- 12.55 mg) than the placebo group (35.99 +/- 25.84 mg), P = 0.019. Pain scores, measured with a VAS, were 26% to 66% lower in the indomethacin vs placebo group at rest (P = 0.006), but not with cough, for all times assessed. There was no difference in blood loss (at 12 hr) or time to tracheal extubation for both groups. The combination of indomethacin with morphine after cardiac surgery results in reduced postoperative pain scores and opioid use without an increase in side effects.",1999.0,0,0
125,10451131,Epidural tramadol for postoperative pain after Cesarean section.,S Siddik-Sayyid; M Aouad-Maroun; D Sleiman; M Sfeir; A Baraka,"To compare the post-operative analgesic effect of 100 mg vs 200 mg epidural tramadol and saline in patients undergoing elective Cesarean section. Sixty healthy women undergoing Cesarean delivery with epidural anesthesia were randomly allocated into three groups (n = 20 in each). Patients received, at skin closure via the epidural catheter, 100 mg tramadol (Group I), 200 mg tramadol (Group II) or 10 ml saline (Control group). Pain scores and side effects were evaluated at 1, 2, 4, 8, 12 and 24 hr after surgery. Mean times to the first analgesic administration, as well as the cumulative doses of analgesic requirements over 24 hr postoperatively were compared. The mean time to first analgesic administration was longer in patients who received 100 mg tramadol (4.5 +/- 3.1 hr) and the 200 mg tramadol (6.6 +/- 3.4 hr) than in those who received placebo (2.8 +/- 2 hr). The mean cumulative doses of meperidine over 24 hr were less in the 100 mg tramadol group (0.3 +/- 0.3 mg x kg(-1)) and the 200 mg tramadol group (0.3 +/- 0.3 mg x kg(-1)) than in the control group (0.7 +/- 0.4 mg x kg(-1)). Also, the mean doses of diclofenac over 24 hr were less in the 100 mg tramadol group (156 +/- 59 mg) and the 200 mg tramadol group (142 +/- 62 mg) than in the control group (214 +/- 70 mg). However, no difference was obtained between patients receiving 100 mg and 200 mg tramadol concerning all parameters studied. Epidural tramadol 100 mg can provide adequate postoperative analgesia without respiratory depression in patients after Cesarean delivery.",1999.0,0,0
126,10451133,Addition of femoral 3-in-1 blockade to intra-articular ropivacaine 0.2% does not reduce analgesic requirements following arthroscopic knee surgery.,S K Schwarz; L G Franciosi; C R Ries; W D Regan; R G Davidson; K Nevin; S Escobedo; B A MacLeod,"To test the hypothesis that the addition of a preincisional femoral 3-in-1 block to intra-articular instillation with ropivacaine 0.2% at the end of surgery improves postoperative pain control in patients undergoing arthroscopic anterior cruciate ligament reconstruction (ACLR) under general anesthesia. In a prospective, randomized, placebo-controlled, double-blind trial, we studied 44 patients scheduled for inpatient ACLR. Prior to incision, the treatment group (n = 22) received a femoral 3-in-1 block with 40 ml ropivacaine 0.2%, augmented by infiltrations of the lateral and anteromedial incisions with 20 ml ropivacaine 0.2% at the end of the procedure. The control group (n = 22) received saline 0.9% instead of ropivacaine. All patients received an intra-articular instillation with 30 ml ropivacaine 0.2% at the end of surgery. The primary efficacy variable was 24 hr morphine consumption postoperatively standardized by weight, administered intravenously via a patient-controlled analgesia (PCA) pump. There was no difference between both groups in 24 hr PCA morphine consumption postoperatively (control, 0.45 +/- 0.44 [mean +/- SD] mg x kg(-1); treatment, 0.37 +/- 0.50 mg x kg(-1); p = 0.55). No difference was found in postoperative visual analog scale pain scores, adverse events, or vital signs. In the treatment group, R = 10/22 patients did not require postoperative morphine compared with R = 6/22 in the control group (P = 0.35). We found no effect of a femoral 3-in-1 block with ropivacaine 0.2% on postoperative analgesic consumption, compared to intra-articular instillation with ropivacaine 0.2% alone, in patients undergoing ACLR under general anesthesia.",1999.0,0,0
127,10455841,The analgesic efficacy of tramadol versus ketorolac in day-case laparoscopic sterilisation.,A J Putland; A McCluskey,"We conducted a prospective, randomised, double-blind study to compare the analgesic efficacy of intravenous tramadol 1.5 mg.kg-1 and ketorolac 10 mg in 60 ASA grade 1 and 2 patients scheduled to undergo day-case laparoscopic sterilisation by application of Filshie clips. Patients who received tramadol had significantly less postoperative pain in the recovery room (p = 0.007) and at discharge from the day-surgery unit (p = 0.03), and they required rescue analgesia with morphine less often (p = 0.02) than patients who received ketorolac. No difference in either the incidence or severity of nausea and vomiting was observed between the two groups. Both analgesic drugs were well tolerated at the doses given in the study, although dry mouth was significantly more common after the administration of tramadol (p = 0.009). Three patients in the tramadol group and five in the ketorolac group required overnight admission due to pain or nausea and vomiting.",1999.0,0,0
128,10456240,Low frequency of meperidine-associated seizures in sickle cell disease.,S Z Nadvi; S Sarnaik; Y Ravindranath,"Pain control measures in sickle cell diseases are not uniform. Most clinicians use parenteral morphine or meperidine for severe pain. Reports of seizures associated with meperidine have led to a growing reliance on intravenous morphine, usually with patient-controlled devices. Acceptance of morphine has been poor among patients, and many prefer meperidine. The aim of this retrospective study was to determine the incidence of meperidine-associated seizures in a large, mostly pediatric population with sickling disorders. The results suggest that the incidence of seizures with meperidine is extremely small (0.4% of patients; 0.06% of admissions). The risk of seizures should not dissuade clinicians from using this drug.",1999.0,0,0
129,10456820,Intravenous ketoprofen and epidural sufentanil analgesia in children after combined spinal-epidural anaesthesia.,H Kokki; K Tuovinen; H Hendolin,"Epidural opioid analgesia has become more popular for postoperative pain treatment in children. Epidural opioids are associated with adverse effects such as respiratory depression, excessive sedation, protracted vomiting, urinary retention and pruritus. Following minor surgery, ketoprofen has a synergistic effect with opioids, resulting in an improved analgesia without increase in incidence of adverse effects. To see whether this is also true following major surgery, we compared the effect of i.v. ketoprofen and placebo as an adjuvant to epidural sufentanil analgesia. A prospective, randomised, double-blind, placebo-controlled, parallel-group study design was used in 58 children, aged 1-15 years, receiving a standardised combined spinal-epidural anaesthesia. Intravenous ketoprofen or saline was provided as a bolus and a continuous infusion in addition to epidural sufentanil infusion, which was adjusted as clinically required. Epidural bupivacaine was used for rescue analgesia. The study drug infusion was discontinued when pain scores were <3 on a 0-10 scale for 6 h with an epidural sufentanil infusion rate of 0.03 microg kg(-1) h(-1). Children in the ketoprofen group received less rescue analgesia (none/29 vs. 8/29 children in the placebo group). In the ketoprofen group, criteria to discontinue epidural sufentanil were achieved more often (14 vs. 6 children) before the end of the 72 h study period. Less children in the ketoprofen group suffered pruritus (13 vs. 4). The incidence of nausea/retching and vomiting was similar (11 vs. 12) in both groups. In this study, ketoprofen as a background analgesic to epidural sufentanil provided improved postoperative analgesia and reduced incidence of adverse effects of the epidural opioid.",1999.0,0,0
130,10457875,Oral tramadol: analgesic efficacy in children following multiple dental extractions.,J A Roelofse; K A Payne,"In a randomized double-blind study, 60 children, aged 4-7 years, undergoing dental extractions of six or more teeth under day-case general anaesthesia, were assigned to receive either tramadol drops 1.5 mg kg-1 (n = 31), or placebo (normal saline) (n = 29), 30 min before surgery. In addition, all received anxiolytic pre-medication of oral midazolam 0.5 mg kg-1 (max 7.5 mg) at the same time. No differences were seen in behaviour, respiratory or cardiovascular assessments. In both groups, 93% were drowsy pre-anaesthetic, 3% were asleep but rousable and less than 4% exhibited minor distress. At induction, mild weeping occurred in 9.7% of the tramadol group and 6.9% of the placebo group (P > 0.05). Active awake recovery took 48.8 min, SD 32.6 in the tramadol group and 36.4 min, SD 29.6 in the placebo group (P > 0.05). Post-operative analgesia (paracetamol 120 mg) was given to 19.4% of the tramadol group compared with 82.8% of the placebo group (P < 0.05), after which the Hannalah objective pain scale scores were comparable. Analysis of the Oucher six faces pain scale showed significantly better analgesia in the tramadol group at all time points, the pain score being half that of the placebo group at 60 min and one third from 60 to 120 min (P < 0.05). No adverse respiratory or cardiovascular effects were seen. For children undergoing multiple extractions, 10.7, SD 3.0, effective postextraction analgesia was provided.",1999.0,0,0
131,10457880,Tramadol suppositories are less suitable for post-operative pain relief than rectal acetaminophen/codeine.,M A Pluim; J T Wegener; J Rupreht; A G Vulto,"The suitability of tramadol suppositories for inclusion in our hospital formulary for the treatment of mild to moderate post-operative pain was evaluated. In an open randomized trial, rectal tramadol was compared with our standard treatment acetaminophen/codeine suppositories. We expected tramadol to be equally effective as our current standard but with fewer side effects. Forty patients were treated with either tramadol suppositories 100 mg 6 hourly (qds) or acetaminophen/codeine suppositories 1000/20 mg qds. Patients were comparable with regard to demographic data and type of surgery and anaesthesia. Post-operative pain was scored with the aid of a Visual Analogue Scale before each drug administration, at rest and during movement. Side effects, notably nausea and vomiting, were recorded by interviewing the patients and by inspecting the nursing report. There was no difference in pain scores between the two groups. The incidence of nausea and vomiting was significantly higher in the tramadol-treated (84%) than in the acetaminophen/codeine treated group (31%). The relative risk of experiencing an episode of nausea under treatment with tramadol was 2.7 (95% confidence interval: 1.3-5.3; P = 0.0001) as compared with acetaminophen/codeine. We conclude that for acute treatment of mild to moderate post-operative pain frequent nausea and vomiting makes tramadol suppositories less suitable than acetaminophen/codeine.",1999.0,0,0
132,10458255,Implementing guidelines for cancer pain management: results of a randomized controlled clinical trial.,S L Du Pen; A R Du Pen; N Polissar; J Hansberry; B M Kraybill; M Stillman; J Panke; R Everly; K Syrjala,"Pain and symptom management is an integral part of the clinical practice of oncology. A number of guidelines have been developed to assist the clinician in optimizing comfort care. We implemented clinical guidelines for cancer pain management in the community setting and evaluated whether these guidelines improved care. Eighty-one cancer patients, aged 37 to 76 years, were enrolled onto a prospective, longitudinal, randomized controlled study from the outpatient clinic settings of 26 western Washington-area medical oncologists. A multilevel treatment algorithm based on the Agency for Health Care Policy and Research Guidelines for Cancer Pain Management was compared with standard-practice (control) pain and symptom management therapies used by community oncologists. The primary outcome of interest was pain (Brief Pain Inventory); secondary outcomes of interest were all other symptoms (Memorial Symptom Assessment Scale) and quality of life (Functional Assessment of Cancer Therapy Scale). Patients randomized to the pain algorithm group achieved a statistically significant reduction in usual pain intensity, measured as slope scores, when compared with standard community practice (P < .02). Concurrent chemotherapy and patient adherence to treatment were significant mediators of worst pain. There were no significant differences in other symptoms or quality of life between the two treatment groups. This guideline implementation study supports the use of algorithmic decision making in the management of cancer pain. These findings suggest that comprehensive pain assessment and evidence-based analgesic decision-making processes do enhance usual pain outcomes.",1999.0,0,0
133,10463519,Intravenous ondansetron for the control of opioid-induced nausea and vomiting. International S3AA3013 Study Group.,G Sussman; J Shurman; M R Creed; L S Larsen; T Ferrer-Brechner; D Noll; J Allegra; R Montgomery; D Schreck; E Grafstein; G Ramalanjaona; V Patel; J Ducharme; P Ortenwall; E Foster; M Ames,"This randomized, double-masked, placebo-controlled, multicenter trial was conducted in 9 countries to assess the safety and efficacy of 2 doses of intravenous ondansetron (8 and 16 mg) for the control of opioid-induced nausea and vomiting. A total of 2574 nonsurgical patients who presented with pain requiring treatment with an opioid analgesic agent participated in this trial. The most common presenting painful condition was back or neck pain, reported by approximately one third of patients. A total of 520 patients (317 females, 203 males) developed nausea or vomiting after opioid administration and were randomly assigned to receive a single dose of 1 of 3 study treatments: placebo (n = 94), ondansetron 8 mg (n = 215), or ondansetron 16 mg (n = 211). Ondansetron 8 and 16 mg led to complete control of emesis in 134 of 215 patients (62.3%) and 145 of 211 patients (68.7%), respectively. Results with both doses were significantly better than those seen with placebo (43 of 94 patients [45.7%]). Complete control of nausea was achieved in 6.8% of placebo patients, 14.8% of ondansetron 8-mg-treated patients, and 19.4% of ondansetron 16-mg treated patients; only ondansetron 16 mg was significantly better than placebo (P = 0.007). Significantly more patients who received ondansetron 8 mg than patients who received placebo were satisfied/very satisfied with their antiemetic treatment, as assessed by 4 patient-satisfaction questions. Significantly more patients who received ondansetron 16 mg compared with placebo were satisfied/very satisfied on 2 of 4 satisfaction questions. In conclusion, based on the observed incidence of opioid-induced nausea and vomiting in this study, it may be more appropriate to treat symptoms on occurrence rather than administering antiemetic agents prophylactically. The results of this study demonstrate that intravenous ondansetron in doses of 8 or 16 mg is an effective antiemetic agent for the control of opioid-induced nausea and vomiting in nonsurgical patients requiring opioid analgesia for pain.",1999.0,0,0
134,10465680,Memantine is a clinically well tolerated N-methyl-D-aspartate (NMDA) receptor antagonist--a review of preclinical data.,C G Parsons; W Danysz; G Quack,"N-methyl-D-aspartate (NMDA) receptor antagonists have therapeutic potential in numerous CNS disorders ranging from acute neurodegeneration (e.g. stroke and trauma), chronic neurodegeneration (e.g. Parkinson's disease, Alzheimer's disease, Huntington's disease, ALS) to symptomatic treatment (e.g. epilepsy, Parkinson's disease, drug dependence, depression, anxiety and chronic pain). However, many NMDA receptor antagonists also produce highly undesirable side effects at doses within their putative therapeutic range. This has unfortunately led to the conclusion that NMDA receptor antagonism is not a valid therapeutic approach. However, memantine is clearly an uncompetitive NMDA receptor antagonist at therapeutic concentrations achieved in the treatment of dementia and is essentially devoid of such side effects at doses within the therapeutic range. This has been attributed to memantine's moderate potency and associated rapid, strongly voltage-dependent blocking kinetics. The aim of this review is to summarise preclinical data on memantine supporting its mechanism of action and promising profile in animal models of chronic neurodegenerative diseases. The ultimate purpose is to provide evidence that it is indeed possible to develop clinically well tolerated NMDA receptor antagonists, a fact reflected in the recent interest of several pharmaceutical companies in developing compounds with similar properties to memantine.",1999.0,0,0
135,10467917,Use and efficacy of low-dose ketamine in the management of acute postoperative pain: a review of current techniques and outcomes.,R L Schmid; A N Sandler; J Katz,"Ketamine hydrochloride is a well known general anesthetic and short acting analgesic in use for almost 3 decades. The role of the NMDA receptor in the processing of nociceptive input has led naturally to renewed clinical interest in N-methyl-D-aspartate (NMDA) receptor antagonists such as ketamine. This paper reviews the use and efficacy of low-dose ketamine in the management of acute postoperative pain. The literature was obtained from a computer search of the MEDLINE database from 1966 through December 1998. Studies were included for review if they were randomized, prospective, controlled, double-blind and reported pain scores. We evaluate the clinical literature and discuss the efficacy of low-dose ketamine in the management of acute postoperative pain when administered alone or in conjunction with other agents via the oral, intramuscular, subcutaneous, intravenous and intraspinal routes. Low-dose ketamine is defined as a bolus dose of less than 2 mg/g when given intramuscularly or less than 1 mg/kg when administered via the intravenous or epidural route. For continuous i.v. administration low-dose ketamine is defined as a rate of < or =20 microg/kg per min. We conclude that ketamine may provide clinicians with a tool to improve postoperative pain management and to reduce opioid related adverse effects. The evidence suggests that low-dose ketamine may play an important role in postoperative pain management when used as an adjunct to local anesthetics, opioids, or other analgesic agents. Further research is required in the following areas: (a) dose-finding studies for ketamine as an adjunct to opioids and local anesthetics (b) efficacy and optimal route of administration (c) the role of S(+)-ketamine; (d) the influence of ketamine on long-term outcome such as chronic pain (e) long-term physical and chemical stability of mixtures containing ketamine (f) spinal toxicity of ketamine and (g) effects of low-dose ketamine on cognitive and memory functioning after surgery.",1999.0,0,0
136,10467919,Does sex make a difference in the prescription of treatments and the adaptation to chronic pain by cancer and non-cancer patients?,D C Turk; A Okifuji,"The literature suggests that the sex of patients is an important factor in understanding how they are treated by health care professionals and how they adapt to their symptoms. In two groups of patients with chronic pain (n = 428 non-cancer (Study 1) and n = 143 cancer-related (Study 2)), men and women were compared on medications prescribed, treatment history, and coping and adaptation. In Study 1 with the non-cancer pain patients, there were no significant differences between the sexes in past treatments, current analgesic use, pain, or disability. Women were significantly more depressed and were more likely to receive antidepressants than men. Subgrouping patients on the basis of pain-adaptation responses yielded groups with distinct psychosocial and behavioral characteristics. In Study 2 with the cancer pain patients, men and women did not show significant differences on any variables. Consistent with the results of Study 1, however, psychological subgroups differed significantly in pain severity, mood and disability regardless of sex. The results of both studies suggest that the role of patients' sex in chronic pain may be less important than their psychosocial and behavioral responses. Thus, it appears that knowing the psychological characteristics of patients may be more important than their sex.",1999.0,0,0
137,10470633,"Effects of tramadol and meperidine on respiration, plasma catecholamine concentrations, and hemodynamics.",L H Mildh; K A Leino; O A Kirvelä,"To evaluate the effects of high analgesic doses of tramadol and meperidine on respiration, plasma catecholamine concentrations, and hemodynamic parameters. Randomized, double-blind, cross-over, controlled volunteer study. Laboratory at a university hospital. 8 healthy male volunteers. Tramadol was given as a 150 mg bolus plus a succeeding 3-hour steady infusion of 250 mg (83.3 mg/hr). Meperidine was given in a similar manner as a bolus dose of 112.5 mg plus 187.5 mg in a 3-hour steady infusion (62.5 mg/hr). Experimental pain was induced using a tourniquet. Respiration was studied noninvasively with respiratory inductive plethysmography and pulse oximetry. Arterial line was used for measurement of hemodynamics and blood sampling. Tramadol did not have any clinically significant effects on respiration, breathing pattern, or hemodynamics, but an increase in plasma epinephrine levels was noted. Meperidine bolus decreased tidal volume (p < 0.05, difference from baseline) and pulse oxygen saturation (from 97% to 94%, p < 0.05), but during the succeeding infusion, the respiratory drive, measured as mean inspiratory flow, was enhanced (p < 0.05 difference from baseline), and the respiratory parameters returned to baseline level. No change in hemodynamics was noted, but a significant increase in plasma norepinephrine and epinephrine levels (from 0.9 to 1.6 nmol/L and from 0.3 to 0.8 nmol/L, respectively; p < 0.05) was observed after meperidine administration. Tramadol caused nausea more often than meperidine (p < 0.05, between treatments). Tramadol exhibited a minimal effect on respiration and breathing pattern in healthy volunteers. The respiratory effects of meperidine bolus were predictable with decreasing tidal volume and pulse oxygen saturation. In contrast, during meperidine infusion, adequate respiration was preserved despite the large amount of meperidine infused.",1999.0,0,0
138,10472210,Tramadol revisited.,K Budd; R Langford,,1999.0,0,0
139,10477194,Using opioid analgesics to manage chronic noncancer pain in primary care.,T Parrott,"Opioid analgesics have been considered the drugs of choice for the treatment of moderate to severe cancer and postoperative pain. Cultural attitudes and concerns about abuse have inhibited their use for a larger population of patients who have chronic noncancer pain. Medical literature was searched from 1990 to 1998 using the key words ""opioid analgesics,"" ""opioid abuse,"" and ""chronic pain."" I have also drawn from more than 20 years of experience prescribing opioid analgesics for chronic pain. A case series analysis of 30 patients using opioid analgesics for periods ranging from 6 months to 17 years was performed. The World Health Organization has published a ""three-step ladder"" guide to treatment of cancer pain graded from mild to severe; this guide can be readily applied to the treatment of pain from all sources. Opioid analgesics are the mainstay of treatment for moderate to severe pain. Chronic pain patients offer some difficult challenges for busy primary care physicians. The unique pharmacologic characteristics of opioid medications are important in outpatient management. A four-sheet office management protocol helps to focus efficiently on important clinical issues related to pain control, to monitor for opiate abuse, and to incorporate pain management more effectively in the overall primary care plan of the patient.",1999.0,0,1
140,10483311,[Co-analgesics in the treatment of chronic pain].,A Kopf,"Opioids do not yield adequate analgesic effects in at least one-third of all patients suffering from chronic pain. Nonetheless, in contrast to former opinion there is no type of pain that is principally resistant to opioids, which means that the individual patient's response to opioid administration has to be investigated to determine adequate treatment. Opioids fail most frequently in cases of neuropathic, osseous or sympathetically maintained pain. In these cases there is an indication for early use of co-analgesics. The analgesic potency of anticonvulsives and tricyclic antidepressants has been best documented. A differential indication of the large number of possible coanalgesics should be determined with the help of a detailed pain history focussing on the pain quality. Similar to the WHO analgesic ladder used in (tumor) pain therapy, co-analgesic therapy should only be supplemented by invasive therapeutic procedures after various combinations and alternative substances have proven fruitless. Experience shows that this is necessary only for a small number of patients.",1999.0,0,0
141,10483385,"Change in pain threshold by meperidine, naproxen sodium, and acetaminophen as determined by electric pulp testing.",P L Carnes; B Cook; P D Eleazer; J P Scheetz,"The purpose of this study was to compare changes in pain threshold caused by meperidine, naproxen sodium, acetaminophen, and placebo. The change in pain threshold was measured by electric pulp testing. Acetaminophen elevated the pain threshold statistically significantly. Clinically, however, the superiority of acetaminophen is questionable. No elevation of the pain threshold occurred with narcotic drugs or with nonsteroidal anti-inflammatory drugs: our research shows that the electric pulp tests of patients who have taken these drugs preoperatively will have results similar to those of patients who have taken no drugs. We question the philosophy of administering these drugs for change in pain threshold at the levels used here preoperatively.",1999.0,0,0
142,10485502,Efficacy and tolerability of the specific cyclooxygenase-2 inhibitor DFP compared with naproxen sodium in patients with postoperative dental pain.,K Gottesdiener; D R Mehlisch; M Huntington; W Y Yuan; P Brown; B Gertz; S Mills,"DFP [3-(2-propyloxy)-(4-methyl-sulfonylphenyl)-(5,5-dimethyl)-fu ranone] is a highly specific cyclooxygenase-2 inhibitor (>2500-fold selective in transfected Chinese hamster ovary cell assays) that has demonstrated efficacy in preclinical models of pain and inflammation. The present single-dose, randomized, double-masked, double-dummy, placebo-controlled, parallel-group study was undertaken to compare DFP 5, 25, and 50 mg with naproxen sodium 550 mg and with placebo in 196 patients (mean age, 25.8 years; 187 [95.4%] males) who experienced moderate-to-severe pain after surgical removal of > or =2 third molars. Overall analgesic effect, duration of effect, time to onset of analgesic effect, peak analgesic effect, and tolerability were assessed over a 24-hour postdose period. Both DFP 25 and 50 mg, as well as the active comparator, naproxen sodium 550 mg, were significantly more effective than placebo. The onset of analgesic effect in the DFP 25-mg, DFP 50-mg, and naproxen sodium 550-mg groups did not differ significantly. DFP was generally well tolerated in single doses up to 50 mg. DFP 50 mg was efficacious in the treatment of postoperative dental pain and was indistinguishable from the active comparator, naproxen sodium 550 mg.",1999.0,0,0
143,10485772,Effects of morphine and tramadol on somatic and visceral sensory function and gastrointestinal motility after abdominal surgery.,C H Wilder-Smith; L Hill; J Wilkins; L Denny,"Chronic nociceptive input induces sensitization and changes in regulatory reflexes in animal models. In humans, postoperative somatic and visceral sensitization and the secondary effects on reflex gut motility are unclear. Somatic and visceral sensation and gastrointestinal motility were evaluated after abdominal hysterectomies in 50 patients who were randomized to receive double-blinded postoperative 48-h infusions of morphine or tramadol. Pain scores, rectal distension, skin electric sensation and pain tolerance thresholds, and gastrointestinal transit were assessed before and after operation, during and after analgesic infusions. Pain intensity scores decreased similarly with morphine and tramadol infusions (total doses, 66.8+/-20 mg and 732.4+/-152 mg [mean +/- SD], respectively). Skin pain tolerance thresholds in the incisional dermatome remained similar with morphine and tramadol throughout the study. During morphine infusions, pain tolerance thresholds on the shoulder increased (P<0.05) and then decreased after discontinuation on day 4 (P<0.02) compared with before operation. Rectal distension pain tolerance pressure thresholds increased after operation during morphine infusions (P<0.05). Similar but nonsignificant trends occurred with tramadol. Orocecal and colonic transit times increased after operation with both morphine and tramadol (P<0.005), but gastric emptying was prolonged only with morphine (P = 0.03). AU motility and sensory parameters had returned to preoperative levels by 1 month after operation. Pain control was equally effective with morphine and tramadol infusions. No somatic or visceral sensitization was evident during morphine and tramadol infusions, but pain tolerance thresholds as markers of antinociception were increased more during morphine infusions. The significant sensitization seen only after morphine discontinuation may be due to convergent visceral input. Gut motility was prolonged significantly by visceral surgery itself and also by morphine.",1999.0,0,0
144,10486687,Risk factors for pain and nausea following retinal and vitreous surgery under conscious sedation.,M Mandelcorn; N Taback; E Mandelcorn; C Ananthanarayan,"There have been no studies examining risk factors for pain and nausea during the first day after posterior segment surgery. We performed a study to identify significant risk factors for the development of pain and nausea during the first 24 hours after outpatient vitrectomy or scleral buckle surgery. A total of 257 consecutive patients who underwent vitrectomy (192 patients), scleral buckling (57 patients) or combined vitrectomy-scleral buckling (8 patients) between July 1 and Dec. 31, 1995, were enrolled in this prospective study. The patients' age, sex and ethnicity, the duration of the procedure and the intraoperative use of minor tranquillizers, hypnotic agents, narcotic analgesics or major tranquillizers were recorded. Each patient rated his or her postoperative pain and nausea on two separate 100-mm lines. The left end of the line represented no pain (or nausea) whatsoever, and the right end of the line represented severe pain (or nausea). The distance of the recorded point from the origin of the line was used as the outcome measure for pain and nausea. All the data were analysed statistically by means of logistic regression analysis and descriptive statistics. The median pain scores were 1.0 for the patients who underwent vitrectomy, 47.0 for those who underwent scleral buckling and 35.0 for those who underwent combined vitrectomy-scleral buckling. The median nausea scores were 14.5, 45.0 and 55.5 respectively. The only variable that was identified as a predictor of postoperative pain or nausea was the intraoperative use of narcotic analgesics: in the vitrectomy group, postoperative nausea occurred almost three times as often among patients who received these agents as among those who did not (odds ratio 2.6, p = 0.00). The identification of the intraoperative use of narcotic analgesics as a risk factor for nausea in the first 24 hours after outpatient vitrectomy suggests that, when possible, these agents should be avoided during surgery.",1999.0,0,0
145,10486991,Palliative care: clinical approach to chronic pain and intestinal obstruction.,G Hanks,"Many patients with terminal cancer receive inadequate treatment for pain and other symptoms. Yet, using oral medications in a simple stepwise approach, we should be able to control pain in up to 80% of patients.",2000.0,0,0
146,10488254,Evaluation of the effects of the addition of morphine sulfate to a standard Bier block solution in peripheral arm surgery.,T E Ceremuga; E A Gelinas; J L Gonzales; J M Ramos-Alarilla,"The purpose of this study was to analyze postoperative pain differences in patients undergoing peripheral arm surgery. Differences between patients' perceived pain who received 2 mg of morphine sulfate added to the standard Bier block solution and the standard Bier block solution without morphine were studied. A quasi-experimental nonequivalent control group design was utilized. Thirty adult subjects (22 men and 8 women) ages 21 to 76 years constituted the convenience sample. Pain scores were measured by a verbal descriptor scale at the following times: upon admission to the postanesthesia care unit, at 30 minutes and 60 minutes after surgery, and at 24 hours postoperatively. A two-tailed Mann-Whitney U test was used to analyze pain scores for the two groups (P < .05). No statistically significant differences were found in postoperative pain between the group receiving a Bier block solution with 2 mg of morphine sulfate and the group with a standard Bier block solution without morphine sulfate. The mean scores for the morphine sulfate group were lower in each time period measured. This study suggests a questionable benefit for adding 2 mg of morphine sulfate to a Bier block solution. A larger sample may have yielded different results. Many issues remain undecided regarding the potential role of opioids in various regional anesthetic techniques. Further studies are warranted to investigate the peripheral effects of opioids and to understand the mechanisms of action of opioid analgesics at peripheral sites.",1999.0,0,0
147,10488295,Effect of intrathecal fentanyl dose on the duration of labor analgesia.,D C Celeski; L Heindel; J Haas; C A Vacchiano,"The short duration of effective analgesia produced by intrathecal fentanyl (ITF) at doses ranging from 5 to 25 micrograms limits the drug's use for the management of labor pain. The understanding of the potential of ITF related to duration of analgesia in the labor patient is derived from studies of and clinical experience with ITF at doses not exceeding 25 micrograms and less. We hypothesized that by increasing the dose beyond 25 micrograms, a prolonged duration of analgesia could be achieved. The purpose of the present study was to compare the difference in duration of effective analgesia and adverse effects produced by 25, 37.5, and 50 micrograms of ITF. A sample population of 60 term parturient women with uncomplicated singleton pregnancies who were in active labor and requesting pain control were randomly assigned to 1 of 3 groups: group 1, 25 micrograms (n = 20); group 2, 37.5 micrograms (n = 20); and group 3, 50 micrograms (n = 20). The ITF was then administered by an anesthesia provider blinded to the dose via a combined spinal epidural technique. The time from injection to the time of request for subsequent pain control (considered the duration of effective analgesia), maternal and fetal vital signs, and adverse effects were recorded at specific intervals until the patient requested activation of the epidural catheter or delivery occurred, ending participation in the study. Statistical analysis using a 1-way analysis of variance and considering a P value of < .05 to be significant revealed no difference in duration of effective analgesia between the groups. Statistical differences in the incidence of adverse effects, particularly uterine hyperstimulation, hypotension, pruritus, nausea, and fetal heart rate decelerations were not evident using the Fisher Irwin test and a significance of P < .05. The findings of the present study demonstrate that there is no real advantage of using doses of ITF greater than 25 micrograms in quality and duration of effective labor analgesia.",1999.0,0,0
148,10488677,An international survey of cancer pain characteristics and syndromes. IASP Task Force on Cancer Pain. International Association for the Study of Pain.,A Caraceni; R K Portenoy,"The optimal assessment of cancer pain includes a detailed description of pain characteristics and classification by both syndrome and likely mechanisms. In the clinical setting, the interpretation of this information is aided by knowledge of the available clinical experiences on these aspects of the pain. Unfortunately, existing data are limited. There have been few large surveys of cancer pain characteristics and syndromes, and comparative data from patients in different parts of the world are entirely lacking. To better define the characteristics of cancer pain syndromes the Task Force on Cancer Pain of the International Association for the Study of Pain (IASP) conducted a prospective, cross-sectional, international, multicenter survey of pain specialists and their patients. From a total of 100 clinicians who described themselves as cancer pain practitioners in the IASP membership directory, 51 agreed to participate in the survey and a total of 58 provided data. These clinicians resided in 24 countries and evaluated a total of 1095 patients with severe cancer pain mostly requiring opioid medication, using a combination of patient-rated and observer-rated measures. The patient-rated scales comprised a pain intensity measure chosen from the brief pain inventory. The observer-rated information included demographic and tumor-related data, and responses on checklists of pain syndromes and pathophysiologies. Patients were heterogeneous in terms of demographics and tumor-related information. More than 76% had a Kamofsky performance status score < or = 70. Almost one-quarter of the patients experienced two or more pains. A large majority of the patients (92.5%) had one or more pains caused directly by the cancer; 20.8% of patients had one or more pains caused by cancer therapies. The average (SD) duration of pain was 5.9 (10.5) months. Approximately two-thirds of patients (66.7%) reported that the worst pain intensity during the day prior to the survey was > or = 7 on a 10-point numeric scale. The factors that were univariately associated with higher pain intensity included the presence of breakthrough pain, somatic pain or neuropathic pain, age younger than 60 years, and lower performance status score. A multivariate model suggested that the presence of breakthrough pain, somatic pain, and lower performance status were the most important predictors of intense pain. Pains that were inferred by the treating clinician to be nociceptive and due to somatic injury occurred in 71.6% of the patients. Pains labeled nociceptive visceral were noted in 34.7% and pains inferred to have neuropathic mechanisms occurred in 39.7%. In a broad classification, the major pain syndromes comprised bone or joint lesions (41.7% of patients), visceral lesions (28.1%), soft tissue infiltration (28.3%), and peripheral nerve injuries (27.8%). Twenty-two types of pain syndromes were most prevalent. Large differences in the diagnosis of breakthrough pain by clinicians of different countries suggest that this phenomenon is either defined or recognized differently across countries. These data confirm, in segment of the cancer population experiencing severe pain, in different parts of the world, that cancer pain characteristics, syndromes and pathophysiologies are very heterogeneous. Predictors of worsening pain can be identified. The data provide a useful context for the interpretation of pain-related information acquired in both clinical and research settings. They suggest the need for future studies and the potential usefulness of a written checklist for cancer pain syndromes and pathophysiologies.",1999.0,0,0
149,10490154,Comparison of 0.25 mg and 0.1 mg intrathecal morphine for analgesia after Cesarean section.,T Yang; T W Breen; D Archer; G Fick,"To test the hypothesis that 0.1 mg intrathecal morphine plus NSAIDs provides satisfactory analgesia post-Cesarean section with fewer side effects than 0.25 mg intrathecal morphine. Sixty women, scheduled for elective Cesarean section under spinal anesthesia, were randomized to receive either 0.1 mg or 0.25 mg intrathecal morphine combined with hyperbaric bupivacaine 0.75% and 20 microg fentanyl. All patients received a 100 mg indomethacin suppository at the end of surgery and 500 mg naproxen p.o. b.i.d. was started the evening of surgery and continued until discharge. A blinded researcher recorded the pain, pruritus, and nausea scores, the time to first request for additional analgesics, a visual analogue scale (VAS) satisfaction score, and the use of additional opioids, antipruritics, and/or antiemetics. Of the 60 patients enrolled, two were not included in the data analysis because of protocol violations leaving 30 patients in the 0.1 mg group and 28 in the 0.25 mg group. There were no differences in the VAS pain scores or the number of women requesting an opioid other than codeine between the two groups. The VAS pruritus scores in the 0.1 mg group were lower throughout the 24 hr (P < 0.001). Fewer women in the 0.1 mg group (4/30 vs 12/28) requested nalbuphine to treat itching (P = 0.018). Nausea scores were lower in the 0.1 mg group (P < 0.001). The use of 0.1 mg intrathecal morphine plus NSAIDs provides analgesia of similar quality to 0.25 mg but with fewer undesirable side effects following Cesarean section.",1999.0,0,0
150,10490156,,,,,0,0
151,10490157,Intraoperative high dose fentanyl induces postoperative fentanyl tolerance.,Y Y Chia; K Liu; J J Wang; M C Kuo; S T Ho,"In a randomized, double-blind clinical trial, we compared the postoperative analgesic effect and dose consumption of fentanyl after intraoperative high dose and low dose fentanyl administration. Sixty ASA class I to II female patients undergoing total abdominal hysterectomy (TAH), were randomly allocated to receive either 1 microg x kg(-1) (low dose group, n = 30) or 15 microg x kg(-1) (high dose group, n = 30) fentanyl during induction of anesthesia. Anesthesia depth was maintained with inhalation of halothane in the low dose group, or combined with 100 microg x hr(-1) fentanyl i.v. in the high dose group. Postoperative pain was treated with an intravenous patient-controlled analgesia system and was assessed with a visual analog pain score at rest. Patients in the high dose group had higher pain intensity at four and eight hours postoperatively, more fentanyl consumption and a greater incidence of emesis in the postoperative period of 16 hr than those in the low dose group (P < 0.05). Heart rate, blood pressure, and respiratory rate were similar between the two groups. Our results suggest that acute fentanyl tolerance develops after administration of high dose fentanyl during surgery and, consequently, results in a higher postoperative pain intensity and greater fentanyl consumption.",1999.0,0,0
152,10492054,Relative potency of controlled-release oxycodone and controlled-release morphine in a postoperative pain model.,G B Curtis; G H Johnson; P Clark; R Taylor; J Brown; R O'Callaghan; M Shi; P G Lacouture,"The relative analgesic potency of single doses of oral controlled-release oxycodone and oral controlled-release morphine were compared in a randomized, double-blind trial using a postoperative pain model. Women (n = 169) with moderate to severe pain following abdominal hysterectomy received single oral doses of controlled-release oxycodone, 20 mg or 40 mg, or controlled-release morphine, 45 mg or 90 mg. Assessments were made at 30 min, 60 min, then hourly after dosing for 12 h or until remedication. The most precise estimates of relative potency showed that controlled-release oxycodone was 1.8 times more potent than controlled-release morphine for total effect (95% confidence limits 1.09-2.42; lambda 0.44) and 2.2 times more potent for peak effect (95% confidence limits 0.96-4.59; lambda 0.71). Controlled-release oxycodone at doses of 20 mg or 40 mg was comparable with controlled-release morphine at doses of 45 mg or 90 mg, respectively, for total and peak analgesic effects. For the two higher doses, time to peak relief was approximately 1 h shorter with controlled-release oxycodone than with controlled-release morphine. Most patients reported onset of analgesia within 1 h with all doses. Side effects were similar with the two opioids. Oral controlled-release oxycodone was twice as potent as oral controlled-release morphine in this single-dose, relative potency assay. When converting patients from oral morphine to oral oxycodone, an initial oral oxycodone dose of one-half the oral morphine dose is recommended.",1999.0,0,0
153,10492407,"Combination of intra-articular tenoxicam, lidocaine, and pethidine for outpatient knee arthroscopy.",M Elhakim; M Nafie; A Eid; M Hassin,"Studies of intra-articular non-steroidal anti-inflammatory drugs have revealed an analgesic effect equivalent to that of intra-articular local anaesthetic agents and morphine. The aim of this study was to evaluate the analgesic effect of intra-articular lidocaine, pethidine and tenoxicam compared with that of lidocaine and pethidine on postoperative pain after arthroscopy. After day-case knee arthroscopy, 60 patients were randomly allocated to one of three groups to receive 20 ml of a solution containing 0.9% saline (group S), 2% lidocaine and 10 mg preservative-free pethidine (group LP) and 2% lidocaine, 10 mg preservative-free pethidine and 20 mg tenoxicam (group LPT). Postoperative pain was assessed using a visual analogue scale and measuring analgesic requirements. Pain scores were significantly lower in the LP group than in the S group at 1 and 2 h after surgery. From 4 h until the end of the first postoperative day, pain scores were significantly lower in the LPT group of patients at rest and on knee flexion than in the other two groups; these patients also used less oral analgesics (P<0.05). The combination of 20 ml lidocaine 2%, 10 mg pethidine and 20 mg tenoxicam given intra-articularly provided superior analgesia and reduced oral analgesic requirement during the first day after arthroscopy compared with lidocaine and pethidine alone.",1999.0,0,0
154,10498025,,,,,0,0
155,10506672,Generalizing from a controlled trial: the effects of patient preference versus randomization on the outcome of inpatient versus outpatient chronic pain management.,A C de C Williams; M K Nicholas; P H Richardson; C E Pither; J Fernandes,"Patients accepting randomization in a randomized controlled trial (RCT) may not be representative of the clinical population from which they are drawn, calling into question the generalizability of study findings. Comparison of randomized and non-randomized inpatient and outpatient samples at baseline and in treatment outcomes up to one year was made to determine whether the findings of the RCT generalized to non-randomized patients in the same treatment program. One hundred and twenty one patients with intractable pain, randomized between inpatient, outpatient and waiting list control, were compared with 128 who elected for either inpatient or outpatient treatment. Treatment was a group-based multidisciplinary cognitive-behavioral treatment program aimed at enabling patients to return to more normal function despite persistent pain, delivered to mixed groups of randomized and elective patients, and outcome was measured by physical performance, pain impact on function, mood, and drug use. Agreement to randomization was a function of travelling distance from home to hospital. Non-randomized patients largely resembled their randomized counterparts before and after treatment. In order to indicate the clinical significance of results, analyses were conducted using numbers needed to treat (NNTs). NNTs estimate the number of patients required in the treatment condition for one of them to achieve the specified outcome who would not have achieved it in the comparison condition. Across a range of measures at one month follow-up, comparison of inpatients with outpatients gave NNTs between 2.3 and 7.5, and comparison of inpatients with waiting list controls gave NNTs between 2.3 and 3.6. At one year inpatients showed greater likelihood than outpatients of maintaining these treatment gains.",1999.0,0,0
156,10506675,"Tramadol relieves pain and allodynia in polyneuropathy: a randomised, double-blind, controlled trial.",S H Sindrup; G Andersen; C Madsen; T Smith; K Brøsen; T S Jensen,"It is generally believed that opioids relieve neuropathic pain less effectively than nociceptive pain and that they have no effect on some of the key characteristics of neuropathic pain such as touch-evoked pain (allodynia). Tramadol is an analgesic drug acting directly on opioid receptors and indirectly on monoaminergic receptor systems. The aim of this trial was to determine whether tramadol relieved painful polyneuropathy and reduced allodynia. The study design was randomised, double-blind, placebo-controlled and cross-over. After baseline observations, 45 patients were assigned to one of the two treatment sequences. The dose of tramadol slow-release tablets was titrated to at least 200 mg/day and at highest 400 mg/day. During the two treatment periods of 4 weeks duration, patients rated pain, paraesthesia and touch-evoked pain by use of 0-10 point numeric rating scales. Mechanical allodynia induced by stimulation with an electronic toothbrush was rated at the end of each treatment period with a similar scale. Thirty-four patients completed the study. Their ratings for pain (median 4 vs. 6, P=0.001), paraesthesia (4 vs. 6, P=0.001) and touch-evoked pain (3 vs. 5, P<0.001) were lower on tramadol than on placebo, as were their ratings of allodynia (0 vs. 4, P=0.012). The number needed to treat to obtain one patient with >/=50% pain relief was 4.3 (95% confidence interval 2.4-20). It is concluded that tramadol appears to relieve both ongoing pain symptoms and the key neuropathic pain feature allodynia in polyneuropathy.",1999.0,0,0
157,10509323,Role of methadone in the management of pain in cancer patients.,E Bruera; C M Neumann,"In most cancer patients who are treated with opioid analgesics for pain control, the type of opioid needs to be changed at least once because of the presence of side effects or the need to escalate analgesic doses to toxic levels. Methadone may be an excellent alternative in such patients due to its lack of known active metabolites, high lipid solubility, excellent absorption following oral and rectal delivery, and extremely low cost. However, it has unique problems, such as a long, unpredictable half-life and greater potency than previously assumed. At present, methadone is viewed as a second-line opioid for chronic cancer pain. Better pharmacokinetic and clinical studies are required to establish the role of methadone in this setting. Issues to be explored include a potential role in treating patients who have poorly responsive pain syndromes, such as neuropathic pain, or who develop a rapid tolerance to other opioids; the possibility of extending dosing intervals to every 12 or 24 hours; and its possible use as a first-line opioid.",1999.0,0,0
158,10510918,Analgesia during extracorporeal shock wave lithotripsy using the Medstone STS lithotriptor: a randomized prospective study.,M M Issa; R El-Galley; D E McNamara; S Segall,"To investigate and compare the effectiveness of three analgesic protocols for pain management during extracorporeal shock wave lithotripsy (ESWL) in a prospective, randomized clinical trial. Seventy-four patients were randomized into three groups before ESWL; group A (n = 23) received 10 mg morphine sulfate (MS), group B (n = 25) 60 mg ketorolac tromethamine (KT), and group C (n = 26) topical 2.5% lidocaine/prilocaine gel (Emla). Each method of pain management during ESWL was assessed using a standard 10-point linear pain scale and by the requirement for supplemental analgesia during treatment. Supplemental analgesia was administered intravenously using a patient-controlled analgesic pump. The results were compared between the three groups, as were such parameters as body habitus, stone burden, stone location, number of shock waves, and the presence of ureteral stents. Pain severity averaged 4.6 points on the pain scale for the three groups combined. Pain tended to be more severe in group C (5.4) than in group A (4.3) or group B (4.1); however, the differences were not statistically significant (P>0.05). The amount of supplemental analgesia was similar in all three groups. Stone burden, stone location, and number of shock waves did not influence the severity of pain or analgesic requirement during ESWL. The analgesic requirement was significantly less in patients with ureteral stents (n = 32) than in patients without (n = 42), averaging 10 mg versus 24 mg MS, respectively (P = 0.01). KT was not associated with adverse events such as bleeding. MS was more likely to cause oversedation and nausea or vomiting, necessitating naloxone and antiemetic therapy, respectively. The use of KT was safe and effective for premedication before ESWL; patients receiving KT before ESWL reported lower pain scores and required less supplemental analgesia requirement than those who received MS or Emla; however, the differences were not statistically significant. Patients receiving Emla recorded the highest pain scores. Patients with ureteral stents had lower pain scores and required less supplemental analgesia.",1999.0,0,0
159,10514020,Risk-benefit assessment of opioids in chronic noncancer pain.,B Bannwarth,"Opioids have been accepted as appropriate treatment for acute and cancer pain, but their role in the management of chronic nonmalignant pain is the subject of much debate, mainly due to concerns about waning efficacy, the potential for neuropsychological impairment and the development of drug addiction. Controlled clinical trials demonstrated that opioids may be effective in both nociceptive and neuropathic noncancer pain, although the former responded more consistently than the latter. Gastrointestinal and CNS adverse effects were frequent in most studies. Observational studies have generated contradictory findings regarding efficacy and safety as well as the risk of drug addiction in patients with chronic noncancer pain receiving long term opioid therapy. However, they suggest that opioids may be effective in individual cases, whichever the pathophysiological mechanism of pain. Taken together, the available data indicate that the outcomes associated with opioid therapy vary markedly across patients experiencing chronic nonmalignant pain. The main consensus is that a subset of these patients may gain substantial benefit from opioid analgesics without requiring rapidly escalating doses or developing intolerable adverse effects or drug addiction. Prescribing guidelines have been developed to assist practitioners in selecting the appropriate patients and ensuring an acceptable risk : benefit ratio of opioid therapy. Finally, it must be emphasised that chronic pain is a complex entity wherein analgesics, including opioids, are only part of the treatment.",1999.0,0,0
160,10520911,,,,,0,0
161,10522577,Tourniquet inflation during arthroscopic knee ligament surgery does not increase postoperative pain.,J Hooper; O P Rosaeg; B Krepski; D H Johnson,"A double-blind clinical trial was conducted to determine the effect of inflation of a thigh tourniquet during anterior cruciate ligament repair on arthroscopic visibility, duration of procedure, postoperative pain and opioid consumption. Thirty patients were randomly allocated into two groups; Group I had the thigh tourniquet inflated during surgery whereas the tourniquet was not inflated in Group II patients. All patients received standardized general anesthesia and postoperative pain management. Supplemental analgesia was provided with i.v. morphine via a patient-controlled analgesia (PCA) apparatus. Verbal pain rating scores (0-10) were obtained after surgery. Arthroscopic visibility was impaired in Group II patients (P < 0.0001), but this was ameliorated by increased irrigation flow or addition of epinephrine. Duration of surgery was similar in both groups. There was no difference between groups in postoperative morphine consumption (9.8 +/- 7.1 mg in Group I vs 11.4 +/- 10.2 mg in Group II) or in postoperative pain scores between groups. Inflation of a thigh tourniquet did not result in increased pain or opioid consumption after arthroscopic ACL surgery. Arthroscopic visibility was somewhat impaired in some patients without the use of tourniquet. Finally, the duration of the surgical procedure was not increased in patients where the tourniquet was not inflated during the ACL repair.",1999.0,0,0
162,10522738,Opioid therapy of chronic pain: assessment of consequences.,S R Savage,"This paper will review what is known about key issues of importance in the clinical use of opioids for the treatment of intractable non-cancer related pain, and will attempt to describe the evolving areas of consensus among clinicians who treat pain and addiction regarding various aspects of use of opioids for the treatment of chronic non-cancer pain.",1999.0,0,0
163,10522739,Opioid rotation in chronic non-malignant pain patients. A retrospective study.,A B Thomsen; N Becker; J Eriksen,"The clinical advantage of opioid rotation is probably due to incomplete cross-tolerance favouring analgesia more than adverse effects. The objectives of opioid rotation in chronic non-malignant patients are 1): rotation between different long-acting opioids (LAO) to improve analgesia and reduce side-effects, and 2): rotation from short-acting opioids (SAO) to LAO to establish stable analgesia in order to minimise withdrawal symptoms, risk of tolerance and addiction. A retrospective analysis of 37 rotations between different LAO and 59 rotations from SAO to LAO. The main reason for opioid rotation was insufficient pain relief. Opioid rotations resulted in significantly better pain control in 59% (CI95=49-76%) of the patients rotated between different LAO and 73% (CI95=60-84%) of the patients rotated from SAO to LAO. During rotations symptoms of withdrawal and overdosing were relatively frequent in both groups. No significant dose changes were seen when rotating between different LAO. However, the consequence of rotation from SAO to LAO was a 74% increase in the opioid dose (CI95=30-117%). Opioid rotations between different LAO resulted in better pain control and fewer side-effects at dose levels predicted to be equianalgesic. The majority of the patients rotated from SAO to LAO obtained improved analgesia, but the cost was a 74% increase in the opioid dose.",1999.0,0,1
164,10524468,Intrathecal coadministration of bupivacaine diminishes morphine dose progression during long-term intrathecal infusion in cancer patients.,R T van Dongen; B J Crul; J van Egmond,"To determine the difference in intrathecal morphine dose progression between a continuous intrathecal infusion of a morphine/bupivacaine mixture and morphine for pain relief in patients with cancer. Patients were treated with intrathecal drugs in a randomized study and followed prospectively until death. Institute for Anesthesiology, Department of Pain Treatment, University Hospital Nijmegen, St Radboud, The Netherlands. Twenty patients with cancer were selected for intrathecal treatment because of either side effects or inadequate relief during conventional pain treatment. Intrathecal drug infusion rates and medication were adjusted according to pain relief and side effects. Progression of intrathecal morphine dose during a phase of adequate analgesia in both groups following regression analysis and analysis of possible treatment related side effects. The combination of intrathecal morphine and bupivacaine resulted in a diminished progression of the intrathecal morphine dose (slope of regression line = 0.0003 vs. 0.005, p = 0.0001) during a phase of stable analgesia in comparison with the morphine group. No serious side effects presented. The diminished intrathecal morphine dose increase in the combination group is considered to be due to a synergistic effect of bupivacaine on the intrathecal morphine-induced antinociception. A dose increment during long-term intrathecal infusion in cancer patients appears to be related to both disease progression and tolerance phenomena.",1999.0,0,0
165,10524469,Intravenous titration with morphine for severe cancer pain: report of 28 cases.,L Radbruch; G Loick; S Schulzeck; A Beyer; J Lynch; M Stemmler; G Lindena; K A Lehmann,"In a multicenter study, 28 patients with cancer pain and insufficient pain relief with analgesic treatment according to step II of the guidelines of the World Health Organization (WHO) were switched to oral slow-release morphine. Patients received intravenous morphine through a patient-controlled pump (PCA) for the first 24 hours (bolus = 1 mg, lockout interval = 5 minutes, maximum dose = 12 mg/hour). From day 2 patients were treated with oral slow-release morphine. Daily doses were calculated from the requirements of the day before. Breakthrough pain was treated with PCA until stable doses were reached (<2 boluses/day) and then with oral immediate-release morphine solution. Pain intensity was reported in a diary four times a day, in addition to mood, activity, and quality of sleep once daily. Mean duration until adequate pain relief reported (<30 on a 101-step numerical scale; NRS) was 5 hours (range = 80-620 minutes). Mean pain intensity was reduced from 67 NRS to 22 NRS. Mean doses of oral morphine were 133 mg/day initially and then 154 mg/day on day 14. Serious adverse events such as respiratory depression were not observed. Two patients terminated the study due to progressive symptoms of gastrointestinal obstruction. Seventy-five percent of the patients evaluated the effectiveness of the analgesic regime as good. Dose finding with intravenous PCA may be appropriate for a small minority of patients with severe pain. Higher treatment costs and the risk of complications are drawbacks of this method compared with conventional oral titration.",1999.0,0,0
166,10524470,"Efficacy and safety of controlled-release versus immediate-release oxycodone: randomized, double-blind evaluation in patients with chronic back pain.",M E Hale; R Fleischmann; R Salzman; J Wild; T Iwan; R E Swanton; R F Kaiko; P G Lacouture,"To compare the efficacy and safety of controlled-release oxycodone given every 12 hours with immediate-release oxycodone given four times daily in patients with persistent back pain. Randomized, double-blind, active-controlled, two-period crossover trial. Fifty-seven adult outpatients with stable, chronic, moderate-to-severe low back pain despite analgesic therapy were enrolled; 47 were randomized; 11 discontinued for side effects, most commonly nausea and vomiting. Controlled-release oxycodone tablets given every 12 hours; immediate-release oxycodone tablets given four times daily; dose titration with controlled-release or immediate-release for up to 10 days; double-blind treatment for 4-7 days each. Patients' pain scores (0 = none, 1 = slight, 2 = moderate, 3 = severe). Pain intensity decreased from moderate to severe at baseline to slight at the end of titration with both oxycodone formulations. The daily oxycodone dose was 40 mg or less in 68% of patients. During double-blind treatment, mean pain intensity was maintained at 1.2 (0.1 SE) with controlled-release and at 1.1 (0.1 SE) with immediate-release oxycodone. The most common adverse events were constipation, nausea, pruritus, somnolence, and dizziness. Controlled-release oxycodone given every 12 hours was comparable with immediate-release oxycodone given four times daily in efficacy and safety, and it provides convenient, twice-daily, around-the-clock treatment for selected patients with persistent back pain that is inadequately controlled by nonopioids or as-needed opioid therapy.",1999.0,1,1
167,10525594,[Effects of long-term opioid therapy on psychomotor function in patients with cancer pain or non-malignant pain].,B Larsen; H Otto; E Dorscheid; R Larsen,"Despite increasing use of oral opioids in cancer and non cancer pain, little is known about the effects of long-term opioid therapy on psychomotor performance. This study was designed to investigate the effects of long-term opioid analgesia on attention and reaction time in cancer pain and in non-malignant pain. Three groups of patients (n=128) were studied: 48 patients on long-term opioid therapy (group O; including 33 patients with cancer pain and 15 patients with chronic non-malignant pain), 30 patients receiving non-opioid analgesic therapy for chronic non-malignant pain (group NO) and a control group (group K) of 50 patients without pain and analgesic therapy. Attention was determined by Brickenkamp's d2-test, continuous reaction time by Schuhfried's method (Wiener Determinationsgerät, Mödling, Austria). In addition, a modified questionnaire developed by Zerssen was used to determine the patient's current mood. Pain, fatigue and anxiety levels were estimated by visual analogue scales. Although no significant difference in attention/concentration could be demonstrated between the three groups, patients taking opioids performed Brickenkamp's test a little worse and also demonstrated a significant decline in this parameter with advancing age. Also, in cancer patients attention/ concentration was more impaired than in non-cancer opioid patients. Auditory and optical reaction times were significantly slower in patients on opioids than in the non-opioid analgesic group and highly significant slower than in the control group, while in the more complex combinations test no such difference could be demonstrated. In addition, a highly significant deterioration in reaction times with increasing age could be demonstrated for opioid patients compared to the other groups, while only a non significant prolongation was found between cancer and non-cancer patients on opioid therapy. Long-term opioid therapy produces a slight (non significant) impairment of psychomotor performance in patients with cancer pain or non-malignant chronic pain. These effects become significantly more pronounced with increasing age and in patients with cancer pain, indicating a higher susceptibility of the elderly towards opioids. These results indicate that, particularly in older patients receiving long-term opioid for cancer oder non-cancer pain, careful evaluation of their effects on psychomotor function is necessary in order to estimate patient's ability to perform his daily activities. However, since opioid effects were only minimal in the non-elderly other factors like basic disease, opioid dose, physical condition and age seem to be of greater importance than the effects of opioids per se.",1999.0,0,1
168,10529851,"Prospective, randomized comparison of epidural and combined spinal epidural analgesia during labor.",M Van de Velde; K Mignolet; E Vandermeersch; A Van Assche,"The analgesic efficacy and incidence of maternal, fetal and neonatal side-effects of combined spinal epidural (CSE) and epidural (EPI) analgesia, using a mixture of bupivacaine 0.125%, epinephrine (1.25 micrograms.ml-1) and sufentanil (0.75 microgram.ml-1) for the relief of labor pain, were randomly and prospectively compared in 110 parturients. A 29 gauge Whitacre tip spinal needle was used to perforate the dura in CSE patients. Compared to EPI, CSE resulted in rapid (326 +/- 22 vs 766 +/- 79 sec, p < 0.05), excellent analgesia, using less bupivacaine (23.5 +/- 2.3 vs 33.9 +/- 2.9 mg, p < 0.05) and sufentanil (12.5 +/- 1.0 vs 16.5 +/- .7 micrograms, p < 0.05). A tendency to improved patient satisfaction in the CSE group was observed. The incidence of maternal or neonatal side effects was similar in both groups. No PDPH was observed. We conclude that CSE analgesia results in excellent pain relief during labor with immediate gratification as compared to epidural analgesia.",1999.0,0,0
169,10530535,Anesthetic methods for reduction of acute shoulder dislocations: a prospective randomized study comparing intraarticular lidocaine with intravenous analgesia and sedation.,J Kosnik; F Shamsa; E Raphael; R Huang; Z Malachias; G M Georgiadis,"A prospective, randomized, nonblinded clinical trial was undertaken to evaluate whether local intraarticular lidocaine injection (IAL) is equally effective in facilitating reduction of acute anterior shoulder dislocations (AASD) as intravenous analgesia/sedation (IVAS). The setting was an urban, Level 1, trauma center. Patients enrolled presented to the emergency department (ED) with radiographically confirmed AASD and were randomized either to the IVAS group or the IAL group. Ease of reduction and pain associated with reduction were measured subjectively using a 10-point scale. There were 49 patients entered into the study, 20 in the IVAS group and 29 in the IAL group. There was no statistically significant difference between mean +/- SD pain scores of 3.32+/-2.39 in the IVAS group and 4.90+/-2.34 in the IAL group (P = .18), or mean +/- SD ease of reduction scores of 3.32+/-2.36 in the IVAS group and 4.45+/-2.46 in the IAL group (P = .12). Although IVAS tended to have a higher success rate (20 of 20) than IAL (25 of 29) in this study, Kaplan-Meier estimates for delayed time-events curves applying the log-rank test showed that this difference was not statistically significant overall (P = .16). However, with reduction rate evaluated as a function of time delay in seeking treatment, patients presenting 5.5 hours after dislocation were more likely to fail treatment with IAL (P = .00001). Additionally, half of the patients in the IAL group who had experience with IVAS did not favor IAL. Emergency physicians should be aware of IAL as an alternative technique that may be considered in patients when there are reasons to avoid systemic analgesia or sedation.",1999.0,0,0
170,10531625,A new method for detoxifying opioid-dependent patients.,W Glatt,"The purpose of the study was to investigate a new method for detoxifying opioid-dependent patients. Butorphanol is an opiod with mixed agonist-antagonist properties, and is marketed as a nasal spray. Undiluted, it will cause significant physical withdrawal symptoms in a population dependent on opioids. Forty patients dependent on opioids were detoxified using dilute butorphanol spray. The initial concentration was 40% and gradually reduced. This technique was highly successful in keeping this difficult group of patients engaged in the treatment process for a longer period. This time increased the probability of getting these patients involved with postdetoxification services. There was a subset of patients who had chronic pain and were opioid dependent, who had adequate control of pain with butorphanol spray at 10 to 20% concentration. This unique and unusual approach is worthy of open discussion and further scientific studies.",1999.0,0,0
171,10534607,The kappa opioid nalbuphine produces gender- and dose-dependent analgesia and antianalgesia in patients with postoperative pain.,R W Gear; C Miaskowski; N C Gordon; S M Paul; P H Heller; J D Levine,"Nalbuphine, pentazocine, and butorphanol, mixed agonist/antagonist opioids that induce analgesia by acting predominantly at kappa opioid receptors, have recently been shown in single-dose studies to have greater analgesic efficacy in women than in men. In the current experiments, the first placebo controlled dose response study of opioid analgesic efficacy that examines for gender differences, nalbuphine (5, 10, or 20 mg) and placebo were evaluated in 62 men and 69 women for the treatment of moderate to severe postoperative pain following extraction of impacted wisdom teeth. In a randomized, open injection, double blind experimental design, pain intensity was recorded on a 10 cm visual analog scale (VAS) immediately prior to drug administration (baseline) and at 20 min intervals thereafter. Although responses to placebo were similar in men and women, for all doses of nalbuphine women exhibited significantly greater analgesic response than men, compatible with our previous results. Unexpectedly, men receiving the 5 mg dose of nalbuphine experienced significantly greater pain than those receiving placebo; only the 20 mg dose of nalbuphine in men produced significant analgesia compared to placebo. While a similar antianalgesic effect was not observed in women, only the 10 mg dose of nalbuphine produced significant analgesia compared to placebo. These results suggest that the optimal analgesic dose of nalbuphine for women is lower than the highest dose that can be safely administered. In contrast, the antianalgesic effect of nalbuphine suggests avoidance of its routine use for postoperative analgesia in men until further studies clarify this issue. Because gender differences in other mixed kappa agonists/antagonists (i.e. pentazocine and butorphanol) have previously been shown, these results may generally apply to this class of opioid analgesics.",1999.0,0,0
172,10534971,Reduction in constipation and laxative requirements following opioid rotation to methadone: a report of four cases.,P J Daeninck; E Bruera,"Constipation is a common symptom in cancer patients, especially in those who are receiving opioid analgesics for pain. Although several articles have recently examined constipation with respect to causation and treatment, little research has been done to elucidate the effects of different opioids on the bowel. Recent research has found that laxative doses may be lower in patients using methadone as an analgesic, but changes in constipation were not measured. We report here on four cases in which patients had improvement in constipation and decreased laxative requirements following opioid rotation to methadone.",1999.0,0,0
173,10536549,Analgesic efficacy of paracetamol and diclofenac in children receiving PCA morphine.,N S Morton; K O'Brien,"We studied 80 children, aged 5-13 yr, who received PCA with morphine after appendicectomy using a standardized tracheal general anaesthetic. All patients received morphine 0.1 mg kg-1 before surgical incision and all had wound infiltration with bupivacaine 1 mg kg-1 at the end of surgery. Patients were allocated randomly to receive postoperative analgesia with PCA morphine alone, morphine plus diclofenac 1 mg kg-1, morphine plus paracetamol 15-20 mg kg-1 or morphine plus a combination of both diclofenac and paracetamol. Cumulative morphine consumption was significantly reduced by concurrent administration of diclofenac but no additive effect of paracetamol was demonstrable with the doses used in the study. Analgesia, as assessed by movement pain scoring, was significantly improved by the addition of diclofenac despite lower morphine consumption. Adverse effects and duration of PCA were comparable in the four groups.",2000.0,0,0
174,10539379,"Transdermal fentanyl in patients with chronic, nonmalignant pain: a case study series.",K A Milligan; C Campbell,"Four cases of patients with chronic, nonmalignant pain who received transdermal fentanyl are presented. These indicate that some patients may benefit from such treatment but also serve to emphasize the importance of careful patient selection and assessment.",1999.0,0,1
175,10540058,The effect of rectal diclofenac on pruritus in patients receiving intrathecal morphine.,S Colbert; D M O'Hanlon; S Galvin; F Chambers; D C Moriarty,"In this prospective randomised study, pruritus and pain were evaluated in patients undergoing abdominal surgery in which intrathecal morphine was administered. Each patient received intrathecal morphine 0.3 mg prior to induction, followed by a standard anaesthetic. The patients were randomly allocated to one of two groups. One group received 100 mg of rectal diclofenac immediately post-induction. Patients receiving diclofenac had significantly lower pruritus scores at 30 min (p = 0.0076), 2, 4, 8 and 24 h postoperatively, as well as significantly reduced pain scores at each time point (p < 0.0001 at each study interval). Morphine consumption in the first 24 h was also significantly lower in this group. In conclusion, rectal administration of diclofenac significantly reduces the incidence and severity of postoperative pruritus. It also significantly reduces pain and further analgesic requirements postoperatively.",1999.0,0,0
176,10541775,Assessment of analgesia in human chronic pain. Randomized double-blind crossover study of once daily repro-dose morphine versus MST continus.,S Peat; P Sweet; Y Miah; M Barklamb; U Larsen,"This study evaluated Repro-Dose morphine (RDM; Reliadol from Nycomed Pharma), a new once daily controlled-release morphine formulation, against twice daily MST Continuous (MST) at steady state in patients with chronic opioid responsive pain. A randomized double-blind two-way crossover design was used to evaluate the efficacy and adverse effects of RDM once daily or MST twice daily, at the same total daily doses, in patients with chronic stable pain (dose range 20-120 mg per day). During the RDM limb of the study active drug was administered in the evening and placebo in the morning. Dextromoramide was provided as escape analgesia throughout the study. Following a 5-day screening period, during which stability of oral opioid dose was verified, patients underwent two 5-day treatment periods, (one MST, one RDM) in random sequence. Pain scores, escape analgesia requirements and side-effects were compared using data from days 3, 4 and 5 of each treatment period. Any events or medication changes occurring during the study period thought liable to influence analgesia were regarded as protocol violations. Overall assessment and period preference was assessed by direct questioning. RDM treatment was regarded as successful if the amount of escape medication required during the RDM period was equal to or less than that required during the MST period. Forty-seven patients were included in the study, of whom 40 completed both periods [the intention to treat (ITT) population], 31 in strict accordance with the protocol [the per protocol (PP) population]. Results were similar for both populations. There was no significant difference in pain scores or incidence of adverse events occurring during the MST and RDM periods. For the ITT population, requirements for escape medication during the RDM period were less than, equal to or greater than those recorded during the MST period for 14, 15, and 11 patients, respectively. Twenty-nine of 40 patients (72.5%) were therefore RDM treatment successes (95% confidence interval 56.1-85.4%). The percentage of patients preferring RDM (45%) combined with those with no preference (32.5%) was significantly higher than those preferring MST (22.5%; P = 0. 0003). Oral morphine administered as RDM once daily is at least as effective and well tolerated as MST twice daily, with over 70% of patients in this double-blind crossover study reporting that RDM was equal or superior to MST.",1999.0,1,1
177,10548210,Effect of patient-controlled analgesia on pulmonary complications after coronary artery bypass grafting.,R Gust; S Pecher; A Gust; V Hoffmann; H Böhrer; E Martin,"To determine whether treatment with patient-controlled analgesia (PCA) alone or in combination with nonsteroidal anti-inflammatory drugs can prevent postoperative pulmonary complications after cardiac surgery, when compared with conventional nurse-controlled analgesia. Randomized controlled trial. University Medical Center. A total of 120 patients undergoing elective coronary artery bypass grafting. After extubation of the trachea, 120 patients were randomly allocated to three different methods of postoperative pain relief for 72 hrs. In group 1, patients received PCA with a bolus of 1.5 mg piritramide combined with a 10-min lockout interval. Group 2 patients were treated with a combination of PCA and administration of nonsteroidal anti-inflammatory drugs prescribed three times per day. Patients of group 3 received conventional nurse-controlled analgesia. Postoperative assessment included daily visual analog pain scoring (VAS) and chest radiographs. All chest radiographs were graded for the extent of atelectasis by a radiologist blinded as to treatment using a scale from 0 to 9 for each of the three lung fields of the right and left lungs. Chest radiograph atelectasis scores and VAS values were similar among the three groups on the first and second days. On the third day, the chest radiograph atelectasis scores of the left lower and the right middle lung field were significantly better in the groups treated with PCA alone (4.7 +/- 3.0; 0.3 +/- 1.0) and in combination with nonsteroidal anti-inflammatory drugs (3.9 +/- 1.1; 0.4 +/- 1.2) than in the control group (5.5 +/- 3.1; 0.8 +/- 1.8). Furthermore, on the third day, the VAS values for maximum pain were higher in the control group (42.6 +/- 19.7) compared with the VAS values in the two groups with PCA (32.2 +/- 17.9 and 34.5 +/- 21.0). PCA significantly decreases postoperative pulmonary atelectasis in patients after coronary artery bypass grafting when compared with nurse-controlled analgesia. In addition, patients treated with PCA experienced a higher quality of analgesia. We therefore conclude that treatment with PCA may reduce respiratory complications after coronary artery bypass grafting.",1999.0,0,0
178,10548704,Comparison of anesthetic methods for microlaparoscopy in women with unexplained infertility.,H Takeuchi; M Jinushi; Y Nakano; Y Sato; Y Toyonari; A Mizushima; Y Kuwabara,"To evaluate the effectiveness of ketamine compared with fentanyl as analgesia or sedation for microlaparoscopy. Prospective, randomized study (Canadian Task Force classification I). University-affiliated hospital. Forty-one infertile women. Twenty-one patients were randomly assigned to have analgesia with fentanyl and 20 sedation with ketamine during microlaparoscopy. Maximum doses were 0.2 and 200 mg, respectively. Local anesthesia was provided with 0.25% bupivacaine 5 ml injected into cannula sites. Abnormal findings such as endometriosis and periadnexal adhesions were identified in 24 patients. Ablation, coagulation, and adhesiolysis were easily performed in 14 (82.4%) of 17 women receiving ketamine, but difficulties were encountered in operating on 16 patients receiving fentanyl. Ketamine was administered to 10 patients (47.6%) in the fentanyl group because anxiety and pain were not sufficiently controlled by fentanyl. There were no significant differences in visual analog scale scores and recovery time between groups. On questionnaire, 19 (95%) of 20 patients receiving ketamine indicated they would choose the same anesthesia again if offered, compared with only 4 (19%) of 21 receiving fentanyl (p <0.001). Microlaparoscopy in infertile women was performed more effectively under sedation with ketamine than with fentanyl.",1999.0,0,0
179,10549465,An assessment of prochlorperazine buccal for the prevention of nausea and vomiting during intravenous patient-controlled analgesia with morphine following abdominal hysterectomy.,P I Williams; M Smith,"The effectiveness of prochlorperazine buccal as an anti-emetic for the prevention of post-operative nausea and vomiting in patients using intravenous patient-controlled analgesia with morphine following abdominal hysterectomy has been assessed in a randomized, double-blind, placebo-controlled study. Forty-nine female patients participated with 26 allocated to the prochlorperazine buccal group and the remainder to the placebo group. Each received either placebo or prochlorperazine buccal 6 mg, in each case by the buccal route, 1 h prior to anaesthesia with further doses at 6, 18, 30 and 42 h, respectively. Symptom scores in respect of nausea, pain and sedation, the number without nausea, the number without vomiting and the requirement for rescue anti-emetic therapy were noted for each 4-h period during the 48-h study. Morphine utilization and taste associated with the study material were recorded. Data for 21 patients in the placebo group and 25 patients in the prochlorperazine buccal group were available for analysis. Patients in the prochlorperazine buccal group showed significantly lower mean nausea scores at 4-8 h (placebo group: mean nausea score 0.95; prochlorperazine buccal group: mean nausea score 0.36; P < 0.05) and at 16-20 h (placebo group: mean nausea score 1.24; prochlorperazine buccal group: mean nausea score 0.48; P < 0.05). Furthermore, the prochlorperazine buccal group showed significantly more patients without nausea at 4-8 h (placebo group: 11 patients out of 21; prochlorperazine buccal group: 20 patients out of 25; P < 0.05) and at 16-20 h (placebo group: nine patients out of 21; prochlorperazine buccal group: 18 patients out of 25; P < 0.05). The prochlorperazine buccal group showed a significantly higher number of patients rating the taste as unsatisfactory (placebo group: two patients out of 21; prochlorperazine buccal group: nine patients out of 25; P < 0.05). Intravenous droperidol is the current gold standard prophylactic anti-emetic in post-operative nausea and vomiting associated with intravenous patient controlled analgesia with morphine usage. This study has demonstrated a peri-operative prochlorperazine buccal regimen to be effective in post-operative nausea and vomiting prophylaxis in the use of intravenous patient controlled analgesia with morphine. Prochlorperazine buccal should be considered as an effective, inexpensive option for the prevention of post-operative nausea and vomiting in post-operative intravenous patient controlled analgesia with morphine administration.",1999.0,0,0
180,10549929,Bilateral anterior cingulotomy for chronic noncancer pain.,H A Wilkinson; K M Davidson; R I Davidson,"To document the value of bilateral anterior cingulotomy for patients with intractable chronic noncancer pain. Twenty-three patients who underwent 28 cingulotomies between 1979 and 1996 for chronic refractory pain were sent questionnaires regarding their subjective response to the surgery and its impact on their pain. Questions dealt with pre- and postoperative pain, ability to resume work or usual activity, medications, family and social interactions, and overall benefit of cingulotomy. Results were compared with long-term (average, 8 yr) clinical follow-up. In 13 patients, pain was predominantly caused by lumbar adhesive arachnoiditis or ""failed back."" The remainder had venous occlusive disease, ischemic bilateral leg pain, phantom leg pain, postoperative neck pain, or atypical facial pain. Eighteen patients returned questionnaires; two patients died of unrelated causes. Seventy-two percent of patients reported improvement in their pain, 55% were no longer taking narcotics, 67% noted improvement in their family life, and 72% noted improvement in their social interactions. Fifty-six percent of patients reported that the cingulotomy was beneficial, and 28% returned to their usual activities or work. Thirty-nine percent of patients developed transient or well-controlled seizures. Five patients required a second cingulotomy, and one patient did well despite developing brain abscesses. Patient assessments corresponded closely with clinical assessments. Bilateral anterior cingulotomy is safe for patients with refractory chronic pain. Seizures reported in this series were well controlled with medication. More than half of all respondents thought they had a positive outcome and that cingulotomy was beneficial to them. There were no deaths related to the procedure.",1999.0,0,0
181,10551571,Effect of the frequency of transcutaneous electrical nerve stimulation on the postoperative opioid analgesic requirement and recovery profile.,M A Hamza; P F White; H E Ahmed; E A Ghoname,"Transcutaneous electrical nerve stimulation (TENS) at either an acupoint or dermatome corresponding to the surgical incision produces comparable decreases in postoperative opioid requirements and opioid-related side effects. However, the effect of the frequency of the electrical stimulus on the postoperative analgesic response to TENS therapy has not been studied. One hundred women undergoing major gynecological procedures with a standardized general anesthetic technique were enrolled in the study. Patients were randomly assigned to four groups: group I, patient-controlled analgesia (PCA) plus sham TENS (no stimulation); group II, PCA plus low-frequency (2-Hz) TENS; group m, PCA plus high-frequency (100-Hz) TENS; group IV, PCA plus mixed-frequency (2- and 100-Hz) TENS. The PCA device was programmed to deliver 2-3 mg intravenous boluses of morphine with a lockout interval of 10 min. The TENS device was used every 2 h during the day. Standard 100-mm visual analog scales were used to assess pain, sedation, fatigue, and nausea at specific intervals after surgery. Mixed frequency (2 and 100 Hz) of stimulation decreased morphine requirements by 53% compared with the sham group; low (2-Hz) and high (100-Hz) frequencies produced 32% and 35% decreases, respectively. All three ""active"" TENS groups reduced the duration of PCA therapy, as well as the incidence of nausea, dizziness, and itching. TENS decreased postoperative opioid analgesic requirements and opioid-related side effects when utilized as an adjunct to PCA after lower abdominal surgery. Use of TENS at mixed (2- and 100-Hz) frequencies of stimulation produced a slightly greater opioid-sparing effect than either low (2-Hz) or high (100 Hz) frequencies alone.",1999.0,0,0
182,10551756,Managing intractable pain with an intrathecal catheter and injection port: technique and guidelines.,D Meenan; J A Lagares-Garcia; S Kurek; D Craig; J Green; W Fritz,"The objective of our study was to describe an effective technique for the management of chronic intractable pain in patients with intermediate life expectancy or as a long-term screening device prior to implantable pump therapy. In the study, an InDura intraspinal catheter is connected to a BardPort, which is accessed transdermally. We describe our surgical technique, recommended dosage calculations, cost comparison to an implantable infusion pump, and our experience with 13 cases. In our series of 13 patients, there was one seroma and one dural leak. There were no infections, and all were functioning well in the 12 cancer patients until their deaths. One case was converted to an implantable pump. There were no malfunctions or infections of the intrathecal infusion system in the 12 cancer patients. This intrathecal drug infusion system should be considered in the treatment armamentarium for chronic intractable pain and cancer pain.",1999.0,0,0
183,10562783,Combined epidural-spinal opioid-free anaesthesia and analgesia for hysterectomy.,T Callesen; L Schouenborg; D Nielsen; H Guldager; H Kehlet,"Postoperative nausea and vomiting (PONV) are major problems after gynaecological surgery. We studied 40 patients undergoing total abdominal hysterectomy, allocated randomly to receive opioid-free epidural-spinal anaesthesia or general anaesthesia with continuous epidural bupivacaine 15 mg h-1 or continuous bupivacaine 10 mg h-1 with epidural morphine 0.2 mg h-1, respectively, for postoperative analgesia. Nausea, vomiting, pain and bowel function were scored on 4-point scales for 3 days. Patients undergoing general anaesthesia had significantly higher nausea and vomiting scores (P < 0.01) but significantly lower pain scores during rest (P < 0.05) and mobilization (P < 0.01). More patients undergoing general anaesthesia received antiemetics (13 vs five; P < 0.05), but fewer received supplementary opioids on the ward (eight vs 16; P < 0.05). We conclude that opioid-free epidural-spinal anaesthesia for hysterectomy caused less PONV, but with less effective analgesia compared with general anaesthesia with postoperative continuous epidural morphine and bupivacaine.",1999.0,0,0
184,10562784,Postoperative pain after adenoidectomy in children.,E Nikanne; H Kokki; K Tuovinen,"We have investigated if pain intensity or analgesic requirements in hospital predicted pain intensity, pain duration or analgesic requirements at home in 611 children, aged 1-7 yr, after day-case adenoidectomy. We also investigated if ketoprofen 0.3-3.0 mg kg-1, administered pre-emptively i.v. during operation, modified pain at home. In hospital, a prospective, randomized, double-blind, placebo-controlled study design was performed. A standard anaesthetic technique was used in all children and fentanyl i.v. was available for rescue analgesia. After discharge, the study design was open, experimental, prospective and longitudinal. On return home, children were prescribed ketoprofen tablets 5 mg kg-1 day-1. Parents were asked to complete an analgesia diary; non-responders were contacted by telephone. The response rate was 91%. The number of doses of fentanyl given in hospital correlated with pain intensity at home (P < 0.001). There were no other correlations and no pre-emptive effect of ketoprofen.",1999.0,0,0
185,10566922,Comparison of patient-controlled analgesia (PCA) with tramadol or morphine.,W W Pang; M S Mok; C H Lin; T F Yang; M H Huang,"To compared the clinical efficacy of tramadol and morphine using a patient-controlled analgesia (PCA) delivery system. In a prospective, randomized, double blind study, we evaluated 80 adult patients scheduled for elective hip or knee arthroplasty with general inhalational anesthesia. When patients complained of pain in the recovery room, patients were randomized to receive either tramadol or morphine by titration in 30 min to achieve analgesia (VAS < or =4). Equivalent volumes containing either 30 mg x ml(-1) tramadol or 1 mg x ml(-1) morphine were used for PCA with a lockout interval of 10 min. The patients were followed six-hourly for 48 hr for VAS, satisfaction rate, analgesic dose, and side effects. Patients obtained adequate analgesia with either drug. More patients had very good satisfaction scores in the morphine group in the recovery room (43% vs. 23%, P<0.05) and at 24 hr (40% vs. 20%, P<0.05) than those in the tramadol group. More nausea was evident in the tramadol group (48% vs. 11% in recovery room and 28% vs. 12% in 24 hr, P<0.05) than in the morphine group. Vomiting was also more (28% vs. 5% in recovery room, 15% vs. 3% in 24 hr, P<0.05). Morphine produced more sleepiness (45% vs. 23% in recovery room, P<0.05 and 35% vs. 15% in 24 hr, P<0.05). Tramadol PCA can provide effective analgesia following major orthopedic surgery provided sufficiently high doses are given for loading and by patient demand. However, the incidence of nausea/vomiting is also higher causing decreased satisfaction.",1999.0,0,0
186,10567729,"NMDA and opioid receptors: their interactions in antinociception, tolerance and neuroplasticity.",J Mao,"Over the last several years, significant progress has been made in our understanding of interactions between the N-methyl-D-aspartate (NMDA) and opioid receptors. Such interactions have been demonstrated at two distinct sites: (1) modulation of NMDA receptor-mediated electrophysiological events by opioids; and (2) intracellular events involving interactions between NMDA and opioid receptors. Furthermore, a considerable number of studies have shown the involvement of such interactions in neural mechanisms of nociceptive transmission, antinociception in acute and chronic pain states, opioid tolerance/dependence, and neuroplasticity. Importantly, emerging evidence indicates that activation of NMDA receptors may differentially modulate functions mediated by distinct opioid receptor subtypes, namely mu, delta, and kappa receptors. These studies have greatly enriched our knowledge regarding both NMDA and opioid receptor systems and have shed light on neurobiology of both acute and chronic pain. The advancement of such knowledge also promotes new strategies for better clinical management of pain patients.",1999.0,0,0
187,10568861,Intraarticular morphine versus dexamethasone in chronic arthritis.,A Stein; A Yassouridis; C Szopko; K Helmke; C Stein,"Intraarticular morphine inhibits pain after knee surgery without overt toxicity. This study examined intraarticular morphine in chronic arthritis. We undertook a randomized double-blind comparison between intraarticular morphine (3 mg), dexamethasone (4 mg) and saline (3 ml) in 44 patients with chronic inflammatory arthritis or osteoarthritis of the knee. Pain (the primary outcome measure) was assessed at rest and during activity for 6 days using a visual analog scale (VAS) and the McGill pain questionnaire. Before drug injections and on day 6 synovial leukocyte counts (the secondary outcome measure) were taken. During the first 6 h after injection both morphine and dexamethasone significantly reduced VAS and pain rating indices (PRI) in comparison to saline. Both substances also produced a significant reduction of PRI compared to saline during the subsequent 5 days. No patient displayed untoward side effects. Synovial leukocyte counts were lower after morphine than after saline. In conclusion, intraarticular morphine produces analgesia of similar magnitude to dexamethasone and it may have antiinflammatory actions in chronic arthritis.",1999.0,0,0
188,10568873,Effects of intravenous methylnaltrexone on opioid-induced gut motility and transit time changes in subjects receiving chronic methadone therapy: a pilot study.,C S Yuan; J F Foss; M O'Connor; J Osinski; M F Roizen; J Moss,"In this preliminary study, we evaluated the effects of methylnaltrexone, a peripheral opioid-receptor antagonist, on chronic opioid-induced gut motility and transit changes in four subjects with chronic methadone-induced constipation. Subjects participated in this single blind, placebo controlled study for up to 8 days. We gave placebo the first day; for the remainder of the study, we gave intravenous methylnaltrexone (0.05-0.45 mg/kg) twice daily. During the study period, we recorded oral-cecal transit time and opioid withdrawal symptoms, as well as laxation response based on the frequency and consistency of the stools. Subjects 1 and 2 who were administered methylnaltrexone 0.45 mg/kg, a dose previously administered in normal volunteers, showed immediate positive laxation. Subject 2, after positive laxation response, had severe abdominal cramping, but showed no opioid systemic signs of withdrawal. The subject was discontinued due to the cramping. In Subjects 3 and 4, we reduced the methylnaltrexone dose to 0.05-0.15 mg/kg. The latter two subjects also had an immediate laxation response during and after intravenous medication without significant side effects. The stool frequency of these four subjects increased from 1-2 times per week before the study to approximately 1.5 stool per day during the treatment period. Oral-cecal transit times of Subjects 1, 3, and 4 were reduced from 150, 150 and 150 min (after placebo) to 90, 60 and 60 min (with methylnaltrexone), respectively. Our preliminary results demonstrate that low dose intravenous methylnaltrexone effectively reversed chronic methadone-induced constipation and delay in gut transit time. Thus, we anticipate that cancer patients receiving chronic opioids may also have increased sensitivity to methylnaltrexone, and that low dose methylnaltrexone may have clinical utility in managing opioid-induced constipation in chronic-pain patients.",1999.0,0,0
189,10575502,[Mechanisms of opioid tolerance and opioid dependence].,A Muller; B Koch; F René; A L Boutillier; V See; J P Loeffler,"Prescription of opiates to non cancer chronic pain patients is controversial, partly because of the risk of tolerance and dependence development. The two objectives of that review were: a) to identify the factors which may explain the variability of tolerance and dependence in clinical practice; b) to analyse the cellular mechanisms of occurrence of those phenomenons. To our own file, we added articles retrieved in the Medline database, using, alone or in combination, following key-words (opiate, tolerance, dependence, opiate receptor, pain treatment, cAMP, cGMP, NO, NMDA, protein kinase, gene). Out of nearly 450 articles, we selected less than 200. Tolerance, defined as loss of opioid efficacy with time, is extremely variable and depends on pain mechanisms, intrinsic efficacy and administration modality of the opioid, as well as co-administration of other agents. Physical dependence is a consequence of the intrinsic and extrinsic adaptations concerning structures as locus coeruleus, paragigantocellular nucleus, spinal cord. Acute and chronic application of opiates and withdrawal give rise to cellular adaptations which depend on the nature and efficacy of the opiate, the type of receptor and second messengers, as well as the type of cell line under study. These cellular mechanisms have consequences on neuronal excitability and gene expression. They constitute a model of cellular tolerance and dependence, but cannot explain the subtelties encountered in clinical practice.",1999.0,0,0
190,10583349,Ondansetron is more effective than metoclopramide for the treatment of opioid-induced emesis in post-surgical adult patients. Ondansetron OIE Post-Surgical Study Group.,F Chung; R Lane; C Spraggs; B McQuade; M Jacka; H H Luttropp; S Alahuta; S Rocherieux; M Roy; P Duvaldestin; P Curtis,"Nausea and vomiting are common side effects of opioids administered for pain control. This double-blind, randomized, parallel-group study evaluated the anti-emetic efficacy and tolerability of single intravenous (i.v.) doses of ondansetron 8 mg, ondansetron 16 mg and metoclopramide 10 mg in the treatment of opioid-induced emesis. Adult patients undergoing low emetogenic surgical procedures, using a standardized anaesthesia regimen were assessed for 24 h following administration of study anti-emetic to treat established post-surgical opioid-induced emesis. A total of 4511 patients were enrolled of whom 1366 experienced opioid-induced emesis and received randomized study medication. Ondansetron 8 mg and 16 mg were significantly better than metoclopramide 10 mg (P < 0.05) for both complete control of emesis, complete control of nausea and other efficacy measures. There were no significant differences between the two ondansetron groups. All three treatments were well tolerated. In conclusion, this large, multicentre study demonstrates that ondansetron is more effective than metoclopramide in the treatment of opioid-induced emesis following administration of post-surgical opioids to control pain.",1999.0,0,0
191,10583355,Comparison of intra-articular fentanyl and intra-articular bupivacaine for post-operative pain relief after knee arthroscopy.,J S Pooni; K Hickmott; D Mercer; P Myles; Z Khan,"A randomized double-blinded study consisting of 107 patients was conducted to compare the effect on post-operative pain relief of intra-articular fentanyl and intra-articular bupivacaine after knee arthroscopy. The results showed that intra-articular bupivacaine produced superior analgesia in the immediate post-operative period. At 2 h post-operatively, the intra-articular bupivacaine group had a mean pain score of 2.0 (standard deviation 2.1, P < 0.05) compared with the intra-articular fentanyl group which had a mean pain score of 3.2 (standard deviation 2.3, P < 0.05). After 2 h post-operatively, intra-articular bupivacaine and intra-articular fentanyl had a similar effect on pain scores. The mean pain score 18 h post-operatively was 2.7 for the intra-articular bupivacaine group (standard deviation 2.2, P value 0.6) compared with the intra-articular fentanyl group which had a mean pain score of 2.8 (standard deviation 1.9, P value 0.6).",1999.0,0,0
192,10593159,Post-operative pain control--prescription pattern and patients' experience.,O A Soyannwo,"The prescription pattern for post-operative pain and patients' experience with pain relief were studied in 200 adult patients who had anaesthesia and surgery at the University College Hospital, Ibadan. Intermittent intramuscular injection of analgesics were prescribed for 192 patients (96%) while other routes were intravenous injections (2%), intravenous infusion (1%) and intermittent epidural injection (1%). Moderate to severe pain was reported by 46% and 49.5% of the patients immediately after surgery and before subsequent analgesic doses were due respectively. Pain disturbed patients from sleeping, moving in bed and coughing. It also made patients cry (20%), feel depressed (23%), anxious (12.5%) and angry (14.5%). Despite the high incidence of pain and the associated disturbances, 178 patients (89%) still found overall pain relief satisfactory.",1999.0,0,0
193,10593465,"Intraarticular, epidural, and intravenous analgesia after total knee arthroplasty.",J A Klasen; S A Opitz; C Melzer; A Thiel; G Hempelmann,"After total knee arthroplasty, patients regularly suffer from severe pain. It is unclear whether epidural or systemic pain therapy is superior in terms of postoperative pain relief, patients' comfort and side effects. A new therapeutic approach, intraarticular opioids, has been suggested with the detection of opioid receptors in inflamed tissue. This method has proven suitable for clinical use in small operations (e.g. knee arthroscopy). In this study, we compared epidural analgesia and intraarticular application of morphine plus ""on-demand"" intravenous analgesia to ""on-demand"" intravenous analgesia alone. Thirty-seven patients, scheduled for total knee arthroplasty, were randomly assigned to three treatment groups: in group 1 (EPI) patients received bolus doses of morphine via an epidural catheter; in group 2 (IA) an intraarticular bolus of 1 mg of morphine was applied at the end of the operation with subsequent use of a patient-controlled analgesia (PCA) pump; group 3 (Control), in which only PCA was provided, served as control for both analgesic procedures. Main outcome measures included visual analogue pain scales, total morphine consumption, and stress hormones. No statistically significant differences in visual analogue pain scales could be detected between the three groups. Application of intraarticular morphine did not reduce the amount of analgesics required for postoperative analgesia as compared to intravenous analgesia alone. Application of epidural morphine significantly suppressed beta-endorphine release, but did not significantly influence other stress hormones as compared to the control group. Epidural and intravenous analgesia after total knee arthroplasty are equivalent methods of pain relief. In major orthopaedic procedures, application of intraarticular morphine does not reduce analgesic requirements.",1999.0,0,0
194,10594428,Speed of onset of regional analgesia in labour: a comparison of the epidural and spinal routes.,J S Nickells; D J Vaughan; N K Lillywhite; B Loughnan; M Hasan; P N Robinson,This study compares the speed of onset of effective analgesia in two randomly assigned groups of patients requesting analgesia in labour. Patients in the combined spinal-epidural group (n = 69) were given a subarachnoid injection of 1.5 ml containing bupivacaine 2.5 mg and fentanyl 25 microg for initiation of analgesia. Patients in the epidural group (n = 73) were given an epidural injection of 10 ml containing bupivacaine 12.5 mg and fentanyl 50 microg. Mean (SD) onset times to the first pain-free contraction were 10.0 (5.7) min in the combined spinal-epidural group and 12.1 (6.5) min in the epidural group (p = 0.054). Patients in the combined spinal-epidural group suffered a higher incidence of motor weakness and proprioceptive deficit than those in the epidural group (p = 0.01). The incidence of technique failure and side-effects was similar in the two groups. It is our contention that the statistically nonsignificant difference in onset times does not justify the additional potential for side-effects and the extra cost of the equipment involved in the combined spinal-epidural technique.,2000.0,0,0
195,10597055,The role of pancreaticoduodenectomy in the treatment of severe chronic pancreatitis.,S M Vickers; C Chan; M J Heslin; A Bartolucci; J S Aldrete,"Chronic pancreatitis remains a debilitating disease with few definitive options for treatment. The purpose of this study was to evaluate the benefit of pancreaticoduodenectomy in the treatment of chronic pancreatitis. The results were evaluated by standard descriptive statistics. In a retrospective study, we reviewed the patients at a single institution undergoing pancreaticoduodenectomy between 1994 and 1997 for complications of chronic pancreatitis. Patients were evaluated for preoperative indication for surgery and perioperative morbidity and mortality, as well as long-term results. Thirty-two patients underwent pancreaticoduodenectomy for chronic pancreatitis; 56 per cent (18) underwent pylorus-preserving and 44 per cent (14) underwent classic pancreaticoduodenectomy. The mean age of these patients was 56+/-14.7 years (range, 23-79). All patients underwent preoperative CT scan and endoscopic retrograde cholangiopancreatography. The preoperative indication for surgery in 81 per cent (26) of these patients was intractable pain in the setting of a nondilated pancreatic duct. The other 19 per cent were treated for biliary/pancreatic duct stricture and pancreatic head fibrosis (mass suspicious of malignancy). Fifty-three per cent of the patients had a history of previous abdominal surgery. There were no perioperative deaths. The mean postoperative stay was 12.2+/-7.4 days. The postoperative morbidity rate was 31 per cent (10), consisting of 25 per cent with delayed gastric emptying, 3 per cent with pneumonia, and 3 per cent with wound infections. There was no occurrence of pancreatic fistulas. With a mean follow-up of 40 months (range, 10-52 months), 85 per cent reported a significant improvement in pain with 71 per cent being pain free and not requiring narcotics. Twenty per cent developed new-onset diabetes. The overall event survival rate at 5 years was 97 per cent. Thus, in a selected group of patients with severe chronic pancreatitis, resection of the head of the pancreas achieved relief of symptoms and was a safe and effective treatment for chronic pancreatitis.",1999.0,0,0
196,10597883,The role of dopamine in the nucleus accumbens in analgesia.,N Altier; J Stewart,"Opioid and psychostimulant drugs have long been used for the relief of chronic pain in the clinical situation. Animal studies confirm that these drugs alleviate persistent or tonic pain. Little is known, however, about the neural systems underlying the suppression of tonic pain except that they are different from those mediating the suppression of phasic (i.e., sharp and short-lasting) pain. Although spinal and brainstem-descending pain suppression mechanisms play a role in mediating the inhibition of tonic pain, it appears that this response is additionally mediated by the activation of mechanisms lying rostral to the brainstem. Recent studies suggest that the activation of mesolimbic dopamine (DA) neurons, arising from the cell bodies of the ventral tegmental area (VTA) and projecting to the nucleus accumbens (NAcc), plays an important role in mediating the suppression of tonic pain. Other studies suggest that this pain-suppression system involving the activation of mesolimbic DA neurons is naturally triggered by exposure to stress, through the endogenous release of opioids and substance P (SP) in the midbrain.",1999.0,0,0
197,10598433,Effects of diclofenac and intra-articular morphine/bupivacaine on postarthroscopic pain control.,Y Gürkan; L Kiliçkan; L Buluc; S Müezzinoglu; K Toker,"This study was undertaken to compare analgesic effects and requirements for supplemental analgesic therapy after knee arthroscopy in patients given intraarticular morphine/bupivacaine, diclofenac i.m., or both compared with placebo. In a randomised, double-blind controlled trial 40 patients were divided into four groups. Patients received 25 ml of 0.25% bupivacaine and 2 mg of morphine intraarticularly in group I, 75 mg of diclofenac i.m. in group III, the combination of 75 mg of diclofenac i.m. and 25 ml of 0.25% bupivacaine and 2 mg of morphine intraarticularly in group II, and placebo in group IV. Postoperative analgesia was provided with fentanyl in the recovery room and acetaminophen was given for subsequent pain relief. In the postoperative period, VAS scores for pain were highest in the placebo group, whereas they were lowest in the combination group. VAS scores were significantly lower in group I and II than group IV at the postoperative 2nd hour (p < 0.05). VAS score was significantly lower in group II than groups III and IV at the postoperative 3rd hour (p < 0.01). VAS scores were significantly lower in group I, II and III than group IV at the postoperative 6th hour (p < 0.05). Fentanyl consumption was significantly lower in group II than group IV (p < 0.05). Acetaminophen consumption in groups II and III were significantly lower than group IV (p < 0.05). The combination of diclofenac i.m. and intraarticular morphine/bupivacaine appears to be the most beneficial analgesic combination due to its lower VAS scores and supplemental analgesic requirements in the postoperative period.",1999.0,0,0
198,10598634,Intrathecal drug therapy for chronic pain: from basic science to clinical practice.,P M Dougherty; P S Staats,,1999.0,0,0
199,10603686,Pain in adult recipients of blood or marrow transplant.,C Pederson; L Parran,"Severe pain is a problem for most bone marrow transplant (BMT) recipients. The purpose of this descriptive study was to describe the pain experience of adults undergoing autologous BMT, allogeneic BMT, or peripheral blood stem cell transplant. The sample consisted of 20 adults, 21 to 54 years of age. Using investigator-developed structured interview guides, investigators interviewed each participant four times: on the day of transplant, then at 3-weekly intervals. Investigators used a content analysis approach when analyzing data. During the first interview, 18 participants said that they were told to expect mouth sores during BMT, yet only six said that they actually expected to experience mouth sores during BMT. During successive interviews, 13 reported mouth sores. Eight other pain sites were reported. Participants reported that their tolerance of mild, moderate, and severe pain decreased over 2 weeks, and they named a wide variety of factors that caused or relieved pain. Ten said that they used nonpharmacologic techniques to feel more comfortable. Seven said that their BMT pain was worse or more difficult than they had expected. Overall pain ratings ranged from 0 to 8 on a 0 to 10 scale, M = 4.5. Five said the side effects of analgesics bothered them more than their pain. Most of them said a pain-rating scale was useful. Three weeks post-BMT, seven said they still experienced pain. Implications for clinical practice, research, and education are discussed.",1999.0,0,0
200,10608201,Epidural anesthesia in infants.,J F Desparmet,,1999.0,0,0
201,10608204,Preincisional dextromethorphan decreases postoperative pain and opioid requirement after modified radical mastectomy.,C S Wong; C T Wu; J C Yu; C C Yeh; M M Lee; P L Tao,"To examine whether preincisional dextromethorphan (DM) improved analgesia after modified radical mastectomy (MRM). Sixty patients (ASA I-II) scheduled for MRM were included and randomly allocated into two groups. Patients in the treatment group (DM) received 40 mg DM and 20 mg chlorpheniramine maleate (CPM) i.m., and those in the control group received 20 mg CPM i.m. alone 30 min before skin incision. Meperidine, 1 mg x kg(-1) i.m., was given for postoperative pain relief as required. The time to first meperidine injection, total meperidine consumption, worst pain score, bed-rest time, and side effects were recorded every 24 hr for 48 hr after surgery by a resident anesthesiologist on a double-blind basis. A longer time to first meperidine injection (19.2 +/- 1.6 vs 1.5 +/- 0.23 hr, P < 0.001) and lower meperidine consumption (0[10] vs 75[50] mg, median [interquartile range], P < 0.001) were observed in the DM group than in the control group. The bed-rest time was shorter in the DM than in the control group (18.0[4] vs 23.0[19] hr, P < 0.001). No difference was noted in worst VAS pain score. Meperidine-related side effects (nausea, vomiting, pruritus, dizziness, headache) were more frequent in the control (10/30) than in the DM group (3/30, P < 0.05). The number of patients who required meperidine injection for pain relief was lower in the DM (7/30) than in the control group (25/30, P < 0.005). No DM- or CPM-associated side effects were observed. Preincisional IM. DM treatment decreased postoperative pain and opioid requirement after MRM surgery.",1999.0,0,0
202,10609351,Rhabdomyolysis-induced acute renal failure after morphine overdose--a case report.,C H Shen; C J Hung; C C Wu; H W Huang; W M Ho,"The 39-year-old male in this report was a victim of C4 spinal cord injury for 7 years. He was regularly followed up at our pain clinic and psychiatric out-patient department (OPD) for treatment of his chronic pain with morphine, anticonvulsant and sedatives. At the night of December 15, 1997, he took approximately 0.1 gm of morphine and a certain number of flurazepam pills. On the next day, he experienced numbness and paresis in both legs in association with painful swelling of both thighs. Then he sought medical advice at our hospital and was admitted for investigation on December 20, 1997. Laboratory examination revealed elevated creatine kinase activity, increased urine myoglobin concentration and raised plasma creatinine, signifying the development of acute muscle damage. The excreted urine morphine concentration was as high as 6,384 ng/mL. Increased PYP uptake in the proximal portion of both thighs was noted on muscle scan. These abnormalities were resolved gradually over two weeks under conservative treatment. Morphine-induced rhabdomyolysis complicated by acute renal failure was highly suspected.",1999.0,0,0
203,10617261,Severe respiratory depression in a patient with gastroparesis while receiving opioids for pain.,J D Clark; T Edwards,"To increase awareness of the possibility of severe respiratory depression when oral opioids are used in patients with gastrointestinal motility disorders. A major county hospital affiliated with a university. A patient with severe pain from diabetic muscle necrosis with a history of gastroparesis. Attempted pain control with oral and transdermal opioids. Pain control in our patient was attempted using potent oral opioids on two occasions. However, this patient suffered severe respiratory depression after each attempt. Transdermal delivery of fentanyl eventually provided satisfactory pain relief without side effects. We conclude that patients with gastrointestinal motility disorders may be at high risk for side effects of oral opioids due to altered absorption kinetics. Suggestions are made for alternative strategies for opiate delivery in patients with gastrointestinal motility disorders.",2000.0,0,1
204,10618936,Dose-dependency of intra-articular morphine analgesia.,R Likar; S Kapral; H Steinkellner; C Stein; M Schäfer,"We have examined if the analgesic effects of intra-articular morphine are dose-dependent in patients undergoing elective arthroscopic knee surgery. At the end of surgery, patients were allocated randomly to one of four groups to receive intra-articular saline (n = 22), or morphine 1 mg (n = 24), 2 mg (n = 21) or 4 mg (n = 19). After operation, patients remained in hospital overnight and pain intensity was assessed using a visual analogue scale at 1, 2, 3, 6, 9, 12, 18 and 24 h after intra-articular injection. Patients requesting additional analgesia received a loading dose of piritramide 0.1 mg kg-1 i.v. and were connected to a PCA device using the same drug. Increasing doses of intra-articular morphine were associated with greater analgesic effects and less supplementary analgesic requirements.",2000.0,0,0
205,10618937,"Analgesia after intracranial surgery: a double-blind, prospective comparison of codeine and tramadol.",H M Jeffrey; P Charlton; D J Mellor; E Moss; M Vucevic,"We have compared codeine and tramadol in a prospective, double-blind study of postoperative analgesia in 75 patients after elective intracranial surgery. Twenty-five patients received codeine 60 mg, tramadol 50 mg or tramadol 75 mg i.m. Patients receiving codeine had significantly lower pain scores over the first 48 h after operation (P < 0.0001). Although there was no difference in visual analogue scale (VAS) scores between the three groups at 24 h, the codeine group had significantly lower scores at 48 h (P < 0.0001). The tramadol 75 mg group had significantly higher scores for both sedation and nausea and vomiting (P < 0.0001 for both scores). We conclude that codeine 60 mg i.m. provided better postoperative analgesia than tramadol after craniotomy and that tramadol 75 mg should be avoided because of its side effects of increased sedation and nausea and vomiting.",2000.0,0,0
206,10618939,,,,,0,0
207,10626714,Patient supplemented epidural analgesia after major abdominal surgery with bupivacaine/fentanyl or ropivacaine/fentanyl.,M Berti; G Fanelli; A Casati; A Albertin; S Palmisano; F Deni; V Perotti; G Torri,"To compare analgesic efficacy and occurrence of motor block and other side effects during patient supplemented epidural analgesia (PSEA) with either ropivacaine/fentanyl or bupivacaine/fentanyl mixtures. In a prospective, randomized, double-blind study, 32 ASAI-III patients undergoing major abdominal surgery received an epidural catheter at the T8- T10, followed by integrated general epidural anesthesia. Postoperative epidural analgesia was provided using a patient controlled pump with either ropivacaine 0.2%/2 microg x ml(-1) fentanyl (group Ropivacaine, n = 16) or bupivacaine 0.125%/2 microg x ml(-1) fentanyl (group Bupivacaine, n = 16) [background infusion 4-6 ml x hr(-1), 1.5 ml Incremental Doses and 20 min lock out]. Verbal pain rating score, number of incremental doses, consumption of epidural analgesic solution and rescue analgesics, sedation (four-point scale), and pulse oximetry were recorded by a blind observer for 48 hr after surgery. No differences in pain relief, motor block, degree of sedation, pulse oximetry and other side effects were observed between the two groups. The number of incremental doses and the volume of analgesic solution infused epidurally were higher in patients receiving the bupivacaine/fentanyl mixture (10 [0-52] I.D. and 236 [204-340] ml) than in patients receiving the ropivacaine/fentanyl solution (5 [0-50] I.D. and 208 [148-260] ml) (P = 0.03 and P = 0.05, respectively). Using a ropivacaine 0.2%/2 microg x ml(-1) fentanyl mixture for patient supplemented epidural analgesia after major abdominal surgery provided similar successful pain relief as bupivacaine 0.125%/2 microg x ml(-1) fentanyl, but patients receiving bupivacaine/fentanyl requested more supplemental.",2000.0,0,0
208,10626715,Epidural naloxone reduces pruritus and nausea without affecting analgesia by epidural morphine in bupivacaine.,J H Choi; J Lee; J H Choi; M J Bishop,"To determine whether epidural naloxone preserved analgesia while minimizing side effects caused by epidural morphine. Eighty patients undergoing combined epidural and general anesthesia for hysterectomy were randomly assigned to one of four groups. All received 2 mg epidural morphine bolus one hour before the end of surgery and a continuous epidural infusion was started containing 4 mg morphine in 100 ml bupivacaine 0.125% with either no naloxone (Group 1, n = 20), 0.083 microg x kg(-1) x hr(-1) of naloxone (Group 2, n = 20), 0.125 microg x kg(-1) x hr(-1) of naloxone (Group 3, n = 20) or 0.167 microg x kg(-1) x hr(-1) of naloxone (Group 4, n = 20). Analgesia and side effects were evaluated by blinded observers. The combination of epidural morphine and bupivacaine provided good analgesia. Eight hours after the end of surgery, the pain score in the group receiving the highest dose of naloxone was lower than in the control group (VAS 1.2 vs. 2.0, P<0.05) but there was less pruritus in the high-dose naloxone group (itching score 1.3 vs. 1.9, P<0.05). Pain scores were no different in any of the naloxone groups from the control group. Itching was less in both of the higher dose naloxone groups (P<0.05 at 8, 16, and 32 hours). The incidence of vomiting in the control group was 40% vs. 5% for high dose naloxone group (P<0.05). Epidural naloxone reduced morphine-induced side effects in dose-dependent fashion without reversal of the analgesic effect.",2000.0,0,0
209,10626931,Stereotactic surgery: what is past is prologue.,P J Kelly,"Two old and simple simple concepts, a three-dimensional positioning stage and a coordinate system, were combined in 1906 to create a new one: the stereotactic method. For 25 years, it found little application until it was rediscovered for investigations in small animals. After the first human subcortical stereotactic procedure was performed in 1947, stereotactic methods found greatest application in the placement of subcortical lesions in the treatment of movement disorders. Rapid advances in the development of instrumentation, methods, and understanding of human neuroanatomy and neurophysiology resulted. However, a dormant period followed the introduction of L-dopa in 1968. The advent of computer-based medical imaging applied to the stereotactic method encouraged adaptation of stereotactic methods to the management of intracranial tumors, the rapid development of new surgical hardware, and the rediscovery of old methods and evolution of new ones for the treatment of movement disorders. In addition, the incorporation of computer systems as stereotactic surgical instruments further increased the capabilities of stereotactic methods. Radiosurgical applications increased with the proliferation of gamma units and the development of linear accelerator-based radiosurgical methods. Computers are used to fuse and reformat imaging databases for surgical planning, simulation, and frameless stereotactic intraoperative guidance. As a result, surgical procedures have become more effective in meeting preoperative goals and less invasive. Low-cost, high-speed, microprocessor-based workstation computers and intuitive user interfaces have increased the acceptance into mainstream neurosurgery. It is anticipated that a significant portion of neurosurgery, and probably most surgical procedures in general, will comprise computer-based interventions guided by volumetric imaging-defined data sets acquired preoperatively or by intraoperative imaging systems. The stereotactic surgery of the future may employ all or a combination of the following technologies: frameless stereotactic surgery, robotic technology, microrobotic dexterity enhancement, and telepresence robotics.",2000.0,0,0
210,10627347,"Postoperative analgesia after arthroscopic knee surgery: a randomized, prospective, double-blind study of intravenous regional analgesia versus intra-articular analgesia.",N M Graham; M D Shanahan; P Barry; S Burgert; I Talkhani,"The aim of this study was to determine the quality of postoperative analgesia in patients undergoing arthroscopic knee surgery using preoperative intravenous regional analgesia. After initial consultation with a statistician, we allocated 36 patients randomly and double-blind to 1 of 3 groups. Group A received intravenous regional analgesia preoperatively, group B received standard postperative intra-articular analgesia, and group C received saline and acted as the placebo. Our results showed no statistically significant difference in pain levels between the groups. However, there was a significantly larger amount of morphine administered by patient-controlled pumps in the placebo group when compared with the 2 treatment groups. There was no such difference between the 2 treatment groups. We concluded that preoperative regional analgesia in this setting is as good as but no better than intra-articular analgesia and that neither technique has any advantages over diclofenac plus patient-controlled analgesia.",2000.0,0,0
211,10628627,A randomized comparison of ketorolac tromethamine and morphine for postoperative analgesia in critically ill children.,M W Lieh-Lai; R E Kauffman; H G Uy; M Danjin; P M Simpson,"To evaluate the efficacy of a single dose of ketorolac compared with morphine for the relief of pain in children, and to determine the safety of ketorolac. Tertiary pediatric intensive care unit in a university-affiliated hospital. Prospective, randomized, double-blind, parallel, single-dose, positive control study. Children admitted to the intensive care unit with postoperative pain. Patients received a single dose of either morphine or ketorolac as the first postoperative analgesic when the pain score indicated significant pain. Blood pressure, heart rate, and urine output were recorded, as well as blood urea nitrogen, creatinine, bleeding time, hematuria or proteinuria, and aspartate aminotransferase. Side effects such as nausea and vomiting were noted. Morphine was used for rescue treatment if the patient continued to have significant pain > or =30 mins after study drug administration. Of the 102 children studied, 48 received morphine and 54 received ketorolac. The percentage of patients reporting pain relief in the first and second hours after drug administration was not different between groups. Likewise, the proportion of patients who met the criteria for pain relief during the entire evaluation period was not different between groups. There was a trend toward fewer patients who received ketorolac requiring remedication in the first 4 hrs compared with those who received morphine, but this trend did not reach statistical significance. More patients in the morphine group failed to achieve pain relief at any time after the dose compared with those who received ketorolac. There were no differences between the two groups in physiologic or laboratory variables. Vomiting was more common in patients who received ketorolac. Ketorolac is comparable to morphine in relief of postoperative pain in children. A single dose of ketorolac does not result in abnormal postoperative bleeding or alter renal function. However, ketorolac may cause nausea and vomiting in some patients.",2000.0,0,0
212,10629624,"Efficacy of pamidronate in breast cancer with bone metastases: a randomized, double-blind placebo-controlled multicenter study.",R Hultborn; S Gundersen; S Ryden; E Holmberg; J Carstensen; U B Wallgren; S Killany; L Andreassen; G Carlsson; N Fahl; T Hatschek; H H Sommer; Y Hessman; B Hornmark-Stenstam; S Johnsborg; R Klepp; R Laino; L G Niklasson; C M Rudenstam; A Sundbeck; M Söderberg; G Tejler,"To evaluate the efficacy of pamidronate 60 mg i.v. q 4 weeks in women with advanced breast cancer with skeletal metastases. 404 woman with skeletal metastases from breast cancer in Sweden and Norway were included in a randomized, placebo-controlled, multicenter study. Except for the study medication, other palliative treatment was chosen at the discretion of the physician. Skeletal related events, i.e. increased pain, treatment of hypercalcemia, pathologic fractures of long bones or pelvis, paralyses due to vertebral compression, palliative radiotherapy for skeletal metastases, surgery on bone and change of antitumor therapy were recorded every third month as well as a self-estimated pain-score using visual Analog Scales and analgesic consumption. There was a significantly increased time to progression of pain (p < 0.01), to hypercalcemic events (p < 0.05) as well as for the cumulative number of skeletal related events (p < 0.01) in favor for the pamidronate group. No statistically significant reduction of pathologic fractures of long bones or pelvis, or pareses due to vertebral compression occurred. No statistically significant differences were found for the need of radiotherapy and surgery on bone. The pamidronate group faired better regarding performance status (p < 0.05). There was a statistically not significant lower consumption of opioid analgesics in the pamidronate group (p = 0.14). Pamidronate 60 mg i.v. q 4 weeks reduces skeletal events and improves the quality of life in women with bone metastases from breast cancer.",2000.0,0,0
213,10630837,Amphetamines to counteract opioid-induced sedation.,P J Corey; A M Heck; R A Weathermon,"To describe the data regarding the use of amphetamines and amphetamine derivatives to counteract opioid-induced sedation. Sedation is a major dose-limiting adverse effect of opioid therapy for many patients. Several reports have evaluated the use of amphetamines and amphetamine derivatives, such as mazindol, dextroamphetamine, and methylphenidate, to counteract opioid-induced sedation, with limited results. General use of amphetamines for the treatment of opioid-induced sedation is not recommended. However, these agents may be effective for certain patients who experience dose-limiting sedation with opioids and have exhausted all other options available to manage this adverse effect More research is needed to identify appropriate candidates for therapy, the preferred amphetamine, and the optimal dose.",2000.0,0,0
214,10631438,"[Analgo-sedation in intensive care: a quantitative, EEG-based trial with propofol 1% and 2%].",S Albrecht; H Ihmsen; K Suchodolski; C Frenkel; J Schüttler,"The primary aim of this study was to find out whether adequate long-term sedation (> or = 72 h) can be achieved in critically ill patients with an EEG median frequency controlled closed-loop system for the application of propofol 1% and 2%. Moreover, we investigated the pharmacokinetics and pharmacodynamics of propofol with respect to possible tolerance and compared the quality of sedation of both propofol formulations and their lipid load. After institutional approval and written consent, 16 ASA II-IV patients were included in this study. Main inclusion criterion was the necessity for prolonged sedation/analgesia for at least 72 h. Sedation was induced and maintained using continuous infusion of propofol 1% (n = 7) or 2% (n = 9). Analgesia was maintained with continuous infusion of alfentanil. The EEG was recorded from four leads (Fp1,2 and C3,4) and the EEG median frequency was obtained from the power spectrum (0.5-32 Hz). Propofol was administered computer-controlled with a median frequency setpoint depending on the depth of sedation which was assessed clinically using a modified Ramsay score. Alfentanil was applied as TCI. Arterial plasma concentrations were measured by HPLC (propofol) and RIA (alfentanil). Pharmacokinetics of propofol and alfentanil were derived using a three compartment model. All patients were successfully sedated for 77 +/- 9 h. The median EEG frequency during sedation was stable at 1.5 +/- 0.2 Hz. The sedation score increased from 1 in the first 12 h to values between 2 and 3 for the remaining sedation period. At the same time, propofol plasma concentrations increased from 0.7 +/- 0.3 microgram/ml to 1.8 +/- 1.3 micrograms/ml. The patients required an average of 2.5 mg/kg/h propofol and 0.030 mg/kg/h alfentanil. Pharmacokinetics of propofol 2% showed an increased volume of distribution when compared to propofol 1%. Alfentanil clearance was found to be reduced with four patients having extremely small clearance values (33 +/- 3 ml/min). Triglyceride values increased up to 4.5 +/- 1.2 mmol/l for patients receiving propofol 1% and remained within normal range for propofol 2%. The EEG median frequency can be used for closed-loop control of propofol even for long-term sedation in critically ill patients. EEG median frequencies were similarly low as in deeply anaesthetised patients. No differences in quality of sedation were seen between the two propofol formulations, but propofol 2% seems to be advantageous due to lower lipid load and triglyceride values. Increasing concentrations of propofol at unchanged sedation scores and EEG median frequencies may indicate development of tolerance.",2000.0,0,0
215,10632947,Pain management of junctional epidermolysis bullosa in an 11-year-Old boy.,Y K Chiu; J S Prendiville; S M Bennett; C J Montgomery; T F Oberlander,"Epidermolysis bullosa is a group of hereditary blistering disorders for which there is no definitive therapy. Wound care is an important component of management. Regular dressing changes are required to protect blistered and eroded skin, and to prevent secondary infection and sepsis. These dressing changes can be very painful for patients with extensive erosions. We report our experience of pain management in an 11-year-old boy with severe junctional epidermolysis bullosa. Amitryptiline and cognitive behavioral techniques were effective in relieving chronic pain and discomfort. Oral midazolam 0.33 mg/kg administered 20 minutes prior to baths and dressing changes substantially improved his tolerance of wound care.",2000.0,0,0
216,10643361,[Knowledge about amd attitude to postoperative pain therapy of health personnel. A questionnaire survey].,J Højsted; K L Hellum,"From research results published over the last years it appears that many surgical patients are still undertreated for their postoperative pain. The study was performed in order to reveal the attitudes and knowledge of physicians and nurses towards postoperative pain therapy. Questionnaires were sent to physicians and nurses at the surgical and anaesthesiological wards at the hospital. The study revealed that the real purpose of postoperative pain management, to ensure early mobilization and nutrition of the patients, did not receive proper attention. Too many of the house staff accepted that the patients should have moderate or severe pain, especially the younger physicians. The house staff is still concerned about the risk of inducing dependency when using opioids. The knowledge of the analgesics used in the ward is not sufficient and inappropriate methods of administration of opioids are still used. Educational intervention to improve the staff's knowledge about pain management in postoperative care is strongly needed.",2000.0,0,0
217,10643545,The effects of morphine on dyspnea and ventilatory function in elderly patients with advanced cancer: a randomized double-blind controlled trial.,C Mazzocato; T Buclin; C H Rapin,"Dyspnea represents a very frequent and distressing symptom in patients with advanced cancer. This study was undertaken to assess the efficacy of morphine on dyspnea and its safety for ventilatory function in elderly advanced cancer patients. Nine elderly patients with dyspnea due to lung involvement were randomized to receive either morphine subcutaneously (5 mg in seven opioid-naïve patients and 3.75 mg in two patients on top of their regular oral dose of 7.5 mg q4 h) or placebo on day 1. On day 2, they were crossed over to receive the alternate treatment. Dyspnea was assessed every fifteen minutes using a visual analogue scale (VAS: 0-100 mm) and the ordinal scale developed by Borg (0-10 points). Pain, somnolence and anxiety were assessed using VAS. Respiratory effort, respiratory rate and oxygen saturation were also measured repeatedly. Mean changes in dyspnea 45 minutes after injection were -25 +/- 10 mm and -1.2 +/- 1.2 points for morphine, versus 0.6 +/- 7.7 mm (P < 0.01) and -0.1 +/- 0.3 points (P = 0.03) for placebo on VAS and Borg scale, respectively. No relevant changes were observed in somnolence, pain, anxiety, respiratory effort and rate, and oxygen saturation. Morphine appears effective for cancer dyspnea, and it does not compromise respiratory function at the dose level used.",2000.0,0,0
218,10645303,Serotonin syndrome with fluoxetine plus tramadol.,S Kesavan; G M Sobala,,2000.0,0,0
219,10647800,Methylnaltrexone for reversal of constipation due to chronic methadone use: a randomized controlled trial.,C S Yuan; J F Foss; M O'Connor; J Osinski; T Karrison; J Moss; M F Roizen,"Constipation is the most common chronic adverse effect of opioid pain medications in patients who require long-term opioid administration, such as patients with advanced cancer, but conventional measures for ameliorating constipation often are insufficient. To evaluate the efficacy of methylnaltrexone, the first peripheral opioid receptor antagonist, in treating chronic methadone-induced constipation. Double-blind, randomized, placebo-controlled trial conducted between May 1997 and December 1998. Clinical research center of a university hospital. Twenty-two subjects (9 men and 13 women; mean [SD] age, 43.2 [5.5] years) enrolled in a methadone maintenance program and having methadone-induced constipation. Laxation response, oral-cecal transit time, and central opioid withdrawal symptoms were compared between the 2 groups. The 11 subjects in the placebo group showed no laxation response, and all 11 subjects in the intervention group had laxation response after intravenous methylnaltrexone administration (P<.001). The oral-cecal transit times at baseline for subjects in the methylnaltrexone and placebo groups averaged 132.3 and 126.8 minutes, respectively. The average (SD) change in the methylnaltrexone-treated group was -77.7 (37.2) minutes, significantly greater than the average change in the placebo group (-1.4 [12.0] minutes; P<.001). No opioid withdrawal was observed in any subject, and no significant adverse effects were reported by the subjects during the study. Our data demonstrate that intravenous methylnaltrexone can induce laxation and reverse slowing of oral cecal-transit time in subjects taking high opioid dosages. Low-dosage methylnaltrexone may have clinical utility in managing opioid-induced constipation.",2001.0,0,0
220,10650230,Safety and efficacy of diclofenac ophthalmic solution in the treatment of corneal abrasions.,P A Szucs; A H Nashed; J R Allegra; B Eskin,"To determine whether the use of diclofenac ophthalmic solution is a safe and effective analgesic in the treatment of traumatic corneal abrasions in the emergency department. We conducted a prospective, randomized, double-blinded, placebo-controlled clinical trial. Consenting consecutive patients with corneal abrasions who presented to a community-based ED from August through February 1998 were randomly assigned to receive either diclofenac or control vehicle drops. Pain relief was measured using a visual Numeric Pain Intensity Scale (NPIS) before and after treatment. Exclusion criteria were as follows: age younger than 18 years, pregnancy, history of glaucoma, ocular infection, recent eye surgery, other signs of ocular trauma, narcotics within 6 hours, minimal pain (NPIS score <3), and any allergy to diclofenac or nonsteroidal anti-inflammatory drugs. Patients were discharged with study drug or control vehicle solution, a topical antibiotic, oxycodone-acetaminophen as a rescue analgesic, and a pain diary. The outcome measurements were improvement in NPIS score 2 hours after treatment, use of oxycodone-acetaminophen, and occurrence of any adverse effects. Forty-nine patients were enrolled in the study; 25 received diclofenac and 24 received control vehicle drops. Both groups were similar in gender, age, pretreatment pain duration, NPIS score, and analgesic use. There was significantly greater improvement in the 2-hour NPIS score in the diclofenac group (3.1; 95% confidence interval [CI] 2.3 to 4) compared with the control group (1.0; 95% CI 0.1 to 2.0). The difference between the 2 groups was 2.1+/-1.3 (95% CI 0.8 to 3.4). There was a trend toward fewer patients taking rescue oxycodone-acetaminophen in the diclofenac group (20%; 95% CI 4% to 36%) versus the control group (42%; 95% CI 22% to 62%). Other than transient mild stinging, there were no complications associated with diclofenac use. Diclofenac ophthalmic solution appears to be a safe and effective analgesic in the treatment of traumatic corneal abrasions in the ED.",2000.0,0,0
221,10651671,Analgesic effect of low-dose intrathecal morphine and bupivacaine in laparoscopic cholecystectomy.,C Motamed; H Bouaziz; D Franco; D Benhamou,"We assessed the peri-operative analgesic efficiency of low-dose intrathecal morphine combined with a low dose of bupivacaine after elective laparoscopic cholecystectomy since postoperative pain in such procedures, although less than after a conventional open technique, may be significant, particularly during the first 12-24 h. After informed consent, 34 ASA I or II patients were randomly allocated to one of two groups to receive either a lumbar intrathecal injection of morphine (75 or 100 microg) combined with 5 mg of isobaric bupivacaine (spinal group) or a subcutaneous injection of a saline solution (control group). Intra-operatively, opioid requirements, blood pressure response and heart rate changes after insufflation were recorded. Postoperatively, morphine requirements, pain scores and opioid-related side-effects were assessed by a physician blinded to the randomisation. Intra-operative opioid requirements did not differ significantly between groups. Mean (SD) postoperative morphine requirements were significantly lower in the spinal group [13 (10) vs. 23 (10) mg; p = 0.04] as were postoperative pain scores (p < 0.001). Side-effects were of comparable incidence and severity between groups. Low-dose intrathecal morphine combined with low-dose bupivacaine provided effective postoperative analgesia for elective laparoscopic cholecystectomy.",2000.0,0,0
222,10655908,Postoperative analgesia with i.v. patient-controlled morphine: effect of adding ketamine.,G Adriaenssens; K M Vermeyen; V L Hoffmann; E Mertens; H F Adriaensen,"We have studied the effect of adding ketamine to i.v. morphine patient-controlled analgesia (PCA) for the treatment of pain after laparotomy. Thirty patients were allocated randomly to receive PCA with saline or ketamine in a double-blind, randomized study. Analgesia was started in the recovery room when visual analogue scale (VAS) scores were > 4. A bolus dose of morphine 3 mg was given to all the patients followed by i.v. PCA. Simultaneously, an infusion of ketamine 2.5 micrograms kg-1 min-1 or saline was started. Pain scores, morphine consumption and side effects were noted for up to 48 h after the start of PCA. VAS scores decreased significantly with time (P = 0.0001) and were similar (P = 0.3083) in both groups. Cumulative morphine consumption at 48 h was significantly lower in the ketamine group (28 mg) than in the control group (54 mg) (P = 0.0003). Nausea was less frequent in the ketamine group (P = 0.03).",2000.0,0,0
223,10663002,[A prospective randomized study on inguinal hernia repair according to the Shouldice technique. Benefits of local anesthesia].,B Friemert; J Faoual; G Hölldobler; H P Becker; L Lampl; H Gerngross,"The aim of this randomized controlled study was to show whether local anesthesia (LA) leads to a decrease of postoperative pain in inguinal hernia repair in comparison with general anesthesia (AA). Sixty volunteer patients were randomly assigned into a LA group and an AA group. All patients had an unilateral primary inguinal hernia and underwent inguinal hernia repair (Shouldice technique). Methods to determine pain were the visual analog scale (VAS), peak flow measurement, the measurement of the FEV1 %, and analgesic consumption. Up to the third postoperative day we measured a decreased pain level in the LA group. The anesthesia procedure was never changed. No essential complications occurred. Therefore, it was concluded that local anesthesia has more advantages than general anesthesia.",2000.0,0,0
224,10666521,Involvement of presurgical pain in preemptive analgesia for orthopedic surgery: a randomized double blind study.,S Aida; H Fujihara; K Taga; S Fukuda; K Shimoji,"Preemptive analgesia (PA) is effective in animal models but its clinical effectiveness remains controversial. We examined the effect of preexisting pain on PA. Subjects were recruited from patients needing orthopedic surgery. Some had presurgical pain (fracture surgery and arthritic surgery), while others had no presurgical pain (removal surgery for a tumor, nail or plate). Epidural morphine or a saline control was given preemptively before surgery and maintained until skin closure. Following skin closure, naloxone or placebo was injected intravenously to erase the aftereffects of the morphine. After total recovery, the PCA pump was set to inject epidural morphine. Pain intensity after surgery was measured by a visual analogue scale (VAS), and the amount of morphine used within 48h after surgery. PA was significantly effective for removal surgery, but ineffective for fracture or arthritic surgery. For the fracture and arthritic surgery PA treatment groups, there was a significant correlation between pre- and postsurgical (6h) spontaneous pain, while the corresponding control groups showed no significant correlation. Postsurgical VAS values in the fracture and arthritic surgery control groups increased significantly compared with presurgical VAS values. PA was effective when presurgical pain was absent, but ineffective when presurgical pain was present. We propose that central sensitization is already established by presurgical pain, and preserved until the termination of surgery. The ineffectiveness of PA did not depend on whether the pain was acute (fracture surgery) or chronic (arthritic surgery).",2000.0,0,0
225,10666525,Treatment outcome of chronic non-malignant pain patients managed in a danish multidisciplinary pain centre compared to general practice: a randomised controlled trial.,N Becker; P Sjøgren; P Bech; A K Olsen; J Eriksen,"This randomised controlled study investigated the effect of outpatient multidisciplinary pain centre treatment (MPT) compared with treatment by a general practitioner after initial supervision by a pain specialist (GP-group) and with a group of patients waiting for 6 months before treatment was initiated (WL-group). One-hundred-and-eighty-nine chronic non-malignant pain patients were studied. At referral, and after 3 and 6 months patients filled in questionnaires evaluating pain intensity, health related quality of life (HRQL) and use of analgesics. HRQL was evaluated using the Medical Outcome Study-Short Form (SF-36), the Hospital Anxiety and Depression scale (HAD) and the Psychological General Well-being Scale (PGWB). After 6 months patients allocated to MPT (n=63) reported statistically significant reduction in pain intensity (VAS-score, P<0.001), improvement in psychological well-being (PGWB, P<0.001), quality of sleep (P<0.05) and physical functioning (SF-36-Phycical Functioning, P<0.05). No improvements were seen in the GP-group (n=63). In the WL-group (n=63) a statistically significant deterioration was observed in PGWB-scores, HAD-scores and in 6 of 8 SF-36-subscores (P </= 0.05). A reduction in use of opioids administered on demand was obtained in the group receiving MPT (P<0.001). In the MPT- and GP-groups a decrease in the use of short acting opioids was observed (P<0.01). No change in use of analgesics was seen in the WL-group. The study showed that (i) in the MPT-group there was a significant reduction in pain intensity and improvement of HRQL compared to the WL-group, and (ii) the mere establishment of a pain diagnosis and a pain management plan by a pain specialist was not sufficient to enable the referring GP to manage severely chronic pain patients.",2000.0,0,0
226,10666549,Co-administration of sub-antinociceptive doses of oxycodone and morphine produces marked antinociceptive synergy with reduced CNS side-effects in rats.,F B Ross; S C Wallis; M T Smith,"Oxycodone and morphine are structurally related, strong opioid analgesics, commonly used to treat moderate to severe pain in humans. Although it is well-established that morphine is a mu-opioid agonist, this is not the case for oxycodone. Instead, our recent studies have shown that oxycodone appears to be a kappa-opioid agonist (Ross and Smith, 1997). In the current study, we now show that co-administration of sub-antinociceptive doses of oxycodone (putative kappa-opioid agonist) with morphine (mu-opioid agonist) to rats by both the intracerebroventricular and by systemic routes (intraperitoneal and subcutaneous), results in markedly increased (synergistic) levels of antinociception. Behaviourally, rats co-administered sub-antinociceptive doses of oxycodone and morphine were similar to control rats dosed with saline, whereas rats that received equi-potent doses of either opioid alone, were markedly sedated. These results suggest that co-administration of sub-analgesic doses of oxycodone and morphine to patients may provide excellent pain relief with a reduction in opioid-related CNS side-effects. Controlled clinical trials in appropriate patient populations are required to evaluate this possibility.(1)",2000.0,0,0
227,10668859,Clinical pharmacokinetics of transdermal opioids: focus on transdermal fentanyl.,S Grond; L Radbruch; K A Lehmann,"Transdermal delivery allows continuous systemic application of opioids through the intact skin. This review analyses the pharmacokinetic properties of transdermal opioid administration in the context of clinical experience, with a focus on fentanyl. A transdermal therapeutic system (TTS) for fentanyl has been developed. The amount of fentanyl released is proportional to the surface area of the TTS, which is available in different sizes. After the first application of a TTS, a fentanyl depot concentrates in the upper skin layers and it takes several hours until clinical effects are observed. The time from application to minimal effective and maximum serum concentrations is 1.2 to 40 hours and 12 to 48 hours, respectively. Steady state is reached on the third day, and can be maintained as long as patches are renewed. Within each 72-hour period, serum concentrations decrease gradually over the second and third days. When a TTS is removed, fentanyl continues to be absorbed into the systemic circulation from the cutaneous depot. The terminal half-life for TTS fentanyl is approximately 13 to 25 hours. The interindividual variability of serum concentrations, partly caused by different clearance rates, is markedly larger than the intraindividual variability. The effectiveness of TTS fentanyl was first demonstrated in acute postoperative pain. However, the slow pharmacokinetics and large variability of TTS fentanyl, together with the relatively short duration of postoperative pain, precluded adequate dose finding and led to inadequate pain relief or, especially, a high incidence of respiratory depression; such use is now contraindicated. Conversely, in cancer pain, TTS fentanyl offers an interesting alternative to oral morphine, and its effectiveness and tolerability in this indication has been demonstrated by a number of trials. Its usefulness in chronic pain of nonmalignant origin remains to be confirmed in controlled trials. In general, TTS fentanyl produces the same adverse effects as other opioids, mainly sedation, nausea, vomiting and constipation. In comparison with oral morphine, TTS fentanyl causes fewer gastrointestinal adverse events. The risk of hypoventilation is comparatively low in cancer patients. Sufentanil and buprenorphine may also be suitable for transdermal delivery, but clinical results are not yet available. Transdermal morphine is only useful if applied to de-epithelialised skin. However, iontophoresis may allow transdermal administration of opioids, including morphine, with a rapid achievement of steady state concentrations and the ability to adjust delivery rates. This would be beneficial for acute and/or breakthrough pain, and initial clinical trials are in progress.",2000.0,0,1
228,10669269,Continuous epidural analgesia with bupivacaine-fentanyl versus patient-controlled analgesia with i.v. morphine for postoperative pain relief after knee ligament surgery.,M Silvasti; M Pitkänen,"Both epidural analgesia and intravenous patient-controlled analgesia (PCA) have been found efficacious after various types of surgery. We compared the efficacy, safety, side effects and patient satisfaction of these methods in a randomized double-blind fashion after elective anterior cruciate ligament reconstruction of the knee. Fifty-six patients had an epidural catheter placed at the L2-L3 interspace. Spinal anaesthesia with 15 mg of plain bupivacaine 5 mg/ml was performed at the L3-L4 interspace. After surgery the patients were randomly divided into three groups: 19 received a continuous epidural infusion with bupivacaine 1 mg/ml and fentanyl 10 mg/ml (F10), 19 patients received bupivacaine 1 mg/ml and fentanyl 5 microg/ml (F5) and 18 patients received saline (S). The rate of the epidural infusions was 0.1 ml kg(-1) h(-1). Each patient could also use an intravenous (i.v.) PCA device with 40 microg/kg bolus doses of morphine with a lockout period of 10 min and a maximum dose 240 microg kg(-1) h(-1). At the end of surgery ketoprofen 100 mg i.v. was given and continued orally three times a day. Patients were assessed for pain with a visual analogue scale (VAS) at rest and during activity, side effects and satisfaction at 3, 9 and 20 h. Both epidural infusions (F10, F5) provided better analgesia than epidural saline plus i.v. PCA (S) (P<0.05). There was slightly less nausea in the S group (NS). In spite of the difference in the quality of pain relief, there was no difference between the groups in patient satisfaction regarding analgesic therapy. Epidural infusion of fentanyl (1 microg kg(-1) h(-1) or 0.5 microg kg(-1) h(-1)) and bupivacaine (0.1 mg kg(-1) h(-1)) provided better pain relief but more side effects than intravenous morphine patient-controlled analgesia after knee ligament surgery. Almost all patients in all groups were satisfied with their pain relief.",2000.0,0,0
229,10670117,The effects of tramadol versus fentanyl in attenuating hemodynamic response following tracheal intubation.,W W Pang; C H Lei; D P Chang; C C Tung; M H Huang,"Tramadol is a novel central acting analgesic. It has been used as a complement to general anesthesia and an effective agent for postoperative analgesia. However, the influence of tramadol on the hemodynamic response following laryngoscopy and tracheal intubation is less known. Forty patients of both sexes, 16-50 year old, ASA physical status I or II, scheduled for elective surgery were randomly divided into equal groups in this prospective, double blind study. After obtaining the baseline data, the patient was given 3 micrograms/kg fentanyl (Group F) or 3 mg/kg tramadol (Group T). Then induction of anesthesia in a uniform and standardized manner was carried out by an anesthesiologist who was blind to the medication. The hemodynamic parameters were measured and recorded immediately after induction but prior to laryngoscopy, 3, 6, and 9 min after intubation, and before incision. We also observed any unusual effect in the postoperative care unit. Chi-square test, Student's t-test and paired t-test were used for statistical comparison. A P less than 0.05 was considered statistically significant. All patients had a successful induction and intubation. Differences in baseline values were not significant, nor were the differences in the values following induction. After laryngoscopy and intubation, heart rate increased significantly above the baseline level in both groups. The increase of heart rate was significantly more at 6 and 9 min (P < 0.05) and lasted longer in the tramadol group. After intubation, systolic, mean and diastolic arterial pressure (SAP, MAP, DAP) increased significantly above baseline in both groups too, except for DAP in fentanyl group. At 6 and 9 min, the MAP and DAP were significantly higher in tramadol than in fentanyl group (P < 0.05). Six patients in tramadol group had mild pain on injection of tramadol. When administered right before thiopental induction, 3 mg/kg tramadol did not display a better attenuation against the increase of hemodynamic profiles than did 3 micrograms/kg fentanyl following tracheal intubation.",2000.0,0,0
230,10670264,[Efficacy of 0.1 mg of subarachnoid morphine combined with bupivacaine on postoperative analgesia in total hip arthroplasty].,J M Mendieta Sánchez; J I Fernández-Liesa; G Marco; A Panadero; M J Sánchez-Ledesma; A Macías,"To analyze the analgesic efficacy, safety and side effects of subarachnoid morphine (0.1 mg) with bupivacaine in patients undergoing total hip arthroplasty. Thirty patients scheduled for total hip replacement under spinal anesthesia with bupivacaine were randomly assigned to two groups according to whether local anesthetic with 0.1 mg subarachnoid morphine was also provided or not (group M [n = 15] and group S ņ = 15[, respectively). Top-up analgesia with morphine was available through a patient-controlled device. Postoperative pain was assessed on a visual analogue scale (VAS) and consumption of intravenous morphine in the first 48 hours after surgery was recorded. VAS scores (mean +/- SD) were significantly lower in the first six hours in group M, but no differences between the two groups were observed thereafter. Total consumption of morphine at 48 hours was much lower in group M (6.80 +/- 7.74 mg) than in group S (31.38 +/- 13.17 mg). The incidence of nausea was high in both groups (46%). Slight pruritus affected 26.6% of patients in group M. Urinary retention necessitating temporary placement of a catheter was observed only in group M, where the incidence was 35.7%. No cases of respiratory depression occurred. Drowsiness was observed in 26.6% of patients in group S in comparison with 6.6% in group M. Combining 0.1 mg morphine and bupivacaine for total spinal anesthesia during hip arthroplasty significantly decreased the consumption of intravenous morphine during the first 48 hours after surgery. No respiratory depression occurred and the only side effects were urinary retention and mild pruritus and drowsiness.",2000.0,0,0
231,10671837,A comparison of patient-controlled epidural analgesia following gynaecological surgery with and without a background infusion.,K Wong; J L Chong; W K Lo; A T Sia,"We conducted a randomised, controlled study to investigate the effect of adding a background infusion to patient-controlled epidural analgesia for postoperative pain relief. Forty-two patients scheduled for elective lower abdominal gynaecological surgery received patient-controlled epidural analgesia postoperatively using a mixture of 0.2% ropivacaine and 2.0 microg x ml-1 fentanyl. Patients in group B (n = 20) were given a background infusion of 5 ml x h-1, whereas those in group N (n = 21) were not. There was no difference in pain scores or patient satisfaction scores between the two groups. Patients in group B had a higher total drug consumption (156.8 +/- 34.8 ml vs. 89.5 +/- 41.0 ml; p < 0.0001) and incidence of side-effects (71.4% vs. 30.0%; p = 0.007). Motor blockade during the 24-h study period was also greater in group B (median [range] area under the curve 7.5 [0.0-39.0] h vs. 3.0 [0.0-36.0] h; p = 0.035). We conclude that the addition of a background infusion to patient-controlled epidural anaesthesia is not recommended as it confers no additional benefits.",2000.0,0,0
232,10671840,Evoked potential monitoring in anaesthesia and analgesia.,A Kumar; A Bhattacharya; N Makhija,"Electrophysiological monitoring of selected neural pathways of the brain, brainstem, spinal cord and peripheral nervous system has become mandatory in some surgery of the nervous system where preventable neural injury can occur. Evoked potentials are relatively simple methods of testing the integrity of various aspects of the nervous system. This review covers the variety of evoked potentials that can be monitored and outlines the principles of their measurement. Their use in specific situations and how factors such as anaesthesia might affect them is presented.",2000.0,0,0
233,10674503,A comparison of patient-controlled analgesia fentanyl and alfentanil for labour analgesia.,P K Morley-Forster; D W Reid; H Vandeberghe,"To determine the analgesic efficacy of equipotent doses of PCA (patient-controlled analgesia) fentanyl and PCA alfentanil for labour pain. Twenty three, ASA I - II parturients between 32-42 wk gestational age in whom epidural analgesia was contraindicated were randomized to receive PCA fentanyl (Group F)or alfentanil (Group A). Plain numbered vials contained 21 ml fentanyl 50 microg x ml(-1) or alfentanil 500 microg x ml(-1). A one millilitre loading dose was administered. The PCA solution was prepared by diluting 10 ml study drug with 40 ml saline and the PCA pump was programmed to deliver a dose of 2 ml, delay of five minutes and a basal rate of 2 ml x hr(-1). Maternal measurements obtained were hourly drug dose, total dose, Visual Analog Pain Score (VAPS) q 30 min, sedation score q 1 hr and side effects. Neonates were assessed by 1,5, and 10-min Apgar scores, umbilical venous and arterial blood gases and neurobehavioural scores at four and 24 hr. Mean VAPS from 7 - 10 cm cervical dilatation were higher in Group A than in Group F (85.7+/-13.9 vs. 64.6+/-12.1; P<0.01) There were no inter-group differences in VAPS from 1-3 cm, or from 4-6 cm dilatation, in maternal sedation scores or side effects, or in neonatal outcomes. In the doses prescribed in this study, PCA fentanyl was found to provide more effective analgesia in late first stage labour than PCA alfentanil.",2000.0,0,0
234,10680109,"Low doses of epidural ketamine or neostigmine, but not midazolam, improve morphine analgesia in epidural terminal cancer pain therapy.",G R Lauretti; J M Gomes; M P Reis; N L Pereira,"To examine analgesia and adverse effects of combination epidural pain therapy consisting of administration of morphine with either low dose of ketamine, neostigmine, or midazolam in terminal cancer pain patients. Randomized double-blind study. Teaching hospital. 48 terminal cancer patients suffering from chronic pain. Patients were randomized to one of four groups (n = 12). The concept of visual analog scale (VAS), which consisted of a 10-cm line with 0 equaling ""no pain at all"" and 10 equaling ""the worst possible pain"" was introduced. All patients were taking oral amitriptyline 50 mg at bedtime. Pain was initially treated with epidural morphine 2 mg twice daily (12-hr intervals) to maintain the VAS below 4/10. Afterwards, VAS scores > or = 4/10 at any time were treated by adding the epidural study drug (2 ml), which was administered each morning, just after the 2-mg epidural morphine administration. The control group (CG) received 2 mg of epidural morphine (2 ml). The ketamine group (KG) received 0.2 mg/kg epidural ketamine (2 ml). The neostigmine group (NG) received 100 micrograms epidural neostigmine (2 ml). The midazolam group (MG) received 500 micrograms epidural midazolam (2 ml). Patients received the study drugs on a daily basis. Duration of effective analgesia was measured as time from the study drug administration to the first patient's VAS score > or = 4/10 recorded in days. The groups were demographically the same. The VAS pain scores prior to the treatment were also similar among groups. Only the patients in the KG demonstrated lower VAS scores compared to the MG (p = 0.018). Time since the epidural study drug administration until patient complaint of pain VAS > or = 4/10 was higher for both the KG and NG compared to the CG (KG > CG, p = 0.049; NG > CG; p = 0.0163). Only the KG used less epidural morphine compared to the CG during the period of study (25 days) (p = 0.003). The association of either low-dose epidural ketamine or neostigmine (but not midazolam) to epidural morphine increased the duration of analgesia in the population studied (gt;20 days) compared to the CG and MG (8 to 10 days) when administered in the early stages of terminal cancer pain therapy, without increasing the incidence of adverse effects.",2000.0,0,0
235,10687523,Evaluation of the combination of flurbiprofen and tramadol for management of endodontic pain.,A M Doroschak; W R Bowles; K M Hargreaves,"Effective management of endodontic pain represents a continuing challenge. In this study, we evaluated the efficacy of flurbiprofen and a novel centrally acting analgesic, tramadol, alone and in combination, for reducing pain in endodontic emergency patients. Patients (n = 49) were administered a local anesthetic and underwent pulpectomy. They were then administered, on a double-blind basis, either: (i) placebo (one capsule to start and then every 6 h); (ii) flurbiprofen (100 mg loading dose and then 50 mg every 6 h); (iii) tramadol (100 mg loading dose and then 100 mg every 6 h); or (iv) the combination of flurbiprofen and tramadol (as above). Pulpectomy combined with placebo medication resulted in a 50% reduction in pain by 24 h (p < 0.01). Patients treated with flurbiprofen and tramadol reported less pain, compared with placebo treatment at 6 and 24 h (p < 0.01 for both). These results suggest that a nonsteroidal anti-inflammatory drug/opiate combination, together with endodontic therapy, may be useful in the management of endodontic pain.",2000.0,0,0
236,10691216,Lumbar epidural morphine in humans and supraspinal analgesia to experimental heat pain.,M S Angst; B Ramaswamy; E T Riley; D R Stanski,"Epidural administration of morphine is a common analgesic technique to manage pain. Morphine spreads from the epidural space to the cerebrospinal fluid and then rostrally, causing side effects mediated by the brain stem. However, data on the rostral spread of morphine-mediated analgesia are sparse. This study examined the rostral spread of analgesic effects on heat and electrical pain after epidural administration of morphine. In a randomized, double-blinded, placebo-controlled, crossover study, 5 mg morphine or saline placebo were injected into the lumbar epidural space in nine healthy volunteers. Correct needle placement was confirmed with fluoroscopy. Analgesia to experimental nociceptive heat and electrical stimuli was measured at lumbar (L4), thoracic (T10), cervical (C2), and trigeminal (V2) levels before and 2, 5, 10, and 24 h after epidural injection. Plasma samples for assaying morphine concentrations were drawn before and after each analgesic evaluation. Epidural morphine significantly attenuated experimental heat pain at all dermatomes tested compared with saline placebo. Analgesic effects were significant at L4 after 2, 5, and 10 h, at T10 after 5, 10, and 24 h, and at V2 after 10 h. Electrical pain was attenuated at the lumbar and thoracic but not at the cervical dermatome. Analgesic effects were significant at L4 after 2, 5, and 10 h and at T10 after 5 and 10 h. Morphine plasma concentrations were below the detection limit (1 ng/ml) in eight of the nine subjects 10 h after epidural injection. Lumbar epidural injection of morphine attenuated cutaneous heat pain up to the trigeminal dermatome during a 24-h observation period. In a clinical context, this implies that some types of pain may be attenuated up to the supraspinal level after lumbar epidural administration of morphine.",2000.0,0,0
237,10691220,Preemptive intravenous morphine-6-glucuronide is ineffective for postoperative pain relief.,C Motamed; X Mazoit; K Ghanouchi; F Guirimand; K Abhay; T Lieutaud; S Bensaid; C Fernandez; P Duvaldestin,"Morphine-6-glucuronide (M-6-G), a major metabolite of morphine, is reported to be more potent than morphine when administered intrathecally; however, its efficiency remains under debate when administered intravenously. This study was designed to assess the analgesic efficiency of intravenous M-6-G for the treatment of acute postoperative pain. After informed consent was obtained, 37 adults (American Society of Anesthesiologists physical status I-II) who were scheduled for elective open knee surgery were enrolled in the study. General anesthesia was induced with thiopental, alfentanil, and vecuronium and was maintained with a mixture of nitrous oxide/isoflurane and bolus doses of alfentanil. At skin closure, patients were randomized into three groups: (1) morphine group (n = 13), which received morphine 0.15 mg/kg; (2) M-6-G group (n = 12), which received M-6-G 0.1 mg/kg; and (3) placebo group (n = 12), which received saline. At the time of extubation, plasma concentration of morphine and M-6-G was measured. Postoperative analgesic efficiency was assessed by the cumulative dose of morphine delivered by patient-controlled analgesia. Opioid-related side effects were also evaluated. No difference was noted in patient characteristics and opioid-related side effects. Morphine requirements (mean +/- SD) during the first 24 h in the M-6-G group (41+/-9 mg) and the placebo group (49+/-8 mg) were significantly greater (P<0.05) compared with the morphine group (29+/-8 mg). A single intravenous bolus dose of M-6-G was found to be ineffective in the treatment of acute postoperative pain. This might be related to the low permeability of the blood-brain barrier for M-6-G.",2000.0,0,0
238,10691230,Comparison of intravenous or epidural patient-controlled analgesia in the elderly after major abdominal surgery.,C Mann; Y Pouzeratte; G Boccara; C Peccoux; C Vergne; G Brunat; J Domergue; B Millat; P Colson,"Patient-controlled analgesia (PCA) with intravenous morphine and patient-controlled epidural analgesia (PCEA), using an opioid either alone or in combination with a local anesthetic, are two major advances in the management of pain after major surgery. However, these techniques have been evaluated poorly in elderly people. This prospective, randomized study compared the effectiveness on postoperative pain and safety of PCEA and PCA after major abdominal surgery in the elderly patient. Seventy patients older than 70 yr of age and undergoing major abdominal surgery were assigned randomly to receive either combined epidural analgesia and general anesthesia followed by postoperative PCEA, using a mixture of 0.125% bupivacaine and sufentanil (PCEA group), or general anesthesia followed by PCA with intravenous morphine (PCA group). Pain intensity was tested three times daily using a visual analog scale. Postoperative evaluation included mental status, cardiorespiratory and gastrointestinal functions, and patient satisfaction scores. Pain relief was better at rest (P = 0.001) and after coughing (P = 0.002) in the PCEA group during the 5 postoperative days. Satisfaction scores were better in the PCEA group. Although incidence of delirium was comparable in the PCA and PCEA groups (24% vs. 26%, respectively), mental status was improved on the fourth and fifth postoperative days in the PCEA group. The PCEA group recovered bowel function more quickly than did the PCA group. Cardiopulmonary complications were similar in the two groups. After major abdominal surgery in the elderly patient, patient-controlled analgesia, regardless of the route (epidural or parenteral), is effective. The epidural route using local anesthetics and an opioid provides better pain relief and improves mental status and bowel activity.",2000.0,0,0
239,10692629,Debilitating chronic pain syndromes after presumed intraneural injections.,B R Kaufman; E Nystrom; S Nath; G Foucher; A Nystrom,"This report presents seven patients with severe disability established at the time of a peripheral nerve block. In most of the cases, the injection was administered as a routine procedure by an experienced anesthesiologist. The patient histories suggest that the condition, which can be resistant to all treatment, in most cases could have been avoided if careful attention had been given to the occurrence of pain during the nerve block. It is likely that the risk of devastating iatrogenic disability can be minimized if a few basic principles are respected during the administration of peripheral nerve blocks.",2000.0,0,0
240,10699770,Nitrous oxide for colonoscopy: a randomized controlled study.,G M Forbes; B J Collins,"Intravenous sedation/analgesia for colonoscopy is accompanied with certain risks and postprocedure drowsiness. We sought to determine whether inhaled nitrous oxide (Entonox: 50% nitrous oxide, 50% oxygen) provides adequate analgesia for colonoscopy and the impact of this agent on recovery. All patients undergoing outpatient colonoscopy were considered for the study (n = 248) except those with previous colonic resection. Data for patients unsuitable for randomization (n = 58) and those who declined to participate (n = 88) were also analyzed. One hundred two patients were randomized to receive inhaled Entonox alone (n = 56) or intravenous midazolam and meperidine (n = 46). Forty-nine (88%) patients randomized to Entonox underwent complete colonoscopy without conversion to intravenous medications. Entonox patients reported more pain (p < 0.0001), tolerated colonoscopy less well (p < 0.0001), were less satisfied (p = 0.01), and less willing to undergo colonoscopy again under the same circumstances (p = 0.04). Of patients receiving intravenous medication, 91% found colonoscopy less unpleasant and 9% as unpleasant as anticipated; this compares with 52% and 21% Entonox patients, respectively, and an additional 27% Entonox patients who found colonoscopy more unpleasant than anticipated. Recovery was faster among Entonox patients (median 30 versus 60 minutes, p < 0.0001). Entonox is less effective than midazolam with meperidine for colonoscopy but is acceptable in many patients and allows faster recovery.",2000.0,0,0
241,10699771,Patient-controlled analgesia for conscious sedation during colonoscopy: a randomized controlled study.,E Stermer; L Gaitini; M Yudashkin; G Essaian; A Tamir,"The aim of this study was to assess whether patient-controlled anesthesia (PCA) can improve patient tolerance for colonoscopy. We compared baseline sedation and analgesia with baseline sedation and PCA. Fifty-six consecutive patients were alternatively allocated to 1 of 2 groups: either to control group (n = 28) to receive standard sedation (meperidine and midazolam as baseline and additional doses of meperidine administered by the anesthesiologist) or to a PCA group (n = 28) to receive the same baseline premedication but additional analgesia with meperidine being self-administered. Cardiopulmonary parameters were recorded and tolerance for the examination was evaluated by a numeric rating scale, 0 meaning ""no pain"" and 10 meaning ""maximal pain."" Patients' mean pain score (on a scale of 0 to 10) was 4.85 +/- 3.74 for the PCA group and 5.30 +/- 3.53 (not significant) for the control group. Physicians' assessment of patient tolerance registered a lower numeric rating score than patients' assessment. The duration of the procedure was slightly longer in the PCA group. None of the patients experienced a decline in oxygen saturation below 90%; a decrease in expiratory carbon dioxide during the examination was noted in both groups of patients, particularly during the first minutes of the examination. Mean additional sedation per patient in the PCA group was slightly higher, but not significantly different. Our results suggest that patient-controlled analgesia during colonoscopy is as effective as standard sedation with respect to patient tolerance and safety of the examination.",2000.0,0,0
242,10700784,Combined spinal-epidural analgesia in labour: comparison of two doses of intrathecal bupivacaine with fentanyl.,B B Lee; W D Ngan Kee; V Y Hung; E L Wong,"We have compared intrathecal bupivacaine 1.25 mg and fentanyl 25 micrograms (group A) with bupivacaine 2.5 mg and fentanyl 25 micrograms (group B), for combined spinal-epidural analgesia in 49 labouring parturients in a prospective, randomized, double-blind study. Onset and quality of analgesia were similar in both groups, with median visual analogue scale pain scores of 0 achieved in 5-10 min. Median duration of analgesia was longer in group B (median 120 (range 90-120) min) compared with group A (75 (75-105) min) (P = 0.013). Median upper sensory level was higher in group B compared with group A at 15 min (T6-7 vs T11, P = 0.003) and at 30 min (T6 vs T11-12; P = 0.001). Motor block was greater in group B: seven patients had a modified Bromage score > or = 1 compared with none in group A at 15 min (P = 0.017). Group B also had a greater decrease in arterial pressure. Patient-midwife satisfaction scores and other side effects were similar. We conclude that intrathecal bupivacaine 1.25 mg with fentanyl 25 micrograms provided analgesia of similar onset and quality compared with bupivacaine 2.5 mg and fentanyl 25 micrograms. Although the duration of analgesia was shorter, the incidences of motor block and hypotension were less with the smaller dose.",2000.0,0,0
243,10700786,Effect of oral and i.v. tenoxicam in postoperative pain after total knee replacement.,K A Eggers; B J Jenkins; I Power,"We have evaluated the effect of oral and i.v. tenoxicam on postoperative pain after unilateral total knee replacement in a double-blind, randomized, controlled study. Tenoxicam was administered to two groups of patients, either before (40 mg orally) or after (40 mg i.v.) surgery, then at 24 h after surgery (40 mg i.v.) and at the end of each day for 8 days (20 mg orally). A third group were given placebo at all times. All patients had access to PCA morphine for the first 48 h and then co-dydramol tablets for the duration of the study. We studied 101 patients, mean age 67 yr. There was no significant reduction in the requirement for PCA morphine for the duration of the study in either of the treatment groups, or for co-dydramol in the first 2 days, but tenoxicam significantly reduced the need for co-dydramol over the remaining 7 days. There were no significant differences in mobility between groups. There was a high incidence of adverse events reported, with a similar number in each of the three groups.",2000.0,0,0
244,10701800,Interstitial cystitis and the potential role of gabapentin.,H C Hansen,"Gabapentin, an antiepileptic agent, is a safe and versatile medication also used in the adjunctive treatment of painful disorders. These include neuropathic pain, such as postherpetic neuralgia, diabetic neuropathy, and the pain of reflex sympathetic dystrophy. Interstitial cystitis, a painful disease entity, shares many common features of these chronic pain states, and the use of gabapentin can assist in pain control. Gabapentin, as an adjunctive agent, may reduce use of cotherapeutics such as narcotics. Two patients with interstitial cystitis improved functional capacity within their activities of daily living and received adequate pain control with the addition of gabapentin to their medication regimen.",2000.0,0,0
245,10705425,Effects of 3 analgesic regimens on the perception of pain after removal of femoral artery sheaths.,T R Fulton; G I Peet; M A McGrath; J D Hilton; R E Smith; A F Sigurdsson; Q G Forrest,"Effective pain management after removal of femoral artery sheaths after percutaneous transluminal coronary angioplasty is highly individualized and requires frequent, accurate assessment and administration of analgesics as needed. To determine which of 3 analgesic regimens is most effective in decreasing patients' perception of pain with the fewest side effects after removal of a femoral artery sheath. 130 adult who had undergone percutaneous transluminal coronary angioplasty and were in an 8-bed cardiac short-stay unit in a 1400-bed acute care hospital. Patients were randomized to receive either intravenous morphine, intravenous fentanyl, subcutaneous lidocaine around the sheath site, or an intravenous placebo before sheath removal. Rescue analgesia (intravenous fentanyl) was made available to all groups. Patients used a visual analog scale to assess pain within 10 minutes before, 1 minute after, and 20 minutes after sheath removal. Pain levels, frequency of side effects, and use of rescue analgesia were compared among groups. Age, sex, number of stents, and frequency of hematomas did not differ significantly among groups. Pain ratings, use of rescue analgesia, and side effects (nausea, vomiting, or vasovagal symptoms) were not significantly different among treatment groups. Ratings of pain were slightly higher immediately after sheath removal in all groups. For most patients, removal of femoral artery sheaths and manual compression for hemostasis are relatively pain-free. Pain scores among patients given analgesia with subcutaneous lidocaine, intravenous morphine, or intravenous fentanyl were not significantly different from pain scores among control patients.",2000.0,0,0
246,10719944,Multiple dose pharmacokinetics of oral transmucosal fentanyl citrate in healthy volunteers.,T D Egan; A Sharma; M A Ashburn; J Kievit; N L Pace; J B Streisand,"Oral transmucosal fentanyl citrate (OTFC) is a solid form of fentanyl that delivers the drug through the oral mucosa. The clinical utility of multiple doses of OTFC in the treatment of ""breakthrough"" cancer pain is under evaluation. The aim of this study was to test the hypothesis that the pharmacokinetics of OTFC do not change with multiple dosing. Twelve healthy adult volunteers received intravenous fentanyl (15 microg/kg) or OTFC (three consecutive doses of 800 microg) on separate study sessions. Arterial blood samples were collected for determination of fentanyl plasma concentration by radioimmunoassay. The descriptive pharmacokinetic parameters (maximum concentration, minimum concentration, and time to maximum concentration) were identified from the raw data and subjected to a nonparametric analysis of variance. Population pharmacokinetic models for all subjects and separate models for each subject were developed to estimate the pharmacokinetic parameters of fentanyl after multiple OTFC doses. The shapes of the profiles of plasma concentration versus time for each dose of OTFC were grossly similar. No change was noted for maximum concentration or time to maximum concentration over the three doses, while minimum concentration did show a significantly increasing trend. Terminal half-lives for intravenous fentanyl and OTFC were similar. A two-compartment population pharmacokinetic model adequately represented the central tendency of the data from all subjects. Individual subject data were best described by either two- or three-compartment pharmacokinetic models. These models demonstrated rapid and substantial absorption of OTFC that did not change systematically with time and multiple dosing. The pharmacokinetics of OTFC were similar among subjects and did not change with multiple dosing. Multiple OTFC dosing regimens within the dosage schedule examined in this study can thus be formulated without concern about nonlinear accumulation.",2000.0,0,0
247,10720861,"Local anesthesia for extracorporeal shock wave lithotripsy: a double-blind, prospective, randomized study.",A K Türker; S Ozgen,"The efficacy of local anesthesia in decreasing intravenous analgesic requirements during extracorporeal shock wave lithotripsy with a second-generation lithotriptor was studied. Subcutaneous infiltration was performed before the procedure. Sixty-nine patients (ASA I-II) were randomly allocated into four groups. Lidocaine 1% plus epinephrine (5 microg/ml) were infiltrated subcutaneously in a group of patients with ureteral stones (group UL), and a group with renal stones (group RL). The same amount of saline was administered to a group of patients with ureteral stones (group UC), and a group with renal stones (group RC). Patients with ureteral stones needed higher doses of intravenous analgesic. Neither patients with renal stones nor patients with ureteral stones administered local anesthetic required less intravenous analgesic than patients given placebo. Local anesthesia did not decrease the requirement of intravenous doses of analgesics in patients treated with a second-generation lithotriptor (Dornier MPL 9000).",2000.0,0,0
248,10723296,Meperidine utilization and compliance with Agency for Health Care Policy and Research guidelines in a tertiary care hospital.,J E Pellegrini; J Paice; M Faut-Callahan,"The Agency for Health Care Policy and Research (AHCPR) established guidelines for the use of meperidine (demerol), a common inpatient analgesic. These guidelines define standards of care for acute and chronic cancer pain management and address many of the problems with meperidine and its metabolite, normeperidine. The purpose of this study was to determine whether meperidine was prescribed in compliance with AHCPR guidelines, whether patients exhibited any adverse reactions to meperidine, and to determine the analgesic efficacy of meperidine. Three hundred inpatient charts were reviewed and identified meperidine as the primary analgesic in 157 nonobstetric inpatients. Age, sex, weight, dosing interval, route of administration, duration of meperidine use, serum chemistry values, primary diagnosis, associated medical conditions, and medications concurrently being taken with meperidine were the parameters analyzed. An interview was conducted to ascertain medical and drug history, chronicity of pain syndromes, analgesic drug history, and analgesic efficacy. A visual analog scale for pain (range = 0 to 10) and an analgesic satisfaction survey (range = 1 to 5) were used. Of 157 patients, 124 (79.8%) were in conflict with AHCPR guidelines. The most frequent conflict was found to be suboptimal dosing regimen and treatment of chronic pain. Often concurrent analgesics were given with the meperidine to achieve adequate analgesia. Higher analgesic satisfaction scores were noted when meperidine was given with concurrent analgesics. Meperidine also was administered to patients in renal failure or with medications contraindicated with meperidine use. No significant adverse effects were noted with meperidine use in this sample population other than an increased incidence of confusion in the elderly population.",2000.0,0,0
249,10725965,Fibromyalgia and pain management.,J S Sartin,,2000.0,0,0
250,10730079,Preoperative epidural morphine using double-catheter technique for esophagectomy.,K Mizutani; Y Oda; T Terai; H Yukioka; A Asada,"This study was undertaken to determine whether preoperative epidural morphine using double-catheter technique would improve postoperative analgesia in patients undergoing esophagectomy with or without continuous intraoperative epidural lidocaine in a randomized double-blind and controlled manner. Thirty patients undergoing esophagectomy for esophageal cancer received preoperative epidural morphine 2 mg at T 6-7 and 2 mg at L 3-4 through the catheters, respectively. Thereafter, continuous thoracic epidural infusion of either 1% lidocaine (lidocaine group, n = 15) or normal saline solution (control group, n = 15) at 6 ml/h was initiated. After surgery, mean verbal rating scale of pain (0 to 10) at rest was maintained below 4 and pain on deep breathing was maintained mild in all patients in both groups. There was no significant difference in these values between the groups. In conclusion, preoperative epidural morphine using double-catheter technique provided adequate analgesia following esophagectomy. The addition of intraoperative continuous epidural lidocaine did not improve analgesia.",2000.0,0,0
251,10730731,Diclofenac premedication but not intra-articular ropivacaine alleviates pain following day-case knee arthroscopy.,P Rautoma; U Santanen; R Avela; H Luurila; V Perhoniemi; O Erkola,"To compare the postoperative analgesic effects of 50 mg diclofenac p.o. before surgery and intra-articular ropivacaine injected after diagnostic day-case knee arthroscopy performed under spinal anesthesia. In a randomized, double-blind investigation, 200 ASA physical status 1-2 outpatients, age 18-60 yr, received either 50 mg diclofenac p.o. or placebo one hour before operation (100 patients per group), and intraarticular injections of either 20 ml of ropivacaine 0.5% or 20 ml of saline 0.9% (50 patients in each premedication groups). Patients received 50 mg diclofenac p.o. prn and, if needed, 0.1 mg x kg(-1) oxycodone im for postoperative pain relief. Patients were discharged home with a supply of 50 mg diclofenac tablets and were given a sheet of paper with knee pain VAS scales and a questionnaire of analgesics taken. Patients rated their VAS scores eight hours after surgery and in the moming and at the end of the first and the second postoperative days, respectively. The only statistically significant difference was found when the diclofenac groups were combined and compared with the combined placebo premedication groups. The VAS scores of knee pain at eight hours after the operation were 19+/-22 in the two diclofenac premedication groups and 32+/-28 in the two placebo groups (P = 0.001). Diclofenac premedication p.o. reduced the VAS scores at eight hours postoperatively while intra-articular ropivacaine did not.",2000.0,0,0
252,10730733,Comparison of combined spinal-epidural and low dose epidural for labour analgesia.,D L Hepner; R R Gaiser; T G Cheek; B B Gutsche,"To compare the combined spinal-epidural (CSE) technique with the epidural technique with regard to time to initiate and manage, motor block, onset of analgesia and satisfaction during labour. Upon requesting analgesia, 50 healthy term parturients were randomized in a prospective, double-blind fashion to receive either CSE analgesia or lumbar epidural analgesia in the labour floor of a university hospital at an academic medical centre. The epidural group (n = 24) received bupivacaine 0.0625%-fentanyl 0.0002% with 0.05 ml in 10 ml local anesthetic sodium bicarbonate 8.4% and epinephrine 1:200,000. The CSE group (n = 26) received intrathecal 25 microg fentanyl and 2.5 mg bupivacaine. Additional analgesia was provided upon maternal request. There were no differences (P>0.05) in time to perform either technique, motor blockade, or parturient satisfaction or in the number of times that the anesthesiologist was called to perform any intervention. Although the first sign of analgesia was not different between the two groups, the onset of complete analgesia was more rapid with the CSE technique (Visual Analogue Pain Score (VAPS) at five minutes < three: 26/26 vs. 17/24, P+/-0.001). Although epidural analgesia with a low concentration of local anesthetic and opioid mixture takes longer to produce complete analgesia, it is a satisfactory alternative to CSE.",2000.0,0,0
253,10735341,Treatment of nonmalignant chronic pain.,D A Marcus,"Nonmalignant, chronic pain is associated with physical, emotional and financial disability. Recent animal studies have shown that remodeling within the central nervous system causes the physical pathogenesis of chronic pain. This central neural plasticity results in persistent pain after correction of pathology, hyperalgesia, allodynia, and the spread of pain to areas other than those involved with the initial pathology. Patient evaluation and management focus on pain symptoms, functional disabilities, contributory comorbid illnesses, and medication use or overuse. Treatment of chronic pain involves a comprehensive approach using medication and functional rehabilitation. Functional rehabilitation includes patient education, the identification and management of contributing illnesses, the determination of reachable treatment goals and regular reassessment.",2000.0,0,0
254,10735342,Approach to the vaso-occlusive crisis in adults with sickle cell disease.,S H Yale; N Nagib; T Guthrie,"The vaso-occlusive crisis, or sickle cell crisis, is a common painful complication of sickle cell disease in adolescents and adults. Acute episodes of severe pain (crises) are the primary reason that these patients seek medical care in hospital emergency departments. Frequently, however, the pain is incompletely treated. Despite advances in pain management, physicians are often reluctant to give patients adequate dosages of narcotic analgesics because of concerns about addiction, tolerance and side effects. It is important to recognize a pain crisis early, correct the inciting causes, control pain, maintain euvolemia and, when necessary, administer adequate hemoglobin to decrease the hemoglobin S level. The family physician and the hematologist must work together to treat acute pain episodes promptly and effectively, manage the long-term sequelae of chronic pain and prevent future vaso-occlusive crises.",2000.0,0,0
255,10735909,Interventional pain therapy for intractable abdominal cancer pain.,D P Seamans; G Y Wong; J L Wilson,,2000.0,0,0
256,10736080,Continuous epidural butorphanol relieves pruritus associated with epidural morphine infusions in children.,J B Gunter; J McAuliffe; T Gregg; N Weidner; A M Varughese; D M Sweeney,"We examined the efficacy of epidural butorphanol to either prevent or relieve pruritus associated with epidural morphine infusion in children. Forty-six children were randomized to receive either epidural morphine (M) or epidural M with butorphanol (B) for postoperative analgesia. They received bupivacaine and either M 50 microg.kg-1 or the same dose of M plus B 10 microg.kg-1. Following surgery, a continuous infusion of 0.1% bupivacaine with either M 20 microg.ml-1 or M 20 microg.ml-1 + B 4 microg.ml-1 was given at a rate of 0.3 ml.kg-1.h-1. Pain scores and pruritus scores were recorded every 4 h during epidural infusion. Subjects with a pruritus score=2 received diphenhydramine 0.5 mg.kg-1 i.v. and were switched to an alternate epidural infusion; subjects receiving M (group M) were switched to M+B while subjects receiving M+B (group B) were switched to hydromorphone (H) 4 microg.ml-1. There was no difference in the initial incidence of pruritus (group M 11/18; group B 13/28). No subject in group M required a second change of epidural infusion because of continued pruritus after being switched to M+B; five of 13 subjects in group B continued to experience pruritus after being switched to H and required a second change of epidural infusion or an alternate analgesic modality (P=0.038). The median pruritus score in the first 24 h after changing epidural infusions was 0 in subjects in group MDelta (changed from M to M+B) and 1 in subjects in group BDelta (changed from M+B to H; P=0.012). While the median sedation score in the first 24 h was 1 in both groups, there was a greater incidence of sedation scores of 2 in group B than group M (28% vs 12.3%; P=0.021). B 10 microg.kg-1 was not effective in preventing pruritus associated with bolus epidural administration of M 50 microg.kg-1 in children. B 1.2 microg.kg-1. h-1 was effective in relieving pruritus associated with continuous epidural infusion of M 6 microg.kg-1.h-1.",2000.0,0,0
257,10736083,A comparison of rectal and intramuscular codeine phosphate in children following neurosurgery.,A McEwan; P E Sigston; K A Andrews; H A Hack; A M Jenkins; L May; N Llewelyn; A MacKersie,"Codeine is frequently used for postoperative analgesia in children. Intramuscular injections are not ideal and the rectal route may be preferable. We compared rectal and intramuscular codeine administered following neurosurgery. 20 children (over 3 months) undergoing elective neurosurgical procedures, were randomized to receive either rectal or intramuscular codeine phospate (1 mg.kg-1) at the end of the procedure. Serum levels of codeine and morphine were assayed at intervals following administration (0, 30, 60, 120, 240 min). Fentanyl was the intraoperative analgesic and postoperative rescue analgesia was paracetamol, diclofenac and intramuscular codeine. The Children's Hospital of Eastern Ontario Pain Scale was used to assess analgesia. Peak codeine levels in both groups were observed at 30 min and morphine levels were consistently low. The plasma codeine levels were significantly greater at 30 and 60 min following intramuscular injection, and were associated with slightly better analgesia scores, but did not reach statistical significance. However, the peak plasma level occurred at similar times in both groups. Codeine is absorbed as rapidly via the rectal route compared with the intramuscular route but the peak levels are lower.",2000.0,0,0
258,10737286,"Around-the-clock, controlled-release oxycodone therapy for osteoarthritis-related pain: placebo-controlled trial and long-term evaluation.",S H Roth; R M Fleischmann; F X Burch; F Dietz; B Bockow; R J Rapoport; J Rutstein; P G Lacouture,"Although opioid analgesics have well-defined efficacy and safety in treatment of chronic cancer pain, further research is needed to define their role in treatment of chronic noncancer pain. To evaluate the effects of controlled-release oxycodone (OxyContin tablets) treatment on pain and function and its safety vs placebo and in long-term use in patients with moderate to severe osteoarthritis pain. One hundred thirty-three patients experiencing persistent osteoarthritis-related pain for at least 1 month were randomized to double-blind treatment with placebo (n = 45) or 10 mg (n = 44) or 20 mg (n = 44) of controlled-release oxycodone every 12 hours for 14 days. One hundred six patients enrolled in an open-label, 6-month extension trial; treatment for an additional 12 months was optional. Use of controlled-release oxycodone, 20 mg, was superior (P<.05) to placebo in reducing pain intensity and the interference of pain with mood, sleep, and enjoyment of life. During long-term treatment, the mean dose remained stable at approximately 40 mg/d after titration, and pain intensity was stable. Fifty-eight patients completed 6 months of treatment, 41 completed 12 months, and 15 completed 18 months. Common opioid side effects were reported, several of which decreased in duration as therapy continued. Around-the-clock controlled-release oxycodone therapy seemed to be effective and safe for patients with chronic, moderate to severe, osteo-arthritis-related pain. Effective analgesia was accompanied by a reduction in the interference of pain with mood, sleep, and enjoyment of life. Analgesia was maintained during long-term treatment, and the daily dose remained stable after titration. Typical opioid side effects were reported during short- and long-term therapy.",2000.0,1,1
259,10740327,A double-blind randomised trial of leuprorelin acetate prior to hysterectomy for dysfunctional uterine bleeding.,A D Weeks; S R Duffy; J J Walker,"To evaluate the use of pre-operative leuprorelin acetate for reducing the morbidity from hysterectomy for nonfibroid menorrhagia. A double-blind, randomised, placebo-controlled trial. Gynaecology department in a large university teaching hospital. Fifty-one women without uterine fibroids awaiting abdominal or vaginal hysterectomy for dysfunctional uterine bleeding. Participants received leuprorelin acetate or placebo for eight weeks prior to hysterectomy. Operative blood loss, operative difficulty, first day morphine use, speed of return to 'normal health'. The study and control groups were similar as regards prognostic factors. Two women in the study group withdrew because of side-effects. Although a 34% reduction in uterine volume was seen in those treated with leuprorelin, there were no significant differences in operative blood loss (183 mL in the study group vs 285 mL in controls, P = 0.27), operation time (39 vs 49 min, P = 0.64) or operative difficulty (visual analogue scale 3.0 vs 4.0, P = 0.09). Furthermore, there was no difference between the groups in post-operative morbidity or rate of recovery. Treating women with leuprorelin acetate for 8 weeks prior to surgery for nonfibroid menorrhagia has no significant operative or post-operative benefits.",2000.0,0,0
260,10740552,Wound infiltration with bupivacaine after surgery to the cervical spine using a posterior approach.,L H Pobereskin; J R Sneyd,"We have compared pain scores, morphine consumption and duration of stay for 50 adults who underwent elective cervical spine surgery via a posterior incision in a prospective, double-blind, placebo-controlled, randomized study. During wound closure, the paravertebral muscles and subcutaneous tissues were infiltrated with 40 ml of saline (control) or 0.25% bupivacaine. There were no significant differences in pain scores, morphine consumption or duration of stay between groups. In view of the potential risks of wound infiltration in the cervical region, we consider that this practice should be abandoned.",2000.0,0,0
261,10740555,I.v. regional diamorphine for analgesia after foot surgery.,M G Serpell; E Anderson; D Wilson; N Dawson,"Opioids administered to peripheral tissues can have significant analgesic effects in doses which would not be effective centrally. We have assessed the effects of regional diamorphine 2.5 mg i.v. in 14 patients undergoing surgical correction of bilateral arthritic foot deformities in a prospective, randomized, double-blind study. Patients acted as their own controls as only one foot received the active drug. Visual analogue scale (VAS) pain scores and wound tenderness were measured over 72 h. Diamorphine did not improve median VAS area under the curve pain scores during the first 6 h after surgery (33 (95% confidence intervals (CI) 25-46) vs 24 (17-35)). It also did not effect wound hypersensitivity when tested at 72 h after surgery (95 (47-125) vs 90 (50-125) g). There were no significant adverse effects.",2000.0,0,0
262,10741821,What is the quality of the implemented meta-analytic procedures in chronic pain treatment meta-analyses?,D Fishbain; R B Cutler; H L Rosomoff; R S Rosomoff,"Meta-analysis (MA) is the application of quantitative techniques for the purposes of summarizing data from individual studies. This type of review has many advantages over traditional reviews. However, different investigators performing MAs on the same data set have reached different conclusions. These reliability problems have been attributed to differences in the quality of the implemented meta-analytic procedures. We, therefore, examined the chronic pain treatment meta-analytic literature for MA procedure quality and for the consistency of conclusions. DESIGN, SETTING, PARTICIPANTS, OUTCOME MEASURES: Chronic pain treatment MAs were isolated according to inclusion/exclusion criteria. Data from these MAs were abstracted into structured tables. Table format reflected eight meta-analytic procedures identified previously as being important to MA implementation quality. These were: adequacy of retrieval, publication bias, inclusion/exclusion criteria, abstraction of data, quality, homogeneity/heterogeneity, independence, and statistical versus clinical interpretation. Each meta-analytic procedure was then independently rated by two raters. Rating results were then analyzed by procedure for each individual MA for percentage scores out of 100%, and mean scores. For MAs addressing the same topic area (pain facility treatment, antidepressant treatment, manipulation treatment) direction of effect size was noted. Mean effect sizes were calculated for these subgroups. Sixteen chronic pain treatment MAs fulfilled inclusion/exclusion criteria. Mean procedure ratings indicated that four procedures may not be implemented adequately. These were publication bias, abstraction of data, quality, and homogeneity/heterogeneity. There was wide MA implementation score variability, with 37.5% scoring less than 50%. The effect sizes of the MA subgroups demonstrated replicate nonvariability. Some meta-analytic procedures could be interpreted to be implemented inadequately in some chronic pain treatment MAs. There is wide variability between individual chronic pain treatment MAs on adequacy of implementation of these procedures. However, the effect sizes of the different MA subgroups demonstrated consistency. This finding indicates that for these MA subgroups, MA results are consistent between authors. In addition, chronic pain MAs, as compared with other groups of MAs, appear to address some of the procedures in a more adequate fashion. Future chronic pain MAs should concentrate on improving the quality of their methods with particular emphasis on the above four procedures. Because of potential validity problems with these results, these data cannot and should not be used to make administrative decisions about previous MAs.",2000.0,0,0
263,10743444,"Effect of continuous epidural 0.2% ropivacaine vs 0.2% bupivacaine on postoperative pain, motor block and gastrointestinal function after abdominal hysterectomy.",H Jørgensen; J S Fomsgaard; J Dirks; J Wetterslev; J B Dahl,"We have investigated the effect of 24-h postoperative continuous epidural infusion of 0.2% ropivacaine or 0.2% bupivacaine 8 ml h-1 on pain, request for supplementary analgesics, motor block and gastrointestinal function, in a double-blind, randomized study in 60 patients undergoing open hysterectomy. There were no significant differences between groups in pain, number of patients requesting supplementary analgesics, motor block, ability to walk or time to first flatus or stool. In the subgroup of patients who received supplementary analgesics, patients in the ropivacaine group received significantly more ketorolac than patients in the bupivacaine group. Time to discharge from hospital was similar with ropivacaine and bupivacaine.",2000.0,0,0
264,10743445,Effect of meloxicam on postoperative pain after abdominal hysterectomy.,J P Thompson; P Sharpe; S Kiani; O Owen-Smith,"We studied 36 patients, allocated randomly to receive meloxicam 15 mg rectally (n = 18) or placebo suppository (n = 18) before total abdominal hysterectomy in a double-blind study. Visual analogue scores for pain at rest (P < 0.005), on movement (P < 0.05) and on coughing (P < 0.05) were significantly decreased in the meloxicam group during the first 24 h after surgery. Mean 24-h PCA morphine requirements were 33.2 (SD 16.9) mg and 38.2 (20.8) mg in the meloxicam and placebo groups, respectively (ns). There was no difference in the incidence of nausea, vomiting or sedation between groups.",2000.0,0,0
265,10743448,Postoperative pain management and recovery after remifentanil-based anaesthesia with isoflurane or propofol for major abdominal surgery. Remifentanil Study Group.,E Kochs; D Côté; L Deruyck; V Rauhala; M Puig; E Polati; J Verbist; B Upadhyaya; C Haigh,"We have assessed if recovery times after morphine or fentanyl, given before terminating remifentanil anaesthesia with isoflurane or propofol, are compromised. We studied patients undergoing elective, major abdominal surgery, allocated randomly to receive remifentanil and isoflurane (n = 277) or remifentanil and propofol (n = 274) anaesthesia. Twenty-five minutes before the end of surgery, patients received fentanyl 0.15 mg or morphine 15 mg in a randomized, double-blind manner followed by a second dose (fentanyl 0.05 mg, morphine 7 mg) for moderate or severe pain in recovery. Recovery was rapid and at an Aldrete score > or = 9 (median 12-15 min), 42-51% of patients reported none or mild pain. However, 26-35% of patients reported severe pain and > 90% required a second dose of opioid within 21-27 min after anaesthesia.",2000.0,0,0
266,10743462,Infiltration of the abdominal wall with local anaesthetic after total abdominal hysterectomy has no opioid-sparing effect.,J R Klein; J P Heaton; J P Thompson; B R Cotton; A C Davidson; G Smith,"We have measured the effect of infiltration of the deep and superficial layers of the abdominal wound on morphine consumption and pain for 48 h after operation, in 40 patients undergoing total abdominal hysterectomy, in a double-blind randomized study. Patients received wound infiltration with 0.9% normal saline 40 ml or 40 ml of 0.25% bupivacaine with epinephrine 1:200,000. There were no significant differences between groups in morphine consumption, linear analogue scores for pain at rest or on movement, nausea or sedation during the first 48 h after operation. We conclude that infiltration of the deep and superficial layers of the wound of a Pfannenstiel incision with local anaesthetic solution did not confer additional analgesia in patients undergoing major gynaecological surgery.",2000.0,0,0
267,10743822,Double blind randomized placebo control trial of controlled release codeine in the treatment of osteoarthritis of the hip or knee.,P M Peloso; N Bellamy; W Bensen; G T Thomson; Z Harsanyi; N Babul; A C Darke,"Pain is the cardinal feature of osteoarthritis (OA), and with advancing disease there is loss of function and increasing pain even at times of joint rest. Few studies have evaluated the role of opioid analgesics in treating the pain of OA. This randomized, double blind, parallel group study compared the efficacy and safety of a 12 hourly controlled release codeine formulation (Codeine Contin) with placebo in patients with chronic pain due to OA of the hips and/or knees. The 4 week treatment period, following an analgesic washout phase of 2-7 days, included weekly clinic evaluations, at which the dose was escalated as appropriate, and daily patient diary completion. Pain (daily), stiffness, and physical function (weekly) were assessed using the multidimensional, self-administered WOMAC (visual analog scale version) questionnaire. Sixty-six eligible patients completed the study. The mean initial and final daily doses of controlled release codeine were 50 mg every 12 h at baseline and 159 mg every 12 h at the final assessment. All variables in the efficacy analysis indicated superiority of controlled release codeine over placebo. The WOMAC pain scale showed an improvement of 44.8% over baseline in the controlled release codeine group compared with 12.3% taking placebo (p = 0.0004). For the WOMAC stiffness and physical function scales the improvements over baseline on controlled release codeine were 47.7% and 49.3%, respectively compared with 17.0% and 17.0%, respectively, with placebo (p = 0.003; p = 0.0007). Controlled release codeine was also significantly better than placebo on measures of sleep quality and requirement for supplemental acetaminophen. Single entity controlled release codeine is an effective treatment for pain due to OA of the hip or knee.",2000.0,1,1
268,10743823,Efficacy of tramadol in treatment of chronic low back pain.,T J Schnitzer; W L Gray; R Z Paster; M Kamin,"To evaluate the efficacy and safety of tramadol in the treatment of chronic low back pain. A 3 phase trial: (1) a washout/screening phase; (2) a 3 week, open label, run-in phase; and (3) a 4 week, randomized, placebo controlled, double blind treatment phase. Three hundred eighty outpatients between 21 and 79 years with chronic low back pain with no or a distant history of back surgery enrolled in the open label phase and were treated with tramadol up to 400 mg/day. At the end of the open label phase, patients who tolerated tramadol and perceived benefit from it were randomized to continue treatment with tramadol or to convert to placebo in the double blind phase. Reasons for discontinuing from the open label phase included adverse events, 78 patients (20.5%); drug ineffective, 23 patients (6.1%); and other reasons, 25 patients (6.6%). Two hundred fifty-four patients entered the double blind phase, during which the daily dose was maintained within the range 200-400 mg tramadol or equivalent amount of placebo. The primary outcome measure in the double blind phase was the time to discontinuation due to inadequate pain relief. The distribution of time to therapeutic failure was significantly (p < or = 0.0001) different in the tramadol group compared to placebo. Kaplan-Meier estimate of the cumulative discontinuation rate due to therapeutic failure was 20.7% in the tramadol group and 51.3% in the placebo group. There were significantly lower (p < or = 0.0001) mean pain visual analog scores (10 cm scale) among tramadol patients (3.5 cm) compared to placebo patients (5.1 cm) at the final visit of the double blind phase. Tramadol patients scored significantly better on the McGill Pain Questionnaire (p = 0.0007) and the Roland Disability Questionnaire (p = 0.0001). Five of 127 tramadol treated patients and 6/127 placebo treated patients discontinued treatment during the double blind phase due to an adverse event. Commonly reported adverse events with tramadol included nausea, dizziness, somnolence, and headache. Among patients who tolerated it well, tramadol was effective for the treatment of chronic low back pain.",2000.0,0,0
269,10747210,Patient-controlled epidural analgesia with morphine or morphine plus ketamine for post-operative pain relief.,P H Tan; M C Kuo; P F Kao; Y Y Chia; K Liu,"Sixty patients were randomly assigned to two equal groups. Group I received epidural morphine 1 mg after surgery and used a patient-controlled analgesia device programmed to deliver morphine 0. 2 mg h-1, 0.2 mg per bolus. Group II received an epidural loading dose of morphine 1 mg plus ketamine 5 mg and used a patient-controlled analgesia device programmed to deliver morphine 0. 2 mg+ketamine 0.5 mg h-1, morphine 0.2 mg+ketamine 0.5 mg per bolus with a lockout time of 10 min. The mean morphine consumption was 8. 6+/-0.7 mg for group I and 6.2+/-0.2 mg for group II. Although group II utilized significantly less morphine (P < 0.05), pain relief was significantly better in group II than in group I (P < 0.05) in the first 3 h. Vomiting occurred more frequently in group I (26%) than in group II (13%). The frequency and severity of pruritus and level of sedation were similar in the two groups. These findings suggest that patient-controlled epidural analgesia with morphine plus ketamine may provide effective analgesia with a lesser dose of morphine and fewer subsequent side effects, compared with patient-controlled epidural analgesia with morphine alone after lower abdominal surgery.",2000.0,0,0
270,10747212,Efficacy and side effects of tramadol versus oxycodone for patient-controlled analgesia after maxillofacial surgery.,M Silvasti; P Tarkkila; M Tuominen; N Svartling; P H Rosenberg,"Tramadol, a weak opioid mu-receptor agonist, may have a favourable potency and side effect profile for intravenous patient-controlled analgesia (PCA). In a prospective, double-blind, randomized study involving 54 patients, tramadol was compared with oxycodone in PCA after maxillofacial surgery. All the patients were given diclofenac sodium 1 mg kg-1 intramuscularly and dexamethasone 8 mg twice a day. Post-operatively patients received tramadol or oxycodone by a PCA apparatus (lockout 5 min, tramadol 0.3 mg kg-1 bolus, oxycodone 0.03 mg kg-1 bolus). During the immediate recovery period, opioid was administered i.v. in a double-blind fashion, either tramadol 10 mg or oxycodone 1 mg increments until the pain control was judged to be satisfactory by the patient. Pain was assessed at rest and during activity (mouth opening) before and after loading, at 2 h after commencing the PCA, as well as at 21.00 and at 09.00 hours on the following morning. Side effects were recorded. The potency ratio of tramadol to oxycodone was found to be approximately 8:1. There was no significant difference between the groups in the VAS scores for pain. No respiratory depression was identified. Tramadol was found to provide adequate analgesia after maxillofacial surgery without risk of respiratory depression. However, the incidence of nausea was slightly greater in the tramadol group than in the oxycodone group (44% vs. 28%, NS).",2000.0,0,0
271,10749965,"""We don't carry that""--failure of pharmacies in predominantly nonwhite neighborhoods to stock opioid analgesics.",R S Morrison; S Wallenstein; D K Natale; R S Senzel; L L Huang,"We have observed that many black and Hispanic patients receiving palliative care at a major urban teaching hospital are unable to obtain prescribed opioids from their neighborhood pharmacies. In this study, we investigated the availability of commonly prescribed opioids in New York City pharmacies. We surveyed a randomly selected sample of 30 percent of New York City pharmacies to obtain information about their stock of opioids. For each pharmacy, U.S. Census estimates for 1997 were used to determine the racial and ethnic composition of the neighborhood (defined as the area within a 0.4-km [0.25-mile] radius of the pharmacy) and the proportion of residents who were more than 65 years old. Data on robberies, burglaries, and arrests involving illicit drugs in 1997 were obtained for the precinct in which each pharmacy was located. We used a generalized linear model to examine the relation between the racial or ethnic composition of neighborhoods and the opioid supplies of pharmacies, while controlling for the proportion of elderly persons at the census-block level and for crime rates at the precinct level. Pharmacists representing 347 of 431 eligible pharmacies (81 percent) responded to the survey. A total of 176 pharmacies (51 percent) did not have sufficient supplies of opioids to treat patients with severe pain. Only 25 percent of pharmacies in predominantly nonwhite neighborhoods (those in which less than 40 percent of residents were white) had opioid supplies that were sufficient to treat patients in severe pain, as compared with 72 percent of pharmacies in predominantly white neighborhoods (those in which at least 80 percent of residents were white) (P<0.001). Pharmacies in predominantly nonwhite neighborhoods of New York City do not stock sufficient medications to treat patients with severe pain adequately.",2000.0,0,0
272,10752810,Carbamezapine for pain management in Guillain-Barré syndrome patients in the intensive care unit.,M Tripathi; S Kaushik,"To evaluate carbamezapine (CBZ) for neuritic pain relief in Guillain-Barré syndrome (GBS) patients in the intensive care unit (ICU). Prospective, double-blind, randomly allocated cross-over study days. ICU in a tertiary care university hospital. Twelve consecutive, conscious adult (22-54 yrs) patients with GBS during recovery from the muscular weakness and receiving pressure-support ventilation in the ICU. All patients complained of severe backache and/or leg cramps and tenderness in muscles, and they required opioids for pain relief. CBZ (100 mg every 8 hrs) or equivalent placebo was given to nursing staff in coded powder form. Medication was given to patients through a nasogastric feeding tube. The same coded medicine was given for 3 days, and after a 1-day omission, a second set of coded powder was given for the next 3 days in a randomized, double-blind, crossover fashion. Pethidine (1 mg x kg(-1)) was given intravenously in between, if the pain score was >2. Group 1 (n = 6) patients were given a placebo on the first 3 days, followed by CBZ. Group 2 (n = 6) patients were given CBZ on the first 3 days, followed by a placebo. In these two study periods of different medications, we observed and scored pain (1, no pain; 5, severe pain), sedation (1, alert; 6, asleep, does not respond to verbal command), and total pethidine requirement per day. In group 1 patients, a significant (p < .001) improvement in the sedation score and a low requirement for pethidine was observed 3 days later, when CBZ was started. However, in group 2 patients, a gradual increase in the pethidine requirement and a high sedation score were noteworthy in the later days of placebo medication. Observations were also analyzed for CBZ days vs. placebo days. Overall, the pain score (1.7 +/- 0.8) during the CBZ period of both regimens was significantly (p < .001) lower than during the placebo days (3.1 +/- 0.9). Significantly higher doses of pethidine (3.7 +/- 0.9 mg/kg/day) were used on the placebo days than on the CBZ days (1.7 +/- 1.0 mg/kg/day). The pain in GBS has a dual origin, and we recommend CBZ as an adjuvant to treat pain in GBS patients, during the recovery phase in the ICU, to reduce the narcotic requirement.",2001.0,0,0
273,10755497,Trends in medical use and abuse of opioid analgesics.,D E Joranson; K M Ryan; A M Gilson; J L Dahl,"Pain often is inadequately treated due in part to reluctance about using opioid analgesics and fear that they will be abused. Although international and national expert groups have determined that opioid analgesics are essential for the relief of pain, little information has been available about the health consequences of the abuse of these drugs. To evaluate the proportion of drug abuse related to opioid analgesics and the trends in medical use and abuse of 5 opioid analgesics used to treat severe pain: fentanyl, hydromorphone, meperidine, morphine, and oxycodone. Retrospective survey of medical records from 1990 to 1996 stored in the databases of the Drug Abuse Warning Network (source of abuse data) and the Automation of Reports and Consolidated Orders System (source of medical use data). Nationally representative sample of hospital emergency department admissions resulting from drug abuse. Medical use in grams and grams per 100,000 population and mentions of drug abuse by number and percentage of the population. From 1990 to 1996, there were increases in medical use of morphine (59%; 2.2 to 3.5 million g), fentanyl (1168%; 3263 to 41,371 g), oxycodone (23%; 1.6 to 2.0 million g), and hydromorphone (19%; 118,455 to 141,325 g), and a decrease in the medical use of meperidine (35%; 5.2 to 3.4 million g). During the same period, the total number of drug abuse mentions per year due to opioid analgesics increased from 32,430 to 34,563 (6.6%), although the proportion of mentions for opioid abuse relative to total drug abuse mentions decreased from 5.1% to 3.8%. Reports of abuse decreased for meperidine (39%; 1335 to 806), oxycodone (29%; 4526 to 3190), fentanyl (59%; 59 to 24), and hydromorphone (15%; 718 to 609), and increased for morphine (3%; 838 to 865). The trend of increasing medical use of opioid analgesics to treat pain does not appear to contribute to increases in the health consequences of opioid analgesic abuse.",2001.0,0,0
274,10758470,"A comparative study of patient-controlled epidural diamorphine, subcutaneous diamorphine and an epidural diamorphine/bupivacaine combination for postoperative pain.",C Gopinathan; I Sockalingham; M A Fung; S Peat; M H Hanna,"This randomized double blind study investigates the relative efficacies of controlled analgesia (PCA) regimens in three different patient groups: epidural diamorphine 2.5 mg followed by PCA bolus 1 mg with a 20-min lockout (Gp1), subcutaneous diamorphine 2.5 mg followed by PCA bolus with a 10-min lockout period (Gp2) and epidural diamorphine 2.5 mg in 4 mL of 0.125% (w/v) bupivacaine followed by a PCA bolus of 1 mg diamorphine in 4 mL 0.125% (w/v) bupivacaine with a 20-min lockout (Gp3). Patients were evaluated at 0, 1, 2, 3, 4, 8, 12, 16, 20, 24 and 48 h. Patients in Gp2 consumed significantly more diamorphine than those in Gp1 or Gp3 (P < 0.05), but their pain scores were higher only at 1, 2 and 3 h (P < 0.05) with respect to Gp3 and at 1 h with respect to Gp1. Fewer side effects (sedation, pruritus and nausea as assessed by anti-emetic requirements) occurred in Gp2 compared to Gp1 (P < 0.05). Fewer patients in Gp2 required catheterization than in Gp3 (P < 0.05). This study indicates that the use of PCA epidural diamorphine, either alone or in combination with bupivacaine, reduces the dose requirement for analgesia but offers little clinical advantage over subcutaneous PCA diamorphine.",2000.0,0,0
275,10760623,Transdermal fentanyl in opioid-naive cancer pain patients: an open trial using transdermal fentanyl for the treatment of chronic cancer pain in opioid-naive patients and a group using codeine.,A P Vielvoye-Kerkmeer; C Mattern; M P Uitendaal,"To treat cancer pain, physicians often decide to jump directly from step 1 of the World Health Organization (WHO) analgesic ladder to step 3. The use of transdermal fentanyl in patients with cancer pain who had either used no opioid before, or only codeine, is evaluated in the present trial. Both opioid-naive (N = 14) and codeine-using (N = 14) patients started with transdermal fentanyl in the lowest available delivery rate (25 microg/hr). Immediate-release oral morphine was present as ""rescue"" medication. Transdermal fentanyl provided good to excellent pain relief in the majority (68%) of these patients. During the study, 5 patients continued with 25 microg/hr, and the others used a higher dose. Clinically relevant respiratory depression was not observed. The common side effects of opioids were found; constipation was mentioned by 3 patients (11%). Transdermal fentanyl appeared a safe analgesic in these opioid-naive cancer pain patients. In this study, WHO step 2 could be skipped without untoward complications.",2000.0,0,0
276,10764171,Patient-controlled intranasal analgesia: effective alternative to intravenous PCA for postoperative pain relief.,S Toussaint; J Maidl; R Schwagmeier; H W Striebel,"To investigate whether the nasal route for fentanyl administration in patient-controlled analgesia (PCA) provides as effective postoperative analgesia as intravenous PCA. Patient-controlled intranasal or intravenous analgesia with fentanyl was investigated in 48 patients (ASA I-III) on the day of surgery (orthopedic, abdominal or thyroid) in a prospective, randomized, double-blind, double-dummy study. Fentanyl was given in a bolus of 25 microg for intranasal and 17.5 microg for i.v. PCA, lockout interval six minutes. The first requested dose was doubled in both groups. Pain intensity (101-point numerical rating scale) and vital parameters were observed at 11 measurement points during the 240 min study. Patients were asked for side effects at every measurement point and for their satisfaction at the end of the study by the same investigator (J.M.). Onset of analgesia, the first reduction in pain intensity on the numerical rating scale, was 21 +/- 11 min (range 15-45 min) in intranasal and 22 +/- 16 min (range 15-90 min) in i.v. PCA. Pain intensity was reduced from 55 +/- 11 to 11 +/- 10 in the intranasal group and from 53 +/- 8 to 11 +/- 6 in the i.v. PCA group. Vital parameters remained stable and side effects were comparable in both groups. The judgement ""excellent"" or ""good"" was given by 21 of 23 patients treated intranasally and 24 of 25 patients treated intravenously. Intranasal PCA with fentanyl was an effective alternative to i.v. PCA in postoperative patients.",2000.0,0,0
277,10764172,Intrathecal morphine suppresses NK cell activity following abdominal surgery.,T Yokota; K Uehara; Y Nomoto,"The effects of morphine on natural killer (NK) cell activity were investigated in patients who underwent hysterectomy. Forty patients were divided into four groups of ten. The groups received intrathecal 0.5 mg morphine (Group IT0.5), intrathecal 0.1 mg morphine (Group IT0.1) or 10 mg morphine i.v. (Group IV). The remaining ten patients served as controls and received inhalation anesthesia alone (Group C). Blood samples were withdrawn before and two hours after surgery and on postoperative days one and two to determine the blood NK cell activity using a chromium release assay with K562 cells as targets, plasma catecholamines and cortisol levels. The postoperative pain score and side effects were studied in the four groups. In Group IT0.5, the NK cell activity was lower on postoperative day 1 (23.9 +/- 8.4%) than the baseline level (45.7 +/- 13%) before surgery, and recovered on postoperative day 2. In Groups IT0.1, C and IV, the NK cell activities showed no significant changes. In all four groups, neither plasma adrenaline nor noradrenaline concentrations changed. In all four groups, the plasma cortisol levels increased after surgery, on postoperative days 1 and 2. The pain score was lower two hours after surgery and on postoperative day 1 in Group IT0.5 than in the other groups. These results suggest that long-lasting analgesic effects of intrathecal 0.5 mg morphine suppress the immune response following abdominal surgery.",2000.0,0,0
278,10764173,Peroperative titration of morphine improves immediate postoperative analgesia after total hip arthroplasty.,L Pico; S Hernot; I Nègre; K Samii; D Fletcher,"To determine the Influence of peroperative titrated morphine on postoperative pain control. Forty patients received general anesthesia for total hip arthroplasty (THA) and were divided into two groups of 20. In the Peroperative group (Perop group;) morphine was titrated at the end of surgery (3 mg i.v. every 5 or 10 min) in spontaneously breathing intubated patients, until the respiratory rate (RR) decreased. No morphine was administered to Postop group. In the Post Anesthesia Care Unit (PACU) patients in Perop and Postop groups received morphine until adequate pain relief VAS < or = 30 mm. Patients used patient-controlled analgesia (PCA) for the next 24 hr. In the PACU, the delay for analgesia, doses of morphine used and incidence of side effects were recorded. In the Perop group, patients received 10.3 +/- 1.3 mg (2-20 mg) as peroperative titration and had achieved adequate analgesia more rapidly than in the Postop group (42 +/- 7 min vs 76 +/- 7 min); P = 0.0026). Analgesia in the PACU in the Postop group required larger doses of morphine (15.4 +/- 1.5 mg;) than in the Perop group (7.3 +/- 1.3 mg; P = 0.0004). The respiratory rate decrease during peroperative morphine titration was correlated to the morphine dose needed in the PACU (P = 0.035). Respiratory depression in the PACU was more common in the Postop group than in the Perop group (five patients vs no patient P = 0.017). This study demonstrated that the peroperative administration of morphine can facilitate immediate postoperative pain management.",2000.0,0,0
279,10764185,In the arms of Morpheus the development of morphine for postoperative pain relief.,G R Hamilton; T F Baskett,"To analyse the historical development of morphine for postoperative analgesia and how this development was shaped by the evolution of anesthetic techniques. After a systematic review of the literature, information was gathered from primary sources. In ancient medicine, some plant derivatives were used to alleviate pain including: alcohol, cannabis, mandrake, and opium. Over the past two centuries, opium and its derivatives have become the most widely used analgesics for severe pain. Before the development of general anesthesia, surgery was only performed out of extreme necessity. It is probable that an analgesic such as opium would have been given following surgery although its use may not have been recorded. The first description of postoperative opium was by James Moore in 1784. Morphine was isolated from opium by Friedrich Serturner in 1805. However, it was not until the development of the hypodermic needle and syringe nearly 50 yr later that the use of morphine became widespread. Over the last century, various delivery systems for morphine have been developed including subarachanoid and epidural injection, and more recently patient-controlled intravenous, epidural and intranasal analgesia. In addition, many new opioids have been synthesized. Since its isolation from opium almost 200 yr ago, morphine remains the most widely used analgesic and the standard against which all new opioids for postoperative pain relief are compared.",2000.0,0,0
280,10773501,"Additional droperidol, not butorphanol, augments epidural fentanyl analgesia following anorectal surgery.",Y Kotake; M Matsumoto; K Ai; H Morisaki; J Takeda,"To examine the effects of additional droperidol or butorphanol to epidural fentanyl infusion on postsurgical analgesia. Prospective, randomized, single blinded clinical study. University-affiliated medical center. 60 ASA physical status I and II patients undergoing anorectal surgery by one surgeon. Patients were randomly allocated to the following groups according to the medication that was continuously administered into the epidural space: 1) Group C (n = 20) received 0.4 mg fentanyl in 40 ml of 0.125% bupivacaine; 2) Group D (n = 20) received 2.5 mg droperidol and 0.4 mg fentanyl in 40 ml of 0.125% bupivacaine; and 3) Group B (n = 20) received 2 mg butorphanol and 0.4 mg fentanyl in 40 ml of 0.125% bupivacaine over 24 hours postoperatively. Postsurgical analgesia and the incidence of fentanyl-related complications, such as nausea/vomiting, somnolence, pruritus, and respiratory depression, were assessed for 24 hours postoperatively. At 16 and 24 hours after surgery, 75% of patients in Group D reported no pain versus 35% in Group C (p < 0.05). In addition, the overall visual analogue scale examined at 24 hours was significantly lower in Group D than that in Group C (22 +/- 17 mm vs. 44 +/- 22 mm, respectively; p < 0.05). Simultaneously, the incidence of postoperative nausea/vomiting was lower in Group D compared with Group C (20% vs. 60%; p < 0.05). On the other hand, butorphanol did not modify the analgesic effects or complications of epidural fentanyl infusion. In this study population, additional droperidol, not butorphanol, improved postsurgical analgesia accompanied by less incidence of nausea/vomiting during epidural fentanyl administration.",2000.0,0,0
281,10773513,Complex regional pain syndrome (CRPS) with resistance to local anesthetic block: a case report.,F R Maneksha; H Mirza; P J Poppers,"We present a case of complex regional pain syndrome (CRPS) Type 1 in a 12-year-old girl. The patient did not respond to the usual therapeutic modalities used to treat CRPS, including physical therapy, lumbar sympathetic block, epidural local anesthetic block, intravenous lidocaine infusion, or other oral medications. Of note is the fact that, during epidural block, the patient demonstrated a resistance to local anesthetic neural blockade in the area of the body involved with the pain problem. The mechanism of this resistance could be related to the changes in the dorsal horn cells of the spinal cord, secondary to activation of N-methyl-D-aspartate receptors, which may play a role in the pathophysiology of this pain syndrome.",2000.0,0,0
282,10779656,Effect of preoperative oral dextromethorphan on immediate and late postoperative pain and hyperalgesia after total abdominal hysterectomy.,S Ilkjaer; L F Bach; P A Nielsen; M Wernberg; J B Dahl,"Dextromethorphan is a noncompetitive N-methyl-D-aspartate (NMDA) receptor antagonist known to inhibit wind-up and NMDA-mediated nociceptive responses of dorsal horn neurons. Experimental and clinical studies indicate that NMDA-receptor antagonists may potentiate the effect of analgesics such as morphine, local anesthetics and NSAIDs. Results from previous clinical studies of dextromethorphan in postoperative pain are conflicting, possibly related to administration of insufficient doses of the drug. Fifty patients scheduled for non-malignant elective abdominal hysterectomy in general anesthesia were randomized to receive oral dextromethorphan 150 mg, or placebo 1 h before surgery. The patients received patient-controlled analgesia with morphine for 24 h postoperatively as the only analgesic. Patient-controlled analgesia (PCA) morphine consumption was reduced with 30% from 0-4 h after operation in patients receiving dextromethorphan compared with placebo (P=0.02); no differences were observed from 5-24 h postoperatively. There were no significant differences between groups for visual analogue scale scores at rest, during cough, or during mobilization, pressure pain detection thresholds, von Frey hair pain detection thresholds, or peak flow. At 24 h after operation, hyperalgesia to von Frey hair stimulation proximal to the surgical wound was easily detected in 23 of 25 patients receiving dextromethorphan, and in 22 of 25 patients receiving placebo, with no significant difference between groups. Pooled data from both groups showed a weak but significant correlation between the extent of hyperalgesia at 24 h after operation, and total 24 h postoperative PCA morphine consumption (Rs=0.28, P=0.05). Three months postoperatively, hyperalgesia was still detectable in 18 of 22 examined patients in the dextromethorphan group, and in 16 of 23 patients in the placebo group, without statistical differences between groups. There were no significant differences in side-effects (nausea, vomiting, sedation). In conclusion, oral dextromethorphan 150 mg reduced PCA morphine consumption immediately (0-4 h) after hysterectomy, without prolonged effects on pain or wound hyperalgesia. A positive correlation between the magnitude of wound hyperalgesia at 24 h after operation, and total 24 h postoperative PCA morphine consumption was demonstrated.",2000.0,0,0
283,10781115,Postoperative pain control following remifentanil-based anaesthesia for major abdominal surgery.,S Albrecht; J Fechner; G Geisslinger; A B Maass; B Upadhyaya; H Moecke; C Haigh; J Schüttler,"Eighty patients undergoing major abdominal surgery using remifentanil-based anaesthesia were randomly allocated in a double-blind manner to receive an intravenous bolus of fentanyl, buprenorphine, morphine or piritramide 20 min before the end of surgery. A reduced dose was administered postoperatively when patients reported moderate pain. Subsequent analgesia was provided by patient-controlled analgesia (PCA). The mean time from the end of anaesthesia to spontaneous respiration was 9 +/- 5 min. At first pain assessment, 63% of patients reported no or mild pain; 80% of patients required the second opioid bolus, those receiving piritramide needed the bolus significantly later than patients receiving buprenorphine or fentanyl. First PCA requirement also occurred significantly later in the piritramide group. This technique provided effective postoperative pain relief and transition to routine PCA and did not compromise recovery.",2000.0,0,0
284,10783429,Advances in pain management for older adult patients.,J L Abrahm,"Management of pain is crucial to the success of any program of care and support for dying patients and their families. Pain can be controlled in more than 90% of older adults. Components of an effective program include comprehensive, repeated pain assessment; detection and treatment of complicating medical and psychological disorders (e.g., delirium); spiritual concerns; and the judicious use of nonpharmacologic and pharmacologic therapies, radiation, and radiopharmaceuticals. Strategies that enable clinicians to prevent and treat the expected complications of nonsteroidal anti-inflammatory and opioid therapies are reviewed. Strategies to change opioid agents or routes to minimize opioid-induced side effects and to provide effective pain relief as death nears are presented.",2000.0,0,0
285,10784070,Intrathecal grafting of unencapsulated adrenal medullary tissue can bring CD4 T lymphocytes into CSF: a potentially deleterious event for the graft.,J Tkaczuk; J C Bes; H Duplan; B Sallerin; M Tafani; J P Charlet; M Abbal; Y Lazorthes; E Ohayon,"Adrenal medullary tissue including chromaffin cells was grafted intrathecally in cancer patients to relieve intractable pain. The central nervous system (CNS) is considered an immune privileged site. Therefore, non-HLA-matched and unencapsulated tissue was grafted in 15 patients and 1 sham control in a series of at least 20 grafts. We observed an increase in CSF lymphocyte counts in 15/20 allografts (75%). In contrast to peripheral blood, CD4 T cells predominated in the CSF, but failed to exhibit an activated phenotype (CD25+ CD45RO+ HLA-DR+). The positive effect of graft on pain, the high met-enkephalin levels, the absence of any increase in CSF cytokine levels particularly for IFN-gamma or IL-2 (but not IL-10 and IL-6), indirectly indicated that the graft was tolerated despite the presence of CSF lymphocytes. The single treatment failure and three of four cases of partial efficacy occurred in grafts where CSF lymphocytes were present. Moreover, when assayed (n = 7), the CD4+ CSF lymphocytes still retained the capacity to exhibit ex vivo a normal or enhanced frequency of T CD4 cells producing IFN-gamma and IL-2. Taken together, our observations indicate that impairment of the local immunosuppressive balance can lead to activation of those CSF CD4 T cells and drive a rejection process. This study suggests further work on the purification and/or the immunoisolation of tissues grafted in the CNS will be necessary, particularly when the possibility of long-term and repeated grafting is considered.",2000.0,0,0
286,10786738,"Day-case laparoscopy: a comparison of prophylactic opioid, NSAID or local anesthesia for postoperative analgesia.",M A Salman; M E Yücebaş; F Coşkun; U Aypar,"The study was aimed to evaluate the analgesic efficacy, postoperative comfort, recovery characteristics and side effects of three different analgesic agents administered prophylactically. Eighty patients undergoing day-case minor operative laparoscopy were randomly allocated into four groups to receive tenoxicam 20 mg i.v. (Group T), fentanyl 100 microg i.v. (Group F), 5 ml of bupivacaine 2.5 mg/ml for infiltration of trocar sites (Group B), 30, 10 and 5 min before incision respectively. Bupivacaine, 35 ml, 2.5 mg/ml was also administered into the pelvic cavity in Group B. Group P received only placebo. Postoperative pain, analgesic requirements, first response to verbal stimulus, first analgesic requirement, ability to walk without help, to drink and to void, blood pressures, SpO2 and respiration rates were recorded in the PACU. Postoperative pain was evaluated by verbal rating scale. Pain scores, analgesic requirements and side effects were evaluated by telephone calls until the 48th postoperative hour. Postoperative pain scores were lower and time to requirement of rescue analgesics was longer in groups F and B compared to Group P. In the PACU, analgesic requirements were lower in Group B, compared to Group P. Nausea and vomiting were increased in Group F. Tenoxicam 20 mg i.v. was found to be ineffective whereas bupivacaine was superior to other groups in reducing pain and analgesic requirements. Bupivacaine also increased time to first analgesics and obtained better recovery characteristics, underlining its value in prophylactic pain management compared to the other two agents.",2000.0,0,0
287,10790552,"Prospective randomized blinded trial of pulmonary function, pain, and cosmetic results after laparoscopic vs. microlaparoscopic cholecystectomy.",W Schwenk; J Neudecker; J Mall; B Böhm; J M Müller,"The size of laparoscopic instruments has been reduced for use in abdominal video endoscopic surgery. However, it has yet to be proven that microlaparoscopic surgery will actually result in clinically relevant benefits for patients. Fifty patients were randomized in a blinded fashion to receive either elective laparoscopic (MINI), (n = 25) or microlaparoscopic (MICRO) (n = 25) cholecystectomy. Pulmonary function (FVC, FEV (1)), analgesic consumption during patient-controlled analgesia (PCA), pain perception by visual analogue score (VAS), and the cosmetic result (by the patient's self-assessment) were evaluated postoperatively as clinically relevant end points. Age, sex, body mass index (BMI), preoperative pulmonary function, pain perception, and operative time were similar for the two groups. At 8:00 PM on the day of surgery, FVC (MINI: 1.96 L [range, 1.48-2.48]; MICRO: 2.13 L) [(range, 1.61.-2.50)] and FEV (1) (MINI: 1.17 L/sec) [range, 0.87-1. 48]; MICRO: 1.34 L/sec [range, 1.05.-2.14] were also similar (each p = 0.5). From surgery to the 3rd postoperative day, cumulative PCA morphine doses were comparable (MINI: 0.15 mg/kg bw [range, 0.09-0. 23]; MICRO: 0.21 mg/kg bw [range, 0.10-0.42]; p = 0.4), but overall VAS scores for pain while coughing were higher in the laparoscopic group (406 [range, 358-514]) than in the microlaparoscopic group (365 [range, 215-427]; p = 0.02). The cosmetic result was judged to be slightly superior by the microlaparoscopic patients (10 [range, 9-10]), as compared to those in the laparoscopic (9 [range, 8-10]) group (p = 0.04). Because microlaparoscopic cholecystectomy has some minor advantages over laparoscopic surgery, it should be considered for use in selected patients.",2000.0,0,0
288,10790605,[Recent pharmacologic approaches to pain].,N Attal; D Bouhassira,"The identification of compounds that can effectively and safely treat chronic pain is a major challenge of biomedical research. One approach is to optimize currently active analgesic treatments, notably by reducing their side effects. An example of this approach is the recent development of a novel class of nonsteroidal antiinflammatory drugs (NSAIDs), the cyclo-oxygenase 2 inhibitors, that lack the limiting gastrointestinal side effects of the traditional NSAIDs. Another approach, based on the recent development of molecular biology, is to develop analgesic compounds acting on new targets. These include notably ion channel blockers (TTX-resistant sodium channel blockers specific for nociceptors, N-type calcium channel blockers), nicotine receptor agonists, peptide receptor antagonists, N-methyl-D-aspartate (NMDA) receptor antagonists, vanilloids, new opioid compounds, cannabinoids, selective alpha2-adrergic agonists, purinergic modulators. Most of these compounds are currently in preclinical or early clinical investigation. However, the development of more predictable in vitro and in vivo tests and the broadening use of clinical models of experimental pain, will hopefully help increase the proportion of drugs that will become successful analgesics in clinical practice.",2000.0,0,0
289,10794581,Addiction: part II. Identification and management of the drug-seeking patient.,L P Longo; T Parran; B Johnson; W Kinsey,"The medications most often implicated in prescription drug abuse are opioid analgesics, sedative-hypnotics and stimulants. Patients with acute or chronic pain, anxiety disorders and attention-deficit disorder are at increased risk of addiction comorbidity. It is important to ask patients about their substance-use history, including alcohol, illicit drugs and prescription drugs. Patients who abuse prescription drugs may exhibit certain patterns, such as escalating use, drug-seeking behavior and doctor shopping. A basic clinical survival skill in situations in which patients exert pressure on the physician to obtain a prescription drug is to say ""no"" and stick with it. Physicians who overprescribe can be characterized by the four ""Ds""-dated, duped, dishonest and disabled. Maintaining a current knowledge base, documenting the decisions that guide the treatment process and seeking consultation are important risk-management strategies that improve clinical care and outcomes.",2000.0,0,0
290,10794994,[Per- and postoperative pain].,E Calenda,"We have made a huge amount of progress over the last decade, but we must continue to clear a way through the undergrowth. Per- and postoperative pain is typical of acute pain and is characterized by an excess of nociception due to tissue injury, visceral distention or disease. It contrasts with chronic pain which has been going on for 3 to 6 months. PATHWAYS OF PAIN: We know that the spinothalamic cord is involved in nociceptive activity. Two pathways are of great interest. One ends in a nucleus of the hypothalamus and the second in the amygdala. Both are involved in affective and emotional activity. Treatment of postoperative pain requires first that one be aware that pain is a reality and secondly that it must be assessed with various scales. Only then can the therapeutic strategy set about using the different methods available. Strategy must be continuously assessed to improve its efficacy. Different kinds of treatment can be used during the per- and postoperative period including enteral (paracetamol, nonsteroidal analgesic and antiinflammatory drugs (NSAIDs)) or parenteral (paracetamol, NSAIDs, morphine or similar) analgesic drugs. Local anesthesia seems however to be more effective. Several factors are involved in per- and postoperative pain. Its treatment is based on comprehensive team work in which each person represents a link in the therapeutic chain. For the future, we can expect to see the appearance of new drugs, processes or associations able to prolong postoperative analgesia.",2000.0,0,0
291,10798466,A drug use evaluation of selected opioid and nonopioid analgesics in the nursing facility setting.,G W Cramer; B S Galer; M A Mendelson; G D Thompson,"To determine the medical conditions for which selected analgesics are most frequently prescribed in nursing facilities (NFs), describe the use of pharmacologic and nonpharmacologic pain therapies, and determine the frequency and quality of pain assessment in NF residents. A multicenter, 3-month retrospective drug use evaluation conducted by consultant pharmacists. Eighty-nine NFs having no more than 25% of their patient census representing special populations (e.g., head trauma). A total of 2065 adult NF residents who received at least one selected analgesic. Primary indication for analgesics, pain type, method of pain assessment, nonpharmacologic therapies for pain, prescribed analgesics and regimens, and comorbid conditions were recorded. A total of 54.3% of residents had one indication for analgesic therapy, 31.0% had two indications, and 14.7% had three or more indications. Arthritis was the most prevalent indication for analgesics (41.7% of residents), followed by bone fracture (12.4%) and other musculoskeletal conditions (9.7%). More residents (76.8%) were reported to have chronic pain than acute pain (19.9%), and 3.0% had both chronic and acute pain. Pain type was unknown for 0.2% of residents. Observational pain assessments were used more frequently (for 55.9% of residents) than objective methods (16.6%), and pain was not assessed in 40.6% of residents. Most residents (69.4%) received no nonpharmacologic treatment for pain. Of the 2542 opioid and nonsteroidal anti-inflammatory drug (NSAID) prescriptions, 67.6% were for opioids, 24.8% were for NSAIDs, and 7.6% were for tramadol. Propoxyphene-containing drugs were the most frequently prescribed opioid group, and propoxyphene with acetaminophen was the most frequently prescribed analgesic (35.6% of all analgesics). Most analgesics (63.2%) were prescribed on an as-needed (prn) basis. The findings show a lack of adequate pain assessments, little use of nonpharmacologic interventions, and inappropriate use of analgesic medication. The small percentage of residents with chronic pain assessed objectively suggests the difficulty of monitoring pain progression in NFs. The prescribing of analgesic for most residents (with propoxyphene used most often, long-acting opioids used infrequently, and frequent prn use) was inconsistent with recommended pain therapy in older people and attests to the urgent need to educate NF practitioners on the appropriate use of analgesics.",2000.0,0,0
292,10808729,[Tizanidine in the treatment of acute withdrawal symptoms in heroin dependent patients].,I Sós; N Kiss; J Csorba; J Gerevich,"One of the treatment alternative of withdrawal symptoms of patients suffering from opiate dependence is to apply the clonidine in combination or itself. This remedy is not in commercial trade in our country. It is expectable according to the recent data analysing the effects of the alfa2 adreneregic agonist tizanidine that tizanidine has the similar protective effect as clonidine with the resembling target point. Based on this theory a research was done, in the course of which the i.v. heroin users who presented themselves at the Drug Outpatient Department of Buda between 1.10.1998-8.01.1999. were divided into two groups. The groups had got the usual detoxification treatment, but in the experimental group tizanidine were given in 3 x 8 mg/day dose too. Sixteen patients were in the tizanidine group, 10 patients were in the control group. The patients estimated the intensity of 7 symptoms of withdrawal (sweating, nervousness, insomnia, tremor, diarrhoea, muscle pain, drug craving) on a subjective scale day by day. The analysis showed that the tizanidine treatment decreased the intensity of the withdrawal symptoms in every symptom type examined. The ten days long acute withdrawal period were accomplished by all of the patients, but in the short course of the following (mean 9 and 11 weeks in the treated and the control groups respectively) there were three relapses in each group (3/16 in the treated and 3/10 in the control).",2000.0,0,0
293,10812139,Patient-controlled epidural analgesia with morphine in renal transplant patients.,E Arslan Akpek; Z Kayhan,,2000.0,0,0
294,10812259,Preinjury treatment with morphine or ketamine inhibits the development of experimentally induced secondary hyperalgesia in man.,T Warncke; A Stubhaug; E Jørum,"We examine the effect of morphine or ketamine (N-methyl-D-aspartate receptor antagonist; NMDA) treatment on secondary hyperalgesia. Drug treatment started preinjury and continued into the early postinjury period. Hyperalgesia was induced by a local 1 degrees burn injury covering 12.5 cm(2) on the medial side of the calf. In this double-blind, cross-over study, 12 healthy volunteers received, on 3 separate days and in randomized order: (1) placebo; (2) morphine, bolus 150 microg/kg + infusion 1 microg/kg per min and 0.5 microg/kg per min; and (3) ketamine, bolus 60 microg/kg + infusion 6 microg/kg per min and 3 microg/kg per min. Bolus + infusion started 30 min before injury and ended 50 min after it. The area of secondary hyperalgesia was quantitated using punctate (von Frey filaments) and brush stimuli (electric brush). On the day of placebo, all subjects developed an area of hyperalgesia to punctate and brush stimuli outside the thermal injury (secondary hyperalgesia). We show that ketamine or morphine treatment starting preinjury significantly reduces this development (P<0.01, both). In a previous study, we found that postinjury treatment alone with morphine did not affect secondary hyperalgesia, whereas ketamine did so significantly. The differential response to morphine administered pre- or postinjury may be relevant to the recently shown NMDA receptor mediated interaction of central hyperexcitability and morphine antinociception. The effect of ketamine supports the hypothesis of the role of NMDA receptor mediation in central hyperexcitability.",2000.0,0,0
295,10812417,Postoperative pain management.,K A Holder; T B Dougherty; V H Porche; J S Chiang,"Postoperative pain can be effectively managed, even in the most complex oncologic procedures. Although the primary agents for treatment of severe pain continue to be opioids, routes of administration and dosing regimen have undergone a dramatic metamorphosis in the past 10 years. The intramuscular injection given every 4 hours has been replaced by patient-controlled analgesia and epidural techniques. Management of ancillary issues that contribute to an increased perception of pain (i.e., stress, depression, anxiety, and inflammation) must be included in an effective multimodal plan. Closer attention to the treatment of pain can obviate the consequences of poorly managed pain, which we are only beginning to understand. In this day of active consumerism in medicine, patients have come to expect improved pain management. Early outcome studies are beginning to confirm the belief that improved pain management translates into between outcomes and earlier dismissals. In the first century BC, Publilius Syrus, a Latin mime, wrote, ""There are some remedies worse than the disease."" For centuries, pain was inextricably linked to treatment. We may now be approaching a time in the development of medical care when this is no longer true.",2000.0,0,0
296,10815009,Nutritional supplementation with Chlorella pyrenoidosa for patients with fibromyalgia syndrome: a pilot study.,R E Merchant; C A Carmack; C M Wise,"Fibromyalgia syndrome is a common, chronic musculoskeletal disorder of unknown aetiology. While available therapy is often disappointing, most patients can be helped with a combination of medication, exercise and maintenance of a regular sleep schedule. The objective of the present study was to determine if adding nutritional supplements derived from the unicellular green alga, Chlorella pyrenoidosa, produced any improvements in the clinical and functional status in patients with moderately severe symptoms of fibromyalgia syndrome. Eligible patients had 2+ palpable tenderness at 11 or more of 18 defined tender points and had a tender point index (TPI) of at least 22. Each day for 2 months, participants consumed two commercially available Chlorella-based products, 10 g of 'Sun Chlorella' tablets and 100 mL of liquid 'Wakasa Gold'. Any amelioration of symptoms was validated and quantified using semi-objective and subjective outcome measures systematically administered at clinic visits on days 0, 30 and 60 of the diet therapy. Eighteen of the 20 patients enrolled completed the 2 month trial. The average TPI for the group which at onset was 32, decreased to a mean of 25 after 2 months. This decrease was statistically significant (p = 0.01), representing a 22% decrease in pain intensity. Blood samples taken on each occasion indicated no significant alterations in serum chemistries, formed elements, and circulating lymphocyte subsets. Compilations of the results of patient interviews and self-assessment questionnaires revealed that seven patients felt that the dietary supplement had improved their fibromyalgia symptoms, while six thought they had experienced no change, and five believed the symptoms had worsened over the time of the trial. The results of this pilot study suggest that dietary Chlorella supplementation may help relieve the symptoms of fibromyalgia in some patients and that a larger, more comprehensive double-blind, placebo-controlled clinical trial in these patients is warranted.",2000.0,0,0
297,10817004,[Comparative study of the effects of morphine and tramadol in the treatment of postoperative pain].,R Casali; A Lepri; Q Cantini; S Landi; G P Novelli,"To compare morphine and tramadol in the treatment of postoperative pain (POP), using a system of Patient Controlled Analgesia (PCA).  Randomised comparative study on 88 patients, undergoing general major surgical operations (gastrectomy, colectomy and hemicolectomy). PCA i.v.: group M treated with morphine (at a dilution of 1 mg/ml) and group T with tramadol (at a dilution of 10 mg/ml). Loading dose: 0.05 mg/kg for the group treated with morphine and 0.5 mg/kg for the group treated with tramadol. Baseline infusion: 1.5 ml/h. Bolus on demand: 0.2 ml every 30 minutes. At T0, after 1 hour, 3 and 18 hours assessment of pain intensity, level of sedation, respiratory and cardiocirculatory parameters. After 18 hours assessment of the amount of drug administered, the number of boluses requested and given and any side effects. ANOVA test, Student ""t"", chi 2. A statistically significant reduction in POP was found after 1 hour, 3 and 18 hours with no significant differences between the two groups. No statistically significant differences in cardiocirculatory or respiratory parameters or level of sedation were found. Few side effects were observed. Tramadol determines pain relief similar to morphine, with the advantage that it does not lead to abuse, tolerance or addiction.",2000.0,0,0
298,10829145,Constipation and the use of laxatives: a comparison between transdermal fentanyl and oral morphine.,L Radbruch; R Sabatowski; G Loick; C Kulbe; M Kasper; S Grond; K A Lehmann,"Constipation and the use of laxatives were investigated in patients with chronic cancer pain treated with oral morphine and transdermal fentanyl in an open sequential trial. Forty-six patients were treated with slow-release morphine 30-1000 mg/day for 6 days and 39 of these patients were switched to transdermal fentanyl 0.6-9.6 mg/day with a conversion ratio of 100:1. Median fentanyl doses increased from 1.2 to 3.0 mg/day throughout the 30-day transdermal treatment period. Twenty-three patients completed the study. Two patients died from the basic disease while treated with transdermal fentanyl, 12 patients were excluded for various reasons, and not enough data for evaluation were available for two patients. Mean pain intensity decreased slightly after conversion although the number of patients with breakthrough pain or requiring immediate-release morphine as a rescue medication was higher with transdermal fentanyl. The number of patients with bowel movements did not change after the opioid switch but the number of patients taking laxatives was reduced significantly from 78-87% of the patients per treatment day (morphine) to 22-48% (fentanyl). Lactulose was used mainly and was reduced most drastically, but other laxatives were also used less frequently. In this study transdermal fentanyl was associated with a significantly lower use of laxatives compared to oral morphine. The difference in the degree of constipation between the two analgesic regimens should be confirmed in a randomized double-blind study that takes into account both constipation and use of laxatives.",2000.0,0,0
299,10832944,Medical students' attitudes toward pain and the use of opioid analgesics: implications for changing medical school curriculum.,S M Weinstein; L F Laux; J I Thornby; R J Lorimor; C S Hill; D M Thorpe; J M Merrill,"Barriers to pain management include physicians' lack of knowledge and attitudes. Our aim was to investigate future physicians' knowledge and attitudes toward pain and the use of opioid analgesics. We tested a medical school class during their freshman and senior years. Stepwise regression analysis was used to identify the personal traits that predicted opiophobia. The professionalization process of medical training may reinforce negative attitudes. Psychologic characteristics were associated with reluctance to prescribe opioids, and fears of patient addiction and drug regulatory agency sanctions. Consistent attitudes were found in senior medical students with preferences for certain specialty areas and the practitioners of their future specialties, suggesting a ""preselection"" effect. Higher scores on reliance on high technology, external locus of control, and intolerance of clinical uncertainty were associated with higher scores on one or more of the three dimensions of opiophobia. Implications for medical education are discussed.",2000.0,0,0
300,10832945,Physicians' attitudes toward pain and the use of opioid analgesics: results of a survey from the Texas Cancer Pain Initiative.,S M Weinstein; L F Laux; J I Thornby; R J Lorimor; C S Hill; D M Thorpe; J M Merrill,"Despite extensive progress in the scientific understanding of pain in humans, serious mismanagement and undermedication in treating acute and chronic pain is a continuing problem. This study was designed to examine the barriers to adequate pain management, especially as they might be associated with community size and medical discipline. A 59-item survey was used to measure physicians' attitudes, knowledge, and psychologic factors that contribute to pain management practices. Overall, a significant number of physicians in this survey revealed opiophobia (prejudice against the use of opioid analgesics), displayed lack of knowledge about pain and its treatment, and had negative views about patients with chronic pain. There were significant differences among groups of physicians based on size of geographic practice area and medical discipline. New educational strategies are needed to overcome these barriers and to improve pain treatment in routine medical practice. The effect of practice milieu must be taken into consideration.",2000.0,0,0
301,10833307,Adrenal medullary explants as an efficient tool for pain control: adhesive biomolecular components are involved in graft function ex vivo.,H Duplan; J C Bès; M Tafani; B Sallerin; J Sagen; E Ohayon; Y Lazorthes; J Tkaczuk,"Adrenal medullary (AM) tissue transplantation into the central nervous system has been reported as a potential source of opioid peptides and catecholamines, which have analgesic effects useful in the control of chronic pain. Clinical trials, involving allogeneic graft of whole tissue explants into the subarachnoid space of the lumbar spinal cord, have already been reported. The aim of the present study was to determine whether adhesion and function of AM explants were related in some extent and how this relationship could account for improvement of AM tissue in terms of analgesic activity before grafting. Our experiments demonstrated a significant correlation between the adherent state of AM organoids during culture and a sustained secretion of Met-enkephalin and catecholamines by chromaffin cells (CC). These findings suggest that optimal culture condition for AM organoid adhesion can be defined for maintenance of tissue, prior to transplantation. Using immunocytochemistry, flow cytometry, and ELISA assays we showed that different cell adhesion molecules (CAMs) and extracellular matrix ECM proteins were expressed and released by AM cells during culture. Adherent AM organoids expressed increased levels of specific neural CAMs (NCAM and HNK-1 epitope) and integrin chains (beta1, alpha1, alpha2, alpha4, alpha5) and deposited markedly higher levels of fibronectin, but also laminin and collagen IV. Those molecules and probably adhesion processes they control might be involved in the maintenance of the CC-secreting neuroendocrine phenotype through cellular signaling pathways.",2000.0,0,0
302,10834668,Alfentanil reduces the febrile response to interleukin-2 in humans.,C Negishi; J S Kim; R Lenhardt; D I Sessler; M Ozaki; K Vuong; H Bastanmehr; A R Bjorksten,"Manifestation of intraoperative fever is impaired by volatile anesthetics and muscle relaxants. Opioids are common anesthetic adjuvants and remain the dominant treatment for postoperative surgical pain and sedation of critically ill patients. The effect of opioids on normal thermoregulatory control is well established. However, the extent to which these drugs might inhibit fever remains unknown. Accordingly, we tested the hypothesis that relatively low plasma concentrations of the mu-receptor agonist alfentanil reduce fever magnitude. Prospective, randomized, crossover study. Outcomes Research Laboratory, at the Department of Anesthesia and Perioperative Care, University of California, San Francisco. Eight healthy male volunteers, aged 25-31 yrs, each studied on three separate days. Each volunteer was given an intravenous injection of 30 IU/g interleukin (IL)-2, followed 2 hrs later by 70 IU/g. One hour after the second dose, the volunteers were randomly assigned to three doses of alfentanil: a) none (control); b) a target plasma concentration of 100 ng/mL; and c) a target concentration of 200 ng/mL. Opioid administration continued for 5 hrs. Alfentanil significantly reduced the febrile response to pyrogen, decreasing integrated tympanic membrane temperatures from 7.5+/-2.2 degrees C x hr on the control day, to 4.9+/-1.5 degrees C x hr with 100 ng/mL alfentanil, and to 5.1+/-1.7 degrees C x hr with 200 ng/mL alfentanil (p = .011). Peak temperatures were also significantly reduced from 38.5+/-0.4 degrees C on the control day, to 38.0+/-0.4 degrees C on the 100 ng/mL-alfentanil day and 38.0+/-0.6 degrees C on the 200-ng/mL day (p = .019). Plasma cytokine concentrations increased after IL-2 administration, roughly in proportion to the elevation in core temperature. However, cytokine concentrations did not differ significantly among the treatment groups. Alfentanil significantly reduced the febrile response to IL-2 administration. However, the reduction was comparable at plasma concentrations near 100 and 200 ng/mL. These data indicate that concentrations of opioids commonly observed in critical care patients significantly inhibit the manifestation of fever.",2000.0,0,0
303,10835989,Weak analgesics and nonsteroidal anti-inflammatory agents in the management of children with acute pain.,J D Tobias,"The PSIs include acetaminophen, NSAIDs, and salicylates. They can be used alone for the treatment of mild pain or as an adjunct to opioid analgesia. In children, most experience is with acetaminophen and ibuprofen. For the treatment of mild to moderate pain, these agents can be administered as needed or at fixed intervals. The latter dosing scheme may provide a more consistent serum level, thereby improving analgesia. The major advantages of acetaminophen are its availability as a suppository for PR administration and its lack of effects on renal and GI function, adverse effects that may be seen with the NSAIDs. Many of the effects on platelet functioning, RBF, and the GI tract may be eliminated with the introduction of NSAIDs that selectively inhibit COX II without effects on COX I, the enzyme present in the GI tract, renal system, and platelets. Future evaluations with these agents in the pediatric population are needed. For more severe pain, the NSAID salicylate or acetaminophen can be combined with a weak opioid, such as codeine, oxycodone, or hydrocodone. When using oral analgesics, factors that may interfere with effective analgesia include a child's refusal to take the medication, ineffective doses and dosing regimens, decreased bioavailability following PO administration, inability to tolerate PO medications because of nausea or vomiting, altered GI motility, and a delayed onset caused by slow absorption. With such caveats in mind, the PO route provides an effective and cost-effective means for many patients. It should be considered as the primary route for pediatric patients in the treatment of mild to moderate pain, even in the hospital setting.",2000.0,0,0
304,10835994,Migraine and headache in childhood and adolescence.,D Annequin; B Tourniaire; H Massiou,"Headache is one of the most common physical complaints of children and adults. The authors have provided definitions of headache, a classification system, diagnostic evaluations appropriate for children, and treatment options for patients with acute and chronic headache. Also, this article has emphasized the importance of diagnosing and treating migraine headache, a painful malady that is extensively underestimated and misdiagnosed in the pediatric population and one that can be treated acutely and when appropriate prophylactically with great success. Lack of a specific biologic marker, specific investigation, or brain imaging reduce these clinical entities too often to a psychological illness. Nonpharmacologic treatments are pivotal to manage chronic headaches. Migraine therapy, if administered early and through the appropriate route, could provide important and rapid relief.",2000.0,0,0
305,10839074,"The effect of paracetamol, fentanyl, and systematic assessments on children's pain after tonsillectomy and adenoidectomy.",J P Hamers; H Huijer Abu-Saad; F E Geisler; M A van den Hout; H J Schouten; R J Halfens; H A van Suijlekom,"Various clinical protocols are used to manage early postoperative tonsillectomy and/or adenoidectomy (T&A) pain in children. Although believed to be effective, these protocols are not evidenced-based. Therefore, a double-blind, randomized, placebo controlled (2 x 2) factorial design was used (1) to evaluate the effectiveness of 2 pain protocols used interchangeably to manage early postoperative T&A pain and (2) to investigate whether nurses' systematic pain assessments improve pain management. In the first protocol children receive a loading dose (30 to 50 mg/kg) of paracetamol (acetaminophen) Formularium der Nederlandse Apothekers (Formulary of the Dutch Royal Society for the Advancement of Pharmacy) intraoperatively, followed by regular doses (70 to 100 mg/kg/24 hours) of paracetamol. In the second protocol children receive the first protocol, plus intramuscular fentanyl citrate (1 microgram/kg) intraoperatively. Subjects were 83 healthy children between the ages of 3 and 12 years, admitted for T&A as an outpatient procedure. The child's pain was measured using observation scales (Children's Hospital of Eastern Ontario Pain Scale and Face Legs Activity Cry Consolability Scale), a visual analogue scale, and self-report measures (Faces Pain Scale and Oucher). Neither pain protocol sufficiently relieved early postoperative T&A pain, and systemic pain assessments did not improve the effectiveness of analgesics. Further research evaluating the effectiveness of pain management protocols is needed.",2000.0,0,0
306,10839903,The dose-response of intrathecal sufentanil added to bupivacaine for labor analgesia.,C A Wong; B M Scavone; M Loffredi; W Y Wang; A M Peaceman; J N Ganchiff,"Regional analgesia for labor often is initiated with an intrathecal injection of a local anesthetic and opioid. The purpose of this prospective, randomized, blinded study was to determine the optimal dose of intrathecal sufentanil when combined with 2.5 mg bupivacaine for labor analgesia. One hundred seventy parous parturients with cervical dilation between 3-5 cm were randomized to receive intrathecal 0 (control), 2.5, 5.0, 7.5, or 10.0 microg sufentanil combined with 2.5 mg bupivacaine, followed by a lidocaine epidural test dose, for initiation of analgesia (34 patients in each group). Visual analog scores and the presence of nausea, vomiting, and pruritus were determined every 15 min until the patient requested additional analgesia. Fetal heart rate tracings were compared between groups. Groups were similar for age, height, weight, oxytocin dose, duration of labor, and baseline visual analog scores. Duration of action was significantly shorter for control patients (39 +/- 25 min [mean +/- SD]) compared with those administered sufentanil, all doses (93 +/- 32, 93 +/- 47, 94 +/- 33, 97 +/- 39 min), but was not different among groups administered 2.5, 5.0, 7.5, or 10.0 microg sufentanil. More patients who received 10 microg sufentanil reported nausea and vomiting than did control patients. The severity of pruritus increased with administration of 7.5 and 10.0 microg sufentanil. There was no difference in fetal heart rate changes among groups. Intrathecal bupivacaine (2.5 mg) without sufentanil did not provide satisfactory analgesia for parous patients. However, bupivacaine combined with 2.5 microg sufentanil provided analgesia comparable to higher doses, with a lower incidence of nausea and vomiting and less severe pruritus.",2000.0,0,0
307,10839907,"Ropivacaine, 0.1%, plus sufentanil, 0.5 microg/ml, versus bupivacaine, 0.1%, plus sufentanil, 0.5 microg/ml, using patient-controlled epidural analgesia for labor: a double-blind comparison.",C Fischer; P Blanié; E Jaouën; C Vayssière; I Kaloul; J C Coltat,"This study compared the administration of 0.1% ropivacaine and 0.5 microg/ml sufentanil with that of 0.1% bupivacaine and 0.5 microg/ml sufentanil via patient-controlled epidural analgesia route during labor. Two hundred healthy pregnant women at term with a single fetus with a vertex fetal presentation were randomized in a double-blind fashion to receive either 0.1% ropivacaine and 0.5 microg/ml sufentanil or 0.1% bupivacaine and 0.5 microg/ml sufentanil using a patient-controlled epidural analgesia pump (5-ml bolus dose, 10-min locked-out period, no basal infusion). Pain score on a visual analog scale, Bromage score (0-3), level of sensory block, patient-controlled epidural analgesia ratio, drug use, supplemental boluses, and side effects were recorded at 30 min and then hourly. Mode of delivery, duration of first and second stages of labor, umbilical cord pH, Apgar scores of the newborn, and a measure of maternal satisfaction were recorded after delivery. No differences were seen between the two groups for pain scores on a visual analog scale during labor, volume of anesthetic solution used, mode of delivery, or side effects. Motor block during the first stage of labor was significantly less in the ropivacaine group than in the bupivacaine group (no motor block in 97.8 of patients vs. 88.3%, respectively; P < 0.01). Duration of the second stage of labor was shorter in the ropivacaine group (1.3 +/- 1.0 vs. 1.5 +/- 1.2 h [mean +/- SD]; P < 0.05). Maternal satisfaction was greater in the bupivacaine group (91 +/- 13 mm for contraction, 89 +/- 19 mm for delivery on a visual scale: 0 = not satisfied at all, 100 = fully satisfied) than in the ropivacaine group (84 +/- 21 and 80 +/- 25 mm; P < 0.0001). Patients in the ropivacaine group requested more supplemental boluses to achieve analgesia during the second stage of labor than those in the bupivacaine group (29.7 vs. 19.8%, respectively, requested one or more supplemental boluses; P < 0.05). Delivered as patient-controlled epidural analgesia, 0.1% ropivacaine and 0.5 microg/ml sufentanil produce less motor block but are clinically less potent than 0.1% bupivacaine and 0.5 microg/ml sufentanil.",2000.0,0,0
308,10839912,Preemptive analgesia by intravenous low-dose ketamine and epidural morphine in gastrectomy: a randomized double-blind study.,S Aida; T Yamakura; H Baba; K Taga; S Fukuda; K Shimoji,"Morphine and ketamine may prevent central sensitization during surgery and result in preemptive analgesia. The reliability of preemptive analgesia, however, is controversial. Gastrectomy patients were given preemptive analgesia consisting of epidural morphine, intravenous low-dose ketamine, and combinations of these in a randomized, double-blind manner. Postsurgical pain intensity was rated by a visual analog scale, a categoric pain evaluation, and cumulative morphine consumption. Preemptive analgesia by epidural morphine and by intravenous low-dose ketamine were significantly effective but not definitive. With epidural morphine, a significant reduction in visual analog scale scores at rest was observed at 24 and 48 h, and morphine consumption was significantly lower at 6 and 12 h, compared with control values. With intravenous ketamine, visual analog scale scores at rest and morphine consumption were significantly lower at 6, 12, 24, and 48 h than those in control subjects. The combination of epidural morphine and intravenous ketamine provided definitive preemptive analgesia: Visual analog scale scores at rest and morphine consumption were significantly the lowest at 6, 12, 24, and 48 h, and the visual analog scale score during movement and the categoric pain score also were significantly the lowest among the groups. The results suggest that for definitive preemptive analgesia, blockade of opioid and N-methyl-d-aspartate receptors is necessary for upper abdominal surgery such as gastrectomy; singly, either treatment provided significant, but not definitive, postsurgical pain relief. Epidural morphine may affect the spinal cord segmentally, whereas intravenous ketamine may block brain stem sensitization via the vagus nerve during upper abdominal surgery.",2000.0,0,0
309,10846913,[Ketorolac versus tramadol: comparative study of analgesic efficacy in the postoperative pain in abdominal hysterectomy].,G Ollé Fortuny; L Opisso Julia; F Oferil Riera; M Sánchez Pallarés; R Calatayud Montesa; I Cabré Roca,"To compare the analgesic efficacy of tramadol to that of ketorolac trometamol administered intravenously and at fixed times over the 24 hours after abdominal hysterectomy. This controlled, double blind, randomized clinical trial enrolled 76 women undergoing abdominal hysterectomies. Two treatment groups were formed: the TRA (Tramadol) group received 100 mg and the KET (Ketorolac) group 30 mg administered every 6 hours intravenously. Patients were ASA I-II and aged 35 to 65 years old. Patients were excluded from the study if hysterectomy was performed because of a tumor, or if there was a history of bleeding dyscrasias, of gastric or duodenal ulcers or of allergy to drugs in the study or if other analgesics had been used within 15 days of surgery. Analgesic efficacy was assessed using a visual analog scale (VAS) and a verbal response scale (VRS). Need for top-up analgesia was recorded, as were the number of patients withdrawing before the end of the study and the side effects attributable to treatment. The mean VAS score throughout the study was 3.6 for the TRA group and 4.4 for the KET group (non-significant, p = 0.05). Likewise, VRS scores were similar. In the first 12 h after surgery, VAS scores in the TRA group were statistically lower than those of the KET group (p < 0.05). Nine patients abandoned the study before it ended: 3 in group TRA and 1 in the KET group. Three withdrew in the TRA group (2 because of vomiting and 1 for administrative reasons). Six left the KET group (4 for uncontrolled pain, 1 for impossible intubation and 1 for administrative reasons. In the TRA group, 38% experienced vomiting whereas only 8% did so in the KET group. No serious postoperative complications were recorded. During the first 12 hours following surgery, a 100 mg dose of tramadol has been shown to provide more effective pain relief than 30 mg of ketorolac administered intravenously every 6 hours. The only drawback to administering the drug intravenously was the high incidence of postoperative vomiting.",2000.0,0,0
310,10846914,[Usefulness of meperidine in anesthesiology].,P Cruz Pardos; I Garutti Martínez,"Meperidine was the first synthetic opioid agent. It acts mainly as an antagonist of mu (#m) receptors and has an analgesic potency ten times greater than that of morphine. Like other opioid drugs, meperidine causes nausea, vomiting, urinary retention and respiratory depression; a point of difference, however, is that it acts on nerve fibers and has properties similar to those of local anesthetics. It has therefore been used as an alternative to other opioids for anesthetic blockade. We review the indications and contraindications of meperidine administered by different routes. For pain, epidural administration has proven to be a good alternative to intravenous administration and epidural meperidine has been combined with local anesthetics using lower doses of both drugs and producing fewer side effects. Intradural meperidine has been used as the sole anesthetic agent in various types of surgery, its principal advantage being that it provides long-lasting postoperative analgesia. Spinal meperidine has the advantage over morphine of a lower incidence of respiratory depression, particularly late-occurring depression. An intravenous route has been used for treating moderate to severe pain, for regional anesthesia, for premedication and for analgesia during anesthesia. Meperidine's action on kappa receptors has meant that it is considered the most effective drug for treating postanesthetic trembling. Although meperidine has been used effectively to treat non-surgical pain, mainly from colic, this review focuses on its usefulness in the perioperative period.",2000.0,0,0
311,10849455,Chronic pain disorder following physical injury.,J Streltzer; B A Eliashof; A E Kline; D Goebert,"Pain disorders that are primarily associated with psychological factors are of great clinical concern, but they are difficult to study because of the inability to make valid or reliable diagnoses by structured interview alone. The authors confront this difficulty by using an injured subject population that had extensive psychiatric and medical evaluations. Those who developed somatoform pain disorder (SPD) were compared with a control group who did not. The SPD group had distinctive associated factors: more sites of pain, spread of pain beyond area of original injury, and substantially more opiate and benzodiazepine use. Compensation/litigation influenced symptoms more in the SPD group. Psychotherapists often supported the patient's viewpoint that the pain was physical and to be endured.",2000.0,0,0
312,10852643,Treatment of postherpetic neuralgia: an update.,G E Kanazi; R W Johnson; R H Dworkin,"Postherpetic neuralgia (PHN) is a chronic pain syndrome that is often refractory to treatment and can last for years, causing physical and social disability, psychological distress, and increased use of the healthcare system. In this paper we provide an update on recent developments in the treatment of PHN. We emphasise the results of recent studies that provide an evidence-based approach for treating PHN that was not available until very recently. In randomised, controlled clinical trials, the topical lidocaine patch, gabapentin, and controlled release oxycodone have been shown to provide superior pain relief in patients with PHN when compared with placebo. It has also recently been demonstrated that the tricyclic antidepressant nortriptyline provides equivalent analgesic benefit when compared with amitriptyline, but is better tolerated. Based on these results, nortriptyline can now be considered the preferred antidepressant for the treatment of PHN, although desipramine may be used if the patient experiences unacceptable sedation from nortriptyline. The topical lidocaine patch, gabapentin and controlled release oxycodone all appear to be as effective as tricyclic antidepressants in the treatment of patients with PHN, and the results of these recent studies suggest that each of these treatments should be considered early in the course of treatment. Additional controlled trials are needed to compare the efficacy and tolerability of these 4 treatments- tricyclic antidepressants, gabapentin, the topical lidocaine patch and controlled release opioid analgesics--used singly and in various combinations in the treatment of patients with PHN.",2000.0,0,0
313,10853429,[The use of Oxadol in tablet form for the treatment of chronic pain syndrome in late-stage cancer patients].,A I Evtiukhin; O Iu Kuznetsova; L V Gorokhov; I V Dunaevskiĭ,"Chronic pain management with tablets of oxadol, a non-narcotic central-action analgetic, was studied in 30 patients, focusing on combinations with ""basic"" drugs of the opiate and opioid group. Combined administration of tramal and oxadol for moderate pain relief raised the analgesic effect and improved certain parameters of quality of life. Possible side-effects and indications in cases of well-advanced tumor were established.",2000.0,0,0
314,10858825,Intravenous morphine for emergency treatment of cancer pain.,K S Kumar; M R Rajagopal; A M Naseema,"Despite the wide use of the World Health Organization (WHO) analgesic ladder for the relief of cancer pain, it is not uncommon to find patients presenting with severe pain to palliative care centres. This is more so in the developing world, where facilities for pain relief are few and the health care system is not well organized. It has been the practice in a pain and palliative care clinic in south India to give repeated boluses of 1.5 mg of morphine intravenously every 10 min to patients presenting with severe pain. An audit of the procedure was undertaken by a retrospective study of 793 case notes. Seventy-nine per cent of patients had total relief of their pain with intravenous morphine. Three per cent of patients experienced side-effects during the procedure. These included nausea and vomiting, itching, giddiness, restlessness, dyspnoea, chest pain, disorientation and a feeling of uneasiness. Thirty-two per cent of patients had drowsiness, which was one of the end-points of the procedure. It is concluded that intravenous morphine in repeated boluses of 1.5 mg every 10 min is a safe and effective method of managing cancer pain emergencies in a clinical setting in a developing country.",2000.0,0,0
315,10859453,Abrogation of the negative influence of opioids on IL-2 immunotherapy of renal cell cancer by melatonin.,P Lissoni; M Mandalà; F Brivio,"IL-2 immunotherapy has been proven to be effective in the treatment of metastatic renal cell cancer (RCC). However, several drugs commonly used in the palliative therapy of cancer may potentially influence IL-2 efficacy, since the anticancer immunity has appeared to depend on complex interactions between immune system and psychoneuroimmunomodulation. In particular, experimental studies and preliminary clinical investigations have shown that the opioid substances, namely morphine, may suppress the anticancer immunity and the efficacy of IL-2 itself. In contrast, other neuroactive substances, in particular the pineal hormone melatonin (MLT), have been proven to stimulate the immune response, including the anticancer immunity, and to abrogate opioid-induced immunosuppression. On this basis, a study was planned to evaluate the effect of a concomitant MLT administration on the efficacy of IL-2 immunotherapy in advanced cancer patients chronically treated with morphine for cancer-related pain. The study was carried out in 30 metastatic RCC patients under chronic therapy with morphine at oral doses ranging from 60 to 120 mg/day. Patients were randomized to receive morphine alone or morphine plus MLT (20 mg/day orally in the evening). The immunotherapeutic cycle consisted of IL-2 subcutaneous administration at a dose of 6 million IU/day for 6 days/week for 4 consecutive weeks. In nonprogressing patients, a second cycle was planned after a 21-day rest period. The percent of partial responses achieved in patients treated with morphine alone was significantly lower than that observed in patients concomitantly treated with MLT (1/16 vs. 4/14, p<0.05). Moreover, the 3-year percent of survival was significantly higher in patients concomitantly treated with MLT (p<0.01). In contrast, no diminished analgesic efficacy of morphine occurred in patients concomitantly treated with MLT. This preliminary study seems to suggest that the negative influence of morphine therapy for cancer-related pain on the clinical efficacy of IL-2 cancer immunotherapy may be abrogated by the concomitant administration of the immunomodulating pineal neurohormone MLT.",2000.0,0,0
316,10861154,Lumbar plexus block reduces pain and blood loss associated with total hip arthroplasty.,R D Stevens; E Van Gessel; N Flory; R Fournier; Z Gamulin,"The usefulness of peripheral nerve blockade in the anesthetic management of hip surgery has not been clearly established. Because sensory afferents from the hip include several branches of the lumbar plexus, the authors hypothesized that a lumbar plexus block could reduce pain from a major hip procedure. In a double-blind prospective trial, 60 patients undergoing total hip arthroplasty were randomized to receive general anesthesia with (plexus group, n = 30) or without (control group, n = 30) a posterior lumbar plexus block. The block was performed after induction using a nerve stimulator, and 0.4 ml/kg bupivacaine, 0.5%, with epinephrine was injected. General anesthesia was standardized, and supplemental fentanyl was administered per hemodynamic guidelines. Postoperative pain and patient-controlled intravenous morphine use were serially assessed for 48 h. The proportion of patients receiving supplemental fentanyl intraoperatively was more than 3 times greater in the control group (20 of 30 vs. 6 of 29, P = 0.001). In the postanesthesia care unit, a greater than fourfold reduction in pain scores was observed in the plexus group (visual analogue scale [VAS] pain score at arrival 1.3 +/- 2 vs. 5.6 +/- 3, P < 0.001), and ""rescue"" morphine boluses (administered if VAS > 3) were administered 10 times less frequently (in 2 of 28 vs. in 22 of 29 patients, P < 0.0001). Pain scores and morphine consumption remained significantly lower in the plexus group until 6 h after randomization (VAS at 6 h, 1.4 +/- 1.3 vs. 2.4 +/- 1.4, P = 0.007; cumulative morphine at 6 h, 5.6 +/- 4.7 vs. 12.6 +/- 7.5 mg, P < 0.0001). Operative and postoperative (48 h) blood loss was modestly decreased in the treated group. Epidural-like distribution of anesthesia occurred in 3 of 28 plexus group patients, but no other side-effects were noted. Posterior lumbar plexus block provides effective analgesia for total hip arthroplasty, reducing intra- and postoperative opioid requirements. Moreover, blood loss during and after the procedure is diminished. Epidural anesthetic distribution should be anticipated in a minority of cases.",2000.0,0,0
317,10862437,Setting up a pain management programme. The Ayrshire experience.,C Martin; T Carney; T Obonyo; L Lamont,"A controlled trial of an outpatient cognitive behavioural pain management programme for sufferers of non-cancer chronic pain is described. A multidisciplinary team set up a programme of ten half day sessions for groups of ten to fourteen patients aiming to improve activity levels and control over pain; to reduce maladaptive pain behaviours and drug intake; to mitigate negative mood; to modify unhelpful beliefs and to maintain treatment gains by operant and cognitive methods. Self report questionnaires were employed before and six weeks, six months and one year after the programme. Fifty-eight patients entered the study group and 39 patients completed the programme and initial follow up with further attrition in long term follow up. There were no changes in the waiting list control group of twelve subjects but the study group made significant short and long term improvements in pain severity, activity levels, mood, coping and experienced fewer catastrophizing thoughts.",2000.0,0,0
318,10863042,Human chromaffin cell graft into the CSF for cancer pain management: a prospective phase II clinical study.,Y Lazorthes; J Sagen; B Sallerin; J Tkaczuk; H Duplan; J C Sol; M Tafani; J C Bès,"A number of pre-clinical studies have demonstrated the value of adrenal medullary allografts in the management of chronic pain. The present longitudinal survey studied 15 patients transplanted for intractable cancer pain after failure of systemic opioids due to the persistence of undesirable side-effects. Before inclusion, all the patients had their pain controlled by daily intrathecal (I-Th) morphine administration. The main evaluation criteria of analgesic activity of the chromaffin cell allograft was the complementary requirement of analgesics and in particular the consumption of I-Th morphine required to maintain effective pain control. Out of the 12 patients who profited from enhanced analgesia with long-term follow-up (average 4.5 months), five no longer required the I-Th morphine (with prolonged interruption of systemic opioids as well), two durably decreased I-Th morphine intake and five were stabilized until the end of their follow-up. Durable decline and stabilization were interpreted as indicative of analgesic activity by comparison with the usual dose escalation observed during disease progression. In most cases, we noted a relationship between analgesic responses and CSF met-enkephalin levels. The results of this phase II open study demonstrate the feasibility and the safety of this approach using chromaffin cell grafts for long-term relief of intractable cancer pain. However, while analgesic efficacy was indicated by the reduction or stabilization in complementary opioid intake, these observations will need to be confirmed in a controlled trial in a larger series of patients.",2000.0,0,0
319,10863050,Spinal cord stimulation: a possible therapeutic alternative for chronic mesenteric ischaemia.,A Ceballos; L Cabezudo; M Bovaira; P Fenollosa; B Moro,"A 78-year-old male patient had chronic, unrelieved abdominal pain due to mesenteric ischaemia. Unsuccessful pharmacological approaches included oral morphine plus coadjuvants as well as a sympathetic celiac plexus block which gave pain relief that lasted for 72 h. In order to obtain long-lasting relief, a trial epidural stimulating electrode was implanted after obtaining informed consent and Ethical Committee approval. Complete analgesia was achieved during a trial period of 2 weeks. Thereafter, a spinal cord stimulator was implanted. At the time of writing, 11 months after implantation, the degree of analgesia is complete. We believe that spinal cord stimulation may represent an alternative approach in controlling pain due to mesenteric ischaemia.",2000.0,0,0
320,10868557,Combination hydrocodone and ibuprofen versus combination oxycodone and acetaminophen in the treatment of postoperative obstetric or gynecologic pain.,M Palangio; G L Wideman; M Keffer; C J Landau; E Morris; R T Doyle; J G Jiang; M Damask; A de Padova,"The objective of this study was to compare the effectiveness of combination hydrocodone and ibuprofen with that of combination oxycodone and acetaminophen in the treatment of moderate to severe postoperative obstetric or gynecologic pain. Hydrocodone 7.5 mg with ibuprofen 200 mg is the only approved fixed-dose combination analgesic containing an opioid and ibuprofen. This randomized, double-blind, parallel-group, single-dose, active-comparator, placebo-controlled study compared the effects of a 2-tablet dose of hydrocodone 7.5 mg and ibuprofen 200 mg with those of a 2-tablet dose of oxycodone 5 mg and acetaminophen 325 mg and placebo. Analgesia was assessed over 8 hours. Mean pain relief (PR) scores were similar for the hydrocodone with ibuprofen and oxycodone with acetaminophen groups (n = 61 and 59, respectively) at 0.5, 1, 1.5, 2, 2.5, 3, 4, and 7 hours and significantly greater for the hydrocodone with ibuprofen group at 5, 6, and 8 hours (P < or = 0.05). Mean pain intensity difference (PID) scores were similar for hydrocodone with ibuprofen and oxycodone with acetaminophen at 0.5, 1, 1.5, 2, 2.5, 3, and 4 hours and significantly greater for hydrocodone with ibuprofen at 5, 6, 7, and 8 hours (P < or = 0.05). Total PR scores were similar for hydrocodone with ibuprofen and oxycodone with acetaminophen for the 0- to 3- and 0- to 4-hour intervals and significantly greater for hydrocodone with ibuprofen for the 0- to 6- and 0- to 8-hour intervals (P < 0.05). The sum of the PID scores was similar for hydrocodone with ibuprofen and oxycodone with acetaminophen for the 0- to 3-, 0- to 4-, 0- to 6-, and 0- to 8-hour intervals. The median estimated time to onset of analgesia, mean peak PR score, median time to remedication, and mean global assessment score were similar for hydrocodone with ibuprofen and oxycodone with acetaminophen. Assay sensitivity was demonstrated by the presence of statistically significant differences between both active treatments and placebo (n = 60). The number of patients experiencing adverse events was similar for each of the 3 groups (11 [18.0%], hydrocodone with ibuprofen; 7 [11.9%], oxycodone with acetaminophen; and 6 [10.0%], placebo). In this study, a 2-tablet dose of combination hydrocodone 7.5 mg and ibuprofen 200 mg was as effective as a 2-tablet dose of combination oxycodone 5 mg and acetaminophen 325 mg in the treatment of moderate to severe postoperative obstetric or gynecologic pain. Both treatments were superior to placebo. The results of this study suggest that the combination of hydrocodone 7.5 mg and ibuprofen 200 mg may offer prescribers an additional option in combination pain therapy.",2000.0,0,0
321,10874381,An economic evaluation of pain therapy after hysterectomy. Patient-controlled analgesia versus regular intramuscular opioid therapy.,B E Rittenhouse; M Choinière,"To assess the economics of patient-controlled analgesia (PCA) treatment versus regular intramuscular (i.m.) injections of opioid analgesia for pain management after hysterectomy. Cost-minimization analysis was used based on the comparable pain control results achieved in the two treatment groups. Observations were taken of treatment-related events with personnel (mostly nursing) time implications during the trial. Times were then associated with these events in an independent study of personnel activity. Costs were linked by using average wage rates for the various personnel for the Montreal area during the time of the study. Drug and material costs were hospital acquisition costs for all items. The cost of the PCA pump itself was not included in the analysis. Several analyses were performed to test the sensitivity of the results to various assumptions. The results for total costs of the two therapies generally showed PCA to be more costly than regular i.m. injections despite no costs of the pump being included in the analyses. These results were robust with respect to changes in assumptions. Even when intentionally biasing the analysis against i.m. therapy, it was difficult to obtain results that favored PCA. Based upon the institutions and assumptions in this analysis, PCA offers no cost advantages over regular i.m. therapy in the pain management after hysterectomy. Regular i.m. injections provided less costly analgesia.",2000.0,0,0
322,10875715,Postoperative pain management in patients undergoing major surgery after remifentanil vs. fentanyl anesthesia. Multicentre Investigator Group.,H S Minkowitz,"To determine if morphine sulphate was an effective transition analgesic in patients receiving a remifentanil-based anesthetic regimen. Open-label remifentanil or fentanyl was administered to 210 randomized patients undergoing inpatient surgery. Isoflurane and nitrous oxide was administered to all patients. Thirty minutes before the end of surgery, patients receiving remifentanil were randomized to receive morphine 0.15 mg x kg(-1) (R/M15 group) or 0.20 mg x kg(-1) (R/M20 group). Following extubation and prior to patient-controlled analgesia (PCA) initiation, 2 mg boluses of morphine were administered for moderate/severe pain. Efficacy endpoints were total morphine used in the post anesthesia care unit (PACU) and 24 and 48 hr postoperatively; postoperative pain; time to first morphine bolus; time to first PCA administration; and time to recovery endpoints. Mean total morphine used in PACU was not different among groups (15.5 mg, 16.5 mg and 13.3 mg in R/M 15, R/M20 and F groups, respectively). Mean total 24 hr morphine use (58.1 mg, 56.93 mg and 53.6 mg in R/M15, R/M20 and F groups) and mean total morphine used at 48 hr were not different (69.8 mg, 64.7 mg and 62.1 mg in R/M15, R/M20 and F/I groups). Groups were similar with respect to pain severity ratings at all postoperative times. Patients in the fentanyl arm experienced faster times to some recovery endpoints than patients receiving either remifentanil regimen. Morphine sulphate regimens of 0.15 or 0.20 mg x kg(-1) administered 30 min before the end of surgery are equally effective transition regimens for inpatient procedures.",2000.0,0,0
323,10886692,Applications of intrathecal catheters in children.,J D Tobias,"Access to the intrathecal space may be required for sampling of cerebrospinal fluid for diagnostic purposes, for the administration of pharmacological agents, or for cerebrospinal fluid (CSF) drainage to lower intracranial pressure. The current report details five children in whom a percutaneously placed lumbar intrathecal catheter was used: (i) to provide intraoperative surgical anaesthesia instead of general anaesthesia (ii); to deliver intrathecal fentanyl to provide postoperative analgesia (iii); to provide chronic pain control during the terminal stages of metastatic malignancy; (iv) to allow repeated doses of intrathecal chemotherapy; and (v) to allow CSF drainage and prevent CSF leakage following frontal encephalocele repair. The indications and applications of intrathecal catheters in the paediatric aged patient are reviewed.",2000.0,0,0
324,10886699,Recovery after paediatric daycase herniotomy performed under spinal anaesthesia.,H Kokki; M Heikkinen; R Ahonen,"In this prospective survey, recovery in hospital and at home was evaluated in 195 children aged 6 months to 10 years who had undergone herniotomy under spinal anaesthesia as a daycase procedure. Spinal anaesthesia was successful in most of the children, with only two patients being given general anaesthesia. Eighty-three percent of the children had pain at home and 19% had moderate or severe pain. Eighty-five percent of the children needed pain medication at home; the median dose of analgesics was 4 (1-9, 10th and 90th percentiles). Vomiting was noted in two of 195 children in hospital and in 10 of 192 children at home. Eleven children developed a mild position-dependent headache. Most of the children (183/191) recovered their normal daily activities during the first three postoperative days. We conclude that spinal anaesthesia is a safe and effective technique for paediatric herniotomy. Moreover, pain is common following herniotomy and children should be given analgesics for the first two or three postoperative days.",2000.0,0,0
325,10893594,A randomized prospective trial of intrarectal lidocaine for pain control during transrectal prostate biopsy: the Emory University experience.,M M Issa; S Bux; T Chun; J A Petros; A J Labadia; K Anastasia; L E Miller; F F Marshall,"We prospectively evaluated the safety and efficacy of intrarectal lidocaine gel as anesthesia during transrectal prostate biopsy. Of 63 consecutive men undergoing transrectal prostate biopsy 50 who qualified were enrolled in this study. Indications for the procedure were an abnormal prostate on digital rectal examination and/or elevated serum prostate specific antigen. Patients were randomized into group 1-25 who received 10 cc of 2% intrarectal lidocaine 10 minutes before the procedure and group 2-25 controls. No narcotics, sedation or analgesia was given. Pain during biopsy was assessed using a 10-point linear visual analog pain scale. In groups 1 and 2 median patient age was 63 and 66 years (p = 0.139), and median prostate specific antigen was 6.04 (range 1.07 to 263) and 7.24 (range 1.34 to 51.82) ng./ml. (p = 0.337). Digital rectal examination was normal and abnormal in 17 and 15 group 1, and in 8 and 10 group 2 patients, respectively. Ultrasound showed a median prostate volume of 43.6 cc (range 15.3 to 124) in group 1 and 40.3 (range 19.8 to 132) in group 2 (p = 0.710). Final histological results revealed prostate cancer in 7 men (28%) in each group. The median pain score during transrectal prostate biopsy was 2 (range 1 to 5) and 5 (range 1 to 7) in groups 1 and 2, respectively (p = 0.00001). No adverse events were noted. Intrarectal lidocaine gel is a simple, safe and efficacious method of providing satisfactory anesthesia in men undergoing transrectal prostate biopsy. We recommend its routine administration in all patients during this procedure.",2000.0,0,0
326,10894582,Propofol versus midazolam and meperidine for conscious sedation in GI endoscopy.,G Koshy; S Nair; E P Norkus; H I Hertan; C S Pitchumoni,"Propofol (2,6-diisopropyl phenol) is a relatively new intravenous sedative hypnotic with an ideal pharmacokinetic profile for conscious sedation. In this study, we compared the safety and efficacy of propofol versus the conventional regimen of midazolam and meperidine for conscious sedation in GI endoscopy. In this prospective study, 274 patients that included many elderly patients with multiple comorbid conditions underwent GI endoscopic procedures at our hospital. A total of 150 patients received propofol (20-120 mg) and fentanyl (0.25-1.5 mg). The control group of 124 patients was given midazolam (2-6 mg) and meperidine (25-75 mg). The dose of medication was titrated according to patient need and the duration of the procedure. A ""comfort score"" on a scale of 1-4 assessed the efficacy of the drugs based on pain or discomfort to the patient and ease of endoscopy. A ""sedation score"" was used to assess the degree of sedation on a scale of 1-5. The Aldrete score was used to measure recovery from anesthesia at 5 and 10 min after the procedure. After controlling for age, American Society of Anesthesiologists' Physical Status Classification (ASA grade), and type and duration of procedure, logistic regression analysis determined that propofol resulted in 2.04 times better patient comfort (p = 0.033, 95% CI = 1.058-3.923). Propofol was 1.84 times more likely to produce deeper sedation than the regimen of midazolam and meperidine (p = 0.027, 95% CI = 1.071-3.083). The recovery from sedation was faster in patients receiving propofol, although this did not reach statistical significance. The safety parameters between the two groups were comparable. Propofol was associated with a statistically significant improvement in comfort and sedation score when compared to midazolam and meperidine.",2000.0,0,0
327,10895182,Results of the clinical trial of transdermal therapeutic system-fentanyl in strong opioid pre-treated adult patients with cancer-related pain.,N Besova; V Gorbounova; A Saltanov; V Zarouk,,2000.0,0,0
328,10895744,Epidural ropivacaine with fentanyl following major gynaecological surgery: the effect of volume and concentration on pain relief and motor impairment.,R Whiteside; D Jones; S Bignell; C Lang; S K Lo,"In a prospective, randomized, double-blind study, 40 patients undergoing gynaecological oncology surgery received either 0.1% ropivacaine with fentanyl 1 microgram ml-1 or 0.2% ropivacaine with fentanyl 2 micrograms ml-1. A PCEA pump was set to deliver ropivacaine 8 mg with fentanyl 8 micrograms with each successful demand and a lockout period of 15 min without background infusion. Patients were observed for rest and activity pain VAS, side effect incidence, peak expiratory flow rate (PEFR), leg strength, sensory block to cold and pinprick, and PCEA usage into the second postoperative day. Passive and active pain scores for both groups were both satisfactory and comparable for the duration of the study. There were no differences between groups with regard to side effects. There was a 24% increase in total drug used in the high-concentration/low-volume group (P < 0.05). The study demonstrated that PCEA ropivacaine with fentanyl is an effective means of postoperative analgesia for this patient population. Reduced drug consumption with high-volume/low-concentration solution confirms similar findings by other investigators using alternate local anaesthetic agents, and suggests that the therapeutic ratio of ropivacaine is widened if a low-concentration/high-volume solution is used.",2000.0,0,0
329,10895746,Does wound irrigation with triamcinolone reduce pain after surgery to the lumbar spine?,L H Pobereskin; J R Sneyd,"This prospective, randomized study compared postoperative pain scores, morphine consumption and length of stay in 95 adults who underwent elective lumbar spine surgery via a posterior incision. Immediately prior to closure the wound was irrigated with triamcinolone 40, 20 or 0 mg. Visual analogue scale pain scores at 24 h after surgery were median 12 (interquartile range 3-24), 15 (6-34) and 33 (20-59) mm for patients receiving triamcinolone 40, 20 mg or no steroid, respectively (P < 0.0005, Kruskal-Wallis test). Total morphine usage after 24 h was 26 (21-39), 27 (17-43) and 43 (27-73) mg for the same groups (P < 0.001, Kruskal-Wallis test). The proportion of patients discharged from hospital on the first day after surgery was 83.9, 77.4 and 54.8% for patients receiving triamcinolone 40, 20 mg and no steroid, respectively (P < 0.028, chi-squared test). Extra-dural triamcinolone reduces pain after lumbar spine surgery and reduces time to discharge from hospital.",2000.0,0,0
330,10895748,,,,,0,0
331,10907964,Nalmefene to prevent epidural narcotic side effects in pediatric patients: a pharmacokinetic and safety study.,D A Rosen; J L Morris; K R Rosen; E R Nelson; R J Steelman; R A Gustafson; J A Wilhelm; C T Chang; J W Thackara; R F Frye,"To determine the pharmacokinetics and preliminary efficacy of nalmefene in children in preventing epidural-induced narcotic side effects. Double-blind, placebo-controlled study. University-affiliated children's hospital. Thirty-four children (aged 2-12 yrs) undergoing cardiothoracic surgery with epidural anesthesia. Patients were randomized to receive intravenous bolus nalmefene 1 microg/kg or placebo. Six blood samples (one before nalmefene administration and five from 13 randomly designated time points) from each patient were assayed to determine plasma nalmefene concentrations. Patients were assessed for pain, nausea, vomiting, and urinary retention for 24 hours after administration. Concentration-time data were analyzed by a limited sampling strategy with adult pharmacokinetic parameters used as Bayesian priors. A two-compartment, first-order model was fitted to the data using ADAPT II. Pharmacokinetic parameter estimates in these patients were similar to values reported in adults. The initial disposition half-life (t(1/2alpha)) was 0.36+/-0.11 hour, the terminal elimination half-life (t(1/2beta)) 8.7+/-2.3 hours, clearance 0.729+/-0.172 L/kg/hr, and steady-state volume of distribution 7.21+/-2.49 L/kg. Ability to prevent epidural narcotic-induced side effects could not be documented at the 1-microg/kg dose. No statistically significant differences were noted between study and placebo groups with regard to pain, nausea, vomiting, or urinary retention. Nalmefene has similar pharmacokinetics in children as in adults. It was administered safely to these patients and did not produce unmanageable pain.",2001.0,0,0
332,10909571,[Treating hospitalized children in severe pain with oral methadone].,Y Shir; V Shvelzon; G Rosen,"Pain relief is usually inadequate in hospitalized patients, especially in children, either after surgery or with various medical conditions. Among other reasons, this is due to suboptimal use of available analgesic drugs. In the past 2 years oral methadone has become our opioid of choice for severe pain in hospitalized children who can take oral medication. More than 70 babies and children, aged 8 months to 9 years, who suffered mainly from pain due to burns or cancer, were treated by the in-hospital pain service. They received 0.1% methadone syrup, 0.2-0.4 mg/kg/day, for from a few days to more than a month. In most there was significant pain relief with no serious side-effects. In some, treatment could be changed to parent-controlled analgesia after a few days, with no adverse effects. We describe 5 of the children who present the advantages of oral methadone over other opioids.",2000.0,0,0
333,10910490,Acute opioid tolerance: intraoperative remifentanil increases postoperative pain and morphine requirement.,B Guignard; A E Bossard; C Coste; D I Sessler; C Lebrault; P Alfonsi; D Fletcher; M Chauvin,"Rapid development of acute opioid tolerance is well established in animals and is more likely to occur with large doses of short-acting drugs. The authors therefore tested the hypothesis that intraoperative remifentanil administration results in acute opioid tolerance that is manifested by increased postoperative pain and opioid requirement. Fifty adult patients undergoing major abdominal surgery were randomly assigned to two anesthetic regimens: (1) desflurane was kept constant at 0.5 minimum alveolar concentrations and a remifentanil infusion was titrated to autonomic responses (remifentanil group); or (2) remifentanil at 0.1 microg. kg-1. min-1 and desflurane titrated to autonomic responses (desflurane group). All patients were given a bolus of 0.15 mg/kg morphine 40 min before the end of surgery. Morphine was initially titrated to need by postanesthesia care nurses blinded to group assignment. Subsequently, patients-who were also blinded to group assignment-controlled their own morphine administration. Pain scores and morphine consumption were recorded for 24 postoperative h. The mean remifentanil infusion rate was 0.3 +/- 0.2 microg. kg-1. min-1 in the remifentanil group, which was significantly greater than in the desflurane group. Intraoperative hemodynamic responses were similar in each group. Postoperative pain scores were significantly greater in the remifentanil group. These patients required morphine significantly earlier than those in the desflurane group and needed nearly twice as much morphine in the first 24 postoperative h: 59 mg (25-75% interquartile range, 43-71) versus 32 mg (25-75% interquartile range, 19-59; P < 0.01). Relatively large-dose intraoperative remifentanil increased postoperative pain and morphine consumption. These data suggest that remifentanil causes acute opioid tolerance and hyperalgesia.",2000.0,0,0
334,10910491,Subarachnoid meperidine (Pethidine) causes significant nausea and vomiting during labor. The Duke Women's Anesthesia Research Group.,J V Booth; D R Lindsay; A J Olufolabi; H E El-Moalem; D H Penning; J D Reynolds,"The combined spinal-epidural (CSE) technique using bupivicaine-fentanyl has become an established method of pain control during parturition. One limitation is the relatively short duration of effective analgesia produced by bupivicaine-fentanyl. In contrast, subarachnoid meperidine has been shown to provide a long duration of anesthesia in nonobstetric patients. Therefore, the authors tested the hypothesis that subarachnoid meperidine produces a significant increase in the duration of analgesia compared with bupivicaine-fentanyl. Based on a power analysis of preliminary data, the authors intended to recruit 90 patients for the study, randomized to three groups: 2.5 mg bupivicaine-25 microg fentanyl, 15 mg meperidine, or 25 mg meperidine. However, after enrolling 34 patients, the study was discontinued because of a significant increase in nausea or vomiting in the study patients. Nausea or vomiting was substantially increased in both meperidine groups compared with the bupivicaine-fentanyl group: 16 with nausea or vomiting in the meperidine groups (n = 21), compared with 1 in the bupivicaine-fentanyl group (n = 11), P = 0.0011. The mean duration of analgesia provided by 25 mg meperidine was 126 +/- 51 min, compared with 98 +/- 29 min for bupivicaine-fentanyl and 90 +/- 67 min for 15 mg meperidine. These data were not significant (P = 0.27). Although intrathecal meperidine could potentially prolong subarachnoid analgesia during labor, its use was associated with a significant incidence of nausea or vomiting. These data do not support the use of subarachnoid meperidine in doses of 15 or 25 mg for labor analgesia.",2000.0,0,0
335,10911488,[Postoperative pain relief].,R Elimelech; E Eisenberg; M Doitch,"The traditional approach to postoperative pain relief (POPR) is still in effect in many surgical departments in Israel: morphine or meperidine given i.m. ""on demand."" In spite of the availability of modern and more effective approaches for POPR, their utilization in hospitals in Israel is lagging. The aim of this project was to study how POPR is being performed in a randomly chosen academic gynecological department, with the assumption that increased awareness will facilitate the necessary changes needed to improve POPR. Four aspects of POPR were studied in 60 female subjects who underwent elective hysterectomy: patients' attitudes to postoperative pain and its relief ascertained prior to surgery; analgesics, prescribed and delivered; assessment of postoperative pain; and patients' satisfaction with POPR. Results show that patients' fear of postoperative pain is the largest component of their overall fear of the surgical procedure. Although they anticipate intense pain, and expect significant POPR, most women prefer not to receive opioid analgesics. Most patients received an average of 10-20 mg of morphine during the first 2 postoperative days. They reported at least moderate to severe pain on 5 of 6 measurements during that period. Nevertheless, most patients were satisfied with their POPR. It is likely that patients expressed a high level of satisfaction primarily due to their low-level of expectations. Assuming that these results represent the POPR situation nationwide, practical steps should be undertaken for its improvement.",2000.0,0,0
336,10915416,Transdermal fentanyl: new preparation.  An alternative to morphine.,,"(1) Fentanyl, an opiate agonist, was previously available in injectable form for use in anaesthesia.  The new patch form is indicated for the treatment of chronic cancer pain. (2) The clinical assessment mainly involved non comparative trials showing good analgesic efficacy on chronic pain. (3) Given the long time-lag before the effect of fentanyl is felt, a short-acting analgesic should be given when the first patch is applied.  Once adequate relief has been achieved the patch can be used alone to treat chronic pain.  It must be replaced every three days. (4) Fentanyl patches have similar adverse effects to opiate agonists, i.e. gastrointestinal and neuropsychological disorders.  However, the adverse effects of morphine and fentanyl are not always identical in a given patient. (5) Fentanyl patches carry a risk of misuse by opiate addicts and of acute intoxication.",2000.0,0,0
337,10919300,Intraarticular morphine after arthroscopic ACL reconstruction: a double-blind placebo-controlled study of 40 patients.,S Brandsson; J Karlsson; P Morberg; B Rydgren; B I Eriksson; T Hedner,"We compared analgesic effects and pharmacokinetics of intraarticular versus intravenous administration of morphine after arthroscopic anterior cruciate ligament surgery. In a double-blind placebo-controlled study, 40 patients were randomly allocated to one of four treatment groups. Group I received 1 mg morphine intraarticularly and saline intravenously; group II received 5 mg morphine intraarticularly and saline intravenously; group III received 5 mg saline intraarticularly and morphine intravenously and group IV, the control group, received saline both intraarticularly and intravenously. The pain scores were significantly lower in groups I and II at 24 hours postoperatively than in group IV, and in group II during the rest of the postoperative period, as compared to groups III and IV. After intraarticular injection of 1 mg and 5 mg morphine, respectively, low concentrations of morphine-6-glucuronide (M6G) were found in the circulation, while morphine-3-glucuronide (M3G) appeared late after the injection in concentrations that considerably exceeded those of morphine in groups I and II. The analgesic effect of intraarticular morphine together with the low levels of morphine and morphine-6-glucuronide in plasma further strengthens the view that opioids have a peripheral mechanism of action.",2000.0,0,0
338,10919304,"Intraarticular glucocorticoid, morphine and bupivacaine reduces pain and convalescence after arthroscopic ankle surgery: a randomized study of 36 patients.",S Rasmussen; H Kehlet,"In a double-blind randomized study, 36 patients undergoing arthroscopic removal of bony spurs and synovitis causing impingement of the ankle were allocated to intraarticular saline or bupivacaine 15 mg + morphine 5 mg + intraarticular methylprednisolone 40 mg. Combined methylprednisolone, bupivacaine and morphine reduced pain, joint swelling, time of immobilization, duration of sick leave and return to sports after the arthroscopic procedure. In the treatment group, 1 patient had transitory purulent arthritis requiring antibiotics and arthroscopic synovectomy occurred.",2000.0,0,0
339,10919528,Ketorolac versus meperidine: ED treatment of severe musculoskeletal low back pain.,K R Veenema; N Leahey; S Schneider,"The study objective was to assess the efficacy and patient acceptance of ketorolac as an alternative to meperidine for the treatment of severe musculoskeletal low back pain (LBP). A double blinded prospective trial in a convenience sample of patients >18 years of age presenting to an urban university hospital emergency department (ED) was conducted over a 19-month period. Patients were included if the pain was musculoskeletal in origin and was severe enough to warrant parenteral analgesics. Patients were randomized to receive 1 mg/kg meperidine intramuscularly (IM) or 60 mg ketorolac IM. Pain intensity was measured preadministration and at 60 minutes via a 100 mm Visual Analog Scale (VAS). Outcomes measured at 60 minutes were pain intensity decrease (PID), patient satisfaction, rescue analgesia requirement, sedation level, and adverse effects. Clinically significant pain reduction was defined as a PID of at least 13 mm or a reduction in pain of least 30%. One hundred fifty-five patients were enrolled (meperidine = 75, ketorolac = 80) and 153 patients completed the study. At 60 minutes the mean PID was 7 mm less in the ketorolac group (95% confidence interval [CI] - 15 mm to 2.6 mm). Pain reduction of at least 30% occurred in 63% of the ketorolac group versus 67% of the meperidine group (95% CI, odds ratio [OR] .43 to 1.61). Rescue analgesia was required in 35% of the ketorolac group versus 37% of the meperidine group (95% CI, OR .47 to 1.74). Patient satisfaction was less in the ketorolac group (ketorolac 68% satisfied versus meperidine 74% satisfied) however this was not significant (95% CI, OR .66 to 2.72). Sedation level and adverse effects were significantly greater in the meperidine group. Ketorolac shows comparable single dose analgesic efficacy to a single moderate dose of meperidine with less sedation and adverse effects in an ED population with severe musculoskeletal LBP. The trend for greater pain reduction and patient satisfaction with meperidine needs further investigation.",2000.0,0,0
340,10926069,Intra-articular clonidine analgesia after knee arthroscopy.,H Buerkle; V Huge; M Wolfgart; J Steinbeck; N Mertes; H Van Aken; T Prien,"Recently, it was suggested that peripherally-mediated analgesia can be accomplished by the intra-articular delivery of the mu-opioid morphine or of the a2-agonist clonidine. This clinical study assesses the potential peripheral analgesic effect of the combination of morphine and clonidine after intra-articular administration. Sixty patients (American Society of Anesthesiologists status I or II) undergoing arthroscopic repair of the knee during general anaesthesia were randomized to receive after operation, in a double-blind manner, either 1 mg morphine intra-articularly (group 1); 150 microg clonidine intra-articularly (group 2); or 1 mg morphine + 150 microg clonidine intra-articularly (group 3); or normal saline intra-articularly (group 4) in a volume of 30 mL, respectively. Visual analogue pain scores (VAS), duration of analgesia as defined by first demand for supplemental analgesics, subsequent 24 h consumption of postoperative supplementary analgesics, and patient satisfaction were evaluated. Co-administration of morphine + clonidine (group 3) resulted in a significant VAS reduction at 2 h after injection compared with the other groups. There was a tendency towards a lower need for supplementary rescue analgesia and towards a more prolonged analgesia in group 3 (211 min +/- 224 min SD) compared with group 1 (173 min +/- 197 min SD) and group 4 (91 min +/- 21 min SD). More patients were very satisfied with the postoperative analgesic regimen receiving the combination of morphine and clonidine (group 3) at 24 h postoperatively. Thus we conclude, that the peripheral co-delivery of an opioid and an a2-agonist will result in improved postoperative pain relief, when compared with each single agent given alone.",2001.0,0,0
341,10926073,Effect of pre-emptive analgesia on self-reported and biological measures of pain after tonsillectomy.,S Podder; J Wig; S K Malhotra; S Sharma,"This prospective, double-blind, randomized study assessed effect of pre-emptive peritonsillar block in 30 ASA-I children, aged 6-12 years, of both sexes, scheduled for tonsillectomy. Patients were divided into three groups: those in group I received a sham block, whereas peritonsillar blocks with bupivacaine 0.25% were given to the children before tonsillectomy (group II) or immediately after surgery had been completed (group III). Constant pain, pain on swallowing, blood glucose, serum epinephrine and norepinephrine concentrations were measured immediately after surgery and 4h after operation. Patients in group I experienced more pain (P< 0.05) than those in groups II and III, both in the immediate postoperative period and over the next 4 h. Patients in groups II and III experienced similar pain (P> 0.05). The pain experienced when water was swallowed was similar to that of the constant pain. The rise of serum norepinephrine concentration in group II was significantly less (P< 0.05) compared to groups I and III. We found both pre-emptive and postoperative block to be equally effective in treating postoperative pain, with pre-emptive block being more effective in preventing the rise in norepinephrine concentration.",2001.0,0,0
342,10928438,The influence of sufentanil and/or clonidine on the duration of analgesia after a caudal block for hypospadias repair surgery in children.,J C De Mey; J Strobbet; J Poelaert; P Hoebeke; E Mortier,"The aim of this study was to evaluate whether the addition of clonidine, or sufentanil, or both, to a bupivacaine solution for a caudal block prolonged the period of analgesia after operation in children. Sixty ASA class I or II boys, aged between 8 months and 13 years, admitted for hypospadias repair were enrolled into a prospective randomised study. After induction of general anaesthesia and endotracheal intubation the children were allocated into four groups. Group I received 0.5 mL kg(-1) bupivacaine 0.25% caudally, in addition group II received 1 microg kg(-1) clonidine, group III 0.5 microg kg(-1) sufentanil and group IV 0.5 microg kg(-1) clonidine and 0.25 microg kg(-1) sufentanil. The concentrations of clonidine and sufentanil in group IV were halved to reduce possible side-effects with higher dosages. Analgesia and side-effects were assessed 2, 4, 6, 8 and 12 h after operation. No significant differences were found among the four groups for the pain scores at 2, 4, 6, 8 and 12 h. All groups had a similar frequency of vomiting and a comparable appetite and quality of night rest during the first 24 h following the operation. There was no significant difference in the requirement for additional doses of analgesics. The addition of sufentanil, or clonidine, or both, to bupivacaine for caudal administration provides no additional clinical benefit over bupivacaine alone.",2001.0,0,0
343,10929726,Postoperative pain therapy after lumbar disc surgery.,R Filippi; J Laun; J Jage; A Perneczky,"This study was undertaken to determine whether a special postoperative pain administration of tramadol and diclofenac provides any benefits in patients who underwent microsurgical lumbar discectomy. The study consisted of 60 patients undergoing microsurgical lumbar discectomy. Patients were randomly divided into two groups based on the postoperative pain management: 1) Group A (n = 30); no standardized pain therapy; these patients received on demand different analgesics and at variable dosages which were selected by the neurosurgeons; 2) Group B (n = 30); standardized pain therapy with specific dosages of tramadol and diclofenac in regular time intervals during the first 48 hours after surgery. After surgery follow-up data from a special standardized questionnaire were obtained for all 60 patients during the first 48-72 postoperative hours. The patients were asked for course and intensity of pain as well as about some specific circumstances of clinical therapy after surgery. The postoperative pain intensity of patients treated with the special combination of tramadol and diclofenac was significantly diminished (24 hours after surgery: p = 0.0002, 48 h: p = 0.0047, 72 h: p = 0.0034) in relation to the group without standardized pain therapy. Similarly, the frequency of breakthrough pain was significantly reduced (24 h: p = 0.0001, 48 h: p = 0.003, 72 h: p = 0.004). The results suggest that the application of tramadol and diclofenac during the first 48 hours after lumbar microdiscectomy results in a reduction in postoperative pain without complications. We suggest that the use of this combination can be a beneficial adjunct to lumbar disc surgery.",2000.0,0,0
344,10930636,Relief of posttonsillectomy pain with low-dose tramadol given at induction of anesthesia in children.,Z Ozköse; M Akçabay; Y K Kemaloğlu; S Sezenler,"Pain is major problem regarding quality of life in children undergoing tonsillectomy. Preemptive analgesia by medicine given before commencement of surgery is a new way recommended for relief of pain during and after operation. The purpose in this study to evaluate preemptive efficacy and safety of lower dose of tramadol, which was recently introduced in children undergoing tonsillectomy. This study was performed on 45 children undergoing tonsillectomy with or without adenoidectomy as a double-blinded trial, by using tramadol in two dosages (1 and 0.5 mg kg(-1)) and placebo. Pain assessment was done by facial pain score (FPS), visual analog scale (VAS) and postoperative analgesic requirement; further, duration of anesthesia and duration of awakening time, heart rate (HR) and mean arterial pressure (MAP) during and after anesthesia, postoperative nausea and vomiting (PONV) and recall of intraoperative events were recorded. It was found that 73% children in placebo group needed analgesic medicine at the end of the first hour after operation, although no analgesic medicine was needed in tramadol groups (chi(2) test, P<0.001). However, statistically significant decrease in FPS and VAS in tramadol groups were only found up to 15th and 30th min after operation, respectively (Kruskall-Wallis test, P<0.05). On the other hand, intraoperative HR (10th, 20th and 30th min) and MAP (10th and 20th min) were found to be higher in placebo groups (ANOVA variance analysis, Tukey-Kramer test adjusted paired t-test, P<0.001 and <0. 01, respectively). No significant difference was found in the other parameters, and no surgical complication and adverse side effect were occurred in this number of study sample. Tramadol in lower doses (0.5-1 mg kg(-1)) was an efficient preemptive analgesic that could be used at induction of anesthesia in adenotonsillectomies of children for providing both good analgesia during operation as supplementation to propofol anesthesia and postoperative analgesia in only early period.",2000.0,0,0
345,10935004,Geriatric pain management. The anesthesiologist's perspective.,G M Freedman; R Peruvemba,Geriatric patients have a unique physiology that makes their pain management problematic. This article reviews the issue of geriatric pain management from the perspective of the anesthesiologist. It looks at the main causes of geriatric chronic pain and emphasizes the different analgesic modalities available that can provide maximum relief and minimal potential side effects.,2000.0,0,0
346,10936472,Treatment of low back pain exacerbations with willow bark extract: a randomized double-blind study.,S Chrubasik; E Eisenberg; E Balan; T Weinberger; R Luzzati; C Conradt,"Herbal medicines are widely used for the treatment of pain, although there is not much information on their effectiveness. This study was designed to evaluate the effectiveness of willow (Salix) bark extract, which is widely used in Europe, for the treatment of low back pain. We enrolled 210 patients with an exacerbation of chronic low back pain who reported current pain of 5 or more (out of 10) on a visual analog scale. They were randomly assigned to receive an oral willow bark extract with either 120 mg (low dose) or 240 mg (high dose) of salicin, or placebo, with tramadol as the sole rescue medication, in a 4-week blinded trial. The principal outcome measure was the proportion of patients who were pain-free without tramadol for at least 5 days during the final week of the study. The treatment and placebo groups were similar at baseline in 114 of 120 clinical features. A total of 191 patients completed the study. The numbers of pain-free patients in the last week of treatment were 27 (39%) of 65 in the group receiving high-dose extract, 15 (21%) of 67 in the group receiving low-dose extract, and 4 (6%) of 59 in the placebo group (P <0.001). The response in the high-dose group was evident after only 1 week of treatment. Significantly more patients in the placebo group required tramadol (P <0.001) during each week of the study. One patient suffered a severe allergic reaction, perhaps to the extract. Willow bark extract may be a useful and safe treatment for low back pain.",2000.0,0,0
347,10937910,Opioids and their proper use as analgesics in the management of head and neck cancer patients.,A R Thompson,"Opioid analgesics play an important part in the interdisciplinary management of head and neck cancer patients. Acute pain during the initial treatment period and chronic pain after treatment may be undertreated by head and neck surgeons because of unwarranted fear of the opioid side effects and toxicities. Properly used, opioid analgesics are among the safest and most effective medications in the armamentarium of the head and neck surgeon. Knowledge of opioid pharmacology can help surgeons treat pain aggressively in patients while managing side effects and toxicities. This understanding can also address the unique problems in pain management presented in head and neck cancer patients attributable to the involvement by the disease of the aerodigestive tract, which interferes with the oral route of administration of opioid analgesics. Significant difficulties in the use of opioid analgesics arise when the patient is a substance abuser. This article discusses the basic principles of opioid pharmacology, discusses opioid use in head and neck cancer patients, and provides guidelines on the use of opioids in the substance abuser.",2001.0,0,0
348,10942661,The efficacy of spinal cord stimulation for chronic pain.,B Kavar; J V Rosenfeld; A Hutchinson,"A prospective study was undertaken to evaluate the efficacy of spinal cord stimulation (SCS) in the management of chronic pain syndrome. The study included all patients who underwent this procedure at the Royal Melbourne Hospital and the Melbourne Private Hospital over a period of two years. A total of 29 patients were managed by the end of June 1996. These patients were carefully screened by a neurosurgeon (JVR) and a psychiatrist. Of these, 26 patients had a follow up evaluation at the end of August 1996. From the group of 29 patients, four patients failed to obtain any relief during the trial phase of the procedure and thus did not have the stimulator implanted permanently. From the 25 patients who proceeded to have the stimulator implanted, 11 patients had a variable beneficial response, three patients found it to be of marginal benefit, six had no benefit, three patients initially had a good response but subsequently gained no benefit whilst two patients were uncertain of its benefit. It thus appears that SCS was of benefit in 50% of our carefully selected patients with chronic pain syndromes.",2001.0,0,0
349,10945514,Combination hydrocodone and ibuprofen versus combination codeine and acetaminophen for the treatment of chronic pain.,M Palangio; M J Damask; E Morris; R T Doyle; J G Jiang; C J Landau; A de Padova,"The objective of this study was to compare the effectiveness of combination hydrocodone 7.5 mg and ibuprofen 200 mg with that of combination codeine 30 mg and acetaminophen 300 mg for the treatment of chronic pain. Hydrocodone 7.5 mg with ibuprofen 200 mg is the only approved fixed-dose combination analgesic containing an opioid and ibuprofen. In this randomized, parallel-group, double-blind, repeated-dose, active-comparator, 4-week, multicenter study, 469 patients were randomly assigned to receive a 1-tablet (n = 156) or 2-tablet (n = 153) dose of combination hydrocodone 7.5 mg and ibuprofen 200 mg (HI1 and HI2, respectively) or a 2-tablet dose of combination codeine 30 mg and acetaminophen 300 mg (CA, n = 160), the active comparator, every 6 to 8 hours as needed for pain. Efficacy was measured through pain relief scores, number of daily doses of study medication, number of daily doses of supplemental analgesics, number of patients who discontinued therapy due to an unsatisfactory analgesic response, and global assessment scores. Of the 469 patients, 255 (54.4%) were female and 214 (45.6%) were male. The mean age was 51.1 years. Types of chronic pain included back (214; 45.6%), arthritic (145; 30.9%), other musculoskeletal (65; 13.9%), cancer (6; 1.3%), diabetic neuropathic (3; 0.6%), postherpetic neuralgic (5; 1.1%), other neurologic (21; 4.5%), and other unclassified chronic pain (10; 2.1%). During the 48 hours prior to the study, 351 (74.8%) patients had been treated with opioid or opioid-nonopioid combination analgesics. The overall mean daily pain relief score was significantly greater in the HI2 group (2.25+/-0.89) than in the HI1 group (1.98+/-0.87) (P = 0.003) or the CA group (1.85+/-0.96) (P < 0.001). The overall mean number of daily doses of study medication was significantly less in the HI2 group (2.94+/-0.99) than in the HI1 group (3.23+/-0.76) (P = 0.036) or the CA group (3.26+/-0.75) (P = 0.014). The overall mean number of daily doses of supplemental analgesics was significantly less in the HI2 group (0.24+/-0.49) than in the HI1 group (0.34+/-0.58) (P = 0.021) or CA group (0.49+/-0.85) (P = 0.010). The number of patients who discontinued treatment due to an unsatisfactory analgesic response was significantly less in the HI2 group (2; 1.3%) than in the CA group (12; 7.5%) (P = 0.008). HI2 was more effective than HI1 and CA as measured by pain relief scores for week 1 (P < 0.001 vs HI1 and CA), week 2 (P < 0.001 vs HI1 and CA), and week 3 (P = 0.008 vs HI1 and P < 0.001 vs CA); daily doses of study medication for week 1 (P = 0.019 vs HI1 and P = 0.011 vs CA); daily doses of supplemental analgesics for week 1 (P = 0.010 vs HI1 and CA); and global assessment scores for week 1 (P = 0.018 vs HI1 and P < 0.001 vs CA), week 2 (P = 0.005 vs HI1 and P < 0.001 vs CA), and week 4 (P = 0.013 vs HI1 and P = 0.023 vs CA). There were no significant differences between HI1 and CA in any efficacy variable. There were no significant differences in the number of patients experiencing adverse events in the HI2 (127; 83%), HI1 (124; 79.5%), and CA (129; 80.6%) groups. However, the mean number of patients who discontinued treatment due to adverse events was significantly greater in the HI2 group (40; 26.1%) than in the HI1 group (23; 14.7%) (P = 0.013). The results of this study suggest that 2-tablet doses of combination hydrocodone 7.5 mg and ibuprofen 200 mg may be more effective than either 1-tablet doses of this combination or 2-tablet doses of combination codeine 30 mg and acetaminophen 300 mg. Moreover, 1-tablet doses of combination hydrocodone 7.5 mg and ibuprofen 200 mg may be as effective as 2-tablet doses of combination codeine 30 mg and acetaminophen 300 mg.",2001.0,0,1
350,10949061,Evidence-based data on pain relief with antidepressants.,D Fishbain,"This structured review addresses the issue of whether antidepressants have an antinociceptive (analgesic) effect for chronic pain independent of their antidepressant effect. In order to answer this question, human acute pain studies, individual placebo-controlled studies for the treatment of specific chronic pain syndromes, and metaanalytic studies were reviewed and placed into table format. Analysis of this evidence led to the following conclusions: The evidence was consistent in indicating that overall antidepressants may have an antinociceptive effect in chronic pain, and that these drugs were effective for neuropathic pain. There was also some evidence that these drugs could be effective for psychogenic or somatoform disorder-associated pain. This evidence also strongly suggested that serotonergic-noradrenergic antidepressants may have a more consistent antinociceptive effect than the serotonergic antidepressants. Finally, this evidence indicated that antidepressants could be effective for pain associated with some specific pain syndromes, such as chronic low back pain, osteoarthritis or rheumatoid arthritis, fibrositis or fibromyalgia, and ulcer healing. Possible reasons for the conflicting results of studies in this area are presented, and problems that could limit the validity of the conclusions of this review are discussed.",2001.0,0,0
351,10951799,[Epidural analgesia in total gastrectomy--combination of bupivacaine with ketamine or fentanyl].,Z Janković; D Stamenković; S Milosavljević; P Pesko,"The effects of intraoperative epidural administration of ketamine added to bupivacaine were compared with fentanyl added to bupivacaine in patients undergoing total gastrectomy. Prospective, randomized, double blind study was designed to compare: group F: 20 patients (pts) receiving 20 ml of 0.125% bupivacaine and 50 ug of fentanyl and group K: 20 pts in whom 20 ml of 0.125% bupivacaine was combined with 50 mg of ketamine. Pts received an epidural injection through peridural catheter introduced through either T7-8 or T8-9 interspinous space. Non invasive arterial blood pressure, heart rate and ECG were recorded every 5 mins. We measured supplementary fentanyl requirement, ephedrine consumption, first postoperative complain on pain, tracheal extubation time. The groups were comparable with regard to patients characteristics, operation and anaesthesia related factors. There were no difference between groups in mean intraoperative fentanyl requirements (F vs. K = 118.5 (122.5) ug vs. 122.5(122.5)ug) (p n > 0.05), in the duration of epidural pain relief (F vs. K = 393.72 (98.75)min vs.403.63 (111.41)min, in the tracheal extubation time (F vs.K = 52.31 (50.4) vs.46.75 (48.35) min), postoperative sedation score (F vs.K = 1.26 (0.73) vs.1.11 (0.32)) (p > 0.05). Significantly higher systolic blood pressure was measured in group K comparing with group F in 20, 75, 105, 120, 150 min (p > 0.05). Statistically significant more ephedrine was applied in F group (F vs.K = 0.88(1.76)ml vs.0.05(0.23)ml) (p > 0.05). There were no statistically significant differences between groups in heart rate during the operation. None of the pts complained of bad dreams or awakeness during operation. Both fentanyl and ketamine added to bupivacaine and given as a bolus provided good intraoperative analgesia in combination with general anaesthesia, minimal sensorimotor disturbance and early tracheal extubation. In our study fentanyl added to bupivacaine caused higher incidence of hypotension than ketamine added to bupivacaine.",2000.0,0,0
352,10952406,Opioid treatment of painful chronic pancreatitis.,T Niemann; L G Madsen; S Larsen; N Thorsgaard,"Abdominal pain is the dominant symptom in 50-75% of patients with chronic pancreatitis, often requiring opioid analgesics. Fentanyl, a potent synthetic opioid, can be administered percutaneously at a constant dose and is claimed to have fewer systemic side effects. To evaluate transdermal fentanyl plaster versus sustained release morphine tablets as analgesic treatment of painful chronic pancreatitis. In an open randomized crossover trial, 18 patients were included. The treatment period was 4 wk for each drug. All patients had immediate-release morphine tablets as rescue medication. The dosage of transdermal fentanyl had to be increased on average 50% over that indicated by the manufacturer. When this was done and rescue medication was secured, no difference between the two drugs in primary endpoint or patient preference was observed. There was also no difference in the secondary endpoints, pain control, and quality of life. However, skin side effects, mostly mild, occurred in 44% of the patients during treatment with transdermal fentanyl, and the mean daily dose of immediate release morphine was significantly higher during the transdermal fentanyl period than during the sustained-release morphine period (30.7 mg vs. 14.7 mg [p < 0.01]). When given in an appropriate dose, transdermal fentanyl might be useful for treatment of some patients with painful chronic pancreatitis, e.g., when tablet ingestion is difficult. However, the dosage often has to be increased above that recommended by the manufacturer. The need of rescue morphine is considerable and skin side effects often occur. Transdermal fentanyl is, therefore, not the ideal first-choice analgesic in patients with painful chronic pancreatitis.",2001.0,0,1
353,10952476,"Clinical efficacy, safety and pharmacokinetics of a newly developed controlled release morphine sulphate suppository in patients with cancer pain.",F Moolenaar; W J Meijler; H W Frijlink; J Visser; J H Proost,"To compare the efficacy, safety and pharmacokinetics of a newly developed controlled-release suppository (MSR) with MS Contin tablets (MSC) in cancer patients with pain. In a double-blind, randomised, two-way cross-over trial, 25 patients with cancer pain were selected with a morphine (M) demand of 30 mg every 12 h. Patients were divided into two groups. Group 1 received active MSC (30 mg) and placebo MSR, followed by placebo MSC and active MSR (30 mg) each for a period of 5 days. Group 2 started with active MSR and placebo MSC, followed by active MSC and placebo MSR, each for a period of 5 days. Blood for determination of plasma concentration of morphine (M) and its 3- and 6-glucuronides (M3G, M6G) was collected, and area under the plasma concentration-time curve (AUC)0-12 h, peak plasma concentration (Cmax), time to reach Cmax (tmax), and CO and C12 of M, M6G and M3G were determined on day 5 and day 10. Intensity of pain experienced by each patient was assessed every 2 h on a 0-10 scale, while side effects and rescue medication were recorded. Twenty patients (ten patients in each group) completed the study. A pronounced inter-patient variability in plasma concentrations of M, M3G and M6G was observed after administration of both forms. Apart from the C0 and C12, no significant differences in AUC0-12 h, tmax and Cmax of morphine between the rectal and oral route of administration were found. In the case of the metabolites, it was found that AUC0-12 h and Cmax of M6G, and AUC0-12 h, Cmax, C0 and C12 of M3G after rectal administration were significantly lower than after oral administration. However, apart from the tmax of M6G, none of the pharmacokinetic parameters of M, M6G or M3G met the criteria for bioequivalence. There were no significant (P = 0.44) differences in pain intensity score between the oral and rectal forms within the two groups, regardless of the treatment sequence. No treatment differences in nausea, sedation or the demand on escape medication (acetaminophen tablets) between the rectal and oral forms were observed. The newly developed controlled-release M suppository is safe and effective and may be a useful alternative for oral morphine administration in patients with cancer pain.",2001.0,0,0
354,10954816,Thoracoscopic splanchnicectomy for pain control in patients with unresectable carcinoma of the pancreas.,A Saenz; J Kuriansky; L Salvador; E Astudillo; V Cardona; M Shabtai; L Fernandez-Cruz,"Intractable pain is the most distressing symptom in patients suffering from unresectable pancreatic carcinoma. Palliative interventions are justified to relieve the clinical symptoms with as little interference as possible in the quality of life. The purpose of this study was to examine the efficacy and safety of thoracoscopic splanchnicectomy for pain control in patients with unresectable carcinoma of the pancreas. Between May 1995 and April 1998, 24 patients (14 men and 10 women) with a mean age of 65 years (range, 30-85) suffering from intractable pain due to unresectable carcinoma of the pancreas underwent 35 thoracoscopic splanchnicectomies. All patients were opiate-dependent and unable to perform normal daily activities. Subjective evaluation of pain was measured before and after the procedure by a visual analogue score. The following parameters were also evaluated: procedure-related morbidity and mortality, operative time, and length of hospital stay. All procedures were completed thoracoscopically, and no intraoperative complications occurred. The mean operative time was 58+/-22 min for unilateral left splanchnicectomy and 93.5+/-15.6 min for bilateral splanchnicectomies. The median value of preoperative pain intensity reported by patients on a visual analogue score was 8.5 (range, 8-10). Postoperatively, pain was totally relieved in all patients, as measured by reduced analgesic use. However, four patients experienced intercostal pain after bilateral procedures, even though their abdominal pain had disappeared. Complete pain relief until death was achieved in 20 patients (84%). Morbidity consisted of persistent pleural effusion in one patient and residual pneumothorax in another. The mean hospital stay was 3 days (range, 2-5). We found thoracoscopic splanchnicectomy to be a safe and effective procedure of treating malignant intractable pancreatic pain. It eliminates the need for progressive doses of analgesics, with their side effects, and allows recovery of daily activity. The efficacy of this procedure is of major importance since life expectancy in these patients is very short.",2000.0,0,0
355,10958101,Wound closure tramadol administration has a short-lived analgesic effect.,M Naguib; M Attia; A H Samarkandi,"To evaluate the effects of tramadol administration at wound closure on postoperative pain and analgesic requirements in patients undergoing laparoscopic cholecystectomy. In a prospective, randomized, double-blind study 80 patients were allocated into two groups (n = 40 in each) to receive either 200 mg tramadol or placebo i.v. at the time of wound closure. Postoperatively, all patients received tramadol from a patient-controlled analgesia (PCA) device. Pain, analgesic consumption, vital signs and side effects were recorded postoperatively for 24 hr. Administration of 200 mg tramadol at the time of wound closure was associated with a short-lived (60 min) reduction in pain scores and PCA consumption compared with placebo. Although the time to first request for analgesia after surgery was longer in patients who received tramadol at wound closure, there was no difference between the two groups with respect to pain scores or to the requirements of postoperative analgesia over the next 23 hr. The cumulative PCA consumption of tramadol in 24 hr was 139.4+/-108 and 102.4+/-106 mg in the placebo and tramadol groups, respectively (P = 0.06). Wound closure administration of 200 mg tramadol had a short-lived (60 min) analgesic effect but did not affect the long-term pain scores or analgesic requirements after laparoscopic cholecystectomy.",2001.0,0,0
356,10959360,[Thoracoscopic splanchnicectomy for intractable pancreatic pain].,J Kuriansky; A Saenz; L Fernandez-Cruz,"Intractable pain is the most distressing symptom in nonresectable pancreatic carcinoma and in chronic pancreatitis. Recently, thoracoscopic splanchnicectomy has been advocated as a minimally invasive method of pain control in these patients. Between May 1995 and April 1998, 24 patients with nonresectable pancreatic cancer and 4 with chronic pancreatitis, underwent 43 thoracoscopic splanchnicectomies. All suffered from intractable pain, were opiate-dependent and unable to perform normal daily activities. Unilateral left splanchnicectomy was done in 13 and bilateral in 15. All procedures were completed thoracoscopically. Operative time ranged from 25 to 60 min and mean hospital stay was 3 days. Median pain intensity was reduced by 50% in 24 and no further narcotics or analgesics were required. We found thoracoscopic splanchnicectomy a safe and effective procedure for intractable pancreatic pain.",2000.0,0,0
357,10960201,0.2% ropivacaine with or without fentanyl for patient-controlled epidural analgesia after major abdominal surgery: a double-blind study.,M Berti; A Casati; G Fanelli; A Albertin; S Palmisano; G Danelli; L Comotti; G Torri,"To evaluate the effects of adding low concentration of fentanyl to 0.2% ropivacaine when providing patient-controlled epidural analgesia (PCEA) outside the Post-Anesthesia Care Unit. Prospective, randomized, double-blind study. Inpatients at a University Department of Anesthesia. 32 ASA physical status I, II, and III patients, who were scheduled for elective major abdominal surgery, including bowel resection, hepatic resection, and pancreaticoduodenectomy. Patients received standard general/epidural anesthesia. After surgery patients were randomly allocated in a double-blind fashion to receive PCEA with either 0.2% ropivacaine (n = 16) or 0.2% ropivacaine/2 microg/mL fentanyl (n = 16) [background infusion ranging between 4 and 6 mL/hr, with 1.5-mL incremental doses and a 20-min lock-out time]. Dynamic pain during coughing, sedation, pulse oxymetry, hemodynamic variables, and motor block were evaluated at 1, 6, 12, 24, and 48 hours after the end of surgery by a blinded observer. Occurrence of untoward events, including nausea, vomiting, pruritus, need for supplemental oxygen (for SpO(2) < 90%), and respiratory complications, as well as total consumption of PCEA solution and incremental doses given to the patient were also recorded. No differences in pain relief, motor block, degree of sedation, recovery of gastrointestinal motility, and other side effects were observed between the two groups. Patients receiving 0.2% ropivacaine alone requested far more incremental doses (23 doses [0-60] vs. 5 doses [0-25]) (p = 0.006) and needed far more analgesic solution (230 mL [140-282] vs. 204 [130-228]) (p = 0.003) than patients receiving the ropivacaine/fentanyl mixture. Peripheral oxygen saturation was lower at 12, 24, and 48 hours during ropivacaine/fentanyl infusion than in patients receiving ropivacaine alone (12 h: 91% +/- 2% vs. 95% +/- 2%, p < 0.006; 24 h: 93% +/- 1% vs. 96% +/- 2%, p = 0.003; 48 h: 92% +/- 1.8% vs. 96% +/- 1%, p = 0.004). A thoracic epidural infusion of 0.2% ropivacaine, with or without fentanyl, provided effective pain relief in most patients with a very low degree of motor blockade. Adding 2 microg/ml fentanyl to 0.2% ropivacaine reduced total consumption of local anesthetic solution and need for incremental doses, but did not provide clinically relevant advantages in quality of pain relief and incidence of motor block, leading to a significant decrease in peripheral SpO(2), lasting up to 48 hours after surgery.",2000.0,0,0
358,10960893,Naturally occurring antinociceptive substances from plants.,J B Calixto; A Beirith; J Ferreira; A R Santos; V C Filho; R A Yunes,"Despite the progress that has occurred in recent years in the development of therapy, there is still a need for effective and potent analgesics, especially for the treatment of chronic pain. One of the most important analgesic drugs employed in clinical practice today continues to be the alkaloid morphine. In this review, emphasis will be given to the important contribution and the history of Papaver somniferum, Salix species, Capsicum species and Cannabis sativa in the development of new analgesics and their importance in the understanding of the complex pathways related to electrophysiological and molecular mechanisms associated with pain transmission. Recently discovered antinociceptive substances include alkaloids, terpenoids and flavonoid. Plant-derived substances have, and will certainly continue to have, a relevant place in the process of drug discovery, particularly in the development of new analgesic drugs.",2001.0,0,0
359,10964147,Comparison of intravenous patient-controlled analgesia with tramadol versus morphine after microvascular breast reconstruction.,M Silvasti; N Svartling; M Pitkänen; P H Rosenberg,"Tramadol is a weak centrally acting analgesic and it might provide efficacious postoperative pain relief with minimal sedative effects in the use of intravenous patient-controlled analgesia (PCA). Sixty women scheduled to undergo microvascular breast reconstruction under standard general anaesthesia were enrolled in a study on the performance of patient-controlled analgesia with tramadol or morphine with special emphasis on drug- and technique-related side-effects. Seven patients were re-operated within the same day, leaving 25 patients in the tramadol group and 28 in the morphine group for comparison. When postoperative pain occurred, loading doses of either 10 mg tramadol or 1 mg morphine intravenous increments were administered in a double-blind fashion until the pain control was judged to be satisfactory by the patient. After that the patients received tramadol or morphine by a PCA apparatus (lockout 5 min, tramadol 450 microg kg-1, morphine 45 microg kg-1 bolus). In addition, all patients received 500 mg paracetamol rectally, three times a day. The potency ratio of tramadol to morphine was found to be between 8.5 : 1 (loading) and 11 : 1 (PCA). There was neither a significant difference between the groups in the overall satisfaction of the analgesic medication nor in the visual analogue and verbal rate scales for pain. Women in the tramadol group had more nausea and vomiting during the administration of loading doses (P < 0.05) and more patients in the tramadol group (7) than in the morphine group (3) (NS) wanted to discontinue the PCA therapy before the end of the study due to nausea. Sedation or blurred vision prevented the performance of the psychomotor tests in 22 and 32% of the tramadol and morphine patients, respectively. The remaining patients performed similarly in the Digit Symbol Substitution Test. In women receiving intravenous PCA for analgesia after microvascular breast reconstruction tramadol and morphine provided comparable postoperative analgesia with similar sedative effects. However, tramadol was associated with a disturbingly high incidence of nausea and vomiting.",2000.0,0,0
360,10964149,The analgesic efficacy and tolerance of ketoprofen (100 mg) combined with morphine in patient-controlled analgesia after orthopaedic surgery.,J L Didailler; L Dominici; M Dib; C Cohen,,2000.0,0,0
361,10966691,Sedation and analgesia in adult patients: evaluation of a staged-dose system based on body weight for use in abdominal interventional radiology.,S J Skehan; D E Malone; N Buckley; S Matsumoto; J Rawlinson; G Ting; D Graham; J Alexander; S Somers; G W Stevenson,"To evaluate the safety and effectiveness of a systematic protocol for sedation and analgesia in interventional radiology. Ninety-one adult patients underwent 113 abdominal interventional procedures. Fentanyl citrate and midazolam hydrochloride were administered in one to five steps (A, B, C, D, E) until the patient was drowsy and tranquil at the effective loading dose (ELD). Doses per step were as follows: A, fentanyl 1 microg per kilogram of body weight; B, midazolam 0.010-0.035 mg/kg; C, repeat dose in A; D, repeat half the dose in B; and E, midazolam 1-2-mg boluses (maximum, 0.15 mg/kg). The ELD was reached in no procedure after step A, in 70 after B, in 23 after C, and in 18 after D. Step E was needed in two procedures. The mean maximum pain score (scale of 0 to 10) was 3.4; pain scores in 85 (75%) procedures were 4 or less (discomforting). Severe pain occurred in seven (6%) procedures. Hypoxia (oxygen saturation < 90%) occurred in 11 (22%) procedures performed in patients breathing room air and four (6%) performed in those breathing supplemental oxygen (P: =.04). All patients responded to supplemental oxygen. This stepwise ""ABCDE protocol"" allows safe and effective sedation of patients. It is easy to use and may be useful in training radiology residents, staff, and nurses in the techniques of sedation and analgesia. Supplemental oxygen should be used routinely.",2000.0,0,0
362,10966692,,,,,0,0
363,10969513,Home-based patient-controlled epidural analgesia with bupivacaine for patients with intractable herpetic neuralgia.,Y C Tsai; L K Wang; B S Chen; H P Chen,"This clinical report is based on retrospective observation of the outcome and effects of patient-controlled epidural analgesia (PCEA) with bupivacaine infusion administered at home to five patients with intractable herpetic neuralgia. All patients had severe pain (9 or 10 visual analogue scale [VAS]points) confined to the affected dermatomes, which was refractory to medication. The interval between zoster onset and PCEA application ranged from 27 to 60 days (mean, 37.2 d). The average daily amount of bupivacaine used was 36.5 to 91.2 mg (mean +/- standard deviation, 62.4 +/- 19.7 mg). The duration of PCEA therapy ranged from 10 to 28 days (18.4 +/- 7.6 d). One patient developed drug tolerance. All treatments resulted in effective and satisfactory pain relief (VAS, 0-3), with increase in physical activities to normal levels and easing of sleep and appetite impairment. No deleterious effects were found during PCEA therapy. After discontinuation of PCEA, two patients did not complain of pain but still had slight paresthesia, one of them required low-dose antidepressant for 17 days; three patients continued to have occasional sharp pain (VAS, 2-3) and required low-dose antidepressant and analgesic as-needed for one to six months. These results suggest that PCEA with bupivacaine infusion provides effective pain relief in patients with intractable herpetic neuralgia and is a feasible and effective home treatment modality with limited side effects.",2000.0,0,0
364,10971385,Amifostine can reduce mucosal damage after high-dose melphalan conditioning for peripheral blood progenitor cellautotransplant: a retrospective study.,D Capelli; G Santini; C De Souza; A Poloni; G Marino; M Montanari; M Lucesole; M Brunori; D Massidda; M Offidani; P Leoni; A Olivieri,"Amifostine (WR-2721; Ethyol) is a well-known cytoprotector, but a possible role in preventing extrahaematological toxicity after high-dose therapy (HDT) has never been investigated. We compared two historical groups of patients who either received (group A, n = 35) or did not receive (group B, n = 33) amifostine (740 mg/m2) before high-dose (HD) melphalan, followed by autologous infusion of peripheral blood progenitor cells (PBPCs). Amifostine was well tolerated at this dose level. Emesis grade 1-2 was the most important side-effect, but the interruption of infusion was never required. The incidence and median duration of severe mucositis (grade 3-4) was 21% and 0 d (range 0-11 d) in group A and 53% and 7 d (range 0-11 d) in group B. The duration of analgesic therapy was also significantly lower in group A (0 d; range 0-12) than in group B (6 d, range 0-20) (P = 0.0001). Severe diarrhoea (3% vs. 25%; P = 0.01) and emesis (9% vs. 34%; P = 0.01) were also reduced in group A in comparison with group B. No differences were observed between the two groups for haematological recovery. This retrospective study strongly suggests that amifostine can reduce severe mucositis and the use of analgesic drugs in this setting. A randomized study is warranted to confirm these preliminary results.",2000.0,0,0
365,10972049,[Reflex sympathetic dystrophy vs. a factitious disorder].,E J Buijs; F A Klijn; E Lindeman; A J van Wijck,"Three women aged 18, 30 and 21, were admitted with complaints of reflex sympathetic dystrophy. These patients were caught at inducing their symptoms. Factitious disorders may be more common and serious than expected. It is suggested to include this diagnosis routinely in the differential diagnosis when dealing with inexplicable complaints, symptoms or therapy resistance. If factitious disorders are diagnosed it is advised to confront the patients. This is important in order to limit further iatrogenic damage to the patient. It also allows the physician to inform other doctors. After confrontation quite a few patients will stop inducing their symptoms. Most of them become angry, deny self-induction and refuse psychiatric help. Sometimes patients will withdraw from treatment. Despite these negative reactions patient confrontation is mandatory.",2000.0,0,0
366,10972054,[Driving ban for patients on chronic opioid therapy unfounded].,W J Meijler,"Dutch law states that persons who are on treatment with morphine preparations, even if these are slow-release drugs, are unfit to drive a motor vehicle. There is no scientific basis for such a measure, however. On the contrary, current evidence indicates that e.g. cancer patients using 209 mg morphine daily for three months do not differ significantly from a control group with respect to thinking abilities, alertness, concentration, reaction speed and dividing attention. For obvious reasons utmost care must be observed with the use of morphine by traffic participants. But a rigorous prohibition of driving for patients requiring chronic alleviation of severe pain needlessly restricts their mobility.",2000.0,0,0
367,10972635,Dose-response effect of combination hydrocodone with ibuprofen in patients with moderate to severe postoperative pain.,M Palangio; G L Wideman; M Keffer; C J Landau; E Morris; R T Doyle; J G Jiang; M Damask; A de Padova,"The objective of this study was to demonstrate a dose-response effect with 1- and 2-tablet doses of combination hydrocodone 7.5 mg with ibuprofen 200 mg and placebo in patients with moderate to severe postoperative abdominal or gynecologic pain. Hydrocodone 7.5 mg with ibuprofen 200 mg is the only approved fixed-dose combination analgesic containing an opioid and ibuprofen. Previous studies with this combination have demonstrated that the components have an additive analgesic effect as well as efficacy compared with other fixed-dose combination analgesics. This randomized, parallel-group, double-blind, single-dose, placebo-controlled study compared 1 tablet of hydrocodone 7.5 mg with ibuprofen 200 mg (n = 60), 2 tablets of hydrocodone 7.5 mg with ibuprofen 200 mg (n = 60), and placebo (n = 60) in patients with moderate or severe pain after abdominal or gynecologic surgery. Analgesia was evaluated over 8 hours. Mean pain relief (PR) scores were significantly greater for the 2-tablet dose than for the 1-tablet dose at 80 (P = 0.027) and 100 (P = 0.017) minutes and at 2 (P = 0.013), 2.5 (P = 0.012), 3 (P = 0.006), 4 (P = 0.029), 5 (P = 0.002), 6 (P = 0.032), 7 (P = 0.036), and 8 (P = 0.01) hours. Mean pain intensity difference scores were significantly greater for the 2-tablet dose than for the 1-tablet dose at 80 (P = 0.013) and 100 (P = 0.007) minutes and at 2 (P = 0.003), 2.5 (P = 0.002), 3 (P = 0.002), 4 (P = 0.009), 5 (P < 0.001), 6 (P = 0.004), 7 (P = 0.009), and 8 (P = 0.001) hours. Mean total PR scores were significantly greater for the 2-tablet dose than for the 1-tablet dose for all measured time intervals (0 to 3 hours, P = 0.01; 0 to 4 hours, P = 0.006; 0 to 6 hours, P = 0.003; 0 to 8 hours, P = 0.003). Mean sum of pain intensity differences was significantly greater for the 2-tablet dose than for the 1-tablet dose for all measured time intervals (0 to 3 hours, P = 0.004; 0 to 4 hours, P < 0.001; 0 to 6 hours, P < 0.001; 0 to 8 hours, P < 0.001). Mean peak PR score and median time-to-remedication were significantly greater for the 2-tablet dose than for the 1-tablet dose (P < 0.029 and P = 0.017, respectively). Both doses were superior to placebo. There were no significant differences in the number of patients experiencing adverse events between the 2-tablet dose (n = 6 [10.0%]), the 1-tablet dose (n = 4 [6.7%]), and placebo (n = 1 11.7%]). Adverse events were not serious, and none of the patients discontinued therapy because of side effects. This study demonstrated that a 2-tablet dose of hydrocodone with ibuprofen provided significantly more analgesia than a 1-tablet dose (a positive dose-response effect) and that both doses were superior to placebo.",2001.0,0,0
368,10977118,Morphine plus bupivacaine vs. morphine peridural analgesia in abdominal surgery: the effects on postoperative course in major hepatobiliary surgery.,G Barzoi; S Carluccio; B Bianchi; S Vassia; G Colucci; G L Mangiante,"Anaesthesia and surgical procedures lead to a reduction of intestinal motility, and opioids may produce a postoperative ileus, that might delay postoperative feeding. The aim of this prospective randomised study is to test whether or not different kinds of epidural analgesia (Group A: morphine 0.0017 mg/kg/h and bupivacaine 0.125%-0.058 mg/kg/h; Group B: morphine alone 0.035 mg/kg/12h in the postoperative period) allow earlier postoperative enteral feeding, enhance intestinal motility a passage of flatus and help avoid complications, such as nausea, vomiting, ileus, diarrhoea, pneumonia or other infective diseases. We included in the study 60 patients (28 males and 32 females) with a mean age of 61.2 years (range 50-70) and with an ASA score of 2 or 3. All patients had hepato-biliary-pancreatic neoplasm and were candidates for major surgery. We compared two different pharmacological approaches, i.e., morphine plus bupivacaine (30 patients, Group A) versus morphine alone (30 patients, Group B). Each medication was administered by means of a thoracic epidural catheter for the control of postoperative pain. In the postoperative course we recorded every 6 hours peristaltic activity. We also noted morbidity (pneumonia, wound sepsis) and mortality. Effective peristalsis was present in all patients in Group A within the first six postoperative hours; in Group B, after 30 hours. Six patients in Group A had bowel motions in the first postoperative day, 11 in the second day, 10 in the third day and 3 in fourth day, while in Group B none in the first day, two in the second, 7 in the third, 15 in the fourth, and 6 in the fifth: the difference between the two groups was significant (p<0.05 in 1st, 2nd, 4th and 5th days). Pneumonia occurred in 2 patients of Group A, and in 10 of Group B (p < 0.05). We conclude that epidural analgesia with morphine plus bupivacaine allowed a move rapid return to normal gut activity and early enteral nutrition compared with epidural analgesia with morphine alone.",2001.0,0,0
369,10981566,,,,,0,0
370,10981568,Effects of intraperitoneal lidocaine combined with intravenous or intraperitoneal tenoxicam on pain relief and bowel recovery after laparoscopic cholecystectomy.,M Elhakim; H Amine; S Kamel; F Saad,"Previous work has demonstrated that intraperitoneal (i.p.) lidocaine may provide analgesia after laparoscopic cholecystectomy. The aim of this prospective, randomized, double-blind study was to compare pain relief, recovery variables, and side effects after i.p. instillation of lidocaine plus tenoxicam given either i.v. or i.p. after laparoscopic cholecystectomy. Ninety patients were randomly allocated to one of three groups to receive either 200 ml normal saline i.p. and 2 ml of normal saline i.v. (saline group), 200 ml lidocaine 0.1% i.p. and 2 ml tenoxicam 20 mg i.v. (tenoxicam i.v. group), or 200 ml lidocaine 0.1% with 20 mg tenoxicam i.p. and 2 ml of normal saline i.v. (tenoxicam i.p. group). The i.p. instillation was made under the right diaphragm and on the gall bladder bed. VAS pain scores at rest, on movement and during coughing, were measured 2, 4, 6, 12, and 24 h after operation. The time to first demand of analgesia, total analgesic requirement, recovery variables, and side effects were investigated. In the tenoxicam i.p. group, pain scores were significantly lower both at rest and on movement and analgesic consumption was reduced compared with the saline group (P<0.05). In the tenoxicam i.v. group, pain scores at rest were significantly lower compared with the saline group. Although recovery of bowel function was significantly faster in the tenoxicam i.p. group (P<0.05), there were no differences in any other recovery characteristics or incidence of nausea between the groups. Combination of intraperitoneal lidocaine and tenoxicam provided better analgesia on movement, and faster return of bowel function compared with i.p. lidocaine and i.v. tenoxicam during the 24 h period after surgery.",2001.0,0,0
371,10981569,"Randomised, placebo-controlled study of the postoperative analgesic effects of ketoprofen after spinal fusion surgery.",F Aubrun; O Langeron; D Heitz; P Coriat; B Riou,"The additive effect of non-steroidal anti-inflammatory drugs administered with propacetamol after major orthopaedic surgery has not been studied. Thus, we performed a prospective, placebo-controlled study to assess the analgesic effects of ketoprofen in patients undergoing spinal fusion surgery and receiving propacetamol. Fifty patients undergoing spinal fusion surgery received either 100 mg of ketoprofen every 8 h or a placebo, postoperatively. All patients received propacetamol and morphine (intravenous titration followed by patient-controlled analgesia (PCA) over 24 h). Pain was assessed using a visual analogue pain scale (VASpi). Data are mean+/-SD. During morphine titration, ketoprofen did not significantly reduce the dose of morphine (8+/-6 vs 11+/-4 mg, NS) whereas it significantly decreased VASpi (P<0.001). During PCA, ketoprofen significantly reduced morphine consumption (25+/-17 vs 38+/-20 mg, P=0.04) and VASpi (P=0.002). The total postoperative morphine consumption was significantly (33%) reduced with ketoprofen. Ketoprofen reduced morphine requirements and improved postoperative analgesia in patients undergoing major spinal surgery and receiving propacetamol.",2001.0,0,0
372,10981570,Onset and offset of intrathecal morphine versus nalbuphine for postoperative pain relief after total hip replacement.,R Fournier; E Van Gessel; M Macksay; Z Gamulin,"We designed this study to compare the postoperative analgesic effects of intrathecal morphine and nalbuphine, the endpoints being onset and offset of action. Geriatric patients scheduled for elective total hip replacement under continuous spinal anaesthesia were randomized to two double-blinded groups in the recovery room as soon as they experienced a pain score higher than 3 cm on the visual analogue scale (VAS, 0-10 cm). Either 160 microg morphine or 400 microg nalbuphine in 4 ml normal saline were administered intrathecally. Pain scores on VAS, rescue analgesia (diclofenac and morphine, not allowed during the first 60 min), and the adverse effects (respiratory depression, postoperative nausea and vomiting, itching) were recorded for 24 h after surgery. The study was stopped after inclusion of 2 x 12 patients due to slow onset of analgesia in the morphine patients. In the nalbuphine group, when compared to the morphine group, the time to a pain score <3 cm (8+/-6 vs. 31+/-32 min, P<0.001), the time to the lowest pain score (18+/-11 vs. 66+/-75 min, P<0.001) and the time to the first systemic analgesic intervention for a pain score >3 cm (218+/-256 vs. 1076+/-440 min, P<0.05) were significantly shorter. The analgesic requirements during the first 24 h were significantly lower in the morphine group (P<0.001). We conclude that after total hip replacement, administration of intrathecal nalbuphine resulted in a significantly faster onset of pain relief and shorter duration of analgesia than intrathecal morphine.",2001.0,0,0
373,10983898,Chronic pain and neuropsychological functioning.,R P Hart; M F Martelli; N D Zasler,"This review article examines the effect of chronic pain on neuropsychological functioning. Primary attention is given to studies that include patient groups without a history of traumatic brain injury (TBI) or neurologic disorders. Numerous studies were identified that demonstrate neuropsychological impairment in patients with chronic pain, particularly on measures assessing attentional capacity, processing speed, and psychomotor speed. Despite suggestive findings, further studies are needed to clarify the variables that mediate the impact of pain on neuropsychological functioning and the unique role of various symptoms often associated with chronic pain.",2001.0,0,0
374,10989857,Optimal dose of intrathecal clonidine added to sufentanil plus bupivacaine for labour analgesia.,A T Sia,"The combination of intrathecal (IT) 5 microg sufentanil plus 1.25 mg bupivacaine is useful for inducing labour analgesia, albeit of short duration and slow onset. As a supplementation to this regimen, the effect of IT clonidine on the duration of analgesic action was investigated. Forty-eight healthy parturients were randomly assigned into three groups to receive 0 microg (group C0), 15 microg (C15) or 30 microg (C30) of clonidine IT in addition to 5 microg sufentanil plus 1.25 mg bupivacaine IT for labour analgesia. The quality of pain relief was assessed on 0-100 visual analogue scale by the author. The occurrence of side effects was also evaluated before the request for additional analgesia. Clonidine (C15 and C30), produced a longer duration of analgesia than C0 (mean 144 +/- sd 27.9, 165 +/- 31.8 vs 111 +/- 21.9 min, P < 0.01). Also, C15 and C30 produced a more rapid onset and a higher quality of analgesia than C0, (P < 0.01). The most cephalad level of sensory block was higher in C30 than C15 (median T3 vs T4, P < 0.05) but lowest in C0 (median T7 vs T3,T4, P < 0.01). Side effects, sedation and hypotension, occurred more frequently in C30 than in either C0 or C 15, (9 vs 2,5 and 9 vs 1,3, respectively, P < 0.05). The optimal dose of intrathecal clonidine to enhance labour analgesia with the current sufentanil-bupivacaine regimen is 15 microg. In view of the side effect profile, doses greater than 30 microg clonidine are unlikely to be useful.",2001.0,0,0
375,10992829,Effect of peripheral morphine in a human model of acute inflammatory pain.,J Lillesø; N A Hammer; J L Pedersen; H Kehlet,"Several studies have demonstrated the presence of opioid inducible receptors on peripheral nerves and peripheral antinociceptive effects of opioids. However, the effects of peripheral opioid administration in man are controversial. Our study used a randomized, double-blind, placebo-controlled, three-way crossover design in a human model of acute inflammatory pain (heat injury). We studied 18 healthy volunteers who each received morphine locally (2 mg), morphine systemically (2 mg), or placebo on three separate study days. The subjects received morphine infiltration subcutaneously (s.c.). 1 h before heat injury (47 degrees C, 7 min) and naloxone infiltration s.c. (0.2 mg) 2.5 h after the heat injury. Hyperalgesia to mechanical and heat stimuli were examined using von Frey hairs and thermodes, and pain was rated using a visual analogue scale. The burns produced significant hyperalgesia, but local morphine infiltration neither reduced pain during the burn, nor primary or secondary hyperalgesia to mechanical and heat stimuli after the burn. In conclusion, peripherally applied morphine had no acute antinociceptive effects in this human model of acute inflammatory pain.",2000.0,0,0
376,10992830,Efficacy and respiratory effects of low-dose spinal morphine for postoperative analgesia following knee arthroplasty.,P J Cole; D A Craske; R G Wheatley,"A randomized, double-blind study of 38 patients undergoing total knee replacement was undertaken to compare the efficacy and respiratory effects of low-dose spinal morphine and patient-controlled i.v. morphine against patient-controlled i.v. morphine alone. Patients received either morphine 0.3 mg or saline 0.3 ml with 0.5% heavy spinal bupivacaine 2-2.5 ml. Respiratory effects were measured continuously for 14 h postoperatively with an Edentec 3711 respiratory monitor. There was an improvement in pain relief in the intrathecal morphine group, with significantly lower median VAS pain scores on movement at 4 h (0 (median 0-1.5) vs 5 (1.25-7.75) P < 0.01), 12 h (2 (1-5) vs 6 (3-8) P < 0.01) and 24 h (3 (1-5) vs 5 (3-7) P < 0.05) postoperatively, despite using significantly less patient-controlled morphine (20 mg (10.25-26.25) vs 38.5 mg (27-51) P < 0.01) in the first 24 h. There was a small but statistically significant reduction in the median oxygen saturation (SpO2) in the intrathecal morphine group 97 (95-99)% compared with the placebo group 99 (97-99)% (P < 0.05). Although marked disturbances in respiratory pattern were observed in both groups, none of the patients in the study had severe hypoxaemia (SpO2 < 85% > 6 min h-1) and there was no significant difference in the incidence of mild (SpO2 < 94% > 12 min h-1) or moderate (SpO2 < 90% > 12 min h-1) hypoxaemia or in the incidence of episodes of apnoea or hypopnoea in the two groups.",2000.0,0,0
377,10995143,The use of epidural ropivacaine in high doses for the management of pain from invasive carcinoma of the cervix.,G R Harrison,"A case is presented of a young woman with advanced cervical cancer invading the rectum and sacral nerves giving rise to an intractable pain state. The management of her symptoms using a domicillary infusion of diamorphine with high doses of ropivacaine is described. It is believed that this is the first presentation of ropivacaine being used in daily doses approaching 2 g, and the associated problems are discussed.",2000.0,0,0
378,10995147,Development and evaluation of combined rectus sheath and ilioinguinal blocks for abdominal gynaecological surgery.,S M Yentis; P Hills-Wright; O Potparic,"We describe the development of a technique of combined rectus sheath and ilioinguinal blocks for patients undergoing abdominal gynaecological surgery, and its use in a series of 37 patients (21 midline and 16 transverse incisions). Up to 60 ml of bupivacaine 0.25% with adrenaline 1:400,000 was used, depending on the patient's weight. Median (interquartile range) total morphine requirement (including 0.15 mg x kg(-1) given intra-operatively) up to 48 h after surgery was 0.34 (0.2-0.38) [corrected] mg x kg(-1) for midline incisions and 0.47 (0.35-0.64) [corrected] mg x kg(-1) for transverse incisions; no other systemic opioids were given. Six-hourly pain scores within the first 48 h after surgery were < or =1 (mild pain) in 11 out of 21 (52%) and < or =2 (moderate pain) in 18 out of 21 (86%) patients with midline incisions and in 5 out of 16 (31%) and 13 out of 16 (81%) patients with transverse incisions, respectively. No patient had emetic symptoms worse than mild nausea during the 48-h postoperative study period.",2000.0,0,0
379,10998643,DL-phenylalanine markedly potentiates opiate analgesia - an example of nutrient/pharmaceutical up-regulation of the endogenous analgesia system.,A L Russell; M F McCarty,"In the author's clinical experience, concurrent treatment with DL-phenylalanine (DLPA) often appears to potentiate pain relief and also ease depression in patients receiving opiates for chronic non-malignant pain. An analysis of this phenomenon suggests that it may be mediated, at least in part, by up-regulation of the 'endogenous analgesia system' (EAS), a neural pathway that projects caudally from medullary nuclei to the dorsal horn of the spinal column; when stimulated by chronic pain or therapeutic measures such as opiates or acupuncture, the EAS suppresses activation of second-order pain-receptive neurons in the dorsal horn, and thereby alleviates pain. Since serotonin and enkephalins are key neurotransmitters in the EAS, it is reasonable to predict that measures which promote serotonin activity (such as 5-hydroxytryptophan and serotonin-reuptake inhibitors) as well as enkephalin activity (such as D-phenylalanine, an enkephalinase inhibitor) should potentiate EAS-mediated analgesia - a view consistent with much previous medical research. Comprehensive support of the EAS with well-tolerated nutrients and pharmaceuticals may amplify the analgesic efficacy of chronic opiate therapy, while enabling dosage reductions that minimize opiate side-effects. Analogously, this approach may complement the efficacy of acupuncture and other analgesic measures that activate the EAS.",2001.0,0,0
380,10998719,The epidural and intrathecal administration of somatotrophin-release inhibiting factor: native and synthetic analogues.,D P Beltrutti; S Moessinger; G Varrassi,"It is well-known that morphine is the king of analgesics. It is widely used, and administered in various ways for the control of acute and chronic pain states. There are, however, certain types of pain and certain clinical conditions in which morphine cannot be used due to the risk of possible complications. These are usually pain states associated with intracranial hypertension, the presence of serious respiratory problems, the onset of major opioid tolerance, persistent vomiting, and so on. The search for ""alternative analgesics"" has been in progress for a decade, alternatives that could be used alone or in combination for spinal administration in the treatment of complex chronic pain states and with a low incidence of secondary effects. Today, research is carefully assessing the clinical effectiveness and the side effects of a series of drugs for spinal administration, that is, epidural or intrathecal, such as the new narcotics, alpha-2 agonists, central muscle relaxants, calcitonin, and local anesthetics. In this alternative analgesic category we have to mention the somatotrophin-release inhibiting factor (SRIF), which is an ubiquitous native hormone with widespread, predominantly inhibitory actions, and octreotide, its synthetic analogue. In this article we review the literature on the natural drug and its synthetic analogue, paying particular attention to the problems connected with intraspinal administration and analgesic properties.",2001.0,0,0
381,10998721,Failed back surgery syndrome.,V C Anderson; Z Israel,"Over the years, a number of treatments for persistent low back pain following spine surgery, the failed back surgery syndrome (FBSS), have been developed. The complexity of the clinical problem, the multidimensional nature of chronic pain, and general lack of rigorous study design, however, have obscured outcome assessment and hampered efforts to optimize patient selection criteria. Recent work has focused on refinement of existing therapies for FBSS and identification of factors that influence outcome and improve patient selection criteria. In combination with more rigorous study methodology, these efforts have led to improved understanding of the clinical response to a number of pharmacologic, surgical, and neuromodulation therapies for FBSS.",2001.0,0,0
382,10998722,Opioids in chronic pain management: is there a significant risk of addiction?,G M Aronoff,"In the last decade there has been significant controversy about the appropriateness, efficacy, safety, and wisdom of treating chronic pain patients (CPPs) with opioids. Arguments against their use have included concerns about tolerance, dependence, addiction, persistent side effects, and interference with physical or psychosocial functioning. However, considerable experience and research with long-term cancer pain treatment suggests that in appropriately selected patients, opioids have a low morbidity, and a low addiction potential, and in addition to the primary analgesic action, can facilitate reduction in suffering, enhance functional activity level, and improve quality of life without significant risk of addictive behaviors. Some patients, however, are at risk. Risk factors for addiction are discussed in this article.",2001.0,0,0
383,11002713,[Lung function and quality of analgesia after lung resection with epidural alfentanyl].,M Granell Gil; F Aguar Olba; A Arnau Obrer; F Grau Real; A Cantó Armengod; J M Palanca Sanfrancisco,"To evaluate the effects on postoperative pulmonary function and quality of analgesia of two protocols for epidural infusion of alfentanil after lung resection. After informed consent, 30 ASA I-IV patients undergoing chest surgery (lobectomy or pneumonectomy) were randomly assigned to two groups of 15. A catheter was inserted into the epidural space at T5-7 (group T) or L2-3 (group L). After a test dose, an initial bolus of alfentanil (10 micrograms/kg) was administered. After anesthetic induction, epidural analgesia was performed with an infusion of 400 micrograms/h of alfentanil (group L) during and after surgery. Endovenous patent-controlled anesthesia (PCA) was provided with morphine. During the first 24 h after surgery, the following variables were recorded: arterial blood gas concentrations, spirometric parameters, pain on a visual analog scale (VAS) and side effects. ANOVA and Scheffé and chi-square tests were used to analyze the results (p < or = 0.05). In group T, PaO2 was significantly higher at 6 and 18 h (p < or = 0.05), while FEV1 and FVC were significantly higher at 12 and 18 h. Pain assessed by VAS and PCA need for morphine was significantly less in group T. Thoracic epidural analgesia with alfentanil and lidocaine improves postoperative lung function and reduces the need for top-up analgesia in comparison with lumbar epidural infusion of alfentanil.",2001.0,0,0
384,11007224,"Sedation for colonoscopy using a single bolus is safe, effective, and efficient: a prospective, randomized, double-blind trial.",J B Morrow; G Zuccaro; D L Conwell; J J Vargo; J A Dumot; M Karafa; S S Shay,"Practice guidelines call for the careful titration of sedatives and analgesics during endoscopy, with time taken between incremental doses to assess effect. This approach is time-consuming and has never been validated in a prospective trial. The aim of this study was to compare the safety and efficacy of titration, as outlined in practice guidelines, with a single, rapid bolus of sedatives before colonoscopy. Consecutive colonoscopy outpatients were randomized to a single, rapid bolus of meperidine and midazolam or to a titration of doses every 3 min until predefined levels of somnolence were achieved. The colonoscopist was not present during sedation and remained blinded as to which technique was used. Supplemental O2 was given for SaO2 <90% on three or more occasions. Total physician time was calculated from the first injection of sedatives to the removal of the colonoscope. Patient assessments of pain and tolerance were obtained at the time of discharge using visual analog scales of 100 mm (0 = excellent and 100 = unbearable). A total of 101 patients were randomized (49 bolus, 52 titration). Demographic features were similar for both groups. Titration required more physician time than did bolus (32.2 min vs 20.1 min, p < 0.001) and was associated with an increased need for supplemental O2 (44% vs 14%, p = 0.002). Mean tolerance scores were similar (titration 16.3 vs bolus 15.3, p = 0.72). Rapid bolus sedation for colonoscopy saves significant endoscopist time, is associated with less O2 desaturation, and provides equivalent levels of patient comfort. A revision of the guidelines for sedation and analgesia during endoscopy should be considered.",2000.0,0,0
385,11009498,The management of post-herpetic neuralgia.,A L Cunningham; R H Dworkin,,2001.0,0,0
386,11010058,Managing chronic nonmalignant pain: overcoming obstacles to the use of opioids.,S D Passik; H J Weinreb,"Physicians involved in cancer pain management treat thousands of patients with opioids, whose effective analgesia improves overall functioning. Side effects generally are tolerable, and treatment can be maintained with stable doses for long periods. Problems with addiction are infrequent. Many physicians, however, assume that opioids should be used only for chronic malignant pain. Research and clinical experience have demonstrated that opioids can safely and effectively relieve most chronic moderate to severe nonmalignant pain. Fears of addiction, disciplinary action, and adverse effects result in ineffective pain management. With current information on the use of opioids in chronic nonmalignant pain, primary care physicians can overcome these obstacles. Guidelines must clearly define the role of the primary care physician in the proper management of pain and the integration of opioid therapy. Used appropriately, opioids may represent the only source of relief for many patients.",2000.0,0,0
387,11012492,Effects of peribulbar bupivacaine as an adjunct to general anaesthesia on peri-operative outcome following retinal detachment surgery.,D Shende; S Sadhasivam; R Madan,"Sixty premedicated, ASA physical status I or II patients weighing > 25 kg scheduled for elective retinal detachment repair were randomly assigned to receive either peribulbar block with 10 ml of 0.25% bupivacaine (block group) or intravenous morphine 150 microg.kg-1 (morphine group), prior to the induction of general anaesthesia (n = 30 in each group). Patients were evaluated for intra-operative oculocardiac reflex, peri-operative pain relief, recovery from anaesthesia and postoperative nausea and vomiting. Apart from significantly reducing the incidence of oculocardiac reflex (30% vs. 70%, p = 0.0019), peribulbar bupivacaine also attenuated the severity of the reflex. Postoperative pain relief was superior in the block group. More block group patients had the maximum recovery score in the immediate postoperative period (80% vs. 27%, p < 0. 0001) and they achieved complete recovery significantly faster than the morphine group (17.3 (14.7) min vs. 66.7 (29.7) min, p < 0.0001). The incidence (40% vs. 77%, p = 0.004) and severity of postoperative nausea and vomiting were significantly less in the block group. In summary, peribulbar bupivacaine, when administered together with general anaesthesia, attenuated oculocardiac reflex, provided comparable intra-operative and superior postoperative analgesia, resulted in significantly earlier and better recovery from anaesthesia, and significantly reduced the incidence and severity of postoperative nausea and vomiting.",2001.0,0,0
388,11012498,The effect of the addition of ropivacaine or bupivacaine upon pruritus induced by intrathecal fentanyl in labour.,M K Shah; A T Sia; J L Chong,"Sixty patients in early labour were randomly allocated to one of three groups. The control group received intrathecal fentanyl 25 microg, the ropivacaine group received intrathecal fentanyl 25 microg and ropivacaine 2.5 mg while the bupivacaine group received intrathecal fentanyl 25 microg and bupivacaine 2.5 mg. The incidence of pruritus was 100% in controls, compared with 85% in the ropivacaine group (not significant) and 75% in the bupivacaine group (p = 0.003). The severity of pruritus was significantly less in the ropivacaine (p = 0.006) and bupivacaine (p = 0.001) groups. Most patients developed pruritus by 30 min. Pruritus above the abdomen was not reduced in patients receiving local anaesthetics. There were no significant differences in the mean pain visual analogue score, systolic blood pressure, maternal heart rate and upper level of reduced pin-prick sensation in the first 30 min. Intrathecal ropivacaine and, more so, intrathecal bupivacaine reduce the incidence and severity of pruritus from intrathecal fentanyl for labour analgesia.",2001.0,0,0
389,11014391,Flumazenil potentiation of postoperative morphine analgesia.,A A Weinbroum; M Weisenberg; V Rudick; E Geller; D Niv,"The goal of this study was to test the effect of concomitant administration of flumazenil (FL) and morphine (MO) on immediate postoperative analgesia and the MO requirement to control pain in human beings. Thirty-six patients undergoing inguinal hernioplasty under lidocaine epidural anesthesia were enrolled in this double-blind, randomized, controlled study. On the first complaint of pain, either MO (2 mg) only or MO (2 mg) plus FL (0.2 mg) was administered. Additional doses of the same medications administered via a patient-controlled analgesia device with a 10-minute lockout period were available thereafter. The study continued for 2 hours after the loading doses of the medications were administered, with an additional 2-hour period of observation. Thirty-two patients completed the study. Both groups reached a similar satisfactory equianalgesic state (2 in a 0-10 visual analogue scale). The MO plus FL group consumed 9.5 +/- 1.1 mg of MO versus 14.1 +/- 1.1 mg of MO (p < 0.001) in the MO only group. The MO plus FL patients were subjectively (visual analogue scale) more comfortable and less sedated than the MO patients. ""Fine"" coordination (using an electronic maze) and ""coarse"" coordination (measured by transferring a pen from one hand to another as rapidly as possible with both arms placed inside an 80-cm metal frame) in the MO group were worse than in the MO plus FL group. End-tidal CO2 increased and blood pressure decreased in the MO group. There were few and insignificant side effects in the MO group. None of these patients required an MO antagonist, and recovery was prolonged in none. Flumazenil afforded lower MO consumption during the immediate postoperative period. Cognitive, hemodynamic, and respiratory functions were better after MO plus FL than after MO alone.",2001.0,0,0
390,11014399,,,,,0,0
391,11014401,Severe lightning pain after subarachnoid block in a patient with neuropathic pain of central origin: which drug is best to treat the pain?,Z Wajima; T Shitara; T Inoue; R Ogawa,"There have been many reports that spinal anesthesia induces severe lightning pain in the lower limbs of patients with phantom limb pain, tabes dorsalis, or causalgia. We report on a patient with neuropathic pain of central origin who showed newly developed severe lightning pain after therapeutic subarachnoid block (SAB). We performed SAB 16 times in this patient, and he complained of severe pain each time. We investigated which drug was best for treating such induced pain by administering various drugs to the patient. The patient was hospitalized for treatment and observation. The patient was a 48-year-old man with neuropathic pain secondary to an incomplete spinal cord injury at the cervical segment. Various drugs were administered for relieving the newly developed severe pain, and the effectiveness of these agents was compared. Intravenous thiopental, fentanyl, butorphanol, ketamine, midazolam, droperidol, and sevoflurane-oxygen anesthesia were quite effective. Intramuscular butorphanol was not effective. Intravenous physiologic saline and atropine sulfate as a placebo, intrathecal morphine hydrochloride, intravenous mexiletine, and lidocaine were ineffective. Intravenous thiopental (approximately 1 mg/kg) was thought to obtain the best pain relief because it stopped the pain quickly, the dose needed was subanesthetic, and there was no adverse effect.",2001.0,0,0
392,11022617,Get pragmatic about pot.,C Bateman,,2001.0,0,0
393,11025234,Low-dose intrathecal clonidine combined with sufentanil as analgesic drugs in abdominal gynecological surgery.,M C Julião; G R Lauretti,"To determine whether a low dose of spinal clonidine either alone or combined with sufentanil would provide effective analgesia following abdominal surgery, as a supplement to bupivacaine spinal anesthesia. Randomized double-blind study. Gynecological surgery, teaching hospital. 73 ASA physical status I and II patients undergoing gynecological abdominal surgery with spinal anesthesia. Patients were randomly assigned to one of four groups and prospectively studied to examine anesthesia, analgesia, and adverse effects. The control group received saline as the test drug; the sufentanil group received 10 microg of sufentanil; the clonidine group received 30 microg of clonidine; and the sufentanil/clonidine group received 5 microg of sufentanil plus 15 microg of clonidine. All groups received intrathecal 15 mg of bupivacaine (3 mL) plus the intrathecal test drug (2 mL). The concept of visual analog scale (VAS) was introduced. All patients were premedicated with intravenous midazolam. Rescue analgesics were available. The groups were demographically the same. Sensory block to pinprick at 10 min was higher for clonidine and sufentanil/clonidine groups compared to the control group (p < 0.02). Anesthetic time (Bromage score 2) was also longer for clonidine and sufentanil/clonidine groups compared to the control and sufentanil groups (p < 0.05). Time to first rescue analgesics was shorter in the control group compared to the other groups (p < 0.02). The number of IM diclofenac dose injections in 24 hours was higher in the control group compared to all other groups (p < 0.05). The incidence of adverse effects and ephedrine consumption were similar among groups. Intrathecal 15- and 30-microg clonidine doses expanded the anesthesia sensory block and duration of motor block, and provided analgesia.",2001.0,0,0
394,11025237,The influence of preemptive spinal anesthesia on postoperative pain.,S J Vaida; B Ben David; M Somri; M Croitoru; E Sabo; L Gaitini,"To examine the influence of spinal anesthesia on postoperative pain and postoperative opioid requirements. Prospective randomized study. Bnai-Zion Medical Center, Haifa, Israel-a government hospital. 30 ASA physical status I and II unpremedicated women undergoing elective total abdominal hysterectomy were randomly allocated into two groups of 15 patients each using a sealed envelope technique. Patients in Group 1 were given a subarachnoid injection of 12 mg hyperbaric bupivacaine and after 10 minutes general anesthesia was induced. Patients in Group 2 received only general anesthesia. Anesthesia was induced with midazolam and maintained with oxygen, N2O, isoflurane, and pancuronium. No opioids were given intraoperatively. Postoperatively patient-controlled analgesia (PCA) with morphine was initiated in both groups (1 mg x mL(-1), bolus dose 1 mg, lockout interval 10 minutes, and background infusion 1 mg x mL(-1)) at patient first request for analgesic. Pain was assessed over 24 hours by cumulative morphine dose and visual analog score (VAS). Postoperative PCA morphine consumption at 2, 6, and 24 hours following patient first request for analgesic for Groups 1 and 2 were: 3.1 +/- 1 mg versus 7.2 +/- 3 mg (p = 0.04), 13.4 +/- 2 mg versus 17.2 +/- 4 mg (p = 0.03) and 35.9 +/- 8 mg versus 47.7 +/- 8 mg in Group 2 (p = 0.04). VAS scores at 4, 6, 12, and 24 hours postoperatively were not significantly different between the two groups. Preoperative neural blockade may reduce postoperative analgesic requirements.",2001.0,0,0
395,11029125,Double-blind randomized study of tramadol vs. paracetamol in analgesia after day-case tonsillectomy in children.,P E Pendeville; S Von Montigny; J P Dort; F Veyckemans,"Fifty children (2-9 years) scheduled for tonsillectomy were enrolled in a double-blind randomized prospective study to compare postoperative analgesia provided with propacetamol/paracetamol (acetaminophen) or tramadol. A standard anaesthetic technique was used; each patient received sufentanil 0.25 microg kg(-1) intravenously followed with either i.v. propacetamol 30 mg kg(-1) or tramadol 3 mg kg(-1) before surgical incision. For postoperative analgesia, each child received either tramadol drops (2.5 mg kg(-1)) or paracetamol (acetaminophen) suppositories (15 mg kg(-1)), 6 and 12 h after surgery the first day and three times a day during postoperative days 2 and 3. This dosage of paracetamol is lower than the current recommended dosage, which is 40 mg kg(-1) loading dose followed by 20 mg kg(-1) 8 h(-1). Rescue medication consisted of i.v. diclofenac (1 mg kg(-1)) during the first six postoperative hours and oral ibuprofen (6-9 mg kg(-1)) afterwards. Postoperative pain scores (Children's Hospital of Eastern Ontario Pain Scale) in recovery, numerical pain scale in the ward and at home, and rescue analgesic use were significantly lower in the tramadol group. No serious adverse effects were observed.",2001.0,0,0
396,11029568,Epidural fentanyl-bupivacaine compared with clonidine-bupivacaine for analgesia in labour.,S Kizilarslan; B Kuvaki; U Onat; E Sağiroğlu,"Alpha-adrenergic agonists produce pain relief through an opioid independent mechanism and may be alternatives to opioids for combination with local anaesthetics for analgesia during labour. We studied 41 pregnant women. Epidural block was performed with 75 microg clonidine (n = 20) or 50 microg fentanyl (n = 21) combined with 0.125% bupivacaine (10 mL). Maternal vital parameters were measured. Analgesia was evaluated using a visual analogue scale (VAS); sedation was scored using a five-point scale. There were no differences in maternal vital parameters, fetal heart rate (FHR) or Apgar scores between the groups. Analgesia lasted longer in the bupivacaine-clonidine group (139.4 +/- 31 min) compared with the bupivacaine-fentanyl group (127.9 +/- 48 min) (P = 0.42). Additional analgesic requirement was more often in the fentanyl-bupivacaine group and total bupivacaine requirement was less in the clonidine-bupivacaine group (22.5 +/- 12.5 mg vs. 30.9 +/- 12.8 mg) (P = 0.04). This small study confirms that this combination of bupivacaine and clonidine provides satisfactory analgesia for first-stage labour, and of longer duration than bupivacaine-fentanyl.",2001.0,0,0
397,11032271,Intraoperative loading attenuates nausea and vomiting of tramadol patient-controlled analgesia.,W W Pang; M S Mok; S Huang; C P Hung; M H Huang,"To evaluate the adverse effect profile of tramadol by patient-controlled analgesia (PCA) with administration of the loading dose either intraoperatively or postoperatively. Sixty adult patients scheduled for elective abdominal surgery were enrolled into this prospective, randomized, double blind study. The patients were anesthetized in a similar manner. At the beginning of wound closure, the patients were randomly allocated to receive 5 mg x kg(-1) tramadol (Group 1) or normal saline (Group 2). In the post-anesthesia care unit (PACU), when patients in either group complained of pain, 30 mg x ml(-1) tramadol i.v. were given every three minutes until visual analogue scale (VAS) 3, followed by tramadol PCA with bolus dose of 30 mg and five minute lockout interval. Pain control and adverse effect assessments were done in the PACU and every six hours for 48 hr post drug by an independent observer. The loading dose was 290 +/- 45 mg in Group 1 and 315 +/- 148 mg in Group 2. In PACU, more nausea/vomiting both in terms of incidence (13/30, 43% vs 2/30, 6.6%, P < 0.05) and severity (nausea/vomiting score 2.5 +/- 2.0 vs 0.2 +/- 0.6, P < 0.05) was observed in patients with postoperative loading than in those with intraoperative loading of tramadol. Administering the loading dose of tramadol during surgery decreases the nausea/vomiting associated with high dose of tramadol and improves the quality of tramadol PCA in the relief of postoperative pain.",2001.0,0,0
398,11036173,Instrumentation for neuromodulation.,M T Rise,"The explosion in understanding how the central nervous system (CNS) works affords new opportunities to interact with the nervous system to compensate for dysfunction due to disease or injury. Neuromodulation is a term that describes methods that carry out that interaction based on principles of nerve cell physiology. There currently are two neuromodulation techniques used that require implantable devices-neurostimulation and implantable, chronic drug delivery. This article describes the devices used for neuromodulation, the motivation for the different feature sets of the devices, and the physiological and technological principles underpinning their use.",2001.0,0,0
399,11043615,Prophylactic metoclopramide is unnecessary with intravenous analgesia in the ED.,J Talbot-Stern; R Paoloni,"Antiemetics are commonly prescribed as prophylaxis for nausea and vomiting when opiate analgesics are prescribed in the emergency department. This prospective, randomized, double-blind, placebo-controlled trial assessed the incidence of nausea and vomiting after morphine and pethidine (meperidine) analgesia, and the effect of metoclopramide on this incidence. Intravenous morphine or pethidine analgesia was administered with metoclopramide or placebo to 122 opiate-naïve patients with acute severe pain. Seven patients (5.7%) experienced nausea, three in the metoclopramide group and four in the placebo group. One patient (0.8%) had vomiting. The frequency of other side effects was higher in the metoclopramide group (7.9% versus 3.4%). None of these differences reached statistical significance. The low incidence of nausea and vomiting after opiate analgesia, and higher incidence of side effects with metoclopramide, are consistent with controlled data in the literature. Prophylactic metoclopramide should not be used routinely in ED patients receiving parenteral morphine or pethidine analgesia.",2001.0,0,0
400,11048339,[Basics of drug therapy of cancer pain].,G G Hanekop; M T Bautz; D Kettler; F B Ensink,"Industrial countries experience a significant increase of cancer prevalence. Despite recent advances in the treatment of various types of cancer still most of the patients cannot be cured. Especially the advanced incurable stages of cancer, however, often are accompanied by severe pain. Therefore, the high demand for a sufficient pain management and symptom control seems obvious. Throughout the last decades new drugs and techniques for the management of cancer pain have been developed. Most cancer patients should experience sufficient pain-management if existing recommendations for the pharmacological treatment of cancer pain (e.g. WHO-guidelines) are followed consequently. If, nevertheless, intractable pain or ongoing disabling symptoms continue despite proper therapy, every doctor should feel himself obliged to consult an expert in palliative medicine, in order not to tolerate avoidable suffering of his patient.",2001.0,0,0
401,11049008,Adverse effects of opioid analgesic treatment are correlated with a significant elevation in plasma epinephrine in healthy humans.,P Högger,"The purpose of this study was to elucidate the relationship of plasma catecholamine concentrations with experienced pain intensity and analgesic effects in the setting of an experimental pain study with human volunteers. Plasma norepinephrine and epinephrine concentrations of 12 healthy human volunteers were analysed before and during painful electrical tooth-pulp stimulation under medication using the highly potent opioid analgesic tilidine in a fixed tilidine/naloxone combination and with the non-steroidal anti-inflammatory agent bromfenac. Catecholamine levels were compared with pharmacodynamic effects and reported adverse effects. Catecholamine levels revealed a statistically significant increase in plasma epinephrine concentrations (but not norepinephrine concentrations) 60-90 min after administration of tilidine/naloxone. This was correlated with the onset of adverse effects involving vertigo episodes in all reported cases. In contrast, there was no obvious correspondence of epinephrine or norepinephrine plasma concentrations to the experience of pain and analgesia. For comparison, under medication with the non-opioid analgesic bromfenac, only one mild adverse effects were noted, and no changes in plasma epinephrine or norepinephrine could be determined during the experimental sessions. It is proposed that elevated plasma epinephrine concentrations are a newly determined response to opioid-induced vertigo; this has possible clinical implications.",2001.0,0,0
402,11050519,Itching after intrathecal morphine. Incidence and treatment.,R Slappendel; E W Weber; B Benraad; J van Limbeek; R Dirksen,"This study was designed to determine whether low doses of intrathecal morphine still result in itching and it evaluates the outcome of a standardized treatment using promethazine and - for intractable itch - naloxone. Patients (n = 143) scheduled for total hip surgery were allocated to four groups (in a double blind manner) with bupivacaine 20 mg in 4 mL but different doses of intrathecal morphine: Group I, 0.025 mg, Group II, 0.05 mg, Group III, 0.1 mg and Group IV, 0.2 mg. The presence or absence of itching was noted every three hours for a 24-h period. When required, standardized treatment was provided. The incidence of itching was: Group I: 14. 3%; Group II: 21.6%; Group III: 48.6%; and, Group IV: 61.7%. Itch was treated by administering promethazine intramuscularly in 2.9% (Group I); 8.1% (Group II); 10.8% (Group III), and 8.9% (Group IV), respectively. Only in group IV there was a single patient who needed naloxone to treat itching. The incidence and severity of itching is a dose-related side-effect in the dose range of 0.025-0.2 mg of intrathecal morphine. Itching still occurs after the low doses of intrathecal morphine, but symptoms vanish after promethazine 25 mg intramuscularly.",2001.0,0,0
403,11050521,A comparison of the effects on postoperative pain relief of epidural analgesia started before or after surgery.,P Flisberg; K Törnebrandt; B Walther; J Lundberg,"In a randomized, prospective clinical study pain relief and pulmonary function were compared after upper abdominal surgery when thoracic epidural analgesia was instituted either before or after surgery. Twenty-six patients admitted for surgery to treat gastro-oesophageal reflux received thoracic epidural analgesia as an adjunct to general anaesthesia either before or after surgery. Twelve patients received epidural mepivacaine 20 mg mL(-1) and morphine perioperatively. Another 14 patients received an epidural bolus of bupivacaine 2.5 mg mL(-1) and morphine after skin closure. Bupivacaine 2.5 mg mL(-1) with morphine was adminstered to all patients for three postoperative days. No intergroup differences were found regarding pain at rest and mobilization. The requirement for additional analgesics was similar in both groups as well as peak expiratory flow. Thoracic epidural analgesia that had already been induced before surgery, and was continued into the postoperative period, does not seem to add any advantage regarding pain relief and lung function compared with thoracic epidural analgesia instituted in the immediate postoperative period.",2001.0,0,0
404,11060588,The cancer patient with chronic pain due to herpes zoster.,S Modi; J Pereira; J R Mackey,"Postherpetic neuralgia (PHN) is the most common complication of herpes zoster, and as such has been an area of extensive medical research for the past three decades. The patients at highest risk for PHN include those older than 50 years, those with severe acute cases of zoster, and those with shingles in a trigeminal distribution. As persons with malignancy are at a high risk for developing zoster itself, PHN is a complication that will be faced by many of these patients and their caregivers. This article reviews the available treatments and preventative measures for this debilitating condition.",2001.0,0,0
405,11060815,An evaluation of intrathecal ziconotide for the treatment of chronic pain.,K K Jain,"Ziconotide, the synthetic form of cone snail peptide pi-conotoxin MVIIA, is a neurone-specific N-type calcium channel blocker with an analgesic and neuroprotective effect. Intrathecal ziconotide has been recommended for approval by the FDA for the management of chronic pain. Spinally administered ziconotide produces analgesia by blocking neurotransmitter release from primary nociceptive afferents and prevents the propagation of pain signals to the brain. It has an advantage over intrathecal morphine in that there is no development of tolerance after prolonged use. Systemic toxicity is considerably reduced by administration of smaller doses intrathecally and selective delivery to the site of action in the nervous system. Nevertheless, there are neurological adverse effects due to delay in clearance of ziconotide from the neural tissues. Overall, ziconotide has a favourable risk/benefit ratio with advantages over several currently available intrathecal therapies for pain.",2001.0,0,0
406,11063373,Serial bedside emergency ultrasound in a case of pediatric blunt abdominal trauma with severe abdominal pain.,J Pershad; B Gilmore,"We present a case of a teenager with isolated left renal laceration with perirenal hematoma. The patient had presented with severe left upper quadrant (LUQ) pain following blunt abdominal trauma (BAT) sustained during a sledding accident. A screening bedside focused abdominal sonogram for trauma (FAST) rapidly excluded free fluid on two serial examinations, 30 minutes apart. It provided the pediatric emergency physician with a measure of diagnostic confidence that the patient could be safely transported to the CT suite for detailed delineation of his injury. Moreover, narcotic analgesia was liberally administered early in his illness course, without the fear of unmasking potential hypovolemia when it was known that he did not have gross intra-abdominal bleeding on his bedside ultrasound (US). It also provided a working diagnosis of the primary organ of injury. Our hospital, like many pediatric hospitals around the nation, does not have in-house 24-hour radiology support. We suggest that the use of the bedside US be extended to the stable pediatric patient in severe abdominal pain following BAT. It can serve as a valuable, rapid, noninvasive, bedside, easily repeated, fairly accurate triage tool to evaluate pediatric BAT with severe pain.",2001.0,0,0
407,11064492,Treatment of pain in methadone-maintained patients.,M M Scimeca; S R Savage; R Portenoy; J Lowinson,"Patients with opioid dependency experience trauma, acute medical illness and chronic diseases, and may have to undergo surgery to the same extent as other individuals. They need to be treated for relief of symptoms, including pain. Undertreatment or inadequate treatment of pain for these individuals is a particular problem because of opioid dependency and/or methadone maintenance treatment. The guiding principles governing treatment of these patients are to maintain the methadone treatment and to use short-acting narcotics administered at higher doses, and to do so as often as necessary, preferably on a fixed schedule, to relieve the pain. Supplemental analgesic medication may also be employed, except that opiate antagonists must be avoided.",2001.0,0,0
408,11064609,Remifentanil inhibits muscular more than cutaneous pain in humans.,M Curatolo; S Petersen-Felix; A Gerber; L Arendt-Nielsen,"In experimental studies, drug-induced analgesia is usually assessed by cutaneous stimulation. If analgesics act differently on cutaneous and deep nociception, the results of these studies may not be entirely applicable to clinical pain involving deep structures. We tested the hypothesis that opioids have different abilities to inhibit cutaneous and muscular pain. Either the opioid remifentanil or placebo was infused in 12 healthy volunteers in a cross-over fashion. Repeated electrical stimulation (five impulses at 2 Hz) was applied to both skin and muscle. Pain thresholds were recorded. Remifentanil caused a higher increase in the muscular pain thresholds than in the cutaneous pain thresholds (P = 0.035). We conclude that opioids inhibit muscular pain more strongly than cutaneous pain in humans.",2001.0,0,0
409,11064622,Fentanyl versus sufentanil: plasma concentrations during continuous epidural postoperative infusion in children.,C Lejus; D Schwoerer; I Furic; J P Le Moing; J C Levron; M Pinaud,No pharmacokinetic data are available with respect to the plasma concentrations and fentanyl or sufentanil during epidural administration in children. This double-blind randomized study included 12 children (5-12 yr). Patients in group F were given an epidural loading dose of fentanyl 1.5 micrograms kg-1 and in group S sufentanil 0.6 microgram kg-1. Both groups then received a continuous epidural infusion of bupivacaine 5 mg kg-1 day-1 with either fentanyl 5 micrograms kg-1 day-1 or sufentanil 2 micrograms kg-1 day-1. An epidural PCA system was also given to the children (bolus: bupivacaine 0.2 mg kg-1 and fentanyl 0.2 microgram kg-1 or sufentanil 0.08 microgram kg-1). Maximal median concentrations of plasma (0.117-0.247 ng ml-1 for fentanyl and 0.027-0.074 ng ml-1 for sufentanil) were reached approximately 30 and 20 min respectively after the loading doses. These values were similar to those measured after 48 h.,2001.0,0,0
410,11066170,Assessment and management of pain.,G Hansen,,2001.0,0,0
411,11068116,Defining the clinically important difference in pain outcome measures.,J T Farrar; R K Portenoy; J A Berlin; J L Kinman; B L Strom,"The purpose of this study was to determine the levels of change on standard pain scales that represent clinically important differences to patients. Data from analgesic studies are often difficult to interpret because the clinical importance of the results is not obvious. Differences between groups, as summarized by a change in mean values over time, can be difficult to apply to clinical care. Baseline scores vary widely and group mean differences could reflect large changes in a few patients, small changes in many patients, or any combination of these outcomes. Determination of the proportion of patients who have a clinically important improvement in their pain would provide a more interpretable result with direct clinical implications. However, determining a clinically important outcome requires information about the degree of change over time that is clinically important. Data from the titration phase of a multiple cross-over randomized clinical trial of oral transmucosal fentanyl citrate (OTFC) for the treatment of cancer-related breakthrough pain were re-analyzed to examine the differences in pain scores between treatment episodes that did and did not yield adequate pain relief. The scales evaluated were absolute pain intensity difference (PID, 0-10 scale), percentage pain intensity difference (PID%, 0-100% scale), pain relief (PR, 0 (none), 1 (slight), 2 (moderate), 3 (lots), 4 (complete)), sum of the pain intensity difference (SPID over 60 min), percentage of maximum total pain relief (% Max TOTPAR over 60 min), and global medication performance (0 (poor), 1 (fair), 2 (good), 3 (very good), 4 (excellent)). Adequate relief was defined by the patient's decision not to use another dose of opioid medication as a rescue, in addition to the study medication, to treat each painful episode. One hundred thirty OTFC naive patients contributed data on 1268 episodes of breakthrough pain. The scales that were converted to a percentage change yielded the best accuracy in predicting adequate relief, with balanced sensitivity and specificity. The best cut-off point for both the % Max TOTPAR and the PID% was 33%. The best cut-off points for the absolute scales were absolute pain intensity difference of 2, pain relief of 2 (moderate), and SPID of 2. The global medication performance of 2 (good) had excellent values as well. This study presents data-derived cut-off points for the changes in several pain scales, each reflecting the clinically important improvement for patients treating breakthrough cancer pain episodes with OTFC. Confirmation in other patient populations and different pain syndromes will be needed. The use of consistent clinically important cut-off points as the primary outcome in future pain therapy clinical trials will enhance their validity, comparability, and clinical applicability.",2001.0,0,0
412,11069340,Intrathecal alfentanil with and without bupivacaine for analgesia in labour.,D A Hughes; D A Hill,"Combined spinal-epidural (CSE) for analgesia in labour is widely used as a method of providing pain relief while minimising motor blockade. Aiming to further reduce the associated motor weakness, we investigated the use of alfentanil alone as the initial intrathecal injection in a double-blind study. Thirty women were randomly allocated to receive either alfentanil 0.25 mg with bupivacaine 2.5 mg intrathecally, or alfentanil 0.25 mg in the same volume. Onset of analgesia did not differ significantly between groups but duration was significantly longer in those receiving alfentanil-bupivacaine (mean 55 min vs. 40 min; p < 0.05). Quality of analgesia was satisfactory for all women, although the cumulative analgesia scores were significantly lower in the women receiving the alfentanil-bupivacaine mixture (p = 0.003). More women in the alfentanil-bupivacaine group developed both a sensory level (15/15 vs. 6/15; p < 0.01) and sympathetic block (12/15 vs. 4/15; p < 0.01). Sixty per cent of women receiving the alfentanil-bupivacaine mixture demonstrated an impaired ability to straight leg raise compared with none of the women in the alfentanil-saline group (p < 0.01). The incidence of adverse effects in mother and fetus was similar in both groups. We conclude that intrathecal alfentanil 0.25 mg alone as part of a CSE technique provides rapid analgesia of satisfactory quality without detectable motor blockade.",2001.0,0,0
413,11069475,A refractory case of secondary erythermalgia successfully treated with lumbar sympathetic ganglion block.,M Seishima; H Kanoh; T Izumi; M Niwa; Y Matsuzaki; A Takasu; M Ban; Y Kitajima,"A 59-year-old Japanese man with myasthenia gravis, who had a 10-year history of temperature-sensitive pain in the lower extremities, i.e. improved by cooling and worsened by warming, consulted us because the pain had become intolerable during the previous 4 months. Bilateral erythema, swelling and large ulcers were noted on the calves, dorsal aspects of the feet, and soles. Laboratory data showed thrombocythaemia and a positive antibody to the acetylcholine receptor, but were negative for antinuclear and antiphospholipid antibodies. A diagnosis of secondary erythermalgia was made because of the clinical features, the laboratory data, and the lack of family history of this disease. Although steroid pulse therapy, oral aspirin and antiserotonin drugs were ineffective, bilateral lumbar sympathetic ganglion block succeeded in relieving the severe pain and curing the ulcers. The clinical course in our patient suggests that sympathetic ganglion block may be one of the most effective treatments for secondary erythermalgia. Although the mechanism of this effect is uncertain, microcirculation disturbance in secondary erythermalgia, if any, may be improved by this block.",2001.0,0,0
414,11069861,Intractable or chronic pain: there is a difference.,F Tennant; L Hermann,,2001.0,0,0
415,11070965,The effects of preemptive intravenous versus preemptive epidural morphine on postoperative analgesia and surgical stress response after orthopaedic procedures.,L Kiliçkan; K Toker,"The purpose of this study was to evaluate the effect of pre-emptive intravenous versus pre-emptive epidural morphine on both postoperative analgesic consumption and surgical stress response. Sixty patients, ASA I or II, aged 18-85, undergoing total hip or knee replacement were randomly assigned to three groups of 20 patients. In group pre-emptive epidural, patients were administered an epidural injection of 75 micrograms.kg-1 morphine about 45 minute before dermal incision. In group pre-emptive intravenous, patients were administered 0.15 mg.kg-1 of intravenous morphine following induction before dermal incision. In group control, patients were administered intravenous saline following induction before dermal incision. The pre-i.v. group used significantly less morphine than the pre-epi group (p < 0.0003). In all groups, plasma cortisol levels increased as compared to pre-op values, but plasma cortisol increased more significantly in the pre-i.v. and control groups within 4 hrs of surgery and was still significantly elevated at 7 am of the first postoperative morning compared to the pre-epi group (p < 0.001) and the increase persisted to the next morning in patients pre-i.v. and control groups. Although pre-emptive epidural morphine has failed to decrease postoperative analgesic consumption, it has been able to suppress the surgical stress more significantly than intravenous morphine and a saline control.",2001.0,0,0
416,11081593,Acetaminophen versus acetaminophen with codeine after pediatric tonsillectomy.,M S Moir; E Bair; P Shinnick; A Messner,"To compare the effectiveness of acetaminophen versus acetaminophen with codeine after pediatric tonsillectomy and adenoidectomy. Prospective, randomized, double-blind study. Fifty-one children ages 3 to 12 years scheduled for outpatient tonsillectomy and adenoidectomy were studied. Patients were randomly assigned to receive acetaminophen or acetaminophen with codeine in unlabeled bottles for postoperative pain control. The Wong-Baker FACES pain rating scale was used to help children quantify their level of pain after surgery. The level of pain, quantity of pain medication required, presence of side effects, and the percentage of a normal diet consumed was recorded for 10 postoperative days. There was no difference (P > .05, all time points) in the level of postoperative pain reported by the parents and children in the two groups. The acetaminophen with codeine group tended to have increased problems with nausea, emesis, and constipation, but these differences did not reach statistical significance. Children in the acetaminophen group consumed a significantly higher percentage of a normal diet on the first 6 postoperative days (P < .05, all time points). There was no difference in the level of pain control provided by acetaminophen and acetaminophen with codeine as measured by the Wong-Baker FACES pain rating scale. Postoperative oral intake was significantly higher in children treated with acetaminophen alone.",2001.0,0,0
417,11082068,"Ketorolac versus morphine for severe pain. Ketorolac is more effective, cheaper, and has fewer side effects.",G A Jelinek,,2001.0,0,1
418,11082083,Cost effectiveness analysis of intravenous ketorolac and morphine for treating pain after limb injury: double blind randomised controlled trial.,T H Rainer; P Jacobs; Y C Ng; N K Cheung; M Tam; P K Lam; R Wong; R A Cocks,"To investigate the cost effectiveness of intravenous ketorolac compared with intravenous morphine in relieving pain after blunt limb injury in an accident and emergency department. Double blind, randomised, controlled study and cost consequences analysis. Emergency department of a university hospital in the New Territories of Hong Kong. 148 adult patients with painful isolated limb injuries (limb injuries without other injuries). Primary outcome measure was a cost consequences analysis comparing the use of ketorolac with morphine; secondary outcome measures were pain relief at rest and with limb movement, adverse events, patients' satisfaction, and time spent in the emergency department. No difference was found in the median time taken to achieve pain relief at rest between the group receiving ketorolac and the group receiving morphine, but with movement the median reduction in pain score in the ketorolac group was 1.09 per hour (95% confidence interval 1.05 to 2.02) compared with 0.87 (0.84 to 1.06) in the morphine group (P=0.003). The odds of experiencing adverse events was 144.2 (41.5 to 501.6) times more likely with morphine than with ketorolac. The median time from the initial delivery of analgesia to the participant leaving the department was 20 (4.0 to 39.0) minutes shorter in the ketorolac group than in the morphine group (P=0.02). The mean cost per person was $HK44 ( pound4; $5.6) in the ketorolac group and $HK229 in the morphine group (P<0.0001). The median score for patients' satisfaction was 6.0 for ketorolac and 5.0 for morphine (P<0.0001). Intravenous ketorolac is a more cost effective analgesic than intravenous morphine in the management of isolated limb injury in an emergency department in Hong Kong, and its use may be considered as the dominant strategy.",2001.0,0,0
419,11084478,[Management of intractable cancer pain: from intrathecal morphine to cell allograft].,Y Lazorthes; B Sallerin; J C Verdie; J C Sol; H Duplan; J Tkaczuk; M Tafani; R Bastide; J C Bes,"The durable effectiveness of intrathecal morphine administration is well established for the management of intractable cancer pain, after failure of systemic opioids, secondary to the persistence of non-reversible undesirable side effects. Many patients are referred to late in the disease course. This conservative method to control pain of malignant origin must not be reserved for last resort treatment for terminal patients. Intra-cerebro-ventricular morphine administration is a very effective and generally safe method for controlling intractable cancer pain. Because of the chronic implantation of an intra-ventricular catheter this method is somewhat invasive. Its indications remain a simple and effective alternative when the topography of nociceptive pain is diffuse or cephalic. In clinical practice, intrathecal and/or intra-cerebro-ventricular administration of opioids is limited by cost, the need for specialized maintenance and mechanical malfunctions if implantable drug delivery systems, or by the risk of bacterial contamination and ambulatory constraints when repeated daily injections via an intrathecal access port are used. To answer these limitations, cell therapy using intrathecal chromaffin cell allograft is a promising approach for the management of cancer pain refractory to traditional drug therapy and pain lesion surgery. The basic rationale and preclinical studies on experimental pain models have enabled starting prospective clinical trials. Prior to transplantation, handling and preparation of the chromaffin tissue is critical for allograft viability. The initial results of clinical trials with human chromaffin cell grafts from intractable cancer pain have reported long-lasting pain relief, in correlation with met-enkephalin release into the CSF. Convincing evidence will require controlled studies. The limitations of this innovative cell therapy and especially the lack of human adrenal gland availability point to the need for new sources of cells. Perspectives include xenogenic or engineered cell lines.",2001.0,0,0
420,11087888,A new treatment for postherpetic neuralgia.,C P Watson,,2001.0,0,0
421,11093393,Pain control after routine dento-alveolar day surgery: a patient satisfaction survey.,A Joshi; A T Snowdon; J P Rood; H V Worthington,"An audit study which examines patient's opinions on the efficiency of two analgesic regimes prescribed to them following dento-alveolar surgery in our Day Unit. Single centre prospective study. Oral Surgery Day Case Unit One-hundred-and-seventy-four adults undergoing routine dento-alveolar surgery under general anaesthetic were asked to assess their pain control (on a five point scale) 1 hour after surgery, at discharge from hospital and at 24 and 48 hours post-operatively. Post-operatively, patients received ibuprofen 400 mg three times daily for five days or two tablets of paracetamol 500 mg with codeine 30 mg six hourly for 5 days if they were allergic to aspirin or were asthmatics sensitive to aspirin. Patients were not given local anaesthesia intra or post-operatively. Completed records were obtained for 161 (93%) patients. Ibuprofen was apparently adequate in controlling pain for 147 out of 161 patients but on further questioning 42 of these patients took supplemental analgesics and self-prescribed paracetamol or a paracetamol combination. Thirteen patients who were prescribed paracetamol with codeine had adequate pain control and did not take supplemental analgesics. One patient did not require any analgesics post-operatively Telephone contact with patients 24 and 48 hours post-surgery provides a valuable assessment of pain control following discharge from a day surgery unit. Ibuprofen offered satisfactory control of pain for 65% (95) of patients who underwent routine dento-alveolar surgery. Discharge prescriptions must be given with verbal and written instructions to ensure that patients take the correct dose and self-prescription is within safe doses.",2001.0,0,0
422,11097538,Intraoperative vs postoperative morphine improves analgesia without increasing PONV on emergence from ambulatory surgery.,J Wong; E Ritchie; F Chung; S Marshall; F McHardy; J Fortier,"To compare the timing of administration of morphine in patients undergoing painful ambulatory surgical procedures to determine whether there was a difference in postoperative nausea or vomiting (PONV), quality of analgesia, and recovery profile. In a double-blinded, placebo-controlled, prospective study, 70 ASA I-II patients were randomized to receive 0.1 mg x kg(-1) morphine intraoperatively (lop) (n=35), or postoperatively (Pop) (n=35). The severity of nausea and pain were measured using visual analog scales (VAS). There was no difference between the groups in postoperative nausea scores or the incidence of PONV. Upon awakening, patients who received Pop morphine had higher pain VAS scores with movement (7.6 +/- 2 vs 5.4 +/- 3, P < 0.003) and at rest (6.9 +/- 3 vs 5.1 +/- 3, P < 0.013) than the lop morphine group. The total number of PCA attempts and analgesic requirements were similar. Patients who received Pop morphine were able to drink sooner than the lop group (90 +/- 34 vs 111 +/- 38 min, P < 0.05). All other recovery milestones were similar. Times to discharge from hospital were similar. Administration of 0.1 mg x kg(-1) morphine iv intraoperatively improves postoperative analgesia upon emergence from painful ambulatory surgical procedures without increasing the incidence of PONV There was no increase in PONV when morphine was administered intraoperatively rather than postoperatively.",2001.0,0,0
423,11098103,Intravenous morphine in postoperative infants: intermittent bolus dosing versus targeted continuous infusions.,A M Lynn; M K Nespeca; S L Bratton; D D Shen,"Eighty-three infants received i.v. morphine following surgery as a continuous infusion to a targeted morphine concentration of 20 ng ml(-1) (n = 56) or as intermittent bolus doses as needed (n = 27). Ventilation was compared in the two groups by continuous pulse oximetry, by venous blood gases on postoperative day 1 (POD 1) and by CO2 response curves. Infant pain scores were done to assess analgesia every 4 h. Both groups achieved pain scores consistent with analgesia but the bolus group showed a higher percentage of pain scores indicating distress (32 vs. 13%, P < 0.001). Room air saturations of < 90% were seen for 2.3% of POD1 in infusion-treated infants and for 2.5% of POD1 in bolus-treated infants. Mean venous PCO2S were normal in the two groups. Four infants showed ventilatory effects in the infusion group (4/ 56 = 7%); venous hypercarbia in two (2 days, 36 days), oximetry desaturation in one (240 days), both effects in one (6 days). Ventilatory effects were not statistically different between the intermittent bolus-treated and infusion-treated infants but may be clinically important. Monitoring with continuous oximetry is necessary. Morphine clearance increased with age. Infants with detectable morphine also had measurable morphine-6-glucuronide in both groups. Oral intake began at 16 h in both groups and other side effects were infrequent.",2001.0,0,0
424,11103193,Motor block during patient-controlled epidural analgesia with ropivacaine or ropivacaine/fentanyl after intrathecal bupivacaine for caesarean section.,D J Buggy; N A Hall; J Shah; J Brown; J Williams,"We compared patient-controlled epidural analgesia (PCEA) with ropivacaine alone or combined with fentanyl in terms of analgesic efficacy, motor weakness and side-effects in patients who had received spinal anaesthesia for elective Caesarean section. ASA I patients received combined spinal-epidural anaesthesia and were randomly assigned, in a double-blind study, into two groups after operation: group R (n = 23) received PCEA ropivacaine 0.1%, bolus 5 mg, lock-out 15 min, 3 mg h-1 background infusion, and group RF (n = 24) received PCEA 0.1% ropivacaine/fentanyl 2 micrograms ml-1 at identical settings. Pain and satisfaction on a 100 mm visual analogue scale (VAS) and side-effects were noted. Incidence of motor weakness (Bromage grade 1 or higher) was 48% (11/23) at 8 h in group R compared with 13% (3/24) in group RF (P = 0.025). Pain scores on movement were lower in group RF at 8 and 12 h and at rest at 6 and 8 h (P < 0.05 for each comparison). Analgesic consumption was less in RF (P = 0.041), but there was no difference in time to first request for supplementary analgesia. Patient satisfaction with postoperative analgesia (mean (SD)) was higher in RF (79 (23) vs 57 (29) mm, P = 0.045). Caution should be exercised using ropivacaine PCEA after spinal bupivacaine for Caesarean section, because its reputed motor-sparing property may be unreliable.",2001.0,0,0
425,11103484,Short- and long-term effects of regional application of morphine and bupivacaine on the iliac crest donor site.,H Gündeş; L Kiliçkan; Y Gürkan; A Sarlak; K Toker,"We investigated the analgesic effect of regional application of bupivacaine and a morphine-bupivacaine combination on iliac crest donor-site pain in a randomized, double-blind controlled study of 45 patients. Patients were divided into three groups: group I (control group), group II (bupivacaine) and group III (morphine-bupivacaine combination). Pain in the acute stage was evaluated by visual analogue scale scoring and analgesic consumption. Chronic pain and dysesthesia were evaluated at 12 weeks after operation at a follow-up visit. It was found that local bupivacaine administration with or without morphine provided satisfactory analgesia in the acute stage following iliac crest bone harvesting. The amount of analgesic consumption was found to be significantly less with the addition of morphine to bupivacaine, when compared to bupivacaine alone. Effective pain control in the acute stage had a favorable effect on long-term pain and dysesthesia, which are the main complaints after iliac crest bone harvesting. This effect was augmented significantly by addition of morphine to the local anesthetic solution.",2001.0,0,0
426,11103723,Prospective randomized study of analgesic use for ED patients with right lower quadrant abdominal pain.,M Mahadevan; L Graff,"Giving an analgesic to patients with right lower quadrant (RLQ) pain causes greater alteration of abdominal signs predictive of appendicitis than placebo. A randomized double-blinded controlled trial of 68 patients who received either tramadol or placebo. Absence or presence of seven abdominal signs (tenderness on light and deep palpation, tenderness in the RLQ and elsewhere, rebound, cough, and percussion tenderness) and pain (100 mm Visual Analog Scale [VAS]) at 0 and 30 minutes were recorded. The predictive value of each physical finding (PF) was measured using an 11-point PF score weighted by likelihood ratios. There was significant reduction in mean VAS of 14.2 mm (95% CI 5.6 to 22.8) in analgesic group versus 6.5 mm (95% CI 1.6 to 11.4) in placebo group. The analgesic group had less normalization of signs as measured by the PF score in all patients [32 of 154 (20.8%) versus 40 of 121 (33.1 %) (P = .031)] and in those with proven appendicitis [4 of 33 (12.1%) versus 10/22 (45.5%) (P = .014)]. Parenteral use of tramadol in emergency department patients with RLQ pain resulted in significant levels of pain reduction without concurrent normalisation of abdominal examination findings indicative of acute appendicitis.",2001.0,0,0
427,11113287,Pain following spinal cord injury: animal models and mechanistic studies.,C J Vierck; P Siddall; R P Yezierski,,2001.0,0,0
428,11113288,,,,,0,0
429,11113290,A Pain Monitoring Program for nurses: effect on the administration of analgesics.,; ; ; M J Muller,"Both physicians and nurses are responsible for adequate pain management. The aim of this study was to assess pain management behavior of physicians and nurses, and to evaluate the effects of a Pain Monitoring Program for nurses on the extent to which nurses administer analgesics. The Pain Monitoring Program consisted of two components: educating nurses about pain, pain assessment and pain management; and implementing daily pain assessment by means of a numeric rating scale. Several outcomes were distinguished to evaluate the administration of analgesics by nurses: the prescribed analgesics by physicians, the administered analgesics by nurses, and the discrepancy between the ordered and the administered analgesics. The effects of the Pain Monitoring Program on these outcomes were measured in a quasi-experimental design with a non-equivalent control group. In total, 703 patients participated: 358 patients in the control group and 345 in the intervention group. Patients were interviewed twice, i.e. at the beginning and at the end of hospitalization. Results of the control group showed that at the first interview 70% of the patients were prescribed analgesics by physicians and only 74% of those patients were actually administered analgesics by nurses. Consequently, 50% of the patients in pain received analgesics. The administered analgesics was in absolute agreement with the prescribed analgesics in 60% of the patients with routine analgesics and in 85% of the patients with PRN analgesics. The relative difference between ordered and administered routine analgesics was small, namely 15% for opioids and 20% for non-opioids. Similar results of the control group were found for the second interview. In addition, the results showed that the Pain Monitoring Program was effective in improving nurses' administration of analgesics. At the first interview more patients received analgesics that were prescribed on a PRN basis and the doses of administered routine non-opioids including PRN increased. At the time of the second interview, more patients received weak opioids. The Pain Monitoring Program was especially effective in patients with moderate to severe pain. However, the discrepancy between the analgesics ordered by physicians and actually administered by nurses did not change as a result of the Pain Monitoring Program. Based on this study it can be concluded that the use of a simple method such as a numeric rating scale together with pain education for nurses is effective in improving the administration of analgesics by nurses. These are important results because nurses play an essential role in helping patients to cope with their pain. Because the Pain Monitoring Program (PMP) was effective in a heterogeneous population in multiple care settings, the possibility of implementing the PMP in routine nursing practice should be considered.",2001.0,0,0
430,11113680,Surgical aspects of chronic post-thoracotomy pain.,M L Rogers; J P Duffy,"Chronic post-thoracotomy pain is a continuous dysaesthetic burning and aching in the general area of the incision that persists at least 2 months after thoracotomy. It occurs in approximately 50% of patients after thoracotomy and is usually mild or moderate. However, in 5% the pain is severe and disabling. No one technique of thoracotomy has been shown to reduce the incidence of chronic postthoracotomy pain. The most likely cause is intercostal nerve damage, although the precise mechanism for this is not known. Future work needs to examine surgical technique in detail. Until then, patients need to be adequately warned of this sequela of thoracotomy.",2001.0,0,0
431,11119195,Analgesia following paediatric day-surgical orchidopexy and herniotomy.,D Ho; J P Keneally,"We surveyed 90 boys, aged 1-13 years, who had undergone either orchidopexy or herniotomy, in a cohort study. Their pain and vomiting were assessed using a simple 4-point score in the Recovery Unit by the nursing staff, and at home by the parents. There were no significant differences in pain or vomiting scores between the two groups in the immediate postoperative period. However, children having orchidopexy experienced more pain at home during the first night and the following day than those having herniotomy. Nearly one-third of the former group had moderate to severe pain at home, in contrast to less than one-tenth of children having herniotomy, who are also more likely to be painfree on the next day. We concluded that children having herniotomy can be treated adequately at home with paracetamol alone, whereas children having orchidopexy may require supplementation with stronger analgesics.",2001.0,0,0
432,11121933,Evaluation of a pilot regimen for postoperative pain control in patients receiving oral morphine pre-operatively.,J E Peacock; B M Wright; M R Withers; J B Luntley; R E Atkinson,"Postoperative analgesia in patients who receive regular oral opioids pre-operatively is frequently suboptimal. To improve management we introduced a regimen using subcutaneous diamorphine infusions with incremental doses. Infusion doses were calculated as half the daily pre-operative dose of oral morphine with the increments as one-sixth of the infusion dose. Results were recorded on the first two postoperative days before (n = 13) and after (n = 23) commencing the new regimen. The percentage of patients reporting severe pain at rest and on movement were significantly reduced by the new regimen (54% and 69% vs. 13% and 40%, respectively) since the opioid dose as a percentage of the pre-operative dose was significantly higher (160% vs. 352%). There were no instances of excessive sedation or slow respiratory rate in any patient. The use of the regimen has resulted in greater doses of opioids being administered with fewer patients in severe pain without significant complications.",2001.0,0,0
433,11123736,Morphine with or without a local anaesthetic for postoperative intrathecal pain treatment after selective dorsal rhizotomy in children.,K Hesselgard; L G Strömblad; P Reinstrup,"Selective dorsal rhizotomy is a surgical procedure with a selective division of posterior spinal nerve rootlets to treat spasticity in children. The extensive surgical procedure with multilevel laminectomies and the nerve root manipulation result in intense pain postoperatively. Two intrathecal (IT) regimes of pain treatment were compared in these children, concerning their pain relief and possible side-effects. In a prospective study, 12 children (3-6 years of age) with six in each group, received either intermittent IT morphine (5 microg x kg(-1) four times a day) or continuous infusion of a mixture of bupivacaine (40 microg x kg(-1) x h(-1)) and morphine (0.6 microg x kg(-1) x h(-1)). Pain score was lower in the bupivacaine/morphine group (0.2 +/- 1.1) compared to intermittent morphine (2 +/- 2.4) on a scale from 0 to 6 (P less than or = 0.0001). Bupivacaine/morphine resulted in a lower, but not significant, difference in pruritus and lower muscle spasm. Haemodynamic and ventilatory parameters did not differ between the groups. Intrathecal continuous infusion of bupivacaine and morphine was superior to intermittent morphine in the treatment of pain after selective dorsal rhizotomy operations.",2001.0,0,0
434,11123737,Sublingual morphine may be a suitable alternative for pain control in children in the postoperative period.,T Engelhardt; M Crawford,"The purpose of this pilot study was to compare the effects of sublingual morphine with intravenous morphine in the treatment of postoperative pain following adenotonsillectomy in children. Twenty-nine children scheduled for adenotonsillectomy were randomly assigned to group 1 (n=14) receiving 0.1 mg x kg(-1) sublingual morphine and group 2 (n=15) 0.1 mg x kg(-1) intravenous morphine followed by 1 mg x kg(-1) diclofenac rectally in both groups after induction of anaesthesia. Postoperatively, time to first eye opening, sedation score, pain score, time for further analgesia requests and incidence of nausea and vomiting were recorded. There was no statistical significant difference in any of these parameters between the two groups. The results suggest that sublingual morphine may be a suitable alternative to various other routes of opioid administration in children, but further investigations of the sublingual route of administration of opioids in children are required.",2001.0,0,0
435,11124008,Leg edema from intrathecal opiate infusions.,J A Aldrete; ,"Despite the increasing popularity of intrathecal infusions to treat patients with long-term non-cancer-related pain, this therapy is not without serious side-effects. Five out of 23 patients who had intrathecal infusions of opiates for longer than 24 months developed leg and feet edema. As predisposing factors, cardiovascular disease, deep venous thrombosis, peripheral vascular disease, and venous stasis of the lower extremities were considered. Every patient who developed pedal and leg edema after the implantation of an infusion pump was also found to have leg edema and venous stasis prior to the time when the pump was inserted. This complication was severe enough to limit their physical activity, and to produce lymphedema, ulcerations and hyperpigmentation of the skin. Reduction of the edema occurred when the dose of the opiate was decreased, and in two cases in which the infusion was discontinued, there was almost complete resolution of the syndrome. It appears that the pre-existence of pedal edema and of venous stasis is a relative contraindication to the long-term intrathecal infusion of opiates in patients with chronic non-cancer pain.",2001.0,0,0
436,11127110,Use of acupuncture for managing chronic pelvic pain in pregnancy. A case report.,C T Thomas; P G Napolitano,"Chronic pelvic pain is a health problem that affects many reproductive-age women. During reproduction the dilemma is even more challenging. The growing uterus often exacerbates pain, and treatment is limited by the effect on the fetus. A multispecialty approach and alternative medicine are often effective. Recently, the FDA announced the use of acupuncture and acupressure as officially recognized modalities for treatment of chronic pain in oncology patients. Chronic pelvic pain in a 23 year-old primigravida at 27 weeks' gestation was incapacitating on narcotics. After organic causes were ruled out, acupuncture was employed successfully. Outpatient management for the duration of the pregnancy included acupuncture and narcotics for breakthrough pain while maintaining activities of daily living. Spontaneous vaginal delivery without complications at 38 5/7 weeks produced a 3,305-g female infant. The pain resolved immediately following delivery. This case demonstrates the benefit of combined allopathic with alternative forms of medicine. With the use of acupuncture, narcotic use was limited in this gravida while adding to her quality of life by allowing her to maintain normal activity.",2001.0,0,0
437,11129121,Anticonvulsants for neuropathic pain syndromes: mechanisms of action and place in therapy.,I W Tremont-Lukats; C Megeff; M M Backonja,"Neuropathic pain, a form of chronic pain caused by injury to or disease of the peripheral or central nervous system, is a formidable therapeutic challenge to clinicians because it does not respond well to traditional pain therapies. Our knowledge about the pathogenesis of neuropathic pain has grown significantly over last 2 decades. Basic research with animal and human models of neuropathic pain has shown that a number of pathophysiological and biochemical changes take place in the nervous system as a result of an insult. This property of the nervous system to adapt morphologically and functionally to external stimuli is known as neuroplasticity and plays a crucial role in the onset and maintenance of pain symptoms. Many similarities between the pathophysiological phenomena observed in some epilepsy models and in neuropathic pain models justify the rational for use of anticonvulsant drugs in the symptomatic management of neuropathic pain disorders. Carbamazepine, the first anticonvulsant studied in clinical trials, probably alleviates pain by decreasing conductance in Na+ channels and inhibiting ectopic discharges. Results from clinical trials have been positive in the treatment of trigeminal neuralgia, painful diabetic neuropathy and postherpetic neuralgia. The availability of newer anticonvulsants tested in higher quality clinical trials has marked a new era in the treatment of neuropathic pain. Gabapentin has the most clearly demonstrated analgesic effect for the treatment of neuropathic pain, specifically for treatment of painful diabetic neuropathy and postherpetic neuralgia. Based on the positive results of these studies and its favourable adverse effect profile, gabapentin should be considered the first choice of therapy for neuropathic pain. Evidence for the efficacy of phenytoin as an antinociceptive agent is, at best, weak to modest. Lamotrigine has good potential to modulate and control neuropathic pain, as shown in 2 controlled clinical trials, although another randomised trial showed no effect. There is potential for phenobarbital, clonazepam, valproic acid, topiramate, pregabalin and tiagabine to have antihyperalgesic and antinociceptive activities based on result in animal models of neuropathic pain, but the efficacy of these drugs in the treatment of human neuropathic pain has not yet been fully determined in clinical trials. The role of anticonvulsant drugs in the treatment of neuropathic pain is evolving and has been clearly demonstrated with gabapentin and carbamazepine. Further advances in our understanding of the mechanisms underlying neuropathic pain syndromes and well-designed clinical trials should further the opportunities to establish the role of anticonvulsants in the treatment of neuropathic pain.",2001.0,0,0
438,11132737,Addition of dextrose 3.5% to intrathecal sufentanil for labour analgesia reduces pruritus.,A E Abouleish; D Portnoy; E I Abouleish,"To determine whether the addition of a low concentration (3.5%) of dextrose would minimize pruritus while maintaining the quality of analgesia. In a double blind study 48 parturients in early labour were randomized to one of two study groups: dextrose (Dex, n = 24; 10 microg sufentanil in dextrose 3.5%), or normal saline (NS, n = 24; 10 microg sufentanil in normal saline). Parturients received the study drug as the intrathecal injection of the combined spinal-epidural (CSE) technique for labour analgesia. Duration and degree of analgesia were measured until epidural analgesia was initiated or delivery of the baby. The intensity and distribution (above T6, T6-L1, and below L1) of pruritus were measured at five minute intervals during first 25 min after injection. Quality and duration of analgesia did not differ between groups, but the overall incidence of pruritus was less in the Dex group (88% vs 42%, P = 0.001). Within each region, the incidence of pruritus was less in the Dex group. In patients who had pruritus, for the Dex group, the incidence of pruritus in the upper region (>T6) was lower than the NS group. There was no difference in the lower regions. The addition of dextrose 3.5% to intrathecal sufentanil reduced the incidence of pruritus without affecting the duration or quality of analgesia in parturients in early labour. The distribution of pruritus in the Dex group was limited to below T6 suggesting that pruritus to intrathecal sufentanil is mediated at the spinal level.",2001.0,0,0
439,11132739,Non-steroidal anti-inflammatory drugs in treatment of postoperative pain after cardiac surgery.,M S Hynninen; D C Cheng; I Hossain; J Carroll; S S Aumbhagavan; R Yue; J M Karski,"Non-steroidal anti-inflammatory drugs (NSAIDs) are used as analgesic in postoperative pain to reduce opioid side effects, such as drowsiness and nausea. However, NSAIDs have not been used extensively in cardiac surgical patients due to the fear of untoward effects on gastric, renal, and coagulation parameters. This study will evaluate the efficacy and safety of three NSAIDs for pain control in CABG patients. One hundred and twenty patients scheduled for elective CABG surgery were enrolled in randomized, double blind, controlled study. Standardized fast track cardiac anesthesia was used. One dose of drug (75 mg diclofenac, 100 mg ketoprofen, 100 mg indomethacin, or placebo) was given pr one hour before tracheal extubation and a second dose 12 hr later. Pain was treated with morphine iv and acetaminophen po. Visual analogue pain scores were recorded at baseline, 3, 6, 12 and 24 hr after the first dose of drug. There were no differences among the groups in pain scores. Only patients who received diclofenac required less morphine than patients in the control group (P < 0.05). When the total amounts of pain medications were computed to morphine equivalents, only patients in the diclofenac group received less pain medications than the placebo group (P < 0.05). Proportion of patients with postoperative increase of creatinine level (20% and over) did not differ between placebo and drug groups. Non-steroidal anti-inflammatory drugs may be used for analgesia management post CABG surgery in selected patients. Diclofenac appears to have the best analgesic effects by reducing the morphine and other analgesic requirement postoperatively.",2001.0,0,0
440,11135723,Pharmacodynamics of orally administered sustained- release hydromorphone in humans.,M S Angst; D R Drover; J Lötsch; B Ramaswamy; S Naidu; D R Wada; D R Stanski,"The disposition kinetics of hydromorphone generally necessitates oral administration every 4 h of the conventional immediate-release tablet to provide sustained pain relief. This trial examined time course and magnitude of analgesia to experimental pain after administration of sustained-release hydromorphone as compared with that after immediate-release hydromorphone or placebo. Using a 4 x 4 Latin square double-blind design, 12 subjects were randomized to receive a single dose of 8, 16, and 32 mg sustained-release hydromorphone and placebo. The same subjects had received 8 mg immediate-release hydromorphone before this study. Using an electrical experimental pain paradigm, analgesic effects were assessed for up to 30 h after administration, and venous hydromorphone plasma concentrations were measured at corresponding times. The hydromorphone plasma concentration peaked significantly later (12.0 h [12.0--18.0] vs. 0.8 h [0.8--1.0]; median and interquartile range) but was maintained significantly longer at greater than 50% of peak concentration (22.7 +/- 8.2 h vs. 1.1 +/- 0.7 h; mean +/- SD) after sustained-release than after immediate-release hydromorphone. Similarly, sustained-release hydromorphone produced analgesic effects that peaked significantly later (9.0 h [9.0--12.0] vs. 1.5 h [1.0--2.0]) but were maintained significantly longer at greater than 50% of peak analgesic effect (13.3 +/- 6.3 h vs. 3.6 +/- 1.7 h). A statistically significant linear relation between the hydromorphone plasma concentration and the analgesic effect on painful stimuli existed. A single oral dose of a new sustained-release formulation of hydromorphone provided analgesia to experimental pain beyond 24 h of its administration.",2001.0,0,0
441,11137414,Continuous intravenous diclofenac does not induce opioid-sparing or improve analgesia in geriatric patients undergoing major orthopedic surgery.,B Fredman; E Zohar; A Tarabykin; A Shapiro; R Jedeikin,"To assess the analgesic efficacy and perioperative opioid-sparing effects of adjuvant intravenous (IV) diclofenac. Prospective, controlled, double-blind study. Large referral hospital. 40 ASA physical status I, II, and III geriatric patients (>65 years) undergoing open reduction and internal fixation of subcapital fracture of the femur. A standardized general anesthetic was administered. On induction of anesthesia, patients in the diclofenac group received an IV bolus of diclofenac (0.7 mg/kg) followed by a constant infusion (0.15 mg/kg/hr) until the end of surgery. In the saline group, an equal volume of saline was administered. ""Rescue"" fentanyl was administered in response to an increase in mean arterial pressure or heart rate (exceeding 20% of the patient's preinduction ""baseline"" values) that did not respond to a 30% increase in the inspired isoflurane concentration. Postoperative pain was assessed using a four-point patient-generated pain score (1 = none, 2 = mild, 3 = moderate, 4 = severe) as well as number of attempts and actual morphine delivered via a patient-controlled analgesia (PCA) device. The two treatment groups were demographically comparable. The perioperative hemodynamic variables, as well as the induction and ""rescue"" fentanyl dosages, were unaffected by the treatment modality. Pain scores, PCA attempts, and actual morphine delivered were statistically similar between the two groups. Adjuvant IV diclofenac does not improve intraoperative stability or decrease postoperative opioid requirements in geriatric patients undergoing internal fixation of subcapital fracture of the femur.",2001.0,0,0
442,11143184,,,,,0,0
443,11143208,A quality improvement approach to reducing use of meperidine.,D B Gordon; H D Jones; L M Goshman; D K Foley; S E Bland,"In 1991 the University of Wisconsin Hospital and Clinics formed a pain management QI team whose goal was to improve pain management through education, outcome monitoring, and the development of programs intended to improve clinical practice. Longitudinal monitoring mechanisms were established to audit medical records and survey patients to examine both staff practice patterns and patient outcomes. The QI team targeted use of meperidine, one of the most widely used opioid analgesics for the treatment of moderate to severe pain, which is now discouraged as a first-line agent for most painful conditions. A QI process was implemented using a traditional plan-do-check-act (PDCA) model, resulting in a successful and sustained reduction of inappropriate meperidine use. A cause-and-effect diagram helped highlight the multiple factors contributing to the drug's overuse and was used to prioritize targets for action. A flow chart helped to uncover some of the interrelationships between the myths about meperidine and the resultant customary prescribing and administration practices. While most of the strategies were implemented in 1996 (formulary guideline release, change in stock supply and physician orders, staff education and feedback), a significant impact in practice was not seen until late 1997. Ongoing tracking and feedback loops were established to ensure continued low use of meperidine. Use of a QI approach in pain management has been shown to affect the visibility of pain as a clinical priority, enhance interdisciplinary collaboration, facilitate the implementation of clinical guidelines at the bedside, and improve the quality of care for patients.",2001.0,0,0
444,11146613,Comparison of efficacy and side effects of epidural tramadol and morphine in patients undergoing laminectomy: a repeated dose study.,L N Yaddanapudi; J Wig; B Singh; M K Tewari,Tramadol acts through multiple mechanisms and has a low risk of post operative respiratory depression. We compared the efficacy of epidural tramadol with that of morphine for postoperative analgesia in these patients. The demographic data and the summed pain intensity difference scores (SPID) were similar in both the groups. The time to first supplementary dose was significantly shorter in the tramadol group compared to the morphine group (p<0.05). No patient in either group suffered respiratory depression.,2001.0,0,0
445,11148857,Pharmacokinetics of nortilidine and naloxone after administration of tilidine/naloxone solution or tilidine/naloxone sustained release tablets.,U Brennscheidt; K U Seiler; P Thomann,"Valoron N is a compound which consists of the prodrug tilidine (CAS 20380-58-9), from which the active metabolite nortilidine is formed by demethylation in the liver, and the opiate antagonist naloxone (CAS 465-65-6), which prevents the abuse of the analgesic by opiate dependents. The pharmacokinetics of nortilidine and naloxone were studied in 18 male healthy subjects after oral application of tilidine/naloxone solution or tilidine/naloxone retard tablets, respectively. The following report gives the results on investigations of a) dose linearity after application of 25 mg, 50 mg and 100 mg Valoron N solution, b) dose equivalence of Valoron N solution (4 x 50 mg tilidine) and Valoron N retard tablets (2 x 100 mg tilidine) under steady state conditions, and c) the equivalence of different dose strengths of Valoron N retard tablets (50 mg, 100 mg, 200 mg tilidine/tablet). The results obtained in these studies demonstrate a dose linear kinetic for nortilidine after the application of 25 mg to 100 mg tilidine. Furthermore, there is dose equivalence between the tilidine/naloxone solution and tilidine/naloxone retard tablets, which permits the replacing of the solution with the retard tablets. Because of the equivalence of different dose strengths of Valoron N tablets, patients are able to exchange low dosed Valoron N retard tablets for higher-dosed ones (50 mg, 100 mg and 200 mg tilidine/tablet), if necessary. With their constant release of tilidine and the possibility for individual dosage, the retard tablets are efficient analgesics that improve pain therapy considerably for patients with chronic pain.",2001.0,0,0
446,11149429,Use of intranasal fentanyl in children undergoing myringotomy and tube placement during halothane and sevoflurane anesthesia.,J L Galinkin; L M Fazi; R M Cuy; R M Chiavacci; C D Kurth; U K Shah; I N Jacobs; M F Watcha,"Many children are restless, disoriented, and inconsolable immediately after bilateral myringotomy and tympanosotomy tube placement (BMT). Rapid emergence from sevoflurane anesthesia and postoperative pain may increase emergence agitation. The authors first determined serum fentanyl concentrations in a two-phase study of intranasal fentanyl. The second phase was a prospective, placebo-controlled, double-blind study to determine the efficacy of intranasal fentanyl in reducing emergence agitation after sevoflurane or halothane anesthesia. In phase 1, 26 children with American Society of Anesthesiologists (ASA) physical status I or II who were scheduled for BMT received intranasal fentanyl, 2 microg/kg, during a standardized anesthetic. Serum fentanyl concentrations in blood samples drawn at emergence and at postanesthesia care unit (PACU) discharge were determined by radioimmunoassay. In phase 2, 265 children with ASA physical status I or II were randomized to receive sevoflurane or halothane anesthesia along with either intranasal fentanyl (2 microg/kg) or saline. Postoperative agitation, Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) scores, and satisfaction of PACU nurses and parents with the anesthetic technique were evaluated. In phase 1, the mean fentanyl concentrations at 10 +/- 4 min (mean +/- SD) and 34 +/- 9 min after administering intranasal fentanyl were 0.80 +/- 0.28 and 0.64 +/- 0.25 ng/ml, respectively. In phase 2, the incidence of severe agitation, highest CHEOPS scores, and heart rate in the PACU were decreased with intranasal fentanyl. There were no differences between sevoflurane and halothane in these measures and in times to hospital discharge. The incidence of postoperative vomiting, hypoxemia, and slow respiratory rates were not increased with fentanyl. Serum fentanyl concentrations after intranasal administration exceed the minimum effective steady state concentration for analgesia in adults. The use of intranasal fentanyl during halothane or sevoflurane anesthesia for BMT is associated with diminished postoperative agitation without an increase in vomiting, hypoxemia, or discharge times.",2001.0,0,0
447,11149462,Intrathecal morphine in chronic pain management.,A F Kirkpatrick; M P Herndon,,2001.0,0,0
448,11150979,Radial entrapment neuropathy due to chronic injection-induced triceps fibrosis.,G Midroni; R Moulton,"We report two patients who developed progressive, severe, painless radial neuropathies (bilateral in one, unilateral in the other) as a delayed complication of chronic intramuscular analgesic injection. In each instance, exploration of the radial nerve revealed multifocal entrapment within a densely fibrotic triceps muscle at sites between the spiral groove and distal course of the radial nerve near the elbow. Release of the nerve from constriction within the fibrotic triceps muscle produced improvement in all three affected nerves.",2001.0,0,0
449,11152035,Myopexy (Faden) results in more postoperative vomiting after strabismus surgery in children.,M Saiah; A Borgeat; Y A Ruetsch; B Seifert; G Klainguti,"Strabismus correction in children is associated with a high incidence of postoperative nausea and vomiting. The purpose of this prospective, double-blind study was to examine the influence of the surgical method for correction of squint on the incidence of postoperative vomiting. One hundred and twenty consecutive children aged 2-12 years, scheduled for elective strabismus surgery, were enrolled in this prospective, double-blind study. A standardised total intravenous anaesthesia was given to all children. The development of perioperative oculocardiac reflex was noted and the number of episodes of vomiting during the first 48 h postoperatively was recorded. At the completion of the study, the children who were operated with myopexy according to Faden, were allocated to a Faden group, those without a myopexy to the non-Faden group. All the patients included in this study were operated on by the same surgeon with standardised techniques. The Faden group was younger, lighter and the operation time was longer (P<0.05). The incidence of vomiting was greater in the Faden group; 53% versus 12% (P<0.05). The incidence of oculocardiac reflex was similar in both groups; 40% in the Faden versus 28% in the non-Faden group, respectively. The total dose of propofol and alfentanil was similar between the groups. Requirement of analgesics for postoperative pain was similar in both groups. The only independent risk factor for postoperative vomiting was the Faden operation. The surgical method used for strabismus correction in children has a great influence on the incidence of postoperative vomiting. The Faden operation is associated with a very high incidence of postoperative vomiting; this particular group of patients has to be considered as a high risk group for postoperative vomiting and deserves an antiemetic prophylaxis.",2001.0,0,0
450,11153786,Successful treatment of erythromelalgia with intrathecal hydromorphone and clonidine.,S Macres; S Richeimer,The objective of this study was to determine if intractable pain from erythromelalgia could be successfully treated with intrathecal hydromorphone and clonidine. A single case of pain from erythromelalgia refractory to multiple treatment modalities was examined and treated. The setting is an outpatient pain clinic at a major university teaching hospital. Our patient is an 82-year-old woman with hypertension and peripheral vascular disease. Intrathecal opioid and an alpha2-agonist were administered. Outcome was determined by means of patient self-report during office follow-up visits. Administration of intrathecal opioid and an alpha2-agonist can be effective in the treatment of the pain of erythromelalgia and offers an alternative pain treatment modality for patients with unremitting pain refractory to more conservative therapy.,2001.0,0,0
451,11157525,Multicentre randomised controlled trial of nasal diamorphine for analgesia in children and teenagers with clinical fractures.,J M Kendall; B C Reeves; V S Latter; Nasal Diamorphine Trial Group,"To compare the effectiveness of nasal diamorphine spray with intramuscular morphine for analgesia in children and teenagers with acute pain due to a clinical fracture, and to describe the safety profile of the spray. Multicentre randomised controlled trial. Emergency departments in eight UK hospitals. Patients aged between 3 and 16 years presenting with a clinical fracture of an upper or lower limb. Patients' reported pain using the Wong Baker face pain scale, ratings of reaction to treatment of the patients and acceptability of treatment by staff and parents, and adverse events. 404 eligible patients completed the trial (204 patients given nasal diamorphine spray and 200 given intramuscular morphine). Onset of pain relief was faster in the spray group than in the intramuscular group, with lower pain scores in the spray group at 5, 10, and 20 minutes after treatment but no difference between the groups after 30 minutes. 80% of patients given the spray showed no obvious discomfort compared with 9% given intramuscular morphine (difference 71%, 95% confidence interval 65% to 78%). Treatment administration was judged acceptable by staff and parents, respectively, for 98% (199 of 203) and 97% (186 of 192) of patients in the spray group compared with 32% (64 of 199) and 72% (142 of 197) in the intramuscular group. No serious adverse events occurred in the spray group, and the frequencies of all adverse events were similar in both groups (spray 24.1% v intramuscular morphine 18.5%; difference 5.6%, -2.3% to 13.6%). Nasal diamorphine spray should be the preferred method of pain relief in children and teenagers presenting to emergency departments in acute pain with clinical fractures. The diamorphine spray should be used in place of intramuscular morphine.",2001.0,0,0
452,11166969,The effect of opioids on phantom limb pain and cortical reorganization.,E Huse; W Larbig; H Flor; N Birbaumer,"The efficacy of oral retarded morphine sulphate (MST) was tested against placebo in a double-blind crossover design in 12 patients with phantom limb pain after unilateral leg or arm amputation. Two counterbalanced treatment phases of 4 weeks each were initiated with an intravenous test infusion of MST or Placebo. The titration phase was 2 weeks. The dose of MST was titrated to at least 70 mg/day and at highest 300 mg/day. Pain intensity was assessed hourly on visual analog scales during a 4-week treatment-free phase, both treatment phases and at two follow-ups (6 and 12 months). Reorganization of somatosensory cortex, electric perception and pain thresholds as well as selective attention were measured pre- and post-treatment. A significant pain reduction was found during MST but not during placebo. A clinically relevant response to MST (pain reduction of more than 50%) was evident in 42%, a partial response (pain reduction of 25-50%) in 8% of the patients. Neuromagnetic source imaging of three patients showed initial evidence for reduced cortical reorganization under MST concurrent with the reduction in pain intensity. Perception and pain thresholds were not significantly altered whereas attention was significantly lower under MST. Thus, opioids show efficacy in the treatment of phantom limb pain and may potentially influence also cortical reorganization. These data need to be replicated in larger patient samples.",2001.0,1,1
453,11166974,Hyperalgesic responses in methadone maintenance patients.,M Doverty; J M White; A A Somogyi; F Bochner; R Ali; W Ling,"Opioid substitution treatment for dependence may alter sensitivity to pain. Previous studies on pain sensitivity in methadone maintenance patients have yielded contradictory results. This study compared nociceptive responses between 16 patients on stable, once daily, doses of methadone and 16 matched control subjects. Two types of nociceptive stimuli were used: (1) electrical stimulation; and (2) a cold pressor test. Two parameters were measured: detection for onset of pain, and pain tolerance. Methadone patients were tested over an inter-dosing period: at the time of trough plasma methadone concentration (0 h), and 3 h after their daily dose. Control subjects were tested twice 3 h apart. Blood samples were collected to determine plasma methadone concentration. In methadone patients, trough to peak increases in mean R-(-)- and S-(+)-methadone concentrations (118 and 138 ng/ml to 185 and 259 ng/ml, respectively) resulted in significant increases in pain detection and tolerance values for both nociceptive stimuli. Using electrical stimulation, methadone patients' pain tolerance values were lower than controls at 0 h, but higher than controls at 3 h; no significant differences in pain detection values were found. For the cold pressor test, methadone patients detected pain significantly earlier than controls at 0 h, and were also substantially less pain tolerant than controls at both 0 and 3 h. There were no significant differences in pain detection values between the two groups at 3 h. Pain tolerance to pain detection ratios for methadone patients were significantly lower than controls for the cold pressor test at 0 and 3 h, and for electrical stimulation at 0 h only. In summary, the relative pain sensitivity of methadone maintenance patients is determined by the nature of the nociceptive stimulus (e.g. cold pressor test versus electrical stimulation), the plasma methadone concentration (trough versus peak plasma concentration), and whether thresholds are determined for detection of pain or pain tolerance. Although responding to changes in plasma methadone concentration, maintenance patients are markedly hyperalgesic to pain induced by the cold pressor test.",2001.0,0,0
454,11167169,"Epidural fentanyl markedly improves thoracic epidural analgesia in a low-dose infusion of bupivacaine, adrenaline and fentanyl. A randomized, double-blind crossover study with and without fentanyl.",G Niemi; H Breivik,"The objectives of the present study were to evaluate the effects on postoperative pain intensity, pain relief, and side effects when removing fentanyl from an optimally titrated epidural infusion consisting of bupivacaine, fentanyl and adrenaline. A prospective, randomized, double-blind, crossover study was carried out in 20 patients after major upper abdominal surgery requiring a large longitudinal incision. Patients with only mild pain when coughing during thoracic epidural infusion of about 10 ml per hour of bupivacaine 1 mg x ml(-1), fentanyl 2 microg x ml(-1), and adrenaline 2 microg x ml(-1) were included. On the 1st and 2nd postoperative days, each patient was given a double-blind epidural infusion, at the same rate, with or without fentanyl. The effects were observed for 6 h or until pain when coughing became unacceptable in spite of rescue analgesia. Rescue analgesia consisted of up to two patient-controlled epidural bolus injections (4 ml) per hour and intravenous morphine if necessary. Main outcome measures, i.e. pain intensity when coughing and at rest, increased (P<0.001) when fentanyl (19.2+/-5.2 microg x h(-1)) was omitted from the epidural infusion: after 6 h pain intensity when coughing had increased to unacceptable levels in spite of increased consumption of rescue bupivacaine and adrenaline (P<0.001). Within 15-20 min after restarting the triple epidural mixture with fentanyl, pain intensity was again reduced to mild pain when coughing. A low dose of epidural fentanyl (20 microg x h(-1)) markedly improved the pain-relieving effect of bupivacaine and adrenaline infused epidurally at a thoracic level after major upper abdominal surgery. This dose of fentanyl is much too small to relieve severe dynamic pain when given systemically. Therefore, this study indirectly supports the view that a low-dose thoracic epidural infusion of fentanyl has a spinal analgesic site of action.",2001.0,0,0
455,11167437,High-dose intrathecal diamorphine for analgesia after Caesarean section.,R Stacey; R Jones; G Kar; A Poon,"Forty women undergoing elective Caesarean section under spinal anaesthesia using hyperbaric 0.5% bupivacaine were randomly allocated to receive either 0.5 mg or 1 mg intrathecal diamorphine. All women received diclofenac 100 mg at the end of surgery and morphine via a patient-controlled analgesia system. Oral analgesics were not used. Postoperative analgesia was more prolonged and more reliable in the 1-mg group. Mean time to first analgesia was 10.2 h in the 1-mg group and 6.9 h in the 0.5-mg group, and 45% in the 1-mg group used no morphine, compared with 10% in the 0.5-mg group. Mean morphine consumption over 24 h was 5.2 mg in the 1-mg group and 10.6 mg in the 0.5-mg group. Pain scores all tended to be lower in the 1-mg group but this was only significant at 4 h. There were no serious side-effects. Minor side-effects were common but well tolerated, and the incidence did not differ between the groups. If intrathecal diamorphine is used in combination with rectal diclofenac and without oral analgesia, then 1 mg provides superior analgesia to 0.5 mg without any worsening of the side-effects.",2001.0,0,0
456,11172169,Low back pain.,R A Deyo; J N Weinstein,,2001.0,0,0
457,11176086,"Subarachnoid sufentanil for early postoperative pain management in orthopedic patients: a placebo-controlled, double-blind study using spinal microcatheters.",T G Standl; E Horn; M Luckmann; M Burmeister; S Wilhelm; J Schulte am Esch,"Continuous spinal anesthesia is frequently used for intraoperative anesthesia but rarely for postoperative pain management. Because even small doses of local anesthetics can be associated with motor deficits, subarachnoid opioid injection may be an alternative. Eighty patients randomly received a subarachnoid injection of 10 microg sufentanil, 5 mg bupivacaine, 2.5 microg sufentanil plus 2.5 mg bupivacaine, or saline through 28-gauge spinal microcatheters for early postoperative pain relief after major lower-limb surgery (n = 20 in each group). Hemodynamic and respiratory parameters, pain scores, and motor function were monitored, and sufentanil concentrations in plasma and cerebrospinal fluid were measured. Ten additional patients received up to three repetitive injections of 10 microg sufentanil over 24 h. All drugs provided excellent pain relief within 15 min after injection, lasting 128 +/- 61 min with sufentanil, 146 +/- 74 min with bupivacaine, and 167 +/- 78 min with the mixture. Patients receiving bupivacaine showed the highest cephalad extension of sensory block (median, T6) and the most intense motor block, whereas patients given only sufentanil had no motor deficit. The duration of analgesia was shorter after subsequent sufentanil injection (100-115 min) than after the first injection (198 +/- 70 min). Six of 50 patients with sufentanil experienced a short episode of respiratory depression within 30 min after the first injection. Cerebrospinal fluid concentrations of sufentanil peaked at 5 min after injection (183 +/- 167 ng/ml) but were at the level of detection in the plasma. Sufentanil injected through microspinal catheters provided profound pain relief without impairing motor function when compared with bupivacaine. However, close monitoring remains mandatory in this setting.",2001.0,0,0
458,11194730,Getting to grips with heroin and other opioid use.,J B Saunders; A H Richards,,2001.0,0,0
459,11194981,[Systemic review of trials on the use of tramadol in the treatment of acute and chronic pain].,G Savoia; M Loreto; G Scibelli,"The purpose of the study was to verify the effectiveness of tramadol in the treatment of non-oncologic chronic pain, oncologic chronic pain and postoperative acute pain, applying the principles of meta-analytic analysis to randomized clinical trials (TCR). I: Medline research of the TCR on the question in the period between 1989-1999, II: exclusion of single TCR through the question of Moore and Mcquay; calculation of the relative risk reduction (RRR), of the number needed to treat (NNT), of the odds ratio (OR) and of the typical odds ratio (TOR) of the trials which responded to characteristics of correct randomization and blindness, which expressed citation of the patients excluded from trial, and patients with measurable analgesic effectiveness (number of patients with reduction of the pain intensity 50%). 52 trials extracted from Medline: 10 on the treatment of non-oncologic chronic pain, 36 on the treatment of postoperative acute pain and 6 on the treatment of oncologic chronic pain. Responded fully to requirements: 8 studies (3 for non-oncologic chronic pain, 3 for postoperative acute pain and 2 for oncologic pain). The OR was 0.55 (-0.31/1.41); 0.44 (1.04/1.92) and 0.98 (0.5/1.46); the RRR was 0.26 (-0.19/0.71), 0.38 (0.15/0.61), 0.005 (0.19/0.20) and the NNT 6.6 (6.39/6.81), 5.26 (5.12/5.4), infinity in the 3 trials selected between those that concern the treatment of the nononcologic chronic pain (with TOR: 0.57 and confidence index: 0.23-0.9); the OR was 0.36 (1.06/1.78), 0.78 (-0.08/-1.64) and 1.12 (0.54/1.69); the RRR was 0.26 (-0.18/0.7), 0.07 (-0.2/0.35), -0.01 (-0.09/0.07) and the NNT 4.7 (4.42/4.58), 20 (19.8/20.20), infinity in the trials on the treatment of postoperative acute pain (with TOR: 0.4 and confidence index: -0.6-0.86); the OR was 0.53 (-0.67/1.73), 0.27 (-0.71/1.12); the RRR was 0.19 (-0.33/0.72), 0.35 (0.02/0.68) and the NNT 7.1 (6.78/7.42), 3.57 (3.37/3.76) in those that involved the treatment of oncologic chronic pain (with TOR: 0.49 and confidence index: 0.36-0.8). Although the short number of trials which can treated by the metanalytic technique the treatment with tramadol, compared comparison's to drugs (morphine, pentazocine, bupremorphine, etc.) determined a slight improvement in analgesic parameters or at least in analgesic effectiveness.",2001.0,0,0
460,11196544,Opioid therapy for osteoarthritis of the hip and knee: use it or lose it?,P M Peloso,,2001.0,0,0
461,11199374,Buprenorphine or procaine for pain relief in acute pancreatitis. A prospective randomized study.,R Jakobs; M U Adamek; A C von Bubnoff; J F Riemann,"To assess the analgesic efficacy and side effects of buprenorphine and procaine in patients with acute pancreatitis. Forty patients (average age, 50 years; 23 male) with acute pancreatitis or an acute bout of a chronic pancreatitis were prospectively randomized to receive buprenorphine or procaine for pain relief. Both analgesics were administered as constant intravenous (i.v.) infusions and additional analgesics were given on demand. Pain scores were assessed on a visual analogue scale. Close clinical control and laboratory checks were performed during the three-day study period. Patients receiving buprenorphine were significantly less likely to demand additional analgesics (1 versus 14 patients; P < 0.0001). The pain scores for patients in the buprenorphine group were significantly lower over the treatment period in comparison to procaine (P < 0.05). The reduction of pain score was significantly greater during the initial two treatment days using buprenorphine (day 1: 55 versus 25, P < 0.0001; day 2: 62 versus 40, P = 0.005). Side effects were comparable for both groups with the exception of a slightly higher sedation rate under buprenorphine. Constant i.v. application of buprenorphine is more effective than the recommended procaine for pain relief in acute pancreatitis.",2001.0,0,0
462,11204052,Postoperative sleep disturbance: influences of opioids and pain in humans.,A J Cronin; J C Keifer; M F Davies; T S King; E O Bixler,"To test the hypothesis that opioids and pain contribute independently to postoperative sleep disturbance, 10 women undergoing surgery requiring a low abdominal incision for treatment of benign gynecologic conditions were randomized to receive either epidural opioid (fentanyl) (n=6) or epidural local anesthetic (bupivacaine) (n=4) for intraoperative and postoperative analgesia. N/A. N/A. N/A. N/A. Polysomnography was performed in a standard patient room on the preoperative and first three postoperative nights. Pain at rest and with coughing was evaluated using a visual-analogue pain scale each evening and morning. On the first postoperative night, rapid eye movement (REM) sleep was abolished in all patients. On the third postoperative night, the mean +/- SE REM sleep time increased significantly (p=.003) to 9.8% +/- 3.1% in the fentanyl group, and 12.9% +/- 3.8% in the bupivacaine group. Conversely, light non-REM (NREM) sleep (%stage 1 + %stage 2) was higher on the first postoperative night and significantly lower on the third postoperative night (p=0.011). Between group comparison revealed only that the mean % slow-wave sleep (SWS) in the fentanyl group (6.0%, 2.0%, and 14.7%) was different from the bupivacaine group (7.8%, 9.1%, and 10.6%) in the postoperative period after adjusting for the preoperative night % SWS (p=0.021). Pain was well controlled in all patients, but was slightly better controlled in the fentanyl group than in the bupivacaine group on postoperative night 2 (p=0.024). There was no statistically significant association between pain score and any polysomnographically defined stage. Postoperative patients suffer a profound sleep disturbance even when opioids are avoided and pain is well controlled.",2001.0,0,0
463,11205226,Transdermal fentanyl in cancer patients with moderate-to-severe pain: a prospective examination.,G Iconomou; A Viha; A G Vagenakis; H P Kalofonos,"[corrected] The aim of the study was to evaluate prospectively the analgesic efficacy, toxicity and acceptability of the transdermal fentanyl therapeutic system (TTS-F) in Greek cancer patients with moderate-to-severe pain. Forty-eight patients participated in the study: 34 were men and 14 women, mean age was 63, and all but 2 had advanced stage (IV) cancer. Patients received TTS-F for a period of 8 weeks. Doses ranged from 25 to 225 micrograms/h. Thirty-three patients completed the study. Data indicated statistically significant lower pain scores on both NRS and EORTC QLQ-C30 at all follow-ups compared to baseline. In addition, the vast majority of the patients found the transdermal system easy to use and reported as being satisfied or highly satisfied with it. The only observed side-effect was vomiting. In summary, transdermal fentanyl appeared an acceptable, safe and effective method of managing chronic pain induced by malignancies.",2001.0,0,0
464,11207001,Morphine or oxycodone in cancer pain?,T E Heiskanen; P M Ruismäki; T A Seppälä; E A Kalso,"Oxycodone is an opioid analgesic that closely resembles morphine. Oxymorphone, the active metabolite of oxycodone, is formed in a reaction catalyzed by CYP2D6, which is under polymorphic genetic control. The role of oxymorphone in the analgesic effect of oxycodone is not yet clear. In this study, controlled-release (CR) oxycodone and morphine were examined in cancer pain. CR oxycodone and morphine were administered to 45 adult patients with stable pain for 3-6 days after open-label titration in a randomized, double-blind, cross-over trial. Twenty patients were evaluable. Both opioids provided adequate analgesia. The variation in plasma morphine concentrations was higher than that of oxycodone, consistent with the lower bioavailability of morphine. Liver dysfunction affected selectively either oxycodone or morphine metabolism. Three patients with markedly aberrant plasma opioid concentrations are presented. Significant individual variation in morphine and oxycodone metabolism may account for abnormal responses during treatment of chronic cancer pain.",2001.0,0,0
465,11207404,A prospective study comparing i.m. ketorolac with i.m. meperidine in the treatment of acute biliary colic.,D J Dula; R Anderson; G C Wood,"Ketorolac is a nonsteroidal anti-inflammatory medication that is used widely for pain management. Its effects are mediated through the inhibition of prostaglandins, which makes it uniquely different from opioids in relieving pain. We conducted a randomized, prospective, double blind study of patients presenting to our Emergency Department (ED) with a diagnosis of acute biliary colic. Study patients were randomized into one of two treatment groups, meperidine 1.5 mg/kg with a maximum dose of 100 mg or ketorolac 60 mg given intramuscularly (i.m.). The patients rated their pain before and 30 min after medication on a scale of 1 to 10 using a Visual Analog Pain Scale. Overall pain relief was compared between the two groups using a two-sample t test. Thirty patients were enrolled in the study, 16 in the ketorolac group and 14 in the meperidine group. Patients ranged in age from 18 to 71 years and 6 (20%) were male. The average pain score at time 0 was 7.6 for the ketorolac group and 7.3 for the meperidine group. Pain relief at time 30 min was 3.8 in the ketorolac group and 3.9 in the meperidine group, which was not statistically different. The mean global pain score and need for an emergency cholecystectomy were similar in the two groups. Rescue medication for additional analgesia at 30 min was needed in 4 patients in the meperidine group and in 2 patients in the ketorolac group (28.6% versus 12.5%, respectively; NS). In this study of patients with acute biliary colic there was no significant difference in the pain relief achieved by using either ketorolac or meperidine.",2001.0,0,0
466,11207874,Pain management in older adults: prevention and treatment.,F M Gloth,"The release of guidelines in 1998 by the American Geriatrics Society on ""The Management of Chronic Pain in Older Persons"" was a breakthrough in helping to manage pain in this population. Already advances have fostered a need to update recommendations. This article focuses on the treatment strategies available for seniors that are likely to help to fulfill the obligation to relieve pain and suffering in patients. A review was done of the literature using Medline and other search techniques. New pain scales have been developed with seniors in mind and greater testing of older scales in elderly populations have helped to identify measures of pain more suited to frail seniors. Advances in cyclooxygenase inhibition selectivity, alternative medicine, and progress in the identification of nonopioid pain receptors and the development of products to target them are just a few of changes that have altered the way clinicians think about treating pain. The use of hospice in end-of-life palliative care is a valuable resource for clinicians managing pain at that phase in care as well. Tools are available to prevent and treat pain successfully in seniors. Educating clinicians about available assessment tools, techniques and interventions may be the biggest challenge to comforting the older adult in pain.",2001.0,0,0
467,11212050,Epidural naloxone reduces intestinal hypomotility but not analgesia of epidural morphine.,J Lee; J Y Shim; J H Choi; E S Kim; O K Kwon; D E Moon; J H Choi; M J Bishop,"Epidural morphine is associated with decreased bowel motility and increased transit time. Low doses of intravenous naloxone reduce morphine-induced pruritus without reversing analgesia, but the effect of epidural naloxone on bowel motility has not been studied. Therefore we evaluated bowel motility and analgesia when naloxone was co-administered with morphine into the epidural space. Forty-three patients having combined thoracic epidural and general anesthesia for subtotal gastrectomy were randomly assigned to one of two study groups. All received a bolus dose of 3 mg epidural morphine at the beginning of surgery, followed by a continuous epidural infusion containing 3 mg morphine in 100 ml bupivacaine 0.125% with either no naloxone (control group, n = 18) or a calculated dose of 0.208 microg x kg(-1) x hr(-1) of naloxone (experimental group, n = 25) for 48 hr. We measured the time to the first postoperative passage of flatus and feces to evaluate the restoration of bowel function, and visual analog scales (VAS) for pain during rest and movement. Scores were assessed at 2, 4, 8, 16, 24, 36 and 48 hr postoperatively. The experimental group had a shorter time to the first postoperative passage of flatus (5 1.9 +/- 1 6.6 hr vs 87.0 +/- 19.5 hr, P < 0.001 ) and feces (95.3 +/- 25.0 hr vs 132.9 +/- 29.4 hr, P < 0.001). No differences were found in either resting or active VAS between the two groups. Epidural naloxone reduces epidural morphine-induced intestinal hypomotility without reversing its analgesic effects.",2001.0,0,0
468,11217678,[Dexketoprofen-trometamol and tramadol in acute lumbago].,B Metscher; U Kübler; H Jahnel-Kracht,"BACKGROUND, METHOD: The analgesic efficacy and tolerability of dexketoprofen-trometamol (DKPT) was compared with tramadolhydrochloride (TRAM) in a multicentre, randomised, double-blind, clinical trial in 192 Patients with acute low back pain. The initial pain at rest and on movement should be at least 50 mm on a 100 mm visual analogue scale. The daily dose during the 7 days' treatment was 50 mg TRAM t.i.d. (n = 95) or 25 mg DKPT t.i.d. (n = 97). The patients were allowed to take additional Paracetamol up to 4 x 500 mg per day as rescue medication. From the 4th day of treatment pain on movement decreased significantly (p = 0.044) in the DKPT-group in comparison with the TRAM-group. The nocturnal pain decreased during the treatments with a difference in therapies of 22.9% in favour of DKPT. Within the DKPT-group the patients required additional Paracetamol more often only during the 1st day of treatment whereas the patients of the TRAM-group required the additional rescue medication mainly during the first 3 days of treatment. This difference was statistically significant (p = 0.011). Under DKPT treatment patients experienced significantly less adverse events (with an at least ""possible"" causal relationship; p = 0.026). This can be explained by central nervous disturbances that occurred only in the TRAM group. The distribution of gastro-intestinal disorders was identical in both treatment groups. With this results DKPT in comparison with TRAM also showed to be a strong analgesic drug with a better risk-benefit relation due to its better tolerability.",2001.0,0,0
469,11219563,"Opioids for chronic nonmalignant pain. Attitudes and practices of primary care physicians in the UCSF/Stanford Collaborative Research Network. University of California, San Francisco.",M Potter; S Schafer; E Gonzalez-Mendez; K Gjeltema; A Lopez; J Wu; R Pedrin; M Cozen; R Wilson; D Thom; M Croughan-Minihane,"We hoped to determine the attitudes and practices of primary care physicians regarding the use of opioids to treat chronic nonmalignant pain (CNMP). We also examined the factors associated with the willingness to prescribe opioids for CNMP. A survey was mailed to primary care physicians in the University of California, San Francisco/Stanford Collaborative Research Network. This survey contained questions regarding treatment in response to 3 case vignettes, the use of opioids for CNMP in general, and the demographic characteristics of the physicians. Among 230 physicians surveyed, 161 (70%) responded. Two percent of the respondents were never willing to prescribe schedule III opioids (eg, acetaminophen with codeine) as needed for patients with CNMP that persisted unchanged after exhaustive evaluation and attempts at treatment. Thirty-five percent were never willing to prescribe schedule II opioids (eg, sustained-release morphine) on an around-the-clock schedule for these patients. The most significant predictor of willingness to prescribe opioids for patients with CNMP was a lower level of concern about physical dependence, tolerance, and addiction. Primary care physicians are willing to prescribe schedule III opioids as needed, but many are unwilling to use schedule II opioids around the clock for CNMP. Individual prescribing practices vary widely among primary care physicians. Concerns about physical dependence, tolerance, and addiction are barriers to the prescription of opioids by primary care physicians for patients with CNMP.",2001.0,0,0
470,11219564,Meeting the challenge of chronic pain.,H Brody,,2001.0,0,0
471,11220426,Dextromethorphan attenuation of postoperative pain and primary and secondary thermal hyperalgesia.,A A Weinbroum; A Gorodezky; D Niv; R Ben-Abraham; V Rudick; A Szold,"To determine the effect of 90 mg dextromethorphan (DM) p.o. vs placebo 90 min preoperatively, on the immediate and delayed postoperative course. Thirty patients undergoing laparoscopic cholecystectomy or inguinal hernioplasty under general anesthesia were studied. Half (DM) received 90 mg dextromethorphan and half received placebo 90 min before anesthesia. Intravenous Patient Controlled Aanalgesia with morphine was available for two hours within a six-hour observation period; 75 mg diclofenac i.m. prn was given later in PACU and on-ward (24 hr). Pain was assessed using the visual analogue scales. Thermal thresholds for cold and hot sensation and for pain (by limit method) were evaluated at the site of skin incision (primary-) and distantly (secondary hyperalgesia). Von Frey filaments were applied testing touch sensation. Sedation level and morphine consumption were also assessed in PACU. Demographic, surgical and perioperative parameters were similar; no untoward effects were encountered. Pain intensity and sedation were lower, and the feeling of well-being was greater, in the DM patients: one vs five (median), two vs five, five vs two, respectively, P <0.01 (90 min time-point). Thermal application revealed absence of primary and secondary hyperalgesia only in the DM patients; von Frey filaments induced similar pain sensation in both groups. Mean morphine/group, morphine/weight and diclofenac injection rates were approximately 55% lower in the DM group: 2.1 +/- 1.2 (SD) vs 4.7 +/- 2.3, 0.03 +/- 0.02 vs 0.07 +/- 0.03, 1.0 +/- 0.3 vs 2.4 +/- 0.2, respectively, P <0.01. Compared with placebo, DM enabled reduction of postoperative analgesics consumption, improved well-being, and reduced sedation, pain intensity and primary and secondary thermal hyperalgesia.",2001.0,0,0
472,11220429,Dexamethasone prophylaxis of nausea and vomiting after epidural morphine for post-Cesarean analgesia.,J J Wang; S T Ho; C S Wong; J I Tzeng; H S Liu; L P Ger,"To determine the minimum effective dose of dexamethasone in preventing nausea and vomiting associated with epidural morphine for post-Cesarean analgesia. One hundred and eighty parturients (n=45 in each of four groups) requiring epidural morphine for post-Cesarean analgesia were enrolled in this randomized, double-blinded, placebo-controlled study. At the end of surgery, parturients received either dexamethasone, at doses of 10 mg, 5 mg, 2.5 mg, or saline i.v.. Three milligrams epidural morphine were given to all parturients for postoperative analgesia. The incidence of PONV and side effects were estimated for 24 hr after delivery by blinded, trained nurse anesthetists. Parturients who received dexamethasone, either 10 mg or 5 mg were different from those who received saline alone in the following parameters: the total incidence of nausea and vomiting, incidence of > 4 vomiting episodes, number the of parturients requiring rescue antiemetics, and the total number of parturients with no vomiting and/or no antiemetic medication (P < 0.05 to P < 0.01). The differences between dexamethasone 10 mg and 5 mg were not significant. Dexamethasone 2.5 mg was partially effective. Dexamethasone, 5 mg i.v., is suggested as the minimum effective dose in preventing nausea and vomiting associated with epidural morphine for post-Cesarean analgesia.",2001.0,0,0
473,11220944,[Prevention of postoperative pain: pathogenetic bases and clinical aspects].,A M Ovechkin; A V Gnezdilov; M L Kukushkin; D V Morozov; A V Syrovegin; E Iu Khmel'kova; I M Gubkin,"The trial aimed at development of pathogenetically sound complex of therapeutic measures to prevent postoperative pain or relieve it significantly included 1912 patients after elective surgical interventions on the lower part of the body. It is shown that basic factors in postoperative pain prevention are the following: a) adequate relief of preoperative pain syndrome; b) use of spinal or spinal-epidural anesthesia as the leading anesthesia method; c) preoperative epidural administration of opioid analgetic drugs; d) pre-, intra- and postoperative administrations of drugs affecting N-methyl-D-aspartate-receptors (ketamine, magnesium sulphate) as well as inhibitors of kininogenesis and prostaglandinogenesis. The success lies in a multimodality approach to prevention of postoperative pain syndrome, i.e. maximal eradication of all the factors promoting onset of pain during pre-, intra- and postoperative period with a simultaneous impact on peripheral and central mechanisms of acute pain. Such an approach resulted in a complete prevention of postoperative pain in 46.2% patients while the rest patients had much less intensive pain.",2001.0,0,0
474,11223627,[Ultrasound guided alcohol ablation of the celiac plexus in oncology patients with abdominal pain].,G Mathon; A d'Alincourt; E Frampas; F Lerat,"The authors report results of a retrospective study evaluating the efficacy of US-guided alcohol ablation of the celiac plexus in 26 patients with chronic cancer-related abdominal pain. They review the interest of this imaging technique for guidance. Thirty US-guided alcohol ablations were performed in 26 patients. Twenty-two of them had a prancreatic malignancy, 3 had a gastric cancer and 1 had an esophageal cancer. 72% of patients experienced significant pain relief with at least 50% decrease in morphine requirements for two months. Four patients underwent a second ablation because of persistent pain and 3 of them experienced relief. Celiac plexus ablation is considered to be one of the most effective treatments for chronic cancer-related abdominal pain, often used as an adjuvant treatment in the pain management strategy. US guidance is advantageous because it is simple and accurate and enables quick needle placement.",2001.0,0,0
475,11224014,Pain treatment satisfaction in spinal cord injury.,D Murphy; D B Reid,"A survey on pain satisfaction was mailed to 300 individuals with spinal cord injury. Eighty-eight completed surveys were returned, and the results were analyzed. The survey queried the respondents on characteristics of their pain, treatments received, the impact of pain on multiple, life activities and functions and the satisfaction with treatment received to reduce pain. Subjects for the study were selected from the Spinal Cord Injury Registry from the Commonwealth of Virginia in the US. Information was obtained from a survey sent to the subjects who were chosen randomly with respect to age and gender. At least 1 year had elapsed from the time of injury for each individual. Respondents were typically dissatisfied with the results of the treatments received to manage their pain. Pain in individuals with spinal cord injury needs to be addressed in a thorough fashion to reduce the adverse impact on life activities.",2001.0,0,1
476,11226555,Meperidine addiction or treatment frustration?,C I Hung; C Y Liu; C Y Chen; C H Yang; E K Yeh,"There have been few studies of the psychiatric characteristics of analgesics addiction. The physician's perceptions that patients were addicted to analgesics might be partially attributable to frustration with poor response to treatment. In this retrospective study, we evaluated the medical records of 20 subjects (15 male and 5 female) who were perceived as having addiction to meperidine by general physicians. The most common medical diagnosis among these patients was chronic pancreatitis (7/20). Among them, five had a past history of suicide attempt and three had self-injury behavior during the index admission. The fact that subjects were perceived as being addicted might be attributable to a vicious cycle of the following factors: 1) chronic intractable pain; 2) poor staff-patient relationship; 3) lower pain threshold or tolerance due to anxiety or depression; 4) patients with a history or tendency of substance abuse; 5) placebo use and inadequate analgesics regimen. The findings of this study suggest that the importance of the following diagnostic and treatment procedures in these patients: 1) suicide risk should be evaluated; 2) comorbid psychiatric diseases should be treated; 3) factors that cause a vicious cycle in pain control should be identified; 4) misconceptions of opiate analgesics among medical staff should be discussed; 5) poor staff-patient relationship should be managed aggressively; and 6) ""addiction"" is a critical diagnosis that should be avoided if possible.",2001.0,0,0
477,11230472,"Serum prostate-specific antigen decline as a marker of clinical outcome in hormone-refractory prostate cancer patients: association with progression-free survival, pain end points, and survival.",E J Small; A McMillan; M Meyer; L Chen; W J Slichenmyer; P F Lenehan; M Eisenberger,"Validated end points are lacking for clinical trials in hormone-refractory prostate cancer (HRPC). Controversy remains regarding the utility of a posttreatment decline of prostate-specific antigen (PSA). The purpose of this study was to determine whether posttreatment declines in PSA were associated with clinical measures of improvement in a randomized phase III trial of suramin plus hydrocortisone versus placebo plus hydrocortisone. A total of 460 HRPC patients were randomized to receive suramin plus hydrocortisone (n = 229) or placebo plus hydrocortisone (n = 231). All patients had symptomatic, metastatic HRPC requiring opioid analgesics. Clinical end points evaluated included overall survival, objective progression-free survival (OPFS), and time to pain progression (TTPP). An evaluation of overall survival, OPFS, and TTPP as a function of a PSA decline of > or = 50%, lasting at least 28 days, was undertaken by using a landmark analysis at 6, 9, and 12 weeks. A multivariate analysis of the impact of PSA decline was performed on these clinical end points. A decline in PSA of > or = 50% lasting > or = 28 days was significantly associated with a prolonged median overall survival, OPFS, and TTPP, both in the entire group and the suramin plus hydrocortisone group at all three landmarks in both univariate and multivariate analysis. In this prospective, randomized trial of suramin plus hydrocortisone versus placebo plus hydrocortisone, a posttherapy decline in PSA of > or = 50%, lasting 28 days, was associated with prolonged median overall survival, improved median progression-free survival, and median TTPP. This analysis suggests that a posttreatment decline in PSA may be a reasonable intermediate end point in HRPC trials and calls into question the clinical utility of preclinical assays evaluating the in vitro effect of given agents on PSA secretion.",2001.0,0,0
478,11236289,Pot--the pitfalls of pragmatism.,T Modin,,2001.0,0,0
479,11237777,The use of anti-inflammatory drugs in cancer pain.,S Mercadante,"The role of non-steroidal anti-inflammatory drugs (NSAIDs) in cancer pain has been well established in the treatment of mild pain and also alone or in association with opioids for the treatment of moderate to severe pain. Acutely, NSAIDs may be more than mild analgesics, and may provide additional analgesia when combined with opioids. However, NSAIDs have ceiling effects and there is no therapeutic gain from increasing dosages beyond those recommended. As there is no clearly superior NSAID, the choice should be based on experience and the toxicity profile that probably relates to the COX-1:COX-2 ratio. Among the older drugs, ibuprofen seems to have these properties.Non-steroidal anti-inflammatory drugs have been shown to have an opioid-sparing effect. Although the value of a simple narcotic-sparing effect may be questioned in cancer pain treatment, the use of NSAIDs may be useful when the increase in opioid dosage determine the occurrence of opioid toxicity. Like opioids, NSAIDs should not be considered analgesics for a specific type or cause of pain. There is a lack of evidence for any difference between different routes of NSAIDs administration. The long-term toxicity of NSAIDs in cancer pain is poorly defined due to a lack of studies. A variety of strategies have been used in an attempt to reduce the risks associated with NSAID therapy. Those NSAIDs that are weak COX-1 inhibitors may be preferred. In addition, concomitant administration of misoprostol is recommended in patients at increased risk for upper gastrointestinal complications.",2001.0,0,0
480,11240075,"Treatment of severe pain from osteoarthritis with slow-release tramadol or dihydrocodeine in combination with NSAID's: a randomised study comparing analgesia, antinociception and gastrointestinal effects.",C H Wilder-Smith; L Hill; K Spargo; A Kalla,"Opioids are increasingly used in the treatment of chronic non-malignant pain. The aim of this open-label, randomised, parallel group study was to compare analgesia and side-effects of two commonly used opioid analgesics, tramadol and dihydrocodeine, in long-acting formulations in 60 osteoarthritis patients with strong pain despite NSAID's. Dose titration based on effect was performed with the respective immediate release solutions given additionally to tramadol 100 mg bid and dihydrocodeine 60 mg bid during the first 4 days of the 1 month treatment. Electrical sensation and pain thresholds over the osteoarthritic joint and at a distant location and gastrointestinal transit times were performed before and during treatment. Thirty patients with pain controlled by NSAID's alone formed the comparator group. Pain intensities at rest and during movement decreased highly significantly with tramadol and dihydrocodeine from median pre-treatment verbal ratings of over 3 (0=none, 4=unbearable) to 1 and below from the second treatment day onwards (ANOVA P<0.0001). Pain at rest was significantly lower with tramadol (ANOVA P=0.04), but ratings were similar during movement. Mean (95% CI) daily doses on days 1 and 28 were 209 (198-220) mg and 203 (191-206) mg of tramadol, and 129 (122-136) mg and 130 (121-134) mg of dihydrocodeine, respectively. Minor side-effects were more common with tramadol (P=0.04). Changes in bowel functions and symptoms were minor with both treatments, but the frequency of defaecation was lower and stools were harder with dihydrocodeine. Orocaecal transit time remained unchanged and similar to controls with both analgesics. Colonic transit times only increased significantly during treatment with dihydrocodeine. Sensation and pain thresholds were lower pre-treatment in both groups than in controls and increased during treatment. These antinociceptive effects were more marked in the tramadol group and distant from the osteoarthritic joint. We conclude rapid pain relief was achieved with both long-acting tramadol and dihydrocodeine with NSAID's in strong osteoarthritis pain. Minimal dose titration was required and side-effects were minor. Tramadol interfered less with intestinal function and showed greater antinociceptive action.",2001.0,0,0
481,11240084,Breakthrough cancer pain: a randomized trial comparing oral transmucosal fentanyl citrate (OTFC) and morphine sulfate immediate release (MSIR).,P H Coluzzi; L Schwartzberg; J D Conroy; S Charapata; M Gay; M A Busch; J Chavez; J Ashley; D Lebo; M McCracken; R K Portenoy,"Oral transmucosal fentanyl citrate (OTFC); Actiq) is a drug delivery formulation used for management of breakthrough cancer pain. Previous studies with open-label comparisons indicated OTFC was more effective than patients' usual opioid for breakthrough pain. The objective of this study was to compare OTFC and morphine sulfate immediate release (MSIR) for management of breakthrough pain in patients receiving a fixed scheduled opioid regimen. This double-blind, double-dummy, randomized, multiple crossover study was conducted at 19 US university- and community-based hospitals and clinics and comprised 134 adult ambulatory cancer patients. Patients were receiving a fixed scheduled opioid regimen equivalent to 60-1000 mg/day oral morphine or 50-300 microg/h transdermal fentanyl, were using a 'successful' MSIR dose (15-60 mg) as defined by entry criteria, and were experiencing 1-4 episodes of breakthrough pain per day. In open-label fashion, OTFC was titrated such that a single unit (200-1600 microg) provided adequate pain relief with acceptable side effects. Successfully titrated patients entered the double-blind phase of the study and received ten prenumbered sets of randomized capsules and oral transmucosal units. Five sets were the successful OTFC dose paired with placebo capsules, and five sets were placebo OTFC paired with capsules containing the successful MSIR dose. Patients took one set of study medication for each episode of target breakthrough pain. Pain intensity (PI), pain relief (PR) and global performance of medication (GP) scores were recorded. Pain intensity differences (PID) were calculated and 15-min PID was the primary efficacy variable. Adverse events were recorded. Sixty-nine percent of patients (93/134) found a successful dose of OTFC. OTFC yielded outcomes (PI, PID, and PR) at all time points that were significantly better than MSIR. GP also favored OTFC and more patients opted to continue with OTFC than MSIR following the study. Somnolence, nausea, constipation, and dizziness were the most common drug-associated side effects. In conclusion, OTFC was more effective than MSIR in treating breakthrough cancer pain.",2001.0,0,0
482,11240090,"Concentration-effect relationship of intravenous alfentanil and ketamine on peripheral neurosensory thresholds, allodynia and hyperalgesia of neuropathic pain.",A Leung; M S Wallace; B Ridgeway; T Yaksh,"Both mu opioid agonists and N-methyl-D-aspartate (NMDA) receptor antagonists are implicated in the regulation of neuropathic pain in post-nerve injury preclinical pain models. This study characterizes the effects of intravenously infused alfentanil (a mu-receptor agonist) and ketamine (an NMDA-receptor antagonist) on human neuropathic pain states, characterized by allodynia and hyperalgesia. Using diphenhydramine as the placebo, alfentanil and ketamine infusions were given in a randomized double-blind fashion 1 week apart via a computer-controlled infusion (CCI) pump that was programmed to target plasma levels of alfentanil at 25, 50 and 75 ng/ml and ketamine at 50, 100 and 150 ng/ml. At the beginning of each infusion and each targeted plasma level, baseline vital signs, neurosensory testing that included thermal thresholds, thermal pain and von Frey filament thresholds, and spontaneous and evoked pain scores were obtained. Moreover, the areas of allodynia or hyperalgesia to stroking and a 5.18 von Frey filament were mapped at the beginning and the end of each infusion. A total of seven males and five females with post-nerve injury allodynia and hyperalgesia were enrolled in the study. Elevations of cold, warm, hot pain and von Frey tactile thresholds were noted. Dose-dependent increases in cold and cold pain thresholds, and reductions in stroking pain scores were noted in both the alfentanil and the ketamine infusions. In addition, alfentanil showed a statistically significant dose-dependent reduction in both spontaneous and von Frey pain scores. Both the alfentanil and ketamine infusions showed a reduction in the stroking hyperalgesic area and ketamine showed a significant reduction in the von Frey hyperalgesia area. No significant CNS side effects and changes in vital signs were noted. A partial deafferentation state was found in the post-nerve injury patients who presented with allodynia and hyperalgesia. The effects of alfentanil on cold and cold pain thresholds and spontaneous pain scores correlates with previous studies suggesting an opiate central analgesic effect. In addition, the reduction of the hyperalgesic area and evoked pain scores with the alfentanil infusion suggests that opioids may have some peripheral effects in the post-nerve injury patients. Therefore, clinical utilization of opioids with careful titration may be beneficial in post-nerve injury patients with partial deafferentation. With the absence of significant CNS side effects, the ketamine infusion not only demonstrated the well-documented spinal cord mechanism of the NMDA receptor, but the result of the current study also suggests that a peripheral mechanism of NMDA receptor may exist. The relationship between central sensitization and regulation of peripheral NMDA-receptor expression requires further investigation.",2001.0,0,0
483,11240873,Safety and efficacy of peribulbar block as adjunct to general anaesthesia for paediatric ophthalmic surgery.,K Deb; R Subramaniam; M Dehran; R Tandon; D Shende,"Fifty children (age 5-14 years, ASA I-II) undergoing elective ophthalmic surgery were chosen for the study. Of these, 25 received intravenous pethidine (control group) and 25 received a peribulbar block (block group) for perioperative analgesia, and were monitored intraoperatively and postoperatively by an investigator blinded to the analgesic technique. Intraoperative values of haemodynamic variables were significantly higher in the control group (P < 0.01). Requirement for intraoperative rescue analgesic and postoperative analgesia was higher in the control group (P < 0.05 and P < 0.001, respectively). Children in the block group had lower postoperative pain scores at all times. Incidence of oculocardiac reflex was significantly higher (P < 0.001) in the control group. Seventy-six percent of children in the control group had postoperative nausea and vomiting compared to 20% children in the block group (P < 0.001). There were no complications related to the block. Peribulbar block appears to be a safe and useful analgesic technique for paediatric ophthalmic surgery.",2001.0,0,0
484,11242378,Injection therapy for subacute and chronic benign low back pain.,P J Nelemans; R A deBie; H C deVet; F Sturmans,"The Medline and Embase databases containing randomized controlled trials of injection therapy published to 1998 were systematically reviewed. To evaluate the effectiveness of injection therapy with anesthetics, steroids, or both in patients with low back pain persisting longer than 1 month. Two reviewers independently assessed the trials for the quality of their methods. The primary outcome measure was pain relief. Subgroup analyses were performed between trials with different control groups (placebo and active injections), with different injection sites (facet-joint, epidural, and local injections), and with timing of outcome measurement (short- and long-term). Within the resulting 12 (2 x 3 x 2) subcategories of studies, the overall relative risks and corresponding 95% confidence intervals were estimated, using the random effects model of DerSimonian and Laird. In the case of trials using active injections as a control, the results were not pooled. This review included 21 randomized trials. All the studies involved patients with low back pain persisting longer than 1 month. Only 11 studies compared injection therapy with placebo injections (explanatory trials). The methodologic quality of many studies was low: Only eight studies had a methodologic score of 50 points or more. There were only three well-designed explanatory clinical trials: one on injections into the facet joints with a short-term relative risk of 0.89 (95% confidence interval = 0.65-1.21) and a long-term relative risk of 0.90 (95% confidence interval = 0.69-1.17), one on epidural injections with a short-term relative risk of of 0.94 (95% confidence interval = 0.76-1.15) and a long-term relative risk of 1.00 (95% confidence interval = 0.71-1.41), and one on local injections with a long-term relative risk of 0.79 (95% confidence interval = 0.65-0.96). Within the six subcategories of explanatory studies, the pooled relative risks were as follows: facet joint, short-term: relative risk = 0.89 (95% confidence interval = 0.65-1.21); facet joint, long-term: relative risk = 0.90 (95% confidence interval = 0.69-1.17); epidural, short-term: relative risk = 0.93 (95% confidence interval = 0.79-1.09); epidural, long-term: relative risk = 0.92 (95% confidence interval = 0.76-1.11); local, short-term: relative risk = 0.80 (95% confidence interval = 0.40-1.59); and local, long-term: relative risk = 0.79 (95% confidence interval = 0.65-0.96). Convincing evidence is lacking regarding the effects of injection therapy on low back pain. Additional well-designed explanatory trials in this field are needed.",2001.0,0,0
485,11244279,Towards a pain treatment based on the identification of the pain-generating mechanisms?,R Dallel; D Voisin,"Despite continuous improvements in available pain treatments, many patients with chronic pain still remain insufficiently relieved. Although such therapeutic failures are often ascribed to pharmacological or psychological factors, difficulties in elucidating pain-generating mechanisms may be the main cause of insufficient pain management. These difficulties arise from several origins, including the unsuitability of the usual classification of pain, the exclusive use of etiology or symptom criteria as the main dimension of pain to guide the choice of therapeutic agents, the inadequate interpretation of sensory deficit, the lack of identification of the injured tissues, the absence of objective pain assessment by psychophysical methods. In this paper, we review briefly some fundamental knowledge to determine pain treatment based on the identification of the physiopathological mechanisms of pain. We advocate that once pain-generating mechanisms are known, it becomes possible to establish the appropriate treatment of pain.",2001.0,0,0
486,11244701,[Postoperative pain and surgical treatment of trapeziometacarpal osteoarthritis of the thumb after ambulatory surgery].,F Vial; H Bouaziz; G Mekler; C Cornet; M Merle; M C Laxenaire,"The course of pain and the incidence of the side effects from analgesics were evaluated for 15 days in 26 consecutive outpatients who underwent a surgical cure of trapeziometacarpal osteoarthritis of the thumb under regional block. Prospective study. The analgesic regimen prescribed at discharge consisted on a regular administration of a combination of ketoprofen (50 mg.6.h-1) plus the association of acetaminophen and propoxyphene (two tablets.6.h-1). Patients were asked to evaluate their pain using a numerical rating scale graduated from 0 to 10. Data were collected during a telephone interview at day 4, 8 and 15. Overall, patients scrupulously followed the medical prescription. At day four, 80% of patients still needed analgesics. The mean period during which NSAID, acetaminophen and propoxyphene were maintained was 4 and 6 days respectively. Fifty percent of patients reported severe pain during postoperative day 1 and 2. Moderate pain was reported at day 3 and 4 in respectively 54% and 42% of cases. Beyond this period, most patients indicated pain of weak intensity (71% at day 8). Epigastric pain has been noticed for 27% of patients. The surgical correction of trapeziometacarpal osteoarthritis of the thumb is frequently performed according to an ambulatory setting. The fact that 50% of patients reported severe pain during the early postoperative period emphasize the inadequacy of our postoperative pain management for this surgical procedure.",2001.0,0,0
487,11246381,Postoperative narcotic requirement after microscopic lumbar discectomy is not affected by intraoperative ketorolac or bupivacaine.,P F Mack; D Hass; M H Lavyne; R B Snow; C A Lien,"Prospective, randomized, double-blind study. To assess the efficacy of ketorolac and bupivacaine in reducing postoperative pain after microsurgical lumbar discectomy. Microsurgical lumbar discectomy often is performed as an ambulatory procedure. Pain, nausea, and urinary retention may delay discharge. It was hypothesized that intraoperative ketorolac or bupivacaine would reduce postoperative pain as measured by morphine demand. After Institutional Review Board (IRB) approval and informed consent, 30 patients undergoing single-level microsurgical lumbar discectomy under general anesthesia randomly received either intravenous ketorolac, intramuscular bupivacaine, or placebo before wound closure. After surgery, all patients received intravenous, MSO4, patient-controlled analgesia. MSO4 demand was compared between groups at 30 minutes and at 1, 4, 8, 16, 20, and 24 hours after surgery by one-way ANOVA. Pre- and postoperative pain was assessed by using a standard scale and was correlated to postoperative MSO4 demand by Pearson correlation. Significance was assumed at P < 0.05. There were no group differences in age, gender, weight, disc level, preoperative pain, or preoperative use of pain medication. Neither ketorolac nor bupivacaine decreased pain or nausea scores, MSO4 demand, or time to void and ambulation. Preoperative pain was significantly correlated to postoperative narcotic demand (r = 0.46, P < 0.01). Preoperative narcotic or NSAID use was not correlated to either preoperative pain scores or postoperative MSO4 requirement. Neither ketorolac nor bupivacaine decreased the postoperative narcotic requirement in patients undergoing microsurgical lumbar discectomy. Postoperative narcotic requirements are increased in patients who are in severe pain before surgery, regardless of preoperative narcotic use.",2001.0,0,0
488,11260098,Randomized clinical trial of local bupivacaine perfusion versus parenteral morphine infusion for pain relief after laparotomy.,W K Cheong; F Seow-Choen; K W Eu; C L Tang; S M Heah,"Opioids are often used to decrease pain following laparotomy but are associated with unwanted side-effects. The effectiveness of local perfusion of bupivacaine 0.5 per cent following laparotomy was studied. A prospective randomized study involving patients undergoing laparotomy for major colorectal surgery using a left iliac fossa skin crease incision was undertaken. Patients were randomized to receive either intermittent intravenous morphine infusion on demand with patient-controlled analgesia (PCA group) or continuous wound perfusion of local bupivacaine 0.5 per cent for 60 h (LA group). Seventy patients were recruited, 35 in each group. Patient demographics, surgical and recovery variables and complications were comparable in the two groups. The wound lengths were similar (median 14 cm in both groups). There was no statistically significant difference in postoperative pain scores at rest and with movement between the two groups, except for pain scores at rest on the first postoperative day (P = 0.03). The median total amount of morphine used was significantly greater in the PCA group (median 38 versus 0 mg in the LA group; P < 0.001). Direct continuous local wound perfusion of bupivacaine 0.5 per cent is as effective as PCA for postoperative pain relief after laparotomy. It is a safe and feasible alternative to parenteral opioids.",2001.0,0,0
489,11261766,Tolosa Hunt Syndrome--intractable pain treatment with acupuncture?,J Nepp; S Grdser; S Flarrer; A Spacek; C Mudrich; D Stockenhuber; A Wedrich,"The Tolosa Hunt Syndrome (THS) is a painful granular inflammation of the cerebral vessels followed by pain and disorders of the extrabulbar muscles. The therapy consists of corticosteroids and analgetics. There was a 70 year old woman who suffered from painful paresis of the abducent and oculomotor nerves following an infection with Borrelia Burgdorferi--but without ocular symptoms. The treatment with corticosteroids reduced the palsy but she complained of excessively painful attacks in the region of the first branch of the trigeminal nerve. Opiold analgetic therapy did not bring about any relief. Acupuncture is an irritative method with a physical effect on the nervous system: its pain-reducing effect is caused by the activation of transmitters like endorphins in thalamus and brain stem. Knowing this effect, the THS patient, after informed consent, was treated with acupuncture. To measure the extent of pain, a visual analog scale (0: no pain - 10: maximum pain) was used. Acupuncture was performed according to the empirical rules of the Traditional Chinese Medicine (TCM), during a period of 10 weeks and 12 weeks. There was a significant pain relief after acupuncture from VAS 10 to VAS 5. The effect vanished during the next four months. After a second series of 12 sessions pain reduction was reported from VAS 10 to 4. One year after the last Tolosa Hunt Syndrome - intractable pain pain strength ranged between VAS 4 - 6. Therefore acupuncture seems to be a good additional method for reduction of intractable pain.",2001.0,0,0
490,11264560,Comparison of midazolam with or without fentanyl for conscious sedation and hemodynamics in coronary angiography.,S Baris; D Karakaya; R Aykent; K Kirdar; O Sagkan; A Tür,"To compare the hemodynamic and sedative effects of midazolam - with or without fentanyl combination - with placebo in coronary angiography. Prospective, double-blind, randomized study. University medical centre. All patients undergoing coronary angiography. Demographic data, hemodynamic variables, sedation and anxiety scores, amnesia, patient and cardiologist satisfaction, and adverse effects were evaluated and compared among coronary angiography patients taking midazolam, midazolam and fentanyl, or placebo before the procedure. Ninety patients scheduled for coronary angiography were randomly assigned into three groups: a midazolam-placebo group (group MP), a midazolam-fentanyl group (group MF) and a placebo group (group P). Hemodynamic stability was better in each sedation group (groups MP and MF) than in group P. Sedation scores, anxiolysis, and patient and cardiologist satisfaction were not different between the sedation groups. Both techniques of conscious sedation - midazolam and midazolam with fentanyl - are satisfactory for coronary angiography where hemodynamic stability and patient cooperation are required. In such procedures, local anesthesia without sedation may lead to hypertension and increase overall morbidity.",2001.0,0,0
491,11270012,Pre-emptive efficacy of epidural fentanyl in elective abdominal surgery.,A Esmaoğlu; Y Cuha; A Boyaci,"This study determines whether epidural fentanyl given before incision decreases the requirements for opioid analgesia postoperatively, compared with the same dose of epidural fentanyl given after the surgery. Forty patients scheduled to undergo elective abdominal surgery were randomly allocated between two groups according to the time of administered of fentanyl. None of the patients in either group received premedication. Prior to induction of general anaesthesia an epidural catheter was inserted at the L2-3 interspace and flushed with 0.9% NaCl. Patients then received 100 micrograms fentanyl in 10 mL 0.9% NaCl through this catheter either 15 min before awaking at the end of the operation (group I), or else the same dose given at an estimated time of 15 min before the start of surgery (group II). Postoperative analgesia consisted of patient-controlled intravenous fentanyl. The amount of fentanyl used by the patients was noted at 2, 4, 8, 12 and 24 h after surgery. Pain scores and sedation scores were assessed at 0, 2, 4, 8, 12 and 24 h postoperatively. The consumption of fentanyl was similar in both groups in all studied periods postoperatively. The mean pain score was lower for patients in group I than group II immediately after operation. There were no statistically significant differences between the mean pain scores of groups at 2, 4, 8, 12 and 24 h after operation. Mean sedation scores were similar in both groups at all times postoperatively. This study showed that the dose of fentanyl administered epidurally prior to surgical incision did not produce any clinically useful pre-emptive analgesic effect.",2001.0,0,0
492,11270559,A posterior tibial nerve neurilemoma unrecognized for 10 years: case report.,R F Ghaly,"Neoplasms of peripheral nerves can be obscured, especially during the early phase. The author reports a patient with a posterior tibial nerve neurilemoma (schwannoma). For a decade, the tumor was misdiagnosed as nonspecific S1 radiculopathy and psychogenic chronic pain syndrome. The patient's presentation and initial management are unique. A 40-year-old woman reported severe left foot and calf pain, numbness, and weakness. The symptoms were evident during three pregnancies, and they gradually progressed. The neuropathic pain was protracted, despite implantation of a dorsal column stimulator and administration of a wide variety of medications and therapies. The symptoms were unresponsive to both inpatient and outpatient treatments, which resulted in a misdiagnosis of psychogenic pain for more than a decade. Diagnostic scans obtained by computed tomography, ultrasonography, and nuclear scintigraphy confirmed a popliteal fossa mass. A high, large posterior tibial nerve neurilemoma was found intraoperatively, positioned just below the sciatic nerve bifurcation with extensive degenerative features and hemorrhages. Surgical resection provided immediate recovery. Peripheral nerve tumors are rarely acknowledged clinical entities. Chronic unexplained foot and calf pain and a positive Tinel's sign should raise suspicion of posterior tibial nerve neurilemoma. Even in patients who have had such tumors for a decade, surgical resection remains the treatment of choice.",2001.0,0,0
493,11271124,Addiction in patients with chronic pain.,P Compton; C A Estepa,,2001.0,0,0
494,11272678,Oral gabapentin (neurontin) treatment of refractory genitourinary tract pain.,K Sasaki; C P Smith; Y C Chuang; J Y Lee; J C Kim; M B Chancellor,"Refractory genitourinary pain is a common but difficult condition to treat. Examples of chronic genitourinary pain include orchalgia, interstitial cystitis, pain after bladder suspension surgery, nonbacterial prostatitis, and genital pain related to lumbosacral neuropathy. We report our experience with oral gabapentin treatment for this condition. Gabapentin is an anticonvulsant with unclear but therapeutic effects on neurologic pain. Twenty-one patients referred with refractory genitourinary pain were treated with oral gabapentin. There were 9 men and 12 women. In the male patients, the location of pain was testicle (4), bladder (2), penis (1), or prostate (2). In female patients, the pain was located in the urethra (4), bladder (6), vulva (1), or vagina (1). The dose of gabapentin was titrated from 300 up to 2,100 mg/day. Subjective pain severity and 10-cm visual pain scale was used before and 6 months after therapy. The mean dose of gabapentin was 1,200 mg/day (range 300-2,100 mg). Ten of 21 patients reported subjective improvement of their pain. The remaining patients did not perceive any improvement. Gabapentin was well tolerated; only 4 patients dropped out due to side effects. The most common adverse effects were dizziness and drowsiness. Five of 8 patients with interstitial cystitis reported improvement. Although only 10 of 21 patients improved with gabapentin, this cohort included only patients with refractory genitourinary pain that failed a wide range of prior treatments. Gabapentin belongs in the armaterium of the urologist who treats genitourinary pain.",2001.0,0,0
495,11275392,The Amsterdam Pain Management Index compared to eight frequently used outcome measures to evaluate the adequacy of pain treatment in cancer patients with chronic pain.,R de Wit; F van Dam; S Loonstra; L Zandbelt; A van Buuren; K van der Heijden; G Leenhouts; H Huijer Abu-Saad,"There is no 'gold standard' to assess the adequacy of pain treatment in cancer patients. The purpose of the study is to explore the Amsterdam Pain Management Index, a newly designed measure to evaluate the adequacy of cancer pain treatment, and to compare it with eight frequently used outcome measures. The Amsterdam Pain Management Index compares patients' Present Pain Intensity, Average Pain Intensity, and Worst Pain Intensity with a composite score of analgesics used, while correcting for what a patient considers as a tolerable level of pain. The eight frequently used outcome measure consisted of three Pain Intensity Markers, the Pain Relief Scale, the Patient Satisfaction Scale, and three Pain Management Indexes. In a randomized controlled trial, 313 cancer patients with a pain duration of at least 1 month were included and followed-up three times until 2 months postdischarge at home. The experimental group received a Pain Education Program, consisting of tailored pain information and instruction. Results showed that, except for the three Pain Management Indexes, the agreement between the measures was very low to moderate. The test of known-groups comparisons and equivalence between groups indicated that the Amsterdam Pain Management Index showed promising results. The Pain Intensity Markers and the Pain Relief Scale were limited in discriminating between groups, while the Patient Satisfaction Scale showed no differences between patient groups. Although it was possible for the Pain Management Indexes to distinguish between patient groups, the differences were not in the expected direction. The ability of the outcome measures to detect changes over time was clearly demonstrated by all outcome measures. Effects of the intervention were only found for the Amsterdam Pain Management Index and patients' Substantial Worst Pain score. Although support was provided for the use of the Amsterdam Pain Management Index, more research is warranted.",2001.0,0,0
496,11284869,Prolonged epidural catheterisation - a multidisciplinary technique.,J H Raphael; V Knowles; J L Southall; C Beddall; T V Gnanadurai,,2001.0,0,0
497,11289081,"Cyclobenzaprine hydrochloride is a commonly prescribed centrally acting muscle relaxant, which is structurally similar to tricyclic antidepressants (TCAs) and differs from amitriptyline by only one double bond.",J H Lofland; D Szarlej; T Buttaro; S Shermock; S Jalali,,2001.0,0,0
498,11293556,Efficacy and tolerability of celecoxib versus hydrocodone/acetaminophen in the treatment of pain after ambulatory orthopedic surgery in adults.,J S Gimbel; A Brugger; W Zhao; K M Verburg; G S Geis,"Current outpatient management of postoperative pain includes the use of oral opioid analgesics or nonsteroidal anti-inflammatory drugs; however, both types of medications are associated with side effects that can limit their usefulness in the outpatient setting. Two studies with identical protocols assessed the single- and multiple-dose analgesic efficacy and tolerability of celecoxib, a specific cyclooxygenase-2 inhibitor, in the treatment of acute pain after orthopedic surgery. These were multicenter, randomized, placebo- and active-controlled, double-blind, parallel-group trials conducted between January and June 1998. Both consisted of a single-dose assessment period (SDAP) and a multiple-dose assessment period (MDAP). In the SDAP, patients who had undergone orthopedic surgery received a single oral dose of celecoxib 200 mg, hydrocodone 10 mg/acetaminophen 1000 mg, or placebo within 24 hours after the end of anesthesia, with pain assessments conducted over the following 8-hour period. In the MDAP, extending from 8 hours after the first dose of study medication up to 5 days, patients who had received < or =1 dose of rescue medication during the SDAP continued on study medication (placebo recipients were rerandomized to active treatment), which could be taken up to 3 times a day as needed. A total of 418 patients were enrolled in the 2 trials. During the SDAP, 141 patients received celecoxib, 136 received hydrocodone/acetaminophen, and 141 received placebo. During the MDAP, 185 patients received celecoxib and 181 received hydrocodone/acetaminophen. When the combined data were analyzed, mean pain intensity difference (PID) scores generally favored the active treatments over placebo from 1 to 6 hours (with the exception of 1.5 hours) after dosing (P < or = 0.016) and favored celecoxib over the other treatments at 7 and 8 hours after dosing (P < 0.001). The active treatments demonstrated superior summed PID scores through 8 hours (P < 0.001), significantly shorter median times to onset of analgesia (P < 0.05), and significantly longer median times to first use of rescue medication (P < 0.05). During the MDAP, more hydrocodone/acetaminophen-treated patients (20%) than celecoxib-treated patients (12%) required rescue medication (P < 0.05), and the celecoxib group had significantly lower maximum pain intensity scores (P < 0.001, days 2-5), required fewer doses of study medication (P < or = 0.01, days 3-5), and had superior scores on a modified American Pain Society Patient Outcome Questionnaire (P < or = 0.013). In addition, a significantly lower proportion of celecoxib-treated patients experienced adverse events (43%) compared with hydrocodone/acetaminophen-treated patients (89%; P < 0.001). Over 8 hours, patients with moderate to severe pain after orthopedic surgery experienced comparable analgesia with single doses of celecoxib and hydrocodone/acetaminophen. Over a 5-day period, oral doses of celecoxib 200 mg taken 3 times a day demonstrated superior analgesia and tolerability compared with hydrocodone 10 mg/acetaminophen 1000 mg taken 3 times a day. Most patients required no more than 2 daily doses of celecoxib 200 mg for the control of their postorthopedic surgical pain.",2002.0,0,0
499,11294404,Comparison of pulmonary function and postoperative pain after laparoscopic versus open gastric bypass: a randomized trial.,N T Nguyen; S L Lee; C Goldman; N Fleming; A Arango; R McFall; B M Wolfe,"Impairment of pulmonary function is common after upper abdominal operations. The purpose of this study was to compare postoperative pulmonary function and analgesic requirements in patients undergoing either laparoscopic or open Roux-en-Y gastric bypass (GBP). Seventy patients with a body mass index of 40 to 60 kg/m2 were randomly assigned to undergo laparoscopic (n = 36) or open (n = 34) GBP. The two groups were similar in age, gender, body mass index, pulmonary history, and baseline pulmonary function. Pulmonary function studies were performed preoperatively and on postoperative days 1, 2, 3, and 7. Oxygen saturation and chest radiographs were performed on both groups preoperatively and on postoperative day 1. Postoperative pain was evaluated using a visual analog scale and the amount of narcotic consumed was recorded. Data are presented as mean +/- standard deviation. Laparoscopic GBP patients had significantly less impairment of pulmonary function than open GBP patients on the first three postoperative days (p < 0.05). By the 7th postoperative day, all pulmonary function parameters in the laparoscopic GBP group had returned to within preoperative levels, but only one parameter (peak expiratory flow) had returned to preoperative levels in the open GBP group. On the first postoperative day, laparoscopic GBP patients used less morphine than open GBP patients (46 +/- 31 mg versus 76 +/- 39 mg, respectively, p < 0.001), and visual analog scale pain scores at rest and during mobilization were lower after laparoscopic GBP than after open GBP (p < 0.05). Fewer patients after laparoscopic GBP than after open GBP developed hypoxemia (31% versus 76%, p < 0.001) and segmental atelectasis (6% versus 55%, p = 0.003). Laparoscopic gastric bypass resulted in less postoperative suppression of pulmonary function, decreased pain, improved oxygenation, and less atelectasis than open gastric bypass.",2001.0,0,0
500,11296045,Tramadol vs. diclofenac for posttonsillectomy analgesia.,M J Courtney; D Cabraal,"To compare the analgesic efficacy of oral tramadol hydrochloride and oral diclofenac sodium for posttonsillectomy pain management. Single-blind (surgeon and research team members), prospective, randomized, controlled clinical trial. Sixty-four patients 11 years and older undergoing bipolar electrocautery tonsillectomy were randomized to either the oral tramadol or the oral diclofenac postoperative pain group. Patients recorded pain levels twice daily for 14 days using a visual analogue scale. Pain scores for the 14 days were not significantly different between the oral tramadol and oral diclofenac groups. There were no significant differences in the incidence of postoperative hemorrhage and hospital readmission for uncontrolled pain. Oral tramadol can deliver the same analgesic efficacy as oral diclofenac for posttonsillectomy pain relief, which might be beneficial for avoiding the adverse effects of nonsteroidal anti-inflammatory drug therapy.",2001.0,0,0
501,11297334,Pharmacists' knowledge of and attitudes toward opioid pain medications in relation to federal and state policies.,D E Joranson; A M Gilson,"To assess Wisconsin pharmacists' knowledge of and attitudes toward the use of opioid analgesics in the management of chronic cancer and noncancer pain, and to explore the potential for these beliefs to interfere with pharmacist dispensing, the last link of the distribution chain of controlled substances to patients. Mail survey. Urban and rural pharmacies, long-term care facilities, hospitals, and outpatient clinics in Wisconsin in 1998. Representative sample of Wisconsin pharmacists. None. Responses to self-administered questionnaires. Although most respondents were knowledgeable about the issues addressed in this study, there were important exceptions. Not all pharmacists knew what constitutes legitimate dispensing practices for controlled substances under federal or state policy in emergencies or for patients with terminal illnesses, and many were unaware of the important distinctions among addiction, physical dependence, and tolerance. Many respondents did not view the chronic prescribing/dispensing of opioids for more than several months to patients with chronic pain of malignant or nonmalignant origin as a lawful and acceptable medical practice; this was especially true when the patient had a history of opioid abuse. Pharmacists play a pivotal role in ensuring patient access to medications. Viewed in the context of federal and state controlled substances policies, our findings suggest that the incorrect knowledge and inappropriate attitudes of some pharmacists could contribute to a failure to dispense valid prescriptions for opioid analgesics to patients in pain.",2001.0,0,0
502,11300288,"Postoperative pain control in total joint arthroplasty: a prospective, randomized study of a fixed-dose, around-the-clock, oral regimen.",D A Flory; R A Fankhauser; M A McShane,"This randomized, prospective study assessed postoperative pain control in 119 patients undergoing total joint arthroplasty. Group 1 (59 patients) received scheduled, around-the-clock, oral opioids and group 2 (60 patients) received oral opioids on an as-needed basis. Both groups had parenteral opioids available for breakthrough pain. The average scores for group 1 were lower than group 2. Differences were significant in sensory scores (AM day 1; AM and PM day 2), affective scores (PM day 2), total pain (PM day 2), visual analog scale (PM day 2), and present pain intensity index (AM day 1; PM day 2). Group 1 averaged 2.05 breakthrough pain doses and group 2 averaged 3.47 doses (P=.003), an average savings of 17.2% of the cost of pain medications during the first 2 postoperative days. The results indicate that scheduled, around-the-clock, oral opioids are an effective treatment regimen for postoperative pain control in total joint arthroplasty patients.",2001.0,0,0
503,11300386,Patient-controlled epidural analgesia versus continuous epidural analgesia after total knee arthroplasty.,M Silvasti; M Pitkänen,"Patient-controlled epidural analgesia (PCEA) has been found to be an effective method for pain relief during labour and after surgery. The goal of this study was to compare the efficacy of bupivacaine-fentanyl PCEA and continuous epidural infusion with the same mixture for treatment of pain after total knee arthroplasty. Fifty-four patients under spinal anaesthesia were allocated to two groups in this randomized, double-blind study: the PCEA group could demand a bolus of 0.05 ml/kg of the bupivacaine 1.1 mg/ml and fentanyl 5 microg/ml solution, with a lockout interval of 10 min and total dose limit of three bolus doses per hour. The EPI group received a continuous infusion of 0.1 ml kg(-1) h(-1) of the same bupivacaine-fentanyl solution, and only a minimal extra bolus dose of 0.2 ml with the same lockout interval. All the patients received also paracetamol 1 g, orally, three times a day. In addition to pain scores at rest and during leg lifting, the 20-h analgesic consumption and the incidence of side effects were recorded. Forty-nine patients completed the study. The bupivacaine and fentanyl consumption during 20 h was smaller in the PCEA group (P<0.001). Analgesia and the need for rescue-opioid medication were similar in both groups. There were no differences between the PCEA and EPI groups regarding the incidence of side effects. Five patients were confused about how to operate the PCEA apparatus. The amount of bupivacaine-fentanyl solution consumed was significantly less with PCEA than with continuous infusion of bupivacaine-fentanyl solution without affecting the quality of postoperative analgesia after total knee arthroplasty. Several of the elderly patients had difficulties in operating the PCEA apparatus.",2001.0,0,0
504,11300387,Total knee replacement: a comparison of ropivacaine and bupivacaine in combined femoral and sciatic block.,D A McNamee; P N Convery; K R Milligan,"Femoral and sciatic nerve block may improve post-operative analgesia following total knee replacement. To compare the post-operative analgesia following primary total knee replacement provided by spinal anaesthesia alone or in combination with femoral and sciatic nerve block with bupivacaine or ropivacaine. Seventy-five patients were randomised into one of three groups: spinal anaesthesia only; spinal anaesthesia and combined femoral and sciatic nerve block with 1 mg x kg(-1) bupivacaine 7.5 mg x ml(-1) to each nerve; spinal anaesthesia and combined femoral and sciatic nerve block with 1 mg x kg(-1) ropivacaine 7.5 mg x ml(-1) to each nerve. The mean (SD) time to first morphine request was significantly prolonged for both groups receiving combined femoral and sciatic block, 912 (489) min for the bupivacaine group and 781 (394) min for the ropivacaine group (P<0.001) compared with 413 (208) min for the group receiving spinal anaesthesia alone. Morphine consumption was significantly reduced in both groups receiving combined femoral and sciatic block. There were no systemic or neurological sequelae in any of the groups. Femoral and sciatic blockade following intrathecal bupivacaine/diamorphine provided superior analgesia when compared with intrathecal bupivacaine/diamorphine alone. There were no significant clinical differences between the group receiving bupivacaine 7.5 mg x ml(-1) and the group receiving ropivacaine 7.5 mg x ml(-1).",2001.0,0,0
505,11300389,Ropivacaine 1 mg x ml(-1) does not decrease the need for epidural fentanyl after hip replacement surgery.,P A Kostamovaara; J J Laurila; S Alahuhta; T E Salomåki,"Ropivacaine is a new long-acting local anesthetic. Laboratory trials have demonstrated a synergistic analgesic effect between intrathecal opioids and local anesthetics. We tested the hypothesis that addition of ropivacaine 1 mg x ml(-1) to epidural fentanyl (10 microg x ml(-1)) postoperatively decreases the need for fentanyl, improves the quality of analgesia and decreases the side-effects of fentanyl. Forty patients were enrolled in this double-blind, randomized study to receive either fentanyl 10 microg x ml(-1) (group F) alone or fentanyl combined with ropivacaine 1 mg x ml(-1) (group R) for 20 h as an epidural infusion at TH12-L1 or L1-L2 for analgesia after hip replacement surgery. The patients were free to use a patient-controlled epidural analgesia device, which was programmed to infuse 3 ml of the study medication hourly and to allow a 3-ml bolus when needed (maximal hourly dose of fentanyl was 150 microg). The consumption of medication, visual pain scores at rest and on movement, hemodynamic and respiratory parameters, motor and sensory block, nausea, pruritus and sedation were recorded. There were no significant differences between the groups in the total mean fentanyl consumption (1.10+/-0.18 mg in group F, 1.08+/-0.31 mg in group R, 95% CI: -0.14 to 0.19, P = 0.774). The pain scores were similar at rest (median scores < or = 1) and on movement (median scores < or = 3). The adverse effects were similar and of a minor nature, consisting mostly of pruritus and nausea. Addition of ropivacaine 1 mg x ml(-1) to epidural fentanyl 10 microg x ml(-1) did not significantly decrease the requirement for fentanyl administered for pain relief after hip replacement surgery.",2001.0,0,0
506,11301086,Continuous intrathecal morphine treatment for chronic pain of nonmalignant etiology: long-term benefits and efficacy.,K Kumar; M Kelly; T Pirlot,"To analyze, prospectively, the long-term effects of continuous intrathecal morphine infusion therapy in 16 patients with chronic nonmalignant pain syndromes. Twenty-five patients with severe, chronic, nonmalignant pain that had proven refractory to conservative management were considered candidates for trial of intrathecal spinal morphine. Sixteen patients achieved more than 50% pain relief after a trial period of intrathecal morphine infusion. They were implanted with fully implantable and programmable pumps through which morphine was delivered intrathecally on a continuous basis. These patients were followed prospectively and underwent careful evaluation of their functional and mental status, and pain intensity measurements using standardized techniques before treatment and every 6 months thereafter in the follow-up period. The follow-up period ranged from 13 months to 49 months (mean 29.14 months +/- 12.44 months) for the patients who had implanted morphine pumps. The mean morphine dosage initially administered was 1.11 mg/day (range 0.2--6.5 mg/day); after 6 months, it was 3.1 mg/day (range 0.4--8.75 mg/day). In long-term observation, no patient had a constant dosage history. The patients who received intrathecal morphine for longer than 2 years all showed an increase in morphine dosage to more than 10 mg/day. The best long-term results were seen with deafferentation pain and mixed pain, with 75% and 61% pain reduction (visual analog scale), respectively. Nociceptive pain patients had best pain relief initially (78% pain reduction) but it tended to decrease over the follow-up period to 57% pain reduction at final follow-up. The average pain reduction for all groups after 6 months was 67.5% and at last follow-up, it was 57.5%. Ten patients were satisfied with the delivery system and eleven reported improvement in their quality of life. In two patients, morphine was not able to adequately control the pain without producing undesirable side effects requiring the addition of clonidine to their infusion medication. In this series, 12 patients were considered successes and 4 patients were considered failures. In two patients, the intrathecal opioid therapy was unable to produce satisfactory pain relief and in the other two patients the pumps had to be explanted because of intolerable side effects. In our experience, the administration of intrathecal opioid medications for nonmalignant pain is justified in carefully selected patients.",2001.0,0,0
507,11305075,Hydromorphone: pharmacology and clinical applications in cancer patients.,N Sarhill; D Walsh; K A Nelson,"Hydromorphone is a more potent opioid analgesic than morphine and is used for moderate to severe pain. It can be administered by injection, by infusion, by mouth, and rectally. Oral bioavailability is low. The kidney excretes hydromorphone and its metabolites. Some metabolites may have greater analgesic activity than hydromorphone itself but are unlikely to contribute to the pharmacological activity of hydromorphone. With the exception of pruritus, sedation and nausea and vomiting, which may occur less after hydromorphone than after morphine, the side-effects of these drugs are similar. On a milligram basis hydromorphone is five times as potent as morphine when given by the oral route, and 8.5 times as potent as morphine when given intravenously.",2001.0,0,0
508,11305824,Combined pre- and post-surgical bupivacaine wound infiltrations decrease opioid requirements after knee ligament reconstruction.,N N Butterfield; S K Schwarz; C R Ries; L G Franciosi; B Day; B A MacLeod,"To test the efficacy of a combination of selective pre- and post-surgical local anesthetic infiltrations of the knee, compared with standard intra-articular injection at the end of surgery alone, to reduce postoperative opioid requirements following arthroscopic cruciate ligament reconstruction (ACLR). In a double-blind, randomized, controlled trial, we studied 23 patients (ASA I or II) scheduled for elective ACLR under general anesthesia. The treatment group (n = 12) received infiltrations with bupivacaine 0.25% with epinephrine 1:200,000 presurgically (10 ml into the portals, 10 ml at the medial tibial incision site, 10 ml at the lateral femoral incision site, and 10 ml intra-articularly) and postsurgically (5 ml at the medial tibial incision and 10 ml at the lateral femoral incision). The control group (n = 11) received infiltrations with saline 0.9% in the same manner. All patients received a standard intra-articular local anesthetic instillation of the knee (25 ml of bupivacaine 0.25% with epinephrine 1:200,000) at the completion of surgery. Postoperative opioid requirements were lower in the treatment group (5.8 +/- 2.9 mg morphine equivalent) than in the control group ( 13.7 +/- 5.8 mg; P = 0.008). Treatment patients were ready for discharge approximately 30 min earlier than control patients (P = 0.046). There were no adverse events in the treatment group. In the control group, 2/11 patients vomited and a third experienced transient postoperative diaphoresis, dizziness and pallor. We conclude that a combination of selective pre- and post-surgical wound infiltration with bupivacaine 0.25% provides superior analgesia compared with a standard post-surgical intra-articular injection alone.",2001.0,0,0
509,11309009,Fentanyl does not improve the nerve block characteristics of axillary brachial plexus anaesthesia performed with ropivacaine.,G Fanelli; A Casati; L Magistris; M Berti; A Albertin; M Scarioni; G Torri,"The aim of this prospective, randomized, double-blind study was to evaluate the effects of adding 1 microg. kg-1 fentanyl to ropivacaine 7.5 mg. ml-1 for axillary brachial plexus anaesthesia. With Ethics Committee approval and written consent, 30 ASA physical status I-II in-patients, scheduled for orthopaedic hand procedures were randomly allocated to receive axillary brachial plexus block with 20 ml of either ropivacaine 7.5 mg. ml-1 (n=15) or ropivacaine 7.5 mg. ml-1+1 microg. ml-1 fentanyl (n=15). Nerve blocks were placed using a nerve stimulator with the multiple injection technique. A blinded observer recorded the time to onset of surgical block (loss of pinprick sensation in the innervation areas of the hand (C6-C8) with concomitant inability to flex the wrist against gravity and move the fingers when squeezing the hand) and first request for pain medication after surgery. No differences in demography, degree of sedation or peripheral oxygen saturation were observed between the two groups. Median (range) time required to achieve readiness for surgery was 15 min (5-36 min) with ropivacaine alone and 15 min (5-40 min) with the ropivacaine-fentanyl mixture. No differences in the intraoperative quality of nerve block were reported between the two groups. Four patients receiving ropivacaine plain and two patients receiving the ropivacaine-fentanyl mixture did not require analgesics during the first 24 h after surgery (P=0.62). The degree of pain experienced at first analgesic request in those patients asking for pain medication, as well as median consumption of postoperative analgesics, were similar in the two groups. First postoperative analgesic request was made at 11 h (25th-75th percentiles: 9.1-14 h) in patients receiving ropivacaine alone and at 11.8 h (25th-75th percentiles: 9.8-15 h) in patients receiving the ropivacaine-fentanyl mixture (P=0.99). The addition of fentanyl 1 microg. ml-1 to ropivacaine 7.5 mg. ml-1 does not improve the nerve block characteristics of axillary brachial plexus anaesthesia for orthopaedic procedures involving the hand.",2001.0,0,0
510,11309010,"Ropivacaine 1 mg/ml, plus fentanyl 2 microg/ml for epidural analgesia during labour. Is mode of administration important?",J P Smedvig; E Soreide; L Gjessing,"Patient-controlled epidural analgesia (PCEA) with a moderate to high concentration of bupivacaine in obstetrics has been shown to give comparable analgesia and even higher level of satisfaction compared to continuous epidural infusion. We hypothesised that the use of a very low concentration technique (ropivacaine/fentanyl) might result in excessive dosing in the PCEA group, more motor blockade and a negative impact on spontaneous delivery rate. We conducted a randomised, double-blind study of 60 nulliparous women at term comparing low concentration ropivacaine/fentanyl administered in either patient-controlled or fixed continuous infusion mode. Parturients with known predictors of painful deliveries, i.e. breech presentation, primary induction of labour, were not included. Deliveries within 90 min from the start of epidural analgesia were omitted from the evaluation. We found that both groups required a mean of 12 ml/h low concentration mixture (loading and midwife rescue boluses included). There was no difference between groups with respect to spontaneous delivery rate (71%). This low concentration technique resulted in haemodynamic stability without crystalloid preloading, infusion or vasopressor use. Motor blockade of clinical importance was not detected in any patient. We conclude that epidural use of ropivacaine 1 mg/ml+fentanyl 2 microg/ml provides effective analgesia with equal volume requirements irrespective of administration mode, with a high spontaneous delivery rate. Choice of PCEA or CEI (continuous epidural infusion) should be directed by other considerations, most importantly compliance of midwife and possible reduction in workload for anaesthesiology staff.",2001.0,0,0
511,11314621,Postoperative pain management using intravenous patient-controlled analgesia for pediatric patients.,D Shin; S Kim; C S Kim; H S Kim,"Pain control is an important consideration after any surgical procedures. Especially in children, more attention and care are needed during the period of postoperative pain control, which must be both sufficiently safe and effective. In this respect, intravenous patient-controlled analgesia provides improved titration of analgesic drugs, thereby maintaining optimal analgesic status with few side effects. Thirty pediatric patients were randomly divided into two groups: the intravenous patient-controlled analgesia group (with nalbuphine HCl and ketorolac tromethamine) and the conventional pethidine HCl intramuscular group. The degree of analgesia was assessed every 4 hours until the second postoperative day. The intravenous patient-controlled analgesia group had significantly lower pain scores and took less time until they were able to walk to the bathroom, but as many side effects as the control group. We concluded that intravenous patient-controlled analgesia is safe and effective for pediatric patients who have moderate to severe pain after operations such as rib cartilage graft, iliac bone graft, and large flap surgeries.",2001.0,0,0
512,11315787,A randomized trial of controlled-release oxycodone during inpatient rehabilitation following unilateral total knee arthroplasty.,A Cheville; A Chen; G Oster; L McGarry; E Narcessian,"Reliance on ""as-needed"" analgesia following total knee arthroplasty may lead to inadequate control of pain and delayed recovery of function. Preemptive use of controlled-release opioids may improve pain control, accelerate recovery, and reduce the need for inpatient rehabilitative services. This study was designed to determine whether controlled-release opioids enhance post-arthroplasty pain control and facilitate functional recovery during rehabilitation. Fifty-nine patients admitted for inpatient rehabilitation following unilateral total knee arthroplasty were randomized to receive OxyContin (controlled-release oxycodone) (twenty-nine patients) or a placebo (thirty patients) every twelve hours. Both groups could receive on-request, immediate-release oxycodone (5 mg every four hours). The dose of study medication was increased on the basis of the frequency of requests for immediate-release oxycodone. Measures of interest included pain ratings as determined with a visual-analog scale, changes in the range of motion of the knee and quadriceps strength, and improvements in selected Functional Independence Measure scores during the first eight physical therapy sessions. The duration of the hospital stay for rehabilitation also was compared between the two groups. Baseline demographic, clinical, and functional characteristics were similar between the OxyContin and placebo groups. Compared with the placebo group, the patients who received OxyContin reported significantly less pain as well as significantly greater range of motion of the knee (passive motion, p = 0.036; active motion, p< 0.001) and quadriceps strength (p = 0.001) by the eighth physical therapy session. The patients who received OxyContin also were discharged from the rehabilitation hospital at an average of 2.3 days earlier than the patients in the placebo group (p = 0.013). Preemptive use of controlled-release oxycodone during rehabilitation following total knee arthroplasty leads to improved pain control, more rapid functional recovery, and a reduced need for inpatient rehabilitative services.",2001.0,0,0
513,11318765,Lack of effect of ondansetron on the pharmacokinetics and analgesic effects of morphine and metabolites after single-dose morphine administration in healthy volunteers.,K R Crews; B P Murthy; E K Hussey; A N Passannante; J L Palmer; W Maixner; K L Brouwer,"The purpose of this investigation was to study the influence of ondansetron on the single-dose pharmacokinetics and the analgesic effects elicited by morphine and the 3- and 6-glucuronide metabolites of morphine in healthy volunteers. This was a randomized, double-blind, placebo-controlled, two-way crossover study in which six male and six female subjects were administered a single 10 mg intravenous dose of morphine sulphate, followed 30 min later by a single 16 mg intravenous dose of ondansetron hydrochloride or placebo. Serum and urine concentrations of morphine, morphine-3-glucuronide (M3G) and morphine-6-glucuronide (M6G) samples were quantified over 48 h using high performance liquid chromatography with detection by mass spectrometry. Analgesia was assessed in the volunteers with a contact thermode device to provide a thermal pain stimulus. Four analgesic response variables were measured including thermal pain threshold, thermal pain tolerance, temporal summation of pain and mood state. The two treatments appeared to be equivalent based on the 90% confidence intervals (0.6, 1.67) of the least squares means ratio. All least squares means ratio confidence intervals for each parameter, for each analyte fell within the specified range, demonstrating a lack of an interaction. The results of this study suggest that administration of ondansetron (16 mg i.v.) does not alter the pharmacokinetics of morphine and its 3- or 6-glucuronide metabolites to a clinically significant extent, nor does it affect the overall analgesic response to morphine as measured by the contact thermode system.",2001.0,0,0
514,11323121,Mechanisms of opioid-induced pain and antinociceptive tolerance: descending facilitation and spinal dynorphin.,T W Vanderah; M H Ossipov; J Lai; T P Malan; F Porreca,,2001.0,0,0
515,11323149,The analgesic effect of codeine as compared to imipramine in different human experimental pain models.,T P Enggaard; L Poulsen; L Arendt-Nielsen; S H Hansen; I Bjørnsdottir; L F Gram; S H Sindrup,"The hypoalgesic effect of single oral doses of 100 mg imipramine and 125 mg codeine was evaluated in a randomised, placebo-controlled, double-blind, 3-way cross-over experiment including 18 healthy volunteers. Pain tests were performed before and 90, 180, 270, 360 and 450 min after medication. The tests included determination of pain tolerance thresholds to pressure, pain detection/tolerance thresholds to single electrical sural nerve stimulation and pain summation at tolerance threshold to repetitive electrical sural nerve stimulation (temporal summation) and pain experienced during the cold pressor test, rated as peak pain intensity, pain average intensity and discomfort. Compared to placebo, imipramine significantly increased pressure pain tolerance threshold (P = 0.03) and increased pain tolerance threshold (P = 0.05) and pain summation threshold (P = 0.03), but not pain detection threshold to electrical stimulation. Imipramine did not cause significant changes in pain perception during the cold pressor test. Codeine significantly increased pressure pain tolerance threshold (P = 0.02), pain detection (P = 0.04) and pain tolerance threshold (P = 0.01) and pain summation threshold (P = 0.02) to electrical stimulation. In addition, codeine reduced the pain experienced during the cold pressor test (P = 0.04-0.003). It is concluded that both imipramine and codeine inhibit temporal pain summation, whereas only codeine reduces cold pressor pain. Pain summation may be a key mechanism in neuropathic pain. Imipramine has a documented effect on such pain conditions on temporal summation. The present study showed that codeine also inhibits temporal summation, which is in line with the clinical observations indicating that opioids relieve neuropathic pain.",2001.0,0,0
516,11325088,Prospective double-blind study of effect of ketorolac administration after laparoscopic urologic surgery.,G K Chow; M D Fabrizio; T Steer; S R Potter; T W Jarrett; S Gelman; L R Kavoussi,"To decrease postoperative dependence on narcotics for analgesia, we have evaluated ketorolac as an adjunct to perioperative pain control in patients undergoing laparoscopic urologic surgery. Sixty-five patients (34 male, 31 female) were randomized to receive either ketorolac tromethamine (15-30 mg IV q 6 h) or placebo prior to laparoscopic surgery. Patient-controlled analgesia in the form of morphine sulfate was provided. Operative factors such as the type of surgery, operative time, and estimated blood loss were recorded. Postoperative factors such as analog pain score (range 0-10), narcotic usage, and length of stay were evaluated. Fifty-five patients completed the study. The average pain score was 2.2 and 4.5 for the ketorolac and placebo groups, respectively (P < 0.005). The mean amounts of total morphine used were 39.2 mg (ketorolac) and 62.5 mg (placebo) (P = 0.077). The length of stay was not significantly different in the ketorolac (2.5 days) and placebo (2.6 days) groups (P = 0.74). Operative times (P = 0.21) and estimated blood loss (P = 0.60) were not significantly different in the two groups. Ketorolac did not adversely affect renal function; serum creatinine changes were not significantly different from those in the patients receiving placebo (P = 0.50). Laparoscopic pyeloplasty necessitated more narcotic analgesia than did other laparoscopic procedures (P = 0.05). Ketorolac decreases the subjective perception of pain after laparoscopic urologic surgery. It is suggested that ketorolac administration decreases the amount of narcotic usage as well. Time to resumption of oral intake and length of hospital stay were not influenced by use of ketorolac.",2001.0,0,0
517,11331167,"Preoperative oral rofecoxib does not decrease postoperative pain or morphine consumption in patients after radical prostatectomy: a prospective, randomized, double-blinded, placebo-controlled trial.",J J Huang; A Taguchi; H Hsu; G L Andriole; A Kurz,"To evaluate the analgesic efficacy of the rofecoxib po before radical prostatectomy. Prospective, randomized, double-blinded, placebo-controlled trial. Teaching hospital. Anesthetic management was standardized. Patients received either a 50-mg rofecoxib capsule or a placebo capsule po 1 hour before induction of anesthesia. Patient-generated 10-cm visual analog scale (VAS) scores for pain were assessed at 1, 2, 4, 6, 8, and 24 hours after surgery. Morphine consumption was recorded from a patient-controlled analgesia device at the same time. A patient-generated overall pain relief score was obtained at 24 hours after surgery. We were unable to detect any differences between study groups with respect to postoperative morphine consumption, VAS score, or overall pain relief score. When rofecoxib is used po in maximum recommended doses before surgery, it does not provide significant analgesia that results in reduction in pain scores or analgesic requirements for patients after radical prostatectomy.",2001.0,0,0
518,11331168,Comparison of fentanyl and sufentanil in combination with bupivacaine for patient-controlled epidural analgesia during labor.,H Le Guen; D Roy; B Branger; C Ecoffey,"To compare the efficacy of fentanyl plus bupivacaine with sufentanil plus bupivacaine for treatment of pain during labor and delivery using patient-controlled epidural analgesia (PCEA). Prospective, double-blind, clinical investigation. University-affiliated hospital. 226 ASA physical status I and II laboring patients. Patients were randomized to receive 0.125% bupivacaine with fentanyl (2 micro g.ml(-1)) or 0.125% bupivacaine with sufentanil (0.25 micro g.ml(-1)) through PCEA. Maternal analgesia assessed by visual analog scale was recorded before epidural block, 1 and 3 hours after epidural block, at full cervical dilation, and at delivery. Motor blockade assessed by Bromage scale was recorded at delivery. Nine patients in group fentanyl, and 11 in group sufentanil were excluded from the study. Overall analgesia was good and no difference was observed between the two groups. Total boluses of 4 mL bupivacaine-opioid administered and the number of supplementary top-up injections of 5 mL 0.25% bupivacaine were similar in both groups. In group sufentanil, motor blockade and pruritus were significantly lower than in group fentanyl. Nausea was not recorded in any patients. Mode of delivery was similar in both groups, i.e., cesarean section, vacuum or forceps, or spontaneous vaginal delivery. No difference was observed in Apgar scores. Sufentanil is preferable to fentanyl during bupivacaine PCEA as there is less incidence of motor blockade and pruritus.",2001.0,0,0
519,11331334,Strategies to manage the adverse effects of oral morphine: an evidence-based report.,N Cherny; C Ripamonti; J Pereira; C Davis; M Fallon; H McQuay; S Mercadante; G Pasternak; V Ventafridda; Expert Working Group of the European Association of Palliative Care Network,"Successful pain management with opioids requires that adequate analgesia be achieved without excessive adverse effects. By these criteria, a substantial minority of patients treated with oral morphine (10% to 30%) do not have a successful outcome because of (1) excessive adverse effects, (2) inadequate analgesia, or (3) a combination of both excessive adverse effects along with inadequate analgesia. The management of excessive adverse effects remains a major clinical challenge. Multiple approaches have been described to address this problem. The clinical challenge of selecting the best option is enhanced by the lack of definitive, evidence-based comparative data. Indeed, this aspect of opioid therapeutics has become a focus of substantial controversy. This study presents evidence-based recommendations for clinical-practice formulated by an Expert Working Group of the European Association of Palliative Care (EAPC) Research NETWORK: These recommendations highlight the need for careful evaluation to distinguish between morphine adverse effects from comorbidity, dehydration, or drug interactions, and initial consideration of dose reduction (possibly by the addition of a co analgesic). If side effects persist, the clinician should consider options of symptomatic management of the adverse effect, opioid rotation, or switching route of systemic administration. The approaches are described and guidelines are provided to aid in selecting between therapeutic options.",2001.0,1,1
520,11337713,Comparison of morphine and ropivacaine following knee arthroscopy.,F Franceschi; G Rizzello; R Cataldo; V Denaro,"The purpose of this study was to compare the effectiveness of ropivacaine, a new local amidic anesthetic, compared with morphine as an intra-articular drug in controlling pain in patients after arthroscopic knee surgery. Randomized trial. We enrolled 90 patients scheduled to undergo elective knee arthroscopy. Patients were homogenous regarding demographic data and ASA physical status. Procedures included were diagnostic arthroscopies, lateral and medial meniscectomies, meniscal repair, and removal of loose bodies. All cases were treated by the same surgeon, under general anesthesia, using the same procedure. Patients were randomly divided into 3 groups. The first group received ropivacaine 75 mg in 20 mL of saline solution, the second group received 2 mg morphine in 20 mL of saline solution, and the third group received 20 mL of saline solution. No other oral or injectable analgesic administration was allowed. A blind observer assessed the patients' postoperative pain using a 10-cm visual analogue scale (VAS), ranging from no pain (0) to unbearable pain (10). Scores were taken at 0, 1, 4, 6, 12, and 24 hours after drug injection. VAS scores were analyzed using analysis of variance; significance was set at P <.005. None of the patients treated with ropivacaine or morphine needed administration of any other oral or injectable analgesic. No adverse reaction was noted in ropivacaine group. VAS score analysis in the first 4 postoperative hours showed greater effectiveness for ropivacaine versus morphine or placebo with highly significant results (P <.001). In the first 24 postoperative hours, the ropivacaine group versus the morphine group showed no significant differences (P =.207). Although its cost is very high compared with morphine, ropivacaine is a safe, site-specific, and long lasting anesthetic drug with an earlier onset than morphine and almost the same duration, covering the whole postoperative period (24 hours).",2002.0,0,0
521,11343728,,,,,0,0
522,11344385,"Long-acting opioids for chronic pain: pharmacotherapeutic opportunities to enhance compliance, quality of life, and analgesia.",B H McCarberg; R L Barkin,"Effective management of chronic pain has become an increasingly critical issue in health care. Opioid agonists are among the most effective analgesics available for reducing pain perception; however, their chronic use is controversial. This is primarily due to regulatory barriers, misunderstandings about pain management among primary caregivers, fear of adverse side effects, and misconceptions about the potential risks of addiction. Short-acting opioids provide effective analgesia for acute pain but should be avoided as primary analgesics for chronic pain management. Long-acting opioids have greater utility than short-acting opioids in treating chronic pain in patients with consistent pain levels. Results of studies show that improved quality of life is directly related to the use of long-acting opioids in patients with chronic pain of both cancer and noncancer etiology. Short-acting opioids may be used during the initial dose titration period of long-acting formulations and as rescue medication for episodes of breakthrough pain. Clinical experience reveals that selection of an effective pain regimen for the patient with chronic pain, combined with aggressive management of side effects, leads to improved overall functioning and quality of life.",2001.0,0,0
523,11347000,Chronic-pain management--a timely opportunity.,G D Kloeffler; P E Mahan,"During the past decade, there has been an intense debate among pain management specialists in medicine over the appropriate use of medication. This controversy centers around pain control and appropriate narcotic dosage. Dentistry's role in treating chronic pain has become complex because of differing views on pain management protocols. The dental literature regarding chronic-pain management is limited, and dentistry has only a minimal role in pain management. It is time for dentistry to take a larger role in treating chronic pain. The effective use of medications is only one aspect of chronic-pain management. The success rate for managing intractable pain can be substantially improved if practitioners take advantage of early diagnosis, aggressive physiotherapy, and multiple sympathetic blocks, as well as other blocks and antidepressants. For dentists to take an active role in this arena, they need broader education in treatment regimens. Interdependence with physicians and cross-referral between these two professions may lead to more-favorable outcomes, including improved function and quality of life.",2001.0,0,0
524,11348892,Opioids in chronic non-malignant pain.,H McQuay,,2001.0,0,0
525,11348910,Randomised crossover trial of transdermal fentanyl and sustained release oral morphine for treating chronic non-cancer pain.,L Allan; H Hays; N H Jensen; B L de Waroux; M Bolt; R Donald; E Kalso,"To compare patients' preference for transdermal fentanyl or sustained release oral morphine, their level of pain control, and their quality of life after treatment. Randomised, multicentre, international, open label, crossover trial. 35 centres in Belgium, Canada, Denmark, Finland, the United Kingdom, the Netherlands, and South Africa. 256 patients (aged 26-82 years) with chronic non-cancer pain who had been treated with opioids. Patients' preference for transdermal fentanyl or sustained release oral morphine, pain control, quality of life, and safety assessments. Of 212 patients, 138 (65%) preferred transdermal fentanyl, whereas 59 (28%) preferred sustained release oral morphine and 15 (7%) expressed no preference. Better pain relief was the main reason for preference for fentanyl given by 35% of patients. More patients considered pain control as being ""good"" or ""very good"" with fentanyl than with morphine (35% v 23%, P=0.002). These results were reflected in both patients' and investigators' opinions on the global efficacy of transdermal fentanyl. Patients receiving fentanyl had on average higher quality of life scores than those receiving morphine. The incidence of adverse events was similar in both treatment groups; however, more patients experienced constipation with morphine than with fentanyl (48% v 29%, P<0.001). Overall, 41% of patients experienced mild or moderate cutaneous problems associated with wearing the transdermal fentanyl patch, and more patients withdrew because of adverse events during treatment with fentanyl than with morphine (10% v 5%). However, within the subgroup of patients naive to both fentanyl and morphine, similar numbers of patients withdrew owing to adverse effects (11% v 10%, respectively). Transdermal fentanyl was preferred to sustained release oral morphine by patients with chronic non-cancer pain previously treated with opioids. The main reason for preference was better pain relief, achieved with less constipation and an enhanced quality of life.",2001.0,1,1
526,11355054,Chronic pain: treatment barriers and strategies for clinical practice.,M Glajchen,"Chronic pain is a clinical challenge for the practicing physician. Lack of knowledge about opioids, negative attitudes toward prescribing opioids, and inadequate pain-assessment skills combine to create major barriers to pain relief. Patient-related barriers, such as lack of communication and unwarranted fears of addiction, further complicate pain assessment and treatment. The health care system itself can hinder pain relief through practical constraints in the community and fear of regulatory scrutiny by the physician. Information was gathered by doing a literature search, collating clinical information from practice and additional research findings from national meetings, and reviewing the Bulletin of the American Pain Society. Key search terms included ""pain,"" ""chronic pain,"" ""pain management,"" ""pain assessment,"" ""pain treatment,"" and ""barriers to pain management."" Concrete steps for the clinician engaged in the treatment of chronic pain include selection and administration of an effective opioid, dose titration, short- vs long-acting opioids, opioid rotation, ongoing assessment, and consideration of patient preferences. In addition, communication, coping behaviors, and pain education play important roles in the pain equation.",2001.0,0,0
527,11358075,Understanding pain.,R C Haigh; D R Blake,,2001.0,0,0
528,11359591,"A comparison of single dose caudal tramadol, tramadol plus bupivacaine and bupivacaine administration for postoperative analgesia in children.",M Gunduz; D Ozcengiz; H Ozbek; G Isik,"Our aim was to compare the effect of single dose caudal tramadol, tramadol plus bupivacaine and bupivacaine on the management of postoperative pain in children. Sixty-three children in ASA groups I-II, between the ages of 1 and 5 were evaluated for postoperative pain randomly divided into three groups as follows: In group T, only tramadol was given caudally; in group TB, tramadol-bupivacaine was given caudally; in group B, bupivacaine was given alone. Pain was evaluated by using the paediatric objective pain scale (POPS). Sedation was evaluated with a 5-point test. There were no differences with age, weight, haemodynamic and respiratory parameters between groups. For 24 h postoperatively, the POPS value showed no statistically significant difference among groups (P > 0.05). Postoperative analgesia was maintained for 24 h. Nausea and vomiting was found to be higher in the tramadol group than in the bupivacaine group and tramadol-bupivacaine group (P < 0.001 and P < 0.01, respectively). Tramadol used caudally is as effective as bupivacaine in the management of postoperative pain in children and the addition of tramadol to bupivacaine, when both drugs were administered caudally, did not prolong the duration of action of bupivacaine and is a safe agent in children.",2001.0,0,0
529,11359593,A prospective randomized controlled study of the efficacy of ketamine for postoperative pain relief in children after adenotonsillectomy.,R L Aspinall; A Mayor,Adenotonsillectomy is commonly needed by children with obstructive sleep apnoea syndrome. This population is at high risk of life threatening airway obstruction in the postoperative period. Fifty children were studied to test the efficacy of an alternative analgesic to the use of opioids in providing analgesia in the immediate postoperative period. Patients were randomized to receive either 0.1 mg.kg-1 morphine or 0.5 mg.kg-1 ketamine at induction. Ketamine was as effective as morphine with no additional side-effects. Ketamine is a safe and effective alternative to morphine to provide analgesia in the immediate postoperative period after tonsillectomy.,2001.0,0,0
530,11361046,"Double-blind, randomized comparison of the analgesic and pharmacokinetic profiles of controlled- and immediate-release oral oxycodone in cancer pain patients.",J E Stambaugh; R F Reder; M D Stambaugh; H Stambaugh; M Davis,"Thirty patients with cancer pain completed a double-blind crossover study comparing controlled-release (CR) and immediate-release (IR) oxycodone. In open-label titration (2 to 21 days), these patients were stabilized on IR oxycodone qid. They were then randomized to double-blind treatment with CR oxycodone q12h or IR oxycodone qid for 3 to 7 days followed by crossover at the same daily dose. Mean (+/- SD) pain intensity (0 = none to 10 = severe) decreased from a baseline of 6.0 +/- 2.2 to 2.7 +/- 1.1 after titration with IR oxycodone dosed qid. Pain intensity remained stable throughout double-blind treatment: 2.7 +/- 1.9 with CR oxycodone and 2.8 +/- 1.9 with IR oxycodone. Acceptability of therapy and pain scores correlated with plasma oxycodone concentrations for each interval and were similar for both medications (IR and CR oxycodone). Adverse events were similar for both formulations. Following repeat dosing under double-blind conditions, oral CR oxycodone administered q12h provided analgesia comparable to IR oxycodone given qid.",2001.0,0,0
531,11361277,Dextropropoxyphene dependence: a cautionary note.,T Edwin; N Nammalvar; V Ramanujam,"Drug abuse and dependence is common in patients with chronic pain. Of concern are the opioid analgesics prescribed commonly, and its availability over the counter. Often the cause of dependence is iatrogenic. We report a case of a patient with chronic back pain and dextropropoxyphene dependence. With chronic pain being a significant risk factor for drug dependence, increased caution by the prescribing physicians is advisable while treating such patients using opioid analgesics. The dangers of opioid dependence, associated risk factors, and issues regarding the prescription of such medication are discussed to aid prevention of prescription drug abuse seen in general practice.",2001.0,0,0
532,11371738,,,,,0,0
533,11374604,Analgesic effect of low-dose intrathecal morphine after spinal fusion in children.,O Gall; J V Aubineau; J Bernière; L Desjeux; I Murat,"This study was designed to assess the postoperative analgesic effect of low-dose intrathecal morphine after scoliosis surgery in children. Thirty children, 9-19 yr of age, scheduled for spinal fusion, were randomly allocated into three groups to receive a single dose of 0 (saline injection), 2, or 5 microg/kg intrathecal morphine. After surgery, a patient-controlled analgesia device (PCA) provided free access to additional intravenous morphine. Children were monitored for 24 h in the postanesthesia care unit. The three groups were similar for age, weight, duration of surgery, and time to extubation. The time to first PCA demand was dose-dependently delayed by intrathecal morphine. The first 24 h of PCA morphine consumption was 49 +/- 17, 19 +/- 10, and 12 +/- 12 mg (mean +/- SD) in the saline, 2 microg/kg morphine, and 5 microg/kg morphine groups, respectively. Pain scores at rest were significantly lower over the whole study period after 2 and 5 microg/kg intrathecal morphine than after saline, but there was no difference between intrathecal doses. Pain scores while coughing and the incidence of side effects were similar in the three groups. These data demonstrate that low-dose intrathecal morphine supplemented by PCA morphine provides better analgesia than PCA morphine alone after spinal fusion in children. The doses of 2 and 5 microg/kg seem to have similar effectiveness and side-effect profiles, whereas a reduction of intraoperative bleeding was observed in patients who received 5 microg/kg but not 2 microg/kg intrathecal morphine.",2001.0,0,0
534,11379678,Minimum local analgesic dose of intrathecal bupivacaine in labor and the effect of intrathecal fentanyl.,G M Stocks; S P Hallworth; R Fernando; A J England; M O Columb; G Lyons,"Combining bupivacaine with fentanyl for intrathecal analgesia in labor is well recognized, but dosages commonly used are arbitrarily chosen and may be excessive. This study aimed to determine the median effective dose (ED50) of intrathecal bupivacaine, defined as the minimum local analgesic dose (MLAD), and then use this to assess the effect of different doses of fentanyl. In this double-blind, randomized, prospective study, 124 parturients receiving combined spinal epidural analgesia at 2-6-cm cervical dilatation were allocated to one of four groups to receive bupivacaine alone or with 5, 15, or 25 microg fentanyl, using the technique of up-down sequential allocation. Analgesic effectiveness was assessed using 100-mm visual analog pain scores, with less than or equal to 10 mm within 15 min defined as effective. MLAD was calculated using the formula of Dixon and Massey. Pruritus and duration of spinal analgesia were also recorded. Minimum local analgesic dose of intrathecal bupivacaine was 1.99 mg (95% confidence interval, 1.71, 2.27). There were similar significant reductions in MLAD (P < 0.001) for all bupivacaine-fentanyl groups compared with bupivacaine control. There was a dose-dependent increase in both pruritus and duration of spinal analgesia with increasing fentanyl (P < 0.0001). Under the conditions of this study, the addition of intrathecal fentanyl 5 microg offers a similar significant bupivacaine dose-sparing effect as 15 and 25 microg. Analgesia in the first stage of labor can be achieved using lower doses of fentanyl, resulting in less pruritus but with a shortening of duration of action.",2001.0,0,0
535,11388521,Dose-dependent regional cerebral blood flow changes during remifentanil infusion in humans: a positron emission tomography study.,K J Wagner; F Willoch; E F Kochs; T Siessmeier; T R Tölle; M Schwaiger; P Bartenstein,"The current study investigated dose-dependent effects of the mu-selective agonist remifentanil on regional cerebral blood flow (rCBF) in volunteers using positron emission tomography (PET). Ten right-handed male volunteers were included in a 15O-water PET study. Seven underwent three conditions: control (saline), low remifentanil (0.05 microg x kg(-1) x min(-1)), and moderate remifentanil (0.15 microg x kg(-1) x min(-1)). The remaining three participated in the low and moderate conditions. A semirandomized study protocol was used with control and remifentanil conditions 3 or more months apart. The order of low and moderate conditions was randomized. Cardiovascular and respiratory parameters were monitored. Categoric comparisons between the control, low, and moderate conditions and a pixelwise correlation analysis across the three conditions were performed (P < 0.05, corrected for multiple comparisons) using statistical parametric mapping. Cardiorespiratory parameters were maintained constant over time. At the low remifentanil dose, significant increases in relative rCBF were noted in the lateral prefrontal cortices, inferior parietal cortices, and supplementary motor area. Relative rCBF decreases were observed in the basal mediofrontal cortex, cerebellum, superior temporal lobe, and midbrain gray matter. Moderate doses further increased rCBF in mediofrontal and anterior cingulate cortices, occipital lobe transition, and caudal periventricular grey. Significant decreases were detected in the inferior parietal lobes. These dose-dependent effects of remifentanil on rCBF were confirmed by a correlation analysis. Remifentanil induced dose-dependent changes in relative rCBF in areas involved in pain processing. At moderate doses, rCBF responses were additionally detected in structures known to participate in modulation of vigilance and alertness. Insight into the mechanisms of opioid analgesia within the pain-processing neural network may lead to a better understanding of antinociception and opioid treatment.",2001.0,0,0
536,11392067,Thoracic epidural analgesia with morphine does not prevent postthoracotomy pain syndrome: a survey of 159 patients.,J S Hu; P W Lui; H Wang; K H Chan; H N Luk; M Y Tsou; T Y Lee,"This retrospective study sought to determine the incidence of postthoracotomy pain syndrome (PTPS), and whether epidural morphine for the postoperative analgesia could prevent the development of PTPS. We reviewed the charts of 372 patients who had undergone thoracotomy. The majority underwent general anesthesia (GA) combined with thoracic epidural analgesia (TEA). Of the 372 patients, only 159 (42%) were available for interview. Patients were divided into two groups based on the duration of pain, i.e., pain group (pain > 3 months, n = 65) and pain-free group (pain < 3 months, n = 94). Both groups were comparable regarding sex, age, weight, height, smoking, alcohol ingestion, education, marital status, duration of surgery, and the number of patients either receiving GA plus TEA or GA alone. About 41% of the patients experienced PTPS that persisted for 21 +/- 12 mon (follow-up: 28 +/- 12 mon). Most pain was mild or moderate and was usually described as being only a discomfort. Only 6.2% suffered severe pain with shooting, aching, burning or numbness. Patients with PTPS suffered more depression and insomnia. The incidence of PTPS was not different in patients who received GA alone or GA plus TEA (39% vs. 42%). Epidural morphine for postoperative analgesia that continued for 3 days appeared to have no effect in the prevention of PTPS.",2001.0,0,0
537,11394033,Functional anorectal and pelvic pain.,A Wald,"Functional anorectal and pelvic pain syndromes represent a diverse group of disorders that affect the quality of life and about which many physicians possess little understanding. Nongynecologic causes include levator ani syndrome, proctalgia fugax, and coccygodnia, which can often be distinguished by careful history and physical examination. In women, chronic pelvic pain may arise from the uterus, cervix, ovaries, or from endometriosis and pelvic adhesions. This article reviews these diverse disorders and the approach to diagnosis and management.",2001.0,0,0
538,11394604,Does intraarticular morphine improve pain control with femoral nerve block after anterior cruciate ligament reconstruction?,E C McCarty; K P Spindler; E Tingstad; Y Shyr; M Higgins,"In a prospective, randomized, double-blinded manner, we compared the effects of a preoperative intraarticular injection of morphine (5 mg) or a placebo, combined with a postoperative femoral nerve block, on postoperative pain. Sixty-two patients underwent an arthroscopically assisted anterior cruciate ligament reconstruction using patellar tendon autograft under general anesthesia. No statistical difference between the two groups was evident in terms of age, sex, weight, operative time, volume of bupivacaine received with the femoral nerve block, or tourniquet use or tourniquet time. Comparison of visual analog scale pain scores revealed no statistical difference between the groups at any point after the operation. Both groups had a significant decrease in visual analog scale scores after the femoral nerve block, with the lowest mean values 4 hours after the operation (morphine group, 1.7; placebo group, 1.4), and continuing to be significantly less through 24 hours (morphine, 2.6; placebo, 2.9). No significant difference in postoperative narcotic medication use was evident in the recovery room or at home. A post hoc power analysis revealed that the study power reached 87%, with a significance level of 5%. The postoperative femoral nerve block was effective, and intraarticular morphine provided no additional benefit.",2001.0,0,0
539,11398821,,,,,0,0
540,11402361,Pain following spinal cord injury.,P J Siddall; J D Loeser,"Chronic pain is an important problem following spinal cord injury (SCI) and is a major impediment to effective rehabilitation. The reported prevalence of chronic SCI pain is variable but averages 65% with around one third of these people rating their pain as severe. The mechanisms responsible for the presence of pain are poorly understood. However, evidence from clinical observations and the use of animal models of SCI pain suggests that a number of processes may be important. These include functional and structural plastic changes in the central nervous system following injury, with changes in receptor function and loss of normal inhibition resulting in an increased neuronal excitability. A number of specific types of SCI pain can be distinguished based on descriptors, location and response to treatment. Nociceptive pain can arise from musculoskeletal structures and viscera and neuropathic pain can arise from spinal cord and nerve damage. The role of psychological and environmental factors also needs to be considered. Accurate identification of these pain types will help in selecting appropriate treatment approaches. Current treatments employ a variety of pharmacological, surgical, physical and psychological approaches. However, evidence for many of the treatments in use is still limited. It is hoped that future research will identify effective treatment strategies that accurately target specific mechanisms.",2001.0,0,0
541,11406341,Response expectancies in placebo analgesia and their clinical relevance.,A Pollo; M Amanzio; A Arslanian; C Casadio; G Maggi; F Benedetti,"Response expectancies have been proposed as the major determinant of placebo effects. Here we report that different expectations produce different analgesic effects which in turn can be harnessed in clinical practice. Thoracotomized patients were treated with buprenorphine on request for 3 consecutive days, together with a basal intravenous infusion of saline solution. However, the symbolic meaning of this basal infusion was changed in three different groups of patients. The first group was told nothing about any analgesic effect (natural history). The second group was told that the basal infusion was either a powerful painkiller or a placebo (classic double-blind administration). The third group was told that the basal infusion was a potent painkiller (deceptive administration). Therefore, whereas the analgesic treatment was exactly the same in the three groups, the verbal instructions about the basal infusion differed. The placebo effect of the saline basal infusion was measured by recording the doses of buprenorphine requested over the three-days treatment. We found that the double-blind group showed a reduction of buprenorphine requests compared to the natural history group. However, this reduction was even larger in the deceptive administration group. Overall, after 3 days of placebo infusion, the first group received 11.55 mg of buprenorphine, the second group 9.15 mg, and the third group 7.65 mg. Despite these dose differences, analgesia was the same in the three groups. These results indicate that different verbal instructions about certain and uncertain expectations of analgesia produce different placebo analgesic effects, which in turn trigger a dramatic change of behaviour leading to a significant reduction of opioid intake.",2001.0,0,0
542,11411106,[Two cases of successful treatments with steroid for local and systemic hypersensitivity reaction following intravesical instillation of Bacillus Calmette-Guerin].,N Shimasaki; I Yamasaki; M Kamada; T Syuin,"We have found steroid pulse therapy to be effective and safe for local and systemic adverse reactions of BCG therapy. Two cases are reported. Case 1: A 57-year-old woman with initial recurrence of urinary bladder carcinoma was treated with transurethral resection. The histopathological findings were transitional cell carcinoma (TCC), G2 > G1, pT1a. To prevent a second recurrence, she was administered Bacillus Calmette-Guerin (BCG) instillation therapy: 80 mg of BCG, (Tokyo strain) suspended in 40 ml of normal saline, instilled into her bladder weekly. After the fifth week of instillation, she was found to have a cough, sputum, edema of the eyelids, congestion of palpebral conjunctive, severe pain on micturition and pollakisuria. Although she was administered antituberculus, antibiotics and antiallergic drugs, all sign and symptoms were aggravated. Blood, urine and sputum cultures remained negative for mycobacterium. She was later diagnosed as having hypersensitive reactions against BCG and treated with steroid pulse therapy. The signs and symptoms mentioned above were decreased immediately and disappeared after a week. Case 2: A 76-year-old man with initial recurrence of urinary bladder carcinoma was treated with transurethral resection. To prevent a second recurrence, he was instilled the BCG six (6) times. Although no adverse reaction was observed, urinary cytology remained positive (class V) and small papillary tumor was detected at the dome of the bladder. Transurethral biopsy was then performed. The histopathological findings showed TCC, G3, CIS on the dome of bladder. Then he was again administered the same BCG instillation therapy. After the fifth instillation, he complained of severe pain of micturition, pollakisuria and dysuria. Although he was administered antibiotics and antiinflammatory drugs, all signs and symptoms were aggravated. Urine culture remained negative for mycobacterium. He was diagnosed as having hypersensitive reactions against BCG and was treated with two times of steroid pulse therapy. The signs and symptoms mentioned above were decreased immediately and disappeared after the second steroid pulse therapy.",2001.0,0,0
543,11412156,Analgesic efficacy and safety of nefopam vs. propacetamol following hepatic resection.,O Mimoz; P Incagnoli; C Josse; M C Gillon; L Kuhlman; A Mirand; H Soilleux; D Fletcher,"In order to compare the morphine-sparing effect, analgesic efficacy and tolerance of nefopam and propacetamol given at their highest recommended doses, 120 patients undergoing elective hepatic resection were randomly assigned to receive postoperative intravenous patient-controlled analgesia with morphine alone, or in combination with nefopam (20 mg.4 h-1) or propacetamol (2 g.6 h-1). Compared with the control group (43 [7-92] mg), median [range] cumulative morphine consumption for 24 h after the study started was halved in the nefopam group (21 [3-78] mg, p <0.001) and 20% lower in the propacetamol group (35 [6-84] mg, p = 0.15). Analgesia was superior in the nefopam group despite the lower morphine consumption. Adverse effects were comparable in the three groups, except for significantly more nausea in the control group (39% vs. 17 and 26% in the nefopam and propacetamol groups, respectively) and more sweating in the nefopam group (17% vs. 0 and 3% in the control and propacetamol groups, respectively). Overall patient satisfaction was better (p < 0.001) in patients given nefopam (97%) than those receiving morphine alone (82%) or propacetamol (74%).",2001.0,0,0
544,11412157,Minimum local analgesic dose of plain ropivacaine vs. ropivacaine combined with sufentanil during epidural analgesia for labour.,S Palm; W Gertzen; T Ledowski; M Gleim; H Wulf,"We have used the up-and-down allocation technique to assess the relative analgesic potencies of epidural ropivacaine alone and ropivacaine combined with sufentanil 0.75 microg.ml-1 in 42 women requesting epidural analgesia in the first stage of labour. Parturients were randomly allocated to one of the two epidural solutions in a double-blind manner. The concentration of local anaesthetic was determined by the response of the previous parturient: an effective concentration (pain < or = 10 mm on a 10-cm visual analogue pain score within 30 min) resulted in a 0.01% decrease in the concentration of ropivacaine for the next parturient, an ineffective concentration resulted in a 0.01% increase. Minimum local analgesic concentration of ropivacaine alone was 0.13% (95% CI 0.12-0.13%) compared with 0.09% (95% CI 0.08-0.1%) for ropivacaine with sufentanil (p < 0.00001).",2001.0,0,0
545,11412292,A randomized controlled double-blind trial comparing piritramide and morphine for analgesia after hysterectomy.,U R Döpfmer; M R Schenk; S Kuscic; D H Beck; S Döpfmer; W J Kox,"Efficacy and side-effects of piritramide (pirinitramide) and morphine, given intravenously for postoperative analgesia after hysterectomy, were compared in a randomized controlled double-blind trial in 92 ASA class I-III patients. Administration was investigator-controlled during the first 90 min and subsequently via a patient-controlled device. Visual analogue scales for pain intensity and verbal rating scales for side-effects were taken repeatedly. Median visual analogue scores for pain intensity on a 100-mm scale 4, 8 and 24 h after surgery were 10, 8.5 and 5 mm in the piritramide group and 18, 10 and 8.5 mm in the morphine group. These differences are neither statistically nor clinically significant. Median values for nausea on a verbal rating scale from 0 to 3 were zero for both groups at all times with similar ranges. There was no difference in number of episodes of vomiting and retching and usage of antiemetics. The mean amount of piritramide used for initial titration was 15.2 mg; the respective amount of morphine was 15.4 mg. In this setting the two agents are equally effective and show a similar profile of side-effects.",2001.0,0,0
546,11419151,,,,,0,0
547,11421146,The influence of an organizational pain management policy on nurses' pain management practices.,L G Alley,"To examine the influence of a formal organizational pain management policy on nurses' pain management practices. Descriptive correlational. Tertiary-care medical center. 91 nurses providing direct patient care on five study units during a 72-hour study period. Off-going nurses completed three self-administered questionnaires one-half hour before the end of each eight-hour work shift. Opioid administration data also were collected. Data were analyzed using correlational, t test, chi-square, and analysis of variance analyses and descriptive statistics. Nurses' knowledge of the healthcare organization's chronic pain management policy; nurses' knowledge of pain and pain management; nurses' perceived accountability for pain management activities; the ratio of actual amounts of opioid analgesics administered compared with maximum amounts ordered. Nurses' knowledge of pain management and their perceived accountability for pain management were significantly related to knowledge of the organization's chronic pain management policy. Correlations were lower than expected, based on theoretical relationships proposed in the open system study framework. Further research is needed to explore the influence of a high-quality pain management policy on nursing practice and clinical pain management. Better understanding of the influence of organizational policy could lead to much needed improvements in pain management.",2001.0,0,0
548,11421841,Postoperative analgesia by combined continuous infusion and patient-controlled epidural analgesia (PCEA) following hip replacement: ropivacaine versus bupivacaine.,L Bertini; S Mancini; P Di Benedetto; A Ciaschi; O Martini; S Nava; V Tagariello,"Ropivacaine is a new local anaesthetic, which compared to bupivacaine is less toxic and shows greater sensory and motor block dissociation. We hypothesised that treatment of postoperative pain with a combined regimen of continuous epidural infusion and Patient-Controlled Epidural Analgesia (PCEA) using ropivacaine could have given better results compared with those we had obtained using bupivacaine. Patients undergoing total hip replacement were randomly assigned to two groups. They received epidural analgesia for postoperative pain treatment using ropivacaine, 2 mg x ml(-1) or bupivacaine 2 mg x ml(-1). Both drugs were administered as a constant infusion of 6 ml x h(-1) supplemented by PCEA bolus doses of 2 ml. Patients in both groups received morphine intravenously on demand from a patient-controlled analgesia (PCA) device. An independent observer recorded pain scores, intensity of motor block and morphine consumption at regular intervals during the first 24 h after surgery. Fifty-one patients were evaluated. Ropivacaine and bupivacaine, in similar amounts, provided similar results assessed as adequate to very good postoperative analgesia, whereas motor block was significantly more intense in patients treated with bupivacaine. Despite similar analgesic effects, epidural infusion of ropivacaine combined with PCEA provides higher patient satisfaction than equal doses of bupivacaine due to lack of motor block.",2001.0,0,0
549,11432176,"Preemptive effects of a combination of preoperative diclofenac, butorphanol, and lidocaine on postoperative pain management following orthognathic surgery.",C Nagatsuka; T Ichinohe; Y Kaneko,"The aim of the study was to investigate whether preemptive multimodal analgesia (diclofenac, butorphanol, and lidocaine) was obtained during sagittal split ramus osteotomy (SSRO). Following institutional approval and informed consent, 82 healthy patients (ASA-I) undergoing SSRO were randomly assigned to 1 of 2 groups, the preemptive multimodal analgesia group (group P, n = 41) and the control group (group C, n = 41). This study was conducted in a double-blind manner. Patients in group P received 50 mg rectal diclofenac sodium, 10 micrograms/kg intravenous 0.1% butorphanol tartrate, and 1% lidocaine solution containing 10 micrograms/mL epinephrine for regional anesthesia and for bilateral inferior alveolar nerve blocks before the start of surgery. Postoperative pain intensity at rest (POPI) was assessed on a numerical rating score (NRS) in the postanesthesia care unit (PACU) and on a visual analogue scale (VAS) at the first water intake (FWI) and at 24, 48, and 72 hours after extubation. POPI in the PACU was significantly lower in group P than in group C, whereas there were no significant differences at FWI, 24, 48, and 72 hours after extubation in both groups. Preemptive multimodal analgesia was not observed in this study.",2001.0,0,0
550,11437760,Combined pre-incisional oral dextromethorphan and epidural lidocaine for postoperative pain reduction and morphine sparing: a randomised double-blind study on day-surgery patients.,A A Weinbroum; G Lalayev; T Yashar; R Ben-Abraham; D Niv; R Flaishon,"The reduction in acute pain perception following dextromethorphan has previously been investigated in patients undergoing general anaesthesia. This random and double-blind study examined the effects of pre-incisional oral dextromethorphan on postoperative pain and intravenous patient-controlled morphine demand in 60 day-surgery patients undergoing lower body surgery under lidocaine (1.6%-16 ml) epidural anaesthesia after receiving placebo, 60 or 90 mg dextromethorphan, 90 min pre-operatively. Postoperative pain was scored on a visual analogue scale from 1 to 10. In-hospital observation continued for 6 h and for 3 days at home; diclofenac was available throughout. Dextromethorphan-treated patients reported significantly (p < 0.05) less pain and sedation, and felt better. Patients who received dextromethorphan 90 mg had significantly (p < 0.05) lower heart and respiratory rates than those who received 60 mg. Medicated patients required half the morphine and diclofenac of placebo patients: 38% of patients who received 90 mg and 21% who received dextromethorphan 60 mg used no morphine or diclofenac whatsoever, a previously unreported finding.",2001.0,0,0
551,11437873,"A comparison of five solutions of local anaesthetics and/or sufentanil for continuous, postoperative epidural analgesia after major urological surgery.",M Hübler; R J Litz; K H Sengebusch; I Kreinecker; M D Frank; O W Hakenberg; D M Albrecht,"The aim of the present study was to compare and assess the quality of analgesia, the safety and the side-effects after the use of a continuous, thoracic epidural infusion of sufentanil (5 microg h(-1)), 0.25% bupivacaine (10 mL h(-1)), 0.2% ropivacaine (10 mL h(-1)) alone or in combination in patients who had undergone major urological surgery. This prospective, randomized, double-blinded study investigated the efficacy of thoracic epidural infusions after major urological surgery. Patients received a 72-h continuous infusion (10 mL h(-1)) of 0.25% bupivacaine (B), 0.2% ropivacaine (R), 0.25% bupivacaine with 0.5 microg mL(-1) sufentanil (BS), 0.2% ropivacaine with 0.5 microg mL(-1) sufentanil (RS) or 0.5 microg mL(-1) sufentanil only (S). The analysis included 109 patients. The mean visual analogue scale (VAS) scores for pain were highest in the groups R and S (P < 0.001). The PaCO2 values were significantly higher in the groups RS and S (P = 0.003). Motor block occurred more frequently in the groups B and BS than in the other groups (P < 0.001). Sedation, nausea and pruritus were more common in the groups that received sufentanil. A continuous, epidural infusion with these drugs was safe and effective in our patients. The combination of 0.2% ropivacaine plus sufentanil appeared preferable because of the low incidence of motor block.",2001.0,0,0
552,11440921,Cannabinoids for pain and nausea.,E Kalso,,2001.0,0,0
553,11440935,Are cannabinoids an effective and safe treatment option in the management of pain? A qualitative systematic review.,F A Campbell; M R Tramèr; D Carroll; D J Reynolds; R A Moore; H J McQuay,"To establish whether cannabis is an effective and safe treatment option in the management of pain. Systematic review of randomised controlled trials. Electronic databases Medline, Embase, Oxford Pain Database, and Cochrane Library; references from identified papers; hand searches. Trials of cannabis given by any route of administration (experimental intervention) with any analgesic or placebo (control intervention) in patients with acute, chronic non-malignant, or cancer pain. Outcomes examined were pain intensity scores, pain relief scores, and adverse effects. Validity of trials was assessed independently with the Oxford score. Independent data extraction; discrepancies resolved by consensus. 20 randomised controlled trials were identified, 11 of which were excluded. Of the 9 included trials (222 patients), 5 trials related to cancer pain, 2 to chronic non-malignant pain, and 2 to acute postoperative pain. No randomised controlled trials evaluated cannabis; all tested active substances were cannabinoids. Oral delta-9-tetrahydrocannabinol (THC) 5-20 mg, an oral synthetic nitrogen analogue of THC 1 mg, and intramuscular levonantradol 1.5-3 mg were about as effective as codeine 50-120 mg, and oral benzopyranoperidine 2-4 mg was less effective than codeine 60-120 mg and no better than placebo. Adverse effects, most often psychotropic, were common. Cannabinoids are no more effective than codeine in controlling pain and have depressant effects on the central nervous system that limit their use. Their widespread introduction into clinical practice for pain management is therefore undesirable. In acute postoperative pain they should not be used. Before cannabinoids can be considered for treating spasticity and neuropathic pain, further valid randomised controlled studies are needed.",2001.0,0,0
554,11442865,Comparison of caudal morphine and tramadol for postoperative pain control in children undergoing inguinal herniorrhaphy.,D Ozcengiz; M Gunduz; H Ozbek; G Isik,"We compared the quality and duration of analgesia, the effect on perioperative sevoflurane requirement after a single, presurgical caudal block with either tramadol or morphine in children undergoing inguinal herniorrhaphy. Our study was also designed to evaluate the preemptive analgesic efficacy of morphine administered caudally in children. Patients were randomly divided into three groups to receive 2 mg.kg-1 tramadol (group T, preemptive group) or morphine sulphate 0.03 mg.kg-1 (group M, preemptive group). The patients in control group (group C, postincisional group) received morphine sulphate 0.03 mg.kg-1 at the end of surgery, caudally. Cardiorespiratory data, sedation and pain were recorded for 24 h following recovery from anaesthesia. There were no differences between the three groups in baseline blood pressure or heart rate; or duration of anaesthesia, surgery. The inhaled sevoflurane concentration was significantly lower in group M and group T than in the control group. The quality and duration of postoperative pain relief did not differ between the three groups. There were no intergroup differences in postoperative nausea, vomiting, or other complications. Caudal tramadol (2 mg.kg-1) provided reliable postoperative analgesia similar to caudal morphine (0.03 mg.kg-1) in quality and duration of pain relief in our study children who were undergoing herniorrhaphy. We also concluded that presurgical caudal morphine or tramadol reduced perioperative sevoflurane requirements and either presurgical or postsurgical caudal morphine did not make any difference to postoperative analgesia.",2001.0,0,0
555,11444449,Intrathecal bupivacaine with morphine or neostigmine for postoperative analgesia after total knee replacement surgery.,P H Tan; Y Y Chia; Y Lo; K Liu; L C Yang; T H Lee,"To compare the postoperative analgesic efficacy and safety of intrathecal (IT) neostigmine and IT morphine in patients undergoing total knee replacement under spinal anesthesia. Sixty patients scheduled for elective total knee replacement under spinal anesthesia were randomly divided into three equal groups which received IT 0.5% hyperbaric bupivacaine 15 mg with either normal saline 0.5 mL, neostigmine 50 microg, or morphine 300 microg. The maximal level of sensory block, duration of analgesia, time to use of rescue analgesics, the overall 24-hr and four-hour interval visual analogue scale (VAS) pain score, and the incidence of adverse effects were recorded for 24 hr after administration. There was no significant difference in maximal level of sensory block among the three groups. The morphine group had a later onset of postsurgical pain and longer time to first rescue analgesics than the neostigmine group (P <0.05). Overall 24-hr VAS pain scores were significantly higher in the saline group vs the morphine and neostigmine groups (P <0.05). Motor block lasted significantly longer in the neostigmine group than in the morphine and saline groups (P <0.05). The incidence of adverse effects was similar in the neostigmine and morphine groups except for pruritus (70%) occurring more frequently in the morphine group than in the neostigmine and saline groups (0%; P <0.05). Overall satisfaction rates were better in the neostigmine group than in the morphine and saline groups (P <0.05). IT neostigmine 50 microg produced postoperative analgesia lasting about seven hours with fewer side effects and better satisfaction ratings than IT morphine 300 microg.",2002.0,0,0
556,11444452,"Either sufentanil or fentanyl, in addition to intrathecal bupivacaine, provide satisfactory early labour analgesia.",C J Cheng; A T Sia; E H Lim; G P Loke; H M Tan,"The study was aimed primarily at comparing the duration of analgesia produced by intrathecal fentanyl 25 microg with sufentanil 5 microg when added to bupivacaine 1.25 mg as the initial component of the combined spinal epidural (CSE) technique in early labour. Forty healthy parturients were randomly assigned into two groups to receive either intrathecal sufentanil 5 microg plus bupivacaine 1.25 mg (Group S) or intrathecal fentanyl 25 microg plus bupivacaine 1.25 mg (Group F). Apart from the duration of analgesia, pain scores and side effects were also evaluated. There was no significant difference in the duration of analgesia (mean 109 +/- SD 49 min in Group F vs 118 +/- 54 min in Group S, P=0.9). Group F had a more rapid onset of analgesia (P <0.05) and a higher cephalad block (median T4 vs T7, P <0.05) in the first 30 min after the block. No difference in the side effects was detected. Fentanyl 25 microg is a good alternative to sufentanil 5 microg when added to bupivacaine 1.25 mg for early labour analgesia.",2002.0,0,0
557,11453888,Contribution of dihydrocodeine and dihydromorphine to analgesia following dihydrocodeine administration in man: a PK-PD modelling analysis.,J A Webb; A Rostami-Hodjegan; R Abdul-Manap; U Hofmann; G Mikus; F Kamali,"It is not clear whether the analgesic effect following dihydrocodeine (DHC) administration is due to either DHC itself or its metabolite, dihydromorphine (DHM). We examined the relative contribution of DHC and DHM to analgesia following DHC administration in a group of healthy volunteers using a PK-PD link modelling approach. A single oral dose of DHC (90 mg) was administered to 10 healthy volunteers in a randomised, double-blind, placebo-controlled study. A computerized cold pressor test (CPT) was used to measure analgesia. On each study day, the volunteers performed the CPT before study medication and at 1.25, 2.75, 4.25 and 5.75 h postdose. Blood samples were taken at 0.25 h (predose) and then at half hourly intervals for 5.75 h postdose. PK-PD link modelling was used to describe the relationships between DHC, DHM and analgesic effect. Mean pain AUCs following DHC administration were significantly different to those following placebo administration (P = 0.001). Mean pain AUC changes were 91 score x s(-1) for DHC and -17 score x s(-1) for placebo (95% CI = +/- 36.5 for both treatments). The assumption of a simple linear relationship between DHC concentration and effect provided a significantly better fit than the model containing DHM as the active moiety (AIC = 4.431 vs 4.668, respectively). The more complex models did not improve the likelihood of model fits significantly. The findings suggest that the analgesic effect following DHC ingestion is mainly attributed to the parent drug rather than its DHM metabolite. It can thus be inferred that polymorphic differences in DHC metabolism to DHM have little or no effect on the analgesic affect.",2001.0,0,0
558,11459716,Opioid analgesic drugs in older people.,P G Fine,"Many studies have corroborated the finding that older patients in all clinical settings are at risk for insufficient assessment and inadequate management of pain. Opioid analgesics can greatly improve the quality of life and functional capacities of older patients with moderate to severe pain that is not responsive to other therapies; however, these agents are underused in this population. To improve the care of older patients, clinicians must develop expertise in appropriate indications, pharmacologic properties, drug-disease and drug-drug interactions, and ongoing monitoring of opioid analgesic therapy.",2001.0,0,0
559,11459720,Regulatory issues in pain management.,D Fujimoto,"Patients commonly are left to suffer from pain that affects their daily lives. The prevalence of undertreated, moderate to severe pain is a public health problem in many countries, including the United States. In many cases, opioids should be the mainstay for the treatment of this level of pain, but they often are not used or are underdosed. One of the reasons for this underuse most cited by health care professionals is their fear of sanctions by their governing boards, law enforcement, or their misunderstanding of the laws and regulations governing the use of these controlled substances. This article reviews some of the relevant issues of the regulation of controlled substances, updates the reader about the laws, and provides guidance to practitioners about the appropriate use of controlled substances, especially opioids, to manage pain.",2001.0,0,0
560,11459722,Pain in the nursing home.,W M Stein,"The treatment of pain in the nursing home setting continues to present several unique and challenging problems. Increasingly, studies are focusing on the large number of elderly with important pain problems in long-term care. The inclusion of pain as an area of clinical focus in the Minimum Data Set has fueled interest in this problem and will provide solid data for future study. Researchers are attempting to establish reliable and valid data using standardized assessment tools previously validated in younger adults and are attempting use of traditional and cutting-edge assessment tools in cognitively impaired patients. Assessment is being linked to innovative interventions in noncommunicative, cognitively impaired residents using primary care nurses who best know these patients to decipher ""normal"" from ""abnormal"" behavior. The application of available pharmacologic interventions are more challenging because of the higher incidence of side effects in the elderly; part of this problem is the result of the decreased hepatic metabolism and renal clearance present in older patients. The nursing home environment has limited resources that can create logistical concerns in terms of diagnosis and treatment but also can positively limit overly invasive modalities. This article explores these issues and offers suggestions for the appropriate assessment and management of pain in long-term care residents.",2001.0,0,0
561,11460798,Advances in pain.,D J Rowbotham,,2001.0,0,0
562,11460802,Chronic opioid therapy for non-cancer pain.,B J Collett,,2001.0,0,0
563,11460816,Chronic pain after surgery.,W A Macrae,,2001.0,0,0
564,11465012,Glutamate receptors and nociception: implications for the drug treatment of pain.,M E Fundytus,"Evidence from the last several decades indicates that the excitatory amino acid glutamate plays a significant role in nociceptive processing. Glutamate and glutamate receptors are located in areas of the brain, spinal cord and periphery that are involved in pain sensation and transmission. Glutamate acts at several types of receptors, including ionotropic (directly coupled to ion channels) and metabotropic (directly coupled to intracellular second messengers). Ionotropic receptors include those selectively activated by N-methyl-D-aspartate, alpha-amino-3-hydroxy-5-methylisoxazole-4-propionic acid and kainate. Metabotropic glutamate receptors are classified into 3 groups based on sequence homology, signal transduction mechanisms and receptor pharmacology. Glutamate also interacts with the opioid system, and intrathecal or systemic coadministration of glutamate receptor antagonists with opioids may enhance analgesia while reducing the development of opioid tolerance and dependence. The actions of glutamate in the brain seem to be more complex. Activation of glutamate receptors in some brain areas seems to be pronociceptive (e.g. thalamus, trigeminal nucleus), although activation of glutamate receptors in other brain areas seems to be antinociceptive (e.g. periaqueductal grey, ventrolateral medulla). Application of glutamate, or agonists selective for one of the several types of glutamate receptor, to the spinal cord or periphery induces nociceptive behaviours. Inhibition of glutamate release, or of glutamate receptors, in the spinal cord or periphery attenuates both acute and chronic pain in animal models. Similar benefits have been seen in studies involving humans (both patients and volunteers); however, results have been inconsistent. More research is needed to clearly define the role of existing treatment options and explore the possibilities for future drug development.",2002.0,0,0
565,11465562,Comparison of five experimental pain tests to measure analgesic effects of alfentanil.,M Luginbühl; T W Schnider; S Petersen-Felix; L Arendt-Nielsen; A M Zbinden,"Several experimental pain models have been used to measure opioid effects in humans. The aim of the current study was to compare the qualities of five frequently used experimental pain tests to measure opioid effects. The increase of electrical, heat, and pressure pain tolerance and the decrease of ice-water and ischemic pain perception was determined at baseline and at four different plasma concentrations of alfentanil (n = 7) administered as target controlled infusion or placebo (n = 7). A linear mixed-effects modeling (NONMEM) was performed to detect drug, placebo, and time effect as well as interindividual and intraindividual variation of effect. Only the electrical, ice-water, and pressure pain tests are sensitive to assess a concentration-response curve of alfentanil. At a plasma alfentanil concentration of 100 ng/ml, the increase in pain tolerance compared with baseline was 42.0% for electrical pain, 22.2% for pressure pain, and 21.7% for ice-water pain. The slope of the linear concentration-response curve had an interindividual coefficient of variation of 58.3% in electrical pain, 35.6% in pressure pain, and 60.0% in ice-water pain. The residual error including intraindividual variation at an alfentanil concentration of 100 ng/ml was 19.4% for electrical pain, 6.1% for pressure pain, and 13.0% for ice-water pain. Electrical pain was affected by a significant placebo effect, and pressure pain was affected by a significant time effect. Electrical, pressure, and ice-water pain, but not ischemic and heat pain, provide significant concentration-response curves in the clinically relevant range of 200 ng/ml alfentanil or lower. The power to detect a clinically relevant shift of the curve is similar in the three tests. The appropriate test(s) for pharmacodynamic studies should be chosen according to the investigated drug(s) and the study design.",2001.0,0,0
566,11465609,Intraventricular administration of morphine and clonidine.,M S Leong; J F Calabrese; G Heit,,2001.0,0,0
567,11465978,Influence of expectations and actual pain experiences on satisfaction with postoperative pain management.,I Svensson; B Sjöström; H Haljamäe,"Experience of moderate or even severe postoperative pain has remained a clinical problem despite major progress in pain assessment and management. The aim of the present study was to assess any association between different pre- as well as postoperative factors, actual pain experiences in the postoperative period, and the overall patient satisfaction with the pain management. A random sample of surgical patients (n =191) responded to pre- and postoperative questionnaires detailing presence of preoperative baseline pain, expected and actually experienced postoperative pain levels and perceived adequacy of the pain relief provided. Patient satisfaction was assessed and factors of importance for satisfaction/dissatisfaction were analysed. It was found that 88% of the patients had previously undergone surgical procedures and that 53% of these patients claimed to have experienced moderate or severe pain at that time. Current pain prior to the present surgical procedure was reported by 61% of the patients. Most patients (91%) expected pain of moderate to severe intensity and 76% reported to have experienced such pain levels. In spite of this 81% of the patients claimed to be satisfied with the pain management while only 8% were dissatisfied. Sex, age, pre-operative expectation and actual experience of pain relief, and the overall pain experience were found to be factors associated with the probability of being satisfied/dissatisfied. Main characteristics of the dissatisfied patient were a younger age and female sex. It is concluded that patients commonly expect moderate to severe pain in the postoperative period and that the actual pain experience is mainly in accordance with the pre-operative expectations. Therefore, the validity of patient satisfaction as an optimal outcome variable in quality assurance processes of postoperative pain management may be questioned.",2001.0,0,0
568,11468871,Kentucky Board of Medical Licensure. Model guidelines for the use of controlled substances in pain treatment.,,"At its March 2001 meeting, the Kentucky Board of Medical Licensure adopted guidelines relating to physicians accepting gifts from industry, as well as guidelines for the use of controlled substances for the treatment of chronic pain. These guidelines were presented in a report to the KMA Board of Trustees during its April 4, 2001 meeting, and are being published in the Journal to assist physicians in dealing with these two important, but often confusing, issues. The report is being presented in two parts. The section relating to gifts to physicians was published in the June issue of the Journal. Guidelines on the use of controlled substances in treating chronic pain will be addressed in this issue.",2001.0,0,0
569,11472279,Improved recovery after music and therapeutic suggestions during general anaesthesia: a double-blind randomised controlled trial.,U Nilsson; N Rawal; L E Uneståhl; C Zetterberg; M Unosson,"This study was designed to determine whether music or music in combination with therapeutic suggestions in the intra-operative period under general anaesthesia could improve the recovery of hysterectomy patients. In a double-blind randomised clinical investigation, 90 patients who underwent hysterectomy under general anaesthesia were intra-operatively exposed to music, music in combination with therapeutic suggestion or operation room sounds. The anaesthesia was standardised. Postoperative analgesia was provided by a patient-controlled analgesia (PCA). The pain scores were recorded by means of a visual analogue scale. Nausea, emesis, bowel function, fatigue, well-being and duration of hospital stay were studied as outcome variables. On the day of surgery, patients exposed to music in combination with therapeutic suggestions required less rescue analgesic compared with the controls. Patients in the music group experienced more effective analgesia the first day after surgery and could be mobilised earlier after the operation. At discharge from the hospital patients in the music and music combined with therapeutic suggestion group were less fatigued compared to the controls. No differences were noted in nausea, emesis, bowel function, well-being or length of hospital stay between the groups. This double-blind study has demonstrated that intra-operative music and music in combination with therapeutic suggestions may have some beneficial effects on postoperative recovery after hysterectomy. Further controlled studies are necessary to confirm our results.",2001.0,0,0
570,11474385,"Routine versus ""on demand"" sedation and analgesia for colonoscopy: a prospective randomized controlled trial.",V Terruzzi; G Meucci; F Radaelli; N Terreni; G Minoli,"The safety and tolerance of routine sedation and analgesia versus ""on demand"" sedation were compared in patients undergoing colonoscopy. Two hundred forty-nine outpatients were randomly assigned to one of two groups. Group A (n = 125) received midazolam, 0.07 mg/kg intravenously plus meperidine, 0.77 mg/kg intravenously immediately preceding the colonoscope insertion. Group B (n = 124) received the same medication upon request during the procedure. Tolerance was assessed 24 hours later by phone interview performed by a nurse blinded to the medication regimen administered. Eighty-three patients (66%) in Group B required sedation during colonoscopy. Among men in Group B more than 60 years of age, only 23% required sedation. The proportion of patients reporting moderate or severe pain (34% vs. 12.1%, p < 0.001) and of those stating they would not be willing to undergo colonoscopy again in the future (22% vs. 9.7%, p < 0.005) was significantly higher in the ""on demand"" sedation group. By multivariate analysis the randomization group was the single variable independently associated with both such outcomes. The frequency of side effects was similar in the two groups. Administration of sedative and analgesic drugs routinely before colonoscopy is superior to ""on demand"" sedation in terms of tolerance and is not associated with an increase in side effects.",2001.0,0,0
571,11476257,Effects of high-dose heroin versus morphine in intravenous drug users: a randomised double-blind crossover study.,R B Haemmig; W Tschacher,"The purpose of this study is to evaluate the effects of high doses of injected opiates as prescribed maintenance in intravenous drugs users. This was accomplished via a randomised double-blind study with crossover at an outpatient clinic in Bern, Switzerland. The subjects were 39 patients with a long history of intravenous opioid use and persistent abuse despite treatment; they were randomly allocated to two groups. Group A was started on controlled injection of graduated doses of morphine up to a satisfying individual dose and was then switched as a double blind to heroin at a randomly determined day between week three and four. Subsequently this group was given heroin for the remaining two to three weeks of the study. Group B was started on heroin and was then switched to morphine in the same manner. Equipotent solutions of 3% morphine and 2% heroin were administered. The main outcome measures were clinical observations, structural interviews and self report of subjective experiences to assess the effects of the drugs. In 16 cases, the study had to be discontinued owing to severe morphine-induced histamine reactions. Thirteen participants in Group B presented these adverse reactions on the day of the switch-over. Full data were thus only obtainable for 17 participants. Average daily doses were 491 mg for heroin and 597 mg for morphine. The findings indicate that heroin significantly produced a lower grade of itching, flushing, urticaria and pain/nausea. A negative correlation between dose and euphoria was observed for both heroin and morphine. The authors concluded that as heroin produces fewer side effects it is the preferred high-dose maintenance prescription to morphine. The perceived euphoric effects are limited in both substances.",2002.0,0,0
572,11486698,,,,,0,0
573,11487138,Effect of apical trephination on postoperative pain and swelling in symptomatic necrotic teeth.,E Nist; A Reader; M Beck,"The purpose of this prospective, randomized, blinded study was to determine the effect of apical trephination on postoperative pain and swelling in symptomatic necrotic teeth. Fifty emergency patients participated, and each had a clinical diagnosis of a symptomatic necrotic tooth with associated periapical radiolucency. After endodontic treatment, patients randomly received either an apical trephination or mock trephination procedure. The trephination procedure used a Stabident perforator to provide an initial opening in the cortical bone that was enlarged with files (#25 through #120) and an endodontic spoon. Postoperatively, each patient received: ibuprofen; acetaminophen with codeine (30 mg); and a 7-day diary to record pain, percussion pain, swelling, and number and type of pain medication taken. Results demonstrated the use of an apical trephination procedure did not significantly (p > 0.05) reduce pain, percussion pain, swelling, or number of ibuprofen tablets taken in symptomatic necrotic teeth with periapical radiolucencies. The trephination procedure did significantly (p < 0.05) reduce the use of acetaminophen with codeine overall for the 7 days. In conclusion, because there was not a significant reduction in pain, percussion pain, or swelling we cannot recommend the routine use of an apical trephination procedure, as used in this study, in symptomatic necrotic teeth with radiolucencies.",2001.0,0,0
574,11487166,"Effect of prophylactic amoxicillin on endodontic flare-up in asymptomatic, necrotic teeth.",L Pickenpaugh; A Reader; M Beck; W J Meyers; L J Peterson,"The purpose of this prospective, randomized, double-blind, placebo-controlled study was to determine the effect of prophylactic amoxicillin on the occurrence of endodontic flare-up in asymptomatic, necrotic teeth. Seventy patients participated and had a clinical diagnosis of an asymptomatic, necrotic tooth with associated periapical radiolucency. One hour before endodontic treatment, patients randomly received either 3 g of amoxicillin or 3 g of a placebo control in a double-blind manner. After endodontic treatment, each patient received: ibuprofen; acetaminophen with codeine (30 mg); and a 5 1/2-day diary to record pain, swelling, percussion pain, and number and type of pain medication taken. The results demonstrated 10% of the 70 patients had a flare-up characterized by moderate-to-severe postoperative pain or swelling that began approximately 30 h after endodontic treatment and persisted for an average of 74 h. Of the seven patients who had flare-ups, 4 were in the amoxicillin group and 3 were not. Prophylactic amoxicillin did not significantly (p = 0.80) influence the endodontic flare-up. We concluded that a prophylactic dose of amoxicillin before endodontic treatment of asymptomatic, necrotic teeth had no effect on the endodontic flare-up.",2001.0,0,0
575,11488082,[Chronic pain in geriatrics].,B Kennes,"Pain is frequent in communicative or no-communicative, ambulatory, institutionalized or hospitalized veterans. It is associated with severe comorbidity so much more than chronic pain could be neglected and expressed of atypical manner or masked by the absence of classical symptoms in particular in case of dementia or of sensory disorders. Pain detection by clinic examination or by pain assessment's methods and adequate approach by pharmacological and non pharmacological therapies are essential for correct pain management. On pharmacological plan, the strategy of the O.M.S. landings is applicable owing to a more particular attention to secondary effects and drugs interactions. AINS must be manipulated with prudence. There are no reasons to exclude opioides from the therapeutic arsenal but with a reduction of the starting doses, a regular adaptation and a very attentive survey. In drugs of landing 2, tramadol reveals itself as efficient and better tolerated as the codeine and dextropropoxyphene has to be to avoid. The obtaining of a satisfactory result depends on a regular assessment of the pain in a context of polydisciplinar approach (physicians, nurses, paramedicals, other care givers).",2001.0,0,0
576,11490959,[Therapeutic concept for preventing chronic phantom pain after traumatic brachial plexus lesion].,C Simanski; H Bäthis; B Bouillon; G Koch-Epping; T Tiling,"We report on a 29-year-old motorcyclist, who had suffered a traumatic right side arm plexus lesion. The myelo-CT image showed a avulsion of the cervical roots C7/C8. Five days after the accident the patient complained of phantom pain in the right plegic arm and was presented to our acute pain service (APS). The patient complained of lancinating attacks of severe phantom pain in the right arm (visual analogue scale intensity of 80-100 pts.). The initial pain treatment was performed with PCA (piritramide), and because of the lancinating pain character carbamazepine treatment was introduced. The pain intensity increased under carbamazepine (VAS = 100 pts.), and after treatment with five cycles of salmon-calcitonin infusion the pain intensity decreased (VAS = 10 pts). After withdrawal of the infusion therapy with salmon calcitonin the pain intensity increased up to VAS = 70 pts. TENS therapy five times per day showed no analgetic effect. We repeated the calcitonin-infusion therapy and after five i.v. cycles we continued with 200 I.U. salmon calcitonin intranasal per day. The initial phantompain intensity decreased (VAS = 40 pts.), but showed no long term analgesia. The additional psychological treatment with relaxation techniques (Jacobson/Bensen) showed the desired phantom pain relief. An interdisciplinary and multimodal cooperation between anesthesiologists, trauma surgeons, neurosurgeons and psychologists is needed for successful phantom pain treatment after traumatic brachial plexus lesion. Intravenous salmon calcitonin showed only short-term analgetic effect.",2001.0,0,0
577,11491635,Effect of penicillin on postoperative endodontic pain and swelling in symptomatic necrotic teeth.,M Henry; A Reader; M Beck,"The purpose of this prospective, randomized, double-blind, placebo-controlled study was to determine the effect of penicillin on postoperative pain and swelling in symptomatic necrotic teeth. Forty-one emergency patients participated and each had a clinical diagnosis of a symptomatic necrotic tooth with associated periapical radiolucency. After endodontic treatment patients randomly received a 7-day oral dose (twenty-eight 500 mg capsules to be taken every 6 h) of either penicillin or a placebo control in a double-blind manner. Patients also received ibuprofen; acetaminophen with codeine (30 mg); and a 7-day diary to record pain, percussion pain, swelling, and number and type of pain medication taken. The majority of patients with symptomatic necrotic teeth had significant postoperative pain and require analgesic medication to manage this pain. The administration of penicillin postoperatively did not significantly (p > 0.05) reduce pain, percussion pain, swelling, or the number of analgesic medications taken for symptomatic necrotic teeth with periapical radiolucencies.",2001.0,0,0
578,11493236,A mixture of alfentanil and morphine for rapid postoperative loading with opioid: theoretical basis and initial clinical investigation.,G L Ludbrook; P E Macintyre; H Douglas; L Ong; R N Upton,"Pharmacokinetic modelling of estimated central nervous system concentrations was used to devise the optimal mixture of morphine and alfentanil for the treatment of postoperative pain. Modelling revealed that an intravenous opioid pain protocol using an alfentanil-morphine mixture in the proportions 0.75 : 10 mg would provide a profile of analgesia of rapid onset, yet slow offset. The regimen was evaluated in 58 patients in the recovery ward who were randomly allocated to receive analgesia using pain protocols with either morphine or the mixture. Groups were well matched for age, weight and initial pain scores. The mean (SD) time to patient comfort was 27.6 (20.2) min for the mixture and 41.2 (18.6) min for morphine (p = 0.01). Multiple regression analysis revealed that that initial pain score (p = 0.009) and drug group (p = 0.02), but not age, weight or gender were independent predictors of the time to comfort. Drug group was not a significant predictor of adverse effects.",2001.0,0,0
579,11495714,Equianalgesic dose ratios for opioids. a critical review and proposals for long-term dosing.,J Pereira; P Lawlor; A Vigano; M Dorgan; E Bruera,"Clinicians involved in the opioid pharmacotherapy of cancer-related pain should be acquainted with a variety of opioids and be skilled in the selection of doses when the type of opioid or route of administration needs changing. The optimal dose should avoid under-dosing or overdosing, both associated with negative outcomes for the patient. Although equianalgesic dose tables are generally used to determine the new doses in these circumstances, the evidence to support the ratios indicated in these tables largely refers to the context of single dose administration. The applicability of these ratios to the setting of chronic opioid administration has been questioned. A systematic search of published literature from 1966 to September 1999 was conducted to critically appraise the emerging evidence on equianalgesic dose ratios derived from studies of chronic opioid administration. There were six major findings: 1) there exists a general paucity of data related to long-term dosing and studies are heterogeneous in nature; 2) the ratios exhibit extremely wide ranges; 3) methadone is more potent than previously appreciated; 4) the ratios related to methadone are highly correlated with the dose of the previous opioid; 5) the ratio may change according to the direction the opioid switch; and 6) discrepancies exist with respect to both oxycodone and fentanyl. Overall, these findings have important clinical implications for clinicians and warrant consideration in the potential revision of current tables. The complexity of the clinical context in which many switches occur must be recognized and also appreciated in the design of future studies.",2001.0,0,0
580,11495873,Preoperative diclofenac is a useful adjunct to spinal anesthesia for day-case varicose vein repair.,P Rautoma; U Santanen; H Luurila; V Perhoniemi; O Erkola,"To examine if preoperative diclofenac 50 mg or diazepam 10 mg po are useful adjuncts to spinal anesthesia for day-case varicose vein repair. Two hundred ASA physical status I-II outpatients, age 18-60 yr, were randomized to receive either diclofenac 50 mg po or diazepam 10 mg po one hour before operation in a double-blind fashion (100 patients in both groups). If the patient was distressed or feared the spinal puncture and requested sedation, a bolus dose of alfentanil 0.5 mg was given i.v. as a rescue medication. On request, patients received diclofenac 50 mg po and, when needed, oxycodone 0.1 mg x kg(-1) im for postoperative pain relief. They were discharged with a supply of diclofenac 50 mg tablets and were asked to record postoperative pain using a visual analogue scale (VAS) and quantity of tablets taken. The VAS scores (+/- SD) eight hours after surgery, the next morning, and in the morning and at the end of the first and second postoperative days were 23 +/- 21, 12 +/- 17, 11 +/- 15, 8 +/- 15 and 8 +/- 15 in the diclofenac group, and 24 +/- 23, 12 +/- 20, 10 +/- 17, 8 +/- 16 and 7 +/- 14 in the diazepam group, respectively (NS). In the diclofenac and diazepam groups, 31% and 67% of the patients required postoperative diclofenac during the first eight postoperative hours (P <0.05). Diazepam premedication did not alter the number of patients who required alfentanil before spinal puncture. Diclofenac premedication reduced the analgesic requirements during the first eight hours after varicose vein repair.",2001.0,0,0
581,11498314,Evaluation of the safety and efficacy of epidural ketamine combined with morphine for postoperative analgesia after major upper abdominal surgery.,K Subramaniam; B Subramaniam; D K Pawar; L Kumar,"To evaluate the efficacy of the combination of epidural ketamine and morphine compared with epidural morphine alone for postoperative pain relief following major upper abdominal surgery. Prospective, randomized, double-blinded study. Tertiary care referral and teaching hospital. 46 ASA physical status I and II patients who underwent major upper abdominal procedures. Patients were randomly allocated to one of the two treatment groups: patients in Group 1 received epidural morphine 50 microg/kg whereas patients in Group 2 received epidural ketamine 1 mg/kg combined with 50 microg/kg of morphine postoperatively. A blinded observer using a visual analog scale (VAS) for pain assessment followed up patients for 48 hours postoperatively. Top-up dose of epidural morphine was provided when VAS was higher than 4. Analgesic requirements and side effects were compared between the two groups. Only 40 patients completed the study. There were no differences between the two groups with respect to age, gender, weight, duration, or type of surgical procedure or intraoperative opioid requirements. Onset of analgesia was faster (p < 0.001) in Group 2 (11 min) than in Group 1 patients (25 min). The time for first requirement of analgesia was significantly (p < 0.01) longer (19.8 +/- 9.8 hours) in Group 2 patients than Group 1 (12.8 +/- 6.2 hours). Total number of supplemental doses of epidural morphine required in the first 48 hours postoperatively was also significantly less (p < 0.005) in Group 2 compared to Group 1. Patients in Group 2 had higher sedation scores than Group I patients for the first 2 hours postoperatively. None of the patients in either group developed hallucinations or respiratory depression. Other side effects such as pruritus, nausea, and vomiting were also similar in both groups. The addition of epidural ketamine 1 mg/kg to morphine 50 microg/kg improved analgesia after major upper abdominal surgery without increasing side effects.",2001.0,0,0
582,11498324,,,,,0,0
583,11501851,From codeine to transdermal fentanyl for cancer pain control: a safety and efficacy clinical trial.,K Mystakidou; S Befon; E Kouskouni; K Gerolymatos; S Georgaki; E Tsilika; L Vlahos,"Fentanyl is a synthetic opioid, suitable for transdermal delivery, offering an interesting solution as a step 3 opioid in cancer pain treatment. The purpose of the study was to carefully investigate: 1) the feasibility of the direct conversion from codeine to TTS fentanyl, in patients already receiving codeine and requiring strong opioids for their analgesia; 2) the safety of 25 microg/hour incremental steps and at shorter than 72-hour intervals, if clinically required. 130 patients were judged eligible for the study. All the patients were receiving 280-360 mg or more of codeine and required strong opioid for their analgesia. The study lasted 56 days. The initial dose was 25 microg/hour. TTS fentanyl for all patients. Data assessments were made on baseline, day 1, day 2, day 3, in the hospital and thereafter on days 7, 14, 21, 28, 42 and 56. After the patch application, all the patients were given an immediate release oral morphine (5 mg) every 4-6 hours for the first 12 hours and then if needed only as rescue doses. The patients remained in the hospital for the first three days of the study where follow-up (pain score, satisfaction, side effects etc.). was recorded by the palliative care team and by daily cards. The itnitial dose of fentanyl was 25 microg/hour while the mean dose on day 3 was 45.9 microg/hour. All the patients required upward titration of the study medication during follow-up visits. On day 56 the mean dose of fentanyl was 87.4 microg/hour. Mean pain intensity decreased from an initial 5.96 on the baseline to 0.83 on day 3. Karnofsky scale measurements between treatment phases revealed non-significant changes. The rate of overall satisfaction was quite high. Nine patients discontinued the study due to inadequate pain relief or side effects between day 7 and day 28, while five patients died between day 28 and day 56. Constipation, nausea and vomiting were the most common side effects. Skin reaction was relatively mild and acceptable during the study. Under controlled conditions, TTS fentanyl seems to be feasible for direct conversion from mild to strong opioids and additionally, 25 microg/hour incremental steps day by day can be made by palliative care specialists, if clinically required for cancer pain management.",2001.0,0,0
584,11506105,"Preoperative intradermal acupuncture reduces postoperative pain, nausea and vomiting, analgesic requirement, and sympathoadrenal responses.",N Kotani; H Hashimoto; Y Sato; D I Sessler; H Yoshioka; M Kitayama; T Yasuda; A Matsuki,"In a controlled and double-blind study, the authors tested the hypothesis that preoperative insertion of intradermal needles at acupoints 2.5 cm from the spinal vertebrae (bladder meridian) provide satisfactory postoperative analgesia. The authors enrolled patients scheduled for elective upper and lower abdominal surgery. Before anesthesia, patients undergoing each type of surgery were randomly assigned to one of two groups: acupuncture (n = 50 and n = 39 for upper and lower abdominal surgery, respectively) or control (n = 48 and n = 38 for upper and lower abdominal surgery, respectively). In the acupuncture group, intradermal needles were inserted to the left and right of bladder meridian 18-24 and 20-26 in upper and lower abdominal surgery before induction of anesthesia, respectively. Postoperative analgesia was maintained with epidural morphine and bolus doses of intravenous morphine. Consumption of intravenous morphine was recorded. Incisional pain at rest and during coughing and deep visceral pain were recorded during recovery and for 4 days thereafter on a four-point verbal rating scale. We also evaluated time-dependent changes in plasma concentrations of cortisol and catecholamines. Starting from the recovery room, intradermal acupuncture increased the fraction of patients with good pain relief as compared with the control (P < 0.05). Consumption of supplemental intravenous morphine was reduced 50%, and the incidence of postoperative nausea was reduced 20-30% in the acupuncture patients who had undergone either upper or lower abdominal surgery (P < 0.01). Plasma cortisol and epinephrine concentrations were reduced 30-50% in the acupuncture group during recovery and on the first postoperative day (P < 0.01). Preoperative insertion of intradermal needles reduces postoperative pain, the analgesic requirement, and opioid-related side effects after both upper and lower abdominal surgery. Acupuncture analgesia also reduces the activation of the sympathoadrenal system that normally accompanies surgery.",2001.0,0,0
585,11506111,Local administration of morphine for analgesia after iliac bone graft harvest.,S S Reuben; P Vieira; S Faruqi; A Verghis; P A Kilaru; H Maciolek,"Harvesting autogenous bone grafts from the ilium may cause considerable pain and may represent a significant source of postoperative morbidity. The local application of morphine can reduce pain in a rat model of bone damage. We evaluated the analgesic efficacy of administering morphine to the donor bone graft site for spinal fusionsurgery. Sixty patients undergoing cervical spinal fusion surgery using autogenous bone harvested from the ilium were randomly assigned to one of three groups: Group 1 was given saline infiltrated into the harvest site, group 2 was given 5 mg intramuscular morphine; group 3 was given 5 mg morphine infiltrated into the harvest site. After surgery, all patients were given morphine through a patient-controlled analgesia pump. Pain scores both from the harvest and the incision sites, as well as morphine use, were recorded at 2, 4, 6, 8, 12, and 24 h after surgery. At 1 yr after surgery the presence and subjective characteristics of donor site pain were recorded. Total 24-h morphine use (milligrams) was significantly lower (P < 0.0001) in group 3 (33.7+/-8.3 mg, mean +/- SD), compared with either group 1 (64.3+/-6.6 mg) or group 2 (59.6+/-9.3 mg). Pain from the graft site was scored the same at 2 h but remained significantly lower (P < 0.0001) for group 3 at all later time intervals. Pain scores from the incision site were similar among the three study groups. One year after surgery, 25% of patients reported having chronic donor site pain. The association of chronic donor site pain was significantly higher (P < 0.05) in groups 1 (33%) and 2 (37%) compared with group 3 (5%). Low-dose morphine applied to the harvest graft site can reduce local pain, morphine use, and chronic donor site pain after cervical spine fusion surgery.",2001.0,0,0
586,11506112,"A new model of electrically evoked pain and hyperalgesia in human skin: the effects of intravenous alfentanil, S(+)-ketamine, and lidocaine.",W Koppert; S K Dern; R Sittl; S Albrecht; J Schüttler; M Schmelz,"The authors used the analgesics alfentanil, S(+)-ketamine, and systemic lidocaine to examine a new human model of experimental pain and hyperalgesia. Transcutaneous electrical stimulation at a high current density (5 Hz, 67.5+/-6.6 mA) was used to provoke acute pain (numeric rating scale, 5 of 10), stable areas of secondary mechanical hyperalgesia to pin prick (43.6+/-32.1 cm2), and light touch (27.5+/-16.2 cm2) for 2 h. Alfentanil, S(+)-ketamine, and lidocaine were applied for 20 min in a double-blind, placebo-controlled, crossover design in 12 subjects using target controlled infusions. In the placebo session, pain ratings and areas of hyperalgesia were stable during the stimulation period, which facilitated the assessment of analgesic effects. Alfentanil effectively inhibited electrically evoked pain and reduced pin prick hyperalgesia and allodynia during its infusion. S(+)-ketamine-induced inhibition of secondary hyperalgesia was more pronounced and lasted for the whole experimental protocol. Therapeutic levels of systemic lidocaine showed only marginal analgesic effects, but lasting antihyperalgesic effects. A new model of electrically induced pain and hyperalgesia was established, which enabled assessment of the time course of analgesic and antihyperalgesic effects with high temporal resolution and minimum tissue damage and which was further validated by use of common intravenous anesthetics.",2001.0,0,0
587,11508604,Opioids for osteoarthritis of the hip and knee: which opioids for which patients?,B Bannwarth,,2002.0,0,1
588,11509270,Effects of cryoanalgesia on post-thoracotomy pain and on the structure of intercostal nerves: a human prospective randomized trial and a histological study.,N Moorjani; F Zhao; Y Tian; C Liang; J Kaluba; M O Maiwand,"The choice of analgesia in the management of post-thoracotomy pain remains controversial. Although several alternative forms of post-thoracotomy analgesia exist, all have their disadvantages. Cryoanalgesia, localized freezing of intercostal nerves, has been reported to have variable effectiveness and an incidence of long-term cutaneous sensory changes. We carried out an animal study to assess the reversibility of histological changes induced by cryoanalgesia and a prospective randomized trial to compare the effectiveness of cryoanalgesia with conventional analgesia (parenteral opiates). In six anaesthetized dogs, intercostal nerves were exposed to a varying duration of cryo-application (30, 60, 90 and 120 s). The nerves were biopsied and examined histologically at regular intervals over the following 6 months. In the clinical study, 200 consecutive patients undergoing thoracotomy were randomized to cryoanalgesia and conventional (parenteral opiates) analgesia groups. Postoperative pain scores, respiratory function tests and use of opiate analgesia were measured for the two groups. Following application of the cryoprobe, degeneration and fragmentation of the axons was evident with associated inflammatory changes. As the endoneurium remained intact, axonal regeneration took place after the resolution of axonal swelling. Over the course of weeks, recovery of the intercostal nerve occurred and was complete after 1 month for the 30 and 60 s groups. For nerves exposed to longer durations of cryoanalgesia, the time taken for complete recovery was proportionally increased. Clinically, there was a statistically significant (P<0.05) improvement in postoperative pain scores and use of opiate analgesia and an improvement (P>0.05) in respiratory function tests for patients in the cryoanalgesia group. The previously suggested cutaneous sensory changes resolved within 6 months with complete restoration of function. We suggest that cryoanalgesia be considered as a simple, inexpensive, long-term form of post-thoracotomy pain relief, which does not cause any long-term histological damage to intercostal nerves.",2001.0,0,0
589,11511016,A randomized prospective study to assess the efficacy of two cold-therapy treatments following carpal tunnel release.,J Hochberg,"A prospective randomized study was performed comparing the efficacy of controlled cold therapy (CCT) with the efficacy of ice therapy in the postoperative treatment of 72 patients with carpal tunnel syndrome. Immediately after surgery, patients applied either a temperature-controlled cooling blanket (CCT) or a standard ice pack over their surgical dressings. Pain was assessed by visual analog scale and swelling by wrist circumference preoperatively, immediately after surgery, and on postoperative day 3. Patients kept log books of daily treatment times. Narcotic use (of Vicodin ES) was determined by pill count at day 3 and by daily log book recordings. Patients who used CCT showed significantly greater reduction in pain, edema (wrist circumference), and narcotic use at postoperative day 3 than did those using ice therapy. This study indicates that after carpal tunnel surgery, the use of CCT, compared with traditional ice therapy, provides patients with greater comfort and lessens the need for narcotics.",2002.0,0,0
590,11513054,Role of tramadol in reducing pain on propofol injection.,W H Wong; K F Cheong,"Propofol is frequently associated with pain on injection. We evaluated the effect of tramadol in a randomised, double-blind study using a tourniquet venous retention technique. Normal saline placebo was given intravenously to patients in Group 1 (n = 30),tramadol 50 mg to Group 2 (n = 30), and lignocaine 50 mg to Group 3 (n = 30). The venous retention of drugs was maintained for 1 minute, followed by tourniquet release and intravenous administration of propofol. Pain assessment was made immediately after propofol injection. There was a significant reduction in the incidence of pain associated with propofol administration in patients pretreated with lignocaine and tramadol (P < 0.05). In addition, pretreatment with tramadol was as effective as lignocaine in reducing pain on propofol injection.",2001.0,0,0
591,11513283,Assessment and management of pain in neonates.,B J Stevens; L S Franck,"Neonates are capable of experiencing pain from birth onwards. An impressive body of neuroanatomical, neurochemical and biobehavioural evidence, which has accumulated over the past 2 decades, supports this capability. This evidence mandates health professionals to attend to the prevention, elimination, or at the very least, control of pain for infants. This mandate is essential since pain is known to have both immediate and long term effects, especially if pain is untreated and is severe, prolonged or frequently experienced. Therefore, pain must be assessed frequently, not only to measure location, intensity and duration but also to determine the effectiveness of interventions implemented to control pain. An impressive array of measures for assessing acute pain in infants exists which incorporates valid pain indicators in this population. However, there is a need to develop new measures to assess chronic pain conditions and pain in infants in acute situations.",2002.0,0,0
592,11533770,The use of rectal diclofenac for post-cesarean analgesia.,M Rashid; H M Jaruidi,"To determine whether the prophylactic use of rectal diclofenac sodium produces effective analgesia after cesarean section. A randomized single blind controlled trial. The study period was from September 1997-April 1998. Forty patients undergoing both emergency and elective cesarean section were studied, with 20 patients in each arm. The study group received 100 mg rectal diclofenac immediately after cesarean section followed by 50 mg at 12 hours and 100 mg at 36 hours after the surgery. The control group did not receive any diclofenac suppositories. The results showed that the visual analogue score for pain in the study group was significantly less at 12, 18 and 24 hours after surgery (P <0.05). The amount of pethidine consumed was also significantly less (P <0.05) with 28 injections consumed in the study group as compared with 52 in the control group (each pethidine injection = 100 mg). The incidence of sedation and constipation was significantly less (P<0.05) in the study group. However, the incidence of nausea and post-operative pyrexia was comparable in the 2 groups. Rectal diclofenac provides effective analgesia when given after cesarean section. It also reduces the patients opioid requirements with a corresponding reduction in the opioid related side-effects.",2001.0,0,0
593,11535941,Psychosomatic reactions to a stressful environment and an attempt at pharmacological modification.,M Kowalczyk; A Nowicka; B Antkowiak; J Kocik; O Antkowiak,"Extreme environmental conditions significantly influence the functioning of the human organism and trigger distinct stress reactions. In our study we attempted to create an experimental model of complex stress conditions. Healthy male volunteers were isolated, deprived of food and sleep, and exposed to extreme temperatures for 5 consecutive days. Physical fitness and selected somatic parameters and biochemical stress markers were measured in the tested subjects. In addition, changes in behavior and mental status were assessed by means of a set of psychological tests. Finally, the effects of pharmacological modification (administration of clobazam and tramadol) on psychosomatic stress reactions were tested. The results indicate that our experimental stress conditions slightly altered the mental functions of the subjects, increased their anxiety level, hampered their physical efficiency, and led to weight loss. The administration of the drugs beneficially influenced the subjects' memory and physical efficiency.",2002.0,0,0
594,11546738,IV butorphanol reduces analgesia but not pruritus or nausea associated with intrathecal morphine.,T Sakai; T Fukano; K Sumikawa,,2001.0,0,0
595,11549189,Pharmacologic management of acute and chronic pain: focus on drug interactions and patient-specific pharmacotherapeutic selection.,R L Barkin; D Barkin,,2001.0,0,0
596,11553247,Postoperative analgesia in children: comparison of bupivacaine with a mixture of bupivacaine and alfentanil.,D Ozcengiz; Y Güneş; M Ozalevli; G Işik,,2002.0,0,0
597,11554039,,,,,0,0
598,11554054,[Weak opioids].,T Shiratsuchi; S Ogawa,"Weak opioids have been used as analgesics in cancer patients with moderate to severe chronic pain. Codeine is one of the weak opioids which is assigned as a representative analgesic of the 2nd ladder-drugs for the treatment of cancer pain by WHO cancer pain relief programme. Analgesic effect of codeine is recognized when it is administered with 20 mg p.o. or more. Clinical ceiling effect of codeine is seemed to be 200-300 mg/day, although it is described as 600 mg/day in some textbooks. Side effects of codeine are same as those of morphine, therefore, drugs for the side effects should be given to the patients simultaneously when codeine is administered.",2002.0,0,0
599,11558009,Intercostal nerve block with Bupivacaine for post-thoracotomy pain relief in children.,P Matsota; S Livanios; E Marinopoulou,"The purpose of the study is to evaluate the efficacy of Intercostal Nerve Block (ICB) with Bupivacaine (BUP) to produce satisfactory analgesia after thoracotomy in children. We studied 20 children aged between 5 and 12 years, scheduled for thoracotomy under general anaesthesia. The children were randomly divided into two groups. In the first group (n = 10) 3 mg/kg BUP 0.5 % with epinephrine 1 : 200 000 was injected by the surgeon under direct vision, into the intercostal space where thoracotomy was performed. In the control group (n = 10) meperidine 1 mg/kg was administered i.v. at the same surgical time, and afterwards the chest was closed. Postoperatively the vital signs, the side effects and the total postoperative analgesic requirements were recorded. The mean duration of postoperative analgesia produced was longer in the BUP group (p < 0.001). None of the children in BUP group suffered from BUP toxicity, while in the control group a high incidence of vomiting and nausea was noticed (p < 0.005). It is concluded that ICB with BUP produces satisfactory and safe analgesia for the early postoperative period after thoracotomy in children.",2001.0,0,0
600,11562504,Mechanisms of pain.,C L Stucky; M S Gold; X Zhang,"Persistent or chronic pain is the primary reason people seek medical care, yet current therapies are either inadequate for certain types of pain or cause intolerable side effects. Recently, pain neurobiologists have identified a number of cellular and molecular processes that lead to the initiation and maintenance of pain. Understanding these underlying mechanisms has given significant promise for the development of more effective, more specific pain therapies in the near future.",2002.0,0,0
601,11563253,Pain management in the critically ill child.,M Yaster; D G Nichols,"Children frequently received no treatment, or inadequate treatment, for pain and for painful procedures. The newborn and critically ill children are especially vulnerable to no treatment or under-treatment. Nerve pathways essential for the transmission and perception of pain are present and functioning by 24 weeks of gestation. The failure to provide analgesia for pain results in rewiring the nerve pathways responsible for pain transmission in the dorsal horn of the spinal cord and results in increased pain perception for future painful results. Many children would withdraw or deny their pain in an attempt to avoid yet another terrifying and painful experiences, such as the intramuscular injections. Societal fears of opioid addiction and lack of advocacy are also causal factors in the under-treatment of pediatric pain. False beliefs about addictions and proper use of acetaminophen and other analgesics resulted in the failure to provide analgesia to children. All children even the newborn and critically ill require analgesia for pain and painful procedures. Unbelieved pain interferes with sleep, leads to fatigue and a sense of helplessness, and may result in increased morbidity or mortality.",2001.0,0,0
602,11565863,"New pain following cordotomy: clinical features, mechanisms, and clinical importance.",T Nagaro; N Adachi; E Tabo; S Kimura; T Arai; K Dote,"The clinical features, possible causes, and contributing factors associated with novel spontaneous pain following unilateral cordotomy were investigated to clarify the mechanism and clinical importance of this pain. Forty-five patients who underwent cordotomy for severe unilateral cancer pain were included in this study. New pain occurred in 33 (73.3%) of 45 patients. Pathological conditions of tissue demonstrated on imaging corresponded to new pain in eight patients, referred pain in five, and neither of these in 15 patients. New pain was centered opposite the site of the original pain in a mirror-image location in 28 patients and rostral to the original pain in five patients. It was temporary in seven patients, weaker than the original pain in 25, and as severe as the original pain in one patient. The incidence of moderate or severe pain was significantly higher in patients with confirmed tissue disease (six of eight patients) than in those without (six of 20 patients). An important contributing factor to the occurrence of new pain was the achievement of analgesia by performing the cordotomy. The present results indicate that new pain occurs frequently after unilateral cordotomy. Nonetheless, cordotomy may still be indicated for unilateral uncontrollable pain because new pain, when present, was weaker and more easily controlled than the original pain in nearly all cases. The authors speculate that new pain may represent a type of referred pain from the original painful area or may arise from sensitization of contralateral spinal nociceptive circuits due to metastasis or tumor infiltration, and that new pain is potentiated by the interruption of descending inhibitory pathways.",2001.0,0,0
603,11573648,Use of intravenous opioids to reduce airway irritation during induction of anaesthesia with desflurane.,A F Smith; K Rauf,,2001.0,0,0
604,11575284,Selective postoperative inhibition of gastrointestinal opioid receptors.,A Taguchi; N Sharma; R M Saleem; D I Sessler; R L Carpenter; M Seyedsadr; A Kurz,"Postoperative recovery of gastrointestinal function and resumption of oral intake are critical determinants of the length of hospital stay. Although opioids are effective treatments for postoperative pain, they contribute to the delayed recovery of gastrointestinal function. We studied the effects of ADL 8-2698, an investigational opioid antagonist with limited oral absorption that does not readily cross the blood-brain barrier, on postoperative gastrointestinal function and the length of hospitalization. We randomly assigned 79 patients--including 1 whose surgery was canceled--to receive one capsule containing 1 mg or 6 mg of ADL 8-2698 or an identical-appearing placebo capsule two hours before major abdominal surgery and then twice daily until the first bowel movement or until discharge from the hospital. Data were analyzed for 26 patients in each of the three groups; all received opioids for postoperative pain relief. Observers who were unaware of the group assignments evaluated the outcomes. Fifteen patients underwent partial colectomy and 63 underwent total abdominal hysterectomy. Patients given 6 mg of ADL 8-2698 had significantly faster recovery of gastrointestinal function than those given placebo. The median time to the first passage of flatus decreased from 70 to 49 hours (P=0.03), the median time to the first bowel movement decreased from 111 to 70 hours (P=0.01), and the median time until patients were ready for discharge decreased from 91 to 68 hours (P=0.03). Effects in the group that received 1 mg of ADL 8-2698 were less pronounced. Selective inhibition of gastrointestinal opioid receptors by an antagonist with limited oral absorption that does not readily cross the blood-brain barrier speeds recovery of bowel function and shortens the duration of hospitalization.",2001.0,0,0
605,11575712,Differential gene expression--how to find new analgesic targets.,K Befort; M Costigan; C J Woolf,,2002.0,0,0
606,11578883,Hemodynamics and emergence profile of remifentanil versus fentanyl prospectively compared in a large population of surgical patients.,R S Twersky; B Jamerson; D S Warner; L A Fleisher; S Hogue,"To compare the responses to, and hemodynamics associated with surgical stress, recovery profiles, and anesthesiologists' satisfaction following balanced general anesthesia using either remifentanil or fentanyl in a large-scale population. Prospective, 1:1 single blind, randomized, controlled effectiveness study in which patients received either remifentanil or fentanyl in combination with a hypnotic-based anesthesia regimen of either isoflurane or propofol. Multicenter study including 156 hospitals and ambulatory surgery facilities. 2,438 patients (1,496 outpatients and 942 inpatients), 18 years of age or older, scheduled for elective surgeries under general endotracheal anesthesia, with an expected duration of unconsciousness > or =30 minutes. Patients were randomized to receive either intravenous (IV) remifentanil (0.5 microg/kg/min for induction and intubation, with the infusion rate decreased to 0.25 microg/kg/min after intubation) or IV fentanyl (administered according to anesthesiologists' usual practice) as the opioid during surgery. Concomitant hypnotic drugs were either propofol and/or isoflurane (with or without nitrous oxide) titrated according to protocol. Transition analgesia with either morphine or fentanyl was given to the remifentanil patients and, at the anesthesiologists' discretion, in the fentanyl patients. Vital signs, adverse events, and emergence profiles were assessed and recorded. Recovery profile was assessed by recording time spent in the postanesthesia care unit and step-down recovery unit, number and timing of adverse events, timing and dosage of rescue medications, and time to eligibility for discharge (to home or to hospital room). Anesthesiologists' satisfaction with the anesthetic regimen was assessed at the end of surgery. Remifentanil-treated patients exhibited lower systolic and diastolic blood pressures (by 10-15 mmHg) and lower heart rates (by 10-15 bpm) intraoperatively compared to the fentanyl-treated patients. This difference promptly disappeared on emergence. Remifentanil-treated patients responded to verbal command, left the operating room, and (for outpatients) were discharged home sooner than fentanyl-treated patients. Anesthesiologists rated the predictability of response to intraoperative titration, assessment of hemodynamic profiles, and the quality of anesthesia higher in the remifentanil-treated patients. This study confirms previous observations on the hemodynamic properties associated with remifentanil and extends these to a wider context than previously reported. These characteristics provide clinicians with an alternative in opioid-based anesthesia.",2001.0,0,0
607,11579330,The effect of preemptive intravenous morphine on postoperative analgesia and surgical stress response.,L Kiliçkan; K Toker,"Although initial studies of preemptive analgesia showed that preoperative blockade with local anaesthetics or preoperative administration of systemic opioids was more effective in reducing postoperative pain than control conditions involving no treatment, the result of subsequent investigations comparing the effects of preoperative treatment with the same treatment initiated after surgery have produced inconsistent RESULTS. The reasons for the lack of consistency are not clear. Studies about the relationship of preemptive analgesia and both analgesic consumption and surgical stress response are limited. The purpose of this study was to evaluate the effect of preemptive intravenous morphine on both postoperative analgesic consumption and surgical stress response. Sixty patients, ASA I or II, aged 20-60, undergoing total abdominal hysterectomy plus bilateral salpingo-oopherectomy and double-blinded were randomly assigned to three groups of 20 patients. Group I (n=20) received 0.15 mg/kg of morphine following induction and placebo saline during peritoneal closure. Group II (n=20) received placebo saline following induction and 0.15 mg/kg of morphine during peritoneal closure. Group III (n=20) received placebo saline both during induction and peritoneal closure. Blood cortisol, glucose levels and leukocyte count were measured in the pre and postoperative period. Postoperative total morphine consumption was significantly lower in group I compared with group III (p<0.001). In all groups, plasma cortisol levels increased significantly within 4 hours of surgery as compared to pre-op values (p<0.001). Plasma glucose also increased to a significantly higher level in all groups in the postoperative 30 min and 8 hours than in the pre-op values (p<0.001). Postoperative leukocytosis was observed in all groups and the leukocyte count was significantly greater during postoperative 24 h than pre-op values (p<0.001). Preemptive morphine 0.15 mg/kg intravenous has decreased total morphine consumption but has failed to suppress the surgical stress response.",2002.0,0,0
608,11584996,Current treatment practice of herpes zoster.,P W Heald,"The management of herpes zoster infection has been impacted by the development of oral and iv. antiviral therapies. There are clinical and historical features that help optimise the particular therapy course for a given patient. Additionally, there are common features of management in all patients with herpes zoster. In this review an understanding of the pathogenesis of herpes zoster is utilised as a starting point for the development of a rational approach to therapy. Clinical findings that impact decision making are emphasised and the appropriate goals for therapy are discussed.",2002.0,0,0
609,11587108,A biopsychosocial overview of pretreatment screening of patients with pain.,R J Gatchel,"The prevalence and excessive cost of pain, especially when the pain becomes chronic, remains a major health-care problem in the United States. Currently, a biopsychosocial perspective of pain has been found to be the most heuristic approach to understanding and managing it. Using this perspective, an important advance has been made in the possibility of individually tailoring treatment for each patient, with the result being better outcomes. The author reviews the extant literature demonstrating a robust ""psychosocial disability factor"" among injured workers that is important not only in pain perception, but also in the subsequent development of chronic pain-related disability. Such results emphasize the importance of taking into account how psychosocial and physical factors are intertwined in a complex way in determining pain symptomatology. On the basis of these findings, a number of surgical pre-screening approaches have been developed and found to be effective for maximizing surgical outcomes as described by Carragee, Epker, and Block in other papers in this special topics series. Recently, several organizations in the U.S. have also developed new standards for the evaluation of pain. For example, the Joint Commission on Accreditation of Health Organizations (JCAHO) now requires that physicians consider pain as a ""5th vital sign"" in evaluating patients. Such initiatives have created a new mandate to regularly assess and manage all types of pain. The use of opioids, as well as implantable pain-management modalities, are among the options. The author notes that the literature on these modalities focuses on interdisciplinary patient-screening approaches prior to their administration as a way of maximizing treatment outcomes. The papers by Praeger, Jacobs, and Robinson et al. in this special topics series describe the approach to pretreatment assessment for these modalities in detail. Finally, the author presents a stepwise, biopsychosocial approach as the basis for assessment before decisions regarding surgery, opioid maintenance therapy, and implantable pain-management modalities. The author suggests that systematic pretreatment interventions will facilitate a more structured standard of care in the evaluation and treatment of patients with pain and ultimately better outcomes.",2002.0,0,0
610,11587115,"Stability, compatibility, and safety of intrathecal bupivacaine administered chronically via an implantable delivery system.",K R Hildebrand; D D Elsberry; T R Deer,"The only agent approved by the U.S. Food and Drug Administration for chronic intrathecal infusion for the treatment of chronic pain is morphine sulfate. In patients who do not experience adequate relief from intrathecal opioids, bupivacaine is frequently added to increase efficacy. The studies reported here were conducted to demonstrate the stability and compatibility of bupivacaine in a commonly used implantable infusion system and the long-term clinical safety of this therapy. A commercially available bupivacaine solution (7.5 mg/ml) was incubated at 37 degrees C for 12 weeks with intact delivery systems and with the individual materials that comprise the fluid pathway. Intermittent samples were collected and analyzed using liquid chromatography. Materials chronically exposed to bupivacaine were analyzed for mechanical integrity. One hundred eight patients treated with intrathecal bupivacaine (average dose: 10 mg/d, range: 2-25 mg/d) and opioids for an average duration of 86 weeks were monitored clinically (patient interviews and neurologic examinations) approximately every 4 weeks. Bupivacaine concentrations remained greater than 96% of the starting material after chronic exposure to the delivery system materials or the intact pump-catheter systems. and the mechanical integrity of the delivery system and materials remained intact. When combined with intrathecal morphine or hydromorphone, no clinical evidence of drug-induced toxicity or complications was observed in any patient. Supplementing opioid therapy with bupivacaine allowed the pain patient to continue to be effectively managed using an implantable intrathecal delivery system. Bupivacaine is stable and compatible with a commonly used implantable drug infusion system. In this study, chronic supplementation of intrathecal opioids with bupivacaine was a safe method for providing continued management of chronic pain of cancer or noncancer origin.",2002.0,0,0
611,11589258,Tramadol/acetaminophen combination tablets and codeine/acetaminophen combination capsules for the management of chronic pain: a comparative trial.,W S Mullican; J R Lacy; TRAMAP-ANAG-006 Study Group,"Opioid/acetaminophen (APAP) combination analgesics are widely prescribed for the relief of moderate pain. Tramadol is a synthetic analgesic that has been shown to be effective both alone and in combination with APAP. The purpose of this study was to compare the efficacy and tolerability of tramadol/APAP tablets with codeine/APAP capsules. This 4-week, randomized, double-blind, parallel-group, active-control, double-dummy, multicenter trial compared tramadol/APAP (37.5 mg/325 mg) with codeine/APAP (30 mg/300 mg) for the management of chronic nonmalignant low back pain, osteoarthritis (OA) pain, or both in adults. Pain relief (scale, 0 = none to 4 = complete) and pain intensity (scale, 0 = none to 3 = severe) were measured 30 minutes and then hourly for 6 hours after the first daily dose each week. Patients and investigators assessed the efficacy (scale, 1 = poor to 5 = excellent) of each medication, and patients recorded daily doses of study and rescue medications. A total of 462 patients (mean age, 57.6 years) were randomly assigned to treatment, with 112 (24%) reporting chronic low back pain, 162 (35%) reporting OA pain, and 188 (41%) reporting both low back and OA pain; 309 patients (67%) received tramadol/APAP and 153 (33%) received codeine/APAP. Pain relief and changes in pain intensity were comparable from day 1, as early as 30 minutes after the first dose, and lasted for at least 6 hours. Total pain relief scores (11.9 for tramadol/APAP; 11.4 for codeine/APAP) and sum of pain intensity differences (3.8 for tramadol/APAP; 3.3 for codeine/APAP) were also comparable throughout. Overall assessments of efficacy by patients (mean score 2.9 in each treatment group) and investigators (mean score 3.0 for tramadol/APAP, 2.9 for codeine/APAP) were similar for the 2 treatment groups. Equivalent mean doses (3.5 tablets or capsules daily) and maximum daily doses (5.5 tablets or 5.7 capsules) were used in the 2 treatment groups. The overall incidence of adverse events was comparable, with a significantly higher proportion of patients in the codeine/APAP group reporting somnolence (24% [37/153] vs 17% [54/309], P = 0.05) or constipation (21% [32/153] vs 11% [35/309], P < 0.01) and a larger proportion of patients in the tramadol/APAP group reporting headache (11% [34/309] vs 7% [11/153], P = 0.08). The results of this study suggest that tramadol/APAP tablets (37.5 mg/325 mg) are as effective as codeine/ APAP capsules (30 mg/300 mg) in the treatment of chronic nonmalignant low back pain and OA pain and are better tolerated.",2002.0,0,0
612,11589259,"Rofecoxib versus codeine/acetaminophen in postoperative dental pain: a double-blind, randomized, placebo- and active comparator-controlled clinical trial.",D J Chang; J R Fricke; S R Bird; N R Bohidar; T W Dobbins; G P Geba,"In recent studies of acute pain and primary dysmenorrhea, rofecoxib, a nonsteroidal anti-inflammatory drug that selectively targets the cyclooxygenase-2 enzyme, was found to be similar in efficacy to ibuprofen and naproxen sodium. The purpose of this study was to determine the analgesic efficacy of a single oral dose of rofecoxib 50 mg compared with the combination of codeine 60 mg/acetaminophen 600 mg in a model of postsurgical dental pain. In this double-blind, placebo- and active comparator-controlled, parallel-group study, patients experiencing moderate or severe pain after the surgical extraction of > or = 2 third molars, at least 1 of which was a mandibular impaction, were randomized to receive placebo, rofecoxib 50 mg, or codeine 60 mg/acetaminophen 600 mg. Patient evaluations of pain intensity, pain relief, and global assessments were recorded throughout the 24-hour period after dosing. The 2-stopwatch method was used to determine time to confirmed perceptible pain relief. The primary end point assessing overall analgesic effect was total pain relief over 6 hours (TOPAR6). Secondary end points were patient global assessment of response to therapy (PGART) at 6 hours, onset of analgesia, peak analgesic effect, and duration of analgesia. A total of 393 patients were enrolled; 182 received rofecoxib, 180 received codeine/acetaminophen, and 31 received placebo. The overall analgesic effect of rofecoxib 50 mg was greater than that of codeine 60 mg/acetaminophen 600 mg for TOPAR6 (12.4 vs 7.0; P < 0.001) and PGART at 6 hours (P < 0.001). The onset of analgesic effect was similar for rofecoxib and codeine/acetaminophen. Peak analgesic effect as measured by peak pain relief scores during the first 6 hours was significantly greater in the rofecoxib group compared with the codeine/acetaminophen group (P < 0.001), as was the duration of analgesic effect measured by the time to rescue analgesia (9.6 hours vs 2.3 hours, P < 0.001). Adverse events were reported in 33.0%, 46.1%, and 32.3% of patients treated with rofecoxib, codeine/acetaminophen, and placebo, respectively. The most common adverse events were nausea (6.0%, 25.0%, and 9.7%, respectively) and vomiting (3.8%, 18.3%, and 6.5%, respectively). Significantly more patients in the codeine/acetaminophen group than in the rofecoxib group experienced adverse events overall (P < 0.050) and nausea in particular (P < 0.001). In this study of moderate to severe postoperative dental pain, the analgesic efficacy of rofecoxib 50 mg was greater than that of codeine/acetaminophen, with a lower incidence of adverse events and nausea.",2002.0,0,0
613,11591972,Long-term follow-up of thoracoscopic splanchnicectomy for chronic pancreatitis pain.,J W Maher; F C Johlin; D Heitshusen,"Thoracoscopic splanchnicectomy (SPL) has been reported to give excellent short-term pain relief in chronic pancreatitis. This study prospectively evaluates the long-term efficacy of SPL in pancreatitis patients. Chronic pancreatitis patients with severe pain unrelieved by standard therapy completed a standard 10-point analogue pain scale prior to surgery and at postoperative visits. Midline and left-sided pain was treated with left SPL; right-sided pain was treated with right SPL. If pain recurred on the contralateral side, contralateral SPL was done. Fifteen patients underwent SPL. Eleven of them required narcotics preoperatively. Follow-up is complete and ranges from 4.2 to 6.1 years (median, 5.75). All patients had constant pain prior to surgery. Following SPL, it decreased in the short term to a mean of 3.9 attacks a month. At long-term follow-up, the mean number of attacks was 8.6 per month. Preoperatively, the mean score for worst pain within the last 2 months was 9.1. This score decreased to 3.9, but at long-term follow-up it had increased to near preoperative values (8.6). Current severity of pain decreased from 7.2 preoperatively to 2.9 at short-term follow-up, but at long-term follow-up it had increased. The degree of disability decreased from 9.1 preoperatively to 5.1 at short-term follow-up, but in the long term it increased toward preoperative values. Although eight patients were narcotic free at early follow-up, only three remained narcotic free in the long-term. Thoracoscopic SPL offers short-term relief of pain from chronic pancreatitis, but the relief is not durable in most cases. Similarly, there are short-term improvements in degree of disability, mood, and freedom from narcotic use that are not sustained in the long-term. Nevertheless, two-thirds of patients stated that they would have the surgery again.",2002.0,0,0
614,11600260,,,,,0,0
615,11603137,Intravenous regional anaesthesia using lignocaine and tramadol.,S M Tan; L L Pay; S T Chan,"This prospective, randomised, double-blind study was designed to assess if the addition of 50 mg tramadol to 30 mL 0.5% lignocaine would improve the efficacy of intravenous regional anaesthesia. Fifty-four adult patients undergoing upper limb surgery were randomly allocated to receive either 30 mL 0.5% lignocaine and 1 mL normal saline (group A) or 30 mL 0.5% lignocaine and 50 mg tramadol (group B). They were then assessed for onset of sensory and motor block and the VbAS score for tourniquet pain. Although more patients in group B had a faster onset of sensory and motor block, this was not significantly different. Patients in group B had a significantly lower VbAS score 30 min after tourniquet inflation and after change over to the distal tourniquet (P < 0.05). There were no complaints of postoperative nausea and vomiting. Two patients in group B developed localised skin urticaria of the forearm which resolved with the release of the tourniquet. There is a positive trend that tramadol might improve the quality of intravenous regional anaesthesia.",2002.0,0,0
616,11605110,Preinsertion local anesthesia at the trocar site improves perioperative pain and decreases costs of laparoscopic cholecystectomy.,N W Hasaniya; F F Zayed; H Faiz; R Severino,"Local anesthesia at the trocar site in laparoscopic cholecystectomy is expected to decrease postoperative pain and hence expedite recovery. The aims of this prospective randomized study were to investigate the effect of local anesthesia and to discover whether it is cost effective. For this study, 100 patients undergoing laparoscopic cholecystectomy were randomized into two groups. The 43 study patients were injected with 0.5% bupivacaine hydrochloride at the trocar site before the trocars were inserted. They then were compared with 41 control patients who received no local anesthesia. The remaining 16 patients were excluded from the study. The postoperative pain was evaluated at the standard four trocar sites at 4 h and 24 h after surgery on a scale 1 (the mildest pain the patient had ever experienced) to 10 (the most severe pain the patient had ever experienced). Postoperative pain medications and their cost were evaluated. There was no difference between the two groups with regard to gender, age, weight, operative time, estimated operative blood loss, and bile culture. The patients who received bupivacaine at the trocar site clinically had less pain (p < 0.001 for all four sites) both at 4 and 24 h after surgery. The treatment group patients used less mepiridine and promethzine than the control group (p = 0.001 and 0.002, respectively) postoperatively. Overall, the patients who had local anesthesia used less postoperative pain and antiemetic medication than the control patients (p = 0.02). This afforded a significant decrease in the costs and charges of these medications (p = 0.004 and 0.005, respectively). Three patients in the study group were discharged from the hospital the day of surgery. Preinsertion of local anesthesia at the trocar site in laparoscopic cholecystectomy significantly reduces postoperative pain and decreases medication usage costs.",2002.0,0,0
617,11692348,"Tramadol drops in children: analgesic efficacy, lack of respiratory effects, and normal recovery times.",K A Payne; J A Roelofse,"Tramadol hydrochloride is a racemic mixture of two enantiomers. It has analgesic activity suitable for mild to moderate pain, part of its analgesic activity being modulated via mu receptors. Adult studies have raised the question of increased electroencephalographic activity. The study examined the analgesic efficacy, respiratory effects, and behavior plus recovery-influencing properties of tramadol in the pediatric patient. Day-case dental extraction children, aged 4-7 years having 6 or more extractions, were studied. Tramadol drops, 3 mg/kg, plus oral midazolam, 0.5 mg/kg, were administered 30 minutes prior to a sevoflurane in N2O and O2 anesthetic. Forty children received this premedication treatment (T) and 10 entered a placebo control group (P), where no tramadol was administered. Entry was random, double blind, and parallel. Analgesic efficacy was measured using the Oucher face pain scale (OFPS), with responders scoring three or less. Respiration was measured by rate and oxygen saturation. Behavior and ease of mask induction were assessed on a 4-point scale. Recovery was measured with the Aldrete scale. Parameters were measured from 30 minute preanesthetic to 120 minute postanesthetic. Analgesic efficacy was shown, with an OFPS score of 11.42 (SD 18.66) (T) and 29.80 (SD 25.14) (P) (P < .05). Responders on tramadol were 77.5% versus 0% on placebo (P < .05). No respiratory depression was seen; rates and oxygen saturations were the same preanesthetic and postanesthetic. Similarly, the two groups had no cardiovascular differences. Preanesthetic behavior patterns were the same (P > .05), with 85% of the tramadol group being drowsy but awake versus 90% in the placebo group. Similarly satisfactory induction behavior was seen in 95% of the tramadol group and 90% of the placebo group. Recovery times were 48.6 minutes (SD 32.3) (T) and 43.1 minutes (SD 32.5) (P) (P > .05). It is concluded that tramadol at 3 mg/kg has no clinical respiratory depressant effect and that behavior and recovery times are unaffected. Analgesic efficacy is demonstrated.",2002.0,0,0
618,11696730,Intrarectal lidocaine during transrectal prostate biopsy: results of a prospective double-blind randomized trial.,S S Chang; G Alberts; N Wells; J A Smith; M S Cookson,"Recent reports have indicated the benefit of anesthesia during prostate biopsy. To assess this finding objectively we performed a prospective randomized double-blind study to compare patient pain with and without local anesthesia during transrectal ultrasound guided prostate biopsies. Between August 2000 and March 2001, 108 men undergoing transrectal ultrasound guided biopsy of the prostate were randomized in double-blind fashion to receive intrarectal 2% lidocaine gel or intrarectal lubricant alone. No patient received pre-procedure narcotics or sedation. Pain associated with biopsy was determined using a horizontal linear visual analog pain scale. Pain scores in the 2 treatment groups were compared and possible predictors of increased pain were examined. The 2 groups were similar in demographic characteristics. There was no significant difference in pain score in the 2% lidocaine and lubricant alone groups (28.3 versus 28.9 mm., p = 0.88). Previous biopsy, time since previous biopsy, physician, number of biopsies and prostate volume did not correlate with pain score, while age correlated negatively with the score (r = -0.27, p = 0.005). A single complication involving a vasovagal episode resolved spontaneously. Intrarectal lidocaine gel provides no significant therapeutic or analgesic benefit compared with lubricant alone for transrectal ultrasound guided biopsy of the prostate. In younger patients more discomfort is associated with this procedure.",2002.0,0,0
619,11698029,Opioids in chronic pain.,R Przewłocki; B Przewłocka,"The advance in our understanding of the biogenesis of various endogenous opioid peptides, their anatomical distribution, and the characteristics of the multiple receptors with which they interact open a new avenue for understanding the role of opioid peptide systems in chronic pain. The main groups of opioid peptides: enkephalins, dynorphins and beta-endorphin derive from proenkephalin, prodynorphin and proopiomelanocortin, respectively. Recently, a novel group of peptides has been discovered in the brain and named endomorphins, endomorphin-1 and -2. They are unique in comparison with other opioid peptides by atypical structure and high selectivity towards the mu-opioid receptor. Another group, which joined the endogenous opioid peptide family in the last few years is the pronociceptin system comprising the peptides derived from this prohormone, acting at ORL1 receptors. Three members of the opioid receptor family were cloned in the early 1990s, beginning with the mouse delta-opioid receptor (DOR1) and followed by cloning of mu-opioid receptor (MOR1) and kappa-opioid receptor (KOR1). These three receptors belong to the family of seven transmembrane G-protein coupled receptors, and share extensive structural homologies. These opioid receptor and peptide systems are significantly implicated in antinociceptive processes. They were found to be represented in the regions involved in nociception and pain. The effects of opioids in animal models of inflammatory pain have been studied in great detail. Inflammation in the periphery influences the central sites and changes the opioid action. Inflammation increased spinal potency of various opioid receptor agonists. In general, the antinociceptive potency of opioids is greater against various noxious stimuli in animals with peripheral inflammation than in control animals. Inflammation-induced enhancement of opioid antinociceptive potency is characteristic predominantly for mu opioid receptors, since morphine elicits a greater increase in spinal potency of mu- than of delta- and kappa-opioid receptor agonists. Enhancement of the potency of mu-opioid receptor agonists during inflammation could arise from the changes occurring in opioid receptors, predominantly in affinity or number of the mu-opioid receptors. Inflammation has been shown to alter the expression of several genes in the spinal cord dorsal horn. Several studies have demonstrated profound alterations in the spinal PDYN system when there is peripheral inflammation or chronic arthritis. Endogenous dynorphin biosynthesis also increases under various conditions associated with neuropathic pain following damage to the spinal cord and injury of peripheral nerves. Interestingly, morphine lacks potent analgesic efficacy in neuropathic pain. A vast body of clinical evidence suggests that neuropathic pain is not opioid-resistant but only that reduced sensitivity to systemic opioids is observed in this condition, and an increase in their dose is necessary in order to obtain adequate analgesia. Reduction of morphine antinociceptive potency was postulated to be due to the fact that nerve injury reduced the activity of spinal opioid receptors or opioid signal transduction. Our recent study with endogenous ligands of the mu-opioid receptor, endomorphins, further complicates the issue, since endomorphins appear to be effective in neuropathic pain. Identification of the involved differences may be of importance to the understanding of the molecular mechanism of opioid action in neuropathic pain, as well as to the development of better and more effective drugs for the treatment of neuropathic pain in humans.",2002.0,0,0
620,11702324,[Postoperative pain therapy with hydromorphone and metamizole. A prospective randomized study in intravenous patient-controlled analgesia (PCA)].,K A Lehmann; F Paral; R Sabatowski,"Most potent opioid analgesics available in Germany have been investigated for use in postoperative patient-controlled analgesia (PCA). To conclude an older comparative series, it was the aim of the present study to define analgesic potency, side effects and patient acceptance of hydromorphone and its interaction with the non-opioid analgesic metamizole. A total of 120 patients recovering from elective abdominal or orthopaedic surgery, performed under standardised general anaesthesia, were randomised into 3 double-blind treatment groups to receive intravenous PCA demand doses of hydromorphone 283 micrograms (low dose, LD), 566 micrograms (high dose, HD) or a combination of hydromorphone 283 micrograms and metamizole 50 mg (low dose hydromorphone + metamizole, LM). Demand-independent low-dose background infusions were added to deliver hydromorphone at 67.9 micrograms/h in all groups, with additional metamizole at 12 mg/h in group LM. Lockout times were set to 2 min. After an average observation time of 24.5 +/- 2.6 h (mean, SD) since start of PCA, cumulative PCA hydromorphone doses in groups LD, HD and LM were 7.8 +/- 3.3, 12.1 +/- 4.8 and 7.5 +/- 2.0 mg, respectively, with the well known large inter-individual variability in all groups. Although hydromorphone consumption was significantly higher in group HD, self-reported pain intensities (VAS, retrospective pain scores) were quite comparable between the groups. Low dose, PCA bolus-linked metamizole did not significantly reduce hydromorphone consumption nor improve patient acceptance. Side-effects were typical for potent postoperative opioids, but never required special treatment; haemodynamic or respiratory complications were not observed in any patient. It can be concluded by comparison with other PCA opioid investigations performed under the same study protocol that hydromorphone is about 3-4 times as potent an analgesic as morphine under the conditions of intravenous postoperative PCA. Due to a favourable patient acceptance, hydromorphone can be recommended as a suitable alternative to other opioids for the treatment of postoperative pain.",2002.0,0,0
621,11702609,Treatment of pain in severe burns.,G Gallagher; C P Rae; J Kinsella,"Burn pain can cause psychologic and functional difficulties, and is difficult to predict from wound depth. The initial painful stimulation of nerve endings by the burn with continued painful stimuli result in peripheral and central mechanisms causing amplification of painful stimuli, and the development of chronic pain syndromes that can be difficult to treat. In order to assess the effect of analgesic interventions it is essential to measure the patient's pain in a simple and reproducible manner. A number of tools exist for this measurement, ranging from longer and more detailed techniques such as the McGill pain questionnaire most suited to relatively stable pain, to visual analogue scores and picture-based scores for children. Pain management begins with the acute injury, with initial measures such as cooling of the burn and use of inhalational agents such as oxygen/nitrous oxide mixtures. On arrival in hospital, for any but trivial burns, intravenous opioids are appropriate and should be administered as small intravenous boluses titrated against effect. Following the initial resuscitation, pain may be divided into background pain and that associated with procedures. These often require different analgesic interventions. Background pain may be treated with potent intravenous opioids by infusion or patient controlled analgesia and then on to oral, less potent opioids, followed by other oral analgesics. Often drug combinations work best. More severe procedural pain may be treated with a variety of interventions from a slight increase in therapy for the background pain to more potent drugs, local blocks, or general anaesthesia. In addition to drug-based methods of managing burn pain, a number of nonpharmacologic approaches have been successfully employed including hypnosis, auricular electrical stimulation, massage, and a number of cognitive and behavioural techniques.",2002.0,0,0
622,11703246,Patient-controlled pethidine after major upper abdominal surgery: comparison of the epidural and intravenous routes.,P P Chen; E W Cheam; M Ma; K K Lam; W D Ngan Kee; T Gin,"We compared epidural (n = 17) and intravenous (n = 20) patient-controlled analgesia (PCA) using pethidine (bolus 10 mg, lockout interval 10 min, 4-h maximum dose 3 mg.kg(-1)) after total gastrectomy. We found that mean (SD) pethidine consumption in the first 24 h was 33% less in the epidural group [255 (85) mg] than in the intravenous group [379 (129) mg, p = 0.002], although most of this difference occurred in the first 8 h. Plasma concentrations of pethidine were lower at 8 h (p < 0.01) in the epidural group, but were similar at 24 h. Pain scores, side-effects, patient satisfaction and patient outcome were similar between groups. Epidural and intravenous pethidine PCA provided similar efficacy after major abdominal surgery, although the epidural route can reduce the amount of pethidine used initially.",2002.0,0,0
623,11703580,Pain management in polycystic kidney disease.,Z H Bajwa; S Gupta; C A Warfield; T I Steinman,"Pain is a common complaint in patients with autosomal-dominant polycystic kidney disease, and a systematic approach is needed to differentiate the etiology of the pain and define an approach to management. A thorough history is the best clue to the multifactorial causes of the pain, superimposed upon an understanding of the complex innervation network that supplies the kidneys. The appropriate use of diagnostic radiology (especially MRI) will assist in differentiating the mechanical low back pain caused by cyst enlargement, cyst rupture and cyst infection. Also, the increased incidence of uric acid nephrolithiasis as a factor in producing renal colic must be considered when evaluating acute pain in the population at risk. MRI is not a good technique to detect renal calculi, a frequent cause of pain in polycystic kidney disease. If stone disease is a possibility, then abdominal CT scan and/or ultrasound should be the method of radiologic investigation. Pain management is generally not approached in a systematic way in clinical practice because most physicians lack training in the principles of pain management. The first impulse to give narcotics for pain relief must be avoided. Since chronic pain cannot be ""cured,"" an approach must include techniques that allow the patient to adapt to chronic pain so as to limit interference with their life style. A detailed stepwise approach for acute and chronic pain strategies for the patient with autosomal dominant polycystic kidney disease is outlined.",2002.0,0,0
624,11706463,Nurses' personal opinions about patients' pain and their effect on recorded assessments and titration of opioid doses.,M McCaffery; B R Ferrell; C Pasero,"In many clinical settings, nurses have a vital role in pain assessment and titration of opioid doses. Surveys of nurses have revealed knowledge deficits in these areas that are thought to contribute to under-treatment of pain. The present study surveys nurses' decisions about assessment and treatment of pain in 2 patient situations and confirms that nurses continue to undertreat severe pain. As shown in previous studies, nurses may be more influenced by the patient's behavior than the patient's self-report of pain, especially in relation to decisions about opioid titration. Nurses are less likely to increase a previously safe but ineffective dose of opioid for a smiling patient than a grimacing patient. Survey results reveal a tendency for nurses' personal opinions about the patients' pain, rather than their recorded assessments, to influence choice of opioid dose and to contribute to undertreatment of pain.",2002.0,0,0
625,11706465,Pain after gynecologic surgery.,M Good; M Stanton-Hicks; J A Grass; G C Anderson; M Makii; J Geras,"This article provides a descriptive profile of pain in 80 women during the first 2 days after gynecologic surgery in 4 hospitals. Surgical procedures included abdominal hysterectomy, oophorectomy, and laparotomy. Average pain was moderate on both days, but paired t tests indicated that pain increased significantly during ambulation on day 1 (P = .009, sensation; P < .001, distress) and on day 2 (P = .007, sensation; P = .030, distress). They both (P = .001) decreased significantly during rest on day 1, but not on day 2. Analysis of quartiles indicated that one fourth of the sample suffered severe sensation pain at all points on day 1 (60 to 74 mm on a 100-mm visual analogue scale), and moderate to severe sensation on day 2 (40 to 60 mm). The lowest quartile had mild pain on both days (11 to 28 mm on day 1, and 7 to 14 mm on day 2). Some patients (30%) reported that pain interrupted their sleep on the first 2 nights, and difficulty sleeping on the first postoperative night for any reason (65%) was related to greater pain during the next 2 days (r = .25 to .43). Although 41% of the women had previously used relaxation techniques for stress or pain, only 9% used it for pain after surgery. Results suggest that postoperative patients have moderate to severe pain that is incompletely relieved with patient-controlled analgesia. Nurses should encourage patients to press the patient-controlled analgesia button more often, report unrelieved pain, and use nonpharmacologic interventions.",2002.0,0,0
626,11707825,"A randomized, placebo-controlled study of outpatient premedication for bone marrow biopsy in adults with lymphoma.",A P Wolanskyj; G Schroeder; P R Wilson; T M Habermann; D J Inwards; T E Witzig,"The outpatient bone marrow biopsy and aspiration (BMBA) procedure performed with local anesthetic is often poorly tolerated in adults. This prospective, randomized, placebo-controlled, double-blind trial was designed to determine whether oral (p.o.) lorazepam and hydromorphone reduces pain and anxiety during BMBA. Eligible patients had lymphoma, had no prior BMBA, and were > or = 18 years old. Since patients had bilateral BMBA, each served as their own control. Patients were stratified by anxiety level using the Spielberger Trait Anxiety Scale and randomized to: A) placebo for the first BMBA and 2 mg lorazepam and 2 mg hydromorphone p.o. for the contralateral BMBA, or B) placebo for both BMBAS. Changes in pain and anxiety experienced between the first and second BMBA were measured by the Visual Analogue Scale (VAS) and the Spielberger State Anxiety Scale at the time of the BMBA and 24 hours later. Twenty-seven patients were enrolled and 25 were evaluable; there were 17 males and eight females. The median age was 57 years (range, 28-79 years). Overall, BMBA was reported as painful in both arms, with a median VAS pain score after the second BMBA of 3.9 (scale, 0-10) for arm A and 5.8 for arm B (P = 0.21). There was no difference in the change in pain, anxiety, or recalled anxiety between treatment arms (all P values > 0.05). The difference in the change in recalled pain was of borderline significance (P = 0.07) and consistent with benzodiazepine-induced anterograde amnesia.",2002.0,0,0
627,11709114,,,,,0,0
628,11709865,An educational implementation of a cancer pain algorithm for ambulatory care.,A R Du Pen; S Du Pen; J Hansberry; B Miller-Kraybill; J Millen; R Everly; N Hansen; K Syrjala,"Algorithms are proposed as a means of operationalizing guidelines or standards for cancer pain management. Professional education is used as the means to translate knowledge into practice. Outcomes measurement is the gold standard for validating improvement. This study used an educational intervention to transfer knowledge on implementing a previously tested algorithm for cancer pain management into community outpatient oncology clinics and, subsequently, measuring patient outcomes. Physicians and nurses from 9 Puget Sound clinics were randomized by institution blocks to either ""training"" or ""no training."" Role model physician/nurse teams were the core faculty for a day-long seminar. Written reference materials and documentation tools were provided to the trained physician/nurse teams. A total of 105 patients of trained and untrained providers were accrued and assessed over 4 months. Patients of trained providers had a significant reduction in usual pain over the 4 months of data collection compared with patients of untrained providers (t = 2.0; p = .05). Improvements were modest in the prescription of opioid analgesics and dramatic in the prescription of co-analgesics for neuropathic pain. There was a clear deterioration in the impact of the training over time. The most significant effect occurred within the first 140 days after the intervention and was followed by a gradual return to baseline practice. In conclusion, algorithmic interventions can be successfully transferred into community practice, but further work must be performed to develop methods for securing retention of knowledge and maintaining improved outcomes.",2002.0,0,0
629,11709934,Neuropathic complications of mandibular implant surgery: review and case presentations.,J M Gregg,"Injuries to trigeminal nerves during endosseous implant placement in the posterior mandible appear to occur acutely in approximately 5-15 of cases, with permanent neurosensory disorder resulting in approximately 8%. Nerve lateralization holds even higher risks from epineurial damage or ischaemic stretching. Neuropathy from implant compression and drill punctures can result in neuroma formation of all types, and in some cases precipitate centralized pain syndrome. Two patterns of clinical neuropathy are seen to result; hypoaesthesias with impaired sensory function, often seen with phantom pain, and hyperaesthesias with minimal sensory impairment but presence of much-evoked pain phenomena. The clinician must differentiate, through careful patient questioning and stimulus-response testing, those patients who are undergoing satisfactory spontaneous nerve recovery from those who are developing dysfunctional or dysaesthetic syndromes. Acute nerve injuries are treated with fixture and nerve decompression and combined with supportive anti-inflammatory, narcotic and anti-convulsant therapy. Surgical exploration, neuroma resection and microsurgical repair, with or without nerve grafting, are indicated when unsatisfactory spontaneous sensory return has been demonstrated, and in the presence of function impairment and intractable pain.",2002.0,0,0
630,11713727,Grafting of the peritonsillar fossa with an acellular dermal graft to reduce posttonsillectomy pain.,A P Sclafani; A A Jacono; J N Dolitsky,"Adult tonsillectomy is a common surgical procedure that is accompanied by masked postoperative pain. Analgesics are usually only partially effective, and the use of narcotics such as codeine is often poorly tolerated because of associated nausea. Because the pain associated with tonsillectomy is believed to arise from the large areas of exposed parapharyngeal muscle, we hypothesized that acellular dermal grafting of the peritonsillar fossa, providing biologic coverage to these areas, would result in a notable reduction of postoperative pain. We did a double-blind, prospective study, with 10 adult patients undergoing electrodissection tonsillectomy concurrently with grafting of 1 peritonsillar fossa with an acellular dermal graft (ADG) (AlloDerm, LifeCell Corp, The Woodlands, TX), whereas the other side of the throat received no treatment and was designated as the control side. Patients were examined on postoperative days 1, 7, and 14, and completed pain questionnaires on postoperative days 1, 3, 5, 7, and 14. ADG grafting of the peritonsillar fossa resulted in a statistically significant reduction in pain (by approximately 50%) on postoperative days 1, 3, 5, and 7, compared with the control side. Two patients experienced partial graft sloughing within the first 10 postoperative days, but no other untoward effects such as bleeding, graft aspiration, or infection, were associated with ADG of the peritonsillar fossa. This study suggests that AlloDerm grafting of the peritonsillar fossa is a potentially useful, alternative means of reducing pain in the adult tonsillectomy patient and has potential use in reconstruction of oropharyngeal defects. Because of the cost of the graft, we suggest its use in selected difficult adult cases, but not as part of routine adult tonsillectomy.",2002.0,0,0
631,11724223,Tramadol and acetaminophen tablets for dental pain.,R A Medve; J Wang; R Karim,"The purpose of this work was to compare the efficacy and time to analgesia of a new tramadol/acetaminophen combination tablet to those of tramadol or acetaminophen (APAP) alone. A meta-analysis was performed of 3 separate single-dose, double-blind, parallel-group trials in patients with moderate or severe pain following extraction of 2 or more third molars. Patients in each study were evenly randomized to a single dose of tramadol/APAP (75 mg/650 mg), tramadol 75 mg, APAP 650 mg, ibuprofen 400 mg, or placebo. Active control with ibuprofen was used to determine model sensitivity. Pain relief (scale, 0-4) and pain intensity (scale, 0-3) were reported at 30 minutes after the dose and then hourly for 8 hours. Total pain relief over 8 hours (TOTPAR8) and the sum of pain intensity differences (SPID8) were calculated from the hourly scores. Time to onset of pain relief was determined by the double-stopwatch technique, and patients were advised to wait at least 2 hours before taking supplemental analgesia. Patients assessed overall efficacy (scale, 1-5) upon completion. In all, 1197 patients (age range, 16-46 years) were evaluable for efficacy; treatment groups in each study were similar at baseline. Pain relief was superior to placebo (P < or = .0001) for all treatments. Pain relief provided by tramadol/ APAP was superior to that of tramadol or APAP alone, as shown by mean TOT-PAR8 (12.1 vs 6.7 and 8.6, respectively, P < or = .0001) and SPID8 (4.7 vs 0.9 and 2.7, respectively, P < or = .0001). Estimated onset of pain relief was 17 minutes (95% CI, 15-20 minutes) for tramadol/APAP compared with 51 minutes (95% CI, 40-70 minutes) for tramadol, 18 minutes (95% CI, 16-21 minutes) for APAP, and 34 minutes (95% CI, 28-44 minutes) for ibuprofen. Median time to supplemental analgesia and mean overall assessment of efficacy were greater (P < .05) for the tramadol/APAP group (302 minutes and 3.0, respectively) than for the tramadol (122 minutes and 2.0) or APAP (183 minutes and 2.7) monotherapy groups. A new combination analgesic, tramadol/APAP, is superior to tramadol or APAP alone with respect to pain relief and duration of action. It is also superior to tramadol alone with respect to time to onset.",2002.0,0,0
632,11731064,Intra-articular morphine as analgesic in temporomandibular joint arthralgia/osteoarthritis.,T List; A Tegelberg; T Haraldson; G Isacsson,"The aim of this study was to determine the analgesic efficacy of a single dose intra-articular injection (i.a.) of morphine in 53 patients with unilateral arthralgia/osteoarthritis of the temporomandibular joint (TMJ). This randomized, double-blind, parallel group, multicenter study included a screening visit, a treatment visit, and a follow-up visit 1 week after treatment. Recordings of visual analog scales (VAS) pain intensity scores at maximum mouth opening (main efficacy variable) and at jaw rest were made directly before a 1-ml i.a. injection into one TMJ of either 1.0mg morphine-HCl, 0.1mg morphine-HCl, or saline (placebo). The pain intensity was also recorded at the follow-up and in a diary 3 days before and 5 days after the injection. The VAS pain score at maximum mouth opening was considerably reduced 1-10h after injection but without significant differences between groups. At the follow-up, the median VAS pain score at maximal mouth opening was significantly lower in the 0.1-mg morphine group than in the 1.0-mg morphine group (P<0.043) or the saline group (P<0.021). A significant increase in pain pressure threshold over the affected joint was seen in the 0.1-mg morphine group compared with the saline group at the follow-up but not 1 and 2h post-injection. The incidence of adverse events was small and did not differ between the treatment groups. In conclusion, one i.a. injection of 0.1mg morphine significantly increased the pain pressure threshold and mouth opening ability, but evidence for the analgesic property of the locally applied opioid was inconclusive. No dose-effect relation and no significant short-term analgesic property were seen. Although statistically significant, the magnitude of the reduced VAS pain intensity score was not clinically relevant at the 1-week follow-up.",2002.0,0,0
633,11731509,Lack of adherence with the analgesic regimen: a significant barrier to effective cancer pain management.,C Miaskowski; M J Dodd; C West; S M Paul; D Tripathy; P Koo; K Schumacher,"To evaluate oncology outpatients' level of adherence to their analgesic regimen during a 5-week period. A random sample of 65 adult oncology outpatients with a Karnofsky performance status score of >or= 50, an average pain intensity score of >or= 2.5, and radiographic evidence of bone metastasis were recruited for this longitudinal study from seven outpatient settings. On a daily basis, patients rated their level of pain intensity and recorded pain medication intake. Adherence rates for opioid analgesics prescribed on an around-the-clock (ATC) and on an as-needed (PRN) basis were calculated on a weekly basis. Overall adherence rates for ATC opioid analgesics ranged from 84.5% to 90.8% and, for PRN analgesics, from 22.2% to 26.6%. No significant differences over time were found in either of these adherence rates. One factor that seems to contribute to ineffective cancer pain management is poor adherence to the analgesic regimen.",2002.0,0,0
634,11731751,Implementing sevoflurane anesthesia with small doses opioid for upper abdominal surgery. Postoperative respiratory function after either remifentanil or fentanyl.,A Casati; A Albertin; G Danelli; F Deni; M Scarioni; R Santorsola; D Nucera,"The aim of this prospective, randomized study was to compare the effects on intraoperative cardiovascular homeostasis, recovery profile and postoperative oxygen saturation after sevoflurane anesthesia with small doses of either remifentanil or fentanyl in combination with postoperative epidural analgesia. With Ethical Committee approval and written patient consent, 30 ASA physical status I-II patients scheduled for elective upper abdominal surgery were randomly allocated to receive sevoflurane general anesthesia implemented with small doses of either remifentanil (n = 15) or fentanyl (n = 15), followed by postoperative epidural analgesia. Remifentanil group patients received a 1 mg kg-1 bolus infused during a 60 sec period followed by a 0.15 mg kg-1 min-1 infusion; while patients of Fentanyl group were given a 3 mg kg-1 initial dose followed by 50 mg boluses as requested (according to the time to peak effect of the two drugs, the initial dose was given 5 min before induction in Fentanyl group, and 1 min before induction in Remifentanil group). Postoperatively, oxygen saturation was continuously recorded and stored on a computer during the first 12 h after surgery. SpO2 decrease < 90% for more than one minute was considered as a minor respiratory complication. The median sevoflurane's MAC-hour was 2.7 (1.4 - 4.9) in patients receiving remifentanil infusion and 4.1 (2.2 - 5.7) in those patients receiving fentanyl during surgery (P = 0.005). However, no differences in the recovery times were observed between the two groups. Similar pain relief was reported during coughing in the two studied groups at discharge from the recovery area and during the following study period. No major respiratory complication was observed throughout the study. Oxygen therapy was required in three patients of Fentanyl group only 20% (P = 0.22); however, 11 patients in the same group (73%) showed at least one minor respiratory complication (SpO2 < 90% for more than 1 min), with a median of 1 (range 0 - 12) episode per patient, compared with no episode in Remifentanil group (P = 0.0005). Implementing sevoflurane anesthesia with very small remifentanil infusion provides a safe and effective hemodynamic control reducing sevoflurane consumption during the procedure, and produces less respiratory effects postoperatively as compared with intermittent bolus administration of fentanyl.",2002.0,0,0
635,11731754,Ketorolac vs tramadol in the treatment of postoperative pain during maxillofacial surgery.,M Zackova; S Taddei; P Calò; A Bellocchio; M Zanello,"This study aims to assess the best postoperative analgesia during maxillofacial surgery by using small doses of ketorolac or tramadol or their association and evaluates the presence of adverse effects due to NSAID or opioid use. After their informed consent, 51 patients ASA I and II undergoing major maxillofacial surgery, were randomised in three groups and the following protocol was used: group K received ketorolac (30 mg i.v.) at the time of skin closure and repeated after 8 hrs and 16 hrs from the end of the operation. Group T received tramadol (100 mg i.v.) in the same condition; and group KT received first tramadol (100 mg i.v.) during surgery and then ketorolac (30 mg) was given in the administrations that followed. Meperidine 50 mg was used in case of unsatisfactory analgesia. Pain was evaluated using pain intensity scores 2, 4, 6, 12 and 24 hours from the end of the operation. Data was analysed using Anova and c2 test. The groups were comparable with regard to age, weight, duration of surgery. Very good postoperative analgesia was recorded in three groups. There is no difference statistically between K, T and KT groups in the pain scores measured. Only a low number of patients required opioids administration to achieve adequate analgesia. The patients were considered to have achieved excellent analgesia in 64.8% in T group, in 41.2% of the K group and in 58.8% of the KT group. There were no cases of insufficient analgesia. We did not find a significant difference considering BP, HR, respiratory depression in the post-operative period. Vomiting was registered in 41.2% of this T group vs 11.2% of the K group and in 35.5% of the KT group. Ketorolac and Tramadol produced comparable, effective and low cost postoperative analgesia during maxillofacial surgery. There are only statistically significant differences considering side effects.",2002.0,0,0
636,11732382,Piroxicam versus tenoxicam in spine surgery: a placebo controlled study.,K De Decker; M Vercauteren; V Hoffmann; B Lasters; H Adriaensen,"In double-blind trial 60 patients undergoing spine surgery were randomized to receive either placebo, tenoxicam 40 mg intravenously (i.v.), tenoxicam 40 mg intramuscularly (i.m.) or piroxicam 40 mg i.m., immediately following the induction of general anesthesia. As compared to placebo, the 24 hour morphine consumption was reduced in all groups. This reduction was only statistically significant (p = 0.023) in the i.v. group (21.7 +/- 11.27 versus 36.53 +/- 20.33 mg). Rest and dynamic pain scores were significantly lower in both tenoxicam groups but more consistently in the i.v. group. With piroxicam only rest pain scores at 24 hours were lower. Less urinary retention was noticed in the i.v. tenoxicam group. This study shows that, following spine surgery, i.v. tenoxicam induces a morphine sparing effect (41%) while offering lower rest and dynamic pain scores and a lower incidence of urinary retention.",2002.0,0,0
637,11736778,Comparison of continuous epidural infusion of ropivacaine and sufentanil with intravenous patient-controlled analgesia after total hip replacement.,S Kampe; G Randebrock; P Kiencke; U Hünseler; K Cranfield; D P König; C Diefenbach,"We assessed the efficacy of an epidural infusion of ropivacaine 0.1% and sufentanil 1 microg x ml(-1), comparing it with intravenous patient-controlled analgesia using piritramide in this prospective, randomised, double-blind study of 24 ASA physical status I-III patients undergoing elective total hip replacement. Lumbar epidural block using ropivacaine 0.75% was combined with either propofol sedation or general anaesthesia for surgery. Epidural infusion and patient-controlled analgesia were started after surgery. Twelve patients received an epidural infusion of ropivacaine 0.1% and sufentanil 1 microg x ml(-1) at a rate of 5-9 ml x h(-1) and an intravenous patient-controlled analgesia device loaded with saline. Eleven patients received an epidural infusion of saline at the same rate and intravenous piritramide via the patient-controlled analgesia device. Motor block was negligible in both groups. The epidural ropivacaine group had significantly lower visual analogue pain scores at rest 4 h after surgery (p < 0.01), and on movement 4 h (p < 0.01) and 8 h (p < 0.05) after surgery, than the intravenous piritramide group. The piritramide group experienced significantly more adverse events than the epidural group (p < 0.001), especially hypotension (p < 0.01) and vomiting (p < 0.05). Patients in the epidural ropivacaine group were more satisfied with the pain management (p < 0.05). We conclude that the epidural infusion of ropivacaine 0.1% and sufentanil 1 microg x ml(-1) is superior to intravenous opioid by patient-controlled analgesia in preventing pain after total hip replacement, with fewer adverse effects and greater patient satisfaction.",2002.0,0,0
638,11736779,Adenotonsillectomy in children: a comparison of morphine and fentanyl for peri-operative analgesia.,K Mukherjee; V Esuvaranathan; C Streets; A Johnson; A S Carr,"This study compared the effectiveness and side-effects of intra-operative fentanyl with fentanyl and morphine for elective adenotonsillectomy in a double-blind study, in 60 children randomly allocated to receive either intravenous fentanyl 1 microg x kg(-1) intra-operatively or intramuscular morphine 100 microg x kg(-1) at induction. All children received a standard anaesthetic induction with intravenous fentanyl 1 microg x kg(-1) and propofol 4-5 mg x kg(-1) and maintenance with oxygen, nitrous oxide and isoflurane. Pain scores, emetic episodes and supplemental morphine requirements were recorded for 24 h postoperatively. The overall incidence of postoperative vomiting was high in both groups: 70% in the fentanyl group and 78% in the morphine group. The incidence of postoperative vomiting was lower in the fentanyl group (p < 0.03) in the first 4 h, but similar by 24 h. Children who received morphine at any time in the first 24 h had more median (range) episodes of vomiting [2 (0-7)] than children receiving fentanyl only [l (0-3); p < 0.03]. Administration of rescue anti-emetics, pain scores in recovery and pain scores over the next 24 h were similar between the two groups.",2002.0,0,0
639,11744583,Transdermal ketoprofen mitigates the severity of postoperative sore throat : [Le kétoprofène transdermique réduit le mal de gorge postopératoire].,M Ozaki; K Minami; T Sata; A Shigematsu,"To evaluate prospectively the incidence and severity of postoperative sore throat in 63 orotracheally intubated patients undergoing general anesthesia for various surgical procedures and to determine whether postoperative sore throat could be attenuated by treatment with the transdermal nonsteroidal anti-inflammatory drug ketoprofen applied on the anterior skin of the neck during operation. Patients were randomly assigned to have treatment with ketoprofen (ketoprofen group) or to have placebo tape treatment (control group). Postoperative analgesia was obtained by continuous epidural infusion of local anesthetics, and no narcotics were administered intraoperatively or postoperatively. All patients were interviewed postoperatively after 12-20 hr using a scoring scale questionnaire. Sore throat was scored as 0=no sore throat, 1=minimal, 2=mild, 3=moderate, 4=severe. In the control group, 16 of 32 patients had a sore throat. In the ketoprofen group, less patients (ten of 31 patients) had a sore throat (not significant). The severity of sore throat was alleviated significantly in the ketoprofen group (P <0.05). This study suggests the pain caused by tracheal intubation is relieved by intraoperative topical use of transdermal ketoprofen.",2002.0,0,0
640,11744586,"Intraoperative single-shot ""3-in-1"" femoral nerve block with ropivacaine 0.25%, ropivacaine 0.5% or bupivacaine 0.25% provides comparable 48-hr analgesia after unilateral total knee replacement.",H P Ng; K F Cheong; A Lim; J Lim; M E Puhaindran,"To compare analgesia after intraoperative single shot ""3-in-1"" femoral nerve block (FNB) in combination with general anesthesia using ropivacaine 0.25%, ropivacaine 0.5% with bupivacaine 0.25% for total knee replacement (TKR). We performed a randomized, double-blind study in 48 patients for elective TKR under general anesthesia. Patients were randomized to one of four groups (C: sham block, R1: ""3-in-1"" FNB using 30 mL of ropivacaine 0.25%, R2: ""3-in-1"" FNB using 30 mL of ropivacaine 0.5%, B: ""3-in-1"" FNB using 30 mL of bupivacaine 0.25%). Verbal pain score (VPS) both at rest and movement were assessed for 48 hr after TKR (0=none; 1=mild; 2=moderate; 3=severe). Total morphine consumption and its associated side effects, duration of hospitalization after operation were also compared. There were no differences in patients' physical characteristics, intraoperative morphine usage, operation time, tourniquet time or length of hospitalization between the four groups. When compared with group C, the VPS was significantly lower in groups R1, R2 and B at one, four, eight, 24 and 48 hr after TKR (P <0.05). The morphine requirement of groups R1, R2 and B were also significantly lower when comparing with group C up to 48 hr postoperatively (P <0.05). There were no significant differences in VPS and postoperative morphine requirement at any time between groups R1, R2 and B. ""3-in-1"" FNB with ropivacaine provided analgesia that was clinically comparable to that of bupivacaine up to 48 hr after TKR. Increasing the concentration of ropivacaine from 0.25% to 0.5% failed to improve the postoperative analgesia of ""3-in-1"" FNB.",2002.0,0,0
641,11744587,Methadone is safe for treating hospitalized patients with severe pain.,Y Shir; G Rosen; A Zeldin; E M Davidson,"Methadone is still regarded as a second line opioid for patients suffering from severe pain, and is rarely used in hospitalized patients. The infrequent use of methadone is probably due to its long plasma half-life that could lead to accumulation and toxicity. In the present study we report that clinically effective analgesic doses of methadone, given either epidurally or orally, can be used safely for prolonged treatment in hospitalized patients. Over a five-year period we administered methadone at Hadassah Hospital in Jerusalem to 3,954 in-patients with severe pain, 12% of whom were younger than 17 yr. Satisfactory pain relief was recorded in more than 85% of the patients. None of the patients treated with oral methadone developed serious side effects. Three patients, treated with epidural methadone (0.09%), developed a clinically significant respiratory depression. In all three cases, epidural pump failure or pump misprogramming resulted in methadone overdose. None of the children or adults treated with methadone developed addiction during hospitalization. Based on its analgesic properties and marked safety profile, we suggest that methadone could be added to the analgesic armamentarium of in-hospital health-care providers. Moreover, methadone could serve as the opioid of first choice in some in-patient populations.",2002.0,0,0
642,11745266,Intravenous methadone in the management of chronic cancer pain: safe and effective starting doses when substituting methadone for fentanyl.,J Santiago-Palma; N Khojainova; C Kornick; D J Fischberg; L H Primavera; R Payne; P Manfredi,"Patients often are rotated from other opioids to methadone when side effects occur before satisfactory analgesia is achieved. Various strategies have been proposed to estimate safe and effective starting doses of methadone when rotating from morphine and hydromorphone; however, there are no guidelines for estimating safe and effective starting doses of methadone when rotating from fentanyl. The authors prospectively observed 18 consecutive patients experiencing chronic pain from cancer who underwent opioid rotation from intravenous patient-controlled analgesia (PCA) with fentanyl to intravenous PCA with methadone. Patients were switched from fentanyl to methadone because of uncontrolled pain associated with sedation or confusion. A conversion ratio of 25 microg/hour of fentanyl to 0.1 mg/hour of methadone was used to calculate the initial dose of methadone in all patients. Mean pain scores decreased from 8.1 to 4.8 on Day 1 after the switch and to 3.22 on Day 4 after the switch. Mean sedation scores were 1.5 before the switch and 0.44 and 0.16 on Days 1 and 4, respectively. Among the 6 patients who experienced confusion while on fentanyl before the switch, 5 improved within 2 days of the switch. None of the patients experienced toxicity from methadone. On the basis of this preliminary study, the authors suggest that when switching from intravenous fentanyl to methadone a conversion ratio of 25 microg/hour of fentanyl to 0.1 mg/hour of methadone may be safe and effective.",2002.0,0,0
643,11750924,Protein kinases modulate the cellular adaptations associated with opioid tolerance and dependence.,J G Liu; K J Anand,"Prolonged opioid exposure occurs frequently as a result of clinical use or drug abuse. Research using different ligands, cell lines, and animal models in the past three decades has elucidated some correlation between the biochemical events and behavioral changes resulting from opioid tolerance, dependence and addiction. For the most part, opioid tolerance and dependence are associated with up-regulation of the cAMP pathway, mediated by the supersensitization of adenylyl cyclase and by the altered coupling of opioid receptors to stimulatory G proteins. Neuroadaptive changes in signal transduction following prolonged opioid exposure are mediated by protein kinase systems, such as protein kinase C (PKC), cyclic AMP-dependent protein kinase (PKA), Ca2+/camodulin-dependent protein kinase II (CaMKII), G protein-coupled receptor kinases (GRKs) and mitogen-activated protein kinases (MAPKs). Intermediate steps between opioid receptor activation and the second- or third-messenger cascades include GRK-mediated receptor endocytosis and intracellular trafficking, as well as interactions with excitatory amino acid receptors and regulation of nitric oxide synthesis. Thus, prolonged occupancy by opioid receptor agonists can have differential effects on opioid receptor internalization, down-regulation and desensitization, and in the supersensitization of adenylyl cyclase, which contribute to the development of opioid tolerance and dependence. We discuss the role of various protein kinases in the signaling mechanisms underlying these differences. Clearer understanding of the molecular mechanisms of opioid tolerance and dependence will help in the treatment of patients suffering from acute and chronic pain, or drug dependence and addiction.",2002.0,0,0
644,11756911,,,,,0,0
645,11758154,[Neuropathic pain syndromes: from their diagnosis to the return to work. Proposal of a model for rapid evaluation and therapy based on their pathogenic mechanisms].,M Buonocore; C Bonezzi,"The therapeutic approach to neuropathic pain differs significantly among physicians. This is in large part because of the relative paucity of randomized clinical trials and the scarcity of comparative studies with different drugs. Clinical studies on the efficacy of a drug or a technique are generally referred to the pathologic diagnosis and not to the pain mechanism. We have learned from animal models the different pain mechanisms which may be involved in the peripheral nerves and the spinal cord. Unfortunately, one mechanism could be responsible for many different symptoms, while the same symptom can be caused by different mechanisms. The authors propose a simple model to evaluate the patients in order to define the mechanisms involved an to select the treatment strategy. The diagnostic model allows classification of the patient into four groups according to pain mechanism (spinal neurons sensitization due to deafferentation, ectopic discharges in peripheral nociceptive C fibers, spinal neurons sensitization due to ectopic discharges in peripheral nociceptive C fibers, spinal neurons sensitization due to nociceptors sensitization). The authors propose also a second step in which a fifth mechanism, adrenosensitivity, is evaluated. Treatment options may target any of the mechanisms discussed. Drugs and analgesic techniques can be classified according to their action on pain mechanisms. The authors identify in the literature some drugs and techniques which can be tested in each defined groups. A complementary and multidisciplinary rehabilitative approach of chronic pain patients is recommended.",2002.0,0,0
646,11759562,The impact of nalmefene on side effects due to intrathecal morphine at cesarean section.,J E Pellegrini; S L Bailey; J Graves; J A Paice; S Shott; M Faut-Callahan,"Nalmefene is a long-acting opioid antagonist that provides long-term relief from side effects of intrathecal morphine sulfate. A randomized, double-blind, placebo-controlled study was conducted to determine whether prophylactic nalmefene could decrease side effects of intrathecal morphine given during cesarean section, without affecting analgesia. Sixty parturients were given 0.25 mg of intrathecal morphine, 12.5 micrograms of fentanyl, and 11.25 to 15 mg of bupivacaine. A dose of 0.25 microgram/kg of nalmefene or placebo was given by intravenous piggyback immediately after delivery of the neonate. Nausea, vomiting, pruritus, and level of sedation were assessed for a 24-hour period using a 4-point ordinal scoring system. Pain was assessed by using a 0- to 10-point verbal analogue scale. A 5-point analgesic satisfaction survey also was completed. Subjects who received nalmefene required supplemental analgesia at a median of 6.00 hours after intrathecal morphine, compared with 14.12 hours in the placebo group (P = .037). No differences were found between the groups in the incidence of pruritus, nausea and vomiting, level of sedation, or analgesic satisfaction. We concluded that nalmefene at a dose of 0.25 microgram/kg does not decrease the incidence of side effects but increases the need for supplemental analgesics.",2002.0,0,0
647,11763873,States respond to growing abuse of painkiller.,S Wasserman,"OxyContin has been touted as a ""miracle"" drug for its abilities to ease chronic pain. But a growing number of addicts are obtaining it illegally because of the immediate, intense ""high"" it gives them.",2002.0,0,0
648,11765070,Randomized trial of opioids versus tricyclic antidepressants for radiation-induced mucositis pain in head and neck cancer.,E Ehrnrooth; C Grau; R Zachariae; J Andersen,"Patients who receive radiotherapy for head and neck cancer are likely to develop painful mucositis. The pain is characterized by a burning or stinging sensation similar to neuropathic pain sensations. The purpose of the present study was to compare the analgesic effect of a tricyclic antidepressant (TC), commonly used in the treatment of neuropathic pain, with the effect of opioids on radiation-induced mucositis pain. Forty-three patients receiving 66-68 Gy external radiation according to the DAHANCA guidelines (the Danish Head and Neck Cancer Study Group) were randomized to either morphine or TC when mucositis pain was insufficiently managed with weak analgesics. Patients with insufficient pain control in either treatment arm received supplementary medication from the opposite treatment arm. Pain was evaluated weekly using a VAS scale and the McGill Pain Questionnaire. The degree of mucositis and the degree of depression were measured at the same time intervals. Twenty-two patients entered the opioid arm and 21 the TC arm. Two patients in each arm were non-evaluable. VAS pain scores were significantly reduced in the opioid treatment arm one week after randomization (p = 0.01). Eight patients in the TC arm were managed with TC alone, but for 11 patients it was necessary to add morphine. The 20 evaluable patients in the morphine arm required no additional treatment. There were no significant differences in side effects between the two groups. Higher pain scores in the TC arm, but not in the opioid arm, were significantly correlated with higher BDI scores. Some head and neck cancer patients with radiation-induced nucositis pain may have sufficient pain control on TC alone. This might be useful in patients with relative counter-indications to opioid treatment.",2002.0,0,0
649,11768686,Chronic pain management and the surgeon: barriers and opportunities.,K F Lee; J B Ray; G P Dunn,,2002.0,0,0
650,11773815,Epidural administration of low-dose morphine combined with clonidine for postoperative analgesia after lumbar disc surgery.,Vincent Bonhomme; Anne Doll; Pierre Yves Dewandre; Jean François Brichant; Keyvan Ghassempour; Pol Hans,"This study evaluates the efficacy and side effects of a low dose of epidural morphine combined with clonidine for postoperative pain relief after lumbar disc surgery. In 36 of 51 patients who accepted the procedure, an epidural catheter was inserted (L1-L2 level). General anesthesia was induced with propofol and sufentanil, and maintained with sevoflurane in O2/N2O. After emergence from anesthesia, epidural analgesia was initiated according to two randomly assigned protocols: 1 mg of morphine with 75 microg of clonidine (Group M) or 12.5 mg of bupivacaine with 75 microg of clonidine (Group B), in 10 mL saline. Piritramide was administered during the first postoperative 24 hours using a patient-controlled analgesia device (PCA). The following parameters were recorded: piritramide consumption during the first 24 hours; pain at rest during the first postoperative hours (D0), during the first night (D1), and during the first mobilization; [visual analogue scale (VAS)]; and the occurrence of drowsiness, motor blockade, respiratory depression, nausea, vomiting, itching, micturition problems, and bladder catheterization during D0 and D1. Epidural administration of morphine-clonidine significantly improved postoperative pain relief and reduced piritramide consumption as compared to epidural bupivacaine-clonidine. Side effects did not differ between groups except for a higher incidence of micturition problems in Group M during D1. The occurrence of bladder catheterization was not significantly higher in that group. We conclude that a low dose of epidural morphine combined with clonidine offers a better postoperative analgesia than does bupivacaine-clonidine. The excellent analgesic conditions were obtained at the expense of a higher incidence of difficulties in initiating micturition.",2002.0,0,0
651,11774176,Diffuse alveolar damage and recurrent respiratory failure: report of 6 cases.,D Savici; A L Katzenstein,"We report 6 patients in whom diffuse alveolar damage (DAD) was found on 1 or more lung biopsy specimens and who experienced recurrent episodes of acute respiratory failure. The patients ranged in age from 43 to 55 years. Two to five episodes of respiratory failure occurred in each over a period of 4 months to 2 years. One patient developed evidence of chronic lung disease; while the others remained well between episodes. Lung biopsies showed the acute stage of DAD in 3, overlapping acute and organizing stages in 3, and the organizing stage in 2. A definite cause was not identifiable in any. However, 4 had been treated with narcotics for chronic pain before the first episode, and 1 received this treatment before the recurrent episode. Three also were receiving psychotropic drugs for anxiety and depression. Five patients had evidence of gastroesophageal reflux disease (GERD) and/or hiatal hernia, 2 of whom underwent Nissen fundoplication in hopes of preventing future recurrences. Although a definite cause of the recurrent DAD was not identified, the findings suggest the possibility of a reaction to narcotics and/or psychotropic drugs in some patients, with a possible additional effect of GERD. A drug history should be carefully elicited in patients with recurrent DAD, and all potentially toxic drugs should be stopped.",2002.0,0,0
652,11781912,A randomized clinical trial to assess the efficacy of intramuscular droperidol for the treatment of acute migraine headache.,Peter B Richman; John Allegra; Barnet Eskin; James Doran; Ulrich Reischel; Costas Kaiafas; Ashraf H Nashed,"In a recent case series, we reported that intramuscular droperidol appeared to be an effective therapy for the treatment of acute migraine headache. The objective of the study was to further assess the efficacy of intramuscular droperidol for the treatment of acute migraine headache. The study design was a randomized, clinical trial set in a community-based ED. The population was a convenience sample of ED patients who met International Headache Society acute migraine criteria. Exclusions included pregnancy, use of narcotic or phenothiazine medications within 24 hours. For the protocol, patients were randomized to 1 of 2 treatment groups. Patients and physicians were blinded as to the treatment provided. Patients recorded their initial pain on a 100mm Visual Analog Scale (VAS) Patients were randomized to receive either 2.5 mg droperidol intramuscularly; the other group received 1.5 mg/kg meperidine intramuscularly. After 30 minutes patients recorded their pain on the VAS and recorded their preference for the medication on a Likert Scale. Physicians recorded the incidence of any side effects and the need for rescue medication. Statistical analysis consisted of categorical variables that were analyzed by chi-square, continuous interval data by t-tests and ordinal data by Mann-Whitney U test. The primary outcome parameters were mean VAS score change and the percentage of patients who wanted to go home without rescue medication. The study had an 80% power to detect a 26 mm difference in the mean change in VAS between groups. Of the 29 patients who were enrolled, 15 received droperidol. Both groups were similar with respect to age (30.7 +/- 8.9 years droperdol v 32.7 +/- 9.9 years meperidine; P =.59), female sex (73% v 71%; P =.91), mean headache duration (24.7 +/- 28.3 v 18.3 +/- 25.8 hours; P =.55). The droperidol group had a higher mean initial VAS score (88 v 76 mm; P =.03). The 2 groups were similar with regard to outcome, including: mean change in VAS score (47 v 37 mm; P =.33), average Likert score (1.1 v 1.9; P =.85), and the percentage of patients who did not want rescue medication (67% v 57%; P =.61). The incidence of sedation was 6.7 v 14.3%. Akathisia occurred in 13.3% of pts who received droperidol. We found that intramuscular droperidol was similar in efficacy to meperidine with a low incidence of side effects.",2002.0,0,0
653,11782325,Continuous epidural infusion of racemic methadone results in effective postoperative analgesia and low plasma concentrations.,Pilar Prieto-Alvarez; Isabel Tello-Galindo; Jesus Cuenca-Peña; Maria Rull-Bartomeu; Carmen Gomar-Sancho,"To compare two protocols of epidural administration of racemic methadone for postoperative analgesia (continuous infusion and intermittent bolus), focussing on plasma concentration, analgesic efficacy and side effects. Ninety patients undergoing abdominal or lower-limb surgery were randomly assigned to two groups in a prospective double-blind design. The continuous infusion patients (n=60) received initial doses of 3 to 6 mg followed by 6 to 12 mg by continuous infusion over 24 hr. The bolus administration patients (n=30) received repeated boluses of 3 to 6 mg of racemic methadone every eight hours. Pain intensity was assessed on a visual analog scale. Amount of supplementary analgesia was recorded, as was the incidence of side effects. Plasma methadone concentrations were determined by high performance liquid chromatography. Treatment was continued for 72 hr. Pain relief was good and comparable in both groups throughout the three days of treatment. No accumulation of plasma racemic methadone was observed in either group, although the concentrations were significantly higher in the bolus group. Miosis was significantly more frequent in the bolus group. Plasma methadone concentrations were significantly lower with continuous infusion. Plasma methadone accumulation, which is considered the main disadvantage for its purported influence on the incidence of side effects, did not occur at the doses used over the three days of treatment that we report.",2002.0,0,0
654,11782329,Addition of bupivacaine 1.25 mg to fentanyl confers no advantage over fentanyl alone for intrathecal analgesia in early labour.,Evangeline H L Lim; Alex T H Sia; Kahoe Wong; Hsiao Ming Tan,"a) To evaluate the effect of adding 1.25 mg of bupivacaine to intrathecal fentanyl on the duration of analgesia in an Asian population and b) to examine if the baricity of the local anesthetic at this dose has any bearing on the duration and quality of block. Forty-eight parturients in early labour received combined spinal epidural (CSE) analgesia to evaluate a) the effect of adding 1.25 mg of bupivacaine to intrathecal (IT) fentanyl 25 microg on the duration of analgesia and b) the effect of baricity of intrathecal local anesthetic on the duration and quality of the block. Patients were randomly allocated to receive: IT fentanyl 25 microg plus normal saline (Group f, n=16), IT fentanyl 25 microg plus plain bupivacaine 1.25 mg (Group f+pb, n=16) and IT fentanyl 25 microg plus heavy bupivacaine 1.25 mg (Group f+hb, n=16). The two components of the IT injectate (total of 2.25 mL) were given sequentially. Group f+hb had the lowest sensory dermatomal block (T7 vs T4 (Group f), T5 (Group f+pb), P <0.01). There were no differences in the duration of analgesia and incidence of side effects among the groups. We found no advantage of adding 1.25 mg bupivacaine to fentanyl 25 microg. At this dose, the baricity of bupivacaine has no effect on the duration of analgesia.",2002.0,0,0
655,11782331,"Lidocaine with fentanyl, compared to morphine, marginally improves postoperative epidural analgesia in children.",Francisco Reinoso-Barbero; Barbara Saavedra; Sara Hervilla; Jesús de Vicente; Beatriz Tabarés; María S Gómez-Criado,"To compare the epidural administration of fentanyl (1 microg/mL) combined with lidocaine 0.4% to preservative-free morphine for postoperative analgesia and side effects in children undergoing major orthopedic surgery. In a prospective, double-blind study, 30 children, ASA I-II, 2-16-yr-old, were randomly allocated to receive immediately after surgery either epidural F-L (epidural infusion at a rate of 0.1-0.35 mL/kg/hr of 1 microg/mL of fentanyl and lidocaine 0.4%) or epidural M (bolus of 20 microg/kg of morphine in 0.5 mL/kg saline every eight hours). Both groups received 40 mg/kg of iv metamizol (dipyrone) every six hours. In the F-L Group, blood samples were taken on the second and third postoperative day to determine total lidocaine concentrations. Adequacy of analgesia using adapted pediatric pain scales (0-10 score) and side-effects were assessed every eight hours postoperatively. Resting pain scores were under 4, 95% of the time in the F-L Group and 87% of the time in the M Group (Chi square=4.674, P <0.05). The frequency of complications was very similar in both groups. The F-L Group total plasma lidocaine concentrations were directly related to the dose received, and below the toxic range in all patients. Postoperative epidural fentanyl with lidocaine infusion provides slightly better analgesia than conventional bolus administration of epidural morphine. Side-effects or risk of systemic toxicity were not augmented by the addition of lidocaine to epidural opioids.",2002.0,0,0
656,11782332,Epinephrine reduces the sedative side effects of epidural sufentanil for labour analgesia.,Kevin P Armstrong; Brent Kennedy; James T Watson; Patricia K Morley-Forster; Irvan Yee; Ronald Butler,"The use of opioids in labour analgesia has primarily been as an adjuvant to local anesthetics. For early labour, satisfactory analgesia with epidural sufentanil alone is possible. This study evaluates the impact of epinephrine on sedative side effects and analgesia related to the latter technique. After Institutional Review Board approval and informed consent this prospective, randomized, double-blind study evaluated 43 nulliparous subjects requesting epidural analgesia. The study site, a tertiary care obstetric unit, accommodates 3500-4500 deliveries annually. Group selection was randomized and blinded by selection of a sealed envelope containing a number which corresponded to a premixed labelled syringe of saline or epinephrine (100 microg/mL). An epidural catheter was placed in a standardized fashion. All subjects received 40 microg of sufentanil and 0.5 mL from the premixed syringe, diluted to 10 mL with NaCl. A blinded observer collected data on maternal sedation, lightheadedness, hemodynamics, oxygenation, and fetal heart rate over a one-hour period following sufentanil injection. The addition of epinephrine significantly (P <0.05) reduced the incidence of sedation and lightheadedness after epidural sufentanil at all data collection points, except two. Analgesic duration was also significantly prolonged by this addition (120 +/- 56 vs 84 +/- 32 min). Maternal satisfaction was high regardless of solution. Forty micrograms of epidural sufentanil produces satisfactory analgesia in early labour. The addition of epinephrine improves the side effect profile of this technique while prolonging the duration of analgesia. Epidural sufentanil requires attention to maternal monitoring of oxygenation as maternal desaturation occurred in both groups.",2002.0,0,0
657,11782819,"Valdecoxib, a COX-2-specific inhibitor, is an efficacious, opioid-sparing analgesic in patients undergoing hip arthroplasty.",Frederic Camu; Tessa Beecher; David P Recker; Kenneth M Verburg,"Opioid agents are highly effective analgesics after orthopedic surgery but are associated with several adverse effects. Valdecoxib is a new, highly selective cyclooxygenase (COX)-2-specific inhibitor with a rapid onset of action and significant analgesic properties that is being developed for the management of acute pain. The objective of this study was to demonstrate the opioid-sparing efficacy of valdecoxib as part of a multimodal treatment of pain associated with hip arthroplasty. This multicenter, multiple-dose, double-blind, parallel-group study compared the opioid-sparing effects, analgesic efficacy, and safety of 20- and 40-mg doses of valdecoxib twice daily with placebo in patients receiving morphine by patient-controlled analgesia after hip arthroplasty. Study medication was first administered 1 to 3 hours preoperatively. The total amount of morphine administered, pain intensity, and patient's global evaluation of study medication were assessed over a period of 48 hours. Patients receiving 20 or 40 mg valdecoxib twice daily required on average 40% less morphine than those receiving placebo after hip arthroplasty. Pain intensity levels and patient satisfaction were significantly improved in both valdecoxib groups compared with placebo. Valdecoxib and placebo were equally well tolerated. Pre- and postoperative administration of valdecoxib reduces the amount of morphine required for postoperative pain relief and provides greater analgesic efficacy compared with morphine alone. Thus, valdecoxib has significant clinical utility for acute pain management in orthopedic surgery patients.",2002.0,0,0
658,11785593,Comparison of alfentanil and morphine in the prehospital treatment of patients with acute ischaemic-type chest pain.,T Silfvast; L Saarnivaara,"Patients with acute myocardial ischaemic pain would benefit from rapid pain relief. The clinical usefulness of alfentanil, which has a rapid onset of action, was therefore assessed as the initial pain relieving opioid in patients suffering from acute myocardial ischaemic pain. The effects of alfentanil were compared with those of morphine in the prehospital treatment of 40 haemodynamically stable patients suffering from acute ischaemic-type chest pain. After initial assessment, the patients were given either 0.5 mg alfentanil or 5 mg morphine intravenously in a randomized double-blind fashion. The dose was repeated 2 minutes later if severe pain persisted. Arterial pressure, heart rate, respiratory rate and pain expressed on a visual analogue scale was measured before and at 2, 4, 6, 10 and 15 minutes after administration of drugs. After randomization, four patients were excluded. Sixteen patients received alfentanil and 20 patients morphine. Pain relief was faster (p < 0.005) in the alfentanil group than in the morphine group. Alfentanil was found to provide effective analgesia during the follow-up period of 15 minutes. No haemodynamic or respiratory side effects occurred. It is concluded that alfentanil is an effective analgesic in the prehospital treatment of myocardial ischaemic pain.",2002.0,0,0
659,11800047,Relative sensitivity to alfentanil and reliability of current perception threshold vs von Frey tactile stimulation and thermal sensory testing.,R Park; M S Wallace; G Schulteis,"Recent technological advances claim to allow quantitative measurement of the functional integrity of both large and small diameter sensory nerve fibers using the current perception threshold (CPT) sensory testing device. This device has yet to be validated against the corresponding gold standard references for sensory testing (thermal sensory testing [TST]) and von Frey tactile hair stimulation [VF]) to correlate its evaluation of similar sensory nerve perceptions. A baseline neurosensory examination using the CPT, TST and VF methods was performed on 19 healthy volunteers. Using a randomized, double-blind, placebo-controlled design, each subject received an alfentanil or diphenhydramine (as a placebo control) infusion in separate study sessions. The order of the study sessions was randomized and separated by 1 week. The 3 neurosensory examinations were repeated at 3 different targeted plasma levels of study drug. Changes in neurosensory thresholds were then compared between the 3 methods. All CPT measurements and the cold pain measurement showed a significantly higher degree of variability than the other TST and VF measurements. There appeared to be a correlation between the CPT 5 Hz pain threshold and the TST cold pain and warm sensation; intravenous alfentanil significantly elevated all 3 detection thresholds. In addition, there was no effect of alfentanil on the VF or the CPT 2000 Hz thresholds. However, we did not see the predicted relation between the 250 Hz CPT stimulus and cool sensation. From these studies, there is some evidence that similar fiber tracts may be measured between the CPT, TST, and VF methods, especially with the CPT 5 Hz measures and C-fiber tract activity.",2002.0,0,0
660,11810326,[Treatment of cancer pain with opioid analgesics in outpatients 1993 and 1996. Results of a population based evaluation].,H Munzinger; E Horstkotte; W Hoffmann,"Pertinent guidelines recommend opioid-type analgesics for management of severe pain. However, in the past, opioids were prescribed for only a minority of these patients. In this representative study we examined the prevalence of cancer patients with and without opioid prescription in their final year of life in 1993 and 1996 in Bremen, Northern Germany. Complete four-months-samples of patients with cancer in Bremen were abstracted from the death certificates of 1993 and 1996. For the final years of these patients information on opioid-type prescriptions were recorded using the duplicates kept in the pharmacies. To assure data privacy the matching was performed in a cryptographic computer program installed on laptop computers. A total 489 (453) prescriptions could be matched to 435 (421) deceased patients with cancer in 1993 (1996) in 92% of all pharmacies in Bremen. In 1996, 20% of the patients with cancer received at least one prescription, including 14.5% who received opioids for eight weeks or longer. Average morphine-equivalent for each treated patient was 3712 mg (median=462 mg). There was no trend in prescription prevalence and the proportion of prescribing medical practices. The proportion of patients who received opioids for longer periods increased 4%. However, among the treated patients the average morphine-equivalent increased 23%. The prescription prevalence of opioids remains low among cancer patients in their final year of life. However, our study provides some evidence for positive developments with respect to prescription times and dosage between 1993 and 1996. These changes are likely due to a limited subgroup of practioners.",2002.0,0,0
661,11810336,[Developments in pain therapy in Germany: from neglected symptom to major health issue].,D Soyka,"Modern pain therapy began with the discovery of morphine by Sertürner in 1803. The following continuous introduction of new analgesics promised an end of pain as a bane of mankind. Reality, however, soon proved different. Today patients with chronic pain rather than those with acute pain are in the focus of pain therapy. Only since the beginning of interdisciplinary treatment including psychological and psychosomatic approaches progress has been achieved in chronic pain. The first specialised pain clinic opened by Bonica in the USA and the founding of the International Association for the Study of Pain (IASP) have been milestones in the treatment of chronic pain. Today several associations and societies are active promoting both the needs of patients suffering from chronic pain and the needs of the professionals treating pain patients. Although recently physicians can qualify in specialised pain therapy there are still by far too few specialists to provide sufficient care for all chronic pain patients in Germany.",2003.0,0,0
662,11810364,[Abuse of opioid therapy in somatoform pain disorder. A contribution from a psychosomatic/pain therapist point of view to the discussion of the indication of opioids in nonmalignant pain based on 8 cases].,S Wambach; P Rohr; W Häuser,"We report 8 in-patients with nonmalignant chronic pain (main diagnosis: 7 somatoform pain disorders, 1 eating disorder) and with abuse of opioid therapy, which we have treated within 2 years in an tertiary centre. In all patients the inefficacy of opioids with regard to pain symptomatology could be demonstrated. Because the ICD-10 criteria of addiction cannot be fully applied to patients under opioid therapy because of chronic pain we suggest as criteria the intake of opioids because of positive psychotropic effects, the demand of high dosage of short acting opioids with inefficacy of similar long acting opioids dosage, the uncontrolled raising of dosage with illegal procurement and reluctance of the patient to stop opioid therapy because of proved inefficacy of pain control. These criteria applied 4% of all in-patients treated because of chronic pain and 30% of all in patients with somatoform pain disorder of our interdisciplinary unit fulfilled within two years the criteria of opioid therapy abuse. The risk of abuse of opioid therapy described in pain therapy literature for patients with substance abuse is also relevant for patients with somatoform pain disorder. Therefore a qualified psychotherapeutic evaluation before starting an opioid therapy for nonmalignant pain in order to exclude a somatoform pain disorder or to assess a substance dependency is mandatory. Patients with somatoform pain disorder should be treated with opioids only in clinical studies. A prior or present history of substance abuse given chronic opioid therapy for nonmalignant pain should only be performed in close cooperation of addiction- and pain therapists.",2002.0,0,0
663,11811608,An audit of morphine prescribing in a hospice.,S H Neo; E C Loh; W H Koo,"This audit was designed to investigate the morphine prescribing pattern in a hospice. A review of 358 medical charts of all existing patients was conducted with a set of questionnaire. The prevailing practice was compared with an established standard guideline. One-third (35%) of patients were receiving morphine. Several deficiencies in morphine prescribing were identified. These include omission of breakthrough morphine dosing, use of morphine as p.r.n. (when necessary) alone for chronic pain, absence of review after prescribing treatment, and lack of double dosing at night. Prophylactic laxative and anti-emetics were often not co-prescribed. Despite much of what is known about the pharmacology and therapeutic use of morphine, there is much variation and even inappropriate prescription in a palliative care institution. Implementation of recommended European guidelines and education may improve morphine prescribing habits. However, such guidelines may have to be validated in future studies to see if they need to be revised to suit our local population.",2002.0,0,0
664,11817492,Effects of an opioid taper algorithm in hematopoietic progenitor cell transplant recipients.,Leslie Parran; Carol Pederson,"To examine the effects of an opioid taper algorithm on the length of taper, pain levels, withdrawal symptoms, and satisfaction with pain management in hematopoietic progenitor cell transplant (HPCT) recipients and nurse documentation of patient response to taper. Quasi-experimental. A 32-bed HPCT unit in a large tertiary U.S. healthcare center. 106 HPCT recipients, 5-64 years of age. In phase 1, baseline data were collected from 45 patients during opioid tapers, with no study intervention. In phase 2, an opioid taper algorithm was implemented as the study intervention for 61 patients. Phase 1 and phase 2 pretaper and taper opioid dosage, length of taper, nurse documentation, patient-reported pain and withdrawal symptoms, and nurses' perspectives about the use of tapers. Use of the algorithm in phase 2 resulted in decreasing taper time by a mean of 0.4 days, a significant decrease in withdrawal symptoms, a significant increase in only 1 of 10 aspects of nurse documentation, and no significant differences in patient self-reports of worst pain or satisfaction with pain management. Nausea, vomiting, diarrhea, insomnia, and runny nose were the withdrawal symptoms reported most frequently. Use of the algorithm improved tapering practice somewhat without disadvantaging patients. Use of an opioid taper algorithm may promote consistency of tapering practice.",2002.0,0,0
665,11832216,Regulation of opioid receptor trafficking and morphine tolerance by receptor oligomerization.,Li He; Jamie Fong; Mark von Zastrow; Jennifer L Whistler,"The utility of morphine for the treatment of chronic pain is hindered by the development of tolerance to the analgesic effects of the drug. Morphine is unique among opiates in its ability to activate the mu opioid receptor (MOR) without promoting its desensitization and endocytosis. Here we demonstrate that [D-Ala(2)-MePhe(4)-Gly(5)-ol] enkephalin (DAMGO) can facilitate the ability of morphine to stimulate MOR endocytosis. As a consequence, rats treated chronically with both drugs show reduced analgesic tolerance compared to rats treated with morphine alone. These results demonstrate that endocytosis of the MOR can reduce the development of tolerance, and hence suggest an approach for the development of opiate analogs with enhanced efficacy for the treatment of chronic pain.",2002.0,0,0
666,11833521,Meeting the therapeutic challenge of the patient with osteoarthritis.,Cathryn Todd,"To discuss the diagnosis of osteoarthritis and the efficacy of available pharmacologic and nonpharmacologic treatment options. Published reports on the diagnosis and treatment of osteoarthritis were identified through a MEDLINE search of English-language journal articles using a focused title search for the keywords acetaminophen, nonsteroidal anti-inflammatory, COX-2 nonsteroidal, opioids, capsaicin, tramadol, glucosamine, hyaluronic acid, and osteoarthritis and by reviewing the bibliographies of selected reviews. The American College of Rheumatology (ACR) guidelines, as updated in September 2000, for the treatment of osteoarthritis of the hip and knee were analyzed with appropriate references to clinical and scientific studies, review articles, and other published guidelines. Each patient's medical history and level of pain should decide the most appropriate treatment. Nonpharmacologic therapies should always be included in the treatment regimen. If further pain management is required, the most appropriate pharmacologic treatments are acetaminophen or nonsteroidal anti-inflammatory drugs for mild-to-moderate pain, tramadol or opioid combinations for moderate-to-moderately severe pain, and opioids for severe pain. Adjunctive treatments, intraarticular injections, and surgery are also viable options for some patients. If used properly, the ACR guidelines for the treatment of osteoarthritis are important tools in the care of the patient with this disease.",2002.0,0,0
667,11833838,Combination hydrocodone and ibuprofen versus combination oxycodone and acetaminophen in the treatment of moderate or severe acute low back pain.,Mark Palangio; Elena Morris; Ralph T Doyle; Bruce E Dornseif; Thomas J Valente,"Introduced in 1997, the combination of hydrocodone and ibuprofen is the only fixed-dose combination analgesic containing an opioid and ibuprofen that has been approved by the US Food and Drug Administration. This study compared the efficacy and tolerability of combination hydrocodone 7.5 mg and ibuprofen 200 mg (HC/IB) with those of combination oxycodone 5 mg and acetaminophen 325 mg (OX/AC) in the treatment of moderate or severe acute low back pain. This was a multicenter, randomized, double-blind, parallel-group, repeat-dose study lasting up to 8 days. The recommended dosing of the study medications was 1 tablet every 4 to 6 hours, not to exceed 5 tablets per day. If adequate pain relief was not obtained, patients were permitted to take up to 4 doses per day of supplemental analgesic medication-the nonopioid component of the assigned study medication (ibuprofen 200 mg or acetaminophen 325 mg). Measures of efficacy included mean daily pain relief scores (0 = no relief, 1 = slight relief, 2 = moderate relief, 3 = good relief, and 4 = complete relief), mean daily number of tablets and doses of study medication, mean daily number of tablets and doses of supplemental analgesic medication, global evaluation (poor, fair, good, very good, or excellent), and results on the modified 36-item Short-Form Health Survey (SF-36). All efficacy measures were analyzed on an intent-to-treat basis. Tolerability was evaluated based on adverse events reported spontaneously or elicited by the in vestigators using nonsuggestive questioning, as well as on the number of patients discontinuing treatment because of adverse events. The study enrolled 147 patients (75 HC/IB, 72 OX/AC). The most common cause of low back pain was muscular/ligamentous injury (97/147; 66.0%), followed by degenerative disk disease (27/147; 18.4%). At baseline, 80 patients (54.4%) reported experiencing moderate pain, and 67 patients (45.6%) reported experiencing severe pain. There were no significant differences between HC/IB and OX/AC with regard to mean ( +/- SD) daily pain relief scores (2.40 +/- 1.06 vs 2.50 +/- 1.01, respectively), mean daily number of tablets of study medication (1.80 +/- 1.70 vs 2.20 +/- 1.60), mean daily number of doses of study medication (1.80 +/- 1.65 vs 2.10 +/- 1.58), mean daily number of tablets of supplemental analgesic medication (0.60 +/- 1.13 vs 0.50 +/- 0.99), mean daily number of doses of supplemental analgesic medication (0.60 +/- 1.07 vs 0.50 +/- 0.90), global evaluations, or mean scores on the modified SF-36. In addition, there were no significant differences in the proportion of patients experiencing adverse events with HC/IB (47; 62.7%) and OX/AC (45; 62.5%). Adverse events were consistent with those generally associated with the component analgesics and predominantly involved the central nervous system and gastrointestinal system. The results of this study suggest that HC/IB and OX/AC are similarly effective and tolerable in relieving moderate or severe acute low back pain. Additional controlled longitudinal trials are necessary to evaluate the clinical utility of HC/IB in treating acute low back pain.",2002.0,0,0
668,11834781,Placebo and opioid analgesia-- imaging a shared neuronal network.,Predrag Petrovic; Eija Kalso; Karl Magnus Petersson; Martin Ingvar,"It has been suggested that placebo analgesia involves both higher order cognitive networks and endogenous opioid systems. The rostral anterior cingulate cortex (rACC) and the brainstem are implicated in opioid analgesia, suggesting a similar role for these structures in placebo analgesia. Using positron emission tomography, we confirmed that both opioid and placebo analgesia are associated with increased activity in the rACC. We also observed a covariation between the activity in the rACC and the brainstem during both opioid and placebo analgesia, but not during the pain-only condition. These findings indicate a related neural mechanism in placebo and opioid analgesia.",2002.0,0,0
669,11840097,Perioperative use of corticosteroid and bupivacaine combination in lumbar disc surgery: a randomized controlled trial.,Hasan Mirzai; Idil Tekin; Handan Alincak,"A prospective and controlled study of perioperative use of combined local anesthetic and corticosteroid in lumbar disc surgery. The anti-inflammatory mechanism of corticosteroids is considered to be caused by the inhibition of phospholipase A2, which plays an important role in the pain mechanism of lumbar disc problems. Although some authors have demonstrated that the use of intramuscular bupivacaine during lumbar discectomy resulted in a marked reduction of postoperative back pain, others have reported that the key intervention was probably the administration of epidural corticosteroid. The coadministration of these two drugs in lumbar disc surgery for the relief of postoperative back pain has yet not been studied adequately. Assessment of the combined use of perioperative corticosteroids and bupivacaine for the relief of postoperative pain after lumbar disc surgery. Forty-four selected patients had acute-onset single-level unilateral herniated nucleus pulposus that were refractory to conservative management. All patients underwent lumbar disc surgery under standard general anesthesia. Before surgical incision, the skin and subcutaneous tissues were infiltrated with 10 mL of 1% lidocaine with 1:200,000 adrenaline to produce local vasoconstriction. During wound closure, 20 mL 0.9% saline in Group 1 (n = 22) and 20 mL 0.25% bupivacaine in Group 2 (n = 22) were injected into the paravertebral muscles and subcutaneus tissues. In addition, a piece of autologous fat taken from the wound was first soaked in 40 mg of methylprednisolone for 10 minutes, then placed over the exposed nerve root, and the remaining steroid was flushed into the wound in Group 2. The wound was closed after drug administration in both groups. In the postoperative period, all patients received 100 mg of meperidine intramuscularly when needed and were allowed to receive a second dose at least 4 hours later than the first dose for postoperative analgesia. Postoperative back pain intensity, heart rate, and mean arterial pressure were assessed 1, 3, 6, and 12 hours after the conclusion of surgery. Visual analog scale pain scores for the postoperative recordings were lower in Group 2 than in Group 1, but these findings were not statistically significant. Patients in Group 1 received 77.3 +/- 48.8 mg meperidine, and those in Group 2 received 31.8 +/- 45.5 mg meperidine, for pain medication in the first 12 hours (P < 0.05). Heart rate and mean arterial pressure were not significantly different between the two groups in all recording periods. It is concluded that the perioperative use of bupivacaine and corticosteroids during lumbar discectomy maintains effective postoperative analgesia and decreases opioid usage without complications.",2002.0,0,0
670,11841719,Efficacy of the morphine-Adcon-L compound in the management of postoperative pain after lumbar microdiscectomy.,Luciano Mastronardi; Marco Pappagallo; Fabrizio Puzzilli; Carlo Tatta,"Epidural analgesia is a pharmacological technique for operative and postoperative pain control. It has been used with lumbar microdiscectomy to facilitate management of surgical pain, shorten patient recovery time, and increase patient satisfaction with the procedure and the hospital stay. Adcon-L (Gliatech, Inc., Cleveland, OH) (adhesion control in a barrier gel) has been demonstrated to act as a barrier to the development of epidural fibrosis after lumbar procedures, minimizing the formation of fibrotic scar and improving the long-term outcome. In this study, we used Adcon-L as a vehicle to administer 1 mg of morphine epidurally to patients who underwent lumbar microdiscectomy. Our objective was to evaluate the safety and analgesic efficacy of this compound. A randomized, controlled, double-blind study was conducted in 100 patients. Patients were randomized to two groups: the morphine-Adcon-L (M-ADL) group (n = 51 patients) or the Adcon-L control group (n = 49 patients). Outcome measures included: 1) a visual analog scale to assess the intensity of spontaneous low back and radicular pain, 2) a straight leg-raising maneuver to assess the degree of leg elevation in relation to evoked sciatic pain, 3) postoperative time to comfortable walking, 4) duration of postoperative hospitalization, 5) required amount of postoperative analgesics, and 6) postoperative work time loss. No intraoperative or postoperative complications were observed. No clinically relevant adverse events, such as urinary retention, respiratory disturbances, or wound infections were reported in the M-ADL group. At the time of hospital discharge, results were as follows: 1) the M-ADL group had significantly lower pain intensity scores (mean value of postoperative visual analog scale, 12.3 mm +/- 0.9 in the M-ADL group versus 24.7 mm +/- 11.5 in the control group[P < 0.0001]); 2) the M-ADL group consumed significantly less analgesics: 57.4% of M-ADL patients versus 95.9% of controls received analgesics in the hospital, and 23.5% of M-ADL patients versus 55.1% of controls used analgesics at home (P < 0.0001); 3) the M-ADL group had significantly shorter hospital stays (1.37 +/- 0.07 d versus 2.53 +/- 0.12 d in the control group[P < 0.0001]); 4) the M-ADL group had a significantly higher degree of symptomatic leg elevation in the straight leg raising (mean postoperative straight leg-raising test, 64.41 degrees +/- 1.59 versus 57.77 degrees +/- 1.85 in the controls[P = 0.02]); and 5) the M-ADL group lost significantly less postoperative work time (21.67 +/- 0.92 d versus 29.47 +/- 1.18 d in the control group). In addition, at 1 year of follow-up, there was no clinical evidence of late-onset neurological complications. The epidural application of the compound M-ADL after lumbar microdiscectomy was found to be safe and effective, and it significantly improved postoperative pain control and return to function.",2002.0,0,0
671,11843742,A comparison of patient-controlled analgesia administered by the intravenous or intranasal route during the early postoperative period.,M Ward; G Minto; J M Alexander-Williams,"Intranasal administration of lipophilic opioids has been shown to be an effective method of administration which is devoid of major side-effects. Whether it is as effective as intravenous administration for patient-controlled analgesia (PCA) has been investigated for fentanyl and pethidine, but not for diamorphine. This study reports a randomised controlled trial designed to compare the effectiveness of diamorphine administered as PCA utilising either the intranasal or intravenous routes. We investigated 52 consecutive patients undergoing primary lower limb joint replacement surgery. Patients were randomly allocated to receive PCA diamorphine, administered either intravenously (0.5 mg bolus, 3 min lockout) or intranasally (1.0 mg bolus, 3 min lockout). Pain was assessed using a Visual Analogue Score (VAS) at rest and on movement on five occasions over the first 36 h postoperatively. The results demonstrated that patients in the intranasal PCA group had significantly higher VAS scores than the intravenous group, both at rest (intranasal median 35.5 vs. intravenous median 20; p = 0.030) and on movement (intranasal median 64 vs. intravenous median 50; p = 0.016). However, significantly fewer patients in the intranasal group compared with the intravenous group suffered episodes of vomiting (intranasal 0/24 vs. intravenous 6/24 patients; p = 0.022). We suggest that if a maximal reduction in pain score is considered the goal of PCA management, the intravenous route is preferable to the intranasal route.",2002.0,0,0
672,11851660,Randomized clinical trial of laparoscopic versus open abdominal rectopexy for rectal prolapse.,M J Solomon; C J Young; A A Eyers; R A Roberts,"The objectives of this study were to compare both subjective clinical outcomes and the objective stress response of laparoscopic and open abdominal rectopexy in patients with full-thickness rectal prolapse. Abdominal rectopexy for patients with rectal prolapse is well suited for a laparoscopic approach as no resection or anastomosis is necessary. Forty patients with a full-thickness rectal prolapse were randomized before operation to a laparoscopic group and an open group. They agreed to conform to a clinical pathway (CP) of liquid diet (CP1) and full mobility (CP2) on day 1, solid diet (CP3) on day 2 and discharge (CP4) before day 5. Their compliance was monitored by an assessor blinded to the operative group, who also rated pain and mobility. Patient-controlled morphine use was documented. Neuroendocrine and immune stress response and respiratory function were measured. Some 75 per cent of all clinical pathway objectives of early recovery were achieved in the laparoscopic group compared with 37 per cent in the open group (P < 0.01). Significant differences in favour of laparoscopy were noted with regard to narcotic requirements, and pain and mobility scores. Differences in objective measures of stress response favouring laparoscopy were found for urinary catecholamines, interleukin 6, serum cortisol and C-reactive protein. No differences were noted in respiratory function but significant respiratory morbidity was greater in the open group (P < 0.05). None of the measured outcomes, subjective or objective, favoured the open group apart from operating time, which was significantly shorter (153 versus 102 min; P < 0.01). This study has demonstrated significant subjective and objective differences in favour of a laparoscopic technique for abdominal rectopexy. The advantages were all short term but no evidence of any adverse effect on longer-term outcomes was observed.",2002.0,0,0
673,11865132,Effects of IV morphine in central pain: a randomized placebo-controlled study.,N Attal; F Guirimand; L Brasseur; V Gaude; M Chauvin; D Bouhassira,"To investigate the effects of IV morphine on central pain syndromes through quantitative sensory testing and to assess the long-term benefit of oral morphine. After an initial open titration phase aiming to determine the maximal tolerated dosage of IV morphine, the efficacy of morphine infusion (9-30 mg; mean dosage, 16 mg) was assessed in a double-blind, placebo-controlled and crossover fashion in 15 patients with poststroke- (6 patients) or spinal cord injury- (9 patients) related pain. All of the patients subsequently received sustained oral morphine. Morphine significantly reduced the intensity of brush-induced allodynia but had no effect on other evoked pains (i.e., static mechanical and thermal allodynia/hyperalgesia). The effects of morphine on ongoing pain were not significantly different from those of the placebo, but 7 patients (46%) responded to morphine. There was a correlation between the effects of morphine on spontaneous pain and the decrease of the responses to suprathreshold thermal stimuli on the nonpainful contralateral side, suggesting that these effects were related to the general antinociceptive activity of the drug. The effects of IV morphine were correlated with those of oral morphine at 1 month, but only 3 patients (20%) were still taking morphine after 1 year. IV morphine induces analgesic effects on some components of central neuropathic pain syndromes, but only a minority of patients may benefit from long-term opioid treatment.",2002.0,0,0
674,11866673,Pharmacoeconomics of opioid therapy for chronic non-malignant pain.,Dawn A Marcus,"Chronic non-malignant pain (CNMP) is widely prevalent and associated with significant costs. Costs related to chronic pain include medical services and medications, treatment of medication-related toxicity and work absenteeism. The use of non-narcotic analgesics is associated with inadequate pain-relief for many patients, as well as significant and costly organ toxicity. When used appropriately and judiciously, opioid medications can be a useful addition to the treatment plan for patients with CNMP. Opioids can provide long-term, safe and cost-effective pain relief.",2002.0,0,0
675,11873026,Cesarean delivery: a randomized trial of epidural analgesia versus intravenous meperidine analgesia during labor in nulliparous women.,Shiv K Sharma; James M Alexander; Gary Messick; Steven L Bloom; Donald D McIntire; Jackie Wiley; Kenneth J Leveno,"Controversy concerning increased cesarean births as a result of epidural analgesia for relief of labor pain has been attributed, in large part, to difficulties interpreting published studies because of design flaws. In this study, the authors compared epidural analgesia to intravenous meperidine analgesia using patient-controlled devices during labor to evaluate the effects of labor epidural analgesia, primarily on the rate of cesarean deliveries while minimizing limitations attributable to study design. Four hundred fifty-nine nulliparous women in spontaneous labor at term were randomly assigned to receive either epidural analgesia or intravenous meperidine analgesia. Epidural analgesia was initiated with 0.25% bupivacaine and was maintained with 0.0625% bupivacaine and fentanyl 2 microg/ml at 6 ml/h with 5-ml bolus doses every 15 min as needed using a patient-controlled pump. Women in the intravenous analgesia group received 50 mg meperidine with 25 mg promethazine hydrochloride as an initial bolus, followed by 15 mg meperidine every 10 min as needed, using a patient-controlled pump. A written procedural manual that prescribed the intrapartum obstetric management was followed for each woman randomized in the study. A total of 226 women were randomized to receive epidural analgesia, and 233 women were randomized to receive intravenous meperidine analgesia. Protocol violations occurred in 8% (38 of 459) of women. There was no difference in the rate of cesarean deliveries between the two analgesia groups (epidural analgesia, 7% [16 of 226; 95% confidence interval, 4-11%] vs. intravenous meperidine analgesia, 9% [20 of 233; 95% confidence interval, 5-13%]; P = 0.61). Significantly more women randomized to epidural analgesia had forceps deliveries compared with those randomized to meperidine analgesia (12% [26 of 226] vs. 3% [7 of 233]; P < 0.001). Women who received epidural analgesia reported lower pain scores during labor and delivery compared with women who received intravenous meperidine analgesia. Epidural analgesia compared with intravenous meperidine analgesia during labor does not increase cesarean deliveries in nulliparous women.",2002.0,0,0
676,11880017,Low-dose dexamethasone reduces nausea and vomiting after epidural morphine: a comparison of metoclopramide with saline.,Jann Inn Tzeng; Chung Hsi Hsing; Chin Chen Chu; Ying Hui Chen; Jhi Joung Wang,"To compare the efficacy of a low dose of dexamethasone (5 mg) with metoclopramide 10 mg and saline in preventing nausea and vomiting after epidural morphine in posthysterectomy analgesia. Randomized, placebo-controlled study. Inpatient surgery at Municipal Women's and Children's General Hospital. 120 ASA physical status I and II women receiving epidural morphine for posthysterectomy analgesia. All patients received epidural morphine 3 mg for postoperative analgesia. The dexamethasone group (n = 40) received dexamethasone 5 mg, the metoclopramide group (n = 40) received metoclopramide 10 mg, and the saline group (n = 40) received saline. The occurrence of nausea and vomiting appeared more frequently during 6 to 24 hours following the administration of epidural morphine. The total frequency of nausea and vomiting in the dexamethasone group was significantly lower than that of the metoclopramide and saline groups during this period, with reporting frequencies of 21%, 49%, and 53%, respectively (p <.05 each). However, the difference between metoclopramide and saline did not reach statistical significance. Dexamethasone 5 mg was more effective than metoclopramide or saline in the prevention of nausea and vomiting associated with epidural morphine for postoperative analgesia.",2002.0,0,0
677,11880827,The clinical efficacy of piroxicam fast-dissolving dosage form for postoperative pain control after simple lumbar spine surgery: a double-blinded randomized study.,Chathchai Pookarnjanamorakot; Wichien Laohacharoensombat; Suphaneewan Jaovisidha,"A prospective, randomized, double-blinded clinical trial was conducted. To study the efficacy of piroxicam fast-dissolving dosage form in reducing postoperative pain after simple lumbar spine surgery. Many reports mention the use of nonsteroidal antiinflammatory drug for relieving postoperative pain, but study still is lacking on their use in spine surgery. For this study, 50 patients who underwent discectomy or one-level laminectomy were randomly sampled into two groups: 21 patients in the placebo control group and 29 patients in the study group. In addition to a normal postoperative analgesic regimen, each patient received placebo or piroxicam fast-dissolving dosage form (2 tablets administered sublingually 1 to 3 hours before surgery). This regimen was repeated with 2 tablets after 24 hours, then 1 tablet after 48 hours. Postoperative pain was evaluated every 6 hours by a visual analog scale for 3 days. The amount of morphine usage was measured on postoperative days 1, 2, and 3. Postoperative variables such as blood loss, length of wound, and time of operation also were recorded. There was no difference between the groups with respect to age, weight, height, gender, and type of operation. The postoperative pain of the study group, as measured by visual analog scale, showed significant improvement (P < 0.05) during the postoperative period 12 to 42 hours after surgery. The study group used less morphine, but their usage showed no significant difference on postoperative days 1, 2, and 3. When the visual analog scale between the types of operation was compared, the scale for the discectomy group was better than that for the laminectomy group. The results of the postoperative variables showed no difference between the groups in terms of postoperative blood loss, length of wound, and time of operation. Sublingual administration of piroxicam fast-dissolving dosage form after simple spine surgery is effective and efficient in relief of postoperative pain. Because of its low side effects and high toleration, piroxicam fast-dissolving dosage form may be considered as an alternative for postoperative pain control during the early postoperative period.",2002.0,0,0
678,11880840,,,,,0,0
679,11882773,Stability of pain parameters and pain-related quality of life in adolescents with persistent pain: a three-year follow-up.,Joke A M Hunfeld; Christel W Perquin; Wieke Bertina; Alice A J M Hazebroek-Kampschreur; Lisette W A van Suijlekom-Smit; Bart W Koes; Johannes C van der Wouden; Jan Passchier,"Many juveniles with chronic pain of no known organic cause recover. Because adolescents whose pain persists may have chronic pain as adults, a subsample of 42 adolescents from a prevalence study in which continuation of their pain was observed throughout the study period was investigated quantitatively and qualitatively. All mothers (n = 42) completed a questionnaire on the impact of the adolescent's pain on the family. The authors tested the hypothesis that pain parameters, pain-related quality of life, and impact of pain on the family would deteriorate over time. Three-year follow-up questionnaires, diaries, and interviews were used. The study was conducted in the general population in the Rotterdam area. Adolescents (aged 12-18 years) who indicated chronic pain in our previous prevalence study and in a diary and questionnaire each year of the 3-year follow-up were included in the study. The most prevalent pains were limb pain and headache. The pain intensity was mild (33 mm on a visual analog scale), very frequent (72% of all diary entries), and associated with relatively poor functional status and poor psychological and somatic functioning. The pain parameters, pain-related quality of life, and impact of pain on the family (i.e., restrictions in social life and problems in dealing with the stress of the adolescent's pain) remained surprisingly stable across the assessments. The interviews showed that pain had become part of the daily life of several adolescents, who structured their activities and sleeping hours to prevent aggravation of pain. In particular, adolescents with headache reported problems with cognitive activities, whereas those with limb pain and back pain reported problems with physical activities. For adolescents with persistent pain with no known organic cause, intensity and frequency of pain, quality of life, and impact of pain on the family did not change. Generally, they seemed to cope quite well with their pain. In view of these results, further studies should involve follow-up of adolescents with persistent pain into adulthood to establish the determinants of their pain and to find out whether they maintain their adaptive ways of living with their pain.",2002.0,0,0
680,11887541,The morphine-sparing effect of metoclopramide on postoperative laparoscopic tubal ligation patients.,Robin D Gibbs; Beth Ann Movinsky; Joseph Pellegrini; Charles A Vacchiano,"Metoclopramide traditionally has been used as a prokinetic and antiemetic, but recently it also has been investigated as an agent to enhance analgesic efficacy. No definitive studies have been undertaken to determine whether metoclopramide can decrease postoperative analgesic requirements. The present study examined the effects of the administration of metoclopramide on the postoperative opioid analgesic requirements and pain intensity scores of patients following laparoscopic bilateral tubal ligation under general anesthesia. Fifty-six subjects were enrolled in this double-blind, placebo-controlled, prospective study. Subjects were randomized into 2 groups, a control placebo group (n = 30) and an experimental metoclopramide group (n = 26), and were assessed for pain intensity using a numeric rating scale. Assessments were recorded at 3 time intervals. Total postoperative opioid requirements also were recorded. Numeric rating scale pain scores were noted to be similar in both groups at all 3 time intervals examined. However, total postanesthesia care unit (PACU) morphine requirements were significantly higher in the placebo group than the metoclopramide group (P = .031). This study demonstrated that metoclopramide administered preoperatively can significantly decrease morphine requirements in the PACU but had no impact on pain intensity as rated by numeric rating scale pain scores.",2002.0,0,0
681,11892635,Patient-controlled epidural fentanyl following spinal fentanyl at Caesarean section.,D W Cooper; E Garcia; P Mowbray; M A Millar,"Spinal fentanyl can improve analgesia during Caesarean section. However, there is evidence that, following its relatively short-lived analgesic effect, there is a more prolonged spinal opioid tolerance effect. The effectiveness of postoperative epidural fentanyl analgesia may therefore be reduced following the use of spinal fentanyl at operation. This randomised, double-blind study was designed to assess whether patient-controlled epidural fentanyl could produce effective analgesia following 25 microg of spinal fentanyl at operation. Patients undergoing elective Caesarean section received spinal bupivacaine combined with either fentanyl 25 microg (fentanyl group; n = 18) or normal saline (saline group; n = 18). Patient-controlled epidural fentanyl was used for postoperative analgesia. The fentanyl group used a mean of 23.4 (SD 14.5) microg x h(-1) of fentanyl, compared with 27.0 (10.8) microg x h(-1) for the saline group (p =0.41). Using a 0-100 mm visual analogue score for pain, the maximum pain score recorded at rest for the fentanyl group was median 24 [IQR 15-35] mm, compared with 15 [13-45] mm for the saline group (p = 0.41). The maximum pain score recorded on coughing for the fentanyl group was 29 [24-46] mm, compared with 27 [19-47] mm for the saline group (p = 0.44). Nine of the fentanyl group rated postoperative analgesia as excellent and nine as good, compared with 10 of the saline group who rated it as excellent and eight as good (p = 0.74). Epidural fentanyl can produce effective analgesia following the use of 25 microg spinal fentanyl at Caesarean section.",2002.0,0,0
682,11903078,Cost-effectiveness of analgesia after Caesarean section. A comparison of intrathecal morphine and epidural PCA.,M Vercauteren; K Vereecken; M La Malfa; H Coppejans; H Adriaensen,"Patient-controlled analgesia (PCA) techniques and intrathecal morphine are the most widely used treatments for post-Caesarean section pain. However these methods have not been compared with respect to analgesic quality and cost differences. Fifty-three patients scheduled for elective or semi-urgent Caesarean section were randomized to receive for postoperative analgesia either epidural PCA with a mixture containing bupivacaine 0.06% and sufentanil 1 microg x ml(-1) or intrathecal morphine 0.15 mg together with the spinal anaesthetic and to be supplemented with paracetamol and tramadol. Analgesic efficacy, side-effects and costs were calculated during 48 h. VAS pain scores both at rest and during mobilization were lower in the PCA group, more particularly during the second postoperative day. Nausea and vomiting were more frequently registered in the morphine treated patients. PCA treated patients stayed longer in the recovery room but required fewer nurse interventions on the surgical ward. Manpower and drug costs were equal in both groups. The differences in total costs (Euro) amounted to euros 33 and were mainly caused by the more expensive equipment required for epidural PCA. Satisfaction and hospital discharge were similar for both treatments. It was concluded that epidural PCA induced better pain relief, caused less nausea/vomiting but was more expensive than intrathecal morphine.",2002.0,0,0
683,11903939,The analgesic efficacy and neuroendocrine response in paediatric patients treated with two analgesic techniques: using morphine-epidural and patient-controlled analgesia.,Pervin Bozkurt,"Pain treatment is one of the main concerns of paediatric anaesthesiologists. The purpose of this study was to assess and compare the quality of analgesia and stress suppression by morphine when used [epidural (single shot) (EP) or with intravenous (i.v.) for patient-controlled analgesia (PCA) in children]. Forty-four children, aged 5-15 years, and who were undergoing major genitourinary or lower abdominal surgery with a standardized general anaesthesia technique, were included in this study. In the EP group (n=24) 0.1 mg x kg(-1) morphine in 0.2 ml x kg(-1) saline were given epidurally at the L3-4 level and in the PCA group (n=20) 0.1 mg x kg-1 morphine was given i.v. immediately after intubation. Postoperative PCA bolus doses were 0.5 mg for patients weighing less than 20 kg, 1 mg for children weighing 20-30 kg and 1.5 mg for children weighing 30-40 kg. Blood samples were withdrawn following induction and at 1, 8, 12 and 24 h after morphine administration for measurement of blood glucose, insulin, cortisol and morphine levels. Patients were observed for 24 h postoperatively; heart rate, systolic blood pressure, respiratory rate, FACES pain scores, sedation scores and complications were recorded. The PCA group received 0.56 +/- 0.33 mg x kg(-1) x day(-1) morphine. The FACES pain scores, sedation scores, cortisol, blood glucose and insulin levels were similar in both groups. Haemodynamic and respiratory evaluations and cortisol levels were stable but blood glucose and insulin changes at certain time periods were significant (P < 0.05). Serum morphine levels and incidence of vomiting were different between groups (P < 0.05). Serum morphine levels were similar at the first hour. Both techniques provided sufficient pain relief and attenuated the hormonal response without life-threatening complications.",2002.0,0,0
684,11904788,"A double-blind, randomised, parallel group, multinational, multicentre study comparing a single dose of ondansetron 24 mg p.o. with placebo and metoclopramide 10 mg t.d.s. p.o. in the treatment of opioid-induced nausea and emesis in cancer patients.",J Hardy; S Daly; B McQuade; M Albertsson; V Chimontsi-Kypriou; P Stathopoulos; P Curtis,"Nausea and emesis are common side effects of opioid drugs administered for pain relief in cancer patients. The aim of this study was to compare the anti-emetic efficacy and safety of ondansetron, placebo and metoclopramide in the treatment of opioid-induced nausea and emesis (OIE) in cancer patients. This was a multinational, multicentre, double-blind, parallel group study in which cancer patients who were receiving a full opioid agonist for cancer pain were randomised to receive one of oral ondansetron 24 mg once daily, metoclopramide 10 mg three times daily, or placebo. Study medication was started only if the patient experienced nausea and/or emesis following opioid administration. Efficacy and safety assessments were made over a study period of 24 h from the time of the first dose of anti-emetics/placebo. The study was terminated prematurely because of the difficulties in recruiting patients satisfying the stringent entry criteria. Ninety-two patients were included in the intent-to-treat population: 30 patients received placebo, 29 patients ondansetron and 33 patients metoclopramide. There was no statistically significant difference between the groups in the proportion achieving complete control of emesis (33% of patients on placebo, 48% on ondansetron and 52% on metoclopramide) or complete control of nausea (23% of patients on placebo, 17% on ondansetron and 36% on metoclopramide). Rescue anti-emetics were required in 8 of 33 patients on metoclopramide, 4 of 29 on ondansetron, and 3 of 30 on placebo. The incidence of adverse events was very low and similar in all treatment groups. Neither ondansetron 24 mg once daily nor metoclopromide 10 mg t.d.s. given orally was significantly more effective than placebo in the control of OIE in cancer patients.",2002.0,0,0
685,11907388,Postoperative pain management after supratentorial craniotomy.,Eric Verchère; Bruno Grenier; Abdelghani Mesli; Daniel Siao; Mussa Sesay; Pierre Maurette,"The aim of this study was to compare the analgesic efficacy of three different postoperative treatments after supratentorial craniotomy. Sixty-four patients were allocated prospectively and randomly into three groups: paracetamol (the P group, n = 8), paracetamol and tramadol (the PT group, n = 29), and paracetamol and nalbuphine (the PN group, n = 27). General anesthesia was standardized with propofol and remifentanil using atracurium as the muscle relaxant. One hour before the end of surgery, all patients received 30 mg/kg propacetamol intravenously then 30 mg/kg every 6 hours. Patients in the PT group received 1.5 mg/kg tramadol 1 hour before the end of surgery. For patients in the PN group, 0.15 mg/kg nalbuphine was injected after discontinuation of remifentanil, because of its mu-antagonist effect. Postoperative pain was assessed in the fully awake patient after extubation (hour 0) and at 1, 2, 4, 8, and 24 hours using a visual analog scale (VAS). Additional tramadol (1.5 mg/kg) or 0.15 mg/kg nalbuphine was administered when the VAS score was > or = 30 mm. Analgesia was compared using the Mantha and Kaplan-Meier methods. Adverse effects of the drugs were also measured. The three groups were similar with respect to the total dose of remifentanil received (0.27 +/- 0.1 mircog/kg/min). In all patients, extubation was obtained within 6 +/- 3 minutes after remifentanil administration. Postoperative analgesia was ineffective in the P group; therefore, inclusions in this group were stopped after the eighth patient. Postoperative analgesia was effective in the two remaining groups because VAS scores were similar, except at hour 1, when nalbuphine was more effective (P = .001). Nevertheless, acquiring such a result demanded significantly more tramadol than nalbuphine (P < .05). More cases of nausea and vomiting were observed in the PT group but the difference was not significant (P < .06). In conclusion, pain after supratentorial neurosurgery must be taken into account, and paracetamol alone is insufficient in bringing relief to the patient. Addition of either tramadol or nalbuphine to paracetamol seems necessary to achieve adequate analgesia, with, nevertheless, a larger dose of tramadol to fulfill this objective.",2002.0,0,0
686,11912374,Analgesia for shock wave lithotripsy.,John Parkin; Francis X Keeley FX; Anthony G Timoney,"We evaluated the effectiveness of and patient preference for analgesia used during shock wave lithotripsy by comparing diclofenac alone with a combination of diclofenac and patient controlled analgesia, that is alfentanil. A total of 64 patients were treated using a Lithotriptor S (Dornier Medical Systems, Marietta, Georgia) and randomized to receive diclofenac alone or combined with an alfentanil patient controlled analgesia pump. If treated twice, they crossed over to the alternative form of analgesia. A record was maintained of the site and size of the stone, maximum power achieved, number of shocks, amount of alfentanil used and need for additional analgesia. After treatment patients scored on a visual analog scale the maximum level of pain and satisfaction with analgesia. There was no difference in the mean size of the stone treated (8.6 and 7.5 mm.), energy level (71% and 71% or approximately 17 kV.) or number of shocks (3,000 and 2,900, respectively) in the groups. Only 2 patients in the diclofenac group required additional analgesia and there were no significant side effects from either treatment. The mean pain scores were not significantly different in the diclofenac and patient controlled analgesia groups (3.54 and 2.93, respectively, (p = 0.34), although those on patient controlled analgesia were more satisfied (7.72 versus 9.14, p = 0.04). Of the 38 patients who presented twice 58% preferred diclofenac alone. This study suggests that there is no significant difference in the level of pain experienced with diclofenac alone or when combined with an alfentanil patient controlled analgesia pump during shock wave lithotripsy. However, patients are more satisfied with treatment when a patient controlled analgesia pump is available.",2002.0,0,0
687,11913803,The prevention of propofol injection pain by tramadol or ondansetron.,D Memiş; A Turan; B Karamanlioglu; G Kaya; Z Pamukçu,"To compare the efficacy of tramadol and ondansetron in minimizing the pain due to injection of propofol in 100 patients. An intravenous cannula was inserted in the dorsum of the hand. After tourniquet application to the forearm, tramadol 50 mg (Group 1, n = 50) or ondansetron 4 mg (Group 2, n = 50) was injected. The tourniquet was released after 20 s, and propofol 5 mL was administered over 5 s. The patients were observed and asked if they had pain in the arm and the response was assessed. Nausea and vomiting and degree of sedation were recorded for the first postoperative 24 h. Twenty-one patients in Group 1 and 14 patients in Group 2 reported no pain. Slight pain was seen in 15 patients in Group 1 and in 18 patients in Group 2. Moderate pain was seen in 10 patients in Group 1 and 15 patients in Group 2. Severe pain was seen in four of the patients in Group 1 and three patients in Group 2. There was no significant difference of pain between Groups 1 and 2, but we found a significant reduction of nausea and vomiting in the ondansetron group compared with the tramadol group (P = 0.033). Tramadol or ondansetron are equally effective in preventing pain from propofol injection. The added benefit of a reduction in nausea and vomiting after operation in the ondansetron group may be a reason to prefer this drug.",2002.0,0,0
688,11927450,A randomized clinical trial of analgesia in children with acute abdominal pain.,Michael K Kim; Richard T Strait; Thomas T Sato; Halim M Hennes,"To evaluate the effects of intravenous morphine on pain reduction, physical examination, and diagnostic accuracy in children with acute abdominal pain. A randomized, double-blind, placebo-controlled clinical trial was conducted at an emergency department of a tertiary care children's hospital. Children aged 5-18 years with abdominal pain of < or =5 days' duration, pain score > or =5 on a 0-10 visual analog scale, and need for surgical evaluation were eligible. Following the initial assessment, patients were randomized to receive either 0.1 mg/kg morphine or an equal volume of saline. The pediatric emergency medicine physician and surgical consultant independently recorded the areas of tenderness to palpation and percussion, and their diagnoses before the study medication and 15 to 30 minutes later. Sixty patients were enrolled, and 29 received morphine and 31 received saline. The demographic characteristics between the two groups were similar. The median reduction of pain score between the two study groups was 2 (95% CI = 1 to 4; p = 0.002). There was no significant change in the areas of tenderness in both study groups. Children with surgical conditions had persistent tenderness to palpation and/or percussion. There was no significant change in the diagnostic accuracy between the study groups and between the physician groups. All patients requiring laparotomy were identified and no significant complication was noted in the morphine group. Intravenous morphine provides significant pain reduction to children with acute abdominal pain without adversely affecting the examination, and morphine does not affect the ability to identify children with surgical conditions.",2002.0,0,0
689,11929502,Use of opioid medications for chronic noncancer pain syndromes in primary care.,M Carrington Reid; Laura L Engles-Horton; MaryAnn B Weber; Robert D Kerns; Elizabeth L Rogers; Patrick G O'Connor,"To define the spectrum of chronic noncancer pain treated with opioid medications in 2 primary care settings, and the prevalence of psychiatric comorbidity in this patient population. We also sought to determine the proportion of patients who manifested prescription opioid abuse behaviors and the factors associated with these behaviors. A retrospective cohort study. A VA primary care clinic and an urban hospital-based primary care center (PCC) located in the northeastern United States. A random sample of VA patients ( n=50) and all PCC patients ( n=48) with chronic noncancer pain who received 6 or more months of opioid prescriptions during a 1-year period (April 1, 1997 through March 31, 1998) and were not on methadone maintenance. Information regarding patients' type of chronic pain disorder, demographic, medical, and psychiatric status, and the presence of prescription opioid abuse behaviors was obtained by medical record review. Low back pain was the most common disorder accounting for 44% and 25% of all chronic pain diagnoses in the VA and PCC samples, respectively, followed by injury-related (10% and 13%), diabetic neuropathy (8% and 10%), degenerative joint disease (16% and 13%), spinal stenosis (10% and 4%), headache (4% and 13%) and other chronic pain disorders (8% and 22%). The median duration of pain was 10 years (range 3 to 50 years) in the VA and 13 years in the PCC sample (range 1 to 49 years). Among VA and PCC patients, the lifetime prevalence rates of psychiatric comorbidities were: depressive disorder (44% and 54%), anxiety disorder (20% and 21%), alcohol abuse/dependence (46% and 31%), and narcotic abuse/dependence (18% and 38%). Prescription opioid abusive behaviors were recorded for 24% of VA and 31% of PCC patients. A lifetime history of a substance use disorder (adjusted odds ratio [OR], 3.8; 95% confidence interval [CI], 1.4 to 10.8) and age (adjusted OR, 0.94; 95% CI, 0.89 to 0.99) were independent predictors of prescription opioid abuse behavior. A broad spectrum of chronic noncancer pain disorders are treated with opioid medications in primary care settings. The lifetime prevalence of psychiatric comorbidity was substantial in our study population. A significant minority of patients manifested prescription opioid abusive behaviors, and a lifetime history of a substance use disorder and decreasing age were associated with prescription opioid abuse behavior. Prospective studies are needed to determine the potential benefits as well as risks associated with opioid use for chronic noncancer pain in primary care.",2002.0,0,0
690,11929512,Chronic pain and narcotics: a dilemma for primary care.,Yngvild Olsen; Gail L Daumit,,2002.0,0,0
691,11939683,Treatment of sickle cell pain.,Karen F Marlowe; Michael F Chicella,"Sickle cell disease affects 70,000 Americans who experience an average of 0.8 painful episodes each year. The pathophysiology of sickle cell pain is not completely understood. The disease is characterized by both acute and chronic pain syndromes. Patients with sickle cell pain often encounter barriers to receiving appropriate care, including lack of continuity of care and perceived opiate addiction. Studies describing pharmacotherapy for sickle cell pain have been primarily retrospective and uncontrolled. In analyzing the available literature regarding pathophysiology, assessment, and treatment of sickle cell pain, we found a need for increased practitioner education and intervention to improve the level of care provided to patients with this disease.",2002.0,0,0
692,11939924,Ropivacaine 2 mg/mL vs. bupivacaine 1.25 mg/mL with sufentanil using patient-controlled epidural analgesia in labour.,K Hofmann-Kiefer; K Saran; A Brederode; H Bernasconi; B Zwissler; D Schwender,"In recent studies, minimum local analgesic concentrations have been defined as 0.93 mg/mL for bupivacaine and 1.56 mg/mL for ropivacaine for epidural analgesia for the first stage of labour, resulting in an analgesic potency ratio of 1 : 0.6. In the current study we compared ropivacaine and bupivacaine in a PCEA system (combined with sufentanil) taking this potency ratio into account but administering drug doses providing sufficient analgesia for all stages of labour. In a prospective, double-blinded study 114 parturients were randomised to receive either ropivacaine 2 mg/mL with sufentanil 0.75 microg/mL or bupivacaine 1.25 mg/with sufentanil 0.75 microg/mL. After epidural catheter placement, PCEA was available with boluses of 4 mL, a lock-out time of 20 min and no basal infusion rate. We evaluated pain intensity during contractions, sensory and motor function, duration of labour, mode of delivery and neonatal outcome. Consumption of local anaesthetic and opioid drugs and PCEA system variables were recorded. Mean total consumption as well as mean hourly drug consumption was significantly increased in the ropivacaine-sufentanil group. No differences in analgesic quality, sensory or motor blocking potencies or neonatal outcome variables between groups were detected. Frequency of instrumental deliveries was significantly increased in the ropivacaine-sufentanil group. The results support the findings of previously published studies postulating ropivacaine to be 40-50% less potent for labour epidural analgesia compared to bupivacaine. However, we observed an increased frequency of instrumental deliveries with ropivacaine. To evaluate the clinical relevance of these findings, further investigations are warranted.",2002.0,0,0
693,11939925,Comparison of the opioid-sparing efficacy of diclofenac and ketoprofen for 3 days after knee arthroplasty.,M Silvanto; M Lappi; P H Rosenberg,"Comparative postoperative non-steroidal anti-inflammatory drug (NSAID) studies in orthopedic patients have usually been restricted in time to the first postoperative day. The opioid-sparing effect of NSAIDs may be beneficial postoperatively as long as pain otherwise restricts ambulation and rehabilitation. We therefore compared the analgesic efficacy of the maximum recommended doses of diclofenac and ketoprofen for 3 days after knee arthroplasty. We studied 64 knee arthroplasty patients, operated on under spinal anesthesia. In a randomized, double-blind and placebo-controlled fashion, the patients received either i.v. diclofenac 75 mg (n = 24), ketoprofen 100 mg (n = 24) or saline (n = 16) in the recovery room, followed by oral diclofenac 150 mg/day, ketoprofen 300 mg/day or placebo, respectively, for 3 days, supplemented by patient-controlled analgesia (PCA) with i.v. oxycodone. The mean consumption of oxycodone during the first, second and third study days was 45.3, 22.3 and 15.2 mg in the diclofenac group, 43.5, 37.5 and 21.8 mg in the ketoprofen group, and 61.2, 45.9 and 36.1 mg, respectively, in the placebo group. Oxycodone consumption was significantly lower (P < 0.05) in the ketoprofen group than in the placebo group in the postoperative period 13-24 h and 61-72 h. Diclofenac was superior to placebo in the postoperative period 25-48 h (P < 0.01), 49-60 h (P < 0.05) and to ketoprofen at 49-60 h (P < 0.05). During administration of diclofenac on days 1-3 and ketoprofen on day 2, the mean pain scores (VAS) were lower than in the placebo group (P < 0.05). Six patients had difficulties in operating the PCA device. There were no differences in blood loss. We conclude that in the first day after knee arthroplasty (13-24 h), ketoprofen exerted an opioid-sparing effect. After day 1 (25-60 h), with the doses used, diclofenac proved to be better than placebo, whereas ketoprofen was not.",2002.0,0,0
694,11943517,Double-blind evaluation of transdermal nitroglycerine as adjuvant to oral morphine for cancer pain management.,Gabriela R Lauretti; Marcelo V Perez; Marlene P Reis; Newton L Pereira,"To examine analgesia and adverse effects following transdermal application of nitroglycerine (a nitric oxide generator) combined with oral morphine, in cancer pain patients. Randomized, double-blind study. Teaching hospital. 36 patients suffering from cancer pain. Patients were divided into two groups (n = 18). All patients were regularly taking oral amitriptyline 50 mg at bedtime. Pain was evaluated using a 10-cm visual analog scale (VAS). The morphine regimen was individually adjusted to a maximal oral dose of 80 to 90 mg/day, to maintain the VAS score less than 4/10 cm. When patients complained of pain (VAS equal or greater than 4/10), despite taking 80 to 90 mg of oral morphine daily, the transdermal test drug was supplemented as follows: the control group received a placebo patch daily, and the nitroglycerine group received a 5-mg/24-hour nitroglycerine patch daily. Patients were free to manipulate their daily morphine consumption at the time the test drug was administered, to keep VAS less than 4/10 cm. After the introduction of the transdermal test drug, patients were evaluated by the staff on a weekly basis as outpatients, over four consecutive weeks. The groups were similar in respect to demographic data and VAS pain scores before the treatment. The daily consumption of oral morphine was smaller in the nitroglycerine group compared with the control group after the 14th day of evaluation (p < 0.002). Patients from the control group in general complained of somnolence, compared with the nitroglycerine group. Transdermal nitroglycerine was an effective coadjuvant analgesic. In conjunction with its opioid tolerance sparing function, delivery of nitric oxide donors together with opioids may be of significant benefit in cancer pain management in delaying morphine tolerance and decreasing the incidence of adverse effects related to high doses of opioids.",2002.0,0,0
695,11943525,"Continuous epidural, not intravenous, droperidol inhibits pruritus, nausea, and vomiting during epidural morphine analgesia.",Ken Nakata; Tadanori Mammoto; Takashi Kita; Hiroshi Taniguchi; Noriko Kanbara; Tetsuya Akamatsu; Toshiko Sakai; Yoshihiko Kishi,"To investigate whether continuous epidural droperidol and intravenous (IV) intraoperative droperidol inhibit pruritus and postoperative nausea and vomiting (PONV) during epidural morphine analgesia. Randomized, double-blinded, controlled study. Metropolitan cancer center. 120 ASA physical status I and II patients undergoing thoracic or abdominal surgery with general anesthesia combined with epidural anesthesia. Patients received an intraoperative epidural injection of 2 mg morphine hydrochloride, followed postoperatively by a continuous epidural infusion of morphine hydrochloride 4 mg/day for 4 days. Patients were randomly allocated to four groups: Group A = control group, Group B = intraoperative single IV injection of droperidol (2.5 mg), Group C = postoperative continuous epidural droperidol infusion (2.5 mg/day), and Group D = intraoperative IV injection of droperidol (2.5 mg) and postoperative continuous epidural droperidol infusion (2.5 mg/day). The frequency and severity of pruritus and PONV in each group were evaluated during the postoperative period. Continuous epidural infusion of droperidol significantly reduced the frequency and severity of pruritus and PONV induced by epidural morphine without causing significant side effects. Intraoperative single IV injection of droperidol was effective for PONV (p < 0.05) but not for pruritus. Postoperative epidural droperidol infusion significantly decreased both the frequency and severity of pruritus and PONV during postoperative continuous epidural morphine analgesia. IV intraoperative droperidol significantly reduced the frequency and the severity of PONV but not pruritus.",2002.0,0,0
696,11952445,Rectally administered diclofenac (Voltaren) reduces vomiting compared with opioid (morphine) after strabismus surgery in children.,B Wennström; B Reinsfelt,"Nausea, vomiting and pain are common complications after strabismus surgery in children. Diclofenac, a non-steroid anti-inflammatory drug, is widely used to treat acute and chronic pain but there are few reports of its use given rectally in children undergoing strabismus surgery. This open randomised study was designed to investigate the analgesic and anti-emetic properties of rectally administered diclofenac compared with opioid (morphine) given i.v. in connection with strabismus surgery in children. After obtaining approval from the local ethics committee and written informed consent from the parents, 50 ASA class I-II children, 4-16 years of age, were randomised to receive either rectally administered diclofenac (Voltaren) 1 mg/kg or i.v. opioid (morphine) 0.05 mg/kg perioperatively. The children were consecutively operated upon from May 1999 to January 2001. Anaesthesia was induced with fentanyl and propofol and maintained with propofol. Nitrous oxide was omitted. The postoperative pain was assessed after arrival at the post anaesthesia care unit (PACU) by using the validated Wong and Baker scale (FACES) Pain Rating Scale. Postoperative nausea and vomiting (PONV) was assessed by measuring the frequency of vomiting and the degree of nausea. In the diclofenac group the incidence of PONV during the first 24 h was 12% (of which one child had severe vomiting). The incidence of PONV was much higher, 72% (P = 0.0000), in the morphine group, where 56% of the children also had severe vomiting. There were no difference in pain score between the two groups. Recovery time at the PACU was longer (P < 0.002) and the postoperative analgesic requirement higher in the morphine group (10 vs. 5 children). No children needed overnight admission to the hospital. Diclofenac given rectally is an effective analgesic for this kind of surgery and gives less postoperative nausea than i.v. morphine. No serious adverse events were observed.",2002.0,0,0
697,11954700,Pain model and fuzzy logic patient-controlled analgesia in shock-wave lithotripsy.,J S Shieh; L W Chang; M S Wang; W Z Sun; Y P Wang; Y P Yang,"Pain control in conscious patients was investigated using a push-button, demand-driven supply of drugs. A fuzzy logic patient-controlled analgesia (PCA) algorithm was compared with a conventional algorithm, for alfentanil administration in extracorporeal shock-wave lithotripsy. The conventional PCA algorithm used an initial dose of 0.25mg, a fixed infusion rate of 60 mg h(-1) and a fixed bolus size of 0.2 mg with a 1 min lockout. The fuzzy logic PCA algorithm used an initial dose of 0.25 mg, a changeable infusion rate and a bolus size of 0.1 or 0.05 mg. The infusion rate was adjusted according to a look-up table that accepted the button-pressing history over the last three lockout intervals. The look-up table was designed using fuzzy logic. The bolus size was adjusted according to the button-pressing history over the past two lockout intervals. Twelve patients were treated using conventional PCA, and thirteen were treated with PCA + fuzzy logic control (FLC). PCA + FLC patients consumed 45% less drug. Also, PCA + FLC patients had a mean delivery/demand ratio of 82%, compared with 60% in conventional PCA. When the pain intensity scale was analysed, PCA + FLC patients had acceptable pain intensity at 62%, compared with 44% in conventional PCA.",2002.0,0,0
698,11966550,Efficacy of ropivacaine compared with ropivacaine plus sufentanil for postoperative analgesia after major knee surgery.,C Lorenzini; L B Moreira; M B C Ferreira,"This study compared the analgesic efficacy of an epidural infusion of ropivacaine and ropivacaine with sufentanil following major knee surgery. In a double-blind clinical trial, 115 adult patients received either epidural ropivacaine (R group, 2 mg.ml(-1)), or ropivacaine (2 mg.ml(-1)) with sufentanil (RS group, 1 microg.ml(-1)), using a patient-controlled epidural analgesia technique. Pain scores (visual analogue scale, VAS, and the simple descriptive scale, SDS), side-effects, motor block and treatment quality were recorded at 6, 12 and 24 h after the insertion of the epidural catheter. In the RS group, analgesic efficacy was significantly greater than in the R group between 12 and 24 h following insertion of the epidural catheter (VAS: 92.9% vs. 72.9%, p = 0.009). There was no significant difference during the other periods. Pruritus, nausea and vomiting were significantly more frequent in the RS group. Good postoperative analgesia was obtained with an epidural infusion of ropivacaine (2 mg.ml(-1)). When this local anaesthetic was administered with sufentanil, there was an improvement in the analgesic effect but a significant increase in the number of patients who reported adverse effects. The differences were more pronounced 12 h after the beginning of the analgesic schedule. This study failed to demonstrate any worthwhile clinical benefit from the addition of sufentanil.",2002.0,0,0
699,11967625,"Behavioral pharmacology of buprenorphine, with a focus on preclinical models of reward and addiction.",Thomas M Tzschentke,"Buprenorphine is a potent mu-receptor partial agonist and is widely used as an analgesic drug. It is also increasingly considered to be an alternative to methadone in the maintenance and eventual detoxification of heroin addicts, and also in the treatment of cocaine addiction. So far, buprenorphine has been available as a sublingual tablet and as a solution for IV injection. Recently, a new transdermal formulation of buprenorphine in slow-release matrix patches has been introduced (Transtec) for the treatment of intermediate to severe pain. The aim of this paper is to review, from a preclinical perspective, the current status of what is known about the behavioral pharmacology of buprenorphine, with a particular emphasis on the issues of reward, addiction, and dependence. It will also point to open questions that should be addressed in the future to improve our understanding of the effects and the mechanisms of action of this drug. Since buprenorphine is a potent opioid drug, the issue of addiction and dependence in this context is an important one. Although there are still some gaps in the behavioral pharmacological characterization of buprenorphine, the general conclusion that can be drawn from the reviewed literature is that despite the high affinity of buprenorphine for the mu receptor it appears to be a remarkably safe drug, with a benign overall side effect profile and low addictive and dependence-inducing potential. This favorable side effect profile appears to be due, to a large extent, to the partial agonistic properties of the drug, in combination with its particular receptor kinetics (i.e. very slow dissociation from the mu receptor after binding).",2002.0,0,0
700,11972998,Analgesic effects of dextromethorphan and morphine in patients with chronic pain.,Tarja Heiskanen; Brita Härtel; Marja-Liisa Dahl; Timo Seppälä; Eija Kalso,"N-methyl-aspartate (NMDA) receptor antagonists have been shown to improve opioid analgesia in the animal model. The cough suppressant dextromethorphan is a clinically available NMDA-receptor antagonist. In this randomised, double-blind, placebo-controlled study 20 patients with chronic pain of several years duration were given 100 mg of oral dextromethorphan or matching placebo 4 h prior to an intravenous infusion of morphine 15 mg. Pain intensity and adverse effects were assessed at 0, 4, 5 and 7 h. Dextromethorphan had no effect on morphine analgesia: the mean (+/-SEM) visual analogue scores for pain relief (VAS, 0-100 mm) at the end of the morphine infusion were 38 (+/-6) for dextromethorphan+morphine and 38 (+/-7) for placebo+morphine. VAS scores for pain intensity were comparable both at rest and at movement at all time points. The most common adverse effects reported were dizziness, nausea and sedation. There were no significant differences in either the incidence or severity of adverse effects. In conclusion, oral dextromethorphan 100 mg had no effect on pain relief by intravenous morphine 15 mg in patients with chronic pain.",2002.0,0,0
701,11981144,A comparison of intrathecal fentanyl and sufentanil for labor analgesia.,Kenneth E Nelson; Traci Rauch; Victor Terebuh; Robert D'Angelo,"The use of intrathecal opioids for labor analgesia continues to gain popularity, but there are limited data to guide this use. Previously, the authors established the ED50 for 60 min of labor analgesia from intrathecal sufentanil using an up-down sequential allocation study design. The current study first establishes an ED50 for intrathecal fentanyl using this same study design to establish an intrathecal potency ratio for fentanyl and sufentanil and then uses this ratio to compare the efficacy, duration of analgesia, and side effects from comparable doses of intrathecal fentanyl and sufentanil. Seventy-five healthy nulliparous women requesting labor analgesia were enrolled in this two-part study. In phase I, 20 women received varying doses of fentanyl to establish an ED50 for 60 min of labor analgesia. In phase II, 55 women were randomized to receive either 36 microg intrathecal fentanyl or 8 microg sufentanil (2 times the ED50s) via a combined spinal-epidural technique and by double-blinded design. Pain relief, side effects, block height, maternal hemodynamics, and fetal heart rate were assessed throughout the study. The duration of spinal analgesia was considered to be the time from injection of study drug to the time of the patient's first request for additional analgesia. The ED50 of intrathecal fentanyl for 60 min of labor analgesia was found to be 18.2 microg, and therefore, the potency ratio of intrathecal sufentanil to intrathecal fentanyl at the ED50 level is 4.4:1. The duration of spinal analgesia was significantly longer from 8 microg intrathecal sufentanil than from 36 microg intrathecal fentanyl (104 +/- 34 vs. 79 +/- 34 min, P = 0.009). Otherwise, patient demographics, maternal hemodynamics, duration of labor, mode of delivery, motor block, subjective leg weakness, pruritus, nausea, pinprick sensory levels, visual analog scale pain scores, fetal bradycardia, and Apgar scores were similar between groups. The relative potency of intrathecal sufentanil to fentanyl for labor analgesia is 4.4:1. When using intrathecal opioids alone for early labor analgesia, 8 microg sufentanil produces labor analgesia lasting approximately 25 min longer than from 36 microg fentanyl, without a statistically significant increase in side effects. However, when making a choice between fentanyl and sufentanil, one must consider other important factors, such as the higher cost of sufentanil and the greater risk of dosing error due to the higher potency of sufentanil compared with fentanyl.",2002.0,0,0
702,11983659,Low-dose ketorolac improves analgesia and reduces morphine requirements following posterior spinal fusion in adolescents.,Hamish M Munro; Sarah R Walton; Shobha Malviya; Sandra Merkel; Terri Voepel-Lewis; Randall T Loder; Frances A Farley,"To determine if low-dose ketorolac would improve analgesia while minimizing unwanted side effects in adolescents following posterior spinal fusion (PSF). A prospective randomized double-blind placebo-controlled trial assessed the analgesic effects of low-dose ketorolac following PSF. Thirty-five adolescents aged 11-17 yr were randomly assigned to receive placebo or 0.5 mg x kg(-1) ketorolac (maximum of 15 mg) six hourly postoperatively for 36 hr in conjunction with standard morphine patient controlled analgesia (PCA). Pain and sedation were assessed twice daily for the first three postoperative days (POD). The incidence of side effects related to both non-steroidal anti-inflammatory agents and opioids were recorded. Adolescents in the ketorolac group received an average dose of 0.2 mg x kg(-1) (average exposure 1.2 mg x kg(-1)), had lower pain scores on POD one and two (P < 0.05) and consumed less morphine in the postanesthesia care unit and on POD two. There was no difference in the incidence of pruritus, nausea, vomiting or constipation, but patients in the ketorolac group tolerated activity better on POD one (P < 0.05). There were no differences between groups with regard to postoperative blood loss or transfusion requirements. Fourteen patients were followed for two years and the incidence of curve progression, hardware failure or back pain at final follow-up was not different. Low-dose ketorolac in conjunction with morphine PCA improved the quality of analgesia and reduced morphine requirements following PSF compared to placebo without increasing the incidence of non-steroidal anti-inflammatory side effects.",2002.0,0,0
703,11984100,Pain management autobiographies and reluctance to use opioids for cancer pain management.,Karen L Schumacher; Claudia West; Marylin Dodd; Steven M Paul; Debu Tripathy; Peter Koo; Christine A Miaskowski,"Although pain management education results in improved pain control for some patients, it does not work for all patients because some patients remain reluctant or unwilling to use prescribed analgesics to their optimal effect. In a randomized clinical trial that tested the effectiveness of the PRO-SELF Pain Control Program, 11 patients declined to increase their analgesic use despite moderate to severe pain. These patients were selected for a qualitative analysis of their audiotaped discussions about pain management with their intervention nurses. This analysis revealed that these patients often spontaneously provided detailed explanations about why they were reluctant or unwilling to take analgesics in general or opioids in particular. We termed these explanatory accounts pain management autobiographies because of their narrative character and multilayered, richly detailed quality. Pain management autobiographies included stories about (1) previous experience with chronic pain management, including stigmatizing interactions with clinicians and family members; (2) bad experiences with cancer pain management, including severe constipation; and 3) strongly held conventions about medication use, including the belief that all medications are ""toxins"" that should be avoided. The study findings suggest that a small subset of patients with cancer pain may need interventions such as individual or family counseling or alternative pain management strategies to augment education about opioids.",2002.0,0,0
704,11993078,[Postoperative pain therapy in minimally invasive direct coronary arterial bypass surgery. I.v. opioid patient-controlled analgesia versus intercostal block].,H Behnke; G Geldner; J Cornelissen; M Kahl; F Möller; J Cremer; H Wulf,"Lately introduced cardiosurgical procedures such as MIDCAB enable an early extubation immediately after surgery. This also requires an adequate anesthesia regime and especially a sufficient postoperative analgesia. Patient controlled analgesia (PCA) and intercostal nerve blockade (ICB) were evaluated for their suitability for postoperative pain relief in patients undergoing a MIDCAB procedure. After approval by the local ethic committee and obtaining written informed consent 43 patients were included in this study. Anesthesia was induced and maintained in a total intravenous standardised manner with propofol, remifentanil, cisatracurium and additionally glyceroltrinitrate, clonidine and esmolol were given as needed. After revascularisation patients were randomly assigned to one of two groups receiving either 7.5 mg piritramid i.v. before extubation and continuing a PCA with 2 mg boli and a 10 min lockout, or an ICB with ropivacaine 1% (4 times 5 ml). Additionally all patients received 1 g paracetamol rectally before induction of anesthesia and 1 g metamizol i.v. at the end of surgery. A rescue medication of 3.75 mg piritramid i.v. was allowed. A pain score (NRS 0-10), the Aldrete score (AS 0-12) and oxygen saturation were obtained 1, 4, and 8 h after extubation. The ICB group showed a significantly greater pain reduction in the first (5.8 +/- 1.8 vs. 7.3 +/- 1.9; P < 0.02) and fourth h (3.6 +/- 1.3 vs. 4.6 +/- 1.4; P < 0.02), respectively. Transfer to an intermediate care ward one hr after extubation was achieved more often in the ICB group according to the AS (ICB 9.6 +/- 1.5 vs. PCA 8.9 +/- 1.2; P < 0.05), too. There was no difference with respect to the oxygen saturation. The additional piritramid demand was 9.3 mg in the ICP group and 5 mg in the PCA group in the first 8 hours postoperative. ICB gives a better pain relief in the early postoperative phase after MIDCAB procedures compared to a PCA. Both regimes are adequate in order to provide a sufficient pain relief and help to avoid prolonged postoperative mechanical ventilation. These will enable an early transfer of patients to an intermediate care station and save ICU capacity.",2002.0,0,0
705,12006313,"Chronic pain, bereavement and overdose in a depressed elderly woman.",W David Strain; Michael Lye,,2002.0,0,0
706,12040568,[Non-oncologic chronic pain relief with opioids].,C A Pimenta; M J Teixeira; C F Correa; F S Müller; F C Goes; R M Marcon,"Opioids for non cancer pain control are controversial. The evaluation of the pain relief, changes in quality of life and complications due to long term infusion of opioids in the lumbar subarachnoid space in 11 patients with non cancer pain were the goals of this study. Patients were previously treated with drugs and surgical procedures, without significant pain relief. Patients were asked to compare pain characteristics and daily life activities before and after this treatment. The long term spinal opioids through implantable pumps for non-oncologic pain produced pain relief but did not improve the quality of life in the majority of the cases.",2002.0,0,0
707,12043315,[Evaluation of analgesic action of fluvoxamine compared with efficacy of imipramine and tramadol for treatment of sciatica--open trial].,Janusz Kwasucki; Adam Stepień; Grzegorz Maksymiuk; Barbara Olbrych-Karpińska,"At present time tricyclic antidepressants (TA) are important tools in therapy of chronic pain. However administration of TA produce a number of side effects. Antidepressants of new generation, selective serotonin reuptake inhibitors (SSRI) induce less side effects in patients than TA. The aim of the study was to estimate an analgetic effect of antidepressant of new generation--fluvoksamine (Fevarin) in treatment of ischialgia and comparison with an analgetic effect of impramine and tramadol--opoid receptors antagonist. 70 patients with sociatic neuralgia were included to the research. They were at random divided into three groups. First one was treated with tramadol consisted of 22 persons (18 men and 4 women, average age--42.9 y.), second one treated with impramine consisted of 24 persons (18 men and 6 women, average age--43.2 y.) and third one treated with fluvoksamine consisted of 24 persons (15 men and 9 women, average age--42.3 y.). Observation time was 19 days. Pain intensity was evaluated in four degree descriptive scale. Before and after treatment clinical symptoms of depression were estimated in groups of patients treated with impramine or fluvoksamine by Zung's Depression Scale. There were no statistically significant differences in analgetic effect after treatment with fluvoksamine or impiramine. There was meaningly few number of side effects in the group treated with fluvoksamine. Fluvoksamine and impramine have similar effectiveness in treatment of ischialgia, that is why fluvoksamine should be considered as medication when TA are contraindicated.",2002.0,0,0
708,12043483,[Pain relief in induced abortion--considerable differences between hospital departments].,Maria Bäckman; Lill Hagman; Lena Lendahls,"Women undergoing medical abortions require different types of pain relief, severe pain being a problem. This study compared the pain relief required during a medical abortion at the Departments of Gynecology in Kalmar and Karlskrona. The case notes of 100 women at each department were examined. Considerable differences between the two departments were found. In Kalmar women were mainly given paracetamol and dextropropoxyphene at the start of the procedure, while in Karlskrona women were usually given suppository diclofenac. In Kalmar 42 per cent of the women needed some form of opiate during the abortion, while in Karlskrona only 8 per cent required opiates.",2002.0,0,0
709,12054097,EN-3231. Endo Pharmaceuticals.,Nat Monck,"Endo (which acquired Algos in July 2000) has developed EN-3231, a combination of morphine and dextromethorphan, for the treatment of moderate-to-severe chronic pain. In October 1998, the FDA accepted for filing the company's NDA submission on EN-3231, which was submitted in August 1998. However, in August 1999, Algos received a 'non-approvable' letter from the FDA for EN-3231. In September 2000, the company met with the FDA to discuss what information the FDA required in order to approve EN-3231. The FDA requested a second pivotal trial, which Endo initiated promptly. Endo hoped to file its supplement to the NDA during 2002.",2002.0,0,0
710,12054098,E-TRANS fentanyl. ALZA.,Kyriaki Mystakidou,"ALZA and Crescendo are developing E-TRANS fentanyl, an electrotransport system (ETS) delivery offentanyl that allows self-titration of the drug by the patient, for the potential management of acute pain. The product was previously being developed in collaboration with Janssen, but by February 2000, Janssen was no longer involved in its development. In January 1998, Janssen, ALZA and Crescendo had plans to develop the product for the potential treatment of chronic pain in addition to the acute pain indication; however, no further development for this indication has been reported since that date. ETS is able to deliver drugs that normally would not diffuse across the skin. A small electric current passes through the patient's skin, between the two electrodes on the patch. Charged drug molecules are attracted to the electrode of the opposite polarity to their own. Manipulating the charge on drug molecules is relatively easy in most instances, so the technology should be applicable to the majority of drugs that do not lend themselves to passive diffusion. ETS technology is also potentially useful in delivering rapid boluses of drug on demand. In February 2000, Merrill Lynch predicted E-TRANS fentanyl sales at US $30 million in 2002, rising to US $131 million in 2004. Analysts at SG Cowen predicted in March 2001, that E-TRANS fentanyl would be rolled out during 2003 and that sales would reach US $40 to 50 million in 2004. In April 2001, Merrill Lynch predicted earliest launch in 2003.",2002.0,0,0
711,12054148,Transdermal fentanyl for the management of cancer pain: a survey of 1005 patients.,L Radbruch; R Sabatowski; F Petzke; A Brunsch-Radbruch; S Grond; K A Lehmann,"Transdermal fentanyl was released in Germany in 1995. From October 1996 to February 1998 transdermal treatment was documented for 1005 patients (506 men and 499 women with a mean age of 60 years, range 20-92 years) with chronic pain in an open survey including 290 physicians from hospitals and general practitioners throughout Germany. Most patients suffered from cancer pain and only 11 patients had chronic pain from non-malignant disease. Physicians were asked to complete a questionnaire for patients treated with transdermal fentanyl on initiation of therapy (day 0), and days 3, 6, 18, 30 thereafter, followed by monthly follow-up intervals. Patients were asked to complete a pain diary. Transdermal therapy was documented from day 0 for 824 patients, while 181 patients had been treated with transdermal fentanyl before admission in the survey. Most of the other 824 patients had been treated with other step 3 opioids (55% of the patients) or step 2 opioids (23%) before conversion to transdermal fentanyl, whereas 8% had been treated only with non-opioids and 14% had received analgesics only as required or not at all before initiation of transdermal therapy. The most important reasons for switching to transdermal opioid therapy were insufficient pain relief with the previous medication followed by a variety of gastrointestinal symptoms impeding oral analgesic therapy. Initial fentanyl doses ranged from 0.6 to 9.6 mg/day (25 to 400 microg/h) with a median of 1.2 mg/day (50 microg/h). Median doses slowly increased throughout the observation period to 2.4 mg/day (100 microg/h) after 4 months of treatment. Most patients continued transdermal therapy until the time of death (47% of patients). Other reasons for discontinuation were inadequate pain relief (10%), pain relief with other analgesic regimens (10%), other symptoms than pain (5%), rejection of transdermal therapy by the patient (6%) or miscellaneous (16%). Adverse events were documented as the reason for discontinuation of transdermal therapy in 49 patients (5%). Dyspnoea was documented for seven patients as the reason for discontinuation. One of these patients, as well as another patient with an episode of apnoea, had to be treated with artificial respiration for several hours, but both patients recovered without sequelae. Transdermal therapy with fentanyl was safe and efficient in this national survey. Transdermal fentanyl can be recommended for treatment of moderate to severe cancer pain and probably may even be used as a first-line drug on step 3 of the World Health Organization recommendations in selected patient groups.",2002.0,0,0
712,12067866,Loss of intrathecal morphine analgesia in terminal cancer patients is associated with high levels of excitatory amino acids in the CSF.,Chih-Shung Wong; Yi-Chen Chang; Chun-Chang Yeh; Go-Shine Huang; Chen-Hwan Cherng,"To examine excitatory amino acid (EAA) levels in the cerebrospinal fluid (CSF) of patients on long-term morphine treatment for terminal cancer pain relief and to correlate these with morphine's analgesic effect. Fourteen terminal cancer patients suffering severe pain and requiring long-term opioid treatment for pain relief were included. An intrathecal (IT) catheter was implanted at the L(3-4)/L(4-5) level and advanced 10 cm in a cephalad direction. IT morphine injection was started at 100 microgram q 12 hr with a daily incremental dose of 50 microgram until the effective dose was reached. The CSF was sampled (2 mL) as follows: 1) before the first IT morphine injection, 2) when the effective dose of morphine was reached, 3) when loss of morphine's analgesic effect at the effective dose (pain visual analogue scale > 5), and 4) after consecutive increases of the morphine dose (50 microgram, IT, daily) for satisfactory pain relief and up to double the effective dose. The concentrations of glutamate and aspartate in the CSF were determined. CSF levels of glutamate and aspartate at the effective dose of morphine were lower than the baseline levels and increased when pain intensity increased and when morphine's analgesic effect was lost. Long-term IT morphine administration was accompanied by an increase of EAA level in the CSF that was associated with a loss of morphine's analgesic effect.",2002.0,0,0
713,12091067,A randomised controlled study on the use of anti-inflammatory drugs in patients with cancer pain on morphine therapy: effects on dose-escalation and a pharmacoeconomic analysis.,S Mercadante; F Fulfaro; A Casuccio,"The role of non-steroidal anti-inflammatory drugs (NSAIDs) in cancer pain has been well established in the treatment of mild pain and in association with opioids in the treatment of moderate to severe pain. The aim of this study was to verify the effects of NSAIDs on morphine escalation in advanced cancer patients with pain followed-up at home and to assess the pharmacoeconomic implications. A prospective randomised controlled study was carried out in 156 consecutive advanced cancer patients with pain followed-up at home in the period December 1999-December 2000. In this group of patients, 47 were selected with pain progression after 1 week of opioid stabilisation. Patients were randomly assigned to one of two groups: group 'O' patients were treated with continuing opioid escalation according to their clinical needs; group 'OK' received ketorolac 60 mg/daily orally (p.o.) in three doses and then continued opioid escalation according to their clinical situation. Performance status, doses of morphine before and after starting treatment, mean weekly pain intensity (assessed by means of a numerical scale from 0 to 10), mean weekly symptoms intensity, adverse effects and pain mechanisms were recorded. Moreover, drug costs per day in both groups were calculated. Patients who received ketorolac in addition to morphine showed a better analgesia after a week in comparison to the group treated with morphine only (P=0.005). Thereafter, morphine escalation was slower and the maximum morphine dose was lower in the group treated with ketorolac. The incidence and the severity of gastric discomfort was more evident in patients treated with ketorolac, while constipation was significantly increased in patients who received morphine only. Drug costs per day were similar in both groups; statistical differences were observed in patients who started on lower morphine doses (<100 mg/daily) in the two groups (4.3 in the ketorolac-morphine group versus 3.4 in the morphine group; P=0.012). The use of NSAIDs reduces the need for an opioid dose escalation or allows the use of lower doses. Their use is associated with a more intense gastric discomfort, but results in less opioid-related constipation. The eventual additive cost for NSAIDs therapy is negligible, especially in patients taking high doses of morphine.",2002.0,0,0
714,12099170,Morphine oral--Elan Corporation. Avinza.,,,2003.0,0,0
715,12124509,[Pain management and the use of analgesics in dermatology].,A Bouloc; J Revuz,"To determine pain assessment and management, and the use of analgesics in dermatology. Two hundred and sixty six patients hospitalised in a dermatology university department (Henri-Mondor, Créteil) between November 1999 and April 2000 were enrolled in a prospective study. Clinical evaluation of pain intensity and evolution were studied using a visual analogic scale (VAS) pain score at presentation, during hospitalisation, and at discharge. Prescription and consumption of analgesics were also studied. Fifty-nine percent of the patients experienced pain. Eighty-four percent of them had mild or moderate to severe pain (VAS<7/10) and were relieved with non or mild opioid analgesics (discharge VAS<4/10). Sixteen percent of them had intense pain requiring morphine (VAS score >=7/10). Pain management is very important in dermatology. Every physician should know its principles since dermatologists play a crucial role in the patient's care.",2003.0,0,0
716,12126033,Managing chronic pain in the primary care setting.,Dawn A Marcus,,2002.0,0,0
717,12135164,Calculating the cost for drug treatment including the adverse drug reactions treatment cost (primer for fentanyl TTS in Bulgaria).,G I Petrova; I N Getov,"This study presents the estimation and comparison of the direct outpatient costs associated with the use of Morphine slow-tard tabul and trans-dermal therapeutic system /TTS/ with Fentanyl for the treatment of the chronic pain in oncological patients. There are compared all outpatients' costs for the medicines under consideration--Morphine slow-tard tabul in two different packages and Fentanyl TTS. The calculation summarizes the price of the drug therapy for 15 days course, costs for care (physician, pharmaceutical, nursing), transport, storage. After the assessment of the costs for prophylactics and treatment of the adverse drug reactions /ADR/ associated with the use of the compared drugs by creating the ""Decision tree"" the respective cots are added to the direct cost of patients treatment. The direct treatment costs with Fentanyl TTS exceeded those with Morphine slow-tard with 10% and thus reflects the total costs for outpatient practice. The costs of treatment of the ADRs are higher with 69% for Morphine slow-tard due to high probability of appearance of the ADRs, their seriousness and duration.",2002.0,0,0
718,12139528,Nasal administration of opioids for pain management in adults.,O Dale; R Hjortkjaer; E D Kharasch,"Nasal administration of opioids may be an alternative route to intravenous, subcutaneous, oral transmucosal, oral or rectal administration in some patients. Key features may be self-administration, combined with rapid onset of action. The aim of this paper is to evaluate the present base of knowledge on this topic. The review is based on human studies found in Medline or in the reference list of these papers. The physiology of the nasal mucosa and some pharmaceutical aspects of nasal administration are described. The design of each study is described, but not systematically evaluated. Pharmacokinetic studies in volunteers are reported for fentanyl, alfentanil, sufentanil, butorphanol, oxycodone and buprenorphine. Mean times for achieving maximum serum concentrations vary from 5 to 50 min, while mean figures for bioavailability vary from 46 to 71%. Fentanyl, pethidine and butorphanol have been studied for postoperative pain. Mean onset times vary from 12 to 22 min and times to peak effect from 24 to 60 min. There is considerable interindividual variation in pharmacokinetics and clinical outcome. This may partly be due to lack of optimization of nasal formulations. Patient-controlled nasal analgesia is an effective alternative to intravenous PCA. Adverse effects are mainly those related to the opioids themselves, rather than to nasal administration. Some experience with nasal opioids in outpatients and for chronic pain has also been reported. Nasal administration of opioids has promising features, but is still in its infancy. Adequately designed clinical studies are needed. Improvements of nasal sprayer devices and opioid formulations may improve clinical outcome.",2002.0,0,0
719,12151917,Efficacy and safety of intravenous parecoxib sodium in relieving acute postoperative pain following gynecologic laparotomy surgery.,Scott F Barton; Fred F Langeland; Michael C Snabes; Diane LeComte; Michael E Kuss; Shobha S Dhadda; Richard C Hubbard,"This study tested the hypothesis that an injectable cyclooxygenase (COX)-2-specific inhibitor will be at least as effective and well tolerated as a COX-nonspecific conventional nonsteroidal antiinflammatory drug (NSAID) by comparing the analgesic efficacy and tolerability of one intravenous dose of parecoxib sodium, an injectable prodrug of the novel COX-2-specific inhibitor, valdecoxib, with ketorolac and placebo in postoperative laparotomy surgery patients. Intravenous morphine, 4 mg, was studied as a positive analgesic control. In this multicenter, double-blinded, placebo-controlled study, women experiencing moderate-to-severe pain on the first day after abdominal hysterectomy or myomectomy received one intravenous dose of parecoxib sodium, 20 or 40 mg, ketorolac, 30 mg, morphine, 4 mg, or placebo. Analgesic efficacy and tolerability were evaluated for 24 h postdose or until patients, whose pain was not adequately controlled, opted to receive rescue analgesia. Two hundred two patients were enrolled. All treatment groups had comparable demographics and baseline pain status. All active treatments had an equally rapid time to onset of analgesia (10-23 min). Overall, each parecoxib sodium dose and ketorolac were significantly superior to morphine and placebo for most measures of analgesic efficacy at most time points, including a significantly longer (two- to threefold) time to rescue analgesia (P </= 0.05). All treatments were well tolerated. Single intravenous doses of parecoxib sodium, 20 mg and 40 mg, have comparable analgesic effects and are well tolerated after laparotomy surgery. Parecoxib sodium appears to be as effective as intravenous ketorolac, 30 mg, and superior to intravenous morphine, 4 mg.",2002.0,0,0
720,12162598,Acute and postoperative pain in children: a Swedish nationwide survey.,M Karling; M Renström; G Ljungman,"Many studies demonstrate inadequate pain treatment in children. The aim of this nationwide survey was to evaluate the prevalence of acute and postoperative pain in children; extent of, and reasons for, inadequate pain therapy; therapy methods; pain-management structure; and the need for education of healthcare professionals. Questionnaires concerning these points were sent to all departments in Sweden involved in the treatment of children. The response rate was 75% (299/ 395). Answers from physicians and nurses showed that, despite treatment, moderate to severe pain occurred in 23% of patients with postoperative pain and 31% of patients with pain of other origin. Postoperative pain seemed to be a greater problem in units where children were treated along with adults and in departments where fewer children were treated. According to 45% of physicians and nurses, treatment of pain could often or always be managed more efficiently. Pain assessments were performed regularly in 43% of all departments, but pain measurement was less frequent; 3% of the departments had no formal organization for pain management; and 15% never or infrequently used potent opioids. Educational needs were high. Insufficient pain treatment seemed to be mostly related to organizational aspects, such as inadequate prescriptions. Anxiety in children or parents also contributed to ineffective pain treatment. Swedish treatment practices for the management of pain in children roughly follow the published guidelines, but many improvements are still necessary. Acute pain in children is still undertreated in Swedish hospitals. This seems to be related mainly to organizational aspects.",2003.0,0,0
721,12167149,"Debate: analgesic overuse is a cause, not consequence, of chronic daily headache. Analgesic overuse is not a cause of chronic daily headache.",David W Dodick,,2002.0,0,0
722,12215866,Transdermal fentanyl for the treatment of back pain caused by vertebral osteoporosis.,J D Ringe; H Faber; O Bock; S Valentine; D Felsenberg; M Pfeifer; H W Minne; S Schwalen,"Pain relief for patients with osteoporosis is important to maintain mobility and facilitate physical therapy. Transdermal fentanyl may be useful but has not been studied systematically. Patients with at least one osteoporotic vertebral fracture requiring strong opioids were enrolled and received transdermal fentanyl. Treatment history, pain, ease of physical therapy, and quality of life were recorded at baseline and after 4 weeks. Of 64 patients enrolled, 49 completed the study; 12 withdrew because of adverse events, most commonly nausea, vomiting, or dizziness. Pain at rest and on movement decreased significantly from baseline to final assessment (mean scores 7.84 and 8.55, respectively, at baseline, falling to 3.56 and 4.50 after 4 weeks). Quality of life improved significantly, and 61% of patients were satisfied with the treatment. Ability to undergo physical therapy improved significantly. Transdermal fentanyl is useful for the treatment of severe back pain caused by osteoporosis.",2003.0,1,1
723,12230351,Torsade de pointes associated with very-high-dose methadone.,Mori J Krantz; Laurent Lewkowiez; Helen Hays; Mary Ann Woodroffe; Alastair D Robertson; Philip S Mehler,"Methadone is an effective treatment for opioid dependency and chronic pain. A methadone derivative, levacetylmethadol, was withdrawn from the European market after being associated with torsade de pointes. To date, no association between methadone and this arrhythmia has been described. To evaluate a series of methadone-treated patients experiencing torsade de pointes. Retrospective case series. Methadone maintenance treatment programs in the United States and a pain management center in Canada. 17 methadone-treated patients who developed torsade de pointes. Chart review for concomitant arrhythmia risk factors and quantification of corrected QT interval (QTc). The mean daily methadone dose was 397 +/- 283 mg, and the mean QTc interval was 615 +/- 77 msec. Fourteen patients had a predisposing risk factor for arrhythmia. A cardiac defibrillator or pacemaker was placed in 14 patients; all 17 patients survived. This series raises concern that very-high-dose methadone may be associated with torsade de pointes. Given the likely expansion of methadone treatment into primary care, further investigation of these findings is warranted.",2002.0,0,0
724,12237200,Anger and pain sensitivity in chronic low back pain patients and pain-free controls: the role of endogenous opioids.,Stephen Bruehl; John W Burns; Ok Yung Chung; Pamela Ward; Benjamin Johnson,"The experience of anger (i.e. trait anger) and anger management style (i.e. anger-in, anger-out) are related to sensitivity to acute and chronic pain stimuli, although underlying mechanisms are unknown. This study tested whether anger variables are associated with impaired endogenous opioid antinociceptive activity, and whether these relationships differed between chronic pain patients and healthy normals. Forty-three chronic low back pain (LBP) sufferers and 45 pain-free normals received opioid blockade (8 mg naloxone i.v.) or placebo blockade (saline) in randomized, counterbalanced order in separate sessions. During each session, subjects participated in a 1-min finger pressure pain task followed by an ischemic forearm pain task (maximum duration 5 min), providing pain intensity ratings during and immediately following each task. As a measure of opioid antinociceptive function, drug effects were derived by subtracting placebo from blockade condition pain ratings. Multivariate general linear model analyses indicated that anger-out, but not anger-in, had significant main effects on both finger pressure drug effects (P < 0.05) and ischemic task drug effects (P < 0.05). As hypothesized, high anger-out scores were associated with an absence of opioid analgesia during the acute pain tasks; low anger-out scores were associated with effective opioid analgesia. A similar non-significant trend was noted for trait anger on finger pressure drug effects (P < 0.06). Anger-out x LBP/normal interactions were non-significant, suggesting that links between anger-out and drug effects were similar for patients and normals. Controlling for depression did not eliminate the significant relationship between anger-out and drug effects. Findings suggest that anger-in and anger-out affect pain sensitivity through different mechanisms: only the effects of anger-out may be mediated by endogenous opioid dysfunction.",2002.0,0,0
725,12239500,Massive OxyContin ingestion refractory to naloxone therapy.,Aaron B Schneir; Tyler F Vadeboncoeur; Steven R Offerman; James D Barry; Binh T Ly; Saralyn R Williams; Richard F Clark,"OxyContin (oxycodone hydrochloride controlled release) is a long-acting preparation of oxycodone that is used as an opioid analgesic to treat chronic pain conditions. We report a patient who ingested a massive quantity of OxyContin and had altered mental status, noncardiogenic pulmonary edema, and hypoventilation that proved refractory to naloxone administration. She required mechanical ventilation for 3 days before recovering completely. The severity and length of poisoning was likely related both to the quantity and formulation of the oxycodone ingested.",2002.0,0,0
726,12269850,Valdecoxib.,Douglas Ormrod; Keri Wellington; Antona J Wagstaff,"In ten large, well-controlled, randomised trials (n = 203 to 1089), valdecoxib, a selective inhibitor of cyclo-oxygenase-2, was significantly more effective than placebo in the treatment of osteoarthritis, rheumatoid arthritis and pain associated with primary dysmenorrhoea, and for postsurgical analgesia. Valdecoxib 1.25 to 10mg twice daily and valdecoxib 10mg once daily were more effective than placebo for the relief of pain in patients with osteoarthritis of the knee, and dosages above 5mg twice daily were similar in efficacy to naproxen 500mg twice daily. Similarly, valdecoxib 5 and 10 mg/day were as effective for osteoarthritis of the hip as naproxen 500mg twice daily. In patients with rheumatoid arthritis, valdecoxib 10, 20 or 40 mg/day was significantly more effective than placebo, and similar in efficacy to naproxen 500mg twice daily; there were no significant differences in efficacy between the three dosages of valdecoxib. Valdecoxib 20 or 40mg administered 1 to 3 hours before and 12, 24 and 36 hours after hip arthroplasty provided significantly better analgesia than placebo, and significantly reduced the amount of morphine taken by patients. Single doses of valdecoxib 10 to 80mg administered before foot or oral surgery provided significantly better analgesia than placebo; when administered after oral surgery, valdecoxib 20 or 40mg provided greater sustained analgesia than oxycodone 10mg/paracetamol 1000mg or rofecoxib 50mg. In contrast to three nonselective nonsteroidal anti-inflammatory drugs (NSAIDs), valdecoxib 40mg twice daily did not cause significant changes in platelet function and bleeding times. Chronic users of NSAIDs who were switched to valdecoxib 10 or 20 mg/day for 12 weeks experienced significantly fewer gastroduodenal erosions or ulcers than patients receiving ibuprofen 2400 mg/day or diclofenac 150 mg/day for 12 weeks. Valdecoxib was generally well tolerated in clinical trials, with a similar incidence of adverse events to placebo.",2002.0,0,0
727,12297763,Clinical outcomes in patients who undergo extracorporeal shock wave lithotripsy for chronic calcific pancreatitis.,Richard A Kozarek; John J Brandabur; Terrence J Ball; Michael Gluck; David J Patterson; Fouad Attia; Renee France; L William Traverso; Paul Koslowski; Robert P Gibbons,"There is controversy as to whether extracorporeal shock wave lithotripsy fragmentation and ERCP retrieval of pancreatic stones are associated with relief of chronic pain or relapsing attacks of pancreatitis. Our most recent experience with this technology is reviewed. Forty patients with chronic calcific pancreatitis who required extracorporeal shock wave lithotripsy between 1995 and 2000 to facilitate pancreatic duct stone removal were retrospectively reviewed. Data collected included patient presentation, number of lithotripsy and ERCP sessions required, complications, and outcomes measures to include pre- and post-ESWL pain scale, monthly oxycodone (5 mg)-equivalent pills ingested, yearly hospitalizations, and need for subsequent surgery. A single extracorporeal shock wave lithotripsy session was required for 35 patients who underwent a total of 86 ERCPs to achieve complete stone extraction from the main pancreatic duct. Minor complications occurred in 20%. There was one episode of pancreatic sepsis that was treated with antibiotics and removal of an occluded pancreatic prosthesis. At a mean [SD] follow-up of 2.4 (0.6) years, 80% of patients had avoided surgery and there was a statistically significant decrease in pain scores (6.9 [1.3] vs. 2.9 [1.1]; p = 0.001), yearly hospitalizations for pancreatitis (3.9 [1.9] vs. 0.9 [0.9]; p = 0.001), and oxycodone-equivalent narcotic medication ingested monthly (125 [83] vs. 81 [80]; p = 0.03). Extracorporeal shock wave lithotripsy fragmentation of pancreatic duct calculi in conjunction with endoscopic clearance of the main pancreatic duct is associated with significant improvement in clinical outcomes in most patients with chronic pancreatitis.",2002.0,0,0
728,12370455,"Opioids versus antidepressants in postherpetic neuralgia: a randomized, placebo-controlled trial.",S N Raja; J A Haythornthwaite; M Pappagallo; M R Clark; T G Travison; S Sabeen; R M Royall; M B Max,"Tricyclic antidepressants (TCA) provide less than satisfactory pain relief for postherpetic neuralgia (PHN), and the role of opioids is controversial. To compare the analgesic and cognitive effects of opioids with those of TCA and placebo in the treatment of PHN. Seventy-six patients with PHN were randomized in a double-blind, placebo-controlled, crossover trial. Each subject was scheduled to undergo three treatment periods (opioid, TCA, and placebo), approximately 8 weeks' duration each. Doses were titrated to maximal relief or intolerable side effects. The primary outcome measures were pain intensity (0 to 10 scale), pain relief (0 to 100%), and cognitive function. Analyses included patients who provided any pain ratings after having received at least a single dose of a study medication. Fifty patients completed two periods, and 44 patients completed all three. Mean daily maintenance doses were morphine 91 mg or methadone 15 mg and nortriptyline 89 mg or desipramine 63 mg. Opioids and TCA reduced pain (1.9 and 1.4) more than placebo (0.2; p < 0.001), with no appreciable effect on any cognitive measure. The trend favoring opioids over TCA fell short of significance (p = 0.06), and reduction in pain with opioids did not correlate with that following TCA. Treatment with opioids and TCA resulted in greater pain relief (38 and 32%) compared with placebo (11%; p < 0.001). More patients completing all three treatments preferred opioids (54%) than TCA (30%; p = 0.02). Opioids effectively treat PHN without impairing cognition. Opioids and TCA act via independent mechanisms and with varied individual effect.",2002.0,0,0
729,12387704,Tricyclic antidepressants and fibromyalgia: what is the mechanism of action?,Kim Lawson,"Fibromyalgia is a chronic pain disorder of which other clinical features, such as persistent fatigue and disordered sleep, may be a secondary consequence. The initial pharmacological approach to treating the disorder is the management of the pain. Tricyclic antidepressants are the most effective drugs in use so far, especially when administered in combination with other therapies (e.g., selective serotonin re-uptake inhibitors), which suggests modulation of the neurotransmitters serotonin and noradrenaline. The effectiveness of amitriptyline and related tricyclic antidepressants, however, is consistent with the involvement of mechanisms, such as potassium channel modulation and NMDA receptor antagonism, in addition to or in place of the modulation of monoamine neurotransmitters. Investigation of the importance of each of the pharmacological properties of amitriptyline and related molecules in the management of fibromyalgia could provide clues for the rational design of new drugs.",2003.0,0,0
730,12390045,The assessment and management of chronic pain in children.,C Robert Chambliss; Judith Heggen; David N Copelan; Robert Pettignano,"Chronic pain in children and adolescents is frequently misdiagnosed by caregivers. It is not treated until it results in the loss of routine ability and function. Chronic pain is often associated with underlying diseases commonly seen in childhood, including sickle cell disease, malignancy, rheumatologic disorders, inflammatory bowel disease, trauma, and states where there is no identifiable etiology. Chronic pain differs from acute pain in that it serves no useful function. Untreated or under-treated chronic pain will result in the unnecessary suffering of the patient, disruption of family routine, and cohesiveness and restriction of the child's daily activities, thereby increasing long-term disability. Accurate and repeated assessment of chronic pain is required for therapy to be effective. Assessment of chronic pain in children is difficult due to their developing cognitive abilities. The assessment of childhood pain varies with the child's age, type of pain, situation, and prior painful experiences. Assessment tools such as the Varni-Thompson Pediatric Pain Questionnaire and the Visual Analog Scale are helpful for both the patient and physician in helping to identify situations that precipitate pain, to rate the level of pain and determine if therapy has been effective. Documentation of pain assessments and the effectiveness of interventions in the medical record should be included as a routine part of all patient records. Most caregivers have extensive experience in the treatment of acute pain in children but are often not comfortable with the management of complicated and chronic pain states. The therapy for chronic pain in children is multifactorial. It can include agents from multiple classes of pharmacologic agents (nonsteroidal anti-inflammatory drugs, opioids, tricyclic antidepressants, and antineuroleptics) nonconventional therapies (acupuncture and pressure and aromatherapy), as well as herbal and homeopathic remedies.",2003.0,0,0
731,12399016,"A phase 1 study of the cholecystokinin (CCK) B antagonist L-365,260 in human subjects taking morphine for intractable non-cancer pain.",Gary J McCleane,"To investigate the safety and tolerability of L-365,260 in human subjects taking morphine for intractable pain. An open label study of nine adult subjects. Two doses of L-365,260 were administered to all subjects separated by a 4 h interval (three received 10 mg, three 30 mg and three 60 mg). Haemodynamic and respiratory variables were recorded from immediately prior to first drug administration to T + 600 min. In addition, continuous electrocardiogram (ECG) monitoring and serial 12 lead ECGs were recorded along with pain and side effect measurements. No major side effects were observed. L-365,260 was well tolerated. No abnormalities in blood pressure, heart rate, respiratory rate or ECG measurements were recorded. Minor side effects were observed. L-365,260 can be safely administered at the doses investigated to human subjects receiving morphine for intractable pain.",2003.0,0,0
732,12405366,Treatment of chronic pain by using intrathecal drug therapy compared with conventional pain therapies: a cost-effectiveness analysis.,Krishna Kumar; Gary Hunter; Denny D Demeria,"The object of this study was to compare the cost-effectiveness of intrathecal drug therapy (IDT) with that of conventional pain therapy (CPT) in patients suffering from chronic low back pain caused by failed back syndrome. In this study, the authors tabulated actual costs, in Canadian dollars, in a consecutive series of patients undergoing IDT within the Canadian health care system and have compared them with costs in a control group in the same environment. The influence of these treatments on the quality of life (QOL) was also analyzed. The authors report on a series of 67 patients suffering from failed back syndrome, 23 of whom underwent implantation of a programmable drug delivery pump and 44 of whom acted as controls. Patients were followed for a 5-year period during which the investigators tabulated the actual costs incurred for diagnostic imaging, professional fees, implantation costs including hardware, nursing visits for maintenance of the pumps, alternative therapies, and hospitalization costs for breakthrough pain. From this data, cumulative costs for each group were calculated for a 5-year period. Patient responses on the Oswestry Pain Questionnaire were analyzed to assess the impact of treatment on QOL. The actual cumulative costs for IDT during a 5-year period were $29,410, as opposed to $38,000 for CPT. High initial costs of equipment required for IDT were recovered by 28 months. After this time point, managing patients with CPT became the more expensive treatment option for the remainder of the follow-up period. The Oswestry Disability Index showed a 27% improvement for patients in the IDT group, compared with a 12% improvement in the control group. In patients who respond to this treatment, IDT is cost effective in the long term despite high initial costs of implantable devices.",2002.0,0,0
733,12406539,"Comment on: Doverty et al, Hyperalgesic responses in methadone maintenance patients (Pain 2001;90;91-6).",J David Clark,,2003.0,0,0
734,12412178,Effect of topical morphine for mucositis-associated pain following concomitant chemoradiotherapy for head and neck carcinoma.,Leandro C A Cerchietti; Alfredo H Navigante; Marcelo R Bonomi; Mariel A Zaderajko; Pablo R Menéndez; Catalina E Pogany; Berta M C Roth,"Oral mucositis is the dose-limiting toxicity for patients receiving concurrent chemoradiotherapy regimens for tumors of the head and neck area. Currently, the management of established mucositis includes the use of topical anesthetics and systemic analgesics. Based on the clinical evidence of pain alleviation by topical morphine in patients with some inflammatory and painful conditions, a clinical study was undertaken to determine this effect on mucositis-associated pain. Twenty-six patients with head and neck malignancies treated with concomitant chemoradiotherapy for head and neck carcinoma who had severe painful mucositis (World Health Organization Grade 2 or higher) were enrolled. Patients were randomly assigned to morphine mouthwash (MO; 14 patients) or magic mouthwash (MG), a mixture of equal parts of lidocaine, diphenhydramine, and magnesium aluminum hydroxide (12 patients). The duration of severe pain was 3.5 days less in the MO group compared with the MG group (P = 0.032). The intensity of oral pain was also significantly lower in the MO group compared with the MG group (P = 0.038). No patient in the MO group required third-step opiates for alleviation of the mouth pain. There was a significant difference in duration of severe functional impairment (P = 0.017). Five patients in the MG group complained of local side effects and only one in the MO group (P = 0.007). For patients with head and neck carcinomas receiving concomitant chemoradiotherapy, MO is a simple and effective treatment to decrease the severity and duration of pain and the duration of functional impairment.",2003.0,0,0
735,12421793,Hitting them where it hurts? Low dose nalbuphine therapy.,M Woollard; T Jones; K Pitt; N Vetter,"To determine if low dose nalbuphine provides an adequate reduction in pain with minimal side effects. Prospective cohort of 115 patients given nalbuphine by paramedics in Wales and the English borders. (1) Mean total dose of nalbuphine administered, change in pain score, time to adequate pain relief (score below four), and change in respiratory rate and systolic blood pressure; (2) proportion of patients continuing to suffer moderate to severe pain on arrival at hospital; (3) incidence of adverse events. Full data were obtained for all patients. The mean total dose of nalbuphine administered was 6.09 mg (range 2.5 to 12.5 mg). This was significantly higher in trauma than ischaemic chest pain patients (7.03 versus 5.13 mg). The mean reduction in pain score was -3.97 (95% CI -4.38 to -3.57, p<0.001). The mean time to adequate pain relief (where this was achieved) was 15.7 minutes (95% CI 13.4 to 17.9 minutes). On arrival at hospital 60% of patients (n=69, 95% CI 50.9 to 68.5%) still met ambulance criteria for analgesia (70.7% of trauma patients and 49.1% with ischaemic chest pain). Systolic blood pressure fell by a mean of -3.67 (95% CI -6.76 to -0.58, p=0.02) and respiratory rate increased by a mean of 1.63 (95% CI 1.08 to 2.17, p<0.001). Two patients complained of nausea (1.74%, 95% CI 0.5 to 6.0%). No other adverse events were reported. Low dose nalbuphine results in few adverse events, but offers poor pain control for a high proportion of patients.",2003.0,0,0
736,12422998,Pharmacogenomics as molecular autopsy for postmortem forensic toxicology: genotyping cytochrome P450 2D6 for oxycodone cases.,Paul J Jannetto; Steven H Wong; Susan B Gock; Elvan Laleli-Sahin; B Charles Schur; Jeffrey M Jentzen,"Pharmacogenomics, the study of the impact of heritable traits on pharmacology and toxicology, may serve as an adjunct for certifying opioid fatalities. Oxycodone, frequently prescribed for the relief of moderate to severe pain, is metabolized by cytochrome P450 (CYP) 2D6, encoded by a polymorphic gene with three mutations (*3, *4, and *5) with a combined 95% allelic frequency and about 10% prevalence. Individuals with variant alleles are more susceptible to oxycodone toxicity. By assessing the prevalence of CYP2D6 polymorphisms and covariables, we hypothesized that oxycodone fatality may be partially due to poor drug metabolism caused by CYP2D6 variant alleles. From the Milwaukee County Medical Examiner's Office (MCMEO), a retrospective analysis of 15 oxycodone cases was followed by genotyping blood samples for the variant alleles by conventional and real-time PCRs. Institutional Review Board approval was obtained. Oxycodone, extracted from blood and/or urine, was quantitated by GC-MS. The results show two homozygous for 2D6*4 and four heterozygous for 2D6*4. The MCMEO was not significantly different from those in the control group (n = 26) (p > 0.05, Fisher's Exact Test). However, genotyping CYP2D6 provided a more definitive interpretation of the oxycodone toxicity in four cases. Therefore, pharmacogenomics may serve as an adjunct in the determination of the cause and manner of death in forensic toxicology and a pharmacogenomic algorithm for genotyping has been proposed.",2003.0,0,0
737,12434263,[Consultation or liaison psychotherapy service--what difference does it make for an outpatient pain clinic?].,V Köllner; O Oster; H Gress; F Macher-Hanselmann; B Larsen,"Even if the effectiveness of psychotherapy emphasising a cognitive behavioral approach is clearly shown by randomised controlled trials, it is difficult to motivate chronic pain patients to use this type of treatment. We compared the effectiveness of consultation and liaison models of co-operation between an outpatient pain clinic and a psychosomatic department in creating motivation to psychotherapy. In a retrospective design we collected data of all patients seen in the pain clinic during two periods of 6 months before ( N=165) and after ( N=277) changing from a consultation to a liaison model. Clinical data were documented by the MASK system (Hildebrandt u. Pfingsten 1993). Depression was screened using a depression scale (vgl. Zerssen 1973), somatic complaints by listing of complaints (vgl. Zerssen u. Koeller 1976) and two short screening questionnaires. In the liaison model diagnostic sessions with the consulting psychotherapist were significantly more often recommended by physicians from anaesthesia departments (25.6% vs 13.9%; p<0.01) and accepted by patients (63.3 vs 30.4%; p<0.01). In both systems 80% of the patients accepted the suggested psychotherapy. After changing to the liaison type of co-operation, there was a significant decrease in the prescription of opioid and benzodiazepine drugs. The liaison model of co-operation was significantly more effective to enhance physician's and patient's motivation for a psychosomatic approach to pain treatment. Psychotherapy is better accepted by patients suffering from chronic pain if it is offered in a multidisciplinary context and in the familiar surroundings of the pain clinic.",2003.0,0,0
738,12434605,Long-term opioid treatment: the role of pain facilitatory system.,Chih-Shung Wong,,2002.0,0,0
739,12434612,Long-term opioid treatment in Behçet's syndrome with intractable abdominal pain--a case report.,Hsiang-Chien Tseng; Yeong-Ray Wen; Jui-Yuan Chen; Chia-Ling Lee; Gong-Jhe Wu; Yi Chang; Shan-Chung Swei,"Opioids are the most potent and effective analgesics available for treating acute and chronic cancer pain, but its usefulness in treating non-cancer chronic pain is still controversial. We report a 23-year-old male suffering from Behçet's disease with persistent excruciating abdominal pain. Oral non-steroid anti-inflammation analgesics and milder opioids (codeine and tramadol) failed to relieve the pain. His excruciating abdominal pain resulting from ulcerative viscera aggravated with repeated gastrointestinal tract surgeries. Intravenous morphine given through patient-controlled analgesia (PCA) could effectively reduce his pain with minimal side effects. No sign of physical or psychological dependence was observed during the period of opiate administration, and no withdrawal phenomenon was found as the dosage was tapered. During the total treatment course of 213 days, the daily dose of morphine once surged up to 259.2 mg. The long-term opioid treatment and its possible effects are, herein, discussed.",2002.0,0,0
740,12435995,"Behavioral and cognitive-behavioral treatment for chronic pain: outcome, predictors of outcome, and treatment process.",Lance M McCracken; Dennis C Turk,"A literature review was conducted. To examine the outcome of behavioral (BT) and cognitive-behavioral treatment (CBT), collectively referred to as BT-CBT, for chronic pain, to identify the predictors of treatment outcome, and to investigate the change processes associated with these treatments. Numerous controlled clinical trials of BT-CBT for chronic pain, alone or more commonly in multidisciplinary treatment contexts, suggest that these treatments are effective. However, further study is needed to examine which outcome variables change, when, for whom, and how. Published literature was gathered from Medline, PsychLit, and searches of relevant journals. Overall, BT-CBT for chronic pain reduces patients' pain, distress, and pain behavior, and improves their daily functioning. Differences across studies in sample characteristics, treatment features, and assessment methods seem to produce varied treatment results. Also, some patients benefit more than others. Highly distressed patients who see their pain as an uncontrollable and highly negative life event derive less benefit than other patients. Decreased negative emotional responses to pain, decreased perceptions of disability, and increased orientation toward self-management during the course of treatment predict favorable treatment outcome. Current BT-CBT helps many patients with chronic pain. Continuing clinical research should improve the matching of treatments with patient characteristics and refine the focus of treatments on behavior changes most associated with positive outcome. Further study of fear, attention, readiness to adopt self-management strategies, acceptance of pain, and new combinations of interdisciplinary treatments may lead to improved interventions.",2003.0,0,0
741,12435997,Spinal cord stimulation for chronic pain of spinal origin: a valuable long-term solution.,Richard B North; F Todd Wetzel,"A literature review was conducted. To review the indications and efficacy of spinal cord stimulation, particularly in reference to chronic pain of spinal origin. The first spinal cord stimulation was implanted by Shealy in 1967 via a subarachnoid route. Early systems were plagued with a high rate of complications and technical problems. With the evolving technology, especially the advent of multichannel programmable systems and more precise epidural placement, the ability of spinal cord stimulation to treat various pain syndromes improved. This article reviews the literature on spinal cord stimulation from 1967 to the present. The literature is reviewed, with a particular focus on recent studies investigating the efficacy of spinal cord stimulation for low back pain. Most studies are limited by the same flaws, namely, retrospective study design. At this writing, the few published randomized prospective studies have suggested that spinal cord stimulation may be superior to repeat surgery. Complication rates have declined to approximately 8%, and reoperation is necessary in approximately 4% of patients. When current percutaneous techniques are used, a lead migration rate lower than 3% may be achieved. For certain topographies, laminotomy leads may be superior, particularly with regard to low back pain. The ultimate efficacy of spinal cord stimulation remains to be determined, primarily because of limitations associated with the published literature. However, on the basis of the current evidence, it may represent a valuable treatment option, particularly for patients with chronic pain of predominantly neuropathic origin and topographical distribution involving the extremities. The potential treatment of other pain topographies and etiologies by spinal cord stimulation continues to be studied.",2003.0,0,0
742,12435999,Neuraxial medication delivery: the development and maturity of a concept for treating chronic pain of spinal origin.,Joshua P Prager,"A literature review and synthesis were performed. To summarize the history, use, and innovation related to neuraxial drug delivery for the treatment of intractable back pain. The discovery of opioid receptors in the early 1970s provided a rational basis for the delivery of opioid drugs intraspinally. Epidural or intrathecal infusions deliver drugs directly to opioid receptors, limit systemic exposure, and by decreasing the opioid dosage required for pain relief, generally reduce side effects. The benefits of short-term spinal analgesia led to investigation of longer-term continuous subarachnoid opioid infusions for the management of both cancer pain and noncancer pain, such as that of spinal origin.  Unique features of this article include an updated pain continuum, updated indications for intrathecal therapy, a detailed comparison of trial techniques, a detailed comparison of the advantages of different types of pumps, a synopsis of troubleshooting for inadequate efficacy, and an updated statement regarding intrathecal pumps and radiologic procedures, including MRI scanning. Some challenges remain. Large-scale well-controlled studies could answer some perplexing questions regarding efficacy in patients with noncancer or neuropathic pain. Patient selection criteria undoubtedly will be refined and validated as more patients are treated. In addition, further investigation of specifically targeted medications or drug combinations for intraspinal use could increase efficacy, reduce side effects, and expand indications. Intraspinal medication delivery has become an effective technique for control of intractable pain in appropriately selected patients seen by spine surgeons.",2003.0,0,0
743,12436003,Chronic pain of spinal origin: the costs of intervention.,Barry N Straus,"The cost of chronic benign spinal pain is large and growing. The costs of interventional treatment for spinal pain were at a minimum of $13 billion (U.S. dollars) in 1990, and the costs are growing at least 7% per year. Medical treatment of chronic pain costs $9000 to $19,000 per person per year. The costs of interventional therapy is calculated. Methods of evaluating differential treatments in terms of costs are described. Cost-minimization versus cost-effectiveness approaches are described. Spinal cord stimulation and intraspinal drug infusion systems are alternatives that can be justified on a cost basis. Cost minimization analysis suggests that epidural injections under fluoroscopy may not be justified by the current literature.",2003.0,0,0
744,12444233,,,,,0,0
745,12470171,Pain management: a call for papers.,Catherine D DeAngelis,,2003.0,0,0
746,12476511,Management of cancer-related and noncancer-related chronic pain in Connecticut: successes and failures.,Anita J Tarzian; Stephen M Davidson; Diane E Hoffmann,"Findings are reported from a survey of Connecticut HMO patients who had one of three conditions associated with pain: cancer, arthritis, and neuropathic diagnoses. From each group, 145 patients were randomly selected to receive a mailed survey. The overall eligible response rate was 73%. About two thirds had experienced pain for over a year, and the same percentage was experiencing pain at the time of the survey. Seventy-three percent of respondents with cancer pain (RCs) rated their pain in the moderate range, compared to 37.5% of respondents with arthritis pain (RAs) and neuropathic pain (RNPs). More RAs and RNPs (41.5%) rated their pain in the severe range. Twenty-three percent of both RCs and RAs and 31% of RNPs had received no effective treatment for their pain. The percentage of respondents using prescription narcotics at the time of the survey was low (16%), and had dropped by almost half from the proportion using them in the past (29%). Side effects of pain medications and attitudes toward opioids were implicated as reasons for discontinuing pain medications. Respondents described substantial negative impact of pain on their abilities to perform various activities, but this had improved from the time when they first experienced their pain. Overall, the findings indicate that improvements have been made in the treatment of pain, particularly for patients with cancer pain. There is still room for improvement, particularly for individuals with chronic neuropathic pain. Specific recommendations are discussed.",2002.0,0,0
747,12476746,[Treatment of pain with opioid analgesics and the role of TTS-fentanyl (Durogesic)].,M Persoli-Gudelj,"Current opinions in chronic pain treatment with opioid analgesics are presented in this review. Justified use of opioid analgesics in treatment of chronic non-malignant pain in inflammatory and degenerative processes is emphasised. Advantages of opioid analgesics compared with non-opiod analgesics are stressed. New form of opioid--a patch, Durogesic TTS, recently registered in Croatia, is described. After brief review of pharmacodynamics and pharmacokinetics of Durogesic, authors experiences in both chronic malignant pain and chronic non-malignant pain treatment with this analgesic are described. Trial was performed in Pain clinic of Karlovac General Hospital as a part of international multicentric clinical trial. Regarding efficacy, compared to the previous therapy, TTS fentanyl was evaluated positively by patients, both in pain control and ease of use, and by the author, for around the clock, non-invasive administration. Slow dose adjustment in rapid illness progression was recognised as disadvantage.",2003.0,0,0
748,12476759,[Treatment of chronic pain--use of transdermal fentanyl (Durogesic TTS)].,Durdica Babić-Naglić; Zrinka Jajić; Zoja Gnjidić; Biserka Stambuk,"Incorrect treatment of chronic pain is common cause of patient's discontentment and suffering. The problem is mostly occurring because of inappropriate pain treatment. The WHO guidelines recommends declining of prejudices and using of strong opioids in therapy after the unsatisfactory treatment with weaker analgesics. Strong opioid analgesic fentanyl in transdermal system (Durogesic TTS) is introduced. In rheumatology, it is recommended for all conditions characterised by chronic pain with intensity 4 and more on the VAS scale (0-10). It is mostly used in rheumatoid arthritis, osteoarthritis, low back pain and neuropathic pain. Durogesic TTS provides continuous pain relief for 72 hours, with constant serum concentrations. It has to be gradually titrated and starting dose is 25 micrograms/h. Possible adverse events (nausea, vomiting, constipation, sedation, itching) are short termed, transitory and easily managed. Results of some clinical trials and personal experiences that are proving its efficacy and safety are presented.",2003.0,0,0
749,12481194,"Dihydroetorphine: a potent analgesic: pharmacology, toxicology, pharmacokinetics, and clinical effects.",Satoshi Ohmori; Yasunori Morimoto,"Dihydroetorphine (DHE) is one of the strongest analgesic opioid alkaloids known; it is 1000 to 12000 times more potent than morphine. Several in vitro and in vivo studies have shown that DHE is a selective mu-opioid receptor (OP(3)) agonist that also binds and activates all human recombinant mu-, delta-, and kappa-opioid receptors (OP(3), OP(1), and OP(2)). The onset of the analgesic effect of DHE in rodents is rapid, 5 to 15 min after parenteral administration; the duration of action is short, the analgesic effect disappears within 120 min after administration. By oral administration much higher doses of DHE are required to produce analgesic effects. These characteristics are accounted for by the pharmacokinetic properties of DHE in the rat, namely, by rapid distribution of DHE from the injection site to the brain and rapid metabolism by glucuronidation in the gut and liver followed by elimination into the bile. Continuous infusion and repeated administration of DHE lead to the development of tolerance to analgesia, physical dependence, and a rewarding effect in normal rats but not in animals with formalin-induced inflammation. Although formalin-induced inflammation is only one type of pain stimulus, these findings suggest that DHE addiction would be observed only in the case of pain-free conditions. Clinical reports in China show that sublingual doses of DHE, 20 to 180 microg, produce a potent analgesic effect with only mild side effects, including dizziness, somnolence, nausea, vomiting, constipation, and shortness of breath. To improve the short-lasting effect following sublingual administration, transdermal delivery of DHE via a patch has been investigated. The patch formulation of DHE produces continuous analgesic effect with minimal physical dependence and rewarding effect in rats suffering from chronic pain. This patch formulation, which is very suitable for DHE, may be viable for the treatment of severe pain and is likely to improve patients' quality of life.",2003.0,0,0
750,12481467,[Efficacy and safety of acetaminophen-codeine in the treatment of pain].,Ph Hantson,"The treatment of acute or chronic pain of variable intensity and origin, is efficiently achieved by the association of paracetamol and codeine. At a dose of 1000 mg paracetamol and 60 mg of codeine, this association is considered one of the most efficient as compared to other analgesics of level II in the OMS classification, like tramadol.",2003.0,0,0
751,12487620,Responsible prescribing of opioids for the management of chronic pain.,Bruce Nicholson,"The management of patients with chronic pain is a common clinical challenge. Indeed, chronic pain is often inadequately controlled in patients with cancer and in those with non-cancer chronic pain. Because of the complex nature of chronic pain, successful long-term treatment is more difficult than for acute pain. Most often acute pain is nociceptive, whereas chronic pain can be nociceptive (i.e., in response to noxious stimuli), neuropathic (i.e., initiated by a primary lesion or dysfunction in the nervous system) or mixed in origin. Opioids are the current standard of care for the treatment of moderate or severe nociceptive pain. Opioids mediate their actions by binding and activating receptors both in the peripheral nervous system and those that are found in inhibitory pain circuits that descend from the midbrain to the spinal cord dorsal horn. Opioid agonists exert a number of physiological responses including analgesia, which increases with increasing doses. The use of opioids to manage pain in patients with cancer is well accepted. The WHO step-wise algorithm for analgesic therapy based on pain severity reserves the use of opioid therapy for moderate and severe pain. The WHO algorithm has proven to be highly effective for the management of cancer pain. However, the use of opioids to treat patients with chronic non-cancer pain is controversial because of concerns about efficacy and safety, and the possibility of addiction or abuse. The results of clinical surveys and retrospective case series involving patients with non-cancer chronic pain have been inconsistent in regard to resolving these controversial issues. The oral route of drug administration is most appropriate for patients receiving opioids; although rectal, transdermal and parenteral routes of administration are used in specific situations. For continuous chronic pain, opioids should be administered around-the-clock and several long-acting formulations are available that require administration only once or twice daily. Opioid doses should be titrated according to agent-specific schedules to maximise pain relief and maintain tolerability. Adverse effects include constipation, nausea and vomiting, sedation, cognitive impairment and respiratory depression. Tolerance to the analgesic and adverse effects as well as physical dependence, which causes withdrawal symptoms upon discontinuance, may occur with opioid use. Estimates of addiction rates among patients with chronic non-cancer pain range from 3.2 to 18.9%. Successful pain treatment and symptom management is an attainable goal for the majority of patients with chronic pain. Further controlled clinical trials are needed to define the role of opioid therapy in chronic non-cancer pain, and to establish criteria for patient selection and specific treatment algorithms.",2003.0,0,0
752,12488379,Comparison between patient-controlled analgesia and subcutaneous morphine in elderly patients after total hip replacement.,H Keïta; N Geachan; S Dahmani; E Couderc; C Armand; M Quazza; J Mantz; J M Desmonts,"The goal of this study was to evaluate the effectiveness on postoperative pain, and cognitive impact, of patient-controlled analgesia (PCA) compared with subcutaneous (s.c.) injections of morphine in elderly patients undergoing total hip replacement (THR). Forty patients older than 70 yr were randomly assigned to two different postoperative analgesic techniques for 48 h: i.v. PCA morphine (dose, 1 mg; lockout interval, 8 min; PCA group) or regular s.c. morphine injections (SC group). Postoperative pain was assessed at rest and when moving, using a visual analogue scale (VAS) every 4 h. A Mini Mental Status (MMS) examination was used to assess cognitive functions before surgery, at 2 h, 24 h and 48 h after surgery, and at hospital discharge. Side-effects were also recorded systematically during the first 48 h after surgery. The PCA group showed significantly lower pain scores than the SC group both at rest and during mobilization. However, the clinical significance of pain scores was weak. There was no intergroup difference in postoperative MMS scores. The incidence of side-effects was similar in both groups. We conclude that in healthy elderly subjects undergoing THR, the flexibility of the analgesic regimen is more important than the route of administration with regard to efficacy, adverse effects and recovery of cognitive function.",2003.0,0,0
753,12491562,The Holy Grail: long-acting local anaesthetics and liposomes.,Stuart A Grant,"The ability to provide an extended duration of analgesia of days following a single injection without the need for catheters, pumps and infusion systems would be a great benefit in acute and chronic pain. Exciting progress is being made in our ability to combine local anaesthetics with liposomes and polymer microspheres. These interesting formulations in animal models have allowed up to 4 days of analgesia. Their use clinically will be a great advance which could possibly occur in the near future.",2003.0,0,0
754,12492792,"Comparison of epidural, continuous femoral block and intraarticular analgesia after anterior cruciate ligament reconstruction.",M Dauri; M Polzoni; E Fabbi; T Sidiropoulou; S Servetti; F Coniglione; P Mariani; A F Sabato,"The purpose of this study was to compare three locoregional techniques of pain management after arthroscopic anterior cruciate ligament reconstruction (ACLR). Sixty ASA I-II subjects were enrolled after obtaining written informed consent. Patients were randomly allocated to three groups of 20 subjects. The first group (EPI) received epidural ropivacaine 0.2% plus sufentanil 0.2 micro g ml-1, at 5 ml h-1. Patients in the second group (CFB) were given a continuous infusion of the same analgesic mixture through a femoral catheter. The third group (IA) received a continuous intraarticular infusion of ropivacaine 0.2% plus sufentanil 0.2 micro g ml-1, at 5 ml h-1. All subjects were allowed PCA boluses of 5 ml of local anesthetic. Analgesia was assessed for 36 h after the end of surgery by means of a visual analog scale (VAS) and a verbal scale (VS), as well as the number of PCA boluses administered and the amount of supplementary i.v. ketorolac, if given. The VAS and VS scores were significantly higher in group IA during the 24 h following surgery. Ketorolac requirement was higher in group IA throughout the postoperative observation. Adverse effects were similar in all groups except for urinary retention, which was significantly more frequent in group EPI. We conclude that either epidural or continuous femoral nerve block provide adequate pain relief in patients who undergo ACLR, whereas intraarticular analgesia seems unable to cope satisfactorily with the analgesic requirements of this surgical procedure.",2003.0,0,0
755,12492794,Comparison of the catheter-technique psoas compartment block and the epidural block for analgesia in partial hip replacement surgery.,G Türker; N Uçkunkaya; B Yavaşçaoğlu; A Yilmazlar; S Ozçelik,"The aim of this study was to compare the intra- and postoperative analgesia provided by the catheter-technique psoas compartment block and the epidural block in hip-fractured patients. We also compared hemodynamic stability, motor blockade, ease of performing the technique, and complications. Thirty patients who underwent partial hip replacement surgery were included in this prospective single-blind study. Subjects were randomly assigned to Group E (n=15; general anesthesia plus epidural block with 15 ml of 0.5% bupivacaine) or Group P (n=15; general anesthesia plus psoas compartment block with 30 ml of 0.5% bupivacaine). Hemodynamic parameters were recorded at 10-min intervals intraoperatively. Regional anesthesia procedure time, number of attempts at block, intraoperative blood loss, and need for supplemental fentanyl and/or ephedrine were noted. Postoperatively, a patient-controlled analgesia device delivered an infusion and boluses of bupivacaine/fentanyl. Pain, motor blockade, ambulation time, patient satisfaction with analgesia, and complications were recorded postsurgery. The epidural required significantly more attempts than the psoas block, thus procedure time was longer in this group. Group E also showed significantly greater drops in mean arterial blood pressure from baseline at 30, 40 and 50 min after the start of general anesthesia. Significantly more Group E patients required epinephrine supplementation. The groups were similar regarding pain scores (at rest and on movement) and patient satisfaction, but Group E had higher motor blockade scores, longer ambulation time, and significantly more complications. The continuous psoas compartment block provides excellent intraoperative and postoperative analgesia with a low incidence of complications for partial hip replacement surgery",2003.0,0,0
756,12495966,The use of regional anaesthetic blockade in a child with recurrent erythromelalgia.,C M Harrison; J M Goddard; C D Rittey,"Primary erythromelalgia is a rare condition, which is characterised by redness, burning pain, and increased temperature of the extremities. We describe a 6 year old boy with symptoms of erythromelalgia and the difficulty surrounding treatment of this condition. Severe pain responded to the use of regional anaesthetic blocks.",2003.0,0,0
757,12502992,Preoperative cardiac events in elderly patients with hip fracture randomized to epidural or conventional analgesia.,Idit Matot; Arieh Oppenheim-Eden; Ruand Ratrot; Julia Baranova; Elyad Davidson; Sharon Eylon; Amos Peyser; Meir Liebergall,"Perioperative myocardial ischemia occurs in 35% of unselected elderly patients undergoing hip fracture surgery. Perioperative epidural analgesia may reduce the incidence of adverse cardiac events. The effect of early administration of epidural analgesia during the stressful period, on cardiac events was evaluated in a prospective randomized study in 68 patients with hip fractures who either had known coronary artery disease or were at high risk for coronary artery disease. On admission to the emergency room, patients were assigned to receive a usual care analgesic regimen (intramuscular meperidine, control group, n = 34) or continuous epidural infusion of local anesthetic and opioid (epidural group, n = 34). Monitoring in the preoperative period included a preoperative history and physical examination, daily assessment of cardiac adverse events, serial electrocardiograms, cardiac enzymes, and pain scores. Preoperative adverse cardiac events were significantly more prevalent in the control group compared with the epidural group (7 of 34 0 of 34; = 0.01). Adverse cardiac events included fatal myocardial infarction in three, fatal congestive heart failure in one, nonfatal congestive heart failure in one, and new onset atrial fibrillation in two. The incidence of intraoperative and postoperative adverse cardiac events was similar for the two groups. The significant difference between groups in the incidence of preoperative cardiac events prompted interruption of the study after the planned interim analysis. The authors' data indicate that compared with conventional analgesia, early administration of continuous epidural analgesia is associated with a lower incidence of preoperative adverse cardiac events in elderly patients with hip fracture who have or are at risk for coronary artery disease. Preoperative epidural analgesia may be advantageous for this surgical population.",2003.0,0,0
758,12507703,Analgesia from a peripherally active kappa-opioid receptor agonist in patients with chronic pancreatitis.,James C Eisenach; Randall Carpenter; Regina Curry,"Preclinical studies suggest that visceral afferents constitutively express kappa-opioid receptors (KORs) and that noxious visceral stimuli can be inhibited at a peripheral site by KOR activation. To test the relevance of these observations to humans, we infused, in a randomized, double blind manner, a peripherally selective KOR agonist (ADL 10-0101) or placebo into six patients with chronic pancreatitis and ongoing abdominal pain despite mu-opioid agonist therapy. Pain was assessed using a pain magnitude estimate, an open ended scale of each patient's choosing and compared to their rating of pain from a 1.6 cm(2) thermode applied to the skin and heated to 49 degrees C for 5s. Normalizing pain scores to this rating as 100, pain prior to study drug treatment was 4070, and was unaffected by placebo infusion in the two individuals receiving this therapy. In contrast, ADL 10-0101 infusion reduced pain score from 63+/-7.6 (mean+/-SE) prior to infusion to 23+/-15 4h after infusion (P<0.05 vs. baseline). One patient receiving placebo and one receiving ADL 10-0101 experienced a mild headache during the study. One patient receiving ADL 10-0101 experienced restlessness and another had assymptomatic transient dysrhythmia upon standing after the 4h study. Neither of the treatments affected blood pressure, heart rate, respiratory rate, or oxyhemoglobin saturation, and no patient experienced nausea during the study. These limited data support the hypothesis that human visceral afferents express KOR and that peripherally restricted KOR agonists produce analgesia in patients with chronic visceral pain.",2003.0,0,0
759,12507707,Characterization of the analgesic actions of adenosine: comparison of adenosine and remifentanil infusions in patients undergoing major surgical procedures.,Atsuo F Fukunaga; George E Alexander; Charles W Stark,"Perioperative pain is still a major problem, and new pharmacological means should be explored to mitigate such pain. Adenosine is an ubiquitous endogenous substance; when exogenously administered, it provides a number of salutary effects including neuromodulation, antinociception, and cytoprotective actions. The aim of this study was to characterize the perioperative antinociceptive-analgesic effects of intraoperative adenosine infusion and determine the duration of actions in the postoperative period, and compare them to those of remifentanil in patients undergoing major surgical procedures in a double-blind study.Sixty-two patients were randomly assigned to one of the two treatments. After standard induction of anesthesia, the lungs were mechanically ventilated. Anesthesia was maintained with a constant alveolar concentration of inhaled anesthetics (3% desflurane and 65% nitrous oxide in oxygen). A variable-rate of intravenous infusion of adenosine (50-500 microg kg(-1) x min(-1)) or remifentanil (0.05-0.5 microg kg(-1) x min(-1)) was initiated 5 min before the skin incision and was titrated to maintain systolic blood pressure and heart rate within 20% of baseline values during surgery. Postoperative evaluations included the level of sedation, degree of pain severity, opioid analgesic (fentanyl, morphine) consumption, and cardiorespiratory variables for 48 h. Intraoperative inhibition of the cardiovascular responses to surgical stimulation could be equally achieved by adenosine or remifentanil, and both could maintain excellent hemodynamic stability. Postoperatively, however, there were striking differences: (1). initial pain score was reduced by 60% (P<0.001) in the adenosine group compared to the remifentanil group and it remained lower throughout the 48 h recovery period; (2). postoperative morphine requirements during the first 0.25, 2 and 48 h were consistently lower in the adenosine group as compared to the remifentanil group (78, 71 and 42%, P<0.001, respectively); (3). adenosine patients remained significantly less sedated at all evaluations; (4) the end-tidal and arterial carbon dioxide values in the remifentanil group were significantly higher when patients were admitted to the postanesthesia care unit. No adverse effect of adenosine was observed at any time. Intraoperative adenosine infusion provided a salutary recovery from anesthesia associated with a pronounced and sustained postoperative pain relief. Compared to remifentanil, adenosine significantly reduced the opioid requirements and minimized the side effects including protracted sedation, cardiorespiratory instability, nausea, and vomiting in the postoperative recovery period.",2003.0,0,0
760,12507714,"Immediate- or sustained-release morphine for dose finding during start of morphine to cancer patients: a randomized, double-blind trial.",P Klepstad; Stein Kaasa; Ase Jystad; Bjørn Hval; Petter C Borchgrevink,"A titration procedure using immediate-release morphine given 4-hourly is recommended during start of oral morphine for cancer pain. This recommendation is not based on evidence from controlled studies, and many physicians start morphine treatment with controlled-release morphine. We included 40 patients with malignant disease and pain despite treatment with opioids for mild to moderate pain in a randomized, double-blind, double-dummy, parallel-group study comparing titration with immediate-release morphine given 4-hourly with titration with sustained-release morphine given once daily. The primary end point was the time needed to achieve adequate pain relief Secondary end points were other symptoms (nausea, tiredness, lack of sleep, vertigo, appetite and constipation), health related quality of life and patient satisfaction. The mean times needed for titration were 2.1 (95% CI; 1.4-2.7) days using immediate-release morphine and 1.7 (95% CI; 1.1-2.3) days using sustained-release morphine. Patients titrated with immediate-release reported statistically significant more tiredness at the end of titration. We observed no other differences in adverse effects or health related quality of life functions between the two treatments. Similar global satisfactions with the morphine treatments were reported. In conclusion, a simplified titration using sustained-release morphine once daily is equally effective as immediate-release morphine given 4-hourly.",2003.0,0,0
761,12509611,Is thiopurine methyltransferase genetic polymorphism a major factor for withdrawal of azathioprine in rheumatoid arthritis patients?,H Corominas; M Domènech; A Laíz; I Gich; C Geli; C Díaz; F de Cuevillas; M Moreno; G Vázquez; M Baiget,"To determine whether the presence of thiopurine methyltransferase (TPMT) alleles associated with reduced or absent activity of thiopurine methyltransferase is a major factor for withdrawal of azathioprine (AZA) in rheumatoid arthritis (RA) patients. The TPMT genotype, including the variable number of tandem repeats (VNTR) pattern in the 5' untranslated region, was analysed in 111 patients with long-standing RA. Azathioprine (AZA) therapy was used in 40 patients (36%) as a disease-modifying anti-rheumatic drug. Seven out of 111 RA patients (6.3%) were carriers of a mutant allele, TPMT3A (G(460)-->A, A(719)-->G) being the mutant allele observed most frequently. In the group of 40 AZA-treated patients, therapy was discontinued in six patients because of side-effects and in 26 patients because of lack of efficacy. Three patients presented moderate side-effects and were homozygous for the wild-type TPMT allele, whereas the remaining three patients, who developed gastrointestinal effects with severe nausea and vomiting, were TPMT3A carriers. In this observational study, the absence of response, probably due to the low-dose scheme used, was the major cause of AZA withdrawal in our series of RA patients. TPMT genotyping may allow the use of high doses of AZA in patients with normal TPMT alleles to improve the efficacy of this immunosuppressive drug. Our data support the relationship between gastrointestinal intolerance and thiopurine metabolic imbalance.",2003.0,0,0
762,12514150,Tramadol 2.5 mg x kg(-1) appears to be the optimal intraoperative loading dose before patient-controlled analgesia.,Wei-Wu Pang; Hurng-Sheng Wu; Chien-Chiung Tung,"We previously established that a 5 mg x kg(-1) intraoperative dose can reduce the nausea/vomiting associated with tramadol patient-controlled analgesia (PCA). This study was conducted to identify the most appropriate initial dose to improve the quality of tramadol PCA. During general anesthesia, 60 patients undergoing knee arthroplasty were randomly allocated to receive 1.25 mg x kg(-1) (Group I), 2.5 mg x kg(-1) (Group II), 3.75 mg x kg(-1) (Group III), or 5 mg x kg(-1) (Group IV) tramadol. The emergence condition was recorded. The titration of additional tramadol 20 mg + metoclopramide 1 mg doses by PCA every five minutes was performed in the postanesthesia care unit (PACU) until the visual analogue scale (VAS) score was < or = 3. An investigator blinded to study group recorded the VAS and side effects every ten minutes. In the PACU, significantly more tramadol (8.4 +/- 3.1 vs 4.3 +/- 2.1, 2.5 +/- 1.8, and 0.4 +/- 0.3, P < 0.05), and a higher incidence (15/15 vs 5/15, 3/15, and 2/15, P < 0.05) of PCA use was observed in Group I compared to Groups II-IV. VAS was significantly higher in Group I than in Groups II-IV at zero and ten minutes (P < 0.05). Unexpected delayed emergence anesthesia (> 30 min) was observed in Group III (n = 1) and in Group IV (n = 2). Sedation was more important in Groups III and IV than in Groups I and II (P < 0.05). When considering efficacy and side-effect profile, 2.5 mg x kg(-1) of tramadol is the optimal intraoperative dose of this drug to provide effective postoperative analgesia with minimal sedation.",2003.0,0,0
763,12514457,Differential analgesic effect of tenoxicam on the wound pain and uterine cramping pain after cesarean section.,Hsing-Wen Hsu; Ya-Jung Cheng; Li-Kuei Chen; Yong-Ping Wang; Chen-Jung Lin; Chien-Nan Lee; Wei-Zen Sun,"Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely used to enhance opioid analgesia in the acute pain service. The question, however, of whether NSAIDs produce a similar extent of potentiation among different types of pain, has not been thoroughly investigated. A randomized, placebo-controlled, double-blind study was performed to characterize the analgesic effect of tenoxicam, a long-acting NSAID, on resting wound pain, evoked wound pain, and uterine cramping pain after cesarean section. Saline (n = 48) or 20 mg tenoxicam (n = 45) was intravenously injected immediately after clamping the umbilical cord. All patients were instructed to obtain maximal postoperative analgesia by intravenous patient-controlled morphine. RESULTS Tenoxicam profoundly reduced the intensity of uterine cramping pain (3.6 [2.0-5.6] versus 5.5 [3.4-6.6]; p < 0.01) but had no additional effect on wound pain at rest, with movement, changing position, sitting, and walking. Intraoperative injection of 20 mg tenoxicam decreased the demand ratio for patient-controlled analgesia (PCA) and 24-hour morphine consumption by approximately 30%. The data show that tenoxicam potentiates opioid analgesic effect on the somatic and visceral types of pain to different extents, and they suggest that intraoperative injection of 20 mg tenoxicam is sufficient to enhance intravenous PCA morphine on uterine cramping pain for the first 24 hours after cesarean section.",2003.0,0,0
764,12516895,Implantable devices for pain control: spinal cord stimulation and intrathecal therapies.,Elliot Krames,"Untreated chronic pain is costly to society and to the individual suffering from it. The treatment of chronic pain, a multidimensional disease, should rely on the expertise of varying health care providers and should focus not only on the neurobiological mechanisms of the process but also on the psychosocial aspects of the disease. Implantable devices are costly and invasive, and such efficacious therapies should be used only when more conservative and less costly therapies have failed to provide relief of pain and suffering. Spinal cord stimulation provides neuromodulation of neuropathic, but not nociceptive, pain signals and when used for appropriate indications in the right individuals provides approximately 60-80% long-term pain relief in 60-80% of patients trialled for efficacy. Intrathecal therapies with opioids such as morphine, fentanyl, sufentanil or meperidine--or non-opioids such as clonidine or bupivacaine--provide analgesia in patients with nociceptive or neuropathic pain syndromes. Baclofen, intrathecally, provides profound relief of muscle spasticity due to multiple sclerosis, spinal cord injuries, brain injuries or cerebral palsy.",2003.0,0,0
765,12517545,"Effects of morphine analgesia on diagnostic accuracy in Emergency Department patients with abdominal pain: a prospective, randomized trial.",Stephen H Thomas; William Silen; Farah Cheema; Andrew Reisner; Sohail Aman; Joshua N Goldstein; Alan M Kumar; Thomas O Stair,"Because of concerns about masking important physical findings, there is controversy surrounding whether it is safe to provide analgesia to patients with undifferentiated abdominal pain. The purpose of this study was to address the effects of analgesia on the physical examination and diagnostic accuracy for patients with abdominal pain. The study was a prospective, double-blind clinical trial in which adult Emergency Department (ED) patients with undifferentiated abdominal pain were randomized to receive placebo (control group, n = 36) or morphine sulphate (MS group, n = 38). Diagnostic and physical examination assessments were recorded before and after a 60-minute period during which study medication was titrated. Diagnostic accuracy and physical examination changes were compared between groups using univariate statistical analyses. There were no differences between control and MS groups with respect to changes in physical or diagnostic accuracy. The overall likelihood of change in severity of tenderness was similar in MS (37.7%) as compared with control (35.3%) patients (risk ratio [RR] 1.07, 95% confidence interval [CI] 0.64-1.78). MS patients were no more likely than controls to have a change in pain location (34.0% versus 41.2%, RR 0.82, 95% CI 0.50-1.36). Diagnostic accuracy did not differ between MS and control groups (64.2% versus 66.7%, RR 0.96, 95% CI 0.73-1.27). There were no differences between groups with respect to likelihood of any change occurring in the diagnostic list (37.7% versus 31.4%, RR 1.20, 95% CI 0.71-2.05). Correlation with clinical course and final diagnosis revealed no instance of masking of physical examination findings. Results of this study support a practice of early provision of analgesia to patients with undifferentiated abdominal pain.",2003.0,0,0
766,12525267,Antidepressants for chronic neuropathic pain.,Lori Reisner,"Tricyclic antidepressants have been used to manage pain for several decades, and are superior treatments for some patients suffering from neuropathic pain. Unfortunately, older antidepressants have dose-limiting side effects that can lead to drug intolerance. The most common are anticholinergic side effects, although some patients experience sexual dysfunction. Cognitive impairment, sedation, and orthostatic hypotension also are relatively common. Taking an overdose of tricyclic antidepressants can be lethal in overdose. Several weeks of therapy may be required before antinociception occurs, but tricyclic antidepressants in optimal doses appear to be the most effective treatment for neuropathic pain; this is supported by systematic reviews comparing them with other agents. Newer medications such as atypical antidepressants and anticonvulsants may be overtaking older antidepressants, but they should not be overlooked as important options for the management of pain.",2003.0,0,0
767,12528880,Evolving role of the neurologist in the diagnosis and treatment of chronic noncancer pain.,Peter Lars Jacobson; J Douglas Mann,"The neurologist has become increasingly involved in the multidisciplinary treatment of patients with chronic noncancer pain (CNP). Chronic noncancer pain affects a diverse patient population with multiple underlying diagnoses and associated therapies. Following the model of the American Board of Anesthesiology and the American Society of Anesthesiologists for practice guidelines and subspecialty requirements, neurologic pain management is now recognized as a subspecialty of neurology by the American Academy of Neurology and the American Board of Psychiatry and Neurology. Current basic and clinical research into the neuropathology, neurophysiology, neurochemistry, and neuropharmacology of chronic pain continues to expand diagnostic and therapeutic options. Informed regulatory agencies and professional organizations such as the American Academy of Neurology recognize the undertreatment of patients with CNP and provide clear recommendations to help neurologists in the ethical and effective treatment of patients with pain. Improved education of neurologists, other health care professionals, patients, and the media about evolving standards of pain care and therapy will produce a more supportive environment for the compassionate and ethical treatment of patients with CNP.",2003.0,0,0
768,12532190,New directions in pain management.,Ross D MacPherson,"Pain medicine is one of the most rapidly developing medical specialties of today. While there are many modalities that can be used in managing the patient in pain, drug treatment remains, for the most part, the cornerstone of treatment. Opioids retain their position as the foundation of most analgesic strategies, although they tend to be used nowadays in combination with adjuvant analgesics such as paracetamol and nonsteroidal antiinflammatory drugs. The range of available opioids has also been expanded with drugs such as hydromorphone and oxycodone, originally developed almost a century ago. This expanded choice has resulted in the concept of opioid rotation in chronic pain states, an approach that is aimed at maintaining pain control while minimizing adverse effects. Nonsteroidal antiinflammatory drugs continue to play an important role, especially as adjuvants, and the development of drugs such as celecoxib and refecoxib, highly specific for the inhibition of cyclooxygenase 2 pathway has been a further advance. The treatment of neuropathic pain continues to be a challenge to the clinician. While this has traditionally been treated with drugs from the anticonvulsant, antiarrhythmic and anti-depressant groups, results from these treatments have often been less than satisfactory. This has led to the development of completely new drug classes that modulate neuronal transmission in pain pathways, some of which are derived from exotic animal sources, such as the conotoxins from the marine snail family and epibatidine from a species of frog. The role of cannabinoids remains controversial.",2003.0,0,0
769,12544931,Clinical characteristics of chronic back pain as a function of gender and oral opioid use.,Roger B Fillingim; Daniel M Doleys; Robert R Edwards; Daniel Lowery,"A cross-sectional analysis of data derived from patients with chronic spinal pain undergoing evaluation at a multidisciplinary pain treatment center was conducted. To determine whether pain severity, psychological status, and physical disability differed as a function of gender and opioid use, and whether the clinical correlates of opioid use differed in women and men with chronic back pain. Gender differences in the experience of pain have been widely reported. For example, in the general population, several chronic pain conditions are more prevalent among women than among men, and many experimental studies demonstrate lower pain thresholds and tolerances among women. In addition, recent evidence from studies of experimental and acute clinical pain suggests that responses to analgesic medications may differ in women and men. The sample consisted of 240 patients (35% women) with low back, upper back, or neck pain undergoing evaluation for treatment at a multidisciplinary pain center. The patients were classified as opioid or nonopioid users on the basis of self-report and medical record review. All the patients completed a battery of clinical assessments, including measures of pain severity, psychological adjustment, self-reported disability, functional tasks, and pain tolerance. Analyses were conducted to examine clinical variables as a function of gender and opioid use. The results indicated that opioid use was associated with greater self-reported disability and poorer function in both women and men. However, the association of opioid use with affective distress differed between women and men. The women using opioids showed lower affective distress, whereas the opioid-using men reported greater affective distress. Opioid use was not associated with pain severity, although the women reported greater pain than men. These findings indicate that both opioid use and gender are significant predictors of clinical status of patients with chronic spinal pain. More interesting, these two variables interact because opioid use was associated with increased affective distress among the men, but the reverse was true for the women. In addition, the women reported greater pain severity, which is consistent with some previous findings. Potential explanations for these findings are presented, and the practical implications are discussed.",2003.0,0,0
770,12545257,Prospective comparative study of the effectiveness of epidural morphine and ropivacaine for management of pain after spinal operations.,B Al-Khalaf; F Loew; M Fichtl; E Donauer,"Evaluation of the effectiveness of local application of morphine or ropivacaine for treatment of local and radicular pain after lumbar disc operations. Critical review of the literature about the possibilities of management of postoperative pain after spinal operations. A total of 113 patients were randomly given 5 mg morphine sulfate (N=42), 10 ml 0,25% ropivacaine (N=42) or physiological NaCl solution (N=21) locally after lumbar disc operation before wound closure. Postoperative lumbar and radicular pain was scored by the patients from 0 to 10 and registered on the evening of the day of operation and on the 1., 2., 3., and 5. days. Mean pain numbers of the 3 groups have been compared, subdivided into local lumbar and in radicular pain. Our own results have been compared with the results of reports in the literature. In our own study the morphine group had less lumbar and less radicular pain on all 5 days than both of the two other groups. This difference was statistically significant on days 0, 1, 2, and 3. The ropivacaine group was on all days less effective than the morphine group, better than the placebo group on the operation and first day, but the difference against the placebo group was statistically not significant. Local application of 5 mg morphine sulfate is effective in prevention or reduction of postoperative lumbar and radicular pain after lumbar disc operations. Ropivacain is less effective. The routine application of epidural morphine at the end of spinal operations can be recommended. It also can be justified to try to prolong the morphine effect by mixing it into a paste as described by Needham and by Hurlbert, and to irrigate the operative field with ropivacaine at the end of the operation.",2003.0,0,0
771,12552209,Prospective study on incidence and functional impact of transient neurologic symptoms associated with 1% versus 5% hyperbaric lidocaine in short urologic procedures.,Doris Tong; Jean Wong; Frances Chung; Mark Friedlander; Joseph Bremang; Gabor Mezei; David Streiner,"The objectives of this study were to compare the incidence, onset, duration and pain scores of transient neurologic symptoms (TNS) with 1% versus 5% hyperbaric lidocaine in spinal anesthesia for short urological procedures in a large prospective study. This study would also evaluate patient satisfaction, and impact of TNS on functional recovery to assess the clinical significance of TNS. This was a multicenter, double-blind, randomized controlled trial. Four hundred fifty-three patients undergoing short transurethral procedures were randomized to receive 1% or 5% hyperbaric lidocaine. Eighty milligrams of 1% or 5% hyperbaric lidocaine was administered. During the first 3 days after surgery, the presence of TNS, its intensity and duration, and patient functional level were recorded. An intention-to-treat analysis was used. There was no difference in the incidence of TNS (21% vs. 18%) between 1% versus 5% lidocaine. Patients with TNS had significantly higher pain scores (5.3 +/- 3 vs. 2.3 +/- 3) than patients without TNS during the first 24 h. This difference in pain scores persisted until 72 h postoperatively. There was a significant difference in the daily activities functional scores (2.2 +/- 1 vs. 1.4 +/- 0.8) of TNS non-TNS patients during the first 24 h postoperatively. There was no difference in the incidence of TNS between the 1% versus 5% spinal lidocaine groups. Pain scores were higher in patients with TNS than those who did not have TNS. During the first 48 h postop, a small proportion of patients who had TNS experienced functional impairment of walking, sitting, and sleeping.",2003.0,0,0
772,12552210,Antinociceptive effect of low-dose intrathecal neostigmine combined with intrathecal morphine following gynecologic surgery.,Raquel A Almeida; Gabriela R Lauretti; Anita L Mattos,"The purpose of this study was to determine whether combination of 1-5 microg intrathecal neostigmine would enhance analgesia from a fixed intrathecal dose of morphine. A total of 60 patients undergoing gynecologic surgery were randomized to one of five groups. Patients received 15 mg bupivacaine plus 2 ml of the test drug intrathecally (saline, 100 microg morphine, or 1-5 microg neostigmine). The control group received spinal saline as the test drug. The morphine group received spinal morphine as test drug. The morphine + 1 microg neostigmine group received spinal morphine and 1 microg neostigmine. The morphine + 2.5 microg neostigmine group received spinal morphine and 2.5 microg neostigmine. Finally, the morphine + 5 microg neostigmine group received spinal morphine and 5 microg neostigmine. The groups were demographically similar. The time to first rescue analgesic (minutes) was longer for all patients who received intrathecal morphine combined with 1-5 microg neostigmine (median, 6 h) compared with the control group (median, 3 h) (P < 0.02). The morphine group (P < 0.05) and the groups that received the combination of 100 microg intrathecal morphine combined with neostigmine (P < 0.005) required less rescue analgesics in 24 h compared with the control group. The incidence of perioperative adverse effects was similar among groups (P > 0.05). The addition of 1-5 microg spinal neostigmine to 100 microg morphine doubled the duration to first rescue analgesic in the population studied and decreased the analgesic consumption in 24 h, without increasing the incidence of adverse effects. The data suggest that low-dose spinal neostigmine may improve morphine analgesia.",2003.0,0,0
773,12552363,"Cognitive and motor function after administration of hydrocodone bitartrate plus ibuprofen, ibuprofen alone, or placebo in healthy subjects with exercise-induced muscle damage: a randomized, repeated-dose, placebo-controlled study.",George J Allen; Tamara L Hartl; Shannon Duffany; Stefanie F Smith; Jaci L VanHeest; Jeffrey M Anderson; Jay R Hoffman; William J Kraemer; Carl M Maresh,"Medications combining hydrocodone bitartrate and non-steroidal anti-inflammatory agents appear more beneficial than anti-inflammatory medications alone in treating pain and inflammation from acute soft tissue trauma, but opiate side effects may include sedation and impaired cognitive and motor performance. Performance on complex cognitive and motor tasks was evaluated in healthy subjects with exercise-induced muscle damage who were treated with a hydrocodone-ibuprofen combination, ibuprofen alone, or placebo. This double-blind, randomized, placebo-controlled, repeated-dose clinical trial compared the effects of hydrocodone bitartrate (7.5 mg) plus ibuprofen (200 mg), ibuprofen alone, and placebo on cognitive and motor function in 72 healthy college men. Muscle damage in the quadriceps of each subject's dominant leg was induced by an eccentric exercise protocol. Subjects took the study medication four times daily (every 4-6 h) for 5 days. Forty minutes after medication ingestion at the same time each day, subjects underwent tests of attention/concentration, motor performance, and reaction time. Four trained assessors rotated among subjects so that none tested the same participant on more than three occasions. Repeated measures analyses of covariance revealed no between-group differences on a complex memory and cognition task or complex reaction time. Subjects using hydrocodone bitartrate plus ibuprofen performed significantly less well on a simple tracking task and made significantly more errors on a simple reaction-time task than the other two groups. These deficits were found to be highly transitory and not related to confusion or fatigue. Hydrocodone plus ibuprofen was not associated with deterioration in complex cognition but was related to very transitory decrements in tasks involving simple hand-eye coordination.",2003.0,0,0
774,12560304,Best evidence in anesthetic practice: prevention: epidural anesthesia and analgesia does not reduce 30-day all-cause mortality and major morbidity after abdominal surgery.,Sugantha Ganapathy; Colin J L McCartney; W Scott Beattie; Vincent W S Chan,,2003.0,0,0
775,12560305,The addition of droperidol or clonidine to epidural tramadol shortens onset time and increases duration of postoperative analgesia.,Ercan Gürses; Hülya Sungurtekin; Erkan Tomatir; Canan Balci; Mustafa Gönüllü,"To compare tramadol alone and the combinations of either tramadol-clonidine or tramadol-droperidol with regard to analgesic and adverse effects. After Ethic's Committee approval and patient informed consent were obtained, epidural catheters were inserted preoperatively at the L(3-4) interspace in 90 ASA physical status I-II adult patients undergoing lower abdominal surgery. Anesthesia was standardized. Patients were randomly assigned to one of three groups. Group I (T) patients received tramadol 75 mg, Group II (TD) patients received tramadol 75 mg plus droperidol 2.5 mg, and Group III (TC) patients received tramadol 75 mg plus clonidine 150 microg in a total volume of 10 mL administered as a single epidural injection in the postanesthesia care unit. The onset time of analgesia and duration of analgesia, visual analogue pain scores, sedation, nausea scores, vital signs and side effects were recorded. Duration of analgesia was similar in both the TD and TC groups, and significantly longer than in the T group (P < 0.001). Group TC patients displayed a significant increase in sedation scores and decrease in blood pressure and heart rate when compared with other groups (P < 0.001). No adverse effects were observed in Group TD, while nausea scores were high in both the T and TC groups (P < 0.001). Pain score, respiration rate, and SpO(2) values were similar in all study groups. We conclude that epidural tramadol in combination with droperidol or clonidine prolongs the duration of analgesia; however, droperidol appears to be a better alternative when adverse effects and antiemetic properties are taken into consideration.",2003.0,0,0
776,12560306,Intradermal sufentanil does not improve lidocaine-induced local anesthesia.,Maximilian W B Hartmannsgruber; Peter G Atanassoff; Arne Budde; Sorin J Brull; Zeev N Kain; David G Silverman,"Peripheral opioid receptors may result in antinociceptive effects when occupied by opioids. This study examined intradermally injected sufentanil (S), a highly lipid soluble opioid, administered with and without lidocaine (L), in a thermal pain model. Nine volunteers were instructed on the method of magnitude estimation of pain before undergoing baseline testing with seven seconds thermal stimuli between 44 and 52 degrees C, delivered by a contact thermal stimulator at five cutaneous forearm sites. Then, four sites randomly received injections of equal volumes (0.1 mL) of either normal saline (NS), lidocaine 0.5% (L), sufentanil 0.75 microg (S), lidocaine 0.5% plus sufentanil 0.75 microg (L+S), and one site was not injected and served as reference (REF). Testing was repeated at six, 30, 60, 90, 120, and 150 min following injection. The pain elicited by each stimulus was normalized to the subject's response to the 50 degrees C stimulus at the REF site. Baseline testing showed small (P = ns) differences in pain scores. At six minutes, the lidocaine sites (L, L+S) had pain scores that were mean 83% (range 78-88%) lower than the other sites (P < 0.05), but there was no difference between the L and L+S sites or between the S and NS or REF sites. At 30 and 60 min these pain scores were mean 38% (29-44%) and 20% (8-30%) less than at the REF, NS, and S sites (P = ns). At 90 min and later times, the pain scores had returned to baseline. These results suggest that intradermal sufentanil alone has no analgesic effect. Further, in combination with lidocaine, sufentanil does neither potentiate nor prolong the analgesic effect of lidocaine.",2003.0,0,0
777,12560940,A model of acute symptom control unit: Pain Relief and Palliative Care Unit of La Maddalena Cancer Center.,Sebastiano Mercadante; Patrizia Villari; Patrizia Ferrera,"Palliative care in Italy was provided solely on a home care basis until a couple of years ago. In recent years different realities have been created according to personal experience, quite apart from new resources provided by the National Health System. The first Pain Relief and Palliative Care Unit in Sicily, the largest region in Italy, was established in March 1999. Most members of the regular staff of this Unit have a background in anesthesiology. Activity in the Unit has grown progressively, with 460 admissions in the last year. The characteristics of the first 1,000 patients admitted, the principal protocols for diagnostic and therapeutic procedures, such as those for hitherto intractable pain, nutrition and hydration, interventional procedures for symptom control, and emerging problems, a project called ""Island with no pain,"" and activities in the fields of formation and research are described.",2003.0,0,0
778,12562408,Effect of intra-operative magnesium sulphate on pain relief and patient comfort after major lumbar orthopaedic surgery.,Ch Levaux; V Bonhomme; P Y Dewandre; J F Brichant; P Hans,"The effects of intra-operative magnesium sulphate on pain relief after major lumbar surgery were investigated in 24 patients. Patients were randomly allocated to receive either an infusion of 50 mg x kg(-1) magnesium sulphate or an equivalent volume of saline at induction of anaesthesia. Anaesthesia was induced with propofol and remifentanil. Tracheal intubation was facilitated using rocuronium. Maintenance was achieved with remifentanil and sevoflurane in nitrous oxide/ oxygen. Intra-operative monitoring included standard equipment and neuromuscular transmission. During surgery, neuromuscular block recovery was longer in the magnesium group. Postoperative opioid consumption and pain scores were lower in the magnesium group. The first night's sleep and the global satisfaction scores were better in the magnesium group. The results of the study support magnesium sulphate as a useful adjuvant for postoperative analgesia after major lumbar surgery.",2003.0,0,0
779,12563577,Supplemental oxygen is not required in trauma patients treated with IV opiates.,Leena H Mildh; Anneli Piilonen; Olli A Kirvelä,"The risk of respiratory depression can prevent the proper use of opioids in trauma patients and lead to use of supplemental oxygen. However, high FiO(2) might contribute to atelectasis formation and consequently to relative hypoxia. Supplemental oxygen also can cause a risk of fire. In a randomized, controlled study we evaluated the need and effects of supplemental oxygen in 13 patients with extremity trauma who were treated pain-free with an intravenous opioid, oxycodone (dose range 6.75-13.6 mg). After opioid injection, 7 patients received 40% supplemental oxygen and 6 were breathing room air. Pulse oxygen saturation (SpO(2)), arterial blood gases, and hemodynamic parameters were monitored for 30 minutes. Atelectasis formation was evaluated with a computed tomography scan. No hypoxia, hypoventilation, or significant atelectasis formation was detected in any of the patients. Accordingly, routinely given supplemental oxygen was not considered necessary in these patients because no complications were seen.",2003.0,0,0
780,12566175,"A randomised, double blind, placebo controlled crossover study of the cholecystokinin 2 antagonist L-365,260 as an adjunct to strong opioids in chronic human neuropathic pain.",Gary J McCleane,"The aim of this study was to establish if the cholecystokinin (CCK) 2 antagonist L-365,260 augments the analgesic effect of morphine in human subjects with chronic neuropathic pain. This is a randomised, double blind, placebo controlled study of 40 adult subjects taking morphine for neuropathic pain. Each received placebo, L-365,260 30 mg and L-365,260 120 mg in three divided doses daily separated by a washout period in random order. Pain, activity, sedation, sleep and side effects were recorded along with 12 lead ECGs, renal and liver function tests and full blood pictures. L-365,260 failed to augment the analgesic effect of morphine at any of the dose levels used. Side effects were minor. There were no changes in ECGs and biochemical indices were unaltered with its use. The CCK 2 antagonist L-365,260 does not augment the analgesic effect of morphine in subjects with chronic neuropathic pain. L-365,260 was well tolerated and side effects from its use were minor.",2003.0,0,0
781,12568639,"Morphine/dextromethorphan--Endo: E 3231, Morphidex.",,,2003.0,0,0
782,12577163,[Postoperative analgesia with tramadol and metamizol. Continual infusion versus patient controlled analgesia].,U M Stamer; F Höthker; K Lehnen; F Stüber,"The study compares the i.v. analgesia of tramadol and dipyrone delivered either as continuous infusion or as patient controlled analgesia (PCA). After approval by the local ethics committee and informed consent 203 patients recovering from abdominal surgery were randomly assigned to pain treatment either by PCA or continuous intravenous infusion. Both groups received the same analgesic drug combination of tramadol (20 mg/ml) and dipyrone (200 mg/ml). The PCA bolus was set to 1 ml, the continuous infusion varied between 0-8 ml/h according to individual needs. Demographic and surgery related data were compared between the treatment groups, as well as pain scores, analgesic consumption and response rates over a 48 hour study period.A patient was assessed as non responder when rescue medication was necessary during the study period or the patient rated analgesia as insufficient during the final interview. In total,data of 191 patients (infusion-group: 94, PCA-group: 97) could be analyzed. Tramadol consumption was higher in the infusion group compared to the PCA-group (48 hours: 1009.4+/-494.4 vs. 813.0+/-585.3 mg;p<0.001) with no difference in pain scores. In the infusion group, significantly more interventions were necessary to adjust the infusion rate to individual needs (min-max: 1-15 vs. 0-2). The number of non responders amounted to 30 (31.9%) and 18 (18.6%;p=0.03) in the infusion and PCA group, respectively. PCA with tramadol and dipyrone can be considered an alternative for postoperative pain management and provided a more individualized treatment approach with lower analgesic consumption and more responders compared to a continuous infusion.",2003.0,0,1
783,12579384,,,,,0,1
784,12579390,[Correlation between intrathecal opioids and gynecomastia -- a case report].,I Hosbach; M Zenz,The intrathecal application of opioids is promoted as a safe and cost-efficient method to treat chronic pain of nonmalignant origin. But the way of application could trigger the appearance of otherwise rare side-effects. One of those side-effects could be the alteration of androgen hormones. Can a long-time-application of intrathecal opioids result in gynecomastia? Case-report of a 49 year old with chronic back and limb pain. Research for publications. The close link between the begin of intrathecal application of opioids and the onset of gynecomastia in this patient refers to a causal correlation. Historic publications and new findings from animal research are supporting our hypothesis. Further research is needed to support the clinical suspicion of a correlation between intrathecal opioids and gynecomastia. In case of a opioid-produced gynecomastia tests of the oestrogen-testosterone-ratio should be performed. An early substitution of testosterone could prevent a full fledged gynecomastia.,2003.0,0,0
785,12580983,Comparative study of analgesic efficacy and morphine-sparing effect of intramuscular dexketoprofen trometamol with ketoprofen or placebo after major orthopaedic surgery.,M H Hanna; K M Elliott; M E Stuart-Taylor; D R Roberts; D Buggy; G J Arthurs,"Multimodal analgesia is thought to produce balanced and effective postoperative pain control. A combined therapy with nonsteroidal anti-inflammatory drugs (NSAIDs) and opiates could result in synergistic analgesia by acting through different mechanisms. Currently there are very few parenterally administered NSAIDs suitable for the immediate postoperative period. Therefore, this study was undertaken to assess the analgesic efficacy, relative potency, and safety of parenteral dexketoprofen trometamol following major orthopaedic surgery. One hundred and seventy-two patients elected for prosthetic surgery, were randomized to receive two intramuscular injections (12 hourly) of either dexketoprofen 50 mg, ketoprofen 100 mg or placebo in a double-blind fashion. Postoperatively, the patient's pain was stabilized, then they were connected to a patient- controlled analgesia system (PCA) of morphine for 24 h (1 mg with 5 min lockout). The mean cumulative amount of morphine (CAM) used was of 39 mg in the dexketoprofen group and 45 mg in the ketoprofen group vs 64 mg in the placebo group. (Reduction in morphine use was approximately one-third between the active compounds compared with placebo (adjusted mean difference of -25 mg between dexketoprofen and placebo and -23 mg between ketoprofen and placebo. These differences were statistically significant: P </= 0.0003; 95% CI -35, -14. Pain-intensity scores were consistently lower with the active compounds, the lowest corresponded to the dexketoprofen-treated patients. Regarding sedation, there were statistically significant differences between the two active compounds and placebo only at the 2nd and 13th hours. Wound bleeding was specifically measured with no statistically significant differences found between all the groups. Intramuscular administration of dexketoprofen trometamol 50 mg has good analgesic efficacy both in terms of opioid-sparing effect and control of pain after major orthopaedic surgery.",2003.0,0,0
786,12583865,"Cold allodynia and hyperalgesia in neuropathic pain: the effect of N-methyl-D-aspartate (NMDA) receptor antagonist ketamine--a double-blind, cross-over comparison with alfentanil and placebo.",E Jørum; T Warncke; A Stubhaug,"Cold allodynia and hyperalgesia are frequent clinical findings in patients with neuropathic pain. While there have been several clinical studies showing the involvement of central sensitization mechanisms and N-methyl-D-aspartate (NMDA) receptor activation in mechanical allodynia/hyperalgesia and ongoing pain, the mechanisms of thermal allodynia and hyperalgesia have received less attention. The aim of the present study was to examine the effect of the NMDA-receptor antagonist ketamine on thermal allodynia/hyperalgesia, ongoing pain and mechanical allodynia/hyperalgesia in patients with neuropathic pain (11 patients with post-traumatic neuralgia and one patient with post-herpetic neuralgia). All the patients were known to suffer from severe cold allodynia (cold pain detection threshold (CPDT): 23.8 degrees C, median value). The mu-opioid agonist alfentanil was used as an active control. The study design was double-blind and placebo-controlled and the drugs were administered i.v. (bolus dose and infusion). CPDT in the asymptomatic contralateral area was found to be significantly decreased (cold allodynia) compared to CPDT in site- and age-matched normal controls. Heat pain detection thresholds were found to be normal and no consistent heat hyperalgesia occurred. Alfentanil significantly reduced cold allodynia (by increasing CPDT) in symptomatic area (P=0.0076). Ketamine did not significantly increase the threshold. Significant and marked reductions of hyperalgesia to cold (visual analogue score at threshold value) were seen following both alfentanil (4.5 before, 1.4 after, median value) and ketamine (6.8 before, 0.4 after, median value). Alfentanil and ketamine also significantly reduced ongoing pain and mechanical hyperalgesia. It is concluded that NMDA-receptor mediated central sensitization is involved in cold hyperalgesia, but since CPDT remained unaltered, it is likely that other mechanisms are present.",2003.0,0,0
787,12588070,What is the most effective approach to chronic pain?,Robert D Gillette,,2003.0,0,0
788,12594139,Remifentanil and nitrous oxide reduce changes in cerebral blood flow velocity in the middle cerebral artery caused by pain.,I H Lorenz; C Kolbitsch; M Hinteregger; P Bauer; M Spiegel; T J Luger; C Schmidauer; W Streif; K P Pfeiffer; A Benzer,"Cerebral blood flow is affected by painful stimuli, and analgesic agents may alter the response of cerebral blood flow to pain. We set out to quantify the effects of remifentanil and nitrous oxide on blood flow changes caused by experimental pain. We simulated surgical pain in 10 conscious volunteers using increasing mechanical pressure to the tibia. We measured changes in cerebral blood flow velocity in the middle cerebral artery (CBFV(MCA)) caused by the pain, using transcranial Doppler sonography. We gave increasing doses of remifentanil (0.025, 0.05 and 0.1 micro g kg(-1) min(-1)) or nitrous oxide [20%, 35% and 50% end-tidal concentration (FE'(N(2)O))] and compared these effects on blood flow changes. Nitrous oxide increased CBFV(MCA) only when given at 50% FE'(N(2)O). Remifentanil did not affect CBFV(MCA). Pain increased CBFV(MCA). Both agents attenuated this pain-induced change in CBFV(MCA) with the exception of nitrous oxide at 20% FE'(N(2)O). Inhalation of nitrous oxide or adminstration of remifentanil attenuated pain-induced changes in CBFV(MCA).",2003.0,0,0
789,12594140,Intrathecal morphine and clonidine for coronary artery bypass grafting.,P Lena; N Balarac; J J Arnulf; J Teboul; F Bonnet,"After cardiac surgery adequate postoperative analgesia is necessary. We assessed analgesia using intrathecal morphine and clonidine. In a double-blind randomized study, 45 patients having coronary artery bypass graft surgery were allocated randomly to receive i.v. patient-controlled analgesia (PCA) morphine (bolus, 1 mg; lock-out interval, 7 min) (control group), either alone or combined with intrathecal morphine 4 microg kg(-1) or with both intrathecal morphine 4 microg kg(-1) and clonidine 1 microg kg(-1). Intrathecal injections were performed before the induction of general anaesthesia. Pain was measured after surgery using a visual analogue scale (VAS). We recorded i.v. PCA morphine consumption during the 24 h after operation. Morphine dosage [median (25th-75th percentiles)] was less in the first 24 h in the patients who were given intrathecal morphine + clonidine [7 (0-37) mg] than in other patients [40.5 (15-61.5) mg in the intrathecal morphine group and 37 (30.5-51) mg in the i.v. morphine group]. VAS scores were lower after intrathecal morphine + clonidine compared with the control group. Time to extubation was less after intrathecal morphine + clonidine compared with the i.v. morphine group [225 (195-330) vs 330 (300-360) min, P<0.05]. Intrathecal morphine and clonidine provide effective analgesia after coronary artery bypass graft surgery and allow earlier extubation.",2003.0,0,0
790,12594144,Comparison of local anaesthetic effects of tramadol with prilocaine for minor surgical procedures.,H Altunkaya; Y Ozer; E Kargi; O Babuccu,"Recent studies have shown that a local anaesthetic action of tramadol 5% was able to induce a sensory block to pinprick, touch, and cold similar to that of lidocaine 1%. The aim of this study was to compare the local anaesthetic effects of tramadol hydrochloride with prilocaine. Sixty ASA I or II patients, undergoing excision of the cutaneous lesions under local anaesthesia, were included in the study. Patients were randomly assigned to receive either 1 ml of tramadol 5% (Group T, n=30) or 1 ml of prilocaine 2% (Group P, n=30) intradermally, in a double-blinded fashion. The degree of the burning sensation and pain at the injection site was documented. Sensory block was assessed 1 min after injection. The patient was asked to report the degree of sensation and to grade touch and pinprick sensation. Two minutes after drug administration, incision was performed and intensity of pain, felt by the patient was evaluated on a four-point scale (0-3). Any local adverse effects were recorded. There was no difference in the quality of block between the two groups. Side effects were noted in both groups with a significant increase in the incidence of local reaction (rash) in Group T (seven patients) when compared with Group P (one patient) (P<0.05). Seven patients in Group T vs four patients in Group P complained of burning at the injection site (P>0.05). Intradermal tramadol 5% can provide a local anaesthesia similar to the prilocaine but the incidence of local adverse effects is higher.",2003.0,0,0
791,12607659,Pain treatment with a COX-2 inhibitor after coronary artery bypass operation: a randomized trial.,Franz F Immer; Alexsandra S Immer-Bansi; Nathalie Trachsel; Pascal A Berdat; Verena Eigenmann; Michele Curatolo; Thierry P Carrel,"Adequate analgesic medication is mandatory after cardiac operations. Cyclooxygenase-2 inhibitors represent a new therapeutic option, acting primarily on the response to inflammation. We compared a cyclooxygenase-2 inhibitor (etodolac) with two traditional drugs: a nonselective cyclooxygenase inhibitor (diclofenac) and a weak opioid (tramadol) on postoperative pain and renal function in patients undergoing coronary artery bypass operations. Sixty consecutive patients were randomized into three groups: (1) group A patients who received tramadol; (2) group B patients who received diclofenac; and (3) group C patients who received etodolac. For measurement of analgesic effect, the visual analogue scale was assessed up to postoperative day 4. Creatinine-clearance was determined before and at the end of study medication, and serum creatinine and urea were monitored daily for renal effects. Study medication was given on postoperative days 2 and 3. Side effects and additional pain medication were recorded. The visual analogue scale was lower in group C (p < 0.05) from postoperative days 2 to 4 and in group B (p < 0.05) from postoperative days 3 to 4 compared with group A. Amount of additional pain medication and incidence of side effects were significantly less in group C compared with group A. We observed a short-lasting elevation of serum creatinine and urea in groups B and C compared with group A (p < 0.05). At the doses analyzed, etodolac and diclofenac produced better postoperative pain relief with less side-effects than tramadol. A short-lasting impairment of renal function was found in patients treated with etodolac and diclofenac.",2003.0,0,0
792,12612511,"Single bolus of midazolam versus bolus midazolam plus meperidine for colonoscopy: a prospective, randomized, double-blind trial.",Franco Radaelli; Gianmichele Meucci; Vittorio Terruzzi; Giancarlo Spinzi; Gianni Imperiali; Enrico Strocchi; Nicoletta Lenoci; Natalia Terreni; Giovanna Mandelli; Giorgio Minoli,"The aim of this study was to determine whether a single bolus of meperidine in addition to midazolam improves patient tolerance during colonoscopy. Consecutive patients undergoing outpatient colonoscopy were randomly assigned in double-blind fashion to receive a single rapid intravenous bolus of 5 mg of midazolam and placebo (Group A, n = 125) or 5 mg midazolam plus 50 mg meperidine (Group B, n = 128). Tolerance (4-point scale: 1 excellent, 4 unbearable), pain (4-point scale: 1 none, 4 severe) and willingness to undergo another colonoscopy were assessed 24 to 48 hours later in a telephone interview conducted by an independent observer blinded to the regimen of sedative medication. Significantly more patients in Group A reported moderate or severe pain (28% vs. 9%; p < 0.001), poor or unbearable tolerance (18% vs. 6%; p < 0.01) and unwillingness to undergo colonoscopy again in the future (14% vs. 5%; p < 0.05). By multivariate analysis, randomization to the midazolam group and younger age were the only variables independently associated with the risk of reporting at least one of these outcomes. Recovery time, frequency of oxygen desaturation, and need for supplemental oxygen were not significantly different between the 2 groups. The addition of a single bolus of meperidine to midazolam improves patient tolerance and lessens pain during colonoscopy without significantly increasing the frequency of side effects or prolonging recovery time.",2003.0,0,0
793,12615585,Nebulized fentanyl for relief of abdominal pain.,Joel M Bartfield; Robert D Flint; Mara McErlean; John Broderick,"To compare the efficacies of nebulized vs. intravenous fentanyl for the relief of abdominal pain. This randomized, double-blind, double-placebo-controlled study compared nebulized and intravenous fentanyl (1.5 micro g/kg). Group I received intravenous fentanyl and nebulized saline. Group II received nebulized fentanyl and intravenous saline. Pain scores were measured at baseline and at 15 and 30 minutes after the study drug, using a 100-mm visual analog scale. Thirty minutes after the study drug, the subjects were offered rescue medication. The groups were compared for changes in pain scores at 30 minutes (primary outcome, t-test), changes in pain scores at 15 minutes (t-test), and need for rescue medication (Fisher's exact test). Significance was defined as p < 0.05. Fifty subjects (24 group I, 26 group II) were enrolled. The groups were similar with respect to mean baseline pain (72 mm group I, 74 mm group II) and demographics. A statistically significant difference in changes in pain scores at 15 minutes favoring group I (25 mm vs. 10 mm, p = 0.005) was not evident by 30 minutes (25 mm vs. 16 mm, p = 0.24). The groups were not different with respect to need for rescue medication (50% in group I compared with 69% in group II, p = 0.25). Nebulized fentanyl provides comparable analgesia to that of intravenous fentanyl.",2003.0,0,0
794,12620606,The mu-opioid agonist remifentanil attenuates hyperalgesia evoked by blunt and punctuated stimuli with different potency: a pharmacological evaluation of the freeze lesion in humans.,Jörn Lötsch; Martin S Angst,"Experimental pain models inducing hyperalgesia, i.e. an increased sensitivity to noxious stimuli often present in clinical pain, are important tools for studying antinociceptive drug profiles. The correct interpretation of results obtained in these models necessitates their mechanistic understanding. This study evaluated the freeze lesion, an experimental model of hyperalgesia, in humans. Twelve healthy subjects were tested with mechanical (brush, punctuated and blunt) and electrical (5, 250, and 2000 Hz sine wave current) stimuli before and after freezing the skin, and during a computer-controlled infusion of the mu-opioid agonist remifentanil targeting five different plasma concentrations between 0 and 6 ng/ml in a two-staged, single occasion, randomized, and double blind study design. Pharmacodynamic modeling techniques were used to describe the effect of freezing and drug administration on the mechanical and electrical pain thresholds. Freezing the skin resulted in hyperalgesia to blunt and punctuated stimuli and lowered the respective pain threshold by 29 and 73%. Hyperalgesia to brushing or electrical stimuli was not detected. Remifentanil attenuated hyperalgesia to blunt stimuli about twice as potently as hyperalgesia to punctuated stimuli, as indicated by a significantly steeper linear relationship between the remifentanil plasma concentration and the increase of the pain threshold to blunt stimuli. Remifentanil attenuated electrical pain with greater potency for low frequency stimulation. The potency difference of remifentanil suggests that different neuronal mechanisms mediate hyperalgesia to blunt and punctuated stimulation. Absence of brush-evoked and electrical hyperalgesia is compatible with the view that mechanical hyperalgesia to blunt and punctuated stimulation of the freeze lesion is predominantly caused by a peripheral mechanism.",2003.0,0,0
795,12622108,"A comparison of total intravenous with balanced anaesthesia for middle ear surgery: effects on postoperative nausea and vomiting, pain, and conditions of surgery.",K Mukherjee; C Seavell; E Rawlings; A Weiss,"We compared postoperative nausea and vomiting (PONV), pain and conditions for surgery in patients scheduled for middle ear surgery. In a double-blind study, 100 patients were randomly allocated to receive either balanced anaesthesia (group A) using fentanyl, propofol and isoflurane, or total intravenous anaesthesia (group B) using propofol and remifentanil infusions. Pain scores, nausea/vomiting scores, conditions for surgery and analgesic requirements were recorded for 18 h post operatively. In the recovery ward, patients in group B suffered significantly less PONV (p = 0.026) with a reduced requirement for anti-emetic medication (p = 0.023); however, this difference was not maintained on the ward. The overall incidence of PONV was 34% and 17% in groups A and B, respectively. Initial pain scores were higher in group B in the recovery ward (p = 0.003) and patients required more morphine administration (p = 0.002); however, pain scores were similar on the ward. Conditions for surgery were found to be better in group B.",2003.0,0,0
796,12622499,Intravenous patient-controlled analgesia after thoracotomy: a comparison of morphine with tramadol.,H Erolçay; L Yüceyar,"This study examined the quality of analgesia together with the side-effects produced by tramadol compared with morphine using intravenous patient-controlled analgesia during the first 24 h after thoracotomy. Forty-four patients scheduled for thoracotomy were included in the study. Morphine 0.3 mg kg(-1) was given interpleurally 20 min before a standard general anaesthetic. In the postanaesthetic care unit, the patients were randomly allocated to one of two groups to self-administer tramadol or morphine using a patient-controlled analgesia device throughout a 24 h period. The patient-controlled analgesia device was programmed to deliver tramadol 20 mg as an intravenous bolus or morphine 2 mg with a lockout time of 10 min. Mean cumulative morphine and tramadol consumption were 48.13 +/- 30.23 and 493.5 +/- 191.5 mg, respectively. There was no difference in the quality of analgesia between groups. Five (26.3%) patients in the tramadol group and seven (33%) in the morphine group had nausea, and three of the latter patients vomited. The incidence rate of vomiting with tramadol was 5.2%. All vital signs were within safe ranges. Sedation was less in the tramadol group, but not statistically significant. In this clinical setting, which includes interpleural morphine pre-emptively, postoperative analgesia provided by tramadol was similar to that of morphine at rest and during deep inspiration. Side-effects were slight and comparable between the patients receiving morphine and tramadol.",2003.0,0,0
797,12624694,[Opioid therapy in chronic non-malignant pain].,A Kopf; W Janson; C Stein,"In long-term treatment opioids seem to have only minimal side-effects compared with other analgesics and co-analgesics.Nevertheless, some risks have to be considered. While immunosuppression, neurotoxicity, teratogenity, tolerance and addiction are clinically not relevant or very rare, cognitive impairment, sedation and obstipation may have a clinical impact.However, these symptoms can usually be managed by adjuvant medication and patient education. Treatment of non-malignant pain with opioids can only be considered on an individual basis. Scientific evidence for general treatment with opioids, treatment of specific pain syndromes or treatment with certain opioids is not available. In conclusion, only recommendations regarding opioid treatment for certain chronic pain syndromes can be made. In only a minority of patients can a long-term analgesic effect be expected.Therefore, careful evaluation of alternative options of pain management is necessary before opioid therapy is started. With standardized documentation responders may be distinguished from non-responders. For clinical practice of long-term opioid therapy in non-malignant pain a specialized knowledge in pain management is a prerequisite. Future studies with more sophisticated methodology will be necessary to advocate more precise guidelines.However, the therapeutic recommendations from the DGSS consensus conference allow a safer,well structured and validated use of opioids for chronic non-malignant pain.",2003.0,0,0
798,12625310,Prevention of propofol-induced injection pain by remifentanil: a placebo-controlled comparison with lidocaine.,K D Roehm; S N Piper; W H Maleck; J Boldt,"In a randomised, double-blind study we compared the efficacy of continuous remifentanil infusion (0.25 microg x kg(-1) x min(-1) with 40 mg lidocaine and placebo in the prevention of injection pain due to intravenous propofol administration (1.5-2 mg x kg(-1)) in 155 patients scheduled for elective surgery. Pain severity was evaluated using a four-point scale. The incidence of injection pain was 62% in the placebo group and could be reduced significantly by using remifentanil (30%; p < 0.0015) or lidocaine (33%; p < 0.005). Analysis of the pain scores showed a significant difference between remifentanil and placebo (p < 0.00005) as well as between lidocaine and placebo (p < 0.0002). There was no significant difference between remifentanil and lidocaine. Remifentanil provided effective pain relief, comparable with lidocaine, and is an alternative as part of an intravenous anaesthesia regimen to using another concomitant drug.",2003.0,0,0
799,12626865,[Comparison of two different methods of analgesia. Postoperative course after colorectal cancer surgery].,Kestutis Rimaitis; Irena Marchertiene; Dainius Pavalkis,"The purpose of our study is to compare two methods of postoperative analgesia in colorectal cancer patients after resectional operations, and to evaluate advantages and limitations of each method on the postoperative course of these patients. One hundred patients scheduled to undergo elective colorectal cancer surgery were randomized into two groups; after general anesthesia, one group received epidural analgesia (n=50) and the second one - intramuscular pethidine analgesia (n=50). Visual analogue scale at rest and on coughing was used to compare intensiveness of pain between the two groups during the day of surgery and first three postoperative days. Patients' mood and self-satisfaction were evaluated using self-assessment manikin scale. Side effects of both analgesia techniques were registered. All complications and postoperative hospital stay were also evaluated. Visual analogue scale pain scores at rest and on coughing were significantly better in epidural analgesia group as compared to systemic intramuscular pethidine analgesia group (p<0.05). Additional analgesics were needed for 10 (20%) and 28 (56%) patients respectively to keep visual analogue scale pain scores below 5. Adverse effects such as profound sedation, nausea and vomiting were more frequent in systemic intramuscular pethidine group, but pruritus - very uncommon to compare with epidural analgesia group (p<0.05). There were no significant differences between the two groups in respect to complications and postoperative hospital stay. Epidural analgesia has demonstrated significantly better effectiveness than intramuscular pethidine analgesia after colorectal cancer surgery with fewer adverse events. Self-assessment manikin scores showed better self-satisfaction in patients of epidural analgesia group as compared to patients in systemic pethidine group.",2003.0,0,0
800,12628052,Pain: psychiatric aspects of impairment and disability.,Gerald M Aronoff; Janice M Livengood,"Patients with chronic pain frequently experience a complex and convoluted journey through the health care system that often is unrewarding for all involved. As job satisfaction and financial security diminish during our economic recession, the impact of the disability epidemic becomes more profound. There often is no direct correlation between objective impairment and a patient's request for disability status. Injured workers maintained on workers' compensation may have an increased risk for developing chronic pain syndromes unresponsive to conventional treatments. These patients may have significant financial, psychosocial, and environmental reinforcement for maintenance of their disability and little incentive to return to work. Excessive pain behavior may lead to unnecessary diagnostic testing or invasive procedures and result in iatrogenic complications and prolonged disability. Patients with chronic pain syndrome who have not had psychosocial treatment may not be at maximum medical improvement. The purpose of this paper is to help the readership identify types of psychiatric, psychologic, and psychosocial issues that can coexist in patients with chronic pain who are applying for disability, and to help treating physicians avoid contributing to iatrogenic pain and disability by performing needless and potentially harmful procedures on patients who may be better served with an emphasis on psychiatric or psychologic care.",2003.0,0,0
801,12631041,Analgesic effect of i.v. paracetamol: possible ceiling effect of paracetamol in postoperative pain.,T W Hahn; T Mogensen; C Lund; L S Jacobsen; N-C Hjortsoe; S N Rasmussen; M Rasmussen,"Despite the widespread use of paracetamol for many years, the analgesic serum concentrations of paracetamol are unknown. Therefore the correlation between serum paracetamol concentrations and the analgesic effect was studied. Sixty-four women undergoing laparoscopic sterilization were included in a double-blind, placebo-controlled, randomized study. Patients were given i.v. propacetamol 40 mg kg(-1) (group H), 20 mg kg(-1) (group I), 10 mg kg(-1) (group L) or placebo after surgery. Alfentanil was available via patient-controlled analgesia (PCA) during the 4-h postoperative study period. The patients' self-reported pain was registered on the visual analog scale (VAS). A pharmacokinetic model was fitted to the paracetamol data. One to 3 h after injection of propacetamol the alfentanil consumption was significantly (P = 0.01-0.04) higher in the placebo group compared with groups H, I, and L receiving propacetamol. There were no significant differences between the amounts of alfentanil consumed in groups H, I, and L. Initial VAS-scores were moderate (5.4-6.2), and declined significantly (P < 0.0001) over time, with no difference between groups. Paracetamol followed an open two-compartment model with i.v. administration and first order elimination. The estimated concentrations immediately (t = 0) after injection were 56 mg l(-1) (H), 28 mg l(-1) (I) and 14 mg l(-1) (L). We showed a significant opioid-sparing effect of paracetamol in the immediate postoperative period. Pharmacokinetic data were in accordance with other studies. Our results suggest that a ceiling effect of paracetamol may be present at i.v. doses of 5 mg kg(-1), i.e. a serum concentration of 14 mg l(-1), which is a lower dose than previously suggested.",2003.0,0,0
802,12631450,Medical therapy for chronic pancreatitis pain.,Virmeet V Singh; Phillip P Toskes,"Chronic pancreatitis should be considered in all patients with unexplained abdominal pain. Management of abdominal pain in these patients continues to pose a formidable challenge. The importance of small duct disease without radiographic abnormalities is now a well-established concept. It is meaningful to determine whether patients with chronic pancreatitis have small duct or large duct disease because this distinction has therapeutic implications. Diagnostic evaluation should begin with simple noninvasive and inexpensive tests like serum trypsinogen and fecal elastase, to be followed where appropriate by more complicated measures such as the secretin hormone stimulation test, especially in patients with suspected small duct disease. No universal causal treatment is available. Non-enteric-coated enzyme preparations are useful for treatment of pain, whereas enteric-coated enzyme preparations are preferred for steatorrhea. Octreotide is used increasingly for abdominal pain that is unresponsive to pancreatic enzyme therapy. When medical therapy for chronic pancreatitis pain has failed, endoscopic therapy, endoscopic ultrasound-guided celiac plexus block, and thoracoscopic splanchnicectomy, performed by experts, may be considered for a highly selected patient population. Surgical ductal decompression is appropriate in patients with considerable pancreatic ductal dilation. The role and efficacy of cholecystokinin-receptor antagonists, antioxidants, and antidepressant drugs remain to be defined.",2003.0,0,0
803,12636344,Challenges and choices in drug therapy for chronic pain.,Scott M Fishman; David Teichera,"By treating chronic pain effectively, physicians can improve the quality of their patients' lives considerably. This article reviews the mechanisms and treatment of chronic pain, with emphasis on overcoming the barriers to effective analgesia.",2003.0,0,0
804,12637117,"Analgesic efficacy and tolerability of transdermal buprenorphine in patients with inadequately controlled chronic pain related to cancer and other disorders: a multicenter, randomized, double-blind, placebo-controlled trial.",Reinhard Sittl; Norbert Griessinger; Rudolf Likar,"Buprenorphine is a potent opioid analgesic that is available in sublingual and parenteral formulations. A new formulation, buprenorphine transdermal delivery system (TDS), has been developed. The aim of this study was to compare the analgesic efficacy and tolerability of the 3 available dosages of buprenorphine TDS (35.0, 52.5, and 70.0 microg/h) with placebo. This was a randomized, double-blind, placebo-controlled, multicenter study. Patients with chronic, severe pain related to cancer or other diseases and inadequately controlled with weak opioids were randomized to receive buprenorphine TDS 35.0, 52.5, or 70.0 microg/h or placebo patch for up to 15 days. A new patch was applied every 72 hours, for a total of 5 patches. All patients were permitted rescue analgesia with sublingual buprenorphine tablets (0.2 mg) as required for breakthrough pain. A total of 157 patients (86 women, 71 men; mean [SD] age, 58.7 [11.8] years) were initially enrolled in the study. Buprenorphine TDS was associated with significantly higher response rates than was placebo at the 35.0- and 52.5-microg/h dosages (36.6% and 47.5%, respectively, vs 16.2%; P=0.032 and P=0.003, respectively) and a numerically higher response rate at 70.0 microg/h (33.3%), although this difference did not reach statistical significance. Patients treated with buprenorphine TDS experienced a 56.7% reduction in use of sublingual rescue analgesic during the study compared with an 8% reduction with the placebo patch. A total of 43.5% of patients treated with buprenorphine TDS reported good or complete pain relief compared with 32.4% in the placebo group. Pain intensity decreased in a dose-dependent manner with buprenorphine TDS, and the duration of sleep uninterrupted by pain was improved by the end of the study. More than three fourths (78.8%) of patients in the placebo and buprenorphine TDS groups reported at least 1 adverse event (AE) during the study. The most common AEs were central nervous system and gastrointestinal symptoms. The majority of treatment-related AEs were mild or moderate in intensity and were typical of those occurring at the beginning of therapy with a strong opioid. Buprenorphine TDS was shown to be an effective analgesic against chronic, severe pain in this study population. Patients treated with this new formulation of buprenorphine showed improved duration of sleep and reduced need for additional oral analgesics.",2003.0,0,1
805,12641396,Genetic analysis of pain mechanisms.,Daphné A Robinson; Min Zhuo,"Pain is the major reason for visits to the doctor. It is a complex sensation, with both a sensory and an emotional component. Its detailed regulation at all levels of the central nervous system, from the periphery to the cortex, has hindered our understanding of the neurobiological basis of pain. Furthermore, injury can produce long-lasting changes in pain pathways and chronic pain. The recent use of genetically modified organisms has significantly advanced our comprehension of the molecular and cellular mechanisms underlying pain. In this article we present the current state of knowledge regarding pain transmission, modulation, and plasticity, and some of the contributions made by studies of genetically altered mice. The cellular mechanisms explaining observed phenotypes, the involvement of supraspinal areas, and the plasticity underlying chronic pain are the three areas just beginning to be explored.",2003.0,0,0
806,12641688,Tramadol for pain relief in children undergoing tonsillectomy: a comparison with morphine.,Thomas Engelhardt; Elizabeth Steel; Graham Johnston; Derek Y Veitch,"Pain control for paediatric patients undergoing tonsillectomy remains problematic. Tramadol is reported to be an effective analgesic and to have a side-effect profile similar to morphine, but is currently not licensed for paediatric use in the UK. We conducted a prospective, double-blind, randomized controlled trial in children who were scheduled for elective tonsillectomy or adenotonsillectomy at the Royal Aberdeen Children Hospital. Following local ethics committee approval and after obtaining a drug exemption certificate from the Medicines Licensing Agency for an unlicensed drug, we recruited 20 patients each into morphine (0.1 mg.kg(-1)), tramadol (1 mg.kg(-1)) and tramadol (2 mg.kg(-1)) groups. These drugs were given as a single injection following induction of anaesthesia. In addition, all patients received diclofenac (1 mg.kg(-1)) rectally. The postoperative pain scores, analgesic requirements, sedation scores, signs of respiratory depression and nausea and vomiting, as well as antiemetic requirements, were noted at 4-h intervals until discharge. There were no statistically significant differences in age, weight, type of operation or induction of anaesthesia, 4-h sedation and pain scores and further analgesic requirements. There were no episodes of respiratory depression. Morphine was associated with a significantly higher incidence of vomiting following discharge to the wards (75% versus 40%, P=0.03) compared with both tramadol groups. Tramadol has similar analgesic properties, when compared with morphine. The various pharmaceutical presentations and the availability as a noncontrolled substance may make it a useful addition to paediatric anaesthesia if it becomes licensed for paediatric anaesthesia in the UK.",2003.0,0,0
807,12644419,Lumbar epidural fentanyl: segmental spread and effect on temporal summation and muscle pain.,U Eichenberger; C Giani; S Petersen-Felix; T Graven-Nielsen; L Arendt-Nielsen; M Curatolo,"Despite extensive use, different aspects of the pharmacological action of epidural fentanyl have not been clarified. We applied a multi-modal sensory test procedure to investigate the effect of epidural fentanyl on segmental spread, temporal summation (as a measure for short-lasting central hyperexcitability) and muscle pain. Thirty patients received either placebo, 50 or 100 micro g single dose of fentanyl epidurally (L2-3), in a randomized, double-blind fashion. Heat pain tolerance thresholds at eight dermatomes from S1 to fifth cranial nerve (assessment of segmental spread), pain threshold to transcutaneous repeated electrical stimulation of the sural nerve (assessment of temporal summation) and pain intensity after injection of hypertonic saline into the tibialis anterior muscle (assessment of muscle pain) were recorded. Fentanyl 100 micro g, but not 50 micro g, produced analgesia to heat stimulation only at L2. Surprisingly, no effect at S1 was detected. Both fentanyl doses significantly increased temporal summation threshold and decreased muscle pain intensity. The findings suggest that a single lumbar epidural dose of fentanyl should be injected at the spinal interspace corresponding to the dermatomal site of pain. Increased effect on L2 compared with S1 suggests that drug effect on spinal nerve roots and binding to opioid receptors on the dorsal root ganglia may be more important than traditionally believed for the segmental effect of epidurally injected fentanyl. Epidural fentanyl increases temporal summation threshold and could therefore contribute to prevention and treatment of central hypersensitivity states. I.M. injection of hypertonic saline is a sensitive technique for detecting the analgesic action of epidural opioids.",2003.0,0,0
808,12644426,,,,,0,0
809,12645349,[Delirium is certainly not an unavoidable complication of pain control in the terminal phase of life].,W van der Ligt; M Koelewijn; Z Zylicz,"In three terminal patients, a man aged 19 years who suffered from progressive osteosarcoma, a man aged 71 years with a small-cell pulmonary carcinoma, and a 68-year-old woman with cerebral metastases from a mammary carcinoma, delirium developed due to increased dosage of opioids for seemingly intractable pain (the first two patients) and dexamethasone (third patient). The delirium subsided after opioid rotation, administration of drugs for neuropathic pain, and treatment with an antipsychotic, respectively. This enhanced the patients' quality of terminal life and quality of dying. In terminal patients, analgesics-induced delirium must be considered, diagnosed and treated without delay.",2003.0,0,0
810,12647080,[Surgical pain management. A Germany-wide survey including the effect of clinical guidelines].,E Neugebauer; S Sauerland; V Keck; C Simanski; J Witte,"Over the last few years, various studies have aimed at improving the diagnosis and therapy of perioperative and posttraumatic pain. In an anonymous postal survey, 2,393 German surgical clinics were asked to describe several aspects of their clinical pain treatment. In order to assess the influence of interdisciplinary guidelines on surgical pain therapy, the results of this survey were compared to a survey from 1997. The response rate was 30.8% ( n=738). Pain was measured quantitatively in 11.4% ( n=80) of hospitals, a figure which is unchanged since 1997. In pain treatment,however, some changes were discernible: while 46.6% of all hospitals in 1997 used patient-controlled analgesia often or occasionally, this proportion has risen to 64.5%.Both, the national acute pain guidelines and the WHO chronic pain guidelines were well known (71.3% and 74.7%) and accepted (98.8% and 98.5%, respectively). Among those surgeons who knew the national guidelines,93.7% reported that they used them clinically. In 149 hospitals (20.2%), local guidelines have been developed either anew or from existing guidelines. Although clinical guidelines are widely used, pain therapy in surgical patients has improved only marginally.",2003.0,0,0
811,12648204,Lidocaine versus ropivacaine for continuous interscalene brachial plexus block after open shoulder surgery.,A Casati; F Vinciguerra; M Scarioni; G Cappelleri; G Aldegheri; P Manzoni; G Fraschini; J E Chelly,"This study compared the postoperative infusion of 1% lidocaine and 0.2% ropivacaine for continuous interscalene analgesia in patients undergoing open shoulder surgery. Forty patients undergoing open shoulder surgery received an interscalene brachial plexus block with 30 ml of either 1.5% lidocaine (n = 20) or 0.5% ropivacaine (n = 20), followed by a continuous patient-controlled interscalene analgesia with 1% lidocaine or 0.2% ropivacaine, respectively. A blinded observer recorded the quality of analgesia and recovery of motor function during the first 24 h of infusion. Onset of the block occurred after 7.5 (5-40) min with lidocaine and 30 (10-60) min with ropivacaine (P = 0.0005). Postoperative pain intensity was higher with lidocaine than ropivacaine for the first 8 h of infusion. The ratio between boluses given and demanded from the pump was 0.5 (0.13-0.7) with lidocaine and 0.7 (0.4-1.0) with ropivacaine (P = 0.005). Rescue IV tramadol was required during the first 24 h of infusion by 16 patients of the lidocaine group (84%) and eight patients of the ropivacaine group (46%) (P = 0.05). At the 16 h and 24 h observation times a larger proportion of patients receiving ropivacaine had complete regression of motor block (70% and 95%) than patients receiving lidocaine (50% and 55%) (P = 0.05 and P = 0.013, respectively). Although 1% lidocaine can be effectively used for postoperative patient-controlled interscalene analgesia, 0.2% ropivacaine provides better pain relief and motor function.",2003.0,0,0
812,12656645,Opioid-induced bowel dysfunction: pathophysiology and potential new therapies.,Andrea Kurz; Daniel I Sessler,"Opioid treatment for postoperative or chronic pain is frequently associated with adverse effects, the most common being dose-limiting and debilitating bowel dysfunction. Postoperative ileus, although attributable to surgical procedures, is often exacerbated by opioid use during and following surgery. Postoperative ileus is marked by increased inhibitory neural input, heightened inflammatory responses, decreased propulsive movements and increased fluid absorption in the gastrointestinal tract. The use of opioids for chronic pain is characterised by a constellation of symptoms including hard dry stools, straining, incomplete evacuation, bloating, abdominal distension and increased gastroesophageal reflux. The current management of opioid-induced bowel dysfunction among patients receiving opioid analgesics consists primarily of nonspecific ameliorative measures. Intensive investigations into the mode of action of opioids have characterised three opioid receptor classes -mu, delta and kappa- that mediate the myriad of peripheral and central actions of opioids. Activation of mu-opioid receptors in the gastrointestinal tract is responsible for inhibition of gut motility, whereas receptors in the central nervous system mediate the analgesic actions of opioids. Blocking peripheral opioid receptors in the gut is therefore a logical therapeutic target for managing opioid-induced bowel dysfunction. Available opioid antagonists such as naloxone are of limited use because they are readily absorbed, cross the blood-brain barrier, and act at central opioid receptors to reverse analgesia and elicit opioid withdrawal. Methylnaltrexone and alvimopan are recently developed opioid antagonists with activity that is restricted to peripheral receptors. Both have recently shown the ability to reverse opioid-induced bowel dysfunction without reversing analgesia or precipitating central nervous system withdrawal signs in non-surgical patients receiving opioids for chronic pain. In addition, recent clinical studies with alvimopan suggest that it may normalise bowel function without blocking opioid analgesia in abdominal laparotomy patients with opioid-related postoperative ileus.",2003.0,0,0
813,12657858,"Parecoxib sodium, a parenteral cyclooxygenase 2 selective inhibitor, improves morphine analgesia and is opioid-sparing following total hip arthroplasty.",T Philip Malan; Gregory Marsh; Sam I Hakki; Evie Grossman; Louise Traylor; Richard C Hubbard,"This study examined the opioid-sparing effectiveness, analgesic efficacy, and tolerability of postoperative administration of the parenteral cyclooxygenase 2 selective inhibitor, parecoxib sodium, in total hip arthroplasty patients. This was a multicenter, multiple-dose, randomized, double-blind, placebo-controlled study to compare the opioid-sparing effects, analgesic efficacy, and tolerability of postoperative 20 and 40 mg intravenous parecoxib sodium with placebo in hip arthroplasty patients. The first dose of study medication was administered after surgery with an intravenous bolus dose of 4 mg morphine when patients first requested pain medication; remedication with the study medication occurred at 12 and 24 h. Subsequent morphine doses (1-2 mg) were administered by patient-controlled analgesia. Efficacy was assessed by total morphine used, pain relief and pain intensity, time to last dose of morphine, and Global Evaluation rating of the study medication. Parecoxib sodium, 20 and 40 mg, reduced the total amount of morphine required over 36 h by 22.1% (56.5 mg morphine) and 40.5% (43.1 mg morphine), respectively, compared with placebo (72.5 mg morphine; P < 0.01). Patients receiving 20 and 40 mg parecoxib sodium experienced significantly greater maximum pain relief compared with those in the placebo group (P < 0.05). Patients who received 20 and 40 mg parecoxib sodium discontinued PCA morphine earlier than patients receiving placebo and had significantly higher Global Evaluation ratings. Parecoxib sodium, 40 mg, plus morphine demonstrated a significantly lower incidence of fever and vomiting compared with placebo plus morphine. Administration of parecoxib sodium with PCA morphine resulted in significantly improved postoperative analgesic management as defined by reduction in opioid requirement, lower pain scores, reduced time on PCA morphine, and higher Global Evaluation ratings.",2003.0,0,0
814,12660386,Oral opioid therapy for chronic peripheral and central neuropathic pain.,Michael C Rowbotham; Lisa Twilling; Pamela S Davies; Lori Reisner; Kirk Taylor; David Mohr,"Although opioids are commonly used to treat chronic neuropathic pain, there are limited data to guide their use. Few controlled trials have been performed, and many types of neuropathic pain remain unstudied. Adults with neuropathic pain that was refractory to treatment were randomly assigned to receive either high-strength (0.75-mg) or low-strength (0.15-mg) capsules of the potent mu-opioid agonist levorphanol for eight weeks under double-blind conditions. Intake was titrated by the patient to a maximum of 21 capsules of either strength per day. Outcome measures included the intensity of pain as recorded in a diary, the degree of pain relief, quality of life, psychological and cognitive function, the number of capsules taken daily, and blood levorphanol levels. Among the 81 patients exposed to the study drug, high-strength levorphanol capsules reduced pain by 36 percent, as compared with a 21 percent reduction in pain in the low-strength group (P=0.02). On average, patients in the high-strength group took 11.9 capsules per day (8.9 mg per day) and patients in the low-strength group took close to the 21 allowed (18.3 capsules per day; 2.7 mg per day). Affective distress and interference with functioning were reduced, and sleep was improved, but there were no differences between the high-strength group and the low-strength group in terms of these variables. Noncompletion of the study was primarily due to side effects of the opioid. Patients with central pain after stroke were the least likely to report benefit. The reduction in the intensity of neuropathic pain was significantly greater during treatment with higher doses of opioids than with lower doses. Higher doses produced more side effects without significant additional benefit in terms of other outcome measures.",2003.0,0,1
815,12660393,Opioids and chronic neuropathic pain.,Kathleen M Foley,,2003.0,0,0
816,12662119,Pain management in children with sickle cell disease.,Jennifer Stinson; Basem Naser,"Sickle cell disease (SCD) is one of the most common inherited diseases worldwide. The disease is characterized by chronic hemolytic anemia, as well as acute and chronic complications. One of the most intractable problems encountered by children with SCD is the painful episode that results from tissue ischemia due to vaso-occlusion. Pain related to SCD is unique among pain syndromes due to the unpredictable, recurrent, and often persistent nature of the disease, as well as the recurring and essential need for the use of opioids. Painful vaso-occlusive episodes (VOE) are a principal cause of morbidity and account for a significant number of emergency department and hospital admissions. When untreated or inadequately managed, the pain of VOE may cause both short- and long-term consequences. Despite the fact that pain is an almost universal feature of the disease, children with SCD may form one of the most undertreated and understudied populations. One of the factors contributing to poor pain management is conflicting perceptions between patients, their families, and healthcare professionals about pain that is reported and analgesia that is required. Pain management guidelines have recently been published in an effort to overcome barriers in the assessment and management of pain related to SCD. Although there is considerable variability in the way SCD pain is managed, the standard treatment protocol for painful episodes has been rest, rehydration, and analgesia. However, pain control for children with SCD is often a difficult and complex process, and one that requires frequent systematic pain assessments and continuous adjustment of comfort measures, especially analgesics. There are a variety of analgesic agents to choose from, such as acetaminophen (paracetamol), oral or parenteral nonsteroidal anti-inflammatory drugs, and oral or parenteral opioids. Each of these options has advantages and disadvantages to their use. Continuous infusions of analgesics and patient controlled analgesia have been shown to be effective and widely used in hospital settings to manage severe pain. However, the opioid dose required to achieve pain relief varies considerably within each painful episode, from one episode to another, and between individual patients. Although not yet curable in humans, pain related to SCD can be effectively managed in most patients by using a comprehensive approach that incorporates pharmacologic, psychologic, behavioral, and physical pain management strategies.",2003.0,0,0
817,12666001,[Can the addition of clonidine improve the analgesic efficacy of low dose intrathecal morphine? A randomised double-blind trial].,M Gehling; M Tryba; T Lüsebrink; A Zorn,"To evaluate the influence of intrathecal clonidine on spinal morphine analgesia and adverse effects after major orthopaedic surgery. The study was approved by the local Ethics Committee.After written informed consent, 45 ASA I-III patients scheduled for hip or knee replacement were included. Patients were randomly allocated to receive either placebo, 0.1 mg morphine or 0.1 mg morphine+50 microg clonidine in addition to 15 mg bupivacaine intrathecally. The primary outcome parameter was the time to first opioid request. Statistical differences were calculated with U-test or Fisher's exact test. Clonidine did not result in a significant improvement of postoperative analgesia. The mean time until first opioid request was for placebo 10.3+/-7.9 h, for 0.1 mg morphine 23.0+/-3.9 h and for 0.1 mg morphine+ 50 microg clonidine 21+/-6.9 h, respectively. Clonidine significantly increased the rate of adverse effects. Our trial did not confirm an improved analgesia with the combination of intrathecal morphine and clonidine. Due to increased adverse effects the combination of intrathecal clonidine and morphine does not seem to be a reasonable alternative in the management of postoperative pain after orthopaedic surgery.",2003.0,0,0
818,12670809,Non-opioid analgesia improves pain relief and decreases sedation after gastric bypass surgery.,James M Feld; Charles E Laurito; Mihail Beckerman; Joseph Vincent; William E Hoffman,"Several non-opioid drugs have been shown to provide analgesia during and after surgery. We compared sevoflurane anesthesia with fentanyl analgesia to sevoflurane and non-opioid drug treatment for gastric bypass surgery and recovery. Thirty obese patients (body mass index > 50 kg.m(-2)) undergoing gastric bypass were randomized to receive sevoflurane anesthesia with either fentanyl or a non-opioid regimen including ketorolac, clonidine, lidocaine, ketamine, magnesium sulfate, and methylprednisolone. Morphine use by patient-controlled analgesia (PCA) pump and pain score measured by visual analogue scale were determined in the postanesthesia care unit (PACU) and for the first 16 hr after surgery. Sedation was evaluated in the PACU. Investigators assessing patient outcomes were blinded to the study group. Fentanyl treated patients were more sedated in the PACU compared to the non-opioid group. Non-opioid treated patients required 5.2 +/- 2.6 mg.hr(-1) morphine by PCA during their stay in the PACU while patients anesthetized with fentanyl used 7.8 +/- 3.3 mg.hr(-1) (P < 0.05). Fentanyl and non-opioid treated patients showed no difference in pain score one or 16 hr after surgery. Our results show that non-opioid analgesia produced pain relief and less sedation during recovery from gastric bypass surgery compared to fentanyl.",2003.0,0,0
819,12670812,Intrathecal + PCA morphine improves analgesia during the first 24 hr after major abdominal surgery compared to PCA alone.,Jean-Michel Devys; Anne Mora; Benoît Plaud; Christian Jayr; Agnès Laplanche; Bruno Raynard; Philippe Lasser; Bertrand Debaene,"To compare, over a 48-hr follow-up period, the analgesia and side-effects of patient controlled iv analgesia (PCA) with morphine alone vs combined intrathecal and PCA morphine (IT+PCA) in patients undergoing major abdominal surgery. Sixty adult patients undergoing abdominal surgery for cancer were randomly allocated to receive preoperative IT (0.3 or 0.4 mg) plus postoperative PCA morphine or postoperative PCA morphine alone. Postoperative analgesia was tested at rest and while coughing on a visual analogue pain scale and morphine consumption was recorded. Patients' satisfaction, arterial oxygen saturation, respiratory rate, episodes of nausea, vomiting and pruritus were also noted. Analgesia at rest and while coughing was significantly better in the IT+PCA morphine group (rest: P = 0.01; coughing: P = 0.005) on the first postoperative day only. IT+PCA morphine constantly provided adequate analgesia during this period. Morphine consumption was lower in the IT+PCA morphine group during this period also (IT+PCA: 9 (17) vs PCA: 40 (26); mg of morphine, mean (SD), P = 0.0001). No difference was found in pain relief and morphine consumption between the groups on the second postoperative day. Nausea and vomiting were more frequent with IT+PCA morphine on the first postoperative day. No respiratory depression occurred in either group. Satisfaction was high in both groups. IT+PCA morphine improves patient comfort constantly during the first postoperative day after major abdominal surgery. However, after the first postoperative day, IT+PCA morphine provides no additional benefit.",2003.0,0,0
820,12670813,,,,,0,0
821,12681176,[Clinical characteristics of children with chronic pain in a pediatric pain unit: oncologic pain versus non-oncologic pain].,M J Millán-Millán; F Reinoso-Barbero; M P Díaz-Miguel; J García-Consuegra; S I Pascual-Pascual; B Olsen-González; F Carceller-Benito,"Despite undoubted scientific advances in the field of chronic pain in children, there is no evidence of clinical application of this knowledge. To describe the experience of a pediatric pain unit (PPU) specifically dedicated to the treatment of chronic pain in children. We performed an analytic, observational, retrospective, cohort study of the clinical features of the first 42 patients treated for chronic pain in the PPU during a two-year period. The patients were assigned to two groups: an oncologic group and a non-oncologic group. ANOVA was used to analyze quantitative variables and the Chi-square test was used to analyze qualitative variables. No significant differences were found between the two groups in the demographic variables studied (age and sex). Concerning the type of treatment used, no significant differences were found in effectiveness or compliance. However, treatment duration was significantly longer in the non-oncologic group than in the oncologic group (74.2 days vs 37.5 days, p(0.008). The duration of non-oncologic chronic pain before attending the PPU (mean: 557 days) influenced the effectiveness (r 5 0.781; p 5 0.0001) and duration of treatment (r 5 0.61; p 5 0.0051). However, the duration of previous chronic oncologic pain was significantly shorter (mean: 34 days) and showed no influence on treatment effectiveness or duration. The pediatric population presents chronic pain syndromes that can be appropriately treated in a PPU with conventional, easy to manage analgesics. We recommend the establishment of pediatric pain units similar to those for adults, using a multidisciplinary approach to mitigate children's suffering.",2003.0,0,0
822,12686003,Pain management in older adults.,Margo L Schilling,"Pain is a common complaint of older adults. Persistent pain has a significant negative impact on elderly individuals' sense of well being, physical function, and quality of life. Increasing age and cognitive impairment are risk factors for undertreatment of persistent pain. Safe and effective therapy is available for pain syndromes that commonly affect older adults. Recognition of failure of health providers to appropriately assess and manage persistent pain has led to the recent development and adoption of regulatory guidelines for the implementation of effective pain management programs.",2003.0,0,0
823,12688385,The role of spinal cholecystokinin in chronic pain states.,Zsuzsanna Wiesenfeld-Hallin; Xiao-Jun Xu; Tomas Hökfelt,"It is well established that cholecystokinin (CCK) reduces the antinociceptive effect of opioids. The level of CCK and CCK receptors, as well as CKK release, exhibits considerable plasticity after nerve injury and inflammation, conditions known to be associated with chronic pain. Such altered CCK release coupled in some situation with changes in CCK receptor levels may underlie the clinical phenomenon of varying opioid sensitivity in different clinical pain conditions. In particular, neuropathic pain after injury to the peripheral and central nervous system does not respond well to opioids, which is likely to be caused by increased activity in the endogenous CCK system. CCK receptor antagonists may thus be useful as analgesics in combination with opioids to treat neuropathic pain.",2003.0,0,0
824,12694143,Post-thoracotomy pain after thoracic epidural analgesia: a prospective follow-up study.,E Tiippana; E Nilsson; E Kalso,"Pain becomes chronic in 22-67% of patients who undergo a thoracotomy. Thoracic epidural analgesia (TEA) has replaced less invasive methods to manage postoperative pain. We wanted to find out if active use of TEA, combined with extended pain management at home, reduces the incidence of chronic post-thoracotomy pain. All consecutive thoracotomy patients during a 16-month period were included. On the ward, pain was measured daily by VAS during rest and coughing and the consumption of analgesics was registered. The patients were interviewed one week after discharge by telephone and by a questionnaire after 3 and 6 months to find out how much pain they had. A total of 114 patients were recruited. The data were analysed from 89 patients who had had TEA and 22 who had had other methods. TEA was effective in alleviating pain at rest and during coughing. In the TEA patients the incidence of chronic pain of at least moderate severity was 11% and 12% at 3 and 6 months, respectively. One week after discharge 92% of all patients needed daily pain medication. TEA seems effective in controlling evoked postoperative pain, but technical problems occurred in 24% of the epidural catheters. The incidence of chronic pain was lower compared with previous studies where TEA was not used. The patients had significant pain and needed regular pain medication and instructions during the first week after discharge. Extended postoperative analgesia up to the first week at home is warranted.",2003.0,0,0
825,12694144,"The minimally effective concentration of adrenaline in a low-concentration thoracic epidural analgesic infusion of bupivacaine, fentanyl and adrenaline after major surgery. A randomized, double-blind, dose-finding study.",G Niemi; H Breivik,"We have documented that adrenaline 2.0 micro g.ml- 1 markedly improves relief of dynamic pain when added to a thoracic epidural analgesic infusion of bupivacaine 1 mg.ml- 1 and fentanyl 2 micro g.ml- 1. Concern about possible adverse effects on spinal cord blood flow, expressed by others, prompted us to find the lowest concentration of adrenaline needed to produce effective and reliable pain relief after major surgery. A prospective, randomized, double-blind, parallel group study was carried out in 36 patients after major thoracic or upper abdominal surgery. Patients with only mild pain when coughing during titrated thoracic epidural infusion of approximately 9 ml per hour of bupivacaine 1 mg.ml- 1, fentanyl 2 micro g.ml- 1, and adrenaline 2.0 micro g.ml- 1 were included. The study was conducted as a dose-finding study comparing three different adrenaline concentrations in the epidural mixture (0.5, 1.0, and 1.5 micro g.ml- 1) with each other and with adrenaline 2.0 micro g.ml- 1 in our standard epidural mixture. On the 1st postoperative day, the patients were randomly allocated into three equal groups of 12 patients each, and given a double-blind epidural infusion at the same rate, but with different adrenaline concentrations (0.5, 1.0, or 1.5 micro g.ml- 1). The effects were observed for 4 h or until pain when coughing became unacceptable in spite of rescue analgesia. Rescue analgesia consisted of up to two patient-controlled epidural bolus injections per hour (4 ml) and subsequent i.v. morphine, if necessary. All patients received rectal paracetamol 1 g, every 6th hour. Main outcome measures were pain intensity at rest and when coughing, evaluated by a visual analogue scale and an overall quality of pain relief score. The extent of sensory blockade was evaluated by determining dermatomal hypaesthesia to cold. Pain intensity when coughing increased (P < 0.001) and the number of hypaesthetic dermatomal segments decreased (P < 0.002) when the concentration of adrenaline was reduced below 1.5 micro g.ml- 1 in the triple epidural mixture. This change started within two hours after reducing the concentration of adrenaline below 1.5 micro g.ml- 1. The differences in pain intensities at rest were less pronounced. After 4 h with adrenaline 0.5 or 1.0 micro g.ml- 1 pain intensity when coughing was unacceptable in spite of rescue analgesia. After restarting the standard epidural mixture with adrenaline 2.0 micro g.ml- 1, pain intensity was again reduced to mild pain when coughing and the sensory blockade was restored. Occurrence of pruritus increased with a decreasing adrenaline concentration. Adrenaline in a dose-related manner improves the pain-relieving effect and sensory blockade and decreases the occurrence of pruritus of a low-concentration thoracic epidural analgesic infusion of bupivacaine 1 mg. ml- 1 and fentanyl 2 micro g.ml- 1 after major thoracic or upper abdominal surgery. The minimally effective concentration of adrenaline, when added to bupivacaine 1 mg.ml- 1 and fentanyl 2 micro g.ml- 1, to maintain relief of dynamic pain is approximately 1.5 micro g.ml- 1. The data clearly document that dynamic, cough-provoked pain is a more sensitive outcome measure for postoperative pain relief than pain at rest.",2003.0,0,0
826,12694145,"Randomized, double-blind, placebo-controlled study of the effect of rectal paracetamol on morphine consumption after abdominal hysterectomy.",O Kvalsvik; P C Borchgrevink; L Hagen; O Dale,"Paracetamol is widely used for postoperative analgesia. The effect is well documented in minor and moderate extensive surgery, but the effect of paracetamol as an adjunct to opioids in major abdominal surgery is less examined. Seventy-eight patients scheduled for elective, benign, and abdominal hysterectomy were included in a prospective, randomized, double-blind, parallel group, placebo-controlled study to evaluate the effect of rectal paracetamol in conjunction with intravenous patient-controlled analgesia (PCA) morphine. Paracetamol 1000 mg or placebo suppositories were given four times daily during the 60-h study period. I.V. morphine was administered via a PCA pump, limited to maximum of 12 mg h-1. Morphine consumption, pain and morphine-related adverse effects were recorded. A single-point analysis was comprised of serum concentrations of paracetamol and morphine. Sixty patients were evaluated: 30 in each group. A 16.6% reduction in overall-accumulated morphine consumption in the treatment group (99.6 vs. 83.3 mg) was observed (NS, P = 0.06). Mean paracetamol serum concentration was 0.03 mmol l-1 (range: 0.01-0.06 mmol l-1). None of the patients had a paracetamol concentration within the therapeutic range for antipyretic efficacy. Patients with a higher paracetamol concentration had a lower concomitant morphine (P = 0.025) and morphine-6-glucuronide (P = 0.014) concentration 2 h after paracetamol administration. A dosage of rectal paracetamol 1000 mg four times daily is too low, as all displayed a suboptimal serum paracetamol concentration. To study the effect of rectal paracetamol after major surgery we have to increase the dose, as higher serum concentrations of paracetamol may cause lower serum concentrations of morphine.",2003.0,0,0
827,12695891,[Postoperative pain therapy with tilidin and tilidin retard as an oral patient-controlled analgesia after uncomplicated myocardial revascularization].,T H Cegla; F Walter; A Borchers; M Trenz,"The purpose of this study was to evaluate whether or not the combination of tilidin and tilidin retard as oral patient-controlled analgesia provide a suitable pain management in patients after uncomplicated myocardial revascularization. We conducted a randomised phase IV study to evaluate the effectiveness of postoperative analgesia with tilidin and tilidin retard. Patients with a baseline tilidin retard and tilidin liquid demand medication (group B, 42 patients) were compared with a base line paracetamol and tramadol-HCl liquid demand medication (group A, 44 patients). All patients received the first dose of study medication at the second postoperative day after evaluation of the individual pain score using NRS (numeric rating scale). Pain relief in group B was significantly better only at the second postoperative day (NRS 1,8 compared to 3,3 in group A), associated with tolerable side effects and comfortable handling. The combination of sustained release with immediate release drugs as a patient controlled analgesia provides suitable and comfortable analgesia after myocardial bypass surgery.",2003.0,0,1
828,12697593,Age- and therapy-related effects on morphine requirements and plasma concentrations of morphine and its metabolites in postoperative infants.,N J Bouwmeester; J N van den Anker; W C J Hop; K J S Anand; D Tibboel,"To investigate clinical variables such as gestational age, sex, weight, the therapeutic regimens used and mechanical ventilation that might affect morphine requirements and plasma concentrations of morphine and its metabolites. In a double-blind study, neonates and infants stratified for age [group I 0-4 weeks (neonates), group II > or =4-26 weeks, group III > or =26-52 weeks, group IV > or =1-3 yr] admitted to the paediatric intensive care unit after abdominal or thoracic surgery received morphine 100 micro g kg(-1) after surgery, and were randomly assigned to either continuous morphine 10 micro g kg(-1) h(-1) or intermittent morphine boluses 30 micro g kg(-1) every 3 h. Pain was measured using the COMFORT behavioural scale and a visual analogue scale. Additional morphine was administered on guidance of the pain scores. Morphine, morphine-3-glucuronide (M3G) and morphine-6-glucuronide (M6G) plasma concentrations were measured before, directly after, and at 6, 12 and 24 h after surgery. Multiple regression analysis of different variables revealed that age was the most important factor affecting morphine requirements and plasma morphine concentrations. Significantly fewer neonates required additional morphine doses compared with all other age groups (P<0.001). Method of morphine administration (intermittent vs continuous) had no significant influence on morphine requirements. Neonates had significantly higher plasma concentrations of morphine, M3G and M6G (all P<0.001), and significantly lower M6G/morphine ratio (P<0.03) than the older children. The M6G/M3G ratio was similar in all age groups. Neonates have a narrower therapeutic window for postoperative morphine analgesia than older age groups, with no difference in the safety or effectiveness of intermittent doses compared with continuous infusions in any of these age groups. In infants >1 month of age, analgesia is achieved after morphine infusions ranging from 10.9 to 12.3 micro g kg(-1) h(-1) at plasma concentrations of <15 ng ml(-1).",2003.0,0,0
829,12697594,Dextromethorphan and intrathecal morphine for analgesia after Caesarean section under spinal anaesthesia.,D M A Choi; A P Kliffer; M J Douglas,"Dextromethorphan is an N-methyl-D-aspartic acid antagonist which can attenuate acute pain with few side-effects. In this prospective, randomized, double-blind study of dextromethorphan and intrathecal morphine, we investigated postoperative pain, pruritus, nausea and vomiting in women undergoing Caesarean section under spinal anaesthesia. Women were allocated randomly to one of six groups, to receive intrathecal morphine 0.05, 0.1 or 0.2 mg plus oral dextromethorphan 60 mg or placebo. The addition of dextromethorphan did not reduce postoperative pain scores (P=0.83). Compared with women receiving intrathecal morphine 0.05 mg, women receiving higher doses had a significantly higher incidence of nausea and vomiting [odds ratio for intrathecal morphine 0.1 mg, 4.0 (95% confidence interval 1.2-14.1); for intrathecal morphine 0.2 mg, 7.9 (2.3-27.1)]. Compared with women receiving intrathecal morphine 0.05 mg, women receiving higher doses also had a significantly higher incidence of pruritus [odds ratio for intrathecal morphine 0.1 mg, 3.2 (95% confidence interval 1.3-8.2); for intrathecal morphine 0.2 mg, 3.7 (1.4-9.5)]. Women receiving dextromethorphan had a lower incidence of nausea and vomiting [odds ratio 2.6 (1.1-6.3)]. Postoperative pain after Caesarean section under spinal anaesthesia was not reduced by the addition of oral dextromethorphan to a multimodal approach including intrathecal morphine.",2003.0,0,0
830,12697595,Comparison of intrathecal isobaric bupivacaine-morphine and ropivacaine-morphine for Caesarean delivery.,C O Oğün; E N Kirgiz; A Duman; S Okesli; C Akyürek,"This study was designed to evaluate the effects of intrathecal isobaric bupivacaine 0.5% plus morphine and isobaric ropivacaine 0.5% plus morphine combinations in women undergoing Caesarean deliveries. Twenty-five parturients received ropivacaine 15 mg and morphine 150 micro g (RM group) and twenty-five parturients received bupivacaine 15 mg and morphine 150 micro g (BM group) for spinal anaesthesia. Sensory and motor block, haemodynamics, postoperative analgesia, fetal outcomes, and side-effects were evaluated. Intrathecal bupivacaine-morphine and ropivacaine-morphine provided effective sensory anaesthesia and motor block. Time to reach complete motor block was shorter and time to complete recovery from motor block was longer in the BM group than the RM group (P<0.05). The time to regression of two dermatomes and time for the block to recede to the S2 dermatome were similar in both groups (P>0.05). Time to first complaint of pain and the mean total consumption of tenoxicam were similar in both groups (P>0.05). APGAR scores at 1 and 5 min were similar in the two groups, as were mean umbilical blood pH values (P>0.05). Hypotension and pruritus were the most common side-effects in both groups during the operation. Intrathecal isobaric ropivacaine 0.5% 15 mg plus morphine 150 micro g provides sufficient anaesthesia for Caesarean delivery. The ropivacaine-morphine combination resulted in shorter motor block, similar sensory and postoperative analgesia.",2003.0,0,0
831,12699520,A randomised double-blind evaluation of adenosine as adjunct to sufentanil in spinal labour analgesia.,K Rane; A Sollevi; M Segerdahl,"Intrathecal injection of sufentanil offers labour pain relief of short duration. This double-blind randomised study evaluates if the combination of adenosine to sufentanil could give relevant prolongation (40%) of the duration of sufentanil spinal analgesia. Twenty-five healthy parturients requesting labour analgesia were included. Patients received 10 micro g of sufentanil + 500 micro g of adenosine or 10 micro g of sufentanil intrathecally. Pain intensity and duration of pain relief were assessed. Pain relief was equal between groups. Duration of analgesia was not increased by adenosine + sufentanil, 99 +/- 54 min, vs. sufentanil, 89 +/- 56 min. Adding 500 micro g of adenosine to 10 micro g of sufentanil could not provide any prolongation of labour pain relief.",2003.0,0,0
832,12699521,Ketamine reduces swallowing-evoked pain after paediatric tonsillectomy.,M Elhakim; Z Khalafallah; H A El-Fattah; S Farouk; A Khattab,"Ketamine efficacy as an analgesic adjuvant has been studied in several clinical settings with conflicting results. The aim of this study was to investigate the effect of ketamine on spontaneous and swallowing-evoked pain after tonsillectomy. Fifty children were randomized to receive premedication with either ketamine 0.1 mg kg(-1) i.m. or placebo given 20 min before induction of a standard general anaesthesia. All children received rectal diclofenac 2 mg kg(-1) and fentanyl 1 micro g kg(-1) i.v. before surgery. The ketamine group showed significantly lower pain scores both at rest and on swallowing, with less total paracetamol consumption (P < 0.05) during the 24 h after surgery. Significantly more patients required postoperative morphine titration in the control group (P < 0.05). The time to the first oral intake, and duration of i.v. hydration, were significantly shorter and the quality of oral intake was significantly better in the ketamine group (P < 0.05). There were no differences in the incidence of vomiting or dreaming between the groups. Premedication with a small dose of ketamine reduces swallowing-evoked pain after tonsillectomy in children who received an analgesic regimen combining an opioid and a NSAID.",2003.0,0,0
833,12701975,"Adding ketoprofen to intravenous patient-controlled analgesia with tramadol after major gynecological cancer surgery: a double-blinded, randomized, placebo-controlled clinical trial.",S Tuncer; L Pirbudak; O Balat; M Capar,"Ketoprofen is a NSAIDs of the 2-aryl propionic acid class commonly used in the treatment of inflammatory rheumatic disease, acute pain and fever. Clinically, ketoprofen seems to reduce morphine requirements by 33 to 40% with ketoprofen's supposed central mechanism of analgesia. We evaluated the efficacy and safety of intravenous (IV) ketoprofen as an adjuvant to IV PCA (patient controlled analgesia) with tramadol after major gynecological cancer surgery for postoperative analgesia. Fifty patients were enrolled in this double-blinded, randomized, placebo-controlled study. Patients were allocated randomly to two groups: group I (25 patients) served as a control group, with patients receiving saline; group II (25 patients) received ketoprofen. Patients received an intravenous bolus of saline or 100 mg ketoprofen at the end of surgery. Then, PCA was given as a 20 mg tramadol bolus and 10 min lockout time. Pain relief was regularly assessed using a visual analog scale. Tramadol consumption, side-effects, and patient satisfaction were noted during the 24 hours after the surgery. No significant difference was observed in pain score, side-effects and patient satisfaction between the groups (p > 0.05). The cumulative PCA-tramadol consumption was lower in the ketoprofen-treated patients than placebo-treated patients (p < 0.05). Our results demonstrate that a single dose of 100 mg ketoprofen reduced tramadol consumption for treatment of postoperative pain after major gynecological cancer surgery.",2003.0,0,0
834,12708207,[Analgesia and sedation in the subarachnoid anesthesia technique: comparative study between remifentanil and fentanyl/midazolam].,E Calderón; A Pernia; M D Román; A C Pérez; L M Torres,"To assess the efficacy and safety of remifentanil in comparison with fentanyl-midazolam for analgesia and sedation during subarachnoid anesthesia. Sixty ASA I-III patients between 25 and 75 years old and scheduled for inguinal hernia repair were enrolled. Before the subarachnoid block, the patients were randomly assigned to receive an intravenous infusion of 0.1 microgram.Kg-1.min.-1 of remifentanil (group R) or 1 microgram.Kg-1 of fentanyl and 0.02 mg.Kg-1 of midazolam (group F). Ten minutes later a subarachnoid block to L3-L4 was performed with 10 mg of hyperbaric bupivacaine. We recorded intensity of pain during performance of the block on a simple verbal scale, the observer's assessment of alertness/sedation (OAA/S), hemodynamic variables, respiratory frequency and SpO2, level of comfort and side effects. Over 70% of patients had no pain or slight pain during the subarachnoid puncture and absence of pain was significantly greater in group R than in group F (37% vs. 16%, p < 0.05). Sedation was adequate during surgery in both groups (OAA/S 2-3). There were no differences in level of comfort between the two groups. The incidences of hypoxemia, hypoventilation and excessive sedation were significantly higher in group R (40%, 20% and 16%, respectively; p < 0.05). Remifentanil is more effective for treating pain associated with a subarachnoid block and provides cardiovascular stability with a limited level of sedation per dose, but its use is associated with a high incidence of respiratory depression.",2003.0,0,0
835,12712491,"Preoperative and postoperative dextromethorphan provides sustained reduction in postoperative pain and patient-controlled epidural analgesia requirement: a randomized, placebo-controlled, double-blind study in lower-body bone malignancy-operated patients.",Avi A Weinbroum; Benjamin Bender; Jacob Bickels; Alexander Nirkin; Nissim Marouani; Shoshana Chazam; Isaac Meller; Yehuda Kollender,"Pain is mediated centrally by N-methyl-D-aspartate (NMDA) receptors. The antinociceptive effects of preincision dextromethorphan (DM), an NMDA antagonist, have been demonstrated in surgical patients under general or epidural anesthesia. The authors investigated the effects of DM on postoperative pain and other parameters in patients undergoing surgery for bone malignancy under standardized combined general and epidural anesthesia using patient-controlled epidural analgesia (PCEA) postoperatively. Patients received placebo or DM 90 mg (30 patients per group) in a double-blind manner preoperatively and on each of the two following days. Postoperative PCEA consisted of 1.6 mg ropivacaine plus 4 microg/mL fentanyl both continuously and by demand up to 96 hours, starting when subjective pain intensity was greater than or equal to 4/10 (visual analog score). Rescue drugs on demand (paracetamol or dipyrone orally) were also available. The DM patients experienced about 50% (P < 0.01) less pain than their placebo counterparts for more than 2 postoperative days and they rated their overall maximal pain intensity by one-half that estimated by the placebo-treated patients (P < 0.01). The DM group also consumed 30-50% less epidural analgesics than the total amount consumed by the placebo-medicated group (P < 0.01) and demanded significantly (P < 0.05) fewer rescue drugs on the first postoperative day. They were less sedated (40-60%, P < 0.01) and reported 50% fewer overall side effects (P < 0.05). The groups were similar for the need for urinary catheterization, time of first ambulation, and/or discharge home. A 3-day DM administration is associated with better pain reduction in patients undergoing surgery for bone malignancy under combined general and epidural anesthesia with postoperative PCEA compared with placebo without increasing side effects.",2003.0,0,0
836,12719047,Sevoflurane requirements during coloproctologic surgery: difference between two different epidural regimens.,Maylin Koo; Antoni Sabaté; Antonia Dalmau; Imma Camprubi,"To examine the influence of epidural morphine on the end-tidal sevoflurane concentration titrated to maintain bispectral index (BIS) values between 40 and 50. Prospective, double-blinded clinical trial. Anesthesia department of a university hospital. 40 ASA physical status I, II, and III patients scheduled for elective coloproctological surgery. Patients were randomized to receive via a thoracic epidural catheter either a) bupivacaine 0.25% (10 mL) and saline 0.9% (2 mL) as a bolus followed by an infusion of bupivacaine 0.25% (5 mL/hr) or b) bupivacaine 0.25% (10 mL) and morphine 0.1% (2 mL) as a bolus followed by an infusion of bupivacaine 0.25% plus morphine 0.025% (5 mL/hr). Anesthesia was induced with propofol, fentanyl 2 microg kg(-1) and atracurium and maintained with sevoflurane and nitrous oxide in oxygen. Sevoflurane level was titrated to maintain a BIS value between 40 and 50. After extubation, patients were asked about the presence of pain. There was no significant difference between groups of end-tidal sevoflurane concentrations at identical BIS values and hemodynamic values at any time in the study. However, the morphine group had a lower pain score level at extubation than did the plain bupivacaine group (no pain on movement, 79% vs. 31.5%, p < 0.01). Adding morphine to the bupivacaine epidural solution did not reduce sevoflurane requirements but did provide high-quality postoperative analgesia, mainly just after tracheal extubation.",2003.0,0,0
837,12719050,,,,,0,0
838,12720597,Pharmacotherapy of neuropathic low back pain.,Michael H Moskowitz,"Neuropathic low back pain is examined from a structural standpoint, distinguishing processes that start from chronic inflammation and mechanical compromise and cross into the realm of neuropathy with primary neurogenic pathophysiology. The disease of chronic pain is discussed, examining peripheral and central changes in neuroanatomy, neurophysiology, and neuromolecular dynamics. The limitations of inadequate random controlled trials regarding long-term pharmacologic interventions are contrasted with excellent work in the basic science of chronic pain. Complex rational pharmacologic strategies for structural pathology, central pain processes, sites of medication action, and differing routes of administration are delineated.",2003.0,0,0
839,12724679,Patient-controlled bupivacaine infusion into the infrapatellar fat pad after anterior cruciate ligament reconstruction.,Hall F Chew; Nick A Evans; William D Stanish,"The goal of the study was to determine the safety and analgesic efficacy of a patient-controlled infusion pump that dispenses bupivacaine extra-articularly to the infrapatellar fat pad after anterior cruciate ligament (ACL) reconstruction with ipsilateral bone-patellar tendon-bone autogenous graft. Prospective clinical study. Twenty-one consecutive patients were enrolled in the study. After surgery, the catheter of a bupivacaine infusion pump was implanted extra-articularly onto the infrapatellar fat pad. Ten patients were given infusion pumps with 50 mL of 0.5% bupivacaine to be self-administered for analgesia. Eleven patients were given infusion pumps with 50 mL of 0.25% bupivacaine. Opioid analgesics were available if patients were unable to control the pain solely with the bupivacaine pump. Historic controls consisted of 62 consecutive patients who underwent ACL reconstruction before study initiation. Patients recorded volumes of self-administered bupivacaine; also recorded were postoperative pain levels using a visual analog scale (VAS). Opioid analgesic usage was measured and compared with historic controls. Amount of bupivacaine infused and VAS recorded pain levels were not significantly different between the 0.5% and the 0.25% bupivacaine groups. Opioid analgesic usage was significantly reduced when the 0.5% bupivacaine group was compared with historic controls (mean morphine equivalents via intramuscular route: 0.5% group, 17.6 mg; historic controls, 66.4 mg; P =.015). This was also significant when normalized by patient weight (0.5% group, 0.227 mg/kg; historic controls, 0.880 mg/kg; P =.023). Opioid usage in the 0.25% group (35.7 mg and 0.540 mg/kg) was also less than historic controls; however, this was not statistically significant. Infrapatellar fat pad infusion with 0.5% bupivacaine may provide enhanced analgesia after ACL reconstruction with ipsilateral bone-patellar tendon-bone autogenous graft. A double-blinded, randomized control trial with a greater number of patients is required to confirm these findings.",2003.0,0,0
840,12725478,Intravenous morphine for rapid control of severe cancer pain.,J T Harris; K Suresh Kumar; M R Rajagopal,"This randomized controlled trial compared intravenous route with oral route for initial dose titration of morphine in 62 patients with end-stage cancer and severe pain. Patients in the intravenous group received 1.5 mg intravenous bolus doses of morphine every ten minutes till pain relief was total or until they became drowsy. After that they got oral morphine at a dose equal to the total initial intravenous requirement four-hourly. Patients in the oral group got oral morphine 5 mg doses (if opioid-naïve) or 10 mg (if already on weak opioid) four-hourly. Patients in both groups had the option to receive rescue doses of their regular oral dose as and when needed, if necessary hourly. Twenty-seven of 31 in the intravenous group had either total or satisfactory pain relief by the end of one hour, whereas only eight of 31 in the oral group had a similar result. After 24 hours and later both groups had similar results. There was no immediate serious side effect in any of the patients. The late side effects were similar in the two groups. In the intravenous group, the ratio of initial intravenous dose requirement to the subsequent regular single oral dose after two days centred around 1:1 (range 1:0.5-1:3.3). This study found the intravenous method to be safe, effective and superior to the traditional method in providing immediate relief to severe cancer pain.",2003.0,0,0
841,12734151,Prior ibuprofen exposure does not augment opioid drug potency or modify opioid requirements for pain inhibition in total hip surgery.,Marian L T Bugter; Ris Dirksen; Khem Jhamandas; Robert Slappendel; Eric W G Weber; Brian Milne,"In previous animal studies, a prior exposure to non-steroidal anti-inflammatory drugs (NSAID) augmented opioid drug potency. This study was designed to answer the question whether a similar effect can be attained in man. The objective was to use NSAID for preoperative pain reduction and at the same time use the NSAID exposure to reduce opioid requirements for pain inhibition in major orthopedic surgery. In this double-blind, randomized study, 50 patients scheduled for total hip surgery were included. Patients of Group I received a placebo drug three times a day two weeks before surgery, and those allocated to Group II received ibuprofen (600 mg) three times a day. For surgical anesthesia, all patients received intrathecal bupivacaine 20 mg plus 0.1 mg morphine in a total volume of 4 mL. The preoperative or postoperative visual analogue scale pain scores or the amount of iv morphine showed no differences between the two groups in the first 24 hr after surgery. The median total blood loss in the ibuprofen group was 1161 mL vs 796 mL in the placebo group (P < 0.01). Pretreatment with ibuprofen before major hip surgery does not improve the pain scores or reduce morphine requirement but significantly increases blood loss. Considering the presence of relevant adverse effects, pretreatment with a non-selective NSAID is not recommended.",2003.0,0,0
842,12734164,"Pain, nausea, vomiting and ocular complications delay discharge following ambulatory microdiscectomy.",Shaheen Shaikh; Frances Chung; Charles Imarengiaye; Damian Yung; Mark Bernstein,"Nowadays, microsurgical discectomy is being performed as an outpatient procedure. A retrospective chart review was done to document factors that delayed discharge or led to unanticipated admission. After Institutional Review Board approval, the hospital medical records of 106 patients who underwent microsurgical discectomy on an ambulatory basis were reviewed. All patients were operated upon by a single surgeon at the Toronto Western Hospital. Perioperative data were collected on specifically designed data sheets. All anesthetic and surgical factors that affected discharge were noted. Of the 106 patients reviewed, only six required unanticipated admission. Two patients were admitted due to nausea and vomiting, one due to severe pain, one due to urinary retention and two were surgical causes (dural tear). Eight patients had delayed discharge. Anesthesia causes were severe nausea, severe pain, low oxygen saturation, sore throat and dry eyes. Two patients had surgical causes. The incidence of postoperative nausea was 61% and postoperative vomiting was 9.4%. Eighty patients (75.4%) complained of pain in the postanesthesia care unit. Of these, 33.9% had visual analogue pain scale scores more than 6. Ambulatory lumbar microdiscectomy can be carried out as an ambulatory procedure with an acceptably low unanticipated admission rate (5.7%). The percentage of patients with severe nausea (16%) and pain (33.9%) is high. Adequate perioperative pain management and effective control of nausea and vomiting may further improve the patients' experience after anesthesia for ambulatory microdiscectomy.",2003.0,0,0
843,12743480,Law relating to the classification and regulation of controlled drugs.,Bridgit Dimond,"Mary, a newly qualified staff nurse, was asked by the night sister to draw up a syringe of morphine for a patient who was in severe pain. She had understood that she should not be doing this on her own, but the night sister said that they were too short of staff to provide another person.",2003.0,0,0
844,12745039,"High altitude headache: efficacy of acetaminophen vs. ibuprofen in a randomized, controlled trial.",N Stuart Harris; Richard P Wenzel; Stephen H Thomas,"Ibuprofen has been shown to be more effective than placebo in the treatment of high altitude headache (HAH), but nonsteroidal anti-inflammatory agents have been linked to increased incidence of gastrointestinal (GI) side effects and high-altitude pulmonary edema (HAPE). We postulated that acetaminophen, which does not share ibuprofen's theorized causal link to GI side effects or HAPE, could provide effective HAH therapy. We conducted a prospective, randomized, double-blind, clinical trial of ibuprofen vs. acetaminophen in the Solu Khumbu, Nepal: Mt. Everest Base Camp, Pheriche, Dingboche (4240 m to 5315 m). Seventy-four consecutive patients (ages 13 to 61 years) were randomized, were assessed with the Lake Louise Acute Mountain Sickness (AMS) criteria, and received a physical examination (which included vital signs, oxygen saturation as measured by pulse oximetry (SpO(2)), and assessment of clinical Lake Louise AMS criteria). Patients then received either 400 mg of ibuprofen (IBU) or 1000 mg of acetaminophen (ACET), and were asked to rate their cephalgia using a 10-cm visual analog scale (VAS). Thirty-nine patients received IBU, and 35 received ACET. Baseline Lake Louise AMS scores were identical in the two groups (mean = 5.9). No differences in mean VAS scores between IBU and ACET groups were noted at time 0 (presentation), 30, 60, or 120 min. No cases of HAPE or high altitude cerebral edema were noted during the study period. In this study population, acetaminophen was as effective as ibuprofen in relieving the pain of HAH.",2003.0,0,0
845,12746341,Experts debate widening use of opioid drugs for chronic nonmalignant pain.,Mike Mitka,,2003.0,0,0
846,12746360,Prevalence and characteristics of chronic pain among chemically dependent patients in methadone maintenance and residential treatment facilities.,Andrew Rosenblum; Herman Joseph; Chunki Fong; Steven Kipnis; Charles Cleland; Russell K Portenoy,"Little is known about the prevalence and characteristics of chronic pain among patients with different types of chemical dependency. To estimate the prevalence and to examine the characteristics of chronic severe pain in chemically dependent populations receiving methadone maintenance or inpatient residential treatment. Representative samples of 390 patients from 2 methadone maintenance treatment programs (MMTPs) and 531 patients from 13 short-term residential substance abuse treatment (inpatient) programs, all in New York State, were surveyed in late 2000 and early 2001. Prevalence of chronic severe pain, defined as pain that persisted for more than 6 months and was of moderate to severe intensity or that significantly interfered with daily activities. Chronic severe pain was experienced by 37% of MMTP patients (95% confidence interval [CI], 32%-41%) and 24% of inpatients (95% CI, 20%-28%; P =.03). Pain of any type or duration during the past week was reported by 80% of MMTP patients and 78% of inpatients. Among those with chronic severe pain, 65% of MMTP patients and 48% of inpatients reported high levels of pain-related interference in physical and psychosocial functioning. Among MMTP patients, correlates of chronic pain in a multivariate model were age (odds ratio [OR], 2.08; 95% CI, 1.17-3.70), chronic illness (OR, 1.88; 95% CI, 1.07-3.29), lifetime psychiatric illness (OR, 1.77; 95% CI, 1.06-2.97), psychiatric distress (OR, 1.63; 95% CI, 1.22-2.18), and time in treatment (OR, 2.23; 95% CI, 1.06-4.68). Among inpatients, the correlates of chronic pain were race (blacks vs whites: OR, 0.52; 95% CI, 0.31-0.90; Hispanics vs whites: OR, 0.48; 95% CI, 0.24-0.95), drug craving (OR, 2.78; 95% CI, 1.54-5.02), chronic illness (OR, 2.17; 95% CI, 1.37-3.43), and psychiatric distress (OR, 1.36; 95% CI, 1.03-1.81). Among those with chronic severe pain, inpatients were significantly more likely than MMTP patients to have used illicit drugs, as well as alcohol, to treat their pain complaint (51% vs 34%, P =.005) but were less likely to have been prescribed pain medications (52% vs 67%, P =.01). Chronic severe pain is prevalent among patients in substance abuse treatment, especially MMTP patients. Pain is associated with functional impairment and correlates of pain vary with the population. Self-medication for pain with psychoactive drugs appears especially problematic among substance users who enroll in drug-free treatment programs. Substance abuse treatment programs need to develop comprehensive and structured pain management programs.",2003.0,0,0
847,12747344,The analgesic effect of oral morphine or pentazocine for extracorporeal shock wave lithotripsy.,Yin-Yi Han; Hsueh-Chia Lu; Hsin-Jung Tsai; Shu-Shya Hseu; Kwok-Hon Chan; Shen-Kou Tsai,"Extracorporeal shock wave lithotripsy (ESWL) in these days is usually carried out on ambulatory or outpatient basis. With the application of a lithotriptor of modern version an appropriate yet cost-effective analgesia with minimal side effects for ESWL is mandatory. The analgesic effect of oral morphine (30 mg) was compared with that of pentazocine (100 mg) in a prospective study comprising 100 patients undergoing ESWL with a lithotripter of improved version for urinary tract stones. All patients received orally lorazepam 1 mg as sedative together with the appointed tested drug 30 min before the procedure. The analgesic effects of both drugs were assessed having recourse to the pain scale and efficacy scale. There were 94% of patients in the pentazocine (mixed agonist-antagonist) group who felt satisfied with the regimen and stood the procedure well without resort to supplemental drug, as compared with the morphine (potent mu-agonist) group in which only 70% of patients did so. Although the adverse effect such as dizziness was found in the pentazocine group, the degree of sleepiness produced by its deeper sedation effect was to the advantage of patients during the lithotripsy procedure. There were no significant changes in intergroup mean blood pressure (MBP), but heart rate (HR) was higher and O2 saturation (SpO2) was lower in the pentazocine group after treatment. Both narcotics did not induce renal colic in our study. Also, pentazocine 100 mg plus lorazepam 1 mg given orally did not induce psychotomimetic reaction intraoperatively or postoperatively. We concluded that oral pentazocine at 100 mg plus lorazepam 1 mg, could offer satisfactory analgesia in patients undergoing ESWL for urinary tract stones with a lithotripter of improved version.",2003.0,0,0
848,12753444,Side-effects of postoperative epidural analgesia in children: a randomized study comparing morphine and clonidine.,G Cucchiaro; C Dagher; C Baujard; A M Dubousset; D Benhamou,"Morphine is widely used in association with local anaesthetics for postoperative epidural analgesia. There are no data on the prolonged use of clonidine for postoperative analgesia in children. The primary outcome of this randomized, double-blind trial was to compare the incidence of side-effects after epidural infusion of clonidine or morphine, in association with ropivacaine in children. After institutional approval, 26 children, aged 3-12 years, who were scheduled for abdominal surgery, had an epidural catheter placed after induction of general anaesthesia. Patients were then randomized to two different groups. After an initial bolus of 2.5 mg x kg-1 0.25% ropivacaine with either 40 micro g x kg-1 morphine (group M, n = 14) or 1 micro g x kg-1 clonidine (group C, n = 12), an epidural infusion was started at a rate of 0.4 ml x kg-1 x h-1. The patients in the M group received an infusion of 0.08% ropivacaine with 10 micro g.ml-1 morphine, those in the group C an infusion of 0.08% ropivacaine with 0.6 micro g.ml-1 clonidine. The two groups were similar with respect to age, sex and weight. One patient in the C group was excluded for misplacement of the epidural catheter. The incidence of vomiting and pruritus was significantly higher in the M group compared with the C group (64% and 85% versus 0%, respectively). The incidence of pain was significantly higher in the C group compared with the M group (73% versus 29%) as well as the need for rescue analgesia medications. Epidural clonidine is followed by a significantly lower incidence of side-effects. However, its analgesic effects, at least at the doses used in this study, are less potent than those of epidural morphine.",2003.0,0,0
849,12753877,"Tramadol and acetaminophen combination tablets in the treatment of fibromyalgia pain: a double-blind, randomized, placebo-controlled study.",Robert M Bennett; Marc Kamin; Rezaul Karim; Norman Rosenthal,"To evaluate the efficacy and safety of a combination analgesic tablet (37.5 mg tramadol/325 mg acetaminophen) for the treatment of fibromyalgia pain. This 91-day, multicenter, double-blind, randomized, placebo-controlled study compared tramadol/acetaminophen combination tablets with placebo. The primary outcome variable was cumulative time to discontinuation (Kaplan-Meier analysis). Secondary measures at the end of the study included pain, pain relief, total tender points, myalgia, health status, and Fibromyalgia Impact Questionnaire scores. Of the 315 subjects who were enrolled in the study, 313 (294 women [94%], mean [+/- SD] age, 50 +/- 10 years) completed at least one postrandomization efficacy assessment (tramadol/acetaminophen: n = 156; placebo: n = 157). Discontinuation of treatment for any reason was less common in those treated with tramadol/acetaminophen compared with placebo (48% vs. 62%, P = 0.004). Tramadol/acetaminophen-treated subjects also had significantly less pain at the end of the study (53 +/- 32 vs. 65 +/- 29 on a visual analog scale of 0 to 100, P <0.001), and better pain relief (1.7 +/- 1.4 vs. 0.8 +/- 1.3 on a scale of -1 to 4, P <0.001) and Fibromyalgia Impact Questionnaire scores (P = 0.008). Indexes of physical functioning, role-physical, body pain, health transition, and physical component summary all improved significantly in the tramadol/acetaminophen-treated subjects. Discontinuation due to adverse events occurred in 19% (n = 29) of tramadol/acetaminophen-treated subjects and 12% (n = 18) of placebo-treated subjects (P = 0.09). The mean dose of tramadol/acetaminophen was 4.0 +/- 1.8 tablets per day. A tramadol/acetaminophen combination tablet was effective for the treatment of fibromyalgia pain without any serious adverse effects.",2003.0,0,0
850,12755658,Pretreatment with ibuprofen to prevent electroconvulsive therapy-induced headache.,Marianna Leung; Yitzchak Hollander; Glen R Brown,"Although electroconvulsive therapy (ECT) has been widely recognized as an effective treatment for severe depression and various other psychiatric illnesses, adverse effects have been frequently reported, especially a high incidence of headache. Analgesics, such as acetaminophen, narcotics, or nonsteroidal anti-inflammatory drugs (NSAIDs), are commonly used to treat ECT-induced headache. The objective of this study was to determine whether pretreatment with ibuprofen would prevent the onset or decrease the severity of headache that occurs after ECT. All inpatients on the psychiatric units who required ECT treatment were asked to participate in the study. Thirty-four patients were randomly assigned to receive either ibuprofen, 600 mg, or placebo orally 90 minutes prior to the initial ECT session, with the alternate treatment given for the second ECT treatment. Patients were asked to complete a questionnaire prior to and after the first 2 ECT treatments regarding the pattern, severity, and onset of headache. Severity of the headache was measured on a visual analogue scale (VAS). Ten patients experienced headache in neither treatment arm, while 7 patients experienced headache in both treatment arms. Eleven patients experienced headache with placebo but not with ibuprofen, while 2 patients experienced headache with ibuprofen but not with placebo. Ibuprofen was significantly more effective than placebo in preventing the onset of headache post-ECT (p =.022). The mean +/- SD VAS headache scores were 1.49 +/- 1.54 and 0.54 +/- 0.91 in the placebo and ibuprofen arms, respectively. Ibuprofen was significantly more effective than placebo in reducing the severity of ECT-induced headache (p =.007). Ibuprofen premedication reduced the frequency and severity of headache post-ECT and should be considered for appropriate patients who suffer from ECT-induced headache.",2003.0,0,0
851,12762545,"Methadone-related deaths in Hennepin County, Minnesota: 1992-2002.",Angelique Gagajewski; Fred S Apple,"Methadone maintenance therapy (MMT) is the only currently established medical therapy for heroin addiction. However, MMT still remains controversial. In Hennepin County, Minnesota, methadone is one of the top ten drugs reported in medical examiner investigated deaths and one of the most commonly diverted pharmaceuticals. This report reviews the role of methadone in medical examiner deaths over a 10-year period, 1992-2002. We compare cause and manner of death (accidental, natural, suicide) and methadone blood concentrations for decedents who were members of MMT programs with illicit users and those prescribed methadone for chronic pain. Findings reveal that 65% of decedents with measurable blood methadone concentrations were not participating in MMT programs. A total of 96 cases were identified, with the majority white (90.5%) and male (76.8%). MMTP program members were the minority (34.7%) of the methadone positive deaths and 39% were illicit users. Fifteen percent were chronic pain patients with almost half of this group dying from overdose. Methadone concentrations of drug caused/related deaths (0.18-3.99 mg/L) overlapped with those of deaths not attributable to methadone (0.18-3.03 mg/L) with no definable lethal level. Interpretation of methadone blood concentrations must be done in the context of the clinical history for determining cause of death, and may be confounded by postmortem redistribution.",2003.0,1,1
852,12765890,Analgesic effects of parecoxib following total abdominal hysterectomy.,A Ng; G Smith; A C Davidson,"Forty-eight ASA I-II patients undergoing total abdominal hysterectomy (TAH) were studied in a double blind, randomized placebo controlled trial of parecoxib for postoperative analgesia. All patients were given propofol 2-4 mg kg(-1) i.v., a non-depolarizing muscle relaxant, morphine 10 mg i.v. and prochlorperazine 12.5 mg i.m. intraoperatively. Their lungs were ventilated with nitrous oxide and isoflurane 1-1.5% in oxygen. Morphine was self-administered for postoperative analgesia via a patient controlled analgesia (PCA) device. Patients were allocated randomly to receive either parecoxib 40 mg i.v. or normal saline on induction of anaesthesia. Twelve patients did not complete the study. Of the remaining 36 patients, there was no significant difference between the treatment groups in age, weight, ASA status, duration of surgery, or intraoperative dose of morphine. However, mean (95% CI) 24 h morphine consumption of 54 (42-65) mg in the parecoxib group was significantly (P=0.04) lower than that of 72 (58-86) mg in the placebo group. Pain intensity scores on sitting up were significantly lower (P=0.02) in the parecoxib group compared with placebo. There was no significant difference between the treatment groups in pain intensity scores at rest and on deep inspiration, or in nausea, total number of vomiting episodes, median number of rescue antiemetic doses, and sedation scores. Parecoxib 40 mg i.v. may be recommended in patients having TAH as it provides morphine-sparing analgesia.",2003.0,0,0
853,12766651,Relationships between measurement of pain using visual analog score and morphine requirements during postoperative intravenous morphine titration.,Frédéric Aubrun; Olivier Langeron; Christophe Quesnel; Pierre Coriat; Bruno Riou,"Although intravenous morphine titration is widely used to obtain rapid and complete postoperative pain relief, the relationship between measurement of pain and morphine requirements varies, and the evolution of pain during titration is poorly understood. Intravenous morphine titration was administered as a bolus of 2 (body weight < or = 60 kg) or 3 mg (body weight > 60 kg) during the immediate postoperative period in the PACU. The interval between each bolus was 5 min. The visual analog scale (VAS) score threshold required to administer morphine was 30, and pain relief was defined as a VAS score of 30 or less. Data from 3,045 patients were analyzed. The mean initial VAS score was 73 +/- 19 (mean +/- SD), and the mean morphine dose required to obtain pain relief was 0.17 +/- 0.10 mg/kg, i.e., a median of four boluses (range, 1-20). When patients were grouped according to several classes of initial VAS score (31-39, 40-49, 50-59, 60-69, 70-79, 80-89, 90-100), it seemed that the relationship between VAS score and morphine requirements was a sigmoid curve. A VAS score of 70 or greater predicted the need for a high (>0.15 mg/kg) morphine dose (sensitivity, 0.77; specificity, 0.54). During the pain relief process, the relationship between VAS score and time was depicted by a sigmoid curve. A VAS score of 70 or greater should be considered indicative of severe pain. The relationship between the initial VAS score and morphine requirements is not linear, and the evolution of the VAS score during the pain relief process is described by a sigmoid curve.",2003.0,0,0
854,12766657,,,,,0,0
855,12770651,Interleukin balance and early recovery from anesthesia in elderly surgical patients exposed to beta-adrenergic antagonism.,Eileen Q Shyong; Eliana Lucchinetti; Thomas M Tagliente; Sabera Hossain; Jeffrey H Silverstein; Michael Zaugg,"To determine whether proinflammatory and antiinflammatory cytokines, as measured in blood specimens, would correlate with improved SF-36 physical composite scores observed in elderly surgical patients who were administered perioperative atenolol. Post hoc analysis of data from a randomized clinical study. Department of Anesthesiology, Mount Sinai Medical School, New York. 59 ASA physical status II, III, and IV patients > or =65 years of age, who were scheduled for major elective noncardiac surgery. Patients were randomized to one of three anesthetic regimens to receive 1) perioperative management without beta-adrenergic antagonism, 2) preoperative and postoperative administration of atenolol, or 3) intraoperative atenolol as a major component of the anesthetic regimen. Blood samples were drawn perioperatively at seven different time points. Interleukin-1 beta, interleukin-6, interleukin-1ra, and interleukin-10 were measured using enzyme-linked immunosorbent assay (ELISA) kits. Also, recovery from anesthesia and physical/mental well-being (SF-36 questionnaire) were determined perioperatively. Compared with control patients, atenolol-treated patients experienced improved postoperative physical well-being, which paralleled the previously reported faster recovery from anesthesia and a decreased need for perioperative analgesics. Improved postoperative physical well-being of atenolol-treated patients was specifically caused by an ameliorated bodily pain score, a major component of the physical composite score of the SF-36 questionnaire. The cytokine response of these elderly surgical patients was similar to that of younger patients, and the perioperative profile of proinflammatory and antiinflammatory cytokines was not affected by atenolol. Perioperative administration of atenolol to elderly surgical patients markedly improves physical sense of well-being, which coincides with improved postoperative pain control and decreased analgesic requirements. This improvement experienced by patients receiving atenolol is not related to alterations in perioperative cytokine response.",2003.0,0,0
856,12774874,The effect of ultra low dose epidural analgesia on newborn breastfeeding behaviors.,Sharon Radzyminski,"To determine whether a difference in breastfeeding behaviors could be observed between newborns whose mothers received epidural analgesia for labor pain relief and those newborns whose mothers received no pain medication in labor. There were two groups of neonates in this study. One group was born to mothers who received epidural analgesia, and one group was born to mothers who received no pain medication for labor. Both groups were observed for initial breastfeeding behaviors using the Premature Infant Breastfeeding Behavior Scale following birth and at 24 hours. Central nervous system functioning in the newborn was measured with the Neurologic and Adaptive Capacity Score at 2 and 24 hours of age. A large tertiary hospital in northeast Ohio. Fifty-six breastfeeding mother-newborn dyads. All mothers were healthy multiparae who gave birth vaginally to normal, full-term, healthy newborns. Newborns were observed for rooting, latch on, sucking, swallowing, activity state, and neurobehavior. There were no statistically significant differences in breastfeeding behaviors at birth or at 24 hours of age. A possible cause for the lack of significant results may have been the ultra low dose of bupivacaine and fentanyl used in this sample.",2003.0,0,0
857,12777643,"What is pain management, and what is its relevance to the rheumatologist?",R G Cooper; C K Booker; C C Spanswick,,2003.0,0,0
858,12783923,Why it hurts: researchers seek mechanisms of cancer pain.,Ken Garber,,2003.0,0,0
859,12784350,A safe and effective method for converting patients from transdermal to intravenous fentanyl for the treatment of acute cancer-related pain.,Craig A Kornick; Juan Santiago-Palma; Glenn Schulman; Peter C O'Brien; Stephen Weigand; Richard Payne; Paolo L Manfredi,"The delayed effects (12-16 hours) of transdermal fentanyl make dose titration difficult during acute exacerbations of cancer pain. Patients at the authors' institution routinely are switched from transdermal to intravenous (IV) fentanyl using a 1:1 (transdermal:IV) conversion during severe episodes of pain. The authors evaluated nine consecutive hospitalized patients with cancer who had severe pain for up to 6 days following the conversion from transdermal to IV fentanyl. Pain intensity was rated using an 11-point (0-10) verbal numeric rating scale (NRS). All 9 patients initially reported their pain intensity with movement as >or= 8 during treatment with transdermal fentanyl. Eight patients initially reported their pain at rest as >or= 8. In each patient, all transdermal patches were removed, and a continuous infusion (CI) delivering IV fentanyl at the same hourly rate was initiated simultaneously. Demand boluses of IV fentanyl equivalent in dosage to 50-100% of the CI rate remained available by patient-controlled analgesia (PCA). Pain intensity (0-10), sedation (0-3), and hourly fentanyl requirements (micrograms per hour) were assessed and recorded immediately prior to patch removal and at least once daily after the initiation of IV fentanyl. The CI and demand boluses were titrated whenever necessary on the basis of pain intensity and supplemental PCA use. All 9 patients reported mild levels (<or= 4) of pain at rest within 5 days. The median time to achieve mild levels of pain at rest was 1.5 days. Six patients achieved mild levels of pain with movement within 3 days. Three patients never achieved mild levels of pain with movement while receiving IV fentanyl. No serious side effects were reported. The conversion from transdermal to IV fentanyl can be accomplished safely and effectively using a 1:1 (transdermal:IV) conversion during acute exacerbations of cancer pain.",2003.0,0,0
860,12791112,Comparison between instillation of bupivacaine versus caudal analgesia for postoperative analgesia following inguinal herniotomy in children.,Andreas Machotta; Anna Risse; Sven Bercker; Rita Streich; Dirk Pappert,"In this study we compare the postoperative pain relief for inguinal herniotomy in children provided by instillation of bupivacaine into the wound with that provided by a caudal block. Fifty-eight children aged 0-5 years having elective unilateral hernia repair were studied in this prospective, randomized, single-blind study. Anaesthesia was induced and maintained with oxygen, nitrous oxide, sevoflurane and propofol. Patients were randomly assigned to receive caudal analgesia with 1.0 ml.kg-1 body weight (BW) bupivacaine 0.25% or wound instillation with 0.2 ml.kg-1 BW bupivacaine 0.5% at the end of surgery. Pain was assessed over 24 h using a modified 10-point objective pain scale. During the first postoperative hour in the postanaesthesia care unit (PACU), intravenous (i.v.) piritramide (0.05 mg.kg-1) was administered to any child scoring 5 or more points on the pain scale. On the ward, rectal acetaminophen was administered by a staff nurse when considered necessary. Thirty children in the caudal group and 28 children in the wound instillation group were studied. There were no statistically significant differences between the groups regarding need for i.v. opioids, discharge time from the PACU and administration of acetaminophen. No statistically significant differences in postoperative pain score were observed in 16 of a total of 17 postoperative observations. No complications and no adverse effects were observed. Instillation of bupivacaine into a wound provides postoperative pain relief following hernia repair, which is as effective as that provided by a postoperative caudal block.",2003.0,0,0
861,12791114,Comparison of 0.2% ropivacaine and 0.25% bupivacaine for axillary brachial plexus blocks in paediatric hand surgery.,K L Thornton; M D Sacks; R Hall; R Bingham,"The purpose of this study was to compare the use of ropivacaine 0.2% with bupivacaine 0.25% for axillary brachial plexus block in children undergoing hand surgery. In a double-blind, randomized study, 35 children undergoing hand surgery received axillary brachial plexus blocks with 0.5 ml.kg-1 of either 0.2% ropivacaine or 0.25% bupivacaine. Pain scores were noted at 0, 3, 6, 12 and 24 h after surgery. The time to first dose of codeine phosphate and the total doses of all analgesics given were recorded. There was no significant difference between the two groups in pain scores, the time to first dose of codeine phosphate or in analgesic requirements in the first 24 h. Ropivacaine 0.2% is as effective as bupivacaine 0.25% for axillary brachial plexus blocks in children undergoing hand surgery.",2003.0,0,0
862,12791115,Does ketamine or magnesium affect posttonsillectomy pain in children?,Jennifer E O'Flaherty; Charles X Lin,"Many previous studies have suggested a role for the N-methyl-D-aspartate (NMDA) receptor antagonists ketamine and magnesium in decreasing postoperative pain and analgesic requirements in adults, but none has investigated these medications in children. This randomized, double-blind, placebo-controlled study evaluated the effects of ketamine and magnesium in children undergoing tonsillectomy. Eighty patients, aged 3-12 years, were randomly assigned to four groups. Patients received either ketamine 0.15 mg.kg-1, magnesium sulphate 30 mg.kg-1, ketamine 0.15 mg.kg-1 plus magnesium sulphate 30 mg.kg-1, or placebo intravenously 5 min prior to the start of surgery. Intraoperative analgesia was standardized, and included fentanyl and dexamethasone. There were no differences among the groups with respect to pain assessment postoperatively. Compared with placebo, the treatment groups did not require less fentanyl in the postanaesthesia recovery room or consume less codeine in the first 24-h postoperatively. There was no evidence of synergism between ketamine and magnesium. There were no differences among the groups in the incidence of nausea, vomiting, sedation, bleeding, or dreaming postoperatively. This study did not demonstrate a decrease in pain or analgesic consumption in children undergoing tonsillectomy when pretreated with a small dose of ketamine and/or magnesium.",2003.0,0,0
863,12791116,Double-blind randomized placebo-controlled trial of the effect of ketamine on postoperative morphine consumption in children following appendicectomy.,P Dix; S Martindale; P A Stoddart,"Ketamine has an opioid sparing effect following surgery in adults. This study investigated whether a similar effect is seen following appendicectomy in paediatric patients. Seventy-five ASA 1 or 2 children aged 7-16 years were recruited, and randomly allocated to one of three groups. Following a standard anaesthetic for appendicectomy, all were prescribed patient controlled analgesia (PCA) morphine with paracetamol and nonsteroidal anti-inflammatory drugs (NSAIDS) as required for postoperative analgesia. In addition the control group received a saline infusion postoperatively, the ketamine bolus group received 500 micro g.kg-1 intravenous (i.v.) ketamine preincision and a saline infusion postoperatively, and the ketamine infusion group received 500 micro g.kg-1 i.v. ketamine preincision and a ketamine infusion at 4 micro g.kg-1 min-1 postoperatively. Morphine consumption, rescue analgesia requirement and side-effects were recorded postoperatively. There was no difference in morphine consumption between the groups. The ketamine infusion group required more doses of rescue analgesia and reported more side-effects than the control group. Five patients, all in the ketamine infusion group, reported hallucinations. In this paediatric population intravenous ketamine did not have a morphine sparing effect. The increased incidence of side-effects, especially hallucinations, reported by patients given a ketamine infusion may limit the further use of postoperative ketamine in children.",2003.0,0,0
864,12791117,Comparison of patient-controlled analgesia with and without a background infusion after appendicectomy in children.,Karamehmet Yildiz; Elvan Tercan; Kudret Dogru; Ugur Ozkan; Adem Boyaci,"There have been many studies using patient-controlled analgesia (PCA) and opioids for postoperative analgesia in children. In this study, we investigated the efficacy, usefulness and analgesic consumption of two different PCA programmes [bolus dose alone (BD) or bolus dose with background infusion (BD + BI)] to evaluate postoperative analgesia for children after emergency appendicectomy. Forty children, aged between 6 and 15 years and ASA class I or II, undergoing emergency appendicectomy were randomly allocated into two groups. The children were given a loading dose of pethidine 0.3 mg.kg-1 and 150 micro g.kg-1 bolus intravenously in group BD (n = 20) and pethidine 0.3 mg.kg-1 loading dose, 75 micro g.kg-1 bolus and 15 micro g.kg-1.h-1 background infusion in group BD + BI (n = 20). The lockout interval was 20 min in both groups. There were no significant differences in pain, sedation and nausea scores during the 24-h postoperative period between the groups (P > 0.05). Pethidine consumption was significantly lower in group BD + BI than that in group BD for the first 24-h period (P < 0.05). We demonstrated that both these PCA programmes were effective and reliable for postoperative pain relief in children. We believe that giving information about PCA to the children and their parents is useful during the preoperative period. However, the background infusion with lower bolus dose in PCA did not increase pethidine consumption.",2003.0,0,0
865,12792556,"Sex differences in opioid analgesia: ""from mouse to man"".",Rebecca M Craft,"Numerous experimental studies, conducted primarily over the past 10 years, show that there are sex differences in opioid analgesia. This review summarizes the published literature on sex differences in analgesia produced by acute administration of drugs acting at mu-, kappa-, and delta-opioid receptors, in animals and humans. Additionally, methodological issues in research into opioid sex differences are discussed. Procedural variables that may influence the outcome of studies examining sex differences in opioid analgesia include modality and intensity of the noxious stimulus used in the pain test, opioid type (efficacy and selectivity), and experimental design and data analytic techniques. Subject variables that may be important to consider include subject genotype and gonadal steroid hormone state of the subject at the time of analgesia testing. Evidence is provided for multiple mechanisms underlying sex differences in opioid analgesia, including both pharmacokinetic and pharmacodynamic factors. Future research directions are suggested, such as examining sex differences in opioid tolerance development, sex differences in opioid analgesia using models of acute inflammatory pain and chronic pain, and sex differences in effects of opioids other than analgesia, which may limit their therapeutic use.",2003.0,0,0
866,12799971,[Effect on morphine and other opioids on immune function].,G Ernst; P Pfaffenzeller,"Already 1898 first clinical observations of a possible immune suppression after morphine intake were published. Today there are many reports describing opioid effects on nearly all parameters of the immune system. The question arises, whether there exists any evidence for clinical (harming) effects on patients. Recent experimental and clinical publications are reviewed. Results are summarized, pathophysiological mechanisms and clinical conclusions discussed. Morphine and other opioids have immunomodulating effects on nearly all measurable parts of the immune system (macrophages, granulocytes, nk-cells; mediators like Interleukin 1, 2 and 6, TNF). However, most studies did not include pain models, and in addition, high morphine doses were used. First studies using a combined pain/morphine-approach report immune stimulating effects. There are three pathophysiological mechanisms under discussion, including opioid receptors on immune competent cells, central opioid receptors activating the adrenergic system and opioid-induced steroid release with consecutive immunosuppression. It is completely unclear, if there is any relevance of these findings for clinical settings. The question whether use of opioids can harm chronic pain patients is unsolved. There is an urgent need for studies in clinical settings with clinical relevant parameters.",2003.0,0,0
867,12799972,[Hydromorphone--review of pharmacological properties and therapeutic efficacy with special regard to a controlled release preparation].,G Lindena; H Arnau; J Liefhold,"Hydromorphone is a micro receptor agonist opioid. According to WHO recommendations, hydromorphone is to be classified in step III of pain therapy. An oral formulation with a prolonged duration of action of 12 hours has been evaluated only recently. The controlled release capsule is especially suited for the regular twice a day administration in cases of severe and persistent pain. The oral formulation of hydromorphone increases the number of opioid analgesics available for pain therapy in step III. Hydromorphone is recommended when morphine fails to produce sufficient pain relief (despite increase of doses) or causes intolerable side effects (despite treatment of symptoms). In principle, no differences in efficacy of morphine and hydromorphone are to be expected. However, clinical experience shows that changing one opioid analgesic to another one can improve the treatment of patients so that hydromorphone may replace another opioid analgesic to which a patient fails to respond well or develops side effects. The dose of hydromorphone equivalent to 2 times 30 mg controlled release morphine is about 2 times 4 mg. The values for the absorption, bioavailability and maximum plasma concentration after the administration of controlled release hydromorphone every 12 hours -of three times the dose- are equivalent to those of an immediate release tablet given every 4 hours. In several open label and controlled studies, hydromorphone proved to be of good efficacy in the treatment of acute and persistent pain, especially in patients with severe cancer pain. With regard to the incidence of side effects, no significant differences between morphine and hydromorphone could be established. In general, the side effects of hydromorphone are typical for opioid analgesics. In conclusion, controlled release hydromorphone seems to be well suited for the control of severe chronic pain when given twice daily.",2003.0,0,0
868,12801435,Current management of postherpetic neuralgia.,Louis M Panlilio; Paul J Christo; Srinivasa N Raja,"The herpes zoster rash occurs when a dormant varicella zoster virus reactivates in dorsal root and cranial nerve ganglia. Pain that persists in the region where this rash occurred after the cutaneous lesions have healed is termed postherpetic neuralgia (PHN). A wide variety of therapies has been used with varying degrees of success to prevent the occurrence of PHN and to reduce pain with established PHN. In this review, we discuss the clinical presentation of PHN, current strategies for the prevention and management of this disease, and observations that have increased our understanding of the neural mechanisms involved in PHN. Several classes of drugs are effective in attenuating the pain and hyperalgesia caused by PHN, but no single drug leads to the complete relief of symptoms. Additional research is needed to improve treatment strategies and define the role of invasive pain management techniques in cases where PHN is associated with intractable pain.",2003.0,0,0
869,12801599,Induction of pain facilitation by sustained opioid exposure: relationship to opioid antinociceptive tolerance.,Michael H Ossipov; Josephine Lai; Todd W Vanderah; Frank Porreca,"Opioid analgesics are frequently used for the long-term management of chronic pain states, including cancer pain. The prolonged use of opioids is associated with a requirement for increasing doses to manage pain at a consistent level, reflecting the phenomenon of analgesic tolerance. It is now becoming clearer that patients receiving long-term opioid therapy can develop unexpected abnormal pain. Such paradoxical opioid-induced pain, as well as tolerance to the antinociceptive actions of opioids, has been reliably measured in animals during the period of continuous opioid delivery. Several recent studies have demonstrated that such pain may be secondary to neuroplastic changes that result, in part, from an activation of descending pain facilitation mechanisms arising from the rostral ventromedial medulla (RVM). One mechanism which may mediate such pain facilitation is through the increased activity of CCK in the RVM. Secondary consequences from descending facilitation may be produced. For example, opioid-induced upregulation of spinal dynorphin levels seem to depend on intact descending pathways from the RVM reflecting spinal neuroplasticity secondary to changes at supraspinal levels. Increased expression of spinal dynorphin reflects a trophic action of sustained opioid exposure which promotes an increased pain state. Spinal dynorphin may promote pain, in part, by enhancing the evoked release of excitatory transmitters from primary afferents. In this regard, opioids also produce trophic actions by increasing CGRP expression in the dorsal root ganglia. Increased pain elicited by opioids is a critical factor in the behavioral manifestation of opioid tolerance as manipulations which block abnormal pain also block antinociceptive tolerance. Manipulations that have blocked enhanced pain and antinociceptive tolerance include reversible and permanent ablation of descending facilitation from the RVM. Thus, opioids elicit systems-level adaptations resulting in pain due to descending facilitation, upregulation of spinal dynorphin and enhanced release of excitatory transmitters from primary afferents. Adaptive changes produced by sustained opioid exposure including trophic effects to enhance pain transmitters suggest the need for careful evaluation of the consequences of long-term opioid administration to patients.",2003.0,0,0
870,12803270,Preoperative oral celecoxib versus preoperative oral rofecoxib for pain relief after thyroid surgery.,B Karamanlioğlu; C Arar; A Alagöl; A Colak; I Gemlik; N Süt,"The study compared the analgesic efficacy and safety of two preoperatively administered cyclo-oxygenase-2 inhibitors, celecoxib and rofecoxib. Ninety adult patients undergoing thyroid surgery were divided into three groups (each n = 30). They were given a single oral dose of placebo, celecoxib 200 mg or rofecoxib 50 mg 1 h before induction of anaesthesia. All patients received a standard anaesthetic. Intraoperative blood loss was measured. Pain scores, sedation scores, heart rate, mean arterial pressure and respiratory rate were noted at 0, 1, 2, 4, 6, 12 and 24 h postoperatively. Analgesic (meperidine) requirements and adverse effects were recorded during the first postoperative 24 h. Compared with placebo, pain scores were significantly lower with rofecoxib at all time points (P < 0.05) and were significantly lower with celecoxib (P < 0.05) during the first 4 h. Pain scores were significantly lower with rofecoxib compared with celecoxib at 6, 12 and 24 h (P < 0.05). The average cumulative 24 h meperidine dose was significantly lower with both celecoxib (54.9 +/- 34.4mg) and rofecoxib (42.8 +/- 40.9 mg) compared with placebo (76.8 +/- 6.2 mg) (P < 0.01 and P < 0.001, respectively). There were no differences in the intraoperative blood loss, heart rate, mean arterial pressure, respiratory rate, sedation scores and incidence of adverse effects among groups. The preoperative administration of rofecoxib 50 mg and less so of celecoxib 200 mg provide a significant analgesic benefit with regard to postoperative pain relief and decrease in additional opioid requirements after thyroid surgery.",2003.0,0,0
871,12803592,"Effective pain relief from intra-articular saline with or without morphine 2 mg in patients with moderate-to-severe pain after knee arthroscopy: a randomized, double-blind controlled clinical study.",L A Rosseland; A Stubhaug; F Grevbo; O Reikerås; H Breivik,"Intra-articular (IA) morphine has given good and prolonged pain relief in some studies when given at the end of arthroscopic procedures in the knee joint. However, similar studies have not been able to document any local analgesic effect of morphine. A large number of the negative studies have not demonstrated any assay sensitivity. We have documented that around 40% of patients have only very mild or no pain after arthroscopic procedures in the knee joint. This obviously is a confounding factor, reducing assay sensitivity when all patients are included in IA morphine studies. By leaving a soft catheter IA in 57 patients and including only patients who developed moderate-to-severe pain within 1 h after an arthroscopic procedure in the knee joint under general anaesthesia, we included 40 patients. These patients had a mean pre-treatment baseline pain of about 50/100 on a 100-mm visual analogue scale (VAS) for pain intensity. A randomized, double-blind controlled comparison of saline 10 ml with or without morphine 2 mg followed. Test drugs were administered through the IA catheter. Pain intensity and pain relief, consumption of rescue analgesics and global evaluation of effect and adverse effects were measured up to 36 h thereafter. Pain intensity decreased from about 50 to about 10-15/100 in both groups and the sum of pain intensity differences at 2 and 22 h was not significantly different between the two groups. Global evaluation of effects and adverse effects, as well as consumption of rescue analgesics during 36 h after arthroscopic procedures, were also similar in the two groups. Only 70% of 57 patients had pain of moderate-to-severe intensity within 1 h after an arthroscopic procedure of the knee joint under general anaesthesia. IA injection of saline 10 ml and saline 10 ml with morphine 2 mg were both associated with pain relief. These findings may have implications for interpretations of a majority of published studies on IA morphine.",2003.0,0,0
872,12803598,Fentanyl decreases propofol requirement for laryngeal mask airway insertion.,T Goyagi; M Tanaka; T Nishikawa,"Since fentanyl is a potent depressant of the upper airway reflex, preadministration of fentanyl may facilitate insertion of the laryngeal mask airway (LMA) using propofol. Accordingly, we tested the hypothesis that fentanyl pretreatment would reduce the dose of propofol required for the LMA insertion. Forty-one healthy patients without sedative premedication were randomly assigned to either fentanyl group, receiving fentanyl 2 microg kg-1 intravenously, or control group, receiving equal volumes of normal saline. Then, 3 ml of 2% lidocaine was given intravenously to alleviate pain associated with propofol administration. Thirty s after the fentanyl or saline injection, a predetermined dose of 1% propofol was given at a rate of 100 mg min-1. Insertion of the LMA was attempted 90 s after the completion of the propofol injection. The dose of propofol given to a particular patient was determined by the response of the preceding patient in that group to a higher or lower dose, using the up-and-down method. The first patient in each group received 2.5 mg kg-1 of propofol, while the step-size was 0.25 mg kg-1. Patients responses were assessed by a blinded observer. ED50 and ED95 of propofol requirements were significantly less in the fentanyl group (0.82, 1.17 mg kg-1, respectively) than those in the control group (2.39, 2.62 mg kg-1, P < 0.001). Our results indicate that preadministration of fentanyl 2 microg kg-1 decreases the propofol requirement for the LMA insertion.",2003.0,0,0
873,12807305,Envenomation by the Mexican beaded lizard: a case report.,F Lee Cantrell,"Envenomations by venomous lizards are rare. A single report of envenomation by a Mexican beaded lizard (Heloderma horridum) has been published. Further, anaphylaxis secondary to lizard envenomation has only been reported with the Gila monster. We report an envenomation that resulted in both systemic toxicity and anaphylaxis. A 40-year-old male was bitten on his hand by a captive Mexican beaded lizard. The patient experienced severe local pain, dizziness, vomiting, and diaphoresis. Upon arrival to the hospital, he was lethargic, vomiting, and in severe pain with marked swelling of his hand, lips, and tongue. His blood pressure was 110/63 mm/Hg with a pulse of 60 beats/minute. The patient's oxygen saturation decreased to 55%, and he required oxygen, although cyanosis was not observed. He was treated with normal saline, diphenhydramine, methylprednisolone, famotidine, ondansetron, morphine, and hydromorphone. The patient was admitted to intensive care where he continued to complain of severe pain requiring morphine. Local X-ray revealed only soft tissue swelling. Remarkable initial laboratory values included WBC 18,500 k/mm3 with 80% segs. Over the next eight hours, the patient's symptoms gradually improved. He had persistent local swelling at the bite site along with erythematous streaking up the forearm. He had an uneventful hospital course until his eventual discharge the following day. Significant envenomations by members of the Helodermatidae family are rare. Systemic toxicity usually resolves within one to two days with supportive care. Prior envenomations may predispose patients to anaphylactic reactions.",2003.0,0,0
874,12809961,"Tramadol/acetaminophen combination tablets for the treatment of chronic lower back pain: a multicenter, randomized, double-blind, placebo-controlled outpatient study.",Gary E Ruoff; Norman Rosenthal; Donna Jordan; Rezaul Karim; Marc Kamin; Protocol CAPSS-112 Study Group,"Tramadol and acetaminophen (APAP) have both shown efficacy in the treatment of lower back pain. The combination of these 2 agents has demonstrated synergistic analgesic action in animal models at specific ratios. This study assessed the long-term (3-month) efficacy and safety of tramadol 37.5 mg/APAP 325 mg combination tablets in the treatment of chronic lower back pain. Patients with at least moderate lower back pain (pain visual analog [PVA] score >/=40 mm on a 100-mm scale) were randomized to receive up to 8 tablets of tramadol/APAP per day or placebo for 91 days. Medication was titrated from 1 to 4 tablets/d by day 10. The primary efficacy measure was PVA score at the final visit. Secondary measures included scores on the Pain Relief Rating Scale (PRRS), Short-Form McGill Pain Questionnaire (SF-MPQ), Roland Disability Questionnaire (RDQ), and 36-Item Short-Form Health Survey (SF-36); the incidence of discontinuation due to insufficient pain relief (Kaplan-Meier analysis); and overall assessments of medication by the patients and investigators. Three hundred eighteen patients (161 tramadol/APAP, 157 placebo) were included in the intent-to-treat population, defined as all patients who took >/=1 dose of study medication and had >/=1 postrandomization efficacy measurement. The mean age of the study population was 53.9 years, 63.2% were female, 90.3% were white, and the mean baseline PVA score was 70.0 mm. There were no significant differences between groups at baseline. Tramadol/APAP significantly improved final PVA scores (P = 0.015) and final PRRS scores (P < 0.001) compared with placebo. Tramadol/APAP also significantly improved RDQ scores (P </= 0.027) and scores on many subcategories of the SF-MPQ, including total score (P = 0.021). The tramadol/APAP group had significant improvements on the role-physical (P = 0.005), bodily pain (P = 0.046), role-emotional (P = 0.001), mental health (P = 0.026), reported health transition (P = 0.038), and mental component summary (P = 0.008) subscales of the SF-36. The cumulative incidence of discontinuation due to insufficient pain relief was 22.1% for tramadol/APAP and 41.0% for placebo (P < 0.001). Treatment-emergent adverse events in the tramadol/APAP group included nausea (13.0%), somnolence (12.4%), and constipation (11.2%). In this study, tramadol 37.5 mg/APAP 325 mg combination tablets were effective and had a favorable safety profile in the treatment of chronic lower back pain.",2003.0,0,0
875,12815785,[Morphine--myths and facts].,T Weber; K Zawiła; A Macheta; J Andres,Morphine in the form of opium tincture accompanies the mankind for several thousands years. At the beginning of the twentieth century morphine has been isolated from opium and it was used initially to treat ... opium addicts. At present it plays an important role in the treatment of severe pain of different origins and (more seldom) in the premedication for general anaesthesia. Despite its side effects it is irreplaceable especially in the treatment of cancer pain. Nowadays the chronic use of oral morphine preparations has been supported by medical authorities who at the same time warn against incorrect dosage and combination with other drugs. Many clinical data concerning oral morphine show that it is safe and effective even in the patients with advanced cancer and poor performance status. Our paper lists myths and common mistakes connected with morphine use and confronts them with well established facts confirming its effectiveness in cancer pain treatment.,2003.0,0,0
876,12821301,Drugs from the deep: marine natural products as drug candidates.,Burkhard Haefner,"In recent years, marine natural product bioprospecting has yielded a considerable number of drug candidates. Most of these molecules are still in preclinical or early clinical development but some are already on the market, such as cytarabine, or are predicted to be approved soon, such as ET743 (Yondelis). Research into the ecology of marine natural products has shown that many of these compounds function as chemical weapons and have evolved into highly potent inhibitors of physiological processes in the prey, predators or competitors of the marine organisms that use them. Some of the natural products isolated from marine invertebrates have been shown to be, or are suspected to be, of microbial origin and this is now thought to be the case for the majority of such molecules. Marine microorganisms, whose immense genetic and biochemical diversity is only beginning to be appreciated, look likely to become a rich source of novel chemical entities for the discovery of more effective drugs.",2003.0,0,0
877,12822048,Quality of life improvement after videothoracoscopic splanchnicectomy in chronic pancreatitis patients: case control study.,Wojciech Makarewicz; Tomasz Stefaniak; Marlena Kossakowska; Andrzej Basiński; Marek Suchorzewski; Aleksander Stanek; Zbigniew B Gruca,"The authors report on the effectiveness of videothoracoscopic splanchnicectomy (VSPL) as a method of pain treatment in patients with chronic pancreatitis (CP). A minimally invasive technique, VSPL is used in CP as an alternative method of pain treatment. The aim of the investigation was to evaluate by a prospective, semirandomized case-control study the influence of VSPL on the quality of life and the level of pain suffered by patients with CP. The study groups consisted of 32 patients who underwent VSPL between March 2000 and January 2001 and a control group of 32 CP patients who received conservative treatment. The effect of the therapy on subjective pain measures and multiparametric quality of life was measured before VSPL and throughout the first year thereafter. In the follow-up period there was a significant decrease in intensity of pain and an improvement in the quality of life of the patients-most significantly concerning emotional well-being and functioning in everyday life. We conclude that the VSPL is a safe, effective, and minimally invasive procedure and recommend that it be used in such cases.",2003.0,0,0
878,12822825,Acute painful neuropathy (insulin neuritis) in a boy following rapid glycemic control for type 1 diabetes mellitus.,Jennifer L Wilson; Deborah K Sokol; Lisa H Smith; Riley J Snook; Steven G Waguespack; John C Kincaid,"We report a case of acute, painful polyneuropathy in a boy with newly diagnosed type 1 diabetes mellitus associated with a precipitous drop in hemoglobin A1c. After initiation of insulin, the patient's hemoglobin A1c dropped from 14.1 to 7.6%, and he developed severe pain in his feet, which prevented him from walking. Nerve conduction studies were consistent with mild to moderate sensorimotor peripheral neuropathy. Initially, he required opiate analgesics for pain control. Three months after presentation, the patient showed dramatic improvement and regained his ability to walk. Although not well described in the pediatric literature, this case represents insulin neuritis, one of the few diabetic neuropathies that has a favorable outcome.",2003.0,0,0
879,12826550,The continuous epidural infusion of ropivacaine 0.1% with 0.5 microg x mL(-1) sufentanil provides effective postoperative analgesia after total hip replacement: a pilot study.,Sandra Kampe; Peter Kiencke; Achilles Delis; Marion Auweiler; Dietmar Pierre König; Stefan-Mario Kasper,"To assess the analgesic efficacy and functional outcome of postoperative epidural infusion of ropivacaine combined with sufentanil in a randomized, controlled trial. Thirty-two ASA I-III patients undergoing elective total hip replacement (THR) were included. Lumbar epidural block using 0.75% ropivacaine was combined with either propofol sedation or general anesthesia for surgery. On arrival in the recovery room, the epidural infusion was commenced at a rate in mL calculated as follows: (height in cm - 100) x 0.1. Eleven patients received an epidural infusion of ropivacaine 0.1% with 0.5 microg x mL(-1) sufentanil (Group R+S0.5), ten patients ropivacaine 0.1% with 0.75 microg x mL(-1) sufentanil (Group R+S0.75), and 11 patients ropivacaine 0.1% with 1 microg x mL(-1) sufentanil (Group R+S1) over a postoperative study period of 44 hr. All patients had access to iv piritramide via a patient-controlled analgesia (PCA) device. Postel-Merle-d'Aubigné scoring system (PMA score) was assessed preoperatively, three weeks after surgery, and three months after surgery by an orthopedic surgeon blinded to study group. Motor block was negligible in all three groups. After eight hours of epidural infusion, sensory block had regressed completely in all patients. There was no significant difference with regard to visual analogue scale (VAS) scores (at rest: P = 0.55, on movement: P = 0.63), consumption of rescue medication (P = 0.99), patient satisfaction (P = 0.22), and the incidence of adverse events. All treatment regimens provided effective postoperative analgesia with only a minimal use of supplemental opioid PCA. There was no difference between groups regarding orthopedic PMA score (pain: P = 0.24, mobility: P = 0.65, and ability to walk: P = 0.44). Ropivacaine 0.1% with 0.5 microg x mL(-1) sufentanil for postoperative analgesia after THR provides efficient pain relief and, compared with 0.75 and 1 microg x mL(-1) sufentanil, reduces sufentanil consumption without compromise in patient satisfaction, VAS scores, and functional outcome.",2003.0,0,0
880,12826854,Effect of combining naloxone and morphine for intravenous patient-controlled analgesia.,James B Sartain; John J Barry; Christopher A Richardson; Helen C Branagan,"An early study showed that a naloxone infusion decreased the incidence of morphine-related side effects from intravenous patient-controlled analgesia. The authors tested the hypothesis that a more convenient combination of morphine and naloxone via patient-controlled analgesia would decrease the incidence of side effects compared to morphine alone. Patients scheduled for hysterectomy under general anaesthesia were enrolled in a double-blind, randomized, placebo-controlled trial. Patients received a standardized general anesthetic and postoperative patient-controlled analgesia. They were randomized to receive 60 mg patient-controlled analgesia morphine in 30 ml saline or 60 mg morphine in 30 ml saline with naloxone 0.8 mg. Parameters for patient-controlled analgesia were a 1-mg bolus of morphine with a 5-min lockout and no background infusion. Patient recall of nausea, vomiting, itching, and pain (at rest and with movement) were assessed at 6 and 24 h postoperatively by verbal rating score. Pain was also assessed by a 0- to 100-mm visual analog score, and sedation was assessed by an observer. The amount of morphine used and the requirements for symptomatic treatment were also recorded. Ninety-two patients completed the study, with no significant differences in outcomes between groups. At 24 h, the incidence of nausea was 84.8% in each group; the incidence of pruritus was 56.5% in the naloxone group and 58.7% in the placebo group. There were also no differences in symptomatic treatment requirements, pain scores, morphine use, or sedation between groups. The median dose of naloxone received equated to 0.38 microg x kg-1 x h-1 over 24 h. There was no benefit from administering naloxone combined with morphine via patient-controlled analgesia.",2003.0,0,0
881,12826855,Differential modulation of remifentanil-induced analgesia and postinfusion hyperalgesia by S-ketamine and clonidine in humans.,Wolfgang Koppert; Reinhard Sittl; Karin Scheuber; Monika Alsheimer; Martin Schmelz; Jürgen Schüttler,"Experimental studies and clinical observations suggest a possible role for opioids to induce pain and hyperalgesia on withdrawal. The authors used a new experimental pain model in human skin to determine the time course of analgesic and hyperalgesic effects of the mu-receptor agonist remifentanil alone or in combination with the N-methyl-D-aspartate-receptor antagonist S-ketamine or the alpha(2)-receptor agonist clonidine. Thirteen volunteers were enrolled in this randomized, double-blind, placebo-controlled study. Transcutaneous electrical stimulation at a high current density (2 Hz, 67.3 +/- 16.8 mA, mean +/- SD) induced acute pain (numerical 11-point rating scale: 5-6 out of 10) and stable areas of mechanical hyperalgesia to punctate stimuli and touch (allodynia). The magnitude of pain and area of hyperalgesia were assessed before, during, and after drug infusion (remifentanil at 0.1 microg x kg-1 x min-1 and S-ketamine at 5 microg x kg-1 x min-1 over a period of 30 min, respectively; clonidine infusion at 2 microg/kg for 5 min). Remifentanil reduced pain and areas of punctate hyperalgesia during infusion. In contrast, postinfusion pain and hyperalgesia were significantly higher than control. During infusion of S-ketamine, pain and hyperalgesia decreased and gradually normalized after infusion. When given in combination, S-ketamine abolished postinfusion increase of punctate hyperalgesia but did not reduce increased pain ratings. Clonidine alone did not significantly attenuate pain or areas of hyperalgesia. However, when given in combination with remifentanil, clonidine attenuated postinfusion increase of pain ratings. Opioid-induced postinfusion hyperalgesia could be abolished by S-ketamine, suggesting an N-methyl-d-aspartate-receptor mechanism. In contrast, elevated pain ratings after infusion were not reduced by ketamine but were alleviated by the alpha(2)-receptor agonist clonidine. The results of this study suggest different mechanisms of opioid-induced postinfusion antianalgesia and secondary hyperalgesia.",2003.0,0,0
882,12826856,Postoperative morphine consumption in the elderly patient.,Frédéric Aubrun; Dorothea Bunge; Olivier Langeron; Gérard Saillant; Pierre Coriat; Bruno Riou,"It has been suggested that the dose of intravenous morphine used during postoperative titration is not modified by aging. The authors therefore studied morphine requirements in patients undergoing total hip replacement. Intravenous morphine titration was administered as boluses, then subcutaneous morphine was administered every 4 h over 24 h. Pain was assessed by use of the visual analog scale (0 to 100), and the threshold required to administer morphine was 30. Young and elderly (> or =70 yr old) patients were compared. Data are mean +/- SD or odds ratio (OR) [95% CI]. Two hundred twenty-four patients (68%) were young and 105 (32%) were elderly. The initial visual analog scale was not significantly different between groups. The dose of intravenous morphine in the postanesthesia care unit was not significantly different between young and elderly patients (0.15 +/- 0.11 vs. 0.14 +/- 0.10 mg/kg, P = NS), in contrast to the dose of subcutaneous morphine (0.18 +/- 0.18 vs. 0.11 +/- 0.11 mg/kg, P < 0.001) in the ward. Only severe pain (visual analog scale of 70 or greater; OR, 10.5 [4.5-24.8]) was significantly associated with a high dose (greater than 0.15 mg/kg) of intravenous morphine, whereas severe pain (OR, 2.5 [1.6-4.0]), age less than 60 yr (OR, 2.3 [1.4-3.8]), and absence of a nonsteroidal antiinflammatory drug (OR, 1.9 [1.2-3.1]) were significantly associated with a high dose (greater than 0.12 mg/kg) of subcutaneous morphine. The dose of intravenous morphine during titration is not modified in elderly patients, in contrast to the dose administered subcutaneously over a prolonged period.",2003.0,0,0
883,12828498,Pain in terminally ill patients: guidelines for pharmacological management.,Jay R Thomas; Charles F von Gunten,"Successful pharmacological treatment of pain in terminally ill patients is possible most of the time. It requires a determination of the type of pain syndrome (i.e. nociceptive, neuropathic or mixed). Complete pain assessment also requires an understanding of other dimensions of suffering that a patient may be experiencing on psychological, social and spiritual/existential levels. The World Health Organization has introduced a three-step approach to treating pain. Opioids are the mainstay of therapy for moderate to severe pain at the end of life. Familiarity with the pharmacokinetics, equianalgesic dose and adverse effects of opioids is necessary for their safe and effective use. In addition, adjuvant analgesics such as antiepileptic drugs, antidepressants and local anaesthetics are often needed to optimise pain control, especially in patients with neuropathic pain. Given the complex aetiology of pain states, combinations of classes of adjuvants may sometimes be needed for effective treatment.",2003.0,0,0
884,12837876,Comparison of propofol/fentanyl versus ketamine/midazolam for brief orthopedic procedural sedation in a pediatric emergency department.,Sandip A Godambe; Vanessa Elliot; Dana Matheny; Jay Pershad,"To compare the effectiveness of 2 medication regimens, propofol/fentanyl (P/F) and ketamine/midazolam (K/M), for brief orthopedic emergency department procedural sedation. This study was powered to compare recovery times (RT) and procedural distress as measured by the Observational Score of Behavioral Distress-revised (OSBD-r; range: 0-23.5 with 23.5 representing maximal distress). We conducted a prospective, partially-blinded controlled comparative trial comparing intravenous P/F with K/M in a convenience sample of 113 patients aged 3 to 18 years old undergoing orthopedic procedural sedation. All medications were administered by the intermittent intravenous bolus method. An independent sedation nurse recorded total sedation time and RT. Effectiveness was measured using 6 parameters: 1) patient distress as assessed by independent blinded observers after videotape review using the OSBD-r; 2) orthopedic satisfaction score (Likert scale 1-5); 3) sedation nurse satisfaction score (Likert 1-5); 4) parental perception of procedural pain using a 0 to 100 mm Visual Analog Scale with the upper limit being ""most pain""; 5) patient recall of the procedure; and 6) 1 to 3 week follow-up. RT and total sedation time were significantly less in the P/F group than in the K/M group (33.4 minutes vs 23.2 minutes). The mean OSBD-r scores during manipulation were 0.084 and 0.278 for the K/M and P/F groups, respectively. Although this difference was statistically significant (95% confidence interval for the mean difference -0.34 to -0.048), both regimens were successful in keeping the scores low. There was no statistical difference between the groups in the other measures of effectiveness. There was a statistically significant difference between the groups in the occurrence of desaturation and late side effects. RT with P/F is shorter than with K/M. P/F is comparable to K/M in reducing procedural distress associated with painful orthopedic procedures in the pediatric emergency department. Although propofol has a greater potential of respiratory depression and airway obstruction as compared with ketamine, it offers some unique advantages including a quicker offset and smoother recovery profile.",2003.0,0,0
885,12839235,Current concepts in acute pain management.,Mai-Phuong Huynh; John A Yagiela,"Analgesics most commonly prescribed in dentistry for acute pain relief include the nonsteroidal anti-inflammatory drug, acetaminophen, and various opioid-containing analgesic combinations. The NSAIDs and presumably acetaminophen act by inhibiting cyclooxgenase enzymes responsible for the formation of prostaglandins that promote pain and inflammation. Opioids such as codeine, hydrocodone, and oxycodone stimulate endogenous opioid receptors to bring about analgesic and other effects. Numerous clinical studies have confirmed that moderate to severe pain of dental origin is best managed through the use of ibuprofen or another NSAID whose maximum analgesic effect is at least equal to that of standard doses of acetaminophen-opioid combinations. If an NSAID cannot be prescribed because of patient intolerance, analgesic preparations that combine effective doses of an orally active opioid with 600 to 1,000 mg of acetaminophen are preferred in the healthy adult. On occasion, prescribing both an NSAID and an acetaminophen-opioid combination may be helpful in patients not responding to a single product. In all cases, however, the primary analgesic should be taken on a fixed schedule, not on a ""prn"" (or as needed) basis, which only guarantees the patient will experience pain.",2003.0,0,0
886,12840615,Spousal responses are differentially associated with clinical variables in women and men with chronic pain.,Roger B Fillingim; Daniel M Doleys; Robert R Edwards; Daniel Lowery,"Spousal responses have been related to clinical variables in patients with chronic pain. For example, solicitous responses from spouses have been associated with greater levels of pain and disability among patients with chronic pain. However, few investigators have determined whether spousal solicitousness produces different effects in women versus men with chronic pain. The present study examined pain reports, medication use, psychosocial factors, functional measures, and pain tolerance in patients with chronic pain. Subjects included 114 female and 213 male chronic pain patients, who described their spouses as either high or low in solicitousness on the Multidimensional Pain Inventory. Measures of pain severity, affective distress, physical function, medication use, and pain tolerance were examined in women and men with high versus low scores on spousal solicitousness. Among males only, high spousal solicitousness was associated with greater numerical ratings of pain and greater self-reported disability compared with patients with low solicitous spouses. Among females only, the high spousal solicitousness patients showed lower pain tolerance, greater pain-related interference, poorer performance on functional tasks (eg, timed walking, lifting, and carrying tasks), and greater use of opioid medications. In both women and men, spousal solicitousness was associated with higher scores on the MPI pain severity scale. These results extend previous findings demonstrating a relationship between spousal responses and patients' adjustment to pain; however, the pattern of these effects appears to be moderated by the sex of the patient. Implications for assessment and treatment of chronic pain are discussed.",2003.0,0,0
887,12842375,Patients with chronic pain and abnormal pituitary function require investigation.,Z Merza; N Edwards; S J Walters; J Newell-Price; R J M Ross,"Misuse of opioids is associated with abnormalities of pituitary function. Patients with chronic pain frequently complain of fatigue and undergo endocrine testing. To test whether oral opioid treatment causes abnormal pituitary function we prospectively assessed pituitary function in 37 patients with chronic pain who were receiving either oral opioid analgesia or non-opioid analgesia. Oral opioid treatment was not associated with abnormal pituitary function although a few patients had abnormal results mainly related to obesity. Our results suggest that patients with chronic pain who have abnormal endocrine results should have a complete assessment, since abnormal test results cannot be attributed to their analgesia.",2003.0,0,0
888,12846707,Effects of systemic and epidural morphine on antidiuretic hormone levels in children.,Pervin Bozkurt; Guner Kaya; Yuksel Yeker; Fatis Altintas; Mefkur Bakan; Munire Hacibekiroglu; Gulsev Kavunoglu,"Although the use of opioids during general anaesthesia suppresses stress response to surgery and pain, the effects on antidiuretic hormone (ADH) are controversial. The aim of this study was to find the effects of morphine with either intravenous infusion or epidural route on ADH and other stress hormones. Fifty children aging (1-15 years) undergoing major genito-urinary or abdominal operations were included in this study. The patients were allocated randomly to two groups receiving either a single dose of epidural morphine 0.1 mg.kg-1 (EP group, n = 25) postinduction or morphine infusion (INF group; n = 25) at 0.02 mg.kg-1.h-1 following 0.05 mg.kg-1 bolus. Blood samples were withdrawn for plasma ADH, osmolality, glucose, cortisol, insulin and morphine level analysis following induction and 1, 5, 12 and 24 h after initial morphine administration. The two groups were similar in demographic factors, pain scores, sedation scores, and incidence of nausea and vomiting. The amount of morphine received was different between groups and the changes in serum levels of morphine were statistically significant in EP group ( P < 0.05). The changes in cortisol, blood glucose and insulin levels were insignificant in both groups (P > 0.05). The changes of ADH levels were significant at time-points in both groups, reaching control levels at the 24th hour (P < 0.05). Despite the effective pain therapy and suppression of cortisol and insulin response to surgical stimulus, the increase in ADH secretion is not effected by systemic or epidural morphine administration.",2003.0,0,0
889,12855350,Long term effects of oral sustained release morphine on neuropsychological performance in patients with chronic non-cancer pain.,V Tassain; N Attal; D Fletcher; L Brasseur; P Dégieux; M Chauvin; D Bouhassira,"Morphine is increasingly used in patients with chronic non-cancer pain, but a major concern associated with chronic use relates to possible cognitive side-effects. The aim of this long-term prospective study was to evaluate the cognitive impact of oral sustained release morphine in patients with non-cancer pain. A battery of neuropsychological tests to explore attention, psychomotor speed and memory was administered. The effects of morphine on pain, quality of life, mood, subjective memory impairment and side-effects were also investigated. Evaluations were performed at baseline in patients free from opioids and then after 3, 6 and 12 months. Twenty-eight patients were included: 18 received oral sustained morphine (range 40-140 mg/day), ten patients stopped morphine prematurely because of side-effects or insufficient pain relief and were followed as a control group. There was no impairment of any neuropsychological variable over time in the morphine treated patients in comparison with the control group. Two measures of information processing speed - the Stroop interference score and the digit symbol test were improved at 6 and 12 months and there were significant correlations with the pain relief and improvement of mood. Self-reported memory impairment improved notably in responders to morphine. Morphine induced persisting effects on pain, and to a lesser extent on quality of life and mood. The visual analog scale score for side-effects increased at 12 months and essentially consisted of gastrointestinal disorders. This study demonstrates that 12 months treatment with oral morphine does not disrupt cognitive functioning in patients with chronic non-cancer pain and instead results in moderate improvement of some aspects of cognitive functioning, as a consequence of the pain relief and concomitant improvement of well-being and mood.",2003.0,1,1
890,12859464,A new formulation of nasal fentanyl spray for postoperative analgesia: a pilot study.,M J Paech; C B Lim; S L Banks; M W M Rucklidge; D A Doherty,"Twenty-four gynaecological patients receiving postoperative patient-controlled analgesia were enrolled in an open cross-over pilot study evaluating two new formulations of nasal fentanyl spray. The primary outcome was the bioavailability of nasal fentanyl in comparison with intravenous fentanyl. This manuscript describes the clinical outcomes of quality of postoperative analgesia and patient acceptability. There were 21 complete data sets for both sequences of the cross-over design. In randomised order, patients received approximately 50 microg of fentanyl in a single dose by intranasal and intravenous administration, but separated by at least 2 h. Analgesia was of rapid onset (within 5 min) and similar quality. There was no significant difference in side-effects. Four patients experienced mild nasal stinging and although 10 (42%) preferred intravenous administration, seven (29%) preferred intranasal and six (25%) had no preference. We conclude that these formulations of fentanyl, delivered as nasal spray, have potential clinical utility.",2003.0,0,0
891,12859501,Intranasal fentanyl for postoperative analgesia after elective Caesarean section.,P Wong; F D Chadwick; J Karovits,,2003.0,0,0
892,12860958,Randomized clinical trial of an implantable drug delivery system.,Mellar P Davis; Declan Walsh; Ruth Lagman; Susan B LeGrand,,2003.0,0,0
893,12860959,"Randomized clinical trial of an implantable drug delivery system compared with comprehensive medical management for refractory cancer pain: impact on pain, drug-related toxicity, and survival.",Carla Ripamonti; Cinzia Brunelli,,2003.0,0,0
894,12861471,Fibromyalgia syndrome: an overview of potential drug targets.,Mike Briley; Chantal Moret,"Fibromyalgia syndrome (FMS) is a chronic disease of widespread and debilitating pain. The cause of FMS is unknown and its risk factors are poorly understood. It occurs frequently in the general population where it is often co-morbid with other rheumatoid and pain disorders, and psychiatric disorders such as anxiety and depression, making diagnosis particularly difficult. Several types of drugs are used to treat FMS, but none are specifically approved for this indication. FMS appears to be strongly associated with depression or at least with some symptoms of depression, and antidepressants appear to be effective in the treatment of this disorder. The advent of new classes of antidepressants with fewer side effects than older drugs has suggested new avenues of therapy for patients diagnosed with FMS.",2003.0,0,0
895,12861979,"British Neuroscience Association--17th National Meeting: 13-16 April 2003, Harrogate, UK.",Paul Chazot,,2003.0,0,0
896,12864718,Chronic pain-related disability and use of analgesia and health services in a Sydney community.,Fiona M Blyth; Lyn M March; Michael J Cousins,"To describe the clinical features, antecedents and impact of chronic pain. Telephone survey of randomly selected household respondents. Northern Sydney Health Area, metropolitan Sydney, July to September 1998. 2092 English-speaking residents aged 18 years or over. Age- and sex-adjusted prevalence of chronic pain (pain experienced every day for 3 months in the previous 6 months), pain-related disability, and use of health services and analgesic medications. Chronic pain affected 474/2092 respondents (22.1%; 95% CI, 20.2%-24.0%), with high levels of pain-related disability in 129/439 (27%). Nominated causes of chronic pain were injury in 173 (38%), most commonly sports injury (54; 13%), and a health problem in 132 (29%). Pain was work-related in 62 (14%). A musculoskeletal condition was the leading diagnosis (127; 26%). Of the 474 with chronic pain, 374 (78%) had consulted at least one health practitioner for pain in the previous 6 months, comprising medical practitioners (consulted by 292 [60%] and including general practitioners [55%]), allied health professionals (245; 50%), and alternative practitioners (99; 21%). Current or recent use of oral analgesic medications (often over-the-counter preparations) was common (339; 70%). Higher levels of pain-related disability were associated with greater use of medications and health services. Our study shows that chronic pain is common and often results from injury. It highlights the importance of timely interventions to prevent progression from acute to chronic pain and the need for a coordinated approach to managing pain-related disability.",2003.0,0,0
897,12867686,A comparison of intravenous ketoprofen versus pethidine on peri-operative analgesia and post-operative nausea and vomiting in paediatric vitreoretinal surgery.,R Subramaniam; B Ghai; M Khetarpal; M S Subramanyam,"To compare the efficacy of ketoprofen and pethidine for peri-operative analgesia and post-operative nausea and vomiting in children undergoing vitreoretinal surgery and surgery for retinal detachment. Children aged 7 to 16 years and ASA I status, undergoing vitreo-retinal surgery were randomly allocated to receive either ketoprofen 2mg/kg or pethidine 1mg/kg intravenously for peri-operative analgesia. In all patients, general anaesthesia was induced with thiopentone and intubation was facilitated with vecuronium bromide and maintained with 33% oxygen in nitrous oxide and isoflurane. Intra-operative and post-operative monitoring was done by an observer blinded to the technique. Intra-operative rescue analgesia was used if heart rate and/or blood pressure increased by 25% from pre-incision values. Post-operative pain and episodes of nausea and vomiting were evaluated at recovery (0 hour), 2, 6 and 24 hours intervals. Standard rescue analgesia and anti-emetic agents were administered if required. Eighty-six children were enrolled in the study. Forty-four received ketoprofen while 42 received pethidine. Intra-operative analgesia was comparable in both the groups and no significant difference was found in the requirement of intra-operative rescue analgesia, as well. Postoperatively 6/44 (13.6%) children in ketoprofen group had pain at recovery compared to 17/42 (40.4%) in pethidine group. Pain at 2, 6 and 24 hours, and postoperative analgesic requirement were not significantly different among the two groups. Post-operative nausea, vomiting, and antiemetic requirement were significantly less in the ketoprofen group at all time intervals. Ketoprofen is a satisfactory alternative analgesic to pethidine for vitreoretinal surgery and results in a lower incidence of postoperative nausea and vomiting.",2003.0,0,0
898,12873263,Modafinil treatment of opioid-induced sedation.,Lynn Webster; Megan Andrews; Gregory Stoddard,"The purpose of this study was to assess the efficacy of modafinil in combating opioid-induced sedation. A 1-year retrospective chart review of all patients receiving modafinil, a wake-promoting agent, to treat opioid-induced sedation. Opioid-induced sedation was measured using Epworth Sleepiness Scale (ESS). Outpatient, private practice. Eleven adult patients, six female and five male, being treated with opioids for chronic, nonmalignant pain. A significant decrease was observed between pretreatment and posttreatment ESS measurements during modafinil treatment. The results suggest an improvement in opioid-induced sedation in patients treated for nonmalignant pain.",2003.0,0,0
899,12873264,Treating pain patients at risk: evaluation of a screening tool in opioid-treated pain patients with and without addiction.,Robert Friedman; Victor Li; Deepak Mehrotra,"Patients receiving opioid treatment for chronic pain, many of whom were hospitalized with medical complications of substance abuse, were asked to complete a screening questionnaire to help validate a simple self-administered survey. Questions relating to tobacco abuse and prior treatment for drug and alcohol abuse distinguished patients with addiction and pain from opioid-treated chronic pain patients.",2003.0,0,0
900,12873265,The need to identify predictors of aberrant drug-related behavior and addiction in patients being treated with opioids for pain.,Steven D Passik; Kenneth L Kirsh,,2003.0,0,0
901,12873266,Pain and the pharmacist.,David E Joranson; Debra Elliot; Arthur G Lipman,,2003.0,0,0
902,12873269,"Medico-legal rounds: medico-legal issues and alleged breaches of ""standards of medical care"" in opioid rotation to methadone: a case report.",David A Fishbain; R B Cutler; Brandly Cole; John Lewis; R Steele Rosomoff; H L Rosomoff,"The objectives of this medico-legal case report were the following: 1) To present an example of a medico-legal problem that developed as a result of a decision to rotate a chronic pain patient (CPP) to methadone in order to taper the CPP from oxycodone; 2) To present both the plaintiff's and defendant's expert witnesses' opinions as to if and where the care of that patient fell below the ""standard of medical care;"" and 3) Based on these opinions, to develop some recommendations on how, in the future, pain medicine physicians and other physicians should proceed, in order to avoid allegations of breach of ""standards of care"" when using methadone. This is a case report of a CPP treated at a regional hospital pain clinic. Methadone rotation was used in order to taper the CPP from oxycodone because of addictive disease. During the rotation process, the CPP expired. This had medico-legal consequences. Expert witnesses differed as to whether methadone caused the death. Pain physicians should proceed with caution in using methadone for opioid rotation.",2003.0,0,0
903,12873270,Medico-legal commentary.,Ben A Rich,,2003.0,0,0
904,12873275,Effectiveness and safety of new oxycodone/acetaminophen formulations with reduced acetaminophen for the treatment of low back pain.,Arnold R Gammaitoni; Bradley S Galer; Peter Lacouture; John Domingos; Thomas Schlagheck,"To evaluate the analgesic effectiveness/safety of the new oxycodone 7.5- and 10-mg/acetaminophen 325-mg (Percocet) formulations in patients with low back pain (LBP) suboptimally responsive to nonsteroidal anti-inflammatory drugs, muscle relaxants, tramadol, cyclo-oxygenase-2 inhibitors, and/or prn opioids. Prospective, open-label, nonrandomized, 4-week trial. Multicenter. Thirty-three men and women (mean age: 52.2 years) with LBP (mean duration: 10.9 years). All prior analgesics were discontinued, and oxycodone/acetaminophen was dosed three times a day (TID), titrated to clinically meaningful pain relief. Initial oxycodone/acetaminophen dose: 2.5/325 mg TID; maximum: 20/650 mg TID. Effectiveness: Brief Pain Inventory (BPI) and Neuropathic Pain Scale 4 score (sharp, hot, dull, and deep pain). Quality of life: BPI and North American Spine Society Lumbar Spine questionnaire. Adverse events, physical/neurologic examinations, vital signs, and clinical laboratory tests. In all, 28 of 33 patients (85%) completed the study; discontinuations were for adverse events (N=3), patient choice (N=1), and lack of effectiveness (N =1). The mean oxycodone/acetaminophen dose at the end of treatment was 8.2/325 mg TID. After 4 weeks, treatment significantly reduced BPI pain intensity and improved pain relief (P < 0.0005), improved Neuropathic Pain Scale 4 score (P =0.007), reduced pain interference with quality of life (P < 0.0004), and reduced disability (P < 0.0001). Treatment was found to be safe and well tolerated. Adverse events were those most commonly expected from an opioid, and most were of mild-to-moderate intensity. The primary purpose of this study was to preliminarily test the effectiveness of the new formulations of oxycodone/acetaminophen with reduced acetaminophen in the clinical practice setting. The results from this trial suggest that these formulations are effective in the treatment of moderate-to-severe chronic LBP. Most patients (67%) reported significant pain relief/tolerable side effects with a TID dosing frequency or less (mean: 3.04 doses/day), suggesting chronic pain patients can experience meaningful pain relief with around-the-clock dosing of oxycodone/acetaminophen and minimal risk of hepatotoxicity. Further long-term, controlled studies of the efficacy/safety of the new formulations of oxycodone/acetaminophen in LBP are warranted to fully characterize efficacy in this patient population and corroborate the findings from our study.",2003.0,0,0
905,12873276,Conversion to oral controlled-release oxycodone from intravenous opioid analgesic in the postoperative setting.,Brian Ginsberg; Raymond S Sinatra; Lauri J Adler; James C Crews; Allen H Hord; Charles E Laurito; Michael A Ashburn,"This study assessed conversion factors utilized by physicians to transfer postoperative patients from intravenous opioids to oral controlled-release (CR) oxycodone and the subsequent analgesic effectiveness. This was a multicenter, open-label, usual-use study of 189 hospitalized postoperative patients receiving opioid (usually morphine) intravenous patient-controlled analgesia (IV PCA) for at least 12 to 24 hours post-procedure. Patients who were tolerant of oral medications and without signs of paralytic ileus were converted to oral CR oxycodone, given every 12 hours for up to 7 days. The mean (+/-SE) conversion factor used to convert IV PCA morphine to CR oxycodone was 1.2 +/- 0.1 (N=159). The initial CR oxycodone doses, based on individual conversion factors from IV PCA morphine, produced significant reductions in pain intensity (scores <or=4) within 6 hours after the initial dose. The mean +/- SE initial dose of CR oxycodone, for patients converted from IV PCA morphine, was 27 +/- 1 mg; that for all patients was 29 +/- 2 mg. Pain at the end of the first 12 hours was controlled with these initial doses. The most common adverse events were constipation, nausea, and pruritus. Administered at least 12 hours following abdominal, orthopedic, or gynecologic surgery, an initial oral CR oxycodone dose calculated by multiplying the amount of IV morphine used in the previous 24 hours (immediate postoperative period) by a conversion factor of 1.2, on average, provided adequate pain control during the subsequent 12-hour dosing interval and for a maximum of 7 days. Adverse events were consistent with opioid side effects.",2003.0,0,0
906,12873285,Eosinophilic exudative pleural effusion after initiation of tizanidine treatment: a case report.,Ghassan Moufarrege; Evan Frank; Donna D Carstens,"In this case report, we present a 42-year-old man with history of chronic low back pain after a work-related injury. The patient failed multiple therapeutic modalities both conservative and interventional, including numerous spinal injections and placement of a spinal cord stimulator. Finally, an intrathecal morphine pump was placed to control his pain in addition to oral pain medications. The course of the treatment included adding a muscle relaxant, tizanidine (Zanaflex), to control spasms in the lower extremities. Six weeks after starting tizanidine, a large pleural effusion was noted incidentally on a computerized tomography scan of the thoracic and lumbar spine. The patient underwent work-up for the pleural effusion; all tests came back negative. Finally, a drug reaction to tizanidine was suspected. The drug was discontinued, and 4 weeks later the pleural effusion resolved.",2003.0,0,0
907,12878618,Comparison of different quantitative sensory testing methods during remifentanil infusion in volunteers.,B Gustorff; K H Hoerauf; P Lierz; H G Kress,"The aim of this study was to compare thermal and current sensory testing stimuli with respect to opioid responsiveness. Eighteen healthy volunteers were randomized in a placebo-controlled, double-blind crossover study to receive an infusion of remifentanil 0.08 micro g kg(-1) min(-1) or saline for 40 min. Test procedures included determination of pain perception thresholds (PPT) and pain tolerance thresholds (PTT) to heat, cold, and current at 5, 250 and 2000 Hz, at baseline and at the end of the infusion. Both current at 5 Hz (PPT 3.69 (SD 2.48) mA vs 2.01 (1.52) mA; PTT 6.42 (2.79) mA vs 3.63 (2.31) mA; P<0.001) and 250 Hz (PPT 4.31 (2.42) mA vs 2.89 (1.57) mA; PTT 7.08 (2.68) mA vs 4.81 (2.42) mA; P<0.001) and heat (PPT 47.4 (2.7) degrees C vs 45.2 (3) degrees C; PTT 51.1 (1.8) degrees C vs 49.7 (1.8) degrees C; P<0.05) detected a significant analgesic effect of remifentanil compared with placebo. No analgesic effect was shown on cold or current at 2000 Hz. The magnitude of responsiveness of current stimuli at 5 Hz and 250 Hz was superior to heat stimuli. Both current (5 and 250 Hz) and heat sensory testing detected a significant analgesic effect of a remifentanil infusion compared with saline. There was more response to current testing.",2003.0,0,0
908,12878619,Pre-emptive analgesic efficacy of tramadol compared with morphine after major abdominal surgery.,H Unlugenc; M Ozalevli; Y Gunes; T Guler; G Isik,"Studies of pre-emptive analgesia in humans have shown conflicting results. This prospective, randomized, double-blind, controlled study was designed to test the hypothesis that a reduction in postoperative morphine consumption can be achieved by tramadol administered after induction of anaesthesia. Ninety patients were allocated randomly to receive i.v. tramadol (1 mg kg(-1)) (Group T), morphine (0.1 mg kg(-1)) (Group M) or saline 2 ml (Group S) after induction of anaesthesia. At peritoneal closure, a standardized (0.1 mg kg(-1)) morphine loading dose was given to all patients for postoperative pain management. Patients were allowed to use a patient-controlled analgesia (PCA) device giving bolus doses of morphine 0.025 mg kg(-1). Discomfort, sedation, pain scores, cumulative morphine consumption, and side-effects were recorded at 1, 2, 6, 12 and 24 h after the start of PCA. There were no significant differences between groups in mean pain, discomfort, and sedation scores at any study period. Cumulative morphine consumption was significantly lower in Group M at 12 and 24 h after starting the PCA than in Group S. In Group T, it was lower only after 24 h (28% less in Group M and 17% less in Group T; P<0.017). There were no significant differences in morphine consumption between Groups T and M. Tramadol (1 mg kg(-1)), administered after induction of anaesthesia, offered equivalent postoperative pain relief, and similar recovery times and postoperative PCA morphine consumption compared with giving morphine 0.1 mg kg(-1). These results also suggest that presurgical exposure to systemic opioid analgesia may not result in clinically significant benefits .",2003.0,0,0
909,12878621,Emetic effects of morphine and piritramide.,C Breitfeld; J Peters; T Vockel; C Lorenz; M Eikermann,"Successful management of postoperative pain requires that adequate analgesia is achieved without excessive adverse effects. Opioid-induced nausea and vomiting is known to impair patients' satisfaction, but there are no studies providing sufficient power to test the hypothesis that the incidence of opioid-induced nausea and vomiting differs between micro -opioid receptor agonists. Thus, we tested the hypothesis that the incidence of vomiting and nausea differs between morphine and piritramide. In a prospective, randomized, double-blind fashion, we administered either morphine (n=250) or piritramide (n=250) by patient-controlled analgesia (PCA) for postoperative pain relief. We used a bolus dose of 1.5 mg with a lockout time of 10 min. Incidence and intensity (numerical rating scale) of postoperative nausea, vomiting, pain, patient satisfaction (score 0-10), side-effects (score 0-3) and drug consumption were measured. Mean drug consumption did not differ between the piritramide and morphine groups (30.8 (SD 22.4) mg day(-1) vs 28.4 (21.8) mg day(-1)) during the first postoperative day and there were no significant differences in the overall incidence of nausea (30% vs 27%) and vomiting (19% vs 15%). Intensity of nausea correlated inversely (P=0.01) with morphine consumption but not with piritramide consumption. Pain scores both at rest (2.2 (1.9) vs 2.6 (2)) and during movement (4.4 (2.2) vs 4.9 (2.3)) were slightly but significantly less with morphine. Opioid-induced emesis was observed in about one-third of the patients using morphine and piritramide for PCA and the incidence of vomiting was one-half of that. Potential differences in the incidence of vomiting during PCA therapy between these micro-opioid receptor agonists can be excluded.",2003.0,0,0
910,12883507,Emergency department analgesia for fracture pain.,Julie C Brown; Eileen J Klein; Charlotte W Lewis; Brian D Johnston; Peter Cummings,"We analyze records of all emergency department (ED) patients with extremity or clavicular fractures to describe analgesic use, compare analgesia between adults and children, and compare analgesia between the subset of these adults and children with documented moderate or severe pain. Among children, we compare treatment between pediatric and nonpediatric facilities. Analysis of the ED component of the National Center for Health Statistics National Hospital Ambulatory Medical Care Survey for 1997 through 2000 was conducted. The proportion of patients with closed extremity and clavicular fracture that received any analgesic and narcotic analgesic medications was determined for each age category. Survey-adjusted regression analyses compared pain and narcotic medications by age and ED type (pediatric versus other). Analyses were repeated for the subset of patients with moderate or severe pain severity scores. Of 2,828 patients with isolated closed fractures of the extremities or clavicle, 64% received any analgesic and 42% received a narcotic analgesic. Pain severity scores were recorded for 59% of visits overall, 47% of children younger than 4 years, and 34% of children younger than 1 year. Among patients with documented moderate or severe pain, 73% received an analgesic and 54% received a narcotic analgesic. Compared with adults, a lower proportion of children (< or = 15 years) received either any analgesic or a narcotic analgesic (P <.001). After adjustment for confounders and survey design, the proportion of patients aged 0 to 3, 4 to 8, 9 to 15, 16 to 29, 30 to 69, and 70 years and older who received any analgesic was 54% (95% confidence interval [CI] 41% to 67%), 63% (95% CI 57% to 68%), 60% (95% CI 57% to 64%), 67% (95% CI 62% to 73%), 68% (95% CI 64% to 72%), and 58% (95% CI 52% to 65%), respectively; the proportion who received a narcotic analgesic was 21% (95% CI 11% to 31%), 30% (95% CI 22% to 37%), 27% (95% CI 23% to 32%), 47% (95% CI 40% to 54%), 51% (95% CI 46% to 56%), and 41% (95% CI 35% to 48%), respectively. Compared with children treated in other EDs, children treated in pediatric EDs were about as likely to receive any analgesia (adjusted relative risk [RR] 1.1; 95% CI 0.9 to 1.3) or narcotic analgesia (adjusted RR 0.9; 95% CI 0.6 to 1.2). In pediatric and adult patients, pain medications were frequently not part of ED treatment for fractures, even for visits with documented moderate or severe pain. Pain severity scores were often not recorded. Pediatric patients were least likely to receive analgesics, especially narcotics.",2003.0,0,0
911,12884990,Comparison of the effects of two intrathecal anaesthetic techniques for transurethral prostatectomy on haemodynamic and pulmonary function.,K H Walsh; C Murphy; G Iohom; C Cooney; J McAdoo,"Transurethral prostatectomy is routinely performed under spinal anaesthesia. This technique can cause hypotension, which is particularly undesirable in the elderly. The objective was to compare spinal anaesthesia for transurethral prostatectomy using hyperbaric bupivacaine 15 mg (control group) and hyperbaric bupivacaine 10 mg (limiting spread by maintaining the upright position for 15 min) and fentanyl 25 microg (fentanyl group) in terms of haemodynamic and pulmonary function. Thirty ASA I-III patients were randomly selected and underwent spinal anaesthesia with either hyperbaric bupivacaine 15 mg (immediately positioned supine) or hyperbaric bupivacaine 10 mg (upright for 15 min) and fentanyl 25 microg. The greatest changes in mean arterial pressure (P = 0.9), ephedrine requirements (P = 0.8) and mean maximum change in forced vital capacity (P = 0.5) were similar in both groups. The addition of fentanyl 25 microg to bupivacaine 10 mg and limiting the spread of the block does not improve either haemodynamic or pulmonary function compared with bupivacaine 15 mg in patients undergoing transurethral prostatectomy.",2003.0,0,0
912,12886915,A comparison of intra-operative or postoperative exposure to music--a controlled trial of the effects on postoperative pain.,U Nilsson; N Rawal; M Unosson,"The effect of intra-operative compared to postoperative music on postoperative pain was evaluated in a controlled trial. In all, 151 patients undergoing day case surgery for inguinal hernia repair or varicose vein surgery under general anaesthesia were randomly allocated to three groups: group 1 listened to music intra-operatively, group 2 listened to music postoperatively and group 3, the control group, listened to 'white noise'. The anaesthetic and postoperative analgesic techniques were standardised. Pain was assessed using a numeric rating scale (0-10) and patients requirements for postoperative morphine, paracetamol and ibuprofen was recorded. The effect of music on nausea, fatigue and anxiety was also investigated. The results showed that patients exposed to music intra-operatively or postoperatively reported significantly lower pain intensity at 1 and 2 h postoperatively and patients in the postoperative music group required less morphine at 1 h compared to the control group. No differences were noted in the other variables. This study demonstrates that there is a short-term pain-reducing effect of music therapy however, the beneficial effects do not differ if the patient is exposed to music intra-operatively or postoperatively.",2003.0,0,0
913,12886917,"A comparison of cyclizine, ondansetron and placebo as prophylaxis against postoperative nausea and vomiting in children.",C M O'Brien; G Titley; P Whitehurst,"Nausea and vomiting is a relevant and common problem with unfavourable sequelae in children undergoing some plastic surgery procedures. There is a lack of anti-emetic trials performed in children, with only a few investigating the roles of the older anti-emetic agents such as cyclizine compared with newer ones such as ondansetron. This randomised, controlled, double-blind study examined the effectiveness of a single dose of ondansetron (0.1 mg x kg-1), cyclizine (20 mg) and placebo (normal saline) in the prevention of postoperative nausea and vomiting in 150 children (mean age 3.6 years) undergoing plastic genitourinary procedures. Rates of previous postoperative nausea and vomiting and motion sickness were comparable across the groups. Postoperative vomiting was significantly reduced with ondansetron prophylaxis (p = 0.006) but there was no detectable anti-emetic effect with cyclizine. Furthermore, cyclizine caused pain on injection (p < 0.001).",2003.0,0,0
914,12890955,Patient-controlled epidural analgesia after major urologic surgeries. A comparison of tramadol with or without bupivacaine.,Anis Aribogan; Nurcan Doruk; Atilla Aridogan; Sule Akin; Okan Balcioglu,"The efficiency and safety of patient-controlled epidural analgesia by using tramadol alone and combined with bupivacaine were investigated for postoperative pain treatment after major urological surgeries. For PCEA: in group I (n = 17) a loading dose of 20 mg tramadol with a continuous infusion of 1 mg/ml tramadol at a rate of 8 ml/h was given. In group II (n = 17), patients received an initial loading dose of 20 ml bupivacaine 0.125% and a supplemental continuous infusion of 8 ml/h. In group III (n = 17), a loading dose of 20 mg tramadol with 20 ml bupivacaine 0.125% were given and a supplemental infusion of 1 mg/ml tramadol in 20 ml bupivacaine 0.125% combination was begun with a rate of 8 ml/h. A demand epidural bolus dose of 5 ml with a lockout time of 30 min was also used in all patients. VAS for pain intensity, vital signs, sedation scale and side effects was monitored at 0, 15, 30 min and 1, 2, 3, 4, 8, 12, and 24 h of the postoperative period. Statistical significance was determined using Kruskal-Wallis, Fisher's exact, analysis of variance for repeated measurements and Tukey tests. The hemodynamic values and sedation scales were insignificantly different (p > 0.05). The adequate analgesia was provided in all patients. However VAS values were significantly lower in group III than in groups I and II at every measurement (p < 0.05). The incidence of side effects in all three groups was low (p > 0.05). In conclusion, we suggested that a combination of tramadol with bupivacaine can provide the most effective and safe postoperative analgesia with minimal risk for side effects.",2003.0,0,0
915,12894165,Attacking pain at its source: new perspectives on opioids.,Christoph Stein; Michael Schäfer; Halina Machelska,"The treatment of severe pain with opioids has thus far been limited by their unwanted central side effects. Recent research promises new approaches, including opioid analgesics acting outside the central nervous system, targeting of opioid peptide-containing immune cells to peripheral damaged tissue, and gene transfer to enhance opioid production at sites of injury.",2003.0,0,0
916,12907327,Incomplete response to endoscopic sphincterotomy in patients with sphincter of Oddi dysfunction: evidence for a chronic pain disorder.,Jeffrey D Linder; Joshua C Klapow; Sheri D Linder; C Mel Wilcox,"The efficacy of endoscopic treatment of sphincter of Oddi dysfunction (SOD) with endoscopic sphincterotomy (ES) remains controversial. Although some studies have shown a positive impact on patient symptoms after treatment, these reports have been largely qualitative and evaluated on short-term response. The aim of our study was to quantitatively measure the long-term outcomes of endoscopic therapy in patients with SOD. Thirty-three patients with suspected SOD underwent selective sphincter of Oddi manometry (SOM) of the biliary and/or pancreatic sphincter. Each patient completed a telephone-based survey measuring symptomatic pain before and after SOM +/- ES. The questioner was blinded to the results of SOM. The patients with normal SOM or SOD but who did not undergo ES served as controls. Of these 33 patients (27 women, mean age 48.7 yr, range 13-74), 19 (57.5%) were found to have SOD (12 biliary, six pancreatic, one both). The average follow-up was 18.1 months (range 7-34). Of the patients with SOD, 17 (89%) underwent ES. At follow-up of the 19 patients undergoing ES, five were taking narcotics for persistent pain, two were taking antidepressants, and 15 identified the endoscopic therapy as the reason for their relief. Of the 14 controls, seven were taking narcotics, seven were taking antidepressants, and two identified the endoscopy as the reason for their relief; some patients were taking both antidepressants and narcotics. Patients found to have SOD who undergo ES are more likely to be improved on long-term follow-up when compared with patients with suspected SOD but normal manometry without ES. However, almost uniformly, despite ES, patients continue to have pain, which is consistent with most chronic pain disorders and which suggests a multifactorial cause for the pain.",2003.0,0,0
917,12911209,Silent gastric perforation in a pancreatic cancer patient treated with neurolytic celiac plexus block.,Masahiko Takahashi; Akiko Yoshida; Takeshi Ohara; Hiroyuki Yamanaka; Yoko Yamamoto; Satoshi Toraiwa; Toshimichi Nakaho; Makoto Yamamuro,,2003.0,0,0
918,12918185,Preoperative oral administration of fast-release morphine sulfate reduces postoperative piritramide consumption.,Ana Reiter; Ernest Zulus; Thomas Hartmann; Klaus Hoerauf,"The aim of this prospective randomized placebo-controlled double-blind study was to investigate the effect of premedication with morphine sulfate on postoperative pain. Ninety-eight ASA I-III patients undergoing total replacement of the knee or hip joint were randomly assigned to one of two groups. Group 1 received 20 mg morphine sulfate p.o. approximately one hour before the start of surgery; group 2 received placebo. After surgery, piritramide was administered via patient-controlled analgesia over 24 hours. Piritramide consumption and pain scores (visual analog scale) were recorded. The duration of surgery (mean +/- SD) was comparable in the two groups (group 1: 145 +/- 42 min, group 2: 131 +/- 35 min). In group 1 the cumulative piritramide consumption during 24 hours postoperation was significantly less than in the placebo group (37.5 +/- 12.5 mg versus 46.8 +/- 22.1, t-test, p < 0.05), although similar pain scores were recorded (group 1: 4.8 +/- 1.8 and 3.6 +/- 1.7, group 2: 4.8 +/- 1.6 and 3.4 +/- 2.0, at 1 and 24 hours, respectively). These data show that the preoperative oral administration of morphine sulfate, regardless of its short half-life, can reduce postoperative consumption of opioids at similar pain levels.",2003.0,0,0
919,12923661,Life-threatening thrombotic thrombocytopenic purpura (TTP) in a patient with sickle cell-hemoglobin C disease.,H E Lee; V J Marder; L J Logan; S Friedman; B J Miller,We report a patient with hemoglobin sickle cell-hemoglobin C disease who developed the clinical syndrome of thrombotic thrombocytopenic purpura (TTP) during admission for typical acute pain crisis. The potential for multiorgan involvement secondary to vaso-occlusive crisis complicated the diagnosis and overlapped with the patient's clinical presentation of chronic bone pain and hemolytic anemia. Clinical improvement and normalization of laboratory parameters followed rapidly in response to plasma exchange therapy.,2003.0,0,0
920,12925248,Effect of celecoxib and dexamethasone on postoperative pain after lumbar disc surgery.,Matthias Karst; Tanja Kegel; Anne Lukas; Wolf Lüdemann; Samii Hussein; Siegfried Piepenbrock,"This study was designed to assess the efficacy of perioperative administration of celecoxib (Celebrex; Pharmacia GmbH, Erlangen, Germany) in reducing pain and opioid requirements after single-level lumbar microdiscectomy. We studied 34 patients (mean age, 44.26 yr; standard deviation [SD], 13.09 yr) allocated randomly to receive celecoxib 200 mg twice a day for 72 hours starting on the evening before surgery or placebo capsules in a double-blind study. Fourteen patients received 20 to 80 mg dexamethasone intravenously during surgery (mean, 40 mg; SD, 19.22 mg) because of visible signs of compression of the affected nerve root. After lumbar disc surgery, patients were monitored for visual analog scores for pain at rest and on movement, patient-controlled analgesia (PCA) piritramide requirements, and von Frey thresholds in the wound area. Pain scores decreased and wound von Frey thresholds increased continuously until discharge, with no intergroup differences. Mean 24-hour PCA piritramide requirements were 22.63 mg (SD, 23.72 mg) and 26.14 mg (SD, 22.57 mg) in the celecoxib and placebo groups, respectively (P = not significant). However, patients with intraoperative dexamethasone (n = 14) required only 10.29 mg (SD, 8.55 mg) 24-hour PCA piritramide, in contrast to the 34.25 mg (SD, 24.69 mg) needed in those who did not receive intraoperative dexamethasone (P = 0.001). In addition, 24 hours after the operation, pain scores on movement were significantly lower in the dexamethasone subgroup (P = 0.003). Celecoxib has no effect on postoperative pain scores and PCA piritramide requirements. The intraoperative use of 20 to 80 mg dexamethasone is able to significantly decrease postoperative piritramide consumption and pain scores on the first day after surgery.",2003.0,0,0
921,12925476,Minimum dose of intrathecal diamorphine required to prevent intraoperative supplementation of spinal anaesthesia for Caesarean section.,S Saravanan; A P C Robinson; A Qayoum Dar; M O Columb; G R Lyons,"Intraoperative discomfort during spinal anaesthesia for Caesarean section is the commonest cited anaesthetic cause of litigation in obstetric practice. Intrathecal opioids are used to improve intraoperative comfort and postoperative analgesia for these operations. The minimum intrathecal diamorphine dose that prevents intraoperative supplementation requires determination. After ethics committee approval, 200 ASA I, II women with > or = 37 weeks gestation and planned for elective Caesarean section under combined spinal-epidural anaesthesia were recruited. They were randomized into four groups to receive hyperbaric bupivacaine 0.5% 12.5 mg with diamorphine 0.2, 0.3, 0.4 or 0.5 mg by intrathecal injection. The need for intraoperative i.v. supplementation with alfentanil, time to first requests for postoperative analgesia, incidence of nausea and vomiting and requirement for antiemetic and antipruritic were noted. Intraoperative supplementation was inversely proportional to the dose of diamorphine used (P=0.004). The ED(95) value for intrathecal diamorphine to prevent intraoperative supplementation was 0.39 mg. Mean time interval for request for postoperative analgesia was 446 min in the 0.2 mg group, 489 min in the 0.3 mg group, 601 min in the 0.4 mg group and 687 min in the 0.5 mg group (P=0.003 for trend). Incidence of nausea, vomiting and pruritus increased with dose of diamorphine used (P values for trend: nausea, 0.04; vomiting, 0.008; pruritus, 0.004). Requests for antiemetic increased with dose but achieved significance only for requirement for second antiemetic (P=0.03). Request for antipruritic did not achieve significance. The ED(95) for the amount of intrathecal diamorphine required to prevent intraoperative supplementation during spinal anaesthesia for Caesarean section is 0.4 mg in clinical terms. Times to first requests for analgesia, incidence of nausea, vomiting and pruritus increase with dose.",2003.0,0,0
922,12927414,Determination of tramadol in hair using solid phase extraction and GC-MS.,Kamal A Hadidi; Jamal K Almasad; Thair Al-Nsour; Samih Abu-Ragheib,"Tramadol is a centrally acting synthetic analgesic with mu-opioid receptor agonist activity, it is a widely prescribed analgesic used in the treatment of moderate to severe pain and as an alternative to opiates. Tramadol causes less respiratory depression than morphine at recommended doses. Its efficacy and low incidence of side effects lead to its unnecessary prescribing in patients with mild pain. Tramadol was classified as a ""controlled drug"" long after its approval for use in Jordan. Analysis of drugs of abuse in hair has been used in routine forensic toxicology as an alternative to blood in studying addiction history of drug abusers. A method for the determination of tramadol in hair using solid phase extraction and gas chromatography-mass spectrometry (GC-MS) is presented, the method offers excellent precision (3.5-9.8%, (M)=6.77%), accuracy (6.9-12%, M=9.4%) and limit of detection 0.5 ng/mg. The recovery was in the range of 87-94.3% with an average of 90.75%. The calibration curve was linear over the concentration range 0.5-5.0 ng/mg hair with correlation coefficient of 0.998. The developed method was tested on 11 hair samples taken from patients using tramadol as prescribed by their physician along with other different drugs in treating chronic illnesses. Tramadol was detected in all hair samples at a concentration of 0.176-16.3 ng/mg with mean concentration of 4.41 ng/mg. The developed method has the potential of being applied in forensic drug hair testing. In Jordan, hair drug testing started to draw the attention of legal authorities which stimulated forensic toxicologists in recent years to develop methods of analysis of drugs known or have the potential to be abused.",2003.0,0,0
923,12927624,Different lipid profiles as constituencies of liquid formula diets do not influence pain perception and the efficacy of opioids in a human model of acute pain and hyperalgesia.,I R Pahl; W Koppert; C Enk; R Sittl; S Mühldorfer; E G Hahn; M Schmelz; D Schwab,"Nutritional support and pain control by medication are often used concomitantly, but interactions are hardly investigated. A randomised, double-blind, cross-over study in ten right-handed volunteers was performed evaluating the influence of cholecystokinin (CCK)-excretion on the perception of pain in a standardised model. CCK-excretion was induced by a liquid formula diet with either long- or medium-chain triglycerides (LCT, MCT). Plasma samples were drawn over a 60 min period in 15-min intervals and CCK and somatostatin (SMS) were measured by radioimmunoassay (RIA). Gastric emptying was evaluated by C-13-breath testing. Transcutaneous electrical stimulation at a high current density (5 Hz, 70.1+/-5.8 mA) was used to provoke acute pain and stable areas of secondary mechanical hyperalgesia and pinprick allodynia for 2 h. Ongoing pain ratings as well as extension of pinprick-hyperalgesia and allodynia were compared between both liquid formula diets. In a second series of experiments, alfentanil (4.1+/-0.5 mg) was administered for 90 min using target-controlled infusions and measurements were performed as stated above. Oral administration of LCT as well as MCT may lead to different CCK blood levels, but we found no evidence for CCK-induced effects on pain sensation, touch-evoked allodynia, secondary hyperalgesia or morphine-induced anti-nociception in humans. In our studies, liquid formula diets did not influence acute pain perception or the efficacy of opioids in a human model of pain.",2003.0,0,0
924,12935788,Appropriate and responsible use of opioids in chronic non-cancer pain.,Harald Breivik,,2003.0,0,0
925,12935789,Recommendations for using opioids in chronic non-cancer pain.,Eija Kalso; Laurie Allan; Paul L I Dellemijn; Clara C Faura; Wilfried K Ilias; Troels S Jensen; Serge Perrot; Leon H Plaghki; Michael Zenz,"1. The management of chronic pain should be directed by the underlying cause of the pain. Whatever the cause, the primary goal of patient care should be symptom control. 2. Opioid treatment should be considered for both continuous neuropathic and nociceptive pain if other reasonable therapies fail to provide adequate analgesia within a reasonable timeframe. 3. The aim of opioid treatment is to relieve pain and improve the patient's quality of life. Both of these should be assessed during a trial period. 4. The prescribing physician should be familiar with the patient's psychosocial status. 5. The use of sustained-release opioids administered at regular intervals is recommended. 6. Treatment should be monitored. 7. A contract setting out the patient's rights and responsibilities may help to emphasize the importance of patient involvement. 8. Opioid treatment should not be considered a lifelong treatment.",2003.0,0,0
926,12935801,Transdermal fentanyl: informed prescribing is essential.,Joy R Ross; Columba Quigley,"While morphine is historically the gold standard for the management of severe cancer pain, some patients either do not achieve adequate analgesia, or suffer intolerable side-effects. For these patients an alternative opioid is recommended. One such alternative is the potent mu opioid agonist fentanyl, delivered in a transdermal controlled release formulation. Similar to morphine, transdermal fentanyl is effective for the management of moderate to severe cancer pain. However, inappropriate prescribing of transdermal fentanyl, particularly in the clinical setting of unstable pain, can cause significant opioid toxicity, as highlighted in the case reports described.",2003.0,0,0
927,12938592,A prospective randomized clinical trial on pain control after major abdominal surgery.,Franco Ceriati; Giovanni Domenico Tebala; Germano De Cosmo; Carlo Saraceni; Claudio Coco; Francesco Bosco; Luigi Mariani; Emanuela Ceriati; Antonella Zumbo,"This study was conducted in order to investigate the advantages and limitations of four analgesic modalities: a) epidural morphine; b) intravenous morphine; c) patient controlled intravenous morphine (patient-controlled analgesia); and d) non-steroidal anti-inflammatory drugs. Eighty patients undergoing major abdominal surgical procedures were prospectively and randomly treated with one of the above-mentioned analgesic methods. Evaluation of pain perception was done using the visual analogue pain score and the simple descriptive scale 4 hours after the procedure, in the early morning on postoperative day 1 and in the afternoon on postoperative days 1, 2 and 3. The need for supplementary analgesia and the onset of complications, if any, were also evaluated for each patient. Patient-controlled intravenous morphine yielded the best analgesic effect over the entire period. Epidural morphine was more effective in the very early postoperative period compared to modalities (b) and (d). Non-steroidal anti-inflammatory drugs, on the other hand, were more effective on the later postoperative days. None of the patients in group C needed supplementary analgesia, as against 20% in group A, 55% in group B and 40% in group D. Patients with hypochondriasis scores > 70 or depression scores > 70 required supplementation of analgesia more often. Morphine proved to be the drug of choice. Drug titration may be modulated in relation to the psychological characteristics of the patient. The best drug titration modality, in fact, is patient-controlled analgesia.",2003.0,0,0
928,12953725,Patient-controlled epidural analgesia after thoracic and upper abdominal surgery using sufentanil with and without bupivacaine 0.125%.,R Poopalalingam; M Y H Chow; L T Wong,"Epidural sufentanil can relieve postoperative pain after thoracic and upper abdominal surgery but it has some unwanted side effects. Patient-controlled epidural analgesia (PCEA) allows patients to titrate and reduce their analgesic requirements. The study aims to assess the use of demand-only PCEA after thoracotomy and upper abdominal surgery using sufentanil with or without bupivacaine in terms of pain control, amount of analgesic required and side effect profile. After the Hospital Ethics Committee approval and written informed consent, 34 ASA I and II patients were enrolled in this prospective, randomised, double-blinded controlled study. Post-operatively, after achieving adequate analgesia in the recovery, the patients were randomised to receive either sufentanil 1 microg/ml in normal saline (Group S) or sufentanil 1 microg/ml with bupivacaine 0.125% (Group SB) in a demand-only PCEA programme. Pain scores, side effects and amount of analgesia used were reviewed every hour. The demographic profile of both groups was similar. The amount of sufentanil used was higher in Group S than in Group SB but it was not statistically significant. The numbers of patients with high pain scores at rest and during movement were not significantly different between the two groups. The side effect profiles of both groups were similar. The PCEA demand-only programme using sufentanil 1 microg/ml with and without bupivacaine 0.125% was satisfactory after thoracotomy and upper abdominal surgery in our patient population. The addition of bupivacaine to sufentanil did not significantly reduce the amount of sufentanil required, the pain scores or the side effects.",2003.0,0,0
929,12960555,Analgesic efficacy of inhaled morphine in patients after bunionectomy surgery.,John B Thipphawong; Najib Babul; Richard J Morishige; Hugh K Findlay; Keith R Reber; Gary J Millward; Babatunde A Otulana,"The AERx Pain Management System (Aradigm Corporation, Hayward, CA) is a novel pulmonary delivery system for the systemic administration of morphine. The authors compared the relative analgesic efficacy and safety of the AERx Pain Management System with those of placebo and intravenous morphine in an orthopedic postsurgical pain model. Eighty-nine male and female PS-1 to PS-3 patients underwent standardized bunionectomy surgery and received multiple doses of inhaled or intravenous placebo, inhaled morphine (one inhalation [2.2 mg] or three inhalations [6.6 mg]), or intravenous morphine (4 mg) in a blinded fashion. Open-label rescue morphine (2 mg) was also available as needed. Pain intensity, pain relief, and time to pain relief were measured after the first dose. Global evaluation, morphine consumption, vital signs, and adverse events were monitored for 8 h after treatment. Blinded study personnel performed all treatment administrations and pain assessments. Three inhalations of morphine and 4 mg intravenous morphine provided comparable single- and multiple-dose analgesia. One inhalation of morphine was statistically indistinguishable from placebo. Three inhalations of morphine and 4 mg intravenous morphine both consistently demonstrated significantly greater analgesic efficacy than did placebo and one inhalation of morphine. Comparable analgesic efficacy was demonstrated between a carefully matched dose of inhaled and intravenous morphine in a postsurgical pain model.",2003.0,0,0
930,12969043,Sacrococcygeal local anaesthesia versus general anaesthesia for pilonidal sinus surgery: a prospective randomised trial.,M Z Naja; M F Ziade; M El Rajab,Sixty patients scheduled for pilonidal sinus surgery were prospectively randomly assigned to receive general anaesthesia or sacrococcygeal local anaesthesia with a newly-described technique. Patients in the general anaesthesia group spent more time in the operating theatre and recovery room than did those in the local anaesthesia group (p < 0.05). Two thirds (67%) of the patients in the local anaesthesia group left hospital on the day of surgery compared to only 17% of patients in the general anaesthesia group (p < 0.05). Visual analogue scale pain scores performed during the 3-day follow-up period favoured the local anaesthetic technique (p < 0.05). Postoperative analgesia requirements were greater in the general anaesthesia group than in the local anaesthesia group (p < 0.05). The majority of patients and surgeons expressed satisfaction with local anaesthesia. Sacrococcygeal local anaesthesia appears to be a successful alternative to general anaesthesia for pilonidal sinus surgery.,2003.0,0,0
931,12974832,Topical ketamine in the treatment of mucositis pain.,Neal E Slatkin; Michelle Rhiner,"Ketamine oral rinse provided effective palliation of intractable mucositis pain in a 32-year-old woman with squamous carcinoma of the tongue undergoing radiation therapy. Pain at rest and with eating decreased with ketamine, allowing for a tapering of her opiate dose. No side effects of ketamine were reported. Treatment benefits most likely arose from the inhibition by ketamine of peripheral N-methyl D-aspartate receptors, though other mechanisms of action may have been contributory. Further evaluation of topical ketamine in the treatment of mucositis-related pain, and, potentially, other causes of inflammatory oral pain, are warranted.",2003.0,0,0
932,14499422,Controlled-release oxycodone relieves neuropathic pain: a randomized controlled trial in painful diabetic neuropathy.,C Peter N Watson; Dwight Moulin; Judith Watt-Watson; Allan Gordon; John Eisenhoffer,"Painful neuropathy is one of the most common long-term complications of diabetes mellitus and often proves difficult to relieve. Patients with diabetic neuropathy with moderate or greater pain for at least 3 months, were evaluated for efficacy, safety and health-related quality of life (QOL) while receiving controlled-release (CR) oxycodone (OxyContin) or active placebo. Patients underwent washout from all opioids 2-7 days before randomization to 10 mg CR oxycodone or active placebo (0.25 mg benztropine) q12h. The dose was increased, approximately weekly, to a maximum of 40 mg q12h CR oxycodone or 1 mg q12h benztropine, with crossover to the alternate treatment after a maximum of 4 weeks. Acetaminophen, 325-650 mg q4-6h prn was provided as rescue. Thirty-six patients were evaluable for efficacy (21 men, 15 women, mean age 63.0+/-9.4 years). CR oxycodone resulted in significantly lower (P=0.0001) mean daily pain (21.8+/-20.7 vs. 48.6+/-26.6 mm VAS), steady pain (23.5+/-23.0 vs. 47.6+/-30.7 mm VAS), brief pain (21.8+/-23.5 vs. 46.7+/-30.8 mm VAS), skin pain (14.3+/-20.4 vs. 43.2+/-31.3 mm VAS), and total pain and disability (16.8+/-15.6 vs. 25.2+/-16.7; P=0.004). Scores from 6 of the 8 SF-36 domains and both summary scales, Standardized Physical Component (P=0.0002) and Standardized Mental Component (P=0.0338) were significantly better during CR oxycodone treatment. The number needed to treat to obtain one patient with at least 50% pain relief is 2.6 and clinical effectiveness scores favoured treatment with CR oxycodone over placebo (P=0.0001). CR oxycodone is effective and safe for the management of painful diabetic neuropathy and improves QOL.",2003.0,0,1
933,14499423,"The analgesic effect of oral delta-9-tetrahydrocannabinol (THC), morphine, and a THC-morphine combination in healthy subjects under experimental pain conditions.",Myrtha Naef; Michele Curatolo; Steen Petersen-Felix; Lars Arendt-Nielsen; Alex Zbinden; Rudolf Brenneisen,"From folk medicine and anecdotal reports it is known that Cannabis may reduce pain. In animal studies it has been shown that delta-9-tetrahydrocannabinol (THC) has antinociceptive effects or potentiates the antinociceptive effect of morphine. The aim of this study was to measure the analgesic effect of THC, morphine, and a THC-morphine combination (THC-morphine) in humans using experimental pain models. THC (20 mg), morphine (30 mg), THC-morphine (20 mg THC+30 mg morphine), or placebo were given orally and as single doses. Twelve healthy volunteers were included in the randomized, placebo-controlled, double-blinded, crossover study. The experimental pain tests (order randomized) were heat, cold, pressure, single and repeated transcutaneous electrical stimulation. Additionally, reaction time, side-effects (visual analog scales), and vital functions were monitored. For the pharmacokinetic profiling, blood samples were collected. THC did not significantly reduce pain. In the cold and heat tests it even produced hyperalgesia, which was completely neutralized by THC-morphine. A slight additive analgesic effect could be observed for THC-morphine in the electrical stimulation test. No analgesic effect resulted in the pressure and heat test, neither with THC nor THC-morphine. Psychotropic and somatic side-effects (sleepiness, euphoria, anxiety, confusion, nausea, dizziness, etc.) were common, but usually mild.",2003.0,0,0
934,14499431,What decline in pain intensity is meaningful to patients with acute pain?,M Soledad Cepeda; Juan M Africano; Rodolfo Polo; Ramiro Alcala; Daniel B Carr,"Despite widespread use of the 0-10 numeric rating scale (NRS) of pain intensity, relatively little is known about the meaning of decreases in pain intensity assessed by means of this scale to patients. We aimed to establish the meaning to patients of declines in pain intensity and percent pain reduction. Upon arrival to the postanesthesia care unit, postsurgical patients rated their baseline pain intensity on both a 0-10 NRS and on a 4-point verbal scale. Patients whose NRS was higher than 4/10 received intravenous opioids until their pain intensity declined to 4/10 or lower. During opioid titration, patients were asked every 10 min to rate pain intensity on a NRS and to indicate the degree of pain improvement on a 5-point Likert scale from 'no improvement' to 'complete pain relief'. Seven hundred adult patients were enrolled. For patients with moderate pain, a decrease of 1.3 units (20% reduction) corresponded to 'minimal' improvement, a decrease of 2.4 (35% reduction) to 'much' improvement, a decrease of 3.5 units (45% reduction) corresponded to 'very much' improvement. For patients with severe pain, the decrease in NRS pain score and the percentage of pain relief had to be larger to obtain similar degrees of pain relief. The change in pain intensity that is meaningful to patients increases as the severity of their baseline pain increases. The present findings are applicable in the clinical setting and research arena to assess treatment efficacy.",2003.0,0,0
935,14499444,Potential utility of the peripheral analgesic properties of morphine in stomatitis-related pain: a pilot study.,Leandro C A Cerchietti; Alfredo H Navigante; Miguel W Körte; Alejandro M Cohen; Patricia N Quiroga; Edda C Villaamil; Marcelo R Bonomi; Berta M Roth,"To determine the potential clinical utility of peripheral opioid action using a clinical model of cancer treatment-induced inflammation and pain that allowed for topical application of morphine in the damaged tissue (oral mucosa). This pilot study followed a two blocks design. Ten patients with painful oral mucositis were enrolled in the first block (dose-response relationship finding) and randomized in two groups to receive oral rinses with 15 ml of either 1 per thousand or 2 per thousand morphine solution. Twenty-two patients were enrolled into the second block (efficacy and safety determination). Additionally, serum concentrations of morphine were measured in five representative patients. In the first block (n=10) a dose-response relationship for topical morphine was found. Rinses with 2 per thousand -morphine solution showed better pain relief (median 80%, range 70-80%) than those with 1 per thousand (median 60%, range 55-70%; P=0.0238). Therefore, subsequent patients enrolled for the second block (n=22) received oral rinses with 2 per thousand -morphine solution. In these patients the time to good (>or=50%) or to complete (100%) pain relief was 28 (+/-12)min after the first mouthwash, and the duration of relief was on average 216 (+/-25)min. Twenty patients (90%) received the successive mouthwashes every 3 h and 10% of them every 2 h. The duration of severe pain at the moment of swallowing was 5.17 (+/-1.47) days. Only six patients needed supplementary analgesia, and the time elapsed before the first supplemental analgesic was 1.18 (+/-0.8) days. The duration of severe functional impairment was 1.52 (+/-1.31) days, thus allowing us to feed the patient by mouth with liquid-food supplementation. During our experiment no systemically active detectable concentrations of morphine were found (GC-MS analysis). The most important side effect attributable to morphine mouthwashes was burning/itching sensation (very mild to mild intensity). Patients with painful chemoradiotherapy-induced stomatitis could be alleviated using topical morphine mouthwashes.",2003.0,0,0
936,14500164,Behavioral monitoring and urine toxicology testing in patients receiving long-term opioid therapy.,Nathaniel P Katz; Summer Sherburne; Michael Beach; Robert J Rose; Janet Vielguth; Joyce Bradley; Gilbert J Fanciullo,"No study has examined the role of urine toxicology in addition to behavioral monitoring in patients receiving opioid therapy for chronic pain. All patients maintained on chronic opioid therapy by the two senior authors at two university pain management centers were monitored for 3 yr with urine toxicology testing and for behaviors suggestive of inappropriate medication use. We retrospectively extracted demographic information, aberrant drug-taking behaviors, and urine toxicology information from the medical record. For 122 patients maintained on chronic opioid therapy, 43% (n = 53) had a ""problem"" (either positive urine toxicology or one or more aberrant drug-taking behaviors). Of patients with no behavioral issues, 21% (n = 26) had a positive urine screen for either an illicit drug or a nonprescribed controlled medication. Of patients with a negative urine screen, 14% (n = 17) had one or more behavioral issues. Monitoring both urine toxicology and behavioral issues captured more patients with inappropriate drug-taking behavior than either alone. Requiring a report of behavioral issues and urine toxicology screens for patients receiving chronic opioids creates a more comprehensive monitoring system than either alone. Monitoring both urine toxicology and aberrant behavior in chronic-pain patients treated with opioids identified more problem patients than by monitoring either alone. The authors recommend routine urine testing on all patients prescribed opioids for noncancer pain and as a required element in all opioid analgesic studies.",2003.0,0,1
937,14504156,Effect of intrathecal tramadol administration on postoperative pain after transurethral resection of prostate.,J A Alhashemi; A M Kaki,"Tramadol administered epidurally has been demonstrated to decrease postoperative analgesic requirements. However, its effect on postoperative analgesia after intrathecal administration has not yet been studied. In this double-blind, placebo-controlled study, the effect of intrathecal tramadol administration on pain control after transurethral resection of the prostate (TURP) was studied. Sixty-four patients undergoing TURP were randomized to receive bupivacaine 0.5% 3 ml intrathecally premixed with either tramadol 25 mg or saline 0.5 ml. After operation, morphine 5 mg i.m. every 3 h was administered as needed for analgesia. Postoperative morphine requirements, visual analogue scale for pain at rest (VAS) and sedation scores, times to first analgesic and hospital lengths of stay were recorded by a blinded observer. There were no differences between the groups with regard to postoperative morphine requirements (mean (SD): 10.6 (7.9) vs 9.1 (5.5) mg, P=0.38), VAS (1.6 (1.2) vs 1.2 (0.8), P=0.18) and sedation scores (1.2 (0.3) vs 1.2 (0.2), P=0.89). Times to first analgesic (6.3 (6.3) vs 7.6 (6.2) h, P=0.42) and length of hospital stay (4.7 (2.8) vs 4.4 (2.2) days, P=0.66) were similar in the two groups. Intrathecal tramadol was not different from saline in its effect on postoperative morphine requirements after TURP.",2003.0,0,0
938,14505840,Mapping dermatomes during selective dorsal rhizotomy: case report and review of the literature.,Andrew N Nemecek; Anthony M Avellino; Robert Goodkin; James Little; Michel Kliot,"Studies suggest that the pattern of dermatomal segmental innervation in any given patient, may differ from the classic dermatomal maps first described in the 1890s. Such variability may limit the effectiveness of selective dorsal rhizotomy for treatment of neurogenic pain. A 46-year-old male presented with a 27-year history of intractable pain in his left arm after being shot during the Vietnam War; multiple surgical and medical therapeutic modalities failed to produce durable pain relief. The patient underwent selective dorsal rhizotomy, with intraoperative dermatomal and mixed somatosensory evoked potential recordings. Pre- and postrhizotomy recordings were compared, effectively mapping this patient's dermatomal pattern. At 4 years' follow-up, the patient remains pain free. Intraoperative monitoring of somatosensory evoked potentials during dorsal rhizotomy for neurogenic pain can be used to establish the degree to which an individual's pattern of segmental innervation conforms to the traditionally described dermatomes.",2003.0,0,0
939,14508326,Use of a continuous local anesthetic infusion for pain management after median sternotomy.,Paul F White; Shivani Rawal; Paige Latham; Scott Markowitz; Tijani Issioui; Lei Chi; Suzanne Dellaria; Chen Shi; Lisa Morse; Caleb Ing,"The use of large doses of opioid analgesics to treat pain after cardiac surgery can prolong the time to tracheal extubation and interfere with recovery of bowel and bladder function in the postoperative period. Therefore, the authors investigated the efficacy of a continuous infusion of bupivacaine 0.25% or 0.5%, at the median sternotomy site, for 48 h after cardiac surgery in reducing the opioid analgesic requirement and improving the recovery process. In this prospective, randomized, placebo-controlled, double-blind clinical trial, 36 consenting patients undergoing open-heart surgery with a standardized general anesthetic technique had two indwelling infusion catheters placed at the median sternotomy incision site at the end of surgery. The patients were randomly assigned to receive normal saline (control), bupivacaine 0.25% or bupivacaine 0.5% via an elastomeric infusion pump at a constant rate of 4 ml/h for 48 h. Patients evaluated their chest pain using an 11-point verbal rating scale, with 0 = no pain to 10 = worst pain imaginable. In addition, the postoperative opioid analgesic requirements and opioid-related adverse effects were recorded. Patient satisfaction with their pain management was assessed at specific intervals during the postoperative period using a 100-point verbal rating scale, with 1 = highly dissatisfied to 100 = highly satisfied. Finally, serum bupivacaine concentrations were measured 24 and 48 h after surgery. Compared with the control group, there was a statistically significant reduction in verbal rating scale pain scores and patient-controlled analgesia morphine use in the bupivacaine-0.5% group. Patient satisfaction with their pain management was also improved in the bupivacaine-0.5% (vs. control) group. However, there were no significant differences in patient-controlled analgesia morphine use between the bupivacaine-0.25% and control groups. Although the duration of the intensive care unit stay (30 vs. 34 h, respectively) was not significantly decreased, the time to ambulation (1 +/- 0.5 vs. 2 +/- 1 days, respectively) and the duration of hospital stay (4.2 vs. 5.7 days, respectively) were lower in the bupivacaine-0.5% group than in the control group. Mean +/- SD serum bupivacaine concentrations at 48 h in the bupivacaine-0.25% and bupivacaine-0.5% groups were 0.5 +/- 0.5 and 1.3 +/- 0.7 microg/ml, respectively. A continuous infusion of bupivacaine 0.5% at 4 ml/h is effective for decreasing pain and the need for opioid analgesic medication as well as for improving patient satisfaction with their pain management after cardiac surgery. Patients in the bupivacaine-0.5% group were able to ambulate earlier, leading to a reduced length of hospital stay.",2003.0,0,0
940,14508328,Pharmacokinetics of an implanted osmotic pump delivering sufentanil for the treatment of chronic pain.,Dennis M Fisher; Norma Kellett; Rainer Lenhardt,"A matchstick-sized implanted osmotic pump (Chronogesic) that delivers sufentanil subcutaneously for more than 90 days is being developed to treat chronic pain. This study evaluates pharmacokinetic characteristics related to the absorption of sufentanil using a prototype 60-day system. Twelve opioid-naive volunteers were given naltrexone to prevent opioid effects. Sufentanil, 60 microg, was infused intravenously over 6 h, then 48 h later, the pump was implanted subcutaneously in the upper arm under local anesthesia. Pumps were removed 9 days later. In six volunteers, fever (1.6-3.3 degrees C) was induced with interleukin-2. Plasma was sampled and population pharmacokinetic modeling was performed to estimate in vivo release rate and absorption half-life. Bioavailability was calculated by comparing in vivo to in vitro release rates. The impact of perturbations in release rate on sufentanil plasma concentration (Cp) was simulated. Fever had no systematic effect on Cp. Release rate estimated in vivo was similar to that measured in vitro; bioavailability did not differ from 100%. Absorption half-life was 16.2 h. Simulation demonstrated that supplemental release of sufentanil from the implant (as might occur with local heating) increases Cp an average of 2.5-2.8% per hours supplemental dose. An implantable osmotic pump delivered sufentanil in vivo at the rate predicted from in vitro experiments. The rate at which sufentanil was absorbed from the subcutaneous space (half-life > 16 h) was markedly slower than reported with subcutaneous or intramuscular administration of large volumes of dilute opioids; this slow absorption dampens potential changes in Cp if release rate is perturbed.",2003.0,0,0
941,14515286,Randomized clinical trial comparing epidural anaesthesia and patient-controlled analgesia after laparoscopic segmental colectomy.,A J Senagore; C P Delaney; N Mekhail; A Dugan; V W Fazio,"This randomized clinical trial compared the use of thoracic epidural anaesthesia-analgesia (TEA) with morphine patient-controlled analgesia (PCA) for pain relief after laparoscopic colectomy. Patients scheduled for segmental laparoscopic colectomy were randomized to receive TEA or PCA. Patients in the TEA group received bupivacaine and fentanyl before incision and after surgery by continuous infusion for 18 h. Patients in the PCA group self-administered morphine using an intravenous pump. The postoperative care plan was otherwise identical for the two groups. Postoperative pain was measured during ambulation using a visual analogue pain score. The study included 38 patients (18 TEA, 20 PCA), 16 of whom underwent right hemicolectomy or ileocolectomy and 22 sigmoid colectomy. Operating times, patient weight and distribution of American Society of Anesthesiologists grade were similar in the two groups. The mean(s.e.m.) total dose of drugs administered was 64(41) mg morphine in the PCA group, and 79(42) mg bupivacaine and 205(140) micro g fentanyl in the TEA group. Postoperative pain scores were significantly better in the TEA group at 6 h (mean(s.e.m.) 2.2(0.4) versus 6.6(0.5) with PCA; P = 0.001) and 18 h (2.2(0.3) versus 4.0(0.4); P = 0.003). Hospital stay was similar in the two groups. TEA significantly improved early analgesia following laparoscopic colectomy but did not affect the length of hospital stay.",2003.0,0,0
942,14519710,Analgesic effect of the synthetic cannabinoid CT-3 on chronic neuropathic pain: a randomized controlled trial.,Matthias Karst; Kahlid Salim; Sumner Burstein; Ingomar Conrad; Ludwig Hoy; Udo Schneider,"1',1'dimethylheptyl-Delta8-tetrahydrocannabinol-11-oic acid (CT-3), a potent analog of THC-11-oic acid, produces marked antiallodynic and analgesic effects in animals without evoking the typical effects described in models of cannabinoids. Therefore, CT-3 may be an effective analgesic for poorly controlled resistant neuropathic pain. To examine the analgesic efficacy and safety of CT-3 in chronic neuropathic pain in humans. Randomized, placebo-controlled, double-blind crossover trial conducted in Germany from May-September 2002. Twenty-one patients (8 women and 13 men) aged 29 to 65 years (mean, 51 years) who had a clinical presentation and examination consistent with chronic neuropathic pain (for at least 6 months) with hyperalgesia (n = 21) and allodynia (n = 7). Patients were randomized to two 7-day treatment orders in a crossover design. Two daily doses of CT-3 (four 10-mg capsules per day) or identical placebo capsules were given during the first 4 days and 8 capsules per day were given in 2 daily doses in the following 3 days. After a washout and baseline period of 1 week each, patients crossed over to the second 7-day treatment period. Visual analog scale (VAS) and verbal rating scale scores for pain; vital sign, hematologic and blood chemistry, and electrocardiogram measurements; scores on the Trail-Making Test and the Addiction Research Center Inventory-Marijuana scale; and adverse effects. The mean differences over time for the VAS values in the CT-3-placebo sequence measured 3 hours after intake of study drug differed significantly from those in the placebo-CT-3 sequence (mean [SD], -11.54 [14.16] vs 9.86 [21.43]; P =.02). Eight hours after intake of the drug, the pain scale differences between groups were less marked. No dose response was observed. Adverse effects, mainly transient dry mouth and tiredness, were reported significantly more often during CT-3 treatment (mean [SD] difference, -0.67 [0.50] for CT-3-placebo sequence vs 0.10 [0.74] for placebo-CT-3 sequence; P =.02). There were no significant differences with respect to vital signs, blood tests, electrocardiogram, Trail-Making Test, and Addiction Research Center Inventory-Marijuana scale. No carryover or period effects were observed except on the Trail-Making Test. In this preliminary study, CT-3 was effective in reducing chronic neuropathic pain compared with placebo. No major adverse effects were observed.",2003.0,0,0
943,14532814,Chronic pain syndrome after laparoscopic radical nephrectomy.,Michael G Oefelein; Yildirim Bayazit,,2003.0,0,0
944,14550900,Dose ratio is important in maximizing naloxone enhancement of nalbuphine analgesia in humans.,Robert W Gear; Newton C Gordon; Christine Miaskowski; Steven M Paul; Philip H Heller; Jon D Levine,"The analgesic effect of kappa partial agonist opioids (i.e. nalbuphine, pentazocine and butorphanol) is significantly greater in women. Recent evidence suggests that this sexual dimorphism may result from a naloxone-sensitive anti-analgesic effect that is activated along with, and summates with, the analgesic effect of these agents, resulting in decreased analgesia or increased pain. For example, nalbuphine (5 mg) produces profound anti-analgesia (i.e. enhanced pain) in men, but addition of a low dose of the opioid receptor antagonist naloxone (0.4 mg, opioid antagonist) induces significant analgesia in men and enhances nalbuphine analgesia in women. To further delineate the dose-dependent relationship of nalbuphine and naloxone, we recently evaluated the effect of a lower dose of nalbuphine (2.5 mg) with and without naloxone (0.4 mg) on dental postoperative pain. In women, nalbuphine alone induced modest short duration analgesia, which was antagonized by the addition of naloxone. In men, this dose of nalbuphine alone did not produce analgesia or anti-analgesia, and naloxone did not alter the response to nalbuphine. Thus, it appeared that the 2.5 mg dose of nalbuphine was not sufficient to induce anti-analgesia while the 0.4 mg dose of naloxone was able to antagonize the analgesic effect of nalbuphine, at least in women. In the current study, we tested the hypothesis that an important determinant of naloxone enhancement of nalbuphine analgesia is the dose ratio of nalbuphine to naloxone. Since a dose ratio of 12.5:1 (i.e. 5 mg nalbuphine:0.4 mg naloxone) resulted in analgesic enhancement, but a dose ratio of 6.25:1 (2.5 mg:0.4 mg) did not, we tested the same, lower, dose of nalbuphine (2.5 mg) in combination with a lower dose of naloxone (0.2 mg) to maintain the 12.5:1 dose ratio. This lower dose of naloxone significantly prolonged the analgesic effect of nalbuphine in both men and women, suggesting that the anti-analgesic effect of nalbuphine is present in both sexes at the 2.5 mg dose and that the dose ratio of nalbuphine to naloxone is an important determinant of the analgesic efficacy of this combination.",2003.0,0,0
945,14551548,Evaluation of postoperative bupivacaine infusion for pain management after anterior cruciate ligament reconstruction.,J Winslow Alford; Paul D Fadale,"Postoperative pain control has received increasing attention by health care providers in the new millennium. In fact, pain was called the ""sixth vital sign"" by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in 2001. The continued challenge of effective, safe analgesia in the outpatient setting has promoted the use of various devices designed to deliver local anesthetic directly to the surgical site. We endeavored to evaluate the efficacy of one such device currently in use. Prospective, randomized, placebo-controlled, double-blinded study. In this study, 49 consecutive patients were prospectively enrolled and randomly assigned to 1 of 3 groups after anterior cruciate ligament (ACL) reconstruction. Patients and investigators were blinded to group assignment. Group 1 (control group) received no catheter. Group 2 (placebo group) received an infusion catheter filled with saline. Group 3 (experimental group) received the same catheter filled with 0.25% bupivacaine solution. All patients received an ipsilateral femoral nerve block with 30 mL 0.25% bupivacaine and 20 mL 0.25% bupivacaine intra-articular injection. Patients recorded narcotic consumption and pain levels on visual analogue scales twice a day for 4 days after surgery. The catheters were removed on day 4 and physical therapy performance was recorded. The patients were then asked to continue to record pain ratings and medication consumption for an additional 4 days after catheter removal. All patients underwent bone-patellar tendon-bone ACL reconstruction by the senior author (P.D.F.). Seven patients were excluded from the study for ineffective femoral nerve block or catheter disconnection or occlusion. Narcotic consumption and the maximum, minimum, and median pain ratings were analyzed by analysis of variance. Median pain ratings show lower pain levels (P <.03) for both catheter groups versus the control group. No significant differences were found between the catheter groups for the median pain ratings, but lower maximum pain ratings were seen in the bupivacaine group compared with both placebo and no-catheter control subjects. Postoperative narcotic consumption was also lower in both catheter groups versus control subjects (P <.03). Physical therapy data revealed no difference in range of motion on postoperative day 4. More patients were able to perform straight leg raises during the first therapy session in both the saline placebo catheter group (70%) and bupivacaine group (72%) compared with the control group (50%). The data suggest some element of placebo benefit at median pain ratings but a protective effect of the bupivacaine at maximum pain levels.",2003.0,0,0
946,14552104,[Postoperative patient-controlled analgesia is more effective with epidural methadone than with intravenous methadone in thoracic surgery].,F Parramon; Ch García; P Gambús; J Vilaplana; N Aragonés; A Villalonga,"To compare the efficacy and side effects of epidural and intravenous methadone for postoperative patient-controlled analgesia (PCA) after thoracic surgery. A randomized, single-blind trial enrolling 30 patients distributed in 2 groups to receive intravenous methadone (ivPCA group) or epidural methadone (epPCA group). Patients in both groups were administered a loading dose of 0.05 mg.kg-1 followed by infusion of 0.5 mg.h-1. The patients could self-dose 0.5 mg with a lock-out interval of 10 minutes and a maximum of 4 doses per hour. Patient characteristics, type and duration of surgery and fentanyl dose were recorded. Pain was assessed on a visual analog scale (VAS). Level of sedation, respiratory rate and occurrence of nausea, vomiting and pruritus were also recorded over the first 24 hours. The 2 groups were comparable. Pain was greater in the ivPCA group than in the epPCA group in the second hour (VAS 3.93 +/- 1.9 and 2.4 +/- 1.65, respectively; P < .05) and the third hour (VAS 3.57 +/- 1.65 and 1.5 +/- 1.16, respectively; P < .05). The total dose of methadone administered was 25.34 +/- 5.65 mg in the ivPCA group and 18.82 +/- 3.52 mg in the epPCA group (P < .002). There were no significant differences in side effects. The results suggest that epidural methadone has an intrinsic spinal effect regardless of whether or not there is extra-spinal action arising from syste mic absorption. Epidural methadone provides a more adequate analgesic effect in less time and at a lower dose. Both approaches provide good postoperative analgesia with few side effects.",2003.0,0,0
947,14567137,Mechanisms of action of intrathecal medications.,Richard K Simpson,"Intrathecal delivery of medications for the management of chronic pain syndromes reflects a modern targeted delivery system with the potential for even greater efficacy than is outlined in Tables 1 and 2. The twentieth century ushered in the development of parenteral approaches of medical therapy for chronic pain and other diseases that were superior to the traditional oral delivery methods known in the preceding century. Targeted drug delivery represents a significant advancement in the treatment of patients with chronic pain and is likely be the method of choice for the twenty-first century. This method of delivery is best represented by current drug delivery systems, such as the intrathecal drug pump. Traditional pharmacologic agents will still be used in the twenty-first century; however, the development of novel compounds, transplanted tissues, and genetic engineering will likely usher in a new era of pain management, including their use as analgesics for intraspinal infusion.",2003.0,0,0
948,14567139,Intrathecal medication delivery.,Richard D Penn,"This brief review of intrathecal pain medication delivery has emphasized the unusual but useful pharmacology of CSF drug delivery, the new study definitely showing that the method is helpful in cancer pain, and the rare complication of mass formation at the catheter tip. As new medications are developed for intrathecal delivery, this field is likely to expand, especially if a wider range of dorsal horn receptor mechanisms underlying pain processing can be modified. The changes in spinal cord signaling that are induced by chronic pain states are being investigated, and new possibilities for intervention are likely. the availability of a reliable well-understood way of delivering such new therapies by implanted drug pumps will speed the process. Intrathecal morphine for chronic pain has an important role in helping many patients with a wide variety of pain conditions and, as with all pain treatment, is woefully underused.",2003.0,0,0
949,14567142,Psychologic evaluation for patients undergoing neuroaugmentative procedures.,Daniel M Doleys,"Neuroaugmentative and neuromodulation therapy continues to expand. New applications are being found for existing technology, such as the use of SCS therapy in the treatment of head pain. The potential impact of existing therapies is enhanced by new discoveries as exemplified by the availability and demonstrated efficacy of different pharmacologic agents and combinations of agents in intrathecal therapy [39]. Increased attention is being paid to cortical stimulation, including motor cortex stimulation and deep brain stimulation. We must, however, not let our fascination for gadgets betray sound sense. The role of psychosocial factors in the outcome of more ""objective"" and measurable problems, such as spasticity and tremor versus pain, remains an open area of investigation. Although psychologic issues may not be as prevalent in the amelioration of such problems, they may influence the patient's overall level of satisfaction with the therapy and improvement in quality of life.",2003.0,0,0
950,14567145,Anatomy and physiology of chronic pain.,Joshua M Rosenow; Jaimie M Henderson,"Although much has been accomplished in the past several decades, treatment of chronic pain remains imperfect. This article presents the anatomy and physiology of the pain system along with the neurobiologic changes that occur in the establishment and maintenance of chronic pain states.",2003.0,0,0
951,14569261,Types and effectiveness of treatments used by people with chronic pain associated with spinal cord injuries: influence of pain and psychosocial characteristics.,E G Widerström-Noga; D C Turk,"Postal survey. Because of the high prevalence and inadequate control of pain following spinal cord injury (SCI), it is important to have information about the factors associated with the use of specific pain therapies. We conducted this study to evaluate the ability of pain characteristics and psychosocial factors to predict the use of treatments. The Miami Project to Cure Paralysis (Miami, FL, USA). People with SCI (n=120) were mailed a packet containing a questionnaire with questions regarding demographic factors, pain characteristics, and pain treatments along with a copy of the Multidimensional Pain Inventory. A total of 59% of the respondents had been prescribed treatment or self-initiated efforts to treat pain over the previous 18-month period. The most common treatments used by this sample were massage (26.6%), opioids (22.5%) and nonsteroidal anti-inflammatory drugs (NSAIDs) (20%). The most effective treatments overall were 'physical therapies' with 50% receiving these treatments indicating that their pain was 'considerably reduced' or that they were 'pain free.' Opioids and anticonvulsants were perceived to be the most effective pharmacological agents prescribed (33.3 and 23.8% reporting their pain was considerably better or eliminated, respectively). People using prescription medication reported significantly greater pain severity, more widespread pain, more descriptive adjectives, more evoked pain, greater difficulty in dealing with pain, and more interference and decreased activity levels due to pain, compared to people not using prescription medication. A combination of greater difficulty in dealing with pain, intense pain, presence of evoked pain, and higher level of perceived support from significant others was predictive of taking prescription medication. People taking prescription medication reported significantly more intense pain with neuropathic characteristics that significantly affected daily life and routine activities. A substantial percentage of individuals with pain related to SCI did not obtain significant pain relief from prescription medications. None of the factors assessed predicted the use of nonprescription treatments. The results of this study confirm the inadequacy of available modalities to manage chronic pain related to SCI.",2003.0,0,0
952,14570359,Disability and chronic pain after open mesh and laparoscopic inguinal hernia repair.,Michael Bozuk; Rob Schuster; David Stewart; Kathrin Hicks; Gregory Greaney; Kenneth Waxman,"Proponents of laparoscopic inguinal hernia repair maintain that the associated costs and risks are offset by faster recovery and less postoperative pain. It was our hypothesis that the incidence of chronic pain in both groups of our patients was not as high as reported in the literature. Patients for the study were identified from a community hospital medical record database. A total of 229 patients were available and agreed to participate in the study. Data collected included the patient's current pain level at the hernia site, pain medication currently used, narcotics currently used, return to normal work, and return to normal activity. Overall, 19.7 per cent of patients complained of mild pain, but only 2.2 per cent classified this as moderate or severe. Mild pain was noted more often in the open repair patients compared with the laparoscopic group. However, there was no difference in the frequency of moderate or severe pain. The time to return to work was longer in the open repair group than the laparoscopic repair group, but there were large ranges in both groups. The inability to return to full preoperative activity was infrequent and equivalent in both open and laparoscopic hernia repair groups. In our study of 229 patients undergoing elective open or laparoscopic inguinal hernia repair at a community hospital, we have found a low incidence of moderate or severe chronic pain. In addition, we found that this procedure did not interfere with return to work at 6 months or return to daily activities in either the laparoscopic or open repair group.",2003.0,0,0
953,14570631,Intrathecal clonidine and severe hypotension after cardiopulmonary bypass.,Ferenc Puskas; Enrico M Camporesi; Colleen E O'Leary; Michael Hauser; Fadi V Nasrallah,"The use of intrathecal clonidine as an adjunct for the management of chronic pain, intra- and postoperative analgesia is gaining an increase in popularity. However, antinociceptive doses of intrathecal clonidine may produce pronounced hemodynamic side effects, including hypotension and bradycardia. In this report, we present a case of severe hypotension after cardiopulmonary bypass in a patient with intrathecal clonidine infusion. We postulate that the intrathecally administered alpha 2-agonist clonidine reduced our patient's ability to tolerate the hemodynamic lability that is present during the separation from cardiopulmonary bypass by potentially inhibiting sympathetic nervous system activity, renin-angiotensin system, or vasopressin release. The authors report a case of severe hypotension after cardiopulmonary bypass in a patient receiving intrathecal clonidine infusion for chronic neuropathic pain.",2003.0,0,0
954,14570792,Epidural versus intrathecal morphine for postoperative analgesia after Caesarean section.,C Dualé; C Frey; F Bolandard; A Barrière; P Schoeffler,"Perispinal anaesthesia for Caesarean section allows injection of epidural (ED) or intrathecal (i.t.) morphine to provide long-lasting postoperative analgesia. To compare these two routes, a prospective, randomized, double-blinded study of 53 patients undergoing elective Caesarean section was performed. Combined spinal-epidural anaesthesia with 6 mg of i.t. hyperbaric bupivacaine plus sufentanil 5 microg, and additional ED lidocaine was used. Additionally, each patient received either 2 mg (2 ml) of ED morphine plus 1 ml of i.t. normal saline (ED group, n=28), or 0.075 mg (1 ml) of i.t. morphine plus 2 ml of ED normal saline (i.t. group, n=25). Additional postoperative analgesia was given in the form of propacetamol and ketoprofen, plus self-administered i.v. morphine. No major respiratory depression occurred. Time to first demand of morphine was similar in the ED (307.5 min) and i.t. (310 min) groups, as was the incidence of side-effects such as sedation, pruritus, nausea, and vomiting. During the first 24 postoperative hours, VAS pain scores were greater in the i.t. group (P=0.032), as was additional morphine consumption (4 vs 1.5 mg) (P=0.03). The ED protocol was more effective than the i.t. protocol, whilst side-effects were similar.",2003.0,0,0
955,14576555,"Efficacy, safety, and pharmacokinetics of levobupivacaine with and without fentanyl after continuous epidural infusion in children: a multicenter trial.",Jerrold Lerman; Judith Nolan; Rob Eyres; Mark Schily; Peter Stoddart; Christopher M Bolton; Frank Mazzeo; Andrew R Wolf,"Levobupivacaine, the levo-enantiomer of bupivacaine, is as potent as bupivacaine but less toxic. Therefore, the authors investigated the efficacy, safety, and pharmacokinetics of perioperative epidural levobupivacaine with and without fentanyl in children. After Research Ethics Board approval and informed written consent, 120 healthy children aged 6 months to 12 yr who were scheduled to undergo urologic or abdominal surgery were randomized in a double-blinded and concealed manner to receive one of four epidural solutions as a continuous infusion for 24 h: 0.125% levobupivacaine; 0.0625% levobupivacaine; 1 mug/ml fentanyl; or the combination, 0.0625 levobupivacaine and 1 mug/ml fentanyl. After induction of anesthesia and tracheal intubation, a lumbar epidural catheter was sited, a loading dose was administered (0.75 ml/kg levobupivacaine, 0.175%), and the epidural infusion was commenced. The primary endpoint was the need for rescue analgesia (morphine) in the first 10 h after surgery. Pain, motor strength, and side effects were recorded for 24 h. Venous blood was collected from 18 children to determine the plasma concentrations of levobupivacaine and/or fentanyl before and 2, 4, 8, 16, 24, and 26 or 30 h after the start of the epidural infusion. Of the 114 children who were analyzed for intention to treat, a similar number of children in each group reached the 10-h mark. The time to the first dose of morphine in the first 10 h was less in the plain fentanyl group (P < 0.044). All other effects were similar among the four groups. The plasma concentration of levobupivacaine increased during the infusion period, reaching a maximum of 0.76 +/- 0.11 mug/ml in the 0.125% group and 0.48 +/- 0.12 mug/ml in the 0.0625% group by 24 h. The plasma concentration of fentanyl also increased steadily, reaching a maximum concentration of 0.37 +/- 0.11 ng/ml by 24 h. We conclude that 0.0625% levobupivacaine without fentanyl is an effective perioperative epidural solution in children when infused at a rate of 0.3 ml. kg-1. h-1. The plasma concentrations of 0.125% and 0.0625% levobupivacaine and fentanyl (1 mug/ml) at the end of a 24-h infusion are low.",2003.0,0,0
956,14580102,Celiac plexus block: evaluation of injectate spread by three-dimensional computed tomography.,K Iki; Y Fujita; H Inada; M Satoh; T Tsunoda,"We describe a case of pancreatic cancer in which the spread pattern of injectate during neurolytic celiac plexus block was evaluated by three-dimensional helical computed tomography. Three-dimensional images provide excellent visualization of the spread patterns of injectate in a target site, which appears to provide patients with effective relief from intractable pain.",2003.0,0,0
957,14580120,"Functional imaging and pain: behavior, perception, and modulation.",Carlo A Porro,"Time-dependent increases of local metabolic or blood flow rates have been described in spinal cord and brain during acute and chronic pain states in experimental animals, in parallel with changes of different behavioral endpoints of pain and hyperalgesia. In healthy human volunteers, pain intensity-related hemodynamic changes have been identified in a widespread, bilateral brain system including parietal, insular, cingulate, and frontal cortical areas, as well as thalamus, amygdala, and midbrain. Specific patterns of activity may characterize hyperalgesic states and some chronic pain conditions. Forebrain nociceptive systems are under inhibitory control by endogenous opioids and can be affected by acute administration of mu-opioid receptor agonists. Anticipation of pain may in itself induce changes in brain nociceptive networks. Moreover, pain-related cortical activity can be modulated by hypnotic suggestions, focusing or diverting attention, and placebo. These findings begin to disclose the spatio-temporal dynamics of brain networks underlying pain perception and modulation.",2003.0,0,0
958,14585551,The problem of assessment bias when measuring the hospice effect on nursing home residents' pain.,Ning Wu; Susan C Miller; Kate Lapane; Pedro Gozalo,"This study examined the observed differential documentation of pain on nursing home (NH) resident assessments (minimum data sets [MDS]) when dying residents were and were not enrolled in hospice. We studied 9,613 NH residents who died in 6 states in 1999 and 2000. Documented pain was compared among three groups of residents who were categorized by their hospice exposure. At the time of their last MDS completion, residents in hospice were more likely to receive opioids for their moderate to severe pain than were non-hospice residents and residents enrolled in hospice after the last MDS assessments. However, hospice residents were twice as likely as non-hospice residents and 1.3 times as likely as residents who eventually enrolled in hospice to have pain documented. These counterintuitive findings suggest that there is differential documentation of pain on the MDS when hospice is involved in care, perhaps because of superior pain assessment by hospice.",2003.0,0,0
959,14585554,Comparative efficacy and safety of long-acting oral opioids for chronic non-cancer pain: a systematic review.,Roger Chou; Elizabeth Clark; Mark Helfand,"Opioids have been endorsed as appropriate treatment for refractory chronic non-cancer pain when used according to published guidelines. They are widely used for this indication. However, there appear to be gaps in our understanding of the efficacy and safety of individual long-acting opioids compared to each other or as a class compared to short-acting opioids. This systematic review summarizes and assesses the evidence for the comparative efficacy and safety of long-acting opioids in the management of chronic non-cancer pain. Randomized trials (for comparative efficacy and adverse events) and observational studies (for adverse events only) that included non-parenteral long-acting opioids were sought using electronic databases, handsearching reference lists, and soliciting pharmaceutical company submissions. Searches were performed through October 2002. The validity of each included study was assessed using a data abstraction form and predefined criteria. An overall grade was allocated for the body of evidence for each key question. A total of 16 randomized trials (comparative efficacy and adverse events), enrolling 1427 patients, and 8 observational studies (adverse events) of 1190 patients were included in this review. No randomized trial was rated good quality; observational studies were generally of poorer quality than the trials. There was insufficient evidence to prove that different long-acting opioids are associated with different efficacy or safety profiles. There was also insufficient evidence to determine whether long-acting opioids as a class are more effective or safer than short-acting opioids. A subgroup of three studies on long-acting versus short-acting oxycodone was more homogeneous and provided fair evidence that these formulations are equally effective for pain control.",2003.0,0,1
960,14585556,Hypogonadism and sexual dysfunction in male cancer survivors receiving chronic opioid therapy.,Arun Rajagopal; Rena Vassilopoulou-Sellin; J Lynn Palmer; Guddi Kaur; Eduardo Bruera,"The purpose of this study was to determine the prevalence of central hypogonadism and sexual dysfunction in male cancer survivors exposed to chronic high-dose oral opioid therapy. We studied 20 male patients with cancer-related chronic pain who were disease-free for at least one year. All patients consumed at least 200 mg-equivalent of morphine on a daily basis for at least one year. Participants completed the Sexual Desire Inventory questionnaire and serum levels of testosterone, follicle-stimulating hormone (FSH), and luteinizing hormone (LH) were assessed. Serum testosterone levels were reduced in these patients. The median value was 140 ng/dL (normal 241-827). There was no compensatory increase in FSH and LH. The median FSH level was 3.5 mIU/mL (normal 1.4-18.1). The median LH level was 2.1 mIU/mL (normal 1.5-9.3). The mean dyadic sexual desire score was 23.9+/-15.7 (normal value, 42.8+/-8.9). The mean solitary sexual desire score was 1.3+/-1.9 (normal value, 10.6+/-1.9). Our data suggest that chronic exposure to high-dose oral opioid therapy may result in marked central hypogonadism and sexual dysfunction. Given the increasing use of long-term opioid therapy for chronic pain syndromes, further investigation into these findings is warranted.",2003.0,0,0
961,14594148,Low-dose methadone has an analgesic effect in neuropathic pain: a double-blind randomized controlled crossover trial.,John S Morley; John Bridson; Tim P Nash; John B Miles; Sarah White; Matthew K Makin,"The analgesic effectiveness and adverse effect incidence of a daily dose of 10 or 20 mg of oral methadone were evaluated in 18 patients with a diverse range of chronic neuropathic pain syndromes, who had all responded poorly to traditional analgesic regimens. Analgesia was seen after each dose of methadone. As compared with placebo, the 20 mg daily dose (given as 10 mg bd) resulted in statistically significant (P = 0.013-0.020) improvements in patient Visual Analogue Scale ratings of maximum pain intensity, average pain intensity and pain relief, recorded at the same time daily. The analgesic effects extended over 48 hours, as shown by statistically significant (P = 0.013-0.020) improvements in all three outcomes on the rest days instituted between each daily dose. Analgesic effects (lowered maximum pain intensity and increased pain relief, on the day of dosing only) were also seen when the lower daily dose of 10 mg methadone (given as 5 mg bd) was used, but these failed to reach statistical significance (P = 0.064 and 0.065, respectively). Interpatient analysis showed that the analgesic effects were not restricted to any particular type of neuropathic pain. Patient compliance was high throughout the trial. One patient withdrew during the 10 mg and six during the 20 mg methadone treatment periods. This is the first double-blind randomized controlled trial to demonstrate that methadone has an analgesic effect in neuropathic pain.",2003.0,0,1
962,14601699,Use of opioids in the treatment of severe pain in terminally ill patients--dying should not be painful.,Timothy J Moynihan,"Pain is a common symptom at the end of life. The vast majority of pain can be readily managed if simple principles of practice are followed. Chronic pain requires continuous analgesia, and severe pain requires use of strong analgesics, most commonly the opioids. In addition to drugs administered continually, short-acting medications must be available for ""breakthrough"" pain. This article reviews the principles of pain management in terminally ill patients, using a case-based demonstration.",2003.0,0,0
963,14612466,Methadone maintenance therapy and chronic pain.,Jon Streltzer; Thomas R Kosten,,2003.0,0,0
964,14612477,Effects of perioperative administration of a selective cyclooxygenase 2 inhibitor on pain management and recovery of function after knee replacement: a randomized controlled trial.,Asokumar Buvanendran; Jeffrey S Kroin; Kenneth J Tuman; Timothy R Lubenow; Dalia Elmofty; Mario Moric; Aaron G Rosenberg,"Controlling postoperative pain after knee replacement while reducing opioid-induced adverse effects and improving outcomes remains an important challenge. To assess the effect of combined preoperative and postoperative administration of a selective inhibitor of cyclooxygenase 2 on opioid consumption and outcomes after total knee arthroplasty (TKA). Randomized, placebo-controlled, double-blind trial conducted June 2001 through September 2002, enrolling 70 patients aged 40 to 77 years and undergoing TKA at a university hospital in the United States. Patients were randomly assigned to receive 50 mg of oral rofecoxib at 24 hours and at 1 to 2 hours before TKA, 50 mg daily for 5 days postoperatively, and 25 mg daily for another 8 days, or matching placebo at the same times. Postoperative outcomes including postsurgical analgesic consumption and pain scores achieved, nausea and vomiting, joint range of motion, sleep disturbance, patient satisfaction with analgesia, and hematologic and coagulation parameters. Total epidural analgesic consumption and in-hospital opioid consumption were less in the group receiving rofecoxib compared with the group receiving placebo (P<.05). Median pain score (visual analog scale [VAS], 0-10) achieved for the knee was lower in the rofecoxib group compared with the placebo group during hospital stay (2.2 [interquartile range [IQR], 1.4-3.2] vs 3.5 [IQR, 2.7-4.3], P<.001) and 1 week after discharge (2.6 [IQR, 1.4-3.5] vs 3.7 [IQR, 2.9-4.7], P =.03). There was less postoperative vomiting in the rofecoxib group (6%) compared with the placebo group (26%) (P =.047), as well as a decrease in sleep disturbance compared with the placebo group on the night of surgery (P =.006) and on the first (P =.047) and second (P<.001) days postoperatively. Knee flexion was increased in the rofecoxib group compared with the placebo group at discharge (active flexion: mean [SD], 84.2 degrees [11.1 degrees ] vs 73.2 degrees [13.6 degrees ], P =.03; passive flexion: 90.5 degrees [6.8 degrees ] vs 81.8 degrees [13.4 degrees ], P =.05) and at 1 month postoperatively (109.3 degrees [8.5 degrees ] vs 100.8 degrees [11.8 degrees ], P =.01), with shorter time in physical therapy to achieve effective joint range of motion. The rofecoxib group was more satisfied with analgesia and anesthesia at discharge compared with the placebo group (median satisfaction score, 4.3 [IQR, 3.0-4.7] vs 3.3 [IQR, 2.3-4.3], respectively; P =.03), and the differences persisted at 2-week and at 1-month follow-up. There was no intergroup difference in surgical blood loss (P>.05 for both intraoperative and postoperative blood loss). Perioperative use of an inhibitor of cyclooxygenase 2 is an effective component of multimodal analgesia that reduces opioid consumption, pain, vomiting, and sleep disturbance, with improved knee range of motion after TKA.",2003.0,0,0
965,14612478,Routine morphine infusion in preterm newborns who received ventilatory support: a randomized controlled trial.,Sinno H P Simons; Monique van Dijk; Richard A van Lingen; Daniella Roofthooft; Hugo J Duivenvoorden; Niesje Jongeneel; Carin Bunkers; Enna Smink; K J S Anand; John N van den Anker; Dick Tibboel,"Newborns admitted to neonatal intensive care units (NICUs) undergo a variety of painful procedures and stressful events. Because the effect of continuous morphine infusion in preterm neonates has not been investigated systematically, there is confusion regarding whether morphine should be used routinely in this setting. To evaluate the effects of continuous intravenous morphine infusion on pain responses, incidence of intraventricular hemorrhage (IVH), and poor neurologic outcome (severe IVH, periventricular leukomalacia, or death). A randomized, double-blind, placebo-controlled trial conducted between December 2000 and October 2002 in 2 level III NICUs in the Netherlands of 150 newborns who had received ventilatory support (inclusion criteria: postnatal age younger than 3 days and ventilation for less than 8 hours; exclusion criteria: severe asphyxia, severe IVH, major congenital malformations, and administration of neuromuscular blockers). Intravenous morphine (100 microg/kg and 10 microg/kg per hour) or placebo infusion was given for 7 days (or less because of clinical necessity in several cases). The analgesic effect of morphine, as assessed using validated scales; the effect of morphine on the incidence of IVH; and poor neurologic outcome. The analgesic effect did not differ between the morphine and placebo groups, judging from the following median (interquartile range) pain scores: Premature Infant Pain Profile, 10.1 (8.2-11.6) vs 10.0 (8.2-12.0) (P =.94); Neonatal Infant Pain Scale, 4.8 (3.7-6.0) vs 4.8 (3.2-6.0) (P =.58); and visual analog scale, 2.8 (2.0-3.9) vs 2.6 (1.8-4.3) (P =.14), respectively. Routine morphine infusion decreased the incidence of IVH (23% vs 40%, P =.04) but did not influence poor neurologic outcome (10% vs 16%, P =.66). In addition, analyses were adjusted for the use of additional open-label morphine (27% of morphine group vs 40% of placebo group, P =.10). Lack of a measurable analgesic effect and absence of a beneficial effect on poor neurologic outcome do not support the routine use of morphine infusions as a standard of care in preterm newborns who have received ventilatory support. Follow-up is needed to evaluate the long-term effects of morphine infusions on the neurobehavioral outcomes of prematurity.",2003.0,0,0
966,14612483,Current status of pain management in children.,Richard F Howard,"Many changes have taken place in pediatric pain management since the undertreatment of children's pain was first reported. Notable advances include an increase in understanding pain during development and improvements in the management of acute pain. Although much more about the safe and effective management of pain in children is now known, this knowledge has not been widely or effectively translated into routine clinical practice. Lack of suitable research on which to firmly establish evidence-based care is likely to have contributed to this situation. A subject of considerable interest recently is the discovery that the experience of pain in early life may lead to long-term consequences. New research findings from laboratory and clinical studies have clearly identified possible mechanisms and provided evidence that long-term behavioral changes can extend far beyond what would be considered the normal period of postinjury recovery. Timing, degree of injury, and administered analgesia and its nature may be important determinants of the long-term outcome of infant pain. Chronic pain, including neuropathic pain, is far more common in children than was thought. The assessment and treatment of this pain and its functional consequences present a considerable unmet challenge. There is a pressing need for further research and clinical development in the management of pain in children.",2003.0,0,0
967,14612484,A capsule history of pain management.,Marcia L Meldrum,"Pain is a complex clinical problem. Assessment depends on verbal report, and the patient's physical perceptions may be modified by cognitive and affective factors. The salience of pain as a problem in its own right has grown since 1945 and new therapeutic alternatives have developed from research and from new theoretical perspectives. This short historical review of the highlights of the history of pain management gives particular emphasis to the 20th century and to chronic and cancer pain.",2003.0,0,0
968,14612486,Pain management.,Catherine D DeAngelis,,2003.0,0,0
969,14612487,JAMA patient page. Pain management.,Janet M Torpy; Cassio Lynm; Richard M Glass,,2003.0,0,0
970,14614170,Opioid therapy for chronic pain.,Jane C Ballantyne; Jianren Mao,,2003.0,0,1
971,14622664,"Long-term intrathecal opioid therapy with a patient-activated, implanted delivery system for the treatment of refractory cancer pain.",Richard L Rauck; David Cherry; Michael F Boyer; Peter Kosek; Joseph Dunn; Kenneth Alo,"The present study evaluated the safety and efficacy of patient-activated delivery of intrathecal morphine sulfate boluses delivered by way of a novel internalized intrathecal delivery system. Patients with refractory cancer pain or uncontrollable side effects were enrolled at 17 US and international sites in this prospective, open-label study. Pain relief, reduction in systemic opioid use, and reduction in opioid-related complications were analyzed both individually and together as a measure of overall success. One hundred forty-nine patients were enrolled and 119 were implanted. Average numeric analog scale pain decreased from 6.1 to 4.2 at 1 month and was maintained through month 7 (P <.01) and through month 13 (P <.05). Systemic opioid use was significantly decreased throughout the study (P <.01). Significant reduction in the opioid complication severity index was demonstrated at all 4 follow-up visits (P <.01). Overall success (>/=50% reduction in numeric analog scale pain, use of systemic opioids, or opioid complication severity index) was reported in 83%, 90%, 85%, and 91% of patients at months 1, 2, 3, and 4, respectively. This study demonstrated that patients with refractory cancer pain or intolerable side effects achieved better analgesia when managed with patient-activated intrathecal delivery of morphine sulfate via an implanted delivery system.",2003.0,0,0
972,14622685,The pharmacokinetics of transdermal fentanyl delivered with and without controlled heat.,Michael A Ashburn; L Lazarre Ogden; Jie Zhang; Georgette Love; Susan V Basta,"Preliminary reports have demonstrated that the application of local heat to the transdermal fentanyl patch significantly increased systemic delivery of fentanyl. The objective of this study was to further evaluate the pharmacokinetic effect of local heat administration on fentanyl drug delivery through the transdermal fentanyl patch delivery system in volunteers. In addition, the study was intended to document the effect of heat on steady-state transdermal fentanyl delivery. This was an open, 3-period, crossover study that evaluated the pharmacokinetics and safety of 25 microg/h transdermal fentanyl administered with and without local heat. During Sessions A and B, subjects received transdermal fentanyl for a 30-hour period. During Session A, heat was applied for 1 hour at the 24-hour time point during the 30-hour period. During Session B, heat was applied for the first 4 hours and then again for 1 hour at the 24-hour time point during the 30-hour period. The order of Sessions A and B was randomized, and a minimum of 2 weeks separated the sessions. Five of the 10 subjects returned to participate in Session C. During Session C, subjects received transdermal fentanyl 25 microg/h for 18 hours. Heat was applied during the first 4 hours of administration and then again for 15-minute periods at the 12- and 16-hour time points. Arterial blood samples for determination of serum fentanyl concentration were collected. Maximum concentration (C(max)), time to maximum concentration (t(max)), and area under the curve (AUC) were determined for each treatment period. Sedation, vital signs, oxygen saturation, and adverse events were recorded. During a period of 36 hours, there were no significant differences in C(max), AUC, or T(max) between transdermal fentanyl delivery with no heat and heat. However, significant differences were seen during the first 4 hours, with C(max) and AUC values almost 3 times higher for the heated administrations than for the administrations without heat. With heat, the mean C(max) was 0.63 ng/mL compared with a C(max) of 0.24 ng/mL without heat (P =.007). With early heat, the mean AUC was 1.22 ng/mL. h compared with 0.42 ng/mL. h without heat (P =.003). There was no statistically significant difference between the median times to achieve peak values (T(max)) during the first 4 hours. The addition of heat at 24 hours resulted in rapid increases in serum fentanyl concentrations for both groups and higher serum fentanyl concentrations for the administration that did not receive heat previously. Applying heat for 15 minutes at the 12-hour and 16-hour time points produced a rapid but short duration increase in serum fentanyl concentrations. The results suggest controlled heat might be used to significantly shorten the time needed to reach clinically important fentanyl concentrations. Controlled heat might be useful to produce rapid increases in serum concentrations for the rapid treatment of breakthrough pain.",2003.0,0,0
973,14622692,Patient characteristics associated with opioid versus nonsteroidal anti-inflammatory drug management of chronic low back pain.,James Breckenridge; J David Clark,"Chronic low back pain is both prevalent and costly in many industrialized nations. Although many modalities exist for the treatment of this condition, few are as commonly used or as controversial as the use of opioids. Many sets of guidelines exist for the prescription of opioids for chronic nonmalignant pain, but little evidence addresses what factors actually contribute to the decision to initiate and maintain patients on these drugs. In these studies we first identified 2 groups of 100 patients each, all with chronic low back pain. Group N patients received long-term nonsteroidal anti-inflammatory drug therapy for the treatment of their pain, whereas Group O received opioids long-term. The identities of the specific analgesics were tabulated. A list of variables including patient characteristics, healthcare utilization factors, and psychologic characteristics were extracted from their medical records. Regression analysis was performed, which resulted in the identification of 4 variables of age, depression, personality disorder, and history of substance abuse as being closely linked to the use of opioids for the treatment of back pain in preference to nonsteroidal anti-inflammatory drugs alone. By using the derived regression equation, 79% of patients could be correctly classified into Group O or Group N. Pain intensity did not predict opioid use. We present alternative explanations for these observations.",2003.0,0,0
974,14622694,Management of opioid side effects in cancer-related and chronic noncancer pain: a systematic review.,Ewan McNicol; Nathalie Horowicz-Mehler; Ruth A Fisk; Kyle Bennett; Maria Gialeli-Goudas; Priscilla W Chew; Joseph Lau; Daniel Carr; Americal Pain Society,"Side effects can limit opioid dosage and reduce quality of life. The purpose of this systematic review was to assess the management of opioid side effects in the context of cancer pain management or, in the event that no evidence was available for cancer pain, for chronic noncancer pain. The side effects studied were constipation, pruritus, nausea and vomiting, myoclonus, sedation, respiratory depression, and delirium. Opioid rotation to manage side effects was also studied. For each side effect, we searched MEDLINE and the Cochrane Controlled Trials Register and identified 657 possible titles for inclusion. Of these, 67 studies met inclusion criteria for analysis. The lack of well-designed, randomized controlled trials and the heterogeneity of populations and study designs made the drawing of firm conclusions difficult and precluded performance of meta-analysis. The type, strength, and consistency of evidence for available interventions to manage opioid side effects vary from strong (eg, on the use of naloxone to reverse respiratory depression or constipation) to weak (eg, changing from the oral to epidural route of morphine administration to manage sedation). Well-designed trials in the specified populations are required to furnish clinicians with secure evidence on managing opioid side effects successfully.",2003.0,0,1
975,14622720,Outcome from integrated pain management treatment for recovering substance abusers.,Shawn R Currie; David C Hodgins; Ann Crabtree; Jacquie Jacobi; Susan Armstrong,"There is little information on the efficacy of pain management for substance abusers with noncancerous chronic pain conditions. The present study describes an outcome evaluation of a pain management group adapted to the needs of patients diagnosed with concurrent chronic pain and substance abuse disorders. A heterogeneous group of 44 patients (66% opioid dependent; 61% musculoskeletal pain) attended a 10-week outpatient group based within a multidisciplinary substance abuse treatment program. Measures of addiction severity, pain, use of self-management techniques, emotional distress, medication use, and functional status were obtained at pretreatment, post-treatment, 3-month, and 12-month follow-ups. Outcome data were analyzed on the group and individual level, the latter using the reliable change index. Intention-to-treat analyses showed significant improvements in pain, emotional distress, medication reduction, and coping style. Half of the patients showed a statistically reliable improvement on at least 1 outcome measure, and half were opioid free at the 12-month follow-up assessment. These results suggest that persons with concurrent chronic pain and substance use disorders are responsive to an integrated treatment model of pain management and relapse prevention.",2003.0,0,0
976,14633551,Ketamine in chronic pain management: an evidence-based review.,Graham Hocking; Michael J Cousins,"Ketamine has diverse effects that may be of relevance to chronic pain including: N-methyl-D-aspartic acid, alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid, kainate, gamma-aminobutyric acid(A) receptors; inhibition of voltage gated Na(+) and K(+) channels and serotonin, dopamine re-uptake. Ketamine has been in clinical practice for over 30 yr; however, there has been little formal research on the effectiveness of ketamine for chronic pain management. In this review we evaluate the available clinical data as a basis for defining the potential use of ketamine for chronic pain. Literature referenced in this review was obtained from a computer search of EMBASE and MEDLINE from 1966 through August, 2002. Search terms included ketamine, ketalar, pain, painful, analgesic, and analgesia. Abstracts were screened for relevance and publications relating to chronic pain use were obtained. Levels of evidence were stratified according to accepted guidelines (level I-IV). For central pain, there is level II and level IV evidence of efficacy for parenteral and oral ketamine. For complex regional pain syndromes, there is only level IV evidence of efficacy of epidural ketamine. For fibromyalgia, there is level II evidence of pain relief, reduced tenderness at trigger points, and increased endurance. For ischemic pain, a level II study reported a potent dose-dependent analgesic effect, but with a narrow therapeutic window. For nonspecific neuropathic pain, level II and level IV studies reported divergent results with questionable long-term effects on pain. For phantom limb pain and postherpetic neuralgia, level II and level II studies provided objective evidence of reduced hyperpathia and pain relief was usually substantial either after parenteral or oral ketamine. Acute on chronic episodes of severe neuropathic pain represented the most frequent use of ketamine as a ""third line analgesic,"" often by IV or subcutaneous infusion (level IV). In conclusion, the evidence for efficacy of ketamine for treatment of chronic pain is moderate to weak. However, in situations where standard analgesic options have failed ketamine is a reasonable ""third line"" option. Further controlled studies are needed.",2003.0,0,0
977,14640337,"Addiction, physical dependence, and tolerance: precise definitions to help clinicians evaluate and treat chronic pain patients.",Howard A Heit,"Pain is among the most common complaints for which people seek medical care; yet pain is also among the most undertreated patient complaints. Reasons for this include reluctance by clinicians to prescribe and support the use of opioids, often due to a fear of addiction. To address this issue, three major health professional organizations that deal with the treatment of pain and addiction, the American Academy of Pain Medicine, the American Pain Society, and the American Society of Addiction Medicine, formed the Liaison Committee on Pain and Addiction (LCPA). The first mission of the LCPA was to formulate precise definitions of the terms addiction, physical dependence, and tolerance. This report explains these definitions and discusses how they apply to clinical practice.",2003.0,0,0
978,14640355,Removing meperidine from the health-system formulary--frequently asked questions.,M Christina Beckwith; Erin R Fox; Jane Chandramouli,"Meperidine is FDA-approved for relieving moderate to severe pain and has been widely used since its introduction in the 1930s. However, the drug is no longer considered a first-line analgesic. Many clinicians recommend that meperidine be removed from health-systems or that its use be restricted, due to concerns about adverse reactions, drug interactions, and normeperidine neurotoxicity. In addition, clinical evidence shows that meperidine has no advantage over other opioids for biliary colic or pancreatitis. The formulary status of meperidine has been extensively discussed at University of Utah Hospitals and Clinics. The Pharmacy and Therapeutics Committee has been working with hospital staff to assess the impact of either removing meperidine from the formulary, or limiting its use. The Drug Information Service developed this document to help pharmacists respond to prescribers' questions and to alleviate the prescribers' concerns about these changes. Information is provided comparing meperidine with other opioids, including dosage equivalency, pharmacodynamics, pharmacokinetics, cost, adverse effects, and drug interactions. Where available, alternatives to meperidine are suggested for various indications.",2003.0,0,0
979,14650359,Tramadol--the impact of its pharmacokinetic and pharmacodynamic properties on the clinical management of pain.,Ulrich Klotz,"Tramadol (CAS 36282-47-0) plays an important role in the management of pain. With its dual mechanism of action (opioid agonist; weak noradrenaline and serotonin reuptake inhibitor) tramadol provides a kind of combined/adjuvant pain therapy. Besides its proven clinical efficacy tramadol is a safe drug as respiratory depression, cardiovascular side effects, drug abuse and dependence are of minor clinical relevance, unlike some other opioids. Following oral administration the bioavailability of tramadol is high (70-90%) and with new slow release preparations twice daily administration enables effective pain control. Tramadol is characterised by low plasma protein binding (20%) and quite extensive tissue distribution (apparent volume of distribution about 3 l/kg). Elimination is primarily by the hepatic route (metabolism by CYP2D6 to an active metabolite and by CYP3A4 and CYP2B6) and partly by the renal route (up to 30% of dose). Elimination half-lives of the active agents range between 4.5 and 9.5 h and total plasma clearance of tramadol is moderately high (600 ml/min). The interaction potential of tramadol is neglectable, as it does not affect the disposition of other drugs. It should be taken into account that inducers (e.g. carbamazepine) or inhibitors (e.g. quinidine for CY2D6) of drug metabolism might modify the elimination of tramadol. Likewise, if kidney (creatinine clearance below 30 ml/min) or hepatic function is severely impaired, some dosage reduction (approximately by 50%) or extension of the dosage interval should be considered. In conclusion, tramadol is an effective and safe analgesic with a very low interaction potential. Therefore it represents a drug of first choice if moderate to severe pain states have to be treated in pediatric, adult and elderly patients including those with poor cardiopulmonary function.",2003.0,0,0
980,7477920,Interleukin-1 beta induces long-term increase of axonally transported opiate receptors and substance P.,A P Jeanjean; S M Moussaoui; J M Maloteaux; P M Laduron,"Interleukin-1 is known to exert pleiotropic effects in host defence mechanisms and in inflammation. Chronic pain, inflammation and interleukin-1 beta enhance the production of substance P. Recently, axonal transport of opiate receptors was found to increase in rat sciatic nerves in the model of Freund's adjuvant-induced arthritis. Here we show that a single intraplantar injection of interleukin-1 beta is able to enhance the axonal transport of mu and kappa opiate receptors and substance P. Indeed, their accumulation was markedly increased in the proximal part of ligated sciatic nerves, but only in the paw injected with interleukin-1. The time course revealed a delayed onset and, more importantly, a long-term increase lasting at least six days, which is in contrast with the short-term pyrogenic effect of interleukin-1. Pretreatment of rats with capsaicin or administration of dexamethasone completely prevented the interleukin-1 beta effect. The present results suggest that interleukin-1 beta may serve as a mediator to sensitize nociceptors in chronic inflammation and possibly in hyperalgesia through long-term changes in neuronal plasticity.",1995.0,0,0
981,7478680,Chronopharmacokinetic variability in plasma morphine concentrations following oral doses of morphine solution.,G K Gourlay; J L Plummer; D A Cherry,"Twenty-six patients with severe pain associated with cancer were entered into a study where they were required to take morphine mixture for 7 days. Prior to this, their morphine dose had been optimised to provide the most favourable balance between pain relief and side effects. After 6 days of taking their optimised morphine dose at 4-hourly intervals, the patients were admitted to the Pain Management Unit such that the doses from 18:00 h on day 6 were taken under direct nursing supervision. Frequent blood samples were collected after the 10:00 h (dose 1), 14:00 h (dose 2) and 18:00 h (dose 3) on day 7. There was a significant difference between the 3 doses with respect to Cmax values for morphine with dose 3 > dose 1 > dose 2. Further, there was considerable variability in the percentage change of either dose 1 or dose 3 Cmax values relative to dose 2. The Cmax values of the active metabolite morphine-6-glucuronide (M6G), measured in 6 of the patients, for the 3 dosing intervals followed a similar trend to the parent drug, but only doses 1 and 2 differed significantly. Similar but less pronounced changes were observed in the area-under-curve parameter calculated for both morphine and M6G during the 3 dosing intervals. There were no significant differences in the Cmin or Tmax parameters for either morphine or M6G between the 3 dosing intervals. These results suggest intra-individual variation in the absorption of morphine or changes in the volume of distribution during the day.(ABSTRACT TRUNCATED AT 250 WORDS)",1995.0,0,0
982,7478682,Epidural clonidine analgesia for intractable cancer pain. The Epidural Clonidine Study Group.,J C Eisenach; S DuPen; M Dubois; R Miguel; D Allin,"Although the vast majority of patients with cancer pain receive effective analgesia from standard therapy, a few patients, particularly those with neuropathic pain, continue to experience severe pain despite large doses of systemic or intraspinal opioids. Animal studies suggest intraspinal alpha 2-adrenergic agonists may be effective in such cases. Eighty-five patients with severe cancer pain despite large doses of opioids or with therapy-limiting side effects from opioids were randomized to receive, in a double-blind manner, 30 micrograms/h epidural clonidine or placebo for 14 days, together with rescue epidural morphine. Pain was assessed by visual analog score (VAS), McGill Pain Questionnaire, and daily epidural morphine use. Success was defined as a decrease in either morphine use of VAS pain, with the alternative variable either decreasing or remaining constant. Blood pressure, heart rate, and degree of nausea and sedation were monitored. Successful analgesia was more common with epidural clonidine (45%) than with placebo (21%). This was particularly prominent in those with neuropathic pain (56% vs. 5%). Pain scores were lower at the end of the treatment period in patients with neuropathic pain treated with clonidine rather than placebo, whereas morphine use was unaffected. Clonidine, but not placebo, decreased blood pressure and heart rate. Hypotension was considered a serious complication in 2 patients receiving clonidine and in 1 patient receiving placebo. This study confirms the findings from previous animal studies which showed the effective, potent analgesic properties of intraspinal alpha 2-adrenergic agonists and suggests that epidural clonidine may provide effective relief for intractable cancer pain, particular of the neuropathic type.",1995.0,0,0
983,7478700,,,,,0,0
984,7478701,Ketamine as an adjunct to morphine in the treatment of pain.,D A Cherry; J L Plummer; G K Gourlay; K R Coates; C L Odgers,"A double-blind multidose trial of the addition of ketamine (0-40 mg, i.m., 8 times per day) to intramuscular morphine therapy was undertaken in a 61-year-old man with chronic back pain related to osteoporosis who had received inadequate pain relief from anterior interbody fusion, dorsal column stimulation and morphine alone. The patient reported only mild side effects. Nausea, tiredness and well-being were not significantly influenced by the ketamine dose level. Visual analogue pain scores prior to each dose were not associated with the ketamine dose level, but pain scores 30 min after doses were significantly reduced in a dose-related manner. In addition, the amount of morphine used by the patient was significantly reduced as the ketamine dose increased. This patient experienced substantial benefit from the addition of ketamine to intramuscular morphine therapy.",1995.0,0,0
985,7478713,The influence of lockout intervals and drug selection on patient-controlled analgesia following gynecological surgery.,B Ginsberg; K M Gil; M Muir; F Sullivan; D A Williams; P S Glass,"This study systematically compared 2 opioids, morphine (MOR) and fentanyl (FEN), and 2 lockout intervals, long (L) and short (S) in patients utilizing patient-controlled analgesia (PCA). Seventy-eight women undergoing gynecological surgery were randomly assigned to 1 of 4 groups: MOR-S (7 min), MOR-L (11 min), FEN-S (5 min), FEN-L (8 min). PCA measures obtained during the first 24 h after surgery included: number of demands/h, number of completed deliveries/h, dose/h, and demand/delivery ratio. Visual analog scales of pain and anxiety were also obtained. Results indicated that pain relief was equivalent with minimal side effects for both opioids. The selection of opioid, however, influenced the pattern of PCA use, with an improved demand/delivery ratio initially for FEN. The lockout intervals chosen for this study did not influence pain or anxiety levels.",1995.0,0,0
986,7481892,Self-care strategies used for acute attack of interstitial cystitis.,D C Webster; T Brennan,"To determine the kinds of self-care used by women with interstitial cystitis and to find effective ways to manage symptoms of acute attack. One hundred thirty-eight women with interstitial cystitis completed a survey indicating how often they used and how effective they found strategies in four physical self-care subdomains (medication, treatment, diet, and body comfort) and three psychologic self-care subdomains (cognitive/stress reduction, distraction, and help-seeking). Descriptions of symptoms during an ""acute attack"" are more consistent with symptoms described ""at onset"" than symptoms experienced ""currently."" Physical strategies most used for acute attack included use of narcotics, antidepressants, and bladder analgesics, in addition to limiting the diet to bland or starchy foods, wearing loose clothing, taking hot baths, and using a heating pad over the pubis. Psychologic strategies most used included watching television, prayer, and seeking support from a significant other, family members, friends, and other patients with interstitial cystitis. Some psychologic and physical strategies found to be effective for other chronic pain conditions, such as biofeedback, alternating use of heat/cold, self-hypnosis, and redefining pain sensations were seldom used. Other nonmedical interventions such as massage and imagery, when used, were found to be more moderately to highly effective. Information about self-care and access to support groups may increase exposure to multiple ways of handling acute attacks.",1995.0,0,0
987,7484044,Respiratory changes during treatment of postoperative pain with high dose transdermal fentanyl.,H H Bülow; M Linnemann; H Berg; T Lang-Jensen; S LaCour; T Jonsson,"This study made a longterm (72 hours) evaluation of the efficacy and possible side-effects of transdermal delivery of fentanyl (TTS-system) for post-operative pain relief. The study was double-blind, placebo-controlled with either a TTS-system delivering fentanyl 100 micrograms.h-1 and rescue analgesic on demand or a placebo system and analgesic on demand. Analgesic consumption, pain, general satisfaction, respiratory rate, and levels of SpO2 and tcCO2 (pulse oximetry and transcutaneous CO2 measuring) were evaluated. Recruitment was stopped after enrolment of 24 patients, on safety grounds. The Fentanyl group was more satisfied with postoperative pain relief (P = 0.008); they had a lower analgesic demand (P < 0.05) but also a lower respiratory rate (P < 0.05) and a higher level of tcCO2 23 hours after application (P < 0.05). There were three cases (25%) of increased PaCO2 (> 6.5 kPa) in the Placebo group but without low PaO2 levels, sedation or bradypnoea. Conversely, there were three cases (33%) in the Fentanyl group with bradypnoea (< 10 breaths/minute), two without influence on PaO2 or PaCO2, but one (no. 24) with bradypnoea, heavy sedation, a marked decrease in PaO2 (5.8 kPa) and increased PaCO2 (7.5 kPa). These findings terminated the study. The 100 micrograms transdermal fentanyl system is agreeable to the patients, but apparently too potent for routine postoperative pain relief due to a risk of respiratory depression. Respiratory frequency can not be relied upon as sole indicator of insufficient respiration.",1995.0,0,0
988,7489418,Caudal analgesia with buprenorphine for postoperative pain relief in children.,R S Kamal; F A Khan,"Caudal buprenorphine was investigated as a postoperative analgesic in a randomized double blind study in thirty children aged 5-12 years undergoing lower abdominal and lower limb surgery. Comparison was made between two groups of patients, one group receiving plain bupivacaine and the other a combination of plain bupivacaine with buprenorphine. Postoperative analgesia was assessed using a linear analogue scale, and by the response to direct questioning of children using an illustration of sequence of faces. Any untoward side effects and the need for additional analgesics were recorded. The degree and duration of analgesia was far superior in the buprenorphine group and there was a highly significant difference in the requirement of postoperative analgesia between the two groups. There were no major adverse side effects and no motor weakness in either groups, however the incidence of nausea and vomiting was higher in the buprenorphine group. It is concluded that a combination of bupivacaine with buprenorphine administered through the caudal epidural space is a safe and reliable means of providing postoperative pain relief in children for up to 24 h.",1995.0,0,0
989,7489439,"Postoperative morphine requirements, nausea and vomiting following anaesthesia for tonsillectomy. Comparison of intravenous morphine and non-opioid analgesic techniques.",S J Mather; J M Peutrell,"Nonsteroidal anti-inflammatory drugs (NSAIDs) have been shown to be as effective as opioid analgesia following tonsillectomy in children. Opioids are still frequently used but tonsillectomy is associated with a high incidence of vomiting. This study has attempted to assess postoperative analgesic consumption and nausea and vomiting after general anaesthesia for tonsillectomy using either paracetamol premedication, paracetamol plus a NSAID or intravenous morphine to provide postoperative analgesia. Some children required a rescue dose of morphine in the recovery room, including some who had received intravenous morphine at induction. Least supplementary morphine was required by those who had received paracetamol plus ketorolac. Postoperative nausea and vomiting was significantly less in the two groups which were not given intraoperative morphine. The number of vomiting incidents was also much less. We conclude that the preoperative administration of paracetamol alone provides satisfactory analgesia in many children but that supplementary analgesia is still required for some.",1995.0,0,0
990,7489472,Paediatric ventilatory effects of morphine and buprenorphine revisited.,K T Olkkola; M A Leijala; E L Maunuksela,"The study describes long term ventilatory effects of 50 or 100 micrograms.kg-1 of morphine or 1.5 or 3.0 micrograms.kg-1 of buprenorphine when given in repeated intravenous (i.v.) doses, in a double blind fashion, to achieve equal levels of analgesia after thoracotomy. The patients were 56 children, six months to six years of age. Ventilatory rate (VR) was measured over the 24 h study period, and arterial carbon dioxide tension (PaCO2) was measured on arrival in the Paediatric Intensive Care Unit (PICU) and at 1, 6, 12 and 18 h. In the buprenorphine groups VRs progressively decreased during the first 2 h and remained significantly lower (P < 0.05) than in the morphine groups for 7 h. For the rest of the study period there were no differences. The PaCO2 values did not differ significantly at any point. For safety, prolonged observation of children is needed after intravenous administration of buprenorphine to ensure the ventilatory rate has stabilized.",1995.0,0,0
991,7490894,Patient controlled analgesia for shock wave lithotripsy: the effect of self-administered alfentanil on pain intensity and drug requirement.,G Schelling; W Weber; G Mendl; H Braun; H Cullmann,"Second generation lithotriptors offer immersion-free treatment and a decrease in shock wave induced pain. Pain sensations caused by advanced lithotriptors vary widely and have a significant impact on clinical management. We tested patient controlled analgesia during extracorporeal shock wave lithotripsy (ESWL) and quantified analgesic requirements by means of patient controlled analgesia during ESWL of renal stones. Patients with renal stone disease undergoing ESWL were randomized prospectively to receive an alfentanil infusion titrated by 4 different anesthesiologists not otherwise involved in the study (22 controls) or to self-administer alfentanil via a patient controlled infusion pump (22 patients). As a measure of individual pain sensitivity the detection, pain and tolerance thresholds of electrocutaneous sensitivity were determined in all patients. Alfentanil was used more often in the patient controlled analgesia group than in the control patients (12 versus 8 required the narcotic, respectively, p = 0.226). Patients using patient controlled analgesia needed less drug (0.5 versus 2.15 mg., p = 0.005, median values), tolerated higher discharge voltages and pain intensities, needed significantly fewer shock waves to complete stone fragmentation (1,612 versus 2,105, p = 0.014) and had shorter treatment times (36.9 versus 46.2 minutes, p = 0.069). There was a significant correlation between the duration of shock wave exposure tolerated without analgesia, and pain (p = 0.0009) and tolerance (p = 0.0020) thresholds but not with regard to detection thresholds (p = 0.1400). Male patients showed significantly higher tolerance thresholds to electrocutaneous stimulation (10.2 versus 6.9 mA., p = 0.0238), which corresponded to longer analgesia-free treatment times in male versus female patients (31.7 versus 19.4 minutes, p = 0.0510). Patient controlled analgesia increases pain tolerance, decreases narcotic requirements, simplifies ESWL as an outpatient procedure and can be used to quantify analgesic requirements during lithotripsy. Pain and tolerance thresholds of electrocutaneous sensitivity are sensitive markers of pain tolerance during lithotripsy, which may be more pronounced in male patients.",1996.0,0,0
992,7493144,A clinical audit for postoperative pain control on 1443 surgical patients.,S L Tsui; R J Lo; W N Tong; J C Yang; A M O'regan; K F Ng; C S Lamg,"Moderate to severe pain occurs in 75 to 100% of patients after major operations. Pain control techniques, for examples the patient controlled analgesia (PCA) and epidural analgesia, are effective in relieving postoperative pain. Routine delivery of these pain control techniques to patients undergoing operations can be provided by an anaesthesiologists-based acute pain service (APS). This manuscript audited postoperative pain management service to 1369 ethnic Chinese patients and 74 patients of other races, over a 30 mon period in a teaching hospital in Hong Kong. The APS was prioritized to elderly patient (36.1%, aged 65 or higher), patients of poor physical condition (27.0% ASA III or IV) and those undertaken major operations. Most patients (1348, 93.4%) received either one of the four standardized analgesic regimens including PCA or epidural analgesia. The median verbal quantitative scale of pain (VQS) at rest/movement were 2.0/4.3 on operative day and 0/0.6 on 4th postoperative day. The morphine consumption in 665 Chinese patients (PCA intravenous morphine) was 26.1 +/- 14.3 mg/kg/h (mean +/- SD) during the first 20 postoperative hours. This decreased to 18.1 +/- 15.1 at 21th to 44th and 18.5 +/- 14.9 at 45th to 68th hours postoperatively. There was no difference in morphine consumption between Chinese patients and other races. The incidence for nausea and vomiting were 26.5% and 13.3%, respectively. Respiratory derangement occurred in 23 patients (1.9%) and almost always accompanied by somnolence. Most patients (1176, 81.5%) rated their postoperative analgesia on discharge from the care of APS. Effective and safe postoperative analgesia in Chinese patients can be achieved with currently available pain control techniques such as epidural and PCA. APS is a practicable approach to deliver these techniques to postoperative patients on a routine basis.",1995.0,0,0
993,7493264,"Pain, pills, and possibilities: drug therapy in peripheral vascular disease.",A M Karch,"Currently, pharmacologic therapy offers no cures for the patient with vascular disease. Drugs are available, however, to prevent or delay the end organ damage of vascular disease, to keep vessels patent as long as possible, and to provide some relief from the pain associated with vascular disease and cell damage. In this article, the author reviews the drugs used to manage hypertension--diuretics, beta blockers, alpha adrenergic blockers, angiotensin-converting enzyme inhibitors, calcium channel blockers, antiadrenergic drugs, and nitroprusside; and drugs used to maintain vessel patency in peripheral vascular disease--peripheral vasodilators and anticoagulants; and reviews one regimen for dealing with the chronic pain of vascular disease--narcotics and tricyclic antidepressants.",1995.0,0,0
994,7495990,Opioid use in HIV patients with neurological changes.,J A Paice; J C Pugliese; J E Fitzpatrick,"The neurological changes that are common in the HIV population may complicate the use of analgesics, particularly opioids. These changes, in combination with care providers' fear of opioids, often lead to the inappropriate use of antagonists, such as naloxone. Used injudiciously, naloxone can lead to withdrawal syndrome, return of severe pain, and other adverse effects. The authors describe the many disease and treatment-related causes for pain in patients with HIV disease, as well as common neurologic conditions that alter cognition and complicate the use of opioids. A case study is included to illustrate the dangers of inappropriate naloxone use.",1995.0,0,0
995,7498863,[Long-term treatment of chronic pain with tilidine-naloxone. An analysis of 50 patients with chronic pain conditions of non-malignant origin].,R Wörz; E Wörz,"50 patients with incurable chronic pain states were treated for a period of between six months and 14 years (median: 31 months) with tilidine-naloxone, and the results of tumor recorded. Amelioration of pain was achieved in an average of 60.7% of the cases. The 16 patients of this series suffering from neuropathic pain who received a somewhat lower dose responded equally as well (60.3% amelioration) as the overall group. In 24 patients suffering from pain, the daily dose remained unchanged throughout the course of treatment, had to be increased in 19, and was reduced in seven patients. In two patients, acceptable side-effects were indicated; in no case were there any signs of drug-induced organic damage. The results show that tilidine-naloxone is a highly effective opioid analgesic with a remarkably favorable benefit-risk ratio for use in long-term treatment.",1995.0,0,0
996,7507585,Chronic pain in the spinal cord injured: statistical approach and pharmacological treatment.,P Fenollosa; J Pallares; J Cervera; F Pelegrin; V Inigo; M Giner; V Forner,"We include in this article the results of a postal inquiry into chronic pain in SCI patients in Valencia (Spain), and our experience with their management. A mailed questionnaire including lesion and chronic pain data was sent to all of the 380 SCI patients who live in the region of Valencia. We received 202 answers, with 145 questionnaires being accurately answered and these were analysed for this study. The results show that chronic pain (that is, lasting more than 6 months) is very common (65.5%). The most frequent type was deafferentation pain (phantom pain), described as burning or a painful numbness. Since 1988 we have been treating a sample of 33 patients suffering from resistant pain according to the following therapies: 1 amitriptyline + clonazepam+NSAID (nonsteroidal antiinflammatory drugs); 2 amitriptyline + clonazepam + 5-OH-tryptophane + TENS (transcutaneous electrical nerve stimulation); 3 amitriptyline + clonazepam + SCS (spinal cord stimulation); 4 morphine, by continuous intrathecal infusion. After almost 4 years using these therapies we can affirm that the results regarding analgesia reached 80% in all cases, and that morphine used by intrathecal route is very safe and useful in selected patients.",1993.0,0,0
997,7509152,Continuous axillary nerve block for chronic pain.,M S Fewtrell; D J Sapsford; M J Herrick; G Noble-Jamieson; R I Russell,Continuous axillary nerve block was used to relieve pain after a chemical burn to the arm in a child on mechanical ventilation after liver transplantation. The analgesia was sufficient to replace parenteral analgesia and allow extubation.,1994.0,0,0
998,7509380,Phase I trial of 3-hour infusion of paclitaxel with or without granulocyte colony-stimulating factor in patients with advanced cancer.,J H Schiller; B Storer; K Tutsch; R Arzoomanian; D Alberti; C Feierabend; D Spriggs,"We conducted a phase I trial of a 3-hour infusion of Taxol (paclitaxel; Bristol-Myers Squibb Co, Princeton, NJ) to identify the maximum-tolerated dose of Taxol as a 3-hour infusion with and without granulocyte colony-stimulating factor (G-CSF) support. Thirty-five patients with advanced, untreatable malignancies were treated with a 3-hour infusion of Taxol once every 3 weeks. Groups of three patients were entered at escalating dose levels of Taxol in a traditional phase I design in each of two parallel arms: arm A, without G-CSF, and arm B, with G-CSF. Patients assigned to the G-CSF arm received G-CSF 5 micrograms/kg/d subcutaneously starting on day 2 for 9 to 14 days. All patients were pretreated with dexamethasone, diphenhydramine, and ranitidine, and were monitored continuously for cardiac arrhythmias during the first treatment. Dose-limiting myelosuppression with Taxol without G-CSF was observed at the 250-mg/m2 dose level. The dose-limiting toxicity for Taxol with G-CSF was peripheral neuropathy at the 300-mg/m2 dose level. One of 35 patients (2.8%) had a grade 3 anaphylactic reaction at 250 mg/m2. No clinically significant cardiac arrhythmias were documented. Twenty-seven of 111 courses (24%) were associated with grade 3 arthralgias or myalgias requiring narcotics for pain control. Taxol plasma concentrations declined in a triexponential fashion, with a final elimination half-life of 10 to 12 hours. The peak Taxol plasma concentrations and total area under the curve (AUC) increased with increasing doses of Taxol, although this increase appeared to be somewhat nonlinear. The maximum dose of Taxol recommended for phase II and III studies, when administered as a 3-hour infusion alone and with G-CSF support, is 210 mg/m2 and 250 mg/m2, respectively. No increased incidence of hypersensitivity reactions or other side effects were observed, with the possible exception of arthralgias and myalgias. If ongoing trials demonstrate that a 3-hour infusion is as efficacious as a 24-hour infusion, we conclude that with proper monitoring and premedication, high-dose Taxol can be safely administered in the outpatient setting.",1994.0,0,0
999,7511475,Undertreatment of cancer pain: barriers and remedies.,S A Grossman,"Over 70% of patients with cancer have moderate to severe pain during their illness and many fear pain more than death itself. There is consensus among experts that most patients can be well-palliated using knowledge, medications, and techniques that are readily accessible. Despite this, only a small proportion of patients with cancer pain receive adequate analgesia. Some of the barriers that interfere with the delivery of appropriate analgesia are patient-related, while others involve health-care providers. Patients frequently do not communicate the intensity of their pain to care-givers and are often hesitant to take opiates. Health-care providers receive scant teaching on cancer pain, have little awareness of pain intensity in their patients, and may be overly concerned about opiate toxicities. They lack appropriate role models in academic institutions and may be concerned about the potential for investigation by law-enforcement agencies. These obstacles can be largely overcome by (a) emphasizing the importance of pain control in cancer patients, (b) considering the etiology of pain in each patient, (c) weighing the full range of available therapeutic options, (d) ensuring that ""user-friendly"" opiate-equivalence information is available, (e) using pain assessment tools routinely and recording pain intensity scores in the medical record, and by (f) not being easily dissuaded from providing adequate doses of opiates for pain relief. The rationale for and current efforts in each of these areas are discussed in this review.",1993.0,0,0
1000,7514506,Hydromorphone patient-controlled analgesia (PCA) after coronary artery bypass surgery.,N R Searle; M Roy; G Bergeron; J Perrault; J Roof; C Heermans; M Courtemanche; C Demers; R Cartier,"We conducted a study to compare the effectiveness of patient-controlled analgesia (PCA) technique to conventional analgesic therapy (CAT) after coronary artery bypass graft (CABG). The PCA group received hydromorphone 0.1 mg.hr-1 basal infusion and bolus doses of 0.2 mg Q 5 min (maximum 1.2 mg.hr-1) while the CAT group received morphine 2.5 mg iv Q 30 min prn until extubation followed by prn meperidine 1 mg.kg-1 im Q 4 hr or acetaminophen 325 mg with codeine 30 mg po (1 or 2 tablets) when oral intake was possible. The degree of pain was assessed using a Visual Analogue Scale (VAS) starting after extubation and every 6-8 hr for the next 60 hr. Holter monitoring was initiated one hour after patient arrival in the Intensive Care Unit (ICU) and continued for 72 hr. Other measured variables were pulmonary function, sedation, side effects and total opioid requirements. Results show that the day-to-day VAS pain score decreased in the PCA group (P < 0.001) while it remained unchanged in CAT patients. The PCA patients had lower VAS pain scores at extubation (P < 0.05). During the third postoperative day, the PCA group had a lower VAS pain score, a lower incidence of severe pain defined as a score > 5 on the VAS scale, and a reduced incidence of myocardial ischaemia (P < 0.01). However, there was no difference in the duration, severity, area under the curve (AUC), or heart rate during ischaemic events. Postoperative pulmonary function was abnormal in both groups (NS) with minimal recovery by the fourth day.(ABSTRACT TRUNCATED AT 250 WORDS)",1994.0,0,0
1001,7516101,[Continuous subcutaneous morphine to patients with terminal cancer. Analgesia at home].,J O Laursen,Since 1992 it has been possible for cancer patients in the county of Southern Jutland to receive terminal care in their own homes. An essential part of this management is effective pain relief; more than 60% of cancer patients have chronic pain. In cases where oral medication or epidural administration of morphine is insufficient or complicated by side-effects continuous subcutaneous morphine administration may be suitable. The patient may be treated in this latter manner for long periods of time. A case story is described where a cancer patient was treated with continuous subcutaneous morphine in his home for more than 257 days without complications or major side-effects.,1994.0,0,0
1002,7517824,Chronic pain--challenge and response.,K Budd,"Tramadol is effective in treating both acute and chronic pain, exhibiting a potency equivalent to that of pethidine, and it has an acceptable adverse event profile. Whilst the most common adverse events are nausea, vomiting, drowsiness and dizziness, as would be expected from an opioid, there is a noticeable lack of respiratory depression. This latter property, together with its low potential for the development of tolerance and dependence, make tramadol a most interesting agent for clinical use. The studies reported in this article illustrate the beneficial and adverse effects of tramadol to enable the clinician to judge the value of this agent.",1994.0,0,0
1003,7517826,New clinical experience with tramadol.,A Sunshine,"The analgesic efficacy of tramadol has been recently reassessed as part of a new clinical development programme to support an application for registration in the USA. This article reviews the results of single dose and short term studies of oral tramadol 50, 75, 100 and 150 mg in various acute pain conditions. In a double-blind single dose study conducted in 161 patients with severe pain following caesarean section, tramadol 75 and 150 mg and the combination of paracetamol 650 mg with dextropropoxyphene napsylate 100 mg were shown to be effective and statistically superior to placebo. The results from this and 17 other similar studies in patients with pain after surgery (n = 1594) or dental extraction (n = 1859) including other comparators were included in a pooled analysis. Tramadol 100 mg was the optimal single dose for acute pain and tramadol 50 mg showed similar analgesic efficacy to codeine 60 mg. Multiple dose short term studies (n = 520) with tramadol 50, 75 and 100 mg demonstrated a statistically significant and dose-dependent reduction in the consumption of either ibuprofen or morphine as escape medication. New pharmacokinetic data show that steady-state plasma tramadol concentrations reached after oral administration of 50 mg doses every 6 hours are similar to those obtained after administration of a 100 mg single oral dose (250 micrograms/L). This rationale is supported by the results of long term studies in which the average daily dose of tramadol was approximately 250 mg.",1994.0,0,0
1004,7521609,Emergencies in palliative care.,A M Smith,"Five groups of events are here considered as emergencies in palliative care: haemorrhage, convulsions, fractures, spinal cord compression and acute confusion. Incidence, causes and management of these form the major part of this article. Emergencies in palliative care also include sudden severe exacerbation of symptoms. Therefore, onset of severe pain, exacerbation of breathlessness, and worsening of other symptoms are also discussed with their appropriate treatment. A small armamentarium of appropriate medications is thus shown to cover treatment of the various emergencies that may arise. As palliative care deals with patients who are suffering from progressive fatal conditions, death is the expected end. Nevertheless, however well the family are prepared, death often appears for them as an emergency. Comment is made regarding this family emergency in the care of terminally ill people. Attention in this article is focussed on medical treatment. In the care of the emergency event, however, and in all palliative care, management includes making the patient comfortable, thinking of the needs of other patients and relatives observing the event, explaining what is happening and is being done, involving other members of the team, and communicating reassurance to the patient and the relatives as well as to other observers.",1994.0,0,0
1005,7521784,Comparative clinical efficacy and safety of immediate release and controlled release hydromorphone for chronic severe cancer pain.,H Hays; N Hagen; M Thirlwell; H Dhaliwal; N Babul; Z Harsanyi; A C Darke,"The short elimination half-life of hydromorphone necessitates 4-hourly dosing to maintain optimal levels of analgesia in patients with chronic cancer pain. The purpose of this study was to compare the clinical efficacy and safety of controlled release hydromorphone administered every 12 hours and immediate release hydromorphone administered every 4 hours in patients with chronic severe cancer pain. Forty-eight patients with stable chronic severe cancer pain were randomized, in a double-masked crossover study, to controlled release hydromorphone every 12 hours or immediate release hydromorphone every 4 hours for 7 days each. Pain intensity was assessed using a visual analog scale (VAS) and the Present Pain Intensity Index of the McGill Pain Questionnaire. Nausea and sedation were also assessed using a VAS. Assessments were made by the patient four times a day at 7:00 a.m., 11:00 a.m., 3:00 p.m., and 7:00 p.m. Use of rescue hydromorphone also was recorded by the patient. Forty-five patients completed the study (26 women, 19 men; mean age, 57.1 +/- 13.6 years) and received a mean daily dose of 76 +/- 133 mg (range, 6-768 mg). There were no significant differences between controlled release hydromorphone and immediate release hydromorphone in overall VAS pain intensity scores (19 +/- 14 vs. 20 +/- 14 mm), ordinal pain intensity scores (1.2 +/- 0.8 vs. 1.2 +/- 0.8) and pain scores by day of treatment or time of day. The daily rescue analgesic consumption during controlled release hydromorphone and immediate release hydromorphone did not differ significantly overall (1.1 +/- 1.1 vs. 1.0 +/- 1.1 doses per day) or with respect to time of day. There were no significant differences in overall VAS sedation scores (18 +/- 18 mm vs. 19 +/- 18 mm) and in overall mean VAS nausea scores (12 +/- 15 mm vs. 11 +/- 14 mm) between controlled release hydromorphone and immediate release hydromorphone. Controlled release hydromorphone administered every 12 hours is as effective as immediate release hydromorphone administered every 4 hours in the management of patients with chronic severe cancer pain. The benefits of controlled release hydromorphone lie in the convenience of its capsule formulation, which can be sprinkled on soft food, and its 12-hour duration of action, which allows patients uninterrupted sleep and improved compliance.",1994.0,0,0
1006,7522977,A comparison of pentamorphone and fentanyl in balanced anaesthesia during general surgery.,W B Kelly; M B Howie; V A Romanelli; J A Duarte; H Rezaei; T D McSweeney,"The purpose of our randomized, double-blind study of 64 unpremedicated healthy patients undergoing surgical procedures with a duration of at least 60 min was to compare 0.75 micrograms.kg-1 and 1 microgram.kg-1 pentamorphone with 5 micrograms.kg-1 and 7.5 micrograms.kg-1 fentanyl to determine which dose of opioid would reduce the requirement for isoflurane supplementation needed to maintain haemodynamic stability. At 21 points during the procedure, the haemodynamic variables of heart rate and systolic, diastolic, and mean arterial pressures were recorded. The use of isoflurane was quantified; the number of patients requiring inhaled anaesthetic, concentration peaks, MAC minutes, and duration of isoflurane use were noted. The number of equal-volume supplemental opioid analgesic doses, postoperative analgesics, occurrence of postoperative nausea, emesis, and antiemetic doses were compared. The four groups exhibited similar patient demographics, total dose of muscle relaxants, types of surgical procedures, and duration of surgery or anaesthesia. Haemodynamic variables were stable with no difference among the four study groups. The patients given pentamorphone demonstrated both delayed requirement (P < 0.05) and shorter duration (P < 0.05) of isoflurane supplementation. Patients given either 5 micrograms.kg-1 or 7.5 micrograms.kg-1 fentanyl needed isoflurane supplementation within 12 +/- 16 min and 12 +/- 17 min from induction respectively; while patients given either 0.75 micrograms.kg-1 or 1 microgram.kg-1 pentamorphone did not require isoflurane supplementation for 37 +/- 10 min and 43 +/- 26 min respectively.(ABSTRACT TRUNCATED AT 250 WORDS)",1994.0,0,0
1007,7525038,Intravenous pamidronate disodium treatment of bone metastases in patients with breast cancer. A dose-seeking study.,D Glover; A Lipton; A Keller; A A Miller; S Browning; R J Fram; S George; K Zelenakas; R S Macerata; J J Seaman,"Treatment of the symptoms of bone metastases currently involves the use of narcotic medication, radiation therapy, or hormonal therapy. Pamidronate disodium, a bisphosphonate, may prove helpful in the palliative treatment of bone metastases in patients with breast cancer as demonstrated in this multicenter, dose-ranging trial. Ambulatory female patients age 18 years or older with breast cancer metastatic to bone and a life expectancy of at least 3 months were eligible for the study. Bone metastases were confirmed by bone scan or bone survey within 6 months of enrollment. Sixty-one patients were treated as outpatients and were randomized to receive one of four intravenous pamidronate regimens for 12 weeks: 30 mg administered every 2 weeks, 60 mg every 4 weeks, 60 mg every 2 weeks, or 90 mg every 4 weeks. The primary efficacy parameter for this study was pain score. The change from baseline in pain score was determined for each patient at each study visit and at endpoint, defined as the last postbaseline evaluation for each patient before or at week 12. Secondary efficacy variables included narcotic scores, urinary calcium/creatinine and hydroxyproline/creatinine ratios, serum osteocalcin and bone alkaline phosphatase concentrations, and bone lesion (radiologic) response. At 3 months, the regimens of 60 mg every 4 weeks, 60 mg every 2 weeks, and 90 mg every 4 weeks resulted in significant reduction in bone pain beginning by week 6 of treatment. The regimen of 30 mg every 2 weeks was not effective. Narcotic use, as reflected by narcotic scores, did not parallel the pain scores, because there was little evidence of any effect for any of the treatment groups. Reduction in bone pain was accompanied by decreases in urinary calcium/creatinine and hydroxyproline/creatinine ratios, and bone alkaline phosphatase concentrations. Side effects of pamidronate were mild and transient. Radiographic changes consistent with healing of lytic lesions were observed in 15 patients (25%). Intravenous pamidronate is a well tolerated treatment that produced significant relief of bone pain in the majority of patients with metastatic breast cancer at the three highest doses tested.",1994.0,0,0
1008,7525518,Current status of systemic intravenous radiopharmaceuticals for the treatment of painful metastatic bone disease.,A N Serafini,"Intractable bone pain secondary to bone metastasis from prostate, lung, breast, and other malignancies is a major problem in the management of the oncological patient. Because a number of factors are implicated in the pathophysiology of bone pain, a multidisciplinary approach in its assessment and treatment is often required. Treatment often includes the use of analgesic drug therapy; however, radiation therapy, hormonal therapy, chemotherapy, and surgery may also be needed. The use of systemic radionuclide therapy may often be helpful to relieve bone pain and improve the quality of life. In the setting of diffuse bone metastasis, intractable to conventional therapy, various radioisotopes have been advocated. These include phosphorous-32, iodine-131, strontium-89, yttrium-90, samarium-153, and rhenium-186, often as either the anionic phosphate or as a ligand (HEDP, EDTMP). When these agents are used, pain relief often occurs in approximately 2-4 weeks and lasts several weeks to months with responses seen in 60-80% of patients, depending on the extent of disease and stage the patient is treated. Retreatment has been possible in certain cases with further palliation being offered and improvement in the various quality of life parameters being noted. Myelotoxicity has been a limiting factor with certain isotopes and has led to the development of less toxic bone seeking agents. Although these each have unique physical and biokinetic properties requiring different doses and protocols for administration, they all appear to localize in osteoblastic metastatic sites in sufficient amounts to provide bone pain palliation.",1994.0,0,0
1009,7527324,Pharmacological management of back pain syndromes.,R W Porter; S H Ralston,"The symptom of back pain may be the result of many different pathologies. As such, patients with back pain require careful assessment to determine whether the cause is from the spine or other systems. For acute mechanical back pain, treatment is often symptomatic. Symptomatic treatment may include analgesics, anti-inflammatories and/or muscle relaxants. Patients may also need hypnotics in the short term to help them sleep at night. However, drug therapy should be reduced and stopped as soon as possible. Furthermore, too much bedrest may be counterproductive. Paracetamol (acetaminophen) is the standard treatment for transient back pain. More severe pain may require the addition of an opioid, such as codeine or dextropropoxyphene. Morphine and pethidine (meperidine) may be necessary in patients with back pain due to neoplastic disease or osteoporotic fracture. However, the opioid analgesics are associated with dependence, tolerance and adverse effects. Nonsteroidal anti-inflammatory drugs (NSAIDs) have analgesic efficacy comparable with paracetamol. Individual patients respond differently to different NSAIDs, and several agents may have to be tried. Long term therapy with NSAIDs is necessary in diseases with an inflammatory component such as ankylosing spondylitis. Calcitonin reduces bone resorption and bone blood flow, and has been suggested to have central analgesic effects. As such, it has been used successfully in patients with Paget's disease, osteolytic bone disease and osteoporosis. Bisphosphonates also inhibit osteoclastic bone resorption and may be useful in Paget's disease, osteolytic metastases and osteoporotic fractures. Other drugs which may be useful in relieving back pain associated with specific circumstances include the tricyclic antidepressants, anxiolytics, antiepileptic agents, corticosteroids, colchicine and chymopapain.",1994.0,0,0
1010,7528184,Intrathecal morphine in the treatment of chronic intractable pain.,F A Chambers; R MacSullivan,Fifteen patients with intractable pain received intrathecal morphine delivered via a programmable (Medtronic) device. In twelve patients the pain was due to cancer and three patients had pain of non malignant origin. All of the patients reported excellent or good relief. A total of 14 complications were reported in 7 patients. Most of these were minor and related to surgical or mechanical problems. One patient with pain of non malignant origin developed serious complications which required the removal of the infusion device. The results of this study show that chronic intrathecal infusion of morphine is superior to conventional forms of analgesia in patients with intractable pain of malignant origin. We would advise that it should remain a therapy of last resort in patients with intractable non malignant pain as the long term side effects are still unknown and the potential for serious side effects still exists.,1994.0,0,0
1011,7535139,Surgical management of cancer pain.,S J Hassenbusch,"Although the technology has improved rapidly and provided many different techniques, information is lacking concerning the application of the technology. These techniques are applied, for the most part, only to patients with severe pain, because many of the nonsurgical options adequately manage pain that is minimal or mild in severity. Decisions for selection of a specific technique can be based on expected survival time, need for focal or diffuse pain control, or preference for ablative or augmentative options. For patients with good prognosis, augmentative techniques or simple ablative techniques are used more frequently, whereas ablative procedures with higher risk or destruction of more tissue are used later. Patients with severe pain and a poor prognosis represent the most difficult treatment group for three reasons: (1) the severity of the pain and the tendency of the pain to worsen significantly during the patient's remaining time, (2) the limited expected survival time of the patient, which some-what limits the use of an expensive, complicated intervention or operation, and (3) the considerable controversy that has been generated by the large number of different treatment options for this group. Because of these issues, there is not a general consensus concerning a treatment algorithm for this group of patients. This emphasizes the need for controlled, comparative studies of systemic treatments and interventional treatments as well as side-by-side comparisons of the efficacy and complications of the different types of surgical techniques. In light of the recently released cancer pain guidelines from the United States Agency for Health Care Policy Research, one would hope that the research of the next 5 years would focus on providing many of the answers to these problems.",1995.0,0,0
1012,7535354,Control of severe pain in children with terminal malignancy.,J J Collins; H E Grier; H C Kinney; C B Berde,"To identify the characteristics of the subset of children with malignancy in whom massive opioid infusions are needed during the terminal phase. Retrospective review of the records of the 199 patients who died of malignancy after treatment at Children's Hospital, Boston, from March 1989 to July 1993, identifying characteristics of patients who required massive opioid infusions (operationally defined as infusion of > 3 mg/kg per hour of morphine dose equivalent) during the terminal phase. Twelve patients (6%) required massive opioid infusions, and eight of these patients required extraordinary measures (epidural or subarachnoid infusion and/or sedation) to achieve adequate analgesia. The duration of epidural or subarachnoid infusions in three patients ranged from 3 to 9 days, and minimal complications occurred. The duration of sedation ranged from 1 to 15 days. Maximal intravenous opioid dosing ranged from 3.8 to 518 mg/kg per hour of morphine equivalent. The maximal infusion rate (exceeding all previous published reports) occurred in an infant with an isolated metastasis in the periaqueductal gray matter, a brain-stem site linked to mediating analgesia and defense reactions. The need for massive opioid dosing in 11 of 12 patients was associated with tumor spread to the spinal nerve roots, nerve plexus, large peripheral nerve, or spinal cord compression. Standard dosing of opioids adequately treats most cancer pain in children; however, a significant group requires more extensive management. These problems occur more commonly among patients with solid tumors metastatic to spine and major nerves.",1995.0,0,0
1013,7538514,Steady-state pharmacokinetics of hydromorphone and hydromorphone-3-glucuronide in cancer patients after immediate and controlled-release hydromorphone.,N Hagen; M P Thirlwell; H S Dhaliwal; N Babul; Z Harsanyi; A C Darke,"Although the pharmacokinetics of oral hydromorphone has been evaluated in healthy volunteers after small single oral doses, data are not available regarding the disposition of hydromorphone and its principal metabolite, hydromorphone-3-glucuronide (H3G), at steady-state and after large oral doses. The authors studied the pharmacokinetics of hydromorphone and H3G after oral administration of an immediate-release (IR) and controlled-release (CR) formulation of hydromorphone at a daily dose of 48 +/- 11 mg (range 6-216 mg) in a randomized, double-blind, steady-state, two-way crossover evaluation in 18 patients with chronic cancer pain. Controlled-release hydromorphone demonstrated equivalent bioavailability and acceptable CR characteristics, when compared with IR hydromorphone (CR vs. IR: AUC0-12 123.10 +/- 20.38 vs. 118.98 +/- 20.92 ng.hr.mL-1, P = NS, Cmax 17.76 +/- 3.07 vs. 19.70 +/- 4.04 ng.mL-1, P = NS, Cmin 6.04 +/- 1.01 vs. 5.28 +/- 1.000 ng.mL-1, P = NS, and Tmax 4.78 +/- 0.78 vs. 1.47 +/- 0.22 hr, P = 0.0008). A significant linear relationship existed between hydromorphone dose and hydromorphone AUC (r = 0.8315, P = 0.0001) and between hydromorphone AUC and H3G AUC (r = 0.8048, P = 0.0001) over a wide dose range. The steady-state molar ratio of H3G to hydromorphone was 27:1. The authors conclude that CR hydromorphone provides a pharmacokinetic profile consistent with 12 hourly dosing and that at steady state, oral hydromorphone is extensively metabolized to H3G, although the pharmacologic activity of this metabolite remains unknown.",1995.0,0,0
1014,7539701,"A randomized, crossover evaluation of methylphenidate in cancer patients receiving strong narcotics.",M B Wilwerding; C L Loprinzi; J A Mailliard; J R O'Fallon; A W Miser; C van Haelst; D L Barton; J F Foley; L M Athmann,"Sedation may be a dose-limiting side-effect of opioid therapy in some cancer patients. This study was designed to evaluate further the use of the psychostimulant, methylphenidate, an agent that has been reported to counter-act opioid-induced sedation, in patients with cancer-related pain. Patients receiving a stable dose of an opioid for cancer-related pain were recruited for this randomized, double-blind, crossover clinical trial. In addition to their regular dose of narcotics, they received 5 days of methylphenidate followed by 5 days of placebo, or vice versa. Our data did not definitively demonstrate any statistically significant benefit for methylphenidate, but did suggest that this drug could mildly decrease narcotic-induced drowsiness and could increase night-time sleep. These data, in conjunction with other published data, suggest that methylphenidate can counteract narcotic-induced daytime sedation to a limited degree.",1995.0,0,0
1015,7540440,Intractable pain and suffering in a cancer patient.,R Payne; M Cunningham; S M Weinstein; S Riberio; R B Patt; J Chiang,,1995.0,0,0
1016,7546255,,,,,0,0
1017,7549165,Memory complaints in chronic pain.,R F Schnurr; M R MacDonald,"In clinical practice, patients with chronic pain frequently report problems with memory functioning. This issue, however, has received little attention in the scientific literature. The present study was designed to investigate this common problem and to stimulate research interest in this neglected and important area. Self-reported memory problems were investigated in two groups of chronic pain patients--patients with pain from acceleration-deceleration automobile accidents (n = 56) and patients with pain from various work accidents (n = 27)--and two control groups involving medical/dental (n = 24) and psychotherapy patients (n = 20). Private practice, chronic pain, rehabilitation psychology services. Our findings suggest that memory complaints are higher in patients with chronic pain than in medical/dental or psychotherapy patients. No differences were found between chronic pain groups. On more general measures of memory complaint, differences between pain patients and controls were attributed to the severity of patients' depression. On a questionnaire designed to be more specific to memory complaint in chronic pain patients, differences in memory complaint between pain patients and controls were found, even after the effects due to depression were statistically removed. Although pain patients often attribute their memory problems to codeine use and/or psychoactive medications, there was no support for this in the present study. Within the limitations of this study, these findings suggest that memory complaints may be related not only to depression but also to the presence of chronic pain. Further research in this area is needed.",1995.0,0,0
1018,7549167,0.0625% bupivacaine with 0.0002% fentanyl via patient-controlled epidural analgesia for pain of labor and delivery.,F M Ferrante; M J Barber; M Segal; N J Hughes; S Datta,"To compare the utility of 0.0625% bupivacaine with fentanyl administered via patient-controlled epidural analgesia (PCEA) to a traditional continuous epidural infusion for pain of labor and delivery. Forty-one women in established labor were randomized to receive either (a) 0.0625% bupivacaine with 2 micrograms/ml fentanyl via PCEA (demand dose = 3 ml, lockout interval = 6 min, background infusion = 6 ml/h, no 1 or 4 h limits) or (b) 0.125% bupivacaine with 2 micrograms/ml fentanyl via continuous epidural infusion (CEI) at 12 ml/h. Supplemental 0.25% bupivacaine (3 ml every 5 min, p.r.n., x 3) was administered for treatment of breakthrough pain upon patient request. The study protocol was double-blind and placebo-controlled. Visual analogue pain scores, motor strength, pinprick level of sensory analgesia and bupivacaine use were assessed by an anesthesiologist unaware of the individual patient's randomization to a particular study group. The cephalad extent of pinprick sensory analgesia was significantly lower during both the first (p < 0.03) and second (p < 0.03) stages of labor in patients receiving PCEA. However, visual analogue pain scores, intensity of motor blockade, and need for physician-administered supplemental bupivacaine were comparable in both groups. Patients receiving PCEA used 40% less bupivacaine per hour while achieving analgesia comparable to patients receiving CEI. The results of this study show that 0.0625% bupivacaine with 2 micrograms/ml of fentanyl is an effective analgesic combination when used via PCEA.",1995.0,0,0
1019,7549168,Ketorolac versus fentanyl for postoperative pain management in outpatients.,R S Twersky; A Lebovits; C Williams; T R Sexton,"The purpose of this study was to compare the efficacy and safety of i.v. ketorolac and fentanyl for moderate to severe postoperative pain in patients undergoing elective surgery in an ambulatory surgery unit. A double-blind randomized trial. An ambulatory surgery unit in a university-affiliated hospital. Sixty-nine patients undergoing elective laparoscopy, inguinal hernia repair, or knee arthroscopy were enrolled. Patients were randomly assigned to receive intravenous ketorolac 30 mg (n = 38) or fentanyl 50 micrograms (n = 31) for moderate to severe postoperative pain. Pain, assessed using a 100-mm visual analog scale and a 5-point verbal pain scale; adverse effects, as well as vital signs were recorded every 15 min for 150 min or until discharge from the postanesthesia care unit, 6 and 24 h after discharge. Pain reduction on both visual analog and verbal scales was significantly greater with fentanyl than ketorolac at 15 min. In addition, the proportion of patients requiring remedication at the 15-min time point was significantly greater in the ketorolac group. However, there were no significant differences between fentanyl and ketorolac between 30 and 150 min after surgery. Notably, pain reduction was significantly greater with ketorolac on the verbal scale at the 6 h measurement. Ketorolac appears not be as effective as fentanyl in treating early postoperative pain. Although fentanyl still appears to be the drug of choice in the early postoperative period, the parenteral use of ketorolac was more effective during the later postoperative period in providing longer lasting analgesia.",1995.0,0,0
1020,7549169,Moclobemide in chronic neuropathic pain: preliminary case reports.,D B Menkes; J P Fawcett; A F Busch; D Jones,"This trial aimed to study moclobemide, a reversible, Type-A selective monoamine oxidase inhibitor, in patients with chronic neuropathic pain. Pain clinic patients suitable for antidepressant therapy were treated for 2 months in an open label, uncontrolled trial with moclobemide 150-600 mg/day. Visual analog scores of pain and affective symptoms, a side-effect checklist, and clinical global impressions of efficacy and tolerability. The trial was terminated after assessment of seven patients; partial analgesic activity was discernible only in one, and beneficial mood effects notable in two others. Significant adverse effects, particularly insomnia and GI disturbance, were reported by the majority of patients. Moclobemide appears to have limited efficacy in the treatment of neuropathic pain.",1995.0,0,0
1021,7549170,Felbamate relieved trigeminal neuralgia.,W P Cheshire,"The analgesic efficacy of the novel anticonvulsant felbamate was evaluated in trigeminal neuralgia. This trial was offered in a tertiary referral center to three outpatients with severe pain who had exhausted other medical options, yet did not wish to undergo surgery. Felbamate was prescribed as the sole analgesic for approximately 1 month. A visual analogue scale was utilized. Felbamate potently diminished the severe pain of trigeminal neuralgia and was well tolerated. The drug was withdrawn because of subsequent reports elsewhere of aplastic anemia and hepatic failure associated with it when used for epilepsy. Preliminary evidence suggested that felbamate was effective in relieving trigeminal neuralgia. Stabilization of neuronal membrane depolarization was the most likely mechanism of action. However, significant potential risks preclude further use of felbamate in the management of nonmalignant pain. Principles that have proven useful in screening for new anticonvulsant drugs might be relevant to the development of methods by which to search for new analgesic drugs.",1995.0,0,0
1022,7549171,Subarachnoid neurolytic block under general anesthesia in a 3-year-old with neuroblastoma.,R B Patt; R Payne; G A Farhat; S K Reddy,"A 3-year-old boy with neuroblastoma complained of severe pain in the left lower extremity. Pharmacologic management had previously been attempted, but severe pain continued, and further upward titration was complicated by sedative effects. Because the focus of treatment had become the controlling of pain, a lumbosacral subarachnoid neurolytic block was performed under general anesthesia. One-time neurolysis was more acceptable to the family than a procedure like epidural analgesia, that requires greater management. Contrast medium was used to monitor the spread of the neurolytic. An epidural catheter was inserted during the neurolytic block procedure for possible future use. The short-term results were good--pain reports and opioid doses decreased greatly, although with increased incontinence. The boy had new abdominal distention and pain 5 days after neurolysis. Opioid doses and sedatives were increased. He died 3 days later.",1995.0,0,0
1023,7560246,"Steady-state pharmacokinetic evaluation of a novel, controlled-release morphine suppository and subcutaneous morphine in cancer pain.",E Bruera; R Fainsinger; K Spachynski; N Babul; Z Harsanyi; A C Darke,"Although the oral route is the preferred method for morphine administration for cancer pain, many patients will require an alternate route of administration at some point during their illness. The authors studied the steady-state pharmacokinetics of morphine after administration of a novel, controlled-release suppository (MS-CRS) and subcutaneous morphine in a randomized, double-blind, two-way crossover evaluation in 10 patients with cancer pain. When administered at a 2.5:1 analgesic ratio, MS-CRS given every 12 hours showed an equivalent extent of absorption compared with subcutaneous morphine given every 4 hours (AUC0-12, 132.5 +/- 30.1 versus 123.8 +/- 27.3 ng.h.mL-1, P = not significant [NS]). Peak morphine concentrations were lower, time of peak was later, and percent fluctuation less after MS-CRS than after subcutaneous morphine (Cmax, 14.7 +/- 2.9 versus 29.9 +/- 5.4 ng/mL, P = .0110; tmax, 3.33 +/- 0.75 versus 2.22 +/- 0.15 hours, P = .0160; fluctuation, 122 +/- 71 versus 356 +/- 123%, P = .00160). Relative bioavailability of MS-CRS using the 2.5:1 analgesic ratio was 105%, and bioavailability from data dose normalized without regard to route specificity in metabolism was 42%. For both routes of administration there was a significant linear relationship between morphine dose and AUC (MS-CRS, r = .8568, P = .0032; subcutaneous morphine, r = .8314, P = .0055). MS-CRS morphine provides a pharmacokinetic profile consistent with dosing every 12 hours; at steady state, the extent of absorption is comparable with that of subcutaneous morphine when administered at a 2.5:1 dose ratio.(ABSTRACT TRUNCATED AT 250 WORDS)",1995.0,0,0
1024,7567716,Chronic testicular pain. A workup and treatment guide for the primary care physician.,N Baum; L Defidio,"Chronic pain syndromes are encountered in every medical practice, and workup can be costly and frustrating. Patients with chronic testicular pain were once referred early to urologists but are now being seen and successfully treated in primary care offices. Referral is usually reserved for diagnosis of questionable testicular masses and for surgery. Antibiotic therapy, often combined with a nonsteroidal anti-inflammatory drug, may be useful--in some cases even when infection has not been identified. Spermatic cord block and transcutaneous electrical nerve stimulation may help relieve pain, although it often recurs. Antidepressants sometimes relieve pain and alleviate the psychogenic symptoms that may accompany it. Many patients benefit from a program at a multidisciplinary pain-management clinic and should complete one before opiate therapy is prescribed. When all conservative efforts have failed and testicular pain continues to diminish the patient's quality of life, orchiectomy may have to be considered. In general, however, we recommend that surgery be undertaken only when a pathologic condition is found and not for pain relief alone.",1995.0,0,0
1025,7570132,Intra-articular morphine and bupivacaine for pain relief after therapeutic arthroscopic knee surgery.,S T Chan,"This randomised, double-blind study compared the analgesic properties of intra-articular injection of morphine and bupivacaine during therapeutic arthroscopic knee surgery. Forty male patients were randomly divided into 4 groups of 10 patients each. Group A received intra-articular injection of 1 mg morphine sulphate in 20 ml saline, Group B received 20 ml of 0.25% bupivacaine while Group C received 1 mg morphine sulphate in 20 ml of 0.25% bupivacaine injected intra-articularly. Group D did not receive intra-articular injection and acted as control. Post-operative pain was assessed by visual analogue score. The morphine group had significantly lower pain score compared to the control group from 4 hours onwards throughout the 24-hour study period (p < 0.05 at 4 hours and p < 0.001 at 24 hours). The bupivacaine group had lower pain score than the control group during the first 4 hours (p < 0.001 at 1 hour and p < 0.05 at 2 hours). At 4 hours, it showed similar analgesic efficacy as morphine. There was no significant analgesic effect at the end of the study period. The combination of the two drugs resulted in satisfactory analgesia throughout the entire study period (p < 0.001 at 1, 2 and 24 hours and p < 0.05 at 4 hours) and appeared to be a simple, safe and effective analgesic technique for patients who underwent therapeutic arthroscopic knee surgery.",1995.0,0,0
1026,7570325,Laparoscopic versus open inguinal herniorrhaphy: preliminary results of a randomized controlled trial.,J S Barkun; M J Wexler; E J Hinchey; D Thibeault; J L Meakins,"Benefits of laparoscopic herniorrhaphy (LH) over open hernia repair (OH) remain unproved. Interim analysis of a prospective randomized controlled trial compared OH with LH where study outcomes were measured by third-party evaluators through patient interviews. Both groups were well matched for all baseline parameters, although LH patients anticipated a quicker postoperative recovery than OH (p = 0.014). No significant difference was noted in operating time or surgeon operative satisfaction. The median duration of hospital stay was 1 day in both groups; LH patients made use of significantly less postoperative narcotics than OH (p = 0.02). No difference was observed in the durations of convalescence (LH, 9.6 +/- 7.6 days; OH, 10.9 +/- 7.4 days). Greater improvements in quality of life were exhibited in LH patients than OH patients 1 month after operation (p = 0.035), with one of the two measures used. A greater percentage of LH patients seemed ""very satisfied with their operation"" (p = 0.07). Complication rates were similar, and a single recurrence, in a patient in the OH group, has been observed after a median follow-up of 14 months. Direct cost measurements showed LH to be 40% more expensive than OH in the context of a Canadian-type health care system. To date, benefits in postoperative pain and possibly quality of life have been detected in the LH group.",1995.0,0,0
1027,7571027,Pain at tumor site after vinorelbine injection: description of an unexpected side effect.,M Colleoni; F Gaion; G Vicario; P Nelli; F Pancheri; G Sgarbossa; P Manente,"Vinorelbine is a new semisynthetic vinka alkaloid that has demonstrated good tolerability and interesting activity in a large spectrum of solid tumors. It was the aim of this paper to report the presence of a rarely documented side effect. In our experience, 135 patients were treated with vinorelbine during the period 10/92 to 11/94 for a total of 1080 cycles. In 26% of the cycles, vinorelbine was administered in monochemotherapy and in 74% in polychemotherapy regimens. The dose of vinorelbine, administered in a weekly schedule, was 25 mg/m2 in 109 patients and 30 mg/m2 in 26 patients. In general, no analgesic premedication was used. Sixty-five patients had lung cancer, 45 had breast cancer, and 25 miscellaneous cancer. Only 4 patients had a previous history of neurotoxicity. Ten patients (7%) had pain in the tumor site within a few minutes of the vinorelbine injection. According to WHO grade, 5 cases had moderate and 5 severe pain. Pain was always reversible. In 5 cases ketorolac was administered after pain detection with resolution of the symptoms; in 4 cases it was necessary to deliver buprenorphine. One patient was admitted to the coronary unit because a myocardial infarction was suspected after retrosternal pain and required i.v. morphine. Seven cases refused to continue the treatment, and 3 cases had no further problem after ketorolac premedication. Although rare, the presence of severe pain after vinorelbine injection may adversely affect the treatment course. Such data are helpful in the recognition and management of this reversible side effect.",1995.0,0,0
1028,7572013,Premedication with sublingual buprenorphine for out-patient arthroscopy: reduced need for postoperative pethidine but higher incidence of nausea.,M Juhlin-Dannfelt; S Adamsen; E Olvon; A Beskow; B Brodin,"The effect of preoperative sublingual buprenorphine (B) on postoperative pain (VAS), the need for postoperative opioid injections and on time to discharge, was evaluated in a prospective randomised double-blind study. Forty ASA I-II patients scheduled for arthroscopy of the knee received premedication with 0.4 mg buprenorphine (group B) and 42 patients were given placebo (group P). Postoperatively, pethidine was given to patients with pain. Three of the 40 patients in group B vs 11 of the 42 in group P received pethidine (P < 0.05). In group B, however, 13 of the 40 patients complained of nausea, prolonging median time to discharge from 155 to 255 minutes (P < 0.05). In group P, 3 of the 42 patients were nauseated, P < 0.01, compared with group B. Time to discharge did not differ between the groups in patients without nausea. The median respiratory rate was significantly lower in group B, but no patient required ventilatory support. In conclusion, premedication with sublingual buprenorphine cannot be recommended for this procedure. It reduces the need for postoperative injections of pethidine but increases the incidence of postoperative nausea which prolongs the recovery time. Careful monitoring is also mandatory because of the possibility of respiratory depression.",1995.0,0,0
1029,7574070,Acute toxic delirium: an uncommon reaction to transdermal fentanyl.,P J Kuzma; M D Kline; J M Stamatos; D A Auth,,1995.0,0,1
1030,7577278,"Comparison of continuous brachial plexus infusion of butorphanol, mepivacaine and mepivacaine-butorphanol mixtures for postoperative analgesia.",Z Wajima; T Shitara; Y Nakajima; C Kim; N Kobayashi; H Kadotani; H Adachi; G Ishikawa; K Kaneko; T Inoue,"We have reported recently that continuous administration of butorphanol into the brachial plexus sheath provided analgesia of a quality superior to that of continuous i.v. administration. In the present study, we have compared postoperative pain relief produced by continuous infusion of one of three types of solution into the axillary sheath: opioid alone, local anaesthetic alone or a mixture of local anaesthetic and opioid. In patients undergoing upper extremity surgery with continuous axillary brachial plexus block, we injected one of the three solutions into the axillary neurovascular sheath: butorphanol 2 mg (group B), 0.5% mepivacaine alone (group M) and 0.5% mepivacaine-butorphanol (group MB); the volume of each solution was 50 ml, administered at a rate of 50 ml per 24 h. At 3 h after operation, visual analogue scale (VAS) scores were significantly higher in group M than in group MB (P < 0.01), and higher in group B than in group MB (P < 0.05).",1995.0,0,0
1031,7577279,Intra-articular analgesia for arthroscopic meniscectomy.,B Lyons; D Lohan; C G Flynn; G P Joshi; T M O'Brien; M McCarroll,"Intra-articular morphine has been shown to provide prolonged analgesia after arthroscopic knee surgery; the addition of local anaesthetic agents has been reported to improve this analgesic effect. Pethidine possesses local anaesthetic properties, and therefore this study was designed to evaluate its analgesic efficacy after arthroscopic meniscectomy. Sixty patients were allocated randomly to receive intra-articular injections of pethidine 50 mg, morphine 5 mg or saline after elective arthroscopic meniscectomy. Postoperative pain was assessed using an interval visual analogue scale and measuring analgesic requirements. Both treatment groups had significantly lower pain scores compared with the control group. Patients in the pethidine group had lower pain scores than those in the morphine group at 0.5, 1 and 2 h, but significantly higher scores at 12 and 24 h. These observations suggest that the local anaesthetic effect of pethidine may be responsible for the improved early analgesia, but its duration of action appears to be less than that of morphine.",1995.0,0,0
1032,7577297,Postoperative brachial plexus neuropathy after total knee replacement under spinal anaesthesia.,K A Eggers; T Asai,"We describe a case of idiopathic postoperative brachial plexus neuropathy. A 68-yr-old man underwent elective total knee replacement under spinal anaesthesia. Two days after surgery, there was sensory loss and weakness in the right forearm and hand, which suggested an ulnar nerve neuropathy. Two weeks later the patient complained of a dull ache between the scapulae, followed by a burning sensation in the forearm and severe pain in the elbow. A diagnosis of brachial plexus neuropathy was made based on clinical examination and nerve conduction studies. The pain disappeared after a few months, although weakness of the right arm persisted 9 months later. The differential diagnosis between brachial plexus neuropathy and ulnar nerve neuropathy is important, as the prognosis of brachial plexus neuropathy is generally good.",1995.0,0,0
1033,7577778,Effects of epidural bupivacaine after thoracotomy.,S Liu; J M Angel; B D Owens; R L Carpenter; L Isabel,"Combinations of bupivacaine and fentanyl are popular for postoperative epidural analgesia. However, there are little data from which to select a rational dose of bupivacaine. The study examined the effects of increasing amounts of epidural bupivacaine on postoperative analgesia, epidural fentanyl consumption, and side effects after thoracotomy. Twenty-four patients were randomized in a double-blind manner to receive intra- and postoperative epidural infusions of either saline, 0.01% bupivacaine, 0.05% bupivacaine, or 0.1% bupivacaine at 10 mL/h. All patients received a standardized combined epidural (120 mg lidocaine and 1.5 micrograms/kg of fentanyl) and general anesthesia. Further postoperative analgesia was provided with fentanyl patient-controlled epidural analgesia (PCEA) only. There were no differences between groups in visual analog scale (VAS) pain scores at rest or cough, but 10 and 5 mg/h of bupivacaine provided better analgesia during physiotherapy (P < .05). The use of 10 and 5 mg/h of bupivacaine led to significant opioid sparing (50% decrease) when compared to saline and 1 mg/h bupivacaine (P < .03). There was a trend toward a greater incidence of orthostasis with the use of bupivacaine at 10 mg/h (P = .09). Incidences of opioid side effects were not different between groups. The results demonstrate improved analgesia with physiotherapy and significant opioid sparing when 10 and 5 mg/h doses of bupivacaine are used. However, the incidence of orthostasis may be increased with the use of 10 mg/h. Thus, 5 mg/h of epidural bupivacaine (.05% at 10 mL/h) improved analgesia, decreased opioid requirements, and did not have detectable hemodynamic effects.",1995.0,0,0
1034,7577779,"Effects of brachial plexus fentanyl on supraclavicular block. A randomized, double-blind study.",K Kardash; A Schools; M Concepcion,"The study examined the effects of adding fentanyl to mepivacaine supraclavicular blocks on block characteristics and postoperative analgesia. Twenty patients undergoing upper extremity surgery with supraclavicular blocks were prospectively randomized to receive 75 micrograms fentanyl either added to the local anesthetic (30 mL mepivacaine 1.5% with epinephrine 5 micrograms/mL) or given intramuscularly. An equivalent volume of normal saline was given in one of the two sites as a control in a double-blind fashion. Sensory and motor block onset, time to completion, and duration were measured. After the operation, patient-controlled analgesia with morphine was administered and the total dose used over 24 hours recorded. Visual analog pain scale (VAS: 0 = no pain, 10 cm = worst pain) was measured at 0, 1, 2, 3, 4, and 12 hours after the operation. There was no statistically significant difference between the two groups in sensory or motor block characteristics. There was a significantly lower VAS score among the patients with fentanyl added to their blocks within the first hour after the operation (1.3 +/- 1.5 cm versus 3.8 +/- 3.1 cm; P < .05), but subsequent VAS scores and total 24-hour patient-controlled analgesia requirements were no different. Adding fentanyl 75 micrograms to mepivacaine supraclavicular blocks has no significant effects on block characteristics. It may enhance postoperative analgesia, but the duration of this effect is too brief to be clinically useful.",1995.0,0,0
1035,7583900,[Analgesia with intra-articular injection of buprenorphine after surgery of the shoulder].,J L Fellahi; J P Magues; B Marquer; A Guérot; M Mansat; B Cathala,"The effect of 10 ml of intra-articular buprenorphine (0.30 mg) or normal saline on postoperative pain after shoulder surgery was studied in a randomized, prospective, double-blind study in 30 ASA I-II patients receiving general anaesthesia. The pain scores (Five Point Scale ranging from ""no pain"" to ""unbearable pain"" and Visual Analog Pain Scale) 1, 2, 3, 4, 6 and 24 hours after surgery, time to first analgesic use and total 6-hours and 24-hours analgesic requirements were recorded. VAPS was significantly lower in the buprenorphine group compared with placebo-treated patients one hour after surgery (p < 0.05). The time to first analgesic use was longer and total 6-h opioid requirements were lower in the buprenorphine group when compared with the control group (p < 0.05). No significant differences were detected in total 24-h analgesic requirements between the two groups. These results indicate that intra-articular injection of buprenorphine after shoulder surgery provides short analgesia. This effect may be mediated by systemic absorption.",1995.0,0,0
1036,7588085,"Transnasal butorphanol. A review of its pharmacodynamic and pharmacokinetic properties, and therapeutic potential in acute pain management.",J C Gillis; P Benfield; K L Goa,"Butorphanol is a synthetic opioid agonist-antagonist analgesic with a pharmacological and therapeutic profile that has been well established since its launch as a parenteral formulation in 1978. The introduction of a transnasal formulation of butorphanol represents a new and noninvasive presentation of an analgesic for moderate to severe pain. This route of administration bypasses the gastrointestinal tract, and this is an advantage for a drug such as butorphanol that undergoes significant first-pass metabolism after oral administration. The onset of action and systemic bioavailability of butorphanol following transnasal delivery are similar to those after parenteral administration. The analgesic efficacy of transnasal butorphanol was generally superior to that of placebo in clinical trials in patients with moderate to severe postoperative pain or migraine headache. Results from single trials indicate that transnasal butorphanol provides pain relief comparable to that of intramuscular pethidine (meperidine) in postsurgical pain and comparable to or greater than intramuscular methadone in migraine headache. Moderate to severe musculoskeletal pain also appears to be responsive to transnasal butorphanol on the basis of results from 1 small noncomparative study. Tolerability of transnasal butorphanol parallels that of the injectable form, with somnolence, dizziness, nausea and/or vomiting reported most frequently. Thus, transnasal butorphanol is a novel formulation of an established analgesic which appears suitable for the short term treatment of moderate to severe pain, especially in an ambulatory setting. Transnasal butorphanol is likely to provide an alternative to oral opioid analgesics, particularly in the presence of nausea or vomiting, or to parenteral opioids when the oral route of administration is not appropriate.",1995.0,0,0
1037,7594383,A prospective blinded study on emergency pain assessment and therapy.,J Ducharme; C Barber,"A prospective blinded observational study was carried out to document acute pain assessment and management in an academic emergency department. Over a 2-month period, 42 patients with a primary complaint of pain were studied. Physicians and nurses did not document levels of pain or changes in pain during patient stays. Eleven of 42 patients had severe pain upon arrival, 5 of whom received medications, only 1 obtaining good relief. No other patient received medication, although five others received some intervention for their pain. Eleven of 38 patients who were discharged home had severe pain on discharge. Despite minimal pain relief, patient satisfaction with pain management was relatively high. Pain assessment and treatment may be poorer than previous retrospective studies have indicated.",1995.0,0,0
1038,7598419,Has postoperative pain been eradicated?,S Sabanathan,"Recent evidence suggests that surgical trauma induces a process of central nervous system sensitisation that contributes to and enhances postoperative pain. These changes are also thought to be the underlying cause of much chronic pain. Central sensitisation is generated not only during surgery, but also postoperatively as a result of the inflammatory response to the damaged tissue. This knowledge provides a rational basis for pro-active, pre-emptive and postoperative analgesic strategies to reduce the neuronal barrage associated with tissue damage. Reduction or elimination of postoperative pain is therefore possible. We advocate the use of continuous extrapleural intercostal nerve block for postoperative analgesia in patients undergoing thoracotomy. When this is begun pre-emptively (by precutaneous, pre-incisional paravertebral block) it is combined with an opiate and a non-steroidal anti-inflammatory drug premedication. In a randomised study of 56 patients, pain scores of less than 0.5 cm on a 10 cm scale were produced, postoperative lung function was preserved and glucose and cortisol responses were significantly unchanged from preoperative values. Evidence that effective perioperative analgesia reduces the incidence of chronic post-thoracotomy chest wall pain was found in a retrospective study of 1000 consecutive thoracotomies. The endpoints of a zero pain score, complete preservation of preoperative lung function and prevention of the stress response to trauma are currently achievable and should be provided for virtually all patients undergoing chest surgery. Pre-empting pain must be the goal for all those involved in the postoperative care of patients.",1995.0,0,0
1039,7599546,Effects of tourniquet time in knee arthroscopy patients receiving intraarticular morphine combined with bupivacaine.,C Klinken,"The purpose of the study was to compare the duration of analgesia and the amount of supplemental postoperative analgesics required when morphine combined with bupivacaine was injected into the knee joint at the end of knee arthroscopy surgery. Varying tourniquet times of 0, 8, or 16 minutes were used after the injection. The variables examined were the duration of analgesia, and the amount of supplemental postoperative analgesics required in each subgroup. A sample of 45 subjects was recruited and studied from an outpatient surgery center. The 45 subjects were randomly assigned to one of three groups (n = 15). At the end of the procedure, morphine combined with bupivacaine was injected into the intraarticular space and the tourniquet was released or left on for an additional 8 or 16 minutes. The duration of analgesia and the amount of supplemental postoperative analgesics administered in a 24-hour period were measured. No statistical differences were found between groups. All patients received analgesia with no reported side effects. Increasing the tourniquet time had no effect on the duration of analgesia or the amount of supplemental narcotics required in the postoperative period.",1995.0,0,0
1040,7600549,Tailoring treatment approaches to the individualized needs of cancer patients with pain.,J A Dalton; C Lambe,"Cognitive-behavioral and behavioral interventions, which have been successfully used to manage chronic pain unrelated to cancer, are an acceptable treatment for the psychobiological factors, including the expression of feelings, associated with pain in cancer patients. However, testing the effectiveness of complex multidimensional programs is difficult because of confounding factors such as progression of disease and measurement of potentially reactive outcomes. Patients were enrolled in theoretically strong individualized treatment programs for 5 weeks, with follow-up observation at 9 and 17 weeks. Weekly strategies were chosen to contribute to the achievement of patient-selected pretreatment goals. Interventions were designed to achieve psychobiological outcomes such as a decrease in inaccurate expectations, an increase in the use of positive comparisons and positive self-statements, a decrease in autonomic arousal, and promotion of self-efficacy. Two case studies provide examples of individual differences in treatment needs and the realities of clinical care.",1995.0,0,0
1041,7606031,Cancer pain and the importance of its control.,G W Hanks,"In 1985 there were almost 5 million deaths from cancer, and it is estimated that in 2015 there will be over 9 million, of which almost three-quarters will be in developing countries. Seventy to eighty per cent of these patients will experience moderate or severe pain at some stage of their illness and at present most of these will die in pain. This is true in spite of the fact that there is substantial evidence which shows that in as many as 80% of patients with cancer pain it is possible to obtain complete relief with orally administered analgesics, either alone or supplemented with co-analgesic (adjuvant) drugs. Management is based on the three-step analgesic ladder whereby the choice of analgesic (non-opioid, weak opioid, or strong opioid) is determined by the severity of pain. The main reasons for failure to achieve control of pain are inexperience and lack of knowledge of the simple principles of effective analgesic use, and in many countries the non-availability of strong opioid analgesics. The most important advances in management have been the simplification and refinement of analgesic treatment which have made relief of cancer pain more widely accessible to patients. The introduction of controlled-release oral formulations of morphine has had a considerable impact because they are convenient and simple to use. The recent development of a long-acting non-invasive transdermal delivery system for strong opioid administration promises a further step forward in terms of flexibility and convenience for cancer patients.",1995.0,0,0
1042,7606034,Transdermal fentanyl: clinical development in the United States.,M A Simmonds,The first clinical experience in the United States of the transdermal therapeutic system (TTS) for delivery of fentanyl in cancer pain was a small study of five patients. Pain relief was established with intravenous (i.v.) fentanyl. A transdermal system was selected to deliver the same hourly dose while the i.v. infusion was tapered over 6 h. The transdermal system was changed every 24 h for a total duration of 3-156 days. A larger multicentre outpatient trial was conducted in 39 patients for a median of 84 days (range 5-365). The TTS fentanyl dose was established from a conversion table based on the dose of oral immediate-release morphine required to control pain. The TTS fentanyl patches were changed every 72 h. Immediate-release morphine was used on an as required basis for incident pain. The initial study demonstrated that steady-state plasma levels were linearly related to the TTS fentanyl dose. The multicentre trial further demonstrated that patients could be converted from oral morphine to an equianalgesic dose of TTS fentanyl and that pain relief could be maintained for a lengthy period of time on an outpatient basis. The systems were used throughout a variety of concomitant complications of the cancer process. This experience demonstrated the safety and clinical effectiveness of TTS fentanyl in the treatment of chronic cancer pain. TTS fentanyl has been used widely in the USA since it was approved for marketing in 1990.,1995.0,0,0
1043,7606037,Transdermal fentanyl in combination with initial intravenous dose titration by patient-controlled analgesia.,D F Zech; K A Lehmann,"Two studies including a total of 70 patients evaluated the efficacy and side effects of a combination of initial patient-controlled analgesia (PCA) for dose finding with transdermal fentanyl administration. Patients, requiring strong opioids for severe cancer pain, received intravenous (i.v.) fentanyl on an on-demand basis over a 24 h period. The amount of fentanyl administered was then used for selecting a suitable transdermal therapeutic system (TTS), which remained in place for 72 h. The size of the second TTS was adjusted according to the amount of supplementary i.v. fentanyl required on day 3. Beginning on day 4, oral or subcutaneous morphine was made available as a rescue medication. The use of TTS fentanyl in combination with initial dose titration using PCA resulted in rapid and statistically significant pain relief in both studies. A respiratory rate below 8 per minute was observed in three patients. Due to adequate symptomatic treatment, other moderate and severe symptoms were relatively rare. TTS fentanyl was shown to be an effective, safe and simple method for long-term pain relief in cancer patients and presents an interesting novel option in the treatment of cancer pain.",1995.0,0,0
1044,7606038,Guidelines for the clinical use of transdermal fentanyl.,R Payne; S Chandler; M Einhaus,"Transdermal (TTS) fentanyl therapy has emerged as an effective alternative to the use of oral opioids for the control of pain in certain cancer patients. These patients are those with moderate to severe chronic pain, with a stable baseline pain pattern. Patients receiving this treatment should first be titrated to stable pain relief with oral opioids and should have recourse during therapy to fast-acting, short-duration analgesics for the control of incident pain. TTS fentanyl dosing schedules should be based upon the patient's requirement for rescue dosing and duration of effective pain control. The average requirement to change fentanyl patches is every 72 h, although 48-h dosing is necessary in a few patients. This novel route of fentanyl administration allows convenient outpatient treatment, the possibility of a lower incidence of side effects, and may thus aid compliance.",1995.0,0,0
1045,7627917,Long term treatment of intractable reflex sympathetic dystrophy with intrathecal morphine.,W J Becker; D P Ablett; C J Harris; O N Dold,"Some patients with reflex sympathetic dystrophy (RD) develop intractable symptoms unresponsive to conventional therapy. Recently, intrathecal morphine therapy has been used with some success in such patients. The clinical course of two patients with intractable reflex sympathetic dystrophy (RSD) is described. Both patients developed intractable leg pain, swelling and autonomic changes after a leg injury. Numerous medical treatments and surgical sympathectomies failed to provide long term relief. Relatively satisfactory symptom control was achieved only with the use of long term intrathecal morphine therapy delivered by subcutaneously implanted infusion pumps. Exacerbations of the RSD continued to occur, at times in association with further leg trauma, but these could be controlled by a temporary escalation of the intrathecal morphine dose. Complications of morphine therapy were relatively minor. A red rash appearing over the pump site was the first sign that a drug catheter break had occurred, necessitating surgical catheter revision. Long term intrathecal morphine therapy is a useful treatment option for patients with intractable severe RSD who have failed other therapies and remain markedly disabled.",1995.0,0,0
1046,7638994,Clinical management of blunt trauma patients with unilateral rib fractures: a randomized trial.,S G Gabram; R J Schwartz; L M Jacobs; D Lawrence; M A Murphy; J S Morrow; J S Hopkins; R F Knauft,"Optimal pain management is essential in blunt trauma patients sustaining significant chest trauma. The purpose of this randomized prospective trial was to measure the difference in pulmonary function in nonintubated patients with unilateral multiple rib fractures receiving two modalities of pain relief: systemic narcotic medications alone or local anesthetics given by intrapleural catheter (IPCs). Forty-two patients were randomized to receive systemic narcotic medications or IPCs for pain control. The patients with IPCs statistically had more compromised pulmonary function as measured by forced vital capacity (FVC) on admission; however, they tended toward a greater objective improvement of FVC on discharge. When analyzing a cohort of severely impaired patients (initial FVC < 20%), half of the systemic medication patients compared to only 10% of the IPC group failed and required another mode of therapy. Catheter complications were minor and did not contribute to overall morbidity. The IPC patients had fewer failures than the systemic medication patients.",1995.0,0,0
1047,7641723,Speed of onset of analgesic effect of intravenous ketorolac compared to morphine and placebo.,A S Rice; E M Whitehead; G O'Sullivan; J Lloyd; R E Bullingham,"The speed of onset of analgesia following intravenous ketorolac, morphine and placebo was investigated in a single-dose, double-blind, randomized, parallel group study of 105 patients. The onset of analgesia was defined as the time at which the pain intensity score reached 50% of the baseline score in 25% of patients. Post-operative patients with moderate or severe pain were dosed and followed for 1 h. Pain reduction by at least 50% occurred in 25% of patients within 40 min (placebo), 15 min (morphine 5 mg), 6 min (morphine 10 mg) and 20 min (ketorolac 10 mg). The pain reduction time for morphine (10 mg) was significantly shorter than that for ketorolac (P = 0.01) or placebo (P < 0.01).",1995.0,0,0
1048,7644238,Analgesic efficacy and safety of single-dose intramuscular ketorolac for postoperative pain management in children following tonsillectomy.,K A Sutters; J D Levine; S Dibble; M Savedra; C Miaskowski,"The efficacy of ketorolac, a non-steroidal anti-inflammatory drug, in the management of moderate to severe pain in adults, has led us to conduct a trial of this analgesic in children following tonsillectomy. Children were randomized to receive intramuscular (i.m.) ketorolac (1 mg/kg, EXP group, n = 45) or saline (CTL group, n = 42) at the completion of surgery. Intravenous (i.v.) fentanyl (0.5 micrograms/kg/dose) was administered in repeated doses postoperatively. Pain intensity was measured using both the Oucher and the Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) to allow for comparison between self-report and behavioral measures of pain intensity. Severity of postoperative bleeding was measured using a 4-point rating scale. The EXP group had a significant reduction in total fentanyl dose (mean: 35.9 micrograms) compared to the CTL group (mean: 48.3 micrograms, t = -2.21, P < 0.03). There was a statistically significant decrease in pre-fentanyl CHEOPS scores in the Post-Anesthesia Care Unit (PACU) in the ketorolac group (F (2, 30) = 5.34, P < 0.01), but not in the saline group (F (2.24) = 2.46, P > 0.05). In the first hour postoperatively, the CHEOPS demonstrated significant decreases in pain intensity scores in response to opioids, in both groups. In the PACU, children were unable to provide a self-report of pain intensity potentially due to a variety of factors (e.g., emergence delirium, agitation, excitement, sedation, and/or pain). However, during the remainder of the postoperative stay, the photographic scale of the Oucher was a more valid measure of pain intensity than the CHEOPS.(ABSTRACT TRUNCATED AT 250 WORDS)",1995.0,0,0
1049,7649468,Psychosocial care in the pediatric hospital. The need for scientific validation of clinical and cost effectiveness.,R Geist,"Emotional and social factors contribute to the outcome of medical treatment of pediatric patients with chronic illness, especially when associated with disability. They are also important in the management of psychosomatic illnesses, chronic pain syndromes, and specific chronic illnesses. In this era of preoccupation with the cost of health care, there is no consensus about the clinical necessity and cost effectiveness of pediatric hospital psychosocial care programs. The validity of psychosocial care as a clinically effective and cost-effective approach to pediatric care, however, can be established only from carefully controlled, well-designed scientific studies. Optimally, these studies should be randomized, prospective, controlled trials that include the reliable identification of specific psychosocial problems and the subsequent validation of treatment approaches. Currently, such controlled studies of the effectiveness of pediatric hospital psychosocial care programs are lacking.",1995.0,0,0
1050,7650230,Single- and multiple-dose pharmacokinetics of dezocine in patients with acute or chronic pain.,J M Wilson; R I Cohen; E A Kezer; S J Schange; E R Smith,"The pharmacokinetic properties of dezocine were examined in 15 patients with acute or chronic pain. In 3 groups of 5 patients each, serum levels were determined at various intervals after single intravenous doses of 5, 10, and 20 mg. After these single doses, dezocine was very rapidly distributed (mean t1/2 alpha less than 2 minutes), and then rather rapidly eliminated (mean t1/2 beta about 4 hours); the apparent volume of distribution was large (mean Vz beta about 6 L/kg) as was the total clearance (mean CL about 1.5 L/h/kg). In 2 groups of 5 patients each, serum levels were determined after the first and third of 3 intravenous doses of 5 or 20 mg given at 3-hour intervals. The pharmacokinetic parameters after these multiple doses were consistent with those after the single doses. Although some observations were suggestive, there was no unequivocal evidence that the pharmacokinetics were dose-related. In 7 serum samples containing dezocine at concentrations ranging from 12.8 to 522 ng/mL, the mean (+/- SE) proportion of dezocine bound to protein was 91.6 +/- 0.8%.",1995.0,0,0
1051,7651250,The use of controlled-release morphine sulfate (MS Contin) in Queensland 1990-1993.,A H Richards,"To investigate the use of controlled-release morphine sulfate (MS Contin, Pharmacia) in Queensland, 1990-1993. Records of 434 patients notified to the Drugs of Dependence Unit (DDU) for prolonged use of MS Contin (as at 16 August 1993) were analysed, the information was verified, and the patients' diagnoses were coded (ICD-9). Estimates of daily drug consumption were calculated from computerised prescription data. Controlled-release morphine sulfate was being used for indications other than its licensed indication ""chronic severe pain of cancer"": 39.9% of the patients received the drug for non-malignant conditions. The dose escalation for patients with non-malignant conditions was significantly less than that of the patients with malignant conditions (P = 0.002). Despite controversy about the use of controlled-release morphine sulfate for chronic pain of non-malignant origin, its use is widespread.",1995.0,0,1
1052,7659429,Acute pain management in patients with prior opioid consumption: a case-controlled retrospective review.,S E Rapp; L B Ready; M L Nessly,"The patient with a history of current opioid consumption presenting in the acute postoperative setting presents a challenge for pain management. Standard treatment dosages and strategies are often ineffective in providing pain relief. This retrospective case-control study reviews 4 years' experience of the Acute Pain Service (APS) at our institution providing care for 202 chronic pain and opioid-consuming (CPOC) patients, 6.6% of 3058 patients undergoing urologic, gynecologic, orthopedic and general surgical procedures. Controls matched for age, gender, date and type of surgery, and postoperative pain relief modality were found for 180 (89%) of these patients. Patients were provided patient-controlled analgesia (PCA), or epidural opioid analgesia (EOA with boluses of preservative-free morphine or bupivacaine (1:16% + 2 micrograms/ml fentanyl (B/F)). Records were reviewed for patient demographics, diagnoses, surgical procedures, pre-operative opioid use, days-on-service, analgesic requirement, pain scores and incidence of moderate/severe side effects. Patient demographics were similar between CPOC and control groups. When considering PCA alone, mean 24-h usage in controls was 42.8 (32.0) mg morphine (MS) equivalents differing significantly from CPOC patients' use of 135.8 (68.5) mg MS equivalents (P = 0.0001). EOA and B/F case studies showed similar results. Moderate sedation was experienced by 50% of CPOC patients receiving PCA. Differences in opioid usage, side effects, pain scores, sedation and prescribed treatment with anxiolytics were shown between CPOC patients and matched controls.(ABSTRACT TRUNCATED AT 250 WORDS)",1995.0,0,0
1053,7669460,Effect of timing of ketorolac administration on patient-controlled opioid use.,J E Rogers; B G Fleming; K C Macintosh; B Johnston; J O Morgan-Hughes,"In order to investigate the analgesic effect of timing of administration of ketorolac 10 mg i.v., we recorded patient-controlled use of diamorphine at 2, 4 and 12 h after abdominal hysterectomy. In a randomized, double-blind trial, 30 patients received ketorolac before skin incision and 28 after skin closure. A control group of 32 patients did not receive ketorolac. We measured operative blood loss and assessed nausea, vomiting and pruritus. After 2 h of patient-controlled analgesia, the median cumulative diamorphine dose in the group given ketorolac before operation was less than that of the control group (95% confidence interval 8-66 micrograms kg-1; P = 0.01). There were no other statistically significant differences in diamorphine consumption between the groups. The frequency of nausea and vomiting was similar in all groups Median blood loss in the group given ketorolac before operation exceeded that of the patients who did not receive ketorolac before operation (95% confidence interval 20-149 ml; P = 0.01). We conclude that the diamorphine-sparing effect of ketorolac attributable to timing of administration was small, conferred no clinical benefit and was accompanied by increased bleeding. No patient given ketorolac complained of pruritus.",1995.0,0,0
1054,7669461,Intrathecal fentanyl for post-thoracotomy pain.,G Sudarshan; B L Browne; J N Matthews; I D Conacher,"This double-blind, placebo-controlled study investigated the efficacy of intermittent doses of intrathecal fentanyl in 30 patients undergoing thoracotomy. They were allocated randomly to three groups, two of which had microspinal catheters inserted into the lumbar subarachnoid space at the end of surgery; the third group acted as a control. Intrathecal fentanyl or 0.9% saline was administered through the catheters and all patients received morphine using a patient-controlled analgesia (PCA) system. Pain scores, morphine consumption and peak expiratory flow rates (PEFR) were recorded on an hourly basis. Intrathecal fentanyl resulted in a faster onset of analgesia (mean visual analogue scale (VAS) score at 1 h = 0.9 compared with 6.3 (95% confidence intervals for the difference -6.8, -4.0) for the other groups; P < 0.001) and significantly lower pain scores at rest, on cough and on movement. PEFR values were consistently higher in the intrathecal fentanyl group. There were no cases of early or delayed respiratory depression.",1995.0,0,0
1055,7669462,Does the addition of morphine to brachial plexus block improve analgesia after shoulder surgery?,N Flory; E Van-Gessel; F Donald; P Hoffmeyer; Z Gamulin,"We have studied 40 patients undergoing elective shoulder surgery for chronically painful conditions. Patients were allocated randomly to two groups and received interscalene brachial plexus block with 0.5% bupivacaine and adrenaline 1/200,000 40 ml either alone or with the addition of morphine 5 mg. All patients also received a general anaesthetic. The quality of the block, analgesic requirements and any complications or side effects were noted in the intraoperative period and during the 48 h after operation. No significant difference was seen in quality of analgesia or patient satisfaction between the two groups.",1995.0,0,0
1056,7673770,Opioid rotation for toxicity reduction in terminal cancer patients.,N D de Stoutz; E Bruera; M Suarez-Almazor,"Accumulation of active (toxic) metabolites of opioids might explain cases of opioid toxicity when high doses are used for long periods of time. Other mechanisms of late toxicity of opioids may be found at the receptor level. Whatever the cause, a change of opioids using equianalgesic doses can be expected to improve symptoms of toxicity in some patients, while maintaining pain control. We reviewed the experience with this technique in patients admitted to the Palliative Care Unit of the Edmonton General Hospital. Of 191 patients, 80 underwent opioid rotation (OR) for cognitive failure, hallucinations, myoclonus, nausea and vomiting, local toxicity, and persistent pain. These leading symptoms improved in 58/80 patients (73%, P < 0.01). Pain control, as measured on a 10-cm visual analogue scale (VAS), improved from 4.4 +/- 2.3 to 3.6 +/- 2.0 (P < 0.004) at a dose significantly lower than that predicted to be equianalgesic (577 +/- 1535 mg before OR versus 336 +/- 593 mg after OR, P < 0.04). We conclude that symptoms of opioid toxicity can be relieved by OR, and that a choice of two or three different opioids is necessary to obtain satisfactory long-term pain control.",1995.0,0,0
1057,7696728,Selective serotonin reuptake inhibitors: pharmacologic profiles and potential therapeutic distinctions.,P R Finley,"To review the respective pharmacologic profiles of the selective serotonin reuptake inhibitors (SSRIs), with particular emphasis placed on clinically relevant distinctions. A MEDLINE search was conducted to identify English language literature published within the last five years on the four SSRIs (fluoxetine, sertraline, paroxetine, fluvoxamine). Previous review articles were scrutinized for additional citations, and manufacturers provided a contemporary bibliography of more recent material. Studies were selected for specific citation on the basis of comparative research merit and the contribution of this original literature to the pharmacologic profile(s) described. All SSRIs appear to be more efficacious than placebo for the acute treatment of major depressive disorder (MDD). Short-term (six-week) efficacy was comparable with that of tricyclic antidepressants for the amelioration of MDD regarded as moderate in severity. Further comparative trials are clearly indicated to demonstrate the therapeutic benefits of SSRIs in specific populations (e.g., geriatric, severely ill) and to demonstrate sustained benefit with long-term prophylaxis. Other potential indications for SSRIs include obsessive-compulsive disorder, panic disorder, bulimia, and chronic pain syndromes. Pharmacokinetic profiles of the four SSRIs reveal similar parametric values, and most quantitative differences are of limited clinical significance. Adverse effects are common but ordinarily mild and transient, primarily restricted to the gastrointestinal tract and central nervous system. Important differences in the prevalence or severity of these adverse effects await the accumulation of further clinical experience and the completion of additional comparative trials. Similarly, the relative propensity of SSRIs to inhibit the metabolism of other medications is currently under investigation. The four SSRIs studied appear to be more similar than they are different. Slowly, important distinctions are beginning to emerge with regard to adverse effect profiles and potential drug interactions. Given that the costs of these respective medications are comparable, such differences may ultimately serve to establish the preferential selection of individual agents in specific clinical situations.",1994.0,0,0
1058,7701459,Pleurectomy for persistent pain in benign asbestos-related pleural disease.,D I Fielding; J L McKeon; W A Oliver; K Matar; I G Brown,"Persistent severe pain is a rare complication of benign asbestos-related pleural disease. Four patients are described in whom pain persisted for more than one year (range 18 months to five years) which was incompletely relieved by opioid medication and nerve blocking procedures. All underwent pleurectomy in an attempt to relieve it. At operation the pleura was considerably thickened in all cases. Two of the four patients had successful relief of pain. The other two had a neuralgic component to their pain before surgery which persisted afterwards. One of these patients underwent successful cervical cordotomy. Pleurectomy may provide relief in patients with constant pleuritic pain due to benign asbestos-related pleural thickening. It seems, however, that patients in whom the pain has a neuralgic component are unlikely to benefit.",1995.0,0,0
1059,7702062,Loin pain hematuria syndrome: pain relief with intrathecal morphine.,J P Prager; A DeSalles; A Wilkinson; M Jacobs; M Csete,"Loin pain hematuria syndrome (LPHS) is characterized by hematuria and incapacitating loin pain. The pain experienced with LPHS is, in general, extremely difficult to treat. Many surgical and pharmacologic therapies have been directed at LPHS pain without success. This report documents successful pain control in a patient with LPHS using long-term intrathecal morphine delivered via an implantable pump. Intrathecal narcotic therapy may provide pain relief for the chronic pain of LPHS.",1995.0,0,0
1060,7703994,Laparoscopic nephrectomy results in better postoperative pulmonary function.,C G Eden; A C Haigh; P G Carter; M J Coptcoat,"The pulmonary response to nephrectomy was studied in 16 patients undergoing laparoscopic (n = 8) or open (n = 8) nephrectomy using a standardized anesthetic technique. Although there was no significant difference between the two groups at 24 hours, postoperative pulmonary function measures (P = 0.02-0.03) and oxygenation (P = 0.03) were significantly better in the laparoscopic surgery group at 48 hours. The median opiate analgesic requirement (P = 0.02) and the number of nights spent in the hospital (P = 0.003) also were significantly lower in this group. The results of this study suggest that laparoscopic nephrectomy offers a real biological advantage in terms of postoperative preservation of lung function and that this might therefore be the safest technique for nephrectomy in patients with limited respiratory reserves.",1994.0,0,0
1061,7709266,Physician views about treating low back pain. The results of a national survey.,D C Cherkin; R A Deyo; K Wheeler; M A Ciol,"Physicians were surveyed regarding their beliefs about treatment efficacy for patients with low back pain. To document physician beliefs about the efficacy of specific treatments and the extent to which these beliefs correspond to current knowledge. Little is known about physician beliefs regarding the efficacy of specific back pain treatments. A national random sample of 2897 physicians were mailed questionnaires that asked about 1) the treatments they would order for hypothetical patients with low back pain and 2) the treatments they believed were effective for back pain. Responses were compared with guidelines suggested by the Quebec Task Force on Spinal Disorders. Almost 1200 physicians responded. More than 80% of these physicians believed physical therapy is effective, but this consensus was lacking for other treatments. Fewer than half of the physicians believed that spinal manipulation is effective for acute or chronic back pain or that epidural steroid injections, traction, and corsets are effective for acute back pain. Bed rest and narcotic analgesics were recommended by substantial minorities of physicians for patients with chronic pain. The Quebec Task Force found little scientific support for the effectiveness of most of the treatments found to be in common use. The lack of consensus among physicians could be attributable to the absence of clear evidence-based clinical guidelines, ignorance or rejection of existing scientific evidence, excessive commitment to a particular mode of therapy, or a tendency to discount the efficacy of competing treatments.",1995.0,0,0
1062,7709644,[Rational therapy of chronic pain conductions by the family physician].,W Sohn; U Schwantes; H Seelbach,"Despite numerous efforts to establish an adequate pain treatment, many patients still do not receive a proper pain therapy. This is unfortunate as it is estimated that between 5 and 7.6 Mi. people are suffering from chronic pain in Germany. This paper is demonstrating an adequate pain management for different diseases including an interdisciplinary approach. Further, we hope to reduce the fear of many physicians for the administration of opioid analgetics to realize a proper pain treatment where indicated.",1995.0,0,0
1063,7715937,"Rapid, reproducible pain relief with [131I]iodine-meta-iodobenzylguanidine in a boy with disseminated neuroblastoma.",J E Westlin; H Letocha; A Jakobson; P Strang; U Martinsson; S Nilsson,"[131I]Iodine-meta-iodobenzylguanidine ([131I]MIBG) is a radioactively labelled substance which is incorporated intracellularly by cells with neuroendocrine differentiation and used in the treatment of neuroendocrine malignancies. The agent was systemically administered on three occasions during a period of 16 weeks to a 4-year-old boy afflicted with disseminated neuroblastoma and suffering from severe pain caused by the disease. Initially, during the weeks immediately prior to radionuclide therapy, the boy required continuous intravenous infusions of morphine. On the 3rd day after each treatment, morphine administration could be discontinued and the boy appeared to be pain free. His appetite returned to normal and he became more mobile. The therapy had a good effect on his pain on each of the three occasions. Recurrent side effects were thrombocytopenia and cystitis. It is concluded that treatment with systemic radiotherapy in the form of [131I]MIBG was easy to perform and effective in this case of disseminated neuroblastoma and illustrates that this primary therapy can be used for palliative purposes.",1995.0,0,0
1064,7718981,Postcholecystectomy syndrome mimicking angina pectoris detected by the morphine provocation test.,H Osawa; M Saito; M Fujii; T Yamanaka; T Yaginuma,"A 66-year old woman had had intermittent anterior chest pain and upper abdominal pain for 15 years. Angina pectoris was diagnosed at the age of 51 years, as she had typical anginal pain that was relieved by nitroglycerine, although coronary arteriography was normal and the ergonovine provocative test was negative. She had undergone cholecystectomy at the age of 38 years. Her bile duct pressure increased markedly after morphine injection and severe pain with the aforementioned distribution was produced. Postcholecystectomy syndrome due to sphincter of Oddi spasm was diagnosed and her pain was relieved by endoscopic sphincterotomy.",1995.0,0,0
1065,7725270,[Acute aortic dissection].,P Weiss,"The acute aortic dissection is a relatively rare event carrying a grave prognosis. It is the most common fatal condition involving the aorta. A high index of suspicion is mandatory because of a mortality rate of 1 to 2% per hour in the first 48 hours. A recent series from the Mayo Clinic using modern diagnostic methods showed that in 62% of the patients the initial impression of aortic dissection was correct, but in 28% this diagnosis was only made post mortem. The clinical suspicion arises from a history of sudden severe pain in the chest or the back, sometimes wandering downwards, and from certain clinical findings like aortic regurgitation, pulse deficits or neurologic manifestations such as cerebrovascular accidents or ischemic paraparesis. ST-segment elevation in the ECG is very unusual in aortic dissection and should direct the clinical focus to acute myocardial infarction. Large-bore peripheral venous access should be established, and pain control should start immediately. Hypertensive patients should be treated first with an intravenous beta-blocking agent. Vasodilators increase aortic wall stress, they should only be administered after a beta-blocking agent. Transfer to a hospital with appropriate diagnostic and surgical is mandatory.",1995.0,0,0
1066,7725714,Managing chronic intractable pain.,J W Chodakiewitz,,1995.0,0,0
1067,7773021,Specifics needed on safe dosage.,M M Librach,,1995.0,0,0
1068,7777878,Alfentanil for conscious sedation during colonoscopy.,J A DiPalma; J L Herrera; F R Weis; D L Dark-Mezick; R S Brown,"This investigation was designed to determine whether the narcotic alfentanil, a relatively new fentanyl derivative with rapid onset of action and offset of activity, alone or in combination with midazolam has advantages over the traditional meperidine and midazolam regimen for conscious sedation. Thirty-five subjects were randomized to receive an initial dose of narcotic and sedative with additional narcotics or sedatives administered as needed. Subjects receiving no midazolam sedative (alfentanil and placebo group, n = 13) had less desaturation and had the need for supplemental oxygen less often than those receiving alfentanil and midazolam (n = 11) or meperidine and midazolam (n = 11). There were no differences as assessed by patient and colonoscopist for tolerance and discomfort, procedure ease, recovery time, complications, electrocardiogram, and blood pressure. Baseline evaluation did not predict the need for supplemental oxygen. We concluded that alfentanil, with or without a sedative, has no advantage over the commonly used meperidine and midazolam regimen.",1995.0,0,0
1069,7777897,Altered responses to medications exposed to excessive temperatures during shipping.,A Strauss,,1995.0,0,0
1070,7782853,Electrical stimulation of the trigeminal nerve root for the treatment of chronic facial pain.,R F Young,"Between March 1990 and December 1992, 23 patients with chronic intractable facial pain due to various forms of injury to the trigeminal nerve or nerve root underwent implantation of an electrical stimulating system to treat their pain. All patients had failed previous extensive pain treatment efforts. A monopolar platinum-iridium electrode was implanted on the trigeminal nerve root via percutaneous puncture of the foramen ovale. All patients experienced at least 50% reduction in pain intensity during a period of trial stimulation and underwent internalization of the electrode and connection to a completely implanted pulse generator. Independent assessment of the effect of stimulation was obtained by a specially trained nurse practitioner. Over a mean follow-up period of 24 months, six patients reported nearly complete relief of pain and six others reported at least a 50% reduction in pain intensity using a visual analog scale. Thus, 12 (52%) of the 23 patients achieved 50% or greater reduction in pain intensity. Although changes in the patterns of analgesic medication usage were few, six patients (26%) now experience a normal life style. Only one complication was seen, namely a dislocated electrode, which was easily replaced. Chronic electrical stimulation of the trigeminal nerve root appears to be an easy and safe technique for providing relief of chronic facial pain related to injury to the trigeminal nerve in a significant number of patients.",1995.0,0,0
1071,7784106,The Chronic Pain Coping Inventory: development and preliminary validation.,M P Jensen; J A Turner; J M Romano; S E Strom,"This paper describes the development and validation of a measure of strategies used by patients to cope with chronic pain, the Chronic Pain Coping Inventory (CPCI). A 104-item measure of pain coping responses and 3 measures of functioning were completed by 176 chronic pain patients. Two-week retest data were provided by 111 of these patients. Item and scale analyses resulted in a 65-item measure that assessed 11 pain coping dimensions. This inventory was then cross-validated in a second sample of chronic pain patients (n = 78), who also completed a measure of pain-related distress. The significant others (typically, spouses) of patients in the second sample rated patients on a significant-other version of the CPCI and on other measures of patient functioning. The results support the reliability of the CPCI scales. Four scales (Guarding, Resting, Asking for Assistance, and Task Persistence) predicted patient- and significant other-reported patient adjustment. Eight scales (Guarding, Opioid Medication Use, NSAID Use, Sedative-Hypnotic Medication Use, Resting, Asking for Assistance, and Exercise/Stretch) demonstrated moderate-to-strong relationships between patient and significant-other versions, further supporting their validity.",1995.0,0,0
1072,7784107,"Beneficial effects of ketamine in a chronic pain state with allodynia, possibly due to central sensitization.",J Persson; G Axelsson; R G Hallin; L L Gustafsson,"Allodynia is a well-known component of neuropathic pain resulting from injury to the nervous system. Clinical pain states with allodynia in connection with longstanding superficial wounds have, however, not been reported in the literature. In this case a chronic pain state developed in a previously healthy 17-year-old girl in and around a persistently suppurating appendectomy wound. There was no spontaneous pain but pronounced allodynia in the wound and in the surrounding skin. Quantitative thermal tests showed abnormal thresholds for several sensory modalities confirming abnormal processing of sensory input from the involved area. The pattern of sensory abnormalities evaluated with thermal testing changed transiently and the allodynia diminished during a phentolamine block. Since the pain responded poorly to opioids and ketamine has been reported to reduce allodynia, it was administered in a sub-dissociative bolus dose during wound dressing. The wound was essentially unchanged after treatment for 3 months but the allodynia and sensory aberrations had decreased significantly. We interpret these results as a de-sensitizing effect in the long term of repeated NMDA-receptor blockade by ketamine in a chronic pain state, with indications of central sensitization, partially maintained by sympathetic activity.",1995.0,0,0
1073,7802313,,,,,0,0
1074,7802322,[First experience in the use of a new Russian narcotic analgesic prosidol in oncology].,N A Osipova; G A Novikov; M S Vetsheva; B M Prokhorov; V A Beresnev; N A Loseva; S Iu Zemskaia; T A Smolina,"Prosidol, a new Russian narcotic analgesic, was used in various dosage forms (buccal and oral tablets, injection solution) in 113 cancer patients for the treatment of chronic pain, as a component of total anesthesia, and for postoperative analgesia. The best results were attained with the universal noninvasive dosage form, buccal tablets, used for the treatment of chronic pain in incurable patients. Analgesic properties of buccal prosidol are close to those of tramadol, the drug is well tolerated by the patients and causes no grave side effects. As a drug for postoperative analgesia prosidol was highly effective in patients after extracavitary oncologic surgery and less effective after thoracal and abdominal interventions. As a component of total anesthesia prosidol is inferior to fentanyl and approximately similar to promedol. An advantage of prosidol is its highly effective universal noninvasive dosage form, buccal tablets, which may be used for rapid analgesia in any situation.",1994.0,0,0
1075,7805941,The chemotherapeutic management of chronic and persistent orofacial pain.,E L Truelove,"The use of medication in chronic orofacial pain is not without risk. It is important to be vigilant regarding side effects, including abuse. The treatment of chronic pain can be frustrating and confusing because most patients with pain experience remissions and relapses. The initial report of reduced pain by the patient to any of the treatments that have been attempted may lead to false optimism about the nature of the condition or the potential long-term response to medication. With time the patient may report a reduced response to the medication and suggest either a higher dose or a different medication. In such patients it is important to reexamine the original differential diagnosis. When in doubt, additional consultation with pain centers, other clinicians with experience in managing patients with chronic pain, and consultation with the patient's physician may be needed. If the patient develops an abnormal personality or behavioral profile, referral to a specialist in behavioral medicine may also be needed. The treatment of chronic benign pain should proceed as planned, being careful not to place the patient in an ""at-risk position"" regarding medications and their effects or side effects.",1994.0,0,0
1076,7809761,The natural history of disc herniation and the influence of intervention.,H Weber,"The natural history of lumbar disc herniation must be considered when evaluating the influence and outcome of intervention. The combination of clinical signs and symptoms and corresponding radiologic findings permits a more certain diagnostic conclusion compared with many other obscure back disorders. The relationship between low back pain and a herniated disc is unclear. Mechanical compression and chemical changes may be the source of nerve root symptoms. Studies have shown that the natural course of acute radiculopathy has a good prognosis. Bed rest, information, and analgesics usually are sufficient therapeutic measures. Prolongation of symptoms requires radiologic examination. The decision regarding continued conservative therapy versus surgical intervention must be evaluated. Chemonucleolysis and percutaneous nucleotomy are being used, but the indications are uncertain.",1994.0,0,0
1077,7813214,Important principles of effective pain management.,D Platt,,1994.0,0,0
1078,7824099,Adenosine triphosphate deficiency: a genre of optic neuropathy.,J F Rizzo,"To offer clinical evidence that deficiency of vitamin B12 may adversely affect the neuronal function of patients who also have the 14,484 mitochondrial DNA mutation associated with Leber's hereditary optic neuropathy (LHON). A case of a 27-year-old man with vitamin B12 deficiency and the 14,484 mitochondrial DNA mutation is presented and the literature on causes of some metabolic optic neuropathies reviewed. Visual loss and neurologic symptoms of vitamin B12 deficiency occurred together, at a time when the level of vitamin B12 was subnormal. Vision and other sensory functions began to improve within 2 months of vitamin therapy, and normal vision eventually was restored. The relatively prompt improvement and the eventual complete recovery of vision following vitamin replacement therapy suggest that the subnormal level of vitamin B12 precipitated visual loss. Given the clinical similarities of subnormal vitamin B12, LHON, and nutritional/tobacco amblyopia, deficiency of adenosine triphosphate might be a unifying etiology for several types of optic neuropathy. This energy hypothesis provides a theoretical basis for the enigmatic phenomena of centrocecal scotomata and recovery of visual function after prolonged blindness.",2001.0,0,0
1079,7832313,Successful treatment of a massive intrathecal morphine overdose.,S B Groudine; C Cresanti-Daknis; P D Lumb,,1995.0,0,0
1080,7854795,Intrathecal morphine and clonidine in the management of spinal cord injury pain: a case report.,P J Siddall; M Gray; S Rutkowski; M J Cousins,Neuropathic pain following spinal cord injury (SCI) can be difficult to manage using currently available pain management techniques. We describe a case of chronic pain following SCI which failed to respond to a variety of approaches including intrathecal administration of morphine. Use of clonidine in addition to the morphine resulted in a marked decrease in pain. The use of intrathecal clonidine with or without opioids may present an effective alternative in the management of intractable SCI pain and other forms of neuropathic pain.,1994.0,0,0
1081,7859960,Selective sedation for colonoscopy.,F Seow-Choen; A F Leong; C Tsang,"A study of selective sedation for colonoscopy was conducted in two parts. All procedures were performed by one experienced colonoscopist. In the first phase, 41 patients received intravenous sedation before colonoscopy and were then prospectively randomized to either a ""not-reversed"" group, which did not receive flumazenil before withdrawal of the colonoscope, or to a ""reversed"" group, which received flumazenil before colonoscope withdrawal. None of the 20 patients reversed and 1 of the 21 patients not reversed experienced pain during the withdrawal phase of colonoscopy. Sixty percent of patients in the reversed group and 10% in the not-reversed group remembered the colonoscopic findings being explained during the procedure. Ninety percent and 81% of patients in the reversed and not-reversed groups, respectively, expressed a preference to be awake to watch the withdrawal of the colonoscope. In the second phase of this study, 40 patients underwent colonoscopy without prior intravenous sedation. Sedation was given only if pain was experienced during the procedure. Thirty percent had no pain at all, 55% minimal pain, 8% moderate pain, and 3% severe pain. Twenty-three percent required intravenous sedation, whereas 78% did not receive any sedation. Ninety-three percent were willing to undergo another colonoscopy without prior sedation. Only 8% preferred prior intravenous sedation before any future colonoscopy.",1994.0,0,0
1082,7876491,Chronic peripheral nerve pain treated with direct electrical nerve stimulation.,D W Strege; W P Cooney; M B Wood; S J Johnson; B J Metcalf,"Chronic somatic peripheral nerve pain was treated prospectively in 24 nonrandomized patients by a program of direct electrical nerve stimulation. Patients qualified for the program if anesthetic (lidocaine) nerve block of the involved cutaneous zone of the peripheral nerve relieved symptoms and transcutaneous electrical nerve stimulation transiently improved and did not exacerbate somatic pain. Results were judged according to a pain score. Patients noted improved sleep and complete absence of the need for narcotic pain medication. On the basis of subjective and objective criteria, 18 patients had good or excellent results and 6 had implant failures. Of the six patients with failures, three failed the trial period and did not have implantation, and three had no significant pain relief and were judged as treatment failures. Three patients had late equipment failure after initial good results. Most patients had some relief of pain, which increased their quality of life and eliminated the need for narcotic analgesia. Direct electrical nerve stimulation should be considered for somatic peripheral nerve pain that has not been ameliorated with other methods. It will reduce, although not necessarily eliminate, pain and pain behavior in most patients.",1994.0,0,0
1083,7879706,Pharmacological management of chronic pain: a clinician's perspective.,D A Cherry; G K Gourlay,"Of the currently available mu agonist drugs, the following are relatively contraindicated: 1. Methadone--unpredictable duration of action [5]. 2. Pethidine--unwanted central effects, metabolised to an active metabolite and too short acting. 3. Codeine--too weak and with constipating side-effects. 4. Fentanyl--too short acting. 5. Oxycodone--too short acting although suppositories may overcome some theoretical disadvantages. 6. Dextropropoxyphene--weak agonist which is possibly metabolised to a cardiotoxic metabolite [6]. Morphine remains the drug of choice for chronic pain when administered in a sustained release preparation. MS Contin, a slow release oral formulation of morphine, is available and has a predictable duration of action lasting from 8-12 h, while improved formulations are about to be released in the near future in some countries. Prescribers need to take into account the relatively poor oral bioavailability of morphine when calculating the daily morphine dose.",1994.0,0,0
1084,7884435,Pain and depression in patients with newly diagnosed pancreas cancer.,D P Kelsen; R K Portenoy; H T Thaler; D Niedzwiecki; S D Passik; Y Tao; W Banks; M F Brennan; K M Foley,"To evaluate the prevalence of pain and depression, their correlation, and their effect on quality of life in patients with recently diagnosed adenocarcinoma of the pancreas (PC). Cross-sectional pain and psychosocial distress were assessed using validated instruments, including the Memorial Pain Assessment Card (MPAC), Beck Depression Inventory (BDI), Hopelessness Scale (BHS), and Functional Living Index-Cancer (FLIC). Patients were evaluated before their first operation for PC or first treatment with chemotherapy at a large tertiary-care cancer center. One hundred thirty patients with proven PC were studied: 83 before their operation and 47 before their first chemotherapy treatment. At the time of study entrance, 37% of patients had no pain and an additional 34% had pain that was mild or less severe. Only 29% of patients had moderate, strong, or severe pain. Chemotherapy patients reported significantly more intense pain than did preoperative patients (P = .02). Symptoms of depression were assessed using the BDI and BHS scales. A substantial minority of patients (38%) had BDI scores > or = 15, which suggests high levels of depressive symptoms. There was a significant correlation between increasing pain and depressive symptoms among those who experienced pain. Quality of life was assessed using the Weekly Activity Checklist (WAC) and the FLIC. Compared with patients who had no pain or mild pain, patients with moderate or greater pain had significantly impaired functional activity (P = .03) and poorer quality-of-life scores (P = .02) when compared with those with lesser degrees of pain. There were significant correlations between increasing pain and depression and between pain and depressive symptoms and impaired quality of life and function. Our results indicate that moderate or severe pain and symptoms of depression are not as prevalent in recently diagnosed PC patients as is generally believed. However, one third have inadequate pain control despite the use of oral analgesics. These patients can be identified by the use of a simple self-report instrument (the MPAC card). Quality of life and function are adversely affected by moderate or greater levels of perceived pain intensity. A simple and rapid assessment is possible and can identify high-risk patients in need of intervention that may improve quality of life.",1995.0,0,0
1085,7888292,"Analgesics and ENT surgery. A clinical comparison of the intraoperative, recovery and postoperative effects of buprenorphine, diclofenac, fentanyl, morphine, nalbuphine, pethidine and placebo given intravenously with induction of anaesthesia.",A A van den Berg; N M Honjol; N V Prabhu; S Datta; C J Rozario; R Muraleedaran; D Savva,"1. Vomiting and restlessness following ENT and eye surgery are undesirable, and may be related to the emetic and analgesic effects of any analgesic given to augment anaesthesia during surgery. 2. To rationalise the choice of analgesic for routine ENT surgery we examined the intraoperative, recovery and postoperative effects following the administration of either buprenorphine (3.0 to 4.5 micrograms kg-1), diclofenac (1 mg kg-1), fentanyl (1.5 to 2.0 micrograms kg-1), morphine (0.1 to 0.15 mg kg-1), nalbuphine (0.1 to 0.15 mg kg-1), pethidine (1.0 to 1.5 mg kg-1) or saline (as control) given with the induction of anaesthesia in 374 patients. A standardised anaesthetic technique with controlled ventilation using 0.6-0.8% isoflurane in nitrous oxide and oxygen was employed. The study population constituted 7 similar groups of patients. 3. Intraoperatively, their effects on heart rate and blood pressure, airway pressure and intraocular pressure, were similar. This implies, most surprisingly, that neither their analgesic nor their histamine releasing effects were clinically evident during surgery. By prolonging the time to extubation at the end of anaesthesia, only buprenorphine, fentanyl, morphine and pethidine provided evidence of intraoperative respiratory depression. 4. Postoperatively, buprenorphine was associated with severe respiratory depression, prolonged somnolence, profound analgesia and the highest emesis rate. Diclofenac exhibited no sedative, analgesic, analgesic sparing, emetic or antipyretic effects. Fentanyl provided no sedative or analgesic effects, but was mildly emetic. Morphine provided poor sedation and analgesia, delayed the requirement for re-medication and was highly emetic. Nalbuphine and pethidine produced sedation with analgesia during recovery, a prolonged time to re-medication and a mild emetic effect. None provided evidence, from analysis of postoperative re-medication times and analgesic consumption, of any pre-emptive analgesic effect. 5. We conclude that nalbuphine (mean dose 0.13 mg kg-1) and pethidine (mean dose 1.35 mg kg-1), given individually as a single i.v. bolus during induction of anaesthesia, are the most efficacious analgesics for routine in-patient ENT surgery.",1994.0,0,0
1086,7892017,Physicians' attitudes and practices regarding the long-term prescribing of opioids for non-cancer pain.,D C Turk; M C Brody; E A Okifuji,"Prescribing long-term opioids for patients with chronic pain is controversial. The primary purpose of this study was to examine physicians' beliefs about and prescribing of the long-term use of opioids in the treatment of chronic pain patients. Concerns about regulatory pressure and appropriateness of education regarding opioids were also examined. The design was a stratified random sample. In the United States, 6962 physicians were randomly selected from two states in each of five regions of the country (Northeast, Midwest, Southeast, Southwest, and Pacific). Physicians from seven medical specialties (Family Practice, Internal Medicine, Physical Medicine and Rehabilitation, Rheumatology, Orthopedic Surgery, Neurosurgery, and Neurology) were surveyed and 1912 (27.46%) responded. A survey consisting of questions regarding years of practice, number of chronic pain patients treated, frequency of prescribing long-term opioids, concerns about opioids, goals of treatment, beliefs about education regarding opioids, and concerns about regulatory pressures was used. Based on the physicians who responded, it appears that prescription of long-term opioids is relatively wide-spread. Differences were noted by region, specialty, and the requirement for the use of multiple prescriptions for schedule II drugs. Physicians in the Midwestern United States were the least likely to prescribe the long-term use of opioids. Rheumatologists and general practitioners were significantly more likely to prescribe long-term opioids than were surgeons, neurologists, or physiatrists and were more likely to emphasize the importance of symptom improvement as an appropriate goal even in the absence of functional improvements.(ABSTRACT TRUNCATED AT 250 WORDS)",1994.0,0,0
1087,7892030,Difficult management of pain following sacrococcygeal chordoma: 13 months of subarachnoid infusion.,J L Aguilar; P Espachs; G Roca; D Samper; C Cubells; F Vidal,"We report on a patient suffering severe pain following a long-standing sacral chordoma in whom management of therapy and pain was extremely difficult. Because orally administered morphine was observed to be ineffective in the early stages of treatment, we tried to achieve pain relief by using epidural morphine. This was also unsatisfactory. Intrathecal infusion of morphine and bupivacaine through a catheter inserted at the L2-L3 level was also found to be ineffective; only a segment block was observed. A structural anomaly of the spine was suspected and confirmed by myelography, showing metastasis at L3. Pain relief improved when an infusion of morphine+bupivacaine was employed through a catheter placed at the L4-L5 level below the blockage. A major problem which continued throughout the course of the disease was the daily occurrence of episodes of unbearable sharp pain that required addition of midazolam to the local anesthetic/opioid subarachnoid infusion. The patient received this mixture through an intrathecal port during the last 13 months of life, a gradually increasing dose being necessary. Periods of analgesia were followed by occasional crises of intense sharp pain suggesting incomplete relief. No serious complications or meningitis occurred. This case emphasizes the difficulty in managing pain in this type of cancer.",1994.0,0,0
1088,7894279,,,,,0,0
1089,7894286,Model of scientific reasoning.,R Melzack,,1995.0,0,0
1090,7897521,A comparison of intrathecally administered narcotic and nonnarcotic analgesics for experimental chronic neuropathic pain.,J W Leiphart; C V Dills; O M Zikel; D L Kim; R M Levy,"The antinociceptive actions of morphine and tizanidine (an alpha 2-adrenergic agonist) administered intrathecally in a rat model of mononeuropathic pain were investigated. Tizanidine increased to normal levels the intensity of a noxious pressure stimulus required to induce paw withdrawal (p < 0.01) and decreased the duration of limb withdrawal from both normal-temperature and cooled floors in a dose-dependent manner (p < 0.01). Tizanidine had virtually no effect on the latency of paw withdrawal from a noxious heat stimulus. In comparison, morphine significantly decreased, in a dose-dependent manner, limb withdrawal from the normal-temperature and cooled floors and increased to cutoff values the withdrawal latencies of both noxious heat and pressure stimuli (p < 0.01). The effect of tizanidine was limited to the hyperalgesic limb and served to normalize reactive latencies, whereas morphine affected both hindlimbs and increased latencies to supranormal cutoff values. These data suggest that intrathecal tizanidine may be more specific than morphine in reversing the allodynia and hyperpathia associated with neuropathic pain states and may be of value in the management of patients with these clinical syndromes.",1995.0,0,0
1091,7903677,Implementation of an epidural pain management program.,P A Nowakowski,"The epidural route of administration can be used safely for acute and chronic pain control. Although most frequently used in the obstetrical setting, the epidural route has been used more recently for pain control in general surgical and oncology patients. Nursing policies, physician order sets and nursing documentation provide a consistent approach to patients receiving epidural analgesia. Continuous quality improvement helps to assure patient satisfaction and program quality.",1993.0,0,0
1092,7903843,Pain control during interventional biliary procedures: epidural anesthesia vs i.v. sedation.,D L Harshfield; S K Teplick; J C Brandon,"We performed a study designed to compare epidural anesthesia with IV sedation for the control of pain during interventional biliary procedures. Two hundred sixty-three biliary procedures were performed in 126 patients during a 3-year period. The transhepatic approach was used for all the procedures. Epidural anesthesia was used in 140 procedures and IV sedation was used in 123. Both epidural anesthesia and IV sedation were used in 31 patients who required multiple procedures. The efficacy of each method for control of pain was determined by a subjective rating of the patients' pain during the procedure: from 0 (no pain) to +3 (severe). The ratings were compiled and compared for each of the methods to ascertain which technique best achieved the desired effect. The pain control used depended on the urgency of the procedures and the availability of an anesthesiologist to administer epidural anesthetic. When an anesthesiologist was unavailable, IV sedation was used. The type and amount of drug administered depended on the patient's preference and history. Of the 140 procedures done with epidural anesthesia, patients had no pain to mild pain in 127 (91%) and moderate to severe pain in 13 (9%). All instances of moderate to severe pain were the result of unsuccessful attempts to establish or maintain anesthesia. Of the 123 procedures done with IV sedation, patients had no pain to mild pain in 62 (50%) and moderate to severe pain in 61 (50%). Complications were more frequent when IV sedation was used. Six (5%) occurred, and all were related to hypotension. The hypotensive episodes occurred early in the study, before monitoring of patients was improved; now, continuous updates on vital signs are provided throughout the interventional procedure. With epidural anesthesia, hypotension developed in only one patient (< 1%) and the patient responded to fluid administration. When it is successful, epidural anesthesia can completely eliminate moderate to severe pain in patients undergoing biliary procedures. IV sedation is only 50% effective in this regard. The greater efficacy of epidural anesthesia, coupled with the significantly lower prevalence of hypotension, justifies the additional cost and time associated with epidural anesthesia for pain management in biliary procedures.",1993.0,0,0
1093,7904174,Neuropathic pain: a condition which is not always well appreciated.,W Hamman,,1993.0,0,0
1094,7905216,[Skin lesions after injection abuse. Chronic changes caused by ketobemidone (Ketogan)].,A G Danielsen; I B Hultberg; K Weismann,"Local complications of repeated injections of pentazocine are known among drug abusers. We hereby describe similar reactions in three patients who for several years had abused the opioid analgetic ketobemidone for chronic pain after abdominal surgery, and in six drug addicts who regularly injected ketobemidone tablets dissolved in water. In all nine patients an impressive clinical picture with disfiguring woody fibrosis and multiple irregular ulcers and scars surrounded by hyperpigmentation on the upper and lower extremities was seen. The skin lesions had been mistaken for aggressive forms of panniculitis, pyoderma gangrenosum or selfmutilation. Following direct questioning most patients admitted self-administration of the drug to the affected areas. The patients showed an apparent indifference about their extensive disabling skin disease, and no obvious complaints of pain, contrary to what might be expected from the pronounced tissue destruction and inflammation at the injection sites.",1994.0,0,0
1095,7909601,A case of narcotic bowel syndrome successfully treated with clonidine.,V Wong; G Sobala; M Losowsky,"Patients with chronic abdominal pain without an organic basis present a difficult management problem. Some of these patients may be prescribed opiates initially which may result in requiring progressively higher doses for pain relief. In this clinical setting, the suspicion of narcotic bowel syndrome should be borne in mind. With appropriate treatment and counselling, further invasive investigations including laparotomy may be avoided and resolution of symptoms can be achieved with clonidine. This case report demonstrates such a typical clinical scenario and discusses the possible aetiology and pathophysiology of narcotic bowel syndrome as well as the role of clonidine in controlling opiate withdrawal symptoms.",1994.0,0,0
1096,7910424,[Opioid analgesics in the treatment of non-malignant chronic pain].,J Eriksen; T G Clausen; F M Borgbjerg,"Opioid sensitivity, residual pain, development of tolerance, physical and psychological dependence are described and discussed in relation to long-term opioid therapy. Based on this, guidelines for long-term opioid administration are established for chronic pain conditions of non-cancer origin. The indication must be well-considered--a life-long treatment may be instituted. Prior to final initiation of the treatment, a testing of the selected drug and method of administration should be performed. Due to the compliance-reasons, only long acting opioids should be used (controlled release morphine preparations, methadone, buprenorphine) and the route of administration should always be oral. The treatment must be individualised, covering 24 hours a day. The single dosages should be identical and administered with identical time intervals, which are determined by the duration of action of the drug in use. P.r.n.-administration should not be allowed. Only one physician should be responsible for the treatment and for the prescription of the opioid analgesic drugs.",1994.0,0,0
1097,7910792,"[Postlaparoscopic pain syndrome. Results of a prospective, randomized study].",A Pier; M Benedic; B Mann; V Buck,"The so-called post-laparoscopic algesia is a specific impairment of about 63% of the patients who undergo laparoscopic surgical operations. This impairment takes the form of mild to moderate shoulder pain. Eliminating the causes of pain has a clear advantage over symptomatic treatment using analgetics, a fact worth a good consideration especially with the post-operative sojourn at the hospital becoming shorter and shorter. In a prospective controlled study, involving 42 patients subdivided into four groups namely, higher or lower insufflation pressures, chemically inert insufflation gas and control groups; the use of analgetics, lung function, operation duration, amount of insufflated gas, intraperitoneal pH-values and post-operative complications in the various subgroups were compared to each other with regard to post-operative pain perception. The results did not show any significant differences among the groups regarding the main parameters like pH-value or different insufflation pressures etc. These results led to the termination of the study based on the raised criteria since we anticipated the actual cause of the shoulder pain to be due to an unknown factor. By the evaluation of the individual data, it became apparent that, the pains increase with increasing gas consumption, a fact which led to assumption that the pains are caused by a physical effect such as the cooling of the peritoneum.",1994.0,0,0
1098,7914167,Opioids in anaesthesia: a questionnaire survey in Finland.,R Pöyhiä,"A questionnaire was sent to the pharmacies of 88 Finish hospitals with surgical departments to inquire about the consumption of opioids during 1990. Another questionnaire was sent to 480 members of the Finnish Society of Anaesthesiologists to ask how they administer opioids to adult patients. Answers were received from 95% of hospitals and 67% of anaesthetists. Dextropropoxyphene was the most common oral opioid and oxycodone was the most common parenteral opioid used in Finland. Parenteral opioids were consumed almost totally in the hospitals. The anaesthetists reported oxycodone to be the opioid of choice for premedication, postoperative pain and sedation of critically ill patients. Fentanyl was the opioid most commonly used intravenously during balanced anaesthesia and in epidural administration. Epidural opioids were administered by 77% of anaesthetists and patient-controlled analgesia (PCA) technique mostly for intravenous administration by 19%. Only 10% of Finnish anaesthetists were actively involved in the management of chronic pain; the methods they use are discussed. The majority of anaesthetists were satisfied with the currently available opioids.",1994.0,0,0
1099,7914375,[Problems of pain medication and dependence].,K M Hocker,"Based on the experience in a psychosomatic clinic, drug dependency problems among chronic pain patients are reported. The following three theses have evolved: 1. By far most important of all is the problem of tranquilizer abuse, which entails serious, and sometimes dramatic, withdrawal syndromes. An indication for continuous tranquilizer medication does not exist. 2. Compound preparations are problematical, in particular if they contain codeine. We frequently see abuse and even dependence. 3. Opium derivatives continue to be rarely prescribed in non-cancer chronic pain. Several instances of incorrect pain management have been found, such as prescription to substance abusers, on insufficient indication, or prescription on request instead of time-schedule therapy.",1994.0,0,0
1100,7914737,Dexmedetomidine premedication before intravenous regional anesthesia in minor outpatient hand surgery.,M L Jaakola,"To assess the efficacy and safety of intravenous (i.v.) dexmedetomidine, an alpha-2 agonist, as a premedication before i.v. regional anesthesia. Randomized, double-blind, placebo-controlled study with two parallel groups. Day-case surgery unit, Department of Surgery, Turku University Hospital, Turku, Finland. 30 healthy ASA physical status I outpatients scheduled for minor hand surgery with i.v. regional anesthesia. Patients were assigned to one of two groups to receive either dexmedetomidine 1 microgram/kg i.v. (n = 15) or saline placebo i.v. (n = 15) 10 minutes before exsanguination and inflation of a tourniquet. Regional blockade was induced with 0.5% lidocaine 3 mg/kg (maximum 200 mg). Additional fentanyl 1 microgram/kg intraoperatively and oxycodone 0.05 mg/kg postoperatively were administered for analgesia if needed. Dexmedetomidine preoperatively induced 16% to 20% decreases in systolic blood pressure (p < 0.001), diastolic blood pressure (p < 0.001), and heart rate (p < 0.001), which were mainly abolished within the 4-hour postoperative follow-up period. A clinically significant decrease in arterial oxygen saturation was not observed. The subjective intensity of pain during tourniquet inflation was similar in both groups, but fewer intraoperative (p = 0.009) opioid analgesics were needed in the dexmedetomidine group. Dexmedetomidine decreased sympathoadrenal responses: plasma norepinephrine concentration decreased to one-fourth of the baseline level (p < 0.001), and one of its main metabolites, 3,4-dihydroxyphenylglycol, decreased by 27% (p < 0.001). Dexmedetomidine also prevented an increase in plasma epinephrine concentration following tourniquet inflation (p = 0.003). Dexmedetomidine induced subjective sedation (p = 0.002), but the Maddox Wing test did not show any statistically significant differences between the groups. General effectiveness was graded superior in the dexmedetomidine group (p < 0.001). Dexmedetomidine is an effective premedication before i.v. regional anesthesia because it reduces patient anxiety, sympathoadrenal responses, and opioid analgesic requirements.",1994.0,0,0
1101,7915672,Nitrous oxide for colonoscopy discomfort: a randomized double-blind study.,A Lindblom; O Jansson; B Jeppsson; K Törnebrandt; C Benoni; J L Hedenbro,"The possibility of reducing recovery time after colonoscopy was studied using patient-administered nitrous oxide and comparing it with our standard treatment of ketobemidone plus midazolam. Fifty consecutive colonoscopy patients were randomized to receive either (i) intravenous ketobemidone hydrochloride 2.5 mg, midazolam 2.5 mg, and breathing air from a face mask with a demand valve (KHM) or (ii) intravenous saline and a breathing mixture of even parts of oxygen and nitrous oxide (Entonox) from the same valve setup. Patient discomfort during colonoscopy was assessed using visual analogue scales. All patients were allowed to stay for recovery as long as they wanted, and the time was measured. Modified recollection tests were performed prior to colonoscopy and when the patients left the Endoscopy Unit, in order to study the degree of mental impairment induced by the procedure and the medication. All patients had complete colonoscopies of the same duration in both groups. Discomfort during colonoscopy was rated the same in both groups (2p = 0.6413). Both groups of patients scored identically in the precolonoscopy recollection test. Most patients had a lower score after colonoscopy, but Entonox-treated patients scored significantly better than those with KHM (2p = 0.0250). Patients treated with Entonox opted to leave the Unit directly after the procedure (median 0 minutes; interquartile range 0-5 minutes) compared to 38 minutes for those with KHM (interquartile range 10-75 min), 2p < 0.001. It seems from our data that nitrous oxide gives pain relief equal to that in our standard treatment.(ABSTRACT TRUNCATED AT 250 WORDS)",1994.0,0,0
1102,7916546,Intrathecal and epidural somatostatin for patients with cancer. Analgesic effects and postmortem neuropathologic investigations of spinal cord and nerve roots.,P Mollenholt; N Rawal; T Gordh; Y Olsson,"The antinociceptive effects of somatostatin (SST) after intrathecal administration in rats and dogs and analgesic effects after intrathecal or epidural administration in humans were described previously. In this study, we seek to determine the efficacy of SST in cancer pain management and its potential neurotoxicity. Eight patients with intractable cancer pain were studied. Pain intensity was assessed by patients on a four-grade scale (severe, moderate, mild, none). Additional analgesic drug requirements before and concomitant with SST treatment were used to evaluate the pain relief and assessed on a four-grade scale (poor, fair, good, or excellent). Spinal cords of five patients were autopsied. The mean duration of SST treatment was 11.3 days. The mean daily dose was 1,252 micrograms (range 250-3,000 micrograms). In six patients the pain relief was rated ""excellent"" or ""good"" and in two patients it was assessed ""poor"" or ""fair"". None of the patients demonstrated any evidence of neurologic deficit related to the SST treatment. At autopsy, two patients exhibited a moderate demyelination of some spinal dorsal roots and one patient also had a slight demyelination of the dorsal columns. SST administered intrathecally and epidurally was an effective analgesic in patients with terminal cancer. Because the described neuropathologic changes could also be cancer-related or result from chemotherapy or radiation therapy we suggest that further judicious use of SST is justified in this category of patients, if their pain remains unrelieved despite large doses of opioid analgesics.",2001.0,0,0
1103,7935235,Interpleural catheter analgesia for chronic pain treatment--a case report.,A A el-Dawlatly; S R al-Faqih,"In summary, we present a case in which long-lasting relief of upper abdominal cancer pain was achieved by injections of local anesthetic through the interpleural approach. This technique may be a good alternative to coeliac plexus block in selected cases. Furthermore, if pain relief in such a case proves to be only transient, injections of dilute phenol might provide permanent relief.",1994.0,0,0
1104,7936730,Preventive pain management in the postoperative hand surgery patient.,N Hekmat; M Burke; S J Howell,"The purpose of this quasi-experimental clinical study was to investigate differences in postoperative pain management within the hand surgical population. The research question proposed: Is there a difference in the pain experience between postoperative patients who receive an analgesic upon onset of sensation and those who receive an analgesic upon onset of pain? The effectiveness of pain management was compared for two groups of randomly assigned, adult, orthopaedic patients who had undergone elective hand surgery using axillary block anesthesia. The results of this study concluded that more effective pain control was achieved when patients were medicated upon onset of sensation versus onset of pain.",1994.0,0,0
1105,7939279,[Pain in patients with cancer].,E Pichard-Léandri,"All cancer patients will inevitably experience pain during their illness, whether it is cured or not: acute pain induced by the treatment and examinations required for diagnosis; chronic pain associated with the evolution of the disease or sequelae caused by treatment. These pains must be treated imperatively as accompanying symptoms. The practitioner should be able to analyse the components, the physiopathological, the cause(s) and the way in which they occurred. Treatment will then be prescribed, adapted and monitored according to stringent criteria so that optimal efficacy is achieved with a minimum of side effects.",1994.0,0,0
1106,7939282,[Drugs for relief of pain].,A Eschalier; D Jourdan; C Courteix,"Currently, the pharmacology of analgesics can be sum up to three main compounds: morphine, paracetamol and aspirin. The use of antidepressants and anticonvulsants will also be mentioned. Morphine remains the reference compound among centrally acting analgesics both for acute and chronic pain. Its mechanism of action is relatively well known as well as the role of opiate receptors. Paracetamol is largely used as analgesic for relief of slight to moderate pain. Its mechanism of action still remains unclear. Usually the tolerability of this compound is considered as being excellent. However overdosage can induce severe and possible lethal liver necrosis. Aspirin is also a very old and a largely used compound. Its inhibiting effect on cyclooxygenase acts mainly peripherally but it could also act centrally. According to the current knowledge of its mechanism of action, it seems that the main pharmacological properties as well as adverse events of aspirin are all related to its enzyme inhibiting effect. Slight to moderate pain, related or not to inflammatory disease responds well to aspirin and other NSAIDs.",1994.0,0,0
1107,7939283,[Neurosurgical treatments of chronic pain].,M Sindou; P Mertens; Y Keravel,"During these last years the methods and the indications of analgesic neurosurgery have respectively changed toward greater multiplicity and more selectivity. The conservative methods of neurostimulation have acquired a prominent place in some types of pain from neuropathic origin. Their aim is to reinforce inhibitory fibre function. Whatever the technique used, stimulation of peripheral nerves, of posterior funiculi of the spinal cord, of the thalamus or the cerebral cortex, it will be effective only if the target structures are not totally, anatomically and functionally, destroyed. Intrathecal morphine administration, has been shown to be useful to control some cancer-induced pain. Lastly, the techniques of interrupting the pathways of pain, achieving greater selectivity in their effects, remain the preferred treatment for some types of localised pain having precise mechanisms.",1994.0,0,0
1108,7943702,Severe pain in both legs after spinal anaesthesia with hyperbaric 5% lignocaine solution.,S Sjöström; J Bläss,,1994.0,0,0
1109,7945829,Survey of analgesia regimens in burns centres in the UK.,M J Braam; A P Bath; P H Spauwen; F B Bailie,"A survey of the analgesia regimens used in burns units throughout the UK was performed. Continuous intravenous opiate infusions remain the mainstay for providing pain relief in patients in severe pain as a result of burn injuries. Other methods include: patient-controlled analgesia in appropriate patients, bolus doses of opiates combined with Entonox for control of peaks of pain and a wide variety of oral analgesics for less painful burn injuries.",1994.0,0,0
1110,7947421,Survey of opioid use in chronic nonmalignant pain patients.,R N Jamison; K O Anderson; C Peeters-Asdourian; F M Ferrante,"Opioids have been accepted as appropriate treatment for acute and cancer pain, but remain controversial for use with chronic nonmalignant pain. Clinicians are concerned about efficacy, tolerance, addiction, and unwanted side effects. The aim of this study was to survey chronic pain patients who were taking opioids for their pain, to determine the incidence of these adverse conditions. Two hundred seventeen patients who were being treated for their pain at two different pain centers completed a medication questionnaire. The most common diagnosis was low back pain. One hundred twelve patients reported taking oral opioids for their pain. Of the patients who reported taking opioids for their chronic pain, 83% felt that the opioids were moderately beneficial in relieving their pain; 25% felt that the opioid had not lost its ability to relieve the pain over time; 35% reported that they did not need to increase their medication; 36% expressed no fear of addiction or dependence; and 56% reported having no unwanted side effects. The results suggest that chronic nonmalignant pain patients taking opioids for their pain reported some tolerance, fear of addiction, and side effects when taking opioids. However, despite these concerns, some of these patients felt that opioid therapy was very beneficial. Further investigations are needed to determine which patient characteristics predict benefit from opioid therapy for nonmalignant pain.",1994.0,0,0
1111,7956382,,,,,0,0
1112,7958380,"A multiple-dose, double-blind comparison of intramuscularly and orally administered ketorolac tromethamine and Ketogan in patients with pain following orthopaedic surgery.",P H Gebuhr; M Soelberg; W Strauss,"In this multiple-dose, double-blind study 100 patients with moderate, severe or very severe pain following orthopaedic surgery were randomly assigned to receive ketorolac, a non-steroidal anti-inflammatory drug with potent analgesic properties (10 mg), or the standard regimen of Ketogan (a combination product containing the narcotic analgesic, ketobemidone, plus a spasmolytic agent) by intramuscular injection every 1-6 h as needed for pain. When patients were able to tolerate an oral diet and were expected to respond to oral analgesic medication, based on overall pain sensitivity, they were switched to oral doses of the same medication every 4-6 h as needed. A maximum of four daily doses of medication was allowed for up to 10 days. The severity of pain was scored on a five-point scale and was recorded before the first intramuscular dose, at fixed time points thereafter for up to 6 h and at the end of each day. Both treatments were effective immediately after the first dose and during the subsequent multiple-dose phase. There were no statistically significant differences between ketorolac and Ketogan. The results show that 10-mg doses of ketorolac in intramuscular injections followed by 10-mg doses of oral ketorolac are as effective as Ketogan for the treatment of pain following orthopaedic surgery. Ketorolac appears to be better tolerated than Ketogan since significantly fewer patients reported adverse events (P = 0.004) when taking ketorolac.",1994.0,0,0
1113,7976145,Immediate and prolonged effects of pre- versus postoperative epidural analgesia with bupivacaine and morphine on pain at rest and during mobilisation after total knee arthroplasty.,J B Dahl; J J Daugaard; B Rasmussen; K Egebo; P Carlsson; H Kehlet,"Thirty-two patients scheduled for total knee arthroplasty were randomized to receive an identical epidural blockade initiated 30 min before surgical incision (N = 16), or at closure of the surgical wound (N = 16). Before induction of general anaesthesia the epidural catheter was tested with bupivacaine 7.5 mg.ml-1, 2 ml. General anaesthesia was induced with thiopentone, pancuronium or atracurium, and fentanyl 0.1-0.3 mg, and maintained with N2O/O2 and enflurane. The epidural regimen consisted of a bolus of 16 ml of bupivacaine 7.5 mg.ml-1 plus morphine 2 mg, and continuous infusion of bupivacaine 1.25 mg.ml-1 plus morphine 0.05 mg.ml-1, 4 ml.h-1 for the first 24 h, and bupivacaine 0.625 mg.ml-1 plus morphine 0.05 mg.ml-1, 4 ml.h-1, for the next 24 h after operation. Additional morphine 2.5-5 mg was administered i.v. or i.m. for the first 24 h postoperatively, and ketobemidone or morphine 5-10 mg orally or rectally from 24 h to 7 d postoperatively, on request. Paracetamol 1000 mg every 8 h was administered from 48 h to 7 days postoperatively. No significant differences were observed in request for additional opioids, or in pain scores at rest or during mobilisation of the operated limb, during or after cessation of the epidural regimen. These results do not suggest timing of analgesia with a conventional, continuous epidural regimen to be of major clinical importance in patients undergoing total knee arthroplasty.",1994.0,0,0
1114,7978003,The role of pancreatojejunostomy in patients without dilated pancreatic ducts.,R Delcore; F J Rodriguez; J H Thomas; J Forster; A S Hermreck,"To determine the safety and efficacy of longitudinal pancreatojejunostomy in patients with chronic pancreatitis and intractable pain who do not have a markedly dilated pancreatic duct. Ductal decompression by side-to-side, longitudinal pancreatojejunostomy has become the operation of choice for patients with chronic pancreatitis and intractable pain when the pancreatic duct is markedly dilated. However, markedly dilated pancreatic ducts are found in less than 40% of patients with disabling pain. Twenty-eight consecutive patients with intractable pain from chronic pancreatitis, most of whom had minimal or no dilation of the pancreatic duct, were treated with side-to-side, longitudinal pancreatojejunostomy between 1970 and 1993. There were 18 (64%) males and 10 (36%) females. The mean age was 41 years (range 11 to 72). The etiologies for chronic pancreatitis were alcohol (82%), gallstones (7%), trauma (7%), and familial trait (4%). Intractable pain was present for a mean of 4 years (range 0.5 to 12). Thirteen patients (46%) were dependent on narcotics prior to surgery. Twenty-five patients (89%) had minimal (< 8 mm) or no dilation of the pancreatic duct and 3 (11%) had markedly dilated pancreatic ducts (> 10 mm). All experienced complete pain relief in the immediate postoperative period. Twenty-four patients (86%) have remained free of pain after a mean follow-up of 3.5 years (range 1 to 8). In patients with chronic pancreatitis and intractable pain, small pancreatic duct size should not be considered a contraindication to side-to-side, longitudinal pancreatojejunostomy.",1994.0,0,0
1115,7978179,"[Wound infiltration with bupivacaine following pelviscopy does not reduce postoperative pain intensity. Results of a placebo-controlled, double-blind study].",C Maier; F Broer-Boos; D Kube; W D Arp,"The analgetic efficacy of intraoperative infiltration with bupivacaine 0.5% or saline of the skin incisions for the endoscopic trocars was examined in 30 female patients following operative endoscopic pelviscopy in a double-blind study. Infiltration of the peritoneum, abdominal wall, and subcutaneously was performed by endoscopic view before skin suture. There were no significant differences between the two groups in age, duration of surgery, operative technique, intensity of preoperative acute and chronic pain, or state of anxiety. Postoperative pain assessment was performed using a numeric rating scale (NRS) hourly within the first 8 h and after 24 h postoperatively. After 8 h patients were asked for the localisation and description of the worst pain. Cumulative tramadol doses were calculated for 3, 8 and 24 h using patient-controlled analgesia (PCA). Pain intensity within the first 8 h postoperatively did not differ between the bupivacaine and placebo groups (Fig. 1). The mean NRS after bupivacaine infiltration was 4.6 (+/- 2.4) in the 1st-3rd h and 3.4 (+/- 1.8) after 6-8 h (placebo: 4.8 (+/- 2) and 2.4 (+/- 1.7)). In both groups most patients reported lower (40%) or upper (12%) abdominal visceral pain as their worst pain. Pain due to skin incision was noted less, but in equal numbers in both groups. Of the patients in the bupivacaine group 77% and in the control group 80% started with PCA due to increasing pain scores within 60 to 120 min. The numbers of tramadol demands and given doses did not differ (Fig. 2).(ABSTRACT TRUNCATED AT 250 WORDS)",1994.0,0,0
1116,7978671,Local anesthesia is superior to spinal anesthesia for anorectal surgical procedures.,M Fleischer; C P Marini; R Statman; J Capella; K Shevde,"In this prospective study we compared local with spinal anesthesia for anorectal surgical procedures with regard to pain control, recovery time before unassisted ambulation, incidence of postoperative complications, length of hospital stay, and cost effectiveness in 80 consecutive patients. Patients were allocated in two groups: group 1 (n = 52) received local anesthesia, and group 2 (n = 28) had spinal anesthesia. There were no intraoperative complications related to the anesthetic technique, and there was no difference between groups in the number of doses of narcotics required to control postoperative pain (1.2 +/- 1.5 vs 1.8 +/- 1.7 in group 1 and 2 respectively, P > 0.05). Recovery time before unassisted ambulation was significantly longer in group 2 (139 +/- 96 minutes in group 2 vs 82 +/- 62 minutes in group 1, P < 0.05). There were 21/52 complications in group 1 in contrast to 21/28 in group 2, (P < 0.05). There was no difference between groups in the postoperative incidence of nausea, vomiting, headache, weakness, and constipation; however, the incidence of postoperative urinary retention was significantly higher in group 2 (5/52 in group 1 vs 9/28 in group 2, P < 0.05). As a result of urinary retention, more patients in group 2 required overnight hospitalization (12/52 in group 1 vs 21/28 in group 2, P < 0.05). Patients in group 2 required 36 hospital days in contrast to 21 days for patients in group 1, P < 0.05. The difference in hospital days resulted in $18,000 greater cost for patients in group 2.(ABSTRACT TRUNCATED AT 250 WORDS)",1994.0,0,0
1117,7992931,Evaluation of double lesion syndrome with diagnostic spinal anesthesia.,P G Loubser,,1994.0,0,0
1118,7999504,Extradural infusion analgesia for postoperative pain relief.,S Leith; R G Wheatley; I J Jackson; T H Madej; D Hunter,"We describe 4-yr experience providing extradural infusion analgesia in a district hospital for treatment of postoperative pain. A total of 770 patients recovering from major surgery were treated on general surgical wards between April 1989 and March 1993. The results of a retrospective audit showed that pain control, assessed with both a visual analogue scale (VAS score (0-10 cm)) and a verbal rating scale (VRS), was good. At rest, more than 80% of patients scored pain as absent or mild (VAS score 0-3) during the first 24 h, with only 4% experiencing severe pain (VAS score 7-10). On movement, 50% of patients had good pain control (VAS score 0-3) while 20% of patients experienced severe pain (VAS score 7-10). Minor complications such as emetic sequelae and pruritus were common; these conditions were mild and rarely required treatment. Hypotension (< 100 mm Hg) occurred in 34% of patients in the first 24 h. Ventilatory frequencies of 8 b.p.m. or less occurred in 2.6% of patients. Four patients (0.52%) developed severe respiratory depression. These patients demonstrated increased sedation but only one had a low ventilatory frequency. Three patients died while receiving extradural infusion analgesia.",1994.0,0,0
1119,8009339,Reversible urinary retention secondary to excessive morphine delivered by an intrathecal morphine pump.,G S Uppal; T T Haider; A Dwyer; J A Uppal,"Reversible complication of intrathecal morphine delivered by an implanted pump is described in one patient. The patient was evaluated initially using a contrast CT of the thoracic spine as well as urodynamics studies. After decreasing the intrathecally administered morphine from 2 mg/24 hr to .5 mg/24 hr, the patient's neurogenic bladder reversed within 4 days. Implanted pumps to deliver intrathecal narcotic medications are being used currently to treat intractable pain. This is a case report of reversible urinary retention secondary to the intrathecal narcotic.",1994.0,0,0
1120,8015060,Suboptimal treatment results with the Therasonics lithotriptor.,J B Robertson; M O Koch; F K Kirchner; J A Smith,"From July 1988 to August 1991, 174 stone treatments were attempted on 112 stones in 86 patients using a Therasonics lithotriptor. Mean stone diameter was 13 mm. (range 4 to 60). The success rate (defined as no debris or fragments less than 4 mm. in an asymptomatic patient) was 49% and the retreatment rate was 63%. Subjects reported moderate to severe pain during 70 treatment sessions (42%) despite sedation with parenteral narcotics (50 to 100 mg. meperidine and 50 mg. hydroxyzine intramuscularly). One patient had perirenal bleeding requiring a 7-unit blood transfusion. Of the treatments 24 (13%) were aborted, 10 due to pain and 13 because of inability of the operator to position the patient or localize the stone. These results appear to be inferior to those reported with alternative lithotriptors. Modifications that have been made in the Therasonics system may improve stone localization and treatment results.",2001.0,0,0
1121,8018403,The costs of managing severe cancer pain and potential savings from transdermal administration.,K Bloor; B Leese; A Maynard,"The economic evaluation of any new or existing therapy should include a comprehensive appraisal of costs. When evaluating pharmaceutical interventions, it is inappropriate to identify the purchase price alone. Other relevant costs include the costs of time of doctors, nurses and other personnel in administering and monitoring the effects of the therapy, and the costs of treating any side-effects. This study estimates direct National Health Service (NHS) costs in the U.K. of current medical practice in managing severe cancer pain, using a review of the published literature and constructing a cost analysis for four 'typical' patients. Costs are estimated for patients with severe cancer pain in a hospital and an ambulatory setting, with oral and subcutaneous routes of drug administration. The study includes costs of drugs, supplies, equipment and personnel time. The results demonstrate the importance of personnel time costs, and potential cost savings which could result from the use of transdermally administered opioid analgesics.",1994.0,0,0
1122,8022621,Opiate reduction in chronic pain patients: a comparison of patient-controlled reduction and staff controlled cocktail methods.,J A Ralphs; A C Williams; P H Richardson; C E Pither; M K Nicholas,"This study compares the effectiveness of two methods of opiate reduction in 108 chronic pain patients during a 4 week inpatient pain management programme, and at 1-month and 6-month follow-up. Patients chose either the patient-controlled reduction (PCR) or cocktail reduction method, aiming to complete withdrawal by discharge. Use of opiates and other drugs was recorded, and psychological measures taken, at admission, at discharge, and at follow-ups. Patients who opted for the cocktail reduction method started at higher morphine equivalents (P < 0.001), were less confident in their ability to cope without medication (P < 0.05), and rated their everyday activities a more disrupted by pain (P < 0.05). At discharge, 89% of the cocktail group were abstinent from opiates compared with 68% of the PCR group (P < 0.05). By 1-month follow-up, the advantage of the cocktail method had disappeared, with no significant differences between the two groups in mean opiate dose, nor in the proportion of abstinent patients. This was the result of a greater return to opiate use in the cocktail group, with abstinence rates remaining unchanged in the PCR group. By 6-month follow-up, abstinence rates for the groups were equivalent, with 55% of patients remaining off opiates. By this stage, however, non-abstinent cocktail group patients were taking significantly larger doses of opiates than PCR patients (P < 0.05), although in both groups, the dose was well below admission level. Admission opiate dose level was the best predictor both of abstinence at discharge and of subsequent opiate dose level in non-abstinent patients. This study demonstrates that both reduction methods can produce substantial reduction in opiate use by severely impaired chronic pain patients with long medication histories.",1994.0,0,0
1123,8026944,The physician survey on the post-concussion and whiplash syndromes.,R W Evans; R I Evans; M J Sharp,"The post-concussion syndrome (PCS) and whiplash syndrome (WS) have been controversial topics among physicians for many decades. There is little information available on the opinions and practices of physicians. In June of 1992, we performed a national survey by mail of the four physician groups most commonly treating these problems. The number of respondents and response rates were as follows: family physicians, 118, 16%; neurologists, 100, 21%; neurosurgeons, 97, 23%; orthopedists, 82, 13%. The survey instrument contained items on demographics, definitions, causation, prognosis, medico-legal aspects, testing, and treatment. Only a minority of respondents believe that PCS and WS are clearly defined syndromes. A substantial minority report that psychogenic and litigation factors are most responsible for the conditions. Most of the physicians believe that PCS and WS have a 3-6 month recovery time. A significant minority concur that symptoms of the two syndromes resolve when litigation is settled. Most of the physicians order tests to rule out pathology although a minority order tests to reassure patients or because of litigation concerns. Only a minority of respondents believe that effective treatments are available. Not surprisingly, a multitude of conventional and unconventional treatments are sometimes recommended. Many aspects of PCS and WS are controversial among treating physicians. This controversy can have a profound impact on the quality and cost of patient care. Ongoing research is required to discover more effective treatments for mild brain injury and chronic pain.",1994.0,0,0
1124,8041685,Myofascial pain syndrome. Primary care strategies for early intervention.,R R McClaflin,"Diagnosis of myofascial pain syndrome may become less challenging as clinical criteria become better defined. The mechanisms are not well known, and the syndrome occurs in a wide variety of settings. Trigger points with referred pain are the most common feature. Treatment consists of physical modalities (spray-and-stretch techniques and trigger point block) combined with a program of graded muscle stretching and strengthening. Early, aggressive treatment yields an improved prognosis.",1994.0,0,0
1125,8046193,,,,,0,0
1126,8048773,[Postoperative pain therapy at general nursing stations. An analysis of eight year's experience at an anesthesiological acute pain service].,C Maier; K Kibbel; S Mercker; H Wulf,"Despite major advances in knowledge and development of efficient techniques for pain control, many patients on surgical wards suffer from modest to severe pain following surgery or trauma. Therefore, in the University Hospital of Kiel, Germany, an anaesthesiology-based acute pain service (APS) was started in 1985 to improve this situation. Organization of an APS. The anaesthesiologist in training who manages the recovery unit serves as an APS for surgical wards and is supervised by a consultant. The anaesthesists on call are responsible after regular working hours. The activities of the APS are as follows: 1. Induction of sufficient postoperative analgesia in the recovery unit for all surgical patients. 2. Clinical rounds on all patients receiving epidural analgesia (EA), other forms of regional analgesia, or patient-controlled analgesia (PCA) every morning and throughout the day if necessary. 3. Additional consultations for postoperative pain management for other patients on request. 4. Assessment and documentation of the clinical status of the patient, quality of analgesia, and side effects. 5. Writing orders for further treatment. 6. Continuing consultations and informal education for ward nurses, physiotherapists, and surgical staff; formal medical training for ward nurses in postoperative pain management. Activity of the APS. From 1985 to 1992, 1947 patients on normal wards were treated (EA: 1736, PCA: 183). Epidural analgesia was performed using a standard protocol with bupivacaine 0.175%-0.25% infused continuously with top-ups if needed (mean 240 mg/day, range 75-600 mg; median duration 7 days, range 1-53, Table 1). Demand for further treatment was proved by day-to-day withdrawal. Since the introduction of an APS, complications of EA such as hypotension (1985/1986:5.1%; 1987/1992:0.5%, Table 3) and insufficient analgesia due to dislocation or other technical complications could be reduced significantly (Table 3). Dermal infections were seen in 2.6% of patients, with a significantly higher incidence in patients with arteriosclerotic diseases (4.1%). Epidural opioids were used in only 46 selected cases on surgical wards. Nevertheless, 2 cases of marked respiratory depression occurred. The overall risk of complications during postoperative EA could be reduced from 1:11 cases in the first 2 years to 1:20 in the last 6 years since introducing the APS. For other regional procedures (e.g., interpleural analgesia) no complications were recorded. PCA was performed using a standard protocol with tramadol or piritramide without background infusion (Table 6). The loading dose was titrated in the recovery unit.(ABSTRACT TRUNCATED AT 400 WORDS)",1994.0,0,0
1127,8070745,[Drug dependence and withdrawal in chronic pain patients].,R Wörz,"Drug dependence in ""pain patients"" usually involves primary headache syndromes with chronicity resulting from the use of analgesic-psychotropic or ergotamine-containing combination preparations. Since, during the withdrawal phase, enhancement of pain intensity together with other abstinence phenomena are to be expected, hospitalization is usually indicated. Psychosomatic pain syndromes with dependence on benzodiazepine derivatives represent the second largest group. In these patients, withdrawal is effected stepwise, usually on an outpatient basis. Opioid analgesics administered to patients to treat chronic pain do not necessarily lead to the development of tolerance. Occasionally, dependency is observed in organic or psychosomatic pain states. In all three groups, typical addition behavior is rare.",1994.0,0,0
1128,8075466,Acute pain management of the chronic pain patient on opiates: a survey of caregivers at University of Washington Medical Center.,S E Rapp; L M Wild; K J Egan; L B Ready,"The provision of acute pain management for the chronic pain patient can pose a challenge. We sought to characterize management issues. An anonymous survey was distributed to 270 physicians and 212 nurses at University of Washington Medical Center (UWMC) in an attempt to characterize management issues. Caregivers were queried regarding treatment modalities, efficacy of anxiolysis, patient attributes, concern of the quantity of medication, criteria for patient evaluation, and other management issues. Of the respondents, 61.8% were physicians, and 38.2% were nurses. The mean duration in practice was 7.7 years. The responses from the two groups were similar. Seventy-five percent reported using different pain-evaluation techniques for chronic pain patients than those utilized for the ""average"" patient. Pain scores were used frequently in the average patient, whereas ability to perform activities was used more commonly in the chronic pain patient (p < 0.0001). Half of the respondents expressed concern regarding the amount of medication used and level of sedation. The same proportion found anxiolysis to be a helpful adjunct. The use of a time-contingent ""pain cocktail"" as an oral medication was a useful strategy for 88% of respondents. The least labor-intensive modality reported was patient-controlled analgesia (PCA) for 84.5% of respondents; intravenous opiate fusion, 5.3%; and epidural analgesia, 11.2%. The survey describes caregiver concerns regarding this patient population, including medication use, sedation, length of hospital stay, and evaluation techniques.",1994.0,0,0
1129,8077118,"Intraspinal delivery of opiates by an implantable, programmable pump in patients with chronic, intractable pain of nonmalignant origin.",R B Kanoff,"The use of intraspinal therapy for the management of intractable pain from nonmalignant causes has not been widely discussed. An implantable, externally programmable infusion pump was used for intraspinal delivery of morphine sulfate to 15 patients with intractable pain from reflex sympathetic dystrophy, arachnoiditis after spinal surgery, or an unknown cause. Dosage patterns were individualized. At follow-up ranging from 2 to 44 months, pain relief was reported as excellent by 8 patients, good by 3, and fair by 4. Six patients have returned to work. Two patients chose to terminate therapy. Few complications occurred, but most patients needed increasingly larger doses over time to maintain pain relief. Intraspinal infusion of morphine sulfate by use of an implanted, externally programmable pump is safe and effective in selected patients with intractable pain of nonmalignant origin.",1994.0,0,0
1130,8086015,"Open vs. arthroscopic acromioplasty: a prospective, randomized study.",R A Sachs; M L Stone; S Devine,"Between May 1988 and May 1990, 44 patients with Stage II impingement were randomized into open and arthroscopic treatment groups. Forty-one patients were available for final follow-up in May 1991: 22 in the open group, 19 in the arthroscopic group. Comparisons of pain, function, motion, and strength were made preoperatively and at 2, 6, 12, 26, and 52 weeks postoperatively. Final analysis showed that the main benefits of arthroscopic acromioplasty were evident in the first 3 months postoperatively. Arthroscopic patients regained flexion and strength more rapidly than did open patients, had shorter hospitalizations, used less narcotics, and returned more quickly to both work and activities of daily living. By 3 months postoperatively, open patients tended to ""catch up"" with arthroscopic patients, and further recovery was equivalent. In both groups, full recovery took at least 1 year for the majority of patients and in both groups at 1 year > 90% of patients achieved a satisfactory result. Because of its medical and economic advantages for both the patient and the health-care system, we conclude that arthroscopic acromioplasty should become the procedure of choice for patients with impingement syndrome refractory to conservative treatment.",1994.0,0,0
1131,8088198,"Combined traditional Chinese medicine and Western medicine. Relieving effects of Chinese herbs, ear-acupuncture and epidural morphine on postoperative pain in liver cancer.",Q S Li; S H Cao; G M Xie; Y H Gan; H J Ma; J Z Lu; Z H Zhang,"In the evaluation of Chinese herbs (A), ear-acupuncture (B) and epidural morphine (C) to relieve postoperative pain and abdominal distension, sixteen male patients with primary liver cancer were observed. This study was conducted by means of orthogonal experiment and double blind, randomized design. The patients received various treatments according to the display of the orthogonal table L16(2)15 which corresponds to 2(3) factorial experiment design. C+ (morphine 2 mg) was given before the peritoneum was sutured. A+ (orally administered) and B+ were given 24 hours after operation. 50-100 mg of pethidine was given when the pain intensity VAS (0-100) exceeded 50-70. The observation parameters included plasma leucine enkephalin (LEK), postoperative total dosage of narcotics administered for 5 days, VAS for pain and pain reliever, abdominal distension, urinary retention, constipation, etc. The results were as follows: a. Patients who had received A (A+B+C+, A+B+C-, A+B-C-, A+B-C+); C (C+A+B+, C+A+B-, C+A-B+, C+A-B-), or B (B+A+C+, B+A+C-, B+A-C+, B+A-C-) produced better analgesic effects than those who had received placebo. The A, B, and C reduced narcotics 650, 450 and 550 mg respectively when compared with placebo. The effects of A and C were of statistical significance (P < 0.05), while AB, BC, and AC interactions were not found; b. A and B minimized abdominal distension and urinary retention, while C prolonged them. As compared with the placebo, A and B accelerated restoration of bowel peristalsis (P < 0.05, ANOVA). Both A and B decreased it for 165 hours, while epidural morphine prolonged it for 49 hours; and c.(ABSTRACT TRUNCATED AT 250 WORDS)",1994.0,0,0
1132,8090511,Study of the sensitivity of the diabetes-induced pain model in rats to a range of analgesics.,C Courteix; M Bardin; C Chantelauze; J Lavarenne; A Eschalier,"The streptozocin-induced diabetic rat has been put forward as a model of chronic pain with signs of hyperalgesia and allodynia that may reflect signs observed in diabetic humans. The aim of this work was to assess, in streptozocin-induced diabetic rats, the pharmacological activity to several analgesic drugs known to be effective (clomipramine, amitriptyline, desipramine, clonidine, lidocaine), ineffective (aspirin), or with a doubtful effectiveness (morphine) in human painful diabetic neuropathy. The animals were submitted to a mechanical pain test (paw pressure) and the ability of the drugs to reverse diabetes-induced hyperalgesia was tested. The tested antidepressants (0.125-8 mg/kg, i.v.) were slightly effective in diabetic rats; amitriptyline and clomipramine induced a weak effect, whereas desipramine was more active, suggesting noradrenergic specificity. This was confirmed by the effectiveness of clonidine (50, 100, 150 micrograms/kg, s.c.). Lidocaine (1-9 mg/kg, i.v.) had prolonged efficacy on mechanical hyperalgesia. Aspirin (100 mg/kg, i.v.) was without effect and morphine (0.5-4 mg/kg, i.v.) induced a dose-dependent antinociceptive effect but at doses twice as high as those used in normal rats. These results demonstrate the high pharmacological predictivity of this model of painful diabetes and suggest that in this pathological condition, among the drugs acting on monoaminergic transmission, noradrenergic drugs seem the most active.",1994.0,0,0
1133,8091514,Pharmacology of chronic pain.,A Dray; L Urban; A Dickenson,"Chronic pain, which is associated with prolonged tissue damage or injuries to the peripheral or central nervous system, results from a number of complex changes in nociceptive pathways. These include alterations of cell phenotype and changes in the expression of proteins such as receptors, transmitters and ion channels, as well as modifications of neural structure, for example, cell loss, nerve regeneration and synaptic reorganizations. The resultant increase in neural excitability can be reduced with receptor-selective drugs that block peripheral or central chemical mediators or that control ectopic activity or cellular phenotype changes. In this article, Andy Dray, Laszlo Urban and Anthony Dickenson focus on some current mechanistic aspects of chronic pain imposed by inflammation and peripheral neuropathy, and review in particular the molecular changes involving the pharmacology of nociceptive pathways since these have important implications for the management of pain.",1994.0,0,0
1134,8107739,High-dose intravenous methylprednisolone therapy for pain in children and adolescents with sickle cell disease.,T C Griffin; D McIntire; G R Buchanan,"The management of episodes of severe pain in patients with sickle cell disease is a difficult clinical problem. We studied 36 children and adolescents with sickle cell disease who had 56 acute episodes of severe pain (44 in 27 patients with sickle cell anemia, 8 in 7 patients with sickle cell-hemoglobin C disease, and 4 in 2 patients with sickle cell-beta (+)-thalassemia). The patients were randomly assigned in double-blind fashion to receive an intravenous infusion of either saline placebo or high-dose methylprednisolone (15 mg per kilogram of body weight, to a maximum of 1000 mg) on their admission to the hospital and again 24 hours later. All the patients received intravenous morphine sulfate until severe pain abated and were then given acetaminophen with codeine. For all episodes of pain, the duration of inpatient analgesic therapy (intravenous and oral) was significantly shorter for the patients who received methylprednisolone than for those given placebo (mean, 41.3 vs 71.3 hours; P = 0.030). The difference was still significant (31.0 vs. 62.5 hours; P = 0.010) when we excluded seven episodes that were complicated by the chest syndrome (three in the methylprednisolone group and four in the placebo group). The patients who received methylprednisolone had recurrent episodes of pain shortly after the discontinuation of therapy more often than did the patients receiving placebo. No adverse effects of methylprednisolone were observed. A short course of high-dose methylprednisolone decreased the duration of severe pain in children and adolescents with sickle cell disease, but patients who received methylprednisolone had more rebound attacks after therapy was discontinued. On balance, corticosteroids are promising as an adjunct to supportive therapy for painful episodes in children and adolescents with sickle cell disease.",1994.0,0,0
1135,8110639,Continuous spinal anesthesia for cancer and chronic pain.,S E Abram,"The use of spinal opioids for intractable pain is limited by development of tolerance and opioid resistance of some types of pain. The literature regarding clinical experience with spinal mu opioid agonists for chronic and cancer pain was reviewed. Experimental use of intrathecal non-mu opioid agonists and non-opioid agonists and antagonists was also reviewed. Intrathecal mu agonists, particularly morphine, are effective for most patients with cancer pain, though in some patients rapid tolerance or marked resistance develop. Varied results are seen among chronic pain patients. Delta opioid agonists and a variety of non-opioid agonist analgesics are effective in standard analgesic testing paradigms, and some agents are effective in clinical trials. NMDA and NK-1 receptor antagonists are effective in models that produce sensitization of spinal dorsal horn neurons. A number of new agents appear to have promise as intrathecal drugs for patients with intractable chronic and cancer pain.",1993.0,0,0
1136,8111982,Neurosurgical procedures for chronic pain. General neurosurgical practice.,R B North,,1993.0,0,0
1137,8117641,Topical diclofenac in the treatment of ocular pain after excimer photorefractive keratectomy.,N A Sher; J M Frantz; A Talley; P Parker; S S Lane; C Ostrov; E Carpel; D Doughman; J DeMarchi; R Lindstrom,"Following excimer laser photorefractive keratectomy, patients experience significant ocular pain until corneal reepithelialization. Despite the use of cold compresses, bandage soft contact lenses, cycloplegics, narcotics, and topical corticosteroids, the pain has not been adequately controlled in many patients. A randomized, double-masked, parallel-group study of diclofenac sodium 0.1% ophthalmic solution and its placebo vehicle was evaluated. Patients undergoing excimer myopic photorefractive keratectomy on their second eye were admitted overnight. Postoperative procedures included two drops of diclofenac or placebo immediately after surgery and then qid until reepithelialization, topical tobramycin (qid), 0.1% fluorometholone (q2h), cycloplegics, and a disposable soft contact lens. Thirty-two patients (diclofenac = 16, placebo = 16) were evaluated from +30 minutes to +96 hours by several types of questionnaires. Most patients who received placebo experienced pain, starting within 1 hour, peaking at 4 to 6 hours and lasting 36 to 48 hours. The diclofenac-treated patients rarely experienced the early peak in pain, had less pain overall until 72 hours postoperatively, and experienced significantly less photophobia and burning/stinging. Significantly fewer patients on diclofenac required oral narcotics. Three patients (diclofenac = 2, placebo = 1) developed corneal infiltrates, the etiology of which is not known. In a separate study we conducted, there was no difference in epithelial healing times between the diclofenac-treated eyes and those not receiving the drug. Diclofenac appears to significantly reduce the ocular pain following excimer photorefractive keratectomy.",1993.0,0,0
1138,8121746,Epidural analgesia in the management of severe vaso-occlusive sickle cell crisis.,M Yaster; J R Tobin; C Billett; J F Casella; G Dover,"To determine whether continuous epidural analgesia could effectively decrease pain and thereby improve the management of severe vaso-occlusive crisis in children with sickle cell disease who were unresponsive to conventional analgesic therapy. Retrospective observational study. A tertiary care hospital with a large pediatric sickle cell patient referral population. The study describes nine children in 11 painful vaso-occlusive crises, unresponsive to high-dose systemic opioids, nonsteroidal anti-inflammatory drugs, and adjunctive measures, who underwent continuous epidural analgesia to control pain. Subjective pain scores, arterial oxygen saturation monitoring, and plasma lidocaine levels. Placement of an epidural catheter for the administration of a continuous infusion of local anesthetic, alone, or in combination with fentanyl, in the management of vaso-occlusive crisis. An initiation of epidural analgesic therapy, 8 of 9 patients reported severe pain (8 to 10 on a scale of 0 to 10, 0 = no pain, 10 = the worst pain they ever experienced). Analgesic was immediate (pain score 0 to 2) in 8 of 9 patients, and continuously effective in 9 of 11 crises. Five patients required either the addition of fentanyl or changing the local anesthetic from lidocaine to bupivacaine to maintain analgesia for 2 to 5 days. In 7 of 9 patients, oxygen saturation dramatically increased from 87 to 95% to 99 to 100% after epidural analgesia was initiated. In all patients, plasma lidocaine levels ranged from 1.1 to 4.6 mg/L and dose-related toxicity did not occur. One patient developed hypotension secondary to high sympathetic blockade (T-4), one had an inadvertent dural puncture during insertion of the catheter, one had the epidural catheter removed for fever, and one achieved analgesia only transiently. There were no other complications, and epidural analgesia was not associated with sedation, respiratory depression, or limitation of movement. All epidural catheters were cultured on removal, and colonization did not occur. Epidural analgesia with local anesthetics administered alone or in combination with fentanyl effectively and safely treats the pain of sickle cell vaso-occlusive crisis unresponsive to conventional pain management and does so without causing sedation, respiratory depression, or significant limitation on ambulation. Furthermore, early treatment of painful crisis with this technique may improve oxygenation, a critical factor in the evolution of further sickling.",1994.0,0,0
1139,8132434,Classification of daily and near-daily headaches: proposed revisions to the IHS criteria.,S D Siberstein; R B Lipton; S Solomon; N T Mathew,"The International Headache Society (IHS) headache classification, while a major advance, does not adequately classify the daily and near-daily headache disorders known as chronic daily headache (CDH). We believe that chronic daily headache is a group of disorders which includes chronic tension-type headache (CTTH), transformed migraine (TM), new daily persistent headache (NDPH), and hemicrania continua (HC). We propose specific criteria for transformed migraine, new daily persistent headache, and hemicrania continua, and have modified the criteria for chronic tension-type headache.",1994.0,0,0
1140,8150402,"[Fear, violence and depression--does too little serotonin make the mind ill?].",J Demling,,1994.0,0,0
1141,8153780,Postoperative analgesia after major shoulder surgery with interscalene brachial plexus blockade: etidocaine versus bupivacaine.,B H Dorman; J M Conroy; T A Duc; G R Haynes; R J Friedman,"Postoperative pain is commonly treated with significant doses of narcotics, occasionally resulting in side effects including nausea, pruritus, and respiratory depression. One potential advantage of regional anesthesia is profound postoperative analgesia that reduces exposure to potent narcotics. To evaluate the efficacy of two long-acting local anesthetics, bupivacaine and etidocaine, in providing pain relief after major shoulder surgery, we randomized 20 patients to receive either bupivacaine or etidocaine for brachial plexus block as the primary anesthetic for shoulder surgery. Surgeons, patients, and the acute pain service were blinded as to drug selection. After the patient was sedated, an interscalene block was placed with the use of a nerve stimulator to facilitate proper needle placement. Forty milliliters of either 0.5% bupivacaine or 0.75% etidocaine containing 5 micrograms/mL epinephrine was injected into the brachial plexus sheath. An additional 8 mL of local anesthetic was administered for superficial cervical plexus blockade. Intraoperative sedation was accomplished with an intravenous infusion of methohexital as needed. After surgery, patients received a standard patient-controlled analgesia protocol providing incremental doses of morphine. The degree of postoperative analgesia resulting from residual local anesthetic effect was expressed as the time until first morphine requirement and the total dose of morphine required during the first 24 hours postoperatively. We found no statistically significant intergroup differences either in time of initial use of morphine or in the total dose of morphine required in the first 24 hours. Both etidocaine and bupivacaine provide prolonged analgesia after major shoulder surgery when injected into the brachial plexus. Bupivacaine, however, possesses significant cardiotoxicity and has a relatively delayed onset in peripheral neural blockade. Etidocaine is less cardiotoxic and also has a more rapid onset of effect. Thus etidocaine may be a preferable agent for interscalene block for major shoulder surgery.",2001.0,0,0
1142,8153781,"Comparison of oral ketorolac, intramuscular morphine, and placebo for treatment of pain after orthopedic surgery.",M A Maslanka; J R de Andrade; T Maneatis; L Bynum; E DiGiorgio,"Using a randomized, double-blind, placebo-controlled, parallel, single-dose, single-center, 6-hour study, we compared the analgesic response and tolerability of oral ketorolac tromethamine and intramuscular morphine sulfate and placebo. The study group comprised 176 patients with moderate, severe, or very severe pain after hip or knee surgery at a teaching hospital. Patients received either 10 mg of ketorolac orally, 10 mg of morphine intramuscularly, 5 mg of morphine IM, or placebo. Patients rated pain intensity at baseline and pain intensity and pain relief at 30 minutes, 1 hour, and hourly thereafter for 6 hours. At study completion, we evaluated overall patient ratings of pain relief and occurrence of adverse events. Summed pain intensity difference scores and total pain relief scores showed the active medications to be significantly superior to placebo and not significantly different from each other. The 10-mg dose of morphine showed a small advantage over ketorolac in peak analgesic effect, but the onset of pain relief was comparable among the active agents. The incidence of adverse events among the active-treatment groups was similar, though there was a numerical trend favoring ketorolac over 10 mg of morphine. We found oral ketorolac to be an effective alternative to parenteral opioids for the treatment of pain after hip or knee surgery in patients who can tolerate oral medication.",1994.0,0,0
1143,8156242,"Malignant and non-malignant chronic pain: therapy, opioids and fears. Swiss Centre for Paraplegia, Nottwil, 6 May 1993.",F Stiefel,,1993.0,0,0
1144,8159602,Picenadol in a large multicenter dental pain study.,D J Goldstein; R L Brunelle; R E George; S A Cooper; P J Desjardins; G W Gaston; G E Jeffers; L T Gallegos; D C Reynolds,"To estimate the analgesic dose of picenadol hydrochloride equal to codeine 60 mg in a dental pain model. Randomized, double-blind, parallel, dose-response study. Four university-based dental clinics. Four hundred eight adult patients with moderate or severe pain after extraction of one or more impacted molar teeth plus bone removal. Patients received orally administered single doses of picenadol 15 and 30 mg, codeine phosphate 30 and 90 mg, or placebo. Single oral doses of picenadol 15 and 30 mg, an opioid agonist-antagonist, were compared with codeine 30 and 90 mg and placebo in 408 patients with moderate or severe pain from third molar extraction in a randomized, double-blind, parallel study. Assessments were performed for pain intensity, pain relief, and adverse events for up to 6 hours after drug administration. Picenadol 30 mg and codeine 90 mg were more effective than placebo based on sum of pain intensity differences, total pain relief, peak pain relief, and duration of analgesia (p < 0.05). Compared with placebo, the frequency of adverse events was highest for patients receiving codeine 90 mg (p < 0.05). No patients discontinued due to adverse events, and all such events resolved spontaneously. Picenadol 22 mg was estimated to be equianalgesic to codeine 60 mg, and picenadol 30 mg was safe in this dental pain model.",1994.0,0,0
1145,8160486,The outcome status of chronic pain patients 4 years after multidisciplinary care.,T E Tyre; D E Walworth; E M Tyre,"Thirty-three patients previously treated for a variety of chronic pain syndromes (largely non-surgical back problems) were selected for study on the basis of 2 years or greater post-discharge status. A patient profile was developed revealing an 86% successful return-to-work rate and minimal use of narcotics 4 years after discharge. In addition, there was relatively low use of either inpatient or outpatient medical services after treatment. These patient behaviors were specific goals of the pain management program in which these patients had participated. Interesting data were also collected on medication use after treatment and methods of pain control used most successfully. Selected outcome variables were also studied across specific diagnostic categories (surgical v non-surgical back problems, amputee pain, reflex sympathetic dystrophy, and others) for this group. In general, rather compelling positive outcomes are shown for the long-term effects of multi-disciplinary pain management.",1994.0,0,0
1146,8170183,Pathophysiology of pain.,S A Cross,"To review the pain pathways in the central and peripheral nervous system and the actions of drugs used to treat pain. An overview of pain pathways is presented, beginning in the periphery and progressing centrally, and the ascending and descending pathways are described in detail. The nociceptive pathway, consisting of the classic three-neuron chain, is now understood to be a dual system at each level, and the sensation of pain is thought to arrive in the central nervous system with the discriminative component of pain (""first pain"") carried separately from the affective-motivational component of pain (""second pain""). In addition to spinal control mechanisms of nociceptive transmission, descending pathways that originate in three major areas--the cortex, thalamus, and brain stem--can modify functions at the spinal level. At every level of the nervous system, a close relationship prevails between somatic pain pathways and visceral pathways. This relationship likely accounts for the transmission of visceral pain and also for autonomic responses to somatic pain and somatic responses to visceral pain. By understanding the pathways of pain and the transmitters involved, prevention and treatment of pain will be improved.",1994.0,0,0
1147,8172044,Common problems in sickle cell disease.,J H Samuels-Reid,"Sickle cell disease is transmitted as an autosomal recessive trait. Symptoms of pallor, fever, abdominal and joint pain, and swelling of the liver, spleen, hands and feet first appear near the latter part of the first year of life. Intravascular sickling affects all organs. For clinical and therapeutic purposes, exacerbations may be classified as vasoocclusive or pain, aplastic, hemolytic or sequestration crisis. In addition to infection, complications include severe pain, cerebrovascular accidents, cholelithiasis, bone infarction, heart failure, hypotension and priapism. The most common cause of early childhood death is septicemia or meningitis due to Streptococcus pneumoniae. Complications may be reduced or prevented by early diagnosis through newborn screening, patient education, routine immunizations, administration of folic acid, pneumococcal and influenza vaccinations, penicillin prophylaxis, and early diagnosis and aggressive treatment of complications.",1994.0,0,0
1148,8185043,Laparoscopic hernia repair.,O N Panton; R J Panton,"Seventy-nine patients (106 repairs) with inguinal hernias underwent laparoscopic transabdominal preperitoneal hernia repair. The patients included 73 males and 6 females, ranging in age from 19 to 86 years. Twenty-five percent had undergone previous abdominal surgery, and 19% had recurrent hernias. Preoperative diagnosis was 40 right inguinal hernias (RIH), 33 left inguinal hernias (LIH), and 6 bilateral hernias. Intraoperatively, 30 RIH, 22 LIH (1 patient also had a left incisional hernia), 26 bilateral hernias, and 2 femoral hernias were diagnosed and repaired. Twenty patients (25%) had contralateral hernias diagnosed intraoperatively. Average operating time for unilateral repairs was 76 minutes and for bilateral repairs was 110 minutes. Forty-three percent of patients underwent day-care surgery, and 35% were discharged on the first postoperative day. Postoperative complications included 6 cases of transient neuralgias (7%), 3 cord/scrotal hematomas (4%), 1 trocar site hematoma (1%), and 1 case of chronic pain (1%). Follow-up ranged from 1 to 12 months with no recurrences. This study demonstrates the importance of laparoscopy in identifying undiagnosed contralateral hernias, that bilateral hernias can be repaired with no additional morbidity, and that there are high rates of success and safety in laparoscopic hernia repairs in a community hospital.",1994.0,0,0
1149,8197031,Evaluation of two opioid-acetaminophen combinations and placebo in postoperative oral surgery pain.,J A Forbes; J A Bates; I A Edquist; W H Burchfield; F G Smith; M K Schwartz; V Kit; J Hyatt; W E Bell; W T Beaver,"To determine the relative analgesic potency and adverse effect liability of hydrocodone bitartrate 7.5 mg with acetaminophen 500 mg, codeine phosphate 30 mg with acetaminophen 300 mg, and placebo in the treatment of pain following oral surgery. Randomized, double-blind, single-dose, placebo-controlled, parallel-group study with self-ratings at 30 minutes and then at hourly intervals from hour 1 to hour 6. Private, oral surgery practice sites. Three hundred twenty-four outpatients with moderate or severe pain after the surgical removal of impacted third molars were selected. One was lost to follow-up and 32 did not need an analgesic; 232 patients had valid efficacy data. Patients were treated with a single oral dose of hydrocodone bitartrate 7.5 mg with acetaminophen 500 mg, codeine phosphate 30 mg with acetaminophen 300 mg, or placebo when they experienced steady, moderate or severe pain that, in their opinion, required an analgesic. Using a self-rating record, subjects rated their pain and its relief for 6 hours after medicating; estimates of peak and total analgesia were derived from these subjective reports. This study was a valid analgesic assay. Both active treatments were significantly superior to placebo for all measures of analgesic efficacy. The hydrocodone-acetaminophen combination was significantly superior to the codeine-acetaminophen combination for total pain relief and the number of evaluations with 50% relief. Both active treatments manifested an analgesic effect within 30 minutes; the effect persisted for 5 hours for the codeine combination and 6 hours for the hydrocodone combination. Adverse effects were transient, consistent with the pharmacologic profiles of opioids, and none required treatment. A slight advantage in analgesic efficacy was demonstrated in this single-dose study for the hydrocodone-acetaminophen combination. Repeat-dose studies, however, should be conducted to determine the clinical significance of the difference in analgesic effect of these opioid combinations.",1994.0,0,0
1150,8251294,Postoperative analgesia in children using continuous s.c. morphine.,R McNicol,"Sixty children (7 months-20 yr; mean 6.5 yr, median 7-8 yr, mode 1-2 yr) undergoing major surgery received a balanced technique of general anaesthesia combined with bupivacaine as a single injection extradural or peripheral nerve block. Postoperative analgesia consisted of a subcutaneous infusion of morphine 1 mg kg-1 body weight in 20 ml of normal saline [corrected] at a rate of 0.3-0.5 ml h-1, controlled by the nursing staff in the surgical ward. Monitoring included SpO2, pain, sedation and nausea/vomiting scores. Infusions were used for a mean of 38.8 h (range 17-80 h). Ninety-seven percent of recordings of SpO2 were greater than 94% and only one recording in 2361 was less than 90%. Ninety-four percent of pain scores indicated either no pain or slight pain; 1% indicated severe pain. On the order of the medical staff, seven children had the rate of infusion of morphine increased to 0.6 ml h-1 [corrected] because of high pain scores. Sedation scores compatible with children being either awake or asleep but rousable by speech alone were recorded on 99.7% of occasions. No child at any time was unrousable. Of 1248 nausea/vomiting scores, only 2.8% indicated the presence of these side effects; in only two children were they thought to be troublesome. As a result of this audit, nursing staff have been permitted to increase the rate of infusion of morphine to 0.6 ml h-1 [corrected] if required.",1993.0,0,0
1151,8263753,Evaluation of recalcitrant pain in HIV-infected hospitalized patients.,A Anand; L Carmosino; A E Glatt,"Chronic refractory severe pain in HIV-infected patients is a common and often neglected problem. Little data exist evaluating its epidemiology, clinical features, and treatment. Our study assessed all HIV-infected inpatients referred to the pain control service over a 2-year span. All (24) inpatients with HIV infection with chronic refractory severe pain referred to the pain control service (PCS) over a 2-year period were prospectively followed daily by trained specialists who graded the pain, recommended appropriate therapy, and assessed outcome. Ten surviving patients had further long-term outpatient follow-up. The patients included 14 intravenous drug abusers, five of whom were on methadone maintenance. Localized lower-extremity pain was present in 58%. Pain had been present for > or = 1 month in 21 (88%) and for > or = 6 months in 12 (50%). No patient had been on pain control around the clock. After PCS consultation, all surviving patients (21 of 21, 100%) had partial or total pain relief within 2 weeks (eight within 1 week) using around-the-clock opioid analgesia adjusted daily as necessary. No differences were seen between substance abusing/methadone patients and others. No significant adverse reactions or new addiction problems were found. Our conclusion is that effective pain control can be achieved using around-the-clock opioid analgesia in terminal HIV-infected patients with severe, chronic, refractory pain, even if the patients are substance abusers.",1994.0,0,0
1152,8269439,Pentazocine analgesia: is there a niche for Talwin Nx?,J Q Swift; K M Hargreaves,"Pentazocine can be a useful analgesic agent for the management of acute dental pain. It has both central and peripheral opioid activity. In clinical trials, analgesic compounds containing pentazocine have been shown to effectively relieve moderate-to-severe pain. It is an appropriate analgesic for the codeine-sensitive patient. Because of a change in formulation, the potential for abuse has been minimized. Although there is a possibility that the drug may have a psychotomimetic effect, the incidence is low and should not preclude use. Analgesic compounds containing pentazocine are clinically appropriate for the management of surgically induced dental pain.",1993.0,0,0
1153,8278202,The chronic intraspinal use of opioid and local anesthetic mixtures for the relief of intractable pain: when all else fails!,E S Krames,,1993.0,0,0
1154,8280545,Oral bromfenac 10 and 25 mg compared with sublingual buprenorphine 0.2 and 0.4 mg for postoperative pain relief.,D Carroll; T Frankland; C Nagle; H McQuay,"The aim of this single-dose, randomized, positive control, double-dummy, double-blind, parallel group study was to compare oral bromfenac 10 and 25 mg with sublingual buprenorphine 0.2 and 0.4 mg for treatment of postoperative pain. We studied 91 patients with moderate or severe pain after general surgical or orthopaedic operations, using pain intensity, pain relief, adverse effect, mood and sedation outcomes. There was a significant analgesic dose-response for buprenorphine, showing study sensitivity, but not for bromfenac. The two bromfenac treatments were significantly superior to the two buprenorphine treatments. Significantly more patients reported nausea with buprenorphine. There was evidence of a ceiling effect for analgesia with bromfenac.",1993.0,0,0
1155,8287198,"Attitudes of general practitioners in Bizkaia, Spain, towards the terminally ill patient.",A Lopez de Maturana; V Morago; E San Emeterio; J Gorostiza; A O Arrate,"This paper reports the results of a survey of general practitioners in Biscay which investigated the types of narcotics used in the treatment of chronic malignant pain, the degree of their use and the difficulties encountered both in the use of narcotics and the general care of the terminally ill patient. We found that (1) 50% of the doctors surveyed used narcotics in the treatment of at least 60% of their patients with terminal disease; (2) morphine is the most frequently used narcotic, usually being given orally, and (3) those who completed the questionnaire showed themselves to be highly motivated when treating terminally ill patients. However, they considered that their motivation exceeded their level of competence and, according to the majority, collaboration between the different health services and the formation of interdisciplinary teams would be the best way to facilitate an increase in competence.",1993.0,0,0
1156,8295807,Pharmacology of pain management.,D C Tyler,,1994.0,0,0
1157,8304606,Indomethacin suppositories versus intravenously titrated morphine for the treatment of ureteral colic.,W H Cordell; T A Larson; J E Lingeman; D R Nelson; J R Woods; L B Burns; L W Klee,"To develop a protocol for the blinded IV titration of morphine and to compare the analgesic efficacy and side effect profile of indomethacin suppositories versus IV morphine in the treatment of acute ureteral colic. Randomized, double-blind, double-dummy, two-period crossover study. Emergency department of a central-city, teaching hospital. Patients 18 to 75 years of age with pain suggestive of ureteral colic. Exclusions included pregnancy, adverse reactions to the study drugs, chronic nonsteroidal anti-inflammatory drug (NSAID) therapy, or any pain medicine taken within four hours of ED admission. Patients were randomized to one of two groups: indomethacin 100-mg rectal suppository or morphine by IV titration (5-mg loading dose and up to two additional 2.5-mg doses if needed). At the end of 30 minutes, if adequate pain relief had not been obtained, treatment was crossed over. Verbal analog scale (initial pain) and visual analog pain relief scale. Seventy-five patients were entered into the study. Only data from those patients with stone presence confirmed by IV pyelogram or stone passage were analyzed. Twenty-four could not be evaluated (23 who did not meet criteria for stone presence and one whose pain resolved spontaneously before study medications could be administered). Of the remaining 51 patients, 31 received indomethacin first and 20 received morphine first. Morphine recipients reported more pain relief at ten minutes (P = .02), but at 20 and 30 minutes, no significant difference (P = .17 and .74, respectively) existed between the two groups. IV morphine produced more rapid analgesia than rectally administered indomethacin. There were no significant differences in vital sign changes or number of side effects between the two treatment groups. This study is the first to compare an NSAID with morphine administered by IV titration, considered by many to be the ""gold standard"" for relief of acute, severe pain. Future studies could evaluate the simultaneous administration of an opioid combined with an NSAID or compare an IV titrated opioid with an IV NSAID.",1994.0,0,0
1158,8519714,Thoracic versus lumbar administration of fentanyl using patient-controlled epidural after thoracotomy.,F Bouchard; P Drolet,"Epidural fentanyl injection can provide analgesia following thoracotomy, but where to insert the catheter is a matter of debate. The study compares the effects of thoracic and lumbar patient-controlled epidural fentanyl on analgesia, fentanyl requirements, and plasma levels after thoracotomy. Thirty patients were randomized into two groups to receive either thoracic or lumbar patient-controlled epidural fentanyl for postoperative analgesia. Postoperative pain (10 cm, visual analog scale [VAS]) and fentanyl requirements were assessed every 4 hours for 24 hours and at 12-hour intervals for the next day. Fentanyl plasma levels were measured at 8 and 16 hours after surgery. Results were expressed as mean +/- 1 SD and analyzed using Student's t-test, ANOVA, and chi-square analysis at P < .05. Twenty-nine patients completed the study (14 in the lumbar and 15 in the thoracic group). The VAS scores and fentanyl requirements were not significantly different at any time interval in the thoracic group as compared to the lumbar group. VAS scores at 0 hours (4.6) and 4 hours (4.6) in the lumbar group were higher than VAS scores at 12 hours (2.8; P = .04), 16 hours (2.5; P = .02), and 20 hours (2.2; P = .01) in the same group. No significant difference was found between the fentanyl plasma levels of the two groups after 8 hours (lumbar, 0.26 +/- 0.37 ng/mL; thoracic, 0.22 +/- 0.20 ng/mL) or 16 hours (lumbar, 0.36 +/- 0.17 ng/mL; thoracic, 0.44 +/- 0.32 ng/mL). The authors concluded that there is little if any advantage of thoracic over lumbar patient-controlled epidural fentanyl administration in patients after thoracotomy with respect to analgesia, fentanyl requirements, and plasma levels.",1995.0,0,0
1159,8519715,Subarachnoid fentanyl augments lidocaine spinal anesthesia for cesarean delivery.,C M Palmer; D Voulgaropoulos; D Alves,"Fentanyl at doses of 6.25 microgram or more, when to hyperbaric bupivacaine for spinal anesthesia for cesarean delivery, has been reported to markedly increase the duration of analgesia. In this study, subarachnoid fentanyl 15 micrograms was evaluated as the sole adjunct to hyperbaric lidocaine spinal anesthesia in parturients undergoing cesarean delivery at term, to determine its effect on the duration of analgesia and side effects perioperatively. Twenty-eight parturients scheduled for elective cesarean delivery at term were randomized to one of two groups in a prospective, double-blind fashion. Patients in group F received 15 micrograms fentanyl in addition to 80 mg hyperbaric lidocaine for subarachnoid anesthesia, while patients in group N received 0.3 mL normal saline in addition to 80 mg hyperbaric lidocaine. Visual analog pain scores were recorded preoperatively and at regular intervals until the first patient request for additional analgesia. The occurrence of side effects (nausea, vomiting, pruritus, shivering) was recorded at intervals for 4 hours postinduction. All patients received patient-controlled analgesia after delivery, and analgesic requirements for 24 hours postinduction were recorded. There was no difference between groups with respect to visual analog pain scores intraoperatively. The mean duration of effective analgesia was increased in the patients receiving fentanyl from 71 minutes to 101 minutes (Student's t-test, P < .01). No difference was observed between groups with regard to 4-hour or 24-hour analgesic requirements. Patients in group F were significantly less likely to experience nausea (Fisher's exact test, P < .05) and vomiting (chi-square test, P < .05) in the immediate perioperative period, but no differences were noted between groups in the incidence of pruritus or shivering. The addition of fentanyl 15 micrograms to hyperbaric lidocaine for subarachnoid anesthesia for cesarean delivery increases the duration of effective analgesia by approximately 30 minutes compared to plain hyperbaric lidocaine, and provides a protective effect regarding nausea and vomiting in the perioperative period.",1995.0,0,0
1160,8519716,Intravenous ketorolac and subarachnoid opioid analgesia in the management of acute postoperative pain.,K H Gwirtz; H C Kim; D J Nagy; J V Young; R S Byers; D A Kovach; W Li,"Ketorolac is a parenteral nonsteroidal anti-inflammatory drug that provides analgesia through a peripheral mechanism. The purpose of this study was to evaluate whether the scheduled administration of intravenous ketorolac improves the analgesia provided by subarachnoid opioids after surgery. Patients undergoing major urologic surgery were enrolled in a randomized, placebo-controlled, double-blinded study and received one of two analgesic regimens. All patients were given subarachnoid opioid analgesia consisting of morphine (range, 0.55-0.8 mg) plus fentanyl (25 micrograms) at the completion of surgery just prior to awakening. In addition to subarachnoid opioids, patients received four doses of either intravenous placebo (group 1, n = 21) or ketorolac (group 2, n = 17) administered 30 minutes before the anticipated completion of surgery and at 6, 12, and 18 hours after surgery. Patients in group 2 who were 65 years old or older received 30 mg ketorolac initially, with subsequent doses of 15 mg. Those younger than 65 years of age received 60 mg ketorolac initially, with subsequent doses of 30 mg. Pain scores were assessed by a blinded observer using a 10-cm visual analog scale (VAS) at 1, 8, and 24 hours after the operation. Intravenous morphine requirements while in the postanesthesia care unit (PACU) and during the following 24 hours, as well as the incidence of pruritus, nausea, naloxone usage, and bleeding were also recorded. Results were analyzed using the Wilcoxon rank-sum, Fischer's exact, chi-square, and Student's t tests. Patients receiving intravenous ketorolac (group 2) in addition to subarachnoid opioids had significantly lower pain scores 1 hour after surgery, and required less supplementary intravenous morphine within the first 24 postoperative hours (P < .05). The percentage of patients requiring no analgesic intervention while in the PACU was significantly higher for those receiving ketorolac (P = .01). The incidence of opioid-related side effects was similar between groups, and no perioperative bleeding was observed. When used in conjunction with subarachnoid opioids, the scheduled administration of intravenous ketorolac during the first 24 hours after major urologic surgery significantly enhances analgesia and reduces the need for supplemental intravenous opioids without affecting the incidence of side effects. Intravenous ketorolac is a safe and useful adjuvant to subarachnoid opioids in the management of acute postoperative pain.",1995.0,0,0
1161,8519719,Pain relief for thoracotomy. Comparison of morphine requirements using an extrapleural infusion of bupivacaine.,U A Carabine; H Gilliland; J R Johnston; J McGuigan,The effectiveness of a continuous infusion of extrapleural bupivacaine for relief of postoperative pain was assessed in patients undergoing posterolateral thoracotomy under general anesthesia by comparing morphine requirements. Bupivacaine 0.25% was infused at a rate of 5 mL/h through an unkinkable extrapleural catheter that was sited under direct vision at operation. Mean (+/- SD) 24-hour requirements for morphine from a patient-controlled analgesia device were 39 +/- 15 mg for the treated group and 69 +/- 26 mg in the control group (P < .006). Patients in the treated group recorded significantly smaller visual analog scores for pain both at rest (P < .005) and on movement (P < .03) compared to the control group. There were no adverse effects associated with the use of extrapleural bupivacaine in this study. Continuous extrapleural infusion of bupivacaine through unkinkable catheters sited during thoracotomy resulted in decreased intravenous patient-controlled analgesia use and decreased verbal categoric pain scores at rest and during movement.,1995.0,0,0
1162,8519720,Double-blind randomized evaluation of intercostal nerve blocks as an adjuvant to subarachnoid administered morphine for post-thoracotomy analgesia.,M Liu; P Rock; J A Grass; R F Heitmiller; S J Parker; N T Sakima; M D Webb; R B Gorman; C Beattie,"Thoracotomy is associated with pain and compromised pulmonary function. Intercostal nerve blocks (INB) and subarachnoid morphine (SM) act on different portions of the pain pathway. Each is effective for post-thoracotomy pain relief. The combination of these two modalities in relieving post-thoracotomy pain and improving postoperative pulmonary function has not been investigated. In a double-blind study, 20 patients undergoing lateral thoracotomy for lung resection were randomized to receive 0.5 mg SM preoperatively and INB with bupivacaine (INB+) prior to wound closure or 0.5 mg SM with INB using saline (INB-). Visual analog scale pain scores at rest, with cough, and with movement of the ipsilateral arm, forced expiratory volume in 1 second (FEV1), and forced vital capacity (FVC) were measured at 4, 24, 48, and 72 hours after the operation. Opioid use was measured during the initial 24 hours after the operation. At 4 hours, the INB+ group demonstrated better FEV1 (56.6% vs. 40.4% of baseline, P < .05) and FVC values (54.6% vs. 39.6% of baseline, P < .05) and less resting and cough pain (P < .05). However, FEV1 continued to decline in the INB+ group at 24 hours to lower than the INB- group although pain scores were similar beyond 4 hours. Opioid usage during the first 24 hours was similar (INB-, 16.7 mg vs. INB+, 13.2 mg, P = .7). Although postoperative INB provided modest improvements in pain and pulmonary function when used as an adjuvant to 0.5 mg SM for post-thoracotomy analgesia, the benefits were transient. The authors do not recommend adding INB for patients undergoing lateral thoracotomy who receive 0.5 mg SM.",1995.0,0,0
1163,8519722,0.1% bupivacaine does not reduce the requirement for epidural fentanyl infusion after major abdominal surgery.,T E Salomäki; J O Laitinen; V Vainionpää; L S Nuutinen,"Although local anesthesia has been demonstrated to potentiate spinal morphine analgesia in animal studies, results comparing epidural local anesthesia/opioid mixtures with opioid alone are contradictory in clinical studies. The hypothesis was that, although the concentration of bupivacaine (0.1%) was low to minimize its adverse effects, if the infusion rate of a fentanyl/bupivacaine solution was closely adjusted according to need, the presence bupivacaine would reduce the requirement for epidural fentanyl. Forty patients were randomly assigned to receive either fentanyl (10 micrograms/mL) or a fentanyl/bupivacaine (0.1%) mixture epidurally corresponding to the dermatome of the surgical incision in a double-blind fashion for the first 18 hours after major abdominal surgery. The infusion was titrated for each patient to the rate required for pain relief during forced inspiration (pain score < or = 2, maximum 10). Pain scores, the fentanyl doses required, plasma concentrations of fentanyl at 18 hours, and the incidence and severity of adverse effects were recorded. Patients reported similar median pain scores and were equally satisfied with pain relief in both groups. The mean required post-operative fentanyl infusion rate (57.7 +/- 19.5 micrograms/h) and the plasma concentrations (0.84 +/- 0.36 ng/mL) in the fentanyl group were comparable to the infusion rate (54.4 +/- 19.2 micrograms/h) and the plasma concentrations (0.86 +/- 0.36 ng/mL) in the fentanyl/bupivacaine group. Respiratory and cardiovascular functions were preserved, and the incidence of nausea, pruritus, and periods of drowsiness or sleep were similar in both groups. In low concentrations (0.1%), bupivacaine did not reduce the titrated dose of epidural fentanyl required for adequate pain relief during forced inspiration after major abdominal surgery. The incidence and severity of adverse effects were also comparable whether or not low-dose bupivacaine infusion was used.",1995.0,0,0
1164,8522573,Pain management in video assisted thoracic surgery: evaluation of localised partial rib resection. A new technique.,J Richardson; S Sabanathan,"We undertook a re-evaluation of acute and chronic pain generation following Video Assisted Thoracic Surgery (VATS) with regard to chest wall trauma produced by the instruments and their ports. From intercostal space (ICS) measurements made on 40 patients, it was confirmed that both the camera and the staple gun port diameters are too large for insertion without trauma. An instrument was produced (the ""Sari"" Punch, Bolton Surgical Services, Sheffield, England) which cleanly excises an elipse of the superior aspect of a rib, prior to the introduction of the ports. At the same time, the recommended orbit of the instruments about the surgical focus was abandoned in favour of an alignment along one ICS so that only one nerve was potentially traumatised. These modifications were then combined with balanced, pre-emptive and continuous paravertebral analgesia and the efficacy of this approach was evaluated in nine patients undergoing VATS. Operation of the rib punch was easy in all patients and was carried out without clinical or radiological trauma to the rib. Insertion of the ports was easy and access was good to all intrathoracic structures. Postoperative analgesia was good and the mean hospital stay was 2.7 days (range 2-4). Follow-up two months later confirmed a satisfactory surgical procedure and no patients complained of chest wall pain or numbness. We conclude that pain generation with VATS must be seriously considered if the technique is to become truly successful. Balanced, pre-emptive, paravertebral analgesia will protect the central nervous system while the removal of an elipse of rib and alignment of the instruments along one ICS will reduce the likelihood of peripheral nerve trauma.",1995.0,0,0
1165,8526959,[Early detection of opiate-induced respiratory depression in the postoperative phase].,R Graf; S Chrubasik; J Chrubasik; J Schulte-Mönting; E Geller,"We examined in 30 patients the efficacy of regular assessments of respiratory rate (every 15 minutes) and blood gas analysis (at 30, 60, 120, 180 minutes) and continuous monitoring via pulsoximeter and capnometer in recognizing early ventilatory problems. For postoperative analgesia the patients received randomly and double-blind patient-controlled intravenous or epidural analgesia with sufentanil. Within 15 minutes after the initial intravenous bolus injection of 15 micrograms sufentanil respiratory depression occurred in 4 patients. This was alerted by the Oscar-CO2-Monitor and -Pulsoximeter. Oxygen saturation time patterns of pulsoximetry and blood gas analysis correlated significantly (p < 0.001), although the mean values of the methods differed (NS). In contrast, carbon-dioxide pressure time patterns of capnometry and blood gas analysis correlated less significantly (p < 0.01) although the mean values of the methods correlated significantly (p < 0.01). Concomittant monitoring via pulsoximeter and capnometer is therefore superior to regulary assessments of respiratory rate and blood gas analysis and potentially useful for the clinical routine.",1995.0,0,0
1166,8528924,[Ambulatory pain treatment in tumor patients].,A Keseberg,"In this paper causes of pain and factors influencing sensitivity to pain in tumour patients are described. Changes and requests of outpatient therapy with non-opiates versus opiates are further analyzed. Results of pharmacological studies and clinical experiences show that most physicians have unjustified prejudice against prescription, effectiveness and side-effects of opiates. Some typical faults in outpatient therapy are a consequence of this kind of prejudice. An effective outpatient therapy using a phased plan in treatment with drugs could enable most tumour patients to become free of pain.",1995.0,0,0
1167,8532850,Update on cellular transplantation into the CNS as a novel therapy for chronic pain.,K A Czech; J Sagen,"The transplantation of cells that secrete neuroactive substances with analgesic properties into the CNS is a novel method that challenges current approaches in treating chronic pain. This review covers pre-clinical and clinical studies from both allogeneic and xenogeneic sources. One cell source that has been utilized successfully is the adrenal chromaffin cell, since such cells constitutively release catecholamines, opioid peptides, and neurotrophic factors; release can be augmented with nicotine. Other graft sources include AtT-20 and B-16 cell lines which release enkephalins and catecholamines, respectively. For grafting in rodents, adrenal medullary tissue pieces are transplanted to the subarachnoid space. Chromaffin cell transplants can decrease pain sensitivity in normal rats using standard acute pain tests (paw-pinch, hot-plate, and tail-flick). In addition, transplants can restore normal pain thresholds in rodent models of chronic pain (formalin, adjuvant-induced arthritis, and sciatic-nerve tie) which closely similate the pathologies of human chronic pain conditions. Xenografts have been studied due to concerns that future application for human pain may be limited by donor availability. Despite immune privileges of the CNS, xenografts require at least short-term immunosuppression to obtain a viable graft. Cell encapsulation is one method of sustaining a xenograft (in rat and human hosts) while circumventing the need for immunosuppression. Clinical studies have been initiated for terminal cancer patients with promising results as assessed by markedly reduced narcotic intake, visual analog scale ratings, and increased CSF levels of catecholamines and met-enkephalin.",1995.0,0,0
1168,8534463,Epidural scopolamine administration in preventing nausea after epidural morphine.,R Moscovici; G Prego; M Schwartz; O Steinfeld,"To determine the effectiveness of epidural scopolamine in preventing nausea and vomiting in patients receiving epidural morphine. Randomized, double-blind study. Inpatient surgery clinic at a regional general hospital. 50 patients undergoing major abdominal and lower limb surgery. Morphine alone 2.5 to 4 mg was administered via epidural catheter to one group, while the other group received morphine plus scopolamine 0.25 mg via epidural catheter. Occurrence of nausea and vomiting was recorded during the first postoperative day. Compared with the morphine alone group, the incidence of nausea and vomiting was significantly lower in the morphine plus scopolamine group without difference in the adequacy of analgesia. Epidural scopolamine can be used as an adjunct to epidural morphine in effectively reducing the incidence of postoperative nausea and vomiting.",1995.0,0,0
1169,8534465,"Use of analgesics during propofol sedation: a comparison of ketorolac, dezocine, and fentanyl.",M Ramirez-Ruiz; I Smith; P F White,"To evaluate the comparative efficacy and side effect profile of ketorolac 60 mg, dezocine 6 mg, and fentanyl 100 micrograms when used as analgesic supplements to a propofol infusion during monitored anesthesia care (MAC). Randomized, double-blind, placebo-controlled study. Ambulatory surgery facility at a university medical center. 80 outpatients undergoing breast biopsy or inguinal herniorraphy procedures under MAC. All patients received midazolam 2 mg intravenously (IV) followed by 1 ml of the study medication containing either dezocine 3 mg IV, ketorolac 30 mg IV, fentanyl 50 micrograms IV, or normal saline. A propofol infusion was initiated at 75 micrograms/kg/min and then varied to maintain a stable level of sedation (i.e., Observer Assessment of Alertness/Sedation scale score of 3). An additional 1 ml of the same study medication was administered IV 2 to 3 minutes prior to infiltration of the local anesthetic solution. During the operation, supplemental (rescue) medication consisted of fentanyl 25 micrograms IV, bolus injections in all four treatment groups. Propofol infusion and supplemental fentanyl dosage requirements, oxygen saturation values, respiratory rates, recovery times, and postoperative side effects were recorded. Visual analog scales were used to assess sedation, anxiety, pain, and nausea preoperatively (baseline), upon entry into the postanesthesia care unit, and at 30-minute intervals until discharge. The fentanyl and dezocine groups required lower average infusion rates of propofol to maintain a stable level of sedation than the control (saline) group. The saline and ketorolac groups required rescue analgesic medication more frequently and/or larger supplemental dosages of fentanyl than the two opioid analgesic treatment groups. Compared with the three analgesic treatment groups, postoperative pain scores were only marginally higher in the control group. Ketorolac-treated patients had consistently (but not significantly) shorter recovery times to oral intake, ambulation, and discharge than those in the dezocine or fentanyl groups. No postoperative nausea, vomiting, or pruritus was reported in the ketorolac group. Compared with ketorolac 60 mg, fentanyl 100 micrograms and dezocine 6 mg produced a greater decrease in the propofol sedation requirement during MAC. However, the use of ketorolac in combination with propofol for MAC was associated with an improved recovery profile.",1995.0,0,0
1170,8535045,Medical decision-making in a patient with a history of cancer and chronic non-malignant pain.,S K Reddy; S M Weinstein,"The selection of cancer pain treatment modalities depends on careful assessment to establish the pathophysiology of the pain complaint. Treatment may consist of a single modality--e.g., pharmacotherapy--or multiple modalities--e.g., pharmacotherapy, anesthetic intervention, and radiotherapy for bone pain. Cancer patients may present with pain and multiple concomitant medical problems related to their primary neoplastic disease, complications of cancer treatment, or unrelated conditions including preexisting pain of nonmalignant origin. We present the case of a patient with new onset of pain superimposed on chronic nonmalignant pain. This case emphasizes the need for careful assessment and the close cooperation required between the pain consultant and the referring oncology staff to make optimal treatment decisions in the context of a complex medical illness.",1995.0,0,0
1171,8535947,Compounding of preservative-free high-concentration morphine sulfate injection.,J A Grom; L C Bander,"The compounding of a preservative-free high-concentration morphine sulfate injection from nonsterile morphine sulfate is described. High-concentration (50 mg/mL) morphine sulfate injection is compounded by dissolving Morphine Sulfate Powder, USP, in preservative-free sterile water for injection. The solution is pumped through 0.8- and 0.22-micrometer filters into 10-mL sterile vials and quarantined until assays for concentration, sterility, and bacterial endotoxins have been performed. The solution is placed in active inventory and dispensed to nursing units as needed. Total compounding cost per 10-mL vial of morphine sulfate injection is about $9. The expiration date is six months from the date of compounding. This solution has been administered i.m., s.c., i.v., and epidurally to inpatients with advanced cancer and severe pain at an acute care hospital. An acute care hospital compounds batches of preservative-free high-concentration morphine sulfate injection from nonsterile morphine sulfate.",1995.0,0,0
1172,8542854,Comparison of bupivacaine plus buprenorphine with bupivacaine alone by caudal blockade for post-operative pain relief after hip and knee arthroplasty.,F Gao; B Waters; J Seager; C Dowling; M D Vickers,"In a double-blind, parallel group trial, 15 patients who were given a caudal injection of 1.8 mg kg-1 of bupivacaine after induction of anaesthesia, were compared with 15 patients in whom 7.2 mg kg-1 of buprenorphine was added to the same dose of bupivacaine, prior to knee or hip replacement surgery. The duration of analgesia was much longer (mean 606 min vs. 126 min P < 0.001) in those receiving added buprenorphine; mean morphine consumption in the first 24 h was halved (14 mg vs. 28 mg) and patient satisfaction greatly increased. There were no significant differences in the incidence of complications although the group which had added buprenorphine had a lower incidence of vomiting.",1995.0,0,0
1173,8542859,A comparative study of ketorolac and diclofenac on post-laparoscopic cholecystectomy pain.,B Fredman; D Olsfanger; R Jedeikin,"In a randomized, double-blind, placebo-controlled study designed to assess the post-operative analgesic efficacy and cost-effectiveness of ketorolac and diclofenac 60 ASA I and II patients undergoing laparoscopic cholecystectomy were studied. Prior to concluding the operative procedure, an injection (i.m.) of an equal volume of either saline 3 mL, ketorolac 60 mg, or diclofenac 75 mg was administered. All patients received intravenous morphine via a patient-controlled analgesia device (PCA). Post-operative pain intensity was assessed hourly for 4 h, by recording visual analogue score (VAS) for pain, PCA demands and actual morphine administered. PCA demands (mean +/- SD) were greater in the saline treatment group (115 +/- 90) when compared with both the ketorolac (42 +/- 44) and diclofenac groups (74 +/- 77). Furthermore, the saline treatment group received significantly (P < 0.05) more PCA morphine compared with both the ketorolac and diclofenac groups (12.2 mg +/- 5.0 vs. 8.6 mg +/- 5.2 vs. 8.9 mg +/- 4.8). Improved pain scores were demonstrated in both the ketorolac and diclofenac groups compared with the saline group. PCA demands and post-operative morphine requirements were similar in the ketorolac and diclofenac groups. Diclofenac has the added advantage, in our institution, of being 60% less expensive than ketorolac. We conclude that both ketorolac and diclofenac are effective post-operative analgesic drugs. However, economic considerations may favour diclofenac administration.",1995.0,0,0
1174,8542861,The use of lignocaine to reduce pain on i.v. injection of diluted nalbuphine.,A A van den Berg; M Nandagopal; S A Qureshi; D Savva,"A randomized, placebo-controlled, double-blind study was conducted on 66 healthy patients aged 10-61 years undergoing elective ear, nose and throat surgery to assess the incidence and severity of pain associated with intravenous (i.v.) injection of diluted nalbuphine HCl given during induction of general anaesthesia, and to determine the efficacy of adding lignocaine (2 mg mL-1) to nalbuphine to reduce this pain. Injection of saline produced pain of low intensity in 15% of patients and a withdrawal response in 3% of patients. Injection of nalbuphine mixed with lignocaine produced a significantly higher incidence (36%; P < 0.025) and severity (P < 0.025) of pain than saline, but a similar number of responses (6%) to pain. The diluted nalbuphine alone produced the highest incidence (61%) of pain (P < 0.01 vs. saline, P = NS vs. nalbuphine with lignocaine), which was most severe (P < 0.01 vs. saline, P < 0.025 vs. nalbuphine with lignocaine), and caused the highest number (27%) of withdrawal responses (P < 0.01 vs. saline, P < 0.025 vs. nalbuphine with lignocaine). We conclude that diluted nalbuphine 2 mg mL-1 produces pain on i.v. injection into peripheral veins, and that this can be significantly reduced by adding lignocaine 2 mg mL-1 to the solution.",1995.0,0,0
1175,8544547,,,,,1,1
1176,8545138,Custom-made capsules and suppositories of methadone for patients on high-dose opioids for cancer pain.,E Bruera; S Watanabe; R L Fainsinger; K Spachynski; M Suarez-Almazor; C Inturrisi,"In a prospective, open study, 37 advanced cancer patients in poor pain control receiving high doses of subcutaneous hydromorphone (mean daily dose: 276 +/- 163 mg) were switched to methadone by use of custom-made capsules (21 patients) or suppositories (16 patients). The change in opioid took place over 6.5 +/- 3.6 days (oral) and 3.2 +/- 2.7 days (rectal). The methadone/hydromorphone dose ratios were 1.2 +/- 1.3 and 3 +/- 2 for the oral and rectal routes, respectively (P = 0.03) as compared to an expected ratio of 5-7, based on single dose available data. Pain intensity (VAS 0-100 mm) and the number of extra doses of analgesic per day were 51 +/- 22 and 3.2 +/- 2.7 with hydromorphone, versus 34 +/- 21 (P < 0.001) and 2.1 +/- 1.9 (P = 0.03) with methadone, respectively. The total cost of treatment was Canadian $148 +/- 202 with methadone as compared to Canadian $2135 +/- 472 with hydromorphone (P < 0.001). Toxicity was limited to mild sedation in all patients and proctitis in 2 patients on suppositories (one of whom required discontinuation of methadone). Plasma levels obtained in 6 patients on suppositories revealed large inter-individual variation in methadone level (ng/ml) to dose (mg/day) ratio (range: 0.8-8.5). Within individuals, the ratio remained constant over a range of doses. We conclude that a slow switch-over to methadone is a safe, effective and low cost alternative in selected cancer patients receiving high doses of opioids for poor prognostic pain syndromes.",1995.0,0,0
1177,8545140,Treatment of terminal cancer pain in France: a questionnaire study.,A Vainio,"Compared with other European countries, French laws and restrictions concerning the use of opioids are of medium severity only. Still, together with Germany, Belgium and Spain, France belongs to the group of countries with a low national consumption of morphine, calculated by the International Narcotics Control Board of United Nations. In order to elucidate the current practice of French physicians treating cancer pain, a questionnaire study was carried out, using the nationwide register of general practitioners and specialists of a pharmaceutical company. The knowledge of the principles and methods of cancer pain treatment were evaluated with 9 open and 19 multiple-choice questions. The ability of the physicians to apply their knowledge in practice was evaluated by analyzing their suggested treatment of 3 illustrative case histories. The favourite drugs in treating cancer pain were strong opioid agonists, suggested by 25% of the general practitioners and 44% of the specialists for a typical cancer pain patient. The recommended daily doses of opioids were mostly far below the level generally accepted in palliative care. The drug of choice for metastatic bone pain was a combination of paracetamol and codeine, chosen by a third of the general practitioners. Consequently, only 10% and 21% of the treatment suggestions were regarded as adequate. Ninety-two percent of the physicians experienced difficulties in the treatment of cancer pain, inefficacy of treatment being the most important problem.",1995.0,0,0
1178,8545142,"Efficacy of controlled-release codeine in chronic non-malignant pain: a randomized, placebo-controlled clinical trial.",W Arkinstall; A Sandler; B Goughnour; N Babul; Z Harsanyi; A C Darke,"Treatment decisions for the use of opioid analgesics in chronic non-malignant pain are based primarily on survey data, as evidence from well-controlled clinical trials has been lacking. Forty-six patients with chronic non-malignant pain were enrolled in a randomized, double-blind, placebo-controlled evaluation of controlled-release (CR) codeine. Following a 3-7-day diary familiarization period, patients were randomly assigned to 7 days of treatment each with CR codeine q12h or placebo. The CR codeine dose was determined from the consumption of acetaminophen+codeine in the 7 days preceding the study. During both phases, breakthrough pain was treated with acetaminophen+codeine every 4 h as required. Pain intensity was assessed at 08:00 h and 20:00 h using a visual analogue scale (VAS) and a 5-point categorical scale, and rescue analgesic consumption was recorded at the time of use. Thirty patients (17 female, 13 male; mean age: 55.1 +/- 13.4 years) completed the study and were treated with a mean daily CR codeine dose of 273 +/- 78 mg (range: 200-400 mg). CR codeine treatment resulted in significantly lower overall VAS pain intensity scores (35 +/- 18 vs. 49 +/- 16, P = 0.0001), categorical pain intensity scores (1.7 +/- 0.6 vs. 2.2 +/- 0.6, P = 0.0001), and in pain scores by day of treatment and by time of day. Daily rescue analgesic consumption was significantly lower on CR codeine, relative to placebo treatment (3.6 +/- 3.5 vs. 6.1 +/- 3.2 tablets/day, P = 0.0001). There was also a significant reduction in the Pain Disability Index (PDI) on CR codeine, compared to placebo (25.0 +/- 7.7 vs. 35.1 +/- 8.2, P = 0.0001). Patients' and investigators' blinded treatment preference was significantly in favor of CR codeine, relative to placebo (73% vs. 10%, P = 0.0160 and 80% vs. 7%, P = 0.0014, respectively). The incidence of nausea was significantly higher on CR codeine than on placebo (32.6% vs. 11.9%, P = 0.013). Ninety-three percent of patients completing the study requested long-term, open-label treatment with CR codeine. Pain intensity scores at the completion of 19 weeks of long-term evaluation were comparable to those during the double-blind CR codeine treatment. We conclude that treatment with CR codeine results in reduced pain and pain-related disability in patients with chronic non-malignant pain.",1995.0,1,1
1179,8546282,Anaesthesia and adverse effects after intrathecal pethidine hydrochloride for urological surgery.,D Grace; J P Fee,"Anaesthesia, postoperative analgesia and the incidence of adverse effects after intrathecal pethidine hydrochloride 0.50 mg.kg-1 and 0.75 mg.kg-1 were assessed and compared with a conventional technique using isobaric bupivacaine 13.75 mg in patients undergoing transurethral resection of the prostate gland. Sensory and motor block were significantly shorter with both pethidine regimens than with bupivacaine (p < 0.001). Although sensory and motor block were shorter after pethidine 0.50 mg.kg-1 than after pethidine 0.75 mg.kg-1 the difference in duration was clinically insignificant. The incidence of incomplete motor block was significantly greater with pethidine 0.50 mg.kg-1 than with bupivacaine 13.75 mg.kg-1 (p < 0.01). Visual analogue pain scores recorded after the operation were low and were similar in the pethidine groups to those obtained with bupivacaine alone. Mean arterial blood pressure was significantly lower in both pethidine groups compared with the bupivacaine group between 30 and 240 min after intrathecal injection (p < 0.001). However, the within-group reductions in blood pressure were within clinically acceptable limits. The incidences of nausea and emesis were low and emesis occurred in patients in the bupivacaine group only (p < 0.03). Pruritus was seen only in patients receiving pethidine. Intra-operative sedation occurred more often in patients receiving both pethidine 0.50 mg.kg-1 and 0.75 mg.kg-1 compared with patients receiving bupivacaine (p < 0.04). Both pethidine regimens provided acceptable anaesthesia and there were no significant differences between the two regimens in quality of intra-operative anaesthesia, incidence of adverse events or postoperative analgesia.",1995.0,0,0
1180,8550304,Efficacy of patient-controlled analgesia in women cholecystectomy patients.,C Knapp-Spooner; B A Karlik; V Pontieri-Lewis; A Yarcheski,"The purpose of this comparative study was to examine differences in pain intensity, sleep disturbance, sleep effectiveness, fatigue, and vigor between patients undergoing cholecystectomy who received either patient-controlled analgesia (PCA) or intramuscular (IM) injections of narcotics for postoperative pain. The PCA group consisted of 16 women, aged 22-58; the IM group consisted of 10 women, aged 22-60. Data were collected on patients' postoperative days 1 and 2. Findings indicated that patients receiving PCA reported less pain on postoperative day 1 and less fatigue on postoperative day 2 than patients receiving IM injections of narcotics.",1995.0,0,0
1181,8554670,Treatment of painful crises of Fabry disease with morphine.,M Philippart,,1995.0,0,0
1182,8562292,Effects of peripherally and centrally acting analgesics on somato-sensory evoked potentials.,U J Moore; V R Marsh; C H Ashton; R A Seymour,"1. The effects of aspirin 1000 mg, paracetamol 1000 mg, codeine 60 mg on somatosensory evoked potentials (SEPs) were measured in a four-way cross-over study. 2. SEPs were elicited by electrical stimulation of the skin overlying the digital nerve at intensities close to pain threshold. 3. Amplitudes and latencies of both early and late SEPs were recorded, as well as first sensory threshold and subjective pain threshold. 4. None of the study medications affected the amplitude or latency of the late SEP components (100-250 ms post-stimulus). The amplitude of early components (15-30 ms post-stimulus) was also unaffected, but aspirin shortened the latency 30 min after ingestion. 5. Sensory detection and pain threshold to electrical skin stimulation were also unaffected by any of the study medications despite subjective central effects with codeine.",1995.0,0,0
1183,8562297,Respiratory depression following morphine and morphine-6-glucuronide in normal subjects.,P I Thompson; S P Joel; L John; J A Wedzicha; M Maclean; M L Slevin,"1. Morphine 6-glucuronide (M6G) is a metabolite of morphine with analgesic activity. A double-blind, randomised comparison of the effects of morphine and M6G on respiratory function was carried out in 10 normal subjects after i.v. morphine (10 mg 70 kg-1) or M6G (1, 3.3 and 5 mg 70 kg-1). Analgesic potency was also assessed using an ischaemic pain test and other toxic effects were monitored. 2. Following morphine there was a significant increase in arterial PCO2, as measured by blood gases 45 min post dose (0.54 +/- 0.24 (s.d.) kPa, P < 0.001), and in transcutaneous PCO2 from 15 min post dose until the end of the study period (4 h), whereas blood gas and transcutaneous PCO2 were unchanged after M6G at 1.0, 3.3 and 5.0 mg 70 kg-1. This increased PCO2 following morphine was associated with an increase in expired CO2 concentration (FECO2) (0.20 +/- 0.14% expired air at 15 min post dose, P = 0.002), compared with small but significant reductions in FECO2 following morphine 6-glucuronide (-0.15 +/- 0.17% at 1 mg 70 kg-1 P = 0.030, -0.14 +/- 0.15% at 3.3 mg 70 kg-1 P = 0.017, -0.18 +/- 0.11% at 5 mg 70 kg-1 P = 0.024). Maximum transcutaneous PCO2 was significantly increased after morphine (0.63 +/- 0.28 kPa P = 0.009), but was not changed after M6G at 1 mg (0.10 +/- 0.34 kPa P = 0.11) 3.3 mg (0.06 +/- 0.37 kPa P = 0.34) or 5 mg (0.26 +/- 0.07 kPa P = 0.10).(ABSTRACT TRUNCATED AT 250 WORDS)",1995.0,0,0
1184,8564997,Perspectives on opioid tolerance from basic research: behavioural studies after spinal administration in rodents.,C W Stevens,"For tolerance development studies, computer modelling and statistical tests suggested that the equation which best described the decrement of analgesic effect was best served by an exponential decay function. Further analysis of the time course data led to the tentative conclusion that all groups of animals became tolerant at the same rate, regardless of drug or dose. A literature search revealed then, as it does now, that although there are many statements regarding the rate of opioid tolerance, there has been little systematic investigation of this. The Holy Grail of obtaining the rates of tolerance for a number of opioid agents in a systematic study is well within grasp. This information will be needed in clinical practice for the rational choice of opioid with regard to rate of the development of tolerance. The working hypothesis that emerges for the magnitude of opioid tolerance is that more potent agonists produce less tolerance. Further confirmation of this hypothesis has been forthcoming. This suggests that clinical use of more potent opioids, such as fentanyl, should be considered as a substitute for morphine in long term treatment regimens. The working hypothesis for cross-tolerance is that agents acting on the same receptors will show cross-tolerance. Cross-tolerance will also be observed among agents acting on different receptors, but only those that exhibit pharmacological synergy after short term administration. Asymmetry of cross-tolerance can occur, as the magnitude of this cross-tolerance is determined by the relative potency of the toleragen with regard to that of the probe agent. Given the additional factor of receptor selectivity with agents of different receptor classes, types and subtypes, new studies need to be designed combining the toleragen with a selective antagonist to determine the precise receptor mediation of the magnitude of tolerance, and thus cross-tolerance. For example, the delta opioid DADLE infused with a mu selective opioid antagonist would produce an animal strictly tolerant at delta receptors, as DADLE has been implicated to have some effects at mu receptors. In any event, consideration of the quantitative measures of cross-tolerance are extremely important to help shape a rationale treatment plan for patients who may become tolerant to a particular class of analgesics. In general, direct toleragen administration by constant dose, constant rate infusion into local central nervous system (CNS) regions will provide the most rigorous tolerance studies for examination of the pharmacodynamic theories of tolerance, as adaptations in processes affecting central bioavailability, such as dispositional changes in the blood-brain barrier or fibrous encapsulation of an implanted subcutaneous pellet, are circumvented. The above considerations also are relevant for studies of tolerance and cross-tolerance after intracerebroventricular administration or, in general, for tolerance studies after systemic administration. The possibility of probe administration to the same region of CNS that was rendered tolerant, as in the Y-catheter method, further enhances the focus on the pharmacodynamic mechanisms of tolerance without the ancillary and literally peripheral concerns of a dispositional nature. A posological approach to these studies cannot be overemphasized, as it is only through such time consuming and costly experiments that rigorous, quantitative data can be obtained. Such data may help to guide the hand of the physician towards rational therapeutic intervention in the treatment of patients with chronic pain and opioid tolerance.",1994.0,0,0
1185,8569133,"[Pain crises in patients with sickle cell diseases. Pathogenesis, clinical aspects, therapy].",R Dickerhoff; A von Ruecker,"About 70% of all patients with sickle cell disease suffer from pain crises. Pain crises are recurrent episodes of pain that range in severity from mild to severe, usually occur very abruptly and are often localized around joints. Pain crises are caused by vaso-occlusions in the vascular bed of the bone marrow, leading to necrosis, edema and increased pressure. For effective analgesia morphine or morphine analogues are often required. When treating a pain crisis the patient's complaints need to be taken seriously and analgesic therapy should be started promptly with analgesics in proportion to the severity of the patient's pain. With mild pain oral non-opioid analgesics are sufficient, in moderate pain they are given in combination with oral codeine. Severe pain requires IV morphine, also combined with a non-opioid analgesic. Intravenous morphine makes a thorough monitoring of ventilation and level of consciousness mandatory. Sickle cell patients do not become drug dependent if given morphine for adequate analgesia. While bone marrow transplantation has become an accepted treatment modality for sickle cell patients with severe pain crises, treatment with hydroxyurea to increase HbF levels and reduce incidence and severity of pain crises, however, is still experimental.",1995.0,0,0
1186,8570431,Analysis of pain management in critically ill patients.,J K Whipple; K S Lewis; E J Quebbeman; M Wolff; M S Gottlieb; M Medicus-Bringa; K R Hartnett; M Graf; R K Ausman,"We analyzed the adequacy of pain control for 17 trauma patients during the initial part of their stay in the intensive care unit, and assessed reasons for inadequate analgesia, if it occurred. Patients, and physicians, and nurses were interviewed. A verbal pain intensity scale was used to determine whether patients received adequate analgesia. Patients were asked if the pain hindered their activities, and whether they requested pain medication from their caregivers. Caregivers were questioned whether patients received adequate analgesia. Prescribed morphine regimens and the amount of narcotic administered were analyzed. Twenty-seven percent of patients rated pain intensity as moderate and 47% as severe. Ninety-five percent of housestaff and 81% of nurses reported the patients received adequate pain control. Forty-seven percent of the patients who had moderate or severe pain asked their physician for more pain medication, and 65% asked the nurse. Thirteen residents did not order a larger dose of morphine due to concern about respiratory depression or hypotension. Morphine dosages ranged from 1-8 mg intravenously every 1-2 hours as necessary. Nurses administered less than the maximum amount ordered 58% of the time. The mean dosing interval was 2.3 hours. Barriers to adequate pain management were disparity in the perception of pain between patients and caregivers; patients not requesting more analgesia despite despite the presence of moderate to severe pain; and physician and nurse concerns about patients' adverse physiologic response to increased dosages.",1995.0,0,0
1187,8572340,"Effects of combining propofol and alfentanil on ventilation, analgesia, sedation, and emesis in human volunteers.",D J Pavlin; B Coda; D D Shen; J Tschanz; Q Nguyen; R Schaffer; G Donaldson; R C Jacobson; C R Chapman,"Propofol and alfentanil frequently are administered together for intravenous sedation. This study investigated pharmacokinetic and pharmacodynamic interactions between propofol and alfentanil, at sedative concentrations, with specific regard to effects on ventilation, analgesia, sedation, and nausea. Ten male volunteers underwent steady-state infusions on 3 separate days consisting of propofol alone, alfentanil alone, or a combination of the two. Target plasma concentrations for propofol were 150, 300, and 600 ng/ml for 1 h at each concentration; for alfentanil it was 40 ng/ml for 3 h. Assessment included serial measurements of (1) ventilatory function (minute ventilation, carbon dioxide production, end-tidal carbon dioxide, ventilatory response to rebreathing 7% CO2); (2) analgesia (subjective pain report in response to graded finger shock and evoked potential amplitude); (3) sedation (subjective rating, observer scores, and digit symbol substitution test); (4) nausea (visual analog scale, 0-100 mm). During combination treatment, propofol plasma concentration was 22% greater than during propofol alone using replicate infusion schemes (P < 0.009). End-tidal carbon dioxide was unchanged by propofol, and increased equally by alfentanil and alfentanil/propofol combined (delta end-tidal carbon dioxide 7.5 and 6.2 mmHg, respectively). Analgesia with propofol/alfentanil combined was greater than with alfentanil alone. (Pain report decreased 50% by PA vs. 28% for alfentanil, P < 0.05). Sedation was greater with propofol/alfentanil combined than with alfentanil or propofol alone (digit symbol substitution test 30 for propofol/alfentanil combined vs. 57 for alfentanil, and 46 for propofol, P < 0.05). Nausea occurred in 50% of subjects during alfentanil, but in none during propofol/alfentanil combination treatment. The combination of propofol and alfentanil produced greater sedation and analgesia than that with either drug alone. Propofol offset the emetic effects of alfentanil. Equivalent depression of the carbon dioxide response curve, and elevation of end-tidal carbon dioxide occurred with propofol/alfentanil combined and alfentanil.",1996.0,0,0
1188,8573956,Opioid-induced muscle activity: implications for managing chronic pain.,R K Sylvester; R Levitt; P D Steen,"To increase awareness of opioid-induced involuntary muscle hyperactivity and to present management options. A ventilator-dependent 71-year-old man presented with pain caused by metastatic lung cancer. Transdermal fentanyl therapy was titrated to 200 micrograms/h. Two days later a continuous morphine infusion was initiated because of frequent administration of oral morphine solution for breakthrough pain. The patient became progressively less responsive and began exhibiting involuntary muscle hyperactivity thought to represent breakthrough pain. Despite the inability to assess pain control effectively in this unresponsive patient, the morphine infusion rate was increased from 22 to 717 mg/h within 7 days. No change in muscle hyperactivity was observed. Over the last decade involuntary muscle hyperactivity has been documented as an adverse effect of chronic opioid therapy. The literature describing the incidence of this toxicity, possible risk factors for its development, and recommendations for its management are discussed. The occurrence of muscle hyperactivity in an unresponsive patient receiving chronic opioid therapy may represent opioid toxicity. Recommendations for managing opioid-induced muscle hyperactivity include reduction of the opioid dosage and/or administration of clonazepam therapy.",1995.0,0,0
1189,8576660,Patient-controlled analgesia in Thai patients.,V Sanansilp; J Lertakyamanee; S Udompunturak,"We conclude that the intravenous PCA method is acceptable, easy to use, does not depend on the patients' level of education, and is safe for Thai patients. The average pain scores at 48 hours postoperation of the PCA group was significantly lower than for the conventional and the I.M. groups. Satisfaction was quite difficult to assess. Thai culture might influence how much pain is accepted and the patients had not experienced other techniques, so they could not make a comparison. The amount of morphine used by the PCA group was intermediate between that used by the other two groups.",1995.0,0,0
1190,8576671,"Cost-effectiveness analysis of patient-controlled analgesia, intramuscular q.i.d. injection and p.r.n. injection for postoperative pain relief.",V Sanansilp; J Lertakyamanee; S Udompunturak,"We conclude that the intravenous PCA method is a cost-effective technique. Although the PCA device is expensive, the cost-effectiveness analysis should give explicit figures for physicians and the hospital administrators to decide whether they should use the PCA instead of the conventional method.",1995.0,0,0
1191,8583779,"Double-blind, placebo-controlled study of intravenous prostacyclin on hemodynamics in severe Raynaud's phenomenon: the acute vasodilatory effect is not sustained.",K Kingma; H Wollersheim; T Thien,"In 12 patients with severe Raynaud's phenomenon (RP: ischemic ulcers or intractable pain despite use of narcotic analgetics), we studied the acute and long-term hemodynamic effects of epoprostenol on systemic and finger skin circulation. Epoprostenol was infused intravenously (i.v., initial infusion rate of 2 ng/kg/min, with a subsequent increase of 2 ng/kg/min every 30 min to the individually tolerated maximal dose of 8 ng/kg/min) in a triple, 5-h, double-blind, placebo-controlled cross-over study. During epoprostenol infusion, systolic blood pressure (SBP) remained stable, while diastolic BP (DBP) decreased (-8 mm Hg, p < 0.02), with a simultaneous increase in heart rate (HR + 14 beats/min, p < 0.001). Forearm blood flow (FBF) increased and forearm vascular resistance (FVR) decreased during epoprostenol as compared with placebo infusion (p < 0.01). Epoprostenol caused a significant increase in fingertip skin temperature (p < 0.01) as well as in laser Doppler flux (p < 0.02) before and after a standardized cooling test of the hand as compared with placebo. The increase in transcutaneous oxygen tension reached significant difference only during recovery (p < 0.02). No long-term improvement was noted during two additional cooling tests performed 1 and 6 weeks after the completed epoprostenol or placebo triple-infusion cycle. Repeated long-lasting epoprostenol infusion immediately improves the microcirculation, but these effects are not sustained after 1 week.",1995.0,0,0
1192,8584148,Central dysesthesia pain after traumatic spinal cord injury is dependent on N-methyl-D-aspartate receptor activation.,P K Eide; A Stubhaug; A E Stenehjem,"The role of central N-methyl-D-aspartate (NMDA) receptors in the pathogenesis of central pain was examined in nine patients with central dysesthesia pain after spinal cord injury. The central pain syndrome included spontaneous continuous and intermittent pain as well as evoked pain. Pain was evoked by non-noxious stimulation of the skin (allodynia) and by repeated pricking of the skin (wind-up-like pain). The severity of continuous and evoked pain was examined before and after the intravenous infusion of either the NMDA receptor antagonist ketamine (6 micrograms/kg/min after a bolus dose of 60 micrograms/kg), the mu-opioid receptor agonist alfentanil (0.6 microgram/kg/min after after a bolus dose of 7 micrograms/kg), or placebo (0.9% NaCl). A randomized, double-blind, crossover study design was used. It was found that both continuous and evoked pain were markedly reduced by the blockade of NMDA receptors by ketamine as well as by the activation of mu-opioid receptors by alfentanil. Neither ketamine nor alfentanil significantly changed thresholds for the sensation of heat pain. The reduction of pain was not associated with severe side effects; the most severe side effect of ketamine was bothersome dizziness in one patient, and only modest side effects were caused by alfentanil. The present data provide clinical evidence that the development of central dysesthesia pain after traumatic spinal cord injury is dependent on the activation of central NMDA receptors. The results further indicate that mu-opioid receptors are involved in the control of this type of pain.",1995.0,0,0
1193,8584194,[Post-thoracotomy analgesia in pediatric heart surgery: comparison of 2 different techniques].,S Picardo; G Testa; G La Vigna; A Carotti; G Catena,The aim of this study was to compare two different post-operative pain control techniques in pediatric patients undergoing thoracotomy with reference to a control group receiving conventional treatment in the form of endovenous morphine. The post-operative antalgic treatment protocol included the random distribution of patients to three groups: control group: endovenous analgesia with morphine boluses; group 1: intrapleural analgesia with bupivacaine boluses; group 2: caudal epidural analgesia in a single bolus with a mix of bupivacaine and morphine. In the comparison it was seen that the method that offered the most effective pain control and fewest collateral effects was caudal peridural analgesia. The authors conclude by suggesting the use of this method and underlining the need to pay greater attention to the problem of postoperative pain in pediatrics.,1995.0,0,0
1194,8585252,[Acceptability of high colonoscopy using different premedication--a comparison of the effect of midazolam versus midazolam and pethidine from the viewpoint of the patient and the physician].,U B Ehrle; B Horschler; M V Singer,"Invasive endoscopic procedures such as total colonoscopy result in a better patient acceptance, the less discomfort they cause. Therefore a premedication for total colonoscopy is often required. In a prospective, double-blind, placebo-controlled clinical study of 132 patients examined by one experienced endoscopist we compared two premedication schedules: midazolam (mean 5.2 mg i.v.) versus midazolam (mean 4.8 mg) plus pethidin (50 mg). We found that the combination midazolam plus pethidin provides a deeper and more reliable sedation and analgesia than midazolam alone. The combination of both drugs caused also more anterograde amnesia. It was also shown, that the endoscopist scored a higher degree of patient's pain during the examination than the patient did himself. No more negative side-effects such as decrease of arterial partial pressure of oxygen or cardiopulmonary complications were found using the combination of both drugs; they provided to be safe without added risk of hypoxia. Thus, the combination of both drugs can be given as premedication for total colonoscopy.",1995.0,0,0
1195,8590247,Drug-use evaluation of transdermal fentanyl.,A Shamilian,,1995.0,0,1
1196,8590509,,,,,0,0
1197,8592233,Intrathecal granuloma complicating chronic spinal infusion of morphine. Report of three cases.,J P Blount; K B Remley; S K Yue; D L Erickson,Intrathecal morphine delivered by implanted pumps has been used in the treatment of pain caused by terminal cancer. Some authors supports its use in benign pain as well. The authors present three cases in which chronic infiltration of intraspinal narcotic medication was complicated by the formation of a granulomatous mass that became large enough to exert mass effect and induce neurological dysfunction.,1996.0,0,0
1198,8595682,Failure of meperidine wound infiltration to reduce pain after laparoscopic tubal ligation.,L Forgach; B Y Ong,"Many women experience considerable pain and delay in return to regular activity after laparoscopic tubal ligation. We performed a prospective randomized double-blind study to evaluate pain and recovery after laparoscopic tubal ligation and the influence of meperidine wound infiltration. After approval by the Ethics Committee, informed consent was obtained from 60 patients. All patients received naproxen 500 mg po one hour before surgery. Patients were randomized into three groups. All patients received a standard general anaesthetic. Group C patients (n = 18) received normal saline (NS) in the deltoid and NS in the wound. Group S patients (n = 21) received 50 mg of meperidine in the deltoid and NS in the wound. Group W patients (n = 21) received 50 mg meperidine in the wound and NS in the deltoid. After surgery, pain and nausea were treated with morphine and metoclopramide as needed. Following hospital discharge, patients were contacted by telephone daily until they returned to regular activities. The mean maximum pain score of Group S patients was lower than that of Group C patients (P < 0.05). Group S patients required less morphine in the Postanaesthesia Care Unit than the Group C patients (P < 0.05). One Group C patient was readmitted to hospital due to inadequate analgesia with oral medications. Group S patients returned to regular activity earlier than the Group C patients (P < 0.05). It is concluded that wound infiltration with meperidine did not affect postoperative pain or recovery. Intramuscular administration of the same amount of meperidine resulted in less postoperative pain and earlier return to regular activity.",1995.0,0,0
1199,8602664,Role of magnesium sulfate in postoperative analgesia.,M R Tramer; J Schneider; R A Marti; K Rifat,"N-methyl-D-aspartate antagonists may play a role in the prevention of pain. An assessment was made of the effect of the physiologic N-methyl-D-aspartate antagonist magnesium on analgesic requirements, pain, comfort, and quality of sleep in the postoperative period. In a randomized, double-blind study, 42 patients undergoing elective abdominal hysterectomy with general anesthesia received 20% magnesium sulfate or saline (control) 15 ml intravenously before start of surgery and 2.5 ml/h for the next 20 h. Postoperative morphine requirement was assessed for 48 h using patient-controlled analgesia. Maximum expiratory flow (peak flow), pain at rest and during peak flow, and discomfort were evaluated up to the 48th postoperative hour, and 1 week and 1 month after surgery. Insomnia was evaluated after the first and second postoperative nights. Compared to control subjects, magnesium-treated patients consumed less morphine during the first 48h (P<0.03), which was most pronounced during the first 6 h (P<0.004), and experienced less discomfort during the first and second postoperative days (P<0.05-0.005). The magnesium-treated group revealed no change in postoperative sleeping patterns when compared to preoperative patterns. Control patients showed an increase in insomnia during the first and second postoperative nights (P<0.002 and P<0.005, respectively) compared to preoperative values. This is the first clinical study showing that the perioperative application of magnesium sulfate is associated with smaller analgesic requirement, less discomfort, and a better quality of sleep in the postoperative period but not with adverse effects. Magnesium could be of interest as an adjuvant to postoperative analgesia.",1996.0,0,0
1200,8604435,Biological rhythms in pain and in the effects of opioid analgesics.,G Labrecque; M C Vanier,"Pain is difficult and sometimes frustrating to treat, even though new devices and new approaches have been developed in recent years. Pain varies tremendously from one patient to the next, and there are also some studies suggesting that the intensity of pain varies according to time of day. In animal experiments, a relationship between the reaction to pain and the rhythmicity of plasma endorphin concentrations was suggested because reactions to pain (such as jumping from a hot plate) were in phase with plasma endorphin levels: latencies were longest and plasma levels were highest during the resting period of rodents. In human studies, pain induced experimentally was reported to be maximal in the morning, or in the afternoon or at night. These divergent findings may be due to methodological differences, as pain was produced by different methods, many parameters were used to quantify pain intensity, and the psychological aspect of pain was rarely considered by authors. A circadian pattern of pain was found in patients suffering from pain produced by different diseases. For instance, highest toothache intensity occurred in the morning, while biliary colic, migraine, and intractable pain were highest at night. Patients with rheumatoid arthritis reported peak pain early in the morning, while those with osteoarthritis of the knee indicated that the maximal pain occurred at the end of the day. The effectiveness of opioids appears also to vary according to time of day, but large differences in the time of peak and low effects were found. Investigators found that peak pain intensity and narcotic demands occurred early in the morning, while others found maximal pain at the end of the day. Pain is a complex phenomenon and efforts should be made to standardize the methods used in studies and to describe accurately the diseases causing pain because the patterns of pain may be specific to each clinical situation. Further research should be aimed at characterizing the chronobiology of pain in different experimental and clinical situations and to determine when the analgesic drugs are producing maximal effectiveness. This information is needed before clinicians can be persuaded to use chronopharmacological data when they prescribe analgesic drugs to their patients.",1995.0,0,0
1201,8604459,Intrathecal infusion systems for treatment of chronic low back and leg pain of noncancer origin.,U Tutak; D M Doleys,"In this study, 26 patients (average age, 44.3 years) with chronic noncancer pain averaging 115 months' duration had implantation of an infusion pump with intrathecal catheter placement. In general, preservative-free morphine sulfate was used. Average follow-up was 23 months. Measurements of pain reduction, activity improvement, oral medication use, and overall satisfaction by patient, spouse, and clinic staff were obtained. Of the 26 patients, 20 noted a good or excellent outcome. Average daily dosage of intrathecal morphine increased over time by approximately sevenfold. Subjective pain levels decreased an average of 59%, and daily functioning increased 50%. No postoperative complications were noted, but 11 patients required additional surgery (9 for catheter complications). These data support chronic spinal opiate therapy as an option for safe and long-term management of noncancer pain.",1996.0,0,0
1202,8607299,Thoracic paravertebral analgesia.,J Richardson; S Sabanathan,"Thoracic paravertebral nerve blockade, although once widely practised, has now only a few centres which contribute to the literature. Data production has, however, continued and this review correlates this new information with existing knowledge. Its history, taxonomy, anatomy, indications, techniques, mechanisms of analgesia, efficacy, contraindications, toxicity, side effects and complications are reviewed. Thoracic paravertebral analgesia is advocated for surgical procedures of the thorax and abdomen, especially wherever the afferent input is predominantly unilateral eg. thoracotomy, cholecystectomy and nephrectomy. It is also of benefit in the prevention and management of chronic pain. It is a simple undertaking with impressive efficacy. Plasma local anaesthetic levels are acceptable and its side effect and complication rates are low. No mortality has been reported. For unilateral surgery of the chest or truck, thoracic paravertebral analgesia should be considered as the afferent block of choice. For bilateral surgery, its efficacy may be limited by the doses of local anaesthetic which could safely be used and further study in this area in particular is required. This form of afferent blockade deserves greater consideration and investigation.",1995.0,0,0
1203,8610220,"Pain analysis in patients with fibromyalgia. Effects of intravenous morphine, lidocaine, and ketamine.",J Sörensen; A Bengtsson; E Bäckman; K G Henriksson; M Bengtsson,"Pain intensity, muscle strength, static muscle endurance, pressure pain threshold, and pain tolerance at tender points and control points were assessed in 31 patients with fibromyalgia (FM), before and after intravenous administration of morphine (9 patients), lidocaine (11 patients), and ketamine (11 patients). The three different studies were double-blind and placebo-controlled. The patients were classified as placebo-responders, responders (decrease in pain intensity by > 50%) and non-responders. The morphine test did not show any significant changes. The lidocaine test showed a pain decrease during and after the infusion. The ketamine test showed a significant reduction in pain intensity during and after the test period. Tenderness at tender points decreased and endurance increased significantly, while muscle strength remained unchanged. The present results support the hypothesis that the NMDA receptors are involved in pain mechanisms in fibromyalgia. These findings also suggest that central sensitization is present in FM and that tender points represent secondary hyperalgesia.",1995.0,0,0
1204,8614885,Persistent pain associated with long-term intrathecal morphine administration.,W C Parris; P K Janicki; B Johnson; J Livengood; L Mathews,"A 32-year-old man with chronic intractable right lower extremity pain unresponsive to multiple neurosurgical and pharmacologic treatments, including intrathecal morphine administration, was successfully treated with sciatic nerve block, discontinuance of opioid therapy, and psychologic interventions. Plasma and urine ratios of morphine metabolites morphine-3-glucuronide and morphine-6-glucuronide were analyzed at the beginning of our interventions, and the results indicated that morphine-3-glucuronide levels were significantly higher than morphine-6-glucuronide levels. The possible association between the observed morphine metabolite ratio and the intractable pain in patients resistant to opioids may have potential clinical implications.",2001.0,0,0
1205,8615729,Does patient-controlled analgesia achieve better control of pain and fewer adverse effects than intramuscular analgesia? A prospective randomized trial.,L F Nitschke; C T Schlösser; R L Berg; J V Selthafner; T J Wengert; C S Avecilla,"To compare three analgesic regimens in patients undergoing colon resection: patient-controlled morphine sulfate analgesia (PCA), intramuscular (IM) morphine, and IM ketorolac tromethamine. Prospective randomized case series. Rural, private teaching hospital. All patients (307) scheduled to undergo a major colon resection between January 1, 1992, and December 31, 1993, were eligible to participate. Of these, 10 (3%) were missed in the screening process, 132 (43%) declined participation, 73 (24%) were excluded, and 92 (30%) were enrolled and randomly assigned to a treatment group. Ninety-two patients were enrolled in the study. Two patients never received the medication to which they were assigned, owing to administrative error; their data was not analyzed. Of the remaining patients, 31 were randomized to the PCA morphine group, 31 were randomized to the IM morphine group, and 28 were randomized to the IM ketorolac group. The randomly assigned drug was first administered in the post-anesthesia care unit. On arrival on the postoperative ward, the patient was asked to rate his or her pain using both a numerical rating scale and a visual analog scale at 30 minutes; 1, 2, 3, 4, and 6 hours after arrival on the ward; and every 4 hours throughout the first 5 postoperative days. The Mini-Mental State Examination (MMSE) was administered the day before surgery and then daily for the first 5 postoperative days. The first day the patient passed flatus after surgery was also recorded. The end points analyzed were adverse effects, duration of postoperative ileus, degree of pain control, length of hospitalization, and development of postoperative confusion as measured on serial MMSEs. Only two patients, both in the PCA group, reported adverse effects; neither required a change in analgesia group. Significantly more patients assigned to IM ketorolac broke protocol and required alternative analgesia than did patients in the morphine groups (32% ketorolac vs 16% IM morphine and 0% PCA). The ketorolac group had a significantly shorter duration of ileus than either morphine group (P<.0l). The ketorolac group also had significantly lower pain scores (P<.04) and less postoperative confusion than the morphine groups (P<.03), although these results are limited by missing values. The ketorolac group had a significantly shorter length of stay than either morphine group (P<.01), while there was no significant difference between the morphine groups (P=.75). While it appears that ketorolac provides a better postoperative course than either IM or PCA morphine in terms of pain control, postoperative confusion, length of stay, and duration of ileus, 18% of our patients assigned to ketorolac required additional analgesia, and there was a strong patient preference for PCA. Most patients should probably be managed with PCA narcotics, but the addition of ketorolac might reduce narcotic dose and resultant adverse effects. Those patients particularly prone to adverse effects should receive primarily ketorolac.",1996.0,0,0
1206,8623995,"Prophylactic use of epidural mepivacaine/morphine, systemic diclofenac, and metamizole reduces postoperative morphine consumption after major abdominal surgery.",M G Rockemann; W Seeling; C Bischof; D Börstinghaus; P Steffen; M Georgieff,"Surgical trauma induces nociceptive sensitization leading to amplification and prolongation of postoperative pain. While preemptive analgesic treatment with numerous agents has been successful in experimental animals, results of human studies remain conflicting. The authors used a multimodal approach for preemptive analgesia before abdominal surgery: diclofenac and metamizole inhibit prostaglandin synthesis, thus influencing peripheral sensitization; epidural local anesthetics induce conduction block, epidural opioids inhibit nociceptive synaptic transmission, and metamizole induces descending inhibition. The interaction of these drugs might suppress spinal nociceptive sensitization and postoperative analgesic demand. One hundred forty-two patients scheduled for major abdominal surgery were randomly assigned to one of three groups and studied prospectively. Epidural catheters in groups 1 and 2 were placed at interspaces T8-T10, the position of the catheter was confirmed by epidurography, and sensory testing after administration of 5 ml mepivacaine 1%. Group 1 received 75 mg intramuscular diclofenac, 1000 mg intravenous metamizole, 5.3 +/- 1 mg epidural morphine, and 15-20 ml mepivacaine 1% 85 +/- 41 min before skin incision. Epidural analgesia was maintained by injections of 0.1 ml.kg-1.h-1 mepivacaine 1%. Group 2 patients received the balanced analgesia regimen before wound closure (221 +/- 86 min after skin incision). Group 3 patients did not receive any study substances. General anesthesia was induced with 5 mg/kg thiopental and 2 micrograms/kg fentanyl and maintained with enflurane and nitrous oxide. Postoperative analgesia consisted of patient-controlled intravenous morphine over 5 days. Median visual analog scale pain intensities were < 3 cm and did not differ among the groups. Morphine consumption per hour on postoperative day 2 was 0.8 +/- 0.1 mg/h (group 1) < 1.2 +/- 0.1 mg/h (group 2) = 1.1 +/- 0.1 mg/h (group 3) and cumulative morphine consumption (in mg) on the morning of day 5 was 95 +/- 9 (group 1) < 111 +/- 11 (group 2) < 137 +/- 10 (group 3). A significant reduction of patient controlled analgesia requirements could be achieved by our preincisional balanced analgesia regimen compared to application before wound closure. The more distinct difference between patients receiving balanced analgesia and those in the control group is based on the analgesic action of the study substances, which lasted about 14 h.",1996.0,0,0
1207,8625340,Patient-controlled analgesia (PCA) in the domiciliary care of tumour patients.,G Meuret; H Jocham,"Patient-controlled analgesia (PCA) was administered in the domiciliary environment in 143 pre-terminally and terminally ill tumour patients suffering either from excruciating chronic pain or severe chronic/acute complex pain that could not be relieved adequately by oral analgesia. Morphine solutions were infused subcutaneously in concentrations between 1% and 3%. The intravenous route was preferred in patients with indwelling catheters or those susceptible to inflammatory skin reactions at the infusion site. After initial dose adjustment, lasting 2-3 days, the morphine amounts infused by PCA reached a median of 93 mg day(-1) (range 12-464 mg day(-1)). The median was 28% lower than the median dose administered orally. A total of 84% of patients utilized the option of bolus self-administration. The median percentage administered via the bolus mode amounted to 5.3% of the total requirements. During the course of treatment, morphine requirements increased by a median of 2.3 mg day(-1) (range -29 +52 mg day(-1)). Most patients were treated continuously in the home care setting until death, the median duration being 27 days (range 1-437 days). The terminal morphine demands reached a median of 188 mg day(-1) (range 15-1008 mg day(-1)). PCA turned out to be safe and effective, attaining excellent results in 95 (66%) patients and satisfactory pain relief in 43 (30%). PCA proved to be insufficient in five (4%) cases. Side-effects were mild: constipation, fatigue, nausea and local inflammatory skin reactions occurred in 9%. Thus, with support from an experienced mobile nursing team, PCA can be safely administered in the terminal domiciliary care of tumour patients. PCA is superior to oral analgesia, especially in the treatment of severe oscillating pain. PCA provides adequate pain control in about 96% of patients who are poorly responsive to oral opioids.",1996.0,0,0
1208,8628027,Managing cancer pain: basic principles and invasive treatments.,K A Marshall,"Severe pain associated with cancer continues to be a substantial problem for patients, physicians, and the health-care system. During the past 2 decades, major advances have occurred in the understanding of the pathogenesis of pain. Likewise, considerable advances have occurred in the conceptualization of and clinical approach to cancer pain. This article briefly summarizes the basic principles of the treatment of cancer pain and in particular describes the World Health Organization 3-step ""analgesic ladder"" for the treatment of cancer pain. In addition, several invasive approaches for managing various refractory cancer pain syndromes are discussed.",1996.0,0,0
1209,8628581,"Effects of intravenous ketamine, alfentanil, or placebo on pain, pinprick hyperalgesia, and allodynia produced by intradermal capsaicin in human subjects.",K M Park; M B Max; E Robinovitz; R H Gracely; G J Bennett,"The importance of N-methyl-D-aspartate (NMDA) receptor-mediated sensitization of central nervous system (CNS) neurons is well established in animal models of acute and chronic pain. A human model of central sensitization would be useful in screening new NMDA antagonists and establishing dose regimens for clinical trials in patients with pain related to sensitization of CNS neurons. We used this model to examine the effects of intravenous infusions of two centrally acting analgesics, the NMDA receptor antagonist ketamine and the morphine-like opioid agonist alfentanil. Twelve normal subjects completed a 3-session, randomized, double-blind, crossover study. From 25 to 60 min after capsaicin injection, subjects were given intravenous infusions of ketamine (mean dose: 32 mg), alfentanil (mean dose: 3075 micrograms), or saline placebo. Both drugs significantly reduced ongoing pain and pinprick-evoked hyperalgesia during the infusion. The reduction in allodynia evoked by light stroking was statistically significant only for alfentanil. Mean reduction +/- SEM relative to placebo were for ongoing pain: ketamine, 36 +/- 9%; alfentanil, 51 +/- 5%; area of pinprick hyperalgesia: ketamine, 34 +/- 7%; alfentanil, 35 +/- 7%; and area of mechanical allodynia: ketamine, 52 +/- 20%; alfentanil, 70 +/- 12%. Because the drugs were given systemically and produced side effects in all subjects, we cannot specify the site or sites of action nor conclusively rule out a non-specific 'active placebo' response as the cause for reduction of symptoms. Arguing against an 'active placebo' response, however, was the lack of analgesic effect of intravenous midazolam (mean dose; 3.4 mg, titrated to produce side effects of similar magnitude to ketamine and alfentanil) given at 145 min after capsaicin in 9 subjects who had received saline from 25 to 60 min. The results of this study suggest that neural systems sensitive to NMDA receptor antagonists and opioids participate in capsaicin-evoked pain phenomena, and support the feasibility of pharmacological studies using the intradermal capsaicin model.",1995.0,0,0
1210,8628593,Subcutaneous fentanyl and sufentanil infusion substitution for morphine intolerance in cancer pain management.,A Paix; A Coleman; J Lees; J Grigson; M Brooksbank; D Thorne; M Ashby,"Eleven patients with cancer pain in a palliative care and chronic pain service required cessation of morphine due to unacceptable opioid side effects. In this retrospective study fentanyl was evaluated as a second-line subcutaneously infused opioid. Starting doses ranged from 100 to 1000 micrograms/24 h, and the duration of fentanyl infusion was 3-70 days. The clinically derived mean relative potency of fentanyl to morphine infusions was 68:1 (SD +/- 23; range: 15-100), and we now recommend cautious dose conversion at an approximate equivalence of 150-200 micrograms fentanyl for 10 mg morphine in non-opioid naive chronic cancer pain patients. All patients demonstrated an improvement in the adverse effect(s) for which the change in opioid was undertaken. Adequate pain relief was achieved in all but 1 patient with mixed nociceptive and neuropathic pelvic pain for whom an epidural infusion of a local anaesthetic/opioid mixture was required. Fentanyl was changed to the more potent synthetic opioid sufentanil in 2 patients for whom the fentanyl dose necessitated too large a volume for the portable syringe driver in use. The clinically derived sufentanil to fentanyl relative potencies were 24:1 and 16:1, respectively. This achieved good analgesia and maintained the favourable side-effect profile seen with fentanyl. Subcutaneous infusion appears to be a safe and viable route of fentanyl delivery, and provided effective analgesia with a low incidence of adverse effects in this small selected group of patients who were intolerant of subcutaneous morphine. We suggest a trial of subcutaneous fentanyl for selected patients who have intractable adverse effects on morphine, and it is now the second-line infusable opioid in our service. Further prospective evaluation of the role of these two synthetic mu opioid agonists in palliative care practice is warranted, as part of an evolving picture of variation in opioid side-effect profile seen with different drugs within the class.",1995.0,0,0
1211,8639197,Intramuscular prochlorperazine versus metoclopramide as single-agent therapy for the treatment of acute migraine headache.,J Jones; S Pack; E Chun,"To compare the efficacy of intramuscular prochlorperazine and metoclopramide in the short-term treatment of migraine headache in the emergency department 86 eligible adult patients with moderate to severe migraine headache were evaluated prospectively at a university-affiliated community hospital. After randomization, each subject received a 2-mL intramuscular injection of sterile saline, prochlorperazine (10 mg), or metoclopramide (10 mg). No other analgesics were administered during the 60-minute study period; patient assessment of relief was followed using visual analog scales. Reduction in median headache scores was significantly better among those treated with prochlorperazine (67%) compared to metoclopramide (34%) or placebo (16%). Similarly, symptoms of nausea and vomiting were significantly relieved in the prochlorperazine group (chi 2 = 17.1, P < .001). However, rescue analgesic therapy was necessary in the majority of patients treated with prochlorperazine (16/28) and metoclopramide (23/29) after the 60-minute study period. Although intramuscular prochlorperazine appears to provides more effective relief than metoclopramide, these results do not recommend either drug as single-agent therapy for acute migraine headache.",1996.0,0,0
1212,8639213,A new approach to chronic pain in the ED.,D B MacLeod; R Swanson,"Patients presenting to emergency departments (EDs) for primary management of chronic or recurrent nonmalignant pain conditions and their physicians frequently report dissatisfaction, in part because of the impressions created by a small percentage of such patients that frequently visit EDs requesting opioids. Treating such patients with opioids is contrary to many published guidelines, but refusing them increases dissatisfaction. Narcotic registers serve to label patients who are suspected of seeking drugs, thus creating anxiety and often distrust in health care professionals treating them. The four Calgary adult EDs have developed a system that will attempt to remove labels associated with some of these patients, insure communication between patients, their family doctors, and ED staff, and facilitate optimal care of the patients' real problems, be they difficult home management of pain, drug dependence or addiction, or other social issues. Emphasis will be shifted to home management and the family doctor's office. If successful, the system will minimize ED visits by frequent attendees seeking medication for pain control, and should also decrease overall expenditure to the health care system.",1996.0,0,0
1213,8644584,Randomized comparison of flexible versus nonflexible femoral sheaths on patient comfort after angioplasty.,R Waksman; N A Scott; Z M Ghazzal; R Mays; F A Frerichs; J Y Petersen; S B King,"Patients who undergo percutaneous transluminal coronary angioplasty (PTCA) by the femoral approach are usually required to lie flat in bed for 6 to 24 hours, which may result in significant discomfort. This study was performed to evaluate the safety and benefit of a flexible sheath that enables patients to sit at a 60-degree angle while the sheath is in place in the femoral artery. Sixty patients were randomly assigned to receive either flexible or nonflexible sheaths before PTCA. Patients with flexible sheaths were allowed to sit at an angle of 60 degrees after the procedure. Heparin management was the same in both groups. Frequency of calls to nurses for back pain was recorded for both groups. For analgesia, nalbuphine was administered in 2-mg increments. All sheaths were removed the day after the procedure. Femoral ultrasound was used to detect groin complications (hematoma, pseudoaneurysm, or arteriovenous fistula) and was performed in all patients. Baseline characteristics were similar in both groups. There were no differences in ease of sheath insertion or guide catheter movement through the sheaths. The arterial pressure waveform was not dampened in any of the flexible sheath patients while in the sitting position. Patients with flexible sheaths had fewer calls for back pain and required less nalbuphine than patients with nonflexible sheaths. Groin complications were similar in both groups. In conclusion, by allowing patients to sit up to an angle of 60 degrees, flexible sheaths have a beneficial effect in reducing back pain and the need for analgesics after PTCA.",1996.0,0,0
1214,8651535,Evaluation of intrapleural analgesia in the management of blunt traumatic chest wall pain: a clinical trial.,K Short; D Scheeres; J Mlakar; R Dean,"Intrapleural analgesia (IPA) has been successfully used for the relief of chest wall pain. Previous studies investigating its use have yielded conflicting results and have often suffered from design defects. The theoretical lower incidence of respiratory and circulatory depression with IPA suggests significant advantages over epidural analgesia. Patients who had documented blunt chest wall trauma were entered into a prospective, randomized, double-blinded, crossover, placebo-controlled study within 16 hours of their injury. Patients who were intubated or had significant trauma outside of the chest wall were not entered. Intrapleural catheters were placed using a standardized technique. Each patient received either a placebo solution of normal saline or a combination of bupivacaine/lidocaine in a blinded, crossover fashion for two 24-hour periods. Data were obtained on the use of supplementary narcotics, transcutaneous pCO(2') pulse oximetry, pulmonary function tests, and both patient and nursing evaluations of pain based on a numeric analogue scale. A series of 16 patients from a Level I trauma center were identified over a 2-year period. The ratio of male to female was approximately 2:1, with an age range of 35-80 years. There were no complications related to catheter placement or anesthetic toxicity. Mean values for patient and nursing pain ratings revealed opposite trends. We found no significant difference in the mean values for supplemental narcotic use, pCO(2') p0(2') forced vital capacity, or forced expiratory volume between the placebo and the test solution. Although previous studies have suggested that IPA may be beneficial in the management of chest wall pain, this was not confirmed in our study for blunt chest injuries. The addition of IPA to the more traditional use of opioid analgesics was not more effective for management of blunt chest wall pain. Despite our small patient population (n = 16), the crossover design should have allowed clinically significant differences to become evident (alpha value = 0.95). A review of the literature and a historical basis for the evolution in the management of this type of pain is included.",1996.0,0,0
1215,8652316,"Dose requirements, efficacy and side effects of morphine and pethidine delivered by patient-controlled analgesia after gynaecological surgery.",G Stanley; B Appadu; M Mead; D J Rowbotham,"We have compared the dose requirements and side effects of morphine with those of pethidine when administered by patient-controlled analgesia in 40 patients (ASA I-II, 20-65 yr) after elective total abdominal hysterectomy. Patients were allocated randomly, in a double-blind manner, to receive either morphine (bolus dose 2 mg, lockout time 10 min) or pethidine (bolus dose 20 mg, lockout time 10 min) for postoperative pain relief. Mean 24-h morphine and pethidine consumption was 70 (SEM 6.2) mg and 660 (67.8) mg, respectively (ratio 1:9.4). There were no significant differences in postoperative sedation, nausea, pain relief and patient satisfaction (VAS 0-100 mm), and requirements for antiemetics. Four patients receiving pethidine were withdrawn because of postoperative confusion and one receiving morphine because of intractable nausea and vomiting. The 95% confidence interval for this difference between the groups for VAS scores of sedation, nausea and pain were approximately 30 mm.",1996.0,0,0
1216,8653161,Effects of interpleural bupivacaine on pleural chest tube removal pain: a randomized controlled trial.,K A Puntillo,"Moderate to severe pain associated with the removal of pleural chest tubes is poorly controlled with opioids. New methods are needed to manage the pain associated with this procedure. To compare the effects of interpleural injections of 0.25% bupivacaine without epinephrine to those of normal saline on chest tube removal pain in cardiothoracic surgery patients. A randomized, double-blind, placebo-controlled trial was used, with a repeated measures design. Pain intensity and distress were measured before, immediately after, and 1 hour after chest tube removal. Pain sensations and affect were evaluated immediately after chest tube removal. The experimental group (n = 21) received bupivacaine and the control group (n = 20) received normal saline. In both groups pain intensity and distress scores were significantly higher at the time of chest tube removal than immediately before or 1 hour after. No significant differences in pain intensity, distress, sensation, or affect scores were found between the two treatment groups. The 13 patients who received intramuscular ketorolac an average of 3.5 hours before the procedure, independent of the study design, had significantly lower pain intensity scores at the time of chest tube removal than the 26 who did not. These data demonstrate that chest tube removal pain is of moderate to severe intensity and that pleural chest tube injections of bupivacaine were not effective in decreasing chest tube removal pain. However, the decrease in pain associated with the administration of ketorolac warrants future study.",1996.0,0,0
1217,8664090,A double-blind placebo-controlled study to assess the efficacy of a compound analgesic to prevent postoperative pain following oral surgery.,S Sandhu; J P Rood,It has been suggested that small doses of opioid drugs given prior to surgery can reduce postoperative pain. This study was designed to compare the effectiveness of a paracetamol/codeine combination and paracetamol alone in preventing the pain following surgical removal of impacted third molar teeth under general anaesthesia. Analysis of the results showed no statistical differences between treatment groups when compared with placebo. We suggest that the opioids may not be the best drugs available to prevent the moderate to severe pain present following some oral surgery procedures.,1996.0,0,0
1218,8665549,"Intravenous infusion of the NMDA antagonist, ketamine, in chronic posttraumatic pain with allodynia: a double-blind comparison to alfentanil and placebo.",M B Max; M G Byas-Smith; R H Gracely; G J Bennett,"NMDA antagonists and opioids relieve experimentally produced hyperalgesia in animals and humans, presumably by attenuating a heightened central nervous system response to afferent input. A few small studies in patients have suggested that intravenous boluses or rapid infusions of the N-methyl-D-aspartate (NMDA) antagonist ketamine relieve some neuropathic pains but also produce disturbances of cognition and mood. In a randomized, double-blind, crossover trial, we treated eight patients with chronic posttraumatic pain and widespread mechanical allodynia with 2-h intravenous infusions of the NMDA antagonist ketamine (mean dose, 58 mg), the opioid mu-receptor agonist alfentanil (mean dose, 11 mg), and placebo. The patients were selected because extensive sensory testing suggested that altered central processing contributed to their symptoms. The slow rate of drug infusion was chosen to see if pain relief would precede dose-limiting side effects. Means of the peak effect scores achieved during the 2-h infusion were for pain relief: ketamine, 65%, alfentanil, 46%, and placebo, 22% (p < 0.01 for ketamine and p = 0.08 for alfentanil, each compared to placebo); and for relief of allodynia: ketamine, 71%, alfentanil, 57%, and placebo, 21% (p < 0.01 for both ketamine and alfentanil). Appreciable symptomatic relief developed only after the onset of unpleasant drug side effects. After the infusion was stopped, pain relief disappeared before the side effects resolved. We conclude that NMDA antagonists may have promise for the treatment of neuropathic pain, but strategies are needed to improve their therapeutic ratio, such as intrathecal administration or systemic treatment with more selective drugs.",1995.0,0,0
1219,8665876,Pre-emptive versus post-surgical administration of ketorolac for hysterectomy.,T J Parke; S M Lowson; D R Uncles; M O Daughtery; B T Sitzman,"Seventy-seven women who underwent routine vaginal or abdominal hysterectomy were randomly allocated to receive intravenous ketorolac 30 mg either 30 min before surgical incision (pre-emptive group, n = 37), or at the end of the surgical procedure (post-surgical group, n = 40). The patients received routine post-operative care, which included morphine by patient-controlled analgesia, 1 mg per demand with a lockout of 6 min and a background infusion of 1 mg h-1. In addition, pain was assessed at 12 and 24 h using a 100 mm visual analogue scale (VAS), both at rest and on coughing. At 24 h, the median VAS at rest was 24 mm (range 0-80) in the pre-emptive group and 28 mm (range 0-100) in the post-surgical group. The average morphine consumption rate over the first 24 h was 1.9 mg h-1 (SD +/- 0.6) in the pre-emptive group, and 2.2 mg hr-1 (SD +/- 1.1) in the post-surgical group. There were no significant differences on univariate testing. Subsidiary stepwise multiple regression modelling identified age, weight, type of hysterectomy, and the timing of ketorolac administration as significant explanators of post-operative morphine consumption. A statistically significant pre-emptive analgesic effect was therefore identifiable, but the clinical significance is uncertain in relation to the other influences on post-operative analgesic requirements.",1995.0,0,0
1220,8665883,A comparison between ketorolac and diclofenac in laparoscopic sterilization.,P T Chui; T Gin,"We compared ketorolac and diclofenac for the prevention and treatment of post-operative pain in patients undergoing laparoscopic sterilization. Fifty ASA I or II women were allocated randomly to receive either diclofenac 75 mg or ketorolac 30 mg intramuscularly 30-90 min before general anaesthesia. Pain scores were assessed half-hourly in the recovery room and then at 2 h and 4 h in the ward. In the recovery room, pain was treated with a second dose of the study drug, followed by parenteral pethidine if necessary. Four patients in the diclofenac group and five patients in the ketorolac group requested no analgesics after surgery. Fifteen patients from each group had satisfactory analgesia after the second dose of study drug. Pain scores were similar between groups at all times. The median (range) initial pain score in the recovery room was 5 (0-9.5) in the diclofenac group and 5 (1-9) in the ketorolac group. Pain at the injection site was more common after diclofenac than ketorolac (12 vs. 3, P < 0.05). In conclusion, both intramuscular diclofenac and ketorolac were relatively ineffective in controlling the pain after laparoscopic sterilization. The drugs were equally well tolerated, but more patients complained of pain at the injection site after diclofenac.",1995.0,0,0
1221,8666530,Analgesic rebound headache in clinical practice: data from a physician survey.,A Rapoport; P Stang; D L Gutterman; R Cady; H Markley; R Weeks; J Saiers; A W Fox,"Frequent, excessive use of over-the-counter or prescription analgesics may lead to analgesic rebound headache. Little is known about the magnitude of the health problem posed by analgesic rebound headache, its epidemiology, the characteristics of analgesic rebound headache sufferers, or about physicians' approaches to treatment. Four hundred seventy-three practitioners, who had previously expressed an interest in the treatment of headache, were mailed a questionnaire designed to capture information about the frequency and management of analgesic rebound headache and about the characteristics of analgesic rebound headache sufferers. Completed questionnaires were returned by 174 practitioners (37%) from 40 states, the District of Columbia, and Puerto Rico. More than 40% of respondents indicated that analgesic rebound headache was present in at least 20% of their patients. On average, the physicians reported that 73% of patients with analgesic rebound headache were women. Analgesic rebound headache was most likely to occur in patients aged 31 to 40 years. No one analgesic was consistently identified as causative, although acetaminophen, butalbital + aspirin + caffeine, and aspirin were commonly used by patients. Eighty percent of respondents indicated that depression was commonly observed in analgesic rebound headache sufferers; 77% indicated that physical conditions (especially gastrointestinal symptoms) were commonly observed. A variety of therapeutic strategies, including pharmacotherapy, were used in the management of analgesic rebound headache. Analgesic rebound headache was recognized as a distinct entity and a substantive component in more than 40% of the practices of 174 surveyed practitioners. General practitioners, who see a wide variety of patient types with a spectrum of complaints, need to be able to diagnose analgesic rebound headache by taking a good history.",1996.0,0,0
1222,8667132,,,,,0,0
1223,8669216,Evaluation of morphine for patient controlled analgesia with the Infusor system after opiate-free locoregional anesthesia for osteotomy of the foot.,P Van Lancker; E Mortier; A Pieters; G Rolly,"Efficacy and safety of a PCA protocol, without loading dose or background infusion, was investigated in 40 consenting patients after osteotomy of the foot. All patients had intrathecal lidocaine 5% 1.8 ml preoperatively. Postoperative pain relief was provided with morphine from a Baxter Travenol infusor with PC module. The morphine concentration was 2 mg/ml or 3 mg/ml. In order to reach the analgesic blood concentration as quickly as possible, the patients were instructed to start PCA from the very first moment pain occurred. The patients breathed room air. The nursing staff evaluated respiratory and cardiovascular parameters, pain and side effects. Although mean VAS scores were higher than 3 in the early postoperative phase, no supplementary analgesics were required. One patient had urine retention. One patient had a drop in blood pressure at the start of morphine, which was quickly restored with the administration of colloids. Oxygen saturations were lower (SpO2 < 95%) the first hours postoperatively, especially at the first assessment where no morphine was administered. Pain or relative hypovolaemia could be an explanation. Dry mouth and sleepiness were the most frequently reported side-effects, followed by dizziness, vomiting and nausea. Sweating and itching were less frequently reported. The occurrence of the side effects was the highest during the first postoperative day. We conclude that even when morphine is used in PCA without loading dose or background infusion after opiate-free locoregional analgesia, close monitoring is necessary for at least 5 hours.",1995.0,0,0
1224,8669223,A day-care pain clinic--its possibilities and limitations in the treatment of cancer patients.,I Gralow; W von Hornstein; H Voss,"A day-care unit was established to extend facilities of the pain clinic. During its first 2 years of operation 79 patients with cancer-related pain have been treated. Most patients were admitted because of intractable pain but also suffered other symptoms mainly concerning the gastrointestinal and respiratory tract. For more than half of the patients and their families, psychosocial problems were also an important issue. The central aim of the pain management programme is to improve the quality of life of patients with cancer-related pain through appropriate drug based or anesthetic interventions. Control of other symptoms and counseling for both patient and family are an integral part of the holistic approach. The first initial clinical experiences show that the day-care unit provides a noticeable improvement in patient care and constitutes an excellent link between the out- and inpatient therapeutic possibilities.",1995.0,0,0
1225,8677660,[Intraventricular morphine administration as a treatment possibility for patients with intractable pain].,M Seiwald; F Alesch; A Kofler,"The treatment of intractable pain, especially in cancer patients, often sets problems to patient and therapist. While epidural and intrathecal spinal administration of opiates is a routine treatment in pain with a sub-diaphragmatic topography it is almost ineffective in cervicocephalic or thoracic cancer. An alternative here is the administration of morphine into the lateral or third ventricle by a catheter-reservoir system. We report on our experience in the treatment of twenty patients, mostly suffering from cancer (18 cases), from 1990 to 1993. It is shown to be an effective, non-destructive method with minimal side effects in the treatment of nociceptive pain. Analgesia takes effect within a few minutes and the necessary doses are low. Our results agree with those of other authors describing good to excellent results in 95% of patients with somatogenic pain. However, no or only minimal effect is achieved in the treatment of neurogenic pain by intracerebroventricular morphine therapy.",1996.0,0,0
1226,8678265,"[Awareness during general anesthesia. Definition, incidence, clinical relevance, causes, avoidance and medicolegal aspects].",D Schwender; S Klasing; M Daunderer; C Madler; E Pöppel; K Peter,"The possibility that a patient during general anaesthesia is aware of the operation going on and aware of severe pain that might be remembered postoperatively must be very alarming to patients and anaesthetists alike. Furthermore, there is experimental evidence showing that conscious recall of intraoperative events is only the tip of an iceberg; it seems very probable that there is even a higher incidence of unconscious perception during general anaesthesia. Therefore, the following stages of intraoperative awareness must be distinguished: (1) conscious awareness with explicit recall and with severe pain; (2) conscious awareness with explicit recall but no complaints of pains; (3) conscious awareness without explicit recall and possible implicit recall; (4) subconscious awareness without explicit recall and possible implicit recall; (5) no awareness. The incidence of conscious awareness with explicit recall and severe pain has been estimated at less frequent than 1/3000 general anaesthetics. Conscious awareness with explicit recall but no complaints of pain has been reported in the literature with an incidence of 05-2%. With 7-72%, conscious awareness without explicit recall and possible implicit recall shows a very wide range of variation and its occurrence probably depends on the anaesthetic drugs used. Subconscious awareness with possible implicit recall has an incidence of up to 80%, but there are many methodological problems in demonstrating implicit memory of intraoperative events. Reports of intraoperative awareness do not come exclusively from cardiac surgery and obstetrics, but also from all other operative specialties. Postoperatively, patients who experience intraoperative awareness may develop a so-called post-traumatic stress syndrome. Symptoms involve re-experiencing the event awake or in dreams, sleep disturbances, depression, avoidance of stimuli associated with the event. The probability of the development of the post-traumatic stress syndrome seems to coincide with the experience of severe pain. When a patient complains of intraoperative awareness postoperatively the anaesthesiologist should discuss the event frankly with the patient. When the symptoms of the post-traumatic stress syndrome persist a psychotherapy should follow. Causes for intraoperative awareness may be: equipment failure, too-light anaesthesia, e.g. for a caesarean section or for emergency surgery in severely injured or polytraumatized patients, during cardiac surgery, bronchoscopy of difficult intubation. There is interindividual variability in anaesthetic effect; for example, chronic drug or alcohol abuse or overweight may make increased anaesthetic doses necessary. They are at risk for intraoperative awareness. Some general anaesthetics or anaesthetic procedures, e.g. the combination of a relaxant and N2O, opioid mono-anaesthetics, or opioids combined with benzodiazepines, seem to involve a higher risk of intraoperative awareness than do volatile anaesthetics. The bases of litigation are medical malpractice, breach of contract by the anaesthesiologist or lack of informed consent from the patient. Therefore, patients who are at risk of intraoperative awareness should be given detailed information on this special risk before the operation.",1995.0,0,0
1227,8678284,[Patient-controlled analgesia with clonidine and piritramide].,R Sümpelmann; H Büsing; D Schröder; M Rekersbrink; S Krohn; J M Strauss,"Following parenteral administration, clonidine has analgesic effects at both cerebral and spinal levels. Patient-controlled analgesia (PCA) makes it possible to determine equipotent dosages of analgesics by relating analgesic consumption per time to the levels of analgesia obtained in comparable patient populations. Therefore, we studied the equipotency ratios of clonidine and piritramide and the incidence of undesired side effects in the treatment of postoperative pain in patients undergoing maxillo-facial surgery. After approval of the local ethics committee and informed consent 40 patients (age > 18 year, ASA I-III) were studied. Following randomization, the patients each received a PCA device containing either clonidine (bolus 30 micrograms), or piritramide (bolus 1.5 mg) for treatment of postoperative pain (lockout interval 5 min in both groups). During the postoperative period, pain was determined using a visual analogue scale, while analgesic consumption, sedation, haemodynamic parameters, respiration rate, and the occurrence of undesired side effects were documented additionally. The groups had comparable distributions of biometric data, duration of anaesthesia, and ASA classification. Pain level decreased significantly (P < 0.0001) in both groups during the first 2 h of PCA. Mean arterial pressure and heart rate were lower (P < 0.05) in the clonidine group 4 and 6 h after PCA onset, while the degree of sedation after 2 (P < 0.01) and 6 (P < 0.05) h was higher than in the piritramide group. Nausea and vomiting were more frequent (P < 0.05) in the piritramide group. Both groups showed a wide interpatient variation in analgesic requirement. The equipotency ratio clonidine/piritramid was 1:63.7. Intravenous clonidine is a potent analgesic and is suitable or the treatment of postoperative pain following maxillo-facial surgery. The analgesic potency of 150 micrograms clonidine i.v. was equivalent to that of 9.56 mg piritramide i.v. Nausea and vomiting occurred more rarely in the clonidine group, while deeper sedation was observed more frequently than in the piritramide group. Owing to the wide interindividual variation of analgesic consumption, clonidine dosages have to be adjusted to the actual requirements.",1996.0,0,0
1228,8679024,Comparison of intraarticular bupivacaine with the addition of morphine or fentanyl for analgesia after arthroscopic surgery.,A Uysalel; Y Keçik; P Kirdemir; M Sayin; M Binnet,"A randomized study on 30 patients undergoing knee arthroscopy was performed. Group I (n = 15) received 50 mg of 0.25% bupivacaine and 1 mg of morphine, and group II (n = 15) received 50 mg of 0.25% bupivacaine and 100 micrograms of fentanyl. The visual analogue scale was recorded at intervals of 1, 2, 3, 4, 6, 12, 24, and 48 hours after the operation. Supplementary analgesia requirements were also recorded. In group I, pain scores were lower than group II (P < .05) during the 1st, 2nd, 3rd, 12th, 24th, and 48th hours. The duration of analgesia on group I was significantly longer than group II. The combination of intraarticular morphine and bupivacaine has a longer analgesic duration and effect than a combination of fentanyl and bupivacaine.",1995.0,0,0
1229,8679356,Surgical pain is followed not only by spinal sensitization but also by supraspinal antinociception.,O H Wilder-Smith; E Tassonyi; C Senly; P Otten; L Arendt-Nielsen,"Nociception can produce segmental spinal sensitization or descending supraspinal antinociception. We assessed both types of sensory change after surgery during isoflurane-nitrous oxide anaesthesia with or without fentanyl before nociception. Patients undergoing back surgery received fentanyl 3 micrograms kg-1 (n = 15) or placebo (n = 15) before anaesthesia in a prospective, randomized, blinded study. Sensation, pain detection and tolerance thresholds to electrical stimulation were measured before operation at the arm, incision and herniated disc dermatomes (HDD) and 1, 2, 4, 6, 24 h and 5 days after operation, together with pain scores and patient-controlled morphine consumption (duration 24 h). For segmental effects, thresholds were normalized to the thresholds at a distant dermatome (arm). Raw pain thresholds were increased after operation (fentanyl > placebo) and were maximal at 4 h (pain tolerance in HDD: fentanyl +5.2 mA (+62.7%), placebo, +3.8 mA (+44.2%); P < 0.05 vs baseline for both). Normalized sensation thresholds decreased for placebo only (HDD/4 h: placebo, -1.8 (-44.8%), P < 0.05; fentanyl, +0.1 (+5.5%) ns). All changes returned to baseline by 24 h except for the placebo group normalized HDD sensation (d5: placebo, -2.4 (-59.7)%, P < 0.05; fentanyl -0.1 (-5.5%) ns). Pain scores and morphine consumption were similar. The study demonstrated both supraspinal analgesia and spinal sensitization after surgery. Fentanyl administration before operation augmented the former while decreasing the latter, and hence sensitization, especially if neuropathic, may particularly benefit from pre-emptive analgesia.",1996.0,0,0
1230,8679762,Day case laparoscopic cholecystectomy: a safe and cost effective procedure.,A Prasad; R J Foley,"To evaluate the safety and cost effectiveness of laparoscopic cholecystectomy as a day case procedure. District hospital, England. 103 patients undergoing laparoscopic cholecystectomy. Laparoscopic cholecystectomy by a standard four cannula technique. Propofol anaesthesia, prophylactic antiemetics and pre-emptive analgesia were given in all cases. Morbidity and cost. 103 patients have undergone laparoscopic cholecystectomy, 51 of them as day cases. Patients were selected for day treatment if they were under 60 years old, they wanted to go home the same day, they had no history of jaundice or any anaesthetic contraindication, and if there was an adult at home to look after them. Three of those selected as day cases required overnight admission, one because of severe pain and two who required a drain overnight. The median hospital stay was 12 hours (range 10-28 hours) and the cost of the operation was about pounds 419. This is a safe and cost-effective procedure and should be considered in selected patients.",1996.0,0,0
1231,8685854,[Chronic pancreatitis: conservative therapy].,D Radun; P Malfertheiner,"Chronic pancreatitis is mainly due to longstanding alcoholism. In general treatment is based on drug therapy. The clinical appearance is determined by chronic pain, steatorrhoea and eventually by the onset of diabetes mellitus. Beyond other measures total avoidance of alcohol ingestion provides a condition of a more benign course of the disease. Treatment of pain consists of symptomatic therapy and prescription of pancreatic enzymes in order to lessen pancreatic stimulation by inhibition of feedback mechanisms. The same principle applies to the prescription of octreotide which is used only in selected cases since it has failed to prove general effectiveness. Symptoms of exocrine insufficiency are alleviated by substitution of pancreatic enzymes. Attention must be directed on dose and preparation of pancreatic enzymes being used. Treatment of pancreatogenic diabetes resembles therapy of type I diabetes mellitus. In principle treatment of chronic pancreatitis should be adjusted to the highly variable clinical appearance of the disease and requires a systematic approach. It has to be kept in mind that some complications of chronic pancreatitis [e.g. pseudocysts] may require surgical intervention.",1996.0,0,0
1232,8686522,"Intra-operative epidural morphine, fentanyl, and droperidol for control of pain after spinal surgery. A prospective, randomized, placebo-controlled, and double-blind trial.",N G Rainov; T Gutjahr; W Burkert,"The present study was conducted to investigate the analgesic effects of intra-operatively administered epidural morphine in patients undergoing surgery for lumbar disc disease. Three treatment groups were constituted: one with 5.0 mg morphine and 2.5 mg dehydrobenzperidol (DHB) in 10 ml physiological saline, one with 5.0 mg morphine and 0.1 mg fentanyl in the same amount of saline, and one placebo group with saline only. The test solution was injected epidurally via catheter after haemostasis and before closure of the wound. Sixty eight patients were randomly assigned to each of the three groups and subjected to a double-blind evaluation. In the morphine/fentanyl and morphine/droperidol groups, significantly better analgesia was found as compared to the placebo group. No significant difference was found between the morphine/fentanyl and morphine/droperidol groups considering side effects of therapy, as well as duration and quality of analgesia. The side effects in the treatment groups were only slight and not significantly different from the placebo group. It was shown that additional epidural fentanyl offers no significant improvement of postoperative analgesia. No significant reduction of adverse effects could be found in the morphine/droperidol group compared to the morphine/fentanyl group. In conclusion, the intra-operative epidural application of morphine is a safe, effective and simple method for achieving sufficient analgesia in the first 24 hours after lumbar spinal surgery for disc disease.",1996.0,0,0
1233,8686825,Postoperative cognitive impairment in the elderly. Choice of patient-controlled analgesia opioid.,I A Herrick; S Ganapathy; W Komar; J Kirkby; C A Moote; W Dobkowski; M Eliasziw,"This study evaluated the safety and cognitive impact of patient-controlled analgesia with fentanyl compared to patient-controlled analgesia with morphine among elderly postoperative patients. In addition, two screening tests for cognitive impairment, the Mini Mental Status Exam and the Short Portable Mental Status Questionnaire, were compared. Ninety-six elderly patients were randomly allocated to receive patient-controlled analgesia with either fentanyl or morphine following hip or knee arthroplasty. Patients were evaluated postoperatively for clinical confusion, cognitive function test results, adequacy of analgesia, drug use and complications. Fentanyl produced less depression in postoperative cognitive function compared to morphine. The incidence of clinical confusion was not statistically different between groups (4.3% for fentanyl versus 14.3% for morphine). Fentanyl patients used more opioid based on a dose ratio of 100:1 suggesting that this dose ratio is inadequate. The incidence of urinary retention was lower in the fentanyl group. A poor agreement between the two tests of cognitive impairment mandates caution when peri-operative cognitive function is compared using different tests.",1996.0,0,0
1234,8686833,Modification of pain on injection of propofol. A comparison of pethidine and lignocaine.,B Lyons; D Lohan; C Flynn; M McCarroll,"One hundred and fifty ASA 1 and 2 patients were randomly allocated to receive pethidine 25 mg (1 ml), lignocaine 10 mg (1 ml) or 0.9% saline (1 ml) on a double-blind basis, as pretreatment to reduce pain on injection of propofol. Both active treatments were significantly better than placebo at preventing pain (p < 0.01). Lignocaine was most effective in preventing pain in men (p < 0.05) whilst pethidine was more effective in women (p < 0.05).",1996.0,0,0
1235,8686845,Bilateral ilioinguinal nerve blocks for analgesia after total abdominal hysterectomy.,M C Kelly; H T Beers; B K Huss; H M Gilliland,,1996.0,0,0
1236,8688256,"Patient-controlled extradural analgesia with bupivacaine, fentanyl, or a mixture of both, after Caesarean section.",D W Cooper; D M Ryall; F E McHardy; S L Lindsay; S S Eldabe,"In this randomized, double-blind study of 60 patients, we have assessed the analgesic efficacy of extradural bupivacaine and extradural fentanyl, either alone or in combination, after Caesarean section. Patients received 0.1% bupivacaine (group B), fentanyl 4 micrograms ml-1 (group F) or 0.05% bupivacaine combined with fentanyl 2 micrograms ml-1 (group BF) by patient-controlled extradural analgesia (PCEA). Adding fentanyl to bupivacaine reduced the dose of bupivacaine by up to 68%, improved analgesia at rest and decreased PCEA use. Motor and sensory block were decreased, but there was more pruritus. Overall patient satisfaction was increased. Adding bupivacaine to fentanyl reduced the dose of fentanyl by up to 57% without altering pain scores or PCEA use. Sensory block increased but pruritus did not decrease. Bupivacaine 0.05% produced clinically significant leg weakness in three patients. Overall patient satisfaction was not altered. There was a significant additive analgesic effect between 0.05% bupivacaine and fentanyl but no clinical benefit was demonstrated from using the combination compared with fentanyl alone for this group of postoperative patients.",1996.0,0,0
1237,8694152,Patient-controlled alfentanil. Target-controlled infusion for postoperative analgesia.,M G Irwin; R D Jones; A R Visram; G N Kenny,"We have compared the opioid effects of a patient-demand, target-controlled infusion of alfentanil (n = 10), with patient-controlled bolus administration of morphine (n = 10) following major spinal surgery in Chinese patients aged from 11 to 67 years. The same general anaesthesia regimen was used in all patients. One group of patients were given intra-operative morphine analgesia followed by postoperative intravenous morphine patient-controlled analgesia, while the other group received an intra-operative target-controlled infusion of alfentanil. Following surgery, the alfentanil group were given control of a handset and were able to increase the target alfentanil plasma level in 5 ng.ml-1 increments with a 2-min lockout interval. If analgesia was not demanded within a 15-min period, the computer reduced the target concentration by 5 ng.ml-1. All patients had continuous pulse oximetry monitoring and hourly recording of pain, sedation, nausea scores and respiratory rate. Patients receiving alfentanil had the target concentration noted hourly and four blood samples taken during the first 24 h for measurement of plasma alfentanil concentrations by high performance liquid chromatography. The alfentanil infusion system was equally effective as an analgesic technique when compared with morphine patient-controlled analgesia. There were no hypoxaemic episodes (oxygen saturation < 94%), no difference in sedation scores and the incidence of nausea (30%) was the same in both groups. There was a significantly (p < 0.001) lower respiratory rate in the alfentanil group compared with patients receiving morphine at, clinically assessed, equianalgesia. The predicted plasma alfentanil concentrations increased rapidly from about 30 ng.ml-1 during the first 4 h to around 100 ng.ml-1 at the end of the 24-h study period. The precision of the target-controlled infusion system was 75.4% and the mean prediction error (bias) 58.1%, suggesting an underestimation of the measured alfentanil concentrations by the alfentanil infusion system in these Chinese patients.",1996.0,0,0
1238,8694369,New technique for the neurolytic celiac plexus block: the transintervertebral disc approach.,H Ina; T Kitoh; M Kobayashi; S Imai; Y Ofusa; H Goto,,1996.0,0,0
1239,8694951,Controlled multicenter trial of laparoscopic transabdominal preperitoneal hernioplasty vs Shouldice herniorrhaphy. Early results.,J Tschudi; M Wagner; C Klaiber; J Brugger; E Frei; L Krähenbühl; R Inderbitzi; J Hüsler; S Hsu Schmitz,"In February 1993 a prospective randomized multicenter trial was initiated to compare laparoscopic transabdominal preperitoneal hernioplasty to Shouldice herniorrhaphy as performed by surgeons of nonspecialized clinics. Until January 1994, 87 patients with 108 hernias took part in the trial (43 Shouldice and 44 laparoscopic repairs). The laparoscopic procedure took significantly longer than did the open operation but caused less pain as measured by pain analogue score and consumption of paracetamol and narcotics. The postoperative complication rate was 26% in the open and 16% in the laparoscopic group. The patients in the laparoscopic group were discharged earlier and their convalescence was shorter than after open hernia repair. There has been one early recurrence in the laparoscopic and two in the open group to date with a mean follow-up of 201 days. Laparoscopic hernia repair causes less pain than the conventional operation and enables the patient to return to full work and usual activities earlier. The recurrence rate will not be known for 5 years.",1996.0,0,0
1240,8695075,"Effect of ketorolac on bleeding time and postoperative pain in children: a double-blind, placebo-controlled comparison with meperidine.",J D Bean-Lijewski; R D Hunt,"To determine whether ketorolac 0.75 mg/kg would provide a comparable degree of analgesia to that of meperidine 1 mg/kg in terms of postoperative opioid requirements and pain scores in children undergoing surgeries associated with mild to moderate postsurgical discomfort. Randomized, prospective, placebo-controlled, double-blinded study of the initial 6 postsurgical hours. University affiliated teaching hospital. 90 healthy ASA status I and II children scheduled for elective general, orthopedic, or genitourinary procedures associated with mild to moderate postsurgical pain. Extensive surgical procedures associated with a significant risk of bleeding were excluded. Ketorolac 0.75 mg/kg, meperidine 1 mg/kg, or placebo (normal saline) was administered intramuscularly (IM) at the beginning of surgery. Bleeding times were measured prior to and 180 minutes after study drug administration. Time to first rescue medication, total opioid requirement, pain scores, incidence of vomiting and length of stay were evaluated. Placebo-treated patients were rescued earlier (p < 0.0001) and required twice the rescue dosage (p = 0.013) when compared with either the ketorolac or meperidine groups. The ketorolac and meperidine groups did not differ with regard to time until first rescue, cumulative proportion requiring rescue, or the number of rescue doses required. A single dose of IM ketorolac prolonged bleeding time by 53 +/- 75 seconds (p = 0.006). Ketorolac provided analgesia comparable to that of meperidine and significantly reduced opioid requirements. Since ketorolac was not associated with a reduction in postoperative vomiting or length of stay, and in view of the uncertain risk of bleeding, it offers no advantage over meperidine in the management of mild to moderate acute postsurgical pain.",1996.0,0,0
1241,8695078,Patient-controlled intranasal analgesia (PCINA) for the management of postoperative pain: a pilot study.,H W Striebel; T Olmann; C Spies; G Brummer,"To compare patient-controlled intranasal analgesia (PCINA) for post-operative pain management with ward-provided pain therapy. Randomized, prospective pilot study. University medical center. 20 ASA status I and II orthopedic patients. On the first postoperative day, 20 patients were randomized to receive either PCINA for 4 hours followed by 5 hours of ward-provided pain therapy (Group 1; n = 10) or ward-provided pain therapy for 5 hours followed by 4 hours of PCINA (Group 2; n = 10). The PCINA device used permits self-administration up to a maximum 0.025 mg dose of fentanyl every 6 minutes. Pain intensity (101-point numerical rating scale) and vital signs, as well as possible side effects, were registered at 30-minute intervals. Within 30 minutes after the start of PCINA, pain intensity had decreased significantly in both groups. At the 60, 150, 210, 240, 270, 390, 420, and 480 minute measuring points, there was a significant intergroup difference in pain intensity, the level being significantly lower in the PCINA period. The handling of the PCINA device presented no problem to any patient. The PCINA fentanyl requirement was 0.415 +/- 0.083 mg (Group 1) and 0.408 +/- 0.06 mg (Group 2), respectively (NS). The ward-provided pain therapy included pethidine, tramadol, metamizole, acetaminophen, codeine, and diclofenac alone or in combination. Patient satisfaction was greater with PCINA than with ward-provided pain therapy (p < 0.0005). PCINA provides an adequate, noninvasive mode of postoperative pain management. The PCINA device is easy to handle and offers new perspectives in the management of postoperative pain.",1996.0,0,0
1242,8695094,Patient-controlled analgesia with sufentanil: a comparison of two different methods of administration.,R S Sinatra; F B Sevarino; D Paige,"To examine the safety and analgesic efficacy of sufentanil administered via either epidural or intravenous (i.v.) patient-controlled analgesia (PCA) in patients recovering from gynecologic surgery. Randomized, double-blind comparison. Patient care unit at a university medical center. 29 healthy women presenting for major intraabdominal gynecologic surgery with epidural anesthesia who requested postoperative PCA. Following completion of surgery performed using epidural anesthesia with 2% lidocaine and i.v sedation, patients were assigned to one of three treatment groups: Group 1-epidural PCA (EPCA) with sufentanil: 0.3 microgram/kg bolus followed by 8 micrograms/hr infusion plus epidural PCA boluses of 4 micrograms every 6 min as needed; Group 2-i.v. PCA with sufentanil: 0.3 microgram/kg bolus followed by 8 micrograms/hr infusion plus IV PCA boluses of 4 micrograms every 6 min as needed; or Group 3-i.v. PCA with morphine: 0.1 mg/kg bolus followed by 0.5 mg/hr infusion plus i.v. PCA boluses of 1 mg every 6 min as needed. Patients were observed at regular intervals during a 24-hour evaluation period. Visual analog scale (VAS) scores were used to assess analgesia and satisfaction with therapy. Pulmonary function was assessed by monitoring respiratory rate, oxygen (O2) saturation, and forced expiratory flow. Total opioid dose delivered and the presence/severity of side effects was also collected. Sufentanil plasma levels were measured in a subset of eight patients. Patients receiving either EPCA or i.v. PCA sufentanil experienced equivalent analgesia that was more rapid in onset than i.v. PCA morphine. Total dose administered and plasma concentration of drug were similar in both sufentanil groups; however, a greater number of patients in the i.v. delivery group experienced clinically significant O2 desaturation. The main advantage of EPCA sufentanil in this postsurgical setting was its ability to provide a more rapid onset of analgesia than traditional i.v. PCA with morphine while offering greater safety than i.v. sufentanil.",1996.0,0,0
1243,8695137,,,,,0,0
1244,8697547,Epidural analgesia for labour and delivery: fentanyl or sufentanil?,S Cohen; D Amar; C B Pantuck; E J Pantuck; E J Goodman; D H Leung,"The highly lipid soluble opioids, fentanyl and sufentanil, are used in combination with local anaesthetics with/without epinephrine to provide epidural analgesia during labour and delivery. Our aim was to determine whether wither opioid was superior when used with low dose local anaesthetic. In a double-blind study patients were randomized to two epidural infusion groups: Group I (n = 50) fentanyl 2 micrograms.ml-1 with bupivacaine 0.015% and epinephrine 2 micrograms.ml-1, Group II(n = 50) sufentanil 1 microgram.ml-1 with bupivacaine 0.015% and epinephrine 2 micrograms.ml-1. Following a 20 ml bolus of the study solution an infusion was started at 10 ml.h-1. To achieve analgesia patients could receive two boluses of 5 ml of the study solution and if analgesia was still inadequate, a further 5 ml bupivacaine 0.25% was used. Pain and overall satisfaction were assessed with a 10-point visual scale. Plasma samples obtained from the mother at the time the infusion was discontinued and from the umbilical cord vein at delivery were assayed to determine opioid concentration. Pain scores were greater for Group I than for Group II patients throughout the first and second stages of labour (P = 0.002). More patients in Group I (42%) requested a dose of bupivacaine 0.25% than in Group II (6%) (P < 0.001) and the total dose of bupivacaine given to Group I patients was greater than that of Group II, 26.0 +/- 22.0 mg vs. 13.4 +/- 12.6 mg, P = 0.005. There were no differences with respect to first or second stage duration, incidence of side effects, infusion duration, outcome of labour or neonatal Apgar scores. There was no opioid accumulation in either maternal or foetal blood. Epidural opioid infusion with very low dose bupivacaine (0.015%) achieved an overall high level of patient satisfaction in both groups without serious maternal or neonatal side effects. At the fentanyl-to-sufentanil ratio used here patients receiving sufentanil had lower pain scores and substantially fewer patients required bupivacaine rescue.",1996.0,0,0
1245,8697554,Intrathecal ketamine reduces morphine requirements in patients with terminal cancer pain.,C Y Yang; C S Wong; J Y Chang; S T Ho,"Ketamine has been administered epidurally and intrathecally for operative and post-operative pain control. Animal studies showed potentiation of analgesia induced by ketamine and morphine. We hypothesized that intrathecal ketamine would potentiate the effects of intrathecal morphine in the treatment of cancer pain. A double blind, cross over study was designed to evaluate the effect of ketamine on spinal morphine analgesia in terminal cancer pain patients. A two-phase protocol was used; phase M, intrathecal morphine alone twice daily; phase M + K, co-administration of ketamine (1.0 mg) with morphine intrathecally twice daily. The dose of morphine was titrated upwards until acceptable pain relief was achieved, defined by numeric rating scales (0-10) < or = 3, and the rescue dose of morphine was less than 5 mg after each intrathecal administration for two days. The dose of intrathecal morphine was defined as the effective dose. The effective dose of intrathecal morphine in phase M of 0.38 +/- 0.04 mg.day-1 was higher than that in phase M + K (0.17 +/- 0.02 mg.day-1) (P < 0.05). The average pain scales were 7.95 +/- 0.25 before intrathecal drug administration. Pain scales were decreased to 2.2 +/- 0.17 (P < 0.05) in phase M and 1.95 +/- 0.20 (P < 0.05) in phase M + K after the effective dose of morphine had been reached. No serious side effects were observed in this study. The present study demonstrates that ketamine enhances the analgesic effect of morphine, thus reducing the dose of intrathecal morphine.",1996.0,0,0
1246,8698872,No tolerance to peripheral morphine analgesia in presence of opioid expression in inflamed synovia.,C Stein; M Pflüger; A Yassouridis; J Hoelzl; K Lehrberger; C Welte; A H Hassan,"Pain treatment with centrally acting opiates is limited by tolerance. Tolerance is a decreasing effect of a drug with prolonged administration of that drug or of a related (e.g., endogenous) compound acting at the same receptor. This is often associated with a downregulation of receptors. In peripheral inflamed tissue, both locally expressed opioid peptides and morphine can produce powerful analgesia mediated by similar populations of opioid receptors. We hypothesized that the chronic presence of endogenous opioids in inflamed joints might convey downregulation of peripheral opioid receptors and tolerance to the analgesic effects of intraarticular morphine. We assessed these effects after arthroscopic surgery in patients with and without histologically verified synovial cellular infiltration, and we examined synovial opioid peptides and opioid receptors by immunocytochemistry and autoradiography, respectively. We found that, despite an abundance of opioid-containing cells in pronounced synovitis, morphine is at least as effective as in patients without such cellular infiltrations, and there is no major downregulation of peripheral opioid receptors. Thus, opioids expressed in inflamed tissue do not produce tolerance to peripheral morphine analgesia. Tolerance may be less pronounced for peripherally than for centrally acting opioids, which provides a promising perspective for the treatment of chronic pain in arthritis and other inflammatory conditions.",1996.0,0,0
1247,8702050,[A comparative study of intravenous opioid analgesia. Sufentanil and alfentanil for extracorporeal shock-wave lithotripsy in urologic patients].,E Weninger; B Nyga; M Sachs; C Heide; K Mörstedt; N Riegler; S Feller; M Stoschek; K Peter,"Extracorporeal shock-wave lithotripsy (ESWL) is the method of choice for the treatment of solitary stones in the kidney or ureter. Early lithotripters required prolonged immobility of the patient and caused considerable pain, necessitating general or epidural anaesthesia during the procedure. Modern lithotripters are quicker, but still require analgesia. Intravenous opioids are currently the drugs in favour. The opioids most commonly used are fentanyl and its shorter-acting analogue, alfentanil. The latter has a more rapid onset and, because of its reduced lipid solubility, is less cumulative. Sufentanil is a new opioid that is also of the phenylpiperidone group and has been recently licensed and introduced in Germany. Its pharmacokinetic and pharmacodynamic properties suggest an intermediate duration of action, high analgesic potency, and cardiovascular stability with diminished respiratory depression. In this prospective double-blind study, the effects of alfentanil and sufentanil on cardiovascular and respiratory parameters, the quality of analgesia, degree of sedation and the number and type of side-effects were compared. After giving informed consent and with the approval of the hospital ethics committee, 62 patients (ASA I or II) were investigated. They were randomly allocated to two groups, either receiving sufentanil (n = 32) or alfentanil (n = 30) during ESWL. No premedication was given. Excluded were patients with pain prior to treatment, patients treated with a spasmolytic or analgesic drug and those who had undergone ESWL within the last 6 months. The loading dose was given as a 5-min infusion to each group. The heart rate, systolic and diastolic blood pressure, percutaneous oxygen saturation (SpO2), and the transcutaneous capillary carbon dioxide tension (PicCO2) were recorded prior to the procedure (i.e. before administration of opioid), after 1000 and after 2000 shock waves and then 1 and 2 h after the end of lithotripsy. After 1000 and 2000 shock waves, and 1 an 2 h after the treatment, the patients were asked to express their degree of tiredness and pain on a visual analogue scale (VAS). The occurrence of side-effects such as nausea, vomiting, pruritus or other unpleasant sensations were noted by an anaesthesia nurse. Simultaneously, the anaesthetist recorded his/her impression of the patient's tiredness and degree of pain, both by using the VAS. He was not allowed to question the patient, nor was he aware of the patient's own scores. At the end of the observation period both the patient and the anaesthetist related their overall satisfaction with the anaesthetic procedure, again by using the VAS. Data were analysed with the Mann-Whitney-U for comparisons between groups and with the Wilcoxon test within each group. The side-effects were analysed with the Chi-square test. The systolic and diastolic blood pressure remained stable in both groups during and after treatment. The mean heart rate was different between the two groups at the beginning, and after the end of the treatment it dropped in both groups, but no significant difference was seen between groups. The PicCO2 rose from an initial mean of 36.8 mm Hg to a maximum of 44.6 mm Hg after 1000 shock waves in the sufentanil group, and from 37.8 mm Hg to 46.0 mm Hg after 2000 shock waves in the alfentanil group. The differences were significant within groups until 1 h after the end of the treatment, but there was no significant difference between groups. The oxygen saturation SpO2 dropped slightly in both groups. The differences were not significant between groups. In the alfentanil group, one patient had a maximum carbon dioxide tension of 83 mm Hg after 2000 shock waves, whereas in the sufentanil treated group the oxygen saturation fell to 72% in one case. (ABSTRACT TRUNCATED)",1996.0,0,0
1248,8705154,Opioid in peripheral analgesia: intra-articular morphine for pain control after arthroscopic knee surgery.,K Liu; J J Wang; S T Ho; W J Liaw; Y Y Chia,"Some authors reported that a small dose of intra-articular morphine (1-5 mg) injection provided a potent and long-acting analgesic effect on pain after arthroscopic knee surgery. However, many in other reports did not agree to this result. Therefore, the characteristic of the analgesic effect of intra-articular morphine is worth evaluation. In order to rule out the systemic action of intra-articular morphine, we designed a study to compare the efficacy of 3 mg intra-articular morphine with that of 3 mg intravenous morphine in providing analgesia after arthroscopic knee surgery. Sixty patients undergoing arthroscopic knee surgery under spinal anesthesia were randomly divided into two groups (n = 30, each). At the end of surgery, group 1 received 3 mg intra-articular morphine in 15 ml isotonic saline and intravenous isotonic saline 10 ml; group 2 received 15 ml intra-articular isotonic saline and 3 mg intravenous morphine in 10 ml isotonic saline. Postoperative pain was evaluated using visual analogue scale (VAS) during an active or passive flexion of the operated knee joint. Also, additional analgesic consumption requested by patient postoperatively (morphine, 2 mg, iv, each) was recorded. Pain scores were lower in group 1 than in group 2 from 4 to 36 h postoperatively (Mann-Whitney rank-sum test). Also, the consumption of supplemental analgesic morphine was lower in group 1 than in group 2 from 6 to 36 h postoperatively. Intra-articular morphine (3 mg) provided long-lasting analgesia from 6 to 36 h postoperatively and this effect was not due to systemic absorption of morphine.",1995.0,0,0
1249,8706598,Lornoxicam. A review of its pharmacology and therapeutic potential in the management of painful and inflammatory conditions.,J A Balfour; A Fitton; L B Barradell,"Lornoxicam (chlortenoxicam), a new nonsteroidal anti-inflammatory drug (NSAID) of the oxicam class with analgesic, anti-inflammatory and antipyretic properties, is available in oral and parenteral formulations. It is distinguished from established oxicams by a relatively short elimination half-life (3 to 5 hours), which may be advantageous from a tolerability standpoint. Data from preliminary clinical trials suggest that lornoxicam is as effective as the opioid analgesics morphine, pethidine (meperidine) and tramadol in relieving postoperative pain following gynaecological or orthopaedic surgery, and as effective as other NSAIDs after oral surgery. Lornoxicam was also as effective as other NSAIDs in relieving symptoms of osteoarthritis, rheumatoid arthritis, ankylosing spondylitis, acute sciatica and low back pain. Lornoxicam has a tolerability profile characteristic of an NSAID, with gastrointestinal disturbances being the most common adverse events. Limited clinical experience to date suggests that, as with a number of other NSAIDs, lornoxicam may provide a better-tolerated alternative or adjuvant to opioid analgesics for the management of moderate to severe pain. It has also demonstrated potential as an alternative to other NSAIDs for the management of arthritis and other painful and inflammatory conditions. These preliminary findings require confirmation in further comparative and long term studies.",1996.0,0,0
1250,8707552,"The placebo effect in acute headache management: ketorolac, meperidine, and saline in the emergency department.",R N Harden; R H Gracely; T Carter; G Warner,"In a prospective, double-blind, randomized study, ketorolac 60 mg, meperidine 50 mg plus promethazine 25 mg, and normal saline given by intramuscular injection were compared as treatment for acute headache crises. Thirty patients (6 men and 24 women) presenting to an urban emergency department with any type of benign headache were randomized into three groups and filled out the McGill Short-Form Pain Questionnaire with a Pain Rating Index and a Visual Analogue Pain scale. They received one of the study medications and repeated the testing after 1 hour. The objective was to test the efficacy of ketorolac in this population. Separate analyses of the McGill Short-Form (Total, Sensory, Affective, and Pain Rating Index scales) and the Visual Analogue Pain scale responses showed that the three treatments produced a significant reduction in pain (P < .0001), but that pain reduction did not differ among the treatments. This profound reduction observed after administration of a placebo prevented accurate evaluation of the effects of ketorolac. The placebo response must be considered in the design of future trials using intramuscular medications in the acute intervention of headache crises. In addition, the use of a standard analgesic is necessary to demonstrate both assay sensitivity and magnitude of response to placebo.",1996.0,0,0
1251,8708625,Substance abuse among patients with chronic back pain.,R L Brown; J J Patterson; L A Rounds; O Papasouliotis,"Little is known about substance use and substance use disorders among primary care patients with chronic back pain. This study compared groups of patients with and without chronic back pain for the prevalence of substance use and substance use disorders. It also assessed the temporal relationship between the onset of chronic back pain and that of substance use disorders. Adult patients aged 18 to 59 years who made three or more visits for back pain to a family practice clinic were eligible for the pain group. The comparison group consisted of a random sample of patients of the same ages who made appointments with the same clinic. A validated diagnostic interview about substance use disorders and other issues related to substance use was administered. Ninety-two percent of the patients in the chronic pain group reported severe pain, high disability, and severe to moderate limitation of activity. Two thirds (67%) of this group reported having continuous pain, and 21% experienced at least one episode of pain daily. Forty-four percent said their pain continously interfered with their activities, and 31% reported daily disruption of activity. There was little difference, however, in the adjusted rates of lifetime and current substance use disorders between the chronic pain and comparison groups. Lifetime prevalence rates were 54% for the pain group and 52% for the comparison group; current prevalence rates were 23% for both the pain and comparison groups. Substance abuse preceded the onset of pain by as much as 20 years for 77% of patients with chronic pain who had current substance use disorders and 63% of those who had lifetime substance use disorders. Chronic back pain did not connote special risk for current substance use disorders.",1996.0,0,1
1252,8711605,A double-blinded evaluation of intraperitoneal bupivacaine vs saline for the reduction of postoperative pain and nausea after laparoscopic cholecystectomy.,J W Szem; L Hydo; P S Barie,"Intraperitoneal local anesthesia has been reported to reduce postoperative pain after laparoscopy for gynecologic procedures that do not require a great deal of dissection or manipulation of viscera. This study was performed to determine the efficacy of intraperitoneal bupivacaine in laparoscopic cholecystectomy (LC). Fifty-five patients were evaluable in this randomized, double-blind, placebo-controlled study. Twenty-six patients received bupivacaine (0.1%) and 29 patients received placebo (saline). Prior to any dissection of the gallbladder, the surgeon irrigated 100 ml of experimental solution under the right hemidiaphragm, over Glisson's capsule, over the gallbladder serosa, and into the subhepatic space. The operation was then performed as usual. Postoperatively, analgesic medication usage, nausea, vomiting, and pain scores were determined during hospitalization. A questionnaire was given to each patient upon discharge from the hospital in order to continue monitoring medications and pain for the first 48 h at home. Postoperative pain was reduced significantly (P < 0.05) in the patients who received bupivacaine, but the effect was modest and observable only during the first 6 h after surgery. Despite this difference, there was no significant reduction in the amount of analgesic medication used by the patients who received bupivacaine, nor was there any reduction in nausea, vomiting, or shoulder pain when queried specifically. Intraperitoneal bupivacaine offered a detectable, albeit subtle benefit to patients undergoing LC. However, the effect was transient and had little impact upon the patient's convalescence.",1996.0,0,0
1253,8712328,Epidural infusion of low-dose bupivacaine and opioid in labour. Does reducing motor block increase the spontaneous delivery rate?,R Russell; F Reynolds,"Labouring women were randomly allocated to receive epidural infusions during labour of either 0.125% plain bupivacaine (n = 200) or a combination of 0.0625% bupivacaine with either 2.5 micrograms.ml-1 fentanyl or 0.25 micrograms.ml-1 sufentanil (n = 199) each starting at 12 ml.h-1 and adjusted as necessary to maintain analgesia. The dose of bupivacaine, both hourly (p < 0.001) and total (p < 0.001), was significantly lower in the group receiving the combination. Motor block was significantly less common and less severe in the combination group (p < 0.001). These reductions did not result in a significant increase in spontaneous deliveries. Maternal satisfaction with first (p < 0.001) and second stage analgesia (p < 0.001) was significantly increased in the combination group. The addition of opioid to the epidural infusion did not reduce the incidence of perineal pain. There were no significant differences between the groups in neonatal outcome or the incidence of early postnatal symptoms.",1996.0,0,0
1254,8712444,Epidural meperidine after cesarean section. A dose-response study.,W D Ngan Kee; K K Lam; P P Chen; T Gin,"Epidural meperidine is effective for postoperative analgesia, but the optimum dose has not been evaluated. Five doses of epidural meperidine (12.5, 25, 50, 75, and 100 mg) given at the first request for analgesia after cesarean section were compared. Visual analog pain scores, duration of analgesia as defined by time to first patient-controlled epidural analgesia demand, plasma concentrations of meperidine, side effects, and subsequent 24-h consumption of meperidine were evaluated. All doses were effective, but patients took longer to become pain-free after 12.5 mg (median 30 min) compared with 25 mg (median 12 min, P = 0.038), and duration of analgesia was shorter after 12.5 mg (median 83 min) compared with 25 mg (median 165 min, P = 0.0005). Increasing dose to more than 25 mg did not improve onset or duration of analgesia. Plasma concentrations of meperidine were less than minimum effective analgesia concentration for all doses except 100 mg. There was more frequent nausea (P = 0.004) and dizziness (P = 0.0002) after 100 mg compared with smaller doses. Epidural meperidine provides effective postoperative analgesia, although of relatively short duration. A single dose of 25 mg is superior to 12.5 mg, but there is no benefit from increasing the dose to 50 mg or greater.",1996.0,0,0
1255,8712652,Comparison of diclofenac sodium and morphine sulphate for postoperative analgesia after day case inguinal hernia surgery.,A McEvoy; J I Livingstone; C J Cahill,"Postoperative pain may be a significant reason for delayed discharge from hospital, increased morbidity and reduced patient satisfaction with ambulatory hernia surgery. This study compared two postoperative oral analgesic protocols after day case inguinal hernia repair; 30 mg morphine sulphate (MST) and 10 mg metoclopramide every 8 h for 48 h or 75 mg diclofenac twice daily for 48 h. The pain reported in the MST group was significantly greater on both the day of operation and the first postoperative day (P < 0.05, Mann-Whitney U test). A significantly higher proportion of patients taking MST complained of nausea on the day of operation and on the 1st postoperative day (P < 0.05, chi 2). The time taken to walk, dress and leave home alone were achieved in a significantly shorter duration in patients taking diclofenac. We conclude that diclofenac provides effective analgesia, has a more acceptable side-effect profile than morphine sulphate and is the treatment of choice after ambulatory hernia surgery.",1996.0,0,0
1256,8713631,Cancer pain.,W M O'Neill,"An accurate assessment and where possible a precise diagnosis of the underlying mechanism in necessary for the effective management of pain in cancer. The majority of patients respond to oral analgesics, and the range of drugs required is not vast. Adjuvant analgesic drugs will be needed for the treatment of bone pain, visceral pain and neuropathic pain. For the remaining patients who present with difficult and occasionally intractable pain, a multidisciplinary approach using drug and non-drug measures will usually allow significant relief of symptoms.",1996.0,0,0
1257,8714800,The reliability of depression diagnosis in chronic low back pain. A pilot study.,R M Gallagher; P Moore; I Chernoff,"The variability in estimated rates of major depressive disorder (MDD) in chronic pain samples may be accounted for by sample and methodological differences. Most studies rely on a single measure of depression and lack independent or repeated measures. This study investigated the prevalence of psychiatric disorders in a convenience sample of 18 patients disabled by low back pain (LBP) referred to, evaluated, and treated in a comprehensive pain rehabilitation program specifically designed to restore work readiness and return to work. Subjects had one or more spinal conditions, had work-related back pain for more than 6 months (x = 23.8), were Caucasian, predominantly young (x = 37.5) and male (55%), and were disabled on workers' compensation and approved for rehabilitation. The performance of three diagnostic procedures, the Pain Medicine Evaluation, an independent Structured Clinical Interview for DSM-III-R (SCID), and Longitudinal Clinical Diagnosis were compared with the ""gold standard"" of the Final Diagnosis which incorporated information from the other three. Also, the performance of a questionnaire, The Pain & Mood Structural Interview (PMSI), designed to assess the causal relationship of pain and mood and specifically the confounding effects of physical factors, was examined. Thirteen of 18 patients (72%) were diagnosed with MDD at Final Diagnosis. MDD diagnosis was made on 4 of 18 patients (22%) on the initial Pain Medicine Evaluation and on 9 of 18 patients (50%) on the SCID, with only 1 ruled out by the confounding questionnaire, for a SCID current prevalence of 44%. Both the SCID and Pain Medicine Evaluation accurately diagnosed the MDD cases they identified; 9 of 13 MDD cases (69%) were precipitated by a physical factor other than their pain. Three episodes of MDD were ruled out by confounding. These findings are discussed in relation to their implications for assessing pain patients for psychiatric comorbidity.",1995.0,0,0
1258,8714855,"Continuous cervical intrathecal administration of morphine with a new infusion pump, the Anschütz IP 35.1: a case report.",S Van Melkebeke; L Wostyn; P Gellens; F Camu,"The continuous intrathecal administration of low-dose morphine is an effective treatment for chronic neuropathic pain. Several implantable devices can be used for such treatments but they all have limitations. In this case report we opted for a new type of implantable pump, the Anschütz, for the combined cervical intrathecal administration of morphine and clonidine in a patient with severe cervicobrachialgia.",1995.0,0,0
1259,8721468,Is preoperative ketorolac a useful adjunct to regional anesthesia for inguinal herniorrhaphy?,B Ben-David; U Baune-Goldstein; Z Goldik; L Gaitini,"Nonsteroidal antiinflammatory drugs (NSAIDs) have become a popular component of analgesia regimens, particularly in combination with narcotics. We questioned whether there might also be a place for their use in conjunction with regional anesthesia and whether there was a preferable route for NSAID administration. Ilioinguinal and field blocks were performed preoperatively on seventy patients undergoing outpatient inguinal hernia repair. Patients were divided into a control group who received no ketorolac and four study groups who received a preoperative dose of 30 mg ketorolac by one of the following routes: i.v., i.m., p.o., or intrawound (i.w.). The ketorolac in the i.w group was mixed in the syringe with the local anesthetic used for the field block. i.v. and i.m. groups also received ketorolac at the time of the preoperative regional anesthesia and the PO group received the dose at least one hour preoperatively. All patients received a similar general anesthetic intraoperatively. Postoperative pain scores and analgesic requirements were lowest for the i.m., i.v., and i.w. groups. Pain scores and analgesic requirements for the PO group were less than for the control group but more than for the other three groups. Analgesic efficacy therefore ranked: i.m. = i.v. = i.w. > p.o. > control. Though no differences were found between groups in the time to discharge from the recovery room, the ease of nursing care paralleled the findings for pain scores and analgesia requirements. Beyond the analgesia provided by the regional anesthesia of the ilioinguinal and field blocks, the preoperative use of ketorolac further reduced postoperative pain scores and the need for additional postoperative analgesic medication. Comparable outcomes for the i.v., i.m. and i.w. groups indicate the lack of any benefit to concentrating the non-steroidal anti-inflammatory drug at the wound (i.w.) or to achieving high blood levels rapidly (i.v.). In conclusion, ketorolac is a useful supplement to ilioinguinal plus field block regional anesthesia for hernia surgery and is most effective administered parenterally.",1996.0,0,0
1260,8721471,Effect of P-6 acupressure on prevention of nausea and vomiting after epidural morphine for post-cesarean section pain relief.,C M Ho; S S Hseu; S K Tsai; T Y Lee,"Nausea and vomiting are important side effects following administration of epidural morphine for post-Cesarean section pain relief. Stimulation of the P-6 (Neiguan) acupoint is a traditional Chinese acupuncture modality used for antiemetic purpose; it has been found to be effective. The aim of this study was to evaluate the antiemetic effect of P-6 acupressure in parturients given epidural morphine for post-Cesarean section pain relief. In a randomized, double-blind and controlled trial, sixty parturients receiving epidural morphine for post-Cesarean section pain relief were investigated. Parturients were allocated to receive the acupressure bands or placebo bands on the P-6 acupoint bilaterally before the administration of spinal anesthesia and were observed over a 48-hour study period. The incidence of nausea and vomiting was significantly decreased from 43% and 27% in the control group, to 3% and 0% in the acupressure group, respectively (P < 0.05). The results demonstrate that prophylactic use of acupressure bands bilaterally on the P-6 acupoint can significantly reduce incidence of nausea and vomiting after epidural morphine for post-Cesarean section pain relief.",1996.0,0,0
1261,8721797,Assessing the quality of reports of randomized clinical trials: is blinding necessary?,A R Jadad; R A Moore; D Carroll; C Jenkinson; D J Reynolds; D J Gavaghan; H J McQuay,"It has been suggested that the quality of clinical trials should be assessed by blinded raters to limit the risk of introducing bias into meta-analyses and systematic reviews, and into the peer-review process. There is very little evidence in the literature to substantiate this. This study describes the development of an instrument to assess the quality of reports of randomized clinical trials (RCTs) in pain research and its use to determine the effect of rater blinding on the assessments of quality. A multidisciplinary panel of six judges produced an initial version of the instrument. Fourteen raters from three different backgrounds assessed the quality of 36 research reports in pain research, selected from three different samples. Seven were allocated randomly to perform the assessments under blind conditions. The final version of the instrument included three items. These items were scored consistently by all the raters regardless of background and could discriminate between reports from the different samples. Blind assessments produced significantly lower and more consistent scores than open assessments. The implications of this finding for systematic reviews, meta-analytic research and the peer-review process are discussed.",1996.0,0,0
1262,8722735,Acute pain after thoracic surgery predicts long-term post-thoracotomy pain.,J Katz; M Jackson; B P Kavanagh; A N Sandler,"Long-term pain is a common sequela of thoracotomy, occurring in approximately 50% of patients 2 years after thoracic surgery. Despite this alarming statistic, little is known about the factors responsible for the transition of acute to chronic pain. The aim of the present study is to identify predictors of long-term post-thoracotomy pain. Follow-up was for 1.5 years for patients who had participated in a prospective, randomized, controlled trial of preemptive, multimodal analgesia. Subjects were recruited from a tertiary care center. Thirty patients who had undergone lateral thoracotomy were followed up by telephone, administered a structured interview, and classified according to long-term pain status. Present pain status was measured by a verbal rating scale (VAS). Measures obtained within the first 48 h after surgery were compared between patients with and without pain 1.5 years later. These include VAS pain scores at rest and after movement, McGill Pain Questionnaire data, patient-controlled morphine consumption (mg), and pain thresholds to pressure applied to a rib contralateral to the thoracotomy incision. Fifty-two percent of patients reported long-term pain. Early postoperative pain was the only factor that significantly predicted long-term pain. Pain intensity 24 h after surgery, at rest, and after movement was significantly greater among patients who developed long-term pain compared with pain-free patients. A significant predictive relationship was also found at 24 and 48 h using the McGill Pain Questionnaire. Cumulative morphine was comparable for the two groups. Pain thresholds to pressure applied to a rib contralateral to the incision did not differ significantly between the groups. Aggressive management of early postoperative pain may reduce the likelihood of long-term post-thoracotomy pain.",1996.0,0,0
1263,8725927,Prospective outcome evaluation of spinal cord stimulation in patients with intractable leg pain.,D D Ohnmeiss; R F Rashbaum; G M Bogdanffy,"The results of spinal cord stimulation were prospectively evaluated using both subjective patient self-report measures and objective physical functional testing. The purpose of this study was to evaluate prospectively the effects of spinal cord stimulation implantation, performed with the patient awake and providing feedback, in patients with primary reports of intractable leg pain. Spinal cord stimulation has been used for treating chronic pain of many types. However, even among those with intractable lower extremity pain, the outcome results have shown great variability. The surgical procedure was performed with the patient awake and providing feedback to ensure optimal pain relief from the lead placement. The study group comprised 40 patients, ranging in age from 28 to 86 years. The average symptom duration was 65.4 months, and the average number of prior lumbar spine surgeries was 2.3 (range, 1 to 8). The primary data collection periods were preoperative, 6 weeks after, and 12 and 24 months after surgery. Statistically significant improvement in isometric lower extremity function was demonstrated 6 weeks after the spinal cord stimulation implantation. In the more painful leg, the performance increased from 457.5 ft-lb-sec to 629.8 ft-lb-sec (P < 0.01). The performance remained significantly improved at the 12- and 24-month follow-ups. Significant improvement was demonstrated on the physical scale of the Sickness Impact Profile at 6 weeks. At 24 months, all three scales (physical, psychological, and other) as well as the total score were significantly improved. Statistically significant decreases in pain, assessed by changes in visual analog scale scores, were noted in the legs, when walking, and in overall lifestyle. The use of narcotic medication decreased at all follow-up periods. At least 66% of the patients who were taking narcotics before spinal cord stimulation were taking reduced amounts or no narcotics 2 years later. At the time of the 24-month follow-up, at least 70% of patients reported that the procedure helped them, and would recommend it to someone with similar symptoms. Spinal cord stimulation implantation can result in improved physical function and decreased pain in patients who are carefully screened and in whom the implantation is performed with the patient awake to help ensure optimal pain-relieving lead placement.",1996.0,0,0
1264,8735038,Analgesia and analgesic drugs in paediatrics.,A J Ball; S Ferguson,"This article reviews the management of acute and chronic pain in childhood. Many of the common problems are discussed and the range of therapeutic options are reviewed, including possible future advances. The management of pain in neonates is not discussed. The second article of this series will describe the use of sedative drugs in paediatric practice.",1996.0,0,0
1265,8736630,Amitriptyline. A review of its pharmacological properties and therapeutic use in chronic pain states.,H M Bryson; M I Wilde,"Amitriptyline is a tricyclic antidepressant agent which also has analgesic properties. Whether its analgesic effects are linked to its mood-altering activity or attributable to a discrete pharmacological action (or a combination of both) is unknown. Clinical trials demonstrate that oral amitriptyline achieves at least a good or moderate response in up to two-thirds of patients with post-herpetic neuralgia and three-quarters of patients with painful diabetic neuropathy, neurogenic pain syndromes that are often unresponsive to narcotic analgesics. Amitriptyline has also demonstrated efficacy in heterogeneous groups of patients with chronic non-malignant pain. Other possible areas of use for amitriptyline are in patients with fibromyalgia or as an adjuvant for uncontrolled cancer pain, although evidence for the latter application is limited. Adverse events resulting from the antimuscarinic activity of amitriptyline (primarily dry mouth and sedation) are commonly reported, even at the low dosages used for the control of pain. Low starting doses and careful dosage titration may help to minimise these effects. Orthostatic hypotension and tachycardia, sometimes associated with tricyclic antidepressant agents, may also pose a problem in the elderly. In summary, amitriptyline has a valuable place in the treatment of chronic pain conditions that affect the elderly provided that the drug is used judiciously to minimise adverse effects. Importantly, amitriptyline remains the best studied of the antidepressant agents in post-herpetic neuralgia and diabetic neuropathy and is an important and effective treatment option in these syndromes.",1996.0,0,0
1266,8737553,Post-operative pain relief in children following caudal bupivacaine and buprenorphine--a comparative study.,T K Anilkumar; S A Karpurkar; V S Shinde,"Eighty-five paediatric patients (age range: 6 mths-12yrs) undergoing lower abdominal surgery were studied for post-operative pain relief following either caudal bupivacaine (GpI: n = 43) or buprenorphine (GpII: n = 42). Bupivacaine was administered as 0.5ml/kg body weight of 0.25% solution and buprenorphine as 4 micrograms/ml and volume of 0.5 ml/Kg body weight in normal saline. Post-operatively pain was graded on a 4-point scale and behaviour on a 5-point scale. Any post-operative complications and need for additional analgesia were also noted. Bupivacaine provided good pain relief in the early post-operative hours but buprenorphine provided pain relief lasting for 24 hrs or more post-operatively. Post-operative behaviour of 10 patients receiving buprenorphine was graded as cheerful as compared to 2 from bupivacaine group. Till the end of observation period (i.e. 8 hr post-operatively), majority of patients receiving buprenorphine remained cheerful.",1994.0,0,0
1267,8738682,"Additive analgesic effect of codeine and paracetamol can be detected in strong, but not moderate, pain after Caesarean section. Baseline pain-intensity is a determinant of assay-sensitivity in a postoperative analgesic trial.",K Bjune; A Stubhaug; M S Dodgson; H Breivik,"A randomized, double-blind, placebo-controlled single oral dose study was done in order to examine whether codeine has an additive analgesic effect to that of paracetamol for moderate and strong postoperative pain after abdominal surgery. The maximum recommended single dose of paracetamol 1000 mg (Paracet) was compared with a combination of a submaximal dose of paracetamol 800 mg plus codeine 60 mg (Paralgin forte) and placebo for pain relief after Caesarean section in 125 patients. Visual analogue pain intensity score (VAS 0-100 mm) and categorical pain relief score were recorded for 6 hours after the study drug intake. The main efficacy variables analyzed were: pain intensity difference and summed pain intensity differences during the first 3 and 6 h after study drug intake, total pain relief during the first 3 and 6 h, global evaluation score at the end of the observation period, and time to rescue analgesic. Because of protocol violations, 17 patients were excluded from the analysis of effects. Among the 108 patients included in the analysis of analgesic effect, 49 patients had moderate baseline pain (VAS between 40 and 60 mm on a 100 mm scale), and 59 patients had strong baseline pain (VAS more than 60 mm). In patients with strong baseline pain, statistically highly significant differences were documented in efficacy variables between the active drugs and placebo and between the two active drugs. However, in patients with moderate baseline pain, no differences were found between the study drugs in any of the analgesic efficacy variables. This study thus confirms that codeine has additive analgesic effect to paracetamol in pain after surgery. Our results show the importance of initial pain intensity in postoperative assessment of analgesic drugs. Assay-sensitivity and test power are increased by selecting patients with sufficiently high initial pain intensity and by comparing groups of patients with identical surgery and similar demographic variables.",1996.0,0,0
1268,8738689,Rectal administration of morphine in children. Pharmacokinetic evaluation after a single-dose.,S Lundeberg; O Beck; G L Olsson; L O Boreus,"There is limited knowledge about the pharmacokinetics of morphine and its metabolites after rectal administration in children. In this study the pharmacokinetics of two different rectal formulations of morphine were examined and compared with intravenous morphine. Children undergoing elective surgery received rectal morphine 0.2 mg/kg before start of surgery. Ten children (mean age 14 months) received morphine rectally in a hydrogel formulation and another 10 children (mean age 16 months) received morphine rectally in a parenteral formulation. For comparison, 6 children (mean age 21 months) were given the same dose intravenously. The plasma concentrations of morphine, morphine-3-glucuronide (M3G) and morphine-6-glucuronide (M6G) were measured by HPLC over 6 h after drug administration. The mean rectal bioavailability of morphine was 35% (range 18-59) after hydrogel administration and 27% (range 6-93) after the solution. Mean values of Cmax were 76 nmol/l (25-129) and 56 nmol/1 (15-140), respectively. The results showed that morphine gel had a significantly higher bioavailability (P < 0.02) than the solution. The ratios of plasma (M3G + M6G) to morphine were higher after rectal administration (mean 7.5-8.7) than after i.v. injection (mean 5.3), indicating the presence of first-pass metabolism using the rectal route. The rectal morphine hydrogel has pharmacokinetic properties which makes it a useful formulation for premedication and pain alleviation in paediatric patients.",1996.0,0,0
1269,8738759,Stereoselective pharmacokinetics of methadone in chronic pain patients.,K Kristensen; T Blemmer; H R Angelo; L L Christrup; N E Drenck; S N Rasmussen; P Sjøgren,"Ten patients with chronic pain were randomized to an open, balanced, crossover study. Each patients received two different preparations of racemic methadone, i.e., tablets and intravenous infusion. The pharmacokinetic parameters of the R- and S-enantiomers of the racemate are reported. The analgesically active R-methadone has a significantly longer mean elimination half-life than the optical antipode S-methadone (t1/2 = 37.5 and 28.6 h, respectively). The mean total volume of distribution is 496.6 L for R-methadone and 289.1 L for S-methadone. Significant differences in the mean clearance between R- and S-methadone are seen (0.158 and 0.129 L/min, respectively). However, the lagtime after oral administration and the bioavailability did not show differences between the isomers. The data suggest that both enantiomers of methadone should be measured if correlations between pharmacodynamics and kinetics are made due to the stereoselective differences in half-life, total volume of distribution, and clearance.",1996.0,0,0
1270,8742791,"The association of neuropathic pain, morphine tolerance and dependence, and the translocation of protein kinase C.",D J Mayer; J Mao; D D Price,"This series of studies has investigated the involvement of the NMDA receptor and the translocation of PKC in the seemingly unrelated phenomena of neuropathic pain and tolerance and dependence to narcotic analgesic drugs. This work has demonstrated that the NMDA receptor and PKC translocation are importantly involved in neuropathic pain and morphine tolerance or dependence and that these phenomena may be importantly interrelated. Neuropathic pain following nerve injury is a major chronic pain syndrome. Utilizing a rat model of painful peripheral mononeuropathy produced by CCI of the sciatic nerve, the authors have investigated central mechanisms of postinjury neuropathic pain. Behavioral and pharmacological studies indicate that thermal hyperalgesia and spontaneous pain behaviors observed in this model are attenuated by treatment with NMDA receptor antagonists. A consequence of NMDA receptor activation is calcium influx, which in turn can result in translocation of PKC from cytosol to membrane. Inhibitors of intracellular PKC translocation and activation block thermal hyperalgesia and spontaneous pain behaviors after CCI and also reduce the elevated spinal cord neural activity in CCI rats. Furthermore, spinal cord levels of membrane-bound PKC reliably increase in CCI rats as a result of translocation of PKC revealed by the [3H]PDBu autoradiographic assay. This increase in membrane-bound PKC is associated with postinjury neuropathic pain behaviors in CCI rats and both pain-related behaviors and membrane-bound PKC are reduced potently by GM1 ganglioside.",1995.0,0,0
1271,8743238,Chronic opioids for chronic low back pain--solution or problem?,T M Murphy,"The article by Brown et al does not provide data to justify long-term opioid use but does suggest a treatment option for the many patients who have chronic back pain and who want the help that our medical delivery system often does not provide. Having worked in a tertiary referral pain clinic that serves many low back pain patients who have demonstrated the ineffectiveness of chronic opiate therapy, I am strongly ambivalent about recommending prescribing ongoing opioiod therapy for chronic pain patients. The caveats about prescribing opioids for such patients are most appropriate (i.e., do not prescribe opioids for those who have a history of problems with opioid therapy or for whom increased intake is associated with decreased function); however, for patients who do not display these problems (and there could be many out there), I am sympathetic with the sentiments expressed by Brown et al. A trial of these drugs might be warranted if all else fails and continued therapy with opioids seems justified, but only with zealous attention to monitoring function and therapeutic compliance, as outlined by the authors. With regard to the doses needed for control, the method of opioid administration might be important, that is, whether it is in tablets or in a masking vehicle. In this day of open dialogue, it is not fashionable to blind the patient to the drug or dose, but I believe blinding has a place in the care of a particular group of patients whose symptom (pain) can vary considerably with time. I have found that most chronic pain patients rarely, if ever, reduce their analgesic intake in better times, but an attentive physician can if masking vehicles are used. Thus the physician can limit the amount of drug consumed long term. In my personal experiences with comparable chronic nonmalignant pain patients (albeit in different hemispheres), the average opioid maintenance (methadone) dosage was halved by prescribing the drug in a masking vehicle rather than as a tablet. If pain complaints are reduced and if function is improved according to the record (eg, patient is working) and the relatives' report, and if you, the prescribing physician, are happy, then a long-term regimen of opioid therapy is probably fine. Further controlled trials are needed to see whether this therapy works, and if so, what are the optimal agent(s) and dosages, what is optimal monitoring, and most important of all, who is the optimal patient who might derive not only analgesia but also functional benefit rather than compromise from this therapy. If we cannot make patients better, we must not make them worse.",1996.0,0,0
1272,8744657,Comparison of morphine with and without fentanyl for epidural analgesia after major abdominal surgery.,S Chrubasik; J Chrubasik; M Pfisterer; R Hage; J Schulte-Mönting,"The study compared bolus injection of fentanyl versus morphine to supplement epidural infusion of morphine for pain relief after major abdominal surgery. Postoperative epidural analgesia was activated by patient request for pain relief. Thirty patients were given a loading dose (random assignment, double-blind administration) of 2 mg of morphine (group M, n = 15) or 60 micrograms of fentanyl (group F/M, n = 15), along with an epidural infusion of 0.2 mg/h of morphine. Additional boluses of 0.5 mg of morphine (group M) or 25 micrograms of fentanyl (group F/M) were given according to individual need. If patients were painfree for 3 hours, the infusion rate for morphine was reduced by 50%. Both treatments provided similar degrees of analgesia, although onset time was shorter for the F/M group (P < .05). To obtain 24 hours of analgesia, group M needed 18.0 mg of morphine, while group F/M needed 4.7 mg of morphine and 1.48 mg of fentanyl. For group M, mean serum concentrations of morphine decreased from 18 ng/mL at 1 hour from the start of treatment to 5 ng/mL at 24 hours. For group F/M, serum morphine stayed at approximately 4 ng/mL, but serum fentanyl increased from 0.28 ng/mL at 5 minutes to about 0.8 ng/mL at 16 hours. When fentanyl is added continuously to epidural morphine, the resulting higher total serum levels of opioids during prolonged treatment may increase the risk of respiratory depression. Combining the two opioids for the loading dose, however, may be valuable to shorten the onset time of analgesia.",1996.0,0,0
1273,8744659,"Spinal analgesia during labor with low-dose bupivacaine, sufentanil, and epinephrine. A comparison with epidural analgesia.",L Kartawiadi; M P Vercauteren; A L Van Steenberge; H A Adriaensen,"The purpose of this investigation was to evaluate the effectiveness and side effects of combined spinal-epidural (CSE) injection of a bupiv-acaine-sufentanil-epinephrine mixture during labor as compared with epidural analgesia alone. In a randomized trial, 63 parturients presenting for vaginal delivery received either epidural analgesia (10 mL) with 12.5 mg bupivacaine plus 10 micrograms sufentanil and 12.5 micrograms epinephrine or CSE analgesia with a single subarachnoid injection of 1 mg bupivacaine plus 5 micrograms sufentanil and 25 micrograms epinephrine (total volume, 2.5 mL). For this purpose a 29-gauge BD-Quincke spinal needle was used. All subsequent top-ups consisted of 10 mL of the mixture, as used for the patients who received epidural analgesia only. Thirteen patients delivered without requesting a second injection. The time required to obtain satisfactory analgesia (visual analog score < or = 2.5 and/or > 50% improvement) was significantly shorter for those who received the subarachnoid mixture than for the epidural analgesia group (4.0 +/- 0.4 vs 10.4 +/- 0.5 minutes, respectively, P < .001). The duration of analgesia was longer for the CSE group (137.4 +/- 11.5 vs 106.4 +/- 11.8 minutes, P < .05), with more patients being pain-free for longer than 150 minutes (40 vs 8%, P < .05). Less bupivacaine was consumed in the group receiving the subarachnoid mixture (21.6 +/- 2.0 vs 30.7 +/- 2.1 mg, P < .01). Pruritus was more common following subarachnoid than following epidural injection of sufentanil (53.1 vs 25.8%, P < .05). Other side effects related to the injected drugs, such as motor impairment, hypotension, or nausea or vomiting, were not observed. Although all blocks were uneventful, moderate headache compatible with postdural puncture headache occurred in two patients of the CSE group, which necessitated a blood patch after 5 days. The CSE mixture induced long-lasting analgesia, with fast onset and without motor block or hypotension. Pruritus and headache were the major drawbacks of this technique.",1996.0,0,0
1274,8744669,Long-term use of subarachnoid clonidine for analgesia in refractory reflex sympathetic dystrophy. Case report.,A A Kabeer; P A Hardy,A case is presented of intractable reflex sympathetic dystrophy resistant to all other types of treatment. Twice daily subarachnoid clonidine was used to manage the symptoms via an implanted drug delivery system. The patient has successfully administered his own subarachnoid clonidine for over 18 months with no signs of tolerance or toxicity. Continuous subarachnoid clonidine may offer a solution to the management of some cases of intractable reflex sympathetic dystrophy.,1996.0,0,0
1275,8747973,,,,,0,0
1276,8751322,Misuse of prescription drugs.,R E Finlayson,"The elderly person is at risk of drug misuse and related problems because of frequent use of prescription drugs, biologic factors, and social circumstances associated with aging. Confusion, falls, and aggravation of untoward emotional states are examples of the adverse consequences. Diagnosis of drug dependency states is difficult because of the overlap of general medical disorders and mental disorders and a lack of suitable diagnostic criteria for the aged. Two case examples of drug misuse are given, and the management of drug misuse and the treatment of drug dependence on an inpatient and outpatient basis are discussed. Future research directions are suggested.",1995.0,0,0
1277,8751633,Long-term effects of continuous intrathecal opioid treatment in chronic pain of nonmalignant etiology.,M Winkelmüller; W Winkelmüller,"In the present retrospective investigation, the long-term effects of continuous intrathecal opioid therapy via implantable infusion pump systems were examined in 120 patients with chronic, nonmalignant pain syndromes. The follow-up period was 6 months to 5.7 years (mean 3.4 years +/- 1.3 standard error of the mean). Deafferentation pain and neuropathic pain showed the best long-term results, with 68% and 62% pain reduction (visual analog scale), respectively. The mean morphine dosage initially administered was 2.7 mg/day (range 0.3-12 mg/day); after an average of 3.4 years, it was 4.7 mg/day (range 0.3-12 mg/day). In a long-term observation of 28 patients who received intrathecal morphine for longer than 4 years. 18 patients (64.3%) had a constant dosage history and 10 patients (35.7%) showed an increase in morphine dosage to more than 6 mg/day 1 year after dosage determination. In seven cases, a tolerance developed: in four patients the tolerance was controlled by means of ""drug holidays""; but in three patients it was necessary to remove the pump systems. Explantation of the pump system occurred in 22 additional cases for other reasons. Throughout the follow-up period, 74.2% of the patients profited from the intrathecal opiate therapy: the average pain reduction after 6 months was 67.4% and, as of the last follow-up examination, it was 58.1%. Ninety-two percent of the patients were satisfied with the therapy and 81% reported an improvement in their quality of life. The authors' 6-year experience with administration of intrathecal opioid medications for nonmalignant pain should encourage the use of this method in carefully selected patients.",1996.0,0,0
1278,8753920,[Comparative study of the treatment of postoperative pain in function of the surgical service].,S Zavala; M Cañellas; F Bosch; A Bassols; M V Moral; J E Baños,"A high level of pain has been observed among surgical patients and it has been suggested that surgical specialty may be an important factor in pain, although no relation has been conclusively demonstrated. In this study we compared the characteristics of postoperative pain and pain treatment given in several surgical services. We studied 249 patients in orthopedic surgery and traumatology (OST, n = 95), general surgery (GS, n = 66), gynecology and obstetrics (GO, n = 51), urology (URO, n = 16), vascular surgery (VS, n = 9), ophthalmology (OPH, n = 7), otorhinolaryngology (ORL, n = 5). The characteristics of analgesic treatment (type of prescription, drug, route, dose and compliance) were recorded, as were degree of pain expressed on a visual analog scale and a verbal assessment scale 24 h after surgery, and level of patient satisfaction with the analgesic treatment. Thirty percent of the patients reported moderate to unbearable pain the day after surgery. Severe pain was most common in OST patients. Analgesics, mainly diclofenac (52%) and pethidine (36%), were prescribed by protocol for 93% of patients. Although there were differences among the various services, compliance with diclofenac prescription was better; compliance was high among GO patients for both drugs. Over half the patients reported having had severe or unbearable pain during the hours following surgery. Most said relief was sufficient or high (55%) with treatment and described themselves as satisfied or very satisfied (62%) with the analgesic received. Surgery on extremities was the most painful and generated the greatest dissatisfaction. This study suggests that type of surgery may condition the prevalence of and severity of postoperative pain. Although type of surgery and location are important factors, there are sufficient differences and deficiencies in treatment to explain, at least partly, the variation observed.",1996.0,0,0
1279,8756381,"Opioid rotation in patients with cancer pain. A retrospective comparison of dose ratios between methadone, hydromorphone, and morphine.",E Bruera; J Pereira; S Watanabe; M Belzile; N Kuehn; J Hanson,"When a change of opioid is considered, equianalgesic dose tables are used. These tables generally propose a dose ratio of 5:1 between morphine and hydromorphone. In the case of a change from subcutaneous hydromorphone to methadone, dose ratios ranging from 1:6 to 1:10 are proposed. The purpose of this study was to review the analgesic dose ratios for methadone compared with hydromorphone. In a retrospective study, 48 cases of medication changes from morphine to hydromorphone, and 65 changes between hydromorphone and methadone were identified. the reason for the change, the analgesic dose, and pain intensity were obtained. The dose ratios between morphine and hydromorphone and vice versa were found to be 5.33 and 0.28, respectively (similar to expected results). However, the hydromorphone/methadone ratio was found to be 1.14:1 (5 to 10 times higher than expected). Although the dose ratios of hydromorphone/morphine and vice versa did not change according to a previous opioid dose, the hydromorphone/methadone ratio correlated with total opioid dose (correlation coefficient = 0.41 P < 0.001) and was 1.6 (range, 0.3-14.4) in patients receiving more than 330 mg of hydromorphone per day prior to the change, versus 0.95 (range, 0.2-12.3) in patients receiving ae330 mg of hydromorphone per day (P = 0.023). These results suggest that only partial tolerance develops between methadone and hydromorphone. Methadone is much more potent than previously described and any change should start at a lower equivalent dose.",2000.0,0,0
1280,8757574,Routine use of fentanyl infusions for pain and stress reduction in infants with respiratory distress syndrome.,A J Orsini; K H Leef; A Costarino; M D Dettorre; J L Stefano,"To determine whether fentanyl infusions given to premature infants with respiratory distress syndrome reduce stress and improve long- and short-term outcome. Twenty premature infants undergoing mechanical ventilation for respiratory distress syndrome were randomly assigned, in a double-blind fashion, to receive fentanyl by continuous infusion or a volume-matched placebo infusion. A behavioral state score was used to assess the infants' behavior. Cortisol and 11-deoxycortisol levels were measured as physiologic markers of stress. Urinary 3-methyl histidine/creatinine molar ratio was determined and the fractional excretion of urea was measured to assess catabolic state. Ventilatory indexes were recorded for each infant. Infants receiving fentanyl showed significantly lower behavioral state scores (p < 0.04) and lower heart rates (p < 0.001) than those receiving placebo. 11-Deoxycortisol levels were lower in the fentanyl group on days 3, 4, and 5 of the study (p < 0.003). 3-Methyl histidine/creatinine ratios and fractional excretion of urea were not significantly different between the two groups. On the third day of the study, infants receiving fentanyl required a higher ventilator rate (p < 0.01), higher peak inspiratory pressures (p < 0.001), and higher positive end-expiratory pressure (p < 0.0001) than those receiving placebo. There was no difference in long-term outcome with respect to the incidence of bronchopulmonary dysplasia, intraventricular hemorrhage, or sepsis or with respect to the duration of ventilator use. Although there was a reduction in stress markers in the infants receiving fentanyl, we were unable to demonstrate an improvement in catabolic state or long-term outcome. In addition, the infants receiving fentanyl required higher ventilatory support in the early phase of respiratory distress syndrome than did those receiving placebo.",1996.0,0,0
1281,8758156,Epidural morphine for postherpetic neuralgia.,J W Watt; J R Wiles; D R Bowsher,"Eleven patients with established postherpetic neuralgia, unresponsive to antidepressant therapy, entered this single-blind, placebo-controlled study to assess the effectiveness of epidural morphine in the control of the pain of postherpetic neuralgia. Two patients obtained a reduction in pain of greater than 50% following morphine 0.5 mg. The duration of this pain relief was 36 h in one patient and 72 h in the other. Repeated doses, however, were ineffective in one patient and resulted in intolerable side effects in the other. The other six patients who received morphine developed opioid-related side effects without pain relief. Three patients did not receive morphine as they gained significant, long-lasting pain relief from placebo. Two retained that benefit for more than 6 months. Epidural morphine is more likely to produce side effects than pain relief when administered to patients with postherpetic neuralgia.",1996.0,0,0
1282,8758159,Systemic piroxicam as an adjunct to patient-controlled analgesia with alfentanil for postoperative pain relief.,P Van Lancker; J Devulder; G Rolly,"In a double-blind, placebo-controlled study, the non-steroidal anti-inflammatory drug, piroxicam, in combination with alfentanil given in a patient-controlled analgesia system, was compared with alfentanil alone given by the same route for analgesic effect, side effects and acute phase reaction over a 4-day period following anterior cruciate ligament reconstruction of the knee. The patients receiving piroxicam had lower pain scores and consumed less alfentanil. There were no differences with regard to side effects between the two treatment groups, apart from significantly more sedation at 08.00 h on the first postoperative day in the non-piroxicam group. Piroxicam did not influence either the levels of interleukin-6 or the acute phase response to surgery.",1996.0,0,0
1283,8758169,A comparison of epidural infusions of fentanyl or pethidine with bupivacaine in the management of postoperative pain.,C R Cox; M G Serpell; J Bannister; D M Coventry; D R Williams,"A double-blind randomised clinical trial was undertaken in 40 patients undergoing major abdominal surgery. Postoperative pain relief was provided using epidural infusions of 0.06% bupivacaine with fentanyl 4 micrograms.ml-1 (n = 20) (group F) or with pethidine 1.5 mg.ml-1 (n = 20) (group P). Postoperative pain scores using a visual analogue scale (0-100 mm) were not significantly different between the two groups. Median pain scores were 0-19 mm at all times of assessment indicating that good analgesia was provided by both regimens. There was no significant difference between the epidural infusion rates in the two groups. The side effects and effect on pulmonary function were similar in each group. Nine patients were withdrawn from the study (four from group F, five from group P) due to failure of the epidural technique or other complications. Fourteen patients, equally distributed, required a total of 24 epidural 'top-ups' by an anaesthetist because of inadequate analgesia. We demonstrated no advantage with epidural pethidine over fentanyl when used by infusion in combination with bupivacaine in the management of postoperative pain.",1996.0,0,0
1284,8759565,"Pain control after hysterectomy: an observer-blind, randomised trial of lornoxicam versus tramadol.",W Ilias; M Jansen,"This 24-hour, randomised, double-blind, placebo-controlled study compared the efficacy and tolerability of intravenous injections of lornoxicam 4 mg and 8 mg with tramadol 50 mg in 78 female patients aged 20-65 years with moderate to intolerable postoperative pain following mainly hysterectomy. Patients who received lornoxicam 8 mg had a significantly (p < 0.05) longer time to first remedication than placebo recipients and tended to have a greater reduction in pain intensity and a longer time to withdrawal due to ""non-response' than tramadol and placebo patients. Lornoxicam was well tolerated at both doses and was associated with a lower incidence of adverse events than tramadol. Thus, intravenous lornoxicam at a dose of 8 mg is superior to placebo and at least as effective as intravenous tramadol 50 mg in relieving moderate to intolerable post-hysterectomy pain. Furthermore, lornoxicam seems to possess a more favourable tolerability profile than tramadol.",1996.0,0,0
1285,8759577,Analgesic practice for acute orthopedic trauma pain in Costa Rican emergency departments.,T J Jantos; P M Paris; J J Menegazzi; D M Yealy,"Studies in US emergency departments have demonstrated that pain is undertreated in adults and children. Previous studies have also demonstrated cultural differences in the expression and perception of pain. The objective of this investigation was to describe the analgesic practices and patient pain responses in two Costa Rican EDs in light of possible differences due to cultural variation. We carried out a prospective, noninterventional observational assessment protocol of a convenience sample of patients being treated for orthopedic trauma in two university-affiliated urban teaching hospital EDs. Children between the ages of 5 and 12 years and all adults, ages 16 to 63, who presented with painful orthopedic trauma were included. Patients quantified their pain on arriving at and before leaving the ED. Children used a Face Interval Scale ranging from 1 (no pain) to 9 (maximum pain), and adults used a numeric rating scale ranging from 0 to 10. One fourth of pediatric and more than half of all adult patients had no reduction in their pain scores on leaving the ED. Eleven percent of adults and fewer than 4% of children received pain treatment while in the ED. Fewer than half of all patients were sent home with analgesics. We observed no use of opioids in the ED for analgesia. Our data illustrate that both adults and children with severe pain resulting from orthopedic injury in the Costa Rican EDs we studied often receive inadequate or no analgesic treatment. This finding suggests that the phenomenon of oligoanalgesia is more widespread and resistant to cultural differences. We also noted a reluctance to use opioids in this setting.",1996.0,0,0
1286,8759578,"Comparison of intravenous ketorolac, meperidine, and both (balanced analgesia) for renal colic.",W H Cordell; S W Wright; A B Wolfson; B L Timerding; T J Maneatis; R H Lewis; L Bynum; D R Nelson,"To compare the analgesic efficacy and safety of IV ketorolac, the only nonsteroidal antiinflammatory drug indicated for parenteral use in acute pain in the United States, with IV meperidine and with a combination of the two agents in renal colic. We carried out a double-blind, randomized, multicenter clinical trial in the emergency departments of four urban tertiary care teaching hospitals. Our study subjects were 154 patients with suspected renal colic. Each subject received an initial IV dose of ketorolac 60 mg, meperidine 50 mg, or both supplemented as needed beyond 30 minutes with additional doses of meperidine. The main outcome measures were changes in pain-intensity and pain-relief scores, amount of supplemental meperidine required, end-of-study drug tolerability, and adverse events. Analyses of 106 subjects with confirmed renal colic indicated that ketorolac and the combination were significantly better than meperidine alone by all efficacy measures, including pain relief and time elapsed before the need for supplemental meperidine. By 30 minutes, 75% of the ketorolac group and 74% of the combination group had a 50% reduction in pain scores, compared with 23% of the meperidine group (P < .001). The ketorolac and combination groups did not differ significantly in any of the efficacy measures. IV ketorolac, alone or in combination with meperidine, was superior to IV meperidine alone in moderate and severe renal colic. Because many subjects in all three treatment groups received supplemental meperidine and because response to ketorolac alone cannot be predicted, clinicians may choose to initiate treatment with a ketorolac-meperidine combination.",1996.0,0,0
1287,8766220,Nightmares and hallucinations after long-term intake of tramadol combined with antidepressants.,J Devulder; M De Laat; K Dumoulin; A Renson; G Rolly,"Tramadol is a weak opioid with effects on adrenergic and serotonergic neurotransmission that is used to treat cancer pain and chronic non malignant pain. This drug was initiated in association with paroxetine and dosulepine hydrochloride in a tetraparetic patient with chronic pain. Fifty-six days after initiation of the treatment the patient presented hallucinations that only stopped after the withdrawal of psycho-active drugs and tramadol. The case report questions the long term use of pain killers combined with psycho-active drugs in chronic non malignant pain, especially if pain is under control.",1996.0,0,0
1288,8766398,[Combination of intravenous patient-controlled analgesia with epidural anesthesia for postoperative pain therapy].,R Kentner; W Heinrichs; W Dick,"The aim of this study was to prove the hypothesis that a combination of epidural anaesthesia with intravenous patient-controlled analgesia (PCA) could improve perioperative pain management. Patients of the urological department undergoing lower abdominal surgery were randomized for two different pain managements. Patients of group 1 (n = 37) were narcotized, intubated and ventilated for the operation; arriving at the recovery room, they were given a PCA-pump, the drug used was piritramide and the parameters were bolus 2.5 mg, blocking time 20 minutes and no basal infusion rate. In group 2 (n = 37) an epidural catheter was inserted preoperatively followed by narcosis with intubation and ventilation. Additionally, epidural anaesthesia was performed intraoperatively using bupivacaine 0.5%. For postoperative pain management, patients of group 2 were also given a PCA-pump (same parameters as mentioned above) and a continuous epidural infusion was started additionally (bupivacaine 0.1875%, infusion rate 8 ml/h). Patients were monitored at the urological ICU for 36 hours. Assessment of pain (6-degree scale), grade of sedation (4-degree scale), cumulative doses of piritramide, heart rate, blood pressure, respiratory rate, in group 2 additional motoric function (Bromage) and degree of epidural anaesthesia were recorded at fixed time intervals: 0, 1, 2, 3, 5, 8, 11, 15, 19, 24, 28, 32, 36 hours. There was no difference regarding age of patients or type of operation. Assessment of pain showed a significant pain reduction in group 2 compared to group 1 during the first 8 hours. This result was underlined by a significantly smaller dose of piritramide. All other parameters showed no differences except lower blood pressure and heart rate in group 2 for the first three hours. The benefits of better pain management contrast with the risks resulting from combining the two techniques. In our patients we found an improvement of pain management in the early postoperative period. The combination of epidural anaesthesia with intravenous patient-controlled analgesia can be regarded as a further possibility for treating postoperative pain in the sense of ""balanced pain management"".",1996.0,0,0
1289,8766685,[Intrathecal administration of morphine and bupivacaine in the treatment of severe pain in chronic pancreatitis].,R Verheijen; R Slappendel; J B Jansen; B J Crul; R T van Dongen,"A 25-year-old male with idiopathic chronic pancreatitis suffered from severe pain not reacting to medical therapy. Intractable pain persisted after the following procedures: subtotal resection of the pancreas, interpleural administration of bupivacaine, epidural administration of bupivacaine, and thoracoscopic sympathectomy. Eventually, adequate pain relief was achieved with intrathecal administration of morphine and bupivacaine. An infusion pump, externally controlled by radiotelemetry, was implanted subcutaneously for intrathecal drug administration. With this pump the patient was fully ambulant. Intrathecal administration of morphine and bupivacaine through an implanted pump is a possible new technique for pain management in chronic pancreatitis.",1996.0,0,0
1290,8767562,[Oral opioids for long-term treatment of chronic non-cancer pain].,R Dertwinkel; A Wiebalck; M Zenz; M Strumpf,"The treatment of cancer pain with opioids is well accepted. However, the use of opioids for the treatment of non-cancer pain is still a matter of controversy. The main matters of concern are physical dependence and opioid abuse. Another argument against opioids is the lack of efficacy. Experiences with opioids in non-cancer pain have been published on about 850 patients, the longest therapy lasting almost 14 years. 85% of the patients treated with opioids had beneficial effects. In a number of investigations evaluating the opioid sensibility of pain by PCA and intravenous infusions, 67-80% of the patients with neuropathic pain responded to opioids. The efficacy of opioids in the treatment of non-cancer pain was proven in 3 placebo controlled studies. In 2 studies pain reduction in neuropathic pain was similar to that in nociceptive pain. When opioids are used, the administration has to be performed according to well defined standards. The indication for opioids must be made by a specialist in pain management. The diagnosis must clearly reveal an organic origin of the pain. Before the start of therapy the duration as well as the criteria for discontinuation must be set up. The treatment must be controlled by a specialist team and frequent regular follow up investigations must be performed. These must include proper documentation of the pain level, changes in patients' function and in social activities. The reliable intake of prescribed medication must be assured if necessary by laboratory screening. The treatment of non-cancer pain with opioids may be an alternative for those patients, who didn't gain sufficient reduction of pain by other therapies. Standards for this therapy are an absolute necessity and are to be followed closely.",1996.0,0,0
1291,8767568,[Preventive pain therapy. Preventive tramadol infusion versus bolus application in the early postoperative phase].,K Hartjen; M V Fischer; R Mewes; D Paravicini,"Even today, adequate postoperative analgesia is still a great problem. Based on positive results of former studies using a continuous infusion of tramadol for postoperative pain relief, we aimed to improve this regimen. In order to investigate the effectiveness of preventive analgesia, one group of patients was given 100 mg tramadol (Tramal) at the time of extubation, followed by a maintenance infusion. The other group was treated with single boluses of tramadol on demand, thus representing common pain treatment. METHODS. 112 patients undergoing abdominal surgery were chosen at random for this double-blind study. Half of them (preventive group) received an injection of 100 mg tramadol at the time of extubation; the others (on-demand group) were given a placebo instead. A continuous infusion of 500 ml NaCl 0.9% (administered with 30 ml/h) followed, either containing 200 mg tramadol (preventive group) or a placebo (on-demand group) and was maintained until the end of the study. At the first expression of pain, patients in the preventive group received 50 mg tramadol (representing the first subsequent injection) whereas patients of the on-demand group were given 100 mg tramadol as a loading dose. For further treatment of pain, the members of both groups received 50 mg tramadol when necessary. The level of pain was assessed by means of VAS (visual analogue scale) every hour and additionally at first expression of pain, and finally by VRS (verbal rating scale) after eight hours at the end of the study. RESULTS. 112 patients were chosen at random. 18 had to be excluded--two treatment failures, twelve violations of the study protocol and four patients of the on-demand group, who did not ask for treatment for pain and therefore did not receive any tramadol. Hence only 94 patients could be statistically evaluated. 50% of the remaining 48 patients in the preventive group needed none or only one subsequent injection of tramadol, the other 50% needed two or more subsequent injections. However the patients in the on-demand group, now 46, split up into 71.7% who where administered up to one subsequent injection and 28.3% who received more than one subsequent injection. The number of patients who asked for treatment for pain twice or more during the study period totalled 50% in the preventive group and 58.7% in the on-demand group. The average interval between extubation and first expression of pain was 106.3 +/- 84.2 min in the preventive group, and 75.0 +/- 22.7 min in the on-demand group. The intensity of pain evaluated by VAS as that time was comparable: 55.6 +/- 22.7 (preventive) versus (63.4 +/- 18.3 (on demand). The pain relief obtained, shown by the VAS-differences between the first expression of pain and following assessment, came up to 27.7 +/- 22.9 in the preventive group and 30.3 +/- 23.4 in the on-demand group within a period of 46.2 +/- 17.2 min (preventive) and 43.7 +/- 17.2 min (on-demand). Retrograde assessment of pain (VRS) showed that 85.5% of the preventive group found pain relief excellent or good and 78.3% of the on-demand group were of the same opinion. Total consumption of tramadol totalled 281.4 +/- 53.6 mg in the preventive group in comparison with 150.0 +/- 53.7 mg in the on-demand group. CONCLUSIONS. Only 28.3% of patients of the on-demand group received more than one subsequent injection of tramadol in comparison with 50% of the preventive group--an unexpected result. However, it has to be considered that the injection of tramadol given at the first expression of pain in the preventive group was counted as the first subsequent injection already. The patients in the preventive group asked, on average, 30 min later for treatment for pain. The subsequent pain relief in both groups was comparable, although the amount of tramadol administered at that time was higher in the on demand group than in the preventive group (100 mg versus 50 mg+ amount given by infusion). These facts show the efficacy of the preventive infus",1996.0,0,0
1292,8773860,Preoperative ketorolac increases bleeding after tonsillectomy in children.,W M Splinter; E J Rhine; D W Roberts; C W Reid; H B MacNeill,"To compare the incidence of vomiting following codeine or ketorolac for tonsillectomy in children. We had planned to enrol 240 patients, aged 2-12 yr undergoing elective tonsillectomy into a randomized, single-blind study in University Children's Hospital. The study was terminated, after 64 patients because interim analysis of the data by a blinded non-study scientist concluded that the patients were at undue risk of excessive perioperative bleeding. After induction of anaesthesia by inhalation with N2O/halothane or with propofol 2.5-3.5 mg.kg-1 i.v., the children were administered 150 micrograms.kg-1 ondansetron and 50 micrograms.kg-1 midazolam. Maintenance of anaesthesia was with N2O and halothane in O2. Subjects were administered either 1.5 mg.kg-1 codeine im or 1 mg.kg-1 ketorolac i.v. before the commencement of surgery. Intraoperative blood loss was measured with a Baxter Medi-Vac Universal Critical Measurement Unit. Postoperative management of vomiting and pain was standardized. Vomiting was recorded for 24 hr after anaesthesia. Data were compared with ANOVA, Chi-Square analysis and Fisher Exact Test. Thirty-five subjects received ketorolac. Demographic data were similar. The incidence of vomiting during the postoperative period was 31% in the codeine-group and 40% in the ketorolac-group. Intraoperative blood losses was 1.3 +/- 0.8 ml.kg-1 after codeine and 2.2 +/- 1.9 ml.kg-1 after ketorolac (mean +/- SD) P < 0.05. Five ketorolac-treated patients had bleeding which led to unscheduled admission to hospital, P < 0.05, Exact Test. Preoperative ketorolac increases perioperative bleeding among children undergoing tonsillectomy without beneficial effects.",1996.0,0,0
1293,8773867,Epidural morphine vs hydromorphone in post-caesarean section patients.,S H Halpern; R Arellano; R Preston; J Carstoniu; G O'Leary; S Roger; A Sandler,"The purpose of this randomized controlled double blind study was to compare the efficacy of pain relief and the side effects of epidural hydromorphone and morphine in post-Caesarean patients. In all patients, epidural anaesthesia was induced using carbonated lidocaine 2% with 1:200,000 epinephrine and 50 micrograms fentanyl, given in incremental doses. Patients in Group 1 (n = 24) received 0.6 mg hydromorphone and patients in Group 2 (n = 22) received 3 mg morphine after delivery of the infant. Pain, pruritus and nausea were measured using a visual analog scale (at times: baseline, on admission to the recovery room, 3, 6, 12, 18 and 24 hr postoperatively), by the number of requests for additional medications and by an overall satisfaction score. There was no difference between the groups in pain relief of in the incidence and severity of side effects. Pruritus was more pronounced within the first six hours in Group 1 and at 18 hr in Group 2. Hydromorphone provides no clinical benefit over epidural morphine for post operative analgesia following Caesarean section.",1996.0,0,0
1294,8776538,[Treatment of pain with peridural administration of opioids].,S Chrubasik; N Senninger; J Chrubasik,"The advantages and disadvantages associated with epidural opioids require careful selection of the opioid and its dosage. There is presently no ideal opioid available for epidural use. Comparative pharmacokinetic data help to select the appropriate epidural opioid. Morphine (provided it is given in small doses and volumes) is very appropriate for epidural pain treatment, especially for longer periods of treatment, due to excellent analgesia and very low systemic morphine concentrations. The faster onset of analgesia with epidural pethidine, alfentanil und fentanyl make these opioids recommendable. However, due to the increased risk of respiratory depression during continuous treatment, these drugs should not be given over extended periods. Epidural administration of methadone, sufentanil und buprenorphine cannot be recommended since the advantages over systemic use do not outweigh the risks. Epidural tramadol may be useful in clinical routine, if opioids are not available and supervision of the patient is not guaranteed, because tramadol is not restricted by law and has a low potential for central depressive effects. The safety of the patients should be paramount. If patients are harmed by inappropriate opioids or dose regimens this will discredit a valuable for treating postoperative pain. Postoperative epidural dosages should be as low as possible and be titrated to the patient's individual needs for analgesia. Epidural morphine treatment is an alternative to step 4 of the WHO treatment regimen for patients with intractable pain or those suffering from systemic opioid side effects. Careful selection of patients helps to increase successful treatment. If implantable devices (ports or pumps, according to the life expectancy) are employed, the intrathecal route of administration is preferable to the epidural route, as the latter has a 10 times higher morphine dose requirement.",1996.0,0,0
1295,8777117,Comparison of i.v. and s.c. diamorphine infusions for the treatment of acute pain in children.,D Semple; L A Aldridge; E Doyle,"We have compared the i.v. and s.c. routes of administration for diamorphine infusions in children undergoing abdominal surgery. Subjects received general anaesthesia with extradural block and diamorphine up to 20 micrograms kg-1 h-1 after operation. There were no differences between the groups in diamorphine consumption, pain scores or incidence of side effects. The s.c. route appeared to be as effective and safe as the i.v. route for administration of diamorphine infusions in children undergoing elective surgery.",1996.0,0,0
1296,8783317,Management of cancer pain in Denmark: a nationwide questionnaire survey.,P Sjøgren; A M Banning; N H Jensen; M Jensen; M Klee; A Vainio,"A questionnaire survey was carried out with the aim of evaluating knowledge about and practice of cancer pain treatment in Denmark. A questionnaire was sent out to a 10% random sample of Danish physicians. Of these 1411 physicians, 1068 (76%) returned the questionnaires and after exclusion of those doctors who never treated cancer patients, 577 (54%) were analyzed. Their knowledge of the principles and practice of cancer pain treatment was evaluated by means of 14 multiple-choice and open questions. Their ability to apply their knowledge in practice was evaluated by analyzing their suggested treatment of 3 simulated patient cases. The results show that a vast majority (97%) of the physicians were prepared to use opioids conventionally administered for severe pain and that 39% reported the use of other treatment modalities (psychological treatment, antineoplastic therapy, transcutaneous nerve stimulation/acupuncture, etc.). Ninety-seven percent of the physicians recognized difficulties in cancer pain treatment, the most frequent being side effects of drugs and inadequate pain relief. Seventy-five percent considered that their knowledge about pain treatment was fair or better. The overall evaluation of the proposals for pain treatment of the patient cases was primarily based on drug therapy. Adequate doses, correct dose intervals and selection of drugs, routes of administration and other treatments were the requirements for satisfactory answers. It appears that the majority the physicians could treat both pain from bone metastasis (75%) and visceral pain (78%) satisfactorily, while very few suggested co-analgesics for neuropathic pain conditions (20%). Older physicians performed less well than their younger colleagues. Basic pain treatment skills have been acquired by the Danish physicians but, in the future, emphasis should be placed on the treatment of neuropathic pain with co-analgesics and the management of opioid side effects.",1996.0,0,0
1297,8783318,Direct conversion from oral morphine to transdermal fentanyl: a multicenter study in patients with cancer pain.,B Donner; M Zenz; M Tryba; M Strumpf,"Direct conversion from oral morphine to transdermal fentanyl with a ratio of oral morphine/transdermal fentanyl (100:1 mg) daily was examined in patients with cancer pain. Patients with a 'stable and low level of cancer pain' receiving a constant dosage of sustained release morphine during a pre-study phase of 6 days were included in the study. Initial fentanyl dosage was calculated by a conversion table. The transdermal system was changed every 72 h and the dosage was adjusted to the needs of the patients according to the VAS scores and the requirement of liquid morphine, which was allowed to achieve sufficient pain relief. Regression analysis at the end of the study revealed a mean morphine/transdermal fentanyl ratio of 70:1. Pain relief during treatment with transdermal fentanyl was identical to sustained release morphine. However, significantly more patients took supplemental medication with liquid morphine during transdermal fentanyl therapy. The number of patients suffering from pain attacks did not increase with transdermal fentanyl. Constipation and medication with laxatives decreased significantly during fentanyl therapy. Other side effects and vital signs were identical. Three patients suffered from a morphine withdrawal syndrome beginning within the first 24 h of transdermal fentanyl therapy. Cutaneous reactions to the patch were rare, mild and transient. Patients and physicians reported satisfaction with the transdermal therapy. 94.7% of the patients chose to continue the transdermal fentanyl therapy at the end of the study due to better performance in comparison to oral morphine. Due to these results an initial conversion from oral morphine to transdermal fentanyl with the ratio of 100:1 is safe and effective.",1996.0,0,0
1298,8783325,A case of uncommon withdrawal symptoms after a short period of spinal morphine administration.,J Devulder; P Bohyn; F Castille; M De Laat; G Rolly,"A 54-year-old female with chronic failed back surgery syndrome and pain in the back and the right leg was treated by chronic spinal morphine administration by an external pump. After a positive test instillation over a 3-week period the spinal catheter was removed. Within 24 h the patient developed fever, leucocytosis, impaired sense of smell and allodynia and hyperpathia in all 4 limbs. Infection was excluded as a possible cause and a withdrawal after a second test period some weeks later reinitiated the symptoms. The symptoms vanished after restarting the morphine administration. Finally, an internal Medtronic pump was implanted because the patient obtained good pain relief with the test instillation. Good pain relief could be obtained with the daily instillation of 5 mg morphine intrathecally. Fever, leucocytosis, impaired sense of smell, allodynia and hyperpathia in the limbs reappeared a few weeks later. Evaluation showed catheter migration out of the spinal canal.",1996.0,0,0
1299,8783327,Comparison between celiac plexus block and morphine treatment on quality of life in patients with pancreatic cancer pain.,M Kawamata; K Ishitani; K Ishikawa; H Sasaki; K Ota; K Omote; A Namiki,"Twenty-one patients with pancreatic cancer pain were studied to evaluate the effectiveness of celiac plexus block (CPB) on pain relief and quality of life (QOL), compared to the traditional NSAID-morphine treatment. The criteria were morphine consumption, visual analogue pain scale (VAS), performance status (PS) determined by medical and nursing staffs, and answers to QOL questionnaires. Morphine consumption, VAS, PS, and self-assessed QOL scores were taken when the administration of morphine was necessary for pain relief and those scores were used as control. Morphine consumption and the VAS score were recorded at regular weekly intervals and the PS and QOL scores were measured every 2 weeks thereafter. CPB was performed within 2-3 days after the control measurement. The VAS scores of the patients receiving CPB (n = 10) were statistically lower for the first 4 weeks after the procedure than those of the patients receiving the standard NSAID-morphine treatment (n = 11) during the same time period after the control measurement. Morphine consumption was significantly lower in weeks 4-7 (inclusive) following the procedure in the CPB group and continued to be lower thereafter, though not significantly so. Although the PS score slightly improved at the 2nd week after CPB, it was not improved by the start of the NSAID-morphine treatment. Self-assessed QOL scores did not ameliorate statistically after CPB; however, they did deteriorate remarkably in the patients treated only with morphine-NSAID during their survival periods, while they deteriorated only slightly in the CPB group. There were fewer side effects after CPB. These results indicate CPB does not directly improve QOL in patients with pancreatic cancer pain, but it may prevent deterioration in QOL by the long-lasting analgesic effect, limitation of side effects and the reduction of morphine consumption, compared to treatment only with NSAID-morphine.",1996.0,0,0
1300,8785133,Influence of dose and timing of administration of morphine on postoperative pain and analgesic requirements.,M D Mansfield; K S James; J Kinsella,"In a randomized, double-blind study, we have investigated the effect of dose and timing of administration of morphine on postoperative pain and analgesic requirements in 60 patients undergoing hysterectomy, with or without salpingo-oophorectomy. Patients were allocated randomly to one of three groups: during standardized general anaesthesia, group post received morphine 0.15 mg kg-1 i.v. at peritoneal closure after hysterectomy; group pre-low received morphine 0.15 mg kg-1 on induction of anaesthesia; and group pre-high received morphine 0.3 mg kg-1 on induction of anaesthesia. Median postoperative morphine consumption (first 24 h) from a PCA system was 68 mg (group post), 56 mg (group pre-low) and 43 mg (group pre-high), and total perioperative morphine consumption (induction of anaesthesia to end of 24 h after surgery) was 77 mg (group post), 65 mg (group pre-low) and 63 mg (group pre-high). Pain scores (at rest and on movement) were similar in the three groups. A large dose of morphine 0.3 mg kg-1 i.v. on induction of anaesthesia significantly reduced postoperative PCA morphine requirements compared with the smaller dose (0.15 mg kg-1) administered at induction or peritoneal closure, in patients undergoing hysterectomy, with or without salpingo-oophorectomy.",1996.0,0,0
1301,8790278,Microwave diathermy treatment for primary dysmenorrhea.,A R Vance; S H Hayes; N I Spielholz,"This case report documents the use of microwave diathermy in a 31-year-old woman who had had primary dysmenorrhea since menarche began at age 13 years. For 18 years, she had severe monthly pain, frequently resulting in emergency department admissions and 1 to 3 days lost from work. Conventional treatments, including pain-relieving drugs, anti-inflammatory drugs, muscle relaxants, superficial heat, and oral contraceptives, had all been unsuccessful in relieving or abating the intense and debilitating pain. Microwave diathermy (45 W total power) was administered for 20 minutes each month on the day symptoms began (usually the first day of menstruation). Over a 7-month interval, diathermy was followed by almost-immediate and long-lasting relief of symptoms. During the 7 months of treatment, the patient lost no workdays due to severe pain. This case demonstrates the potential use of microwave diathermy as an effective treatment for women with this condition.",1996.0,0,0
1302,8792892,Patient-controlled analgesia with morphine and droperidol following caesarean section under spinal anaesthesia.,D Russell; L A Duncan; W T Frame; S P Higgins; A J Asbury; K Millar,"The addition of droperidol to morphine for patient-controlled analgesia reduces the incidence of nausea and vomiting, but may result in unwanted side effects. We studied 40 women randomised to receive morphine sulphate with or without added droperidol (10mg droperidol/60 mg morphine) by patient-controlled analgesia following elective caesarean section under spinal anaesthesia. Median morphine demand in the 20 h after surgery was 74 mg with morphine alone, and 53 mg with added droperidol, the median consumption of which was 8.8 mg. The incidence of nausea was reduced from 80% to 38.8% (P < 0.01), and that of emesis from 55% to 16.7% (P < 0.05) by the addition of droperidol. Psychomotor function was significantly impaired to a similar degree in both groups and there was no significant difference in sedation scores or pain scores. Subjective drowsiness which resulted in withdrawal from the study occurred in two patients, both of whom were receiving droperidol, and though all patients who completed the study were satisfied with their analgesia overall, significantly more of those receiving unsupplemented morphine (11/19 compared with 4/18, P < 0.05) described it as excellent. The addition of droperidol 10 mg to morphine 60 mg for PCA following caesarean section under spinal anaesthesia reduces the incidence of nausea and emesis, but may result in drowsiness, limiting the usefulness of the technique.",1996.0,0,0
1303,8795659,Effective management of chronic pain. The analgesic dilemma.,B R Stacey,"Despite the fact that pain is a common presenting complaint, its effective management remains an elusive goal surrounded by contradictions and controversy. In this article, Dr Stacey discusses the goals of chronic pain management and the treatment options available, with a focus on pharmacologic therapy and prescribing issues involving currently available analgesics.",1996.0,0,0
1304,8799542,Pain after craniotomy. A time for reappraisal?,N Quiney; R Cooper; M Stoneham; F Walters,"Pain and nausea were prospectively assessed in 52 patients following elective craniotomy. When assessed at 6-hourly intervals the mean pain scores in patients during the first 24 h for all types of craniotomy were relatively low. However, for a period of at least 2 h 18% of patients complained of excruciating pain, 37% of patients complained of severe pain, 29% of patients complained of moderate pain, 4% of patients complained of mild pain and only 12% of patients complained of no pain in the 24 h following craniotomy. The mean dose of codeine phosphate used within the study period was 123 mg (SD 81). No statistically significant differences in severity of pain or use of codeine phosphate were found when comparing patients undergoing craniotomy at different sites. For at least 2 h 37% of patients complained of severe nausea or vomiting, 35% of patients complained of moderate nausea and only 29% of patients reported no symptoms of nausea during the 24-h study period. Again, no statistically significant differences were found in the severity of emetic symptoms when comparing patients undergoing craniotomy at different sites. Contrary to standard assumptions, severe or moderate pain in the first 24 h after craniotomy is common and is poorly treated with codeine phosphate alone.",1996.0,0,0
1305,8800821,An investigation of the ability of oral naloxone to correct opioid-related constipation in patients with advanced cancer.,N P Sykes,"A dose-ranging study of the use of oral naloxone in opioid-related constipation in patients with far-advanced cancer is reported. Naloxone doses were calculated as a percentage of the morphine dose each patient was receiving. Seventeen patients entered the first phase of the study, which had a randomised, double-blind design. Outcome measures were small bowel transit time (SBTT) measured by the lactulose/hydrogen breath test, pain scores and the occurrence of adverse events. One subject was excluded before receiving naloxone. No significant difference between placebo and naloxone occurred in the 14 remaining patients receiving total daily doses of naloxone 10% or less of the 24 h dose of morphine. Two further patients experienced a marked laxative effect with naloxone at 20% of the 24 h dose of morphine. In one of these, SBTT was available and was unchanged from placebo. The other declined to continue with SBTT measurement. Phase two of the study had an open design, in which laxative effects were determined clinically. Naloxone at a maximum dose level of 20% was given to seven patients, up to 40% to two patients and up to 80% to one patient. Four out of the seven patients in the 20% dose level group, and all of the remainder, experienced laxative effects. Two patients experienced symptoms of opioid withdrawal, one of whom also had return of pain. It is concluded that oral naloxone at a daily dose of 20% or more of the prevailing 24 h morphine dose is a potentially valuable therapy for opioid-related constipation. However, opioid withdrawal was observed and it is suggested that initial individual naloxone doses should not exceed 5 mg. Further research is needed into the oral absorption of naloxone, as well as further studies of clinical efficacy and dosing.",1996.0,0,0
1306,8813044,Pharmacologic treatment of cancer pain.,M H Levy,,1996.0,0,0
1307,8814117,A former hockey player with knee and calf pain.,K Patel; A M D'Agostino,"A 37-year-old man presented with severe pain in his left knee and calf. He had no other joint pain, fever, chills, or dysuria. He had previously gone to another hospital, where x-rays of the knees and legs reportedly showed inflammation and arthritis. He had been given oxycodone-acetaminophen, but the pain continued.",1996.0,0,0
1308,8822039,The influence of preanalytical factors on concentrations of morphine and metabolites in patients receiving morphine.,D Westerling; H I Bengtsson; C Thysell; P Höglund,"To examine the importance of preanalytical factors on the sample concentration of morphine, morphine-3-glucuronide and morphine-6-glucuronide, blood samples were drawn in sets of four from 21 patients who were given morphine due to chronic pain or as premedication prior to surgery. Three different sampling tubes, different combinations of incubation temperature and time, and different temperatures during centrifugation were used and compared to reference standard treatment of blood samples using analysis of variance. Blood samples taken in EDTA tubes produced significantly higher (4.8%) concentrations of morphine compared with the reference levels obtained in heparin glass tubes. Incubation of blood samples at body temperature resulted in significantly higher (4.4%) morphine levels compared to reference levels. None of the other conditions studied influenced the sample concentrations of morphine significantly. The levels of the metabolites were not significantly affected under any of the tested conditions. Even if the preanalytical factors investigated in this study had little influence on the results, a standardised procedure is recommended for handling of blood samples for analysis of morphine and its metabolites.",1996.0,0,0
1309,8823393,Low back and cervical spine disorders.,J Rainville; J B Sobel; R J Banco; H L Levine; L Childs,"Neck and back pain are common work-related complaints. The natural history of these symptoms favors rapid recovery. Medical management of workers with these complaints relies on carefully managing this natural history, while attempting to minimize the resulting disability. Medical advice should focus on decreasing patients' fears and encouraging a rapid return to function (including work) as acute pain symptoms improve. Interventions should be as limited as possible and promote self care. Patients with radicular symptoms may require additional interventions but, there, too, the natural history is favorable. Surgery may be necessary in a small percentage of patients with catastrophic and severe neurologic symptoms or persistent, severe pain. Chronic neck and back pain symptoms are commonly encountered. Medical and reversible causes of pain should be sought in such patients. When none is found, interventions aimed at maximizing back and neck function and improving tolerance for physical activities may be beneficial in returning these workers to productive lifestyles.",1996.0,0,0
1310,8823403,Occupational disorders and the management of chronic pain.,P B Polatin; T G Mayer,"Chronic pain affects a small proportion of patients with an occupational injury but can result in astronomical costs for future medical care, indemnity, and social service utilization. To provide adequate treatment, medical practitioners must make a conceptual shift from the disease-intervention model to visualizing chronic pain as a multifactorial syndrome with alterable components. Focusing on deconditioning and disability provides a means to subjective and objective improvement for these patients and gives a better measure of therapeutic success.",1996.0,0,0
1311,8824687,Contribution of monoaminergic modulation to the analgesic effect of tramadol.,J A Desmeules; V Piguet; L Collart; P Dayer,"1. In humans, the central analgesic effect of tramadol 100 mg orally is only partially reversed by the opioid antagonist naloxone (0.8 mg intravenously). As suggested by in vitro and animal data tramadol analgesia may thus result from an action on opioid as well as monoaminergic pathways. We therefore investigated the effect of alpha 2-adrenoceptor antagonism with yohimbine on tramadol analgesia. 2. Healthy volunteers (n = 10) received tramadol (100 mg orally), followed (+3 h) by yohimbine (0.1 mg kg-1 intravenously), and yohimbine + naloxone (0.8 mg intravenously) and their respective placebo according to a randomized, double-blind crossover, placebo (P) controlled design. Analgesia was assessed over 8 h by subjective pain threshold (pain intensity numerical scale--PINS) and objective pain threshold (RIII nociceptive reflex--RIII) monitoring. 3. Tramadol induced a significant increase in both pain thresholds. Peak analgesic effect was observed at 3.7 h (RIII + 39.6 +/- 3.9% and PINS 50.1 +/- s.e.mean 5%) and the analgesia lasted about 6 h. 4. Yohimbine significantly reversed the analgesic effects of tramadol for 2.8 h with a maximum decrease of 97 +/- 4% (RIII) and 67 +/- 12% (PINS), whereas the addition of naloxone abolished tramadol effects throughout the study period with a decrease of 90 +/- 6% (RIII) and 79 +/- 9% (PINS), P < 0.05). 5. Yohimbine alone did not significantly reduce pain thresholds. 6. alpha 2-Adrenoceptor antagonism reverses tramadol effects, thus pointing to the significant role of monoaminergic modulation and the synergy with opioid agonism in tramadol antinociception after a single oral dose.",1996.0,0,0
1312,8826513,The undertreatment of pain in ambulatory AIDS patients.,W Breitbart; B D Rosenfeld; S D Passik; M V McDonald; H Thaler; R K Portenoy,"Pain is highly prevalent in individuals with HIV disease, yet is often overlooked as a symptom requiring clinical intervention. We evaluated the adequacy of analgesic management for pain and identified predictors of pain undertreatment in a sample of 366 ambulatory AIDS patients using a prospective cross-sectional survey design. Two hundred and twenty-six of the 366 ambulatory AIDS patients surveyed reported ""persistent or frequent"" pain over the 2 week period prior to the survey. Adequacy of analgesic therapy was assessed using the Pain Management Index (PMI - a measure derived from the Brief Pain Inventory) and the type and frequency of analgesic medications prescribed for pain. Results indicated that nearly 85% of patients were classified as receiving inadequate analgesic therapy based on the PMI. Less that 8% of the 110 patients who reported ""severe"" pain were prescribed a ""strong"" opioid (e.g., morphine), as suggested by published guidelines. Adjuvant analgesic drugs (e.g., antidepressant medications) were prescribed in only 10% of the patients. Women, less educated patients, and patients who reported injection drug use as their HIV transmission risk factor were most likely to have received inadequate analgesic therapy. These results demonstrate the alarming degree of undertreatment of pain in ambulatory patients with AIDS, and indicates the need to improve the management of AIDS-related pain in this underserved population. Future research should elucidate the factors that impede adequate pain management in order to overcome obstacles to adequate treatment.",1996.0,0,0
1313,8826517,,,,,0,0
1314,8829419,Analgesic effect of incisional morphine following inguinal herniotomy under spinal anesthesia.,C Rosenstock; G Andersen; K Antonsen; H Rasmussen; C Lund,"Opioids have been shown to possess antinociceptive effects after peripheral administration in experimental and clinical studies. The results of clinical studies on intra-articularly administered morphine are, however, conflicting. The objective of this study was to examine a possible analgesic effect of incisionally administered morphine on postoperative pain in patients undergoing inguinal herniotomy. Forty outpatients were included in a double blind randomized, placebo-controlled study. The patients had spinal anesthesia with 1.5-2.0 mL hyperbaric 5% lidocaine. At conclusion of herniotomy morphine 5 mg was injected incisionally in 10 patients, intravenously in 10, and subcutaneously in 10. The placebo group of 10 patients had saline injected in the incision. Postoperative pain was assessed with a visual analog scale at rest and during mobilization. Assessments were made immediately before and at 0, 2, 4, and 6 hours after herniotomy and on the second and seventh postoperative days. At the same times morphine and acetaminophen consumptions were recorded. There were no significant differences in postoperative visual analog scores between the groups. Except for the cumulative morphine requirement from the second to the seventh postoperative day, which was significantly higher in the placebo group than in other groups, no significant differences in cumulative morphine and acetaminophen requirements were found between the groups. A single 5-mg dose of morphine injected in the herniotomy wound did not affect pain scores or supplementary analgesic requirements, which argues against a role of peripheral opioid receptors in mediating analgesia.",1996.0,0,0
1315,8829420,Preoperative spinal bupivacaine does not reduce postoperative morphine requirement in women undergoing total abdominal hysterectomy.,M J Dakin; O Y Osinubi; F Carli,"This study was undertaken to determine whether preoperative spinal anesthesia with local anesthetics would exert a pre-emptive effect on postoperative analgesia by reducing neural afferent stimulation. The authors studied 38 healthy women undergoing total abdominal hysterectomy. Patients were randomly allocated to two groups: group A received a spinal block (T3-S5) prior to induction of anesthesia and surgery, while in group B the block was performed after surgery prior to extubation of the trachea. Patient-controlled analgesia morphine was administered to both groups during the first 24 postoperative hours. Pain and sedation scores at 6, 12, and 24 hours were similar in the two groups. Cumulative morphine consumption at 6 and 24 hours after surgery was similar in both groups; however at 12 hours more morphine was needed in group A (P < .02). The authors were unable to demonstrate that spinal block with bupivacaine before surgery, as opposed to after surgery, decreased the requirement of morphine in the postoperative period.",1996.0,0,0
1316,8829857,Comparison of morphine and morphine with ketamine for postoperative analgesia.,K B Javery; T W Ussery; H G Steger; G W Colclough,"The purpose of this study was to compare morphine with ketamine to morphine alone in a double-blind investigation of postsurgical pain control. Forty-two ASA 1 and 2 patients undergoing elective microdiscectomy were administered either 1 mg.ml-1 of morphine (n = 20) or 1 mg.ml-1 of both morphine and ketamine (n = 22) via iv patient controlled analgesia (IVPCA). Pain relief and side effects were assessed at 24 hr after surgery. The mean (SD) visual analogue scale (VAS) pain rating of 2.3 (1.67) for patients receiving morphine with ketamine was lower (P < 0.001) than the VAS scores of patients receiving only morphine 4.5 (1.54). Patients receiving morphine and ketamine also had less difficulty with side effects, reporting less nausea (P < 0.05), pruritus (P < 0.001), and urinary retention (P < 0.05). Although dysphoria is reported to be a common side effect of ketamine, complaints of dysphoria were rare in both groups, with only one subject (5%) in the morphine with ketamine group and three (15%) subjects receiving morphine alone reporting this side effect. IVPCA ketamine in combination with morphine provides superior postsurgical pain relief at lower dosage and with fewer side effects than morphine alone.",1996.0,0,0
1317,8829858,Intravenous ketorolac vs diclofenac for analgesia after maxillofacial surgery.,P Tarkkila; M Tuominen; P H Rosenberg,"To compare the efficacy of the non-steroidal antiinflammatory drugs (NSAID), ketorolac and diclofenac in prevention of pain after maxillofacial surgery. Sixty ASA I-II patients (30 in each group) received randomly, and double blindly either ketorolac 0.4 mg.kg-1 or diclofenac 1.0 mg.kg-1 iv after general anaesthesia induction, before surgical incision. In the ketorolac group, the same dose was repeated iv three times at six hour intervals. The diclofenac group patients received diclofenac 1.0 mg.kg-1 after 12 hr iv. Rescue analgesic medication consisting of oxycodone 0.03 mg.kg-1 iv, was administered by a patient controlled analgesia apparatus. Two patients in the ketorolac and three patients in the diclofenac group did not need oxycodone during the study period. On average, 12 and 11 doses of oxycodone were needed in the ketorolac and the diclofenac groups, respectively (NS). Side-effects were similar in both groups. All patients except one were satisfied with the pain therapy. Parenteral ketorolac (0.4 mg.kg-1 four times in 24 hr) and diclofenac (1 mg.kg-1 twice in 24 hr) were similar, but insufficient alone, for analgesia after maxillofacial surgery.",1996.0,0,0
1318,8829859,Comparative effects of three doses of intravenous ketorolac or morphine on emesis and analgesia for restorative dental surgery in children.,J P Purday; C C Reichert; P M Merrick,"The optimal dose of intravenous ketorolac tromethamine (ketorolac), a non-steroidal anti-inflammatory drug has not been determined in children. There are only limited published data on the use of intravenous ketorolac for paediatric analgesia. This study compares the analgesic and emetic effect of three different doses of ketorolac with morphine in paediatric dental surgical out-patients. Following institutional approval and parental consent, 120 ASA I or II children, age 2-10 yr were randomized to four groups and received ketorolac 0.75, 1.0, and 1.5 mg.kg-1 or morphine 0.1 mg.kg-1 iv at induction of a standardized anaesthetic. At 15 and 30 min after arrival in the recovery room a blinded observer assessed pain using the Objective Pain Score (OPS). Twenty-four hours after surgery a telephone interview was carried out with a parent at home. There were no differences in demographic data, anaesthesia time, recovery and day-care unit time, OPS and postoperative analgesic requirements in the four groups. Postoperative vomiting in the first 24 hr occurred more frequently in the morphine group than in the other groups (P < 0.0166). No patient had excessive surgical bleeding. Ketorolac, in all doses studied (0.75, 1.0 and 1.5 mg.kg-1) was as effective an analgesic as morphine 0.1 mg.kg-1 given intravenously at induction to children having restorative dental surgery. Its use was associated with a significant reduction in the incidence of postoperative vomiting.",1996.0,0,0
1319,8829938,"Post-operative intravenous continuous analgesia: comparison of buprenorphine, fentanyl and nalbuphine.",C Lejus; Y Blanloeil; T François; S Testa; P Michel; B Dixneuf,"Continuous intravenous infusions of fentanyl, buprenorphine or nalbuphine were investigated to provide pain relief for patients after major abdominal surgery. Buprenorphine (n = 23) was given as a loading dose of 5 micrograms kg-1 and infused at 0.8 micrograms kg-1 h-1. Fentanyl (n = 20) was given as a loading dose of 2 micrograms kg-1 and infused at 0.7 micrograms kg-1 h-1. Nalbuphine (n = 21) was given as a loading dose of 200 micrograms kg-1 and infused at 80 micrograms kg-1 h-1. The infusion rate was increased when analgesia was inadequate, and decreased if respiratory depression occurred. Mean doses were respectively 0.74 +/- 0.15 microgram kg-1 h-1 buprenorphine, 0.68 +/- 0.18 microgram kg-1 h-1 fentanyl, 83 +/- 21 micrograms kg-1 h-1 nalbuphine. Titration of continuous intravenous infusion of buprenorphine and fentanyl provided better analgesia than nalbuphine with smaller doses than those reported in similar studies allowing spontaneous breathing.",1996.0,0,0
1320,8829944,Patient-controlled epidural diamorphine for post-operative pain: verbal rating and visual analogue assessments of pain.,G Kunst; S Chrubasik; A M Black; J Chrubasik; J Schulte-Mönting; J I Alexander,"Twenty-two patients were studied while receiving epidural analgesia with diamorphine after major lower abdominal surgery under combined regional and general anaesthesia. Epidural PCA began when the intraoperative epidural block with bupivacaine wore off enough for the patient to request treatment. It was started with 2 mg of diamorphine and continued with a reducible background infusion that was initially set at 0.2 mg h-1 and supplemented by on-demand doses of 0.2 mg, with a lockout time of 15 min. The patients received routine post-operative monitoring and care, with pain at rest being assessed on a four-point verbal rating scale (VRS, none, mild, moderate, severe) at 5, 10, 15, 30, 45, 60, 90 and 120 min from the start of ePCA, then hourly until 24 h and then 2-hourly until 48 h. VRS on coughing and a 10 cm visual analogue score (VAS) at rest and on coughing were recorded at the same times at 4 h, then 4 hourly until 24 h and then at 48 h, at which times, blood samples were also taken to measure morphine concentrations by radioimmunoassay. Analgesia started promptly and reached a maximum at between 30 and 45 min, accompanied by maximum sedation. Thereafter clinically acceptable analgesia was maintained without undue sedation for 48 h, though pain on coughing was less well controlled than pain at rest. After the initial loading dose of diamorphine, the 95% confidence intervals (CI) for further consumption were 3.7 to 17 mg (average 9.7) in the first 24 h and 2.1 to 12.9 mg (average 6.7 mg) in the second 24 h. The plasma morphine concentrations rose to a plateau by about 15 min, with concentrations within 95% CI from 0 to 11 ng mliters-1 (average 5 ng mliters-1. The VRS and VAS pain scores were analysed by a conservative approach that treated them as ordinal data, and by a parametric approach that treated them as interval data. Both approaches conveyed broadly similar information about the post-operative analgesia.",1996.0,0,0
1321,8832449,Effect of varying intravenous patient-controlled analgesia dose and lockout interval while maintaining a constant hourly maximum dose.,N H Badner; J A Doyle; M H Smith; I A Herrick,"To investigate the effect on the use of intravenous patient-controlled analgesia (PCA) of varying the dose (D) and lockout interval (LI) while keeping the hourly maximum dose constant. Randomized, prospective study. Teaching hospital. 75 patients scheduled to receive PCA morphine following abdominal surgery. Postoperatively, patients were randomly assigned to receive PCA morphine with the following parameters: D = 1 mg, LI = 6 min (Group 1-6), D = 1.5 mg, LI = 9 min (Group 1.5-9), or D = 2 mg, LI = 12 min (Group 2-12), so that each group could receive a maximum hourly dose or 10 mg. Inadequate analgesia was managed by increasing the dose and lockout interval, while excessive sedation or respiratory rate less than 10 breaths/min resulted in decreasing the dose and lockout interval. Patients were assessed for pain [visual analog scale (VAS), verbal rating scale (VRS)] and side effects at 1, 2, 4, and 24 hours. The number of doses administered, missed attempts, and morphine used for the first 24 hours was recorded by automatic printout from the PCA machine. There was no difference in the total 24-hour morphine consumption, analgesia, or incidence of side effects among the three groups at any of the measurement times. Two patients, one each in the 1.5-9 and 2-12 groups, required naloxone for respiratory depression. The number of PCA injections, attempts, missed attempts, and the incidence of dosage adjustment were all significantly higher for the 1-6 group (p < 0.05). The use of 1.0 mg with a 6-minute lockout may represent appropriate dose titration because this group obtained equivalent analgesia, morphine use, and side effects as the two larger dose and lockout groups. However, the increased number of PCA attempts and missed attempts may reflect lower satisfaction with PCA therapy.",1996.0,0,0
1322,8835900,Celiac plexus block as treatment for refractory pain related to sclerosing cholangitis in AIDS patients.,J Collazos; J Mayo; E Martínez; A Callejo; I Blanco,"Sclerosing cholangitis may be a cause of refractory pain in patients infected with the human immunodeficiency virus. We performed celiac plexus block in three such patients with sever pain from sclerosing cholangitis and a poor response to conventional analgesia. The pain had been centered in the epigastrium and/or upper-right quadrant of the abdomen for 2, 10, and 15 weeks, respectively. Computed tomography-guided celiac plexus block with absolute alcohol and bupivacaine was performed. All three patients reported complete disappearance of the pain immediately after the procedure in two cases and 3 days later in the remaining patient. All patients were discharged free of pain and without analgesics and were followed up for 2, 8, and 11 months, respectively, without recurrence of pain. Celiac plexus block deserves further trial for the treatment of severe pain associated with sclerosing cholangitis in patients with acquired immunodeficiency syndrome. The quality of life of our three patients was considerably improved with this relatively simple procedure.",1996.0,0,0
1323,8836263,"Continuous thoracic epidural analgesia versus combined spinal/thoracic epidural analgesia on pain, pulmonary function and the metabolic response following colonic resection.",N B Scott; K James; M Murphy; H Kehlet,"The neuroendocrine response following major surgery has not been previously influenced by either regional anaesthetic techniques or opioid analgesia probably due to insufficient intraoperative afferent neural blockade. In this study we attempted to determine whether significant inhibition of these pathways could be achieved by combining preoperative high spinal anaesthesia with postoperative thoracic epidural anaesthesia. In theory too, there may be additional benefits over perioperative thoracic epidural anaesthesia on pain and pulmonary dysfunction. 20 ASA 1-3 patients undergoing elective colonic surgery were studied. Gp 1 (n = 10) received a high spinal intraoperative block to T4 using 6mls of 0.5% bupivacaine plus continuous epidural 0.125% bupivacaine/0.0025% diamorphine. Gp 2 (n = 10) patients received epidural 0.5% bupivacaine block to T4 plus continuous epidural infusion of 0.125% bupivacaine/0.0025% diamorphine. We measured a) plasma glucose and cortisol at 0, 1, 2, 3, 4, 8 and 24 h; b) forced vital capacity (FVC), forced expiratory volume in the first second (FEV1) and peak flow rate (PFR) preoperatively, at 8 and 24 h; c) visual analogue pain scores (VAS 0-10) at rest, cough and mobilisation at 8 and 24 h; d) block height every hour for 12 hours then 3 hourly; e) 24-hour urine volumes for dopamine, adrenaline and noradrenaline f) 24-hour PCA morphine requirements. The two groups did not differ in age, sex, height, weight, duration of surgery, blood loss or serum albumin. Pain relief was excellent and similar in both groups. The average 24 hour morphine consumption was 10 mg in both groups with no differences in the block height. All the patients had a 30-50% reduction in FEV1, FVC and PFR (P > 0.05). Metabolically, there was no statistical difference between the 2 groups except a higher rise in glucose in Gp1 at 2 and 3 h (P = 0.0312 and 0.014). 24-hour catecholamine studies showed no differences for noradrenaline (P = 0.8), adrenaline (P = 0.47) and dopamine (P = 0.36). Thoracic epidural bupivacaine/diamorphine infusion provided excellent postoperative analgesia following colonic surgery. An intraoperative combined spinal/epidural technique conferred no additional benefit on analgesia, pulmonary function and the neuroendocrine response.",1996.0,0,0
1324,8836264,Intravenous ketoprofen for pain relief after total hip or knee replacement.,P A Kostamovaara; J O Laitinen; L S Nuutinen; M K Koivuranta,"There are few studies in which ketoprofen, a propionic acid derivate NSAID, has been tested as an intravenous postoperative analgesic. The aim of this double-blind, randomized, placebo-controlled work was to study the tolerability and efficacy of intravenous ketoprofen in seventy-six patients undergoing hip or knee total endoprothesis surgery using three different doses. The patients received either ketoprofen 50 mg, 100 mg or 150 mg, or placebo as an initial intravenous loading, followed by an infusion containing 50 mg, 100 mg or 150 mg or placebo, respectively, over the following eleven and a half hours. The consumption of fentanyl was recorded and the patients assessed their pain intensity on a 10-cm visual analogue scale (VAS) at 0, 2, 4 and 12 hours. Possible side-effects were recorded at the same intervals. Patients receiving ketoprofen showed significantly lower total fentanyl consumption and significantly better pain relief at 12 hours was achieved by a 300 mg dose of ketoprofen than by placebo. Side-effects were minimal, with no differences between the groups. A bolus of ketoprofen following continuous infusion of ketoprofen, coupled with a PCA-system, was an effective and safe approach for the relief of postoperative pain.",1996.0,0,0
1325,8836265,Introducing epidural fentanyl for on-ward pain relief after major surgery.,T E Salomäki; H Kokki; M Turunen; U Havukainen; L S Nuutinen,"Epidural opioids have been recommended for analgesia after major surgery. In this report we describe how we introduced a low-cost, on-ward, nurse-based acute pain service using epidural fentanyl after major surgery in the University Hospitals of Oulu and Kuopio. In order to evaluate the feasibility of epidural fentanyl infusion administered by ward nurses, we prospectively assessed pain and side effects during fentanyl infusion (median duration 41 h) after major surgery in 305 consecutive patients in Kuopio. 92% of the patients on the ward who had received epidural fentanyl infusion at 31-54 micrograms h-1 reported at most three episodes of severe pain (/Numerical Rating Scale > 3/ 10) during the initial postoperative days, but there were some patients (8%) who reported several episodes (> 3) of more severe pain (Numerical Rating Scale > 3). Three patients (0.9%) showed a diminished respiratory rate (< 10/min), but only one of them (0.3%) was somnolent. One other patient (0.3%) was not arousable until the cessation of infusion. Nausea and pruritus were minor problems in our patients, but a majority needed a urinary catheter. With well-trained nurses, careful monitoring and appropriate protocols, epidural fentanyl infusion proved to be a feasible method for pain relief after major surgery on a surgical ward.",1996.0,0,0
1326,8836267,Preoperative application of piroxicam gel compared to a local anaesthetic field block for postoperative analgesia.,J J O'Hanlon; G McCleane; T Muldoon,"The non-steroidal anti-inflammatory drugs inhibit prostaglandin synthesis and hence have an analgesic action. Following topical administration, the drug is concentrated in the tissues and so can have a local analgesic effect. This study investigated the effect of the preoperative application of topical piroxicam on postoperative analgesic requirement compared to a placebo group and a conventional local anaesthetic field block. Forty-two patients presenting for in-patient inguinal hernia repair were randomly allocated on a double-blind basis to have either piroxicam gel 15gm applied preoperatively, or an inguinal field block with 20 ml of 0.375% bupivacaine following induction of anaesthesia, or no treatment. Postoperative Visual Analogue Scores for pain on moving in group P, I or C on admission at 1h, 2h, and 4 h following surgery were: 2 vs 1 vs 6.5; 3 vs 3 vs 5; 3 v 2 vs 4.5; 3 vs 2 vs 5.0, respectively (P < 0.005). Median(range) time to first analgesia was 25.4(15-70) min in group I, 30.3(10-49) min in group P; this was not significantly different from group C21.5(7-70) min. Over the first 24 hours the postoperative morphine requirement was significantly less in the two treatment groups 30(20)mg in group I and 34(17) mg in group P and 71(15) in group C, P < 0.0001. There were no apparent NSAID-induced side-effects, or effects on wound healing. The preoperative administration of piroxicam (15gm) topically compared favourably with a preoperative local anaesthetic field block with respect to VAS scores, time to first analgesia and total morphine consumption. And both treatment groups provided significantly superior analgesia than the control group.",1996.0,0,0
1327,8838437,Dose dependent time course of the analgesic effect of a sustained-release preparation of tramadol on experimental phasic and tonic pain.,N Thürauf; W K Fleischer; J Liefhold; O Schmid; G Kobal,"1. The aim of this study was to investigate the analgesic effect and its duration of a new sustained-release preparation of tramadol in an experimental pain model based on pain-related chemosomatosensory evoked potentials (CSSEPs) and subjective intensity estimates of painful phasic and tonic stimuli. 2. Twenty volunteers participated in a randomised, double-blind, three-fold cross-over study. Measurements were obtained before and 0.5, 1, 4, 6, and 12 h after administration of the drug (100 mg, 200 mg and placebo orally). CSSEPs were recorded after stimulation of one nostril with phasic, painful CO2 pulses. The other nostril was stimulated with a constant stream of dry air, which produced a tonic painful sensation. Subjects rated the perceived intensity of phasic and tonic stimuli via visual analogue scales. In order to test for nonspecific effects, acoustic evoked potentials (AEPs) were recorded, the spontaneous EEG was analysed in the frequency domain, the subject's vigilance was assessed in a tracking task, and the side effects of the drug were monitored. 3. The sustained-release preparation of tramadol produced a significant dose-related decrease in CSSEP amplitudes when compared with placebo. The reduction in amplitudes outlasted the observation period of 12 h, demonstrating the prolonged duration of the analgesic effect. 4. A dose-related significant decrease could be observed for the estimates of tonic pain. Similar to the decrease of amplitudes of the CSSEP, the reduction of the ratings of tonic pain outlasted the observation period of 12 h. The observed slight decrease in the estimates of phasic pain under medication did not reach a statistically significant level when compared with placebo. No significant effect could be demonstrated for the perception of the phasic and the tonic pain as determined by the McGill-Questionnaire. 5. A significant dose-related increase in the estimates of the side effects 'drowsiness', 'vertigo' and 'sickness' but not for 'tiredness' could be demonstrated.",1996.0,0,0
1328,8839521,"Comparison of oral transmucosal fentanyl citrate and intramuscular meperidine, promethazine, and chlorpromazine for conscious sedation of children undergoing laceration repair.",S A Schutzman; E Liebelt; M Wisk; J Burg,"To compare oral transmucosal fentanyl citrate (OTFC) with IM meperidine, promethazine, and chlorpromazine (MPC) for conscious sedation of children. This prospective, randomized, single-blinded study involved a convenience sample of 40 children, 3 to 8 years of age, who presented to an urban pediatric emergency department and required laceration repair. Patients were premedicated with either OTFC (10 to 15 micrograms/kg) and a mock injection or intramuscular MPC (2 mg/kg meperidine, .5 mg/kg promethazine, and .5 mg/kg chlorpromazine) followed by a placebo lozenge. Both OTFC and MPC caused significant reductions in activity scores at 15 to 75 minutes after medication administration. Although the MPC group was more sedated, there was no difference between groups in Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) scores during the laceration repair or in the suturing physician's assessment of sedation quality (rated excellent or good for 75% and 69% of OTFC and MPC groups, respectively). Two children (both in the OTFC group) had oxygen saturation levels of less than 95% but required only transient supplemental oxygen. Other adverse events were common but not serious; they differed between groups in type but not number, with vomiting in 45% of the OTFC group and prolonged somnolence in 37% of the MPC group. Mean time to discharge was 99 minutes, with no difference between groups. Both medications reduced activity significantly. Although MPC caused deeper sedation, the medications had comparable effects on patient behavior during the repair and yielded comparable ratings of physician satisfaction. Large numbers of nonserious adverse events occurred in both groups.",1996.0,0,0
1329,8840380,Resolution of tumor pain with EMLA cream.,M B Stegman; C A Stoukides,"A 69-year-old woman was admitted for control of intractable rectal pain caused by a 4-cm malignant mass. She was treated successfully with EMLA (eutectic mixture of local anesthetics) cream applied every 8 hours and covered with a Xeroform dressing. Despite an increase in tumor size to 6 cm, her pain control was maintained with no local or systemic adverse effects. We believe topical EMLA may be effective in managing such lesions. Close patient monitoring is necessary, however, and long-term, controlled studies must be conducted to determine its safety and efficacy in this setting.",1996.0,0,0
1330,8842656,Post-operative pain relief in children following extraction of carious deciduous teeth under general anaesthesia: a comparison of nalbuphine and diclofenac.,I H Littlejohn; M M Tarling; P J Flynn; A J Ordman; A Aiken,"In a randomized double-blind study 60 children, undergoing the extraction of carious deciduous teeth under day-case general anaesthesia, were assigned to receive either intravenous nalbuphine hydrochloride 0.3 mg kg-1 (n = 21), one or more diclofenac suppositories 12.5 mg to a dose of 1-2 mg kg-1 (n = 19), or no analgesia (n = 20). The duration of anaesthesia was longer in the diclofenac group (9.6 min, SD 3.5) compared with control (7.2 min, SD 2.6) and nalbuphine (6.9 min, SD 3.0) groups respectively (P < 0.05). There were no statistically significant differences in post-operative pain scores during the 45 min post-operative period studied between the three groups using an objective pain score. We conclude that using this methodology we were unable to demonstrate any statistically significant differences between the analgesic effects of either intravenous (i.v.) nalbuphine or diclofenac suppositories compared with control.",1996.0,0,0
1331,8842667,The value of continuous blockade of the lumbar plexus as an adjunct to acetylsalicyclic acid for pain relief after surgery for femoral neck fractures.,N L Spansberg; E Anker-Møller; J B Dahl; P Schultz; E F Christensen,"In a randomized, double-blind investigation the analgesic effect of continuous blockade of the lumbar plexus as an adjunct to acetylsalicyclic acid by suppository after surgery for femoral neck fractures under spinal anaesthesia was examined in 20 patients. Before surgery, a catheter was inserted into the femoral nerve sheath. The patients were allocated randomly to receive bupivacaine or saline by bolus and then continuous infusion, started immediately after the operation. No statistically significant differences in additional morphine requirements, visual analogue pain scores or adverse effects were observed between the two treatment groups. It is concluded that continuous blockade of the lumbar plexus as an adjunct to rectal acetylsalicyclic acid offers no major additional pain relief after surgery for femoral neck fractures under spinal anaesthesia.",1996.0,0,0
1332,8844441,Analgesic efficacy of controlled-release oxycodone in postoperative pain.,A Sunshine; N Z Olson; A Colon; J Rivera; R F Kaiko; R D Fitzmartin; R F Reder; P D Goldenheim,"The efficacy and safety of graded doses (10, 20, and 30 mg) of controlled-release (CR) oxycodone was compared with that of immediate-release (IR) oxycodone (15 mg), immediate-release oxycodone 10 mg in combination with acetaminophen 650 mg (APAP), and placebo in a single-dose, double-blind, randomized, parallel-group study. The participants, 182 inpatients experiencing moderate to severe pain after abdominal or gynecologic surgery, provided hourly ratings of pain intensity and relief for 12 hours after administration. All active treatments were significantly superior to placebo for many hourly measurements and for the sum of pain intensity differences (SPID) and total pain relief (TOTPAR). A dose response was found among the three levels of CR oxycodone for pain relief and peak pain intensity difference (PID), with the 20- and 30-mg doses being significantly better than the 10-mg dose. For all active treatments, peak PID and peak pain relief occurred approximately 2 to 4 hours after administration. The median time to onset of relief was 32 minutes for oxycodone plus APAP, 41 minutes for IR oxycodone, and 46 minutes for CR oxycodone 30 mg. Duration of pain relief showed that the 10-, 20-, and 30-mg doses of CR oxycodone had durations of action of 10 to 12 hours compared with IR oxycodone and oxycodone plus APAP (both approximately 7 hours). Typical adverse events, particularly somnolence, occurred in all active treatment groups. Treatment with CR oxycodone was safe and effective in this study, and its characteristics will be beneficial in the treatment of pain.",1996.0,0,0
1333,8845555,Fentanyl remaining in a transdermal system following three days of continuous use.,K A Marquardt; R S Tharratt; N A Musallam,"To determine whether there was a sufficient amount of fentanyl remaining in a patch that had been used continuously for 3 days to warrant establishment of disposal policies to prevent diversion of fentanyl. Nine patches were applied and removed by hospice nurses after 3 days of continuous use on hospice patients with cancer. Patches were analyzed for the remaining fentanyl contents using the Coat-A-Count Fentanyl radioimmunoassay. Five 2.5-mg patches and four 10.0-mg patches were opened, solubilized with methanol, diluted with water, and analyzed in duplicate. An unused 2.5-mg patch also was analyzed as a control and showed a 94% recovery of fentanyl. A methanol blank was negative for fentanyl. The study determined the amount of fentanyl in milligrams remaining in a used patch. Using pharmacokinetics principles, this quantity was compared with a potential lethal dose of fentanyl. Analysis showed 0.7-1.22 mg remaining in the 2.5-mg patches and 4.46-8.44 mg remaining in the 10.0-mg patches. These numbers represent 28-84.4% of the original contents. Using the pharmacokinetic values of the volume of distribution of 4L/kg and a potential lethal blood concentration of 3.7 micrograms/L, one can calculate the potential lethal dose for a 70-kg person to be 1036 micrograms. This is well within the amount remaining in the patch. This study also demonstrated that a wide patient variability exists in the absorption of fentanyl from the patch. There is a sufficient amount of fentanyl available for abuse and misuse after 3 days of therapeutic use. Adequate disposal policies currently are not established and need to be implemented.",1995.0,0,0
1334,8846277,A double-blind comparison of morphine infusion and patient controlled analgesia in children.,R J Bray; A M Woodhams; C J Vallis; P J Kelly; M P Ward-Platt,"The analgesia provided after major abdominal surgery in 30 children by continuous morphine infusion and patient controlled analgesia, also using morphine, was compared using a double-blind, double-dummy design. The groups of children were comparable in age, weight, duration of operation and sex ratio. Pain assessment was carried out by a single observer using a visual analogue scale and the Poker Chip Tool. Assessments took place during two four-hour periods, one on the day of operation and one the following day. Children aged between nine and 15 years achieved better pain relief with patient controlled analgesia. No difference could be shown in children aged between five and eight years.",1996.0,0,0
1335,8846278,Morphine consumption and respiratory depression in children receiving postoperative analgesia from continuous morphine infusion or patient controlled analgesia.,R J Bray; A M Woodhams; C J Vallis; P J Kelly,"Thirty children, aged between five and 15 years, were randomly allocated to receive postoperative analgesia from continuous morphine infusion (CMI) or patient controlled analgesia (PCA), also using morphine. The children's morphine consumption, respiratory rates, oxygen saturations and observation points during which they were sleeping were recorded during two periods, one on the day of operation and one the following day. The median dose of morphine consumed by the children using PCA was significantly larger than that consumed by the children having continuous infusions. Children aged between nine and 15 years using PCA had significantly lower minimum respiratory rates and minimum oxygen saturations than similarly aged children receiving continuous infusions. There was no significant difference between the PCA and CMI groups in the number of observation times that the children were asleep or in the minimum respiratory rates and minimum oxygen saturations in the awake and sleeping children.",1996.0,0,0
1336,8849499,Diagnosing addictive disease in chronic pain patients.,K Miotto; P Compton; W Ling; M Conolly,"As opiate therapy is increasingly accepted for the management of chronic pain, the consultation-liaison psychiatrist is often challenged to diagnose and provide treatment recommendations for addictive disease in chronic pain patients. Reviewed are the defining characteristics of addiction within the context of chronic pain, and the interesting commonalities between addictive disease and chronic pain. Guidelines for assessment of addiction in patients with chronic pain are presented, as are suggestions for the management of these concurrent disorders. Underlying this review is a belief that opiates should not be withheld from persons with chronic pain, even in the presence of addictive disease.",1996.0,0,0
1337,8849504,Referral delay in back pain patients on worker's compensation.,R M Gallagher; P Myers,"Low back pain (LBP), a common illness that may progress to chronic disability, costs many billions for care, lost work, and compensation. Conventional medicine does not effectively restore chronic LBP patients to work; multidisciplinary rehabilitation does, but limited or delayed access risks unnecessary costs, additional morbidity, and permanent disability. The authors examine costs of delayed treatment for 23 disabled LBP patients in a rehabilitation program. Compensation costs average $26,159 per patient, a sum covering treatment for 3 patients. Additional medical and societal costs are estimated. Factors causing delay, such as economic incentives and ignorance about pain, and policies to remediate these problems, are discussed.",1996.0,0,0
1338,8855606,Management of cancer-related pain with transdermal fentanyl.,S Leelanuntakit,This study demonstrates that TTS-fentanyl can provide sufficient pain relief in cancer patients equivalent to that achieved with morphine with additional benefits of convenience and reduced side effects.,1996.0,0,0
1339,8856818,Advances in comprehensive pain management.,T W Koenig; M R Clark,"Chronic pain is a significant public health problem and frustrating for everyone affected by it. Psychiatrists should take an active role in the care of patients with chronic pain. They no longer should wait to make a psychiatric diagnosis by exclusion in the patient who has failed to respond to multiple treatments over a period of years. Recent advances in the treatment of chronic pain include the diagnosis and treatment of psychiatric comorbidity, the application of primary psychiatric treatments to chronic pain, and the development of interdisciplinary efforts to provide comprehensive health care to the patient suffering with chronic pain.",1996.0,0,0
1340,8857627,Inpatient vs. outpatient pain management: results of a randomised controlled trial.,A C Williams; P H Richardson; M K Nicholas; C E Pither; V R Harding; K L Ridout; J A Ralphs; I H Richardson; D M Justins; J H Chamberlain,"Inpatient and outpatient cognitive behavioural pain management programmes for mixed chronic pain patients were compared. Patients were randomly allocated to the 4 week inpatient programme or to the 8 half day per week outpatient programme, or to a waiting list control group. Staff, teaching materials, and setting were the same for the two treatment groups. Patients were assessed pre-treatment, and at 1 month after discharge, and treated patients also at 6 months and 1 year after discharge, by assessors blind to treatment group; assessments included physical, functional and psychological measures, and medication use. In total, 121 mixed chronic pain patients (mean age 50 years; mean chronicity 8.1 years) were included in the study, following medical examination to ensure that no further medical treatment was appropriate. There was no change in the control group; inpatients and outpatients, comparable before treatment, both made significant improvements in physical performance and psychological function, and reduced medication use. Inpatients made greater gains, and maintained them better at 1 year; they also used less health care than outpatients. There were no outstanding predictors of improvement other than treatment group.",1996.0,0,0
1341,8857711,Classification of daily and near-daily headaches: field trial of revised IHS criteria.,S D Silberstein; R B Lipton; M Sliwinski,"Primary chronic daily headache can be subdivided into transformed migraine, chronic tension-type headache, hemicrania continua, and new daily persistent headache. We proposed and tested criteria in 150 consecutive outpatients with chronic daily headache. Based on preliminary analysis, we revised the criteria for transformed migraine. Using the International Headache Society criteria, 43% of the patients could not be classified; using our old criteria, 25% could not be classified; however, using our new criteria, we were able to classify 100%. Seventy-eight percent had transformed migraine, 15.3% had chronic tension-type headache, and 6.7% had other headache disorders.",1996.0,0,0
1342,8861543,Opioid analgesics: comparative features and prescribing guidelines.,N I Cherny,"The term 'opioid' is a generic term for naturally occurring, semisynthetic and synthetic drugs which combine with opioid receptors to produce physiological effects and which are stereospecifically antagonised by naloxone. For clinical purposes, opioids can be classified according to their receptor interactions (agonist, partial agonist, agonist-antagonist and antagonist), the pain intensity for which they are conventionally used (moderate or severe), and their half-life (short or long). Pure agonists conventionally used for moderate pain, short and long half-life pure agonists conventionally used for severe pain, mixed agonist-antagonists and partial agonist opioids are described in detail. The effective clinical use of opioid drugs requires familiarity with drug selection, routes of administration, dosage guidelines and potential adverse effects. Opioids are unequivocally indicated in the management of severe acute pain and moderate to severe pain associated with cancer. There is increasing acceptance of the role of opioids in the management of recurring acute pain, chronic nonmalignant pain of organic origin and severe neuropathic pain. The selection of opioids is influenced by pain intensity, pharmacokinetic and formulary considerations, previous adverse effects and the presence of coexisting disease. Some patients will require sequential trials of several different opioids before a drug which is effective and well tolerated is identified. Opioid agents should be administered by the most comfortable and convenient route that meets the specific needs of the patient. The regimen for opioid medications should generally provide around-the-clock analgesia with provision for rescue doses for the management of exacerbations of the pain not covered by the regular dosage. At all times, uncontrolled pain should be addressed by gradual increase in the opioid dose until either pain control is achieved or intolerable and unmanageable adverse effects supervene. The management of pain with opioid analgesics demands frequent patient assessment and a readiness to re-evaluate the therapeutic plan in the setting of either inadequate relief or adverse effects.",1996.0,0,0
1343,8862367,Thoracoscopic splanchnicectomy for chronic pancreatitis pain.,J W Maher; F C Johlin; D Pearson,"The study was undertaken to quantitate the effects of thoracoscopic splanchnic nerve resection (SPL) on pain from chronic pancreatitis. Patients with chronic pancreatitis pain completed an analog pain scale before operation and at postoperative visits. Midepigastric and left-sided pain was treated with left SPL; right-sided pain was treated with right-sided SPL. If pain recurred on the contralateral side, the patient underwent contralateral SPL. Fifteen patients underwent SPL. Eleven patients required daily narcotics for relief of pain before operation. Eight patients had unilateral SPL, whereas seven ultimately had a bilateral operation (median follow-up, 18 months). Fourteen patients had constant pain before operation, which decreased to a mean of 2.8 attacks per month (p < 0.0001). Before operation, the ""worst pain within last two months"" was 9.1 on pain scale (range, 0 for no pain, to 11 for constant pain). After operation this decreased to 5.1 (p < 0.002). ""Current severity"" of pain decreased from 6.5 before operation to 2.0 after operation (p < 0.0005). The ""amount pain is interfering with daily activities"" decreased from 7.3 before operation to 2.3 after operation (p < 0.0001). Seven patients (46%) no longer require narcotics and are classified as having had good results. Five patients (33%) are classified as improved and have had a major reduction in narcotic needs. Three have had no significant pain relief and are classified as having had poor results. Thoracoscopic SPL offers substantial promise in the therapy of pain from chronic pancreatitis.",1996.0,0,0
1344,8862961,A risk-benefit assessment of tramadol in the management of pain.,L Radbruch; S Grond; K A Lehmann,"Tramadol is a cyclohexanol derivative with mu-agonist activity. It has been used as an analgesic for postoperative or chronic pain since the late 1970s, and became one of the most popular analgesics of its class in Germany. International interest has been renewed during the past few years, when it was discovered that tramadol not only acts on opioid receptors, but also inhibits serotonin (5-hydroxytryptamine; 5-HT) and noradrenaline (norepinephrine) reuptake. This review aims to provide a risk-benefit assessment of tramadol in the management of acute and chronic pain syndromes. Tramadol has been used intraoperatively as part of balanced anaesthesia. Such use is under discussion, however, as it was associated with a high incidence of intraoperative recall and dreaming, and postoperative respiratory depression has been described after intraoperative administration of high doses. Postoperatively, intravenous and intramuscular tramadol has been used with good efficacy. Analgesic doses were comparable with pethidine (meperidine) and 10 times higher than morphine. Nausea and vomiting were the most frequently reported adverse effects. In controlled studies, haemodynamic and respiratory parameters were only minimally impaired. The risk of severe respiratory depression in typical dosages is negligible in comparison with other opioids used for postoperative pain management. Tramadol has been used with good results for the management of labour pain without respiratory depression of the neonate. It was also effective for the treatment of pain from myocardial ischaemia, ureteric colic and acute trauma. Good results have been published for cancer pain management with tramadol in several studies. The potential for abuse or addiction seems to be minimal, and serious complications have not been reported. For patients with severe pain, the efficacy of morphine is superior, and most patients with adequate analgesia from tramadol had to be changed to a more potent opioid after a few weeks due to increased nociceptive input during tumour progression. Tramadol can be recommended as a safe and efficient drug for step II according to the World Health Organization guidelines for cancer pain management.",1996.0,0,0
1345,8866158,Spinal opioid infusions in the treatment of chronic pain of nonmalignant origin.,J Maron; J D Loeser,To review the published literature on the use of spinal opioids in the treatment of chronic pain due to nonmalignant diseases. Literature review. Ten studies describing 146 patients have been located and reviewed. The data are insufficient to permit formal analysis. The proper role of intraspinal opioids in the treatment of chronic pain not due to cancer cannot be determined from the existing literature. Intraspinal opioids should be considered an experimental procedure for chronic pains not due to cancer until better data can be obtained; all patients who receive such therapy should be part of a clinical protocol whose results are published. The development of standardized clinical trial methodology and case reporting protocols would facilitate this process.,1996.0,0,0
1346,8866161,Transcutaneous electrical nerve stimulation (TENS) treatment outcome in long-term users.,D A Fishbain; C Chabal; A Abbott; L W Heine; R Cutler,"Previous reviewers of the literature on transcutaneous electrical nerve stimulation (TENS) outcome have concluded the following: (a) there are few long-term TENS follow-up studies, and (b) fewer studies have addressed the effect of long-term TENS use on outcome variables other than pain (e.g., function). DESIGN/SETTING/PARTICIPANTS/OUTCOME MEASURES: From a population of 2,003 chronic pain patients (CPPs) who bought a TENS device for pain management, 506 patients were randomly selected and interviewed by telephone long enough after purchase to allow at least 6 months of TENS use. The interview process used a structured ""skip"" questionnaire designed to assess the CPPs' perceptions regarding the effectiveness of TENS for a variety of outcome variables. Of the 506 CPPs interviewed, 376 (74.3%) had used their TENS device for 6 months or longer and were defined as long-term users. The responses of this group of CPPs to the telephone questionnaire were then subjected to statistical analysis. Paired t-tests, correlated z-tests, SS Wilks, and chi-square tests demonstrated statistically significant change or improvement (p < 0.05) that paralleled the introduction of TENS use in the following outcome variables: less pain interference with work, home, and social activities; increased activity level and pain management; decreased use of other therapies (e.g., physical therapy, occupational therapy, chiropractic); decreased use of narcotics, tranquilizers, muscle relaxants, nonsteroidal anti-inflammatory drugs and steroids. The results suggest that TENS is associated with improvement on multiple outcome variables in addition to pain relief for CPPs who are long-term users. Also, for some CPPs, long-term TENS use continues to be effective.",1996.0,0,0
1347,8867253,"A comparison of morphine, pethidine and fentanyl in the postsurgical patient-controlled analgesia environment.",A Woodhouse; A F Hobbes; L E Mather; M Gibson,"This study was designed to evaluate whether there is any scientific basis for clinicians' preferences for selecting opioids for use in patient-controlled analgesia (PCA) and to determine whether there are any patients' preferences for being treated with any of these opioids. Results were obtained for 55 postoperative patients recruited to investigate putatively equivalent doses of 3 commonly used opioids--morphine, pethidine and fentanyl--when self-administered postoperatively. No significant differences in the incidence of side effects between groups were found with the exception of more pruritus reported in the group given morphine. Patients who experienced vomiting or pruritus reported a greater intensity of these side effects if receiving morphine and fentanyl than if receiving pethidine. The majority of patients reported being very satisfied with their postoperative pain management and with PCA, with no differences in satisfaction between the 3 opioid-treated groups. A senior consultant anaesthetist, when asked to make a judgement, was not able to identify which agent each patient was receiving with a better than chance accuracy. These findings suggest that while there may be subtle differences in patient response to these 3 commonly used opioids, none was obviously superior when used for postoperative PCA.",1996.0,0,0
1348,8867523,"Analgesic efficacy of the kappa-receptor agonist, enadoline, in dental surgery pain.",A C Pande; R E Pyke; M Greiner; S A Cooper; R Benjamin; M W Pierce,"To study the analgesic efficacy of enadoline, a selective agonist of the kappa-opioid receptor, a double-blind, randomized comparison was made of enadoline versus placebo and a combination of acetaminophen-codeine in patients with pain after surgical extraction of impacted molar teeth. An initial study involving a comparison of enadoline, a combination, and placebo failed to show any analgesic effect of enadoline. Therefore, a second study with the same design but using higher doses of enadoline was conducted. Despite continued safety and tolerability even at the higher doses, enadoline could not be shown to be superior to placebo. The acetaminophen-codeine combination was significantly more effective than enadoline or placebo. Enadoline did not show analgesic efficacy in this study. Possible reasons for this lack of efficacy are discussed.",1996.0,0,0
1349,8868558,Chronic pain control in the elderly.,T J Keay,,1996.0,0,0
1350,8874346,Clinical experience with oral methadone administration in the treatment of pain in 196 advanced cancer patients.,F De Conno; L Groff; C Brunelli; E Zecca; V Ventafridda; C Ripamonti,"The aims of this study were to describe the analgesia, side effects, and dosage and the causes of suspension of treatment in a large sample of advanced cancer patients with pain after treatment with oral methadone from 7 to 90 days. In a retrospective study, data collected for 196 advanced cancer outpatients with moderate to severe pain treated at 8-hour intervals with oral methadone in solution form from February 1993 to February 1995 were analyzed at baseline (time 0) and then at 7, 15, 30, 45, 60, and 90 days. The following parameters were assessed: Karnofsky Performance Status, intensity of pain (using the Integrated Pain Score [IPS], intensity of pain, insomnia, drowsiness, confusion, dry mouth, nausea, vomiting, constipation, and dyspnea (using the Therapy Impact Questionnaire [TIQ], mean daily dose of drug administered, and reasons for withdrawal from study. The period when pain was reduced by > or = 35% with respect to baseline was evaluated with the Palliation Index. The association of the degree of palliation of pain with the age of the patients, tumor site, analgesic treatment taken at baseline, and daily mean dose of methadone administered during the follow-up period was analyzed by means of the Kruskal-Wallis test. A reduction in pain intensity with respect to baseline occurred at each analysis time, and in 55.1% of the patients the reduction during the follow-up period was > or = 35% according to the Palliation Index. The mean dose of oral methadone ranged from 14 mg at day 7 to 23.65 mg at day 90. There was an overall worsening of the other symptoms, but a high percentage of the patients reported an amelioration of insomnia with respect to baseline. There was a statistically significant association (P < .0001) between the Palliation Index and the analgesic therapy administered at baseline. Only 11.2% of the patients withdrew from the study due to analgesic inefficacy and 6.6% due to methadone-related side effects (10 patients with drowsiness and three with severe constipation. Oral methadone administered every 8 hours was shown to be an appropriate analgesic therapy in the treatment of advanced cancer-related pain. The worsening of the other symptoms under study can be considered linked to the progression of the disease, and in fact, only a small percentage of the patients reported methadone-related side effects that warranted suspension of treatment. We consider oral methadone to be a useful analgesic therapy, and it should be considered in clinical practice for the treatment of cancer pain.",1996.0,0,0
1351,8874561,Myoelectric activity in the stomach and duodenum after epidural administration of morphine or bupivacaine.,S E Thörn; G Wickbom; L Philipson; P Leissner; M Wattwil,"Gastric emptying is delayed in patients receiving postoperative pain relief with epidural morphine compared to patients receiving epidural bupivacaine. The electrophysiological basis for this effect is unknown. The aim of this study was to compare the effects of epidural morphine with epidural bupivacaine on gastroduodenal myoelectric activity (EMG) in patients after surgery. Fourteen patients with epidural analgesia who underwent open cholecystectomy were randomly assigned to receive either epidural morphine (EM) or epidural bupivacaine (EB) for postoperative pain relief. During surgery EMG electrodes were placed in the subserosa in the antrum and duodenum and the EMG registration started 3.5 hours after the end of surgery. Gastric emptying measured with the acetaminophen test was studied in the morning the day after surgery. The spike activity in the antrum was significantly lower 160-340 minutes after the administration of morphine in the EM-group compared to the activity in the EB-group (P < 0.04). The incidence of regular slow wave rhythm in the antrum was significantly lower 160-520 minutes after the administration of morphine in the EM-group compared to the EB-group (P < 0.03). Duodenal Phase III activity measured with EMG was significantly more frequent during 160-520 minutes after the morphine administration in the EM-group compared to the EB-group (P < 0.02). The acetaminophen absorption was significantly delayed in the epidural morphine group compared to the epidural bupivacaine group. Gastroduodenal electromyographic activity was significantly changed during epidural morphine compared to epidural bupivacaine. The delayed gastric emptying during epidural morphine may be explained by decreased and uncoordinated contractile activity in the antrum, shown by decreased spike activity and irregular slow wave rhythm. The increased pressure activity in the duodenum, shown by increased Phase III activity, may also impair gastric emptying.",1996.0,0,0
1352,8874573,"Analgesic effect of intraarticular morphine. A controlled, randomised and double-blind study.",O Christensen; P Christensen; C Sonnenschein; P R Nielsen; S Jacobsen,"Opioids produce antinociceptive effect by acting on receptors on peripheral nerves. The clinical relevance of this effect is still debated. The aim of the study was to compare the analgesic effect of morphine intraarticularly with the intramuscular route of administration after knee surgery. Sixty-one patients, ASA 1-2, having elective arthroscopic surgery of the knee were randomised to either an intraarticular or intramuscular dose of morphine 5 mg. The pain sensation was estimated by visual analogue scale and a verbal rating score 0, 1, 2 and 4 hours postoperatively and verbal rating score on the third day. The use of acetaminophen and supplementary opioids were recorded for the first 4 hours postoperatively, from 4 hours until the third day, and from day 3 to day 7 postoperatively. The groups were comparable. Three patients were excluded. There were no statistically significant differences in painscore and consumption of analgesics. Fifty-nine per cent in each group had macroscopic synovitis. In the intraarticular group, there was no increased effect of morphine in the patients with synovitis compared to patients without synovitis. The clinical analgesic effect of 5 mg morphine given intraarticularly is equal to 5 mg morphine given intramuscularly. The occurrence of villous synovitis seems to be of no clinical importance concerning the local effect of morphine.",1996.0,0,0
1353,8874574,Pre-emptive effect of pre-incisional versus post-incisional infiltration of local anaesthesia on children undergoing hernioplasty.,V Dahl; J C Raeder; P E Ernø; A Kovdal,"Although promising in experimental studies of post-traumatic pain, the concept of pre-emptive analgesia is still controversial in a clinical setting. Thus, we wanted to compare the clinical efficacy of wound infiltration with local anaesthesia before surgery with wound infiltration after hernioplasty in children. Fifty children aged 2-10 years scheduled for hernioplasty were randomly assigned into two groups. Group 1 (n = 28) was infiltrated before surgery with bupivacaine 2.5mg/ml, 1mg/kg after induction of general anaesthesia. After surgery they were infiltrated with the same volume of 0.9% saline. Group 2 (n = 22) was infiltrated with 0.9% saline before surgery and bupivacaine 2.5 mg/ml, 1mg/kg after surgery. The study was performed double-blindly. In both groups anaesthesia was induced with thiopenthone and maintained with nitrous oxide and halothane, adjusted to keep haemodynamic measurements stable. All children were given paracetamol 15-20 mg/kg rectally when admitted to the recovery ward. Painscore (OPS) and analgesic requirements were registered postoperatively. After 48 h the parents completed a standardised questionnaire and they were interviewed by telephone after one week. The pre-incisional group needed significantly less halothane during the procedure compared with the post-incisional group (P < 0.05). The pre-incisional group also had a tendency towards faster awakening after the end of anaesthesia and a significantly lower OPS-pain score 30 min after the operation (P < 0.03). There were no differences between the two groups regarding need for additional analgesia: meperidine i.v. during the first 5 h postoperatively, and paracetamol thereafter. There were no differences between the groups regarding activity level, appetite and quality of sleep in the first week. In both groups the need for opioid analgesics was low: 54% in the pre-incisional group and 45% in the post-incisional group did not receive any opioid analgesic treatment. The children were virtually fully recovered after the first 24 h. Perioperative infiltration with a local anaesthetic in children undergoing hernioplasty results in a smooth recovery with little need for opioids postoperatively. Apart from a lower anaesthetic requirement and a reduced postoperative pain level after 30 min in the pre-incisional bupivacaine group, there was no difference between infiltration before (pre-emptive) or after surgery.",1996.0,0,0
1354,8874907,Epidural administered buprenorphine in the perioperative period.,Y Miwa; E Yonemura; K Fukushima,"To study the effect of epidural buprenorphine on minimum alveolar concentration (MAC) of volatile anaesthetics, duration of analgesia and respiratory function in the perioperative period. One hundred and twenty patients, ASA I-II undergoing gynaecological surgery were randomly divided into three studies. The forty patients in each study were randomly divided into four groups depending on the dosage; Group I (control), Group II (80 micrograms. kg-1 morphine), Group III (4 micrograms. kg-1 buprenorphine), Group IV (8 micrograms. kg-1 buprenorphine). The MAC of halothane was measured following epidural administration of the agents in each group. The duration of analgesia was assessed by the first request for pentazocine. Postoperative analgesic effects were assessed by the total dosage of pentazocine required for the 48 hr after surgery. Respiratory rate (RR), minute volume (MV), and PaCO2 were measured during surgery and the postoperative period. The MAC of halothane was reduced in Group IV (P < 0.01). The duration of analgesia was 10.0 +/- 5.1 hr (Mean +/- SE) in Group I, 37.7 +/- 4.7 hr in Group II, 27.1 +/- 7.1 hr in Group III, and 44.4 +/- 4.1 hr in Group IV. Total dosage of pentazocine was lower in Group IV (P < 0.05) than in the other groups. The decrease of RR, MV and the increase of PaCO2 were observed within 60 min in Group III and IV dose dependently. Epidural buprenorphine administered in a dose of 4 or 8 micrograms. kg-1 provides postoperative analgesia that is no less effective than that of morphine.",1996.0,0,0
1355,8880048,Assessment of analgesia in man: tramadol controlled release formula vs. tramadol standard formulation.,T Hummel; S Roscher; E Pauli; M Frank; J Liefhold; W Fleischer; G Kobal,"The present study tested analgesia produced by a new controlled release formulation of tramadol. The investigation employed an experimental pain model based on chemo-somatosensory event-related potentials (CSSERP) in response to painful chemical stimuli applied to the nasal mucosa. Twenty healthy volunteers participated in the experiments, which followed a controlled, randomised, double-blind, 3-way cross-over design. Each of the three medications (tramadol 100 mg [T100], tramadol controlled release 100 mg [TCR100] and tramadol controlled release 150 mg [TCR150]) was administered orally to fasting subjects. There was at least a 6 day washout period between tests. Each experiment was divided into five sessions, which took place before and 2, 4, 6, and 12 h after drug administration. In addition to the assessment of CSSERP, subjects rated the intensity of both the tonic and phasic painful stimuli. Nonspecific drug effects were also monitored by means of frequency analysis of the spontaneous EEG, ratings of adverse effects, and the subjects' performance in a tracking task. The significant reduction of amplitude N1 at central recording positions indicated that TCR 150 was the most effective analgesic 12 h after administration. Both 6 and 12 h after administration TCR 100 was more effective in terms of analgesia compared to T100. In addition, TCR100 appeared to produce fewer adverse effects than the standard formulation of tramadol. The controlled release formulation can be expected to become a valuable tool in peroral therapeutic regimens for chronic pain.",1996.0,0,0
1356,8881618,Alfentanil-mediated analgesia during propofol injection: no evidence for a peripheral action.,I J Wrench; K J Girling; G J Hobbs,"We have investigated if alfentanil acts via peripheral opioid receptors to relieve the pain which occurs on injection of propofol. Thirty seconds before induction of anaesthesia and immediately after a tourniquet at 50 mm Hg greater than systolic pressure was inflated on the upper arm, patients were given either placebo (n = 22), alfentanil 1 mg (n = 22) or lignocaine 40 mg (n = 22) via an i.v. cannula in the dorsum of the hand. Pain during injection of propofol was assessed using a three-point verbal rating scale, recorded at 8-s intervals. We found a significant reduction in pain after lignocaine compared with the two other groups (P < 0.001), but there was no difference between the placebo and alfentanil groups. We conclude that alfentanil does not relieve pain on injection with propofol via an action on peripheral opioid receptors when alfentanil is limited to the forearm for 30 s before induction of anaesthesia.",1996.0,0,0
1357,8882125,Management strategies for chronic pain.,D M Justins,,1996.0,0,0
1358,8882238,An investigation of the potential morphine sparing effect of midazolam.,H E Gilliland; B K Prasad; R K Mirakhur; J P Fee,"The effect of a bolus and continuous infusion of midazolam on postoperative morphine consumption was assessed in a placebo-controlled, double-blind, randomly allocated trial of 50 patients undergoing elective abdominal hysterectomy. Patients in the trial group received a bolus dose of midazolam 5 mg.70 kg-1 at induction followed by an infusion at a rate of 1 mg.70 kg-1.h-1 over the next 48 h. Morphine consumption in the midazolam group was significantly lower in the first 12 h postoperatively (p < 0.02) but there was no significant difference between the two groups thereafter. Patients in the midazolam treated group had lower pain scores over the first 24 h. Also, a significantly greater number of patients in the midazolam group required no antiemetic medication over the 48 h study period (p < 0.05). Assessment of sedation revealed no significant difference between groups. We conclude that low dose midazolam has a significant, but short-lived, morphine sparing effect.",1996.0,0,0
1359,8882255,Intrathecal administration of morphine for elective Caesarean section. A comparison between 0.1 mg and 0.2 mg.,A R Milner; D G Bogod; R J Harwood,"This study compared the quality of analgesia and incidence of adverse effects with two doses of intrathecal morphine in patients undergoing elective Caesarean section. Fifty patients were randomly allocated to receive either morphine 0.1 mg or 0.2 mg in addition to a standard intrathecal dose of 2.5 ml bupivacaine 0.5% in 8% dextrose. The quality of analgesia was assessed using visual analogue scores and the incidence of nausea, vomiting and itching were recorded during the first 24 h postoperatively. There was no statistically significant difference in the quality of analgesia nor in the incidence and severity of itching between the two groups. Fewer patients in the 0.1 mg morphine group experienced postoperative nausea and vomiting (7 versus 14, p < 0.05). We conclude that the use of 0.1 mg morphine intrathecally produces comparable analgesia to 0.2 mg after Caesarean section with significantly less nausea and vomiting.",1996.0,0,0
1360,8882377,Causes and treatment of bone pain of malignant origin.,B Thürlimann; N D de Stoutz,"Pain relief has been one of the oldest and most important duties of the physician. There has been little change with regard to this obligation of all caregivers. One-third of patients with advanced cancer will develop clinically relevant skeletal metastases and chronic pain during the course of their disease. All physicians involved in the treatment of cancer patients should know the basic principles of pain treatment. These are described in the following article with special regard to bone pain of malignant origin. Correct assessment of pain intensity and frequency, as well as of the probable causes of pain, and the administration of adequate analgesic treatment should achieve satisfactory results in the vast majority of patients. Every physician should obtain detailed knowledge of the indications and adequate administration of pain-killing therapy as well as possible adverse effects and their successful treatment. It is important in particular to concentrate on a few nonsteroidal anti-inflammatory drugs (NSAIDs) as well as opiates. Knowledge of adequate doses, maximal recommended daily doses, pharmacological properties, important adverse effects and interactions is essential for success in the daily routine. Only by selecting 2 or 3 drugs from each step in the analgesic ladder (WHO) will the nonspecialised physician obtain sufficient experience for optimal analgesia. Physicians should also not hesitate to contact other specialists (medical oncologists, radiotherapists, neurosurgeons, anaesthesiologists and others) in order to maximise benefit for an individual patient.",1996.0,0,0
1361,8885568,Intractable pain in children with terminal cancer.,J J Collins,,1996.0,0,0
1362,8885955,Chronic pain in cystic fibrosis.,S Ravilly; W Robinson; S Suresh; M E Wohl; C B Berde,"The objective of this study was to examine the incidence and therapy of chronic pain in a group of older patients with cystic fibrosis (CF). We identified two groups of patients followed at the CF Center at Children's Hospital (Boston); the first group consisted of all patients above the age of 5 years who died between 1984 and 1993, and the second was a cohort of 23 additional CF patients who had been referred to the Pain Treatment Service. Medical charts were reviewed for the etiology and therapy of all pain episodes requiring medical intervention. The incidence of chronic pain in this population increased sharply in the last 6 months of life. Headaches (55% of patients) and chest pain (65%) were frequently reported, although back pain (19%), abdominal pain (19%), and limb pain (16%) were also reported. In patients with headache, the main etiologies were hypercarbia or hypoxia, migraine, and sinusitis. The majority of chest pain was musculoskeletal, with pleuritis, pneumothorax, and rib fracture also reported as the cause of chest pain. A variety of nonpharmacological and pharmacological therapies were reported. Forty-one patients (53%) had pain severe enough to require opioid treatment, and 10 patients (13%) received opioids for more than 3 months. In eight patients with more severe pain, regional analgesia was found to be particularly effective. Chronic pain is a common problem in CF, particularly as the patient population ages. When administered with caution, opioids have proven to be effective and safe in this population; regional anesthesia can be used to preserve pulmonary toilet while adequately treating severe pain.",1996.0,0,1
1363,8886735,Can a pharmacological pain analysis be used in the assessment of chronic low back pain?,J Sörensen; S Kalman; H Tropp; M Bengtsson,"A battery of pharmacological tests was used to differentiate the pain in patients with chronic low back pain (CLBP) referred for pain diagnosis and assessment of whether surgery was indicated or not. Forty patients (mean age 39 years, range 22-51 years) suffering from CLBP (mean pain duration 5.9 years, range 1-12 years) participated. Three pharmacological approaches were used: (1) intravenous infusion of morphine, (2) intravenous infusion of lidocaine and (3) a diagnostic epidural opioid blockade. The patients were tested in a single-blind, placebo-controlled fashion. The pain was considered nociceptive if it decreased by 50% or more in response to both intravenous morphine and epidural fentanyl, but increased in response to intravenous naloxone. The pain was considered neuropathic if it decreased by 50% or more in response to both intravenous lidocaine and the epidural local anaesthetic. Patients who registered a pain decrease of 50% or more in response to saline were classified as placebo responders. Those who registered less than 50% pain decrease in all the tests were considered nonresponders. According to the results of the tests, 16 of the patients were classified as having nociceptive pain, 8 neuropathic pain, 2 were placebo responders, 10 non-responders and 4 were unclassified. The results support the idea that this battery of pharmacological tests can be used in the classification of CLBP patients into different pain categories. This approach may prove useful as a guide for further patient evaluation and as a basis for choice of a suitable treatment strategy.",1996.0,0,0
1364,8888306,System theory of pain and of opiate analgesia: no tolerance to opiates.,F C Colpaert,,1996.0,0,0
1365,8888307,The effects of pain on opioid tolerance: how do we resolve the controversy?,H B Gutstein,,1996.0,0,0
1366,8889289,Analgesic efficacy of enadoline versus placebo or morphine in postsurgical pain.,A C Pande; R E Pyke; M Greiner; G L Wideman; R Benjamin; M W Pierce,"Enadoline, a selective agonist of the kappa-opioid receptor, was studied for its analgesic efficacy in patients with pain after obstetric or gynecologic surgery. An initial study involving a comparison of enadoline (2, 5, 15 micrograms), an acetaminophen-codeine (ACET/COD) combination, and placebo showed all treatments to be ineffective analgesics. Therefore, a second study with the same design but using higher doses of enadoline (15 and 25 micrograms) and replacing ACET/COD with morphine 10 mg i.m. was conducted. Enadoline 25 micrograms produced similar pain relief to that of morphine, although of shorter duration, and better than enadoline 15 micrograms or placebo. However, enadoline was associated with dose-limiting neuropsychiatric adverse events, which led to early termination of the study.",1996.0,0,0
1367,8889424,Comparison of ondansetron and metoclopramide for the prevention of post-operative nausea and vomiting after major gynaecological surgery.,P P Chen; P T Chui; T Gin,"The efficacy of ondansetron 4 mg was compared with metoclopramide 10 mg for the prevention of post-operative nausea and vomiting in patients after major gynaecological abdominal surgery. Anaesthesia was standardized using thiopentone, atracurium and methadone for induction followed by isoflurane in nitrous oxide-oxygen mixture. Fifty patients were randomized in a double-blind fashion to either receive intravenous (i.v.) ondansetron 4 mg or metoclopramide 10 mg during closure of the pelvic peritoneum. The incidence and frequency of vomiting, and the incidence of severe nausea was recorded for 24 h after surgery. One patient was excluded because of respiratory depression. In the first 4 h after surgery, five patients (20%) in the ondansetron group (n = 25) and eight patients (33%) in the metoclopramide group (n = 24) vomited, whereas at 4-12 h, this increased to 11 patients (44%) and nine patients (37.5%) respectively. The incidence was 52 and 37.5% respectively in the subsequent 12-24 h. The highest incidence of nausea was in the first 4 h after surgery, being 56 and 37.5% in the ondansetron and the metoclopramide groups respectively. This decreased to less than 25% in both groups in the 12-24 h period. Ondansetron 4 mg and metoclopramide 10 mg had similar but short lasting efficacy for the prevention of vomiting in patients who received continued opioid analgesia after major gynaecological surgery.",1996.0,0,0
1368,8889425,,,,,0,0
1369,8889672,"Human pharmacokinetics of intravenous, sublingual, and buccal buprenorphine.",J J Kuhlman; S Lalani; J Magluilo; B Levine; W D Darwin,"Buprenorphine is a potent opioid analgesic used in the treatment of moderate to severe pain. At higher doses, it has demonstrated potential for treating heroin dependence. This study was undertaken to investigate buprenorphine pharmacokinetics by different routes of administration at dosages approximating those used in opioid-dependence studies. Six healthy men who were nondependent but who had a history of heroin use were administered buprenorphine in a crossover design study by intravenous (1.2 mg), sublingual (4.0 mg), and buccal (4.0 mg) routes of administration. Plasma samples were collected up to 96 h and assayed for buprenorphine and norbuprenorphine by negative chemical ionization tandem mass spectrometry. Plasma concentrations of buprenorphine and norbuprenorphine were analyzed by nonlinear regression analysis with standard noncompartmental methods. Buprenorphine biovailability by the sublingual and buccal routes was estimated as 51.4% and 27.8%, respectively, although there was considerable interindividual variability by both routes of administration. The terminal elimination half-lives were longer for the sublingual and buccal routes than for the intravenous route. The extended elimination half-lives may be due to a shallow depot effect involving sequestration of buprenorphine in the oral mucosa. Norbuprenorphine mean peak plasma concentrations were less than 1 ng/mL and were highly variable among different routes of administration and individuals. The terminal elimination half-life of norbuprenorphine was longer than buprenorphine.",2001.0,0,0
1370,8895711,Effect of intramuscular intraoperative pain medication on narcotic usage after laparoscopic cholecystectomy.,G E Lane; J C Lathrop; D A Boysen; R C Lane,"The purpose of this randomized, double-blind, clinical trial was to determine whether intraoperative, intramuscular (IM) injections of meperidine or ketorolac would improve postoperative pain relief in patients undergoing elective laparoscopic cholecystectomy. A total of 125 patients were entered into five study groups: 1) (N = 23) control placebo; 2) (N = 31) meperidine 100 mg IM intraoperative preprocedure; 3) (N = 20) meperidine 100 mg IM intraoperative postprocedure; 4) (N = 25) ketorolac tromethamine 60 mg IM intraoperative preprocedure; 5) (N = 26) ketorolac tromethamine 60 mg IM postprocedure. All groups were analyzed by comparing the amount of pain medication received in the recovery room, the time until first oral pain medication was requested, the overall amount of pain medication used in the first 24 hours, the percent requiring IM medication, and the pain score ratings from each group. There was decreased pain medication usage in the recovery room in all groups compared to control (P < 0.05). Group 4 had a longer painfree interval than meperidine groups or control. Both Groups 4 and 5 had decreased postoperative narcotic usage. Finally, the analogue pain scores showed that both ketorolac groups had significantly less postoperative pain compared to control, whereas the meperidine groups showed no improvement in postoperative pain relief. Intraoperative ketorolac given preprocedure or postprocedure significantly improved postoperative pain management and facilitated the transition to oral pain medication.",1996.0,0,0
1371,8895942,Pain perception of intravenous heroin users on maintenance therapy with levomethadone.,U Schall; T Katta; E Pries; A Klöppel; M Gastpar,"Methadone is a very potent analgesic drug. Accordingly, maintenance therapy of heroin addicts with methadone may conceal pain producing processes. Here we report on the pain perception of 42 patients on a levomethadone maintenance treatment for intravenous heroin users. Pain perception was measured by single-blind, non-invasive pressure stimulation of the nociceptors located in the dorsal extension aponeurosis and the underlying periosteum of the middle phalanx of a digit before and respectively 1,2, and 4 hours after oral routine drug administration. Measures were related to the individual levomethadone plasma levels. Under steady-state conditions, the pain perception of the patients did not differ from a drug-free placebo control group and was not related to individual levomethadone plasma levels, although an analgesic effect in the reabsorption phase was observed. It is concluded that the individual pain perception of maintained patients is adapted to a normal response range and that even prolonged opioid consumption does not diminish dynamic analgesic responsiveness to levomethadone.",1996.0,0,1
1372,8896015,Peripheral nerve catheterization in the management of terminal cancer pain.,H B Fischer; T M Peters; I M Fleming; T A Else,"Peripheral nerve catheterization techniques were used in two patients with severe pain associated with the terminal stages of metastatic cancer. The first patient had severe upper limb pain and lymphedema secondary to breast carcinoma, and the second patient had an acutely ischemic leg secondary to pelvic obstruction from an ovarian tumor. The goal of treatment was to relieve the pain, which was resistant to opioid drugs, and to optimize the quality of life that remained, estimated to be only a few weeks. The first patient received a continuous brachial plexus block via an epidural catheter, introduced by means of a Tuohy needle and a peripheral nerve stimulator to locate the plexus accurately. The second patient required catheterization of both the sciatic and femoral nerves, again with a peripheral nerve stimulator used to locate the nerves prior to inserting the catheters. Analgesia was established with a bolus of local anesthetic and maintained with a continuous infusion of local anesthetic in the first patient. For the second patient, fentanyl was added to the local anesthetic, as it had been shown to improve analgesia in the lower limb in previous work. In the first patient, the analgesia allowed active treatment of the lymphedema and mobilization of the limb, and she remained pain free until her death 2 weeks later. In the second patient, the infusions controlled the pain both before and after surgical amputation of the limb, until the stump was well healed. Peripheral nerve catheterization proved beneficial in two patients who presented with difficult pain management problems and should be more widely considered for the relief of severe cancer-related pain in both the upper and lower limbs.",1996.0,0,0
1373,8901078,Differential effects of food on the bioavailability of controlled-release oxycodone tablets and immediate-release oxycodone solution.,D P Benziger; R F Kaiko; J B Miotto; R D Fitzmartin; R F Reder; M Chasin,"The effects of a high-fat meal on the bioavailability of oxycodone hydrochloride, administered as a recently developed 40 mg controlled-release (CR) tablet or a 20 mg immediate-release (IR) solution, were evaluated in a randomized crossover study in 22 normal male and female subjects. Serial blood samples were collected for 36 h after dosing and analyzed for oxycodone by a validated method using gas chromatography/mass spectrometry. There was no significant food effect with CR oxycodone as judged by 90% confidence interval (CI) analysis of AUC0-infinity and Cmax values under fed and fasted conditions. For the IR solution, both oxycodone bioavailability and peak plasma oxycodone concentration were significantly altered by consumption of the high-fat meal, with the mean value for AUC0-infinity increasing to 120% (CI = 109-132%) and the mean value for Cmax decreasing to 82% (CI = 47-91%) of values observed in the fasted condition. Adverse events reported for both formulations were mostly mild to moderate in severity and typical of those observed with opioids.",2000.0,0,0
1374,8904255,Does epidural sufentanil provide effective analgesia per- and postoperatively for abdominal aortic surgery?,A A Broekema; K Kuizenga; P J Hennis,"To assess the efficacy of epidural sufentanil in providing per- and postoperative analgesia, 40 patients undergoing elective abdominal aortic surgery received either 50 mu g sufentanil in 10 ml normal saline solution (n = 20, ES group) or 10 ml normal saline (n = 20, control group) via a thoracic epidural catheter. The study solution was given (double-blind and at random) after the patients had been anaesthetized with i.v. midazolam, sufentanil and vecuronium. Anaesthesia was maintained with 60% nitrous oxide in oxygen and halothane at a 1% inspiratory concentration. When patients showed signs of inadequate analgesia, supplementary doses of 25 mu g sufentanil were given i.v. The number of patients requiring additional i.v. sufentanil differed significantly between the two groups: 5 out of 20 patients in the ES group vs 13 out of 20 patients in the control group required additional sufentanil (P<0.05). The mean dose administered i.v. did not differ significantly between the two groups: 105 +/- 109.5 mu g vs 138.5 +/- 126.9 mu g (mean +/- SD) in 5 and 13 patients, respectively. No cardiovascular changes were observed after the epidural bolus dose. Postoperative analgesia, consisting of a continuous epidural infusion of 50 mu g sufentanil in 50 ml bupivacaine 0.125% at a rate of 6-10 ml/h after a bolus dose of 10 ml of this solution, was adequate in the majority of patients, as determined by VAS-scores assessed during the epidural treatment (4.3 +/- 1.5 days).",1996.0,0,0
1375,8904263,Does morphine premedication influence the pain and consumption of postoperative analgesics after total knee arthroplasty?,H Hendolin; L Nuutinen; H Kokki; L Tuomisto,"Evidence of pre-emptive analgetic effect of opioid would offer great potential benefit to patients with postoperative pain, a better pain relief with less opioid. The aim of this double blind randomised trial was to study the effect of intramuscular morphine premedication on postoperative pain. Forty-one patients undergoing total knee arthroplasty were randomly allocated to four groups. Two groups received epidural morphine, 4 mg immediately after operation and 3 mg ten hours later, and two groups the same volume of saline. All patients had access to intravenous PCA-fentanyl. One epidural morphine and one epidural saline group (PreEpiMo and PreMo, respectively) received morphine, 0.14 mg/kg i.m. as premedication. Pain was measured with a visual analogue scale (VAS). Respiration was monitored by means of pulseoximetry, arterial blood gas analysis and rate of breathing. Morphine premedication reduced postoperative pain in the immediate postoperative period in patients with epidural placebo (PreMo), but the effect was absent in patients with PreEpiMo. Epidural morphine (EpiMo) provided stable analgesia with reduced need of PCA-fentanyl. Two patients (10%) (one in EpiMo and one in PreEpiMo) developed respiratory depression requiring naloxone treatment. The dosage of epidural morphine used in this study was a likely explanation of this depression. Nausea, vomiting, itching and urinary retention were the most frequent side effects without significant differences between the groups. In conclusion, morphine premedication had a temporary rest effect on the postoperative pain. Epidural morphine provides a better analgesia than intravenous PCA-fentanyl.",1996.0,0,0
1376,8908224,The combination of morphine with local anaesthetic in rhinoplasty--no evidence of a peripheral morphine effect.,B Ben-David; R A Moscona; S Stahl,"The recognition of a peripheral opioid action has prompted a number of clinical reports demonstrating a prolonged analgesic effect of peripheral opiate. As most studies have used a model of intraarticular instillation of narcotic we examined direct morphine infiltration of the surgical site in a unique clinical model. Sixty patients undergoing primary rhinoplasty were entered into this prospective, randomized, double-blind study. Patients received a standard protocol of premedication, intravenous sedation, and nasal block. Two 2 ml syringes containing saline or morphine 3 mg in saline were provided for IM injection and for addition to the local anesthetic (IW, intrawound): Group I (control)-saline IW, saline IM; Group II morphine IW, saline IM; Group III-saline IW, morphine IM. Intraoperative assessments included need for further sedation, need for further local anesthetic, and degree of bleeding. Recovery room analgesic requirements, pain scores, and recall of intraoperative pain were recorded prior to discharge. Followup phone calls at 24 hours recorded home pain scores and analgesic use during the first postoperative day. Significantly more patients in Group II (9/20) required supplemental local anesthetic intraoperatively compared to Group I (2/20) and Group III (0/20). Significantly more patients in Group II (6/20) recalled their surgical experience as painful compared to Group I (1/20) and Group III (1/20). Group II patients also evidenced significantly more operative bleeding. There were no differences in postoperative pain scores, but Group I patients required analgesic in the recovery room significantly more than in Groups II and III (85% vs 45% and 50%, respectively). There were no differences between groups in analgesic consumption at home. The results of this study indicate that the preoperative injection of intrawound morphine in combination with the local anesthetic both promotes bleeding and has an early pain-enhancing effect while providing no late analgesic benefit beyond that of IM morphine.",1996.0,0,0
1377,8908233,Preoperative ketorolac administration has no preemptive analgesic effect for minor orthopaedic surgery.,C Vanlersberghe; M H Lauwers; F Camu,The utility of preoperative ketorolac administration to reduce the intensity and duration of postoperative pain was compared with placebo in a randomized double-blind design of 60 ASA 1-2 patients scheduled for minor orthopaedic surgery. No opioids nor local anaesthetic blocks were used during surgery. The patients received either 30 mg ketorolac IV before surgery followed by a placebo injection after surgery or the reverse. Postoperative pain intensity was assessed repeatedly for 6 h using a visual analogue scale. No differences in pain intensity were observed between the two groups except for the initial 15-min postoperative assessments in the ketorolac group. The time to first rescue morphine administration and the total morphine consumption during the 6-h observation period were similar. It is concluded that the preoperative administration of ketorolac did not provide a significant preemptive analgesic benefit with regard to postoperative pain relief and opioid dose-sparing effect.,1996.0,0,0
1378,8911798,Pharmacology and clinical experience with tramadol in osteoarthritis.,W A Katz,"Tramadol is a centrally acting analgesic that has been shown to be effective in a variety of acute and chronic pain states. Unlike other centrally acting analgesics, it exerts a dual action by binding to the opioid receptor site in the central nervous system and by weakly inhibiting the reuptake of biogenic amines. Tramadol is rapidly and almost completely absorbed, with an onset of action occurring within 1 hour of oral administration. The recommended dosage is 50 to 100 mg every 4 to 6 hours; however, regular administration is an alternative, particularly for chronic pain states such as osteoarthritis, where the use of the recently developed sustained release formulation may represent an important advantage. Published studies specifically evaluating the use of tramadol in this disease support its effectiveness. Nausea, drowsiness, constipation, dizziness, and sweating have been reported in association with tramadol use. Nausea occurs early in the course of administration, and may be reduced by slowly titrating the dose of tramadol against response. Tramadol would appear to be particularly useful in the elderly population affected by osteoarthritis because, unlike nonsteroidal anti-inflammatory drugs, it does not aggravate hypertension or congestive heart failure, nor does it have the potential to cause peptic ulcer disease. Compared with narcotics, tramadol does not induce significant respiratory depression, constipation, or have significant abuse potential.",1996.0,0,0
1379,8914905,Bupivacaine for postoperative analgesia following endoscopic sinus surgery.,M Friedman; T K Venkatesan; D Lang; D D Caldarelli,"This prospective study was conducted to examine pain after endoscopic sinus surgery (ESS). The hypothesis was that a long-acting anesthetic agent would result in patients experiencing less pain in the 24-hour postoperative period and therefore needing fewer oral analgesics. We randomized 100 patients undergoing ESS to receive either lidocaine (1% or 2%) with epinephrine or bupivacaine (0.25% or 0.5%) with epinephrine as an anesthetic and for a sphenopalatine block. Postoperative pain was assessed with a standard numeric pain assessment scale at baseline and at 2, 6, and 24 hours after surgery. The use of analgesics during this period was also documented. We compared the results between patients receiving bupivacaine and those receiving lidocaine, as well as between patients who required nasal packing and those who did not. We discovered that in general, pain after ESS was less severe than expected. We further found that the type of anesthetic used did not significantly affect postoperative pain; pain score changes and use of analgesics were similar between the two anesthesia groups. Postoperative pain was also similar between the ""packing"" and ""no packing"" groups. Although patients receiving packing had consistently lower increases in pain (and in fact many patients in this group had decreases in pain from baseline), none of the differences between group means was statistically significant.",1996.0,0,0
1380,8916058,Intravenous morphine attenuates pain induced changes in skin blood flow in newborn infants.,A N Moustogiannis; T N Raju; T Roohey; K M McCulloch,"In a previous study we found that pain and discomfort caused a marked increase in skin blood flow in newborn infants, and that skin blood flow decreased after morphine. In this study we tested morphine effect on the skin blood flow response to pain more systematically. Skin blood flow was measured using a laser Doppler technique during 19 percutaneous central venous catheter placements in 18 infants, 10 of whom received intravenous morphine premedication. The mean +/- SD baseline skin blood flow was similar between the two groups: 22.5 +/- 9.5 ml 100 g-1 min-1 in the morphine group, and 23.7 +/- 8.0 ml 100 g-1 min-1 in the no-morphine group, respectively (p = n.s.). During PCVC placement in the morphine treated group, skin blood flow remained low with minimal variability. The mean value was 22.6 +/- 7.7 ml 100 g-1 min-1 (p = n.s. compared to baseline). In 7/9 infants not treated with morphine skin blood flow increased dramatically during PCVC placement, while in two it did not. But the mean skin blood flow in this group of 9 infants during PCVC placement was 45.3 +/- 34 ml 100 g-1 min-1, an overall change of 97% increase from the baseline. This was statistically significant compared with the baseline and the morphine group value during PCVC insertion (p < 0.04). During the 45 min time period after PCVC placement, skin blood flow values between groups again were similar. We conclude that morphine pretreatment for PCVC placement minimizes pain-associated increases in skin blood flow. The issue of whether skin blood flow changes could serve as measures of adequate analgesia needs to be evaluated with further studies.",1996.0,0,0
1381,8917139,Pain relief for renal colic.,G R Bergus,,1996.0,0,0
1382,8917240,Patient-controlled analgesia for mucositis pain in children: a three-period crossover study comparing morphine and hydromorphone.,J J Collins; J Geake; H E Grier; C S Houck; H T Thaler; H J Weinstein; N Y Twum-Danso; C B Berde,"(1) To test the safety and efficacy of a clinical protocol for administering opioid by using patient-controlled analgesia (PCA) for the management of mucositis pain in children after bone marrow transplantation, (2) to compare the efficacy, side-effect profile, and potency ratio of morphine with those of hydromorphone by using PCA as the method of opioid administration, and (3) to obtain pharmacokinetic data on hydromorphone and morphine in this population of children. In this double-blind, three-period crossover study, patients were randomly assigned to receive either morphine (group 1) or hydromorphone (group 2) initially by means of PCA on days 1, 2, and 3 (period 1), to be followed on days 4, 5, and 6 (period 2) with the alternative opioid, followed by the opioid used at the commencement of the study on days 7, 8, and 9 (period 3). A clinical protocol for calculating the PCA commencement opioid dose and subsequent opioid-dose escalation was tested by measures of safety and efficacy. Measures of pain intensity and opioid side effects were made during the three periods. On the last study day (day 10), patients received a continuous infusion of opioid derived from the previous 24-hour PCA opioid requirement, and blood specimens were collected and stored for subsequent opioid analysis. Ten patients were enrolled in this study. Rapid escalation in opioid requirement commonly occurred at the commencement of PCA, followed by a variable plateau phase and then deescalation of opioid requirement after mucositis resolution. The measures demonstrated the safety and efficacy of the clinical protocol. In the concentrations used, there was no statistical difference between the mean daily pain, sedation, nausea and vomiting, and pruritus scores for both opioids (Friedman test). The analysis of variance of the log-total opioid doses per patient during periods 1, 2, and 3 indicated that patients used 27% more hydromorphone than expected from its presumed 7:1 ratio relative to morphine potency used in the PCA infusions. The mean plasma hydromorphone concentration was 4.7 ng/ml (range, 1.9 to 8.9 ng/ml), and the mean clearance was 51.7 ml/min per kilogram of body weight (range, 28.6 to 98.2 ml/min per kilogram). The mean plasma morphine, morphine-6-glucuronide, and morphine-3-glucuronide concentrations were 40.0 ng/ml (range, 15 to 62.5), 168.2 ng/ml (range, 54.4 to 231.9), and 391.0 ng/ml (range, 149.4 to 921.7), respectively. The mean morphine clearance was 34.3 ml/min per kilogram of body weight (range, 19.3 to 58.3). The mean molar ratios of morphine-6-glucuronide/morphine, morphine-3-glucoronide/morphine, and morphine-3-glucuronide/morphine-6-glucuronide were 2.48 (range, 1.4 to 3.3), 5.82 (range, 3.4 to 9.1), and 2.46 (range, 1.1 to 3.3), respectively. The safety and efficacy of a clinical protocol for the administration of opioids by means of PCA for mucositis pain after bone marrow transplantation was demonstrated. In this small study, hydromorphone was not superior to morphine in terms of analgesia or the side-effect profile: a larger study would be needed to show a difference. The clearances of hydromorphone and morphine in the children studied were generally greater than those previously recorded, but this finding may be related to disease or treatment variables. Apart from clearance, the morphine pharmacokinetics in the study population were similar to those previously recorded. Hydromorphone may be less potent in this population of children than indicated by adult equipotency tables.",1996.0,0,0
1383,8919895,[Patient acceptance of patient-controlled intranasal analgesia (PCINA)].,R Schwagmeier; T Oelmann; T Dannappel; H W Striebel,"Patient-controlled intravenous analgesia (i.v.-PCA) represents the gold standard in the management of acute postoperative pain. However, in many countries i.v.-PCA is rarely used. Recent clinical studies demonstrated that intranasal fentanyl titration provides a rapid and safe form and pain management. In the present study we investigated patients' acceptance and assessment of patient-controlled intranasal analgesia (PCINA) and compared it to intravenous PCA and the customarily prescribed pain therapy. After approval by the local ethics committee and written informed consent, 79 ASA physical status I or II patients were investigated on the first postoperative day following orthopaedic surgery. The patients were allocated either to the PCINA group (a maximum of 0.025 mg fentanyl over 6 min), to the i.v.-PCA group (0.025 mg fentanyl bolus, lockout interval 6 min) or to a group of patients who received the customarily prescribed pain management. Following the 8-h investigation period, the patients were questioned regarding their satisfaction with the pain therapy using a 6-point rating scale (ranging from 1 = very good to 6 = not acceptable). The patients were furthermore asked to name the advantages and disadvantages of their pain management. Three patients in the i.v.-PCA group had to be excluded due to pain at the injection site and one patient in the PCINA group because of a surgical complication. Seventy-five patients were finally included, 25 patients per group. No statistically significant intergroup differences regarding age, weight, height and initial pain intensity (evaluated by a 101-point numeric rating scale) were demonstrated. The patients' satisfaction with the mode of pain management was significantly higher in the PCINA (median ""good"") and in the i.v.-PCA group (median ""good"") than in the group who received the customarily prescribed pain management (median ""satisfactory""). This difference was statistically significant (P = 0.0001). No statistically significant difference was demonstrated between the PCINA and i.v.-PCA groups. The patients in the PCINA and in the i.v.-PCA group stated as main advantages the rapid onset of action and good pain relief (n = 25 and n = 25, respectively), as well as their independence from the doctor or nurse (n = 12 and n = 13). The main disadvantages were pain on injection in the i.v.-PCA group and too frequent fentanyl administrations in the PCINA group (n = 6). The results demonstrate that the patients' satisfaction with PCINA is comparable to that with i.v.-PCA. Both PCINA and i.v.-PCA were assessed as superior to the customarily prescribed pain management (P = 0.0001). Patients' acceptance of a given form of pain management is mainly related to its efficiency. However, side effects such as pain on injection with i.v.-PCA, or frequent opioid administration with PCINA, must be considered when assessing a method of pain control. Patients' global assessment includes both efficiency and side effects. PCINA represents an interesting alternative non-invasive method for postoperative pain management.",1996.0,0,0
1384,8919987,[Evaluation of the synergism between ketorolac and morphine in the treatment of postoperative pain].,R Casali; G Girardi; R D Mediati; P Livi; G P Novelli,"The aim of the study is to determine what concentration of ketorolac and morphine administered together i.v. achieve best synergic effect between NSAID antiinflammatory and opioids analgesic properties. Randomized comparative study was carried out on 180 patients, ASA II-IV, undergoing major general surgery, in an University Clinic. Postoperative pain therapy by i.v. PCA: group 1 morphine 0.75 mg.ml + ketorolac 0.75 mg.ml; group 2 morphine 0.50 mg.ml + ketorolac 1.50 mg.ml; group 3 morphine 0.25 mg.ml + ketorolac 1.50 mg.ml; in saline solution. Initial bolus: 2 ml. Continuous infusion 1.5 ml.h. Demand bolus: 0.2 ml. Lockout time: 30 minutes. Evaluations included: pain intensity (T0, T3, T18); total amount of infused drugs (T18); number of valid demands and attempts (T18); amount of autoadministered analgesic drugs in percent of highest available amount (T18); side effects (T18); patient's judgment. ANOVA and Student's ""t""-test. A statistically significant reduction of pain intensity was found after 3 and 18 hours in the three groups, no differences were found among the groups. Group 2 required an amount of autoadministered drugs significantly lower than other groups. Rare side effects. Patient's judgment was generally positive. Results suggest a greater synergetic effect between morphine and ketorolac in concentrations used in group 2.",1995.0,0,0
1385,8923067,The opiate-sparing effect of dipyrone in post-operative pain therapy with morphine using a patient-controlled analgesic system.,G Tempel; B von Hundelshausen; W Reeker,"To determine whether dipyrone has an opiate-sparing effect in post-operative pain therapy compared with placebo during patient-controlled morphine therapy (PCA) and to compare the effects on analgesia and respiratory and coagulation parameters. Randomized, observer-blind, parallel-group, placebo-controlled study. Surgical intensive care unit of a university hospital. 106 adult patients who were to undergo abdominal or urological surgery under 90-min standardized inhalational anaesthesia were entered and 103 were included in the efficacy analysis (53 on dipyrone, 50 on placebo). Preprogrammed PCA (0.03 mg morphine/kg per bolus) with either dipyrone (initially 2.0 g i.v. and 1.0 g/2 ml i.v. at 4, 8 and 16 h) or placebo (saline). Cumulative morphine consumption was calculated automatically during PCA. Pain intensity and pain relief and the investigator's global assessments of efficacy and tolerability were recorded on five-point verbal rating scales. Vital signs, standard laboratory parameters, respiratory rate, partial pressure of carbon dioxide (PCO2) and of oxygen, partial thromboplastin time (PTT) and Quick values were recorded. Total consumption of opiates in the dipyrone group (median 31.6 mg) was significantly less (p = 0.00015) than in the placebo group (median 50.3 mg), while pain relief (area under the curve) AUC was the same for both PCA+dipyrone (median 4.1) and PCA+placebo (median 3.9). Global assessment of efficacy was good to excellent in more than 90% of cases in both groups. Vital signs, respiratory rate, PCO2, PTT and Quick did not differ between groups. Adverse events were mainly nausea and/or vomiting (dipyrone, n = 4; placebo, n = 1); 1 patient in the placebo group had bradycardia. Three serious adverse events were unrelated to study medication. In 1 patient, the PCA programme malfunctioned and had to be changed. Concomitant administration of dipyrone with on-demand morphine (PCA) reduces opiate consumption while maintaining post-operative pain relief with a low incidence of side-effects.",1996.0,0,0
1386,8923168,Cancer pain management: pilot implementation of the AHCPR guideline in Utah.,J B Rischer; S B Childress,"Using the Agency for Health Care Policy and Research's (AHCPR's) 1994 Clinical Practice Guideline for Management of Cancer Pain, HealthInsight, the peer review organization for Utah and Nevada, organized a cooperative project with physicians and nurses from seven acute care hospitals in Utah. The project's purpose was to adapt the guideline into action plans for participating hospitals and provide the tools necessary to address six ""core"" guidelines-to assess and relieve pain, educate the patient/family and health care workers, measure patient satisfaction, and provide a continuum of care postdischarge. GUIDELINE DEVELOPMENT: The guidelines were further adapted to meet the needs of the individual hospitals and were implemented in January 1995. Baseline data was collected on 10 patient records per hospital. Survey results confirmed that although attitudes about cancer pain management were changing, more needed to be done to prevent patient suffering. Follow-up data after one year showed significantly more compliance on all six core guidelines. The oncology nurse manager and the hematology/oncology physician chief at one hospital joined the project team to support their own ongoing efforts to implement the guidelines. At that hospital, patient satisfaction with pain management has since increased from the 60%-80% level to at least 90%. STATEWIDE PROJECT EXPANSION: Statewide expansion was planned in fall 1995 to extend implementation to the remaining acute care hospitals and to other health care settings in Utah and to ease a patient's transition from one setting to another. The project team continues to monitor progress in guideline implementation. Surveys demonstrate that, at the time of diagnosis, up to 45% of cancer patients experience moderate to severe pain; 65%-90% experience severe pain when cancer reaches the advanced stages. Unrelieved cancer pain can cause intense suffering, diminished activity, loss of appetite, and loss of sleep.",1996.0,0,0
1387,8931402,Chronic functional abdominal pain.,D A Drossman,,1996.0,0,0
1388,8931970,Intramuscular diclofenac versus intravenous indomethacin in the treatment of acute renal colic.,E Laerum; O E Ommundsen; J E Grønseth; A Christiansen; H E Fagertun,"We have conducted a clinical trial to compare the pain-relieving effect and safety of diclofenac administered intramuscularly to indomethacin given intravenously. The study was designed as a randomized single-blind trial. It was carried out at Oslo Emergency Hospital (outpatient setting or stay < 24 h). 41 patients with a mean age of 41.6 years received 75 mg diclofenac and 42 patients with a mean age of 45.2 years were given 50 mg indomethacin. The two groups were similar in regard to baseline characteristics except gender distribution. Statistically significant reduction in pain intensity was achieved after 5 min in the diclofenac group (p < 0.01), and after 10 min in the indomethacin group (p < 0.01). The probability of having pain after 1 h was 52% in the indomethacin group and 37% in the diclofenac group (p = 0.11). Rescue medication with pethidine after 2 h was given in 9 and 5 patients, respectively. Four patients in the diclofenac group reported one occurrence of adverse effect each, while 9 patients on indomethacin experienced 14 occurrences, mainly dizziness and nausea. These findings together with a simpler mode of administration indicate that diclofenac may be preferred in the analgesic treatment of renal colic.",1996.0,0,0
1389,8933852,Epidural vs. intravenous infusion of alfentanil in the management of postoperative pain following laparotomies.,M C van den Nieuwenhuyzen; A G Burm; A A Vletter; R Stienstra; J W van Kleef,"This study was designed to compare the efficacy of epidural vs. intravenous administration of alfentanil for treatment of postoperative pain. Twenty patients were randomly allocated to one of the two study groups to receive either an epidural bolus dose (0.75 mg) followed by an epidural infusion (0.36 mg/h) (EPI group) or an intravenous infusion (0.36 mg/h) of alfentanil (IV group) for 24 h. These dose regimens were chosen such that equivalent and subanalgesic plasma concentrations of alfentanil were obtained. PCA-morphine was available to both groups. Morphine consumption, pain scores measured on a Visual Analogue Scale (VAS) and the number of demands were used as variables to evaluate the efficacy of the postoperative analgesic therapy. In addition, plasma concentrations of alfentanil were measured. The mean plasma concentrations of alfentanil were similar and < 20 ng/ml in both groups. Total morphine consumption (EPI: 40 mg, i.v.: 43 mg), pain scores (time when the VAS-score > 3.0: EPI: median 215 min; i.v.: median 215 min) and number of valid demands (EPI: median 25; i.v.: median 34) did not differ between the groups. Compared to intravenous infusion of alfentanil epidural infusion resulting in the same plasma concentrations is not more effective in relieving postoperative pain. In view of this observation we were not able to demonstrate a spinal mechanism of alfentanil.",1996.0,0,0
1390,8936545,Comparison of diclofenac and tenoxicam for postoperative analgesia with and without fentanyl in children undergoing adenotonsillectomy or tonsillectomy.,J E Mendham; S J Mather,"127 children scheduled for elective tonsillectomy or adenotonsillectomy were studied. Anaesthesia was induced with propofol and maintained with a volatile agent. At induction the child received either rectal diclofenac 1 mg.kg-1 with or without fentanyl 0.75 microgram.kg-1 i.v., or intravenous tenoxicam 0.4 mg.kg-1 with or without fentanyl 0.75 microgram.kg-1 i.v. Blood loss was measured peroperatively. Nausea and vomiting scores, sedation scores and pain scores were recorded in the recovery room, at one, two, four and eight h postoperatively and at discharge. There were no significant differences in blood loss between the groups or between nausea and vomiting scores. Pain scores in the tenoxicam without fentanyl group were significantly higher in recovery (P < 0.05) than the diclofenac group without fentanyl and both fentanyl groups. This group required supplemental analgesia earlier although this was not significant. The pain scores in the diclofenac with fentanyl group were significantly lower at one h and four h than the group receiving diclofenac alone (P = 0.008 and 0.02 respectively).",1996.0,0,0
1391,8942328,Extradural clonidine combined with sufentanil and 0.0625% bupivacaine for analgesia in labour.,D Chassard; L Mathon; F Dailler; F Golfier; J P Tournadre; P Boulétreau,"We have studied the use of clonidine combined with low doses of sufentanil and bupivacaine in 45 parturients requiring extradural analgesia for the first stage of labour, in a double-blind, randomized study. We gave 0.0625% bupivacaine 10 ml containing 1:200,000 adrenaline and sufentanil 10 micrograms (1 ml) to which was added 0.9% saline, or clonidine 100 or 150 micrograms (1 ml). We compared the quality (VAS scores) and duration of analgesia, motor block, maternal haemodynamic state (mean arterial pressure and heart rate) and fetal and maternal side effects. Mean duration of anaesthesia was prolonged slightly: 105 (SD 21) min without clonidine, 130 (26) min with clonidine 100 micrograms (P < 0.05 vs control) and 144 (40) min with clonidine 150 micrograms (P < 0.01 vs control, ns vs 100 micrograms). There were no differences in VAS scores, onset times, heart rate, ventilatory frequency, motor block, sedation, pruritus or bradycardia between the groups. Analgesia was associated with a reduction in mean arterial pressure with clonidine. However, these adverse side effects were of minor clinical importance regardless of the extradural clonidine dose, except for a high incidence of fetal heart tracing abnormalities when clonidine 150 micrograms was used. These effects associated with a limited effect on analgesia may curtail the widespread use of clonidine as an adjunct to extradural 0.0625% bupivacaine with sufentanil 10 micrograms during labour.",1996.0,0,0
1392,8943590,A comparison of opioid solutions for patient-controlled epidural analgesia.,A J Smith; T K Haynes; D E Roberts; M Harmer,"Sixty patients took part in a randomised, double-blind study to compare the analgesic and side effects of three opioid-containing solutions for patient-controlled epidural analgesia following abdominal surgery. Patients in group 1 received a solution containing bupivacaine 0.125% with fentanyl 10 micrograms.ml-1, group 2 bupivacaine 0.125% with diamorphine 125 micrograms.ml-1, group 3 pethidine 2.5 mg.ml-1. All groups received 4 ml.h-1 background infusion and 3 ml boluses every 20 min if necessary. There were no significant differences between the groups in visual analogue scale pain scores (p = 0.537) or volumes of solution used at 24 h (p = 0.351) or 48 h (p = 0.105). Motor block was significantly higher in group 2 (p < 0.004) and pruritus occurred significantly less in group 3 (p < 0.05). We conclude that these three solutions produce equivalent analgesia but that pethidine 2.5 mg.ml-1 may be associated with fewer side effects.",1996.0,0,0
1393,8943591,Evaluation of the contribution to postoperative analgesia by local cooling of the wound.,B Brandner; B Munro; L M Bromby; M Hetreed,"Thirty healthy patients undergoing lumbar spine surgery were randomly assigned to one of two groups for postoperative pain relief. Group 1 received morphine via patient controlled analgesia and local cooling of the wound by an externally applied cooling pad while group 2 received patient controlled analgesia alone. There was a significant reduction in morphine consumption when local cooling was applied (18.6 mg versus 30.2 mg at 12 h, 29.0 mg versus 49.6 mg at 24 h, p < 0.05). Patients were also significantly more satisfied with their overall postoperative pain management when cooling therapy was used.",1996.0,0,0
1394,8943593,A double-blind comparison of codeine and morphine for postoperative analgesia following intracranial surgery.,C Goldsack; S M Scuplak; M Smith,"Codeine and morphine were compared in a double-blind study of postoperative analgesia in 40 patients after intracranial neurosurgery. Eighteen patients received codeine phosphate 60 mg and 18 morphine sulphate 10 mg, both by intramuscular injection; 4 patients (10%) required no analgesia. Both drugs provided analgesia within 20 min of injection but morphine was more effective than codeine beyond 60 min (p = 0.01). Fewer doses of morphine than codeine were required (p = 0.003). Nine patients requested one dose of morphine and 9 two doses. Seven patients required three doses of codeine and 1 patient required four doses. Neither drug caused respiratory depression, sedation, pupillary constriction or unwanted cardiovascular effects. We conclude that, in the doses used, morphine is a safe alternative to codeine for analgesia after neurosurgery and has a more persistent action.",1996.0,0,0
1395,8951927,"Pain control after dental surgery: a double-blind, randomised trial of lornoxicam versus morphine.",S E Nørholt; S Sindet-Pedersen; U Larsen; U Bang; J Ingerslev; O Nielsen; H J Hansen; A K Ersbøll,"Lornoxicam is a new non-steroidal anti-inflammatory drug of the oxicam class. This randomised, double-blind, placebo controlled trial compared the analgesic efficacy and tolerability of intramuscular (IM) injections of lornoxicam (4, 8, 16 and 20 mg) with morphine (10 and 20 mg) and placebo in 252 patients with mainly moderate to severe pain following surgical removal of an impacted mandibular third molar. Patients treated with lornoxicam or morphine experienced a significantly greater cumulative pain relief over the 4-h post-injection period (TOTPAR0-4) than placebo recipients. This effect appeared to be dose-dependent, with patients in the lornoxicam 4 mg or morphine 10 mg groups recording significantly lower TOTPAR0-4 scores than patients in the higher dosage groups of these drugs. No significant difference was detected between the morphine 20 mg group and the lornoxicam 8, 16 and 20 mg groups. Lornoxicam was well tolerated at all doses and was associated with a significantly lower incidence of adverse events than morphine 10 or 20 mg. Thus, the analgesic efficacy of IM lornoxicam at doses > or = 4 mg is superior to placebo, and doses > or = 8 mg are at least as effective as IM morphine 20 mg. Furthermore, lornoxicam possesses a more favourable tolerability profile than morphine and thus represents an attractive alternative for the treatment of moderate to severe acute pain.",1996.0,0,0
1396,8951940,Epidural and subcutaneous morphine in the management of cancer pain: a double-blind cross-over study.,E Kalso; T Heiskanen; M Rantio; P H Rosenberg; A Vainio,"Ten patients who suffered from severe cancer-related pain participated in a randomised, double-blind and cross-over study to compare the effectiveness and acceptability of epidural and subcutaneous administration of morphine. The patients titrated themselves pain-free in 48 h using a patient controlled analgesia system. The median daily doses calculated from the consumption of the last 4-h study period were 372 mg for subcutaneous and 106 mg for epidural administration. The two modes of morphine administration turned out to be comparable in terms of both effectiveness and acceptability. Both treatments provided better pain relief with less adverse effects compared with the prestudy oral morphine treatment.",1996.0,0,0
1397,8951944,Cancer pain assessment and management by housestaff.,P A Sloan; M B Donnelly; R W Schwartz; D A Sloan,"Pain control for cancer patients is a significant problem in health care, and lack of expertise by clinicians in assessing and managing cancer pain is an important cause of inadequate pain management. This study was designed to use performance-based testing to evaluate the skills of resident physicians in assessing and managing the severe chronic pain of a cancer patient. Thirty-three resident physicians (PGY 1-6) were presented with the same standardized severe cancer pain patient and asked to complete a detailed pain assessment. The residents then completed questions related to management of the cancer pain patient. In the cancer pain assessment, residents did well in assessing pain onset (70%), temporal pattern of pain (64%), and pain location (73%). However, only 33% and 45% physicians adequately assessed the pain description and pain intensity, respectively, and assessment of pain-relieving factors, previous pain history, and psychosocial history was done poorly or not at all by 70%, 88%, and 94% of residents. Only 58% of the residents were judged to be competent in this clinical cancer pain assessment. In the cancer pain management section, opioid analgesic therapy was prescribed by 98% of residents, and 91% used the oral route. However, only 18% of prescriptions were for regular use and 88% of residents did not provide analgesics for breakthrough pain. A significant number of graduated physicians were judged to be not competent in the assessment and management of the severe pain of a standardized cancer patient. Opioids and NSAIDs were the analgesics of choice; however, most were prescribed on a PRN basis only. Co-analgesics were rarely prescribed. Few physicians managed persistent, severe cancer pain according to the WHO guideline of increasing the opioid dose. The lack of significant difference in scores between junior and senior residents suggest that adequate cancer pain management is not being effectively taught in postgraduate training programs.",1996.0,0,0
1398,8952801,[Analgesia controlled by the patient in pediatrics].,O Colcanap; A Chaumont; A Joly; E Wodey,"The development of patient controlled analgesia (PCA) in children is the result of a search for an analgesia being both maximally efficient and secure, in the management of severe pain. The technique is based on self infusions of an analgesic, mainly morphine, by the child, through a special pump. The quality of the pump is essential in order to exclude any risk of overdosage. In order to prevent potential secondary effects and complications, a careful supervision is mandatory (clinical, by pulse oximetry, regular checking of pump parameters). PCA is applicable to children older than 5 years. The main indications are post-operative and oncological pains.",2000.0,0,0
1399,8955967,Epidural and intravenous bolus morphine for postoperative analgesia in infants.,C M Haberkern; A M Lynn; J M Geiduschek; M K Nespeca; L E Jacobson; S L Bratton; M Pomietto,"To compare two doses of bolus epidural morphine with bolus iv morphine for postoperative pain after abdominal or genitourinary surgery in infants. Eighteen infants were randomly assigned to bolus epidural morphine (0.025 mg.kg-1 or 0.050 mg.kg-1) or bolus iv morphine (0.050-0.150 mg.kg-1). Postoperative pain was assessed and analgesia provided, using a modified infant pain scale. Monitoring included continuous ECG, pulse oximetry, impedance and nasal thermistor pneumography. The CO2 response curves and serum morphine concentrations were measured postoperatively. Postoperative analgesia was provided within five minutes by all treatment methods. Epidural groups required fewer morphine doses (3.8 +/- 0.8 for low dose [LE], 3.5 +/- 0.8 for high dose epidural [HE] vs. 6.7 +/- 1.6 for iv, P < 0.05) and less total morphine (0.11 +/- 0.04 mg.kg-1 for LE, 0.16 +/- 0.04 for HE vs 0.67 +/- 0.34 for iv, P < 0.05) on POD1. Dose changes were necessary in all groups for satisfactory pain scores. Pruritus, apnoea, and haemoglobin desaturation occurred in all groups. CO2 response curve slopes, similar preoperatively (range 36-41 ml.min-1.mmHg ETCO2-1.kg-1) were generally depressed (range, 16-27 ml.min-1.mmHg ETCO2-1.kg-1) on POD1. Serum morphine concentrations, negligible in LE (< 2 ng.ml-1), were similar in the HE and iv groups (peak 8.5 +/- 12.5 and 8.6 +/- 2.4 ng.ml-1, respectively). Epidural and iv morphine provide infants effective postoperative analgesia, although side effects are common. Epidural morphine gives satisfactory analgesia with fewer doses (less total morphine); epidural morphine 0.025 mg.kg-1 is appropriate initially. Infants receiving epidural or iv morphine analgesia postoperatively need close observation in hospital with continuous pulse oximetry.",1996.0,0,0
1400,8955968,Epidural fentanyl improves the onset and spread of epidural mepivacaine analgesia.,T Kasaba; G Yoshikawa; T Seguchi; M Takasaki,"To determine the extent of enhanced blockade by the combined use of epidural fentanyl and mepivacaine. We compared the onset of hypoalgesia, analgesia and the threshold of pressure pain. Thirty patients were randomly divided into three groups. The fentanyl group received 10 ml saline containing 0.1 mg fentanyl, mepivacaine group received 10 ml mepivacaine 1% and a mixed group received 10 ml mepivacaine 1% with 0.1 mg fentanyl. All solutions, without epinephrine, were injected through an epidural catheter at T5-6 to T6-7. The change in sensation, loss of pin-prick and pain threshold sensation, measured by pressure algometer, were assessed at 2.5-min intervals for 15 min at the T4 dermatome. Spread of analgesia was determined at 15 min. Loss of pinprick was more rapid in the mixed, 11.0 +/- 2.7 (SD) min, than in the mepivacaine group, 15.0 +/- 2.9 min, (P < 0.05), although there was no difference in change of sensation. Pressure pain threshold increased with time in the mepivacaine (P < 0.05) and mixed (P < 0.05) groups. It was higher in the mixed than in the fentanyl and mepivacaine groups at 5, 7.5 and 10 min (P < 0.05). The lower level of analgesia was lower in the mixed than in the mepivacaine groups (P < 0.05). Blood pressure was unchanged in the three groups, but heart rate decreased at 7.5, 10, 12.5, and 15 min in the mepivacaine and mixed groups (P < 0.05). The addition of fentanyl to mepivacaine accelerates the onset of analgesia and enhances the analgesic effect of epidural block.",1996.0,0,0
1401,8956390,Ketamine potentiates analgesic effect of morphine in postoperative epidural pain control.,C S Wong; W J Liaw; C S Tung; Y F Su; S T Ho,"Ketamine is currently the only N-methyl-D-aspartate receptor channel blocker in clinical use. This study evaluated the analgesic efficacy of epidurally coadministered ketamine and morphine in postoperative pain control. The patient population consisted of ASA class I and II patients undergoing major joint replacement. Epidural lidocaine was used as the primary anesthesia for the surgery. In phase I of the study, either ketamine (10-30 mg) or morphine (0.5-2 mg) was administered via epidural catheter immediately after surgery. This was done to evaluate the dose-response effect of these drugs when used for postoperative pain relief, and the results were applied to phase II of the study, in which all patients received ketamine pretreatment (total 30 mg) with each dose of lidocaine administered before and during surgery. Forty patients were randomly divided into four groups, each of which received one of three different pain control regimens mixed with 10 ml of saline: group B received 10 mg ketamine, group C 2 mg morphine, and group D 10 mg ketamine plus 0.5 mg morphine while the control group A received 10 mL of saline with no additive. The intensity of pain expressed by patients, as well as the number of intramuscular meperidine (1 mg/kg) injections administered and any side effects that may have occurred, were recorded. Ketamine produced no significant pain relief. A 2-mg morphine dose did produce significant analgesia but was accompanied by a high incidence of side effects. Co-administration of subanalgesic doses of ketamine, 10 mg and morphine, 0.5 mg, however, also produced a strong analgesic effect. Ketamine, although not itself an epidural analgesic agent, potentiates the analgesic effect of morphine, especially when administered as a pretreatment. The resulting lowered dosage of epidural morphine needed for postoperative pain relief reduces, in turn, the incidence of side effects. Pretreatment of patients with ketamine epidurally, followed by injections of combined morphine and ketamine could be a promising new analgesic regimen.",1996.0,0,0
1402,8956391,"Comparative efficacy of epidural, subarachnoid, and intracerebroventricular opioids in patients with pain due to cancer.",J C Ballantyne; D B Carr; C S Berkey; T C Chalmers; F Mosteller,"Although rarely used, intracerebroventricular opioid therapy (ICV) is an option for the control of intractable pain due to cancer when systemic treatments have failed. The aim of the present study is to use available data from published trials to compare ICV with the more common epidural (EP) and subarachnoid (SA) opioid treatments in an attempt to establish the utility and safety of ICV. Because there are no published controlled trials comparing these routes of administration, the combined data from multiple uncontrolled trials were used, with differences between the treatments analyzed statistically. Trials assessing ICV (13 trials, 268 patients). EPI (29 trials, 909 patients) and SA (21 trials, 410 patients) in cancer patients were identified; data on analgesic efficacy, common pharmacologic side effects, and complications were then extracted and the accumulated incidence data analyzed. The findings (weighted means) indicated ICV to be at least as effective against pain as other neuraxial treatments, with 75% of ICV-treated patients obtaining excellent pain relief as compared with 72% of EPI- and 58% of SA-treated patients (not significant). The failure rate of both spinal treatments tended to be greater than that of ICV and was significantly higher in the case of EPI (P = .045). In general, persistent side effects appeared to be more of a problem with the spinal treatments, while transient symptoms occur more often with ICV. Persistent nausea, urinary retention, and pruritus all were more frequent with the two spinal treatments than with ICV, but transient nausea and respiratory depression occurred more often with ICV. Sedation and confusion appeared to occur more often with ICV than with spinal therapy, while constipation and headache were rarely encountered with ICV. There were no real differences in infectious complication rates among the three treatments (except for a lower rate of infection when an implanted pump was used), but technical problems such as catheter blockage, misplacement, or leakage tended to occur less often with ICV. Intracerebroventricular therapy appears to be at least as effective against pain as other neuraxial treatments. The ICV technique is the only fixed system that is associated with fewer technical problems than the use of simple percutaneous epidural catheters (difference 9%, standard error of the difference 3.4). The present state of evidence indicates that ICV is a successful treatment for patients with intractable cancer pain and compares well with spinal opioid treatments in terms of efficacy, side effects, and complications.",1996.0,0,0
1403,8956394,Comparison of wound infiltration with ketorolac versus intravenous regional anesthesia with ketorolac for postoperative analgesia following ambulatory hand surgery.,S S Reuben; K M Duprat,"The purpose of this study was to assess the analgesic effectiveness of ketorolac administered with lidocaine via intravenous regional asesthesia (IVRA) or via wound infiltration following ambulatory hand surgery. The patient population in this double-blind study consisted of 60 patients scheduled for elective ambulatory hand surgery, who were divided into three groups of 20 each. All patients received IVRA with 40 mL 0.5% lidocaine and 5 mL 1% lidocaine infiltrated into the surgical site. Group 1, the control group, received no additional medications; group 2 had 60 mg ketorolac added to the lidocaine used for IVRA; and group 3 had 60 mg ketorolac added to the lidocaine used for wound infiltration. Postoperative pain was assessed by a 10-cm visual analog scale. VAS) 1 hour and 2 hours after tourniquet deflation. In the postanesthesia care unit analgesia was provided with fentanyl until the VAS score reached 3 or lower. Patients were instructed to take one Tylenol No. 3 (acetaminophen with codeine) tablet every 4 hours as needed at home. They were contacted the next day, and the time to first additional narcotics and the total number of tablets taken were recoded. No differences in demographic variables or in operative, tourniquet, or discharge times were noted among the groups. The VAS scores were significantly lower in the two groups who received ketorolac than in the control group (P < .05); the mean time from tourniquet release to first medication was 109 +/- 73 minutes for group 1, 467 +/- 431 for group 2, and 393 +/- 312 for group 3 (P < .05); and the number of tablets taken was 4.1 +/- 1.3 for group 1, 1.8 +/- 1.2 for group 2, and 2.0 +/- 1.3 for group 3 (P < .05). Ketorolac provides similar postoperative analgesia after ambulatory hand surgery when administered with lidocaine either by IVRA or by wound infiltration.",1996.0,0,0
1404,8957972,Comparison of caudal bupivacaine and diamorphine with caudal bupivacaine alone for repair of hypospadias.,A A Kelleher; A Black; S Penman; R Howard,"Forty-five boys undergoing repair of hypospadias were allocated randomly to one of two groups. After induction of anaesthesia, 22 patients received 0.25% caudal bupivacaine 0.5 ml kg-1 and diamorphine 30 micrograms kg-1 and the remaining 23 patients received 0.25% caudal bupivacaine 0.5 ml kg-1 alone. Pain scores (Children's Hospital of Eastern Ontario Pain Scale), sedation scores, ventilatory frequency, analgesic requirements and associated side effects were recorded for the first 24 h after operation. The two groups were indistinguishable in age, weight and duration of surgery. There was a statistically significant reduction in early pain scores. There was also a statistically significant increase in the time to first passage of urine in those boys in the diamorphine group who were not catheterized during operation.",1996.0,0,0
1405,8958487,Potentiation of sufentanil by clonidine in PCEA with or without basal infusion.,M P Vercauteren; V Saldien; P Bosschaerts; H A Adriaensen,"Sufentanil or a sufentanil-clonidine combination was evaluated to determine whether the basal rate in patient-controlled epidural analgesia (PCEA) might affect the daily consumption, quality of analgesia or incidence of side effects. Following Caesarean section delivery, 60 patients were randomly assigned to receive one of the four following PCA regimens (15 patients per group) for the relief of post-operative pain by the epidural route: sufentanil 2 micrograms mL-1 in 0.9% NaCl, demand dose 5 micrograms i.e. 2.5 mL, (group S+ with, group S without an infusion at 2.5 mL hr-1) or sufentanil 2 micrograms mL-1 + clonidine 3 micrograms mL-1, demand dose 5 micrograms sufentanil + 7.5 micrograms clonidine i.e. 2.5 mL (group SC+ with and SC without an infusion of 2.5 ml hr-1). The other PCA settings (Bard I PCA pump) were a lock out of interval of 10 min and a 1 h limit of 20 micrograms sufentanil and 30 micrograms clonidine i.e. 10 mL. The parameters measured were the analgesic drug consumption and number of dose demands during the first 24 h, pain scores at 6 h intervals, side effects and quality of sleep. The concurrent infusion increased the dose requirements regardless of the content of the syringe. Consumption of sufentanil was the highest in those patients receiving the plain solution with a basal infusion. Clonidine addition reduced the dose requirements but only significantly in those receiving the background infusion. Patients treated with the mixture tended to reach lower pain scores than those receiving sufentanil only without basal rate. Patients receiving the mixture with basal rate requested significantly fewer additional demands compared with the three other groups, but this did not influence the quality of sleep. Since side effects were more frequently registered in the patients in this group, it was concluded that the optimum regimen was the sufentanil-clonidine combination but with deletion of the basal rate.",1996.0,0,0
1406,8959160,Intravenous morphine for early pain relief in patients with acute abdominal pain.,S Pace; T F Burke,"To determine whether morphine affects evaluation or outcome for patients with acute abdominal pain. Prospective, double-blind, placebo-controlled administration of morphine sulfate (MS) or normal saline (NS) in the setting of acute abdominal pain. The study was performed at a military ED with an annual census of 60,000 visits. Patients > or = 18 years old who had abdominal pain for < or = 48 hours were included. Patients who were allergic to MS or who had systolic blood pressures < 90 mm Hg were excluded. The physicians indicated a provisional diagnosis, a differential diagnosis, and a provisional disposition. Study solution was titrated to the patient's assessment of adequate analgesia (up to a volume equivalent of 20 mg of MS); pain response was monitored using a visual analog scale (VAS). The patients were followed until diagnosis occurred or symptoms resolved. Of 75 patients enrolled, 71 completed the study; 35 patients received MS and 36 received NS. More than half (44; 62%) of the patients were admitted from the ED; 28 patients underwent surgery. The VAS pain level improved more for the MS group, 3.9 +/- 2.8 cm, than it did for the NS group, 0.8 +/- 1.5 cm (p < 0.01). Study solution dose was less in the MS group than it was in the NS group, 1.5 +/- 0.5 mL vs 1.8 +/- 0.4 mL (p < 0.01). There was no difference between the groups when comparing accuracy of provisional or differential diagnosis with that of final diagnosis. Differences between provisional and actual dispositions were the same in all groups. There were 3 diagnostic or management errors in each group. When compared with saline placebo, the administration of MS to patients with acute abdominal pain effectively relieved pain and did not alter the ability of physicians to accurately evaluate and treat patients.",1996.0,0,0
1407,8959199,Analgesic efficacy of ketorolac.,R G Wheatley,"Ketorolac is an efficient drug for the treatment of moderate to severe pain following minor or intermediate types of surgery. Its use is associated with improved quality of recovery, reduced incidence of side effects and earlier discharge from the recovery unit and the hospital in patients treated on an ambulatory basis. With regard to major surgery ketorolac provides insufficient analgesia when administered as the sole agent during the immediate postoperative period. However, it is an effective adjunct to all forms of opioid analgesia being associated with a significant opioid sparing effect. Large scale studies have demonstrated that this combination of improved analgesia and opioid sparing is of clinical benefit.",1996.0,0,0
1408,8961492,,,,,0,0
1409,8965885,Treatment of postherpetic neuralgia.,T Zenz; M Zenz; M Tryba,,1996.0,0,0
1410,8968175,Interactions between midazolam and remifentanil during monitored anesthesia care.,M N Avramov; I Smith; P F White,"Remifentanil, an ultra-short-acting opioid analgesic, may be useful as an intravenous adjuvant to local anesthesia for treating patient discomfort and pain during monitored anesthesia care (MAC). However, the remifentanil dose requirements, interactions with other commonly used sedative drugs (such as midazolam), and recovery characteristics after ambulatory procedures have not been determined. Therefore, this study was designed to evaluate the safety and efficacy of remifentanil alone and in combination with different doses of midazolam during MAC. Eighty-one healthy consenting women scheduled for elective breast biopsy procedures were randomly assigned to one of four treatment groups according to an institutional review board-approved, double-blind, placebo-controlled protocol. The study medication (containing either saline or 2 mg, 4 mg, or 8 mg of midazolam) was administered intravenously 5 min before starting an infusion of remifentanil at 0.1 microgram.kg-1.min-1. The remifentanil infusion was subsequently adjusted in 0.025- and 0.05-microgram.kg-1.min-1 increments to maintain patient comfort and adequate ventilation during the operation. The level of sedation was assessed at 1- to 10-min intervals during the procedure using the inverted observer's assessment of alertness/sedation (OAA/S) scale, with a score of 1 = awake, alert to 5 = asleep, unarousable. Discomfort and pain were assessed using numerical rating scales. Hemoglobin oxygen saturation, respiratory rate, blood pressure (systolic, diastolic, mean), and heart rate were monitored at 1- to 5-min intervals. Intraoperative amnesia was assessed by asking patients to recall a picture shown 5 min after the study medication was administered. Recovery was evaluated using the Aldrete score and the times to ""home readiness"" and actual discharge. Side effects and patient satisfaction were assessed in a follow-up telephone interview on the first postoperative day. Midazolam produced dose-dependent increases in the median level of sedation. Remifentanil produced a greater reduction in respiratory rate in the 4-mg and 8-mg midazolam groups. However, there were no significant differences in the hemodynamic variables or discharge times. Patients with OAA/S scores of 1 to 3 (""light"" sedation) 5 min after the study medication experienced a greater incidence of intraoperative pruritus and postoperative nausea and vomiting (PONV) compared with those with OAA/S scores of 4 to 5 (""deep"" sedation). Discharge times were prolonged for patients in the light sedation group in whom PONV developed. Use of remifentanil alone for MAC did not provide optimal sedation during local anesthesia. However, 0.05 to 0.1 microgram.kg-1.min-1 remifentanil in combination with 2 mg midazolam given intravenously, provided effective sedation and analgesia during MAC in healthy patients classified as American Society of Anesthesiologists status 1 to 2. Midazolam also produced dose-dependent potentiation of remifentanil's depressant effect on respiratory rate. In outpatients receiving a combination of midazolam and remifentanil during local anesthesia, the level of sedation appears to influence the incidence of both intraoperative pruritus and PONV.",1996.0,0,0
1411,8968197,Intravascular absorption of glycine irrigating solution during shoulder arthroscopy: a case report and follow-up study.,C Ichai; J F Ciais; L J Roussel; J Levraut; M Candito; P Boileau; D Grimaud,,1996.0,0,0
1412,8969879,Outcome measures of a chronic pain program: a prospective statistical study.,J E Hubbard; J Tracy; S F Morgan; R E McKinney,"To provide outcome data measuring objective and subjective variables of an individualized, multidisciplinary, comprehensive pain management program. The study is a prospective evaluation of 50 consecutive patients who completed the pain management program. Objective measures were medication use and return to work. Subjective measures included self-reports of pain levels and completion of a Personal Concerns and Goals Assessment (PCGA) examining issues of lifestyle and emotional well-being. These measures were compared at program onset and completion by using appropriate statistical analyses. Objective measures: Medication use by the study subjects decreased overall by 72% within all drug categories. Opioid use was eliminated. Regarding return to work, the study subjects increased their work hours by twofold overall. Of patients working fewer than 30 h per week at program onset, representing 62% of the study population, a fivefold return to work was observed. Subjective measures: Overall pain levels improved by 33%, with an 18 to 47% improvement in all descriptors (average pain levels on good or bad days, average number of good or bad days). Of the PCGA factors, patients improved 24 to 46% in all categories concerning lifestyle and emotional well-being. Correlative analysis of the data produced prognostic information as well as insights into chronic pain development. This study of objective and subjective outcome measures demonstrates that a comprehensive program employing specific principles and methods produces an effective approach for the management of chronic pain. Patients disabled by chronic pain regain a quality of life that allows them to resume a functioning, productive role.",1996.0,0,0
1413,8971431,Characterization and validation of a pharmacokinetic model for controlled-release oxycodone.,J W Mandema; R F Kaiko; B Oshlack; R F Reder; D R Stanski,"1. Oxycodone is a strong opioid agonist that is currently available in immediate-release (IR) formulations for the treatment of moderate to severe pain. Recently, controlled-release (CR) oxycodone tablets were developed to provide the benefits of twice-a-day dosing to patients treated with oxycodone. The purpose of this investigation was to develop and validate a pharmacokinetic model for CR oxycodone tablets in comparison with IR oxycodone solution. 2. Twenty-four normal male volunteers were enrolled in a single-dose, randomized, analytically blinded, two-way crossover study designed to compare the pharmacokinetics of two 10 mg CR oxycodone tablets with 20 mg IR oxycodone oral solution. Pharmacokinetic models describing the oxycodone plasma concentration vs time profiles of CR tablets and IR solution were derived using NONMEM version IV. The predictive performance of the models was assessed by comparison of predicted oxycodone plasma concentrations with actual oxycodone plasma concentrations observed in a separate group of 21 volunteers who received repeated doses of IR and CR oxycodone for 4 days. 3. The unit impulse disposition function of oxycodone was best described by a one-compartment model. Absorption rate of the IR solution was best described by a mono-exponential model with a lag time, whereas absorption rate of the CR tablet was best described using a bi-exponential model. The absorption profile of the CR tablets was characterized by a rapid absorption component (t1/2abs = 37 min) accounting for 38% of the available dose and a slow absorption phase (t1/2abs = 6.2 h) accounting for 62% of the available dose. Two 10 mg tablets of oral CR oxycodone hydrochloride were 102.7% bioavailable relative to 20 mg of IR oxycodone hydrochloride oral solution. The population model derived after administration of a single dose accurately predicted both the mean and range of oxycodone concentrations observed during 4 days of repeated dosing. The mean prediction error was 2.7% with a coefficient of variation of 54%. 4. The absorption characteristics of CR oxycodone tablets should allow effective plasma concentrations of oxycodone to be reached quickly and for effective concentrations to be maintained for a longer period after dosing compared with the IR oral solution. The CR dosage form has pharmacokinetic characteristics that permit 12 hourly dosing.",1996.0,0,0
1414,8975567,[Comparative assessment of chronic pain syndrome treatment methods in patients with small pelvis neoplasms].,M A Vaisman; S K Gantsev; A A Gazilov; S V Rudoi,,1996.0,0,0
1415,8975568,[Preventive analgesia: true of preventing the postoperative pain syndrome].,A M Ovechkin; A V Gnezdilov; N M Arlazarova; I A Savin; E V Fedorova; E I Khmelkova,"A total of 152 patients subjected to operations mainly of an orthopaedic profile were divided into 8 groups for the development of the optimal method of preventive analgesia. The best results were attained by combined use of opiate premedication, regional blocking as a component of anesthesiologic care, and parenteral diclophenak-Na before and after the operation. 31.5% of patients in this group did not need any postoperative analgesia. In the rest cases we observed the longest postoperative pain-free period, the least intensity of pain, and low need in additional analgesics during the first 24 h postoperation in comparison with the control groups (p < 0.05), in which one or several of the above components were excluded from the protocol of anesthesia. Preventive analgesia reduced the incidence of phantom pain syndrome after limb amputation in patients with the preamputation pain from 63.3 to 25.1%. The postoperative pain syndrome may be prevented if the factors determining it (preoperative pain, intraoperative nociceptive stimulation, and perioperative tissue inflammation) are eliminated simultaneously.",1996.0,0,0
1416,8982890,Postoperative analgesia and intraoperative inhalational anesthetic requirements during umbilical herniorrhaphy in children: postincisional local infiltration versus preincisional caudal epidural block.,J D Tobias,"To determine the postoperative analgesic efficacy of, and the effects on, intraoperative inhalational anesthetic requirements of preincisional caudal epidural block versus postincisional infiltration of local anesthetic following umbilical herniorrhaphy in children. Randomized, double-blind, prospective study. University medical center. 16 ASA status I and II patients (11 males, 5 females), ages 11 to 20 months, weighing up to 17 kg. During standard anesthetic care, 16 children were randomized to receive either caudal block with 1.5 ml/kg of 0.2% bupivacaine (group I) or local infiltration of the surgical site with up to 1.2 ml/kg of 0.25% bupivacaine (Group 2). Patients in Group I had significantly decreased pain scores and requirements for supplemental postoperative intravenous (IV) fentanyl. Five of eight patients in Group 1 did not require supplemental IV fentanyl during their in-hospital postoperative course, while all eight patients in Group 2 required supplemental IV fentanyl. The patients who received caudal epidural block also had decreased intraoperative requirements for isoflurane, shorter time to extubation (4.1 +/- 0.8 min vs. 8.4 +/- 1.5 min), and quicker discharge home (129 +/- 13 min vs. 163 +/- 22 min). Five of eight patients in Group 1 were ready for discharge at our usual time of 120 minutes, as opposed to one of eight patients in Group 2. Preincisional caudal epidural block is more effective in controlling pain following umbilical herniorrhaphy than is postincisional local infiltration.",1996.0,0,0
1417,8983321,Management of chronic non-malignant pain.,S Andersen; G Leikersfeldt,"Chronic non-malignant pain is often treated inadequately because of opiophobia. There is no scientific justification for this fear. With close monitoring and frequent controls, opioids are safe for this kind of pain. There is no scientific evidence that patients with chronic non-malignant pain are more prone to addiction or tolerance. It is also pertinent to consider that the endpoint of chronic pain treatment is not just freedom from pain but global wellbeing.",1996.0,0,0
1418,8984084,"Impact of sumatriptan on workplace productivity, nonwork activities, and health-related quality of life among hospital employees with migraine.",G R Mushet; D Miller; B Clements; G Pait; D L Gutterman,"This prospective, open-label study evaluated the effects of subcutaneous sumatriptan versus usual therapy on workplace productivity, activity time outside of work, and health-related quality of life in 43 men or women who were hospital employees diagnosed with migraine according to international Headache Society criteria. Patients treated migraines with their usual therapy for 12 to 18 weeks followed by subcutaneous sumatriptan for 6 months. Health-related quality of life measurements obtained at baseline, after usual therapy, and after sumatriptan therapy included the Short Form-36 Health Survey and the Migraine-Specific Quality of Life Questionnaire. Patient daily diaries were used to capture data on migraine symptoms and on Lost Workplace Productivity and Non-workplace Activity Time. Traditional clinical efficacy measures were obtained to support the pharmacoeconomic data. Clinical data showed that the percentage of treated migraine days per patient on which the patient experienced relief (moderate or severe pain reduced to mild or none) was 75% with sumatriptan and 25% with usual therapy. The mean time to meaningful relief was 1.1 hours during the sumatriptan phase and 4.2 hours during the usual therapy phase. Lost Workplace Productivity and Nonworkplace Activity Time was 35% lower with sumatriptan therapy (1.5 hours) compared with usual therapy (2.3 hours). Time missed from work due to symptoms, time worked with symptoms, and time normal activities were carried on with symptoms were each lower during sumatriptan therapy compared with usual therapy. Scores on each of the three Migraine-Specific Quality of Life Questionnaire dimensions and on the Role-Emotional dimension of the Short Form-36 were significantly more favorable after sumatriptan than after usual therapy (P < 0.05). These data demonstrate that treatment of migraines with sumatriptan for 6 months following usual therapy for 12 to 18 weeks was associated with improvement in clinical efficacy, reduction in lost workplace productivity and nonworkplace activity time, and enhancement of key dimensions of health-related quality of life among employees of a large university hospital.",1996.0,0,0
1419,8984864,Lack of efficacy of intra-articular opioids for analgesia after day-case arthroscopy.,I J Wrench; P Taylor; G J Hobbs,"A randomised double-blind placebo-controlled trial was undertaken to assess the analgesic efficacy of intra-articular opioids following arthroscopy of the knee. At the completion of surgery, patients received an intra-articular injection of: morphine 1 mg, buprenorphine 30 micrograms or 0.9% saline. There were no differences in pain scores among groups for the first 24 h postoperatively. We have found no clinical evidence for a peripherally-mediated opioid analgesic effect.",1996.0,0,0
1420,8986972,,,,,0,0
1421,8987041,Reduction of propofol pain--fentanyl vs lidocaine.,W A Alyafi; J Rangasami,"To compare the local efficacy of lidocaine and fentanyl in reducing propofol injection pain (PIP), we conducted a prospective randomized double-blind study in 75 ASA I and II adult patients. When administered 20 seconds before propofol with a venous tourniquet, lidocaine but not fentanyl or placebo, reduced the incidence of moderate to severe pain on subsequent injection of propofol (P < 0.001). Two patients (8%) in the lidocaine group (n = 25) experienced a moderate degree of pain and none experienced severe pain. Fifteen (60%) in the fentanyl group (n = 25) experienced moderate or severe degrees of pain, compared with 15 (60%) in the saline group (n = 25). We conclude that lidocaine, acting locally, reduce propofol injection pain while fentanyl does not.",1996.0,0,0
1422,8988384,Results of surgical treatment of spinal thoracic and lumbar metastases.,M Onimus; P Papin; S Gangloff,"The results of surgical treatment of vertebral metastases were evaluated from a retrospective review of a consecutive series of 100 patients, with special reference to anatomoclinical aspects and functional outcome. The primary tumour in most cases was lung, breast, or prostate; it was unknown in 11 cases. Diagnosis of the metastasis occurred 4-86 months after that of the primary tumour (lung metastasis: 4 months; breast metastasis: 86 months; prostatic metastasis: 22 months). Patients complained of vertebral pain in 96 cases and/or radicular pain in 43 cases. Intractable pain was observed in lung metastasis in particular. All patients received analgesics, and 57 received morphinics. Walking was impossible for 50 patients. Thirty-eight patients presented with neurologic deficit; neurologic status varied according to the primary tumour. Treatment included anterior surgery in 58 patients, posterior surgery in 33 patients, and combined surgery in 9 patients. Mean duration of hospitalisation was 12 days. No patient was admitted to the intensive care unit. Mean follow-up was 13.5 months. Eighty-nine patients were dead at follow-up, with an average survival of 10 months. Mean survival time was 7 months for patients with lung metastasis, 12 months for those with breast metastasis and 24 months for those with prostatic metastasis. Ten patients were still alive at follow-up (mean follow-up period 45 months, range 17-72 months). Analgesics were stopped for 62 patients following discharge from hospital. Morphinics had to be continued in seven patients. Thirty-five patients out of 50 (70%) recovered walking capacity. Neurologic status improved in 30 out of 38 patients. Although duration of survival was limited, surgery proved to be beneficial in providing a significant and early improvement in the functional status of more than 80% of patients. A precise evaluation of preoperative pain is necessary. Pain is dependent upon the bony lesion, the primary tumour, and the tumoral topography, which defines the surgical approach.",1996.0,0,0
1423,8996465,Fibromyalgia syndrome: an overview.,S Krsnich-Shriwise,,1997.0,0,0
1424,8997460,,,,,0,0
1425,8999611,[Recurrence of inguinal hernia: ambulatory surgery under local anesthesia].,T Callesen; K Bech; P Hesselfeldt; J Andersen; R Nielsen; O Roikjaer; H Kehlet,"In order to assess the feasibility of repair of a recurrent inguinal hernia in unmonitored local anaesthesia in an ambulatory set-up pain scores and data on patient satisfaction were obtained from 76 unselected patients after 79 consecutive operations. Median age was 63 years, and 25%- and 75% quartiles were 49 and 72 years respectively. All operations were conducted in local anesthesia. Three patients stayed in hospital overnight after the operation. Pain: After one, six and 28 days 27, 14 og 7% respectively had severe pain during function (cough and/or rising). Satisfaction: 82% were satisfied with ambulatory surgery in local anaesthesia, 82% were satisfied with the analgesic therapy (tenoxicam and methadone), but one third needed supplementary analgesics during the first week (acetaminophen was recommended). It is concluded, that ambulatory repair of a recurrent inguinal hernia in unmonitored local anaesthesia is a safe and cost effective alternative to operation in general or spinal anaesthesia.",1996.0,0,0
1426,9001475,Underestimation and undertreatment of pain in HIV disease: multicentre study.,F Larue; A Fontaine; S M Colleau,"To measure the prevalence, severity, and impact of pain on quality of life for HIV patients; to identify factors associated with undertreatment of pain. Multicentre cross sectional survey. 34 HIV treatment facilities, including inpatient hospital wards, day hospitals, and ambulatory care clinics, in 13 cities throughout France. 315 HIV patients at different stages of the disease.  recorded presence and severity of pain and rated quality of life. Doctors: reported disease status, estimate of pain severity, and analgesic treatment ordered. From 30% (17/56) of outpatients to 62% (73/118) of inpatients reported pain due to HIV disease. Pain severity significantly decreased patients' quality of life. Doctors underestimated pain severity in 52% (70/135) of HIV patients reporting pain. Underestimation of pain severity was more likely for patients who reported moderate (odds ratio 24) or severe pain (165) and less likely for patients whose pain source was identified or who were perceived as more depressed. Of the patients reporting moderate or severe pain, 57% (61/107) did not receive any analgesic treatment; only 22% (23/107) received at least weak opioids. Likelihood of analgesic prescription increased when doctors estimated pain to be more severe and regarded patients as sicker. Pain is a common and debilitating symptom of HIV disease which is gravely underestimated and undertreated.",1997.0,0,0
1427,9002589,A prospective comparison of transnasal butorphanol and acetaminophen with codeine for the relief of acute musculoskeletal pain.,R Wolford; J Kahler; P Mishra; P Vasilenko; R DeYoung,,1997.0,0,0
1428,9006618,Methadone-related deaths in New South Wales.,S Sunjic; D Zador,,1997.0,0,0
1429,9010652,Transdermal fentanyl. A review of its pharmacological properties and therapeutic efficacy in pain control.,W Jeal; P Benfield,"Fentanyl is a synthetic opioid with short-acting analgesic activity after intravenous or subcutaneous administration. The low molecular weight, high potency and lipid solubility of fentanyl make it suitable for delivery via the transdermal therapeutic system (TTS). These systems are designed to release the drug into the skin at a constant rate ranging from 25 to 100 micrograms/h, multiple systems can be applied to achieve higher delivery rates. Initially, much of the clinical experience with fentanyl TTS was obtained in patients with acute postoperative pain. However, because of the increased risk of respiratory complications, fentanyl TTS is contraindicated in this setting. Fentanyl TTS is recommended for use in chronic cancer pain. Moreover, in 11 countries worldwide including the US, its use is not restricted to chronic cancer pain; the drug is also available for treatment of general chronic pain, including that of nonmalignant origin. At the start of fentanyl TTS treatment, depot accumulation of the drug within skin tissue results in a significant delay (17 to 48 hours) before maximum plasma concentration is achieved. Approximately half of the cancer patients converted to transdermal fentanyl from other opioid agents required increased dosages after initial application of the patch. However, concomitant use of short-acting morphine maintained pain relief during the titration period, and the use of such supplementary medication decreased with the duration of fentanyl TTS treatment. In patients with chronic cancer pain, changes in visual analogue scale (VAS) pain scores ranged from a 10% increase (worse pain) to > 50% decrease (less pain) during transdermal fentanyl therapy compared with previous opioid treatment. In addition, patient preference for fentanyl TTS was indicated by the number of patient requests (up to 95%) for continued use of the drug at the end of the study. Although fentanyl TTS is contraindicated in patients postoperatively, the efficacy of fentanyl via the transdermal route was investigated in this patient group. Supplementary patient controlled analgesia was significantly reduced in patients who received fentanyl TTS 75 micrograms/h compared with placebo, although this was not apparent until > or = 12 hours after application. Data evaluating pain relief, which was assessed by VAS pain scores, were inconclusive. Preliminary data, although from relatively small numbers of patients, indicate that transdermal fentanyl may be useful in the management of chronic non-malignant pain. Indeed, some patients whose pain was previously uncontrolled became completely pain free. The most frequently occurring adverse events during fentanyl TTS therapy (as with other opioid agents) included vomiting, nausea and constipation, although vomiting and nausea were not clearly associated with the drug. The most serious adverse event was hypoventilation, which occurred more frequently in postoperative (4%) than in cancer patients (2%). In surgical patients, fentanyl-associated respiratory events (reduced respiratory rate and apnoea) generally occurred within 24 hours of patch application; however, there were isolated reports of late onset (> or = 36 hours postsurgery) fentanyl-associated respiratory depression. In cancer patients, the incidence of constipation was reduced by up to two-thirds after switching from oral morphine to transdermal fentanyl. Transient skin irritation associated with the plastic patch or the adhesive, rather than the drug, was reported in a maximum 3% of patients. In summary, transdermal fentanyl is a useful alternative to other opioid agents, which are also recommended on the third step of the WHO analgesic ladder, in the management of chronic malignant pain. Preliminary data indicate that it may be useful in the management of chronic nonmalignant pain. The advantages offered by fentanyl TTS over traditional methods of chronic pain control include its ease of administration, less constipation and the 3-",1997.0,0,0
1430,9010653,Ketorolac. A reappraisal of its pharmacodynamic and pharmacokinetic properties and therapeutic use in pain management.,J C Gillis; R N Brogden,"Ketorolac is a nonsteroidal anti-inflammatory drug (NSAID) with strong analgesic activity. The analgesic efficacy of ketorolac has been extensively evaluated in the postoperative setting, in both hospital inpatients and outpatients, and in patients with various other acute pain states. After major abdominal, orthopaedic or gynaecological surgery or ambulatory laparoscopic or gynaecological procedures, ketorolac provides relief from mild to severe pain in the majority of patients and has similar analgesic efficacy to that of standard dosages of morphine and pethidine (meperidine) as well as less frequently used opioids and other NSAIDs. The analgesic effect of ketorolac may be slightly delayed but often persists for longer than that of opioids. Combined therapy with ketorolac and an opioid results in a 25 to 50% reduction in opioid requirements, and in some patients this is accompanied by a concomitant decrease in opioid-induced adverse events, more rapid return to normal gastrointestinal function and shorter stay in hospital. In children undergoing myringotomy, hernia repair, tonsillectomy, or other surgery associated with mild to moderate pain, ketorolac provides comparable analgesia to morphine, pethidine or paracetamol (acetaminophen). In the emergency department, ketorolac attenuates moderate to severe pain in patients with renal colic, migraine headache, musculoskeletal pain or sickle cell crisis and is usually as effective as frequently used opioids, such as morphine and pethidine, and other NSAIDs and analgesics. Subcutaneous administration of ketorolac reduces pain in patients with cancer and seems particularly beneficial in pain resulting from bone metastases. The acquisition cost of ketorolac is greater than that of morphine or pethidine; however, in a small number of studies, the higher cost of ketorolac was offset when treatment with ketorolac resulted in a reduced hospital stay compared with alternative opioid therapy. The tolerability profile of ketorolac parallels that of other NSAIDs; most clinically important adverse events affect the gastrointestinal tract and/or renal or haematological function. The incidence of serious or fatal adverse events reported with ketorolac has decreased since revision of dosage guidelines. Results from a large retrospective postmarketing surveillance study in more than 20,000 patients demonstrated that the overall risk of gastrointestinal or operative site bleeding related to parenteral ketorolac therapy was only slightly higher than with opioids. However, the risk increased markedly when high dosages were used for more than 5 days, especially in the elderly. Acute renal failure may occur after treatment with ketorolac but is usually reversible on drug discontinuation. In common with other NSAIDs, ketorolac has also been implicated in allergic or hypersensitivity reactions. In summary, ketorolac is a strong analgesic with a tolerability profile which resembles that of other NSAIDs. When used in accordance with current dosage guidelines, this drug provides a useful alternative, or adjuvant, to opioids in patients with moderate to severe pain.",1997.0,0,0
1431,9010701,"Codeine and morphine in extensive and poor metabolizers of sparteine: pharmacokinetics, analgesic effect and side effects.",L Poulsen; K Brøsen; L Arendt-Nielsen; L F Gram; K Elbaek; S H Sindrup,"Codeine O-demethylation to morphine is catalysed by the genetic polymorphic sparteine oxygenase (CYP2D6). The objective of the present study was to assess the analgesic effect of codeine on different types of experimental pain in relation to sparteine phenotype. Fourteen extensive (EMs) and 14 poor metabolizers (PMs) of sparteine completed a randomized, double-blind, three-way, cross-over study with a single oral dose of codeine (75 or 100 mg) against morphine (20 or 30 mg) and placebo. Pain tests performed before and 1, 2, 3, and 4 h after medication included the cold pressor test and pain thresholds for heat and pressure stimulation. Adverse effects were rated by a structured interview. After morphine, morphine and morphine-6-glucuronide were present in equal amounts in plasma of PMs and EMs. After codeine, neither morphine nor morphine-6-glucuronide could be detected in 13 of the 14 PMs, whereas at least one of the compounds could be detected in all EMs. Peak pain and discomfort rated on a VAS scale during the cold pressor test were significantly reduced by morphine in both EMs and PMs, with a median peak change of 8.5 and 7.0 mm, respectively, for peak pain, and 11.5 and 15.5 mm, respectively, for discomfort. Codeine only reduced these pain measures significantly in EMs, with a median peak change of 5.5 mm for peak pain and 10.5 mm for discomfort. Pain detection and tolerance thresholds to heat and pressure were not consistently altered by either morphine or codeine. In PMs, adverse effects were significantly more pronounced on morphine than on codeine and only showed a slight difference between codeine and placebo. In EMs, there was no difference between codeine and morphine and more pronounced adverse effects on both drugs as compared to placebo. This study confirms that codeine O-demethylation depends on CYP2D6; it shows that the 6-glucuronidation of morphine is independent of CYP2D6; it supports the theory that the analgesic effect of codeine depends on its O-demethylation; and it indicates that this is probably also the case for the adverse effects. The results lend no support to the suggestion of a non-opioid analgesic effect of codeine.",1996.0,0,0
1432,9010943,Transdermal fentanyl in postoperative pain.,L J Lehmann; J M DeSio; T Radvany; G B Bikhazi,"The aim of this study was to determine the safety and effectiveness of a transdermal fentanyl delivery system for the relief of pain following abdominal surgery. In a nonblinded, noncrossover, placebo-controlled study, 40 ASA I and II patients of both sexes, 18-69 years of age, who were scheduled for abdominal surgery under general anesthesia, were randomly divided into two groups of 20 patients each. Patients in group I received a transdermal patch containing 0.16 mg/cm2 of fentanyl, which was applied to the skin over the subclavian area 60 minutes before the induction of anesthesia. For body weight less than 60 kg, a 30 cm2 patch was applied, and for weight greater than 60 kg, a 40 cm2 patch was used. A second group of 20 patients received placebo patches of identical size. Approximately 20 to 30 minutes before the expected end of surgery, 60 mg ketorolac was administered intramuscularly. Patients were observed for 36 hours after placement of the patch. If patients reported their pain at rest as 5 or greater at rest on a 0-10 visual analog scale, they were given 30-mg increments of ketorolac 5 to 7 hours apart. If this regimen did not relieve their pain, they received 1,300 mg acetaminophen between two ketorolac doses. If despite this, they still had pain 30 minutes afterward, intravenous morphine was given, and the patients were excluded from further study. The patch was removed in four patients in the fentanyl group and seven in the placebo group for various reasons, which included, inadequate pain relief requiring additional analgesia postoperatively and more than 1 microgram/kg of sufentanil given intraoperatively or immediately prior to the end of surgery. During the 36-hour observation period, 30 doses of 30 mg ketorolac and 14 doses of 1.3 g acetaminophen were given to 13 patients in the placebo group and 18 doses of ketorolac and 8 doses of acetaminophen were administered to 16 in the fentanyl group. The differences in postoperative analgesic requirements were significant. Plasma fentanyl concentrations at 12 and 24 hours after the application of the fentanyl patch were 0.98 +/- 0.14 ng/mL and 1.22 +/- 0.17 ng/mL, respectively. At 8, 16, 24, and 36 hours after application of the patch, the pain relief, assessed by a VAS at rest and with movement, was similar in the two groups. In the fentanyl and control groups, 12 and 5 patients, respectively, experienced nausea, and 2 and 3 patients, respectively, vomited. Similar postoperative analgesia was achieved with less parenteral analgesics in patients who received transdermal fentanyl preoperatively than in control patients. Fentanyl, 50-75 micrograms/h, administered in a transdermal delivery system, did not depress respiratory rate or hemoglobin oxygen saturation. Although the exact role of continuously administered opioids in managing acute postoperative pain has yet to be clearly defined, it is concluded that if properly used, this new transdermal device can be effective in providing a background of analgesia, which may assist in the management of acute postoperative pain as well as some chronic pain states.",1997.0,0,0
1433,9012294,[Pain syndromes in AIDS].,U Wesselmann,"Pain is a major, but largely neglected problem in AIDS patients. The aim of this article is to review the etiology of pain manifestations in AIDS patients in different organ systems and to discuss appropriate treatment strategies. The most common pain symptoms in AIDS patients are headache, oral cavity pain, dysphagia and adynophagia, chest pain, abdominal pain and pain related to peripheral neuropathy. Symptomatic pain treatment should be started while diagnostic work-up is still in progress, so that the patient does not suffer. If etiological treatment is possible, specific treatment pain treatment tapered as tolerated. If etiological treatment is not possible, symptomatic pain treatment should be continued. In view of the multiple organs involved in the presentation of AIDS requiring multiple drugs, careful attention to side effects, contraindications and drug interactions is warranted, when administering pain medications. Fear of the complexity of these issues should, however, not prevent effective pain management for these patients, who suffer from a fatal disease. A multidisciplinary approach to pain in AIDS patients, similar to the approach in patients with cancer, is desirable.",1996.0,0,0
1434,9012303,[The effect of convection warming during abdominal surgery on the early postoperative heat balance].,G Kaudasch; P Schempp; P Skierski; E Turner,"Hypothermia (core temperature < 36 degrees C) is common after longer-lasting surgical procedures. Heat loss mainly occurs during anaesthesia and surgery and leads to increased risk, especially in the early recovery period of elderly patients. In the present study we investigated the effects of intraoperative forced-air warming, administered via an upper-body blanket (""Warm Touch"", Mallinckrodt, USA), with the specific aims of: (1) drawing up heat balances; and (2) analysing postoperative thermoregulation, oxygen consumption (VO2) and cardiovascular reactions of mechanically ventilated patients. The general aim of our study was to compare intraoperative forced-air-warming and conventional patient-insulation with cotton blankets. Twenty four ASA II and III patients scheduled for elective colon surgery were randomly assigned to a control group (n = 12, no warming therapy, upper body covered with a cotton hospital blanket) or a convective warming group (n = 12). Anaesthesia was administered with etomidate (0.2 mg/kg), fentanyl (approximately 10 micrograms/kg) and vecuronium bromide (0.1 mg/kg). During surgery the lungs were mechanically ventilated with 70% nitrous oxide in oxygen and enflurane (end-tidal-concentration max. 0.7%) using a semiclosed circuit with a fresh gas flow of 3 l/min. A hygrophobe heat and moisture exchanger (""Sterivent,"" Darex Corp., Italy) was used. At the end of surgery patients were transferred to the ICU, covered with a hospital cotton-quilt and normo-ventilated using a Bennett 7200 a. Patients were sedated/kept free of pain by administering titrated doses of midazolam and/or piritramide. Postoperative oxygen consumption (VO2) was recorded continuously with a Deltatrac Metabolic Monitor (Datex Corp., Finland). Pre-, intra- and postoperative measurements included heart rate, invasive blood pressure, core-temperature (before and after operation: urinary bladder-temperature, during surgery: oesophageal temperature) and mean-skin-temperature (according to Ramanathan) up to 180 min from the end of surgery. Shivering, pharmacological interventions (e.g. pethidine) and time of extubation were noted. Data are presented as median, minima and maxima. The results were analysed using the Mann-Whitney U test or Chi-Square test (shivering). Statistical significance was assumed when P < 0.05. Both groups were comparable for gender, body weight, height, age, duration of their operations and amount of intraoperative fluids, narcotics and muscle relaxants. Room temperatures in the control group were significantly higher than in the forced air group (24 vs 22 degrees C). Initial setting of the forced-air blower was ""high"" (42-46 degrees high air flow). When the oesophageal-temperature reached 36.5 degrees C, the blower temperature was reduced to 36-40 degrees C. Reduction was necessary approximately 60 min from start in the operation. At the end of surgery/administration to the ICU core-temperatures of both groups differed significantly (35.2/ 35.4 degrees C vs 36.3/36.2 degrees C). Mean-skin temperatures were higher, too, but no statistical analysis was carried out for the intraoperative period, because warm air influenced skin thermometers located on the upper body. At admission to the ICU patients in the control group had a heat loss of 4.4 kJ/kg; those in the convective warming group had a heat-gain of 0.8 kJ/kg. Further measurements of postoperative core temperatures did not differ significantly, but the skin-temperatures of patients who received forced-air warming in the theatre remained higher (P < 0.05) until 120 min from the end of surgery. Shivering was more frequent and lasted longer in the control group (8 patients, 20 min vs 4 patients, 9 min; P < 0.05). Patients in the control group needed more drugs to stop increased cardiovascular reactions (hypertension, tachycardia) or shivering.(ABSTRACT TRUNCATED)",1996.0,0,0
1435,9013162,"Sedation and analgesia for colonoscopy: patient tolerance, pain, and cardiorespiratory parameters.",F Froehlich; J Thorens; W Schwizer; M Preisig; M Köhler; R D Hays; M Fried; J J Gonvers,"Colonoscopy is generally performed with the patient sedated and receiving analgesics. However, the benefit of the most often used combination of intravenous midazolam and pethidine on patient tolerance and pain and its cardiorespiratory risk have not been fully defined. In this double-blind prospective study, 150 outpatients undergoing routine colonoscopy were randomly assigned to receive either (1) low-dose midazolam (35 micrograms/kg) and pethidine (700 micrograms/kg in 48 patients, 500 micrograms/kg in 102 patients), (2) midazolam and placebo pethidine, or (3) pethidine and placebo midazolam. Tolerance (visual analog scale, 0 to 100 points: 0 = excellent; 100 = unbearable) did not improve significantly more in group 1 compared with group 2 (7 points; 95% confidence interval [-2-17]) and group 3 (2 points; 95% confidence interval [-7-12]). Similarly, pain was not significantly improved in group 1 as compared with the other groups. Male gender (p < 0.001) and shorter duration of the procedure (p = 0.004), but not amnesia, were associated with better patient tolerance and less pain. Patient satisfaction was similar in all groups. Oxygen desaturation and hypotension occurred in 33% and 11%, respectively, with a similar frequency in all three groups. In this study, the combination of low-dose midazolam and pethidine does not improve patient tolerance and lessen pain during colonoscopy as compared with either drug given alone. When applying low-dose midazolam, oxygen desaturation and hypotension do not occur more often after combined use of both drugs. For the individual patient, sedation and analgesia should be based on the endoscopist's clinical judgement.",1997.0,0,0
1436,9013369,Pharmacodynamic evaluation of codeine using tooth pulp evoked potentials.,A Suri; M L Kaltenbach; B L Grundy; H Derendorf,"Pain assessment in human volunteers is difficult, and it often requires a large number of subjects to show analgesic efficacy with statistical significance. Electrical tooth pulp stimulation elicits a painful sensation and produces an electroencephalographic (EEG) signal that can be recorded from the scalp when precisely controlled dental stimuli are delivered. These somatosensory evoked potentials (EP) consist of a series of peaks or waves each characterized by their polarity, latency, and amplitude. They are obtained by processing the EEG signals that occur after tooth pulp stimulation. There is good correlation between subjective pain reports and evoked potential amplitudes (N150-P250 component). Thus, EP may provide a useful model for the assessment of analgesic activity in human volunteers. We describe an improved method for producing and recording tooth pulp evoked potentials in six healthy subjects. Only 16 EEG epochs were necessary to get a reproducible EP response from the participants. The approach was applied to study the efficacy of codeine (60 mg administered orally); a decrease in the evoked potential amplitudes after codeine administration was observed. The data were consistent with results from visual analog pain ratings given by the subjects.",1996.0,0,0
1437,9019062,Opioids for chronic non-malignant pain.,D A Conigliaro,"In summary, opioid use for chronic non-malignant pain is justified in a select group of patients who do not respond to a variety of other pain treatment modalities. Proper trials of the analgesics given ""by the clock"" in appropriate dosages with attention to potential side effects and proper documentation is important. Efficacy should be monitored by improvement in function and symptomatology. Undertreatment for fear of addiction or legal consequences should be avoided. Specialized pain clinics may be utilized for consultation regarding the long-term use of opioids or for more advanced pain management strategies, possibly including the use of intraspinal opioid delivery systems.",1996.0,0,0
1438,9023498,"Comparative study of the efficacy of lysine acetylsalicylate, indomethacin and pethidine in acute renal colic.",K S al-Sahlawi; O M Tawfik,"The aim of this study was to compare the analgesic efficacy of intravenous lysine acetylsalicylate 1.8 g, indomethacin 100 mg and pethidine 100 mg in acute renal colic in a randomized double-blind clinical trial. One hundred and fifty patients with acute renal colic were divided into three groups. The first group received lysine acetylsalicylate 1.8 g, the second group received indomethacin 100 mg and the third group received pethidine 100 mg. The degree of pain relief was recorded 5, 15, 30 and 60 min after intravenous administration of the drugs. There was no statistically significant difference between the degree of analgesia provided by pethidine and indomethacin. Lysine acetylsalicylate was less effective than indomethacin and pethidine. It is concluded that intravenous indomethacin is an effective alternative to intravenous pethidine in the treatment of acute renal colic. Intravenous lysine acetylsalicylate is inferior to intravenous indomethacin in treatment of acute renal colic.",1996.0,0,0
1439,9028752,Administration of rectal indomethacin does not reduce the requirement for intravenous narcotic analgesia in acute renal colic.,C Ginifer; A M Kelly,"The aim of this study was to compare the total dose of intravenous pethidine required to give satisfactory analgesia to patients with acute renal colic between two groups, one of which was also administered rectal indomethacin on presentation and one which was not. This was a prospective, randomized, unblinded comparison study. Each group contained 39 patients. Group 1 received rectal indomethacin 100 mg and intravenous pethidine in 25 mg increments until pain was satisfactorily relieved. Group 2 received increments of intravenous pethidine alone. The primary endpoint was total pethidine dose required to achieve analgesia to the patient's satisfaction. No significant difference in total pethidine dose between the groups was found. It was concluded that administration of rectal indomethacin does not reduce the total dose of intravenous pethidine required to relieve the pain of acute renal colic.",1996.0,0,0
1440,9028977,"Efficacy of ketorolac tromethamine and extrapleural intercostal nerve block on post-thoracotomy pain. A prospective, randomized study.",A Carretta; P Zannini; G Chiesa; R Altese; G Melloni; A Grossi,"Post-thoracotomy pain causes severe impairment of the respiratory function. Epidural analgesia is effective in the treatment of post-thoracotomy pain but may give rise to significant side-effects. Other low-risk and cost-effective analgesic treatments are therefore required. Thirty male patients who had undergone pulmonary lobectomy entered a prospective, randomized trial to evaluate the efficacy of ketorolac tromethamine (Group 2) and extrapleural intercostal nerve block (Group 3) with intermittent low-dose bupivacaine. Objective and subjective assessment was carried out at 8, 16, 24 and 48 hours postoperatively. There were no significant differences between Groups 1 (control group) and 2. Vital capacity was significantly lower in Group 3 (p<0.05) than in Group 1 after 16 hours. Forced Vital Capacity was significantly higher in Group 2 than in Group 3 after 16 and 24 hours (p<0.05). Peak expiratory flow was also significantly better in Group 2 than in Group 3 after 16 hours (p<0.05). On-demand opioid consumption was significantly lower in Group 2 (p<0.001) and Group 3 (p<0.05). No side-effects were observed. Ketorolac tromethamine was effective in the treatment of post-thoracotomy pain. Extrapleural intercostal nerve block allowed a significant reduction in the consumption of opioids. These analgesic techniques could be useful as low-risk, cost-effective and reproducible treatments when more effective techniques, such as epidural analgesia, are contraindicated.",1996.0,0,0
1441,9034418,Possible serotonin syndrome associated with tramadol and sertraline coadministration.,B J Mason; K H Blackburn,"To report a possible case of serotonin syndrome associated with coadministration of tramadol hydrochloride and sertraline hydrochloride. A 42-year-old woman developed atypical chest pain, sinus tachycardia, confusion, psychosis, sundowning, agitation, diaphoresis, and tremor. She was taking multiple medications, including tramadol and sertraline. The tramadol dosage had recently been increased, resulting in what was believed to be serotonergic syndrome. Serotonin syndrome is a toxic hyperserotonergic state that develops soon after initiation or dosage increments of the offending agent. Patients may differ in their susceptibility to the development of serotonin syndrome. The (+) enantiomer of tramadol inhibits serotonin uptake. Tramadol is metabolized to an active metabolite, M1, by the CYP2D6 enzyme. If this metabolite has less serotonergic activity than tramadol, inhibition of CYP2D6 by sertraline could have been a factor in the interaction. Clinicians should be aware of the potential for serotonin syndrome with concomitant administration of sertraline and tramadol.",1997.0,0,0
1442,9037996,Pain management for labor and delivery in the 90s.,C F James,"Although variable, labor pain is among the most severe of pain syndromes, and has been described as severe to excruciating in 50 to 70 percent of primiparas. ""Twilight sleep"" or amnesia was commonly used in the first half of this century via potent intramuscular, intravenous and inhalational agents. Subsequently, epidural anesthesia, first caudal then lumbar was used which offered superior pain relief without clouding the sensorium. However, epidurals with local anesthetics also contributed to dense sensory and motor blocks which are not necessary for labor. Presently, both spinal and epidural opioids are used along with decreasing doses of local anesthetics, rendering the laboring patient a relatively pain-free labor but allowing her more mobility and control of her environment.",1997.0,0,0
1443,9037997,Pediatric pain management.,G Lederhaas,"It is now recognized that from the newborn period onwards, children are capable of experiencing pain. This includes the premature infant. The challenge for healthcare providers is to incorporate methods of pain assessment and treatment into their daily practices. The child's understanding of pain closely follows the cognitive and behavioral model developed by Jean Piaget. Based on these developmental stages, pain assessment measures have been developed. Pharmacologic advances have accompanied this improved understanding of infant, child, and adolescent psychology. While acute pain accounts for the majority of children's experiences, recurrent/chronic pain states do occur (e.g. sickle cell related and neuropathic) and can be effectively treated.",1997.0,0,0
1444,9038439,Pretreatment with controlled-release morphine for pain after hysterectomy.,R H Cruickshank; A Spencer; F R Ellis,"In a double-blind randomised study, two dosing regimens for controlled-release morphine tablets were compared against placebo to ascertain the extent of prophylactic postoperative pain control in 51 women undergoing abdominal hysterectomy. One group of patients received controlled-release morphine every 12 h for 2 days before surgery, a second group received a single dose of controlled-release morphine 2 h before surgery and a third group received placebo. Patient-controlled analgesia system demands were compared for the first 38 h after surgery and 10-point pain scores and McGill pain questionnaires were compared for the first 6 postoperative days and at 6 weeks after surgery. During the first 2 days after surgery, patients reported high levels of pain which were similar in all groups. Pain scores on the third and fourth postoperative days were significantly lower in those who had a single pre-operative dose of controlled-release morphine compared with placebo and those who had been treated with-morphine every 12 h for 2 days (p = 0.043 and 0.024 for third and fourth day respectively). Patient-controlled analgesia demands were also fewer and less variable in those patients receiving the single dose of morphine 2 h before surgery. The study shows a beneficial analgesic effect of a single pre-operative dose of morphine, but shows no benefit for a more prolonged pre-operative dosing regimen.",1996.0,0,0
1445,9038463,The effect of glycopyrrolate on postoperative pain and analgesic requirements following laparoscopic sterilisation.,B C Guard; S J Wiltshire,"In order to evaluate the contribution of tubal spasm to pelvic pain following laparoscopic sterilisation, we have studied the effect of glycopyrrolate, an anticholinergic agent with antispasmodic properties, on 60 ASA 1 and 2 patients presenting as day-cases for laparoscopic sterilisation using Filshie clips. In a randomised, double-blind, controlled trial, patients received either glycopyrrolate 0.3 mg or saline intravenously prior to induction of anaesthesia. Compared with the control group, patients receiving glycopyrrolate had significantly reduced immediate postoperative pain scores (p < 0.02) and required significantly less postoperative morphine (p < 0.01). Nausea, vomiting and anti-emetic requirements were also reduced though not significantly. We conclude that glycopyrrolate 0.3 mg at induction of anaesthesia is an effective method of improving the quality of recovery after day-case laparoscopic sterilisation using clips.",1996.0,0,0
1446,9038464,Pain following craniotomy: a preliminary study comparing PCA morphine with intramuscular codeine phosphate.,M D Stoneham; R Cooper; N F Quiney; F J Walters,"We have performed a prospective randomised trial of 30 patients undergoing craniotomy to compare intramuscular codeine phosphate with patient-controlled analgesia using morphine 1 mg bolus with a 10-min lockout and no background infusion. For 24 h postoperatively, pain, nausea, Glasgow coma score, respiratory rate and sedation score were assessed. There was a wide variation in the amounts of morphine requested by the patients in the patient-controlled analgesia group in the first 24 h postoperatively (range 2-79 mg, median 17 mg). There was a small, but non-significant, reduction in pain scores in the patient-controlled analgesia group. There were no significant differences between the two groups in respect of nausea and vomiting, sedation score or respiratory rate. No major adverse effects were noted in either group. Patient-controlled analgesia with morphine is an alternative to intramuscular codeine phosphate in neurosurgical patients which merits further investigation.",1996.0,0,0
1447,9038465,Pre-operative oral administration of morphine in day-case gynaecological laparoscopy.,R Rasanayagam; G Harrison,"The analgesic effect of morphine sulphate 10 mg by mouth given pre-operatively on pain after gynaecological laparoscopy was studied in a randomised, prospective, double-blind, placebo-controlled comparison. Two groups of 56 patients were studied one group undergoing diagnostic laparoscopy and the other laparoscopic sterilisation. All patients received a standard anaesthetic after premedication with morphine or placebo 1 h before the operation. Morphine premedication did not significantly influence postoperative pain as assessed on a visual analogue scale in either group and postoperative opioid consumption was unaffected. Premedication with morphine 10 mg orally does not significantly decrease pain after day-case gynaecological laparoscopy.",1996.0,0,0
1448,9040715,Pain in Guillain-Barré syndrome.,D E Moulin; N Hagen; T E Feasby; R Amireh; A Hahn,"To determine the character, intensity and frequency of pain in Guillain-Barré syndrome (GBS) and to evaluate the response to treatment. A prospective longitudinal study. Academic hospital-based practices. Fifty-five consecutive patients with GBS. Patients were evaluated on admission and at 2, 4, 8, 16, and 24 weeks. Character of pain, pain intensity using Visual Analogue Scale ([VAS] 0 to 10 cm) and Present Pain Intensity of McGill Pain Questionnaire, pain relief (VAS 0 to 10 cm), Disability Grading Scale for GBS. Forty-nine patients (89.1%) described pain during the course of their illness. On admission, mean pain intensity (VAS) was 4.7 +/- 3.3. However, 26 patients (47.3%) described pain that was either distressing, horrible, or excruciating (mean VAS, 7.0 +/- 2.0). The most common pain syndromes observed were deep aching back and leg pain and dysesthetic extremity pain. Pain intensity on admission correlated poorly with neurologic disability on admission (r = 0.26, p = 0.06) and throughout the period of study (r < 0.20, p > 0.10). Forty-one patients (74.5%) required opioid analgesics, with 16 (29.0%) receiving parenteral morphine to provide adequate pain relief. Moderate to severe pain is a common and early symptom of GBS and requires aggressive treatment. Pain intensity on admission is not a predictor of poor prognosis. Back and leg pain usually resolves over the first 8 weeks, but dysesthetic extremity pain may persist longer in 5 to 10% of patients despite motor recovery and the use of adjuvant analgesics.",1997.0,0,0
1449,9040811,Local wound infiltration with bupivacaine in lumbar laminectomy.,M N Cherian; M P Mathews; M J Chandy,"Parenteral administration of narcotics has been the mainstay for postoperative pain relief in patients undergoing lumbar laminectomy. However, this may lead to respiratory depression and nausea, which may be hazardous in these patients. We evaluated the efficacy of wound infiltration with bupivacaine in 45 consecutive patients undergoing elective single-level lumbar laminectomy for intervertebral disc prolapse in a prospective, double-blind, randomized controlled trial. Prior to wound closure, the muscle and subcutaneous tissues were infiltrated with bupivacaine 0.375% or sterile physiologic saline. Postoperatively, the patients were assessed hourly for pain and an analgesic administered if the patient had moderate or severe pain. All the 21 placebo recipients required analgesics in the first 9 hours postoperatively, compared to only 11 of 24 patients who received bupivacaine (p < 0.001). The mean (standard deviation) time before administration of the first dose of analgesic postoperatively in the bupivacaine and placebo recipients was 807.7 (567.6) minutes and 181.4 (110.1) minutes, respectively (p < 0.001). No adverse effects of local wound infiltration were noted. Local wound infiltration with bupivacaine is a safe and effective method for providing postoperative pain relief and reducing narcotic use in patients undergoing lumbar laminectomy.",1997.0,0,0
1450,9040914,Fentanyl transdermal system. Pain management at home.,M A Woodroffe; H Hays,"About 65% of patients with advanced malignancies experience cancer pain. Although oral opioids provide effective analgesia for most of these patients, alternate routes of drug delivery are often necessary as the disease progresses. To study use of Duragesic (fentanyl transdermal system), the only transdermal opioid approved in Canada for treating chronic cancer pain in adults. Transdermal fentanyl was prescribed for a heterogeneous group of 44 patients (aged 29 to 82 years) to treat cancer pain (37 patients), chronic non-malignant pain (six patients), and pain associated with terminal AIDS (one patient), for periods of 2 to 384 days. Patients were treated individually and switched to transdermal fentanyl from other opioids when oral delivery was no longer possible. Doses were titrated as necessary and ranged from 25 micrograms/h to 300 micrograms/h. Incidental pain was treated effectively with short-acting opioids. Eighty percent of patients experienced good analgesia, which led to an overall improvement in their quality of life. Transdermal fentanyl was discontinued for 17% of patients due to intractable nausea, diarrhea, adherence problems, or poor analgesia. Many patients wore the system until they died or until a few days before death when severe increasing pain necessitated parenteral opioids. The side effects of transdermal fentanyl were similar to those of conventional opioids. Patient compliance and acceptance of this noninvasive, continuous system of drug delivery has been excellent; its simplicity of administration allows patients to be cared for at home.",1997.0,0,0
1451,9046313,Surgical interruption of a midline dorsal column visceral pain pathway. Case report and review of the literature.,H J Nauta; E Hewitt; K N Westlund; W D Willis,"A punctate midline myelotomy performed in a patient effectively eliminated residual, intractable pelvic pain, which remained after resolution of uterine cervical cancer. The authors describe the case history of the patient, in whom pain assessments were made, and a surgical procedure performed. Despite large doses of opiate analgesic medications, the patient experienced constant pressure pain in the right lower pelvis, with excruciating pain on bowel movement. Severe weight loss necessitated better pain control. A minimally invasive surgical procedure, a 5-mm deep puncture using a 16-gauge needle on either side of the median septum in the dorsal column of the spinal cord (T-8), resulted in no new neurological deficits. Narcotic medication was tapered, no pain was reported, and the patient resumed daily household activity. Midline myelotomy has typically been performed with the intention of eliminating the crossing fibers of the spinothalamic tract in the anterior white matter commissure. The punctate midline myelotomy described here was performed with the specific intention of interrupting a newly described visceral pain pathway that ascends to higher brain centers through the midline of the dorsal column. The effectiveness of the pain relief seen in this patient suggests that visceral pain of the pelvis in humans may be transmitted in the midline of the dorsal column, as has been recently reported in studies using rats. The effectiveness of the punctate midline myelotomy performed in this one case of pelvic visceral pain suggests that the surgery may eventually be effective in greatly reducing or replacing opiate narcotic medication for visceral pain management.",2001.0,0,0
1452,9050533,The effect of nitrous oxide and carbon dioxide pneumoperitoneum on operative and postoperative pain during laparoscopic sterilization under local anesthesia.,G H Lipscomb; R L Summitt; M L McCord; F W Ling,"To compare carbon dioxide and nitrous oxide pneumoperitoneum with respect to intraoperative and postoperative pain during laparoscopic sterilization under local anesthesia. Randomized, double-blind study of pain during surgery and at 15 minutes, 1 hour, and 24 hours postoperatively. Regional Medical Center, Memphis, Tennessee. Women scheduled for laparoscopic sterilization under local anesthesia. Interventions. Forty-nine patients were randomized to carbon dioxide and 56 to nitrous oxide pneumoperitoneum. Pain was assessed using a modified McGill pain questionnaire. Intraoperative pain was measured by the amount of supplemental narcotic required. Analgesic use in the recovery room and during the first 24 hours postoperatively was compared. Demographics for both groups were similar. The groups had no statistical differences in pain during surgery or at any of the postoperative time periods. Recovery room analgesia requirement was similar, but the nitrous oxide group used fewer pain tables (0.98 vs 0.42 tablets) in the first 24 hours. There is no difference in intraoperative and postoperative pain between nitrous oxide and carbon dioxide pneumoperitoneum for laparoscopic sterilization when used in conjunction with a protocol such as ours.",2001.0,0,0
1453,9050630,Evaluation and management of chronic pelvic pain.,A J Duleba; M D Keltz; D L Olive,"Evaluating patients with chronic pelvic pain is complex. A detailed medical history should be ideally supplemented by psychologic evaluation and assessment of the woman's social background. At the time of physical examination, the location and intensity of the pain should be mapped. Assessment of pain relief with the administration of a local anesthetic to trigger points or selected nerves may be useful in predicting the potential efficacy of surgical interventions such as uterosacral nerve ablation. Appropriate tests include pelvic ultrasound and magnetic resonance imaging. Ultimately, laparoscopy may provide the final diagnosis. Management should address the underlying cause(s) of pain; when this cannot be done, it should focus on treating the pain itself. When appropriate, empiric administration of antidepressants may be considered. In selected women, therapeutic goals may be achieved by electrical stimulation of nerves.",1996.0,0,0
1454,9051539,"Postoperative analgesia using a low-dose, oral-transdermal clonidine combination: lack of clinical efficacy.",M D Owen; E E Fibuch; R McQuillan; W R Millington,"To determine if a lower than previously reported oral-transdermal clonidine regimen could reduce postoperative morphine requirements without producing systemic side effects. Double-blind, randomized, placebo-controlled study. University-affiliated hospital. 29 healthy, ASA physical status I and II females undergoing elective abdominal hysterectomy. Patients received preoperative oral clonidine 4 to 5 mu/kg and a 7 cm2 transdermal clonidine patch (0.2 mg/24 hours) or a placebo tablet and patch. Postoperative patient-controlled analgesia pumps provided morphine during the 48-hour study period. Morphine use, hemodynamic changes, and nonhemodynamic side effects were recorded. Additionally, visual analog pain scales (VAPS) and plasma concentrations of morphine and clonidine were measured. We found that low-dose clonidine had no potentiating effect on morphine analgesia. Postoperative morphine use, VAPS, and morphine plasma levels were similar between the control and clonidine-treated groups. Nevertheless, patients in the clonidine group experienced a significantly greater incidence of intraoperative and postoperative hypotension and bradycardia than did the control group. No differences were noted in the incidence of nonhemodynamic side effects. The low-dose oral-transdermal clonidine regimen evaluated failed to reduce postoperative morphine requirements, although patients who received clonidine were still at risk for developing hypotension.",1997.0,0,0
1455,9051543,Comparison of epidural morphine and oxycodone for pain after abdominal surgery.,M Backlund; L Lindgren; Y Kajimoto; P H Rosenberg,"To compare the efficacy and side effects of epidural morphine and oxycodone for pain following major abdominal surgery. Randomized, double-blind study. 4th Department of Surgery, Helsinki University Central Hospital. 44 adult ASA physical status I, II, and III patients scheduled for elective major abdominal surgery. Thirty-three patients were allocated randomly to one of two epidural groups and 11 patients received oxycodone intravenously (IV). The two epidural groups received either morphine (bolus 0.015 mg/kg followed by an infusion 0.003 mg/kg/hr) or oxycodone (bolus 0.15 mg/kg followed by an infusion 0.03 mg/kg/hr) before induction of standardized anesthesia and for 24 hours thereafter. A third group of patients was given the same dose of IV oxycodone as in the epidural group, serving as an open control group for epidural oxycodone. Blood samples were drawn for plasma opioid concentrations. Postoperatively, pain (at rest and during coughing), nausea, pruritus, sedation, respiratory rate, and hemodynamics were recorded until the end of the infusions. The epidural dose ratio between morphine and oxycodone was 1:8.4 to 9.8 to provide similar analgesia. Side effects occurred similarly in the three groups. Mild respiratory depression was seen in all groups, especially in the IV oxycodone group. In all groups, hemodynamic variables remained within normal limits. In the dosages reported, oxycodone can be used epidurally for acute post-operative pain. The analgesic effect was as good as that of epidural morphine.",1997.0,0,0
1456,9059197,Extradural morphine gives better pain relief than patient-controlled i.v. morphine after hysterectomy.,M Eriksson-Mjöberg; J O Svensson; O Almkvist; A Olund; L L Gustafsson,"We examined if patient-controlled analgesia (PCA) with i.v. morphine provided comparable postoperative analgesia after hysterectomy as extradural morphine, without increasing the incidence of side effects. The study (n = 40) was randomized and double-blind. An extradural catheter was inserted before surgery and anaesthesia was standardized. The extradural group received extradural morphine 0.06 mg kg-1 by the end of surgery and a second dose 6 h later. The i.v. group received an i.v. infusion of morphine 0.2 mg kg-1 after surgery. PCA with morphine 0.04 mg kg-1 i.v. was used in both groups. Pain relief (VAS), side effects and cognitive functions were evaluated for 18 h. Plasma samples were obtained for analysis of morphine concentrations. Mean consumption of PCA morphine was 2.4 mg h-1 for the i.v. group and 1 mg h-1 for the extradural group. Despite unlimited access to morphine, the i.v. group had higher VAS scores as the extradural group (P < 0.001). Plasma concentrations of morphine varied 8-10-fold in both groups. In the i.v. group itching, tiredness, blurred vision and vertigo correlated with cumulative consumption of i.v. morphine whereas in the extradural group this correlation existed only for tiredness. Both groups showed reduced ability to perform tests of cognitive function, indicating a central effect of both i.v. and extradural morphine, despite markedly lower plasma morphine concentrations in the extradural group.",1997.0,0,0
1457,9059198,Target-controlled infusion of alfentanil for postoperative analgesia: a feasibility study and pharmacodynamic evaluation in the early postoperative period.,M C Van den Nieuwenhuyzen; F H Engbers; A G Burm; A A Vletter; J W Van Kleef; J G Bovill,"We have examined the feasibility of target-controlled infusion of alfentanil (TCIA) and the pharmacodynamics of alfentanil in the early postoperative period. Patients were allocated randomly to one of the three groups to receive balanced anaesthesia with bolus injections of fentanyl (group F), sufentanil (group S) or alfentanil (group A). In the recovery room all patients received the same analgesic regimen, comprising TCIA. To evaluate the efficacy of postoperative analgesia, pain scores were measured on a visual analogue scale (VAS) and patients indicated a need for additional analgesia. EC50, the concentration at which, with a 50% probability, patients reported adequate analgesia, was estimated using logistic regression. Six patients did not complain of pain. The time from the last intraoperative bolus injection of opioid until patients complained of postoperative pain was shorter (P < 0.05) in group A (mean 68 min) than in group F (101 min) and group S (136 min). The time to onset of satisfactory analgesia was comparable in the three groups (median 18 min in group F, 15 min in group S and 14 min in group A). EC50 of alfentanil was determined in 28 patients; mean values were 26 ng ml-1 (group F), 39 ng ml-1 (group S) and 52 ng ml-1 (group A). We conclude that TCIA, under the conditions studied, resulted in a fast onset of adequate analgesia, irrespective of the opioid administered during operation. Also, there was no effect of opioids administered during operation on postoperative pharmacodynamics of alfentanil.",1997.0,0,0
1458,9059199,IV perioperative ketoprofen in small children during adenoidectomy.,E Nikanne; H Kokki; K Tuovinen,"We have investigated the analgesic and opioid sparing effect of perioperative i.v. ketoprofen in a randomized, double-blind, placebo-controlled, parallel group study in 164 children, aged 1-7 yr, after adenoidectomy. A standard anaesthetic method was used and all children received fentanyl 1 microgram kg-1 i.v. during induction. Children in the ketoprofen group received ketoprofen 1 mg kg-1 i.v. after induction of anaesthesia followed by an infusion of ketoprofen 1 mg kg-1 over 2 h. Children in the placebo group received 0.9% saline. All children received fentanyl 1 microgram kg-1 i.v. as rescue analgesia. In the ketoprofen group less children required postoperative fentanyl (64% vs 77%, P = 0.006) and the total number of fentanyl doses was smaller compared with the placebo group (mean 1.0 (SD 1.1) (95% confidence intervals (CI) 0.8-1.3) vs 1.5 (1.1) (95% CI 1.2-1.7), P = 0.012). Worst pain observed in the postanaesthesia care unit was also lower in the ketoprofen group both at rest (P = 0.028) and during swallowing (P = 0.001). There were no difference in the number of adverse reactions between the groups. No serious adverse reactions occurred.",1997.0,0,0
1459,9059210,Continuous brachial plexus infusion of butorphanol-mepivacaine mixtures for analgesia after upper extremity surgery.,Z Wajima; T Shitara; Y Nakajima; C Kim; N Kobayashi; H Kadotani; H Adachi; G Ishikawa; K Kaneko; T Inoue; R Ogawa,"We have recently reported that continuous administration of butorphanol into the brachial plexus neurovascular sheath provided superior analgesia compared with that obtained with continuous i.v. administration. Furthermore, we found that analgesia was most pronounced when a mixture of mepivacaine and butorphanol was given and that butorphanol alone ranked next. In this study, we increased the dose of butorphanol, compared with that used in our previous reports, and an initial bolus dose of butorphanol was administered into the brachial plexus neurovascular sheath just after surgery had ended. Thereafter, postoperative pain relief was estimated. In patients undergoing upper extremity surgery with continuous axillary brachial plexus block, group A received a bolus of 1 ml of physiological saline with 1.5% mepivacaine, 10 ml into the brachial plexus sheath followed by a continuous brachial plexus infusion of 0.5% mepivacaine with butorphanol 6 mg at a rate of 144 ml/ 72 h. Group B was given a bolus of butorphanol 1 mg (1 ml) with 1.5% mepivacaine, 10 ml into the brachial plexus sheath and a continuous brachial plexus infusion of 0.5% mepivacaine with butorphanol 6 mg at a rate of 144 ml/72 h. After operation, VAS scores did not differ between the two groups. The time to first use of supplementary analgesia did not differ significantly between the two groups and there were no significant differences in the number of patients who required supplementary analgesia. These results indicate that continuous butorphanol 2 mg day-1 with 0.5% mepivacaine provided sufficient postoperative analgesia after upper limb surgery.",1997.0,0,0
1460,9060030,Transdermal fentanyl in the long-term treatment of cancer pain: a prospective study of 50 patients with advanced cancer of the gastrointestinal tract or the head and neck region.,S Grond; D Zech; K A Lehmann; L Radbruch; H Breitenbach; D Hertel,"This open prospective study evaluated the combination of initial dose titration with patient-controlled analgesia (PCA) and long-term treatment with transdermal fentanyl in 50 cancer patients requiring opioids for severe pain. The delivery rate of the first transdermal therapeutic system (TTS) was calculated from the self-administered intravenous fentanyl dose during the first 24 h. TTS were changed every 48-72 h, and a different patch size was chosen if necessary. Pain intensity (101-step numeric analog scale) and side-effects were assessed daily. The patients were treated for 66 +/- 101 days (range 3-535 days). The average delivery rate was 5.9 +/- 4.1 mg/d. Mean pain intensity decreased from initially 45 +/- 21 to 19 +/- 15 in the titration phase and 15 +/- 11 during long-term treatment. Three patients showed moderate respiratory depression. Other severe side-effects were not observed. Patient compliance and acceptance were excellent. The results suggest that intravenous PCA is useful for initial dose finding, and transdermal fentanyl is effective and safe during long-term treatment of cancer pain.",1997.0,0,0
1461,9061094,Morphine metabolites.,L L Christrup,"Morphine is a potent opioid analgesic widely used for the treatment of acute pain and for long-term treatment of severe pain. Morphine is a member of the morphinan-framed alkaloids, which are present in the poppy plant. The drug is soluble in water, but its solubility in lipids is poor. In man, morphine-3-glucuronide (M3G) and morphine-6-glucuronide (M6G) are the major metabolites of morphine. The metabolism of morphine occurs not only in the liver, but may also take place in the brain and the kidneys. The glucuronides are mainly eliminated via bile and urine. Glucuronides as a rule are considered as highly polar metabolites unable to cross the blood-brain barrier. Although morphine glucuronidation has been demonstrated in human brain tissue, the capacity is very low compared to that of the liver, indicating that the M3G and M6G concentrations observed in the cerebrospinal fluid (CSF) after systemic administration reflect hepatic metabolism of morphine and that the morphine glucuronides, despite their high polarity, can penetrate into the brain. Like morphine, M6G has been shown to be relatively more selective for mu-receptors than for delta- and kappa-receptors while M3G does not appear to compete for opioid receptor binding. The analgesic properties of M6G were recognised in the early 1970s and more recent work suggests that M6G might significantly contribute to the opioid analgesia after administration of morphine. The analgesic potency of M6G after intracerebroventricular (ICV) or intrathecal (IT) administration in rats is from 45-800 timer greater than that of morphine, depending on the animal species and the experimental antinociceptive test used. Furthermore, the development of a sensitive high-performance liquid chromatography (HPLC) assay for the quantitative determination of morphine, M6G and M3G has revealed that M6G and M3G were present in abundance after chronic oral morphine administration and that the area under the plasma concentration-time curve exceeded that of morphine. M3G has been found to antagonise morphine and M6G induced analgesia and ventilatory depression in the rat, which has led to the hypothesis that M3G may influence the development of morphine tolerance. M3G exhibits no analgesic effect after ICV or IT administration. Some studies do, however, indicate that M3G may cause non-opioid mediated hyperalgesia/allodynia and convulsions after IT administration in rats. These observations led to the hypothesis that M3G might be responsible for side-effects, hyperalgesia/allodynia and myoclonus seen after high-dose morphine treatment.",1997.0,0,0
1462,9061100,Psychomotor and cognitive functioning in cancer patients.,P Sjøgren,"Psychomotor and cognitive dysfunction in cancer patients can be classified into two main categories according to etiology: disease-induced factors (metabolic disturbances, brain metastasis, pain, etc.) and treatment-related factors (drugs, antineoplastic therapy, etc.). In particular, the effects of chronic opioid administration in cancer patients have been subjected to investigations, and most studies have been engaged in assessment and treatment of the cerebral dysfunction. Early studies found that cancer patients in chronic oral opioid therapy had prolonged continuous reaction times, and that the opioids seemed to be mainly responsible for the prolongation. Significant dose escalations of opioids (> or = 30%) caused transiently impaired psychomotor and cognitive functions in cancer patients. Cancer patients in chronic oral opioid therapy did not achieve any advantages changing to epidural opioid therapy with regard to faster continuous reaction times and less pain. Large doses of opioids are often required to control severe pain in cancer patients. As increased sedation and impaired psychomotor and cognitive functions often occur, a number of studies have investigated the use of amphetamine derivatives to counteract the sedative side-effects of opioid. These drugs seem promising during high-dose opioid therapy and their use may be particularly rewarding in poor opioid-responsive pain conditions such as incident and neuropathic pain.",1997.0,0,0
1463,9061102,Pharmacokinetics and pharmacodynamics of controlled-release opioids.,R F Kaiko,"While pharmacokinetic/pharmacodynamic relationships for opioids have not been consistently demonstrable or sufficiently predictive, there remain compelling reasons to pursue such relationships. Among the reasons for pursuing pharmacokinetic/ pharmacodynamic relationships is the prospect of predicting the time-action characteristics of new therapeutics on the basis of early studies in normals using pharmacodynamic surrogates for analgesia. The realization of such a model could improve the efficiency of development of analgesics. Four studies involving 98 normals were conducted to determine whether significant and reproducible relationships existed for oxycodone in the form of an oral controlled-release tablet. All studies were analytically blinded and utilized a validated gas chromatographic/mass spectrometric, sensitive (0.2 ng/ml), and specific method for oxycodone (four studies) and oxymorphone (two studies) quantitation in 17 to 20 serial plasma samples over 36 to 48 hours following a single 20 mg (or 40 mg) dose in each study. Concurrent assessments included vital signs and opioid effect VAS questionnaires. The studies demonstrated significant relationships between plasma oxycodone (but not oxymorphone) and pharmacodynamic surrogates (particularly VAS ""drug effect"") and were predictive of the 12-hour duration of pain control and prompt onset of analgesia subsequently demonstrated in multiple clinical studies involving patients with various pathological pain syndromes. The results suggest that investigators can make earlier, accurate predictions of opioid analgesic pharmacodynamics in patients based on pharmacokinetic/pharmacodynamic studies in normal volunteers.",1997.0,0,0
1464,9061103,Opioid use in chronic pain.,H J McQuay,"Many of the important questions for those who prescribe opioids in chronic pain, and important for those who take the drugs, still have to be answered with inadequate evidence, because we lack randomised trials on these topics. Two of the principal reasons for ""failure' of opioids to relieve pain, incident pain and neuropathic pain, are discussed. Some specific adverse effect problems are addressed, and the paper concludes with a section on the vexed issue of opioid prescription in non-cancer pain.",1997.0,0,0
1465,9061105,Pharmacological approaches other than opioids in chronic non-cancer pain management.,H Merskey,"Many pains are controlled by non-addictive procedures ranging from exercise to a variety of analgesic medications. Some pains are controlled by analgesic drugs, but at the cost of intolerable side effects. This is true both for non-steroidal anti-inflammatory drugs and opioids. The worst pains are most often controlled by opioids, but problems of tolerance and addiction limit these successes. This contribution provides a statement on non-addictive, non-opioid drugs which help to control pain. Just as these vary in their success, so they vary also in the strength of the scientific evidence which supports their use. The groups of drugs to be considered can be evaluated in three respects; evidence of analgesic effect in controlled trials; evidence of side-effects compared with control substances and with standard experience; evidence of usefulness in clinical practice. The latter which is the most important for practice often has the least scientific proof. Six main classes of drugs are recognized which provide analgesic effects, other than opioids. 1) Non-steroidal anti-inflammatory drugs are widely accepted as analgesics on the basis of animal studies, numerous controlled investigations and clinical practice. Acetaminophene may not be anti-inflammatory, but is recognized as an effective analgesic which in many other respects resembles the above. 2) Muscle relaxants, e.g. cyclobenzaprine or baclofen have varied actions, but often provide some relief of pain. 3) Antidepressants may be analgesic if they relieve depression which is giving rise to pain. This applies to all anti-depressants. Some antidepressants have been shown to be analgesic in the absence of depression. The best accredited of these is amitriptyline. Antidepressants too have significant side effects. A serotoninergic hypothesis is insufficient to explain the actions of antidepressants in relieving pain in the absence of depression. 4) Phenothiazine neuroleptics (and possibly some others) may be analgesic. Drugs reported to be analgesic include chlorpromazine, fluphenazine, perphenazine, trifluoperazine, methotrimeprazine (levomepromazine) among others. Haloperidol has also been utilized. Well controlled evidence exists with the use of methotrimeprazine (levomepromazine) used as an injection. The analgesic effect of oral neuroleptics is less well established and mostly depends upon clinical observation, withdrawal and re-challenge. 5) Anticonvulsants. 6) Other drugs. Non-steroidal anti-inflammatory drugs and some muscle relaxants, e.g. cyclobenzaprine are best used in the short term. The gastrointestinal side effects of non-steroidal anti-inflammatory drugs have been quite troublesome and over 2% of patients followed over five years are at risk of developing peptic ulceration from such medication. Cyclobenzaprine is best used in short term treatment, but may be used intermittently for chronic pain. Antidepressants, neuroleptics, anticonvulsants and some other drugs can be used long term. Topical analgesic agents may also be used.",1997.0,0,0
1466,9061108,"Analgesia following arthroscopy--a comparison of intra-articular morphine, pethidine and fentanyl.",A Söderlund; L Westman; H Ersmark; E Eriksson; A Valentin; A Ekblom,"It has recently been reported that morphine given in low doses intra-articularly can produce significant analgesia in patients undergoing arthroscopic knee joint surgery. Data are lacking on the effect of other opioids using a local approach for drug delivery. We studied the analgesic effect of intra-articular opioids in 70 patients, divided into 7 groups, subjected to arthroscopic knee surgery in general anesthesia. The dimension of the study was based on a power of 0.8 to detect a 25% difference in pain intensity between those receiving opioids locally versus systemically (alpha = 0.05 and beta = 0.20). Following surgery, but before terminating anesthesia, the patients received one of the following combinations: 1 mg morphine intra-articularly (i.art.) + saline intramuscularly (i.m.), 10 mg pethidine i.art + saline i.m., or 10 micrograms fentanyl i.art + saline i.m. In three additional groups the three opioids were given i.m. and saline given i.art. An additional control group received saline i.art. + i.m. We did not find any significant difference between the groups considering postoperative pain intensity, need for analgesics or considering time to standing/walking or to discharge, analysing each opioid independently. There was, however, a tendency for pethidine i.art. to produce the lowest pain scores both at rest and during movement (P = 0.06). If analysing the results with regards to if opioids were given intra-articularly or systemically, not considering the type of opioid given, we did however, find a significantly lower total sum of pain scores at movement following local administration (P < 0.05). No specific side-effects were detected. We conclude that pethidine given intra-articularly merits further investigation with respect to postoperative analgesia following the activation of peripheral opioid mechanisms.",1997.0,0,0
1467,9062602,Inclusion of pethidine in lidocaine for infiltration improves analgesia following tonsillectomy in children.,M Elhakim; A Y Abdul Salam; A Eid; N Kaschef; B E Mostafa,"Previous work has demonstrated that pethidine exerts local anaesthetic effects on peripheral nerves in vivo. We examined the effects of infiltration anaesthesia by a combination of pethidine and lidocaine on post-tonsillectomy pain and restlessness in children. Eighty children were randomly allocated to receive peritonsillar infiltration postoperatively with 3 ml of lidocaine 2% (1.5 ml on each side) combined with either 0.1 ml pethidine, 10 mg.ml-1, (pethidine group) or 0.1 ml normal saline (control group). Pain and behaviour were assessed at 1, 3, 6 and 12 h postoperatively and on the following morning by the patients and by a nurse blinded to previous treatment. Patients in the pethidine group had lower pain scores than those in the control group at rest as well as swallowing during the whole observation period (P < 0.05). Paracetamol was given to 34/40 children in the control group and to 6/40 children in the pethidine group. The corresponding figures for pethidine administration were 6/40 and 0/40, respectively. Patients in the pethidine group displayed a more rapid return to calm wakefulness than those in the control group (P < 0.01). Inclusion of a low dose of pethidine in lidocaine for tonsillar infiltration improves pain relief after tonsillectomy in children.",1997.0,0,0
1468,9062618,Pharmacokinetic comparison of intravenous and intranasal administration of oxycodone.,A Takala; V Kaasalainen; T Seppälä; E Kalso; K T Olkkola,"For patients with chronic pain, treatment with oral analgesics is considered most convenient and feasible. Sometimes, however, the oral route cannot be used because of difficulties with swallowing, nausea, vomiting and gastrointestinal obstruction. To investigate the applicability of the nasal route for the administration of oxycodone, we studied the intravenous and intranasal pharmacokinetics of oxycodone in healthy volunteers. Ten healthy volunteers (3 males and 7 females) were given either an intravenous bolus of oxycodone hydrochloride 0.05 mg/kg or nasal sprays of oxycodone hydrochloride 0.1 mg/kg in a cross-over manner. Blood was sampled and subjective effects and side effects were recorded for 10 h. After intravenous administration of oxycodone, the plasma clearance of oxycodone was 0.83 +/- 0.33 l/min (mean +/- SD) and the volume of distribution at steady-state 2.02 +/- 1.47 l/kg and the terminal elimination half-life 157 +/- 47 min. After intranasal administration, peak plasma concentration of oxycodone was 13 +/- 6 ng/ml and it was reached in the median time of 25 min. The intranasal bioavailability of oxycodone was 0.46 +/- 0.34. No clinically significant changes in blood pressure or heart rate were observed but all subjects experienced somnolence after both modes of administration. The results of this study show that oxycodone is rapidly and rather effectively absorbed from the nasal mucosa but the interindividual differences are large. The intranasal route may in some cases be an attractive alternative to oral or parenteral administration of opioid analgesics. However, because of large interindividual differences, it is prudent to titrate the dose of intranasal oxycodone individually.",1997.0,0,0
1469,9063048,Analgesic dosing strategies for chronic pain.,R J Gregory,,1997.0,0,0
1470,9066229,Aspects of the problems in treating chronic pain: Florida pain management guidelines.,M Skinner,,1997.0,0,0
1471,9066324,"Baricity, needle direction, and intrathecal sufentanil labor analgesia.",F Ferouz; M C Norris; V A Arkoosh; B L Leighton; L M Boxer; R J Corba,"Intrathecal sufentanil relieves labor pain but centrally mediated side effects are common. Preventing rostral spread of intrathecal sufentanil should limit these side effects. Both direction of the lateral opening of a pencil-point needle and drug baricity modify the spread of intrathecal local anesthetics. This randomized, prospective, double-blind study examines the effects of these variables on intrathecal sufentanil labor analgesia. Forty laboring, full-term parturients, whose cervixes were dilated less than 5 cm and who requested analgesia for labor were enrolled. Combined spinal epidural analgesia was induced in patients in the sitting position. They were allocated to receive 10 micrograms intrathecal sufentanil diluted with either normal saline or dextrose with the aperture of the pencil-point needle directed cephalad or caudad during drug injection. Thus there were four groups of ten patients: dextrose up, dextrose down, saline up, and saline down. Sufentanil was diluted with normal saline to a concentration of 10 micrograms/ml. The study drug was made by mixing 1 ml sufentanil solution with either 1 ml 10% dextrose or 1 ml normal saline. Visual analog scores for pain, pruritus, nausea, and pain relief were recorded before and 5, 10, 15, and 30 min after drug injection. Baricity, but not needle orientation, influenced pain relief and pruritus. Sufentanil in dextrose produced less itching but also less analgesia. Nine of 20 women in the dextrose groups compared with 1 of 20 in the saline groups requested additional analgesia by 30 min. Little or no labor analgesia developed for patients receiving sufentanil with dextrose. A supraspinal action may contribute to intrathecal sufentanil's analgesic efficacy.",1997.0,0,0
1472,9069753,Wound care pain management.,J L Rook,"Undertreatment of all types of acute and chronic pain is common, both in the United States and around the world. Moreover, a literature review of pressure ulcer pain and its management suggests that this area of pain medicine is truly in its infancy. This article includes a discussion of current literature, anatomy and physiology of pain related to pressure and ischemic ulcers and assessment methods. It also describes treatment modalities, including conservative measures, medication management and invasive procedures. Special emphasis is placed on the use of opioid analgesics in the management of severe acute and chronic wound pain.",1996.0,0,0
1473,9074573,Randomised double-blind active-placebo-controlled crossover trial of intravenous fentanyl in neuropathic pain.,P L Dellemijn; J A Vanneste,"The effectiveness of opioid analgesics in non-cancer neuropathic pain is unpredictable and can be disappointing. It is not clear whether opioids, when effective, relieve pain by decreasing pain intensity or pain unpleasantness or by their sedative effect. The aim of this prospective randomised double-blind placebo-controlled crossover trial was to assess relief of pain intensity and pain unpleasantness with intravenous infusions of fentanyl. We compared the analgesic effect of intravenous dose titration of fentanyl with diazepam (active placebo) or saline (inert placebo) in 53 patients with different types of neuropathic pain. Patients were randomly assigned two consecutive infusions: fentanyl plus diazepam (27 patients) or fentanyl plus saline (26 patients). Study medication was infused at a constant rate for a maximum of 5 h. Pain, sedation, and side-effects were assessed from the start of infusion for 8 h. The primary outcome measure was maximum relief of pain intensity. One patient in the fentanyl/diazepam group and two in the fentanyl/saline group were withdrawn. Maximum relief of pain intensity was better with fentanyl than with diazepam (66% [95% CI 53-80] vs 23% [12-35]) or with saline (50% [36-63] vs 12% [4-20]). The beneficial effect of fentanyl was independent of the type of neuropathic pain and the degree of sedation. Fentanyl therapy produced equal relief of pain intensity and pain unpleasantness, whereas diazepam and saline did not reduce either pain index. Patients reported significantly more side-effects while receiving fentanyl than during diazepam or saline infusion (p < 0.0001), but none of the side-effects was severe. Fentanyl may relieve non-cancer neuropathic pain by its intrinsic analgesic effect. The clinical characteristics of neuropathic pain do not predict response to opioids.",1997.0,0,0
1474,9075033,Caudal epidural butorphanol plus bupivacaine versus bupivacaine in pediatric outpatient genitourinary procedures.,C D Lawhorn; J M Stoner; M L Schmitz; R E Brown; F W Stewart; P Volpe; R Shirey,"To investigate the efficacy of adding butorphanol to bupivacaine administered in the caudal epidural space in children undergoing genitourinary (GU) procedures. Randomized, double-blinded, controlled study. University affiliated pediatric hospital. 200 ASA physical status I and II male patients between 6 months and 10 years of age. Patients were randomized to receive either 0.25% bupivacaine with 1:200,000 epinephrine alone (Group 1) or 0.25% bupivacaine with 1:200,000 epinephrine plus 30 micrograms/kg butorphanol (Group 2) administered via the caudal epidural space prior to surgical incision. Patients were evaluated postoperatively until discharge. Measurements included requirement of additional analgesic, sedation, pain/ comfort scores, and a 24-hour analgesic follow-up. Significantly fewer patients in the butorphanol group required rescue morphine sulfate in the postanesthesia care unit (p < or = 0.001). The total number of morphine doses administered to Group 2 was significantly less than Group 1 (p < or = 0.001). 52% of patients in Group 1 compared with 28% in Group 2 required administration of additional analgesics following discharge from the hospital (p < or = 0.003), with 23% of Group 1 requiring a codeine compound compared with 8% in Group 2 (p < 0.03). The addition of 30 micrograms/kg butorphanol to 0.25% bupivacaine with epinephrine via the caudal epidural space is a safe, effective means to increase duration of analgesia following GU procedures.",2001.0,0,0
1475,9075493,Tramadol: a new centrally acting analgesic.,K S Lewis; N H Han,"The pharmacology, pharmacokinetics, efficacy, adverse effects, and dosage and administration of tramadol are reviewed. Tramadol is a synthetic analogue of codeine that binds to mu opiate receptors and inhibits norepinephrine and serotonin reuptake. It is rapidly and extensively absorbed after oral doses and is metabolized in the liver. Analgesia begins within one hour and starts to peak in two hours. In patients with moderate postoperative pain, i.v. or i.m. tramadol is roughly equal in efficacy to meperidine or morphine; for severe acute pain, tramadol is less effective than morphine. Oral tramadol can also be effective after certain types of surgery. Tramadol and meperidine are equally effective in postoperative patient-controlled analgesia. In epidural administration for pain after abdominal surgery, tramadol is more effective than bupivacaine but less effective than morphine. In patients with ureteral calculi, both dipyrone and butylscopolamine are more effective than tramadol. For labor pain, i.m. tramadol works as well as meperidine and is less likely to cause neonatal respiratory depression. Oral tramadol is as effective as codeine for acute dental pain. In several types of severe or refractory cancer pain, tramadol is effective, but less so than morphine; for other types of chronic pain, such as low-back pain, oral tramadol works as well as acetaminophen-codeine. Common adverse effects of tramadol include dizziness, nausea, dry mouth, and sedation. The abuse potential seems low. The recommended oral dosage is 50-100 mg every four to six hours. Tramadol is an effective, if expensive, alternative to other analgesics in some clinical situations.",1997.0,0,0
1476,9083166,Comparative clinical efficacy and safety of a novel controlled-release oxycodone formulation and controlled-release hydromorphone in the treatment of cancer pain.,N A Hagen; N Babul,"The use of oxycodone to treat chronic cancer pain has been hampered by its short elimination half-life, which necessitates administration every 4 hours. This study compared the clinical efficacy and safety of a novel oxycodone formulation with that of hydromorphone in the treatment of cancer pain. In a double-blind crossover study, 44 patients with stable cancer pain were randomized to controlled-release oxycodone or controlled-release hydromorphone, each given every 12 hours for 7 days. Pain intensity, nausea, and sedation were assessed by patients four times daily, and breakthrough analgesia was recorded. Thirty-one patients completed the study (18 women, 13 men; mean age, 56 +/- 3 years) and received a final controlled-release oxycodone dose of 124 +/- 22 mg per day and a final controlled-release hydromorphone dose of 30 +/- 6 mg per day. There were no significant differences between treatments in overall Visual Analogue Scale (VAS) pain intensity (VAS 28 +/- 4 mm vs. 31 +/- 4 mm), categorical pain intensity (1.4 +/- 0.1 vs. 1.5 +/- 0.1), daily rescue analgesic consumption (1.4 +/- 0.3 vs. 1.6 +/- 0.3), sedation scores (24 +/- 4 mm vs. 18 +/- 3 mm), nausea scores (15 +/- 3 mm vs. 13 +/- 3 mm), or patient preference. Two patients experienced hallucinations on controlled-release hydromorphone, but none did while receiving controlled-release oxycodone. Controlled-release oxycodone demonstrated excellent pharmacodynamic characteristics, analgesic efficacy, and safety as compared with controlled-release hydromorphone and represents an important new therapeutic option for cancer pain management.",2000.0,0,0
1477,9084525,[Pre- and intra-operative administration of epidural morphine provides good postoperative pain relief after laminectomy].,T C Kuo; J L Hsu; K S Su; C H Huang; D N Lee; N Y Cherng; W S Chen,"To evaluate the postoperative analgesic effect of epidural morphine administered at different timing in lumbar spine surgery. Eighty-four patients who were scheduled for elective lumbar spine surgery were randomized in three groups. Seventeen patients in group I who received non-steroid analgesics postoperatively (diclophenac sodium 50 mg, iv, q4h) served as control while thirty-six patients in group II who received single dose epidural morphine 3 mg in combination with 10 ml 2% lidocaine given at the lesion site (L4-5 or L5-S1) just before general anesthesia and thirty-one patients in group III who received 3 mg morphine in combination with 3 ml 2% lidocaine administered to the targeted epidural space by means of slow drippings just before wound closure were studied subjects. During the first 24 h postoperatively, the patients in group II and group III suffered a pain which was significantly less in intensity as compared with those in group I (p < 0.05). We used the 10 cm visual analog pain score (VAS) to scale post-operative pain with ""no pain"" and ""worst pain"" respectively anchored at 0 and 10 cm. The incidence of side effects such as pruritus, nausea and vomiting was higher in group II and III than in group I. We did not evaluate the occurrence of urinary retention because routine retention urinary catheterization in all patients hampered us to do so. There were no significant differences in the quality and duration of analgesia between group II and III. Respiratory depression of clinical significance was not observed. Neither decrease in oxygen saturation below 92% registered on pulse oximetry nor decrease in respiratory rate below 12 cycles/min was found in the PACU. Preoperative or intraoperative administration of epidural morphine could provide satisfactory analgesia in lumbar spine surgery during the first 24 h postoperatively.",1996.0,0,0
1478,9084539,"Epidural coadministration of ketamine, morphine and bupivacaine attenuates post-herpetic neuralgia--a case report.",C S Wong; T T Shen; W J Liaw; C H Cherng; S T Ho,"The N-methyl-D-aspartate (NMDA) receptor system plays an important role in nociceptive signal modulation in the central nerve system. There is considerable evidence that NMDA receptor antagonists can abolish hypersensitivity of nociceptors in animal models. In this case report, we described a patient who suffered post-herpetic neuralgia with severe pain, allodynia, and hyperesthesia over right side T2 to T8 dermatomes. Treatment with conventional doses of non-steroid anti-inflammatory drug (NSAID), antidepressant, anticonvulsant and benzodiazepine failed to provide satisfactory pain relief. With the patient's consent, we administered subanalgesic doses of ketamine (10 mg), morphine (1 mg), and 6 ml bupivacaine (0.1%) through the thoracic epidural route. After the treatment, hyperalgesia and allodynia improved dramatically, and the receptive field also reduced. After four weeks' treatment, satisfactory pain relief was achieved with conventional analgesics treatment. The combination of relatively low doses of morphine, ketamine and bupivacaine epidurally provides effective pain relief in this case. The result strongly suggests a synergy from this combination that warrants a formal study of the dose-response relationship involved in this treatment and the mechanism by which this effect is achieved. This regimen provides a promising treatment for the neuropathic pain with limited side effects.",1996.0,0,0
1479,9084945,,,,,0,0
1480,9084947,The use of opioids for the treatment of chronic pain. A consensus statement from the American Academy of Pain Medicine and the American Pain Society.,,,1997.0,0,0
1481,9085303,"Single-patient data meta-analysis of 3453 postoperative patients: oral tramadol versus placebo, codeine and combination analgesics.",R A Moore; H J McQuay,"The analgesic effectiveness and safety of oral tramadol were compared with standard analgesics using a meta-analysis of individual patient data from randomised controlled trials in patients with moderate or severe pain after surgery or dental extraction. Calculation of %maxTOTPAR from individual patient data, and the use of > 50%maxTOTPAR defined clinically acceptable pain relief. Number-needed-to-treat (NNT) for one patient to have > 50%maxTOTPAR compared with placebo was used to examine the effectiveness of different single oral doses of tramadol and comparator drugs. Eighteen randomised, double-blind, parallel-group single-dose trials with 3453 patients using categorical pain relief scales allowed the calculation of %maxTOTPAR. The use of > 50%maxTOTPAR was a sensitive measure to discriminate between analgesics. Tramadol and comparator drugs gave significantly more analgesia than placebo. In postsurgical pain tramadol 50, 100 and 150 mg had NNTs for > 50%maxTOTPAR of 7.1 (95% confidence intervals 4.6-18), 4.8 (3.4-8.2) and 2.4 (2.0-3.1), comparable with aspirin 650 mg plus codeine 60 mg (NNT 3.6 (2.5-6.3)) and acetaminophen 650 mg plus propoxyphene 100 mg (NNT 4.0 (3.0-5.7)). With the same dose of drug postsurgical patients had more pain relief than those having dental surgery. Tramadol showed a dose-response for analgesia in both postsurgical and dental pain patients. With the same dose of drug postsurgical pain patients had fewer adverse events than those having dental surgery. Adverse events (headache, nausea, vomiting, dizziness, somnolence) with tramadol 50 mg and 100 mg had a similar incidence to comparator drugs. There was a dose response with tramadol, tending towards higher incidences at higher doses. Single-patient meta-analysis using more than half pain relief provides a sensitive description of the analgesic properties of a drug, and NNT calculations allow comparisons to be made with standard analgesics. Absolute ranking of analgesic performance should be done separately for postsurgical and dental pain.",1997.0,0,0
1482,9085304,Pharmacokinetics and pharmacodynamics of twenty-four-hourly Kapanol compared to twelve-hourly MS Contin in the treatment of severe cancer pain.,G K Gourlay; D A Cherry; M M Onley; S G Tordoff; D A Conn; G M Hood; J L Plummer,"Twenty-four patients with severe pain related to cancer completed a randomised, double-blind, double-dummy, crossover study examining morphine pharmacokinetics and pharmacodynamics when the same 24-h morphine dose was administered using two modified release oral morphine formulations; either one dose of Kapanol (a new sustained release polymer coated pellet formulation administered in capsule form, Glaxo Wellcome group of companies) per 24 h, or MS Contin (Purdue Frederick Company, Connecticut, USA) administered at 12-h intervals. The morphine dose was optimised for each patient using an immediate release morphine solution in the lead-in period to provide the most favourable balance between pain relief and side-effects. Patients were then randomly allocated to receive their 24-h morphine dose as either Kapanol or MS Contin in period 1. Patients recorded daily measures of pain relief and morphine related side-effects (morphine pharmacodynamics) in a diary. Patients were admitted to the Pain Management Unit on the morning of day 7 (+/- 1 day) and frequent blood samples were collected for 24 h following the 10:00 h dose to fully characterise the pharmacokinetic profile for morphine and its metabolites at steady state. Morphine pharmacodynamics and the amount and timing of rescue medication (dextromoramide) were also recorded during this time. Period 2, which commenced at 10:00 h on day 8, was identical to period 1 except the modified release formulations were changed. The pharmacokinetic profile of Kapanol exhibited a significantly higher Cmin (minimum plasma morphine concentration), less fluctuation in plasma morphine concentration throughout the dosing interval, a longer Tmax (time associated with the maximum morphine concentration) and a greater time that the plasma morphine concentration was > or = 75% of Cmax (an index of the control the formulation exerts over the morphine release rate) compared to that of MS Contin. Some of these pharmacokinetic differences (e.g., Cmin and fluctuation in plasma morphine concentration) were surprising given that the dosing interval for Kapanol (24 h) was double that of MS Contin (12 h). There was no significant difference between the Kapanol and MS Contin treatment phases in any of the pharmacodynamic parameters, morphine related side-effects, the percentage of patients taking rescue medication as well as the amount or time to the first dose of rescue analgesia on day 7 in periods 1 and 2, patient or investigator assessments of global efficacy at the end of periods 1 and 2, or patient treatment preference at the end of the study. Once a day Kapanol provided the same degree of pain relief and morphine related side-effects as 12-h MS Contin.",1997.0,0,0
1483,9087187,"Methadone-related overdose deaths in South Australia, 1984-1994. How safe is methadone prescribing?",P A Williamson; K J Foreman; J M White; G Anderson,"To assess the safety of prescribing of methadone tablets and syrup in South Australia by investigating overdose deaths of patients using prescribed methadone and non-patients using illegally obtained methadone. Surveillance study of deaths related to methadone overdose, 1984-1994. Coroner's Office and the Therapeutic Goods Section of the South Australian Health Commission. Per capita prescription of methadone tablets for chronic pain in South Australia was the highest in Australia in 1994. A large increase in deaths, due mainly to methadone tablets prescribed for chronic pain, occurred in 1993-1994. Illegal diversion of methadone to non-patients was responsible for half of the deaths during these two years. Deaths from overdoses of methadone syrup prescribed in maintenance therapy for drug dependence declined from 1984 to 1994. The relative risk for patient deaths due to methadone tablets versus methadone syrup was estimated to be 7.29 (95% confidence limits, 2.15-31.48). Psychotropic drug combinations were present in 86% of deaths. The methadone syrup program for drug dependence remains relatively safe. Our data raise concerns about prescribing methadone tablets for chronic pain. Better prescriber education and accountability, patient assessment and supervision and advice to patients about concurrent use of alcohol and benzodiazepines are needed.",1997.0,0,0
1484,9088813,Intraarticular morphine administration provides pain relief after knee arthroscopy.,M Kanbak; N Akpolat; T Ocal; M N Doral; M Ercan; K Erdem,"This present study investigated the effects of intraarticular morphine administration in 1 mg and 5 mg doses on post-operative pain relief and analgesic requirements for patients undergoing arthroscopic procedures. At the end of the operation patients were randomly allocated in a double-blinded fashion into three groups. The control group (Group 1) received normal saline 20 mL intraarticularly. The patients in the second and third groups received intraarticular morphine sulphate 1 and 5 mg in saline 20 mL, respectively. Post-operative pain was assessed on the 1st, 6th and 24th hour by visual analogue scale (VSA). Supplementary analgesic requirement and possible complications were also followed. The intensity of pain and analgesic requirement were reduced more in the morphine 5 mg group than in the control group. It is concluded, that the administration of intraarticular morphine 5 mg provides long-lasting and effective analgesia after knee arthroscopy.",1997.0,0,0
1485,9088816,Comparison of metoclopramide and ondansetron for the prevention of nausea and vomiting after intrathecal morphine.,M T Pitkänen; M K Numminen; M K Tuominen; P H Rosenberg,"Nausea and vomiting remain unpleasant side effects of intrathecal (i.t.) morphine and of the numerous therapies tried, only prophylactic intravenous (i.v.) metoclopramide has been reported to be promising. Seventy-three patients, scheduled for orthopaedic prosthesis surgery of the hip or knee were studied. They received 4 mL of plain bupivacaine and 0.3 mg of preservative-free morphine i.t. for anaesthesia. The test drugs given in a double-blind and randomized fashion, were either metoclopramide 20 mg, three times, at 6 h intervals (23 patients), ondansetron, 8 mg, twice, at 12 h intervals (25 patients), or 0.9% saline three times, at 6 h intervals (25 patients). The occurrence of nausea, vomiting and pain was followed for 24 h. The incidences of nausea and vomiting were 60% (15/25) and 56% (14/25) in the saline group, 52% (12/23) and 48% (11/23) in the metoclopramide group, and 52% (13/25) and 40% (10/25) in the ondansetron group. Incidences of severe vomiting were 24, 35 and 12% respectively. Eight patients in the saline group, seven in the metoclopramide and 10 in the ondansetron group did not need additional opioids for post-operative pain relief. We conclude that, metoclopramide and ondansetron were not better than saline in the prevention of post-operative emesis induced by intrathecal morphine.",1997.0,0,0
1486,9089852,Subarachnoid meperidine-morphine combination. An effective perioperative analgesic adjunct for cesarean delivery.,J H Chung; R S Sinatra; F B Sevarino; L Fermo,"Low-dose subarachnoid morphine provides effective perioperative analgesia but may be associated with a transient period of inadequate pain relief between the regression of local anesthetic block and the onset of morphine's analgesic effect. We hypothesized that this period of suboptimal analgesia could be avoided by adding meperidine, a rapid-acting, intermediate-duration opioid. In a double-blind, randomized trial, 49 patients scheduled for elective cesarean delivery received subarachnoid 0.75% bupivacaine, 12 mg in 8.25% dextrose, with either meperidine 10 mg, morphine 0.15 mg, or meperidine 10 mg plus morphine 0.15 mg. Visual analog scale scores for pain and satisfaction were obtained at skin incision, delivery, uterine exteriorization, on arrival in the postanesthesia care unit, and 2, 4, 6, 12, and 24 hours after drug administration. Neonatal Apgar scores and adverse effects were also noted. Postoperative intravenous patient-controlled analgesia (PCA) requirements were recorded for 24 hours. The data were analyzed by chi-square analysis Fisher's exact test, the Wilcoxon rank sum test, and analysis of variance with Tukey's adjustment for multiple comparisons. There were no significant differences in the incidence and severity of side effects, including nausea, vomiting, pruritus, and sedation. Respiratory depression was not observed. Patients treated with morphine alone were least comfortable (P < .006), expressed the lowest satisfaction scores at early observations (P < .002), and required more PCA meperidine (P < .001) than any other group. Patients treated with meperidine alone were comfortable at early observations but required the greatest total amount of PCA meperidine over the first 24 hours (P < .05). Patients in the meperidine-morphine combination group reported the lowest pain scores and highest satisfaction scores at 4-hour and 6-hour observations (P < .03) and required the least total amount of PCA meperidine. The subarachnoid combination of meperidine-morphine provided more uniform analgesia, higher satisfaction, and a lower requirement for intravenous narcotic supplementation than either morphine or meperidine alone in patients recovering from cesarean delivery.",1997.0,0,0
1487,9092278,Treating chronic pain.,S L Montauk; J Martin,Quantifiable and measurable methods accurately assess pain severity and successfully guide physicians in determining which medications and modalities are appropriate and necessary for the treatment of chronic pain. A variety of pain assessment scales and the World Health Organization's three-step analgesic ladder can be the starting point for successful pain management.,1997.0,0,0
1488,9092847,Deep brain stimulation for intractable pain: a 15-year experience.,K Kumar; C Toth; R K Nath,"During the past 15 years, we prospectively followed 68 patients with chronic pain syndromes who underwent deep brain stimulation (DBS). The objective of our study was to analyze the long-term outcomes to clarify patient selection criteria for DBS. Patients were referred from a multidisciplinary pain clinic after conservative treatment failed. Electrodes for DBS were implanted within the periventricular gray matter, specific sensory thalamic nuclei, or the internal capsule. Each patient was followed on a 6-monthly follow-up basis and evaluated with a modified visual analog scale. Follow-up periods ranged from 6 months to 15 years, with an average follow-up period of 78 months. The mean age of the 54 men and 14 women in the study was 51.3 years. Indications for DBS included 43 patients with failed back syndrome, 6 with peripheral neuropathy or radiculopathy, 5 with thalamic pain, 4 with trigeminal neuropathy, 3 with traumatic spinal cord lesions, 2 with causalgic pain, 1 with phantom limb pain, and 1 with carcinoma pain. After initial screening, 53 of 68 patients (77%) elected internalization of their devices; 42 of the 53 (79%) continue to receive adequate relief of pain. Therefore, effective pain control was achieved in 42 of 68 of our initially referred patients (62%). Patients with failed back syndrome, trigeminal neuropathy, and peripheral neuropathy fared well with DBS, whereas those with thalamic pain, spinal cord injury, and postherpetic neuralgia did poorly. DBS in selected patients provides long-term effective pain control with few side effects or complications.",1997.0,0,0
1489,9093740,The use of music during the immediate postoperative recovery period.,R M Heiser; K Chiles; M Fudge; S E Gray,"The most effective approach to managing patients' pain in the immediate postoperative period may include a combination of pharmacologic agents and noninvasive, nonpharmacologic interventions. In this study, nurse researchers evaluated the effect of music on pain and anxiety levels and selected physiologic parameters of two groups of patients who were emerging and recovering from anesthesia. Patients in the treatment group listened to music through head-phones during the last 30 minutes of their surgical procedures and during the first hour in the postanesthesia care unit (PACU). Patients in the control group had identical surgical procedures, received the same preoperative medications, and were managed with the same anesthesia protocol but did not listen to music in the OR or PACU. No differences existed between the two patient groups in the variables measured; however, patients in the treatment group stated that music helped them relax and functioned as a distracter.",1997.0,0,0
1490,9100396,Continuous intravenous dihydroergotamine in the treatment of intractable headache.,R G Ford; K T Ford,"We reviewed data on 171 patients with refractory headache treated by continuous intravenous dihydroergotamine mesylate (i.v. DHE 45) and repetitive i.v. DHE and compared the efficacy of continuous i.v. DHE to repetitive i.v. DHE. One hundred (58.5%) patients had refractory chronic daily headache. Seventy-one (42%) had drug rebound headache. One hundred thirty-eight (81%) had refractory migraine without aura, and 28 (16%) had migraine with aura. Treatment consisted of either continuous i.v. DHE by infusion pump or repetitive i.v. DHE and withdrawal of excessively used analgesics, analgesic narcotics, ergotamines, or benzodiazepines. Eighty-nine (92.5%) patients treated with continuous i.v. DHE became headache-free; the majority, 62 (64.5%), within 3 days. Sixty-five (86.5%) patients treated by repetitive i.v. DHE became headache-free, 50 (66.5%) within three days. The average hospital stay for both treatment groups was 4 days. Twelve (12.5%) of the continuous group and 12 (16%) of the repetitive group were headache-free within 24 hours. The average length of time to become headache-free was similar for the two groups, 3.06 days for continuous i.v. DHE and 2.94 days for repetitive i.v. DHE. The most common side effect was nausea, followed by diarrhea, vomiting, and leg cramps. We conclude that DHE can be accurately and easily administered by continuous i.v. infusion pump, and that continuous i.v. DHE is a safe and efficacious mode of treatment producing results similar to repetitive i.v. DHE.",1997.0,0,0
1491,9104516,Bupivacaine decreases epidural meperidine requirements after abdominal surgery.,S St-Onge; F Fugère; M Girard,"The purpose of this study was to determine the optimal of three concentrations of bupivacaine (0.0%, 0.05%, 0.10%) to add to an epidural infusion of meperidine (1 mg.ml-1) for postoperative pain relief. In this prospective, double blind study, 60 patients undergoing abdominal surgery with general anaesthesia were randomized into three groups to receive for postoperative epidural analgesia: 1) 1 mg.ml-1 meperidine (0% group), 2) bupivacaine 0.05% and 1 mg.ml-1 meperidine (0.05% group), 3) bupivacaine 0.10% and 1 mg.ml-1 meperidine (0.10% group). Postoperatively, the epidural infusion rate was titrated to produce adequate analgesia and pain was assessed at rest and on movement. There were no differences in demographic data, average pain scores or side effects among the three groups. However, there was improvement of pain relief at rest over time in the three groups (P < 0.05). Postoperative epidural analgesic infusion rates increased over time for the three groups (P < 0.05) and were lower in the 0.10% group (mean of 10.0 ml.hr-1) than in the 0% group (mean of 12.6 ml.hr-1) (P < 0.05). More than half of the 0% group had serum meperidine concentrations > 400 g.L-1 to control moderate postoperative pain. Although analgesia was identical among groups, the lower serum concentrations of meperidine support the addition of bupivacaine 0.10% to meperidine when administered as a continuous infusion following abdominal surgery.",1997.0,0,0
1492,9104518,A comparison of three regional anaesthesia techniques for outpatient knee arthroscopy.,B D Goranson; S Lang; J D Cassidy; W N Dust; J McKerrell,"The purpose of this study was to compare intraoperative conditions and postoperative pain control of three peripheral regional anaesthesia techniques for outpatient knee arthroscopic procedures. Sixty patients were randomized to one of three groups. Group 1A received portal injections (10 ml lidocaine 1%), intraarticular lidocaine (20 ml CO2 lidocaine 2% with 1/200,000 adrenaline) and a placebo femoral nerve block (20 ml saline). Group FNB received a femoral 3-in-1 nerve block (20 ml chloroprocaine 2% with 1/200,000 adrenaline), placebo portal injections (10 ml saline) and placebo intraarticular saline (20 ml saline with 1/200,000 adrenaline). Group FNB + IA received a femoral 3-in-1 nerve block, intraarticular lidocaine and placebo portal injections. The following were assessed: intraoperative pain (10 cm VAS: 0 = no pain, 10 = extreme pain), surgical operating conditions (1 = excellent, 4 = unacceptable), intraoperative use of sedation and analgesia, time to discharge, patient satisfaction score (1 = very satisfied, 5 very unsatisfied) and postoperative analgesia. Data were analyzed using ANOVA, Kruskal-Wallis, and Chi-square tests as appropriate, P < 0.05 was considered significant. There were no differences among the groups regarding any of the variables tested. Considerable post-operative pain (VAS > or = 5) was experienced by 20/54 (37%) patients. Any of the three anaesthetic techniques tested provide reliable intraoperative patient and surgical conditions for outpatient knee arthroscopy. Patient discomfort postoperatively was considerable in all groups and requires further investigation.",1997.0,0,0
1493,9104519,Transdermal fentanyl system plus im ketorolac for the treatment of postoperative pain.,D J Reinhart; M E Goldberg; J V Roth; R Dua; I Nevo; K W Klein; M Torjman; D Vekeman,"To assess the safety and efficacy of transdermal fentanyl plus im ketorolac vs im ketorolac alone in the treatment of postoperative pain. Ninety-two patients scheduled for surgery involving moderate to severe postoperative pain were randomized to one of two groups. Group A (n = 46) received an active fentanyl patch and group P (n = 46) received a placebo patch. Patches remained in place for 24 hr. Each patient received intraoperative ketorolac, 60 mg im. Patients were monitored for 36 hr postoperatively and the groups were analyzed for ketorolac usage, pain scores, vital signs, serum fentanyl concentrations, and adverse events. Intramuscular ketorolac was available on demand. Group A had lower pain scores at 8.12, 16 and 24 hr after patch placement (P < 0.05). Group A had lower heart rates, lower respiratory rates and fewer dropouts due to inadequate pain relief (4.3% vs 21.7% P < 0.05). Group A patients also used less ketorolac than group P patients (P < 0.05). The incidence of pruritus was higher in group A patients (19% vs 2%, P < 0.05), while the incidence of nausea and vomiting was not different between the two groups. Transdermal fentanyl was adequate ""stand-alone"" analgesia in only 23.8% of group A patients while 93.7% of the remaining group A patients receiving a combination of transdermal fentanyl and ketorolac had adequate pain relief. The transdermal fentanyl delivery system plus ketorolac im was more effective in controlling post-operative pain than ketorolac im alone. The two treatment modalities were comparable in safety with no difference in serious adverse events.",1997.0,0,0
1494,9104663,Patient controlled analgesia and intramuscular injections: a comparisons of patient pain experiences and postoperative outcomes.,C C Snell; F Fothergill-Bourbonnais; S Durocher-Hendriks,"Despite relatively widespread use of various forms of patient controlled analgesia (PCA), there remain conflicting results in the literature as to the efficacy of PCA. This study was conducted to assess the efficacy and postoperative outcomes of intravenous PCA compared to intramuscular (IM) injections in 73 patients who received major abdominal surgery. These patients were randomly selected and randomly assigned preoperatively to receiving IM or PCA modes of analgesia postoperatively. The following factors were compared: amount of pain; amount of analgesia use; degree of patient satisfaction with pain control both while on parenteral analgesia and after switching to oral; length of time to first ambulation; and length of stay in hospital. Results of the study did not demonstrate a statistically significant difference in any of these, using a P-value of 0.01. The PCA patients took an average of 4.5 hours longer than the IM patients to ambulate postoperatively and the IM patients received at least three times as much antiemetic (P = 0.001). Locus of control was not found to be a major factor in satisfaction or pain levels. Subsequent meta-analyses have also failed to yield significant differences between IM and PCA groups except in patient satisfaction. It is recommended that expansion of PCA programmes with abdominal surgery patients be considered only in cases where there is fiscal advantage or where patient satisfaction can be a driving force.",1997.0,0,0
1495,9105246,"Practice guidelines for chronic pain management. A report by the American Society of Anesthesiologists Task Force on Pain Management, Chronic Pain Section.",,,1997.0,0,0
1496,9107526,Management of sickle pain.,S K Ballas,"Sickle cell disease is characterized by recurrent episodes of acute pain. Some patients also suffer from chronic pain syndromes including avascular necrosis, leg ulcers, and intractable pain. Approaches to rational therapy of sickle pain include pharmacologic, nonpharmacologic, and preventive therapeutic interventions. Pharmacologic treatment of sickle pain entails the use of nonopioid analgesics, opioid analgesics, and adjuvants singly or in combination depending on the severity of pain. Meticulous evaluation and assessment of painful episodes should precede and accompany all approaches to management. The choice of the opioid analgesic, its route of administration, dose, and frequency of administration should be individualized on a case-by-case basis. Meperidine should be avoided whenever possible. Nonsteroidal anti-inflammatory drugs, meperidine, and morphine are contraindicated in the presence of renal failure. Administration of opioids on a fixed schedule or by patient-controlled analgesia is ideal for effective therapy. Nonpharmacologic approaches to manage sickle pain are underutilized and more studies are needed to determine their role in sickle pain. Preventive therapy of sickle pain is best achieved with hydroxyurea, which was found to decrease the frequency of crises significantly, decrease the incidence of acute chest syndrome, and decrease the need for blood transfusion.",1997.0,0,0
1497,9112708,Drug therapy for back pain. Which drugs help which patients?,R A Deyo,"A brief review of current literature and issues on drug therapy for low back pain. To identify current knowledge and future research needs related to drug therapy. Drug therapy is one of many possible treatment choices for symptom relief in patients with low back pain. The variety of drugs used suggests that there is no uniquely successful form of drug therapy. One reason for uncertainty and slow progress in this area is the limited quality of many clinical trials for back pain, with inadequate description of patients and outcomes being common deficits. A selective review of randomized trials and systematic literature syntheses on drug therapy is given. Despite limitations, there is good evidence to support the efficacy of nonsteroidal anti-inflammatory drugs for acute low back pain and fair evidence for the use of muscle relaxants. There is greater controversy about the use of corticosteroids, which have been administered orally, intramuscularly, and epidurally. There is conflicting evidence regarding epidural injection of corticosteroids, but one meta-analysis suggests they may provide a small symptomatic improvement for patients with radiculopathy. Trials of systemic steroids and antidepressant drugs for managing chronic pain are inconclusive. The only randomized trial of local anesthetic injection into trigger points suggested that this treatment was equivalent to that of saline injection, needling without injection, or vapo-coolant spray alone. It seems reasonable to recommend acetaminophen or nonsteroidal anti-inflammatory drugs for patients with acute back pain, with efforts to minimize costs and complications. Muscle relaxants and narcotic analgesics may be appropriate for some patients, but selection criteria are unclear, and these drugs should be prescribed for fixed periods. Drug treatment for chronic low back pain is less clear, and a current controversy centers on the use of chronic narcotic analgesics for such patients. Future research should include evaluating combinations of medications, combinations of medication and physical therapy, systemic corticosteroid therapy, trigger point injections, and narcotic use for patients with chronic pain. Spinal stenosis is common in the older population, and more drug trials are needed for this condition.",1996.0,0,0
1498,9113175,Anesthetic quality during cesarean section following subarachnoid or epidural administration of bupivacaine with or without fentanyl.,C Olofsson; A Ekblom; E Sköldefors; B Wåglund; L Irestedt,"It is often assumed that subarachnoid administration of local anesthetics produces a more profound blockade than epidural anesthesia. Furthermore, the addition of fentanyl has been reported to increase preferentially intraoperative analgesia. In the present study we set out to study these two issues in a randomized and controlled study with respect to perceived pain and discomfort during surgery and postoperative pain. In the present study, 100 parturients subjected to elective cesarean section, 34 nullipara and 66 multipara, received one out of four combinations of the local anesthetic bupivacaine and the opioid fentanyl; group A--bupivacaine 12.5 mg + 10 micrograms fentanyl subarachnoidally, group B--bupivacaine 12.5 mg + saline subarachnoidally, group C--bupivacaine 100 mg + 100 micrograms fentanyl epidurally, group D--bupivacaine 100 mg + saline epidurally; N = 25 in each group. Pain intensity and discomfort during surgery was assessed with a visual analogue scale (VAS). Postoperative pain intensity and need for analgesics postoperatively, ketobemidone, was registered for 24 h following surgery. Intraoperative pain intensity and discomfort did not differ significantly between parturients in any of the four groups Postoperative pain was significantly more intense in parturients receiving local anesthetics subarachnoidally as compared to the epidural groups during the first 6-h period. This difference was also reflected in a significantly increased consumption of analgesics during this period. No significant differences between the groups were observed with regard to hemodynamics (blood pressure), respiration (oxygen saturation) or other effects such as nausea or itching. All neonates had normal Apgar and neonatal adaptive capacity scores (NACS). We conclude that subarachnoidal (12.5 mg) and epidural (100 mg) injections with bupivacaine both produced adequate anesthetic quality in women undergoing elective cesarean section. The addition of fentanyl (10 micrograms subarachnoidally or 100 micrograms epidurally) did not significantly improve the quality of these already profound blockades.",1997.0,0,0
1499,9113177,Intravenous regional analgesia using morphine. The effect on postoperative pain following total knee arthroplasty.,M McSwiney; J Cooper; S Karadia; M Campbell,"We hypothesised that any peripheral action of morphine may contribute to improved postoperative analgesia. The aim of this study was to evaluate the analgesic efficacy of morphine administered preoperatively into an exsanguinated limb prior to total knee arthroplasty. A randomised, double-blind, controlled study was performed in 50 patients having total knee arthroplasty surgery. Patients were divided into two groups. In the study group, 0.125 mg/kg morphine in 60 ml of saline was administered intravenously (iv) into the exsanguinated operative limb via a cannula in the foot. A saline intramuscular (im) injection was administered into the opposite leg. The control group received 60 ml saline iv into the operative leg and 0.125 mg/kg morphine im into the opposite leg. Pain was assessed postoperatively using a 10-point visual analogue scale and by comparing morphine requirements and demand:delivery ratios from a patient-controlled analgesic pump. We found no statistically significant difference between the groups in relation to any of the analgesic measures employed. Intravenous regional analgesia using morphine provides no analgesic advantage over the intramuscular route from 6-24 h postoperatively.",1997.0,0,0
1500,9120965,Intravesical morphine analgesia after bladder surgery.,J W Duckett; T Cangiano; M Cubina; C Howe; D Cohen,"A recent demonstration of peripheral opioid receptors suggested the possibility of delivering morphine locally into the bladder after reimplantation for ameliorating the discomfort of postoperative bladder irritation with spasms. Since we do not use bladder drainage after reimplantation, dripping a morphine solution into the bladder permits contact with the urothelium between voidings. A pilot trial using an arbitrary concentration was subjectively beneficial for treating these patients postoperatively. We now report a prospective randomized study evaluating the effectiveness and dosage of various concentrations of intravesical morphine infusions. A total of 52 children undergoing ureteral reimplantation was randomized to receive 1 of 3 concentrations of intravesical morphine (0.05, 0.375 or 0.5 mg./ml.). A small feeding tube remained in the bladder to drip a continuous infusion postoperatively. Subsequent postoperative pain was treated with meperidine, acetaminophen and codeine, and/or a belladonna and opium suppository. During each shift a nurse assisted the child in assessing pain using a Baker-Wong faces scale. Bladder infusion was discontinued after day 3 postoperatively and plasma morphine levels were measured on the first morning postoperatively. Kruskal-Wallis and paired t tests were used to evaluate significance. Patients reported greater pain in the group infused with 0.05 mg./ml. on 4 of 6 shifts on the first 2 days postoperatively. No difference was noted on postoperative day 3. Plasma morphine was undetectable by high pressure liquid chromatography. This study offers objective evidence that bladder morphine infusion is effective for ameliorating postoperative pain in the first 48 hours after intravesical ureteral reimplantation. The dose given today is 0.5 mg./ml. delivered at 0.04 ml./kg. per hour.",1997.0,0,0
1501,9121810,Nimodipine fails to enhance the analgesic effect of slow release morphine in the early phases of cancer pain treatment.,G Roca; J L Aguilar; C Gomar; V Mazo; J Costa; F Vidal,"We assessed nimodipine's ability to increase the analgesic effect of morphine in 32 patients suffering from cancer pain in a double-blind, placebo controlled cross-over study. Morphine administration began a few days before the start of the study. The analgesic effects of two combinations were compared: morphine (M) plus placebo (P) and morphine plus 90 mg/24 h of nimodipine (N). The study lasted 8 days, including the wash-out period, and the following sequence of treatments was applied: M + P or M + N on days 1, 2 and 3; only M on days 4 and 5; and M + N or M + P on days 6, 7 and 8. Morphine dose was individualised according to the intensity of the patient's pain and the same dose was maintained throughout the study period. Analgesic response was evaluated using four 10 cm visual analogue scales of quantitative variables for pain intensity, pain relief, sleep quality and mood. A verbal rating of qualitative variables was also scored following validated descriptors of pain in the Spanish language. No significant statistical differences were found in analgesic effect between combined treatment with nimodipine or placebo, as measured on any of the scales. In order to take into account both the short duration of treatment (8 days), and nimodipine's pharmacokinetic characteristics (half-life of 6 h and steady state of 36 h), we compared treatment with nimodipine or placebo on the third day of use, at which time, likewise, there were no statistically significant differences on any of the scales. However, when the same statistical tests were used for comparison of results with pre-treatment baseline values, highly significant differences between mean scores on the scales for pain relief and pain intensity were found. Based on these negative results we conclude that nimodipine given orally at a dose of 30 mg every 8 h does not enhance analgesia when associated with morphine in the early phases of treatment for cancer pain. Our study also gives clear evidence of a placebo effect.",1996.0,0,0
1502,9121823,Effect of present pain and mood on the memory of past postoperative pain in women treated surgically for breast cancer.,T Tasmuth; A M Estlanderb; E Kalso,"In our recent retrospective study on breast cancer patients, the intensity of the past postoperative pain was a primary factor in predisposing the development of chronic post-treatment pain. The present prospective study was designed to find out if the remembered intensity of postoperative pain (RIPP) after breast surgery was influenced by the development of chronic pain and if the RIPP had any correlation with the development of depression or anxiety. The patient's estimation of the severity of the RIPP was determined three times in the year after surgery. The state anxiety and depression and the presence of pain in the ipsilateral arm were assessed before the operation, and 1, 6 and 12 mos after surgery. Ninety-three consecutive female patients with breast cancer who were enrolled for surgical treatment were recruited to the study during 1993-1994. The patients were treated with modified radical mastectomy with axillary clearance (n = 53) or breast resection with axillary clearance (n = 40). The patients' records were checked for the consumption of analgesics within the first 48 h after surgery. The patients were analysed in three groups according to the presence or absence of preoperative or chronic post-treatment pain. There was a significant correlation between the RIPP and the consumption of both opioids and NSAIDs on the ward. The women who had chronic pain remembered having had more severe postoperative pain compared with those women who had no chronic pain. The RIPP increased with time in the chronic pain patients whereas it decreased in the patients who had no chronic pain. In all patients the preoperatively measured state anxiety and depression scores were higher than in healthy Finnish women. One year after surgery anxiety and depression had returned to normal levels except in the patients who had chronic pain. Their depression remained at a higher level during the first year after surgery. The results suggest that the amount of postoperative pain may play a role in the development of chronic pain. However, the development of chronic pain is connected to a tendency to overestimate previous pain and to higher levels of depression.",1996.0,0,0
1503,9132032,[Characteristics of pain and its treatment in patients at a nursing home].,M Cañellas Arsegol; F Bosch Llonch; M T Vilarnau Dolcet; M Sola Pares; J E Baños Díez,"Pain is an unique symptom which may constitute minor ailment but also the main complaint of a severe disease. It is one of the main factors that limits quality of life in patients with chronic diseases, specially in those institutionalized in nursing homes (NH). The aim of our study was to determine the characteristics of pain complaints and analgesic treatment, as well as the satisfaction degree of patients with their treatment. To this goal, an observational cross-sectional drug utilization study was undertaken in a sample of 74 patients of a nursing home. All of them were consuming analgesic drugs at the moment of the study and their mean (+/-standard deviation) was 75.5 +/- 13.9 years. The study analyzed several pain characteristics (intensity, etiology, localization and duration) as well as analgesic treatment features (drug, route of administration, prescribed dose and therapeutic compliance). The satisfaction with the therapeutic regimen was also evaluated. Nearly a third (32.4%) of patients described that they suffered severe pain, mostly from peripheral joints (70.1%) and mainly located in legs. The duration of pain was longer than one month in 56.8%. Most of patients were following a chronic treatment with scheduled analgesics, being paracetamol (28.7%) the most consumed drug. However, daily doses were less than considered effective to treat pain. The preferred route of administration was oral. The satisfaction degree varied nong the units of NH, but it was scored as acceptable in most patients. It may be concluded that pain is a highly prevalent issue in NH and, in spite of the provided analgesic treatment, was evaluated as severe by a significant group of patients. Although drugs were prescribed at ""by the clock"" patterns, the daily dose was below the recommended one. In spite of high prevalence of severe pain, patients were satisfied with the analgesic treatment they were receiving.",1996.0,0,0
1504,9132194,Intranasal diamorphine for paediatric analgesia: assessment of safety and efficacy.,J A Wilson; J M Kendall; P Cornelius,"To evaluate the safety and efficacy of intranasal diamorphine as an analgesic for use in children in accident and emergency (A&E). A prospective, randomised clinical trial with consecutive recruitment of patients aged between 3 and 16 years with clinically suspected limb fractures. One group received 0.1 mg/kg intranasal diamorphine, and the other group received 0.2 mg/kg intramuscular morphine. At 0, 5, 10, 20, and 30 minutes pain scores, Glasgow coma score, and peripheral oxygen saturations were recorded; parental acceptability was assessed at 30 minutes. 58 children were recruited, with complete data collection in 51 (88%); the median summed decrease in pain score was better for intranasal diamorphine than intramuscular morphine (9 v 8), though this was not significant (P = 0.4, Mann-Whitney U test). The episode was recorded as ""acceptable"" in all parents whose child received intranasal diamorphine, compared with only 55% of parents in the intramuscular morphine group (P < 0.0001, Fisher's exact test). There was no incidence of decreased peripheral oxygen saturation or depression in the level of consciousness in any patient. Intranasal diamorphine is an effective, safe, and acceptable method of analgesia for children requiring opiates in the A & E department.",1997.0,0,0
1505,9132630,[Analgesic effects of natural growth hormone release inhibitors and their synthetic analogs. Intraspinal administration].,D Beltrutti; F Debernardi; G Pelosi,"The authors examine the pharmacological characteristics, distribution and clinical effects of natural (somatostatin) and synthetic (octreotide) growth hormone release inhibitors (GHRIH). They mainly discuss the analgesic effect of these substances using intraspinal, epidural and subarachnoid administration. The intraspinal use of somatostatin and its synthetic analog, octreotide, are not without risks: among these, it is worth recalling the neurotoxic and vasomotor effects. Further studies may more clearly define these and other secondary effects and also the real indications for these drugs in the context of analgesics for intraspinal use. It is hypothesised that somatostatin and octreotide, owing to their analgesic capacities, may replace the intraspinal administration of opioids in a number of clearly defined clinical conditions, such as severe pain in which opioids are contraindicated.",1997.0,0,0
1506,9135180,A comparison of remifentanil and alfentanil in patients undergoing major abdominal surgery.,J Schüttler; S Albrecht; H Breivik; S Osnes; C Prys-Roberts; K Holder; M Chauvin; J Viby-Mogensen; T Mogensen; I Gustafson; L Lof; D Noronha; A J Kirkham,"The efficacy and safety of remifentanil and alfentanil for patients undergoing major abdominal surgery were compared. Premedicated patients received a loading dose of remifentanil (1.0 microgram.kg-1; n = 116) and a continuous infusion of 0.5 microgram.kg-1.min-1, or a loading dose of alfentanil (25 micrograms.kg-1; n = 118) and a continuous infusion of 1.0 microgram.kg-1.min-1. Propofol was administered (10 mg every 10 s) until loss of consciousness. Patients' lungs were ventilated with 66% nitrous oxide and 0.5% (end-tidal) isoflurane in oxygen. The study drug infusion rate was reduced by 50% 5 min after intubation. Alfentanil was discontinued 15 min before the end of surgery, whereas remifentanil was continued in the immediate postoperative period at a reduced dose. Responses to intubation (28%) and skin incision (17%) occurred approximately twice as often in the alfentanil group (15% and 8%; p = 0.014 and p = 0.037, respectively). More patients receiving alfentanil had one or more responses to surgery (72% vs. 57%; p = 0.016). The time to spontaneous respiration, adequate respiration, response to verbal command and time to recovery room discharge were similar. However, owing to decreased variability, the time to extubation was shorter with remifentanil than with alfentanil (p = 0.048). There was a similar overall incidence of adverse events in both groups, 82% and 75% of patients, respectively. Adverse events associated with remifentanil were rapidly controlled by dose reductions. The incidence of intra-operative hypotension and bradycardia was higher in the remifentanil group (p < or = 0.033). An initial remifentanil infusion rate of 0.1 microgram.kg-1.min-1 titrated to individual need provided postoperative pain relief in the presence of adequate respiration in 71% of patients. When using remifentanil in the immediate postoperative setting, rapid administration of bolus doses and infusion rate increases resulted in a relatively high incidence of muscle rigidity, respiratory depression and apnoea. Changing the postoperative regimen to avoid rapid changes in remifentanil blood concentration resulted in more effective analgesia and dramatically reduced the incidence of adverse events during this period. In patients undergoing major abdominal surgery, remifentanil appears to offer superior intra-operative haemodynamic stability during stressful surgical events compared with alfentanil without compromising recovery from anaesthesia. Remifentanil can be administered as a postoperative analgesic agent at a starting dose of 0.1 microgram-.kg-1.min-1; however, it should only be used in the presence of adequate supervision and monitoring of the patient. Administration of bolus doses is not recommended in this setting.",1997.0,0,0
1507,9135193,"Intrathecal morphine for caesarean section: an assessment of pain relief, satisfaction and side-effects.",M Swart; J Sewell; D Thomas,"In a prospective, randomised, double-blind study of 60 patients who had an elective Caesarean section under spinal anaesthesia we compared 0.1 mg intrathecal morphine with intrathecal saline placebo. All patients received morphine intravenously by patient-controlled analgesia after the operation. Pain, satisfaction and side-effects were assessed at 4 and 24 h after the operation. Pain measured by a 100-mm visual analogue scale was less in the intrathecal morphine group at both times (p < 0.05) and morphine consumption was lower (p < 0.01). At 4 h the intrathecal morphine group had more pruritus (p < 0.001) but there was no difference in satisfaction. At 24 h there was no significant difference in side-effects, but overall satisfaction measured by visual analogue scale was better in the intrathecal morphine group (p < 0.01). Intrathecal morphine improves pain relief and patient satisfaction after Caesarean section.",1997.0,0,0
1508,9135312,Does intrathecal fentanyl produce acute cross-tolerance to i.v. morphine?,D W Cooper; S L Lindsay; D M Ryall; M S Kokri; S S Eldabe; G A Lear,"We have examined the hypothesis that intrathecal fentanyl at operation can increase postoperative i.v. morphine requirements. We studied 60 patients undergoing Caesarean section. All received intrathecal 0.5% plain bupivacaine 2 ml combined with either fentanyl 0.5 ml (25 micrograms) (group F) (n = 30) or normal saline 0.5 ml (group S) (n = 30). In addition, 10 ml of an extradural solution (fentanyl 1 ml (50 micrograms) combined with 0.5% bupivacaine 9 ml) was administered after delivery. Extradural solution was only given before delivery if the intrathecal injection failed to produce a block above T6 or the patient required further analgesia. Postoperative analgesia was provided with i.v. morphine patient-controlled analgesia. At operation, intrathecal fentanyl reduced the need to administer extradural solution before delivery, increased the anaesthetist's satisfaction with analgesia and reduced nausea, but increased pruritus. Up to 6 h after delivery there was no difference in postoperative morphine requirements or pain scores. Between 6 h and 23 h there was a 63% increase in morphine requirements in group F. We consider the most likely explanation for this finding to be that intrathecal fentanyl induced acute spinal opioid tolerance.",1997.0,0,0
1509,9135342,Wound infiltration with local anaesthetic after abdominal hysterectomy.,T F Cobby; M F Reid,The study was performed to investigate if wound infiltration with 20 ml of 0.5% bupivacaine after abdominal hysterectomy improved analgesia and reduced morphine requirements from a patient-controlled analgesia system during the first 6 h after operation. Forty patients undergoing abdominal hysterectomy were allocated randomly to one of two groups. The study was performed in a double-blind controlled manner. Morphine requirements in the first 6 h after operation were similar in both the control (30.3 mg) and bupivacaine (29.0 mg) groups. Cumulative hourly morphine requirements did not differ significantly between the two groups. Pain scores assessed by visual analogue were similar in both groups.,1997.0,0,0
1510,9138761,[Use of opiates for chronic pain].,F Larue,"World Health Organization (WHO) has recommended since 1986 simple methods to control pain due to cancer. The use of analgesic medications, appropriate to the severity of pain reported by the patient, is the key point of WHO guidelines. It has been shown that the use of analgesic medication and particularly of morphine to control severe pain is insufficient for a majority of patients worldwide. This communication presents the main results of French national studies among representative samples of cancer patients and physicians (primary care physicians and medical oncologists) faced with cancer pain. These studies confirm that cancer pain is inadequately treated for 51% of patients and identify among French physicians attitudinal barriers to the proper use of morphine. Results are discussed with regard to the national policy against pain now in progress in France.",1996.0,0,0
1511,9150291,Developments in the treatment of cancer pain in Finland: the third nation-wide survey.,V Kaasalainen; A Vainio; T Ali-Melkkilä,"This survey was designed to investigate the current status of the management of cancer pain in Finland. In 1995 a questionnaire was randomly sent to 5% (n = 546) of Finnish physicians, excluding specialists not expected to treat cancer patients. Two previous surveys, using the same questionnaire, were conducted in 1985 and 1990 by Vainio. The response rate was 53%. Seventy-nine percent of the respondents treated one or less than one cancer patient a week. Sixty-seven percent of them assessed the severity of cancer pain in their patients as being at least moderate. In 10 years, the proportion of physicians suggesting the WHO analgesic ladder principle to their 'typical cancer patient' had increased from 12% to 28%. At the same time, the suggestions of 'analgesic' without definition had decreased from 48% to 6%. Three simulated patient cases were presented. The mean daily dose of opioids suggested for severe terminal cancer pain corresponded to 72 (18-300) mg of intramuscular morphine in 1995, being only 39 (1-77) mg in 1985 for the same simulated patient case. Continuous infusion of opioid was recommended by 59% of the respondents. Non-steroidal anti-inflammatory drugs as the treatment of choice for bone metastases pain in a patient with breast cancer, was recommended by 68% of the respondents. In the case of local severe pain due to recurrent rectal cancer, 63% of the physicians suggested anaesthetic intervention. Insufficient pain relief and lack of experience were the most common difficulties in pain management. Only one-third of the physicians thought that they had enough time and ability to give sufficient psychological support to their patients.",1997.0,0,0
1512,9150295,Blockade of peripheral neuronal barrage reduces postoperative pain.,S M Gordon; R A Dionne; J Brahim; F Jabir; R Dubner,"Peripheral afferent neuronal barrage from tissue injury produces central nervous system hyperexcitability which may contribute to increased postoperative pain. Blockade of afferent neuronal barrage has been reported to reduce pain following some, but not all, types of surgery. This study evaluated whether blockade of sensory input with a long-acting local anesthetic reduces postoperative pain after the anesthetic effects have dissipated. Forty-eight patients underwent oral surgery with general anesthesia in a parallel group, double-blind, placebo-controlled study. Subjects randomly received either 0.5% bupivacaine or saline intraoral injections, general anesthesia was induced with propofol, a non-opioid anesthetic, and 2-4 third molars extracted. Subjects were assessed at 24 and 48 h for postoperative pain and analgesic intake. Blood samples were collected at baseline, intraoperatively and at 1-h intervals postoperatively for measurement of beta-endorphin as an index of CNS response to nociceptor input. Plasma beta-endorphin levels increased significantly from baseline to the end of surgery in the saline group in comparison to the bupivacaine group (P < 0.05), indicating effective blockade of nociceptor input into the CNS by the local anesthetic. Pain intensity was not significantly different between groups at 24 h. Pain at 48 h was decreased in the bupivacaine group as measured by category scale and graphic rating scales for pain and unpleasantness (P < 0.05). Additionally, subjects in the bupivacaine group self-administered fewer codeine tablets for unrelieved pain over 24-48 h postoperatively (P < 0.05). These data support previous animal studies demonstrating that blockade of peripheral nociceptive barrage during and immediately after tissue injury results in decreased pain at later time points. The results suggest that blockade of nociceptive input by administration of a long-acting local anesthetic decreases the development of central hyperexcitability, resulting in less pain and analgesic intake.",1997.0,0,0
1513,9150772,Comparison of continuous epidural infusion of fentanyl and bupivacaine with intermittent epidural administration of morphine for postoperative pain management in children.,T Kart; S Walther-Larsen; T F Svejborg; V Feilberg; K Eriksen; M Rasmussen,"The aim of this study was to compare epidural infusion of bupivacaine and fentanyl and intermittent epidural morphine with regard to analgesic effect, and incidence and severity of side effects in children undergoing major abdominal or genito-urological surgery in order to improve the postoperative pain management of children. A double-blind, block-randomised study design was used. Thirty-one children aged 3 months to 6 years undergoing major abdominal or genito-urological surgery were studied. After induction of anaesthesia a lumbar epidural catheter was placed at L3-4 or L4-5. Postoperatively, the children received either 30 micrograms/kg of morphine every 8 h or a continuous infusion of fentanyl 2 micrograms/ml and bupivacaine 1.0 mg/ml at a rate of 0.25 ml.kg-1.h-1. All children additionally received rectal paracetamol in doses of 50-100 mg.kg-1.d-1 on a regular basis, and amol in doses of 50-100 mg.kg-1.d-1 on a regular basis, and if necessary supplementary intravenous morphine in doses of 50 micrograms/kg. Postoperatively, pain, administration of supplemental morphine and side effects were recorded 5 times by one observer during the day of surgery and the first postoperative day. All children had an epidural catheter throughout the study period. Both regimens provided effective analgesia, but significantly better pain relief was obtained in children receiving the fentanyl/bupivacaine regimen. Sedation, pruritus, vomiting, and administration of antiemetics were seen in both treatment groups, and even though both the incidence and severity of side effects tended to be higher in children receiving morphine, no statistically significant difference was found. No episodes of respiratory depression or motor blockade were noticed. Continuous epidural infusion of fentanyl and bupivacaine was found to be superior to intermittent epidural morphine. The initial regimen should be fentanyl 2 micrograms/ml and bupivacaine 1.0 mg/ml infused at a rate of 0.25 ml.kg-1.h-1.",1997.0,0,0
1514,9161655,Nitroprusside treatment of erythromelalgia in an adolescent female.,J D Stone; M P Rivey; D R Allington,"To report a case of erythromelalgia in an adolescent patient successfully treated with nitroprusside. A 15-year-old girl with erythromelalgia resistant to aspirin therapy received an infusion of nitroprusside. The response of the erythromelalgia to nitroprusside was dramatic, with complete pain resolution within 17 hours after the start of therapy. No relapse of erythromelalgia was seen when nitroprusside was discontinued and the patient remained well after 6 months. This case adds to existing literature substantiating the benefit of nitroprusside for the treatment of erythromelalgia in pediatric patients. Erythromelalgia in children may represent a different disease entity than that seen in adults, which is commonly responsive to aspirin therapy. The pathogenesis of erythromelalgia is unclear and precludes formulating a proposed mechanism by which nitroprusside has benefit in children. Nitroprusside is valuable for erythromelalgia resistant to aspirin therapy in pediatric patients. Because of unanswered questions regarding the disease, aspirin remains the agent of first choice in all patients with this rare disease.",1997.0,0,0
1515,9166993,A clinical study on physiological response in electroacupuncture analgesia and meperidine analgesia for colonoscopy.,H H Wang; Y H Chang; D M Liu; Y J Ho,"Fifty-nine patients underwent consecutive colonoscopic examination with premedication of electroacupuncture analgesia (EA) were compared with conventional meperidine analgesia (MA) in pain relief and changes of neurotransmitters in serum. The results showed that analgesic efficacy of both groups were the same but with less side effects in the EA group (P < 0.01) especially in regard to dizziness. Serum concentration of beta-endorphin in both groups has a similar curve change at 4 different phases during colonoscopy. Serum concentration of epinephrine, norepinephrine, dopamine and cortisol showed no significant difference between these two groups. The analgesic effect of EA and MA during colonoscopic examination may be closely related to beta-endorphin production in serum.",1997.0,0,0
1516,9167372,Pain relief in chronic pancreatitis with epidural buprenorphine injection.,P M Desai,"The management of intractable pain in chronic pancreatitis is difficult. A novel method for its relief is described. Twelve patients were given a mixture of buprenorphine (0.3 mg) and blood (10-15 mL) into the epidural space. All patients had pain relief lasting up to six months. Epidural buprenorphine injection is a simple, safe and effective method for pain relief in chronic pancreatitis.",1997.0,0,0
1517,9167373,Dilatation of radiation-induced esophageal strictures under sublingual buprenorphine analgesia: a pilot study.,D C Desai; S D Wagle; K M Mohandas; V S Swaroop,"Pain during dilatation of radiation strictures is a troublesome complaint. There is little information on sedation and analgesia during this procedure. We performed a pilot study to compare the analgesic efficacy of sublingual buprenorphine and intravenous pentazocine during dilatation of radiation-induced esophageal strictures. Thirty-one patients with esophageal cancer who had radiation-induced strictures were randomized to receive either buprenorphine 0.2 mg sublingually two hours before dilatation (n = 17) or pentazocine 30 mg intravenously five minutes before dilatation (n = 14). Dilatation was considered successful if it could be performed to 12 mm diameter or more. Pain experienced during dilatation was graded as mild, moderate or severe. Sixteen patients in the buprenorphine group and 12 in the pentazocine group were dilated to > 12 mm size (p = ns). Twelve and nine patients respectively in the two groups experienced mild or no pain; ten and six patients had minor side-effects (p = ns). Buprenorphine is useful for sedoanalgesia during dilatation of radiation-induced strictures of the esophagus.",1997.0,0,0
1518,9168213,Use of preincisional ketorolac in hernia patients: intravenous versus surgical site.,N R Connelly; S S Reuben; M Albert; D Page,"This study was designed to determine whether administration of ketorolac directly in the surgical site results in enhanced analgesia. A randomized double-blind study was undertaken at a university-affiliated tertiary care hospital. Thirty outpatients undergoing unilateral inguinal hernia repair by one of two surgeons under local anesthesia with sedation were evaluated. Patients were invited to participate in this investigation at the time of the preoperative surgical visit. Patients who had a contraindication to the use of ketorolac or who refused repair under local anesthesia with sedation were excluded. Patients received ketorolac 60 mg either via the parenteral route or directly in the surgical site (mixed with the local anesthetic). The outcome measures included visual analog pain scores, measured at two different times in the hospital, pain scores at rest and with movement 24 hours after surgery, time to first analgesic, and total analgesic requirement. The study revealed lower 24 hour movement-associated pain scores (P < .02), increased time to first analgesic (P < .03), and decreased oral analgesic consumption (P < .0002) in the surgical site group. Ketorolac provides enhanced patient comfort when it is administered in the surgical site in patients undergoing inguinal hernia repair. It is recommended that clinicians add ketorolac to the local anesthetic solution in such patients.",1997.0,0,0
1519,9168214,"Pain relief after knee arthroscopy: intra-articular morphine, intra-articular bupivacaine, or subcutaneous morphine?",M S Cepeda; C Uribe; J Betancourt; J Rugeles; D B Carr,"This investigation was undertaken to compare analgesic effects, side effects, and requirements for supplemental analgesic therapy after knee arthroscopy in patients given intra-articular (IA) or subcutaneous (SC) morphine, intra-articular bupivacaine, or placebo. In a randomized, double-blind controlled trial, 112 patients, 14-65 years old each received two solutions, one SC and the other IA. Group IAM (n = 30) received 10 mg IA morphine in 20 mL normal saline plus 1 mL of SC normal saline Group IAB (n = 27) received 20 mL IA bupivacaine 0.5% with IA epinephrine plus 1 mL SC normal saline Group SCM (n = 26) received 20 mL IA normal saline plus 10 mg SC morphine in 1 mL. Group P (n = 29) received 20 mL IA normal saline plus 1 mL SC normal saline. Pain was evaluated on arrival in the postanesthesia care unit (PACU), and 30, 45, 60, 90, and 120 minutes afterwards. If pain exceeded 4/10 on a visual analog pain scale in the PACU, 30 mg intravenous ketorolac was given, and if pain persisted, 0.4 mg hydromorphone was added every 7 minutes. After PACU discharge, patients whose pain exceeded 4/10 received oral ketorolac 10 mg every 6 hours; oral acetaminophen plus codeine was added every 4 hours if pain still exceeded 4/10. Analgesic requirements, along with visual analog pain score, sedation, and nausea were recorded every 6 hours for 72 hours. All three active (nonplacebo) pain treatments provided good pain control in the PACU. Side effects were similar in all groups. The placebo group had higher pain scores at 120 minutes (R = .02), higher supplemental analgesic requirements at 60 minutes (P = .04) and 90 minutes (P = .02) and the highest amount of total opioid rescue dose (P = .04). Patients in groups IAB and P had higher visual analog pain scores at 6 hours (P = .04) and 30 hours (P = .049) than those in Groups IAM and SCM. A single 10-mg dose of morphine given either IA or SC provides better and longer-lasting postoperative pain relief after knee arthroscopy than 20 mL IA bupivacaine 0.5% with epinephrine.",1997.0,0,0
1520,9168216,Tramadol and beta-cyclodextrin piroxicam: effective multimodal balanced analgesia for the intra- and postoperative period.,G R Lauretti; A L Mattos; I C Lima,"This study was conducted to evaluate the analgesic efficacy of tramadol, an analgesic with both opioid and nonopioid actions (norepinephrine and serotonin pathways), with beta-cyclodextrin piroxicam, a nonsteroidal antiinflammatory drug, in the perioperative setting. The study population consisted of 48 patients scheduled for minor abdominal procedures, who were assigned to one of four groups of 12 patients each. The premedication was either a placebo tablet or a 192.1-mg beta-cyclodextrin piroxicam tablet, administered orally 30-40 minutes before anesthesia induction. After intravenous administration of tramadol 1.5 mg/kg, anesthesia was induced with an intravenous loading dose of propofol. Anesthesia was maintained an intravenous infusion of propofol at 6-12 mg/kg/h plus either saline or tramadol at 1.2 mg/kg/h, atracurium, and a 2:1 nitrous oxide-oxygen mixture. The control group received a placebo tablet and an infusion of saline with propofol for anesthesia maintenance; the tramadol group received a placebo tablet and a continuous tramadol-propofol infusion; the beta-cyclodextrin piroxicam (BCP) group received a BCP tablet and a continuous saline-propofol infusion; and the beta-cyclodextrin piroxicam-tramadol (BCPT) group received beta-cyclodextrin piroxicam and a continuous tramadol-propofol infusion. The relative propofol consumption by the four groups was control = BCP (P > .05) >tramadol (P < .001) > B-CPT (P < .0002). The time for analgesic rescue decreased in the order BCPT > BCP (P < .0002) = tramadol > control (P < .001). The degree of sedation and the visual analog scores 10-cm scale at the time patients requested rescue analgesics were similar among the groups (P > .05). The combination of tramadol and beta-cyclodextrin piroxicam provided better perioperative analgesia than tramadol alone.",1997.0,0,0
1521,9172009,Oral tramadol and buprenorphine in tumour pain. An Italian multicentre trial.,F Brema; G Pastorino; M C Martini; A Gottlieb; M Luzzani; A Libretti; L Saccà; S Cigolari,"In this multicentre trial tramadol and buprenorphine were compared for the treatment of neoplastic pain no longer responsive to non-steroidal antiinflammatory drugs. A total of 131 adults (86 M, 45F) were treated with tramadol (one 100-mg slow-release tablet every 8-12 h), or buprenorphine (one sublingual 0.2-mg tablet every 6-8 h). The trial was to continue for up to six months. Most patients started treatment with 2-3 tablets/day in both groups, and the mean treatment period was 58 days for tramadol and 51 for buprenorphine. Almost all dose changes needed were made in the first fortnight in both treatment groups, and the largest number of patients dropped out because of inadequate pain relief or progression of the underlying disease. The results achieved in the first two weeks persisted throughout the rest of the trial, and the investigator's assessments on each patient's clinical chart corresponded closely with those that patients made in their own daily diaries. In the four hours after the first dose both drugs virtually halved the severity of pain (measured using a visual analogue scale), and this relief lasted throughout treatment. By the end of the first week the proportion of patients with strong/unbearable pain in the tramadol group had fallen significantly (from 98.4% to 48.1%, p < 0.05), as compared to a drop from 92% to 66.7% for buprenorphine. The quality of sleep also tended to improve in the tramadol group, with the proportion of patients enjoying good or deep sleep rising from 37% to 50%, as compared to 33% to 40-44% with buprenorphine. Karnofsky's and Spitzer's indices reflecting the quality of life did not change in the tramadol group; in the buprenorphine group the Karnofsky index dropped slightly after a fortnight (p < 0.05 between treatments). In the first two months of the trial the number of patients with no/moderate pain rose continuously in the tramadol group (71% and 80% after one and two months); the rise was less marked in the buprenorphine group (number of patients with mild/moderate pain, 45% and 65%). In both the short term and in the longer term, it was found that the levels of efficacy and acceptability were always significantly better in the tramadol group than in the buprenorphine group. General and biological safety in both drugs was good. The most typical side-effects were those characteristic of opioids (nausea and/or vomiting, drowsiness). Adverse reactions were reported in 17 patients taking tramadol (25%) and in 16 taking buprenorphine (26%). There were six drop-outs in the first group (9%) and seven in the second (11%). Serious symptoms arose more frequently in the buprenorphine group (19% cf. 10%). No signs of dependence or tolerance were noted.",1996.0,0,0
1522,9172021,Postoperative analgesia with parenteral opioids: does continuous delivery utilizing a transdermal opioid preparation affect analgesic efficacy or patient safety?,F B Sevarino; D Paige; R S Sinatra; D G Silverman,"To compare, in patients who underwent major orthopedic surgical procedures, the efficacy of intravenous (IV) patient-controlled analgesia (PCA) with morphine combined with continuous administration of two doses of fentanyl or placebo via transdermal therapeutic system with fentanyl (TTSF) patches. Randomized, double-blind, placebo-controlled study. University teaching hospital. 62 patients aged 18 to 65 years, presenting for elective orthopedic surgery and general anesthesia. Patients were randomized to one of three groups: group 1 received two placebo patches; group 2 received a 20 cm2 active patch delivering 50 micrograms/hr of fentanyl and a 30 cm2 placebo patch; group 3 received a 30 cm2 active patch delivering 75 micrograms/hr of fentanyl and a 20 cm2 placebo patch. All patches were placed approximately two hours prior to induction of general anesthesia. General anesthesia was induced with thiopental, intubation facilitated by the use of vecuronium or pancuronium, and anesthesia was maintained with isoflurane in an oxygen/nitrous oxide mixture (O2/N2O). Following surgery, IV morphine was provided using IV PCA with 1.5 mg of morphine with a 6-minute lockout and a 4-hour maximum dosage of 30 mg. The time and dosage of morphine administered was recorded. Vital signs, pain intensity at rest, level of sedation, and arterial oxygen saturation (SpO2) were measured at intervals throughout the 72-hour study period and at 6 and 12 hours following patch removal. The presence of side effects was noted. Visual analog pain scores throughout the 72 hours of the study were not significantly different among groups. Patients receiving active TTSF required less IV PCA morphine at all time intervals. However, total opioid consumption was comparable among groups. The incidence of side effects was similar in all groups. There is no significant advantage to the routine use of continuous transdermal opioid delivery in patients receiving IV PCA after major orthopedic surgery.",1997.0,0,0
1523,9172024,,,,,0,0
1524,9181154,Intrathecal morphine for post-sternotomy pain in patients with myasthenia gravis: effects on respiratory function.,E Nilsson; K Perttunen; E Kalso,"Thymectomy can induce a remission or at least an improvement in myasthenia gravis (MG) patients. After sternotomy MG patients with compromised muscle strength need an excellent postoperative pain relief. This study was designed to evaluate the efficacy of intrathecal morphine (ITM) on ventilatory function among MG patients undergoing trans-sternal thymectomy, when intravenous morphine served as control. Twenty consecutive MG patients were randomised to receive either morphine (10 micrograms/kg) intrathecally at induction or intravenous morphine (30 micrograms/kg) with a patient-controlled analgesia (PCA) device. Anaesthesia was standardised. Forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), respiratory rate, oxygen saturation, arterial blood gases, pain intensity and morphine consumption were assessed during 48 hours. The mean age of the patients was 35 +/- 3.4 years and the mean duration of the disease 1.9 +/- 0.5 years. According to Osserman's classification 70% of the patients belonged to Class IIA and 30% to Class IIB. ITM restored ventilatory function significantly better than iv PCA morphine. FVC recovered to 60% and FEV1 to 57% of the baseline values in the ITM group compared with 32% (P < 0.05) and 37% in the PCA morphine group, respectively. Postpuncture headache occurred in 4/10 patients. Intrathecal morphine provided effective postoperative analgesia and significantly improved ventilatory function when compared with intravenous morphine.",1997.0,0,0
1525,9181158,Intravenous phentolamine test--an aid in the evaluation of patients with persistent pain after low-back surgery?,J Sörensen; M Bengtsson,"Persistent pain following surgery in the treatment of chronic low-back pain patients is still relatively frequent. Most of these patients with persistent pain have clinical signs of neuropathic pain. The neuropathic pain might be sympathetically maintained pain (SMP) or sympathetically independent pain (SIP). Systemic administration of phentolamine, a competitive alpha-adrenergic antagonist, has been used as a diagnostic tool to identify patients with SMP. Thirty-seven patients with persistent pain after low-back surgery (lumbar laminectomy, with or without discectomi, or a posterior fusion, with or without decompression) received intravenous phentolamine (0.5 mg/kg over 30 min) in a single-blind, placebo-controlled manner. Prior to this infusion the patients were classified clinically into different pain groups based on physical examination and imaging findings. An opioid epidural test blockade was used as a control. Clinical classification divided the patients into nociceptive pain (n = 7), neuropathic pain (n = 22) and mixed pain (n = 8). In the phentolamine test there were only one responder, 34 non-responders and 2 patients were placebo-responders. In the control epidural blockade there were 11 non-responders, 23 fentanyl/local anaesthetic-responders and 3 placebo-responders. SMP is either an uncommon cause of persistent pain in this type of failed back surgery patients or the phentolamine test, as we performed it, was unable to identify SMP.",1997.0,0,0
1526,9183421,[Intra-articular analgesia after arthroscopy of the knee].,D Jawish; M C Antakly; F Dagher; E Nasser; N Geahchan,In 33 patients the authors compared two protocols for postoperative analgesia after elective arthroscopy of the knee. One group (n = 11) received plain bupivacaine 0.25% by intra-articular administration. Another group (n = 11) received by the same route a mixture of bupivacaine 0.25% with fentanyl 50 micrograms. The last group (placebo group: n = 11) received the same volume of saline. The combination of bupivacaine with fentanyl reduced postoperative pain more effectively than plain bupivacaine and the analgesic effect was still present 9 hours after the arthroscopy.,1996.0,0,0
1527,9183422,[Evaluation of 2 dosages of fentanyl in caudal anesthesia. A prospective randomized double-blind study].,A Gharsallah; T Atallah; H Hmouda; M Kachoukh; S Chelbi; S Souguir; R Said,"A caudal block is currently performed in children. A randomized and double blind study including two dosages of fentanyl: 0.5 microgram.kg-1 (group I) and 1 micrograms.kg-1 (group II) in association with bupivacaine 0.25% at a dosage of 1 mL.kg-1 was carried out. Two groups of 25 children undergoing urogenital or orthopaedic surgery participated in this study. Analgesia and side effects were evaluated 24 hours postoperatively. Quality and duration of analgesia were similar in the two groups. Furthermore, recovery of anaesthesia was rapid and calm. The frequency of nausea and vomiting was respectively 24% and 20% in groups I and II and did not require any specific therapy. Therefore it appears that caudal block with bupivacaine 0.25% and fentanyl 0.5 microgram.kg-1 is a very satisfactory technique in children when indicated.",1996.0,0,0
1528,9186022,"Prescription opiate abuse in chronic pain patients: clinical criteria, incidence, and predictors.",C Chabal; M K Erjavec; L Jacobson; A Mariano; E Chaney,"Opiates are commonly used to treat patients with chronic nonmalignant pain. There is much controversy over the definition, incidence, and risk factors of prescription opiate abuse in chronic pain treatment. The present study, done at the Seattle VA Medical Center, was designed to create opiate abuse criteria, test inter-rater reliability of the criteria, apply the criteria to a group of chronic pain patients, and correlate the risk of opiate abuse with the results of alcohol and drug testing. A committee of experienced pain providers designed a five-point prescription opiate abuse checklist based on DSM-III-R parameters. The criteria were then applied to patients enrolled in the pain clinic. The reliability of the criteria were determined using two providers who were familiar with every patient in the clinic. Drug, alcohol, and psychosocial testing were correlated with the risk of opiate abuse. A total of 19% (76/403) of all pain clinic patients were using chronic opiates. Thirty-four percent (26/76) met one, and 27.6% (21/76) met three or more of the abuse criteria. The criteria had an inter-rater reliability of > 0.9. There were no differences between chronic opiate users (n = 76) and opiate abusers (n = 21) for a history of drug or alcohol abuse or on psychosocial testing. Prescription opiate abuse criteria for use in patients with chronic nonmalignant pain were designed. The criteria had good reliability and can be applied during normal clinic interactions. The percentage of chronic opiate users who become opiate abusers in pain treatment is within the range reported by others. Past opiate or alcohol abuse or psychosocial testing on clinic admission failed to predict who would become an opiate abuser. The criteria can be used to identify patients who will subsequently require more intensive treatment or intervention or can be used as an outcome to measure to test the effectiveness of treatment strategies.",1997.0,0,1
1529,9187779,Labour analgesia with intrathecal fentanyl decreases maternal stress.,M Cascio; B Pygon; C Bernett; S Ramanathan,"Lumbar epidural analgesia (LEA) decreases maternal stress as measured by maternal circulating plasma catecholamine concentrations. Intrathecal fentanyl (ITF) provides effective labour analgesia but its effect on maternal epinephrine (Epi) and norepinephrine (NE) concentrations is not known. This study assesses whether ITF reduces maternal stress in the same manner as conventional LEA. Twenty-four healthy women in active labour received either 25 micrograms ITF (n = 12) or epidural lidocaine 1.5% (n = 12) for analgesia. Venous blood samples were collected before anaesthesia and at five minute intervals for 30 min following anaesthesia for the measurement of plasma Epi and NE by high performance liquid chromatography. Maternal blood pressure (BP), heart rate (HR), visual analog scores (VAS) to pain and pruritus were recorded at the same time. Both ITF and LEA decreased pain VAS scores, maternal BP, and plasma Epi concentrations with only minimal effects on plasma NE concentrations. Intrathecal fentanyl (ITF) and LEA reduced plasma epi to a similar extent, with ITF reducing the levels slightly faster than LEA. Intrathecal fentanyl(ITF) and LEA reduced plasma Epi concentrations by 52% and 51%, respectively (P value < 0.01). We conclude that ITF is as effective as LEA in producing pain relief in the labouring patient. Intrathecal Fentanyl (ITF) is also capable of reducing maternal plasma epinephrine concentration, thus avoiding the possibly deleterious side effects of excess amounts of this catecholamine during labour.",1997.0,0,0
1530,9188029,Medical and pharmacologic management of upper extremity neuropathic pain syndromes.,G A Mackin,"Written from a neurologic and therapeutically conservative perspective, this review advocates fundamentally medical and pharmacologic management of upper extremity neuropathic pain syndromes, including chronic regional pain syndromes, formerly classified reflex sympathetic dystrophy (RSD) and causalgia. Mandatory steps include, first, a prompt serious attempt to localize the nerve lesion whenever possible using complete, sophisticated neurologic examinations, then thoughtfully selected conventional neurophysiologic and radiologic tests. Strongly discouraged are promiscuous use of ""RSD"" to describe all neuropathic pains, and diagnostic reliance upon thermography and uncontrolled sympathetic blocks. Conservative multidisciplinary diagnostic and treatment teams should often possess a nucleus of neurologist and hand therapist, plus additional consultants including psychiatric. Every physician and therapist managing neuropathic pain must consider psychologic and wellness issues within their responsibilities. Prompt referral to an experienced surgeon is crucial for decompression or repair of relevant, significant, objectively proven (ideally neurophysiologically) nerve and root lesions. Ambiguous professional colloquialisms, ""central pain"" and ""central sensitization,"" unfortunately provide value-laden pretexts for premature invasive treatments, and animate the truly dreadful concept ""central RSD"". Various classes of conventional oral non-narcotic adjuvant analgesics are reviewed, and the inevitability of their empiric, non-formulaic administration. No patient-specific, rationally-identifiable molecular receptor/switch can be deduced clinically or tripped mechanistically to terminate chronic pain. Two promising new non-narcotic centrally-active medications, gabapentin and tramadol, are highlighted as harbingers of future progress. The neglected subtle art of prescription writing is stressed, particularly for medication-sensitive patients. Medical cost containment should promote critical, long overdue outcomes studies comparing conservative and invasive pain treatments.",1997.0,0,0
1531,9190320,[Review of current pharmacologic treatment of pain].,L Brasseur,"Pain is the main reason prompting patients to consult their physicians. In acute conditions, pain has a very particular significance as a warning sign, enabling the physician to attempt a diagnosis. Nevertheless, its detrimental effect upon the individual (even in the case of acute pain) and its cost to society are now widely acknowledged. There can be no doubt about the physical component of pain, but the psychological and social aspects should not be ignored, particularly in the case of chronic pain. There is no single therapeutic approach to pain and, more often than not, successful treatment comprises a combination of several. Pharmacological treatments are undeniably the most common approach. In clinical practice, recent advances have been based upon an improved understanding of 'old' substances such as morphine and, at the same time, research continues in the hope of finding the 'ideal' analgesic-effective in most situations but without adverse effects: this appears to be a somewhat utopian arm at present, considering the number of different causes of pain. An improved understanding of the physiological mechanisms of pain has led, within the field of clinical practice, to several methods of differentiating pain. These depend on whether or not pain responds to morphine, or on the type of pain: pain due to an excess of nociception, pain resulting from deafferentation (caused by damage to nerve pathways) in the central or peripheral nervous system and psychogenic (idiopathic) pain. Likewise, there are several different ways of classifying analgesic treatments: according to the intensity of pain, as with use of the WHO ladder (which is based on the notion of steps) for the treatment of cancer pain; according to the presumed physiopathological mechanism and, in particular, the response to morphine, and according to the presumed central or peripheral mechanism of the drugs. In reality, peripherally acting drugs can also have a central mechanism of action, just as drugs known to have a central mechanism of action can also have peripheral activity. As a result, several therapeutic classes have been identified. Firstly NSAIDs, which act by inhibiting the enzymes that synthesise prostaglandins, cyclooxygenases (COX-1, COX-2), but which also act upon lipo-oxygenases: Their efficacy is interesting, although somewhat limited by both their ceiling effect and the frequent adverse gastrointestinal reactions they produce. Specific inhibitors of COX-2 could well reduce the risk of adverse effects. Opioids constitute the first-line treatment for pain, particularly severe pain. There are several classifications for these drugs. Firstly, weak opioids (such as codeine) and strong opioids (such as morphine) are differentiated. Secondly, a distinction is made between pure agonists (such as morphine), partial agonists (such as buprenorphine), agonist-antagonists (such as nalbuphine) and antagonists (such as naloxone). Finally, agents are distinguished on the basis of their chemical structure (synthetic, semi-synthetic or natural derivatives). These molecules act upon different receptors (mu, delta, kappa, sigma) and, although peripheral mechanisms have been described, their activity occurs mainly at spinal and supraspinal levels. They provide a potent analgesic effect but are also responsible for various adverse effects-nausea, vomiting, sedation, constipation and respiratory depression-which seriously limit their use. As long as the indication is appropriate, these drugs should not be withheld because of fear of dependence or abuse. It has been observed that other adjuvant therapeutic approaches, generally used to treat conditions other than pain, provide pain relief in certain situations. These include corticosteroids, which are-widely used in rheumatology and oncology, and antidepressants, which are frequently used to treat chronic pain, especially that with a neuropathic component. Anti-epileptics are also used, particularly for excrutiating",1997.0,0,0
1532,9190322,[Tramadol in acute pain].,K A Lehmann,"Tramadol has been in clinical use in Germany since the late 1970s and has proven effective in both experimental and clinical pain without causing serious cardiovascular or respiratory side effects. Moreover, the negligible abuse potential of tramadol has meant that it has never been a restricted drug, and it therefore very quickly became the most popular analgesic of its class in Germany. Although tramadol has been used in myocardial emergencies, in trauma and obstetric pain, or to supplement balanced anaesthesia, most studies have investigated postoperative patients. The focus of this article is to review clinical experience with tramadol in the treatment of acute postoperative pain. Tramadol, a synthetic opioid of the aminocyclohexanol group, is a centrally acting analgesic with weak opioid agonist properties, and effects on noradrenergic and serotonergic neurotransmission. In addition, these opioid and nonopioid modes of action appear to act synergistically. Tramadol has been shown to provide effective analgesia after both intramuscular and intravenous administration for the treatment of postoperative pain. The drug is available in formulations suitable for oral, rectal and parenteral administration. Clinically effective analgesic doses of tramadol were comparable to those of pethidine (meperidine) and about 10 times higher than those of morphine. While it is not recommended as a supplement to general anaesthesia because of its insufficient sedative activity, tramadol has been successful in the treatment of postoperative pain. A randomised double-blind study reported acceptable analgesia with postoperative intravenous tramadol 50mg, repeated once if required after 30 minutes. It produced an effect similar to that of morphine 5mg or the alpha 2 agonist, clonidine 150 micrograms. In another study, it was shown that the 50mg dose of tramadol fulfilled the requirements of an analgesic for the treatment of moderate postoperative pain, whereas for severe pain a higher dose was recommended. Tramadol is generally well tolerated, the most common adverse events being nausea and vomiting. In contrast to agents such as morphine and pethidine, clinically relevant respiratory depression is rarely observed during tramadol administration at equipotent doses and consequently it can be recommended for first-line management of postoperative pain instead of morphine. It is also associated with a low incidence of cardiac depression and significantly less dizziness and drowsiness than morphine. Finally, the dependence and abuse potential with tramadol is negligible. Comparative studies have generally shown that tramadol is more effective than NSAIDs for controlling post operative pain. Use of a combination of tramadol and NSAIDs allows the tramadol dose to be reduced and results in a lower incidence of adverse effects. Patient controlled analgesia (PCA) with tramadol has been frequently used and is well accepted by patients. Wide individual variations exist with regard to analgesic requirements and, nowadays, it is generally accepted that adequate pain management implies systematic individualisation of the therapy, i.e. titration of the analgesic effect to individual needs. Demand and loading doses play a decisive role in the success of PCA. Analgesic failures requiring rescue medication are rare, but it should be stressed that these can always occur with weak opioids. In conclusion, tramadol can be recommended as a basic analgesic for the treatment of moderate to severe pain. In the event of analgesic failure with tramadol, there is no reason not to switch to more potent opioids. Although no studies are available regarding its use in the management of postoperative pain after day case surgery, tramadol is frequently administered with good results in such patients. The most important side effects of tramadol are nausea and emesis, which can often be prevented by slow injection and administration of a prophylactic antiemetic such as metoclopramid",1997.0,0,0
1533,9190323,[Treatment of post-herpes zoster pain with tramadol. Results of an open pilot study versus clomipramine with or without levomepromazine].,H Göbel; T Stadler,"To date, no universally applicable recommendations are available for the treatment of patients with postherpetic neuralgia. A mixture of clinical anecdotes, experimental findings and observations from clinical trials form the basis of the medical arsenal for this condition. Tricyclic antidepressants are commonly used, and clinical experience and several investigations have documented their effectiveness. Today, single entity antidepressants, which can be combined with neuroleptics to increase analgesia, are generally recommended for the treatment of postherpetic neuralgia. Some authors also recommend the additional administration of an opioid if analgesia is inadequate. Just over a decade ago, opioids were considered ineffective for the treatment of neuropathic pain; however, more recent investigations relating to the use of opioids, primarily in the treatment of nontumour-related chronic pain, have led to a revision of their use in neuropathic pain. Nevertheless, the use of opioid therapy for neurogenic pain remains controversial. Tramadol is a synthetic, centrally acting analgesic with both opioid and nonopioid analgesic activity. The nonopioid component is related to the inhibition of noradrenaline (norepinephrine) reuptake and stimulation of serotonin (5-hydroxytryptamine; 5-HT) release at the spinal level. In this regard, there are parallels with antidepressants, which are believed to potentiate the effect of biogenic amines in endogenous pain-relieving systems. There is evidence that, in tramadol, both mechanisms act synergistically with respect to analgesia. The aim of this pilot study was to investigate, for the first time, the analgesic efficacy and tolerability of tramadol, compared with the antidepressant clomipramine, in the treatment of postherpetic neuralgia. If necessary, clomipramine was used in combination with the neuroleptic levomepromazine. The study allowed individualised dosages at predetermined intervals up to a maximum daily dose of tramadol 600mg and clomipramine 100mg, or clomipramine 100mg with or without levomepromazine 100mg. 21 (60%) of 35 randomised patients (> or = 65 years) received the study medication over the 6-week period [tramadol n = 10; clomipramine with or without levomepromazine) n = 11]. After 3 weeks' treatment the dosage in both groups remained almost constant for the rest of the 6-week treatment phase (mean daily dose: tramadol 250 to 290mg; clomipramine 59.1 to 63.6mg). Only 3 patients required the combination of clomipramine and levomepromazine. At the outset, both groups recorded an average pain level of 'moderate' to 'very severe'. In correlation with increasing the study medication, this had decreased to 'slight' by the end of the treatment, when 9 of 10 patients in the tramadol group and of 6 of 11 patients in the clomipramine group retrospectively rated their analgesia as excellent, good or satisfactory. The psychological/physical condition of the patients did not change significantly during tramadol treatment. Sensitivity and depression parameters decreased in the clomipramine group. The incidence of adverse events for all patients was similar in both groups (tramadol 76.5%; clomipramine with or without levomepromazine 83.3%). In conclusion, tramadol would appear to be an interesting therapeutic alternative for pain relief in postherpetic neuralgia, particularly in patients who are not depressed. In clinical practice, tramadol and clomipramine can best be used differentially. For example, tramadol could be the drug of first choice in patients with obvious cardiovascular disease (not an uncommon problem in the > or = 65 year age group) in whom antidepressants are contraindicated, and similarly in patients in whom an antidepressant effect is not required. (ABSTRACT TRUNCATED)",1997.0,0,0
1534,9190324,[Effectiveness and tolerance of tramadol in cancer pain. A comparative study with respect to buprenorphine].,A V Bono; S Cuffari,"Opioid analgesics represent one of the most important tools in a sequential pharmacological approach to oncological pain relief. They are recommended by the WHO when nonsteroidal anti-inflammatory drugs (NSAIDs) no longer provide adequate analgesia. However, the use of opioids is limited because of their numerous and often severe adverse effects. This aspect of opioids has motivated continuous research projects aimed at discovering drugs that can provide maximum pain relief but with improved tolerability. Tramadol is a new, centrally acting analgesic with a dual mechanism of action. It shows a selective interaction with mu receptors, which are responsible for nociception, and has weak pharmacodynamic activity on other opioid receptors. At the same time, it acts synergistically on neuroamine transmission by inhibiting synaptic noradrenaline (norepinephrine) reuptake and inducing intrasynaptic serotonin (5-hydroxytryptamine; 5-HT) release. From a pharmacokinetic standpoint, tramadol offers high bioavailability, with similar patterns after oral or parenteral administration (half-life 5 to 7 hours, time to peak plasma concentration 3.1 hours, and approximately 20% plasma protein binding). Although the efficacy of tramadol is comparable to that of other drugs with similar modes of action, the incidence of side effects such as constipation and respiratory depression is lower. The frequency of euphoria and dysphoria is negligible, resulting in little risk of abuse or dependence. It therefore seemed appropriate to further investigate the efficacy and tolerability of tramadol, defined as having only weak potency, in comparison with a widely used opioid, in oncological pain. Buprenorphine was selected as an opioid with a potency equivalent to half that of morphine, but with tolerability that is partially limited by the fact that it frequently gives rise to adverse reactions considered typical of stronger opioids. To compare the analgesic effect and tolerability of tramadol and buprenorphine, 60 patients (44 men, 16 women; average age 61.4 years), all presenting with advanced tumours, were treated orally in a controlled crossover trial with randomised sequences. Patients took both drugs, each for a week, with a 24-hour washout period between treatments. Tramadol was prescribed at the daily dose of 300mg, orally, and buprenorphine at 0.6 mg/day, as a sublingual preparation. Assessments were made of Karnofsky performance status and severity of pain before and during the 4 hours after taking the 2 drugs. Each patient also completed a daily diary recording the severity of pain 1 hour after the dose, the evolution of pain during the day and its severity compared with that on the previous day. They also assessed the duration and quality of sleep. The Karnofsky index changed little with either treatment, but all other variables showed worthwhile improvement, indicating the significant analgesic effect of both drugs. Buprenorphine and tramadol had a similar analgesic effect, although the improvement with the test drug was significant within 1 hour of administration (p < 0.05 compared with baseline) and more marked (p < 0.05 on day 2 compared with buprenorpine). At the end of tramadol treatment, sleep had also improved, both quantitatively and qualitatively (both p < 0.05). The final assessment was significantly in favour of tramadol as regards efficacy (p < 0.05) and patient acceptability (p < 0.01). Thus, tramadol was better tolerated than buprenorphine, and caused fewer and milder adverse reactions. Only 1 patient discontinued tramadol, compared with 18 using reference therapy. Tramadol, although theoretically less potent, nevertheless brought about as much pain relief as the comparator opioid. In conclusion, for this class of drug, tramadol provides an excellent balance between efficacy and tolerability, confirming preliminary studies.",1997.0,0,0
1535,9193930,Current approach to the surgical management of chronic pancreatitis.,H S Ho; C F Frey,"The indications for surgical intervention in chronic pancreatitis are suspicion of malignancy, local complications, and intractable pain. Chronic pancreatitis is a risk factor for development of pancreatic carcinoma, and carcinomas may present, initially with a clinical picture of chronic pancreatitis. Local complications of chronic pancreatitis such as common bile duct or duodenal obstruction and enlarging or symptomatic pseudocyst also mandate surgical intervention. Thrombosis of the splenic vein with left-sided portal hypertension is common and associated with a 10% incidence of gastric variceal hemorrhage, which requires splenectomy. The role of surgery in the management of pain associated with chronic pancreatitis is to provide relief. When the pain interferes substantially with the patient's quality of life or narcotics are required for pain relief, surgical intervention is indicated. Other factors that should be incorporated in assessing the need for surgical intervention are malnutrition due to the inability to eat or malabsorption, the need for frequent hospitalization, and the inability to work. The operation selected for chronic pancreatitis should correct or deal with all structural abnormalities, provide long-term pain relief, have a low mortality and morbidity rate, minimize subsequent exocrine and endocrine insufficiency, and have results independent of abstinence from alcohol. No single operation can provide an optimal solution to the management of pain or these diverse complications of chronic pancreatitis. The operation chosen must be individualized to treat the patient's needs.",1997.0,0,0
1536,9195026,Local anesthesia for arthroscopic surgery of the ankle using pethidine or prilocaine.,L Westman; A Valentin; B Engström; A Ekblom,"Investigation of the intraoperative and postoperative pain-reducing effect of pethidine (meperidine) as compared with local anesthetics given into the ankle joint was performed, in a comparative and double-blind fashion, in 20 patients subjected to arthroscopy of the ankle, diagnostic and surgical procedures. These patients were randomly assigned to one of two groups. Group A consisted of 10 patients receiving prilocaine 5% with adrenaline and the patients of group B received pethidine 5% with adrenaline intraarticularly. During arthroscopy, the patients reported on pain and discomfort using visual analog scales. Ratings did not differ between the two groups, but six patients would not have chosen the local anesthetic technique again. Postoperatively, all patients rated their pain and discomfort at rest and at movement (1, 2, 3, 5, 6, 8, and 24 hours and at three times during 2 following days). No differences were found between the two groups, except for pain at rest through the whole observation period when significant lower values for pethidine. There were no differences in use of analgesics between the two groups. The current study indicates that pethidine is a potential alternative to prilocaine in arthroscopy of the ankle.",1997.0,0,0
1537,9196156,Improvements in survival and clinical benefit with gemcitabine as first-line therapy for patients with advanced pancreas cancer: a randomized trial.,H A Burris; M J Moore; J Andersen; M R Green; M L Rothenberg; M R Modiano; M C Cripps; R K Portenoy; A M Storniolo; P Tarassoff; R Nelson; F A Dorr; C D Stephens; D D Von Hoff,"Most patients with advanced pancreas cancer experience pain and must limit their daily activities because of tumor-related symptoms. To date, no treatment has had a significant impact on the disease. In early studies with gemcitabine, patients with pancreas cancer experienced an improvement in disease-related symptoms. Based on those findings, a definitive trial was performed to assess the effectiveness of gemcitabine in patients with newly diagnosed advanced pancreas cancer. One hundred twenty-six patients with advanced symptomatic pancreas cancer completed a lead-in period to characterize and stabilize pain and were randomized to receive either gemcitabine 1,000 mg/m2 weekly x 7 followed by 1 week of rest, then weekly x 3 every 4 weeks thereafter (63 patients), or to fluorouracil (5-FU) 600 mg/m2 once weekly (63 patients). The primary efficacy measure was clinical benefit response, which was a composite of measurements of pain (analgesic consumption and pain intensity), Karnofsky performance status, and weight. Clinical benefit required a sustained (> or = 4 weeks) improvement in at least one parameter without worsening in any others. Other measures of efficacy included response rate, time to progressive disease, and survival. Clinical benefit response was experienced by 23.8% of gemcitabine-treated patients compared with 4.8% of 5-FU-treated patients (P = .0022). The median survival durations were 5.65 and 4.41 months for gemcitabine-treated and 5-FU-treated patients, respectively (P = .0025). The survival rate at 12 months was 18% for gemcitabine patients and 2% for 5-FU patients. Treatment was well tolerated. This study demonstrates that gemcitabine is more effective than 5-FU in alleviation of some disease-related symptoms in patients with advanced, symptomatic pancreas cancer. Gemcitabine also confers a modest survival advantage over treatment with 5-FU.",2001.0,0,0
1538,9197296,"Alfentanil, but not amitriptyline, reduces pain, hyperalgesia, and allodynia from intradermal injection of capsaicin in humans.",J C Eisenach; D D Hood; R Curry; C Tong,"Intradermal injection of capsaicin produces brief pain followed by hyperalgesia and allodynia in humans, and the latter effects are mediated by spinal N-methyl-D-aspartate mechanisms. Amitriptyline recently was shown to antagonize N-methyl-D-aspartate receptors, and in this study, the authors sought to determine the effect of amitriptyline alone and with the opioid alfentanil on hyperalgesia and allodynia produced by intradermal injection of capsaicin. Forty-six healthy volunteers in the general clinical research center received repeated intradermal injections of capsaicin (100 microg) alone or before and after systemic injection of 4 mg midazolam, 25 mg amitriptyline, alfentanil by computer-controlled infusion, or amitriptyline plus alfentanil. Acute pain and areas of mechanical hyperalgesia and allodynia were determined at specified intervals. Blood was obtained for alfentanil and amitriptyline assay. Capsaicin injection produced acute pain followed by hyperalgesia and allodynia. Alfentanil reduced these pain responses in a plasma-concentration-dependent manner, and reduction in hyperalgesia and allodynia correlated with reduction in acute pain. Amitriptyline alone had no effect and did not potentiate alfentanil. Alfentanil produced concentration-dependent nausea, an effect diminished by amitriptyline. These data correspond with previous studies in volunteers demonstrating reduction in hyperalgesia and allodynia after intradermal injection of capsaicin by systemically administered opioids, and they suggest that this reduction may be secondary to reduced nociceptive input by acute analgesia. These data do not support the use of acute systemic administration of amitriptyline for acute pain, hyperalgesia, and allodynia, although the roles of chronic treatment and spinal administration are being investigated.",1997.0,0,0
1539,9197945,Antinociceptive effects of the kappa-opioid receptor agonist RP 60180 compared with pentazocine in an experimental human pain model.,J Lötsch; W Ditterich; T Hummel; G Kobal,"Agonists at kappa-opioid receptors may preserve the analgesic properties of mu-opioidergic agonists while avoiding their major adverse effects. The present study was aimed to investigate the antinociceptive effects of the new kappa-opioid receptor agonist RP 60180. An experimental pain model was used based on specific pain stimuli and event-related potentials. Effects of RP 60180 were compared to placebo and to pentazocine that served as positive control. Twenty healthy male volunteers participated in a placebo-controlled, randomized, double-blind, five-way cross-over study. Single peroral doses of RP 60180 (0.1, 0.5, and 1.0 mg), pentazocine (50 mg), and placebo were administered. Pain was induced by means of short pulses of gaseous CO2 applied to the nasal mucosa. In response to these stimuli, chemo-somatosensory event-related potentials (CSSERP) and pain ratings were recorded. Maximum antinociceptive effects were observed 2 h after the administration of 1.0 mg of RP 60180 and 50 mg of pentazocine. This was shortly after RP 60180 had reached the maximum plasma concentration and when highest plasma concentrations of pentazocine were measured. Both RP 60180 and pentazocine reduced pain-related CSSERP amplitudes by approximately 40% at this time. Pentazocine tended to produce more side effects. These results indicate the potential therapeutic value of kappa-agonist analgesics.",1997.0,0,0
1540,9200170,Benzodiazepine mediated antagonism of opioid analgesia.,R W Gear; C Miaskowski; P H Heller; S M Paul; N C Gordon; J D Levine,"Activation of supraspinal gamma-aminobutyric acid-A (GABAA) receptors is known to result in antagonism of opioid analgesia. Since benzodiazepines enhance the action of GABA at GABAA receptors, we hypothesized that administration of these agents for preoperative sedation might antagonize the analgesic effects of opioids administered postoperatively. If so, then administration of the benzodiazepine antagonist flumazenil should enhance postoperative morphine analgesia. In a double-blind, placebo-controlled study of patients who received a preoperatively administered benzodiazepine (diazepam) for sedation and a postoperatively administered opioid (morphine) for analgesia, we investigated opioid-benzodiazepine interactions affecting postoperative dental pain. We found that flumazenil significantly enhanced morphine analgesia consistent with the hypothesis that the preoperatively administered benzodiazepine exerts an ongoing antianalgesic effect. In addition, we followed these patients over the first and second postoperative days to determine if there were differences between the drug groups in post-discharge pain, analgesic consumption, or side-effects. Participants receiving flumazenil reported significantly less post-discharge nausea and used significantly less ibuprofen. Since post-discharge pain levels were not significantly different, these results suggest that the patients receiving flumazenil required less analgesic medication to achieve a comparable level of pain control. In summary, our results indicate that the benzodiazepine antagonist flumazenil enhances morphine analgesia and decreases post-discharge side-effects as well as post-discharge need for analgesic medication.",1997.0,0,0
1541,9200172,Hydromorphone analgesia after intravenous bolus administration.,B Coda; A Tanaka; R C Jacobson; G Donaldson; C R Chapman,"This study investigated the analgesic effects of three intravenous bolus doses of hydromorphone (10, 20, 40 micrograms/kg) on experimental pain measures in normal humans. Ten healthy male volunteers participated in four study sessions, one for each of the hydromorphone doses as well as a placebo (saline). They received the four treatments in counterbalanced order under double-blind conditions and with study days at least 1 week apart. During each session subjects underwent repeated electrical tooth pulp stimulation at intensities sufficient to elicit a rating of 'strong pain' before drug administration. Subjective pain reports (PRs) and dental evoked potential amplitude measures (EPs) served as analgesic effect indicators. We observed dose-dependent analgesia as measured by both PR (P = 0.009) and EP (P = 0.017). Area under the PR versus time curve as well as the EP versus time curve decreased in a log dose-dependent fashion. Although the peak effect was poorly defined, the onset of analgesia was rapid, within 5 min, and maximum analgesic effect was seen between 10 and 20 min after maximum plasma hydromorphone concentration. However, within sessions we found a poor correspondence between hydromorphone plasma concentration and effect. Compared to pain report data from other human studies done in our laboratory, hydromorphone has a shorter time to peak effect compared to morphine, and overall, hydromorphone hydrochloride is approximately five times as potent as morphine sulfate on a milligram basis.",1997.0,0,0
1542,9202548,Use of patient-controlled analgesia in extracorporeal shockwave lithotripsy.,C M Chin; K P Tay; F C NG; P H Lim; H C Chng,"To assess the advantages of patient-controlled analgesia (PCA)-in patients undergoing extracorporeal shockwave lithotripsy (ESWL) for urinary stones. Between December 1995 and May 1996, a prospective study was carried out on 100 patients who underwent ESWL for urinary stones. The patients were assigned to two equal groups, one receiving PCA and the other pethidine (control). Patients in the PCA group self-administered varying doses of intravenous alfentanil according to their pain tolerance, while those in the control group were given a single bolus dose of 1 mg/kg body weight intravenous pethidine by the attending urologist before the start of the procedure. The stone site, maximum energy level achieved, number of shock waves given, duration of procedure, pain scores, patient tolerance and acceptance were recorded to assess the efficacy of PCA compared with analgesia controlled by the physician. Both groups were matched for age, body weight, stone location and number of shocks given. The PCA group received a mean of 1.03 mg alfentanil while the control group received a mean of 62.5 mg pethidine. The maximum discharge voltage of 16 kV was achieved in all but one patient (98%) in the PCA group whereas only 21 patients (42%) in the control group attained this level. The mean treatment duration was less in the PCA group (32.8 min) than in the control group (44.5 min), the mean pain score lower (3.76 and 4.62, respectively) and the incidence of nausea and vomiting much less (22% and 60%, respectively). In addition, all 21 patients in the PCA group who had received intravenous pethidine during previous sessions of ESWL chose PCA as the better form of analgesia. There were no adverse effects in the PCA group except for one patient whose arterial oxygen saturation decreased transiently. PCA enables the urologist to achieve better patient compliance through better pain control; its application has maximized the use of lithotripsy and the patients' acceptability for this form of analgesia is confirmed. We recommend that this form of analgesia be used for ESWL.",1997.0,0,0
1543,9202910,"Intravenous administration of tenoxicam 40 mg for post-operative analgesia: a double-blind, placebo-controlled multicentre study.",E P Vandermeulen; H Van Aken; J L Scholtes; F Singelyn; A Buelens; L Haazen,"The analgesic efficacy of tenoxicam, a newer injectable non-steroidal anti-inflammatory drug, for post-operative analgesia after abdominal or orthopaedic surgery in ASA Grade I/II patients is reported. Two hundred and fifty-six patients received a single dose of tenoxicam 40 mg intravenous (i.v.) at the end of surgery and this was repeated 24 h later. These patients were compared, with respect to pain or adverse events, with 258 patients that received placebo. All patients were monitored for the next 72 h. Overall, tenoxicam provided reliable analgesia with comparable pain scores at rest, moving and coughing. The cumulative rescue PCA-morphine consumption was always lower in the tenoxicam treated patients and was most marked at 4 and 24 h after the second injection of tenoxicam. This effect was more pronounced after abdominal surgery. The intravenous administration of tenoxicam was associated with a low incidence of adverse events and a high tolerability.",1997.0,0,0
1544,9203881,Postoperative analgesic effect of intrathecal neostigmine and its influence on spinal anaesthesia.,J G Klamt; A Slullitel; I V Garcia; W A Prado,"A clinical trial was conducted to evaluate the postoperative analgesic efficacy and the safety of intrathecal neostigmine in patients undergoing anterior and posterior vaginoplasty under spinal anaesthesia. Thirty-six patients were randomly divided into three groups to receive: normal saline (1 ml), morphine (100 micrograms in 1 ml of saline) or neostigmine (100 micrograms in 1 ml of saline) intrathecally just before a spinal injection of hyperbaric bupivacaine (0.5%, 4 ml). The mean [SD] time to the first analgesic (nonsteroidal anti-inflammatory drug) administration was significantly prolonged by intrathecal neostigmine (10.7 [4.3] h) and morphine (15.3 [3.0] h) compared with saline (4.5 [1.0] h). The three groups also differed in the number of patients requiring subcutaneous morphine to complement the analgesia provided by the intramuscular nonsteroidal anti-inflammatory drugs and the mean [SD] times for their administration: eight patients in the saline group (8.0 [3.8] h), one patient in the morphine group (18 h) and two patients in the neostigmine group (8 and 12.9 h). The morphine and neostigmine groups showed similar analgesic effectiveness. The characteristics of spinal anaesthesia were not modified by intrathecal morphine or neostigmine. Severe nausea and vomiting, sweating and distress during surgery were the most obvious adverse effects of intrathecal neostigmine. On the other hand, less hypotension was observed in the neostigmine group. The usefulness of intrathecal neostigmine as the sole postoperative analgesic may be restricted by the severity of its adverse effects.",1997.0,0,0
1545,9203892,The effect of glossopharyngeal nerve block on pain after elective adult tonsillectomy and uvulopalatoplasty.,K R Bell; A M Cyna; K M Lawler; C Sinclair; P J Kelly; F Millar; L M Flood,"This controlled, randomised, double-blind study compared whether glossopharyngeal nerve block and intravenous morphine administered peri-operatively, decreased pain following elective adult tonsillectomy and uvulopalatoplasty more than morphine alone. Sixteen of 30 patients undergoing uvulopalatoplasty and 38 of 78 patients having tonsillectomy received bilateral glossopharyngeal nerve blocks, using bupivacaine 0.5% and adrenaline 1:200,000, or no intervention. There were no differences in postoperative analgesic consumption between the two groups. Visual analogue pain scores measured during swallowing in the recovery room and on the ward postoperatively were significantly less overall in uvulopalatoplasty patients who had received a block (p = 0.004). This difference was not found for tonsillectomy. We found no significant differences between groups, in pain scores recorded during the first 5 days at home. We conclude that glossopharyngeal block does not improve analgesia following tonsillectomy although there is short-lived benefit following uvulopalatoplasty.",1997.0,0,0
1546,9205657,Transdermal fentanyl for severe cancer-related pain.,W Yeo; K K Lam; A T Chan; T W Leung; S Y Nip; P J Johnson,"A prospective phase II study was conducted to define the analgesic efficacy, acceptability and toxicity of the transdermal therapeutic system (TTS) of fentanyl in Chinese patients with severe cancer-related pain. A total of 14 patients was treated with TTS fentanyl at doses ranging from 25 to 100 micrograms h-1; initial doses were chosen according to their previous opioid requirement. Standard supportive therapy was given as required. A brief pain inventory (using a 10-point scale) was used to assess patients at days 0, 7 and 14. Pain control on day 14 with TTS fentanyl was successful in six patients, with a reduction in the common side-effects of other opioids and improvement in general well-being. Seven patients did not complete the 14-day trial: two developed dizziness and nausea within 3 h of application; and in five, TTS fentanyl was insufficiently flexible to control increasing pain during the first week. TTS fentanyl was effective and well tolerated in 43% of patients. Acute dizziness and nausea within the first few hours after application and the relative inflexibility of dose-adjustment both limited the use of TTS fentanyl.",1997.0,0,0
1547,9207871,[Preventive analgesic effect of intraoperative administration of ibuprofen-arginine on postmastectomy pain syndrome].,F Lakdja; F Dixmérias; E Bussières; J M Fonrouge; A Lobéra,"The efficacy of preemptive analgesia on postoperative pain is discussed. From experimental neurophysiological data, the present policy of preventive analgesia aims at precluding modifications of the nervous system secondary to a nervous lesion and the appearance of chronic pain, particularly of the neurogenic kind. The post-mastectomy pain syndrome (PMPS) falls within the realm of neurogenic pain and is still poorly understood and underestimated. This study evaluated the preemptive effect of a perioperative administration of an oral non steroid anti-inflammatory, the ibuprofen-arginine, on PMPS. Thirty patients scheduled for partial or total mastectomy with axillary dissection were prospectively and randomly assigned to 2 groups. The ibuprofen-arginine group (group I) (n = 15), received an oral administration of 400 mg of ibuprofen-arginine, 90 min before surgery, 2 h after surgery and then every 8 h in the first 32 postoperative hours. The control group (group C) received in doubled blind a placebo at the same time. At 6 months, we looked after pain or dysesthesia. We confirmed the diagnosis of PMPS in presence of association of diagnosis criterias. Fourteen patients in each group have been included. Eighty-six percent of the patients (13 patients in group I and 11 patients in group C) presented at 6 months dysesthesia of the upper member ipsilateral to the mastectomy and/or the operated breast, appearing either immediately or after a laps of time. Nine patients (group I) and 6 patients (group C) had PMPS. Postoperative radiotherapy and lymphoedema were statistically associated with PMPS (p = 0.019 and p = 0.011). The perioperative preventive administration of a non-steroid anti-inflammatory drug reduces neither the incidence of pain in the first post-operative months, nor the appearance of PMPS at 6 months. These results suggest that others factors than the nervous lesion may play a role in the occurrence of PMPS, as radiotherapy, lymphoedema, but also psychosocials factors.",1997.0,0,0
1548,9212478,Comparison of oral controlled-release morphine with transdermal fentanyl in terminal cancer pain.,J O Wong; G L Chiu; C J Tsao; C L Chang,"Controlled-release morphine (MST) given twice daily provides a simpler and more convenient treatment regimen than 4-hourly opioid administration for the control of cancer pain. Recently, a new formulation of transdermal fentanyl (TDF) has been developed which provides a new route for the treatment of cancer pain. The present study was designed to compare the analgesic efficacy, safety and adverse effects of MST and TDF in the management of chronic cancer pain. In this open, comparative and randomized study, patients were treated with oral morphine hydrochloride immediate-release (MHIR) in the stabilization phase and then the prescription was switched to MST or TDF for 14 days in the treatment phase. Oral MHIR was provided as rescue medication for breakthrough pain. Assessments of the pain intensity, pain frequency, degree of pain improvement, profile of mood states, quality of sleep, activity status and adverse effects were performed before and after the stabilization phase and before and after the treatment phase. Forty of 47 cancer patients completed the study with 20 patients in each group. There were significant (p < 0.05) improvements in pain intensity, pain frequency, mood states and quality of sleep in both groups before and after treatment, while improvement in the activity status was not significant. No specific adverse effects were encountered except for drowsiness which occurred in 6 patients treated with MST and 5 treated with TDF (p < 0.05). Insomnia was significantly improved (p < 0.05) with both regimens compared with that in the period before treatment. There were no significant differences between the two study groups in analgesic efficacy or adverse effects. These results suggest that TDF and MSt are safe and effective analgesics for the management of chronic cancer pain. However, TDF provides a simpler and more convenient treatment for those patients with severe nausea, vomiting or dysphagia.",1997.0,0,0
1549,9215016,Intrathecal infusion of bupivacaine with or without morphine for postoperative analgesia after hip and knee arthroplasty.,M Bachmann; E Laakso; L Niemi; P H Rosenberg; M Pitkänen,"Postoperative pain after major orthopaedic operations can be controlled by continuous intrathecal administration of opioids or local anaesthetics. Effective intrathecal analgesia can be achieved through synergism of low doses of the two analgesic drugs and, possibly, less drug-related adverse effects. Therefore, we have evaluated the usefulness of a combined low-dose bupivacaine and morphine infusion in patients undergoing hip and knee arthroplasty. Spinal anaesthesia was induced in 55 ASA I-III patients with 0.5% bupivacaine 2 ml via a 28-gauge spinal catheter (L3-4 interspace) and 0.5-ml increments were given if needed. Intrathecal 24-h infusions consisted of bupivacaine 2 mg h-1 alone (n = 18), bupivacaine 1 mg h-1 alone (n = 18) or bupivacaine 1 mg h-1 combined with morphine 8 micrograms h-1 (n = 19). The interview after 3, 6, 12 and 24 h included assessment of pain at rest and on movement (VAS scale), occurrence of sensory and motor block and nausea/vomiting. Bupivacaine 1 mg h-1 combined with an infusion of morphine provided as good postoperative analgesia as bupivacaine 2 mg h-1, but motor block disappeared earlier (P = 0.01). Patients in the bupivacaine 1-mg h-1 group required more supplementary doses of oxycodone i.m. than the other groups (P = 0.04). Time to first oxycodone dose from the start of intrathecal infusion did not differ between groups. The frequency of nausea and vomiting was similar in all groups. In spite of this, antiemetic medication was required more often in the bupivacaine 1-mg h-1 group (possible because of opioid rescue medication). On the ward, one patient in the bupivacaine 2-mg h-1 group experienced a new increase in sensory block with concomitant hypotension. One patient in the same group had minor decubitus on the heel of the operated leg, probably because of prolonged motor block. We conclude that intrathecal infusion of a combination of bupivacaine 1 mg h-1 and morphine 8 micrograms h-1 produced adequate postoperative analgesia. Unfortunately, postoperative nausea and vomiting was a frequent disturbing adverse effect.",1997.0,0,0
1550,9220207,"Nonsteroidal anti-inflammatory drugs, traditional opioids, and tramadol: contrasting therapies for the treatment of chronic pain.",M D Aronson,"The treatment of chronic pain is an important function of physicians. In the United States, available drug treatments for chronic pain currently include simple analgesics such as acetaminophen, salicylates and other nonsteroidal anti-inflammatory drugs, traditional opioid drugs, and adjuvant agents (eg, antidepressants, anticonvulsants). Typically, the choice of a drug is made by balancing the indications for treatment, the clinical efficacy of the drug, and its toxicity. An understanding of the mechanism of action of these drugs helps to establish their role in therapy. Tramadol is an effective analgesic that works through a combined mechanism of weak mu receptor binding and the inhibition of serotonin and norepinephrine reuptake. Tramadol has a favorable adverse-effect profile and therefore is likely to have an important role in the management of chronic pain syndromes.",1997.0,0,0
1551,9220215,"Bromfenac sodium, acetaminophen/oxycodone, ibuprofen, and placebo for relief of postoperative pain.",G H Johnson; J D Van Wagoner; J Brown; S A Cooper,"The objective of this double-masked, parallel-group, multicenter, inpatient study was to compare bromfenac with an acetaminophen/oxycodone combination and ibuprofen in patients who had pain due to abdominal gynecologic surgery. In the 8-hour, single-dose phase, 238 patients received single oral doses of bromfenac (50 or 100 mg), acetaminophen 650 mg/oxycodone 10 mg, ibuprofen 400 mg, or placebo. In the multiple-dose phase, 204 patients received bromfenac, acetaminophen/oxycodone, or ibuprofen for up to 5 days. In the single-dose phase, both bromfenac doses produced peak analgesic responses equivalent to acetaminophen/oxycodone, but the responses to bromfenac were longer lasting. Bromfenac produced significantly better overall (8-hour) analgesic summed scores than acetaminophen/oxycodone. Ibuprofen was less efficacious than the other analgesics. The remedication rate was lower in both bromfenac groups than in the other treatment groups. The acetaminophen/oxycodone group reported more somnolence and vomiting. Single doses of bromfenac provided analgesia at least equivalent to that of the acetaminophen/oxycodone combination, with a longer duration of action. Both doses of bromfenac and acetaminophen/oxycodone were superior to ibuprofen in this study.",1997.0,0,0
1552,9220504,The value of end-tidal CO2 monitoring when comparing three methods of conscious sedation for children undergoing painful procedures in the emergency department.,L S Hart; S D Berns; C S Houck; D A Boenning,"Many studies have evaluated conscious sedation regimens commonly used in pediatric patients. Recent advances in capnography equipment now enable physicians to assess respiratory parameters, specifically end-tidal CO2 (et-CO2), more accurately in spontaneously breathing sedated children than was possible in the earlier studies. This study was designed to: 1) compare the safety and efficacy of intravenous fentanyl, intravenous fentanyl combined with midazolam, and intramuscular meperidine-promethazine-chlorpromazine (MPC) compound when used for painful emergency department (ED) procedures: and 2) to determine whether the addition of et-CO2 monitoring enabled earlier identification of respiratory depression in this population. Forty-two children requiring analgesia and sedation for painful ED procedures were randomly assigned to receive either fentanyl, fentanyl-midazolam, or MPC compound. Vital signs, oxygen saturation, and et-CO2 were monitored continuously. Pain, anxiety, and sedation scores were recorded every five minutes. Respiratory depression (O2 saturation < or = 90% for over the minute or any et-CO2 > or = 50) occurred in 20% of fentanyl, 23% of fentanyl-midazolam, and 11% of MPC patients (P = NS). Of those patients manifesting respiratory depression, 6/8 were detected by increased et-CO2 only. MPC patients required significantly longer periods of time to meet discharge criteria than fentanyl and fentanyl-midazolam patients (P < 0.05). No differences were noted in peak pain, anxiety, or sedation scores. Fentanyl, fentanyl-midazolam, and MPC produced a high incidence of subclinical respiratory depression. End-tidal CO2 monitoring provided an earlier indication of respiratory depression than pulse oximetry and respiratory rate alone. MPC administration resulted in a significantly delayed discharge from the ED.",1997.0,0,0
1553,9223200,Ketorolac as an adjunct to patient-controlled morphine in postoperative spine surgery patients.,S S Reuben; N R Connelly; R Steinberg,"This randomized double-blind study was designed to determine whether administration of ketorolac either on schedule or as a component of patient-controlled analgesia (PCA) to patients who have undergone spinal stabilization would decrease PCA morphine use, decrease side effects, and/or enhance analgesia. Eighty inpatients undergoing spine stabilization by one surgeon were evaluated after excluding patients with contraindications to the use of ketorolac or morphine. All patients received PCA morphine. The patients were divided into four groups, which were given either intravenous saline (control group); intravenous ketorolac 15 mg every 6 hours; intravenous ketorolac 30 mg every 6 hours; or ketorolac added to the PCA morphine on a milligram per milligram basis. The outcome measures included pain scores. 24-hour morphine use, level of sedation, and side effect profile at six times during the first 24 postoperative hours. The total dose of morphine (P < .0001) and the cumulative doses for each of the six time periods (P varied between .02 and .0001 for the six time periods) were significantly higher in the control group than in the other three groups. There were no differences in doses administered by the other three groups. The pain scores were also significantly higher in the control group than in the other three groups, with no differences in pain scores among the other three. The sedation scores were higher (ie, patients more sedated) in the control group than in the other three groups at two of the six time periods (periods I and 6; P < .001). Ketorolac should be as a component of the PCA morphine in patients undergoing spine stabilization surgery. This results in decreased morphine consumption, decreased somnolence, and enhanced analgesia in comparison with patients who do not receive ketorolac.",1997.0,0,0
1554,9223201,Addition of morphine to intra-articular bupivacaine does not improve analgesia following knee joint replacement.,N H Badner; R B Bourne; C H Rorabeck; J A Doyle,"In an effort to further decrease postoperative opioid requirements and improve analgesia in patients undergoing elective knee joint replacement, a study was made of the effectiveness of adding morphine to an intra-articular bupivacaine injection given immediately following surgery. In random, double-blind fashion, 75 patients received a 31-mL intra-articular injection consisting of either 30 mL 0.5% bupivacaine with 1:200,000 epinephrine and 1 mL normal saline (group BUP), 30 mL 0.5% bupivacaine with 1:200,000 epinephrine and 1 mg (1 mL) preservative-free morphine (group BUP-MORPH), or 30 mL normal saline with 1:200,000 epinephrine and 1 mg preservative-free morphine (group MORPH). Postoperative analgesia was supplied by patient controlled analgesia (PCA) with morphine. Patients were assessed at 1, 2, 4, and 24 hours for pain (visual analog and verbal rating scales), morphine utilization, and side effects. Knee range of motion was measured before operation and at hospital discharge. There was no difference among the three groups in PCA morphine requirements, pain scores by either scale, range of motion, or incidence of side effects, including somnolence, urinary retention, nausea and vomiting, and pruritus. The addition of 1 mg morphine to an intra-articular injection of 30 mL 0.5% bupivacaine with 1:200,000 epinephrine given at wound closure does not improve analgesia in patients undergoing elective knee joint replacement.",1997.0,0,0
1555,9224487,Overpowering pain. A serious problem comes out of the closet.,M E O'Brien; D Hoel,,1997.0,0,0
1556,9226732,Modulating effects of a cold water stimulus on opioid effects in volunteers.,K M Conley; A Y Toledano; J L Apfelbaum; J P Zacny,"The purpose of this study was to characterize the effect of a painful stimulus on morphine and butorphanol effects in healthy non-drug abusing volunteers. Thirteen subjects with no history of opiate dependence participated in a randomized, placebo-controlled, double-blind, crossover trial in which each subject received saline, 2 mg/70 kg butorphanol, and 10 mg/70 kg morphine, IV, in each of two conditions, periodic forearm immersions into either ice-cold water (2 degrees C) or into warm water (37 degrees C). Both opioids reduced self-reported ratings of pain intensity, indicative of analgesia. Several of the subjective effects of morphine were attenuated either during or in between cold-water immersions, including visual analog scale ratings of ""coasting (spaced out),"" ""high (drug ""high""),"" ""sleepy (drowsy, tired),"" and ""lightheaded"". In contrast, some of butorphanol's subjective effects were increased by the cold-water manipulation. Morphine impaired psychomotor performance during one of the warm-water immersions, but not during the cold-water immersions. Psychomotor impairment induced by butorphanol was not affected by water temperature. This study provides evidence that opioid effects can be modulated by a painful stimulus in humans.",1997.0,0,0
1557,9227003,Analgesia for severe postoperative pain: a comparison of two methods.,A O Amata; L T Popo,,1997.0,0,0
1558,9229164,Pain management in the pediatric intensive care unit.,C R Chambliss; K J Anand,"Critically ill pediatric patients are frequently exposed to acute, established, and chronic pain as a result of their disease processes or intensive care therapies. Despite the availability of many drugs and techniques for providing analgesia, these painful conditions are not adequately treated in a large proportion of children. This article reviews some of the reasons for provision of adequate analgesia and sedation, describes the various classes of drugs commonly used in the pediatric intensive care unit, and lists the techniques and indications for regional and topical anesthesia as well as specific clinical applications for adjuvant analgesic agents. Analgesic approaches that do not have an established record of safety and efficacy in pediatric patients are not reviewed. We propose that adequate and early analgesic interventions will minimize patient's discomfort, maintain metabolic homeostasis, and improve a patient's tolerance of intensive care unit therapies and nursing interventions. Adequate analgesia can be provided to even the sickest child using the drugs, techniques, and novel approaches reviewed.",1997.0,0,0
1559,9231864,Differences among patients in opioid self-administration during bone marrow transplantation.,C R Chapman; G W Donaldson; R C Jacobson; B Hautman,"The distinctive features of individual patients, here termed individual differences, are inescapable aspects of day-to-day patient pain management, but classically designed research studies ignore such differences. This paper introduces statistical pattern visualization methodology for the study of complex individual differences in clinical settings. We demonstrate the application of such methods in patients undergoing bone marrow transplantation (BMT) and suffering severe oral mucositis as a consequence of the aggressive BMT preparative regimen. Oral mucositis produces severe pain and patients often require parenteral opioid medication for several weeks. Unfortunately, the opioid can cause side-effects that limit drug use for pain control. Patients differ in severity and duration of oral mucositis, analgesic response to opioids, and side-effects. We identified and classified individual differences in patterns of drug use, pain control and side-effects in 33 BMT patients who received opioid drug via patient-controlled analgesia (PCA) systems for 7 days or more. These systems allowed bolus dosing and also provided a basic level of analgesic protection through continuous drug infusion. Continuous infusion levels increased or decreased in response to patient bolus self-administration. We employed statistical smoothing (moving average) techniques to remove random variation from the individual data sets and created three-way (trivariate) plots of change over time in drug use, pain and an opioid side-effect (impairment of concentration). The patterns apparent in these plots indicated that 24.2% of patients used PCA optimally (increases in drug use associated with reductions in pain and little or no side-effect), an additional 30.3% manifested a potentially optimal pattern limited by side-effect that worsened with dosing, and 36.4% used PCA suboptimally (modest pain control plus side-effects). In addition, for each subject we created a summary measure for the simultaneous change in three variables: the distance of each day's trivariate score from the origin of a three dimensional plot. This summary measure correlated significantly with the changing severity of patients' oral mucositis over time (r = 0.502). This study demonstrates how interactive graphic techniques can provide a basis for examining changes over time among multiple, correlated variables associated with a single individual. It illustrates the application of such techniques and demonstrates that individual subject data sets merit examination in cases where clinical data reflect human performance.",1997.0,0,0
1560,9232133,Remifentanil versus remifentanil/midazolam for ambulatory surgery during monitored anesthesia care.,M I Gold; W D Watkins; Y F Sung; J Yarmush; F Chung; N T Uy; W Maurer; M Y Clarke; B D Jamerson,"This study was designed to define the appropriate dose of remifentanil hydrochloride alone or combined with midazolam to provide satisfactory comfort and maintain adequate respiration for a monitored anesthesia care setting. One hundred fifty-nine patients scheduled for outpatient surgery participated in this multicenter, double-blind study. Patients were randomly assigned to one of two groups: remifentanil, 1 microgram/kg, given over 30 s followed by a continuous infusion of 0.1 microgram.kg-1.min-1 (remifentanil), remifentanil, 0.5 microgram/kg, given over 30 s followed by a continuous infusion of 0.05 microgram.kg-1.min-1 (remifentanil+midazolam). Five minutes after the start of the infusion, patients received a loading dose of saline placebo (remifentanil) or midazolam, 1 mg, (remifentanil+midazolam). If patients were not oversedated, a second dose of placebo or midazolam, 1 mg, was given. Remifentanil was titrated (in increments of 50% from the initial rate) to limit patient discomfort or pain intraoperatively, and the infusion was terminated at the completion of skin closure. At the time of the local anesthetic, most patients in the remifentanil and remifentanil+midazolam groups experienced no pain (66% and 60%, respectively) and no discomfort (66% and 65%, respectively). The final mean (+/-SD) remifentanil infusion rates were 0.12 +/- 0.05 microgram.kg-1.min-1 (remifentanil) and 0.07 +/- 0.03 microgram.kg-1.min-1 (remifentanil+midazolam). Fewer patients in the remifentanil+midazolam group experienced nauses compared with the remifentanil group (16% vs. 36%, respectively; P < 0.05). Four patients (5%) in the remifentanil group and two patients (2%) in the remifentanil+midazolam group experienced brief periods of oxygen desaturation (SpO2 < 90%) and hypoventilation (< 8 breaths/ min). Remifentanil alone or combined with midazolam provided adequate analgesia and maintained adequate respiration at the doses reported. The low dose of remifentanil combined with 2 mg midazolam, compared with remifentanil alone, resulted in fewer side effects, slightly greater sedation, and less anxiety.",1997.0,0,0
1561,9236751,Role of opioids in chronic non-cancer pain.,A R Molloy; M K Nicholas; M J Cousins,,1997.0,0,0
1562,9236756,"Australian trends in opioid prescribing for chronic non-cancer pain, 1986-1996.",J R Bell,"To identify trends in the use of opioid drugs for chronic non-cancer pain. Review of three sets of official records-the record of Schedule 8 (S8) opioid drugs used in Australia, 1984-1995, from the national Department of Health, Housing and Community Services; New South Wales Department of Health statistical summaries of the number of authorities to prescribe S8 drugs for cancer pain and non-cancer pain for each June from 1990 to 1996; and NSW Department of Health patient records for a cohort of patients first prescribed S8 drugs in 1991. Total quantities of opioids used in Australia; numbers of S8 authorities issued in NSW. Outcome measures for the cohort study were the proportion of patients remaining on opioids long-term, the proportion for whom dose escalated over time, and the diagnoses for which opioids were being prescribed. Between 1986 and 1995, the amount of oral morphine used in Australia rose from 117 to 578 kg. Use of all other oral S8 opioids combined increased from 93 to 149 kg. In NSW, the number of authorities to prescribe for non-cancer pain rose from 3326 in June 1990 to 5743 in June 1996 (73% increase), while cancer pain authorities rose from 2652 to 4831 (82% increase). Sixty-nine of the 102 patients ceased to receive drugs on authority over the five year follow-up. These subjects received opioids for a mean of 19 months. Among the remaining 33 subjects, dose escalation was common. Diagnostic information indicated that may patients had significant psychological and social problems. There has been a dramatic increase in opioid prescribing, a substantial proportion of which is for non-cancer pain. In a sample of patients being treated for non-cancer pain, long term use and dose escalation occurred in one third of cases.",1997.0,0,0
1563,9236757,The use of oral opioids in patients with chronic non-cancer pain. Management strategies.,P J Graziotti; C R Goucke,"The use of oral opioids in non-cancer pain is increasing, but it is not clear that this is improving outcomes for patients. These management strategies were developed as a consensus view between the two authors, who are both Directors of the Australian Pain Society. The strategies were subsequently reviewed and approved by the other Directors of the Society: four anaesthetists specialising in pain management, a pharmacist, a rheumatologist, two rehabilitation physicians and an occupational therapist. A MEDLINE search of the literature since 1966 produced 163 relevant articles, including two randomised controlled trials of oral opioids in non-cancer pain. A small group of patients with chronic non-cancer pain can benefit from the use of oral opioids. Thorough attention to diagnosis and patient history must precede any decision to prescribe opioids. Patients should be psychologically stable. Patient and doctor should-agree beforehand on how to assess the outcome of therapy. Only one doctor (the patient's regular primary carer or pain specialist) should prescribe opioids and assess the response. Sustained release morphine preparations are the drug of choice. A trial of therapy, with goals and endpoint agreed between patient and doctor, should precede any decision to prescribe opioids in the long term.",1997.0,0,0
1564,9240172,The use of surgical sympathectomy in the treatment of chronic renal pain.,B T Andrews; N F Jones; N L Browse,"To assess the efficacy of renal sympathetic denervation in the treatment of chronic renal pain. In a 10-year period, 21 patients suffering from chronic renal pain underwent 27 renal denervation operations, six of which were bilateral. The cause of pain was the loin pain haematuria syndrome in 18 patients. Four operations resulted in complete pain relief to date (median follow-up 53.5 months). Pain relief after the other 23 operations in 18 patients lasted a median of 6 months. Assuming that recurrent pain was due to neuronal regeneration, nine of the 18 patients with recurrent pain underwent a total of 10 re-explorations of the renal pedicle, stripping it of all nerve fibres and areolar tissue. Three of these re-explorations produced complete pain relief to date (median follow-up 40 months). The median pain-free interval of the other seven re-explorations in six patients was 19 months. Renal denervation cures severe intractable pain in about 25% of patients. Recurrence of pain could be prevented in more patients if there was a way of preventing re-innervation.",1997.0,0,0
1565,9240635,Low energy Helium-Neon laser in the prevention of oral mucositis in patients undergoing bone marrow transplant: results of a double blind randomized trial.,D Cowen; C Tardieu; M Schubert; D Peterson; M Resbeut; C Faucher; J C Franquin,"To evaluate the efficiency of Helium-Neon (He-Ne) laser in the prevention of oral mucositis induced by high dose chemoradiotherapy before autologous bone marrow transplantation (BMT). Between 1993 and 1995, 30 consecutive patients receiving an autologous peripheral stem-cell or bone marrow transplant (BMT) after high dose chemoradiotherapy were randomized to possibly receive prophylactic laser to the oral mucosa after giving informed consent. Chemotherapy consisted of cyclophosphamide, 60 mg/kg intravenously (I.V.) on day (d)-5 and d-4 in 27 cases, or melphalan 140 mg/kg I.V. on d-4 in three cases. Total body irradiation (TBI) consisted of 12 Gy midplane dose in six fractions (4 Gy/day for three days). He-Ne laser (632.8 nm wavelength, power 60 mW) applications were performed daily from d-5 to d-1 on five anatomic sites of the oral mucosa. Oral examination was performed daily from d0 to d + 20. Mucositis was scored according to an oral exam guide with a 16 item scale of which four were assessed by the patients themselves. Mean daily self assessment scores for oral pain, ability to swallow and oral dryness were measured. A daily mucositis index (DMI) and a cumulative oral mucositis score (COMS) were established. Requirement for narcotics and parenteral nutrition was recorded. The COMS was significantly reduced among laser treated (L+) patients (p = 0.04). The improvement of DMI in L+ patients was also statistically significant (p < 0.05) from d + 2 to d + 7. Occurrence and duration of grade III oral mucositis were reduced in L+ patients (p = 0.01). Laser applications reduced oral pain as assessed by patients (p = 0.05) and L+ patients required less morphine (p = 0.05). Xerostomia and ability to swallow were improved among the L+ patients (p = 0.005 and p = 0.01, respectively). Requirement for parenteral nutrition was not reduced (p = NS). Helium-Neon laser treatment was well tolerated, feasible in all cases, and reduced high dose chemoradiotherapy-induced oral mucositis. Optimal laser treatment schedules still needs to be defined.",1997.0,0,0
1566,9244023,Analgesia after day case laparoscopic sterilisation. A comparison of tramadol with paracetamol/dextropropoxyphene and paracetamol/codeine combinations.,I M Crighton; G J Hobbs; I J Wrench,"In a prospective, double-blind trial we compared the analgesic efficacy of tramadol during the first 24 h after day case laparoscopic sterilisation with two commonly prescribed combination analgesics. Seventy-five women were allocated randomly to receive oral paracetamol 325 mg/dextropropoxyphene hydrochloride 32.5 mg, tramadol 50 mg or paracetamol 500 mg/codeine phosphate 30 mg as required after a standardised anaesthetic technique. There were no significant differences in average or worst pain, sleep disturbance, mobility, number of tablets taken, satisfaction or preference for stronger analgesia (26.2% of all patients). The incidences of nausea and vomiting were comparable between groups. There was a trend towards a lower incidence of central nervous system side-effects (drowsiness, dizziness, headache) in the paracetamol/codeine group. Tramadol may be considered an alternative analgesic for day case surgery although analgesic regimens of greater efficacy are required for many patients. The relative incidence of side-effects for tramadol and other analgesics requires further evaluation.",1997.0,0,0
1567,9244939,[Analgesic effectiveness and repercussions on the progress of labor of small doses of bupivacaine and fentanyl in continuous peridural perfusion].,M García-Muñoz; J López-Vidal; M A Sevila-Pascual; B Alonso-Miranda; M D Cárceles-Barón; M Canteras-Jordana; F López-Rodríguez,"To compare the analgesic efficacy and repercussion on labor of early administration of two different concentrations of bupivacaine/fentanyl in continuous epidural perfusion, in comparison with a control group receiving no epidural anesthesia. One hundred fifty patients were distributed among 3 groups. Group I (n = 50) received no epidural analgesia. Group II (n = 50) and III (n = 50) received test doses of 3 ml of bupivacaine plus adrenalin 1/200,000. After 5 minutes each patient in the study groups received 13 ml of the solution assigned (group II: 0.04% bupivacaine plus adrenalin 1/2,500,000 and fentanyl 2.5 micrograms/ml; group III: 0.0625% bupivacaine plus adrenalin 1/1,600,000 and fentanyl 2 micrograms/ml). Five minutes later a perfusion of 12 ml/h-1 of the same solution was delivered until dilation was complete. Epidural perfusion was started at 2.5 +/- 0.93 cm of dilation (group II) and 2.3 +/- 0.92 cm (group III). There were no statistically significant differences in either duration of labor until full dilation or expulsion among the groups. Pain assessed on a visual analog scale evolved from a baseline mean of 4.5 to 5 in the three groups, reaching 8.9 +/- 0.74 (group I), 0.24 +/- 0.89 (group II) and 0.28 +/- 0.57 (group III). There were no significant differences in fetal presentation or Apgar scores among the three groups at the end of delivery. Both solutions provide good analgesia during labor with minimum undesirable side effects. Low epidural doses of bupivacaine and fentanyl started early do not affect the course of labor.",1997.0,0,0
1568,9248564,Adenosine for pain control.,A Sollevi,"The antinociceptive actions of adenosine and adenosine analogs in animal models has been known for more than 10 years. The recent development with regard to the pain modulatory effects of adenosine, primarily in clinical studies, has generated a renewed interest in this principle for pain control. This review summarizes the current knowledge in adenosine mediated pain modulation in acute and chronic conditions, with focus on studies in man. The endogenous compound adenosine has various modulatory effects in the peripheral and central nervous system, mediated through specific cell-surface associated receptors. The current view is that adenosine receptors of the A1-subtype are associated with a modulatory effect on pain transmission at spinal cord level. Animal studies have repeatedly demonstrated adenosine- and adenosine analog mediated inhibitory influences on presumed nociceptive reflex responses (1,2). These examinations in rodents have tested acute pain models involving tactile, pressure and heat stimulations. More recently, animal lesion models presumably reflecting chronic pain, has shown that adenosine analogs can suppress nociceptive behaviour both by systemic and intrathecal (i.t.) administration (3,4). Consequently, there is substantial evidence that adenosine can modulate nociceptive input. Further, it has been proposed that endogenous adenosine formation is involved in physiological pain control at the spinal cord level and that its release is involved in the action of opioid antinociception (1). Clinical studies have revealed that adenosine administration by bolus injection or by infusion at doses above 70 micrograms x kg-1 x min-1 is associated with pain symptoms from different parts of the body. This algogenic effect of higher doses of adenosine is probably related to sensitization/activation of peripheral nociceptive afferents (5).",1997.0,0,0
1569,9248571,A new method to evaluate central sensitization to pain following surgery. Effect of ketamine.,A Stubhaug,,1997.0,0,0
1570,9252005,High dose alfentanil pre-empts pain after abdominal hysterectomy.,J Katz; M Clairoux; C Redahan; B P Kavanagh; S Carroll; H Nierenberg; M Jackson; J Beattie; A Taddio; A N Sandler,"This study tested the hypothesis that high dose systemic alfentanil administered before and during abdominal hysterectomy would pre-empt post-operative pain to a greater extent than administration of either low dose alfentanil or no alfentanil perioperatively. Patients (ASA 1 or 2) were randomly assigned to group 1 (n = 15), no opioid; group 2 (n = 15), low dose alfentanil; or group 3 (n = 15), high dose alfentanil. Anaesthesia was induced in group 1 with midazolam and thiopentone and was maintained with isoflurane and 70% N2O in O2. Anaesthesia was induced in group 2 with midazolam, thiopentone and i.v. alfentanil (30 microg kg(-1)), and was maintained with isoflurane, 70% N2O in O2, and bolus doses of i.v. alfentanil (10-20 microg kg(-1)) every hour. Anaesthesia was induced in group 3 with midazolam and i.v. alfentanil (100 microg kg(-1)), and was maintained with 70% N2O in O2, and an infusion of i.v. alfentanil (1-2 microg kg(-1) min(-1)). Blood samples were drawn at 30 and 120 min after surgery and assayed for plasma alfentanil. Morphine consumption and VAS pain scores were consistently lowest in group 3 over the 48 h study period. A composite measure of pain and morphine consumption was significantly lower in group 3 than group 2 up to 6 h after surgery, and significantly lower than group 1 up to 12 h. No adverse effects were observed. A 6-month follow-up did not reveal any significant differences among the three groups. It is concluded that intra-operative high dose alfentanil anaesthetic pre-empts post-operative pain after abdominal hysterectomy, but the effects are small and of short duration. Surgical procedures carried out under general anaesthesia using standard (and even high) doses of opioids intraoperatively provide suboptimal protection from the injury barrage brought about by incision and subsequent noxious surgical events.",1996.0,0,0
1571,9253564,Transition to post-operative epidural or patient-controlled intravenous analgesia following total intravenous anaesthesia with remifentanil and propofol for abdominal surgery.,T A Bowdle; L B Ready; E D Kharasch; W W Nichols; K Cox,"Remifentanil is an ultrashort acting mu opioid, well suited to total intravenous (i.v.) anaesthesia. Pain immediately following emergence from anaesthesia is a potential problem because of the rapid offset. This study investigated the transition from remifentanil/propofol total intravenous anaesthesia to post-operative analgesia with epidural or patient controlled analgesia morphine in 22 patients undergoing major abdominal surgery. A remifentanil post-operative infusion initiated during emergence was titrated in the recovery room for 30 min, at which time 14% of patients had a pain score of 2 and 86% had pain scores of 0 or 1 (0 = no pain; 1 = mild pain; 2 = moderate pain; 3 = severe pain), at a mean infusion rate of 0.086 microgram kg-1 min-1. A smooth transition was then made to either epidural analgesia or patient controlled analgesia with morphine; pain scores were not significantly changed during the transition. Nausea occurred in 16 of the 22 patients, but only following administration of morphine. Epidural analgesia produced significantly lower pain scores on the surgical ward compared with patient controlled analgesia.",1997.0,0,0
1572,9257210,"Effects of intrathecal opioid on extubation time, analgesia, and intensive care unit stay following coronary artery bypass grafting.",A Shroff; G A Rooke; M J Bishop,"To determine if intrathecal opioid decreases time to extubation after coronary artery bypass surgery without compromising postoperative analgesia. Prospective randomized trial. Veterans Affairs Hospital. 21 ASA physical status III and IV men scheduled for elective coronary bypass surgery, who had not received medications that would impair anticoagulation at the time of surgery. Patients were randomized to receive 10 micrograms/kg morphine and 25 micrograms fentanyl intrathecally preoperatively (n = 12) or no intrathecal opioid (n = 9). The latter group received 25 to 50 micrograms/kg fentanyl and 0.05 to 0.1 mg/kg midaxolam intraoperatively, whereas the intrathecal opioid group received intravenous (i.v.) fentanyl and midazolam only as needed. Both groups were administered i.v. morphine and midazolam postoperatively as needed by intensive care unit (ICU) personnel who were blinded to the treatment group. For the first 24 hours postoperatively, pain levels (0 = none, to 10 = most severe) and sedation levels (1 = none, to 5 = unconscious) were measured hourly. The time to extubation and discharge from the ICU was recorded. ECG evidence of myocardial ischemia was noted. Pain scores were low for both groups (1.5), but the intrathecal opioid subjects exhibited less sedation than the high-dose fentanyl subjects [means +/- standard deviation (SD) of 2.3 +/- 0.4 vs. 2.8 +/- 0.5, p = 0.03]. Extubation time was 12 hours shorter in the intrathecal opioid group (2.9 +/- 5.3 vs. 14.7 +/- 6.8, p = 0.001). The five subjects with a one day ICU stay were all in the intrathecal opioid group (p = 0.04). The incidence of myocardial ischemia did not differ between the two groups. Intrathecal opioid can facilitate early extubation and discharge from the ICU without compromising analgesia or increasing myocardial ischemia.",1997.0,0,0
1573,9259870,Intravenous regional anesthesia. Evaluation of 4 different additives to prilocaine.,V Hoffmann; M Vercauteren; A Van Steenberge; H Adriaensen,"Intravenous regional anesthesia (IVRA) is an effective method of producing anesthesia of the extremities. Disadvantages are the rapid loss of anesthesia after the deflation of the tourniquet and the rapid development of postoperative pain. This study compared the effect of four different additives to prilocaine with saline on the development of a complete sensory block, on the return of sensory function after deflation of the tourniquet and on the development of postoperative pain after IVRA for minor orthopedic surgery of the arm. Seventy-five patients, ASA class 1 or 2, were randomly divided into 5 groups. All patients received 30 ml. of prilocaine 1%, together with 5 ml. of additive. In group 1, the additive was saline, in group 2 bupivacaine 0.25%, in group 3 clonidine 150 micrograms in saline, in group 4 sufentanil 25 micrograms in saline and in group 5 tenoxicam 20 mg. The development of a complete sensory block proved significantly faster in the patients receiving sufentanil (4.8 min.) as compared to plain prilocaine (7.5 min.). The return of the sensory function was comparable for all groups. Postoperative pain scores were significantly better in the clonidine and tenoxicam groups.",1997.0,0,0
1574,9259873,Accidental overdosing with intraspinal morphine caused by misprogrammation of a Synchromed pump: a report of two cases.,L Belmans; J P Van Buyten; L Vanduffel; P Vueghs; H Adriaensen,"Spinally administered opioids must be a last step in the therapeutical arsenal of chronic benigne pain. It is an invasive technique not free from adverse effects. Two chronic pain patients received an implantable Synchromed pump for treatment with spinal opiates after a trial period of resp. 3.5 and 5.5 months. Due to a misprogrammation (both on the same day) they received very high doses of spinal opiates. This caused relatively few side effects, which did not seem to require immediate treatment. A short time development of tolerance to life threatening side-effects has been proven by this accidental administration of high-dose intraspinal opiates. It is critical that care providers are knowledgeable and well-trained about implantable infusion systems. Programmation and refills must always be performed with care.",1997.0,0,0
1575,9262274,How effective is patient-controlled analgesia? A randomized comparison of two protocols for pain relief during oocyte recovery.,S Bhattacharya; F MacLennan; M P Hamilton; A Templeton,"Although the conventional method of pain relief during outpatient oocyte recovery involves physician-administered drugs, patient-controlled analgesia (PCA) offers an alternative technique with the potential to give women more control over peroperative analgesia. We conducted a prospective randomized study to compare the effect of fentanyl administered either through a PCA delivery system or by a physician. Thirty-nine women were randomized to PCA during egg collection while 42 were allocated to receive intermittent doses administered by a physician. Pain was evaluated by means of a 100 mm linear analogue scale. The mean (SD) pain score in the PCA group was 38.5 (19.8) while in the other group it was 46.1 (21.3) (P = 0.1). In the PCA group, 64% of women felt very satisfied with their analgesia as compared with 57% in the non-PCA group (P = 0.6). Among the PCA users, 39% of demands were successful. Significantly more fentanyl (97.5 microg) was used in the PCA group than in the other group (84.6 microg) (P = 0.03). Though intraoperative PCA with fentanyl is an effective alternative to physician-administered techniques, many women still feel the need for more analgesia during the procedure.",1997.0,0,0
1576,9263160,Fibromyalgia--are there different mechanisms in the processing of pain? A double blind crossover comparison of analgesic drugs.,J Sörensen; A Bengtsson; J Ahlner; K G Henriksson; L Ekselius; M Bengtsson,"Pain was analyzed in patients with fibromyalgia (FM) in a randomized, double blind, crossover study using intravenous (i.v.) administration of different drugs. In 18 patients with FM muscle pain to i.v. administration of morphine (0.3 mg/kg), lidocaine (5 mg/kg), ketamine (0.3 mg/kg), or saline was studied. Spontaneous pain intensity, muscle strength, static muscle endurance, pressure pain threshold, and pain tolerance at tender points and non-tender point areas were followed. Drug plasma concentrations and effects on physical functioning ability score (FIQ) were recorded. A personality inventory (KSP) was used to related pain response to personality traits. Thirteen patients responded to one or several of the drugs, but not to placebo. Two patients were placebo responders responding to all 4 infusions. Three were nonresponders responding to no infusions. Seven of the responders had a reduction in pain for 1-5 days. Pressure pain threshold and pain tolerance increased significantly in responders. Plasma concentrations were similar in responders and nonresponders. FIQ values improved significantly after the ketamine infusion. Responders scored higher on KSP scales for somatic anxiety, muscular tension, and psychasthenia compared with healthy controls. FM diagnosed according to the American College of Rheumatology criteria seems to include patients with different pain processing mechanisms. A pharmacological pain analysis with subdivision into responders and nonresponders might be considered before instituting therapeutic interventions or research.",1997.0,0,0
1577,9263303,Postoperative pain management.,J D Tobias,"Recent evidence has documented the deleterious physiologic effects of pain and the beneficial results of effective postoperative analgesia. As outlined in this article, a three-step approach is recommended depending on the severity of pain. The three-step approach utilizes a combination of NSAIDs, oral or intravenous opioids. In addition to selecting a particular opioid to use, the practitioner must also consider the route of administration and the mode of administration. All three choices may significantly impact on the efficacy of analgesia. While we continue to use primarily intravenous opioids to treat moderate and severe pain in the hospital setting, future formulations and developments may allow for the increased use of non-parenteral routes.",1997.0,0,0
1578,9268795,Intra-articular morphine and/or bupivacaine in the management of pain after total knee arthroplasty.,D R Mauerhan; M Campbell; J S Miller; J G Mokris; A Gregory; G M Kiebzak,"The purpose of this study was to determine if intra-articular injection of morphine or bupivacaine significantly decreased postoperative pain as well as the use of intravenous narcotics for pain relief in patients undergoing total knee arthroplasty (TKA). In a prospective, double-blind, randomized fashion, 105 patients undergoing TKA were divided into the following 4 groups defined by the intra-articular injection they received: group 1 (n = 27) received saline solution, group 2 (n = 26) received morphine sulfate (5 mg), group 3 (n = 24) received bupivacaine (50 mg), and group 4 (n = 28) received a combination of morphine sulfate and bupivacaine. The injections were administered immediately after wound closure by the Hemovac drainage tubing that remained clamped for 45 minutes after surgery to allow for absorption. Before surgery and at 2, 4, 6, 24, and 48 hours after surgery, pain intensity was recorded using a visual analog scale. Postoperative supplemental intravenous morphine and/or meperidine was administered via a patient-controlled analgesia device, and 24-hour drug usage was tabulated. Results were suggestive of a modest short-term reduction in pain scores in the morphine and bupivacaine treatment groups compared with placebo (saline); however, results were statistically significant only at 4 hours because of the great variability in the pain score data. The total amount of postoperative pain medication used in the first 24 hours after surgery was not statistically significant between the 4 treatment groups. Thus, the results put into question the benefit of postoperative intra-articular administration of morphine or bupivacaine in patients undergoing TKA.",1997.0,0,0
1579,9270762,Intrathecal allograft of chromaffin cells for intractable pain treatment: a model for understanding CNS tolerance mechanisms in humans.,J Tkaczuk; J C Bes; H de Bouet du Portal; M Tafani; H Duplan; M Abbal; Y Lazorthes; E Ohayon,,1997.0,0,0
1580,9272782,Pharmacological classification of central post-stroke pain: comparison with the results of chronic motor cortex stimulation therapy.,T Yamamoto; Y Katayama; T Hirayama; T Tsubokawa,"In an attempt to clarify the neurochemical background of central post-stroke pain and to undertake a pharmacological analysis, the basic pharmacological characteristics of this intractable pain syndrome were investigated by the morphine, thiamylal and ketamine tests. In addition, the correlation between the pharmacological characteristics and the effects of chronic motor cortex stimulation therapy was examined. The study employed 39 central post-stroke pain patients who had intractable hemibody pain associated with dysesthesias, and radiologically demonstrated lesions in the thalamic area (thalamic pain, n = 25) or suprathalamic area (suprathalamic pain, n = 14). The pharmacological evaluations showed that definite pain reduction occurred in eight of the 39 cases (20.5%) by the morphine test, in 22 of the 39 cases (56.4%) by the thiamylal test, and in 11 of 23 cases (47.8%) by the ketamine test. Based on these pharmacological assessments, there was no obvious difference between thalamic and suprathalamic pain. A comparison of the long-term follow-up results of chronic motor cortex stimulation therapy revealed that thiamylal and ketamine-sensitive and morphine-resistant cases displayed long-lasting pain reduction with chronic motor cortex stimulation therapy, whereas the remaining cases did not show good results. We conclude that pharmacological classification of central post-stroke pain by the morphine, thiamylal and ketamine tests could be useful for predicting the effects of chronic motor cortex stimulation therapy. It has recently been suggested that excitatory amino acids may be involved in the development of central post-stroke pain. However, the fact that only 23 of the present 39 cases (59.0%) of thalamic and suprathalamic pain were sensitive to the thiamylal or ketamine test reflects the complex pharmacological background and the difficulties associated with treating central post-stroke pain.",1997.0,0,0
1581,9272793,"Ketamine, an NMDA receptor antagonist, suppresses spatial and temporal properties of burn-induced secondary hyperalgesia in man: a double-blind, cross-over comparison with morphine and placebo.",T Warncke; A Stubhaug; E Jørum,"Effects of morphine and ketamine (NMDA receptor antagonist) on temporally summated pain ('wind-up-like pain') and spatial aspects of secondary hyperalgesia were investigated in 12 healthy volunteers. Hyperalgesia was produced by a local 1 degree burn injury covering 12.5 cm2 on the medial surface of the calf. Primary hyperalgesia was determined by measuring heat pain detection threshold (HPDT) within the site of injury. Spatial aspects of secondary hyperalgesia present outside the site of injury were quantitated by determination of the areas in which a mechanical punctate (von Frey hair, 50.6 mN), or brush stimuli elicited pain sensation. Temporal aspects of secondary hyperalgesia were determined by repetitively pricking the skin with a standard von Frey hair (834 mN) inducing a 'wind-up-like pain'. Morphine 0.15 mg/kg, ketamine 0.15 mg/kg or placebo (NaCl 0.9%) were administrated i.v. on 3 separate days 50 min after the burn injury in a double-blind, placebo controlled, randomised and cross-over design. In all subjects HPDT was significantly reduced within the injured area compared to the pre-injury threshold (primary hyperalgesia). All subjects developed areas of allodynia and hyperalgesia to punctate stimuli and brush stimuli outside the injured area (secondary hyperalgesia). HPDT was not reduced in the area of secondary hyperalgesia. In 95% of the measurements we found a sudden appearance of pain to repeated pricking with a von Frey hair (834 mN) in the area of secondary hyperalgesia ('wind-up-like pain'). Ketamine significantly reduced the area of secondary hyperalgesia both for punctate and brush stimuli in the first measurement 15 min after injection and eight of the 11 subjects reported that the 'wind-up-like pain' disappeared. On the measurements 45 and 75 min after ketamine injection, secondary hyperalgesia and 'wind-up-like pain' reappeared. Morphine did not significantly change the size of the area of secondary hyperalgesia and did not affect 'wind-up-like pain'. Ketamine or morphine did not change thermal detection thresholds. We conclude that spatial and temporal mechanisms, underlying secondary hyperalgesia, are mediated by glutamatergic transmission via NMDA receptors.",1997.0,0,0
1582,9272805,Attention and somatic awareness in chronic pain.,C Eccleston; G Crombez; S Aldrich; C Stannard,"Empirical methods are used to explore the relationship between chronic pain, somatic awareness and attention. Using a primary task paradigm, 46 chronic pain patients performed an attentionally demanding task. Patients were classified according to self reported pain intensity and the extent of their reporting of the perception of bodily sensations (somatic awareness). Results showed that, as predicted, disruption of attentional performance was most pronounced in those who reported high pain intensity and high somatic awareness. Further analysis revealed that these patients also reported high negative affect. These findings are discussed in terms of their theoretical implications for the concept of hypervigilance and their clinical implications for chronic pain control.",1997.0,0,0
1583,9272808,A comparison of pain report and adequacy of analgesic therapy in ambulatory AIDS patients with and without a history of substance abuse.,W Breitbart; B Rosenfeld; S Passik; M Kaim; J Funesti-Esch; K Stein,"Concerns are often raised regarding the credibility of patients' report of pain and this concern is heightened among individuals with AIDS, where many patients have a history of injection drug use. This study compared the pain experience, adequacy of pain management and psychological well-being among patients with AIDS who reported a history of injection drug use (IDU) as their HIV transmission risk factor and patients with other HIV transmission risk factors. Five hundred and sixteen ambulatory AIDS patients participating in a quality of life study completed a series of self-report instruments including the Brief Pain Inventory, the Beck Depression Inventory, the Brief Symptom Inventory, the Functional Living Inventory and the Social Support Questionnaire. Results demonstrated that IDU and non-IDU subjects did not differ significantly in their report of pain prevalence, pain intensity or pain-related functional interference. However, IDU patients were significantly more likely to receive inadequate analgesic medications, reported lower levels of pain relief and a greater degree of psychological distress. There was also no difference in report of pain intensity, pain relief or functional interference among patients who acknowledged continued drug use, those who denied any recent drug use and patients participating in a methadone maintenance program. These data support the validity of AIDS patients' report of pain, at least in research settings, and suggest that undertreatment of pain is not restricted to patients who actively abuse drugs.",1997.0,0,0
1584,9272811,Loss of analgesic effect of morphine due to coadministration of rifampin.,M F Fromm; K Eckhardt; S Li; G Schänzle; U Hofmann; G Mikus; M Eichelbaum,"Methadone withdrawal symptoms have been reported in drug addicts treated with the tuberculostatic rifampin. Whereas this interaction can be explained by induction of phase I drug metabolism (CYP3A4), knowledge about induction of phase II metabolism (e.g., UDP-glucuronosyltransferases = UGTs) and its influence on drug effects in man, however, is very limited. The potent analgesic morphine is metabolized by more than one UGT to the active metabolite morphine-6-glucuronide and to morphine-3-glucuronide, which is devoid of analgesic activity. Thus, differential induction of UGTs involved in metabolism of morphine might lead to decreased or increased analgesic effects, depending on which UGT is preferentially induced. We therefore investigated the influence of the potent enzyme inducer rifampin on analgesic effects and pharmacokinetics of morphine, which is primarily eliminated by phase II metabolism. Ten healthy male volunteers participated in this double-blind, placebo-controlled study with double crossover design. Morphine (10 mg p.o.) and placebo were administered on two separate occasions before and near the end of 13 days of treatment with rifampin (600 mg/day). Blood samples were collected for 31 h. Morphine effects on pain sensation were determined using the cold pressor test. When morphine was given alone, the opioid elicited a significant increase in pain threshold and pain tolerance in comparison to placebo (P < or = 0.05). However, following administration of rifampin no analgesic effect of morphine was observed. In agreement, the area under the serum concentration-time curve (AUC) of morphine and the maximum serum concentration of morphine were considerably reduced during coadministration of rifampin (-27.7 +/- 19.3% and -40.7 +/- 27.1%; P < or = 0.01). Moreover, during treatment with rifampin a proportional reduction of AUCs of morphine-3-glucuronide (P < or = 0.01), morphine-6-glucuronide (P < or = 0.05) and morphine was observed. Since urinary recoveries of both morphine-3-glucuronide and morphine-6-glucuronide were also reduced during administration of rifampin, there is no evidence for a contribution of UGT induction to the observed interaction. In summary, a major drug interaction was observed between morphine and rifampin, which could not be attributed to induction of UGTs, but resulted in a complete loss of analgesic effects of the opioid.",1997.0,0,0
1585,9272818,"Comments on Cervero and Laird, Pain, 68 (1996) 13-23.",W J Roberts; R C Kramis,,1997.0,0,0
1586,9279540,Somatic versus sympathetic mediated chronic limb pain. Experience and treatment options.,W P Cooney,"It has been helpful in our practice to separate somatic from sympathetic-mediated peripheral nerve pain. We would recommend application of the new nomenclature of type I complex regional pain (sympathetic dystrophy) and type II complex regional pain (causalgia) (see Table 1). We believe it is essential that both of these conditions be separated into their early and late phases and that the treatment alternatives be customized for the individual patient and the peripheral nerve involved. If a cast, pin, or external fixation apparatus is associated with peripheral nerve pain, the offending apparatus must be removed immediately and other forms of treatment initiated for the underlying injury. For acute injury and postsurgical pain, narcotic pain medications should be used no longer than 72 hours and careful patient re-examination must be performed if pain persists. Prescription of narcotic pain medications on a continuing basis is often the primary reason for the development of chronic pain syndromes. Physical therapy for the patient with chronic peripheral limb pain must be performed in a pain-free environment. ""No pain, no gain"" does not apply in the treatment of chronic limb pain-rather the reverse: ""Only gain with no pain."" In differentiating between sympathetic pain and somatic pain, the use of the reflex sympathetic dystrophy (RSD) score can be helpful (Table 4). If the pain is somatic, treatment options include: Somatic Pain: Treatment Isolated nerve block Continuous nerve block TENS (external) Direct electrical nerve stimulation (internal) Nerve ablation If the pain is sympathetic in origin, treatments to be considered are: Sympathetic Nerve Pain: Treatment Protection of limb (garment or splint) Combine with active use Sympathetic blocks single continuous Sympathectomy In addition, the treatment of each of those conditions must be directed at the primary condition. Once the two conditions are separated, a careful program of pain management is required. In patients who present with late pain dysfunction, the more commonly observed phenomenon at our institution, the combination of physician, surgeon, and anesthesiologist is essential. The role of physical therapist in restoring function to the injured limb must be discussed and planned carefully. Initial pain management is organized through a qualified anesthesiologist dedicated to this field. Physical therapy follows but only in a pain-free environment. The surgeon's role is to assist and direct the pain management program. Surgeons can be involved in the placement of percutaneous catheters, as well as isolated peripheral nerve blocks. Surgical intervention is limited to the release of compressive neuropathies, nerve transfers, and revascularization of the peripheral nerve bed. The surgeon occasionally may be involved in the manipulation and pinning of contracted joints, as well as release of muscle or joint contractures, followed by a supervised program of early range of motion. Finally, it is important that both physician and surgeon serve as patient advocates when questions of workers' compensation intervene that could deter proper treatment programs or when the patient needs the encouragement and guidance to continue with treatments that don't always initially appear to have immediate results. Finally, requests to the surgeon to find an operative cure must be resisted while continued psychological encouragement is provided.",1997.0,0,0
1587,9279553,Electrical stimulation and the treatment of complex regional pain syndromes of the upper extremity.,W P Cooney,"Clinical, intractable pain in the upper extremity often results from neuroma, direct injury to a peripheral nerve, or repetitive operative insults to a peripheral nerve that has compressive neuropathy. Electrical stimulation applied directly to a single peripheral nerve can provide sufficient relief of pain, improve patient outlook, improve lasting sleep, release the individual from addictive narcotic pain medication, and restore a psychological sense of well-being.",1997.0,0,0
1588,9280026,Postoperative pain control after lumbar spine fusion. Patient-controlled analgesia versus continuous epidural analgesia.,B E Cohen; M B Hartman; J T Wade; J S Miller; R Gilbert; T M Chapman,"A prospective, randomized, double-blind clinical trial. To compare the efficacy of postoperative continuous epidural analgesia versus patient-controlled analgesia in patients undergoing lumbar fusion. Controversy remains regarding the optimal strategy for postoperative pain control. Fifty-four patients were divided into two treatment groups. There was no difference between the groups with respect to age, levels fused, estimated blood loss, and use of spinal instrumentation. Patient-controlled analgesia or epidural analgesia was administered in a double-blind manner for a 3-day postoperative course. Each patient received both an epidural and a patient-controlled analgesia delivery system; 26 received the epidural active agent and 28 received patient-controlled analgesia. Postoperative time to liquids and solid food, ambulation, length of stay, and side effects was recorded. Pain was evaluated by a visual analog scale on postoperative days 1, 2, and 3. Results showed no difference between the groups with reference to diet, ambulation, length of stay, and visual analog scale scores. Minor side effects occurred in 71% of patients in both groups. No major complications occurred. Epidural catheter dislodgment occurred in 11% of patients. The total cost for epidural analgesia was approximately $550 more than that for patient-controlled analgesia for a 3-day postoperative course. These data suggest that there is no clinical advantage of epidural opiate/local anesthetic analgesia over systemic opiate by patient-controlled analgesia for spinal fusion patients. However, possible technical limitations (namely, the low dosage of bupivacaine and placement of the catheter tip) may have prevented adequate delivery of anesthetic to the involved segments. Although the incidence of side effects is similar, cost factors and a high incidence of epidural catheter dislodgment favor use of patient-controlled analgesia.",1997.0,0,0
1589,9280742,[Tramadol chlorhydrate in the management of gyneco-obstetric pain].,C López Rosales; E N Cabrera Magaña; E J Solís,"An open prospective and longitudinal study was carried out including 102 female patients whose pain was due to gyneco-obstetric surgery. The average age was 31.5 years and the average weight was 67 kg. The tramadol hydrochloride was administered as a single 100 mg dose p.o. or i.m., when moderate to intense pain was present. At the beginning of the trial, 96.1% of the patients presented moderate to very intense pain. At the end of the period of the trial, 74% reported none or mild pain. The analgesia began after an average of 17 minutes i.m. and 28 minutes p.o. The identified adverse effects were: nausea 1%, vomiting 5% and somnolence 8%. In accordance with the obtained results, we conclude that tramadol chlorhydrate is a good alternative for the treatment of moderate-to-severe acute pain of obstetric and gynecological origin.",1997.0,0,0
1590,9280995,[Postoperative analgesia with epidural methadone in patients operated for hernia of the lumbar disc].,J Hernández-Palazón; J A Tortosa-Serrano; J L Sánchez-Ortega; J Moya-Solera; J F Martínez-Lage; D Pérez-Flores,"To determine whether the direct application of a single dose of methadone on the dura mater at the end of surgery to repair a lumbar disk hernia provides effective analgesia over the next 24 hours. We conducted a randomized double blind study in 40 ASA I patients undergoing elective herniated disk repair under general anesthesia. The sample was divided into two groups (A and B). Group A patients received a solution of methadone in saline solution (5 mg methadone/5 ml saline) applied to the dura before the end of surgery. Group B patients (controls) received only 5 ml of saline. Pain intensity was assessed on a visual analog scale (VAS) during the postoperative period. Also recorded were the observer's impression and the amount of analgesia (ketorolac) consumed through a system providing patient controlled analgesia. Each group contained 20 patients. Group A patients needed significantly less postoperative analgesia (64.2 +/- 14.3 mg) than group B patients (109.6 +/- 16.5 mg). The VAS scores were significantly lower in group A during the first two hours after surgery and were correlated with the observer's impression. No patients suffered serious complications during the study. Topical administration of 5 mg of methadone on the dura mater at the end of herniated lumbar disk repair is an easy, safe and effective technique for providing postoperative analgesia.",1997.0,0,0
1591,9286886,A comparison of remifentanil and morphine sulfate for acute postoperative analgesia after total intravenous anesthesia with remifentanil and propofol.,J Yarmush; R D'Angelo; B Kirkhart; C O'Leary; M C Pitts; G Graf; P Sebel; W D Watkins; R Miguel; J Streisand; L K Maysick; D Vujic,"The transition from remifentanil intraoperative anesthesia to postoperative analgesia must be planned carefully due to the short duration of action (3-10 min) of remifentanil hydrochloride, a potent, esterase-metabolized mu-opioid agonist. This study compared the efficacy and safety of transition regimens using remifentanil or morphine sulfate for immediate postoperative pain relief in patients who had surgery under general anesthesia with remifentanil/propofol. One hundred fifty patients who had received open-label remifentanil and propofol for intraoperative anesthesia participated in this multicenter, double-blind, double-dummy study and were randomly assigned to either the remifentanil (R) group or the morphine sulfate (M) group. Twenty minutes before the anticipated end of surgery, the propofol infusion was decreased by 50%, and patients received either a placebo bolus (R group) or a bolus of 0.15 mg/kg morphine (M group). At the end of surgery, the propofol and remifentanil maintenance infusions were discontinued and the analgesic infusion was started: either 0.1 microg x kg(-1) x min(-1) remifentanil (R group) or placebo analgesic infusion (M group). During the 25 min after tracheal extubation, remifentanil titrations in increments of 0.025 microg x kg(-1) x min(-1) and placebo boluses (R group), or 2 mg intravenous morphine boluses and placebo rate increases (M group) were administered as necessary at 5-min intervals to control pain. Patients received the 0.075 mg/kg intravenous morphine bolus (R group) or placebo (M group) at 25 and 30 min after extubation, and the analgesic infusion was discontinued at 35 min. From 35 to 65 minutes after extubation, both groups received 2-6 mg open-label morphine analgesia every 5 min as needed. Successful analgesia, defined as no or mild pain with adequate respiration (respiratory rate [RR] > or =8 breaths/min and pulse oximetry > or = 90%), was achieved in more patients in the R group than in the M group (58% vs. 33%, respectively) at 25 min after extubation (P < 0.05). The median remifentanil rate for successful analgesia was 0.125 microg x kg(-1) x min(-1) (range, 0.05-0.23 microg x kg(-1) x min(-1)), and the median number of 2-mg morphine boluses used was 2 (range, 0-5 boluses). At 35 min after extubation, > or = 74% of patients in both groups experienced moderate to severe pain. Median recovery times from the end of surgery were similar between groups. Transient respiratory depression, apnea, or both were the most frequent adverse events (14% for the R group vs. 6% for the M group; P > 0.05). Remifentanil provided safe and effective postoperative analgesia when administered at a final rate of 0.05-0.23 microg x kg(-1) x min(-1) in the immediate postextubation period. Remifentanil provided more effective postoperative analgesia than did intraoperative treatment with morphine (0.15 mg/kg) followed by morphine boluses (< or = five 2-mg boluses). The effects of remifentanil dissipated rapidly after ending the infusion, and alternate analgesia was required. Further studies are underway to define transition regimens that will improve postoperative analgesia in patients receiving anesthesia with remifentanil.",2001.0,0,0
1592,9291514,Prescribing analgesics: the effect of patient age and physician specialty.,M Hauswald; C Anison,"To determine if patient age or physician specialty influences the willingness to prescribe pain medication, a mail survey was made of all emergency physicians, family practice physicians, and pediatricians listed as practicing in a single, middle sized, urban county in the southwest. The survey instrument presented a typical case of otitis media complicated only by pain so severe that the patient had been unable to sleep. Physicians were asked specifically if they would prescribe an analgesic and if so what kind. Emergency and family practice physicians were presented on a random basis with cases that were identical except the age was given at two or 22 years old. Pediatricians were given only the two year old. Eighty percent (137/165) of the surveys were completed and returned. Only 28% of the physicians would prescribe medications stronger than acetaminophen or nonsteroidal antiinflammatory drugs. There was a trend toward more narcotic analgesics for the 22 year old (41 vs 22% Fisher's exact test P = 0.03). Emergency physicians were the most generous, prescribing narcotics (codeine or oxycodone compounds) half the time (50%) versus one quarter of the time (22%) for family practice physicians and pediatricians (Fisher's exact test, P < 0.01). Pediatricians and family practice physicians did not differ (20 vs. 25%, P = 0.8). Potent analgesics are rarely prescribed by our sample physicians. Children are somewhat less likely to receive narcotics than adults with the same complaint. Emergency physicians are more likely to prescribe potent analgesics than are family practice physicians or pediatricians.",1997.0,0,0
1593,9293649,Comparison of epidural butorphanol plus clonidine with butorphanol alone for postoperative pain relief.,P H Tan; A K Chou; J S Perng; H C Chung; C C Lee; M S Mok,"Epidural butorphanol has been shown to produce effective analgesia with less side effects than that of morphine but relatively short duration. Clonidine, an alpha 2-adrenergic agonist, has been reported to provide [corrected] pain relief by epidural administration. Furthermore, epidural clonidine has been shown to potentiate the analgesic effect of epidural morphine. The present study was undertaken to evaluate the analgesic and side effects of epidural administration (Ep) of butorphanol and clonidine. After giving their consents, 60 adult patients scheduled for abdominal surgeries were enrolled in this study. Prior to anesthesia induction, indwelling lumbar epidural catheters were placed in all patients who then received general anesthesia with inhalation anesthetic without narcotic analgesics. In the postoperative period, when the patients first complained of pain, they were divided into 2 equal groups of 30 patients each in a randomized and double blinded fashion with Group I receiving Ep butorphanol 0.5 mg and Group II receiving Ep butorphanol 0.5 mg plus clonidine 75 micrograms. All patients were observed for pain relief, sedation, vital signs, arterial blood gas studies and adverse effects for 12 h. Onset of pain relief with epidural butorphanol began at 5 min and peaked at 20-30 min with a duration of action lasting 4-6 h. The combination of butorphanol and clonidine had numerically superior pain relief than that of butorphanol for the first 30 min but it did not attain statistical significant difference. The duration of action with the combination group was similar to that of butorphanol alone. Incidence of adverse effects were similar in both groups except that hypotension and more pronounced sedation were observed in Group II. Our study showed that the addition of clonidine to epidural butorphanol did not enhance its analgesic effect in any significant manner nor did it reduce the adverse effects. This combination does not seem to offer any advantage for clinical use.",1997.0,0,0
1594,9301399,Extradural buprenorphine suppresses breast feeding after caesarean section.,M Hirose; T Hosokawa; Y Tanaka,"Satisfactory pain relief with postoperative extradural bupivacaine increases the amount of breast feeding after Caesarean section. To investigate the effect of extradural buprenorphine, we have evaluated the amount of breast feeding and the gain in infant weight for 11 days after Caesarean section in patients who received continuous extradural bupivacaine with or without buprenorphine. Extradural buprenorphine significantly decreased both measures although there was no significant difference in pain intensity. We suggest that extradural buprenorphine suppressed breast feeding after Caesarean section.",1997.0,0,0
1595,9305315,Respiratory depression in a child unintentionally exposed to transdermal fentanyl patch.,W E Hardwick; W D King; P A Palmisano,"A 2-year-old boy was found unresponsive after sleeping in bed with his grandmother. After the patient was intubated and ventilated, paramedics discovered a transdermal fentanyl patch on the victim's back. Removal of the patch and treatment with naloxone resolved symptoms. This is the first reported case of secondary exposure to a fentanyl patch causing clinically significant respiratory depression in the pediatric population, and it emphasizes a new hazard of such drug use.",2001.0,0,0
1596,9306789,The stigma and enigma of chronic non-malignant back pain (CNMBP) treated with long-term opioids (LTO).,J R Gardner; G Sandhu,"Certain diseases and drugs, like chronic non-malignant back pain (CNMBP) and opioids, are maligned by society, resulting in sufferers and users experiencing discrimination within the health care system which has the effects of increasing, rather than alleviating their pain and suffering. Many patients with severe CNMBP suffer not because their pain is untreatable but because their pain and personhood have not been validated by doctors and nurses who are opioiphobic. Such ignorances fears, beliefs and biases not only deny some CNMBP patients adequate pain relief but also puts their lives at risk as it has long been recognised that chronic pain can lead to immunosuppression, affecting morbidity and mortality. Beyond the effects on patients, CNMBP treated with long term opioids (LTO) has a profound impact on families, whose pain and suffering is rarely addressed in practice. There is an urgent need to change current practice if CNMBP patients treated with LTO are to maximise their health potential and become responsible consumers of health care.",1997.0,0,0
1597,9307177,An 11-year-old girl with reflex sympathetic dystrophy successfully treated by thoracoscopic sympathectomy.,K Honjyo; Y Hamasaki; M Kita; K Harano; T Totoki; S Miyazaki,"We report on an 11-year-old girl with reflex sympathetic dystrophy (RSD) complaining of severe pain in her right upper extremity. Oral administration of narcotics or non-steroid anti-inflammatory drugs gave no relief in pain. Thoracoscopic electrocauterization of the thoracic sympathetic ganglion at the level of T3 was performed 3 months after the start of symptoms, and brought complete resolution of pain.",1997.0,0,0
1598,9310567,Evaluation of fast track admission policy for children with sickle cell crises: questionnaire survey of parents' preferences.,C R Fertleman; A Gallagher; M A Rossiter,,1997.0,0,0
1599,9311061,Ethical issues in the management of chronic nonmalignant pain.,M Pappagallo; L J Heinberg,"Chronic pain represents a challenge to patients, families, employers, and the physicians who care for these individuals. Opioids remain the mainstay of the analgesic medications for the treatment of both acute and chronic pain. Controlled release preparations of morphine, oxycodone, fentanyl and long acting opioid agents such as methadone and levorphanol have been medically and ethically accepted in managing chronic cancer pain. However, the continued use of these medications for patients with chronic noncancer pain has been fiercely debated. This article attempts to reconcile the medical and ethical dilemma of using opioid medications for chronic noncancer pain. Growing clinical experience in the field of pain medicine has helped to clarify: (1) the misunderstanding of addiction, physical dependence and analgesic tolerance, (2) the misconception that chronic opioid therapy inevitably causes personality changes, depression, and impairment of cognitive and physical function, (3) the lack of information on the correct use of opioid analgesics with regard to titration and management of related side effects. The behavioral management of pain patients undergoing chronic opioid therapy is also discussed. A protocol for optimal patient management is proposed. Particular emphasis is given to the consent form, behavioral contracting, and the consequences of noncompliance. The importance of psychologic evaluation before a long-term opioid trial, to minimize future complications, is stressed. Although most patients on the opioid regimen do well, special attention must be given to patients with current addiction, a past history of addiction, or current misuse of opioid medications. Pharmacologic and conservative interventions are often warranted in those patients with significant behavioral problems. If such strategies fail, and chronic opioid therapy is deemed necessary, some treatment guidelines are offered.",1997.0,0,0
1600,9311401,Perioperative magnesium infusion and postoperative pain.,C H Wilder-Smith; R Knöpfli; O H Wilder-Smith,"NMDA receptor activation is considered one of the mechanisms involved in postoperative pain and hypersensitivity. Magnesium is the physiological blocker of the NMDA-receptor-complex-associated calcium ionophore. The aim of this study was to determine if a pre-, intra- and postoperative infusion of magnesium would reduce postoperative pain. In a prospective, randomised, double-blinded and placebo-controlled study, 24 patients undergoing elective hysterectomy in standardised general anaesthesia received a 5 h infusion of either placebo or magnesium laevulinate (initial bolus 8 mmol: then 8 mmol/h) starting with induction of anaesthesia. Postoperative analgesia was by PCA morphine for the first 48 h and patients were followed for 5 d with regular assessment of pain and side-effect scores. Overall, pain scores were similar with magnesium and placebo infusion, although patients in the magnesium group experienced more episodes of severe or unbearable pain (placebo = 6%, magnesium = 16%, P = 0.02). Median pain scores were higher in the magnesium group only at 3 h postoperatively (P = 0.04): afterwards there were no significant differences. Except for the first postoperative hour (placebo = 12.8 +/- 4.7 mg, magnesium = 9.3 +/- 3.2 mg, P = 0.04), cumulative morphine consumption was similar. Gastrointestinal complication rates and patient satisfaction were similar in both groups. Perioperative magnesium infusion does not improve postoperative analgesia. At the doses used in this study, the use of magnesium is associated with short-term decreases in postoperative analgesia.",1997.0,0,0
1601,9311405,Intravenous versus intraperitoneal morphine before surgery to provide postoperative pain relief.,S H Kalman; A G Jensen; P O Nyström; C Eintrei,"Opioid receptors have been demonstrated on peripheral afferent nerves throughout the body. The aim of the present study was to compare the effects of intravenous and intraperitoneal administration of morphine with regard to pain, postoperative morphine requirement, and recovery after major abdominal surgery, and to describe the pharmacokinetics of intraperitoneal morphine in humans. In a double-blind manner, 30 patients scheduled for major abdominal surgery were randomized to either 50 mg of morphine intravenously (i.v.) or 50 mg of morphine intraperitoneally (i.p.) before operation. Pain was measured on a visual analogue scale and morphine requirements were registered for 3 days. Recovery was measured as time to oral intake of food, time to flatulence and days in hospital. Plasma morphine, morphine-3-glucuronide, and morphine-6-glucuronide concentrations were determined during the first 4 h after morphine administration. During the first postoperative hours there was less pain at rest (P = 0.02) and on coughing (P = 0.004) in the intravenous group. The requirement of additional morphine (P = 0.016) was lower in the intravenous group during the first postoperative day. No major differences in recovery were seen. The plasma concentrations of morphine measured as area under the curve (AUC) during the first 4 h were similar, but the intravenous group showed significantly higher concentrations of the active metabolite morphine-6-glucuronide, (P = 0.016), indicating a difference in pharmacokinetics after intraperitoneal compared to intravenous administration of morphine. Intraperitoneal administration of 50 mg of morphine before major abdominal surgery is less efficient in reducing pain and postoperative morphine requirements than the same amount of morphine given intravenously.",1997.0,0,0
1602,9311407,Analgesia after upper abdominal surgery using extradural administration of a fixed dose of buprenorphine in combination with lignocaine given at two infusion rates: a comparative study.,Z Wajima; T Shitara; G Ishikawa; K Kaneko; T Inoue; R Ogawa,"Extradural administration of combinations of local anaesthetics and opioids are frequently employed for postoperative pain relief. There is a scarcity of data on the analgesic effects of variations of the dose of local anaesthetic drug admixed to a fixed dose of opioid. Twenty-four patients were investigated after elective upper abdominal surgery. During closure of the abdomen, 2% mepivacaine (8 ml) with buprenorphine 0.1 mg (0.5 ml) was given extradurally. After extubation, patients were randomly allocated to receive continuous extradural infusion of a fixed dose of buprenorphine (0.017 mg/h) in combination with 2% lignocaine at either 2.1 ml/h (low rate group, n = 14) or 6.3 ml/h (high rate group, n = 10). Postoperative pain at rest was assessed using visual analogue scale (VAS) scores and pain at movement by Prince Henry Pain Scale (PHPS) scores. Venous plasma lignocaine concentrations were measured. VAS scores at rest were similar in the two groups at 3 h postoperatively, whereas at 6-24 h postoperatively, VAS scores were higher in the low rate group than in the high rate group. PHPS scores were similar in the two groups at 3 h and at 18 h postoperatively, whereas at 6, 9, 12 and 24 h postoperatively, PHPS scores were higher in the low rate group than in the high rate group. Plasma lignocaine concentrations were higher at 23 h postoperatively in the high rate group than at 16 h in both groups, and at 23 h in the low rate group. At 3 h postoperatively, both the systolic and diastolic arterial pressures were higher in the low rate group than control values obtained on admission. Side effects were observed in one patient in the low rate group who complained of dizziness, and in one patient in the high rate group who complained of nausea. When added to a fixed dose of buprenorphine, continuous extradural infusion of 2% lignocaine at high rate provides better postoperative analgesia than when given at low rate without producing significant side effects.",1997.0,0,0
1603,9313274,"Comparative efficacy of patient-controlled administration of morphine, hydromorphone, or sufentanil for the treatment of oral mucositis pain following bone marrow transplantation.",B A Coda; B O'Sullivan; G Donaldson; S Bohl; C R Chapman; D D Shen,"A total of 119 bone marrow transplant patients suffering from oral mucositis pain were enrolled in a randomized, double-blind, parallel-group trial comparing the efficacy of patient-controlled analgesia with morphine, hydromorphone and sufentanil. Patient ratings of pain and side-effects on visual analog scales were gathered daily from the start of patient-controlled analgesia (PCA) therapy until the discontinuation of opioid treatment either because of resolution of oral mucositis pain, intolerable side-effects, inadequate pain control, or complications related to transplantation. Of the 119 enrolled subjects, 100 met the evaluable criteria of developing oral mucositis and remaining on the study for at least 2 days. Multivariate analysis of the outcome measures indicated that the analgesia achieved in all three opioid groups was nearly equivalent, while measures of side-effects, especially for the combination of sedation, sleep and mood disturbances, were statistically lower in the morphine group than in hydromorphone or sufentanil groups. Patients in the hydromorphone group exhibited the most variability in pain control. Event analysis also indicated significant differences in time to treatment failure between the three groups, with the morphine arm exhibiting clear superiority. The proportion of patients discontinued because of inadequate pain relief was much higher in the sufentanil group (7/36) as compared to the hydromorphone (0/34) or the morphine group (1/30). The daily opioid consumption pattern showed a continual dose escalation during the first week of therapy for all groups, coincident with worsening mucositis. Morphine consumption reached a plateau by day 5, whereas hydromorphone and sufentanil consumption continued to rise until days 7 and 9, respectively. Sufentanil dose requirement increased by approximately 10-fold compared to morphine and hydromorphone, whose requirements increased only 5-fold, suggesting the possibility of development of acute pharmacological tolerance in some patients with this phenylpiperidine opioid. This study provides support for the recommendation that morphine is the opioid of first choice when patient-controlled analgesia is employed for the treatment of severe oropharyngeal pain in bone marrow transplantation (BMT) patients.",1997.0,0,0
1604,9313277,Lorazepam as an adjunct to opioid analgesics in the treatment of burn pain.,D R Patterson; J T Ptacek; G J Carrougher; S R Sharar,"Benzodiazepines are commonly used to supplement opioid analgesics in treating procedural pain during the treatment of major burn injuries. To date, no study has investigated whether benzodiazepines actually have an analgesic or anxiolytic effect in such circumstances. Seventy-nine patients admitted to a major regional burn center were randomly assigned to groups that received 1 mg of lorazepam or a placebo in addition to their standard opioid analgesics. A strong analgesic effect of lorazepam was not observed when treatment groups were compared independent of their baseline pain ratings. However when patients who had high baseline pain were compared, lorazepam resulted in a significant reduction in pain ratings (adjusted post-treatment VAS mean score = 54.28; adjusted control VAS mean score = 69.06). Trait anxiety did not predict those patients who had an analgesic effect with lorazepam, but state anxiety did prove to be a covariate with visual analogue score decreases in pain reports.",1997.0,0,0
1605,9316951,Cesarean delivery: a randomized trial of epidural versus patient-controlled meperidine analgesia during labor.,S K Sharma; J E Sidawi; S M Ramin; M J Lucas; K J Leveno; F G Cunningham,"Reports indicate that the administration of epidural analgesia for pain relief during labor interferes with labor and increases cesarean deliveries. However, only a few controlled trials have assessed the effect of epidural analgesia on the incidence of cesarean delivery. The authors' primary purpose in this randomized study was to evaluate the effects of epidural analgesia on the rate of cesarean deliveries by providing a suitable alternative: patient-controlled intravenous analgesia. Seven hundred fifteen women of mixed parity in spontaneous labor at full term were randomly assigned to receive either epidural analgesia or patient-controlled intravenous meperidine analgesia. Epidural analgesia was maintained with a continuous epidural infusion of 0.125% bupivacaine with 2 microg/ml fentanyl. Patient-controlled analgesia was maintained with 10-15 mg meperidine given every 10 min as needed using a patient-controlled pump. Procedures recorded in a manual that prescribed the intrapartum management were followed for each woman randomized in the study. A total of 358 women were randomized to receive epidural analgesia, and 243 (68%) of these women complied with the epidural analgesia protocol. Similarly, 357 women were randomized to receive patient-controlled intravenous meperidine analgesia, and 259 (73%) of these women complied with the patient-controlled intravenous analgesia protocol. Only five women who were randomized and received patient-controlled intravenous meperidine analgesia according to the protocol crossed over to epidural analgesia due to inadequate pain relief. There was no difference in the rate of cesarean deliveries between the two analgesia groups using intention-to-treat analysis based on the original randomization (epidural analgesia, 4% [95% CI: 1.9-6.2%] compared with patient-controlled intravenous analgesia, 5% [95% CI: 2.6-7.2%]). Similar results were observed for the analysis of the protocol-compliant groups (epidural analgesia, 5% [95% CI: 2.6-8.5%] compared with patient-controlled intravenous analgesia, 6% [95% CI: 3-8.9%]). Women who received epidural analgesia reported lower pain scores during labor and delivery compared with women who received patient-controlled intravenous analgesia. Epidural analgesia was not associated with increased numbers of cesarean delivery when compared with a suitable alternative method of analgesia.",1997.0,0,0
1606,9324179,Evaluation of the safety and efficacy of ketorolac versus morphine by patient-controlled analgesia for postoperative pain.,D A O'Hara; G Fanciullo; L Hubbard; T Maneatis; P Seuffert; L Bynum; A Shefrin,"To compare ketorolac tromethamine with morphine for pain management after major abdominal surgery. Double-blind, randomized study. Hospital recovery room and postoperative surgical unit. One hundred ninety-one patients with at least moderate pain after major abdominal surgery. Patients received ketorolac by patient-controlled analgesia (PCA) bolus alone (Ket B), ketorolac by bolus plus infusion (Ket I), or morphine by PCA bolus (morphine), with injectable morphine available for supplementation. Levels of sedation, pain intensity, pain relief, and adverse events were recorded at baseline, at 2, 4, and 6 hours, and at termination. Supplemental morphine was required by 71% of Ket B patients, 67% of Ket I patients, and 38% of morphine patients (p < or = 0.001 for Ket B vs morphine). Although patients receiving ketorolac required more supplemental morphine than the morphine group (6.0 mg Ket I, 6.2 mg Ket B, 4.0 mg morphine), there was a large morphine-sparing effect in both ketorolac groups (total morphine 6.0 mg Ket I, 6.2 mg Ket B, 33.3 mg morphine). Overall pain relief scores were similar for morphine and Ket I groups, and were lower for Ket B than for morphine (p = 0.002). There were no differences among groups in numbers of patients with adverse events. Ketorolac may be effective when administered by PCA device, and has a clear morphine-sparing effect.",1997.0,0,0
1607,9324367,[Epiduritis after long-term pain therapy with an epidural catheter--review of the literature with a current case report].,H Michel; P Steffen; T Weichel; W Seeling,"Patients suffering from vascular disease are often a challenge for the acute pain service. Ischaemia, impaired wound healing, stump and phantom limb pain often require a complex analgesic regimen. Invasive measures such as spinal or epidural catheters can be very helpful but carry the risk of infection, as shown by this case report. A 53-year-old woman with a ten-year history of diabetes developed arterial vascular disease. Her right lower leg had been amputated two years previously. She was now admitted with necroses of the left forefoot. A bypass operation was performed under general anaesthesia. Because of intractable ischaemic pain, she was provided with an epidural catheter by the acute pain service. The bypass occluded, however, and a few days later her left lower leg also had to be amputated, this operation being performed under epidural anaesthesia with bupivacaine. The catheter was subsequently used for postoperative pain control and as a means to prevent phantom limb pain. When signs of superficial catheter infection were noticed days later, the catheter was immediately removed. Intractable pain then developed in the left leg which could not be sufficiently controlled with opioids and NSAIDs, and so a second epidural catheter was inserted one segment rostrally. Several days later the infected vascular prosthesis had to be removed followed by amputation of the thigh, this operation also being performed in epidural anaesthesia. Eleven days after insertion of the first epidural catheter, the patient complained of low back pain and headache. Examination by a neurologist revealed no signs of intraspinal infection. The second epidural catheter dislocated at this point in time and it was decided to introduce a third one, this being the only means to treat the otherwise intractable stump pain. Ten days later meningism, Kernig's sign and leucocytosis developed. NMR tomography detected intraspinal fluid in the epidural space at the dorsal border of the spinal canal. A hemilaminectomy was performed. The spinal epidural space showed signs of inflammation of the adipose tissue, but no pus. A little necrotic material and residues of an old haematoma were removed and the epidural space was lavaged. Specimens taken from the epidural material revealed colonisation with staphylococcus epidermidis, which was sensitive to the broad spectrum antibiotics formerly given to the patient to treat the infection in the left stump. By the next day, all signs of epiduritis had disappeared and the patient recovered completely.",1997.0,0,0
1608,9338902,Does metoclopramide supplement postoperative analgesia using patient-controlled analgesia with morphine in patients undergoing elective cesarean delivery?,B I Danzer; D J Birnbach; D J Stein; M M Kuroda; D M Thys,"Recent studies have shown that metoclopramide may decrease postoperative narcotic requirements in patients undergoing second-trimester induced abortions or prosthetic hip surgery. It is often used to decrease the incidence of nausea and vomiting in the patient undergoing cesarean delivery under regional anesthesia. If metoclopramide were found to be an analgesic adjunct in these patients, it would offer an additional impetus for its routine use. After elective cesarean delivery under spinal anesthesia, 32 patients were monitored for initial and 24-hour postoperative morphine requirements via intravenous patient-controlled analgesia. These patients were divided into two groups. Prior to spinal block, group 1 (n = 17) received 10 mg intravenous metoclopramide, and group 2 (n = 15) received an intravenous saline placebo. No differences were found between groups in the time from spinal placement to the time of pain onset, the amount of morphine necessary to initially achieve comfort, or 24-hour postoperative morphine requirements. (P > .05). This study demonstrates that metoclopramide decreases intraoperative nausea but does not supplement analgesia in patients undergoing elective cesarean delivery.",1997.0,0,0
1609,9343646,The efficacy of intra-articular morphine for postoperative knee arthroscopy analgesia.,M D Richardson; A R Bjorksten; J A Hart; K McCullough,"This article describes two prospective, randomized, double-blind clinical trials designed to investigate this. Trial 1 compared a conventional local anaesthetic agent (100 mg bupivacaine) injected intra-articularly (i.a.) with a control (normal saline) and 1 mg of i.a. morphine. No significant difference was noted in the first 4 hours between the groups with respect to visual analogue pain (VAS) scores. However, at 6 and 24 hours, the group of patients who received 1 mg i.a. morphine recorded lower pain scores and required less supplementary analgesia. Trial 2 assessed the dose response relationship for i.a. morphine comparing 5 mg intravenous (i.v.) morphine (control) with 1 mg and 5 mg i.a. morphine. At early time points (1, 2, and 4 hours) similar VAS pain scores were recorded for both 5 mg i.v. morphine and 5 mg i.a. morphine, both significantly lower than the group receiving 1 mg i.a. morphine. At 6 and 24 hours, 5 mg of i.a. morphine produced significantly lower pain scores, less analgesic requirement, and less sleep disturbance on the first postoperative night than the other groups. It can be concluded from these two studies that 5 mg i.a. was the most effective analgesic following knee arthroscopy.",1997.0,0,0
1610,9346148,"The use of intrathecal morphine for analgesia after posterolateral lumbar fusion: a prospective, double-blind, randomized study.",J C France; S S Jorgenson; T G Lowe; A P Dwyer,"A prospective, randomized, double-blind, placebo-controlled study was undertaken to evaluate the efficacy and safety of intrathecal morphine for postoperative analgesia after posterolateral lumbar fusion. To compare the early postoperative analgesia in patients who receive a single dose of intrathecal morphine intraoperatively with that of patients using a patient-controlled analgesia pump only. Although intrathecal morphine is used as an analgesic in a variety of medical and surgical conditions, very little has been published on its use after posterior lumbar spine surgery. Because the thecal sac is readily available during these procedures, the addition of a single injection of morphine before wound closure can be done with technical ease. If its efficacy and safety can be verified, then it could serve as a useful adjuvant to the postoperative analgesia regimen. Sixty-eight consecutive patients undergoing posterolateral lumbar fusion were randomly assigned to two groups. The experimental group was injected intrathecally with morphine 30 minutes before wound closure, and the control group was similarly injected with a placebo of normal saline solution. All patients were connected to an on-demand patient-controlled analgesia pump to provide any additional necessary analgesia. Their use of the patient-controlled analgesia pump was tabulated by counting the number of demands and the actual amount of morphine delivered. Additionally, a visual analog scale was used to assess pain levels at pre-established regular intervals. The visual analog scale measurements were significantly lower for the intrathecal morphine group initially, but they surpassed those of the control group after 24 hours. Likewise, the number of patient-controlled analgesia pump demands and the amount of narcotic delivered initially were significantly lower in the experimental patients, but again reversed after the first postoperative day. The late rebound in pain and patient-controlled analgesia pump use did not reach statistical significance. There were no significant complications related to the analgesia. Intrathecal morphine can be safe and efficacious as an early postoperative analgesic after lumbar fusion when respiratory monitoring is used.",1997.0,0,0
1611,9349065,Addition of adrenaline to pethidine for epidural analgesia after caesarean section.,W D Ngan Kee; M L Ma; K S Khaw,"We have investigated the addition of adrenaline to epidural pethidine for postoperative analgesia in 40 patients after Caesarean section. In a randomised, double-blind study, patients received pethidine 25 mg with adrenaline 50 micrograms (adrenaline group, n = 20) or pethidine 25 mg without adrenaline (plain group, n = 18) epidurally at the first request for postoperative analgesia. The median duration of analgesia was longer in the adrenaline group (196 min; IQR 123-286) compared with the plain group (96 min; IQR 43-113; p = 0.002) and plasma concentrations of pethidine in the first 30 min after injection were lower in the adrenaline group (p = 0.003). Visual analogue scale pain scores in the first 30 min after injection and onset of analgesia, defined by the time for pain scores to decrease by 50%, were similar between groups. Addition of adrenaline to epidural pethidine has advantages for analgesia after Caesarean section.",1998.0,0,0
1612,9349066,"The addition of opioids to local anaesthetics in brachial plexus block: the comparative effects of morphine, buprenorphine and sufentanil.",J E Bazin; C Massoni; P Bruelle; V Fenies; D Groslier; P Schoeffler,"We compared the duration of analgesia produced by a mixture of lignocaine and bupivacaine, either alone or combined with morphine (75 micrograms.kg-1), buprenorphine (3 micrograms.kg-1) or sufentanil (0.2 microgram.kg-1) in 80 patients after brachial plexus block for orthopaedic surgery of the upper limb. The characteristics of analgesia were evaluated hourly using a visual analogue scale. The analgesia was considered satisfactory for scores of 30 or less. The median duration (range) of satisfactory analgesia was: 11.5 (8-15) h without an opioid, 21 (9-27) h with morphine, 20 (14-34) h with buprenorphine and 24.5 (11-38) h with sufentanil. We conclude that the addition of an opioid to a local anaesthetic mixture lengthens the duration of analgesia.",1998.0,0,0
1613,9350362,Enhanced pain management for postgastrectomy patients with combined epidural morphine and fentanyl.,M Tanaka; S Watanabe; N Matsumiya; M Okada; T Kondo; S Takahashi,"To determine whether clinical advantages could be demonstrated by epidural fentanyl given in addition to epidural morphine for postgastrectomy analgesia. One-hundred and twenty two patients undergoing elective gastrectomy were prospectively studied in a randomised, double-blind fashion. All patients received epidural lidocaine 1.5% with epinephrine (1:200,000) followed by light general anaesthesia for surgical anaesthesia. They were assigned to four groups according to the combinations of each epidural opioid: 2 mg morphine alone, 2 mg morphine + 100 micrograms fentanyl, 4 mg morphine alone, and 4 mg morphine + 100 micrograms fentanyl. Morphine and fentanyl were given epidurally approximately 60 and 15 min, respectively, before the completion of surgery. Addition of epidural fentanyl to both doses of morphine not only decreased intensity of pain associated with coughing during the early postoperative period, but also prolonged the time until the first analgesic request at each morphine dose studied. Of the combination doses, 4 mg morphine + 100 micrograms fentanyl provided the longest time to the first request for analgesic, and was associated with least amount of postoperative analgesic supplement and best patient satisfaction without increasing incidence of side effects. The addition of 100 micrograms fentanyl to 2 mg or 4 mg epidural morphine provides clinical advantages over morphine alone for post-gastrectomy analgesia.",1997.0,0,0
1614,9354733,Pediatric pheochromocytoma. A 36-year review.,S H Ein; J Pullerits; R Creighton; J W Balfe,"Fourteen children (10 boys and 4 girls, aged 8 to 17 years) had 20 pheochromocytomas treated over a 36-year period from 1959 to 1995 inclusive. Nine patients had 11 tumors before 1980; 5 children had 9 tumors up to 1987. There were no new children with pheochromocytomas at our hospital from 1988 to 1995. Hypertension, sweating, headache, and visual blurring were the most common symptoms and signs (average 5 months). The most reliable biochemical investigations were the urinary catecholamines and norepinephrine. Before 1980, intravenous pyelography and angiography were most successful in localizing the tumor, but since then ultrasonography and computerized tomography have been the radiological investigations of choice. Early involvement of the anesthesiologist in the preoperative control of the hypertension is essential; blood pressure (BP) control was achieved with phenoxybenzamine. The main anesthetic drugs used were: sodium thiopental, fentanyl, methoxyflurane, isoflurane, nitrous oxide, and metocurine. Sixteen tumors were adrenal and 4 were extra-adrenal (1 intrathoracic and 1 extradural). All except 2 tumors were completely resected; they ranged in size from 1.3 to 14 cm. Ligation of the tumor's venous drainage was usually associated with a sudden, temporary fall in systemic BP. There were 2 children with malignant tumors. Four patients had five recurrences (second pheochromocytoma) within 6 years, and all were heralded by a return of their original symptoms and signs. One girl was left with no adrenal tissue. The only complication was in a boy with a large, partly-resected malignant right adrenal tumor who had a subphrenic abscess drained and was left with a temporary bile fistula, cirrhosis, and chronic pain. All children were normotensive when discharged from hospital and remain alive and well with a follow-up of 7 to 36 years. There were no deaths. Long-term follow-up is essential. Key word Pheochromocytoma",1997.0,0,0
1615,9357096,Correlation of morphine sulfate in blood plasma and saliva in pediatric patients.,E A Kopecky; S Jacobson; J Klein; B Kapur; G Koren,"This study sought to determine whether saliva concentrations of morphine correlate with plasma levels of morphine in pediatric patients receiving morphine analgesia for severe pain, and to evaluate whether the measurement of saliva morphine concentrations would be a useful, noninvasive, clinical tool to diagnose systemic exposure to morphine. Fifteen pediatric patients were enrolled; for the control group, 18 adult volunteers were recruited. Patients received continuous morphine drips to ameliorate pain caused by a sickle cell vasoocclusive crisis (range, 10-40 micrograms/kg.h). Control subjects were randomized into those receiving acetaminophen with either 8 mg (n = 13) or 30 mg (n = 5) of codeine. All participants fasted at least 2 hours before sample collection. Blood and saliva samples were collected simultaneously. All samples were analyzed by radioimmunoassay for morphine. There was no correlation between saliva and plasma morphine concentrations in either the patients receiving intravenous morphine (r = 0.04, P = 0.89) or in the controls receiving codeine (r = 0.43, P = 0.08). There was no observed difference in the mean counts per minute (CPM) for saliva samples in the pH range 3.96 to 8.06. Saliva concentrations of morphine cannot be used to predict the plasma concentration of morphine in children or adults. However, the concentration of morphine in saliva may be used as a qualitative indicator of systemic exposure to morphine in a subject.",1997.0,0,0
1616,9357099,Quick onset of severe abdominal pain after codeine in an ultrarapid metabolizer of debrisoquine.,P Dalén; C Frengell; M L Dahl; F Sjöqvist,"The authors describe a 33-year-old woman who experienced severe pain in the epigastrium after codeine intake. This side-effect is consistent with that of morphine. Later, the patient was phenotyped and genotyped as an ultrarapid metabolizer with high capacity to metabolize codeine to morphine.",1997.0,0,0
1617,9362428,Mechanisms and management of bone pain.,R Payne,,2000.0,0,0
1618,9366459,Opioid-sparing effects of a low-dose infusion of naloxone in patient-administered morphine sulfate.,T J Gan; B Ginsberg; P S Glass; J Fortney; R Jhaveri; R Perno,"A naloxone infusion is effective in reducing epidural and intrathecal opioid-related side effects. The use of naloxone infusion concomitant with intravenous morphine patient-controlled analgesia (PCA) has not been evaluated, probably because of an expected direct antagonism of the systemic opioid effect. The authors compared the incidence of morphine-related side effects and the quality of analgesia from two small doses of naloxone infusion. Sixty patients classified as American Society of Anesthesiologists physical status 1, 2, or 3 who were scheduled for total abdominal hysterectomies were enrolled in the study. Patients received a standardized general anesthetic. In the postanesthetic care unit, patients received morphine as a PCA. They were randomized to receive either 0.25 microg x kg(-1) x h(-1) naloxone (low dose), 1 microg x kg(-1) x h(-1) (high dose), or saline (placebo) as a continuous infusion. Verbal rating scores for pain, nausea, vomiting, and pruritus; sedation scores; requests for antiemetic; and morphine use were recorded for 24 h. Blood pressure, respiratory rate, and oxyhemoglobin saturation were also monitored. Sixty patients completed the study. Both naloxone doses were equally effective in reducing the incidence of nausea, vomiting, and pruritus compared with placebo (P < 0.05 by the chi-squared test). There was no difference in the verbal rating scores for pain between the groups. The cumulative morphine use was the lowest in the low-dose group (42.3 +/- 24.1 mg; means +/- SD) compared with the placebo (59.1 +/- 27.4 mg) and high-dose groups (64.7 +/- 33.0 mg) at 24 h (P < 0.05 by analysis of variance). There was no incidence of respiratory depression (<8 breaths/min) and no difference in sedation scores, antiemetic use, respiratory rate, and hemodynamic parameters among the groups. Naloxone is effective in preventing PCA opioid-related side effects. Naloxone infusion at 0.25 microg x kg(-1) x h(-1) not only attenuates these side effects but appears to reduce postoperative (beyond 4-8 h) opioid requirements. This dosing regimen can be prepared with 400 microg naloxone in 1,000 ml crystalloid given in 24 h to a patient weighing 70 kg.",1997.0,0,0
1619,9370836,The influence of age upon opioid analgesic use in the patient-controlled analgesia (PCA) environment.,A Woodhouse; L E Mather,"It is often asserted that older patients are more sensitive to opioid analgesics than younger patients but experimental evidence for this assertion remains sparse. Two studies were conducted investigating the relationship between age and opioid analgesic use in the patient-controlled analgesia environment. In study I, the relationship was analysed subsequent to our publication of a study investigating patients' responses to opioid use with patient-controlled analgesia. Fifty-five postoperative patients, stratified into 'older' and 'younger' patients by median age, received morphine or pethidine or fentanyl patient-controlled analgesia. A strong inverse relationship was found between age and fentanyl and morphine use but not between age and pethidine use. Study II was a retrospective study of the medical records of 199 patient-controlled analgesia patients who had received morphine or pethidine patient-controlled analgesia; there were insufficient patients who had used fentanyl for a reasonable sample. There was a difference in morphine use with the younger patients using significantly more morphine than the older patients (< 60 years). Findings were less clear for patients receiving pethidine but there was an inverse correlation between age and pethidine use as well. Overall, the findings of these two studies supported the common clinical belief that older patients require less opioids than younger patients.",1997.0,0,0
1620,9377992,[Postoperative analgesia after endoscopic abdominal operations. A randomized double-blind study of perioperative effectiveness of metamizole].,P Steffen; W Seeling; R Kunz; I Schuhmacher; M Georgieff,"In comparison to conventional operating technique endoscopic surgery reveals numerous advantages, particular rapid mobilisation and earlier discharge from observation. For a effective utilization of these advantages, it is desirable to have a efficient postoperative analgesic scheme, which can be continued into the period after discharge from hospital. In a randomised, prospective double-blind study we investigated the analgesic efficacy of dipyrone in 40 patients, scheduled for endoscopic abdominal surgery (mainly endoscopic cholecystectomy). Patients received before induction of anesthesia either dipyrone (1 g/100 ml NaCl i.v.) or placebo (100 ml NaCl i.v.). These infusions were repeated 6 h and 12 h after first application. After surgery all patients were allowed to self-administer buprenorphine intravenously from a PCA-pump (Bolus 30 micrograms, lockout 5 min in the recovery room, 30 min on the ward). Every hour for the first 6 h and after 24 h, cumulated doses of buprenorphine, pain scores (0-10), pulse, blood pressure and side effects were recorded. Dipyrone-treated patients had significantly less pain immediately after surgery and used a significantly lower cumulated dose of buprenorphine (-67%; 90 micrograms vs. 270 micrograms buprenorphine) in the first 24 h after surgery.",1998.0,0,0
1621,9379069,Transdermal fentanyl as treatment for chronic low back pain.,R K Simpson; E A Edmondson; C F Constant; C Collier,"Management of chronic low back pain often includes oral opioid use. The effectiveness of therapy is dependent upon compliance, which in turn is dependent upon response, side effects, access, and convenience. Our hypothesis was that a transdermal fentanyl system would provide more effective pain management than oral opioids. Fifty patients with chronic low back pain were examined. After litration to levels corresponding to current oral opioid use, each patient was maintained on transdermal fentanyl for one month. Oral opioid therapy was then resumed. Their experience was assessed with the a visual analogue scale for pain intensity, a numerical pain score, the Oswestry disability questionnaire, the pain disability index, and the Verran Snyder-Halpern sleep scale. Significant improvement in pain relief and disability was found with transdermal fentanyl compared with oral opioids. Mild opioid side effects were common, but easily controlled. Use of transdermal fentanyl is an effective alternative to oral opioids for managing chronic low back pain.",2001.0,0,1
1622,9380133,[Malignant pleural mesothelioma in general practice; complex pain problems].,R M Leclercq; A W Jongmans-Liedekerken,"In three patients, men aged 67, 57 and 69 years, malignant pleural mesothelioma was diagnosed. All three had worked as coal miners and were presented with thoracic pain. They were among seven cases of malignant pleural mesothelioma diagnosed in a period of five years in one suburban general practice (adherence: 5600 patients) in the former mining area in the province of Limburg. The terminal phase of the disease was characterized by intractable pain. High doses of opioids and adjuvants were necessary to achieve acceptable pain relief. It is suggested that step one of the 'analgesic ladder for cancer pain management' of the WHO (non-opioids) should be followed soon by step three (strong opioids). Because the incidence of pleural mesothelioma is not yet decreasing, it is important to know that pain management remains a serious problem.",1998.0,0,0
1623,9382217,[A comparison of the analgesic effect of ketanov and tramal in postoperative pain].,N P Babaeva; D V Kuznetsov,"The efficacy of postoperative pain relief by ketanov and tramal was assessed in 42 patients operated on the abdominal organs and lower limb arteries. The time of development of the analgesic effect and duration and depth of analgesia were compared. The drug effects were compared from protocols of clinical examination, hemodynamic changes, and time course of external respiration and blood saturation with oxygen. The findings confirm a high analgesic effect of ketanov, which is not inferior to tramal, and by some parameters even higher.",1998.0,0,0
1624,9385761,Migrainous stroke causing thalamic infarction and amnesia during treatment with propranolol.,J E Mendizabal; F Greiner; W J Hamilton; J F Rothrock,"We report a case of migraine-associated ischemic stroke causing amnesia, wherein treatment with propranolol may have been contributory. The possible mechanisms involved in migrainous stroke occurring in association with use of propranolol are discussed.",1997.0,0,0
1625,9389843,Caudal tramadol for postoperative analgesia in pediatric hypospadias surgery.,D P Prosser; A Davis; P D Booker; A Murray,"Ninety boys, aged 13-53 months, undergoing repair of hypospadias, were allocated randomly to receive 0.8 ml kg-1 of one of three solutions into the caudal extradural space: group B received bupivacaine 2 mg kg-1, group T received tramadol 2 mg kg-1 in 0.9% saline and group BT a mixture of both. Postoperative pain was assessed hourly for 12 h after injection using a modified TPPPS pain score and additional analgesia was administered to those children whose pain scores were > 3/10. Nine patients (30%) in group T required additional analgesia within 1 h of surgery compared with only two (6.7%) and three (10%) patients in groups B and BT, respectively (P = 0.04). Mean duration before additional analgesia was required in the remaining patients was 9.3 (SD 3.0) h in group B, 10.7 (2.2) h in group T and 10.5 (2.0) h in group BT (P > 0.20). There were no significant differences between the groups in mean ventilatory frequency, sedation scores, incidence of emesis, facial flushing or pruritus. We conclude that caudal tramadol had a slow onset of action and that the addition of tramadol to bupivacaine, when both drugs were administered caudally, did not significantly prolong the duration of action of bupivacaine.",1997.0,0,0
1626,9391683,"Continuous intrathecal meperidine via an implantable infusion pump for chronic, nonmalignant pain.",S C Harvey; M G O'Neil; C A Pope; B G Cuddy; T A Duc,"To report a continuous infusion of intrathecal meperidine via an implanted infusion pump for nonmalignant, chronic pain. A 69-year-old white woman had chronic, nonmalignant low-back pain and bilateral leg pain. Multiple drug therapies and other interventional techniques had failed. The patient achieved significant pain relief by a continuous infusion of intrathecal meperidine via an implanted infusion pump. To our knowledge, this is the first report of meperidine administered intrathecally by continuous infusion. Continuous infusion of intrathecal and epidural opiates by implanted infusion pumps is becoming more widely recognized as an alternative treatment for patients with chronic, benign pain. Epidural and intrathecal meperidine is an effective analgesic for short-term surgical procedures. Data reporting effective relief and safety with continuous intrathecal meperidine remain limited. Continuous intrathecal meperidine via an implantable infusion pump may be an effective alternative in the treatment of chronic pain.",1997.0,0,0
1627,9393263,Surgical management of chronic pain from chronic pancreatitis.,A McHale; K J Buechter; I Cohn; J P O'Leary,"Chronic pain from chronic pancreatitis remains a difficult clinical problem. We present the results of surgical attempts to control this pain. For the past 3 years, all patients with chronic pancreatitis and pain requiring high-dose narcotics or hospitalization for pain control were evaluated by the following algorithm. Any anatomic pathology causing ductal dilatation was surgically addressed first (Puestow's procedure, pseudocyst drainage, or sphincteroplasty). If there was no evidence of ductal dilatation, or if pain recurred postoperatively, denervation procedures were performed (splenopancreatic flap, thorascopic sympathectomy, or resection). Pain recurrence was defined as the need for further hospitalization or reoperation. Data were analyzed by comparison of two proportions. Follow-up averaged 26 months. Thirty-seven patients underwent 44 operations solely in an attempt to control pain; 62 per cent were male, and 70 per cent had chronic alcoholic pancreatitis. Our results show that surgical management provides relief in 68 per cent of patients, and no one procedure is clearly superior to others.",2001.0,0,0
1628,9393518,Percutaneous biliary drainage: clinical trial of analgesia with interpleural block.,E Therasse; M Choinière; G Soulez; V L Oliva; P Rousseau; F Fugère; D Boudreault; J R Cusson,"To determine the analgesic efficacy and safety of interpleural block for percutaneous biliary drainage. In this double-blind study, 34 age- and sex-matched patients who were to undergo percutaneous biliary drainage because of malignant biliary obstruction were randomly assigned to the true-block group (30 mL 0.5% bupivacaine block) or placebo-block group; all had access to a patient-controlled analgesia (fentanyl) pump. Self medication, pain reports, blood pressure, heart rate, and oxygen saturation were monitored during and until 8 hours after drainage. The McGill Pain Questionnaire was administered 1 hour after biliary drainage. Patients in the placebo group self administered statistically significantly more fentanyl than did patients in the true-block group (P = .008). Peak pain scores (10-point scale) and McGill Pain Questionnaire scores were statistically significantly higher for the placebo group patients (P = .017 and P = .001, respectively). There were no differences between groups in terms of blood pressure, heart rate, and oxygen saturation. Two patients had pneumothorax caused by the interpleural block. Interpleural block was effective in decreasing pain and opioid requirements during and after percutaneous biliary drainage and did not compromise the cardiopulmonary status of the patient. However, the rate of pneumothorax was higher than previously reported.",1997.0,0,0
1629,9394266,"Medication misuse, abuse and dependence in chronic pain patients.",K Kouyanou; C E Pither; S Wessely,"We report the prevalence of drug use, misuse, abuse, and dependence in 125 chronic pain patients attending specialist pain clinics in South London. A total of 110 patients (88%) were taking medications for their pain problem. Opioid analgesics (69.6%), nonopioids (48%), antidepressants (25%), and benzodiazepines (17.6%) were the drugs most frequently used. Psychoactive substance abuse or dependence (DSM-III-R) was diagnosed in 12%. A total of 9.6% of the patients met the DSM-III-R criteria for substance abuse or dependence in remission. Data are also presented on the misuse and abuse of nonpsychoactive drugs, qualitative information on how patients use drugs, and the information they have received about medication.",1997.0,0,0
1630,9395803,Preoperative versus postoperative pethidine for extraction of impacted third molars.,S T Chew; T C Low,"We have studied the pre-emptive analgesic effects of pethidine by comparing its analgesic effects given before or immediately after operation in a randomized, double-blind study of 40 patients undergoing removal of bilateral impacted third molars under general anaesthesia. Group 1 patients received pethidine 50 mg as a 1 ml injection 1 to 2 hours before operation and normal saline 1 ml intramuscularly immediately after surgery. Group 2 patients received normal saline 1 ml intramuscularly before operation and pethidine 50 mg as a 1 ml injection immediately after surgery. Outcome measures included perception of pain on a visual analogue scale (VAS), the number of patients who required postoperative pethidine, time to first postoperative pethidine injection and total dose of pethidine given. Four patients in group 1 compared to 8 in group 2 required postoperative pethidine but this was not statistically significant. The VAS scores, time to first postoperative pethidine injection and total dose of pethidine also did not differ significantly between the 2 groups. We concluded that preoperative administration of pethidine intramuscularly did not confer additional analgesic effects compared with a similar dose given after surgery.",1997.0,0,0
1631,9399121,Identification of tramadol and its metabolites in blood from drug-related deaths and drug-impaired drivers.,K E Goeringer; B K Logan; G D Christian,"Tramadol is a centrally acting, binary analgesic that is neither an opiate-derived nor a nonsteroidal anti-inflammatory drug and that was approved for use in the United States in 1995. It is used to control moderate pain in chronic pain settings such as osteoarthritis and postoperative cases. Used in therapy as a racemic mixture, the (+)-enantiomer weakly binds to the mu-opioid receptor, and both enantiomers inhibit serotonin and norepinephrine reuptake. Tramadol's major active metabolite, O-desmethyltramadol (ODT), shows higher affinity for the mu-opioid receptor and has twice the analgesic potency of the parent drug. The synergism of these effects contributes to tramadol's analgesic properties with the (+)-enantiomer exhibiting 10-fold higher analgesic activity than the (-)-enantiomer. Although tramadol was initially thought to exhibit low abuse potential, Ortho-McNeil, the drug's manufacturer, recently reported a large number of adverse events attributed to tramadol including abuse by opioid-dependent patients, allergic reactions, and seizures. The high number of adverse reactions has prompted the company to update the prescribing information for the drug. An analytical method using gas chromatography-mass spectrometry (GC-MS) without derivatization for the determination of tramadol and its metabolites is reported. An n-butyl chloride extraction is followed by GC-MS analysis using a 5% phenylmethylsilicone column (30 m x 0.32-micron i.d.). Analysis of 12 blood samples from tramadol-related deaths and four nonfatal intoxications involving tramadol revealed concentrations ranging from 0.03 to 22.59 mg/L for tramadol, from 0.02 to 1.84 mg/L for ODT, and from 0.01 to 2.08 mg/L for N-desmethyltramadol. Three deaths were clearly attributable to acute morphine toxicity, one was a doxepin overdose, and six were multiple drug overdoses. The role of tramadol in each death is explored.",1997.0,0,0
1632,9399364,Benzodiazepine self-administration in humans and laboratory animals--implications for problems of long-term use and abuse.,R R Griffiths; E M Weerts,"Drug reinforcement may represent the primary behavioral-pharmacological mechanism underlying two types of problematic use of benzodiazepines--recreational abuse by polydrug abusers and inappropriate chronic use by patients. High dose polydrug abuse for the purpose of getting high is readily recognized as a significant social problem. Inappropriate chronic benzodiazepine use is more subtle but relatively common: for anxiolytics, 36% of past-year users (3% of the adult population in the US) report using these drugs for 4 consecutive months or longer. The risks of such long-term use are much better documented than the benefits. This paper provides a current review of various problems that have been identified with the long-term use and the recreational abuse of benzodiazepines, including memory impairment, risk of accidents, falls and hip fractures in the elderly, a withdrawal syndrome, brain damage, overuse in the elderly, overuse by chronic pain patients, overuse by alcoholics and recreational abuse among alcoholics and polydrug abusers. A comprehensive review of the literature on benzodiazepine reinforcing effects in humans and laboratory animals is also provided. Drug self-administration studies in humans and laboratory animals provide models of both types of problematic benzodiazepine use. Recreational abuse of benzodiazepines has been modeled in human research with polydrug abusers and in laboratory animal studies, which show that the reinforcing effect of benzodiazepines is intermediate relative to other sedative compounds and is increased in subjects with histories of previous sedative drug self-administration. The problem of inappropriate long-term use of benzodiazepines by people without histories of drug abuse has been partially modeled in human studies showing that benzodiazepines function as reinforcers in subjects with anxiety, insomnia, and histories of moderate alcohol consumption, and in preclinical studies showing stable, low-rate benzodiazepine self-injection with concurrent physical dependence under conditions of continuous availability. Both human and animal research suggests that the drug history and current behavioral context may be important in the establishment of benzodiazepines as reinforcers. Limited human and animal research provides little support for the common belief that physical dependence enhances benzodiazepine reinforcement.",1997.0,0,0
1633,9400460,Bupivacaine infiltration into the neurovascular bundle of the prostatic nerve does not improve postoperative pain or recovery following transvesical prostatectomy.,B Fredman; E Zohar; T Ganim; M Shalev; R Jedeikin,"We assessed the effect of intraoperative bupivacaine infiltration into the neurovascular bundle of the prostatic nerve on postoperative pain and patient outcome. The study included 40 American Society of Anesthesiologists physical status I to III patients undergoing transvesical prostatectomy. Following surgical resection of the prostate the neurovascular bundle of the prostatic nerve was infiltrated with either 10 ml. bupivacaine 0.5% or saline. Postoperative pain intensity was assessed using a patient generated 100 mm. visual analog scale and a patient controlled analgesia device. Additional analgesic requirements, time to ambulation, length of hospitalization and return to normal activity were also recorded. There were no differences in visual analog scale for pain, patient controlled analgesia demands or actual morphine delivered. Similarly, saline versus bupivacaine infiltration did not influence ambulation time (21.3 +/- 2.7 versus 25.0 +/- 11.8 hours, respectively), length of hospitalization (7.06 +/- 0.8 versus 7.11 +/- 0.6 days, respectively), return to normal activity (14.4 +/- 8.8 versus 14.2 +/- 8.2 days, respectively) or patient satisfaction. On postoperative days 1 and 2 more patients in the saline treatment group requested additional oral analgesia compared to the bupivacaine treatment group. However, no statistical difference was demonstrated. Following transvesical prostatectomy, prostatic nerve blockade has no beneficial effects on postoperative pain or patient outcome.",1997.0,0,0
1634,9404175,Comparison of nalbuphine and buprenorphine in total intravenous anaesthesia.,F A Khan; A Zaidi; R S Kamal,Nalbuphine (0.3 mg.kg-1) and buprenorphine (2.5 micrograms.kg-1) were compared as part of a total intravenous anaesthesia regimen using a propofol infusion in 60 patients undergoing laparoscopic cholecystectomy in a randomised double-blind study. Changes in haemodynamic variables greater than 20% from the baseline were noted. No difference was observed in blood pressure but the heart rate was significantly lower in the buprenorphine group. Intra-operative bradycardia (heart rate < 60 beat.min-1) occurred more often in the buprenorphine group. Recovery was fast and comparable with both drugs and no patient reported awareness. Quality of analgesia was similar in both groups. Both drugs provide suitable analgesic supplementation to total intravenous anaesthesia.,1997.0,0,0
1635,9404176,Analgesic and respiratory effect of nalbuphine and pethidine for adenotonsillectomy in children with obstructive sleep disorder.,W Habre; B McLeod,"Opioids may depress respiration and contribute to airway obstruction after adenotonsillectomy for obstructive sleep disorder. We compared the respiratory and analgesic effects of nalbuphine, which has a ceiling effect for respiratory depression, and pethidine in 90 children (aged 2-12 years) with a history of obstructive sleep disorder undergoing adenotonsillectomy. Children were scored for their obstructive sleep disorder history and were randomly allocated to receive intravenously at induction of anaesthesia either nalbuphine 0.1 mg.kg-1 (group N) or pethidine 1 mg.kg-1 (group P). End-tidal carbon dioxide was measured in the recovery period using a nasopharyngeal catheter and oxygen saturation whilst breathing air; pain and sedation scores were recorded for 6 h postoperatively. Both groups were similar with respect to the demographic data and respiratory measurements: mean (SD) oxygen saturation on air in the recovery area (96.2% (1.2) vs. 96.5% (1.1) in group N and P, respectively) and mean (SD) end-tidal carbon dioxide (46.4 (5.5) mmHg vs. 47.7 (4) mmHg in group N and P, respectively). High obstructive sleep disorder score, history of apnoea, hyperactivity and loud snoring were found to be the best predictors of early postoperative oxygen desaturation in both groups.",1997.0,0,0
1636,9404792,The use of analgesics in patients with acute abdominal pain.,F LoVecchio; N Oster; K Sturmann; L S Nelson; S Flashner; R Finger,"Analgesics in patients with acute abdominal pain are often withheld for fear that they may change physical examination findings and thus may be unsafe. We conducted a randomized, prospective, placebo-controlled trial to investigate changes in physical examination following the administration of placebo, 5 mg, or 10 mg of morphine to 49 patients with acute abdominal pain. One patient was withdrawn secondary to inadequate documentation. Of the 48 patients who completed the trial, a statistically significant change in physical examination was noted in both groups receiving analgesics, but not in the placebo group. No adverse events or delays in diagnosis were attributed to the administration of analgesics. We conclude that physical examination does change after the administration of analgesics in patients with acute abdominal pain and that a larger study is needed to evaluate analgesic safety in this subpopulation of emergency department patients.",1997.0,0,0
1637,9406356,"Opioids: overview on action, interaction and toxicity.",K A Lehmann,"The history of opioid use in briefly reviewed, and the presently accepted indications are discussed with reference to dosage, modes of administration, efficacy, duration of effect and speed of onset, and possible side effects. Physicians' fears about dependence and addiction are also touched upon.",1997.0,0,0
1638,9406357,Problems with opiates in cancer pain: parenteral opioids.,P Glare,"Morphine is the preferred drug for the management of moderate-severe chronic cancer pain. The best route of administration is by mouth, because it is simple, safe, convenient, inexpensive and effective. Non-oral modes of administration should be only considered if (a) the oral route becomes unavailable or (b) there is documentation of failure of maximal doses of oral morphine and coanalgesic drugs. Recent developments have made new routes of morphine administration fashionable--in the absence of supportive pharmacokinetic or pharmacodynamic data--even when departure from established practice is not justified. It is important for clinicians to be familiar with the practicalities and problems that limit the utility of the non-oral routes, and the state of current understanding of these options will be reviewed.",1997.0,0,0
1639,9407761,"Acute pain service, Kandang Kerbau Hospital, 1995--a first year's experience.",M K Shah,"To determine the efficacy and safety of the different modes of post-operative analgesia in the first 24 hours for both caesarean section and major gynaecological procedures. Being a purely descriptive study, the patients were not randomised to the post-operative analgesic mode. The choice was made both by the patient and the anaesthetist. The modes employed were continuous intravenous morphine, continuous intravenous pethidine, epidural morphine/bupivacaine, epidural bupivacaine/fentanyl and spinal morphine. During the first 24 hours, the patients' maximum pain scores, ability to sleep well, presence of nausea and/or vomiting, pruritus, respiratory depression and drowsiness and/or giddiness were elicited. Backache and inflammation at the site of insertion of the epidural catheter were also elicited in patients on regional analgesia. They were also asked if they were satisfied with the Pain Service. Out of 2,024 patients, 60% had undergone caesarean section and 40% had undergone major gynaecological procedures. Continuous intravenous morphine, the most common mode, was used in 83% of obstetric patients and 47.9% of gynaecological patients. Only one obstetric patients and one gynaecological patient complained of severe pain at rest while 12 obstetric patients and 3 gynaecological patients had severe pain on movement or coughing. Side-effects, most commonly nausea and/or vomiting and drowsiness and/or giddiness, were present in 8.8% of obstetric patients and 32.5% of gynaecological patients. 99.3% of obstetric patients and 99.6% of gynaecological patients were overall satisfied with their analgesia. Our post-operative analgesic modes were found to be effective and safe.",1998.0,0,0
1640,9412659,A pharmacodynamic study of morphine and its glucuronide metabolites after single morphine dosing in cancer patients with pain.,M Hoffman; J C Xu; C Smith; C Fanelli; V Pascal; C Degaetano; G Meenan; M Lehrer; M Lesser; M Citron,"Eleven morphine naïve patients with cancer-related pain were given a single dose of either intravenous morphine (n = 5) or oral morphine (n = 6). Blood sampling was performed over a 24-hr period and serial pain assessments were made using a categorical scale. Plasma samples were analyzed for morphine, morphine-6-glucuronide (M-6-G), morphine-3-glucuronide (M-3-G), and normorphine using high-performance liquid chromatography. In neither the intravenous nor oral group was there a correlation between analgesia duration and the half-lives of morphine and M-6-G. There was no correlation between the time to peak analgesia and time to peak concentration for morphine or M-6-G. There was no significant difference in absolute concentrations of M-6-G or M-3-6 nor in the ratio of M-3-G to M-6-G at peak analgesia versus relapse.",1997.0,0,0
1641,9414055,Controlled-release oxycodone and morphine in cancer related pain.,T Heiskanen; E Kalso,"Controlled-release (CR) formulations of oxycodone and morphine were compared in 45 patients with chronic cancer pain. The study was started with an open-label, randomised titration phase to achieve stable pain control for at least 48 h, followed by a double-blind, randomised, crossover phase in two periods, 3-6 days each. To blind the study using available tablet strengths, the dose ratio of oxycodone to morphine was set at 2:3. A daily telephone contact was maintained between the patient and the investigator. The patients were asked to assess pain intensity four times a day and acceptability of therapy twice daily, and to record possible adverse effects. Pharmacodynamic evaluations were performed at the end of each double-blind period. The patients were allowed to use escape analgesic (respective opioid as oral solution) as needed. Twenty-seven patients were evaluable for both safety and efficacy. Pain was well-controlled during both stable phases. When the period effect was taken into account the two opioids provided comparable analgesia. If the results of the two periods were combined, the patients consumed significantly more escape doses and the mean pain intensities were significantly greater with CR oxycodone. The total opioid consumption ratio of oxycodone to morphine was 2:3 when oxycodone was administered first, and 3:4 when oxycodone was administered after morphine. The total incidence of adverse experiences reported by the patients was similar, but significantly more vomiting occurred with morphine, whereas constipation was more common with oxycodone.",1997.0,0,0
1642,9416720,Lack of analgesic activity of morphine-6-glucuronide after short-term intravenous administration in healthy volunteers.,J Lötsch; G Kobal; A Stockmann; K Brune; G Geisslinger,"The analgesic activity of morphine-6-glucuronide (M-6-G) is well recognized for its contribution to the effects of morphine and its possible use as an opioid analgesic with a wider therapeutic range than morphine. The present study attempted to quantify the relative contribution of M-6-G to analgesia observed after systemic administration of morphine. In a placebo-controlled, sixfold crossover study in 20 healthy men, the effects of M-6-G were assessed at steady-state plasma concentrations of M-6-G identical to and two and three times higher than those measured after administration of morphine. Morphine and M-6-G were administered as an intravenous bolus followed by infusion over 4 h. Dosage A was M-6-G-bolus of 0.015 mg/kg plus infusion of 0.0072 mg x kg(-1) x h(-1). Dosage B was M-6-G-bolus of 0.029 mg/kg plus infusion of 0.014 mg x kg(-1) x h(-1). Dosage C was M-6-G-bolus of 0.044 mg/kg plus infusion of 0.022 mg x kg(-1) x h(-1). Dosage D was a morphine bolus of 0.14 mg/kg plus infusion of 0.05 mg x kg(-1) x h(-1) for 4 h. Dosage E was M-6-G combined with morphine (doses A + D). Dosage F was a placebo. The analgesic effects of M-6-G and morphine were measured before administration of the bolus and after 3.5 h using an experimental pain model based on pain-related cortical potentials and pain ratings after specific stimulation of the nasal nociceptor with short pulses of gaseous carbon dioxide. Morphine significantly reduced subjective and objective pain correlates compared with placebo. In contrast, M-6-G produced no statistically significant effects. The addition of M-6-G to morphine did not increase the effects of morphine. Morphine produced significantly more side effects than M-6-G. After short-term intravenous administration at doses that produce plasma concentrations of M-6-G similar to those seen after administration of morphine, M-6-G had no analgesic effects in the present placebo-controlled study in healthy volunteers.",1998.0,0,0
1643,9421004,Role of invasive methods in the treatment of chronic pain.,M Zenz; B Donner; M Strumpf; R Dertwinkel,,1998.0,0,0
1644,9422908,Intra-articular morphine and clonidine produce comparable analgesia but the combination is not more effective.,M Gentili; P Houssel; M Osman; D Henel; A Juhel; F Bonnet,"Both intra-articular morphine and clonidine produce analgesia. This study was designed to compare the analgesic effects of the two drugs, used separately and in combination. We studied 90 patients undergoing arthroscopy of the knee under general anaesthesia. Patients were allocated randomly to receive 20 ml of intra-articular isotonic saline solution containing morphine 2 mg, clonidine 150 micrograms or both. Pain was assessed on an visual analogue scale after operation and time for rescue medication was measured. There was no difference in VAS scores between the three groups and the time for rescue analgesic was comparable. We conclude that intra-articular morphine and clonidine have comparable analgesic effects in the doses used. The combination of both drugs did not seem to increase analgesia.",1998.0,0,0
1645,9424683,[Comparative study of postoperative analgesia with methadone and fentanyl in continuous peridural perfusion].,M P Prieto-Alvarez; J G Fuentes-Bellido; J López-Cebollada; J P Lorenzo-Foz,"To determine whether continuous epidural perfusion of fentanyl, which is more liposoluble than methadone, provides a similar level of analgesia with fewer side effects than methadone administered by the same route for postoperative pain. Prospective double blind study of 40 patients, randomly assigned to two groups. Group F (n = 20) received 300 micrograms-1200 micrograms/24 h in epidural perfusion. Group M (n = 20) received 9 mg-18 mg/24 h in epidural perfusion. In both cases treatment was for pain in the first 72 h after abdominal surgery. Analgesia quality was evaluated on a visual analog (VAS) scale from 1 to 10 at rest and moving. Need for complementary analgesia was also recorded, as were side effects related to the technique. Quality of analgesia was good and similar which both drugs. Postoperative pain did not surpass 3 on the VAS at rest or 4.5 while moving, although group F patients' need for complementary analgesia was significantly greater (p < 0.05). The incidence of hypoxemia was greater in group M than in group F (p = 0.05). Continuous epidural perfusion of fentanyl provides good analgesia and is associated with less hypoxemia than is methadone.",1998.0,0,0
1646,9428901,Intrathecal morphine pump as a treatment option in chronic pain of nonmalignant origin.,I F Angel; H J Gould; M E Carey,"Implantable pumps for the delivery of intrathecal morphine have become a common option for administering opiate medication for the management of pain in patients with terminal cancer. Options for treating chronic pain of non-malignant origin are more controversial. This study describes responses to intrathecal morphine administration for managing chronic pain in patients without an underlying malignancy. Eleven patients between the ages of 29 and 81 years, nine with failed back syndrome (FBS) and two with neuropathic pain (NP) from other causes, were chosen from 15 consecutive individuals referred to neurosurgery clinic. The presenting levels of pain and a functional-economic outcome level were determined for each patient. Patients were admitted to the hospital for therapeutic trials and were assessed for the appropriateness of their analgesic response and for adverse responses to the medication. A morphine pump was implanted in five males and six females who were followed for up to 3 years. A good to excellent analgesic response was seen in 8 (73%) patients (6 FBS; 2 NP). In the remaining three patients (27%), the analgesic response was judged poor (3 FBS). In patients with FBS, the total effective response was 67%. Two patients experienced bladder dysfunction requiring pump removal. Other adverse effects of pump placement were rare. The morphine pump was found to be a viable alternative in the management of failed back syndrome. Its use in long-term therapy, however, is not without limitations and should be a last choice option.",2001.0,0,0
1647,9429046,Labour pain management in a parturient with an implanted intrathecal pump.,J Tarshis; J E Zuckerman; N P Katz; S Segal; P S Mushlin,"We report the peripartum anaesthetic management for vaginal delivery of a chronic pain patient with an implanted intrathecal pump. This is the first report describing labour analgesia in a patient with such a device. As intrathecal systems become more popular for the management of nonmalignant pain, this situation is likely to be encountered with increasing frequency in the future. The patient was a nulliparous 23-yr-old with a history of chronic hereditary pancreatitis whose intractable pain had been managed with intrathecal morphine 3 mg.day-1 via an implantable pump for four years. Inadequate time between presentation and onset of labour prevented us from using this system. Intravenous patient controlled analgesia with fentanyl using a bolus of 25 micrograms and a lockout of five minutes was ineffective and epidural analgesia using bupivacaine was initiated and resulted in satisfactory analgesia. The presence of an existing intrathecal delivery system does not preclude the use of supplemental epidural analgesia during labour.",1998.0,0,0
1648,9430814,What factors affect physicians' decisions to prescribe opioids for chronic noncancer pain patients?,D C Turk; A Okifuji,"To evaluate the contribution of pain severity, physical pathology, demographic factors, initiators of symptoms, affective distress, behavioral expressions of pain, and functional activity levels in physicians' decisions to prescribe opioid medication for chronic noncancer pain patients. Patients were examined by a physician and physical therapist, interviewed by a psychologist, and asked to complete a medical history form and a set of self-report questionnaires. Patients who were prescribed opioids were compared with those who were not prescribed opioids on each of these. In addition, logistic regression analysis was performed to determine the best predictors of opioid prescriptions. A total of 191 (96 female and 95 male) consecutive patients referred to a multidisciplinary pain treatment facility diagnosed with a variety of chronic pain syndromes. Neither pain severity nor objective physical pathology influenced physicians' prescribing of opioids medication. Similarly, duration of pain and demographic factors had minimal impact on prescribing of opioids. Patients' behavioral manifestations of pain, distress, and suffering--pain behaviors--and reports of functional disability and distress did distinguish between patients prescribed opioid medications from those who did not. However, when all variables were entered into a logistic regression model, only observed pain behaviors showed a significant association with opioid prescriptions. Physicians' practice in prescribing of opioids appears to be influenced most by patients' nonverbal communications of pain, distress, and suffering. Some of the factors not directly evaluated in this study that may also contribute to the decision to prescribe opioids for chronic noncancer pain patients are discussed.",1998.0,0,0
1649,9430816,Do patient and physician expectations predict response to pain-relieving procedures?,B S Galer; L Schwartz; J A Turner,"To evaluate the relationships between patient and physician pretreatment expectations of pain relief and subsequent pain relief reported by chronic pain patients immediately after treatment. Prospective study of consecutive patients undergoing a procedure in a pain clinic for treatment of chronic pain. Patients rated their current pain level and their expectation of pain relief immediately prior to undergoing a procedure (e.g., intravenous drug infusion, nerve block) for the treatment of chronic pain. Simultaneously and independently, the treating physician completed a similar questionnaire. At completion of the procedure, patients rated their current pain level and degree of pain relief. University of Washington Multidisciplinary Pain Center procedure suite. Forty-six consecutive chronic pain patients. Intravenous drug infusions and nerve blocks. Current pain and pain relief ratings. Patients' pain relief expectation ratings were not correlated significantly with their postprocedure pain relief ratings or pre-post procedure changes in pain ratings. However, a statistically significant correlation was found between physician expectations of pain relief and patient pain relief ratings and patient pre-post procedure changes in pain. The results of this study suggest that physicians are better predictors than are patients of patients responses to these procedures and/or that physicians may somehow subtly communicate their expectations to patients during the procedure, and these expectations then influence patient response. Patient pretreatment expectations may not always play a significant role in nonspecific treatment effects.",1998.0,0,0
1650,9438600,Prospective evaluation of pain in exocrine pancreatic cancer.,A L Grahm; A Andrén-Sandberg,"Although pain is the most feared part of the terminal life of many patients with cancer, the intensity and the quality of the pain is all too often only scantly described. The quality and quantity of pain were prospectively registered by five variables, including a visual analogue scale (VAS), in 46 consecutive patients with exocrine pancreatic cancer. Twenty-seven percent of the patients were completely pain free and 24 (53%) patients reported little or no pain at the time of diagnosis. Only 5 (11%) patients had severe pain. Patients with tumors in the head of the pancreas had less pain than patients with cancer in the body or tail of the pancreas, which could not be explained by stage or size of the tumor. With time there were less and less patients with little or no pain (VAS 0-2), but after 8 and 10 weeks about one third of the patients were still without any pain (VAS < or = 0). With time there was also a tendency to treat patients more frequently with morphine in spite of a low pain score. Preoperative pain simply measured with VAS is an addition to prognostic information. Pain in pancreatic cancer is not as common as usually stated at the time of diagnosis, but is related to the site of the tumor. Eventually more patients are treated with opioid drugs. Evaluation of the pain pattern is an addition to prognostic information.",1998.0,0,0
1651,9439446,Subnanogram-concentration measurement of buprenorphine in human plasma by electron-capture capillary gas chromatography: application to pharmacokinetics of sublingual buprenorphine.,E T Everhart; P Cheung; P Shwonek; K Zabel; E C Tisdale; P Jacob; J Mendelson; R T Jones,"We describe a sensitive and specific method for the measurement of buprenorphine in human plasma. The method involves a structural analog as an internal calibrator, careful control of pH during sample extraction to maximize drug recovery, and back-extraction into acid followed by reextraction to eliminate endogenous interferences. After evaporation, sample residues are derivatized with heptafluorobutyric anhydride and analyzed by separation on a fused-silica polymethylsiloxane capillary column and electron-capture detection. Calibration curves were linear in the ranges 0.1-2.0 micrograms/L and 2.0-20 micrograms/L, with within-run CVs of 9.7% at 0.1 microgram/L to 5.0% at 20 micrograms/L, and total CVs of 15.9% at 0.1 microgram/L to 6.5% at 10 micrograms/L. The limit of quantification was 0.1 microgram/L. The method was utilized in studies to determine the absolute bioavailability of sublingual doses of 2 mg of buprenorphine in 1 mL of 300 mL/L ethanol and the bioequivalence of sublingual 8-mg tablet and 300 mL/L ethanol solution formulations.",2001.0,0,0
1652,9444547,Does allopurinol reduce pain of chronic pancreatitis?,P A Banks; M Hughes; M Ferrante; E C Noordhoek; V Ramagopal; A Slivka,"A dosage of 300 mg/d of allopurinol was not effective in reducing pain or improving activities of daily living in chronic pancreatitis. Allopurinol prevents the generation of oxygen-derived free radicals by inhibiting xanthine oxidase. The purpose of this study was to determine whether allopurinol is effective in reducing pain of chronic pancreatitis. Thirteen patients with chronic pancreatitis who were experiencing abdominal pain requiring medication at least three times each week entered a randomized, double-blind, two-period crossover clinical trial. Patients evaluated their pain daily using a categorical pain intensity scale, numeric pain intensity scale, and a visual analog scale, and weekly completed a McGill Pain Questionnaire and activities of daily living (ADL) questionnaire. The mean baseline score of pain was approx 50% of most severe pain in all scoring systems. There was no significant decrease in pain associated with allopurinol compared to the placebo (p = 0.24-0.75). In addition, there was no benefit in terms of ADL score associated with allopurinol compared with placebo (p = 0.32). Mean uric acid level was decreased by 1.15 mg/dL while patients were taking allopurinol, compared to when they were taking placebo (p = 0.007).",1998.0,0,0
1653,9444665,Postoperative recovery after cholecystectomy by minilaparotomy: a randomized double-blind comparison between alpha-trinositol and placebo.,D Westerling; H H Luttropp; T Holmin; E Landquist,"An opioid-sparing effect of alpha-trinositol (D-myo-inositol 1,2,6-trisphosphate) following cholecystectomy in otherwise healthy patients was suggested by a pilot study. In order to verify this result, pain, pain relief and nausea were studied in patients undergoing elective cholecystectomy by minilaparotomy. The patients were randomized using double-blind design to receive an intravenous infusion of either alpha-trinositol or sodium chloride (placebo) for eight hr after the operation. Pain, pain relief and nausea were evaluated up to 72 hr after surgery using visual analogue scales (VAS). Rescue analgesic medication was registered. As a further measure of pain and/or restrictions caused by pain, peak expiratory flow, walking distance and pressure pain thresholds were assessed. There was no difference between the groups in ratings of pain, pain relief, nausea or amount of analgesic medication given. The mean ratings of pain were significantly higher in the sitting position compared to lying down. Neither pressure pain thresholds, nor the walking distance differed between the patients given alpha-trinositol and placebo, respectively. There were significant reductions of peak expiratory flow and of pressure pain thresholds under both costal margins up to 72 hr after surgery compared to presurgery values. As a conclusion, no analgesic effect of alpha-trinositol at the dosage used was observed in the postoperative patients studied.",1998.0,0,0
1654,9458936,Clinical importance of pain and stress in preterm neonates.,K J Anand,Clinical and laboratory investigations of neonatal pain suggest that preterm neonates have an increased sensitivity to pain and that acute painful stimuli lead to the development of prolonged periods of hyperalgesia. Non-noxious stimuli during these periods of hyperalgesia may expose preterm neonates to established or chronic pain. Acute physiologic changes caused by painful or stressful stimuli can be implicated as important factors in the causation or subsequent extension of early intraventricular hemorrhage (IVH) or the ischemic changes leading to periventricular leukomalacia (PVL). Therapeutic interventions that provide comfort/analgesia in preterm neonates were correlated with a decreased incidence of severe IVH. Long-term follow-up studies of preterm neonates may substantiate the preliminary data associating repetitive painful experiences with some of the neurobehavioral and developmental sequelae resulting from neonatal intensive care.,2000.0,0,0
1655,9466023,Analgesia after upper abdominal surgery with extradural buprenorphine with lidocaine.,Z Wajima; T Shitara; G Ishikawa; T Inoue; R Ogawa,"To determine whether the continuous low thoracic extradural administration of the same dose of lidocaine at low concentration with a high infusion rate or at high concentration with a low infusion rate in combination with a fixed dose of buprenorphine (0.4 mg.day-1) modifies postoperative pain relief. Twenty-eight patients undergoing elective upper abdominal surgery were randomly allocated to one of two groups to receive lidocaine 2%--buprenorphine at a rate of 6.3 ml.hr-1 (2% group, n = 13) or lidocaine 6%-buprenorphine at a rate of 2.1 ml.hr-1 (6% group, n = 15). During suture of the peritoneum, mepivacaine 2% (8 ml) with 0.1 mg (0.5 ml) buprenorphine was infused extradurally. After extubation, the continuous extradural infusion was initiated. Patients were assessed for the level of analgesia with the 10 cm VAS score at rest and with the Prince Henry Pain Scale (PHPS) at 3, 6, 9, 12, 18, and 24 hr postoperatively. The visual analogue scale (VAS) scores at rest did not differ between the two groups except at 18 hr after surgery. The Prince Henry Pain Scale (PHPS) scores were not different between the two groups postoperatively. There was no difference in analgesia produced by the continuous extradural infusion of lidocaine 2%-buprenorphine at a rate of 6.3 ml.hr-1 and that of lidocaine 6%-buprenorphine at a rate of 2.1 ml.hr-1 following upper abdominal surgery.",1998.0,0,0
1656,9466024,"Postoperative analgesia with ""3-in-1"" femoral nerve block after prosthetic hip surgery.",R Fournier; E Van Gessel; G Gaggero; S Boccovi; A Forster; Z Gamulin,"To evaluate the efficacy of a single shot ""3-in-1"" femoral nerve block for prosthetic hip surgery in association with general anaesthesia on post-operative analgesia. Forty patients, ASA 1 to 3, received sham block or ""3-in-1"" femoral nerve block, following Winnie's landmarks with a nerve stimulator, and 40 ml bupivacaine 0.5% with epinephrine were injected after induction of anaesthesia. Vecuronium, 0.1 mg.kg-1, was added after performing the block and anaesthesia was maintained with isoflurane, oxygen 40% and nitrous oxide 60%. Fentanyl, 1.5 microgram.kg-1, was administered before incision to all patients. Heart rate, blood pressure, fentanyl requirements and FETiso were measured throughout surgery. During the post-operative period, 75 mg diclofenac i.m. and/or 0.1 mg.kg-1 morphine s.c. were administered when pain score was > 3/10 and repeated when necessary. Pain scores at first analgesic intervention, at 24 hr and 48 hr as well as diclofenac and morphine requirements after surgery were recorded. There was no difference in anaesthetic requirements during surgery. The time from performance of sham or ""3-in-1"" femoral nerve block to the first analgesic intervention (261 +/- 49 min versus 492 +/- 40 min, P < 0.05) and time from extubation to the first analgesic intervention (61 +/- 44 min vs 298 +/- 39 min, P < 0.05) were prolonged in the study group. However, pain scores and the analgesic requirements in the postoperative periods (24 and 48 hr) were similar. There is a short-term benefit during the first few postoperative hours in using a single shot ""3-in-1"" femoral nerve block to complement general anaesthesia for elective hip surgery.",1998.0,0,0
1657,9466097,The influence of timing of ketorolac administration on post-operative analgesic requirements following total abdominal hysterectomy.,D A Gabbott; A M Cohen; A H Mayor; L A Niemiro; T A Thomas,"One hundred and thirty-seven patients were studied to assess whether the timing of a dose of ketorolac affected cumulative morphine requirements during the first 12 post-operative hours. Pain, sedation and nausea scores, respiratory rate and degree of operative blood loss were also recorded. Thirty-six patients (group A) were given placebo injections pre- and intra-operatively. Thirty-one patients (group B) received placebo pre-operatively and ketorolac 30 mg intra-operatively. Thirty-six patients (group C) received ketorolac 10 mg pre-operatively and ketorolac 20 mg intra-operatively and thirty-four patients (group D) were given ketorolac 30 mg pre-operatively and placebo intra-operatively. Post-operative analgesia was with intravenous (i.v.) morphine administered using a patient controlled analgesia (PCA) device. Analysis of variance revealed a significant difference in morphine consumption at 1, 2, 4, 8 and 12 h postoperatively (P < 0.05) between group A (no ketorolac) and groups B, C and D (ketorolac). However, there were no significant differences between groups B, C and D during the study period. Thus, the timing of ketorolac administration made no difference to overall morphine consumption. Pain, nausea, sedation and respiratory rate scores were similar in all four groups. There was a significantly greater blood loss in patients receiving ketorolac (groups B, C and D) compared with those receiving placebo alone (group A).",1998.0,0,0
1658,9466101,Analgesic effect of intra-articular bupivacaine or diamorphine after arthroscopic surgery of the knee joint in day-case patients.,A Shaw; P J Mobbs; J F Haines; S Rao; M O'Connor,"A prospective, randomized, double-blind, controlled study was conducted to assess the efficacy of intra-articular bupivacaine and diamorphine. Ninety-six day-case patients were allocated randomly to receive intra-articular injections of either 20 mL 0.9% saline (control, n = 35), 20 mL 0.5% plain bupivacaine (n = 31), or 20 mL 0.9% saline with 5 mg diamorphine (n = 30) prior to tourniquet release. Visual analogue scales (VAS) were completed at 1 h, 3 h (discharge) and 24 h, and supplementary analgesia noted. Intra-articular analgesics conferred a noticeable improvement in patient comfort. First, the quantity of supplementary analgesia required prior to discharge was significantly reduced (P = 0.016); second, patients reported a less disturbed night's sleep (P = 0.034).",1998.0,0,0
1659,9466102,Intrathecal sufentanil compared with epidural bupivacaine analgesia in labour.,A Harsten; L Gillberg; L Håkansson; M Olsson,"Epidural analgesia for pain relief during labour has certain disadvantages including slow onset. However, intrathecal sufentanil provides rapid onset and well-controlled analgesia lasting 1-4 h. The aim of this study was to compare the analgesia and the side effects of intrathecal sufentanil with epidural bupivacaine during labour. In a randomized, double-blind and controlled trial 58 parturient women requesting analgesia during labour were studied. The patients received either intrathecal sufentanil 10 micrograms and epidural saline, or intrathecal saline and epidural bupivacaine 20 mg. Visual analogue scores (VAS) for pain, blood pressure, heart rate, respiratory rate, level of sedation and the incidence of pruritus and nausea were recorded. Pain scores were significantly lower between 5 and 90 min after injection in patients receiving intrathecal sufentanil. Pruritus was significantly more frequent among those receiving intrathecal sufentanil. The rapid onset and effective analgesia of intrathecal sufentanil may in certain situations be advantageous.",1998.0,0,0
1660,9466103,"Tramadol in the management of post-operative pain: a double-blind, placebo- and active drug-controlled study.",U M Stamer; C Maier; S Grond; B Veh-Schmidt; E Klaschik; K A Lehmann,"A double-blind, randomized, placebo- and drug-controlled study in which the analgesic efficacy and safety of intravenous (i.v.) tramadol in patients with post-operative pain is reported. One hundred and eighty patients recovering from gynaecological or abdominal surgery were assigned to one of three treatment groups. After titration of an individual loading dose, patients could self-administer tramadol 20 mg, morphine 2 mg or placebo using a patient-controlled analgesia (PCA) device throughout a 48-h period. Criteria of efficacy were a decrease in pain intensity within the first 30 min of at least 20 on a visual analogue scale (VAS) (0 denotes no pain, 100 worst pain imaginable) and satisfactory analgesia in the patient's opinion during the study period. Patients treated with tramadol, morphine and placebo were assessed as responders at 66.7%, 75.0% and 18.3% (P < 0.0001). VAS after the initial bolus were 39.2 +/- 22.1, 35.9 +/- 21.6 and 50.0 +/- 24.2 (P = 0.002), the initial loading dose amounted to tramadol 144.9 +/- 51.2 mg, morphine 12.3 +/- 5.1 mg and placebo 17.2 +/- 4.9 mL. No serious opioid-related adverse events occurred in the patients given tramadol while two patients given morphine developed an impaired respiratory rate and a decreased oxygen saturation to 80% or less. Tramadol proved to be efficacious for PCA treatment of post-operative pain following gynaecological and abdominal surgery.",1998.0,0,0
1661,9467287,"[Severe pain relief with intrathecal infusion. The patient controls, treatment can be provided at home].",P Nitescu; L Appelgren; I Curelaru,"Intrathecal administration of an opioid such as morphine in combination with a local anaesthetic such as bupivacaine is an effective treatment for severe cancer pain. The treatment, which can often be made available in the patient's home, provides relief from pain without unwanted sedation, when high-dose oral or parenteral morphine no longer has any effect. The patient controls the treatment, and can achieve a balance between pain relief and side-effects. The article outlines the routines established at the pain unit at Sahlgrenska Hospital in Gothenburg.",1998.0,0,0
1662,9469518,The urogenital and rectal pain syndromes.,U Wesselmann; A L Burnett; L J Heinberg,"Pain syndromes of the urogenital and rectal area are well described but poorly understood and underrecognized focal pain syndromes. They include vulvodynia, orchialgia, urethral syndrome, penile pain, prostatodynia, coccygodynia, perineal pain, proctodynia and proctalgia fugax. The etiology of these focal pain syndromes is not known. A specific secondary cause can be identified in a minority of patients, but most often the examination and work-up remain unrevealing. Although these patients are often depressed, rarely are these pain syndromes the only manifestation of a psychiatric disease. This review article presents an overview of the neuroanatomy of the pelvis, which is a prerequisite to trying to understand the chronic pain syndromes in this region. We then discuss the clinical presentation, etiology and differential diagnosis of chronic pain syndromes of the urogenital and rectal area and review treatment options. The current knowledge of the psychological aspects of these pain syndromes is reviewed. Patients presenting with these pain syndromes are best assessed and treated using a multidisciplinary approach. Currently available treatment options are empirical only. Although cures are uncommon, some pain relief can be provided to almost all patients using a multidisciplinary approach including pain medications, local treatment regimens, physical therapy and psychological support, while exercising caution toward invasive and irreversible therapeutic procedures. Better knowledge of the underlying pathophysioloigical mechanisms of the urogenital and rectal pain syndromes is needed to allow investigators to develop treatment strategies, specifically targeted against the pathophysiological mechanism.",1998.0,0,0
1663,9469525,Infiltration of morphine into an abnormal wound; effects on pain relief and endocrine/immune response.,M Eriksson-Mjöberg; M Kristiansson; K Carlström; A Olund; J Eklund,"We wanted to evaluate pain relief and endocrine/immune response after local administration of morphine into an abdominal wound. In a randomised double blind design 29 patients undergoing hysterectomy received two blinded injections of morphine and saline. Before surgery the patients in the control group (n = 15) got 10 mg of subcutaneous morphine into an arm and at skin incision 30 ml of saline was infiltrated directly into the wound. The patients in the wound group (n = 14) received 1 ml of saline into an arm before surgery and 10 mg of morphine in 30 ml of saline into the wound at skin incision. Patient controlled analgesia (PCA) with i.v. morphine was used after surgery. Repeated blood samples were obtained from the day before the surgery until 3 days later and analysed for cortisol and interleukin-6 (IL-6). There were no differences between the groups either in pain relief or in the consumption of PCA morphine. The wound group used 47 +/- 15 mg of i.v. morphine and the control group used 50 +/- 16 mg. Peak values for IL-6 and cortisol appeared at 4 h. The area under the curve (AUC) of cortisol at 0-6, 0-10 and 0-20 h was significantly lower in the control group than in the wound group (P < 0.05). High doses of i.v. morphine reduced cortisol and IL-6 levels in the early hours after surgery. The injection of morphine into the wound did not improve pain relief or reduce the consumption of i.v. morphine after surgery. The endocrine stress response to trauma was modified by preoperative administration of morphine.",1998.0,0,0
1664,9469526,Psychological approaches during conscious sedation. Hypnosis versus stress reducing strategies: a prospective randomized study.,M E Faymonville; P H Mambourg; J Joris; B Vrijens; J Fissette; A Albert; M Lamy,"Stress reducing strategies are useful in patients undergoing surgery. Hypnosis is also known to alleviate acute and chronic pain. We therefore compared the effectiveness of these two psychological approaches for reducing perioperative discomfort during conscious sedation for plastic surgery. Sixty patients scheduled for elective plastic surgery under local anesthesia and intravenous sedation (midazolam and alfentanil upon request) were included in the study after providing informed consent. They were randomly allocated to either stress reducing strategies (control: CONT) or hypnosis (HYP) during the entire surgical procedure. Both techniques were performed by the same anesthesiologist (MEF). Patient behavior was noted during surgery by a psychologist, the patient noted anxiety, pain, perceived control before, during and after surgery, and postoperative nausea and vomiting (PONV). Patient satisfaction and surgical conditions were also recorded. Peri- and postoperative anxiety and pain were significantly lower in the HYP group. This reduction in anxiety and pain were achieved despite a significant reduction in intraoperative requirements for midazolam and alfentanil in the HYP group (alfentanil: 8.7 +/- 0.9 microg kg(-1)/h(-1) vs. 19.4 +/- 2 microg kg(-1)/h(-1), P < 0.001; midazolam: 0.04 +/- 0.003 mg kg(-1)/h(-1) vs. 0.09 +/- 0.01 mg kg(-1)/h(-1), P < 0.001). Patients in the HYP group reported an impression of more intraoperative control than those in the CONT group (P < 0.01). PONV were significantly reduced in the HYP group (6.5% vs. 30.8%, P < 0.001). Surgical conditions were better in the HYP group. Less signs of patient discomfort and pain were observed by the psychologist in the HYP group (P < 0.001). Vital signs were significantly more stable in the HYP group. Patient satisfaction score was significantly higher in the HYP group (P < 0.004). This study suggests that hypnosis provides better perioperative pain and anxiety relief, allows for significant reductions in alfentanil and midazolam requirements, and improves patient satisfaction and surgical conditions as compared with conventional stress reducing strategies support in patients receiving conscious sedation for plastic surgery.",1998.0,0,0
1665,9469527,"Cognitive performance, mood and experimental pain before and during morphine-induced analgesia in patients with chronic non-malignant pain.",J Lorenz; H Beck; B Bromm,"This paper investigates subjective, behavioral and neurophysiological changes due to treatment with oral sustained-release morphine in six patients with severe non-malignant pain. Patients rated their mood and clinical pain on visual analog scales (VAS). Experimental pain reactions were quantified by ratings on categorical scales and evoked cerebral potentials (LEP) in response to standardized laser stimuli. A standard auditory oddball task provided reaction time (RT), errors, N1 and P2 of late auditory evoked potentials (AEP), and a P300 component. It was used to measure vigilance and cognitive performance. In parallel with clinical pain reduction, laser pain ratings and LEP amplitudes were significantly reduced. In contrast, auditory P2 and P300 amplitude were found to be even enlarged under morphine. RT and mood also failed to indicate any sedation. It is concluded that LEP indicated the analgesic morphine effects whereas late potentials and P300 from auditory stimuli reflected the perceptual-cognitive status which, instead of being deteriorated by morphine-induced sedation, improved probably due to the removal of pain as a mental stressor.",1998.0,0,1
1666,9469530,Pain epidemiology and health related quality of life in chronic non-malignant pain patients referred to a Danish multidisciplinary pain center.,N Becker; A Bondegaard Thomsen; A K Olsen; P Sjøgren; P Bech; J Eriksen,"This paper presents the results of a detailed study of the pain epidemiology and health related quality of life (HRQL) in 150 chronic non-malignant pain patients consecutively referred to a Danish multidisciplinary pain center. Mean pain severity was 71.6 (SD = 18.5) on the VAS scale. Forty-two percent reported poor quality of sleep. HRQL was evaluated with the Medical Outcome Study-Short Form (SF-36), the Hospital Anxiety and Depression scale (HAD) and the Psychological General Well-Being Scale (PGWB). Compared with the normal population (NP) both SF-36 scores and PGWB scores were significantly reduced (P < 0.001) indicating that physical, psychological and social well-being were severely reduced. On the HAD scale 58% were found to have a depressive or anxiety disorder. Statistically significant but modest correlations were found between pain severity and HRQL. Psychological and social well-being was closely correlated. Sixty-three percent of the referred patients had neurogenic pain conditions. Of these, only 25% were treated with antidepressants or anticonvulsants at referral. Seventy-three percent were treated with opioids at referral. Mean opioid consumption was 64 mg of morphine per day (range 1-280 mg). Compared with the NP the chronic pain patients had used the health care system five times more often in the years prior to referral (P < 0.001). The study confirms the severe multidimensional impact of chronic pain and demonstrates that HRQL of chronic non-malignant pain patients is among the lowest observed for any medical condition.",1998.0,0,0
1667,9469531,Ketorolac potentiates morphine in postoperative patient-controlled analgesia.,P Picard; J E Bazin; N Conio; F Ruiz; P Schoeffler,"The authors conducted a prospective randomised double-blind comparison of patient-controlled analgesia (PCA), with a combination of morphine and ketorolac versus morphine alone and ketorolac alone in the management of postoperative pain after orthopaedic surgery. Forty-two patients were randomly assigned to three groups. Group 1 was given 1 mg/ml morphine, group 2 was given 3 mg/ml ketorolac and group 3 half-doses of each. After a loading dose of 0.07 ml/kg, PCA was started at an initial setting of 1 ml per demand, with a 10-min lock-out interval and no background infusion. Pain was measured at rest and during movements for 48 h. The combination of morphine and ketorolac was more effective than morphine or ketorolac alone in relieving rest pain throughout the study. The combination was also more effective during movement than either drug alone, but only for the first 24 h. The consumption of morphine and ketorolac was significantly lower when the two drugs were administered together. The incidence of urinary retention was highest in the group given morphine alone. The combination of half-doses of morphine and ketorolac is more effective in controlling postoperative pain than either drug alone. This combination also reduces analgesic consumption and morphine-related adverse events.",1998.0,0,0
1668,9469945,Preparation and use of morphine capsules in paediatric patients with burns.,V Amirat-Combralier; B Jentile; R Elias; J M Dejode; P Lagier; M Bues-Charbit; G Balansard,Morphine is an analgesic agent used for the symptomatic relief of moderate to severe pain. The lack of oral paediatric form of morphine hydrochloride has led the pharmacy unit to develop capsules containing 1 mg of morphine. These capsules are prepared in conformity with G.M.P. and controlled by H.P.L.C. 73 burn children were treated in this study with pain suppression without adverse effects. This galenic form may be an adequate candidate for the management of paediatric patients because of its analgesic qualities and of numerous advantages.,1998.0,0,0
1669,9476677,Endogenous morphine levels increase following cardiac surgery as part of the antiinflammatory response?,V Brix-Christensen; E Tønnesen; R G Sanchez; T V Bilfinger; G B Stefano,"Exogenous morphine downregulates the activity of immunocompetent cells such as lymphocytes, granulocytes and macrophages. Furthermore, morphine increases the secretion of CRH, ACTH and glucocorticoids, i.e. substances with inhibitory effects on the immune system. In the present study we tested the hypothesis that endogenous morphine production is increased as part of the antiinflammatory response to cardiac surgery. Sixteen patients submitted to elective coronary artery bypass grafting (CABG) surgery were randomized to either thoracic epidural analgesia combined with general anaesthesia (group I) or high-dose fentanyl anaesthesia (group II). Patients in group I did not receive morphine while patients in group II received systemic morphine for postoperative pain relief. From each patient 18 blood samples were taken perioperatively and tested for morphine. Furthermore, monocyte function with respect to motility and shape was determined by computer-assisted image analysis. A steep increase in plasma morphine concentrations was demonstrated on the first postoperative day in patients in group I (not given morphine). Plasma morphine levels remained significantly elevated during the following five postoperative days. Patients in group II given morphine as pain treatment showed a larger and earlier morphine peak related to the morphine administration. Computer-assisted image analysis of leukocyte behaviour revealed a biphasic increase in cell motility. In conclusion, we demonstrate for the first time that endogenous morphine levels increase after the trauma of surgery. We surmise that morphine is part of the antiinflammatory response to cardiac surgery.",1998.0,0,0
1670,9477052,,,,,0,0
1671,9477056,The dose-response relation of intrathecal fentanyl for labor analgesia.,C M Palmer; R C Cork; R Hays; G Van Maren; D Alves,"This study determined the dose-response relation of intrathecal fentanyl for labor analgesia and described the onset, duration, and quality of analgesia when used as the sole analgesic. Eighty-four parturients in active labor who requested analgesia were randomized to one of seven treatment groups. They received 5-45 microg intrathecal fentanyl as part of a combined spinal-epidural technique. Visual analog pain scores were recorded before and at intervals after injection patients requested additional analgesia. The occurrence and severity of pruritus, nausea, and vomiting were also recorded. Maternal blood pressure was recorded before injection and at intervals after injection. Fetal heart rate was recorded before and 30 min after injection. By 5 min after injection, pain scores were significantly different among groups (P < 0.001). Mean duration of analgesia increased to 89 min as the dose increased to 25 microg. Maternal diastolic blood pressure was significantly lower 10 and 30 min after injection. There was no difference among groups in the incidence of pruritus; nausea and vomiting were uncommon. Fetal heart rates did not change after injection. A dose-response curve indicates that the median effective dose of intrathecal fentanyl for labor analgesia is 14 microg (95% confidence interval, 13-15 microg). Intrathecal fentanyl produces rapid, profound labor analgesia with minimal side effects. These data indicate that there is little benefit to increasing the dose beyond 25 microg when it is used as the sole agent for intrathecal labor analgesia.",1998.0,0,0
1672,9481960,A pilot study comparing ketoprofen and acetaminophen with hydrocodone for the relief of postoperative periodontal discomfort.,K L Reed; J R Smith; T Lie; D F Adams,"The aim of this study was to compare ketoprofen to acetaminophen with hydrocodone (A/H) in a postoperative periodontal pain model. A double-blind protocol was used. Thirty minutes prior to each procedure, subjects were given orally either 100 mg ketoprofen or a placebo tablet. Four hours later, the subjects took either 50 mg ketoprofen (ketoprofen group) or 1000 mg acetaminophen with 10 mg hydrocodone (placebo group). Subjects reported levels of overall discomfort and pain using visual analog scales at eight hourly intervals following the first dose of ketoprofen or placebo. Information about adverse side effects was requested from the patients in the form of a checklist. The results revealed only small differences between the two drug regimens with respect to levels of pain or overall discomfort. A/H provided significantly better pain relief at Hours 5 and 6, while overall discomfort levels were significantly higher with ketoprofen than with placebo at Hours 3 and 4. Pain levels were low for both groups. It is recommended that additional analgesics for mild to moderate pain should be tested.",1998.0,0,0
1673,9481968,Peripheral opioid analgesia in teeth with symptomatic inflamed pulps.,R A Uhle; A Reader; R Nist; J Weaver; M Beck; W J Meyers,"The purpose of this study was to investigate the ability of low-dose fentanyl to produce analgesia when administered via the periodontal ligament injection in teeth with symptomatic, inflamed pulps. All subjects presented for emergency treatment with moderate to severe pain and had a posterior tooth with a clinical diagnosis of irreversible pulpitis. Twenty subjects randomly received either 10 micrograms fentanyl citrate or saline placebo via the periodontal ligament injection in a double-blind manner. The subjects rated their pain prior to injection and rated pain intensity and pain half gone for 59 min postinjection. Low-dose fentanyl delivered via the periodontal ligament injection in inflamed teeth provided significantly greater analgesia than the saline placebo (P < 0.05). Since the dose of fentanyl used was less than the dose required to provide analgesia by a central mechanism, the results of this study may be consistent with a peripheral opioid mechanism of action.",1998.0,0,0
1674,9483591,Chronic pain management in children. Part I: Cancer and phantom pain.,T Dangel,,1998.0,0,0
1675,9487787,[Pain therapy after thoracotomies--systemic patient-controlled analgesia (PCA) with opioid versus intercostal block and interpleural analgesia].,A Ohlmer; R Leger; U Scheiderer; R Elfeldt; H Wulf,"Both regional analgesia and systemic opioid therapy (e.g. PCA) are commonly used for pain relief following thoracic surgery. Many anaesthesiologists are reluctant to use thoracic epidural analgesia on general surgical wards. Therefore, we investigated in a prospective randomised study the efficacy of intercostal blocks (ICB) or interpleural analgesia (IPA) compared to PCA with systemic opioids (PCA). Following ethics committee approval and informed consent, 45 thoracotomy patients were randomised for postoperative pain management: group 1: intravenous PCA with piritramide (PCA-control), group 2: intercostal blocks of the segments concerned with 5 ml bupivacaine 0.5% at the end of surgery and 6 hours thereafter (ICB), group 3: interpleural analgesia with 20 ml bupivacaine 0.25% applied every 4 hours using a catheter placed during surgery near the apex of the pleural space (IPA). Patients in the ICB and IPA groups were able to obtain additional pain relief by PCA with piritramide. Alternative medication for all groups in case of insufficient analgesia was metamizol. Both regional analgesia groups used significantly less piritramide up to the 3rd (IPA) or 7th (ICB) postoperative day than the control group (p < 0.05). The consumption of metamizol was lower as well (n. s.). No significant differences between the study groups were observed with regard to pain scores (visual analogue scale VAS) at rest, during deep inspiration, coughing or mobilisation. Respiratory parameters as forced vital capacity, forced expiratory volume (1 sec) and peak flow (FVC; FEV1; PF) were reduced significantly following thoracotomy and showed a slow restitution in all three study groups without major inter-group differences. Intercostal blocks and interpleural analgesia significantly reduce opioid demand following thoracotomy and are effective means of postoperative pain management. Nevertheless, in contrast to epidural analgesia, both methods have to be supplemented by, or combined with, systemic analgesics in most patients. On the other hand, compared to epidural analgesia, ICB and IPA are less invasive and easier to manage on general surgical wards.",1998.0,0,0
1676,9489595,The effect of duration of dose delivery with patient-controlled analgesia on the incidence of nausea and vomiting after hysterectomy.,A Woodhouse; L E Mather,"Postoperative nausea and vomiting (PONV) may be exacerbated by postoperative opioid analgesics and may limit patients' successful use of these medications when used with patient controlled analgesia (PCA). We tested the hypothesis that the rapid change in blood morphine concentration associated with PCA bolus delivery contributed to PONV, and that prolonging its delivery to a brief infusion would result in decreased PONV. Patients, who were receiving morphine for pain relief via patient-controlled analgesia (PCA) after total abdominal hysterectomy, received 1 mg morphine sulphate incremental doses either over 40 s with a 5 min lockout interval or over 5 min delivery with a 1 min lockout interval. Episodes of nausea, retching and vomiting, along with the use of morphine and the pain relief obtained, were recorded. Data from 20 patients in each group were analysed. Contrary to expectations, most patients in both groups reported nausea postoperatively. Those patients receiving morphine over 5 min experienced more episodes of emesis (36) than those receiving the dose over 40 s (17). Most patients receiving the 40 s doses vomited in the first 12 h (median time 8 h), while those receiving the 5 min doses vomited between 12 and 24 h (median time 19 h) (P = 0.01). There were no differences between groups in the visual analogue pain scores or use of morphine between groups. Reasons for these unexpected findings remain speculative. The high incidence of PONV appears to be inherently high in gynaecological surgery patients and standard antiemetic medication regimens appear to be poorly efficacious. Reasons for the differences in the time-course of emetic episodes between the two groups may be related to differences in the time-course of central opioid receptor occupancy.",1998.0,0,0
1677,9490256,[Diclofenac for treatment of postoperative pain after hip arthroplasty in older patients].,J Litke; A Bohatyrewicz; K Mikulski,"Efficacy of diclofenac in pain relief after hip alloplasty was investigated in 35 patients aged 61-73 (mean 66). We compared ""diclofenac group"" to similar group of patients treated with i.m. morphine Complications and side effects of both therapies have been analyzed. Diclofenac therapy decreased opioids demand thus reduced its side effects. Patient's comfort has been improved also at non-operated sites.",1998.0,0,0
1678,9491040,Consequences of inadequate analgesia during painful procedures in children.,S J Weisman; B Bernstein; N L Schechter,"To explore the effect of inadequate analgesia for painful procedures (bone marrow aspiration, lumbar puncture, or both) on the pain of subsequent procedures. A cohort of patients with cancer who had participated in a placebo-controlled, randomized study that documented the efficacy of oral transmucosal fentanyl citrate for painful procedures rated the pain associated with subsequent procedures performed with open-label oral transmucosal fentanyl. Twenty-one children undergoing diagnostic procedures who had been participants in previous study. All children were given oral transmucosal fentanyl, 15 to 20 microgram/kg, prior to the procedure; at its conclusion they were asked to rate the associated pain. In children younger than 8 years (n = 13), mean pain ratings during each subsequent procedure were consistently higher for those who had received placebo (n = 8) in the original study compared with those who had received the active drug (n = 5). A repeated-measures analysis of variance suggests that this difference is statistically significant (P = .04). Older children (n = 8) did not show this pattern. Inadequate analgesia for initial procedures in young children may diminish the effect of adequate analgesia in subsequent procedures.",1998.0,0,0
1679,9496404,Prolonged central intravenous ketorolac continuous infusion in a cancer patient with intractable bone pain.,R L Gordon,"To report the case of a prolonged intravenous ketorolac continuous infusion given via a central line in a cancer patient with intractable bone pain. A 56-year-old Hispanic man with stage IV non-small-cell lung cancer and multiple bone metastases was admitted to the hospital for intractable pain inadequately controlled at home by conventional therapy. He was treated with an intravenous continuous infusion of ketorolac 120 mg in 250 mL of NaCl 0.9% infused over 24 hours. The ketorolac was given via a central line for 14 days in addition to fentanyl patient-controlled analgesia. Over this time period the patient reported his pain to be well controlled. His requests for bolus doses of fentanyl decreased dramatically and the dose of the continuous intravenous fentanyl was reduced by 22%. In addition, the total daily dose of ketorolac was reduced following a change from intermittent bolus dosing to a continuous infusion. The management of cancer pain secondary to bone metastasis is a difficult and challenging problem frequently encountered by the healthcare team. The use of nonsteroidal antiinflammatory drugs (NSAIDs) as adjuvant therapy is a common practice. However, many terminally ill patients are unable to take oral medications, thus limiting NSAID treatment options. Ketorolac tromethamine is approved by the Food and Drug Administration (FDA) as a parenteral NSAID. As with other NSAIDs, the risk of adverse drug reactions must be considered when using this class of medication. The FDA has approved ketorolac for the short-term (< or = 5 d) management of moderately severe acute pain that requires analgesia at the opioid level, usually in the postoperative setting. However, certain patients may benefit from long-term use exceeding the FDA-recommended guidelines of 5 days of maximum therapy. A prolonged central intravenous ketorolac continuous infusion was successful in treating a cancer patient with intractable bone pain secondary to widely metastatic non-small-cell lung cancer.",1998.0,0,0
1680,9501815,Prospective randomized double-blind trial of neurolytic coeliac plexus block in patients with pancreatic cancer.,E Polati; G Finco; L Gottin; C Bassi; P Pederzoli; S Ischia,"In a randomized double-blind study the efficacy of neurolytic coeliac plexus block (NCPB) was compared with pharmacological therapy in the treatment of pain from pancreatic cancer. Twenty-four patients were divided into two groups: 12 patients underwent NCPB (group 1) and 12 were treated with pharmacological therapy (group 2). Immediate and long-term efficacy, mean analgesic consumption, mortality and morbidity were evaluated at follow-up. Statistical analysis was performed with the unpaired t test, Mann-Whitney U test and Fisher's exact test. Immediately after the block, patients in group 1 reported significant pain relief compared with those in group 2 (P < 0.05), but long-term results did not differ between the groups. Mean analgesic consumption was lower in group 1. There were no deaths. Complications related to NCPB were transient diarrhoea and hypotension (P not significant between groups). Drug-related adverse effects were constipation (five of 12 patients in group 1 versus 12 of 12 in group 2), nausea and/or vomiting (four of 12 patients in group 1 versus 12 of 12 in group 2) (P < 0.05), one gastric ulcer and one gluteal abscess in group 2. NCPB was associated with a reduction in analgesic drug administration and drug-related adverse effects, representing an effective tool in the treatment of pancreatic cancer pain.",1998.0,0,0
1681,9505005,Malpractice risks associated with prescribing medication for chronic headaches.,G N McAbee,,1998.0,0,0
1682,9505784,Effect of dexamethasone on postoperative emesis and pain.,K Liu; C C Hsu; Y Y Chia,"In this double-blind, randomized, placebo-controlled study, we have evaluated the effect of preoperative administration of dexamethasone on postoperative vomiting and pain in 60 women undergoing general anaesthesia for major gynaecological surgery. Dexamethasone 10 mg (group D) or saline (group S) was administered i.v. in a double-blind manner during induction of anaesthesia. Postoperative pain relief was controlled with bolus doses of morphine using an i.v. patient-controlled analgesia device, and patients were assessed for incidence of vomiting, sedation score, verbal pain rating score, time to first morphine demand and morphine consumption at 4, 8, 12 and 24 h after surgery. Six patients in group D and 19 in group S experienced vomiting at least once within the 24-h postoperative period; dexamethasone was effective in reducing the overall incidence of vomiting from 63.3% to 20.0% (P < 0.01). Other variables were similar between the groups, and the influence of dexamethasone on postoperative pain was minimal.",1998.0,0,0
1683,9505982,Analgesic efficacy of a hydrocodone with ibuprofen combination compared with ibuprofen alone for the treatment of acute postoperative pain.,A Sunshine; N Z Olson; E O'Neill; I Ramos; R Doyle,"Hydrocodone is a semisynthetic opioid with analgesic and antitussive properties qualitatively similar to other opioid agonists. Ibuprofen is a nonsteroidal antiinflammatory agent with analgesic and antipyretic activity and is an effective, primarily peripheral-acting antiinflammatory analgesic. The objective of this clinical trial was to determine the additive analgesic effect of the combination of 15 mg hydrocodone bitartrate with 400 mg ibuprofen, relative to 400 mg ibuprofen alone and placebo, in the treatment of postoperative pain. The single-dose analgesic efficacy of the combination of hydrocodone bitartrate with ibuprofen was compared with ibuprofen alone and placebo in 120 patients with moderate or severe postoperative pain after abdominal surgery. Analgesia was measured during the 6-hour period after dosing based on onset of relief, hourly and summary variables, and duration of effect. A significantly greater proportion of patients treated with the hydrocodone/ibuprofen combination reported onset of relief compared with ibuprofen or placebo; however, the distribution functions for time to onset of relief did not differ among treatments. Hydrocodone with ibuprofen and ibuprofen alone were significantly more effective than placebo for all measures of analgesia. The combination of hydrocodone with ibuprofen was significantly superior to ibuprofen for all hourly analgesic evaluations, weighted sum of pain intensity differences (SPID), total pain relief (TOTPAR), and global rating of study medication. No patients in the hydrocodone with ibuprofen group required analgesic remedication during the 6-hour study period, compared with 25% and 82% in the ibuprofen and placebo groups, respectively. The analgesic superiority of 15 mg hydrocodone bitartrate combined with 400 mg ibuprofen compared with 400 mg ibuprofen alone was demonstrated across many efficacy variables.",1998.0,0,0
1684,9511622,Comparison of the safety and efficacy of a combination analgesic Myprodol and Ponstan in the treatment of dental pain.,J F Lownie; M A Lownie; S G Reinach,"A comparison of the efficacy of Myprodol, a combination analgesic (Ibuprofen, Paracetamol and Codeine phosphate) and Ponstan (Mefenamic acid) was undertaken in a randomised double blind trial of 52 patients who underwent surgical removal of impacted or unerupted teeth. Pain scores were measured for patients pre- and post operatively by means of a visual analogue scale and data was analysed using the BMPD package on the ISM main frame computer at the Medical Research Council. The results indicated that although Myprodol and Ponstan were equally adequate and well tolerated in the control of post operative dental pain, Myprodol exceeded Ponstan in duration of analgesia and in the degree of pain intensity control experienced by the patient.",1998.0,0,0
1685,9512842,Epidural ketamine reduces post-operative epidural PCA consumption of fentanyl/bupivacaine.,M E Abdel-Ghaffar; M A Abdulatif; A al-Ghamdi; H Mowafi; A Anwar,"To study the analgesic effect of epidural ketamine on postoperative pain and epidural PCA consumption after total abdominal hysterectomy. Sixty-one ASA I-II patients, 34-60 yr were randomly assigned into three groups. Epidural catheters were inserted before induction of anaesthesia. Patients in group I and II received 30 mg ketamine epidurally before induction of anaesthesia or 20 min after skin incision: group III received placebo. Postoperatively, on first analgesia request, sedation score, Visual Analogue Scale (VAS), Prince Henry Score (PHS) and Bromage motor weakness score were taken and followed by an epidural bolus of 9 ml bupivacaine 0.25% + 50 micrograms fentanyl. Analgesia was maintained by PCA with a mixture of bupivacaine 0.1% + fentanyl 0.001% epidurally. Measurements were repeated at 1, 2, 4, 8, 12 and 24 hr. First analgesia request was 17 +/- 6.8 min in the control group compared with 31.4 +/- 23.8 and 44 +/- 23.1 min for groups I and II respectively. The differences between group III and group I (P < 0.05) and between group III and group II (P < 0.01) were statistically significant. Twenty four hour PCA consumption was 101.2 +/- 47.2, 87 +/- 27 and 162 +/- 38 ml for groups I, II and III respectively. The differences between group III and group I and that between group III and group II were statistically significant (P < 0.001). Epidural ketamine 30 mg reduces post hysterectomy pain as evidenced by prolongation of time to first analgesia request and reduction in postoperative epidural PCA consumption. This effect is manifest whether ketamine is given before induction or 20 min after skin incision.",1998.0,0,0
1686,9512855,"Long-term epidural ketamine, morphine and bupivacaine attenuate reflex sympathetic dystrophy neuralgia.",T C Lin; C S Wong; F C Chen; S Y Lin; S T Ho,"There is considerable evidence that NMDA receptor antagonists can abolish nociceptor hypersensitivity in animals. In the present case report, two patients with reflex sympathetic dystrophy were treated with ketamine, a NMDA antagonist, morphine and bupivacaine. Two patients were referred suffering from severe pain, allodynia, hyperaesthesia, swelling and disability over their right lower legs, diagnosed as reflex sympathetic dystrophy. They had received conventional treatments with non-steroid anti-inflammatory drugs (NSAIDs), steroids, anticonvulsant, antidepressant, epidural lidocaine sympathetectomy and rehabilitation which failed to provide satisfactory pain relief. We administered subanalgesic doses of ketamine (7.5 mg), morphine (0.75 mg) and 6 ml bupivacaine 0.1% via a lumbar epidural catheter three times per day. After several courses of treatment over three and six months, satisfactory pain relief was achieved in each patient. Both are now able to walk with slight weight bearing with the assistance of crutch. The treatment is continuing with further improvement of symptoms and signs. Epidural coadministration of low doses of morphine, ketamine and bupivacaine provided effective pain relief in two patients. This suggests synergy from this combination that provides an alternative treatment for reflex sympathetic dystrophy.",1998.0,0,0
1687,9519171,A randomized crossover study comparing the efficacy and tolerability of a novel once-daily morphine preparation (MXL capsules) with MST Continus tablets in cancer patients with severe pain.,T O'Brien; P G Mortimer; C J McDonald; A J Miller,"The efficacy, tolerability and 24-h duration of action of MXL capsules, a novel once-daily morphine preparation, were compared with twice-daily morphine tablets (MST Continus tablets) in patients with severe cancer pain. Eighty-five patients were recruited to this randomized, double-blind, double-dummy, crossover study. There was no significant difference between the two treatment groups in the number of occasions that escape medication was required, the pain scores at each of three time points throughout the day, and the number of nights woken due to pain. Both preparations were well tolerated with no significant difference in the number or severity of reported symptoms and side-effects. Sixteen patients withdrew from the study, of whom 13 withdrew for nontreatment-related reasons. There was no difference between the preparations in terms of expressed treatment preference. MXL capsules were shown to provide effective analgesia over the 24-h dosing interval which was comparable to that of MST Continus tablets administered twice daily.",1998.0,0,0
1688,9520227,"Double-blind evaluation of short-term analgesic efficacy of orally administered diclofenac, diclofenac plus codeine, and diclofenac plus imipramine in chronic cancer pain.",V Minotti; V De Angelis; E Righetti; M G Celani; R Rossetti; M Lupatelli; M Tonato; R Pisati; G Monza; G Fumi; A Del Favero,"A prospective double-blind randomized trial was conducted on 184 cancer patients with moderate to severe chronic pain to evaluate the analgesic efficacy and tolerability of diclofenac alone (50 mg q.i.d.) or in combination with a weak opioid (codeine 40 mg q.i.d.), or with an anti-depressant (imipramine, 10 or 25 mg t.i.d.). All demographic and clinical characteristics including cancer type, presence of bone metastases, baseline pain severity, neuropathic and nociceptive pain, and depressive state, were well balanced between the three treatment groups. The main analysis of the study was on the VAS scores at visit 2 (day 4). The mean VAS values for both associations imipramine plus diclofenac and codeine plus diclofenac were similar to the association placebo plus diclofenac. Patients on imipramine plus diclofenac and on placebo plus diclofenac were withdrawn mainly for inadequate efficacy, while patients on codeine plus diclofenac discontinued equally for inadequate efficacy or adverse events. In conclusion, in a short-term evaluation the addition of a tricyclic anti-depressant or a weak opioid to diclofenac did not provide further analgesia with respect to diclofenac administration alone.",1998.0,0,0
1689,9520235,Dose-response relationship of opioids in nociceptive and neuropathic postoperative pain.,F Benedetti; S Vighetti; M Amanzio; C Casadio; A Oliaro; B Bergamasco; G Maggi,"The treatment of neuropathic pain with opioid analgesics is a matter of controversy among clinicians and clinician scientists. Although neuropathic pain is usually believed to be only slightly responsive to opioids, several studies show that satisfactory analgesia can be obtained if adequate doses are administered. In the present study, we tested the effectiveness of buprenorphine in 21 patients soon after thoracic surgery (nociceptive postoperative pain) and 1 month after surgery in the same 21 patients who developed postthoracotomy neuropathic pain with a burning, electrical and shooting quality. According to a double-blind randomized study, the analgesic dose (AD) of buprenorphine needed to reduce the long-term neuropathic pain by 50% (AD50) was calculated and compared to the AD50 in the immediate postoperative period. We found that long-term neuropathic pain could be adequately reduced by buprenorphine. However, the AD50 in neuropathic pain was significantly higher relative to the AD50 in the short-term postoperative pain, indicating a lower responsiveness of neuropathic pain to opioids. We also found a strict relationship between the short-term and long-term AD50, characterized by a saturating effect. In fact, if the AD50 soon after surgery was low, the AD50 increase in the long-term neuropathic pain was threefold. By contrast, if the AD50 soon after surgery was high, the AD50 in neuropathic pain was only slightly increased. This suggests that, though neuropathic pain is indeed less sensitive to opioids, in some neuropathic patients a large amount of opioid resistance is already present in other painful conditions.",1998.0,0,0
1690,9522133,Comparison of intrathecal morphine and continuous femoral 3-in-1 block for pain after major knee surgery under spinal anaesthesia.,P Tarkkila; M Tuominen; J Huhtala; L Lindgren,"Major knee surgery is associated with moderate or severe post-operative pain. Intrathecal morphine and continuous femoral 3-in-1 block were compared prospectively in 40 patients for pain after major knee surgery under spinal anaesthesia, with 4 mL isobaric 0.5% bupivacaine. In a random order, 20 patients received preservative free morphine 0.3 mg mixed with spinal bupivacaine. In 20 patients, following spinal anaesthesia with only bupivacaine, femoral 3-in-1 block was performed post-operatively with 0.5% bupivacaine 2 mg kg-1. The block was continued via a catheter with 0.25% bupivacaine 0.1 mL h-1 kg-1 until the next morning (24 h after induction of spinal anaesthesia). Intramuscular oxycodone was given as a rescue analgesic in all patients. Two patients from the femoral group were excluded due to technical failure. Three patients in the morphine group and one patient in the femoral group did not need any additional oxycodone. In the morphine group on average 2.8 (range 0-7) and in the femoral group 3.2 (0-5) additional doses of oxycodone were needed during the 24 h observation period. The mean pain scores were significantly lower in the morphine group at 9 and 12 h into the 24-h trial. Itching was seen only in the morphine group (40% of the patients). Other side effects were similar in the two groups. All patients were satisfied with their pain therapy. Both intrathecal morphine and femoral 3-in-1 block alone were insufficient for the treatment of severe pain after major knee surgery.",1998.0,0,0
1691,9522134,Intra-articular analgesia after arthroscopic knee surgery: comparison of three different regimens.,J De Andrés; J C Valía; L Barrera; R Colomina,"One hundred and three patients ASA grades I-II, 16-80 years of age scheduled for arthroscopic meniscectomy were prospectively studied, and randomly allocated to one of four groups: group 1 (n = 25): 0.25% bupivacaine (50 mg) intra-articular (IA), group 2 (n = 27): 1 mg of 0.1% preservative free morphine chloride in saline, group 3 (n = 26): 1 mg of 0.1% preservative free morphine chloride in 0.25% bupivacaine and group 4 (n = 25): normal saline (0.9%). The volume given was always 20 mL. Ketorolac [Toradol, 30 mg intramuscularly (i.m.)] was used as rescue medication; analgesia was assessed using a visual analogue scale (VAS), a verbal rating scale (VRS), supplemental analgesic consumption post-operatively (SAC) and the presence of side effects. Verbal rating scale and visual analogue scale scores showed better pain control in group 1, 20 min after surgery, and in groups 1 and 2 at 4 h and 10 h as well as in the global VAS. In multifactorial analysis no significant differences among groups or side effects was found, pH analysis of the substances used showed no alterations in the basal pH range. The analgesic efficacy of 20 mL of bupivacaine 0.25% is similar to that of 1 mg of morphine in 20 mL of saline 0.9%. The morphine-bupivacaine mixture was no more efficacious than bupivacaine or morphine alone.",1998.0,0,0
1692,9527748,Comparing analgesic efficacy of non-steroidal anti-inflammatory drugs given by different routes in acute and chronic pain: a qualitative systematic review.,M R Tramèr; J E Williams; D Carroll; P J Wiffen; R A Moore; H J McQuay,"To test the evidence for a difference in analgesic efficacy and adverse effects of non-steroidal anti-inflammatory drugs (NSAIDs) given by different routes. Systematic review of published randomised controlled trials. Relevant trials were comparisons of the same drug given by different routes. Presence of internal sensitivity was sought as a validity criterion. Analgesic and adverse effect outcomes were summarised, and synthesised qualitatively. In 26 trials (2225 analysed patients), 8 different NSAIDs were tested in 58 comparisons. Fifteen trials (58%) compared the same drug by different routes. Drugs were given by intravenous, intramuscular, intrawound, rectal and oral routes in postoperative pain (14 trials), renal colic (4), acute musculoskeletal pain (1), dysmenorrhoea (1), and rheumatoid arthritis (6). Five of the 15 direct comparisons were invalid because they reported no difference between routes but without evidence of internal sensitivity. In all 3 direct comparisons in renal colic, intravenous NSAID had a faster onset of action than intramuscular or rectal. In 1 direct comparison in dysmenorrhoea, oral NSAID was better than rectal. In the 5 direct comparisons in postoperative pain, results were inconsistent. In 1 direct comparison in rheumatoid arthritis, intramuscular NSAID was better than oral. Injected and rectal administration had some specific adverse effects. In renal colic there is evidence that NSAIDs act quickest when given intravenously. This may be clinically relevant. In all other pain conditions there is a lack of evidence of any difference between routes. In pain conditions other than renal colic, there is, therefore, a strong argument to give oral NSAIDs when patients can swallow.",1998.0,0,0
1693,9530458,[Quality of pain management in preclinical care of acutely ill patients].,K Hofmann-Kiefer; K Praeger; M Fiedermutz; A Buchfelder; D Schwender; K Peter,"The aim of this study was to evaluate the quality of pain management in prehospital emergency care and to get more information about the administration of analgesics in prehospital patients. Patients with painful diseases or injuries who had been brought to Munich hospital's were included in the study. Immediately after having reached the hospitals' emergency department, they were evaluated using a 101-point visual analogue scale for the severity of pain at four predefined periods. Information about the patient, the diagnosis, and the analgesic treatment used by the emergency teams were drawn from the patient's chart. A total of 462 patients were included in the study. The mean pain score on arrival of the emergency team was 64 points; 36.5% of the patients were treated with analgesics. In 28.1% the emergency team tried to reduce pain through external measures (i.e., setting of fractures). In 35.3% there was no therapeutic intervention. In cases in which analgesic therapy was initiated, a definite reduction in pain was achieved during emergency care. Visual analogue scores decreased from 70 points at the beginning to 29 points at arrival to the hospital's emergency department. Analgesics were most frequently used for patients with cardiopulmonary diseases (47.2%), followed by patients with traumatic accidents (35.5%) and patients with acute abdominal pain (25.2%). Of the analgesics, opioids were given most frequently (87.0%). Nonopioid analgesic agents were used in 32.1%. The results of our investigation demonstrate that in many cases the administration of analgesics is not individualized to the patients needs. During the prehospital period of emergency care many patients suffer from severe pain. The development of patient-oriented concepts concerning pain management could contribute to improvement of pain therapy in prehospital emergency medicine.",1998.0,0,0
1694,9531122,Continuous-flow cold therapy for outpatient anterior cruciate ligament reconstruction.,F A Barber; D A McGuire; S Click,"This prospective, randomized study evaluated continuous-flow cold therapy for postoperative pain in outpatient arthroscopic anterior cruciate ligament (ACL) reconstructions. In group 1, cold therapy was constant for 3 days then as needed in days 4 through 7. Group 2 had no cold therapy. Evaluations and diaries were kept at 1, 2, and 8 hours after surgery, and then daily. Pain was assessed using the VAS and Likert scales. There were 51 cold and 49 noncold patients included. Continuous passive movement (CPM) use averaged 54 hours for cold and 41 hours for noncold groups (P=.003). Prone hangs were done for 192 minutes in the cold group and 151 minutes in the noncold group. Motion at 1 week averaged 5/88 for the cold group and 5/79 the noncold group. The noncold group average visual analog scale (VAS) pain and Likert pain scores were always greater than the cold group. The noncold group average Vicodin use (Knoll, Mt. Olive, NJ) was always greater than the cold group use (P=.001). Continuous-flow cold therapy lowered VAS and Likert scores, reduced Vicodin use, increased prone hangs, CPM, and knee flexion. Continuous-flow cold therapy is safe and effective for outpatient ACL reconstruction reducing pain medication requirements.",1998.0,0,0
1695,9531132,Analgesic effects of intra-articular morphine during and after knee arthroscopy: a comparison of two methods.,O Lundin; B Rydgren; L Swärd; J Karlsson,"The objective of this study was to compare the analgesic effects of intra-articularly administered bupivacaine with bupivacaine/morphine during and after therapeutic knee arthroscopy. In a prospective, randomized study, 50 patients with clinical signs of medial meniscal injury were allocated to two groups, A and B. The patients in group A received 40 mL of 0.25% bupivacaine while the same dose of bupivacaine combined with 1 mg of morphine sulphate was administered in group B. Pain was estimated using the visual analogue scale (VAS) during surgery and at 2, 4, 6, and 24 hours after the operation was completed. Supplementary analgesic requirements were also registered, as well as the patients' overall rating of the entire procedure. The pain scores were significantly lower in Group B throughout the whole postoperative observation period. However, no significant differences were found between the two groups in terms of intraoperative pain scores, supplementary analgesic requirements, or the overall rating of the procedure. This study provides evidence that arthroscopic surgery can be performed in a safe manner after intra-articularly administered bupivacaine with or without low-dose morphine. The combination of low-dose morphine and bupivacaine did, however, produce a superior postoperative analgesic effect during the 24 hours following knee arthroscopy compared with bupivacaine alone.",1998.0,0,0
1696,9535310,"Continuous infusion of opioid and bupivacaine by externalized intrathecal catheters in long-term treatment of ""refractory"" nonmalignant pain.",P Nitescu; P Dahm; L Appelgren; I Curelaru,"To explore the possibility of obtaining pain relief by continuous intrathecal infusion of bupivacaine and opioid in patients with intractable nonmalignant pain. Prospective, cohort, nonrandomized, consecutive trial. Tertiary care center, institutional practice, hospitalized, and ambulatory care. A total of 90 patients, 40 men and 50 women, 20 to 96 years old (median, 70 years), with various nonmalignant ""refractory"" pain conditions lasting for 0.3 to 50 years (median, 3 years) with nociceptive (n = 9), neurogenic/neuropathic (n = 17), and mixed pain (n = 64) were consecutively included in the study when (a) the pain dominated their lives totally, (b) other methods failed to provide acceptable pain relief, and (c) unacceptable side effects from opioids had occurred. Moribund patients and those with overt psychoses at the time of the assessment were excluded from the study. (a) Insertion of externalized, tunnelled intrathecal catheters (101 in 90 patients). (b) Intrathecal infusion of opioid (morphine 0.5 mg/ml, or buprenorphine 0.015 mg/ml, and/or bupivacaine 4.75-5.0 mg/ml) from external electronic pumps was started in the operating room at a basic rate of 0.2 ml/hour, with optional bolus doses (0.1 ml 1-4 times/hour) by patient-controlled analgesia (PCA). Thereafter, the daily volumes were tailored to give the patients satisfactory to excellent (60-100%) pain relief, with acceptable side effects from the infused drugs, by increase or decrease of the basic rates and/or of the bolus doses, and their timing. (c) Supervision of the patients for 24 hours after catheterization in the postoperative ward. (d) Daily phone contact with the patients, their families, or the nurses in charge. (e) The patients had ad libitum access to nonopioid analgesics/sedatives and to opioids administered by various routes, until they obtained satisfactory pain and anxiolytic relief. (a) Pain intensity (visual analog scores 0-10) and pain relief (0-100%). (b) Daily dosages (opioid administered by intrathecal and other routes, and intrathecal bupivacaine). (c) Scores (0-5) of nonopioid analgesics, gait and ambulation, duration of nocturnal sleep, and (d) rates of adverse effects. During the intrathecal period [range, 3-1,706 days; median, 60 days; totaling 14,686 days, 7,460 (50% of which were spent at home)], 86 patients (approximately 95%) obtained acceptable (60-100%) pain relief. The nocturnal sleep duration increased from <4 to 7 hours (median values), nonopioid analgesic and sedative daily consumption became approximately two times lower, whereas the gait ability and ambulation patterns remained practically unchanged. Five patients still had ongoing treatment after durations of 30 to 1,707 (median, 206) days at the close of the study. In the remaining 85 patients, the intrathecal treatment was terminated because of patients' death (n = 23), replacement of the intrathecal treatment by dorsal column stimulation (n = 1), pain resolution (n = 32), refusal to continue the intrathecal treatment (n = 19), lack of cooperation due to delirium or to manipulation of the pump (n = 8), and loss of efficacy of the intrathecal treatment (n = 2). Thus, in the long run, the intrathecal treatment failed in 29 of the 85 patients with terminated treatment (34%). The principal side-effects and complications, except those attributed to the dural puncture, the equipment, and the long-term catheterization of the subarachnoid space, which are presented separately, were severe bradypnea (n = 1), transient paresthesiae (n = 26), short-lasting pareses (n = 16), temporary urine retention (n = 34), episodic orthostatic arterial hypotension (n = 11), and attempted suicide (n = 5, 3 of which were successful). No neurologic sequelae or death could be attributed to the intrathecal procedure. (ABSTRACT TRUNCATED)",1998.0,0,0
1697,9535316,,,,,0,0
1698,9535319,Opioids and chronic pain.,J P Zacny,,1998.0,0,0
1699,9535320,Opiate abuse or undertreatment?,N M Gajraj; M Hervias-Sanz,,1998.0,0,0
1700,9539056,[Pain therapy after tonsillectomy in adults].,F U Metternich; T Brusis; F Parandeh-Shab,"The postoperative pain and stress experienced by tonsillectomy patients are often underestimated. For this reason traditional methods of analgesia are frequently used but with an ineffective result. Our study involved an analysis of pain sensation with regard to postoperative analgesia after adult tonsillectomies. In all, 150 patients following tonsillectomy were treated with different methods of analgesia, which included Diclofenac monotherapy and combined treatment with Tramadol-retard and Naproxen. Postoperative sensations of pain were realized in a visual analogous pain score, with consideration given to individual experiences of subjective pain. In addition, circulatory and hemopoiesis parameters were controlled. Results showed that the postoperative analgesic effect of Diclofenac was significantly less than that of Tramadol-retard and Naproxen. Diclofenac monotherapy after tonsillectomy was only sufficient in cases involving an individual's low pain sensation. In cases with moderate or stronger pain the tonsillectomy patient requires an effective postoperative analgesia, as achieved with combined therapy using Tramadol retard and Naproxen. Aggravating side effects were not found in both schemes of analgesia.",1998.0,0,0
1701,9540379,[Pain management from the viewpoint of the anesthetist].,O Ingold,"In a pain clinic team the anesthetist has the knowledge and experience concerning the peripheral and central neural blockades. The value of the diagnostic, prognostic and therapeutic blockades is today under discussion. Patients with a chronic regional pain syndrome (CRPS) can find some relief with a series of somatic and sympatholytic blockades, which allow an aggressive physiotherapy. Epidural steroid injections are helpful in radiculopathic pain. In other types of pain (neuropathic, postherpetic, failed back surgery syndrome, abdominal, cervico-cephalgic, phantom limb pain und tumor pain) the spinal cord stimulation (SCS) and the intrathecal morphine pump are approved methods for intactable pain.",1998.0,0,0
1702,9542554,,,,,0,0
1703,9542555,Efficacy of propacetamol in the treatment of postoperative pain. Morphine-sparing effect in orthopedic surgery. Italian Collaborative Group on Propacetamol.,V A Peduto; M Ballabio; S Stefanini,"Combined analgesic regimens have been suggested to improve the treatment of postoperative pain. The aim of our study was to evaluate the analgesic efficacy and tolerability of propacetamol, in combination with morphine. Four i.v. infusions of propacetamol 2 g or placebo were administered, in a double-blind fashion, after orthopedic surgery (n = 97). Morphine was administered by a patient-controlled analgesia (PCA) device. The total dose of morphine, pain intensity and global efficacy of treatment were evaluated. Tolerability was assessed by monitoring blood pressure, heart and respiratory rate, sedation scores, adverse events, and renal and hepatic parameters. The total dose of morphine was significantly decreased in the propacetamol group compared to placebo (9.4 +/- 8.5 mg vs 17.6 +/- 12 mg; P < 0.001), arriving at a sparing effect of 46%. The evolution of pain intensity showed a similar pattern in the two groups. Global efficacy of treatment was rated significantly better by patients receiving the combination propacetamol + PCA morphine (87% of ""good""/""excellent"" ratings vs 65%; P = 0.01). Tolerability was comparable in the two groups. Eight patients in the propacetamol and 4 patients in the placebo group reported adverse events, of mild/moderate intensity, most commonly nausea/vomiting. Renal and hepatic parameters were also seen to be comparable. These results confirm a significant morphine-sparing effect, significantly better scores in the final assessment by patients, and a good tolerability of propacetamol after orthopedic surgery. The drug may, therefore, represent a useful alternative to NSAIDs, as complementary drug to opioids, in the management of moderate/severe postoperative pain.",1998.0,0,0
1704,9542556,Preoperative adjuvant epidural tramadol: the effect of different doses on postoperative analgesia and pain processing.,C H Wilder-Smith; O H Wilder-Smith; M Farschtschian; P Naji,"Tramadol is an analgesic with combined opioid agonist and monoamine reuptake blocker properties, which may be useful as a perioperative analgesic and antinociceptive adjuvant. The dose-dependent effects of adjuvant preoperative epidural tramadol on postoperative analgesia (pain scores and patient-controlled analgesia (PCA) use) and pain processing (heat pain thresholds) were prospectively studied in a double-blind, randomised, placebo-controlled 5-day trial. Forty patients undergoing knee or hip surgery received anaesthesia with epidural lidocaine and epidural tramadol 20, 50 or 100 mg or placebo as a preoperative adjuvant. Postoperative analgesia was by intravenous PCA tramadol in all patients. Postoperative pain scores were similar in all groups. The time to first PCA use was shorter, the total dose and duration of PCA use greater, and side-effects more common with 20 mg tramadol than with 100 mg or placebo (P < 0.05). There were no differences in PCA doses required or side-effects between the tramadol 100 mg and placebo treatment groups. Heat pain tolerance thresholds were increased with 100 mg tramadol at 48 h postoperatively compared to baseline and placebo (P = 0.01). Preoperative adjuvant epidural tramadol does not improve postoperative analgesia after lidocaine epidural anaesthesia compared to placebo. Tramadol 20 mg results in anti-analgesia and increased side-effects. While tramadol 100 mg depresses postoperative pain-processing, as measured by heat pain tolerance thresholds, this is not reflected in improved clinical pain measures.",1998.0,0,0
1705,9545831,,,,,0,0
1706,9545832,[Opioids in treatment of chronic noncancer pain].,E Alon; M Jaquenod; T Pasch,"Opioids have been accepted as appropriate analgesic treatment for pain associated with cancer. However, controversy exists about their use for chronic noncancer pain. Reasons for reluctance are concerned about efficacy and potential adverse effects such as respiratory depression, addiction, physical dependence or intolerance. Many physicians worry about liability and legal restrictions. Nevertheless, pain management of chronic severe pain with opioids can be the only help when alternative methods are too risky of fail to be effective. This article briefly reviews the published literature on this topic and discusses some practical guidelines for the use of opioids in the treatment of non-cancer pain.",1998.0,0,0
1707,9547451,Managing pain after coronary artery bypass surgery.,J Watt-Watson; B Stevens,"Nurses are responsible for assessing patients' pain and intervening with modalities such as opioids. However, after coronary artery bypass surgery, patients experience moderate to severe pain and receive inadequate analgesia. These practices are problematic as unrelieved acute pain is harmful and may result in negative consequences that influence recovery. Consistent with the subjectivity and multidimensionality of pain, as described in Gate Control Theory, patients need to be involved as participants in their care where possible. Pain policies and education programs need to reflect current professional guidelines and be proactive in addressing staff and patient gaps in pain knowledge and misbeliefs.",1998.0,0,0
1708,9549739,The advantages of intrathecal opioids for spinal fusion in children.,M Goodarzi,Two groups of 40 homogeneous patients (ASA physical status (1-2)) with idiopathic scoliosis undergoing spinal fusion with CD instrumentation were studied prospectively. Group A (intrathecal) received a mixture of morphine and sufentanil administered intrathecally at the level of L3-L4 after the induction of anaesthesia. Group B (control) had inhalation and intravenous narcotic anaesthesia. The use of intrathecal opioids resulted in a significant reduction of blood pressure without the use of any hypotensive agents and produced prolonged postoperative analgesia. There was no adverse effect on somatosensory evoked potentials. The dose requirement for the anaesthetic agents was significantly reduced and the blood loss was 27% of their blood volume compared with 53% in the control group. No long or short term impairment of cerebral or spinal function was observed. The use of intrathecal opioids supplemented with other anaesthetic agents is an alternative method with multiple benefits for any major surgery such as spinal fusion.,1998.0,0,0
1709,9552070,Quality of life and cancer pain: satisfaction and side effects with transdermal fentanyl versus oral morphine.,R Payne; S D Mathias; D J Pasta; L A Wanke; R Williams; R Mahmoud,"To compare pain-related treatment satisfaction, patient-perceived side effects, functioning, and well-being in patients with advanced cancer who were receiving either transdermal fentanyl (Duragesic, Janssen Pharmaceuticals, Titusville, NJ) or sustained-release oral forms of morphine (MS Contin, Perdue Frederick Co, Norwalk, CT, or Oramorph SR, Roxanne Laboratories, Columbus, OH). A total of 504 assessable cancer patients participated in this cross-sectional, quality-of-life study. Relevant elements of four validated scales were used--the Functional Assessment of Cancer Therapy-General (FACT-G) scale, the Brief Pain Inventory (BPI), the Medical Outcomes Study (MOS) questionnaire, and the Memorial Symptom Assessment Scale (MSAS)--as well as original scales that were developed and validated for this study. The majority of patients in both treatment groups had late-stage (IV/D) cancer. Patients who received transdermal fentanyl were more satisfied overall with their pain medication than those who received sustained-release oral forms of morphine (P = .035). Fentanyl patients also experienced a significantly lower frequency (P < .002) and impact (P < .001) of pain medication side effects. These results occurred despite the fact that cancer patients who received fentanyl were significantly older (P < .001) and had significantly lower functioning and well-being scores (P = .001). Measures of pain intensity, sleep adequacy, and symptoms demonstrated no significant differences between treatment groups. These data suggest that patients are more satisfied with transdermal fentanyl compared with sustained-release oral forms of morphine. A lower frequency and reduced impact of side effects with transdermal fentanyl may be one reason cancer patients who receive fentanyl are more satisfied with their pain management.",1998.0,0,0
1710,9553208,"[Backache--diagnosis, therapy and prognosis].",J Hildebrandt; M Pfingsten,"Back pain is a common disease causing tremendous costs for treatment, rehabilitation, pension payments and work-loss. The reasons of back pain vary considerably and often remain doubtful. The effectiveness of current treatment concepts has not yet been proven significantly. In accordance with the literature, in chronic pain only multimodal concepts of treatment seem to be successful as far as they take care about somatic, psycho-social, and sport physiological aspects.",1998.0,0,0
1711,9553211,"[Sympathetic reflex dystrophy and phantom pain. Diagnosis, therapy and prognosis].",R Dertwinkel; M Strumpf; M Zenz,"The incidence of phantom limb pain has been significantly underestimated for many years. However, studies published during the recent decade indicate that the real incidence of phantom limb pain may be between 60% and 90%. Reflex sympathetic dystrophy (RSD) occurs with an incidence of about 15.000 new cases every year in Germany. Both diseases show early centralisation and chronification. Hence, only early diagnosis and onset of correct therapy in time provide significant pain reduction. When therapy is started too late, prognosis in regard to sufficient pain reduction is poor. Phantom limb pain can be prevented by proper anaesthesia. Several studies could show the benefit of perioperative continuous regional anaesthesia . None of the patients treated with a combination of local anaesthetics and low dose morphine developed phantom limb pain. Therapy of choice for RSD is the sympathetic blockade. The most suitable method is intravenous regional sympathetic blockade (IVRSB) with guanethidine (2).",1998.0,0,0
1712,9553212,[Non-opioid analgesics and co-analgesics in therapy of chronic pain].,M Gehling; H Niebergall,"Efficacy and side effects of non-opioid-analgesics were analysed in a standardized review of placebo-controlled or double-blind studies. In rheumatoid arthritis, ibuprofen showed the best ratio of effectiveness and side-effects. Naproxen, diclofenac and meloxicam may serve as alternatives. In osteoarthritis, naproxen seems to be superior to diflunisal, meloxicam and diclofenac. In cancer pain, ibuprofen is the treatment of the first choice followed by naproxen and diclofenac. No sufficient data on non-opioids in neuropathic pain were available. The dose administered in the management of chronic pain should be low in order to reduce the incidence of side-effects. The frequency of side-effect-related discontinuation of chronic pain medication was calculated as follows: ibuprofen 3.8%, aspirin 4.7%, piroxicam 4.8%, naproxen 7.4%, meloxicam 13.0% and diclofenac 17.8%. Since differences in efficacy were not clinically relevant, the indication for a special non-opioid-analgesic medication should focus on the prevention of side-effects.",1998.0,0,0
1713,9553234,The analgesic effect of PCA buprenorphine in Taiwan's gynecologic patients.,S T Ho; J J Wang; H S Liu; J I Tzeng; W J Liaw,"The aim of this study was to evaluate the analgesic effect of PCA buprenorphine (intravenous) on postoperative pain in gynecologic patients of Taiwan and the potency ratio of buprenorphine versus morphine, a commonly used potent analgesic. Fifty women undergoing abdominal total hysterectomy under spinal anesthesia were enrolled into the investigation. Patients were randomly divided into 2 groups (n = 25 each). Group 1 received intravenous buprenorphine using PCA device for the management of postoperative pain, whereas Group 2 received PCA morphine for the same purpose. During the first 48 hours postoperatively, we collected the following data: demand and delivery of analgesics, pain scores, vital signs, nausea, vomiting and pruritus. Despite different treatments, we found that pain scores on day 1 and day 2 postoperatively were low and were not significantly different between groups. Also, times of demand for delivery of PCA medication were not significantly different between groups. The cumulative consumption of buprenorphine and morphine within 48 h were 1.5 +/- 0.6 mg and 36 +/- 7 mg, respectively. The potency ratio between buprenorphine and morphine was 24:1. Both treatments showed only minor side effects. We found that PCA buprenorphine (intravenous) could be effective in the treatment of postoperative pain in the gynecologic patients in Taiwan and the potency ratio of buprenorphine versus morphine appeared to be 24:1.",1998.0,0,0
1714,9553237,Comparison of intravenous retention of fentanyl and lidocaine on local analgesia in propofol injection pain.,W W Pang; S Huang; Y T Chung; D P Chang; S S Lin; M H Hong,"With a tourniquet on arm for arresting venous blood flow, we evaluated the efficacy of intravenous (i.v.) retention of fentanyl and lidocaine in reducing the pain on i.v. propofol injection during general anesthesia. One hundred and twelve patients were studied. Following a venous occlusion by a tourniquet inflated to 70 mmHg, patients in Group A (n = 38) received normal saline (NS) 3 ml, while those in Group B (n = 37) and in Group C (n = 37) respectively received fentanyl 150 micrograms or 3 ml and 2% lidocaine 3 ml (60 mg). The venous retention of drug was maintained for 1 min, followed immediately by tourniquet release and propofol 100 mg i.v. injection over 20 s. Both fentanyl and lidocaine treatments (Groups B and C) were significantly better than placebo (Group A) in reducing pain on propofol injection (p < 0.005). Lidocaine 60 mg was more effective than fentanyl 150 micrograms in reduction of pain associated with i.v. propofol (p < 0.001). Injection of fentanyl itself caused pain in 28% of patients as compared to 2% in the lidocaine group. Mild local skin erythema was noted in 14% of patients with fentanyl venous retention versus 0% of patients with lidocaine venous retention. Intravenous retention of fentanyl 150 micrograms, although less effective than that of lidocaine (p < 0.001), showed local analgesic effect in reducing the pain on propofol injection. The hypothetic mechanisms of action were speculated.",1998.0,0,0
1715,9554444,"Oral transmucosal fentanyl citrate: randomized, double-blinded, placebo-controlled trial for treatment of breakthrough pain in cancer patients.",J T Farrar; J Cleary; R Rauck; M Busch; E Nordbrock,"Patients with cancer frequently experience episodes of acute pain, i.e., breakthrough pain, superimposed on their chronic pain. Breakthrough pain is usually treated with short-acting oral opioids, most of which provide some relief after 15-20 minutes, with peak effects after 30-45 minutes. Oral transmucosal fentanyl citrate (OTFC), a unique formulation of the opioid fentanyl, has been shown to provide meaningful pain relief within 5 minutes in patients following surgery. We conducted a multicenter, randomized, double-blinded, placebo-controlled trial of OTFC for cancer-related breakthrough pain. Patients who were 18 years of age or older, receiving the equivalent of at least 60 mg oral morphine or at least 50 microg transdermal fentanyl per day for chronic cancer-related pain, and experiencing at least one episode of breakthrough pain per day were studied. After titration to an effective OTFC dose, subjects were given 10 randomly ordered treatment units (seven OTFC units and three placebo units) in the form of identical lozenges. If acceptable pain relief was not achieved within 30 minutes, subjects were instructed to take their previous breakthrough pain medication (i.e., rescue medication). Pain intensity, pain relief, and use of rescue medication were evaluated at 15-minute intervals over a 60-minute period. Eighty-nine of 92 patients who received the randomized treatment were assessable (i.e., treated with at least one unit of OTFC and one unit of placebo). OTFC produced significantly larger changes in pain intensity and better pain relief than placebo at all time points (two-sided P<.0001). Episodes treated with placebo required the use of rescue medication more often than episodes treated with OTFC (34% versus 15%; relative risk = 2.27; 95% confidence interval = 1.51-3.26; two-sided P<.0001). OTFC appears effective in the treatment of cancer-related breakthrough pain.",1998.0,0,0
1716,9564118,Long-term treatment of cancer pain with transdermal fentanyl.,B Donner; M Zenz; M Strumpf; M Raber,"The long-term therapy of 51 patients using transdermal fentanyl was evaluated. The transdermal therapy was performed for 158 days (range, 15-855 days). The need for increasing dosages of transdermal fentanyl was caused by the progression of the underlying cancer disease (mean initial dose, 69.5 micrograms fentanyl/hr; mean final dose, 167.7 micrograms fentanyl/hr). The transdermal system was changed every third day. Application intervals had to be shortened in 23.5% of the patients. Pain reduction was good throughout the study. Severe side effects did not occur. Constipation and the need for laxatives occurred less frequently than with previously administered oral morphine. Skin tolerance of the transdermal system was good. The treatment of cancer pain with transdermal fentanyl can be performed as a long-term therapy and result in good pain relief. Considering its specific pharmacokinetic properties, it is an alternative medication on step III of the World Health Organization's guidelines for cancer pain management.",1998.0,0,0
1717,9579301,Increased ocular pressure in two patients with narrow angle glaucoma treated with venlafaxine.,M Aragona; M Inghilleri,"Venlafaxine blocks the specific monoamine transporters and is devoid of significant action on muscarinic cholinergic receptors. To our knowledge, no cases of glaucoma have been reported so far. Because pain perception involves both serotonergic and noradrenergic mechanisms, venlafaxine also may be useful in neuropathic pain therapy. We report on two patients with narrow angle glaucoma affected by chronic pain. When venlafaxine treatment was begun, their ocular pressure was steadily around 17-18 mmHg. Venlafaxine was chosen (daily dose 75 mg) because this drug is claimed not to bind on muscarinic cholinergic receptors. However, 4 days later the ocular pressure of the first patient increased to 22 mmHg, which led to suspension of the drug. The ocular pressure of the second patient was 18.5 mmHg after a week, 21 mmHg after 2 weeks, and 23 mmHg after 16 days. One week after suspension, ocular pressure of the patients was 17 and 18 mmHg, respectively. Possible explanations of this ocular effect are offered: pharmacokinetic interference on the drugs used in glaucoma treatment, in vivo action on the muscarinic receptor, indirect effect via dopaminergic receptors, or direct effect on the ocular sympathetic postganglionic neurones. In any case, from a clinical viewpoint, caution should be used when giving venlafaxine to patients with narrow-angle glaucoma, and ocular pressure must be monitored.",1998.0,0,0
1718,9579495,Mood during epidural patient-controlled analgesia with morphine or fentanyl.,K Tsueda; P J Mosca; M F Heine; G E Loyd; D A Durkis; A L Malkani; H E Hurst,"Mood states during epidural opioids are not known. The authors studied the change in mood during the 48-h period of epidural morphine and epidural fentanyl in 47 patients after elective hip or knee joint arthroplasty. An epidural catheter was inserted at the L2-L3 or L3-L4 interspace. Anesthesia was induced with thiopenthal and maintained with isoflurane and nitrous oxide. One hour before the conclusion of the operation, patients received an epidural bolus injection of 2 mg morphine (n = 23) or 100 microg fentanyl (n = 24), followed by the same opiate (125 microg/ml morphine or 25 microg/ml fentanyl) epidurally delivered by a patient-controlled analgesia (PCA) pump in the postoperative period for 48 h. Mood was assessed using the bipolar form of the Profile of Mood States before operation and 24 h, 48 h, and 72 h after operation. There was no significant difference in pain intensity between the groups during epidural PCA. Mood states became more positive over time in the patients who received morphine (P < 0.01 at 48 h) and negative in those who were given fentanyl (P < 0.01 at 24 and 48 h, respectively) compared with those before the operation, and they were more positive in the morphine than in the fentanyl group at 24 h, 48 h (P < 0.05), and 72 h (P < 0.01). Patients in the morphine group were more composed, agreeable, elated, confident, energetic, and clearheaded than were those in the fentanyl group (P < 0.05). There was no correlation between mood scores and pain scores in either group. There was an inverse correlation at 48 h between mood scores and plasma fentanyl concentrations (r = -0.58, P < 0.05). Mood states are significantly more positive during epidural morphine PCA than they are during epidural fentanyl PCA.",1998.0,0,0
1719,9583767,The specific effects of prior opioid exposure on placebo analgesia and placebo respiratory depression.,F Benedetti; M Amanzio; S Baldi; C Casadio; A Cavallo; M Mancuso; E Ruffini; A Oliaro; G Maggi,"Although in most of the cases the placebo response appears to be unpredictable, several factors have been considered in order to explain the placebo analgesic effect. For example, it is widely recognized, albeit with little empirical evidence, that placebo analgesia is more likely to occur after a successful analgesic therapy. On the basis of this assumption, we tested the placebo response in a population of patients who were treated with buprenorphine the day before for relieving postoperative pain. However, due to the high variability of opioid responsiveness, buprenorphine was effective in some patients and poorly effective in some others. Similarly, buprenorphine produced respiratory depression with a large variability, ranging from mild depression to no effect. We found that the placebo analgesic response depended on the buprenorphine analgesic effectiveness of the previous day. Analogously, we found that a placebo respiratory depressant response was more pronounced in those patients with a respiratory depressant response to buprenorphine on the day before, irrespective of the analgesic effectiveness. These specific effects suggest that (1) the placebo effect is experience-dependent; (2) the mechanisms underlying placebo analgesia and placebo respiratory depression are independent from each other and, by considering the role of endogenous opioids in placebo analgesia, might involve different subpopulations of opioid receptors.",1998.0,0,0
1720,9587719,Effect of balanced analgesia with buprenorphine on pain response and general anaesthesia requirement during lithotripsy procedures.,P Tauzin-Fin; S Delort-Laval; M C Krol-Houdek; P Maurette; B Bannwarth,"The effectiveness of a balanced analgesia with buprenorphine ketoprofen-propacetamol for pain control during extracorporeal shock wave lithotripsy (ESWL) was evaluated in order to reduce the requirements for general anaesthesia. Two hundred and ninety-one consecutive patients were included in a randomized, placebo-controlled, double-blind study. Patients in each group received midazolam 5 mg pre-operatively as premedication. The subjects then received either placebo (group 1), buprenorphine 0.3 mg (group 2) or the combination buprenorphine 0.3 mg plus ketoprofen 100 mg and propacetamol 2 g (group 3) intravenously (i.v.) at a constant rate. The treatment was started 45 min prior to ESWL. Pain was assessed using a three-point verbal scale: (0)no pain; (1) moderate pain; and (2) intense pain needing general anaesthesia. The patients assessed their pain intensity on a 0-100 mm visual analogue scale. Only 69% of group 1 patients received ESWL with midazolam premedication. Buprenorphine provided good analgesia in 87% of group 2 patients, while the combination buprenorphine-ketoprofen-propacetamol was effective in 99% of group 3 patients (P < 0.05). The incidence of nausea and vomiting was similar in the buprenorphine groups. No respiratory depression was reported. In conclusion, the buprenorphine-ketoprofen-propacetamol combination provided effective analgesia, allowing ESWL to be performed without the need for general anaesthesia.",1998.0,0,0
1721,9587722,"Comparison of caudal bupivacaine, bupivacaine-morphine and bupivacaine-midazolam mixtures for post-operative analgesia in children.",S Güleç; B Büyükkidan; N Oral; N Ozcan; B Tanriverdi,"Sixty children undergoing inguinal or urogenital surgery were allocated randomly to three groups to receive a caudal injection of either 0.125% bupivacaine 0.75 mL kg-1 with 0.5% midazolam 50 micrograms kg-1 (n = 20) or with 1% morphine chlorhydrate 0.05 mg kg-1 (n = 20), or bupivacaine alone (n = 20) after surgery under general anaesthesia. There were no significant changes in heart rate, blood pressure, respiratory rate or oxygen haemoglobin saturation values in all groups, and there were no significant differences in the incidence of vomiting and pruritus between the groups (P > 0.05). Sedation scores were higher in the bupivacaine-midazolam and the bupivacaine-morphine groups than in the bupivacaine group at 8-12 h post-operatively (P < 0.01). The durations of analgesia were 21.15 +/- 1.2 h in the bupivacaine-midazolam group, 14.50 +/- 1.6 h in the bupivacaine-morphine group and 8.15 +/- 1.3 h in the bupivacaine group. Differences between the bupivacaine-midazolam group and the bupivacaine group (P < 0.001), the bupivacaine-midazolam group and the bupivacaine-morphine group (P < 0.01), and the bupivacaine-morphine group and the bupivacaine group (P < 0.01) were significant. It is suggested that caudal administration of a bupivacaine-midazolam mixture produces a longer duration of post-operative analgesia than a bupivacaine-morphine mixture and bupivacaine alone with sedation for 8-12 h post-operatively.",1998.0,0,0
1722,9587725,Post-operative effects of tramadol administered at wound closure.,J De Witte; G W Rietman; G Vandenbroucke; T Deloof,"The aim of this prospective, randomized and double-blind study was to assess the effects of a high dose of the analgesic tramadol administered at the conclusion of surgery on extubation time, sedation, and post-anaesthetic shivering. Forty adult patients, ASA physical status I or II, underwent laparoscopic surgery of about 1 h duration and received a standardized anaesthesia that was maintained with isoflurane in O2/N2O. Tramadol 3 mg kg-1 (n = 20) was administered intravenously at the beginning of wound closure, and was compared with saline (n = 20). Post-anaesthetic shivering did not occur in any patient who received tramadol, whereas it occurred in 60% of the control group (P < 0.001). There were no adverse effects on time to extubation and sedation, and discharge-ready time was shorter in the tramadol group (P < 0.05 compared with control). Pain scores in the post-anaesthesia care unit (PACU) were statistically not different between the two groups, but significantly more supplemental medication was administered in the control group to treat shivering and/or pain. In conclusion, administration of a high dose of tramadol at the end of surgery prevents post-anaesthetic shivering without prolongation of extubation time, and shortens the PACU/discharge-ready time.",1998.0,0,0
1723,9588381,The management of chronic pain in older persons: AGS Panel on Chronic Pain in Older Persons. American Geriatrics Society.,,,1998.0,0,0
1724,9588567,Spinal cord compression by catheter granulomas in high-dose intrathecal morphine therapy: case report.,K L Cabbell; J A Taren; O Sagher,"The use of chronic intrathecal morphine for the treatment of intractable, nonmalignant pain is becoming more prevalent. A rare but devastating complication of this therapy is the development of spinal cord compression secondary to the formation of intrathecal granulomas. We report three cases of intrathecal granuloma formation in the thoracic subarachnoid space, associated with intrathecal morphine pumps. These three patients were receiving high doses of morphine to control their pain (25 mg/d, 28 mg/d, and 45 mg/d, respectively) when they presented with signs and symptoms of thoracic spinal cord compression. Myelography and postmyelographic computed tomography of the spine revealed masses causing spinal cord compression. Two patients underwent thoracic laminectomies for resection of these masses, and the other patient had the intrathecal catheter removed. A pathological examination revealed sterile granulomas in the resected masses. Intrathecal granulomas are likely to occur with increasing frequency as the use of chronic intrathecal morphine delivery increases in patients with nonmalignant pain. The cause of intrathecal granulomas is unknown, although it is likely that morphine plays a major role in their formation. We think that those patients receiving high doses of morphine are at greater risk for developing this complication.",1998.0,0,0
1725,9595578,[Analgesic efficacy of ketorolac and fentanyl in pediatric intensive care].,A Chiaretti; E Simeone; A Langer; G Butera; M Piastra; L Tortorolo; G Polidori,"To evaluate the efficacy of the two different drugs (Ketorolac and Fentanyl), used singularly or in association, in the management of postoperative pain in Picu. A randomized and prospective study. 52 children were randomly assigned to receive intravenous Ketorolac and/or Fentanyl, according to four different analgesic treatments: A) Ketorolac 1.2 mg/kg every six hrs; B) Ketorolac 1.2 mg/kg (bolus) + 0.21 mg/ kg/hr; C) Fentanyl 1 gamma/kg/hr; D) Fentanyl 1 gamma/kg/hr + Ketorolac 0.21 mg/kg/hr. Each protocol was given to 13 children. The efficacy of treatments were evaluated by child's behaviour (Affective Facial Scale and CHEOPS score) and hemodynamical parameters (systolic and diastolic blood pressure, breathing rate, heart rate, oxygen saturation and oxygen arterial pressure) and analysed by statistical analysis. The children treated with protocol B (Ketorolac in continuous in infusion) showed better pain relief in respect to those treated with protocol A (Ketorolac in bolus), while the most efficient analgesia was obtained with the association of the two analgesic drugs (protocol D). Two cases of bradycardia, one case of hyperazotemia and one case of transaminase increase were noted. Ketorolac presents a good efficient analgesia, particularly evident when administered in continuous intravenous infusion. However, the association of this NSAID with an opioid drug can be favourably proposed in postoperative pain therapy of moderate to severe grade, since the confirmed analgesic efficacy is not aggravated by important side effects.",1998.0,0,0
1726,9598258,Comparison of tramadol and morphine via subcutaneous PCA following major orthopaedic surgery.,D Hopkins; E A Shipton; D Potgieter; C A Van derMerwe; J Boon; C De Wet; J Murphy,"To compare subcutaneous PCA tramadol with subcutaneous PCA morphine for postoperative pain relief after major orthopaedic surgery and for the incidence of side-effects. In a double-blind randomised controlled study 40 patients (20 in each group) self-administered either tramadol or morphine for 72 hr after surgery via s.c. PCA. The following variables were recorded at various time intervals: (i) pain score by means of a visual analogue scale, (ii) drug consumption and total PCA demands, (iii) vital signs (blood pressure and heart rate), (iv) oxygen saturation and respiratory rate, and (v) side-effects (sedation, nausea/vomiting, pruritus, urinary retention and constipation). Both drugs provided effective analgesia. The mean consumption in the first 24 hr was 792 +/- 90 mg tramadol and 42 +/- 4 mg morphine. Thereafter, consumption of both drugs declined markedly. Moderate haemodynamic changes were observed in both the tramadol and morphine groups (with a maximum 20% decrease in mean blood pressure and a maximum 17% increase in heart rate) during the 72 hr period. Both tramadol and morphine were associated with a clinically and statistically significant (P < 0.001) decrease in oxygen saturation, but without changes in respiratory rates. Desaturation was less marked with tramadol. Tramadol appeared to cause more nausea and vomiting than morphine. Sedation was mild and only seen during the first few hours after surgery in both groups. Tramadol is an effective analgesic agent for the relief of acute postoperative pain when administered by PCA via the subcutaneous route. Under these conditions tramadol behaves much like morphine with a similar side-effect profile.",1998.0,0,0
1727,9601161,Comparison of the analgesic and intestinal effects of fentanyl and morphine in rats.,A A Megens; K Artois; J Vermeire; T Meert; F H Awouters,"Clinical studies report a low incidence of intestinal side effects with transdermally administered fentanyl (TTS-fentanyl) in comparison with oral morphine. To support these clinical data, analgesic and intestinal effects of both opioids were compared in rats. After subcutaneous injection, analgesia in the tail withdrawal reaction test was obtained at a peak effect dose of 0.032 mg/kg with fentanyl and 8.0 mg/kg with morphine. This analgesic dose exceeded the ED50 for inhibition of castor oil-induced diarrhea only slightly (1.1 x) in the case of fentanyl (0.028 mg/kg) but markedly (36 x) in the case of morphine (0.22 mg/kg). To reverse completely the antidiarrheal effect of equivalent analgesic doses of the opioids (their ED50S for analgesia lasting 2 hours), much more naloxone was required in the case of morphine (5.4 mg/kg) than in the case of fentanyl (0.19 mg/kg). After oral administration, the difference between both opioids was less pronounced. Analgesia was obtained at 0.85 mg/kg with fentanyl and 32 mg/kg with morphine. This analgesic dose only slightly (1.7 x) exceeded the antidiarrheal dose in the case of fentanyl (0.49 mg/kg) but significantly (6.2 x) in the case of morphine (5.2 mg/ kg). To reverse completely the antidiarrheal effect of equivalent analgesic oral doses of the opioids (their ED50S for analgesia lasting 2 hours), more naloxone was required in the case of morphine (11 mg/kg) than in the case of fentanyl (2.0 mg/kg). Rapid penetration of fentanyl into the brain is thought to be responsible for small dissociation between the analgesic and intestinal effect of this lipophilic opioid. The present data provide preclinical evidence to support the relatively low incidence of intestinal side effects observed clinically with the use of TTS-fentanyl in comparison with orally administered morphine.",1998.0,0,0
1728,9602575,Pre-emptive effect of multimodal analgesia in thoracic surgery.,E Doyle; G M Bowler,"Thirty subjects undergoing posterolateral thoracotomy were allocated randomly to receive one of two analgesic regimens: group Pre received i.v. morphine, i.m. diclofenac and intercostal nerve blocks from T2 to T11, 20 min before operation and placebo injections after operation. Group Post received placebo injections before operation, and i.v. morphine, i.m. diclofenac and intercostal nerve blocks from T2 to T11 at the end of surgery, before discontinuation of anaesthesia. Visual analogue pain scores, extent and duration of intercostal nerve block, analgesic consumption and complications were assessed during the postoperative period by a single blinded observer. Subjects were followed-up for a minimum of 12 months to determine the incidence of post-thoracotomy pain syndrome. During the first 48 h after operation there were lower pain scores in group Pre when taking a vital capacity breath but there were no significant differences between the groups in any other measure. The effects of pre-emptive analgesia given before surgery appeared to be relatively modest in terms of analgesia, analgesic consumption and long-term outcome and were of limited clinical significance.",1998.0,0,0
1729,9602576,Combining propofol with morphine in patient-controlled analgesia to prevent postoperative nausea and vomiting.,S E Bree; M J West; P A Taylor; I G Kestin,"We have studied the antiemetic effects of propofol when mixed with morphine in a patient-controlled analgesia (PCA) pump after major gynaecological surgery. In a double-blind, randomized, controlled study, 50 women, ASA I or II, received a standardized anaesthetic comprising thiopental, morphine, atracurium, nitrous oxide and oxygen with enflurane, and received postoperative PCA with morphine mixed with either 1% propofol or lvelip. The PCA bolus was morphine 1 mg with propofol 5 mg or lvelip 0.5 ml, with a lockout time of 5 min. Postoperative nausea and vomiting (PONV) were assessed by the nursing staff using a four-point ordinal scale and by the patient using a visual analogue scale for 48 h after surgery. The two groups were similar in the potential factors influencing the incidence of PONV. There were no significant differences between the two groups in any of the study measurements of PONV. There were, no side effects after propofol. Propofol, when mixed with morphine in this dose combination for PCA, did not decrease the incidence of nausea and vomiting in women undergoing major gynaecological surgery.",1998.0,0,0
1730,9602595,Intraperitoneal bupivacaine or lidocaine does not provide analgesia after total abdominal hysterectomy.,P B Ali; B R Cotton; K M Williamson; G Smith,"We have compared pain scores at rest and on standardized movement, and morphine consumption using patient-controlled analgesia in 60 patients who had undergone total abdominal hysterectomy. Patients were allocated randomly to one of three groups: in the saline group, 0.9% sodium chloride 50 ml was administered into the pelvic cavity before closure of the peritoneum; in the second group, the solution administered was 20 ml of 0.5% bupivacaine solution with epinephrine 1:200,000 diluted with saline to a final volume of 50 ml; in the third group, the solution used was 20 ml [corrected] of 2% lidocaine with epinephrine 1:200,000 diluted with saline to a final volume of 50 ml. We found that there was no significant difference between the three groups in visual analogue pain scores at 8, 12, 36 or 48 h after operation at rest or on movement, and no significant difference in sedation or dose of antiemetic administered. Mean morphine consumption in the first 24 h was 54.6 (SEM 5.9) mg in the saline group, 55.5 (6.4) mg in the bupivacaine group and 52.5 (5.3) mg in the lidocaine group. In the second 24 h, morphine consumption was 34.9 (6.6) mg, 28.1 (3.5) mg and 28.0 (3.5) mg in the three groups, respectively. We conclude that i.p. administration of local anaesthetic solution into the pelvic cavity did not confer appreciable analgesia in patients undergoing abdominal hysterectomy.",1998.0,0,0
1731,9602960,"Double-blind, single-dose comparison of bromfenac sodium, tramadol, and placebo after oral surgery.",D R Mehlisch,"This double-blind, parallel-group study was performed at a single site in patients with moderate or severe pain after oral surgery to remove one or more impacted third molars. Patients recorded their pain intensity at baseline and were then assigned to receive a single dose of bromfenac sodium (25 mg or 50 mg), tramadol (100 mg), or placebo, using a randomized double-blind code. At regular intervals for up to 8 hours after study drug administration, pain intensity and pain relief were recorded and were used to derive the efficacy variables, total pain relief (TOTPAR), pain intensity difference (PID), and summed pain intensity difference (SPID). Both doses of bromfenac were superior to tramadol and placebo in terms of hourly and peak pain relief and PID. The 3-hour and 8-hour TOTPAR and SPID results for both doses of bromfenac also were significantly superior to those for tramadol and placebo, whereas the scores for tramadol did not show superiority to placebo. Similarly, both doses of bromfenac were superior to tramadol and placebo as measured by patient global assessment, time to meaningful pain relief, and duration of pain relief. Bromfenac was well tolerated and was equivalent to placebo with respect to treatment-emergent study events. Overall, significantly more study events (total), digestive events (particularly nausea and vomiting), and nervous system events (particularly dizziness) occurred in patients treated with tramadol than in those in other treatment groups. Single oral doses of bromfenac were more effective, longer-acting, and better tolerated than single doses of tramadol in providing pain relief after oral surgery.",1998.0,0,0
1732,9603276,Analgesic use disorders among orthopedic and chronic pain patients at a rehabilitation clinic.,U Jonasson; B Jonasson; L Wickström; E Andersson; T Saldeen,"Interviews were conducted with 265 orthopedic and chronic pain patients, using a structured diagnostic instrument (ADDIS/SUDDS) concerning their use of analgesics. Twenty-two percent of the patients met criteria for analgesic use disorders in accordance with DSM-III-R; 18.5% fulfilled DSM-IV criteria. Dextropropoxyphene was the most common analgesic prescribed and was used by 47% of the patients who met criteria for analgesic use disorders. It is concluded that patients with chronic pain using narcotic analgesics are at considerable risk of developing analgesic use disorders. Assessment of the use of analgesics should be offered to pain patients taking narcotic drugs.",1998.0,0,1
1733,9604730,Tramadol in the fibromyalgia syndrome: a controlled clinical trial versus placebo.,G Biasi; S Manca; S Manganelli; R Marcolongo,"This study assessed the analgesic action of tramadol compared with placebo in patients suffering from fibromyalgia syndrome. Twelve patients (11 females, one male) were treated according to a double-blind crossover experimental design. Each patient, after signing informed consent, was randomly allocated to either tramadol (100 mg ampul in 100 ml given intravenously in 15 min doses) or placebo for a single dose treatment. At the second visit, patients crossed over to the other drug for a further single dose treatment. There was a wash-out period of 1 week. Nine patients completed the study, while in three cases (two tramadol, one placebo) the study was discontinued due to the onset of side effects. The assessment of efficacy, carried out at the baseline and 15 min and 2 hours after administration of each dose, involved the use of a visual analog scale (VAS 100 mm) for spontaneous pain and pressure dolorimetry (kg/cm2) at 12 ""symptomatic"" tender points and nine ""control"" tender points for fibromyalgic pain. During the first treatment cycle effective control of spontaneous pain was achieved with tramadol, which determined a reduction of 20.6% while with the placebo spontaneous pain increased by 19.8%. With pressure dolorimetry there were no clinically important differences observed after either active treatment or placebo. The contrasting results found in the present study could be a stimulus for the organization of new projects, which may lead to the identification of an optimal therapeutic approach for fibromyalgic patients, also using tramadol for long periods.",1998.0,0,0
1734,9605375,Comparison of analgesic efficacy of oxycodone and morphine in postoperative intravenous patient-controlled analgesia.,M Silvasti; P Rosenberg; T Seppälä; N Svartling; M Pitkänen,"Morphine has been the standard opioid in patient-controlled analgesia (PCA). Oxycodone, the analgesic potency of which in i.v. administration has been suggested to be slightly greater than that of morphine, has not yet been studied for its efficacy in PCA. Fifty patients, undergoing a plastic reconstruction of the breast or a major operation of the vertebrae, such as lumbar spinal fusion, used PCA for postoperative pain. Patients were randomized to receive either morphine 45 microg/kg or oxycodone 30 microg/kg as i.v. bolus doses. Patients were assessed for pain with a visual analogue scale (VAS) and side effects at 3, 9 and 24 h. Venous blood samples for the measurement of plasma concentration of oxycodone and that of morphine and its metabolites were taken. In this study patients needed, on average, the same amount of oxycodone and morphine in the recovery room and on the ward. There was no difference in the quality of analgesia (VAS) or incidence of side effects, such as nausea, vomiting, pruritus and urinary retention. The plasma concentrations of morphine-6-glucuronide showed that this metabolite might contribute to the analgesia resulting from morphine administration. The same dose of intravenous oxycodone and morphine administered by PCA pump was needed for immediate postoperative analgesia. The two drugs appear to be equipotent.",1998.0,0,0
1735,9605376,Neurolytic thoracic paravertebral block in cancer pain. A clinical report.,H Antila; O Kirvelä,"Paravertebral block has successfully been used in the treatment of acute and chronic pain. The duration of paravertebral block could theoretically be prolonged by using neurolytic agents. We retrospectively analyzed the results of neurolytic paravertebral blocks performed in 7 patients suffering from intense cancer-related thoracic pain. Thirty-seven spinal nerve roots were blocked during 20 visits. Nerve roots were identified by eliciting paresthesia radiating to the painful area. Each root was blocked separately. After test block using 0.5% bupivacaine, the paravertebral blocks were performed with 1-4 ml of 7% phenol in aqua. No technical failures or complications were recorded in the patient files. Pain relief lasted over 2 months after 4 visits (20%), from 1 week to 1 month after 5 visits (25%), and less than 1 week after a single visit (5%). After 9 visits (45%), the results were poor with no significant pain relief. Neurolytic paravertebral block with phenol doses used in our patients appears to have only limited use. Some patients with pain restricted to a small number of thoracic segments may benefit from its use. Because of complication risks, this technique should be limited to intractable pain in cancer patients with poor prognosis.",1998.0,0,0
1736,9606614,Optimal treatment of phantom limb pain in the elderly.,R Baron; G Wasner; V Lindner,"Phantom limb and stump pain is a common sequela of amputation. In geriatric patients with an amputated limb and multiple other illnesses, drug therapy may be problematic and invasive techniques may be risky. Interactions between pathophysiological mechanisms in the peripheral and central nervous systems may be responsible for the initiation and maintenance of chronic phantom limb and stump pain. These mechanisms include: (i) peripheral damage to nociceptive fibres and dorsal root ganglion cells, which acquire abnormal sensitivity to mechanical, thermal and chemical stimuli; (ii) the prolonged sensitisation of central nociceptive 'second order' neurons in the dorsal horn of the spinal cord, which become hyperexcitable and start responding to nonnoxious stimuli; and (iii) the degeneration of nociceptive neurons, which may trigger the anatomical sprouting of low threshold mechanosensitive terminals to form connections with central nociceptive neurons. This may subsequently induce functional synaptic reorganisation in the dorsal horn. The provision of a pain-free perioperative interval using regional anaesthetic techniques is likely to reduce the incidence of phantom limb pain. The therapy of manifest pain is difficult, and treatment should start as soon as possible to prevent chronic pain. In the acute state, the infusion of calcitonin and oral opioid analgesics have proven to be helpful, while established phantom limb pain may respond to antidepressants, anticonvulsants and drugs that mimic or enhance gamma-aminobutyric acid function. Pharmacological treatment should be combined with transcutaneous electrical nerve stimulation, sympathetic blockade and psychotherapy. In addition, new therapeutic strategies are now being tested; examples include capsaicin, new anticonvulsants and N-methyl-D-aspartate antagonists. Patients with severe pain should be referred to a pain specialist to ensure optimal and timely interventional pain management.",1998.0,0,0
1737,9613267,Intrathecal diamorphine for analgesia after caesarean section. A dose finding study and assessment of side-effects.,M C Kelly; U A Carabine; R K Mirakhur,"Eighty women undergoing elective Caesarean section under spinal anaesthesia using hyperbaric bupivacaine 0.5% were randomly allocated to receive, in addition, intrathecal diamorphine 0.125, 0.25 or 0.375 mg or saline. Postoperative morphine requirements, measured using a patient-controlled analgesia system, were reduced in a dose-dependent manner by diamorphine. Pain scores were significantly lower at 2 and 6 h following the two larger doses of diamorphine. Less supplemental analgesia was required intra-operatively if intrathecal diamorphine had been given. The incidences of vomiting and pruritus were also dose-related. No respiratory rates of less than 14 breath.min-1 were recorded and the incidence of oxygen saturation readings less than 95% and 90% did not differ between groups. There were no adverse neonatal effects. Intrathecal diamorphine in the present study was found to be safe in doses of up to 0.375 mg following Caesarean section. However, minor side-effects were frequently observed.",1998.0,0,0
1738,9613276,Epidural anaesthesia as a method of pre-emptive analgesia for abdominal hysterectomy.,J T Richards; J R Read; W A Chambers,"The effect of pre- versus postincisional epidural blockade without the use of systemic opioids was investigated in a randomised, double-blind study of two groups of 25 patients undergoing abdominal hysterectomy performed under general anaesthesia. The first group received, via a lumbar epidural catheter, 0.9% saline (16 ml) 15 min prior to surgical incision and 0.5% bupivacaine (15 ml) and fentanyl 50 micrograms (1 ml) 15 min prior to skin closure. The second group of 25 patients received the same amount of bupivacaine and fentanyl 15 min pre-incision and saline prior to skin closure. Visual analogue pain scores and patient-controlled morphine consumption were measured at specified times for 48 h. We were unable to detect any significant difference in either of the outcome measures of the two groups and thus were unable to demonstrate that epidural blockade using local anaesthetic and opioid has a pre-emptive effect.",1998.0,0,0
1739,9613308,Postoperative respiratory function in children after abdominal surgery. A comparison of epidural and intramuscular morphine analgesia.,E Chabas; C Gomar; A Villalonga; X Sala; P Taura,"Thirty children undergoing urological and abdominal surgery were entered into a randomised trial comparing the effects of epidural and intramuscular morphine on postoperative respiratory function. The forced vital capacity and the forced expired volume in 1 s were measured before and 6 h after surgery and on each of the following seven days. Significant decreases (p < 0.01) in forced vital capacity and forced expired volume in 1 s were seen after surgery. After the first postoperative day, a gradual recovery in pulmonary function was observed but the measured parameters had not returned to their pre-operative control values by the end of the study. There were no statistically significant differences between the two groups during the study with respect to forced vital capacity and forced expired volume in 1 s. The quality of analgesia was better in the epidural morphine group than in the intramuscular morphine group. The incomplete recovery of pulmonary function suggests that pain is not the only cause of postoperative respiratory changes in these patients.",1998.0,0,0
1740,9616462,Opioid rotation: does it have a role?,R Twycross,,1998.0,0,0
1741,9619210,Use of opioids in non-cancer pain.,C N Shannon; A P Baranowski,"The use of opioids for chronic pain of non-malignant origin remains controversial. However, problems anticipated from experience with animal experiments and pain-free abusers seldom cause difficulties when opioids are used appropriately to treat pain. With sensible guidelines, and in the context of a multidisciplinary pain clinic, opioids may provide the only hope of relief to many sufferers of chronic pain.",1998.0,0,0
1742,9623023,Comparison of ketoprofen and morphine for post-operative analgesia in orthopaedic patients.,P Vathana; C Pakpianpairoj; T Prasartritha,"A prospective, open label, randomized study to compare efficacy of intramuscular administration of ketoprofen and morphine for post operative analgesia in elective orthopaedic surgery was performed in 50 patients. The procedures were open reduction and internal fixation of long bone fractures (26 cases), hip replacement (9 cases) and spinal surgery (15 cases). Pain intensity and pain relief in both groups were evaluated at 1, 3 and 6 hours post-injection. There was no significant differences in pain relief of both groups (P = 0.05). The side effects of intramuscular ketoprofen were encountered in only 8 per cent. Ketoprofen injection is an alternative for post operative pain relief.",1998.0,0,0
1743,9623424,Pulmonary function and pain after gastroplasty performed via laparotomy or laparoscopy in morbidly obese patients.,J L Joris; V L Hinque; P E Laurent; C J Desaive; M L Lamy,"We have compared severely obese patients (body mass index > 35 kg m-2) undergoing laparoscopic or open gastroplasty (n = 15 in each group) to determine if laparoscopy results in any benefit in the obese. Postoperative pain, measured on a 100-mm visual analogue scale, and opioid consumption were recorded during the first two days after operation. Tests of pulmonary function were performed and SpO2 was measured 4 h after surgery and on days 1, 2 and 3 after operation. Pain at rest was similar in the two groups, but in the laparoscopy group, requirements for postoperative opioid were 50% less (P < 0.05). Pain intensity during mobilization and on coughing was significantly less after laparoscopy (differences between mean pain scores in both groups ranged from 20 to 32 mm during mobilization and from 32 to 34 mm during coughing). Forced vital capacity, forced expiratory volume in 1 s and peak expiratory flow rate were reduced significantly less after laparoscopic gastroplasty than after open gastroplasty (on day 1 forced vital capacity was reduced by 50% compared with 64%, forced expiratory volume in 1 s was reduced by 50% compared with 66% and peak expiratory flow rate by 45% compared with 60%). SpO2 values were significantly greater in the laparoscopy group (day 1: mean 95 (SD 2)% vs 91 (5)%; day 3: 97 (1)% vs 94 (3)%). This study suggests that the beneficial effects observed after laparoscopic gastroplasty in morbidly obese patients were similar to those reported after laparoscopic cholecystectomy in non-obese patients.",1998.0,0,0
1744,9623426,Addition of clonidine or fentanyl to local anaesthetics prolongs the duration of surgical analgesia after single shot caudal block in children.,I Constant; O Gall; L Gouyet; M Chauvin; I Murat,"Caudal anaesthesia is indicated for surgical procedures lasting less than 90 min. Fentanyl and clonidine are known to prolong postoperative caudal analgesia, but there are no data on their effect on duration of surgical analgesia. We evaluated if the addition of clonidine or fentanyl to local anaesthetics prolonged the duration of surgical analgesia after single shot caudal block in children in a randomized, double-blind study. We studied 64 children, aged 6-108 months, undergoing bilateral correction of vesicoureteral reflux which was expected to last more than 90 min. Patients were allocated to one of four groups: group O received 1 ml kg-1 of a mixture of 0.25% bupivacaine with epinephrine and 1% lidocaine in equal parts; group F received the same mixture of local anaesthetics in addition to fentanyl 1 microgram kg-1; group C received the same mixture of local anaesthetics in addition to clonidine 1.5 micrograms kg-1; and group C + F received the same mixture of local anaesthetics in addition to fentanyl 0.5 microgram kg-1 and clonidine 0.75 microgram kg-1. Single shot caudal block was sufficient in only 57% of children in group O compared with 93% in groups C and F and 86% in group C + F (P = 0.035). Global assessment of anaesthesia, defined as the time from caudal injection to the first administration of analgesic (either during or after surgery), was significantly longer in the three groups of children who received additives compared with local anaesthetics alone (P = 0.035), but there were no differences between the three additive groups. Vomiting was observed only in children who received fentanyl. Addition of clonidine or fentanyl to local anaesthetics prolonged the duration of surgical analgesia of caudal block, allowing single shot caudal anaesthesia to be recommended for surgery lasting 90-150 minutes. Clonidine had some advantages over fentanyl as it did not produce clinically significant side effects.",1998.0,0,0
1745,9624795,"Treatment of pain with sustained-release tramadol 100, 150, 200 mg: results of a post-marketing surveillance study.",S Nossol; M Schwarzbold; T Stadler,"In a post-marketing-surveillance study the use of a sustained-release tramadol preparation (Tramal long 100, 150, 200 mg) was investigated in 3153 patients. The intention was to comply with the legal obligation to carry out product surveillance and to collect data on prescribing behaviour. We focused our attention on drug safety and efficacy. Tramal long was used mainly for severe and very severe pain. The most frequently reported causes of pain were diseases of the locomotor system (49.9%), tumours (24.3%), traumas and fractures (10.1%), and neurogenic (9.3%). The mean daily dose was 235.7 mg, usually divided into two doses. The analgesic effect was described as very good or good by 82.5% of the patients. Adverse events occurred in 6.5% of the patients, mostly in the form of typical opioid side-effects such as nausea (3.4%), dizziness (1.5%) and vomiting (1.1%). Severe or unknown side-effects were not reported.",1998.0,0,0
1746,9627585,"Physiological, hormonal, and behavioral responses to a single fentanyl dose in intubated and ventilated preterm neonates.",R Guinsburg; B I Kopelman; K J Anand; M F de Almeida; C de A Peres; M H Miyoshi,"To study the responses of ventilated preterm neonates to a single dose of opioid. In a randomized, double-blind, controlled trial, 22 mechanically ventilated preterm infants (< or = 32 weeks) were observed before medication and at 30 and 60 minutes after administration of fentanyl (3 micrograms/kg) or placebo. Heart rate, blood pressure, arterial blood gases, ventilator settings, and behavioral measures (Neonatal Facial Coding System and Modified Postoperative Comfort Score) were recorded during each period. Blood cortisol, growth hormone, glucose, and lactate were measured before and at 60 minutes after analgesia. Behavioral measures were assessed at the bedside and from video films recorded during each observation period. Patients presented high basal levels of cortisol, growth hormone, and lactate. Behavioral scales indicated the presence of pain before any medication. In the fentanyl group, the maximum and minimum heart rate decreased and growth hormone level increased after analgesia. At the video analysis of behavioral measures, postoperative comfort score increased and neonatal facial coding system score decreased in the fentanyl group. Single doses of fentanyl analgesia can reduce the physiologic/behavioral measures of pain and stress associated with mechanical ventilation in preterm infants.",1998.0,0,0
1747,9631379,[The influence of premedication with diclofenac or pethidine on pain and postop treatment in lumbar discopathy].,K Przesmycki; J Osuchowski; A Chmielewska; D Mitosek-Sabbo; J Wośko,"206 patients scheduled for spinal surgery (lumbar discopathy) were randomly premedicated with diclofenac, pethidine, diazepam or hydroxizine. The frequency of persisted postoperative pain was evaluated from the 3-ed. postoperative day to the end of hospitalisation--as the need for additional concomitant treatment with dexamethasone and intravenous analgesics. The frequency of persisted pain was significantly decreased in patients premedicated with diclofenac (together with diazepam) before spinal surgery (limited to fenestration) in comparison to patients premedicated with pethidine. The pre-emptive analgesic effect of diclofenac was even more evident in patients treated with non-steroidal anti-inflammatory drugs (NSAID) before surgery, but was not observed in patients after more traumatic surgery (laminectomy) premedicated with diazepam. The results are supporting the important role of NSAID given before surgery to decrease the frequency of persisted pain after spinal surgery (limited to fenestration), in patients treated with NSAID.",1998.0,0,0
1748,9633737,Efficacy of oxycodone in neuropathic pain: a randomized trial in postherpetic neuralgia.,C P Watson; N Babul,"Although opioid analgesics are used in the management of neuropathic pain syndromes, evidence of their efficacy remains to be established. We evaluated the clinical efficacy and safety of oxycodone in neuropathic pain using postherpetic neuralgia as a model. Patients with postherpetic neuralgia of at least moderate intensity were randomized to controlled-release oxycodone 10 mg or placebo every 12 hours, each for 4 weeks, using a double-blind, crossover design. The dose was increased weekly up to a possible maximum of 30 mg every 12 hours. Pain intensity and pain relief were assessed daily, and steady (ongoing) pain, brief (paroxysmal) pain, skin pain (allodynia), and pain relief were recorded at weekly visits. Clinical effectiveness, disability, and treatment preference were also assessed. Fifty patients were enrolled and 38 completed the study (16 men, 22 women, age 70+/-11 years, onset of postherpetic neuralgia 31+/-29 months, duration of pain 18+/-5 hours per day). The oxycodone dose during the final week was 45+/-17 mg per day. Compared with placebo, oxycodone resulted in pain relief (2.9+/-1.2 versus 1.8+/-1.1, p=0.0001) and reductions in steady pain (34+/-26 versus 55+/-27 mm, p=0.0001), allodynia (32+/-26 versus 50+/-30 mm, p=0.0004), and paroxysmal spontaneous pain (22+/-24 versus 42+/-32 mm, p=0.0001). Global effectiveness, disability, and masked patient preference all showed superior scores with oxycodone relative to placebo (1.8+/-1.1 versus 0.7+/-1.0, p=0.0001; 0.3+/-0.8 versus 0.7+/-1.0, p=0.041; 67% versus 11%, p=0.001, respectively). Controlled-release oxycodone is an effective analgesic for the management of steady pain, paroxysmal spontaneous pain, and allodynia, which frequently characterize postherpetic neuralgia.",1998.0,1,1
1749,9633738,Double-blind randomized trial of tramadol for the treatment of the pain of diabetic neuropathy.,Y Harati; C Gooch; M Swenson; S Edelman; D Greene; P Raskin; P Donofrio; D Cornblath; R Sachdeo; C O Siu; M Kamin,"The objective of this study was to evaluate the efficacy and safety of tramadol in treating the pain of diabetic neuropathy. The pain of diabetic neuropathy is a major cause of morbidity among these patients and treatment, as with other small-fiber neuropathies, is often unsatisfactory. Tramadol is a centrally acting analgesic for use in treating moderate to moderately severe pain. This multicenter, outpatient, randomized, double-blind, placebo-controlled, parallel-group study consisted of a washout/screening phase, during which all analgesics were discontinued, and a 42-day double-blind treatment phase. A total of 131 patients with painful diabetic neuropathy were treated with tramadol (n=65) or placebo (n=66) tramadol, which were administered as identical capsules in divided doses four times daily. The primary efficacy analysis compared the mean pain intensity scores in the tramadol and placebo groups obtained at day 42 of the study or at the time of discontinuation. Secondary efficacy assessments were the pain relief rating scores and a quality of life evaluation based on daily activities and sleep characteristics. Tramadol, at an average dosage of 210 mg/day, was significantly (p < 0.001) more effective than placebo for treating the pain of diabetic neuropathy. Patients in the tramadol group scored significantly better in physical (p=0.02) and social functioning (p=0.04) ratings than patients in the placebo group. No statistically significant treatment effects on sleep were identified. The most frequently occurring adverse events with tramadol were nausea, constipation, headache, and somnolence. The results of this placebo-controlled trial showed that tramadol was effective and safe in treating the pain of diabetic neuropathy.",1998.0,0,0
1750,9635520,Controlled-release morphine tablets in patients with chronic cancer pain: a narrative review of controlled clinical trials.,C A Warfield,"Controlled-release (CR) morphine tablets have become routine therapy in the management of cancer pain. Compared with immediate-release (IR) morphine, this formulation provides the benefit of dosing every 12 hours. This study reviewed the 10 published, well controlled, repeated-dose, comparative studies with CR morphine tablets administered every 12 hours to patients with cancer pain. CR morphine tablets were uniformly effective; 98% of patients completed a treatment course of every-12-hours therapy. Although the effective analgesic dose varied considerably from study to study (range, 90-330 mg per day), pain was well controlled with CR morphine tablets as the primary analgesic. Mean pain scores, converted to a common 10-point scale, ranged from 1.1-2.9 across all studies. There was only occasional need for IR morphine rescue medication (range, 2-39 mg per day). The mean discontinuation rate because of side effects or lack of every-12-hours efficacy was 2%. In seven studies that used IR morphine as the comparative agent, CR morphine tablets were found to be equally effective as IR morphine. Twice-daily dosing of CR morphine provides convenient, safe, and effective relief of cancer pain.",2000.0,0,0
1751,9638390,,,,,0,0
1752,9641070,The Management of Intractable Pain Act: what will it mean for physicians and patients in West Virginia?,A H Moss; G Delaura; B Gallagher,,1998.0,0,0
1753,9642529,Drug-induced scleroderma and sclerodermiform conditions.,U F Haustein; B Haupt,,1998.0,0,0
1754,9645186,[Erroneous intravenous injection of adrenaline].,M Meier; F Kenel; M Vogt,"Since a car accident a 29-year-old man had been suffering from chronic pain treated with injections of morphine and tilidine. Because of renewed worsening of pain he went to the emergency doctor who by mistake intravenously injected 1 mg of undiluted adrenaline. The patients immediately collapsed and pulmonary oedema developed. On admission he was hypotensive (85/45 mmHg) and tachycardic (135/min), respiratory rate 36/min. Moist rales were heard throughout the lung. The white cell count was elevated and serum potassium low (3.5 mmol/l). but other routine laboratory tests were unremarkable. Furosemide, nitroglycerin and morphine were injected at once and his general state improved over the subsequent few hours. Chest radiogram on the next day demonstrated marked reduction of the pulmonary oedema. To prevent similar, potentially lethal, accidents, before every i.v. injection two persons should check the name of the drug on the label of the vial or bottle, both on drawing up and before injecting the drug.",1998.0,0,0
1755,9645278,"[Are tramadol enantiomers for postoperative pain therapy better suited than the racemate? A randomized, placebo- and morphine-controlled double blind study].",A Wiebalck; M Zenz; M Tryba; D Kindler; B Donner; U Czekalla,"The goal of this prospective, randomised and double-blind pilot-study was to investigate the analgesic potency and the side-effects of tramadol enantiomers in clinical practice. One hundred patients recovering from orthopaedic surgery with a postoperative pain intensity of more than 50 on a visual analogue scale 0-100 mm (Table 1) were recruited for the study. They were treated in a randomised, double-blind way with a maximal dose of 150 mg i.v.(+)-,(-)-tramadol, racemate, or 15 mg i.v. morphine or saline in the placebo group (5 groups, 20 patients each). The primary criterium of efficacy was the number of responders defined as patients with a pain reduction of at least 20 on VAS after 40 min. In case of pain, responders were allowed to continue with the double-blind drug up to six hours. The non-responders were treated with morphine as the rescue analgesic. The secondary criterium was the incidence and severity of side-effects. Six patients terminated the study prematurely. One patient was excluded because of an allergic reaction to morphine, one patient could not be treated sufficiently with morphine, four were excluded because of protocol violations. There were 8 responders in the (+)-tramadol-,6 in the (-)-tramadol- and 6 in the racemate group, 16* (P < 0.05) in the morphine group, and 5 in the placebo group. Pain intensity after 40 min was reduced by 20 (p < 0.05), 17 (p < 0.05), 17 (p < 0.05), 36 (p < 0.01 vs placebo, p < 0.05 vs (+)-,(-)-tramadol, and racemate group) and 5 mm on the VAS in the (+)-, (-)-, (+/-)-tramadol-, morphine- and placebo-group, respectively. Thirty eight adverse events like nausea, vomiting, PCO2-increase, and urinary retention occurred in 20 patients, most frequently in the (+)-tramadol- and morphine group. Sedation was significantly less profound in the (-)-tramadol group 1-4 h postoperatively. There were no side-effect in the tramadol racemate group. The enantiomers were equal to the racemate in analgesic potency, but inferior by far to morphine. They showed more adverse events and, hence, can not be preferred to the racemate in postoperative pain therapy.",1998.0,0,0
1756,9647432,One-year chromaffin cell allograft survival in cancer patients with chronic pain: morphological and functional evidence.,J C Bés; J Tkaczuk; K A Czech; M Tafani; R Bastide; C Caratero; G D Pappas; Y Lazorthes,"The control of chronic pain through transplantation of chromaffin cells has been reported over the past few years. Analgesic effects are principally due to the production of opioid peptides and catecholamines by chromaffin cells. Clinical trials have been reported with allografts consisting of whole-tissue fragments implanted into the subarachnoid space of the lumbar spinal cord (14,19,36). In the present study, allogeneic grafts were successfully used to control chronic pain in two patients over a period of 1 yr based on patient reported pain scores, morphine intake, and CSF levels of Met-enkephalin. Macroscopic examination at autopsy located the transplanted tissue fragments in the form of multilobulated nodules at the level of the spinal axis and cauda equina. Immunocytochemical microscopy showed neuroendocrine cells are positive for chromagranin A (CGA), and enzymes tyrosine hydroxylase (TH) and dopamine-beta-hydroxylase (DbetaH). The results suggest that there is a relationship between analgesic effect, Met-enkephalin levels in CSF, and the presence of chromaffin cells surviving in spinal subarachnoid space.",1998.0,0,0
1757,9649011,Colonoscopy without sedation.,M S Hoffman; T W Butler; T Shaver,"Colonoscopy is routinely performed with conscious sedation. We wanted to determine if colonoscopy can be successfully completed without sedation and to assess patient tolerance and acceptance. One hundred nine consecutive patients undergoing colonoscopy were examined. The risks and benefits of colonoscopy with or without sedation were explained in a standard format. Patients were then given the option of having colonoscopy without premedication. After the procedure, as well as 2 to 5 days later, patients rated on an analog scale (0, no pain; 5, severe) the severity of pain and willingness to undergo colonoscopy in the future without sedation. Eighty patients underwent colonoscopy without prior sedation. Only 6% (n=5) required sedation to complete the examination. When questioned, 5% experienced no pain, 41% slight or mild pain, 34% moderate pain, and 20% severe pain. Seventy-three percent (n=58) were willing to undergo repeat colonoscopy without sedation, 10% (n=8) were undecided, and 18% (n=14) would request sedation. Pain severity was a strong predictor (p=0.001) of future sedation preference. Colonoscopy without sedation may be completed successfully in most patients and does not undermine many patients' willingness to undergo a similar procedure in the future. Sedation by choice is more cost-effective, may be safer, and should be offered as an alternative to routine intravenous sedation.",1998.0,0,0
1758,9649988,Pharmaco-economic evaluation of a disposable patient-controlled analgesia device and intramuscular analgesia in surgical patients.,J D'Haese; C Vanlersberghe; V Umbrain; F Camu,"The present study contrasted the pharmaco-economics and analgesic efficacy of intramuscular (i.m.) opioid treatment with a parenteral disposable patient-controlled analgesia (PCA) system in two groups of 20 female patients (ASA I-II, aged 35-69 years) scheduled for abdominal hysterectomy. The PCA group received a continuous infusion of 1.5 mg h-1 piritramide, a mu-opioid receptor agonist, with incremental doses of 1.5 mg (lock-out interval = 15 min). The i.m. group received 0.3 mg kg-1 piritramide i.m. when requested by the patient with a minimum interval of 5 h. Pain intensity, sedation and the functional recovery of the patients were followed for 72 h post-operatively. The sum of pain intensity differences (SPID) was used as a measure of analgesic efficiency. Equipment and drug costs, and the demand on nursing time were recorded over 3 days post-operatively. The costs of PCA and i.m. therapies per patient were used to calculate the cost-benefit (cost of treatment vs. nursing time) and cost-effectiveness (cost of treatment vs. SPID) analyses. Both treatments initially provided comparable analgesia, but PCA was more efficient after 16 h and significantly reduced nursing time for pain treatment (PCA = 61 +/- 4 min, i.m. = 88 +/- 5 min; P < 0.001). Functional recovery was not different for either treatment. Cost analysis indicated a better cost-benefit ratio for the i.m. treatment (0.35 vs. 1.1 for PCA treatment), but a similar cost-effectiveness for both treatments (PCA = 1.9 Belgian Francs (BEF) unit-1 SPID; i.m. = 1.7 BEF unit-1 SPID).",1998.0,0,0
1759,9649996,Efficacy of thoracic epidural analgesia following laparoscopic cholecystectomy.,Y Fujii; H Toyooka; H Tanaka,"This study was undertaken to determine whether epidural analgesia has any benefit for post-operative pain relief in patients undergoing laparoscopic cholecystectomy. Patients were randomly assigned to receive post-operative epidural analgesia with a morphine-bupivacaine combination (Group A, n = 22) or placebo (saline) (Group B, n = 22). The same standard general anaesthetic technique, which consists of nitrous oxide and isoflurane in oxygen was used. Analgesia was assessed using visual analogue pain scores (0-10 cm). The evaluation was carried out 24 and 48 h post-operatively. At 24 h after anaesthesia, pain scores in Group A (2.3 +/- 1.2) were lower than those in Group B (4.4 +/- 1.5) (P < 0.05). However, at 48 h post-operatively, no difference in scores was observed between the two groups. In conclusion, epidural analgesia with a morphine-bupivacaine combination improves pain relief during the first 24 h following laparoscopic cholecystectomy.",1998.0,0,0
1760,9649998,Acute pain services in Europe: a 17-nation survey of 105 hospitals. The EuroPain Acute Pain Working Party.,N Rawal; R Allvin,"A 17-nation survey was undertaken with the aim of studying the availability of acute pain services (APS) and the use of newer analgesic techniques, such as epidural and patient-controlled analgesia (PCA). A questionnaire was mailed to selected anaesthesiologists in 105 European hospitals from 17 countries. Depending on the population, between five and ten representative hospitals from each country were selected by a country coordinator. A total of 101 (96.2%) completed questionnaires were returned. A majority of respondents were dissatisfied with pain management on surgical wards. Pain management was better in post-anaesthesia care units (PACUs); however, 27% of participating hospitals did not have PACUs. There were no organized APS in 64% of hospitals, although anaesthesiologists from chronic pain centres were available for consultation. In the hospitals that had APS, the responsible person for the APS was either: (1) a junior anaesthesiologist (senior anaesthesiologist available for consultation); or (2) a specially trained nurse (supervised by consultant anaesthesiologists). Many anaesthesiologists were unable to introduce techniques such as PCA on wards because of the high equipment costs. Although 40% of hospitals used a visual analogue scale (VAS) or other methods for assessment of pain intensity, routine pain assessment and documenting on a vital sign chart was rarely practised. There was a great variation in routines for opioid prescription and documentation procedures. Nursing regulations regarding injection of drugs into epidural and intrathecal catheters also varied considerably between countries. This survey of 105 hospitals from 17 European countries showed that over 50% of anaesthesiologists were dissatisfied with post-operative pain management on surgical wards. Only 34% of hospitals had an organized APS, and very few hospitals used quality assurance measures such as frequent pain assessment and documentation. There is a need to establish organized APS in most hospitals and also a need for clearer definition of the role of anaesthesiologists in such APS.",1998.0,0,0
1761,9650546,"Tramadol hydrochloride: analgesic efficacy compared with codeine, aspirin with codeine, and placebo after dental extraction.",P A Moore; R J Crout; D L Jackson; L G Schneider; R W Graves; L Bakos,"Tramadol hydrochloride is a novel, centrally acting analgesic with two complementary mechanisms of action: opioid and aminergic. Relative to codeine, tramadol has similar analgesic properties but may have fewer constipating, euphoric, and respiratory depressant effects. A two-center randomized double-blind controlled clinical trial was performed to assess the analgesic efficacy and reported side effects of tramadol 100 mg, tramadol 50 mg, codeine 60 mg, aspirin (ASA) 650 mg with codeine 60 mg, and placebo. Using a third molar extraction pain model, 200 healthy subjects were enrolled in a 6-hour evaluation after a single dose of drug. Of the 200 patients enrolled, seven provided incomplete efficacy data or discontinued prematurely and one was lost to follow-up. Using standard measures of analgesia, including total pain relief score (TOTPAR), maximum pain relief score (MaxPAR), sum of pain intensity difference scores (SPID), peak pain intensity difference (Peak PID), remedication, and global evaluations, all active treatments were found to be numerically superior to placebo. ASA/codeine was found to be statistically superior to placebo for all measures of efficacy. Tramadol 100 mg was statistically superior to placebo for TOTPAR, SPID, and time of remedication, whereas tramadol 50 mg was statistically superior to placebo onlyfor remedication time. Codeine was not found to be statistically superior to placebo for any efficacy measure. A greater TOTPAR response compared with all other active measures was seen for ASA/codeine during the first 3 hours of study. The 6-hour TOTPAR scores for the tramadol groups and ASA/ codeine group were not significantly different. Gastrointestinal side effects (nausea, dysphagia, vomiting) were reported more frequently with tramadol 100 mg, ASA/ codeine, and codeine 60 mg than with placebo.",1998.0,0,0
1762,9658268,Serotonin syndrome following the administration of tramadol with paroxetine.,M S Lantz; E N Buchalter; V Giambanco,,2000.0,0,0
1763,9659013,"The effect of education, assessment and a standardised prescription on postoperative pain management. The value of clinical audit in the establishment of acute pain services.",M Harmer; K A Davies,"A study involving 2738 patients in 15 hospitals in the United Kingdom was undertaken to evaluate the effect of simple methods of pain assessment and management on postoperative pain. The study consisted of four parts: a survey of current practice in each hospital; a programme of education for staff and patients regarding pain and its management; the introduction of formal assessment and recording of pain and the use of a simple algorithm to allow more flexible, yet safe, provision of intermittent intramuscular opioid analgesia; and a repeat survey of practice. One hospital from each of the former health regions of England and Wales was selected for inclusion in the project. Hospitals included representatives of different size units (university, large and small district general hospitals). As a result of the study, there was an overall reduction in the percentage of patients who experienced moderate to severe pain at rest from 32% to 12%. The incidence of severe pain on movement decreased from 37% to 13% and moderate to severe pain on deep inspiration from 41% to 22%. Similar decreases were seen in the incidence of nausea and vomiting. There was also a slight reduction in the incidence of postoperative complications. This study shows that simple techniques for the management of postoperative pain are effective in reducing the incidence of pain both at rest and during movement and should form part of any acute pain management strategy.",1998.0,0,0
1764,9661860,Epidural analgesia for postoperative pain control in children.,M D Jones; D D Aronsson; J M Harkins; D F Smail; L D Haugh,"Ninety-eight continuous postoperative epidurals were administered to 87 children. The patients were divided into two groups: group I included 63 cases in which a 0.0625-0.25% solution of bupivacaine was continuously administered; group II included 35 cases in which a similar solution of bupivacaine mixed with 2-10 micrograms of fentanyl was administered. The dose of the epidural medication was titrated by the anesthesiologist according to the patient's age and anticipated level of postoperative pain. The average pain score for all patients for the first 48 h was 1.43. Supplemental analgesia averaging 0.132 mg intravenous morphine/kg/8 h was required in 49 cases (41 in group I and eight in group II). In group I, the average dose of supplemental analgesia was 0.144 mg intravenous morphine/kg/8 h, whereas in group II, it was only 0.056 mg intravenous morphine/kg/8 h. Continuous epidural analgesia is effective in controlling postoperative pain, and the addition of fentanyl reduces the need for systemic narcotics.",1998.0,0,0
1765,9663813,,,,,0,0
1766,9667296,Intrathecal sufentanil produces sensory changes without hypotension in male volunteers.,E T Riley; C L Hamilton; S E Cohen,"Intrathecally administered sufentanil is frequently associated with hypotension and sensory changes in women undergoing labor. In this study, the authors examined whether intrathecally administered sufentanil has similar effects in pain-free individuals with low concentrations of progesterone (i.e., male volunteers). Ten male volunteers were randomly assigned to receive an intrathecal injection of either 10 microg sufentanil or saline in a double-blind fashion. Blood pressure, heart rate, oxyhemoglobin saturation, and temperatures from the body core and skin of the calf and ipsilateral great toe were recorded. Cold and pin prick sensation, motor block, and visual analogue scores for sedation, pruritus, and nausea also were assessed. Current perception thresholds using the Neurometer current perception threshold instrument (Neurotron, Inc., Baltimore, MD) were determined for three frequencies (2,000, 250, and 5 Hz, corresponding to stimulation of Abeta, Adelta, and C fibers, respectively) on the upper and lower extremities. Pruritus and sensory changes to pin prick and cold occurred in the sufentanil group but not the saline group. Neither group had a significant change in blood pressure, heart rate, oxyhemoglobin saturation, sedation, or core temperature. There was a clinically insignificant difference in the calf minus toe temperature index between the saline and sufentanil groups. There was a small increase in the current perception thresholds at 250 Hz in the sufentanil group. Intrathecally administered sufentanil did not affect blood pressure in male volunteers. The other effects of sufentanil, however, were similar to those observed in women undergoing labor. This suggests that the hypotension occurring in these women after intrathecally administered sufentanil is secondary to relief of pain, rather than to a sympathectomy.",1998.0,0,0
1767,9667297,Effect of epidural fentanyl on neonatal respiration.,J Porter; E Bonello; F Reynolds,"The addition of opioids to epidural infusions for laboring mothers may reintroduce the problem of neonatal depression seen with systemic opioids. The authors studied neonatal respiration and neurobehavior in newborns of mothers randomized to receive epidural analgesia with or without fentanyl. One hundred thirty-eight women in labor received loading doses of plain bupivacaine. When pain-free, they received an infusion of either 0.125% bupivacaine alone or 0.0625% bupivacaine with 2.5 microg/ml fentanyl. After delivery, transcutaneous oxygen tension and carbon dioxide tension were recorded in the newborns every 10 s until 90 min after delivery using a transcutaneous oxygen-carbon dioxide monitor. Umbilical venous and arterial acid-base status, Apgar scores, and Neurologic and Adaptive Capacity Scores 2 h and 24 h after delivery were measured. The umbilical venous plasma fentanyl concentration was correlated with indices of neonatal respiration and welfare in the fentanyl group. One hundred fourteen newborns delivered vaginally were studied. In the fentanyl group, the mean (range) maternal dose of fentanyl was 184 microg (range, 53-400), and the umbilical venous fentanyl concentration was 0.077 ng/ml (range, <0.021 to 0.244). There were no significant differences between the groups for any indices of neonatal respiration or neonatal welfare, and the plasma fentanyl concentration did not correlate with any of these indices. The results suggest that fentanyl added to epidural bupivacaine infusions during labor does not depress neonatal respiration or adversely affect neurobehavioral scores and other indices of neonatal welfare.",1998.0,0,0
1768,9667344,Combined intrathecal fentanyl and neostigmine: therapy for postoperative abdominal hysterectomy pain relief.,G R Lauretti; A L Mattos; M P Reis; N L Pereira,"To evaluate the analgesic action of spinal neostigmine as part of a multimodal analgesic therapy approach including spinal neostigmine and spinal fentanyl for postoperative pain relief Randomized, prospective study. Teaching hospital. 50 ASA physical status I and II patients undergoing abdominal hysterectomy. Patients were assigned to one of five groups (n = 10) to receive 15 mg bupivacaine plus 1 ml of the test drug intrathecally. The control group (CG) received saline as the test drug, the fentanyl group (FG) received 25 microg fentanyl; the neostigmine group (NG) received 25 microg neostigmine; the fentanyl-neostigmine 10 microg group (FNG10) was given 10 microg fentanyl plus 10 microg neostigmine; and the fentanyl-neostigmine 25 microg group (FNG25) received 25 microg fentanyl plus 25 microg neostigmine. Pain and nausea were evaluated using a 10-cm visual analog scale (VAS). The analgesic consumption, in 24 hours was greatest in CG, next highest in NG, FG, and FNG10 where consumption was the same in the three groups; and least in FNG25 (p < 0.05). The time to first rescue analgesic medication was greatest for FNG25 compared with the other groups (>5 hours compared with 2 to 3 hours; p < 0.05). VAS showed no statistically significant differences for pain impression, intraoperative and postoperative nausea, or occurrence of vomiting (p > 0.05). The combination of 25 microg neostigmine with 25 microg fentanyl given intrathecally with 15 mg of hyperbaric bupivacaine delayed postoperative pain and lowered the number of rescue analgesics. Because the better quality of analgesia was obtained with an increased (although not statistically significant difference) incidence of untoward side effects, larger samples should be studied before its routine use is recommended.",1998.0,0,0
1769,9667702,Randomized trial of early versus delayed laparoscopic cholecystectomy for acute cholecystitis.,P B Lai; K H Kwong; K L Leung; S P Kwok; A C Chan; S C Chung; W Y Lau,"The aim of this prospective randomized study was to define the optimum management between early and delayed laparoscopic cholecystectomy for patients with acute cholecystitis. Patients were randomized to receive either early laparoscopic cholecystectomy within 24 h of randomization or initial conservative treatment followed by delayed laparoscopic cholecystectomy 6-8 weeks later. There were 53 patients in the early group and 51 in the delayed group. There was no significant difference in conversion rate (early 21 per cent versus delayed 24 per cent), postoperative analgesic requirement (1 versus 2 doses) and postoperative complications. However, the early group had significantly longer operating time (122.8 versus 106.6 min, P = 0.04) and shorter total hospital stay (7.6 versus 11.6 days, P < 0.001). Early laparoscopic cholecystectomy is safe and feasible for acute cholecystitis with the additional benefit of shorter total hospital stay. Apart from a shorter operating time, treating patients with delayed laparoscopic cholecystectomy does not offer additional benefit.",1998.0,0,0
1770,9668148,Superior hypogastric block during microlaparoscopic pain mapping.,J F Steege,Pelvic pain mapping during laparoscopy performed under conscious sedation can provide useful information about visceral and somatic sources of chronic pelvic pain. Diagnostic superior hypogastric plexus block can be performed under direct laparoscopic visualization and the pelvis then remapped to determine if painful areas are supplied by hypogastric plexuses. Results of mapping may allow more informed selection of patients for presacral neurectomy.,1998.0,0,0
1771,9669008,Comparison between epidural infusion of fentanyl/bupivacaine and morphine/bupivacaine after orthopaedic surgery.,M Berti; G Fanelli; A Casati; D Lugani; G Aldegheri; G Torri,"To compare epidural infusions of bupivacaine-fentanyl and bupivacaine-morphine mixtures for postoperative pain relief after total hip replacement. In a prospective, randomized, double-blind study, 30 ASA physical status I-II patients undergoing total hip replacement were studied. Anaesthesia was provided by combined general/epidural anaesthesia without epidural opioids. Postoperative epidural analgesia was by continuous infusion of bupivacaine 0.125% (4 ml.hr-1) with either 0.05 mg.ml-1 morphine (morphine, n = 15) or 0.005 mg.ml-1 fentanyl (fentanyl, n = 15). Visual analogue pain scale (VAS), sedation (four-point scale), respiratory rate, pulse oximetry, rescue analgesics and supplemental oxygen were recorded by a blind observer at 1, 3, 6, 9, 12 and 24 hr after surgery. No differences in pain relief, sedation, or non-respiratory side effects were observed between the two groups. Rescue analgesics were required in three patients in the fentanyl group (20%) and in two receiving morphine (13.3%) (P:NS). Two patients in the fentanyl group and three in the morphine group required oxygen due to SpO2 < 90% (P:NS). Both opioid/bupivacaine mixtures decreased haemoglobin oxygen saturation compared with preoperative values. The mean +/- SD SpO2 values measured at 3, 6, 12 and 24 hr were 94.4 +/- 1, 92.6 +/- 0.9, 92 +/- 0.8, and 92.8 +/- 1 in the morphine group, 95.3 +/- 0.5, 95 +/- 0.5, 94.6 +/- 1.2, and 95.6 +/- 1 in the fentanyl group (P < 0.05). Continuous epidural infusion of bupivacaine-morphine or bupivacaine-fentanyl mixtures provided similar pain relief. Patients receiving morphine showed a more marked decrease in SpO2 than those receiving fentanyl. However, the average SpO2 remained > 90% in both groups.",1998.0,0,0
1772,9672930,A comparison of intramuscular tenoxicam with intramuscular morphine for pain relief following tonsillectomy in children.,C J Sutherland; J E Montgomery; I G Kestin,"A double blind trial was conducted to evaluate the analgesic efficacy of intramuscular tenoxicam for pain relief following tonsillectomy in children. Fifty children, aged 3-10 years, were randomly allocated to receive intramuscular tenoxicam 0.75 mg.kg-1 or intramuscular morphine sulphate 0.2 mg.kg-1 after induction of anaesthesia. Although the tenoxicam group required significantly more postoperative morphine.(mean 57.8 micrograms.kg-1 compared with 26.9 micrograms.kg-1, P = 0.025), the total morphine dose was significantly reduced after tenoxicam (57.8 micrograms.kg-1 compared with 226.9 micrograms.kg-1, P < 0.0001). There was no difference between the quality of analgesia after discharge from recovery. The incidence of postoperative vomiting was significantly reduced after tenoxicam (20%) compared with morphine (71%).",1998.0,0,0
1773,9675378,The role of newer opioids in geriatric anesthesia.,S L Shafer,"The unique features of remifentanil are its rapid clearance and rapid ke0, resulting in a rapid onset and offset of drug effect. It is tempting to speculate that these characteristics will make remifentanil an easy drug to titrate, and that clinicians will not need to consider patient covariates such as advanced age when choosing a dosing regimen. However, the rapid onset of drug effect may be accompanied by rapid onset of adverse events such as apnea and muscle rigidity. The rapid offset of drug effect can result in patients who are in severe pain at a time when the anesthesiologist is ill equipped to deal the problem, for example when the patient is in transit to the recovery room. It is thus important that when treating elderly patients anesthesiologists understand the proper dose adjustment required for the elderly. By adjusting the bolus and infusion doses, the anesthesiologist can hope to avoid the peaks and valleys that might expose these patients to risk. When the proper adjustment is made, the variability in remifentanil pharmacokinetics is considerably less than for any other intravenous opioid. This makes remifentanil the most predictable opioid for treatment of the elderly.",1998.0,0,0
1774,9675625,Painful and non-painful effects of low doses of morphine in migraine sufferers partly depend on excitatory amino acids and gamma-aminobutyric acid.,M Nicolodi,"Having a differential sensitivity to morphine can distinguish migraine suffers from healthy people who are headache-exempt. The aim of the present study was to investigate whether such an abnormal response to morphine challenge is entirely dependent on opioid receptor activation. A role for excitatory amino acids and gamma-aminobutyric acid has been proposed on the basis of the effect of diazepam. As opposed to naloxone, this gamma-aminobutyric acid agonist was found to inhibit the adverse effects of low doses of morphine in migraine sufferers, while at the same time being able to almost abolish morphine-induced miosis in subjects who underwent a short-lasting chronic pretreatment. The capacity of diazepam either to control the adverse effects of morphine or to induce well-being in subjects known to suffer from a central neurogenic pain such as migraine, is noteworthy even regarding the clinical treatment of other painful conditions, such as deafferentation pain, which is known to be not satisfactorily treated by using morphine.",1998.0,0,0
1775,9675626,Analgesic activity of tramadol and pentazocine in postoperative pain.,M Magrini; G Rivolta; C Bolis; D Furiosi,"This controlled, completely randomized trial was designed to compare the efficacy and safety of tramadol and pentazocine in the treatment of postoperative pain. A total of 50 adults were admitted (31 males, 19 females, mean age 48 years) to undergo hemorrhoidectomy or traumatological or abdominal surgery. Following a randomization list, each patient was given one ampul of tramadol (100 mg/2 mL) or pentazocine (30 mg/mL) by intramuscular injection at 8-h intervals for 3 days. Efficacy was assessed on both the basis of severity of pain (rated using a visual analog scale in the 6th h after the first injection and during the 3 days of treatment), and quality of sleep (rated using a five-point scale). Local reactions at the injection site (pain, skin reactions) were also assessed, as were systemic reactions (vital parameters, blood and biochemistry tests), and any untoward events were reported. Both drugs had good antalgic activity, significantly relieving pain in the 3 days of treatment (p < 0.01 from baseline). The first dose of tramadol was significantly more effective than pentazocine after the 1st h and throughout the subsequent 5 h. Final judgments on efficacy and acceptability were in favor of tramadol (p < 0.01 from pentazocine). Local and systemic safety were good, with no reactions at the injection site and no changes in vital parameters or laboratory findings. No patient reported any adverse reactions.",1998.0,0,0
1776,9676769,Efficacy and safety of tramadol HCl in breakthrough musculoskeletal pain attributed to osteoarthritis.,S H Roth,"To evaluate the efficacy of tramadol as adjunctive therapy in patients with musculoskeletal pain attributed to osteoarthritis (OA) who experienced breakthrough pain while taking a nonsteroidal antiinflammatory drug (NSAID). This single center, parallel, placebo controlled, 2 phase study was conducted in adults who experienced breakthrough OA pain while undergoing stable NSAID therapy. In a 24 h open label phase, patients took 100 mg of tramadol followed by 50 mg every 6 h (total 250 mg) in addition to their daily NSAID regimen. Supplemental analgesics were prohibited. Patients who met entry criteria and were willing to continue therapy were randomized to a 13 day double blind phase of adjunctive therapy with tramadol (50-100 mg every 4-6 h as needed for pain) or placebo; NSAID therapy was continued. The primary efficacy endpoint was the time to exit from the study because of therapeutic failure (i.e., insufficient pain relief or an inability to perform activities of daily living). The time to exit from the study because of insufficient pain relief tended to be longer in the tramadol group (250 mg/day) compared with the placebo group (p = 0.066). At the end of the double blind phase, pain at rest was significantly less severe in tramadol treated patients (p = 0.046). In addition, severity of pain on motion tended to be less severe in tramadol treated patients (p = 0.059). General severity of current pain and ability to perform activities of daily living were not significantly different with tramadol or placebo. Patients' overall assessment of therapy (p = 0.022) and investigator's rating of global improvement (p = 0.004) were significantly better with tramadol than with placebo. Tramadol may have a role as adjunctive treatment for breakthrough pain in patients receiving NSAID therapy for musculoskeletal pain attributed to OA.",1998.0,0,0
1777,9677793,[Postoperative analgesia with PCA in 300 patients. A comparison of four therapeutic regimes].,C Giannotti; A Lazzari,"The results of patient-controlled analgesia (PCA) in 300 patients undergoing major operations in general surgery, urology, ENT and obstetrics-gynaecology are presented. An i.v. basic infusion was used on which the patient was able to insert, at minimum intervals pre-established by the physician, boluses of 1/4 of the hourly dose; the drugs used were ketorolac (K), (110 patients-30 mg as a priming dose and 90 mg infused over the subsequent 24 hours), tramadol (90 patient-100 + 300 mg), buprenorphine (55 patients-0.3 + 0.9 mg) and a combination of ketorolac and buprenorphine (45 patients-30 mg of K as priming dose and 60 + 0.6 mg in infusion). during the first 24 hours at pre-established intervals the following data were recorded: efficacy of analgesia (by means of verbal and visual analogues), degree of consciousness, systolic and diastolic blood pressure and heart rate, as well as any onset of adverse side effects, such as drowsiness, nausea, vomiting, itching, urine retention, respiratory depression, gastralgia, pyrosis, allergic reactions, disorientation and excitement. The analgesic efficacy was confirmed by values of the verbal analogue lying between 1.2 and 0.8 in all the therapeutic schemes. The assessment of patients was carried out in the 24 hours following surgical operation, analysing analgesic efficacy and tolerability of the various treatments used. The number of self-administrations carried out by patients was superimposable among treatments and the 4 analgesic schemes determined a valid control of postoperative pain without influencing sensorial capacity. The safety of the various therapeutic schemes studied was also good, there were no variations in haemodynamic parameters and there was only a low incidence of side effects. On the basis of personal experience, patient controlled analgesia has been demonstrated to be an effective, reliable and flexible procedure for the control of postoperative pain.",1998.0,0,0
1778,9679206,The management of postsurgical pain in the elderly population.,J Richardson; K Bresland,"It is likely that the trend towards ever more aggressive surgery in elderly and possibly frail patients will continue, with the lifting of traditional age limits. Recent evidence has show that surgical trauma induces processes of nervous system sensitisation that contributes to and enhances postoperative pain and leads to chronic pain. This knowledge provides a rational basis for pro-active, pre-operative and post-operative analgesic strategies which can reduce the neuronal barrage associated with tissue damage. As well as a reduction or elimination of post-operative pain, an improvement in physiological variables, such as neuroendocrine stress responses and post-operative pulmonary function can be expected. Complete pain control cannot be achieved with a single agent or technique without significant serious adverse effects, a problem which is compounded in the elderly patient due to a combination of slower drug metabolism, decreased organ function and physiological changes in cardiovascular and respiratory reserves. A balanced analgesic regimen that includes an effective afferent block (regional analgesia) is more appropriate. By preventing postoperative pain and its associated neuroendocrine sequelae, major surgical procedures in traditionally unsuitable patients can be seriously considered.",1998.0,0,0
1779,9686089,[Brachial plexus block: effect of the addition of sufentanil to local anesthetic mixture on postoperative analgesia duration].,J E Bazin; C Massoni; D Groslier; V Fenies; M Bittar; P Schoeffler,"To compare the quality and the duration of analgesia produced by a supraclavicular brachial plexus blockade obtained with a mixture of lidocaine and bupivacaine when supplemented or not with sufentanil. Prospective, randomized, double-blind study. The study included 40 patients undergoing osteosynthesis of the upper limb under brachial plexus block, randomly assigned to two groups. The patients of the control group were given 0.5% bupivacaine 1 mg.kg-1 and 1% lidocaine 2 mg.kg-1. Those of the sufentanil group, received the same mixture supplemented with sufentanil 0.2 mg.kg-1. During the postoperative period, the characteristics of analgesia were blindly evaluated every hour for 48 h with a visual analogic scale graduated from 0 to 100. Analgesia was considered satisfactory when the score was below 30. Adverse effects of opiates (drowsiness, pruritus, nausea and vomiting) were also assessed. Oxygen saturation was continuously monitored. Blood pressure, heart and respiratory rates were measured at the same intervals than analgesia. Duration of analgesia are expressed as medians (range) and compared using a Mann and Whitney's U test. The respective durations of satisfactory analgesia were significantly different: 12.5 h (8-17) in the control group versus 24 h (8-48) for the sufentanil group. The adverse effects in the sufentanil group were nausea (2), vomiting (1) and pruritus (1). No respiratory depression was noted. Sufentanil added to a mixture of lidocaine and bupivacaine increases twofold the duration of postoperative analgesia following branchial plexus blockade.",1998.0,0,0
1780,9689372,Preemptive analgesia: its role and efficacy in anterior cruciate ligament reconstruction.,C J Gatt; R D Parker; J E Tetzlaff; M Z Szabo; A B Dickerson,"As more outpatient orthopaedic surgical procedures are performed, postoperative pain control has gained importance. The benefits of preemptive analgesia, the use of analgesics or anesthetics or both before painful stimuli to prevent or reduce pain, have been widely published in the anesthesia and general surgery literature, but not in orthopaedic literature. We prospectively compared the effects, on postoperative pain and narcotic use, of intraarticular preoperative injections of 1) placebo with epinephrine, 2) bupivacaine with epinephrine, and 3) bupivacaine and morphine with epinephrine. Thirty patients (10 in each group) underwent arthroscopic anterior cruciate ligament reconstruction using patellar tendon autograft under general anesthesia. Pain was assessed with a 10-point visual analog scale pre- and postoperatively, and postoperative narcotic pain medication use was recorded. Postoperative pain was significantly greater in group 1 (placebo) than in the preemptive-treatment groups (groups 2 and 3), and in group 2 than in group 3. The differences became less apparent with time, and after 1 hour, no significant differences in pain scores existed between the groups. However, intravenous narcotic pain medication was administered in the recovery room to patients with pain scores greater than 5, equalizing pain scores. Group 3 used significantly less postoperative narcotic medication than group 1. Preemptive analgesia using intraarticular bupivacaine and morphine with epinephrine resulted in lower pain scores during the 1st hour after an arthroscopic anterior cruciate ligament reconstruction than did preemptive treatment with bupivacaine and epinephrine or placebo and epinephrine.",2001.0,0,0
1781,9689426,Comparison of the efficacy and tolerability of a paracetamol/codeine fixed-dose combination with tramadol in patients with refractory chronic back pain.,F O Müller; C L Odendaal; F R Müller; J Raubenheimer; M V Middle; M Kummer,"Fifty-five patients suffering from refractory chronic back pain took part in a double-blind, multiple-dose, randomised, cross-over study to compare the efficacy and tolerability of a fixed-dose capsule preparation containing 500 mg paracetamol (CAS 103-90-2) and 30 mg codeine phosphate 1/2 H2O (CAS 41444-62-6) (talvosilen forte, test preparation) with a reference capsule preparation containing 50 mg tramadol hydrochloride (CAS 22204-88-2), in a regimen of two capsules 8-hourly. There were two treatment periods of up to 7 days each. Cross-over took place, without washout, at the end of 7 days, or sooner if patients were unable to tolerate the first treatment. The test preparation was at least as efficacious as the reference in the treatment of back pain (81% of patients experienced good or satisfactory pain relief). 81% of patients tolerated the test well compared to only 69% receiving the reference, as per protocol analysis. The results of this study suggest that the test product is at least as efficacious as tramadol in the treatment of patients with refractory chronic back pain, whilst being better tolerated.",1998.0,0,0
1782,9690947,Pulmonary administration of aerosolised fentanyl: pharmacokinetic analysis of systemic delivery.,L E Mather; A Woodhouse; M E Ward; S J Farr; R A Rubsamen; L G Eltherington,"Pulmonary drug delivery is a promising noninvasive method of systemic administration. Our aim was to determine whether a novel breath-actuated, microprocessor-controlled metered dose oral inhaler (SmartMist, Aradigm Corporation) could deliver fentanyl in a way suitable for control of severe pain. Aersolised pulmonary fentanyl base 100-300 microg was administered to healthy volunteers using SmartMist and the resultant plasma concentration-time data were compared with those from the same doses administered by intravenous (i.v.) injection in the same subjects. Plasma concentrations from SmartMist were similar to those from i.v. injection. Time-averaged bioavailability based upon nominal doses averaged approximately 100%, and was > 50% within 5 min of delivery. Fentanyl systemic pharmacokinetics were similar to those previously reported with no trends to dose-dependence from either route. Side-effects (e.g. sedation, lightheadedness) were the same from both routes. Fentanyl delivery using SmartMist can provide analgetically relevant plasma drug concentrations. This, combined with its ease of noninvasive use and transportability, suggests a strong potential for field and domicilliary use, and for patient controlled analgesia without the need for i.v. cannulae.",1998.0,0,0
1783,9691878,Comparison between extradural infusion of ropivacaine or bupivacaine for the prevention of postoperative pain after total knee arthroplasty.,T Muldoon; K Milligan; P Quinn; D C Connolly; K Nilsson,"We have compared the analgesia and motor block produced by extradural infusions of ropivacaine and bupivacaine after total knee arthroplasty. Fifty-two patients received 8 ml h1 of either 0.2% ropivacaine or 0.2% bupivacaine by extradural infusion for 24 h after operation. Analgesia was assessed by postoperative visual analogue scale (VAS) and morphine consumption. At rest these were low in both groups; median VAS was 0-13.3 mm for the ropivacaine group and 0-0.5 mm for the bupivacaine group. Over the 24 h of the infusion, the estimated (ropivacaine bupivacaine) difference in wound pain at rest was 5.6 mm (P = 0.017) and on passive movement 11.6 mm (P = 0.016). Median morphine consumption was 30.7 mg in the ropivacaine group and 20.5 mg in the bupivacaine group. In the ropivacaine group, 50% of patients compared with 19% in the bupivacaine group had no motor block 2 h after operation, increasing to 88% for ropivacaine and 56% for bupivacaine by 24 h. Bupivacaine produced significantly more frequent and intense motor block over the 24 h (P = 0.015).",1998.0,0,0
1784,9693241,What are the parameters for predictive selection of patients requiring anesthesia for extracorporeal shockwave lithotripsy?,A Weber; K U Koehrmann; N Denig; M S Michel; P Alken,"Additional anesthesia is required to minimize the tolerable pain level in efficiently performed extracorporeal shockwave lithotripsy (ESWL) with electrohydraulic and electromagnetic sources. In order to assess optimum anesthesia for each patient undergoing a standardized ESWL protocol, pain measurement and scoring were carried out. We attempted to determine the individual type and amount of analgesia prior to treatment. Patients (n = 95) with urolithiasis underwent pain measurement and scoring prior to ESWL. 'Threshold of pain' (TP) and 'maximal tolerable pain (MTP) were assessed by inducing ischemia pain with the submaximum effort tourniquet technique. Pain intensity was assessed by a verbal rating scale (VRS). The results of pain measurement and amount of analgosedation were correlated in two phases. Patients were administered an oral premedication of 0.1 mg/kg midazolam. Phase 1: 60 patients were randomized into three groups: (1) piritramide (0.1-0.3 mg/kg) and midazolam (1-3 mg) i.v. (2) Lidocaine/prilocaine cream topically (30 g) to skin and diclofenac supp. 100 mg. (3) No analgesia. Phase 2: Based on the data of phase 1, cut-off points for TP and MTP were set for female and male patients. In accordance with these results, 35 patients comprised group 1 for anesthesia with piritramide/midazolam, group 2 with lidocaine/prilocaine cream and diclofenac supp. and group 3 for no analgesia at all. The electromagnetic shockwave sources Modulith SLX and Lithostar Plus were utilized. Phase 1: All patients randomized for group 1 (intravenous analgosedation) were treated in accordance with the protocol. 65% of group 2 (cream/suppository) tolerated treatment as planned. 35% of patients selected for ESWL without analgesia (group 3) remained within this group. Patients requiring additional analgosedation displayed lower TP and MTP. The cut-off points for females and males were TP >/=25/35 s and MTP >/=45/60 s, respectively. Phase 2: 20/35 patients were preselected for a nonintravenous protocol. Five out of these 20 violated the protocol. The rate of additionally administered analgesia was lower than in phase 1: 35:10% in group 2 (cream/supp.), 65:40% in group 3 (no analgesia). The TP and MTP levels are lower in patients requiring stronger analgesia. The determined parameters are suitable for patient preselection and individual assessment of anesthesia prior to ESWL. It may be assumed that 50% of patients administered intravenous opioids are overtreated. Routine pain measurement for patient depends on the individual pain tolerance level. A third phase of this study recruiting a large number of patients will contribute to the confirmation of these results.",2000.0,0,0
1785,9696169,Ketorolac versus acetaminophen-codeine in the emergency department treatment of acute low back pain.,G D Innes; P Croskerry; J Worthington; R Beveridge; D Jones,"Acute low back pain is a common problem in the emergency department (ED). Effective management of acute pain enhances early rehabilitation and recovery. Given the importance of inflammatory mediators in pain generation and the adverse effects associated with opioids, it is logical to expect that a non-opioid agent with antiinflammatory and analgesic properties would provide excellent analgesia with fewer adverse effects. This double-blind, randomized, multicenter clinical trial, performed in six university and community hospital EDs, compares the analgesic efficacy and adverse effects of ketorolac to those of acetaminophen-codeine in ED patients with acute musculoskeletal low back pain. Our hypothesis was that ketorolac would provide superior analgesia with fewer adverse effects. One hundred twenty-three patients with acute low back pain were randomized to receive ketorolac (KET, N = 63) or acetaminophen-codeine (ACOD, N = 60). Most (79%) were males, and the mean age was 34.5 years. After baseline clinical assessment, patients were treated with ketorolac (10 mg every 4 to 6 h as needed, up to four daily doses) or acetaminophen-codeine (600 mg-60 mg, respectively, every 4 to 6 h as needed, up to six daily doses) and followed for one week. Pain intensity was assessed on visual analogue and categorical scales. Functional capacity, overall pain relief, and overall medication rating were assessed on categorical scales. Adverse events were documented. Primary outcomes included: 1) Pain intensity differences, based on visual analogue scores, for the 0 to 6 h treatment phase. 2) Incidence of adverse events. Secondary outcomes included analgesic efficacy, functional capacity, and overall subjective drug evaluation at one week. Both drugs provided substantial pain relief, with maximal effect 2.2 h after oral dosing. There were no significant differences in analgesic efficacy, functional capacity, or overall pain relief between the two groups. Sixteen patients (10 KET vs. 6 ACOD, NS) withdrew prematurely because of drug inefficacy. Patients in the ACOD group reported significantly more adverse drug events and serious adverse drug events. Seven patients--all in the ACOD group--withdrew from the study because of adverse drug events. Based on comparable efficacy and a superior adverse event profile, ketorolac was preferable to acetaminophen with codeine for the treatment of acute low back pain in the ED.",1998.0,0,0
1786,9696455,"Nimodipine-enhanced opiate analgesia in cancer patients requiring morphine dose escalation: a double-blind, placebo-controlled study.",R Santillán; M A Hurlé; J A Armijo; R de los Mozos; J Flórez,"The ability of nimodipine, a dihydropyridine calcium antagonist, to reduce the daily dose of oral morphine in cancer patients who had developed dose escalation, was tested in 54 patients under randomized, double-blind, placebo-controlled conditions. We selected patients that required at least two successive increments of morphine to maintain pain relief. A possible pharmacokinetic interaction between nimodipine and morphine was also studied in 14 patients by assaying steady-state serum levels of morphine and its 3- and 6-glucuronides. A total of 30 patients completed the study, 14 and 16 in the nimodipine and placebo groups, respectively. Nimodipine controlled the escalation of the morphine dose in 9 patients (65%), and placebo in 4 (28%), the difference being statistically significant (P=0.03). The dose of morphine was reduced from 313+/-52 to 174+/-33 mg/day (P < 0.001) in the nimodipine group, and from 254+/-26 to 218+/-19 mg/day (not significant) in the placebo group. The percentages of reduction in the daily dose of morphine also showed significant differences between both groups (P=0.02). One week after introducing nimodipine or placebo, while the dose of morphine remained similar to that of the pre-test week, the serum levels of morphine and its glucuronides were not modified significantly. We conclude that the introduction of nimodipine in patients chronically treated with morphine may be a safe alternative to reduce the daily requirements of the opioid. It is suggested that interference with Ca2+-related events may attenuate the development and/or expression of tolerance to morphine in a clinically relevant way.",1998.0,0,0
1787,9696456,Same incidence of adverse drug events after codeine administration irrespective of the genetically determined differences in morphine formation.,K Eckhardt; S Li; S Ammon; G Schänzle; G Mikus; M Eichelbaum,"The analgesic effect and adverse events of the weak opioid codeine is assumed to be mediated by its metabolite morphine. The cytochrome P-450 enzyme CYP2D6 catalysing the formation of morphine exhibits a genetic polymorphism. Two distinct phenotypes, the extensive (EMs) and poor metabolisers (PMs), are present in the population. The prevalence of PMs in the Caucasian population is 7% to 10%. Since PMs do not express functional CYP2D6, they have a severely impaired capacity to metabolise drugs which are substrates of this enzyme. Provided the analgesic effect and the adverse events of codeine are mediated by its metabolite morphine, large phenotype-related differences are to be expected and PMs, as they form only trace amounts of morphine, can serve as a model to test the hypothesis whether the analgesia and adverse events of codeine are mediated by the parent drug or its metabolite morphine. Therefore we have studied in a randomised placebo-controlled double-blind trial the analgesic effect of 170 mg codeine (p.o.) compared to 20 mg morphine (p.o.) and placebo in 9 EMs and 9 PMs using the cold pressor test. The duration and intensity of the side effects were assessed using visual analogue scales (VAS). Codeine and morphine concentrations were measured in serum and urine. Compared to placebo, 20 mg morphine caused a significant increase in pain tolerance in both phenotypes, EMs and PMs (16.2+/-27.4 vs. -0.66+/-27.4 s x h, n=18). However, following administration of codeine, analgesia was only observed in EMs but not in PMs (EMs: 54.9+/-42.2 vs. 1.7+/-4.2 s x h, P < 0.01; PMs: 9.6+/-10.9 vs. 3.3+/-23.7 s x h, not significant). Adverse events were significantly more pronounced after morphine and codeine compared to placebo in both EMs and PMs. In contrast to the phenotype-related differences in the analgesic effect of codeine, however, no difference in adverse events between the phenotypes could be observed. In the pharmacokinetic studies, significant differences between the two phenotypes in the formation of morphine after codeine administration could be observed. Whereas morphine plasma concentrations were similar in PMs (Cmax: 44+/-13 nmol/l: AUC: 199+/-45 nmol x h/l) and EMs (Cmax: 48+/-17 nmol/l); AUC: 210+/-65 nmol x h/l) after morphine administration, following 170 mg codeine, morphine plasma concentrations comparable to those after morphine application were only observed in EMs (Cmax: 38+/-16 nmol/l; AUC: 173+/-90 nmol x h/l). In PMs only traces of morphine could be detected in plasma (Cmax: 2+/-1 nmol/l; AUC: 10+/-7 nmol x h/l). The percentage of the codeine dose converted to morphine and its metabolites was 3.9% in EMs and 0.17% in PMs. The interindividual variability in analgesia of codeine which is related to genetically determined differences in the formation of morphine clearly indicate that this metabolite is responsible for the analgesic effect of codeine. In contrast to the analgesic effect, frequency and intensity of the adverse events did not present significant differences between the two phenotypes. These findings have implications for the clinical use of codeine. Since side effects occurred in both EM and PM subjects, the use of codeine as an analgesic will expose 7% to 10% of patients who are PMs to the side effects of the drug without providing any beneficial analgesic effects.",1998.0,0,0
1788,9696467,Peripheral morphine analgesia in dental surgery.,R Likar; R Sittl; K Gragger; W Pipam; H Blatnig; C Breschan; H V Schalk; C Stein; M Schäfer,"The recent identification of opioid receptors on peripheral nerve endings of primary afferent neurons and the expression of their mRNA in dorsal root ganglia support earlier experimental data about peripheral analgesic effects of locally applied opioids. These effects are most prominent under localized inflammatory conditions. The clinical use of such peripheral analgesic effects of opioids was soon investigated in numerous controlled clinical trials. The majority of these have tested the local, intraarticular administration of morphine in knee surgery and have demonstrated potent and long-lasting postoperative analgesia. As the direct application of morphine into the pain-generating site of injury and inflammation appears most promising, we examined direct morphine infiltration of the surgical site in a unique clinical model of inflammatory tooth pain. Forty-four patients undergoing dental surgery entered into this prospective, randomized, double-blind study. Before surgery they received, together with a standard local anesthetic solution (articaine plus epinephrine) a submucous injection of either 1 mg of morphine (group A) or saline (group B). Postoperative pain intensity was assessed using the visual analog scale (VAS) and numeric rating scale (NRS) at 2, 4, 6, 8, 10, 12, 16, 20 and 24 h after surgery. In addition, patients recorded the occurrence of side effects and the supplemental consumption of diclofenac tablets. Results of 27 patients were analyzed (group A: n=14, group B: n=13). Pain scores which were moderate to severe preoperatively were reduced to a similar extent in both groups up to 8 h postoperatively. Thereafter, pain scores in group A were significantly lower than those in group B for up to 24 h, demonstrating the analgesic efficacy of additional morphine. The time to first analgesic intake and the total amount of supplemental diclofenac were less in group A than in group B. No serious side effects were reported. Our results show that 1 mg of morphine added to a local anesthetic for dental surgery results in significant improvement of postoperative analgesia. Since the majority of dental surgeries is accompanied with an inflammatory reaction, supplemental morphine may be of benefit for the relief of postoperative dental pain.",1998.0,0,0
1789,9697906,Complete analgesia during pleurodesis under thoracic epidural anesthesia.,P M Kempen,"Pain during pleurodesis is frequently severe and poorly suppressed with intravenous narcotics and/or local anesthetic installation. Epidural analgesia is very effective for all types of severe pain including surgical anesthesia, yet has not been reported in treating pleurodesis pain. Thoracic epidural can be safely and extremely effectively utilized when neural pathways are considered, as this case history demonstrates.",1998.0,0,0
1790,9698948,The analgesic effect of racemic ketamine in patients with chronic ischemic pain due to lower extremity arteriosclerosis obliterans.,J Persson; J Hasselström; B Wiklund; A Heller; J O Svensson; L L Gustafsson,"Ketamine in sub-dissociative doses has been shown to have analgesic effects in various pain conditions, including neuropathic and phantom-limb pain, where conventional treatment has often failed. Chronic ischemic pain due to lower extremity arteriosclerosis obliterans often responds poorly to analgesics, and the pain-generating mechanisms are not well understood. Eight patients with rest pain in the lower extremity due to arteriosclerosis obliterans were given sub-dissociative doses of 0.15, 0.30, or 0.45 mg/kg racemic ketamine and morphine 10 mg as a 5-min infusion on four separate days in a cross-over, double-blind, randomised protocol. Plasma levels of (S)- and (R)-ketamine and their nor-metabolites were analysed with an enantioselective high-performance liquid chromatography (HPLC) method. Pain levels were evaluated with a visual analogue scale (VAS). Individual pain levels were highly variable during and after all the infusions but the pooled pain levels showed a dose-dependent analgesic effect of ketamine with a transient but complete pain relief in all the patients at the highest dose (0.45 mg/kg). Side-effects, mainly disturbed cognition and perception, were pronounced and dose-dependent. Morphine 10 mg had an analgesic peak at 20 min and 5/8 patients had complete pain relief. These 3 patients also had high baseline pain scores, indicating a higher analgesic potency for the 0.30 and 0.45 mg/kg ketamine doses than for morphine 10 mg. We have demonstrated a potent dose-dependent analgesic effect of racemic ketamine in clinical ischemic pain. Due to a narrow therapeutic window, this analgesic effect is probably best utilised in combination with other analgesics.",1998.0,0,0
1791,9698949,"Postural post-dural puncture headache after spinal and epidural anaesthesia. A randomised, double-blind study.",H Flaatten; J Felthaus; R Larsen; S Bernhardsen; H Klausen,"This study was conducted in order to investigate the effect of patient expectation in the development of postural post-dural puncture headache (PPDPH). 224 patients less than 55 years scheduled for minor non-obstetric surgery were randomised to receive single-injection spinal (SA) or epidural (EA) anaesthesia. A 27-g Quinke needle was used for SA and a 18-g Tuohy needle for EA. Patients, operating team and postoperative ward personnel were all blinded to the anaesthetic given and so was an independent observer responsible for follow-up after 5-7 days. The occurrence of headache, backache and other complaints was recorded. Headache was classified as PPDPH or non-PPDPH, and duration and intensity of the headache was registered. The quality of anaesthesia was directly evaluated by the surgeon using a VAS scale from 1 (excellent) to 10 (very poor) and indirectly by the supplemental use of opioid analgesia and general anaesthesia in the two groups. 212 patients, 103 SA and 109 EA, with a mean age of 36.7 years, could be fully evaluated. The groups were comparable with regards to age, sex and surgical procedure performed. Headache occurred in 44 patients postoperatively. PPDPH was diagnosed in 16 patients (15.5%) in the SA group and 2 (1.8%) in the EA group (P = 0.0014). Non-PPDPH occurred in 13 patients in each group. PPDPH had significantly greater mean intensity and duration than non-PPHPH. More patients in the EA group had postoperative backache (31.2%) than in the SA group (22.3%), but this difference was not statistically significant. More patients in the EA received general anaesthesia and opioid analgesia than in the SA group, and the surgeon's rating was on average 1.3 in the SA group compared to 2.5 in the EA group (P = 0.0003). SA gave more headache but superior quality of surgical anaesthesia compared with EA. Dural puncture, and not expectation, is the major cause of PPDPH.",1998.0,0,0
1792,9698952,Postoperative analgesia with epidural bupivacaine and low-dose fentanyl--a comparison of two concentrations.,S Sjöström; J Bläss,"The purpose of the study was to compare the analgesic and side effects of two epidurally administered mixtures of bupivacaine and fentanyl with the same drug ratios. One hundred patients scheduled for colorectal surgery were randomized to receive a thoracic epidural infusion of either bupivacaine 0.12% with fentanyl 2 micrograms/ml or bupivacaine 0.24% with fentanyl 4 micrograms/ml during 48 h postoperatively. The pumps were adjusted to keep the visual analogue scale (VAS) pain score at 3 or less (on a scale of 0-10) with a minimum of adverse effects. There were no statistically significantly differences between the two groups in VAS pain scores. The average VAS pain score resting varied between 0.5 and 1, and coughing between 1.9 and 3.4. One case of respiratory depression with breathing frequency 7 occurred in each group, but none of the patients required naloxone. One patient in the low concentration group developed partial motor weakness in both legs 36 h postoperatively. Equal drug amounts--bupivacaine 10.8-11 mg/h and fentanyl 18-18.4 micrograms/h--were given in both groups throughout the study. Both groups had low pain scores with few and comparable adverse effects. It thus seems that the volume is not important when mixtures of bupivacaine and fentanyl in the studies concentrations are infused epidurally at a low thoracic level. Practical reasons favour the higher concentration mixture.",1998.0,0,0
1793,9699104,An evaluation of intercostal nerve blockade for analgesia following renal transplantation.,P Knowles; D Hancox; M Letheren; J Eddleston,"In a double-blinded study we examined the effect of supplementing patient-controlled morphine analgesia with intercostal nerve blockade to identify if this improved analgesia and reduced morphine requirements following renal transplantation. Fifty patients were randomized to receive unilateral intercostal nerve block with either 0.5% bupivacaine or saline to the lower five intercostal nerves. Each block was performed on the side of surgical incision following the completion of surgery. Patients receiving bupivacaine blockade reported reduced pain scores and used less morphine in the initial 4 h following renal transplantation, but did not demonstrate a significant reduction in overall pain scores, total 24 h morphine requirements, or sedation scores. Two patients developed a pneumothorax, neither of which were clinically apparent at the time of diagnosis, and only detected by chest radiography. A chest radiograph should therefore be considered mandatory after intercostal nerve blockade.",1998.0,0,0
1794,9699327,[Opiates in pain management: correct or underestimated use? Data from a university hospital].,A W Daudt; E Hadlich; M A Facin; R M Aprato; R P Pereira,"Opiates use, mainly in the treatment of acute intense pain (post-surgical patients) and chronic pain in oncologic patients has been usually underestimated in general clinical practice. This paper has the objective to assess the pattern of opiates use (Meperidin and Morphine), that is being used in Hospital de Clínicas de Porto Alegre, Rio Grande do Sul (Brazil). Medical teams prescriptions were analyzed using the following parameters: pattern of use, dose, interval and the use of concomitant analgesics. 1,107 prescriptions were analyzed, related to 445 inpatients, in the period from May to July of 1993. Only 6.5% of all prescriptions were considered correct. The pattern if necessary was responsible for 74% of all prescriptions. Pain, either acute or chronic, is not being adequately managed in our hospital.",1998.0,0,0
1795,9701293,"Double-blind, multicenter trial to compare the efficacy of intramuscular dihydroergotamine plus hydroxyzine versus intramuscular meperidine plus hydroxyzine for the emergency department treatment of acute migraine headache.",S C Carleton; R F Shesser; M P Pietrzak; C R Chudnofsky; S Starkman; D L Morris; G Johnson; K J Rhee; C W Barton; J E Chelly; J Rosenberg; M K Van Valen,"To evaluate intramuscular dihydroergotamine in direct comparison with opioid analgesia in the treatment of acute migraine headache. This was a prospective, multicenter, double-blind trial performed in the emergency departments of 11 general hospitals in the United States. One hundred seventy-one patients between the ages of 18 and 60 years who presented to the ED with acute migraine headache were enrolled. Patients were randomly assigned to receive either 1 mg dihydroergotamine (DHE) or 1.5 mg/kg meperidine (MEP) by intramuscular injection. The anti-nauseant hydroxyzine (H) was coadministered in both treatment groups. One hundred fifty-six patients were evaluable. Treatment groups were comparable in sample size, demographics, and baseline measurements of headache pain. Reduction of headache pain as measured on a 100-mm visual analog scale was 41+/-33 mm (53.5% reduction) for the DHE group, and 45+/-30 mm (55.7% reduction) for the MEP group at 60 minutes after treatment (difference=2.2%; 95% confidence interval [CI] -10%, 14.5%; P=.81). Reduction in the severity of nausea and improvement in functional ability were similar between treatment groups. Central nervous system adverse events were less common in the DHE group (DHE 23.5% versus MEP 37.6%, difference-14.1%: 95% CI -28%, 0%). In particular, dizziness was reported less commonly with DHE than MEP (2% versus 15%, difference=-13%: 95% CI -21%, -5%). In this prospective, double-blind trial of a convenience sample of ED patients randomly assigned to one of two treatment regimens, DHE and MEP were comparable therapies for acute migraine. The use of DHE avoids several problems associated with opioid analgesia, including dizziness.",1998.0,0,0
1796,9701294,"Tramadol versus hydrocodone-acetaminophen in acute musculoskeletal pain: a randomized, double-blind clinical trial.",M A Turturro; P M Paris; G L Larkin,"To evaluate the efficacy of an oral tramadol preparation versus that of an oral hydrocodone-acetaminophen preparation in acute musculoskeletal pain. A randomized, prospective, double-blind clinical trial was conducted in an urban teaching emergency department with an annual census of 41,000. Participants comprised a convenience sample of 68 adult ED patients with acute musculoskeletal pain caused by minor trauma. Thirty-three patients received tramadol (100 mg), and 35 patients received hydrocodone-acetaminophen (5 mg hydrocodone with 500 mg acetaminophen). The drugs were prepared in identical-appearing capsules. Pain was evaluated by a 100-mm visual analog scale (VAS) at baseline and at 30, 60, 90, 120, and 180 minutes after dosing. VAS scores were analyzed by 2-way repeated-measures ANOVA, and nominal data were analyzed by Fisher's exact test. Mean pain scores did not differ at baseline (tramadol, 68.3+/-21.8; hydrocodone-acetaminophen, 69.1+/-17.8; P=NS) but were significantly lower in the hydrocodone-acetaminophen group beginning at 30 minutes through 180 minutes. There were 6 dropouts as a result of reported inadequate analgesia, 3 in each group (P=NS). The discharge diagnoses and prevalence of side effects did not differ significantly between groups. Tramadol provides inferior analgesia to hydrocodone-acetaminophen in ED patients with acute musculoskeletal pain.",1998.0,0,0
1797,9702628,A protocol-contract for opioid use in patients with chronic pain not due to malignancy.,A F Kirkpatrick; M Derasari; P L Kovacs; B D Lamb; R Miller; A Reading,"The legal, psychosocial, and medical factors that we believe have contributed to the success of our protocol-contract in prescribing opioids to patients with chronic pain not due to malignancy are outlined. These factors may be applicable to the treatment of a variety of chronic nonmalignant pain syndromes such as postherpetic neuralgia or human immunodeficiency virus/acquired immunodeficiency syndrome. The intended target audience of this paper is the physician (primary care, chronic pain specialist) who is involved in prescribing opioids for the treatment of chronic, nonmalignant pain.",1998.0,0,0
1798,9703640,[Pain therapy in tumor patients and in palliative medicine. 1: Drug therapy].,F B Ensink; M T Bautz; A M Hirn; S Nass; D Kettler; G G Hanekop,"Like other industrial countries Germany experiences a significant increase of cancer prevalence. Recent advances in the treatment of various types of cancer resulted in prolonged survivaltimes of patients. Cancer--especially in advanced incurable stages--often is accompanied by severe pain. Therefore, the need for sufficient pain management and symptomcontrol is obvious. Throughout the last decades new drugs and techniques for the management of cancer-pain have been developed. Most cancer-patients should experience sufficient pain-management if existing recommendations for the pharmacological treatment of cancer-pain (e.g. WHO-guidelines) are followed consequently. In case of intractable pain or ongoing disabling symptoms despite proper therapy consultation of an expert in palliative medicine should always be considered as well as the option to refer the patient to a specialized pain-management center.",1998.0,0,0
1799,9703641,[Pain therapy in tumor patients and in palliative medicine. 2: Invasive measures].,G G Hanekop; M T Bautz; D Beck; D Kettler; F B Ensink,"Anesthesiological and neurosurgical methods in the treatment of cancer pain have to be considered as parts of a holistic approach. To treat cancer pain patients appropriately, an interdisciplinary setting is essential. In the eyes of experienced pain specialists as well as physicians in palliative medicine invasive procedures are only of minor importance. Their use has been steadily decreasing while neuromodulatory (e.g. intraspinal opioids) or stimulatory (e.g. TENS, DBS, SCS) methods gained wider acceptance. The only neurolytic procedure which still has some importance is the neurolysis of the celiac ganglion for alleviation of pain in the upper abdomen mostly due to pancreatic cancer. This approach seems to be highly effective and tends to be afflicted with only minor complications. Other neurolytic blocks have shown solely local and temporal efficacy. In their majority they are unprecise and often accompanied by severe complications. Therefore these procedures should be scheduled only after carefully weighing risk versus benefit. Where suitable, the use of neurolytics is replaced by radiofrequency thermocoagulation, to a lesser degree by cryoanalgesia. Both procedures normally do not yield better analgesia but do result in fewer complications. Physicians tend to treat pain as a completely somatic disorder, but chronic pain states are always bio-psycho-social in nature. In order to achieve an effective pain treatment all influencing variables have to be taken into account. Anesthesiological and neurosurgical procedures are only a part of the possible and necessary treatment options. Especially before using one of the invasive methods described here, it seems imperative to involve the patient in the process of decision making more closely than currently practiced.",1998.0,0,0
1800,9708687,Variation in surgical trauma and baseline pain intensity: effects on assay sensitivity of an analgesic trial.,E K Breivik; G A Björnsson,"The aims of this study were to test the hypotheses that the type of 3rd molar removal determines baseline pain and that baseline pain influences analgesic assay sensitivity. Three groups of patients were studied: (i) 100 patients that had one fully erupted maxillary 3rd molar extracted; (ii) 95 patients that had one lower impacted 3rd molar surgically removed; and (iii) 98 patients that had two ipsilateral impacted 3rd molars surgically removed. In a randomized, double-blind fashion, the patients received (every third hour, three times) either: (i) paracetamol 1g; (ii) paracetamol 1g plus codeine 60 mg; or (iii) placebo. Baseline pain intensity (100 mm Visual Analogue Scale) was significantly lower after extraction (8 mm (2-20)) (=median (25th -75th percentile) than after surgical removal of one 3rd molar (35 mm (15-57)), which was significantly lower than pain intensity after surgical removal of two 3rd molars (49 mm (24-82)). Analgesic effects of the active test drugs were superior to placebo. Paracetamol with and without codeine could be distinguished in patients after surgical removal of one 3rd molar. In conclusion, baseline pain was related to the degree of surgical trauma, but large inter-individual variation in baseline pain intensity reduced the ability to distinguish between paracetamol with and without codeine.",1998.0,0,0
1801,9710394,,,,,0,0
1802,9710397,Transnasal butorphanol is effective for postoperative pain relief in children undergoing myringotomy.,R E Bennie; L A Boehringer; S F Dierdorf; M P Hanna; L J Means,"More than 70% of children require analgesics after bilateral myringotomy and tube placement (BMT). Because anesthesia for BMT is generally provided by face mask without placement of an intravenous catheter, an alternative route for analgesia administration is needed. Transnasal butorphanol is effective in relieving postoperative pain in adults and children. The effectiveness of transnasal butorphanol for postoperative pain management in children undergoing BMT was studied. This double-blinded, placebo-controlled study compared the postoperative analgesic effects of transnasal butorphanol administered after the induction of anesthesia. Sixty children classified as American Society of Anesthesiologists physical status 1 or 2 who were aged 6 months or older and scheduled for elective BMT were randomized to receive transnasal placebo or 5, 15, or 25 microg/kg butorphanol. Postoperative pain was assessed using the Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) on arrival in the postanesthesia care unit and at 5, 10, 15, 30, 45, and 60 min. The CHEOP scores were significantly less in the 25 microg/kg transnasal butorphanol group compared with controls. Significantly fewer children received rescue analgesia in the 25 microg/kg transnasal butorphanol group compared with controls (n = 1 and 8, respectively; P = 0.02). Transnasal butorphanol given in a dose of 25 microg/kg after induction of anesthesia provided adequate postoperative pain relief in children undergoing BMT.",1998.0,0,0
1803,9715298,Comparative study of intrathecal pethidine versus lignocaine as an anaesthetic and a postoperative analgesic for perianal surgery.,L S Chaudhari; D G Kane; B Shivkumar; S K Kamath,"100 patients with ASA risk I & II and undergoing perianal surgery were studied for anaesthetic effects and postoperative analgesia following either intrathecal pethidine or lignocaine. Saddle block was performed either with intrathecal pethidine 5% (50 mg/ml) 0.5 mg/kg or 1 ml of 5% lignocaine. Sensory and motor block postoperative analgesia, need for additional analgesia were studied. The onset of sensory and motor blockade with lignocaine was faster than pethidine. However the sensory and motor blockade lasted longer with pethidine. The duration of postoperative analgesia was 15.39 +/- 5.14 hours as against duration of postoperative analgesia with lignocaine which was 1.3 +/- 0.53 hours. Only 10% of patients in the pethidine group required intramuscular analgesic supplementation whereas 30% of patients in the lignocaine group required intramuscular analgesic supplementation.",1998.0,0,0
1804,9721926,"Spinal kappa1 and kappa2 opioid binding sites in rats, guinea pigs, monkeys and humans.",R M Caudle; A A Finegold; A J Mannes; M D Tobias; D R Kenshalo; M J Iadarola,"Several lines of work demonstrate that there are two subtypes of kappa opioid receptors. Intrathecally administered agonists for the kappa1 subtype are not effective in treating pain, whereas agonists for the kappa2 receptor are anti-hyperalgesic and anti-allodynic. The question addressed here was whether the ratio of spinal kappa1 to kappa2 receptors was conserved across species. Thus, binding experiments were performed on spinal cord membranes from rats, guinea pigs, monkeys and humans. We found that kappa2 receptors were approximately ten times more abundant than kappa1 receptors in all species tested. This suggests that the anti-hyperalgesic and anti-allodynic properties of kappa2 agonists may also be conserved. Therefore, selective kappa2 agonists may be effective in treating chronic pain in humans.",2001.0,0,0
1805,9722068,Effect of low-dose oral glutamine on painful stomatitis during bone marrow transplantation.,P M Anderson; N K Ramsay; X O Shu; N Rydholm; J Rogosheske; R Nicklow; D J Weisdorf; K M Skubitz,"Painful oral mucositis is a common complication after bone marrow transplantation (BMT). Glutamine is a nutrient for rapidly dividing cells and the major energy source for intestinal epithelium. This study tested whether an oral glutamine preparation could decrease the severity of oral mucositis in patients undergoing BMT. Glutamine or a placebo (glycine) were administered from admission until day +28 in 193 BMT patients in a randomized, double-blind, placebo-controlled study at a dose of 1.0 g amino acid/m2/dose swish and swallow four times a day. In autologous BMT patients (n = 87) glutamine was associated with significantly less mouth pain by self report and by opiate use (5.0+/-6.2 days of morphine for glutamine vs 10.3+/-9.8 days for placebo; P= 0.005). Matched sibling BMT patients had no effect by self report and an increased duration of opiate use (23.2+/-5.7 days for glutamine vs 16.3+/-8.3 days for placebo) (P = 0.002). However, day 28 survival of allogeneic patients was improved by glutamine. No significant differences in TPN use, rate of relapse or progression of malignancy, parenteral antibiotic use, acute or chronic GVHD, or days of hospitalization were observed in either autologous or allogeneic recipients. No toxicity of glutamine was observed. We conclude that oral glutamine can decrease the severity and duration of oropharyngeal mucositis in autologous BMT patients but not in allogeneic BMT patients, possibly due to interaction with methotrexate.",1998.0,0,0
1806,9725371,"Prospective, randomized comparison of extrapleural versus epidural analgesia for postthoracotomy pain.",A M Kaiser; A Zollinger; D De Lorenzi; F Largiadèr; W Weder,"Thoracic epidural analgesia is considered the method of choice for postthoracotomy analgesia, but it is not suitable for every patient and is associated with some risks and side effects. We therefore evaluated the effects of an extrapleural intercostal analgesia as an alternative to thoracic epidural analgesia. In a prospective, randomized study, pain control, recovery of ventilatory function, and pulmonary complications were analyzed in patients undergoing elective lobectomy or bilobectomy. Two groups of 15 patients each were compared: one received a continuous extrapleural intercostal nerve blockade (T3 through T6) with bupivacaine through an indwelling catheter, the other was administered a combination of local anesthetics (bupivacaine) and opioid analgesics (fentanyl) through a thoracic epidural catheter. Both techniques were safe and highly effective in terms of pain relief and recovery of postoperative pulmonary function. However, minor differences were observed that, together with practical benefits, would favor extrapleural intercostal analgesia. These results led us to suggest that extrapleural intercostal analgesia might be a valuable alternative to thoracic epidural analgesia for pain control after thoracotomy and should particularly be considered in patients who do not qualify for thoracic epidural analgesia.",1998.0,0,0
1807,9729117,The ordeal of chronic pain.,V Bonicalzi; S Canavero; A Cerutti; B M Micon; F Cerutti; M Clemente; N Montrucchio,,2000.0,0,0
1808,9733274,Comparison of a patient-controlled analgesia system with continuous infusion for administration of diamorphine for mucositis.,L C Pillitteri; R E Clark,"Mucositis remains an important problem following BMT and may delay discharge from hospital. Patient-controlled analgesia (PCA) systems have been reported to be of benefit in controlling BMT-associated mucositis. The present study comprised 65 patients (age range 16-68 years; 19 allografts, 29 peripheral blood stem cell autografts and 17 autologous bone marrow). Subjects were prospectively randomised to receive intravenous diamorphine for pain relief either by conventional continuous infusion (CI) or by PCA, using a Medex Walkman 440 delivery system. Each patient assessed his/her pain control and nausea daily by a visual analogue scale. Twenty-two patients did not require any diamorphine. Four patients required diamorphine for pain other than mucositis, and four patients failed PCA control. Of 35 assessable cases, no difference in pain control was noted between CI and PCA. However, PCA-controlled patients required significantly less diamorphine than CI controlled patients (mean, 131 +/- 23 mg for PCA vs 296 +/- 40 mg for CI; P = 0.001), and PCA required fewer days of diamorphine than CI (mean, 7.17 +/- 0.66 days for PCA, 9.00 +/- 0.65 days for CI; P = 0.03). Side-effects were minimal and equivalent in the two arms. The findings suggest that PCA and CI offer equivalent control of the pain of BMT-associated mucositis, but PCA requires less total consumption and duration of diamorphine therapy.",1998.0,0,0
1809,9741072,Psychotropic adjuvant analgesics for pain in cancer and AIDS.,W Breitbart,"The 'WHO Analgesic Ladder' is a well validated approach for the selection of appropriate analgesic therapy for cancer pain as well as pain in AIDS. The mainstay of analgesic intervention for cancer and AIDS pain of moderate to severe intensity continues to be the appropriate use of opioid analgesics. There is, however, a growing appreciation for the role of adjuvant analgesics, such as antidepressants and other psychotropic medications, at each step of the WHO Analgesic Ladder, particularly in the treatment of neuropathic pain. Knowledge of the indications and usefulness of psychotropic analgesic drugs in cancer and AIDS pain populations will be most important to clinicians practicing in psycho-oncology/AIDS settings, particularly since these drugs are useful not only in the treatment of psychiatric complications of cancer and AIDS, but also as adjuvant analgesic agents in the management of pain. This paper reviews the literature on the use of antidepressants, psychostimulants, neuroleptics, anticonvulsants and other psychotropic analgesics in the management of cancer and AIDS pain. Mechanisms of analgesia, drug selection, and recommendations for clinical usage are discussed. The appropriate and timely use of psychotropic adjuvant analgesic drugs represents an opportunity for active psychiatric contribution to the multidisciplinary management of cancer and AIDS pain.",1998.0,0,0
1810,9742344,Pathogenesis and management of persistent postthoracotomy pain.,R H d'Amours; F X Riegler; A G Little,"Persistent chest wall pain is common after thoracotomy and is usually caused by recurrence or progression of malignancy. It should prompt efforts to identify and treat the causative disease. A minority of patients experience persistent pain not related to neoplasm. This pain may last for years, but is usually not severe. A small subset of these patients experience persistent severe pain, which may be debilitating. The pain may be owing to various causes. Diagnosis and treatment should be individualized and directed toward the causes believed to be present. First-line pharmacologic therapies include NSAIDs, tricyclic antidepressants, antiepileptics, and low-dose opioids. Some patients require more sophisticated treatment from multidisciplinary pain-management clinics. This treatment may include nerve blocks, physical therapy, sympathectomy, cryoneurolysis, or long-term neuromodulation with epidural analgesia or spinal cord stimulation. Because of the severe pain these patients may experience and the difficulty and expense associated with treatment, prevention may be the best strategy for dealing with this problem. Recent laboratory and clinical studies indicate that minimizing perioperative pain can suppress certain alterations in the nervous system that may prevent the genesis and maintenance of chronically painful conditions. This suggests that strategies for avoiding PTPS may begin with aggressive perioperative anesthetic and analgesic techniques. More effective application of knowledge already available from laboratory studies awaits further clinical trials. New drugs such as NMDA inhibitors hold promise for more effective treatment in the future.",1998.0,0,0
1811,9743394,The effect of adding a minidose of clonidine to intrathecal sufentanil for labor analgesia.,F J Mercier; M Dounas; H Bouaziz; V Des Mesnards-Smaja; C Foiret; M N Vestermann; M Fischler; D Benhamou,"Preliminary studies have suggested that the addition of clonidine to intrathecal sufentanil prolongs analgesia without producing motor blockade. Fifty-three nulliparous women in painful labor were included in this prospective, randomized, double-blinded study. Parturients at 2- to 5-cm cervical dilation received either 5 microg sufentanil plus 30 microg clonidine or 5 microg sufentanil intrathecally, followed by 5 mg bupivacaine epidurally. The primary outcome was time until first request for additional analgesia. Visual analog pain scores, sensory changes, blood pressure, heart rate, ephedrine requirements, motor blockade, sedation, pruritus, and nausea were also recorded. All parturients but one had effective analgesia in both groups, with similar sensory levels never exceeding T2. The duration (mean +/- SD) of analgesia was longer in the sufentanil-clonidine group: 125+/-46 versus 97+/-30 min (P = 0.007). The incidence of hypotension and the ephedrine requirements (median with range) were higher in the sufentanil-clonidine group: 63% versus 12% (P < 0.001) and 7.5 mg [range, 0-25.5 mg] versus 0 mg [range, 0-6 mg] (P < 0.0001). The incidence of fetal heart rate abnormalities during the first 30 min after intrathecal injection was similar in both groups (17% vs. 19%). No parturient had motor blockade. The addition of 30 microg clonidine to 5 microg intrathecal sufentanil extended the duration of labor analgesia without producing motor blockade. However, as previously reported with 100-200 microg clonidine, the incidence of hypotension and the ephedrine requirements were also increased, even when 30 microg clonidine only was added.",1998.0,0,0
1812,9743398,Dose-dependent reduction of the minimum local analgesic concentration of bupivacaine by sufentanil for epidural analgesia in labor.,L S Polley; M O Columb; D S Wagner; N N Naughton,"The minimum local analgesic concentration (MLAC) has been defined as the median effective local analgesic concentration in a 20-ml volume for epidural analgesia in the first stage of labor. The aim of this study was to determine the local anesthetic-sparing efficacy of epidural sufentanil by its effect on the MLAC of bupivacaine. In this double-blind, randomized, prospective study, 147 parturients at < or = 7 cm cervical dilation who requested epidural analgesia were allocated to one of four study groups. After a lumbar epidural catheter was placed, study participants received 20 ml bupivacaine (n = 38), bupivacaine with sufentanil 0.5 microg/ml (n = 38), bupivacaine with sufentanil 1 microg/ml (n = 33), or bupivacaine with sufentanil 1.5 microg/ml (n = 38). The concentration of bupivacaine was determined by the response of the previous patient using up-down sequential allocation. The analgesic efficacy was assessed using 100-mm visual analog pain scores, with < or = 10 mm within 30 min defined as effective. The MLAC of bupivacaine alone was 0.104% wt/vol (95% CI, 0.090-0.117). The addition of sufentanil at doses of 0.5 microg/ml, 1 microg/ml, and 1.5 microg/ml resulted in significant reductions (P < 0.0001) in the MLAC of bupivacaine to 0.048% wt/vol (95% CI, 0.030- 0.065), 0.021% wt/vol (95% CI, 0-0.055), and 0.009% wt/vol (95% CI, 0-0.023), respectively. This study showed a significant (P < 0.0001) dose-dependent reduction in the MLAC ofbupivacaine by sufentanil.",1998.0,0,0
1813,9750678,[Controlled analgesia in a burn patient: fentanyl sparing effect of clonidine].,M Viggiano; C Badetti; F Roux; H Mendizabal; V Bernini; J C Manelli,"To determine the sparing effect of clonidine (C) on fentanyl (F) demand in burned patients under PCA. Prospective, randomized, double blind study versus placebo. Twelve consecutive patients with mean burn surface area of 20 +/- 9%, studied between the third and the eighth day post-burn. F was delivered by a PCA pump (bolus: 1 mg.kg-1). In the morning, burn patients received additional F (5 mg.kg-1) before hydrotherapy. After randomisation, C or placebo (P) were alternatively infused over 24 hours. Demands for F during the morning, the afternoon and the evening were noted. Pain scores were measured on a visual analogic scale. In eight patients, plasma levels of F (pF) were iteratively measured. Heart rate, arterial pressure, respiratory rate and SpO2 were monitored. Analgesic demands were 19.5/day under P and 9.5 under C (P < 0.0001). Pain reoccurred for pF of 4.1 under C vs 5.7 under P (P < 0.05) with same pain scores in the two groups. After a pain stimulus, pain scores were lower under F, despite lower pF (P < 0.05). Arterial pressure and heart rate were significantly lowered during the first hour of C infusion. Doses of F and pF required to reach analgesia were very high. Adding C decreases by 50% the F demand and lowers pF. Minor haemodynamic effects were observed during the first hour of C infusion.",1998.0,0,0
1814,9750799,[Prevention of postoperative pain].,D Fletcher,"The pre-emptive analgesia concept suggests that pre-administration of analgesics may enhance the efficacy of these drugs. This review has selected the data from the literature according to two types of methodological criteria: Sackett's criteria, and those specific of pre-emptive analgesia studies. Infiltration, spinal and peripheral nerve blocks using local anaesthetic drugs do not seem to produce pre-emptive analgesia. The few positive results have limited clinical significance. The results concerning opioids are contradictory and the clinical significance is limited. Preoperative oral administration of non steroidal anti-inflammatory drugs (NSAIDs) offers no benefit. Intravenous pre-administration has a limited advantage, but enhances perioperative bleeding. Ketamine, an NMDA receptor antagonist, may have some pre-emptive analgesic properties according to the few studies available. In conclusion, pre-administration of analgesic drugs represents the usual strategy for the anaesthesiologist (spinal or peripheral block, infiltration, opioids). In other cases (NSAIDs, ketamine), pre-administration represents a change in usual practice. This is not justified for NSAIDs; NMDA receptor antagonists may offer an interesting research area. Data concerning pre-emptive analgesia for chronic pain syndrome such as phantom limb pain are quite limited.",1998.0,0,0
1815,9751910,Morphine-midazolam combination doses for presurgical analgesia in children.,M M Atallah; G E Hammouda; M M Saied,"We have examined the use of presurgical morphine-midazolam combination in 80 children aged 2-10 y undergoing repair of hypospadias. They were allocated randomly, in a double-blind study, to receive one of four morphine-midazolam combination doses (n = 20 each); (group I: 75 microg/kg each) [corrected] (group II: 75 microg/kg [corrected] morphine, 50 microg/kg [corrected] midazolam); (group III: 50 microg/kg [corrected] morphine, 75 microg/kg [corrected] midazolam); (group IV: 50 microg/kg [corrected] each). Drugs were given after induction of anesthesia and before the start of surgery. Observational scoring system, using crying, movement, agitation, posture and localization of pain as scoring criteria, was used to assess the children during their stay in the recovery room together with their sedative and/or analgesic requirement. Pre-surgical morphine-midazolam administration produced stable hemodynamic variables with satisfactory postoperative analgesia suggesting 75 microg/kg [corrected] dose of both morphine and midazolam as upper permissible dose, and 50 microg/kg [corrected] each as lower effective dose.",1998.0,0,0
1816,9752300,[Morphine therapy: evaluation of patient information].,J Y Ranchere; M H Delfosse; P Saltel; J F Latour,"Pain is frequent in the course of cancer and can have negative consequences on patients quality of life. The great majority of patients can be helped by simple treatments. The prescription of morphine (M) must be preceded by some explanations. In order to verify the reality of these explanations, a study was done in a 230 comprehensive beds Cancer Centre, with 129 patients, randomized between all the patients hospitalized. In an open questionnaire, different aspects were studied. One hundred answers were studied: 63 patients did not have M at any time: group M-; 37 patients had M (19) or have had M (18): group M+; 97% of the patients in group M+ thought that M decreased pain, for 85% patients in group M-. Morphine treatment was effective in 92% of patients M+, and not very effective in 5%; 67% of patients M- thought that M is efficient but 17% did not know; 76% of patients M+ did not worry about M; 13% worried et 11% did not know. For patients M- only 48% did not worry; 41% worried and 11% did not know. The side effect known by the patients, and spontaneously quoted were constipation (12 patients in M+ group). For 14 patients there was no problem and 2 did not know. In M- group 49 patients did not know. Only 8% of M+ group were afraid by addiction, but 44% in group M-; 97% patients M+ said that they could stop without problem against only 38% of the patients in M- group. For 16% of M+ group, the use of M had a bad signification about their disease, but 52% of M- group thought that if morphine was used in their cases, the meaning would be very bad. The differences between the two groups allow to think that the prescription of M in this study is explained, and that the patients receiving M are rather well informed. Patients with cancer but without M do not have good information and their knowledge is similar than general population. The use of recommended therapy and explanations allowed patients with M therapy to be comfortable with this prescription.",1998.0,0,0
1817,9753804,Pain control following elective gastrointestinal surgery: is epidural anesthesia warranted?,J P Welch; J L Cohen; P V Vignati; L W Allen; J S Morrow; J J Carter,"Fifty-nine patients undergoing elective major gastrointestinal surgery were entered into a prospective, randomized trial between January 1993 and July 1994 comparing the effectiveness, side effects, and hospital costs of postoperative epidural anesthesia (Group 1, n = 29) and intramuscular narcotic injections (Group 2, n = 30). Epidural catheters were inserted by a team that supervised catheter care and infusion rates in the postoperative period. The nonepidural group received intramuscular injections on a regular basis. Patients filled out visual analog scales to measure levels of pain ( 1 = minimal, 10 = maximal) every eight hours. Patient activity, bowel, and urinary function were recorded by the nursing staff. Control of pain (as measured by the daily average visual analog score) was more effective in Group 1 (P < .001) on postoperative days 1-3 (1.3 vs 3.6 on day 1, 0.7 vs 2.6 on day 2, 0.9 vs 3 on day 3). There was no significant difference in mean values between groups 1 and 2 with respect to first ambulation on the hospital ward, onset of liquid diet, intake of solid food, first spontaneous voiding, first bowel movement, length of hospitalization, or charge of hospitalization ($13,439 +/- 7,452 vs $11,821 +/- 6,630). We conclude that epidural anesthesia significantly lessens incisional pain following major elective lower gastrointestinal surgery when compared to analgesic injections alone. However, while not statistically significant, the overall charge was increased by 14% in the epidural group. This finding should be examined in light of the relatively low pain level in patients receiving narcotic injections alone.",1998.0,0,0
1818,9754479,Comparison of oral ketorolac and hydrocodone for pain relief after anterior cruciate ligament reconstruction.,F A Barber; D E Gladu,"The analgesic effectiveness of ketorolac tromethamine was compared with hydrocodone and acetaminophen for pain from an arthroscopically assisted patellar-tendon autograft anterior cruciate ligament reconstruction. There were 125 patients evaluated in a double-blind, randomized, multicenter, and multidose study. A loading dose of parental ketorolac tromethamine was administered and subjects were later given two staged doses of the same ""unknown"" drug with pain evaluations conducted after each dose. For group 1, dose 1 consisted of ketorolac tromethamine 20 mg orally and dose 2 was ketorolac tromethamine 10 mg. For group 2, both dose 1 and dose 2 consisted of hydrocodone 10 mg plus acetaminophen 1,000 mg orally. Efficacy was evaluated by standard analgesic measures. Subjects treated as outpatients showed lower categorical pain intensity for ketorolac tromethamine than hydrocodone and acetaminophen at 1 hour (P=.03), 2 hours (P=.006), and 3 hours (P=.02); lower summed intensity differences for ketorolac tromethamine than hydrocodone and acetaminophen at 3 hours (P=.014) and 4 hours (P=.019); and better total pain relief for ketorolac tromethamine than hydrocodone and acetaminophen at 3 hours (P=.014) and 4 hours (P=.013). With an effective loading dose administered before the subsequent oral dosage, there was statistically better pain reduction with ketorolac tromethamine than with hydrocodone and acetaminophen. Moreover, ketorolac tromethamine was no more likely to cause digestive complaints than hydrocodone and acetaminophen. No bleeding problems were observed in either group. In the outpatient setting, ketorolac tromethamine controls postoperative pain better than hydrocodone and acetaminophen in the immediate postsurgery period.",1998.0,0,0
1819,9755272,Comparison of fentanyl/midazolam with ketamine/midazolam for pediatric orthopedic emergencies.,R M Kennedy; F L Porter; J P Miller; D M Jaffe,"Emergency management of pediatric fractures and dislocations requires effective analgesia, yet children's pain is often undertreated. We compared the safety and efficacy of fentanyl- versus ketamine- based protocols. Patients 5 to 15 years of age needing emergency fracture or joint reduction (FR) were randomized to receive intravenous midazolam plus either fentanyl (F/M) or ketamine (K/M). Measures of efficacy were observational distress scores and self- and parental-report. Measures of safety were frequency of abnormalities in and need for support of cardiopulmonary function and other adverse effects. During FR, K/M subjects (n = 130) had lower distress scores and parental ratings of pain and anxiety than did F/M subjects (n = 130). Although both regimens equally facilitated reductions, deep sedation, and procedural amnesia, orthopedists favored K/M. Recovery was 14 minutes longer for K/M. Fewer K/M subjects had hypoxia (6% vs 25%), needed breathing cues (1% vs 12%), or required oxygen (10% vs 20%) than did F/M subjects. Two K/M subjects required assisted ventilation briefly. More K/M subjects vomited. Adverse emergence reactions were rare but equivalent between regimens. During emergency pediatric orthopedic procedures, K/M is more effective than F/M for pain and anxiety relief. Respiratory complications occurred less frequently with K/M, but respiratory support may be needed with either regimen. Both regimens facilitate reduction, produce amnesia, and rarely cause emergence delirium. Vomiting is more frequent and recovery more prolonged with K/M.",2000.0,0,0
1820,9763809,[The effects of a dose of epidural clonidine combined with intrathecal morphine for postoperative analgesia].,M L Massone; E Lampugnani; M G Calevo; A Gandolfo; G Montobbio; S Fossa,"To evaluate the effectiveness of a single bolus of epidural (ED) clonidine (C) associated with intrathecal morphine (M) on postoperative analgesia after cesarean section (CS). Prospective double-blind randomized study. Obstetric department. Fourty patients ASA 1-2 submitted to combined spinal-epidural block (CSE) for CS. A needle through needle set for CSE was used. The intrathecal block was induced with 2.7-3 ml of isobaric 0.5% bupivacaine (B) and 250 micrograms of M. After ED test with 0.5% B, a single bolus of C 150 micrograms in NS 10 ml (group C, n 20) or NS 10 ml as placebo (group P, n 20) was given through the ED catheter. The observation for 36 hours evaluated analgesia (VAS until the first dose of additional analgesic, total amount of analgesic and time of first analgesic request) and side effects (variations of arterial pressure and heart rate, motor block, sedation, nausea, vomiting, itching, respiratory depression). Groups were statistically compared. In group C lower analgesic request (significantly between 12th and 18th hour) and significant delay of first request (22.5 +/- 4.1 h) were registered. VAS showed significant trend to opposite sign variations (downwards in group C, upwards in group P) at 1, 2 and 12 hours. In group C lower sistolic arterial pressure at 1 and 4 hours, denser motor block at 2 and 4 hours and mild sedation were observed. A single ED bolus of C 150 micrograms after CS significantly enhances and prolongs the analgesic effect of M 250 micrograms without important side effects.",1998.0,0,0
1821,9766832,Sex differences in response to cutaneous anesthesia: a double blind randomized study.,M E Robinson; J L Riley; F F Brown; H Gremillion,"The existing literature on experimentally induced pain indicates that there are sex differences, with females displaying greater sensitivity. In epidemiological studies, sex differences are also noted in the prevalence of a number of pain syndromes, with females reporting more severe pain, more frequent pain, and pain of longer duration. Complicating the interpretation of pain differences between men and women in clinical samples are reports of sex differences in response to pain-reducing medications. Studies in human subjects suggest that women respond better to certain opioid analgesics than men following third molar extraction, but few studies have assessed sex effects in effectiveness of topical anesthetics. The purpose of this study was to test for sex differences in response to a topical anesthetic, Lidocaine, using double blind, placebo controlled experimental methodology, in combination with a magnitude matching psychophysical protocol using a pressure algometer. The subjects were 21 female and 23 male adult volunteers. Twenty-four subjects (12 males and 12 females) were randomly assigned to the Lidocaine condition and 20 subjects were randomly assigned to the placebo control condition (9 males and 11 females). The effect size across sex for subjects in the Lidocaine treatment condition on the response bias variable was large indicating the males rated the stimuli as less painful than the females. Sex differences were not observed for discriminability in the Lidocaine treatment condition. This study did not show sex differences in the placebo condition. These results are particularly interesting in light of previous work that has shown similar pain stimuli (pressure pain) to be the stimulation most sensitive to sex differences. Results of this study suggest that the protocol employed (pressure pain stimulus with magnitude matching task) is sensitive to both anesthetic treatment and sex differences and represents an improvement in pain assessment methodology for use in experimental studies and in the clinic.",2001.0,0,0
1822,9767063,Painful polyneuropathy.,B S Galer,"Painful polyneuropathy is one of the most common chronic pain syndromes neurologists are asked to assess for diagnostic and therapeutic purposes. This article reviews the most current clinical guidelines, including history, pain assessment, physical examination findings, treatment recommendations, and pathophysiologic pain mechanisms underlying this condition. As a result of recent advances, the understanding and therapy of pain associated with polyneuropathy has evolved over the past several years and will continue to do so in the years to come.",2000.0,0,0
1823,9767068,,,,,0,0
1824,9771272,Remifentanil and tramadol.,D J Duthie,"The lack of analgesic efficacy limits tramadol as a sole agent to treat severe pain after surgery. However, it has a relative lack of respiratory depressant and constipating effects compared with morphine and codeine, and does not share the propensity of nonsteroidal anti-inflammatory drugs to provoke asthma, gastrointestinal mucosal damage and renal impairment. It may well have a place in the management of pain after surgery, in combination with another drug, such as paracetamol, or after control of the worst of pain after surgery by a regional local anaesthetic technique.",1998.0,0,0
1825,9771273,Opioid tolerance: the clinical perspective.,B J Collett,,1998.0,0,0
1826,9771300,Postoperative hypoxaemia: continuous extradural infusion of bupivacaine and morphine vs patient-controlled analgesia with intravenous morphine.,C Motamed; A Spencer; F Farhat; J L Bourgain; P Lasser; C Jayr,"We carried out a randomized prospective study in 60 patients who had undergone major abdominal surgery for cancer. For postoperative pain control, 30 patients received continuous extradural infusion of 0.125% bupivacaine 12.5 mg h-1 and morphine 0.25 mg h-1 (EXI group) and 30 received patient-controlled analgesia (PCA) with intravenous morphine (1 mg bolus, 5-min lock-out and maximum dose 20 mg 4h-1). Both groups had general anaesthesia. The two groups were compared for postoperative pain scores, satisfaction, sedation and oxygen saturation. Oxygen saturation was recorded continuously the night before surgery and for two consecutive postoperative nights. Episodes of moderate desaturation (90% > SpO2 85%) were more frequent in the EXI group than in the PCA group (P < 0.05). Pain scores were lower in the EXI group compared with the PCA group at rest and while coughing (P < 0.05). No significant difference was found for patient sedation and satisfaction.",1998.0,0,0
1827,9771301,Patient-maintained analgesia with target-controlled alfentanil infusion after cardiac surgery: a comparison with morphine PCA.,M R Checketts; C J Gilhooly; G N Kenny,"The performance of a patient-demand, target-controlled alfentanil infusion system was compared with that of a traditional morphine patient-controlled analgesia (PCA) pump in 120 adult patients after cardiac surgery. Patients were randomized to one of the two PCA systems for their postoperative analgesia in the intensive care unit and pain, nausea and sedation scores were recorded every 4 h for the first 24 h. Episodes of hypoxaemia, myocardial ischaemia and haemodynamic instability were also recorded. In patients using the alfentanil system the overall median visual analogue pain score was 2.3 (95% Cl 2.3-2.8) compared with 3.0 (95% Cl 2.7-3.2) in those using morphine PCA (P < 0.05), but both systems delivered high-quality analgesia. The two groups did not differ with respect to the overall sedation scores, the frequency of postoperative nausea and vomiting, haemodynamic instability, myocardial ischaemia or hypoxaemia.",1998.0,0,0
1828,9771302,Comparison of remifentanil in combination with isoflurane or propofol for short-stay surgical procedures.,D J Rowbotham; J E Peacock; R M Jones; H M Speedy; J R Sneyd; R W Morris; J P Nolan; D Jolliffe; G Lang,"There are few data in the literature that describe the use of remifentanil when administered as a component of an inhalation or total i.v. anaesthetic (TIVA) technique. We studied 251 male and female patients, aged 18-75 years, ASA I-II, undergoing inguinal hernia repair, arthroscopic knee surgery or varicose vein surgery of at least 30 min duration without premedication. Patients were randomized to receive a remifentanil loading dose of 1.0 microgram kg-1 followed by a continuous infusion of 0.5 microgram kg-1 min-1 in combination with isoflurane (end-tidal concentration 0.6%), (Group I, n = 115) or propofol (initial infusion rate 9 mg kg-1 h-1 reduced to 6 mg kg-1 h-1 after 10 min), (Group P, n = 118). The remifentanil infusion rate was reduced by 50%, 5 min after tracheal intubation. Intraoperative stresses were treated with a remifentanil bolus (1 microgram kg-1) followed by an increase in the remifentanil infusion rate. At the insertion of the last suture, the remifentanil infusion and concomitant anaesthetic were switched off simultaneously. Times to spontaneous respiration, adequate respiration and tracheal extubation were significantly shorter in group I compared with group P (6.4 min vs 7.6 min, P < 0.01; 7.6 min vs 9.3, P < 0.003; 7.8 min vs 9.5 min, P < 0.015). Overall mean systolic blood pressures during surgery were greater in group P compared with group I (P < 0.05) but the absolute differences were clinically insignificant (4-5 mm Hg).",1998.0,0,0
1829,9771314,The anaesthetist's role in acute sickle cell crisis.,V Vijay; J D Cavenagh; P Yate,,1998.0,0,0
1830,9773133,"Adrenaline markedly improves thoracic epidural analgesia produced by a low-dose infusion of bupivacaine, fentanyl and adrenaline after major surgery. A randomised, double-blind, cross-over study with and without adrenaline.",G Niemi; H Breivik,"Basic pharmacological research indicates that there are synergistic antinociceptive effects at the spinal cord level between adrenaline, fentanyl and bupivacaine. Our clinical experience with such a mixture in a thoracic epidural infusion after major surgery confirms this. The objectives of the present study were to evaluate the effects on postoperative pain intensity, pain relief and side effects when removing adrenaline from this triple epidural mixture. A prospective, randomised, double-blind, cross-over study was carried out in 24 patients after major thoracic or abdominal surgery. Patients with only mild pain when coughing during a titrated thoracic epidural infusion of about 10 ml.h-1 of bupivacaine 1 mg.ml-1, fentanyl 2 micrograms.ml-1, and adrenaline 2 micrograms.ml-1 were included. On the 1st and 2nd postoperative days each patient was given a double-blind epidural infusion, at the same rate, with or without adrenaline. The effect was observed for 4 h or until pain when coughing became unacceptable in spite of a rescue analgesic procedure. Rescue analgesia consisted of up to two epidural bolus injections per hour and i.v. morphine if necessary. All patients received rectal paracetamol 1 g, every 8 h. Fentanyl serum concentrations were measured with a radioimmunoassay technique at the start and end of each study period. Main outcome measures were extent of sensory blockade and pain intensity at rest and when coughing, evaluated by a visual analogue scale, a verbal categorical rating scale, the Prince Henry Hospital pain score, and an overall quality of pain relief score. The number of hypaesthetic dermatomal segments decreased (P < 0.001) and pain intensity at rest and when coughing increased (P < 0.001) when adrenaline was omitted from the triple epidural mixture. This change started within the first hour after removing adrenaline. After 3 h pain intensity when coughing had increased to unacceptable levels in spite of rescue analgesia (epidural bolus injections and i.v. morphine). Within 15-20 min after restarting the triple epidural mixture with adrenaline, pain intensity was again reduced to mild pain when coughing. Serum concentration of fentanyl doubled from 0.22 to 0.45 ng.ml-1 (P < 0.01), and there was more sedation during the period without adrenaline. Adrenaline increases sensory block and improves the pain-relieving effect of a mixture of bupivacaine and fentanyl infused epidurally at a thoracic level after major thoracic or abdominal surgery. Serum fentanyl concentrations doubled and sedation increased when adrenaline was removed from the epidural infusion, indicating more rapid vascular absorption and systemic effects of fentanyl.",1998.0,0,0
1831,9773443,Pathophysiological mechanisms of central neuropathic pain after spinal cord injury.,P K Eide,"After spinal cord injury (SCI), between 10% and 20% of the patients may develop central neuropathic pain. This type of chronic pain usually is a very bothersome sequel and represents a major therapeutic challenge since conventional medical and surgical pain therapies generally are ineffective. This review focuses on recent advances in the understanding of the pathophysiology of this pain syndrome. Important clinical features of central neuropathic pain after SCI include loss of sensations mediated by spinothalamic pathways combined with development of abnormal pain perception (spontaneous continuous pain and abnormally evoked pain). Up-regulation of neuronal activity leading to spontaneous and evoked neuronal hyperactivity/hyperexcitability, may be the neurophysiological substrate for development of abnormal pain perception. This paper describes some neurochemical changes that may be important for the induction and maintenance of neuronal hyperactivity and abnormal pain perception: Increased excitatory glutaminergic activity involving N-methyl-D-aspartate (NMDA) receptor activation, may trigger the intracellular cascade reaction leading to upregulation of neuronal activity/excitability. Changes in voltage-sensitive Na+ channels may contribute to changes in nerve membrane excitability. Other important mechanisms may be loss of endogenous inhibition, including reduced gamma-amino-butyric acid (GABA)ergic, opioid and monoaminergic inhibition. These various mechanisms may provide new targets for treatment of a pain syndrome that traditionally has been so difficult to handle.",1998.0,0,0
1832,9774881,[Acute pain due to vinorelbine].,J Cabrera Rodríguez; J Muñoz García,"To report the presence of an uncommon adverse effect, pain in the tumor location, during the administration of the cytostatic agent vinorelbine. Twenty-seven patients with non operable relapses of epidermoid carcinomas of the head and neck were treated with two combinations of cytostatics: mitomycin-c 10 mg/m2 on day 1 plus vinorelbine 25 mg/m2 on days 1, 8 and 15 in twelve patients or carboplatin 300 mg/m2 on day 1 plus vinorelbine 25 mg/m2 on days 1, 8 and 15 in fifteen patients. Six patients had moderate/severe pain in the tumor location; concomitantly, one patient had chest pain. Four patients required major opiates. The clinical picture reverted and no patient had acute or chronic neurotoxicity. The readministration of vinorelbine triggered pain again, and all patients refused to continue the therapeutic program. Vinorelbine can cause pain at tumor location, a nonserious adverse effect which, nevertheless, prevented the continuation of therapy.",1998.0,0,0
1833,9777083,Caudal morphine in paediatric patients: a comparison of two different doses in children after major urogenital surgery.,C K Leong; A S Ng; S L Chew,"We compared the duration of postoperative analgesia and the occurrence of side-effects of two different doses of caudal morphine in children undergoing major urogenital surgery. Fifty-two children aged between 1 and 12 years were randomly selected to receive caudal morphine, either 25 micrograms.kg-1 (Group A) or 50 micrograms.kg-1 (Group B) with 0.5 ml kg-1 of 0.25% plain bupivacaine immediately before surgery. They were monitored for 24 hours in a high dependency area for known complications of epidural morphine. There was no significant difference in postoperative analgesia between the two doses of caudal morphine. Clinically significant respiratory depression or sedation was not detected in either group. The occurrence of vomiting and pruritus was similar in both groups. Urinary retention was not recorded as all children had an indwelling catheter as required by the surgical procedure. We concluded that 25 micrograms.kg-1 of caudal morphine is as effective as 50 micrograms.kg-1 for providing postoperative analgesia in children undergoing urogenital surgery.",1998.0,0,0
1834,9779694,Switching from morphine to oral methadone in treating cancer pain: what is the equianalgesic dose ratio?,C Ripamonti; L Groff; C Brunelli; D Polastri; A Stavrakis; F De Conno,"To define the dose ratio between morphine and methadone in relation to the previous morphine dose and the number of days needed to achieve the same level of analgesia in a group of patients with advanced cancer with pain who switched from morphine to oral methadone. A cross-sectional prospective study of 38 consecutive cancer patients who switched from morphine to oral methadone was performed. The intensity of pain before, during, and after the switching period was assessed through a four-point verbal Likert scale. The relationship between previous morphine dose and the final equianalgesic methadone dose, dose ratio between morphine and methadone, and the number of days required to achieve equianalgesia have been examined by means of Pearson's correlation coefficient, scatter plots, and Cuzick's test for trend respectively. Before the switch, the median oral equivalent daily dose of morphine was 145 mg/d; after the switch, the median equianalgesic oral methadone dose was 21 mg/d. A median time of 3 days (range, 1 to 7 days) was necessary to achieve the equianalgesia with oral methadone; the lower the preswitching morphine dose, the fewer days necessary to achieve equianalgesia with oral methadone (P < .001). Dose ratios ranged from 2.5:1 to 14.3:1 (median, 7.75:1), which indicated that, in most cases, the dose ratio was much higher than that suggested by the published equianalgesic tables. A strong linear positive relationship between morphine and methadone equianalgesic doses was obtained (Pearson's correlation coefficient, 0.91). The dose ratio increased with the increase of the previous morphine dose with a much higher increase at low morphine doses. The results of our study confirm that methadone is a potent opioid, more potent than believed. Caution is recommended when switching from any opioid to methadone, especially in patients who are tolerant to high doses of opioids.",1998.0,0,0
1835,9779695,"Randomized, double-blind, cross-over trial comparing safety and efficacy of oral controlled-release oxycodone with controlled-release morphine in patients with cancer pain.",E Bruera; M Belzile; E Pituskin; R Fainsinger; A Darke; Z Harsanyi; N Babul; I Ford,"Use of oxycodone for chronic cancer pain has been hampered by its short elimination half-life. This study was designed to compare the efficacy and safety of controlled-release formulations of oxycodone and morphine for cancer pain. Thirty-two adult patients with cancer pain and a > or = 3-day history of stable analgesia with oral opioids provided written informed consent and were randomized to controlled-release oxycodone or controlled-release morphine for 7 days. To blind the study using available tablet strengths, the dose ratio of oxycodone to morphine was set at 1:1.5. On day 8, patients were crossed over to the alternate drug for 7 days. Pain intensity was assessed using a visual analog scale (VAS 0 to 100 mm) and a categorical scale (CAT 0 to 4). Side effects were assessed using a checklist (four-point categorical severity) and a nondirected questionnaire. Patients and investigators made blinded global ratings of efficacy and treatment preference. Twenty-three patients completed the study (10 men, 13 women). The VAS and CAT scores were (mean+/-SD) 23+/-21 and 1.2+/-0.8 on controlled-release oxycodone, and 24+/-20 (P=.43) and 1.3+/-0.7 (P=.36) on controlled-release morphine. No period or carryover effect was detected. There were no significant differences in adverse effects (P=.40) or ratings of efficacy and preference. The median oxycodone/morphine dose ratio was 1.5 and the maximum was 2.3. Controlled-release oxycodone is as safe and effective as controlled-release morphine in the treatment of cancer pain.",1998.0,0,0
1836,9779696,Comparison of controlled-release and immediate-release oxycodone tablets in patients with cancer pain.,R Kaplan; W C Parris; M L Citron; D Zhukovsky; R F Reder; B J Buckley; R F Kaiko,"This study compared the clinical efficacy of oxycodone hydrochloride controlled-release (CR) tablets administered every 12 hours with immediate-release (IR) oxycodone tablets administered four times daily in patients with cancer-related pain. Cancer patients who required therapy for moderate to severe pain were randomized to CR oxycodone every 12 hours (n=81) or IR oxycodone four times daily (n=83) for 5 days in a multicenter, double-blind study. Pain intensity was assessed four times daily (categorical scale of none, slight, moderate, and severe); acceptability of therapy was assessed twice daily (categorical scale of very poor, poor, fair, good, and excellent). Pain intensity remained slight during the study, with mean oxycodone doses of 114 mg/d (range, 20 to 400 mg/d) for CR and 127 mg/d (range, 40 to 640 mg/d) for IR. Acceptability of therapy was fair to good with both treatments. While standard conversion ratios provided an acceptable dose for many patients, a protocol amendment that allowed initial titration and use of rescue medication reduced the discontinuation rate for lack of acceptable pain control (from 34% to 4% with CR and from 31% to 19% with IR before and after amendment, respectively) without increasing the discontinuation rate for adverse events (from 8% to 7% with CR and from 13% to 11% with IR). Fewer adverse events were reported with CR (109) than with IR (186) oxycodone (P=.006). CR oxycodone every 12 hours was as effective as IR oxycodone four times daily in managing moderate to severe cancer-related pain and was associated with fewer reports of adverse events.",1998.0,0,0
1837,9779697,"Dose-titration, multicenter study of oral transmucosal fentanyl citrate for the treatment of breakthrough pain in cancer patients using transdermal fentanyl for persistent pain.",J M Christie; M Simmonds; R Patt; P Coluzzi; M A Busch; E Nordbrock; R K Portenoy,"Supplemental, ""as-needed,"" administration of an opioid is a common approach to the problem of breakthrough pain in cancer patients. Oral transmucosal fentanyl citrate (OTFC) is undergoing investigation as a new treatment for breakthrough pain. The primary purpose of the study was to demonstrate that a single-unit dose of OTFC can safely and effectively treat breakthrough pain. A secondary goal was to determine appropriate dosing guidelines. This was a multicenter, randomized, double-blind, dose-titration study in 62 adult cancer patients using transdermal fentanyl for persistent pain. Consenting patients provided 2 days of baseline data to evaluate the performance of their usual breakthrough pain medication. Patients then randomly received 200 microg or 400 microg OTFC in double-blind fashion. (Patients were always assigned, rather than randomized, to 200 microg if 400 microg represented > 20% of around-the-clock medication.) Pain intensity (PI), pain relief (PR), and global satisfaction scores were recorded. OTFC was then titrated until the patient received adequate PR for each episode using one OTFC unit. Orders to titrate up were ignored one third of the time to improve the blind. Two days of baseline data were compared with 2 days of OTFC data after titration identified an effective dose of OTFC. Most patients (76%) found a safe and effective dose of OTFC. There was no meaningful relationship between the around-the-clock opioid regimen and the effective dose of OTFC. In open-label comparisons, OTFC produced a faster onset of relief and a greater degree of PR than patients' usual breakthrough medication. Somnolence, nausea, and dizziness were the most common side effects associated with OTFC. Most patients find a single OTFC dosage that adequately treats breakthrough pain. The optimal dose is found by titration and is not predicted by around-the-clock dose of opioids.",1998.0,0,0
1838,9781549,Nortriptyline versus amitriptyline in postherpetic neuralgia: a randomized trial.,C P Watson; L Vernich; M Chipman; K Reed,"OBJECTIVE (BACKGROUND): Amitriptyline (AT) is a standard therapy for postherpetic neuralgia (PHN). Our hypothesis was that nortriptyline (NT), a noradrenergic metabolite of AT, may be more effective. A randomized, double-blind, crossover trial of AT versus NT was conducted in 33 patients. Thirty-one patients completed the trial. Twenty-one of 31 (67.7%) had at least a good response to AT or NT, or both. We found no difference with regard to relief of steady, brief, or skin pain by visual analog scales for pain and pain relief; mood; disability; satisfaction; or preference between the two drugs. Intolerable side effects were more common with AT. Most patients (26/33) were not depressed, and most responding showed no change in rating scales for depression despite the occurrence of pain relief. We concluded that this study provides a scientific basis for an analgesic action of NT in PHN because pain relief occurred without an antidepressant effect, and that although there were fewer side effects with NT, AT and NT appear to have a similar analgesic action for most individuals.",1998.0,0,0
1839,9782027,Pain after groin hernia repair.,T Callesen; K Bech; R Nielsen; J Andersen; P Hesselfeldt; O Roikjaer; H Kehlet,"The purpose of the study was to provide a detailed description of postoperative pain after elective day-case open inguinal hernia repair under local anaesthesia. This was a prospective consecutive case series study. After 500 hernia operations in 466 unselected patients aged 18-90 years, pain was scored (none, light, moderate or severe) at rest, while coughing and during mobilization, daily for the first postoperative week and after 4 weeks. Pain scores were added together over the first postoperative week. On days 1, 6 and 28, 66, 33 and 11 per cent respectively had moderate or severe pain while coughing or mobilizing. Total pain scores were higher while coughing or mobilizing than at rest (P < 0.001). Younger patients had higher total pain scores than older patients while coughing or mobilizing (P0< 0.01), but not at rest. No significant differences were found between types of surgery or hernia. Pain remained a problem despite the pre-emptive use of opioids, non-steroidal anti-inflammatory drugs and local anaesthesia, irrespective of surgical technique.",1998.0,0,0
1840,9783356,[Surgical pain therapy in inoperable metastatic epigastric tumor by bilateral thoracoscopic splanchnicectomy].,D Inderbitzin; R A Schmid; O Schöb; W Weder,"Patients with unresectable supramesenteric malignancies often suffer from intractable pain. The supramesenteric viscera are supplied by the greater splanchnic nerve. Surgical options to effectively denervate the supramesenteric area are coeliac ganglionectomy, open or percutaneous coeliac ganglion block or transhiatal bilateral splanchnicotomy. The surgical minimally invasive alternative is thoracoscopic splanchnicectomy. In 7 patients pain was scored on a scale from 1 (no pain) to 10 (maximal pain) before and after surgery and weekly thereafter. Five bilateral and 2 left-sided thoracoscopic splanchnicectomies were performed. Operation time was 17 +/- 3 min for each side. The mean pain score dropped from preoperatively (under morphine sulphate medication) 7.4 +/- 0.6 to 4.9 (2.5-8.25) 1 week postoperatively (p = 0.02) and to 4.9 (2.5-6.75) 7 weeks postoperatively (p = 0.02). The relief from back pain was immediate and complete, but abdominal pain tended to recur. Six of our 7 patients and their general practitioners rated the intervention as a success. Thoracoscopic splanchnicectomy affords excellent palliation in patients with unresectable supramesenteric tumour, offering reliable pain control.",1998.0,0,0
1841,9784932,Sustained relief of chronic pain. Pharmacokinetics of sustained release morphine.,G K Gourlay,"There are a number of modified release formulations of morphine with recommended dosage intervals of either 12 or 24 hours, including tablets (MS Contin, Oramorph SR), capsules (Kapanol, Skenan), suspension and suppositories. Orally administered solid dosage forms are most popular but significant differences exist in the resultant pharmacokinetics and bioequivalence status of morphine after both single doses and at steady state. Following single doses, the plasma morphine concentrations showed pronounced differences in the 0- to 12-hour period with a 4- to 5-fold difference in the mean peak concentration (Cmax) for morphine and the time to Cmax (tmax) The area under the concentration-time curve (AUC) from 0 to 24 hours for the 4 formulations show greater similarity. None of the formulations were shown to be bioequivalent according to US Food and Drug Administration (FDA) criteria. At steady state, fluctuations in plasma morphine concentrations throughout a 12-hour dosage interval were greatest for MS Contin and least for Kapanol. In fact, the relatively small fluctuations in plasma morphine concentrations following Kapanol administration suggested the same formulation could successfully be used with a 24-hour dosage interval. The pharmacokinetic parameters of morphine following Kapanol once daily were similar to MS Contin (12 hours) with the obvious exception of the longer tmax. There is also another once daily oral morphine preparation (MXL) which has been shown to be bioequivalent to Kapanol under fasting conditions only in a single dose study in volunteers. Food has been shown to have an effect on the pharmacokinetics of morphine following doses of immediate release solution and the modified release preparations. However, bioequivalence is generally maintained between the fed and fasting states for most preparations. MS Contin tablets have been administered rectally, but morphine pharmacokinetic parameters show greater variability compared with oral administration and the 2 routes are not bioequivalent. The results suggest a slower rate but greater extent of morphine adsorption. Somewhat similar results were obtained when Kapanol granules are administered rectally. The morphine pharmacokinetics following administration of a specifically formulated controlled release suppository showed less variability (rectal bioavailability was 42%). The pronounced differences in morphine pharmacokinetics between the various formulations are not translated into measurable differences in the pharmacodynamic effects of pain relief and adverse effects. The lack of bioequivalence between some of the formulations suggests that care should be exercised if physicians change modified release formulations as dosage adjustments may be necessary in some patients.",1998.0,0,0
1842,9785066,Intercostal nerve blockade with a mixture of bupivacaine and phenol enhance the efficacy of intravenous patient-controlled analgesia in the control of post-cholecystectomy pain.,P Maidatsi; N Gorgias; A Zaralidou; V Ourailoglou; M Giala,"Prolonged nerve conduction blockade has been proposed to result from the summed effects of charged and neutral local anaesthetics. Thirty-seven patients were randomly allocated to receive intravenous patient-controlled analgesia alone or combined with intercostal blockade (T7-T11) with a mixture of 0.45% bupivacaine and 0.6% phenol for post-cholecystectomy analgesia. Adequacy of pain relief was measured by patient scores on a 10-cm visual analogue scale and by dose-demand ratio, amounts of loading dose and total consumption of morphine and also the duration of patient-controlled analgesia in each group. No differences were found between groups in post-operative scores, dose-demand ratios and loading doses of morphine. However, in the combined treatment group, a significantly lower total consumption of morphine (P < 0.05), associated with a shorter duration of patient-controlled analgesia (P < 0.02) and a decreased mean number of unsuccessful demands (P < 0.001) were recorded. Intercostal blockade with bupivacaine-phenol supplements intravenous patient-controlled analgesia for post-cholecystectomy pain relief.",1998.0,0,0
1843,9785068,A prospective study comparing intravenous tenoxicam with rectal diclofenac for pain relief in day case surgery.,S A Colbert; C McCrory; D M O'Hanlon; M Scully; A Tanner; M Doyle,"In a prospective, randomized, double-blind study, we compared intravenous tenoxicam with rectal diclofenac for post-operative pain relief after day case arthroscopy or laparoscopic sterilization. Intravenous tenoxicam (40 mg) was administered as a single bolus at induction, or rectal diclofenac (100 mg) was administered immediately after induction. Both groups were similar with respect to age, weight, sex of the patients, the operation performed and the operative time. There were no significant differences observed between the groups for pain scores at 30 min, 60 min and 24 h post-operatively. The time to first analgesic requirement, the dose of pethidine administered and total analgesic requirements in the first 24 h post-operatively were equivalent in both groups. In view of the similar efficacy of both of these drugs, patient preference and ease of administration, the use of tenoxicam is appropriate in many patients undergoing day case surgery.",1998.0,0,0
1844,9785072,Increased nausea and dizziness when using tramadol for post-operative patient-controlled analgesia (PCA) compared with morphine after intraoperative loading with morphine.,K F Ng; S L Tsui; J C Yang; E T Ho,"Thirty-eight ASA I-III patients undergoing lower abdominal operations were randomly allocated to receive either morphine (group M, patient-controlled analgesia bolus = 1 mg of morphine) or tramadol (group T, patient-controlled analgesia bolus = 10 mg of tramadol) for post-operative patient-controlled analgesia (PCA) after receiving morphine intraoperatively. There were no between-group differences in the pain, sedation or vomit scores. The nausea scores were significantly higher in group T in the initial 20 h and between 32 and 36 h (P < 0.01, 0-4 and 8-12 h; P < 0.05, 4-8, 12-16, 16-20 and 32-36 h). The incidence of dizziness was also significantly higher in group T (68.4% vs. 31.6%, group T vs. group M, P < 0.05). There was no difference in the overall satisfaction. We conclude that the use of tramadol, compared with morphine, for post-operative PCA after intraoperative loading with morphine is associated with more nausea and dizziness, but with similar sedation, quality of analgesia and patient satisfaction.",1998.0,0,0
1845,9787284,Guidelines from the American Geriatric Society target management of chronic pain in older persons.,V L Rose,,1998.0,0,0
1846,9791777,An evaluation of the effectiveness of patient-controlled analgesia after spinal surgery.,C L White; R P Pokrupa; M H Chan,"The purpose of this study was to evaluate the effectiveness of patient-controlled analgesia (PCA) in patients undergoing spinal surgery. Sixty patients undergoing spinal surgery were randomly assigned to receive PCA or the standard approach to postoperative analgesia (intramuscular injections on an ""as needed"" basis). Information on pain intensity at rest and with activity, total daily amount of analgesia, presence of adverse effects, length of time to ambulation and length of hospital stay was collected on all patients. Patients in the PCA group reported lower levels of pain, both at rest and with activity, and were ambulating earlier than patients receiving standard analgesia. There were no differences between the groups in total daily analgesic intake, presence of adverse effects and length of hospital stay. These data suggest that PCA is a safe, effective approach to managing pain after spinal surgery.",1998.0,0,0
1847,9791778,Managing chronic nonmalignant pain with continuous intrathecal morphine.,L Valentino; K V Pillay; J Walker,"One alternative to traditional treatment modalities for chronic pain is continuous intrathecal administration of morphine via an implanted pump. However, relatively little is known about the benefits and long-term complications of this therapy for chronic nonmalignant pain. The purpose of this study was to describe patient responses to continuous intrathecal morphine over the course of one year with respect to morphine dosage used, complications and subjective assessments of pain. Data were obtained from twelve patients who completed one year of therapy. After one year, a 42% reduction in pain as measured by the McGill pain questionnaire had occurred (p < .01). A similar 41% reduction in pain was also present based on the Verbal Descriptor Scale (p < .01). A 35% reduction in the perceived hardship of pain was present (p < .01) accompanied by anecdotal comments that an improvement in the ability to manage activities of daily living had occurred. One patient was able to return to work. A statistically nonsignificant increase in the mean daily dosage of morphine occurred and few long-term adverse effects were present. Complications of implantation occurred in 33.3% of the patients and were successfully managed without discontinuing therapy. In selected patients with chronic pain, intrathecal administration of morphine via an implanted pump can reduce pain with minimal long-term adverse effects or complications.",1998.0,0,0
1848,9793807,An intravenous fluid bolus is not necessary before administration of intrathecal fentanyl for labor analgesia.,M T Shannon; S Ramanathan,"To determine if an intravenous (i.v.) fluid bolus is necessary to prevent any possible hemodynamic sequelae after administration of intrathecal fentanyl in laboring parturients. Prospective, randomized study. Labor suite of a women's tertiary care hospital. 30 ASA physical status I and II parturients in active labor requesting labor analgesia. Patients were randomly divided into two groups of 15. One group received no i.v. fluid prior to the administration of 25 micrograms of intrathecal fentanyl, and the other group received 500 ml of lactated Ringer's solution before the block. Blood pressures [systolic (SBP), diastolic (DBP), mean (MAP)], heart rate (HR), cardiac index (CI; using impedance cardiography), and visual analog scores were measured before the block, after fluids, and then every 5 minutes for 45 minutes after the block. Prenatal baseline blood pressures before the onset of labor were obtained from the obstetrician's office records. Results were analyzed using analysis of variance. All patients reported good pain relief. No patient from either group required treatment for hypotension. In the no fluid group, SBP and MAP decreased 10% and 14%, respectively (p = 0.05), following intrathecal fentanyl administration compared with preblock values obtained during labor but not when compared with prelabor prenatal values. In the fluid group, no significant changes occurred in SBP after intrathecal fentanyl but MAP decreased approximately 12% only in comparison to preblock values. No significant changes were noted in CI in either group. Fluid infusion itself caused an increase in HR and CI of approximately 12% and 9.4%, respectively. Intrathecal fentanyl produces only minimal hemodynamic changes with or without prior fluid administration.",1998.0,0,0
1849,9793813,Comparison of three different doses of intrathecal fentanyl and sufentanil for labor analgesia.,R R Gaiser; T G Cheek; B B Gutsche,"To compare the duration of analgesia and incidence of side effects of three doses of intrathecal fentanyl (25 micrograms, 37.5 micrograms, 50 micrograms) with three doses of intrathecal sufentanil (5 micrograms, 10 micrograms, 15 micrograms). Randomized, double-blind study. Labor suite of the Hospital of the University of Pennsylvania. 60 ASA physical status I and II parturients in active labor who requested analgesia. Patients received one of the six doses of opioid diluted with normal saline to achieve a volume of 1.5 ml intrathecally. Duration of analgesia, contraction pain, degree of pruritus, maternal blood pressure, maternal heart rate, fetal heart rate, Apgar scores, and neurologic and adaptive capacity scores were measured. There was no statistical difference among the doses of fentanyl in duration of analgesia. In addition, there was no statistical difference among the doses of sufentanil. The durations of analgesia for all doses of sufentanil were statistically longer than that for all doses of fentanyl. There was no difference among all the groups for maximal pruritus score. The duration of pruritus did not differ among doses of fentanyl or sufentanil; the duration of pruritus was significantly longer for sufentanil. All groups had a decrease in blood pressure. There was no difference among the groups in regard to the effect on the systolic or diastolic blood pressure. Intrathecal sufentanil produced analgesia of longer duration than fentanyl for all doses studied. The duration of pruritus with sufentanil was also longer.",1998.0,0,0
1850,9799348,The effect of diclofenac (voltarol) and pethidine on ureteric peristalsis and the isotope renogram.,R J Brough; M J Lancashire; J R Prince; M R Rose; M C Prescott; S R Payne; H J Testa,"Diclofenac (a non-steroidal anti-inflammatory drug) and pethidine (a synthetic opiate) are the two analgesics most commonly used to relieve the pain of ureteric colic. Fast frame renography is a non-invasive means of imaging ureteric peristalsis and renal drainage. The aim of this study was to determine the effects of each of these drugs on the drainage pattern of the upper tracts. Twelve normal male volunteers were studied. All underwent a standard fast frame renogram using 75 MBq of technetium-99m-mercaptoacetyltriglycine, and were then administered either 100 mg pethidine or 75 mg diclofenac by intramuscular injection. Fast frame renography was then repeated. Peristalsis was determined from the condensed image of each ureter and the renogram curves were analysed to obtain standard parameters and deconvolution analysis. Diclofenac caused a profound disruption to both ureteric peristalsis and the renogram curve. This effect was not seen after the administration of pethidine. Deconvolution analysis suggests the effects of diclofenac are mediated via a direct effect on drainage rather than by any alteration of blood flow to the kidney. This study suggests that pethidine is the analgesic of choice prior to renography and that inferences about alterations of drainage in the presence of diclofenac should be interpreted with care.",1998.0,0,0
1851,9802048,A research-based guideline for appropriate use of transdermal fentanyl to treat chronic pain.,B Wakefield; J A Johnson; J Kron-Chalupa; L Paulsen,"To describe a research utilization project intended to develop, implement, and evaluate a research-based guideline for the use of transdermal fentanyl. The guideline was based on existing literature, clinical expert knowledge, manufacturer recommendations, and cost considerations. Principles of guideline development and evaluation were based on recommendations from the Agency for Health Care Policy and Research. A comparison of data from baseline to six months after guideline implementation revealed improvements in all criteria. Most of the improvements were maintained at 18 months postguideline implementation. The guideline improved the appropriate use of transdermal fentanyl. Ongoing education and monitoring is necessary to maintain change in practice. The cost-effective use of expensive technology is a concern in the area of health care. Nurses need to promote the appropriate use of pain-management techniques to provide quality care for patients with chronic pain. Guidelines will help nurses to support the use of higher-cost medications in this subpopulation of patients.",1998.0,0,0
1852,9804592,Nociceptive mechanisms modulate ozone-induced human lung function decrements.,A N Passannante; M J Hazucha; P A Bromberg; E Seal; L Folinsbee; G Koch,"We have previously suggested that ozone (O3)-induced pain-related symptoms and inhibition of maximal inspiration are due to stimulation of airway C fibers (M. J. Hazucha, D. V. Bates, and P. A. Bromberg. J. Appl. Physiol. 67: 1535-1541, 1989). If this were so, pain suppression or inhibition by opioid-receptor agonists should partially or fully reverse O3-induced symptomatic and lung functional responses. The objectives of this study were to determine whether O3-induced pain limits maximal inspiration and whether endogenous opioids contribute to modulation of the effects of inhaled O3 on lung function. The participants in this double-blind crossover study were healthy volunteers (18-59 yr) known to be ""weak"" (WR; n = 20) and ""strong"" O3 responders (SR; n = 42). They underwent either two 2-h exposures to air or two 2-h exposures to 0. 42 parts/million O3 with moderate intermittent exercise. Immediately after post-O3 spirometry, the WR were randomly given either naloxone (0.15 mg/kg iv) or saline, whereas SR randomly received either sufentanil (0.2 microgram/kg iv) or saline. O3 exposure significantly (P < 0.001) impaired lung function. In SR, sufentanil rapidly, although not completely, reversed both the chest pain and spirometric effects (forced expiratory volume in 1 s; P < 0.0001) compared with saline. Immediate postexposure administration of saline or naloxone had no significant effect on WR. Plasma beta-endorphin levels were not related to an individual's O3 responsiveness. Cutaneous pain variables showed a nonsignificant weak association with O3 responsiveness. These observations demonstrate that nociceptive mechanisms play a key role in modulating O3-induced inhibition of inspiration but not in causing lack of spirometric response to O3 exposure in WR.",1998.0,0,0
1853,9807845,Prospective and randomized trial of intravenous tenoxicam versus fentanyl and tramadol for analgesia in outpatient extracorporeal lithotripsy.,Y Y Chia; K Liu,"As extracorporeal shock wave lithotripsy (ESWL) is frequently carried out on an outpatient basis, it is crucial to choose an adequate analgesic with less adverse effect. This study evaluated the use of three different intravenous agents: fentanyl, tramadol HCl and tenoxicam in ESWL. One hundred and twenty patients undergoing lithotripsy were randomly assigned to receive either intravenous fentanyl 1 microgram/kg, tramadol HCl 1.5 mg/kg or tenoxicam 0.3 mg/kg before lithotripsy. Pain intensity was recorded using verbal rating pain scales (VRPS). Cases without adequate analgesia (VRPS > 4) or could not tolerate the pain, additional bolus of fentanyl 25 micrograms were given until adequate analgesia was achieved. Side effects were recorded as well. No significant differences were found among groups in demographic data, VRPS, number of total shock waves, cases with supplementary fentanyl, mean dose of supplementary fentanyl or the incidence of dizziness. However, the incidence of nausea or vomiting was significantly higher in fentanyl and tramadol groups comparing with tenoxicam group (15.0% and 25.0% vs. 0.0%). Oxygen saturation in fentanyl group was also significantly lower than the other two groups (p < 0.01). In addition, VRPS had a significant correlation with voltage intensities (p < 0.05). Lithotripsy can be satisfactorily performed by employing fentanyl, tramadol or tenoxicam for analgesia; tenoxicam apparently offers a better analgesic quality with less side effect. Furthermore, the need for stronger analgesia during larger voltage intensity should be tailored to the needs of the individuals.",1998.0,0,0
1854,9813510,Intrathecal diamorphine compared with morphine for postoperative analgesia after caesarean section under spinal anaesthesia.,S W Husaini; I F Russell,"A randomized, double-blind study of 40 women was performed to compare patient controlled anaesthesia (PCA) morphine requirements after spinal anaesthesia for elective Caesarean section. The women received 0.2 mg of either morphine or diamorphine mixed with 0.5% bupivacaine in 8% dextrose. There were no significant differences between the groups in terms of VAS for pain, either while supine or trying to turn over. The median VAS for itching were significantly higher in the morphine group at 3, 4, 6, 8 and 12 h. Similarly, the VAS for drowsiness were significantly higher in the morphine group at 6 and 8 h. Overall there was no difference in the 24-h PCA morphine demands between the two groups (diamorphine patients 5.5 mg, morphine patients 5.0 mg.",1998.0,0,0
1855,9816714,Comparison of PCA nalbuphine and morphine in Chinese gynecologic patients.,S T Ho; J J Wang; H S Liu; O Y Hu; J I Tzeng; W J Liaw,"The aim of this study was to evaluate the efficacy and side effects of PCA nalbuphine (intravenous) versus morphine on postoperative pain in Chinese gynecologic patients. Sixty women undergoing abdominal hysterectomy or myomectomy under spinal anesthesia were enrolled into the investigation. Patients were randomly divided into 2 groups (n = 30 each). Group 1 received intravenous nalbuphine using PCA device for the management of postoperative pain, whereas group 2 received PCA morphine for the same purpose. During the first 48 hours postoperatively, we collected the following data: analgesic doses, pain scores, vital signs, nausea, vomiting, pruritus and dizziness. The results showed that despite different treatments, pain scores on day 1 and day 2 postoperatively were low and were not significantly different between groups. Meanwhile, the cumulative consumption of PCA nalbuphine (32 +/- 10 mg) and PCA morphine (30 +/- 9 mg) was similar. Both treatments showed only minor side effects and the incidence of each side effect was not significant between groups. Both PCA nalbuphine and morphine are effective in the treatment of postoperative pain in Chinese gynecologic patients undergoing hysterectomy or myomectomy after spinal anesthesia and the potency of nalbuphine is similar to that of morphine.",1998.0,0,0
1856,9817288,Morphine versus methadone in the pain treatment of advanced-cancer patients followed up at home.,S Mercadante; A Casuccio; A Agnello; R Serretta; L Calderone; L Barresi,"The aim of this study was to evaluate the analgesic and adverse effects and the doses of methadone in comparison to morphine. A prospective randomized study was performed in a sample of 40 patients with advanced cancer who required strong opioids for their pain management. Patients were treated with sustained-release morphine or methadone in doses titrated against the effect administered two or three times daily according to clinical need. Opioid doses, adjuvant medications, symptoms associated with opioid therapy, pain intensity, and pain mechanisms were recorded. The opioid escalation indices in percentage (OEI%) and milligrams (OEImg) were calculated. The effective analgesic score (EAS) that monitors the analgesic consumption-pain ratio was also calculated at fixed weekly intervals. differences in pain intensity were found. Patients treated with methadone reported values of OEI significantly less than those observed in patients treated with morphine. Seven patients in the methadone group maintained the same initial dosage until death, whereas only one patient in the morphine group did not require opioid dose escalation. A more stable analgesia in time in patients treated with methadone was shown by the low number of gaps in EASs reported. Symptom frequencies and intensities were similar in the two groups. Methadone is a drug of indisputable value in the treatment of cancer pain, and an unbalanced focus on the risks of inappropriate use rather than the benefits should not compromise the use of a relevant alternative to morphine in the management of cancer pain.",1998.0,0,0
1857,9818105,Improved postoperative analgesia with isoflurane than with propofol anaesthesia.,G Boccara; C Mann; Y Pouzeratte; A Bellavoir; A Rouvier; P Colson,"The impact of hypnotic drugs on postoperative analgesia has not been evaluated. We compared the influence of the maintenance of anaesthesia with either propofol or isoflurane on postoperative pain. Forty ASA 1-2 women, undergoing cosmetic abdominoplasty were randomized to receive either 6-12 mg.kg-1.hr-1 propofol i.v. (P, n = 20) or MAC 1-1.5 isoflurane inhalation (Iso, n = 20). The lungs were ventilated with N2O 60% and O2 40%, and 1 microgram.kg-1 fentanyl i.v. provided intraoperative analgesia. Before surgical closure, 2 g propacetamol i.v. were administered. Postoperative analgesia was provided after hourly assessment of pain (VAS 0-100 mm), with 10 mg nalbuphine i.v. if VAS > or = 50 mm, during the eight hours after surgery. Sedation score (awake 0 to unrousable 4) was also recorded. Analgesia satisfaction score (nil 0 to excellent 4) obtained from the patient on discharge. Sedation scores were similar in both groups except in the first postoperative hour, when it was higher in the Iso group. The VAS at rest (15.4 +/- 18.6 vs 29.7 +/- 19.8 mm, P = 0.0001) and nalbuphine requirements (0.13 +/- 0.35 vs 0.70 +/- 0.80 doses, P = 0.004) were lower in the Iso group during the first six hours, although emesis was more frequent than in P (60 vs 25%; P = 0.03). The incidence of analgesia satisfaction score (> or = 3) was similar between the two groups (P: 95; Iso: 75%). These results suggested that isoflurane anaesthesia provides better analgesia than propofol anaesthesia in the first six hours after abdominoplasty.",1998.0,0,0
1858,9821994,Intraoperative awareness in fast-track cardiac anesthesia.,N P Dowd; D C Cheng; J M Karski; D T Wong; J A Munro; A N Sandler,"Fast-track cardiac anesthesia, using low-dose narcotics combined with short-acting anesthetic and sedative agents, facilitates early tracheal extubation after cardiac surgery. The incidence of awareness with this anesthetic technique has not been investigated previously. The purpose of this study was to prospectively investigate the incidence of intraoperative awareness with explicit memory of events during fast-track cardiac anesthesia. Data were collected prospectively over a 4-month period from 617 consecutive adult patients undergoing cardiac surgery at a university hospital. All patients received a fast-track cardiac anesthetic regimen. Patients underwent a structured interview by a research nurse 18 h after extubation. A standard set of questions was asked during this interview to determine if the patient had explicit memory of any event from induction of anesthesia to recovery of consciousness. Nine patients did not complete a postoperative interview because of death (n = 7) or postoperative confusion (n = 2). The last memory before surgery reported in 420 (69.1%) patients was waiting in the holding area at the operating suite, and in the remaining 188 (30.9%) patients it was lying on the operating table before induction of anesthesia. Two patients (0.3%) had explicit memory of intraoperative events. One of the two patients also had explicit memory of pain. Neither patient reported adverse psychological sequelae. The authors report an incidence of awareness in fast-track cardiac anesthesia of 0.3%. This is the lowest incidence of awareness currently reported during cardiac surgery. This low incidence of awareness may be related to the use of a balanced anesthetic technique involving the continuous administration of volatile (isoflurane) or intravenous (propofol) anesthetic agents before, during, and after cardiopulmonary bypass.",1998.0,0,0
1859,9822403,Recent advances: control of chronic pain.,T J Nurmikko; T P Nash; J R Wiles,,1998.0,0,0
1860,9824782,Effects of low-dose morphine on gastric emptying in healthy volunteers.,C S Yuan; J F Foss; M O'Connor; M F Roizen; J Moss,"Appropriate preoperative pain therapy for patients undergoing surgery may be withheld due to the fear that opioids will inhibit gastric emptying and increase the risk of aspiration. Previously, doses of 5 to 10 mg of morphine have been shown to delay gastric emptying time. However, the effect of lower doses of morphine on gastric emptying in humans has not been reported. In this study, the effects of intravenous morphine 0.05 mg/kg-3.5 mg for 70-kg body weight, a dose that can cause analgesia--on gastric emptying were evaluated in a double-blind, randomized, placebo-controlled study in 15 healthy human volunteers using the acetaminophen test. Our data indicated that this low dose of morphine significantly prolonged the gastric emptying time. Thus, even small doses of morphine inhibit gastric emptying. This effect may be important in patients undergoing surgery, in patients receiving other oral medications after surgery in ambulatory settings, and in instances of patient-controlled analgesia.",1998.0,0,0
1861,9834808,Subarachnoid and intravenous PCA versus bolus administration for postoperative pain relief in orthopaedic patients.,I Rundshagen; E Kochs; T Standl; K Schnabel; J Schulte am Esch,"Patient-controlled analgesia (PCA) with intravenous piritramide and subarachnoid bupivacaine was studied during postoperative pain management in comparison with nurse-administered bolus injections. Following general anaesthesia (n = 60) patients randomly received either 3.75-7.5 mg i.v. piritramide on demand (group P-Bolus) or via PCA (group P-PCA; initial bolus: 3.75 mg i.v. piritramide, baseline rate: 1 mg/h, demand-dose 1.5 mg, lockout time: 20 min). Following continuous spinal anaesthesia (n = 60; CSA; 28-G spinal catheter) patients randomly received a subarachnoid injection of 1.5 ml bupivacaine 0.25% every 2-4 h (group B-Bolus) or a baseline infusion of 0.5 ml/h bupivacaine 0.125% plus 0.5 ml bupivacaine 0.125% on demand via PCA (group B-PCA; lockout time: 30 min). Pain ratings were assessed hourly by patients using a visual analogue scale (0 = no pain, 100 mm = unbearable pain). multivariate analysis of variance. While pain scores did not differ between group P-Bolus and P-PCA, group B-PCA showed the lowest pain ratings (18 +/- 22 mm) differing significantly from group B-Bolus (41 +/- 32 mm; P < 0.001). Group P-PCA required more piritramide than group P-Bolus (46 +/- 15 mg vs. 31 +/- 13 mg, P = 0.001). In contrast group B-PCA required less bupivacaine than group B-Bolus (18 +/- 4 vs. 23 +/- 7 mg, P = 0.002). PCA with CSA was more effective than nurse-administered bolus-administration of bupivacaine, while the present study failed to show superiority of i.v. PCA over i.v. bolus-administration of piritramide. PCA using the subarachnoid route is a promising concept for treatment of postoperative pain in orthopaedic patients, while the PCA piritramide regime of this study warrants improvement.",1998.0,0,0
1862,9835978,[Analgesia using continuous axillary block after surgery of severe hand injuries: self-administration versus continuous injection].,H Iskandar; S Rakotondriamihary; F Dixmérias; B Binje; P Maurette,"To compare analgesia produced after surgery for severe hand trauma, by a continuous axillary block obtained either with a continuous injection (CA) or controlled by the patient (PCA). Prospective, randomized study. Forty-two ASA physical class 1 and 2 patients were enrolled over a twelve-month period and randomly allocated either into the CA or the PCA group. After recovery from the surgical block, the axillary plexus was located using a nerve stimulator and a 20 G catheter (Contiplex B Braun) inserted over 5 centimeters into the axillary sheath. In the CA group (n = 21) patients received 0.1 mL.kg-1.h-1 of 0.25% bupivacaine and in the PCA group (n = 21) patients received 0.1 mL.kg-1 boluses of 0.25% bupivacaine with a one hour lock-out period. Data collected were pain intensity rated according to he visual analog scale (VAS), the total volume of bupivacaine injected, the quantity of nalbuphine administered as 10 mg boluses when VAS was = 5, and the patient's satisfaction after removal of the catheter. Statistical analysis used Student t test, ANOVA and chi 2 test. The mean duration of catheter use was 5 +/- 3 days. During this period the amount of bupivacaine was significantly reduced in the PCA group when compared to the CA group (P < 0.001). Similarly, the PCA group required significantly less nalbuphine. Finally, in this group, the satisfaction index was higher than in the CA group (95 versus 52% respectively, P < 0.01). Continuous axillary plexus blockade provides safe and effective postoperative analgesia. With the PCA technique results a lower quantity of bupivacaine is required and patient's satisfaction better.",1998.0,0,0
1863,9836029,Postoperative patient-controlled epidural analgesia with opioid bupivacaine mixtures.,G Ozalp; F Güner; N Kuru; N Kadiogullari,"To determine the efficacy and safety of patient-controlled epidural analgesia of morphine or fentanyl in combination with bupivacaine for postoperative pain relief. Forty ASA I-II patients scheduled for major abdominal surgery were studied. After insertion of a lumbar epidural catheter, patients were given a non-opioid general anaesthetic. After surgery patients complaining of pain, received a loading dose of 2 mg morphine (Group I) or 50 micrograms fentanyl (Group II). For continuing pain, 1 mg morphine in 4 ml bupivacaine 0.125% (0.25 mg.ml-1 morphine and 1 mg.ml-1 bupivacaine, Group I) or 20 micrograms fentanyl in 4 ml bupivacaine 0.125% (5 micrograms.ml-1 fentanyl and 1 mg.ml-1 bupivacaine Group II) were administered. Blood pressure, heart rate, respiratory rate and SpO2 were monitored. Assessments of pain (VAS), nausea-vomiting, motor block, pruritus and sedation were recorded for 24 hr. No difference in pain or sedation was observed between groups. The 24 hr postoperative opioid consumption was 15.50 +/- 7.53 mg morphine and 555.10 +/- 183.85 micrograms fentanyl. Total bupivacaine 0.125% consumption was 58.00 +/- 30.14 ml in Group I and 101.05 +/- 36.77 ml in Group II. One patient in Group II complained of motor weakness in one leg. The incidence of nausea (Group I 45%, Group II 10% P < 0.05) and pruritus (Group I 30%, Group II 5% P < 0.05) was less in patients receiving fentanyl. Both methods were effective in the prevention of pain but, because of fewer side effects, fentanyl may be preferable to morphine.",1998.0,0,0
1864,9836030,Preoperative education and outcome of patient controlled analgesia.,M J Griffin; L Brennan; A J McShane,"To determine the effect of intensive preoperative education on the outcome of Patient Controlled Analgesia (PCA) postoperatively. This prospective randomised study was carried out in a single teaching hospital over three months. One group of patients (n = 42) received a 20 min standardised tutorial regarding PCA use from a single investigator and the other group (n = 43) received no additional education apart from the routine preoperative anaesthetic consultation. A blinded investigator assessed the patients following surgery. Pain scores and morphine consumption, patient satisfaction, side-effect profile and anti-emetic use were recorded at six, 24 and 48 hr postoperatively. Pain scores, satisfaction scores and morphine consumption were similar in both groups throughout the study period. Fewer patients in the tutored group complained of nausea from 6 to 24 hr than did untutored patients (28% vs 51%; P < 0.05). More tutored patients used antiemetic medication from 0 to 6 (28% vs 12%; P < 0.05) and 6 to 24 hr (37% vs 19%; P < 0.05). Side effect profile and requirement for rescue analgesia was otherwise similar in both groups. Our results suggest that specific preoperative education of patients using PCA does not alter pain scores, morphine consumption or patient satisfaction but may result in earlier and more effective use of anti-emetic medication.",1998.0,0,0
1865,9839823,"Intra-articular glucocorticoid, bupivacaine and morphine reduces pain, inflammatory response and convalescence after arthroscopic meniscectomy.",S Rasmussen; A S Larsen; S T Thomsen; H Kehlet,"Convalescence after arthroscopic meniscectomy is dependent on pain and the inflammatory response. The aim of the study was therefore to investigate the effect of intra-articular bupivacaine + morphine + methylprednisolone versus bupivacaine + morphine or saline on postmeniscectomy pain, mobilisation and convalescence. In a double-blind randomized study 60 patients undergoing arthroscopic meniscectomy were allocated to intra-articular saline, intra-articular bupivacaine 150 mg + morphine 4 mg or the same dose of bupivacaine + morphine + intra-articular methylprednisolone 40 mg. All patients were instructed to resume normal activities immediately after operation. Pain during movement and walking, leg muscle force and joint effusion, use of crutches and duration of sick leave were assessed. Combined bupivacaine and morphine significantly reduced pain, time of immobilisation and duration of convalescence. Addition of methylprednisolone further reduced pain, use of additional analgesics, joint swelling and convalescence, improved muscle function and prevented the inflammatory response (acute phase protein) (P < 0.05). A multimodal analgesic and anti-inflammatory treatment may enhance post-arthroscopic convalescence, which depends on the trauma induced inflammatory response and pain.",1998.0,0,0
1866,9841973,,,,,0,0
1867,9844616,Long-term administration of controlled-release oxycodone tablets for the treatment of cancer pain.,M L Citron; R Kaplan; W C Parris; M K Croghan; L H Herbst; R J Rosenbluth; R F Reder; N S Slagle; B J Buckley; R F Kaiko,"We conducted a study of the safety of controlled-release (CR) oxycodone tablets (OxyContin Tablets) administered chronically to patients with cancer-related pain in a usual clinical setting. These patients had participated in 1 of 2 double-blind, active-control studies. Our study was an open, 3-month treatment study that included 87 patients. Patients received CR oxycodone tablets every 12 hr in a manner that reflected typical clinical practice. Supplemental immediate-release (IR) oxycodone was available PRN for breakthrough pain. Patients recorded medication use, adverse events, and evaluations of pain intensity and acceptability of therapy in a daily diary. Forty-four patients (51%) completed all 12 weeks of study; 43 patients (49%) discontinued participation. At baseline and throughout the study period, the overall mean pain-intensity score was slight to moderate. A comparison of initial and final doses showed a significant but modest increase in total daily CR oxycodone dose. An increase or decrease in titration of the oxycodone dose occurred for 66 patients (84%) at least once during the 12-week study period, primarily for increased pain. Forty-four patients (56%) did not undergo dose titration when the latter was indicated. Half of the patients used IR oxycodone rescue almost daily; the mean number of rescue doses per day was 1.5. Despite stable pain control and an increasing total daily CR oxycodone dose, the percentage of patients reporting common opioid-related adverse events decreased over the course of the study. CR oxycodone tablets administered every 12 hr were successfully used to manage cancer pain over a 12-week period. Importantly, side effects diminished over time without a concomitant change in efficacy.",1998.0,0,0
1868,9846064,[Analgesic nephropathy].,I Pintér; J Nagy,"Analgesic nephropathy is a slowly progressive disease caused by the chronic abuse of analgesic mixtures containing two analgesic components combined with potentially addictive substances (coffeine and/or codeine). Pathologically, the nephropathy is characterized by renal papillary necrosis with calcification and chronic interstitial nephritis sometimes in association with transitional-cell carcinoma of the uroepithelium. In the early stage, the clinical characteristics are polyuria, sterile pyuria, sometimes renal colic and haematuria. With further progression of the disease, there are the nonspecific symptoms of advanced renal failure. The incidence of classic analgesic nephropathy among Hungarian patients on chronic renal replacement therapy has proven. There is an urgent need for the estimation of analgesic nephropathy among patients with chronic renal disease and among patients with chronic pain presumably regularly taking analgesics in Hungary. As long as analgesic mixtures containing phenacetin or paracetamol and/or nonsteroidal antiinflammatory drugs and addictive substances are available ""over-the-counter"", analgesic nephropathy will continue to be a problem also in our country.",1998.0,0,0
1869,9846778,Gabapentin for the treatment of postherpetic neuralgia: a randomized controlled trial.,M Rowbotham; N Harden; B Stacey; P Bernstein; L Magnus-Miller,"Postherpetic neuralgia (PHN) is a syndrome of often intractable neuropathic pain following herpes zoster (shingles) that eludes effective treatment in many patients. To determine the efficacy and safety of the anticonvulsant drug gabapentin in reducing PHN pain. Multicenter, randomized, double-blind, placebo-controlled, parallel design, 8-week trial conducted from August 1996 through July 1997. Sixteen US outpatient clinical centers. A total of 229 subjects were randomized. A 4-week titration period to a maximum dosage of 3600 mg/d of gabapentin or matching placebo. Treatment was maintained for another 4 weeks at the maximum tolerated dose. Concomitant tricyclic antidepressants and/or narcotics were continued if therapy was stabilized prior to study entry and remained constant throughout the study. The primary efficacy measure was change in the average daily pain score based on an 11-point Likert scale (0, no pain; 10, worst possible pain) from baseline week to the final week of therapy. Secondary measures included average daily sleep scores, Short-Form McGill Pain Questionnaire (SF-MPQ), Subject Global Impression of Change and investigator-rated Clinical Global Impression of Change, Short Form-36 (SF-36) Quality of Life Questionnaire, and Profile of Mood States (POMS). Safety measures included the frequency and severity of adverse events. One hundred thirteen patients received gabapentin, and 89 (78.8%) completed the study; 116 received placebo, and 95 (81.9%) completed the study. By intent-to-treat analysis, subjects receiving gabapentin had a statistically significant reduction in average daily pain score from 6.3 to 4.2 points compared with a change from 6.5 to 6.0 points in subjects randomized to receive placebo (P<.001). Secondary measures of pain as well as changes in pain and sleep interference showed improvement with gabapentin (P<.001). Many measures within the SF-36 and POMS also significantly favored gabapentin (P< or =.01). Somnolence, dizziness, ataxia, peripheral edema, and infection were all more frequent in the gabapentin group, but withdrawals were comparable in the 2 groups (15 [13.3%] in the gabapentin group vs 11 [9.5%] in the placebo group). Gabapentin is effective in the treatment of pain and sleep interference associated with PHN. Mood and quality of life also improve with gabapentin therapy.",2001.0,0,0
1870,9847656,[Comparative study of preemptive and postincisional lumbar epidural morphine in pulmonary resection. Preliminary report].,M Granell Gil; R García Aguado; M Tommasi Rosso; M D López Alarcón; F Aguar Olba; A Cantó Armengod; J M Palanca Sanfrancisco; F Grau Real,"To evaluate the efficacy and incidence of side effects of two types of lumbar epidural analgesia with morphine, preemptive or postincisional, combined with total intravenous anesthesia in chest surgery. This double-blind prospective study enrolled 20 patients (ASA I-IV) undergoing lobectomy or pneumonectomy. Anesthetic induction and maintenance was provided with propofol, atracurium and alfentanil. Lumbar epidural analgesia (L2-L3) with morphine was provided for group A patients with 2 to 4 mg upon excision of tissue and for group B with 2 to 4 mg during anesthetic induction. The following variables were recorded: arterial blood gas concentrations, heart rate, SpO2, EtCO2, postanesthetic recovery, arterial gases, side effects and pain on a visual analogue scale. Top-up analgesia was provided by intravenous metamizole and/or epidural morphine. For statistical analysis we used ANOVA, chi-square tests and Student-Newman-Keuls tests. The need for propofol and alfentanil during anesthesia, and for morphine and metamizole after surgery were statistically greater in group A. Pain 18 hours after surgery was also greater in group A. No significant differences between groups for other variables was observed. Preemptive analgesia with lumbar epidural morphine in addition to the general anesthesia described here seems to provide higher-quality analgesia with few side effects, reducing the need for propofol and alfentanil during surgery and for postoperative morphine and metamizole.",1998.0,0,0
1871,9848591,A comparison of ketorolac tromethamine/oxycodone versus patient-controlled analgesia with morphine in anterior cruciate ligament reconstruction patients.,J E Popp; W A Sanko; A K Sinha; C C Kaeding,"Effective postoperative analgesia with minimal side effects remains an important goal in enabling increasingly complex surgical procedures to be performed on an outpatient basis. In this study, we examined the efficacy of postoperative analgesia in 90 patients undergoing anterior cruciate ligament reconstruction using a patellar tendon autograft, with a 24-hour hospital stay. Patients were randomized to receive either intramuscular ketorolac supplemented by oral oxycodone, or intravenous morphine via patient-controlled analgesia (PCA) device, for postoperative analgesia. Patients were monitored for 2 hours in the recovery room, then every 4 hours until discharge, for the presence of complications of nausea, vomiting, urinary retention, pruritus, and dizziness. Pain was assessed using a visual analog scale (VAS) on the morning of postoperative day one. All patients were discharged by 24 hours after surgery. Ten (20%) of the patients receiving ketorolac/oxycodone versus 31 (79%) of those receiving PCA morphine experienced postoperative complications (P < .05). Postoperative nausea, vomiting, and urinary retention were each significantly more common in the PCA morphine group (P < .05). The incidence of pruritus and dizziness was low overall. There was no significant difference between groups in the severity of postoperative pain as assessed using a VAS. We conclude that ketorolac/oxycodone may provide comparable analgesia with fewer undesirable side effects than PCA morphine in patients undergoing anterior cruciate ligament reconstruction. Patients receiving ketorolac/oxymorphone may have a better quality recovery and more rapid discharge.",1998.0,0,0
1872,9854758,Opioid therapy for chronic noncancer back pain. A randomized prospective study.,R N Jamison; S A Raymond; E A Slawsby; S S Nedeljkovic; N P Katz,"A randomized, open, long-term, repeated-dose comparison of an anti-inflammatory drug and two opioid regimens in 36 patients with back pain. To examine the long-term safety and efficacy of chronic opioid therapy in a randomized trial of patients with back pain. All participants underwent a 4-week washout period of no opioid medication before being randomly assigned to one of three treatment regimens for 16 weeks: 1) naproxen only, 2) set-dose oxycodone, or 3) titrated-dose oxycodone and sustained-release morphine sulfate. All patients then were assigned to a titrated dose of opioids for 16 weeks and then gradually tapered off their medication for 12 weeks. Finally, all participants were monitored for a 1-month posttreatment washout period. Each patient was called once a week for a report on pain, activity, mood, medication, hours awake, and adverse effects and was monitored carefully for signs of abuse and noncompliance. Weekly reports during the experimental phase showed the titrated-dose group to have less pain (P < 0.001) and less emotional distress (P < 0.001) than the other two groups. Both opioid groups were significantly different from the naproxen-only group. During the titration phase, patients also reported significantly less pain and improved mood. Few differences were found in activity or hours asleep, or between average pretreatment and posttreatment phone-interview and questionnaire variables. No adverse events occurred, and only one participant showed signs of abuse behavior. The results suggest that opioid therapy has a positive effect on pain and mood but little effect on activity and sleep. Opioid therapy for chronic back pain was used without significant risk of abuse. However, tapered-off opioid treatment is palliative and without long-term benefit.",1998.0,1,1
1873,9855333,Safety issues in the pharmacologic management of chronic pain in the elderly.,L A Shimp,"Chronic pain is commonly encountered in elderly patients. About 20-50% of community-dwelling elderly experience it, and 45-80% of nursing home residents may be affected. Selection of pharmacologic therapy for the management of chronic pain must take into consideration the increased potential for adverse effects in this population. Major classes of drugs used to treat chronic pain (nonsteroidal antiinflammatory drugs, opioids, antidepressants) have adverse effects that occur more frequently in elderly than in younger patients. Given the often prolonged duration of therapy, optimal management requires minimizing the risk of adverse reactions.",1998.0,0,0
1874,9856611,Management of chronic pain among elderly patients.,D A Monti; E J Kunkel,,1998.0,0,0
1875,9856707,A randomized study of combined spinal-epidural analgesia versus intravenous meperidine during labor: impact on cesarean delivery rate.,D R Gambling; S K Sharma; S M Ramin; M J Lucas; K J Leveno; J Wiley; J E Sidawi,"Combined spinal-epidural (CSE) analgesia produces rapid-onset pain relief and allows ambulation in early labor. Epidural local anesthetics may contribute to an increase in operative deliveries by decreasing perineal sensation and causing motor weakness. Operative delivery rates might be reduced with CSE, by avoiding or delaying administration of local anesthetics. This study compares the operative delivery rates associated with a CSE technique and those associated with intravenous meperidine for labor analgesia. Healthy parturients at full term were assigned randomly to receive CSE or intravenous meperidine analgesia. The CSE group received 10 microg intrathecal sufentanil, followed by epidural bupivacaine and fentanyl at their next request for analgesia. Parturients receiving intravenous meperidine had 50 mg on demand (maximum, 200 mg in 4 h). Labor and delivery outcomes in both groups were recorded and compared. An intent-to-treat analysis of 1,223 women indicated that CSE does not increase the rate of cesarean delivery for dystocia in nulliparous and parous women (CSE, 3.5% vs. intravenous meperidine, 4; P=not significant) or in nulliparous women alone (CSE, 7% vs. intravenous meperidine, 8%; P=not significant). Profound fetal bradycardia that necessitated emergency cesarean delivery within 1 h of the time the mother received sufentanil occurred in 8 of 400 parturients (compared with 0 of 352 who received meperidine; P < 0.01). However, the method of fetal monitoring differed between the two groups. Despite this, neonatal outcomes were similar overall. Combined spinal-epidural analgesia during labor does not increase the cesarean delivery rate for dystocia in healthy parturient patients at full term, regardless of parity. However, an unexpected increase in the number of cesarean deliveries for profound fetal bradycardia after intrathecal sufentanil was observed. Further investigation is warranted.",1998.0,0,0
1876,9856709,Bupivacaine 0.01% and/or epinephrine 0.5 microg/ml improve epidural fentanyl analgesia after cesarean section.,S Cohen; I Lowenwirt; C B Pantuck; D Amar; E J Pantuck,"The authors studied the addition of bupivacaine and epinephrine, separately and together, to epidural fentanyl to determine whether this improved postcesarean analgesia and reduced the incidence of side effects. After elective cesarean section, 100 parturient patients who received fentanyl (3 microg/ml) epidurally for 48 h were allocated randomly in a double-blinded manner to four groups to receive, in addition to the study solution, 0.01% bupivacaine, 0.5 microg/ml epinephrine, both, or neither. A neurologic assessment of breast-fed neonates was made at 2 and 48 h of life. Plasma fentanyl concentrations were determined in a subset of patients at intervals after treatment. Patients receiving fentanyl alone made more attempts at patient-controlled analgesia (P < 0.01), required a greater total dose of fentanyl (P < 0.01), reported more pain (P < 0.003) and less satisfaction (P < 0.003), and had more nausea and urinary retention (P < 0.05) than all other groups. Patients who received bupivacaine with or without epinephrine had better overall satisfaction scores than those who did not receive bupivacaine (P < 0.001), and they required less fentanyl (P < 0.02) than patients who received fentanyl with only epinephrine. Motor blockade or orthostatic hypotension did not develop in any patient, and all patients could ambulate without difficulty. Neurobehavioral scores, which were similar among all neonates, were within the normal range. Plasma concentrations of fentanyl increased after epinephrine-containing solutions were discontinued. During the conditions of this study, the addition of epinephrine and bupivacaine to a 3-microg/ml epidural fentanyl solution for postcesarean section pain relief provided superior analgesia compared with fentanyl alone or fentanyl with epinephrine. Whether increasing the concentration of fentanyl alone might improve the efficacy of fentanyl remains unclear.",1998.0,0,0
1877,9856712,Efficacy and costs of patient-controlled analgesia versus regularly administered intramuscular opioid therapy.,M Choinière; B E Rittenhouse; S Perreault; D Chartrand; P Rousseau; B Smith; C Pepler,"Many studies have shown the efficacy of patient-controlled analgesia (PCA). However, it is not clear whether PCA has clinical or economic benefits in addition to efficient analgesia. The current study was designed to evaluate these issues by comparing PCA with regularly administered intramuscular injections of opioids after hysterectomy. This prospective study included 126 patients who underwent abdominal hysterectomy and were randomly assigned to receive PCA or regularly timed intramuscular injections of morphine during a period of 48 h. Doses were adjusted to provide satisfactory analgesia in both treatment groups. Pain at rest and with movement, functional recovery, drug side effects, and patient satisfaction were measured using rating scales and questionnaires. The costs of PCA and intramuscular therapy were calculated based on personnel time and drug and material requirements. Comparable analgesia was observed with the two treatment methods, with no significant differences in the incidence of side effects or patient satisfaction. The medication dosage had to be adjusted significantly more frequently in the intramuscular group than in the PCA patients. The PCA did not favor a faster recuperation time compared with intramuscular therapy in terms of times to ambulation, resumption of liquid and solid diet, passage of bowel gas, or hospital discharge. The results of the economic evaluation, which used a cost-minimization model and sensitivity analyses, showed that PCA was more costly than regular intramuscular injections despite the fact that no costs for the pump were included in the analyses. Cost differences in nursing time favoring PCA were offset by drug and material costs associated with this type of treatment. Compared with regularly scheduled intramuscular dosing, PCA is more costly and does not have clinical advantages for pain management after hysterectomy. Because of the comparable outcomes, the general use of PCA in similar patients should be questioned.",1998.0,0,0
1878,9856716,The local addition of tenoxicam reduces the incidence of low back pain after lumbar epidural anesthesia.,Y L Wang; J R Hsieh; H S Chung; C L Yu; A C Ho; P P Lu; P P Tan,"Postepidural backache is a common postoperative complaint after lumbar epidural anesthesia. Useful interventions to decrease the incidence of postepidural backache would be helpful. We performed a prospective, randomized, double-blind study to compare the effect of local addition of tenoxicam on the incidence of postepidural backache after nonobstetric surgery. One thousand unpremedicated ASA physical status I or II patients scheduled for hemorrhoidectomy were assigned randomly to tenoxicam or control groups. Patients in the control group received 25 ml lidocaine, 2%, with epinephrine 1:200,000 epidurally and 4 ml lidocaine, 1%, for local skin infiltration. Patients in the tenoxicam group received 25 ml lidocaine, 2%, with epinephrine 1:200,000 epidurally and 4 ml lidocaine, 1%, with tenoxicam (2 mg) 1:2,000 for local skin infiltration. Patients were interviewed at 24, 48, and 72 h postoperatively using a standard visual analog scale for evaluation of postepidural backache. A patient was considered to have postepidural backache when the postoperative visual analog scale score was higher than the preoperative score. The incidence of postepidural backache in patients in the control group for the 3 days were 22.8%, 17.4%, and 9.2%, all of which were significantly more frequent than observed in the patients in the tenoxicam group (6.8%, 4.0%, and 1.2%, P < 0.01). There was a significant association between backache and multiple attempts at epidural needle insertion. In summary, the local addition of tenoxicam reduced the incidence and severity of postepidural backache.",1998.0,0,0
1879,9860430,"Solitary rectal ulcer induced by excessive use of analgesic suppositories containing paracetamol, caffeine, and codeine.",M G Naumann; R Hintze; M Karaus,"We report the case of a 53-yr-old woman who developed an ulcer of the distal rectum with mild stenosis after prolonged use of suppositories containing paracetamol, caffeine, and codeine. After undergoing extensive diagnostic tests with exclusion of other possible causes, she admitted to the abuse of the suppositories. She was treated with frequent endoscopic balloon dilations to prevent progression of the rectal stenosis. Because of severe pain on defecation, she needed a protective colostomy which could be closed after the healing of the ulcer 7 months later. There was no significant residual stenosis. This case is compared to cases described in the past 30 years.",1998.0,0,0
1880,9861117,Effect of preoperative extradural bupivacaine and morphine on stump sensation in lower limb amputees.,L Nikolajsen; S Ilkjaer; T S Jensen,"We have examined the effect of preoperative extradural bupivacaine and morphine on postoperative stump sensation in 31 patients undergoing amputation of the lower limb in a prospective, randomized, double-blind study. Patients were allocated randomly to one of two groups: group 1 received extradural 0.25% bupivacaine 4-7 ml h-1 and morphine 0.16-0.28 ml h-1 before and during operation; group 2 received extradural saline before and during amputation and conventional analgesics for pain treatment. All patients received general anaesthesia for the amputation and extradural bupivacaine and morphine after operation. Sensory examination of the limb/stump was carried out before amputation, and after 1 week and 6 months. The following were measured: pressure pain thresholds (pressure algometry), touch and pain detection thresholds (von Frey hairs), thermal sensibility (thermal rolls), and allodynia and wind-up-like pain. There were no differences between the two groups at any of the postoperative assessments for mechanical and thermal sensibility or rate of allodynia and wind-up-like pain. Our study suggests that preoperative and intraoperative extradural block had no long-term prophylactic effect on hyperalgesia, allodynia or wind-up-like pain.",1998.0,0,0
1881,9861122,"Ketorolac, diclofenac and ketoprofen are equally efficacious for pain relief after total hip replacement surgery.",P A Kostamovaara; H Hendolin; H Kokki; L S Nuutinen,"We have compared the efficacy of ketorolac 30 mg i.v. followed by infusion at a rate of 90 mg/15.5 h, with that of diclofenac 75 mg followed by infusion of 75 mg/15.5 h or ketoprofen 100 mg followed by infusion of 100 mg/15.5 h, on postoperative pain in 85 patients after hip replacement surgery under spinal anaesthesia in a prospective, double-blind, randomized study. Supplementary analgesia was administered during the 16-h postoperative period with bolus doses of fentanyl delivered by a patient-controlled analgesia system. Mean total consumption of PCA-administered fentanyl was 890 (SD 400) micrograms in the ketorolac group, 920 (550) micrograms in the diclofenac group and 850 (350) micrograms in the ketoprofen group (ns). Median VAS scores were low over the entire study in each group and there was no significant difference between groups. No serious adverse events were recorded.",1998.0,0,0
1882,9861123,Influence of timing of morphine administration on postoperative pain and analgesic consumption.,A Y Millar; M D Mansfield; J Kinsella,"We have investigated if a pre-emptive dose of morphine, given 30 min before skin incision, influenced postoperative pain and morphine consumption after hysterectomy. In a prospective, randomized, double-blind, placebo-controlled clinical study, patients received morphine 0.3 mg kg-1 at induction of anaesthesia or 30 min later at skin incision. The primary endpoint was defined as 24-h morphine consumption via patient-controlled analgesia. We could not demonstrate any difference between the two groups in morphine consumption or pain scores, and we conclude that there was no evidence of pre-emptive analgesia in this study.",1998.0,0,0
1883,9866252,[Current principles of multidisciplinary treatment of pain in orthopedic clinics].,A V Gnezdilov; A M Ovechkin; M L Kukushkin; A V Syrovegin; A M Ivanov; T S Li; L G Ivanova,"Differentiated strategy of treating patients with acute and chronic pain is developed. Preemptive analgesia is a priority trend in the treatment of acute postoperative pain. The most prevalent method of postoperative analgesia is prolonged opioid epidural analgesia carried out in intensive care wards and other wards by an acute pain management team. For treating patients with chronic painful syndromes, protocols of initial clinical and diagnostic evaluation are developed, permitting the choice of individual treatment strategy. Differentiated complex drug therapy planned with consideration for individual course of the painful syndrome is the basis of treating patients with phantom pain syndrome. Algorithms of differentiated therapy of radicular and spondylogenic pain are designed. Stage-by-stage analysis of treatment efficacy is carried out using modern electrophysiological methods. Realization of the proposed organization principles improved the efficacy of postoperative analgesia to 88.2%, prevented the development of postoperative painful syndrome in 35.6% cases, decreased the incidence of phantom pain syndrome after amputation of the limb from 63.3 to 31.6% and increased the efficacy of this syndrome treatment to 70.1%, and increased the efficacy of treating vertebrogenic painful syndromes to 82.3%.",1998.0,0,0
1884,9870575,"The control of severe cancer pain by continuous intrathecal infusion and patient controlled intrathecal analgesia with morphine, bupivacaine and clonidine.",P S Tumber; D R Fitzgibbon,"The management of severe cancer pain may be problematic in spite of recent advances in pain management. A small percentage of patients with severe intractable pain and/or intractable side effects may require more aggressive interventional pain management strategies including the administration of medications continuously by the intrathecal route. A variety of medications, including morphine, bupivacaine, and clonidine, may be used intrathecally for the control of cancer pain. Optimal use of these medications requires individual titration to the patient's needs. We describe a case of severe cancer pain where these medications were used successfully by continuous intrathecal infusion and patient controlled intrathecal analgesia.",1998.0,0,0
1885,9870976,Neuropharmacological dissection of placebo analgesia: expectation-activated opioid systems versus conditioning-activated specific subsystems.,M Amanzio; F Benedetti,"We investigated the mechanisms underlying the activation of endogenous opioids in placebo analgesia by using the model of human experimental ischemic arm pain. Different types of placebo analgesic responses were evoked by means of cognitive expectation cues, drug conditioning, or a combination of both. Drug conditioning was performed by means of either the opioid agonist morphine hydrochloride or the nonopioid ketorolac tromethamine. Expectation cues produced placebo responses that were completely blocked by the opioid antagonist naloxone. Expectation cues together with morphine conditioning produced placebo responses that were completely antagonized by naloxone. Morphine conditioning alone (without expectation cues) induced a naloxone-reversible placebo effect. By contrast, ketorolac conditioning together with expectation cues elicited a placebo effect that was blocked by naloxone only partially. Ketorolac conditioning alone produced placebo responses that were naloxone-insensitive. Therefore, we evoked different types of placebo responses that were either naloxone-reversible or partially naloxone-reversible or, otherwise, naloxone-insensitive, depending on the procedure used to evoke the placebo response. These findings show that cognitive factors and conditioning are balanced in different ways in placebo analgesia, and this balance is crucial for the activation of opioid or nonopioid systems. Expectation triggers endogenous opioids, whereas conditioning activates specific subsystems. In fact, if conditioning is performed with opioids, placebo analgesia is mediated via opioid receptors, if conditioning is performed with nonopioid drugs, other nonopioid mechanisms result to be involved.",1998.0,0,0
1886,9873970,,,,,0,0
1887,9874004,AAPM president's message. Total pain care--new concept? American Academy of Pain Medicine.,J D Haddox,,1999.0,0,0
1888,9874015,Oral methadone for the treatment of severe pain in hospitalized children: a report of five cases.,Y Shir; Z Shenkman; V Shavelson; E M Davidson; G Rosen,"Pain relief is still inadequate in many hospitalized patients, especially children in whom suboptimal use of analgesic drugs is still common. In the past 2 years, oral methadone has been used extensively in our institution for treating children with persistent pain from cancer, burns, or trauma who were capable of oral intake and whose pain was not relieved by nonopioid medications. Tertiary university hospital. Of the 70 children treated thus far with oral methadone, five are described in the present report. Pain relief, acceptability, and side effects of oral methadone in children with pain. Treatment with oral methadone (0.1% in 10% glucose, dose range of 0.2-0.6 mg/kg/day) for time periods of up to 6 weeks resulted in a rapid onset and stable pain relief, with no major side effects. No adverse responses were encountered after discontinuation of treatment. In three of the children, a parent-controlled analgesia regimen was successfully employed. Oral methadone can be recommended for babies and children who have severe pain that is not alleviated by nonopioid medications and who are capable of oral intake.",1999.0,0,0
1889,9876706,Analgesia following major gynecological laparoscopic surgery--PCA versus intermittent intramuscular injection.,D M Rosen; A M Lam; M A Carlton; G M Cario; L McBride,"To compare the use of patient-controlled analgesia to intermittent intramuscular injections of morphine following major gynecological laparoscopic procedures in order to assess differences in level of pain, sedation, episodes of nausea and/or vomiting, hospitalization time and patient satisfaction with their postoperative analgesia. Seventy-two patients undergoing major gynecological laparoscopic surgery were randomized to receive either postoperative analgesia via intermittent intramuscular injection of morphine (Group 1) or patient controlled analgesia (PCA-Group 2). All patients received anesthesia via a standardized protocol. Postoperative pain levels were recorded via a 10 cm visual analogue scale, and sedation scores were recorded on a standard PCA form. Episodes of nausea and vomiting were also recorded on the same form. There were no statistically significant differences between intramuscular analgesia and PCA for any of the factors studied. Most significantly it was found that most patients ceased to require either form of parenteral analgesia within 24 hours of their procedure, regardless of the operating time. It is important for the surgeon to be aware of the effects of postoperative analgesia on his or her patients' level of satisfaction. We do not recommend the use of PCA analgesia following major laparoscopic gynecological surgery.",1999.0,0,0
1890,9884851,Lignocaine plus morphine in bolus patient-controlled intravenous analgesia lacks post-operative morphine-sparing effect.,Y Y Chia; P H Tan; K Y Wang; K Liu,"Lignocaine has been used successfully to treat burn pain and neuropathic pain. We have conducted a randomized, double-blind trial to assess the morphine-sparing effect of intravenous lignocaine in patients with acute pain. After major abdominal surgery, patients were treated with post-operative patient-controlled intravenous analgesia in two groups: group M (n = 25, morphine 0.2 mg mL-1) and group ML (n = 25, morphine 0.2 mg mL-1 plus lignocaine 3.2 mg mL-1). The patient-controlled analgesia system was programmed to deliver a 5 mL bolus with a 50 mL per 4 h limit; the lockout time was 10 min. Both groups closely resembled each other in terms of demographic data, pain intensity, cumulative morphine dose and the morphine-associated nausea, vomiting and pruritus. However, the sedation scores in group ML patients during the first post-operative day were significantly greater than those in group M. The incidence of lignocaine-related lightheadedness and dry mouth was also significantly greater in group ML than in group M. It was concluded that the addition of lignocaine 3.2 mg mL-1 to morphine 0.2 mg mL-1 given via patient-controlled analgesia system does not provide a post-operative morphine-sparing analgesic effect.",1999.0,0,0
1891,9887474,[Influence of sex on reporting pain].,V Piguet; J Desmeules; A F Allaz; M Kondo-Oestreicher; C Constantin; G Schaerer; C Cedraschi; P Dayer,"In many epidemiological pain studies, women more frequently report more intense, frequent and long-lasting or chronic transient pain than men. In our retrospective study including hospitalised patients referred to a pain centre, prevalence of headaches, musculoskeletal pain and somatoform pain was observed in women, as described in the literature. Generally pain intensity was higher in women and pain was more frequently controlled in men, but when intensity and pain control were compared according to the pain aetiologies, no gender difference was found. Drug treatments were adapted to pain aetiologies, which accounted for the observed differences. In hospitalised patients the significant differences observed in intensity, pain control and treatment reflect the heterogeneity of pain aetiologies rather than gender differences.",1999.0,0,0
1892,9889744,Chronic recurrent abdominal pain.,S W Zackowski,"Chronic recurrent abdominal pain remains a common medical and surgical problem, frequently dismissed as functional. Instead, these patients should be approached systematically, based on the pattern of recurrent abdominal pain. It is vital to seek out the potential cause of this type of chronic pain because specific and often curative treatment is available.",1999.0,0,0
1893,9893537,Regional analgesia in early active labour: combined spinal epidural vs. epidural.,C Price; L Lafreniere; C Brosnan; I Findley,"We randomly allocated 93 women in early active labour and requesting epidural analgesia to receive either epidural (n = 48) or combined spinal-epidural analgesia (n = 45). For epidural analgesia 15 ml of bupivacaine 0.1% with 75 micrograms of fentanyl were injected into the epidural space. For combined spinal-epidural analgesia 1 ml of bupivacaine 0.25% with 25 micrograms of fentanyl were injected into the subarachnoid space. For both groups subsequent top-ups of 10 ml of bupivacaine 0.1% with fentanyl 20 micrograms were given using a lightweight patient-controlled epidural analgesia (PCEA) pump with a lockout time of 30 min. We assessed analgesia and the degree of motor blockade and found no significant differences in pain or maternal satisfaction scores between the two groups. The time to first top-up was significantly longer in the epidural group than in the CSE group (p = 0.01). The combined spinal-epidural group had significantly greater motor blockade at 30 min than the epidural group (p = 0.01), but there was no difference after this. The PCEA machine failed completely twice and temporarily many times. We conclude that the combined spinal-epidural technique confers no advantages in early active labour. Also, a lightweight PCEA pump needs to be more reliable before we can recommend its use.",1999.0,0,0
1894,9893539,The respiratory effects of tramadol in children under halothane an anaesthesia.,A T Bösenberg; S Ratcliffe,"In a randomised double-blind, placebo-controlled study, the respiratory effects of intravenous tramadol (1 mg or 2 mg.kg-1) were compared with intravenous pethidine 1 mg.kg-1 under halothane anaesthesia. Children, ASA 1-2 between 2 and 10 years, presenting for inguinal surgery were studied. Once a steady state for halothane was reached, baseline recordings of end-tidal carbon dioxide, oxygen saturation, respiratory rate, tidal volume, minute volume, blood pressure and pulse rate were recorded. Intravenous tramadol 1 mg.kg-1 (T1) or 2 mg.kg-1 (T2) or pethidine 1 mg.kg-1 (PE) or placebo (PL) was then given according to a computer-generated randomisation. Further sets of recordings were taken at 5-min intervals for 20 min prior to commencement of surgery. The rate of recovery was assessed according to Aldrete scoring and the time and need for further analgesia were noted. The postoperative pain intensity was scored by means of a five-point verbal rating scale hourly for 6 h. Eighty-eight children, 22 per group, were studied. The mean age, weight and height were similar in each group. There was a statistically significant difference between the maximum decrease in respiratory rate and increase in end-tidal carbon dioxide between group PE and groups T1/T2 (p < 0.001). Thirteen episodes of apnoea occurred in the PE group, 11 requiring naloxone. The mean respiratory rate was lowest 5 min after injection in all groups. There was a slow increase in respiratory rate until incision in groups T1 and T2. Respiratory rate remained almost unchanged in PL until incision. The decreases in respiratory rate were reflected by increases in end-tidal carbon dioxide, the highest being recorded in the PE group. A lower intensity of pain in the first 2 h was noted in the three opioid groups. During the first 6 h, the proportion of patients requiring a further dose of analgesia was highest in PL and lowest in T2. Tramadol appears safe for use in children.",1999.0,0,0
1895,9893547,The effect of the addition of adrenaline to pethidine for patient-controlled epidural analgesia after caesarean section.,W D Ngan Kee; K S Khaw; M L Ma,"We have investigated the addition of adrenaline to pethidine for patient-controlled epidural analgesia after elective Caesarean section. In a randomised, double-blind study, patients received patient-controlled epidural analgesia for 24 h using pethidine 5 mg.ml-1 with adrenaline 5 micrograms.ml-1 (adrenaline group, n = 40) or pethidine 5 mg.ml-1 without adrenaline (plain group, n = 38). Visual analogue scale pain scores at rest and on coughing measured 2 h, 6 h and 24 h after surgery were similar between the two groups. There was a trend towards lower mean total consumption of pethidine in the adrenaline group (231.5 mg; SD 140.5 mg) compared with the plain group (289.5 mg; SD 139.5 mg; p = 0.071). Patients in the adrenaline group had higher visual analogue scale scores for nausea at 2 h and 24 h and higher scores for pruritus at 2 h compared with the plain group. Addition of adrenaline to pethidine for patient-controlled epidural analgesia does not appear to have significant clinical advantages.",1999.0,0,0
1896,9893549,"Postoperative intrathecal patient-controlled analgesia with bupivacaine, sufentanil or a mixture of both.",M P Vercauteren; K Geernaert; V L Hoffmann; D Dohmen; H A Adriaensen,"In a randomised double-blind study, 45 patients, scheduled for major orthopaedic surgery under continuous spinal anaesthesia, received for relief of postoperative pain patient-controlled analgesia with either sufentanil 2 micrograms.ml-1, bupivacaine 0.0625% or a mixture of both by the intrathecal route. The mean (SD) consumption of sufentanil and bupivacaine during the first 12 h was 65.5 (27.1) micrograms and 18.2 (4.8) mg, respectively. Combining bupivacaine and sufentanil reduced the consumption of both to approximately 40% as compared to the administration of each component separately. Pain relief was very good in all subjects, although this was obtained faster with the combined regimen. Moreover, more patients in this group remained completely painfree during the entire observation period (p < 0.05). The incidence of hypotension was low and not significantly different when the plain bupivacaine group was compared with the two other groups. Nausea and vomiting were significantly more frequently observed in both groups treated with sufentanil. Motor block was not a major problem and was noticed during the first 2 h of treatment only. Tachyphylaxis did not occur. It was concluded that the groups receiving plain bupivacaine and sufentanil alone experienced pain relief of good quality. The use of a mixture, however, accelerated the onset of analgesia, improved the analgesic quality and reduced the doses for both components by 60% but at the expense of a higher incidence of nausea and vomiting.",1999.0,0,0
1897,9915318,Equivalent analgesia and side effects during epidural and pharmacokinetically tailored intravenous infusion with matching plasma alfentanil concentration.,B A Coda; M C Brown; L Risler; K Syrjala; D D Shen,"Recently, several clinical studies comparing intravenous and epidural infusions of fentanyl and its derivatives suggested that epidural infusions act primarily by systemic absorption to produce supraspinal analgesia. To evaluate this hypothesis, the authors used pharmacokinetically tailored intravenous infusions to produce matching plasma alfentanil concentrations during epidural and intravenous administration. The analgesia and side effects achieved with each mode of administration were compared. Twelve volunteers participated in this placebo-controlled crossover study. The pain model was cutaneous electric stimulation of the finger and toe. The test battery included subjective rating of pain intensity; end-tidal carbon dioxide level; pupil size; ratings of alertness, nausea, and pruritus; and a plasma alfentanil assay. On one test day, the participants received epidural alfentanil (400 microg bolus + a 400-microg/h infusion for 2 h) and an intravenous saline infusion. The test battery was administered at regular intervals. On another test day, the participants received epidural saline and a computer-controlled intravenous infusion of alfentanil. The testing protocol was repeated as on the first test day. On the day the placebo was administered, the participants received epidural and intravenous saline infusions. The order of the placebo day was randomized. Plasma alfentanil concentration-time profiles were identical during epidural and intravenous infusions. A nearly equivalent analgesic response was observed with epidural and intravenous alfentanil at the upper and lower extremities. There were no differences in side effects for epidural and intravenous administration. The systemic redistribution of alfentanil accounts for most of the analgesia and effects produced by epidural infusion.",1999.0,0,0
1898,9917081,Slowing the initial titration rate of tramadol improves tolerability.,G E Ruoff,"To examine the effect of three titration schedules on the tolerability of tramadol, and to determine whether slow titration would reduce the frequency of drug discontinuation due to adverse events. Multicenter, outpatient, double-blind, parallel study. Twenty-eight outpatient study centers. Four hundred sixty-five patients with chronic joint pain Interventions. Patients were randomized into one of four treatment groups for 14 days: placebo, or tramadol dosage titrated at 1, 4, or 10 days to achieve the study target dosage of 200 mg/day. They continued taking their dosage of nonsteroidal antiinflammatory drug during the study. Each group was examined to determine if slower titration resulted in a statistically significant trend toward fewer discontinuations due to nausea and/or vomiting and dizziness and/or vertigo. Discontinuation due to any adverse event was similarly analyzed. If the trend was statistically significant, pairwise comparisons were performed to determine the statistical significance among titration rates. A statistically significant trend was seen toward fewer discontinuations as a result of nausea/vomiting, dizziness/vertigo, and any adverse event as the titration rate decreased. Patients with 10-day titration rate required the fewest discontinuations, and this rate was statistically significantly different from both the 1- and 4-day rates for discontinuations. A slower rate of initiating tramadol therapy (50-mg increments every 3 days) improved tolerability with significantly fewer discontinuations due to dizziness or vertigo.",1999.0,0,0
1899,9923808,Effect of topical local anesthetic application to skin harvest sites for pain management in burn patients undergoing skin-grafting procedures.,W S Jellish; R L Gamelli; P A Furry; V L McGill; E M Fluder,"To determine if topical administration of local anesthesia, applied to fresh skin-harvest sites, reduces pain and analgesic requirements after surgery. Nonopioid treatments for pain after therapeutic procedures on patients with burns have become popular because of the side effects associated with narcotics. The topical administration of local anesthesia originally offered little advantage because of poor epidermal penetration. This study compares 2% lidocaine with 0.5% bupivacaine or saline, topically applied after skin harvest, to determine what effect this may have on pain and narcotic use. Sixty patients with partial- or full-thickness burns to approximately 10% to 15% of their body were randomly divided into three groups: group 1 received normal saline, group 2 had 0.5% bupivacaine, and group 3 had 2% lidocaine sprayed onto areas immediately after skin harvest. Blood samples were subsequently obtained to measure concentrations of the local anesthetic. Hemodynamic variables after surgery, wake-up times, emetic symptoms, pain, and narcotic use were compared. Higher heart rates were noted in the placebo group than in those receiving lidocaine or bupivacaine. No differences were noted in recovery from anesthesia or emetic symptoms. Pain scores were lower and 24-hour narcotic use was less in patients who received lidocaine. Plasma lidocaine levels were greater than bupivacaine at all time points measured. Topical lidocaine applied to skin-harvest sites produced an analgesic effect that reduced narcotic requirements compared with patients who received bupivacaine or placebo. Local anesthetic solutions aerosolized onto skin-harvest sites did not affect healing or produce toxic blood concentrations.",1999.0,0,0
1900,9924240,Patient-controlled interscalene analgesia with ropivacaine after major shoulder surgery: PCIA vs PCA.,A Borgeat; E Tewes; N Biasca; C Gerber,"We have compared the efficacy of patient-controlled interscalene analgesia (PCIA) using ropivacaine with patient-controlled analgesia (PCA) using nicomorphine in 60 patients (n = 30 in each group), in a prospective, randomized study. In both groups, all patients received interscalene block with 0.75% ropivacaine before induction of anaesthesia. Six hours after interscalene block, patients in group PCIA received continuous infusion of 0.2% ropivacaine at a rate of 5 ml h-1 with a bolus dose of 3 or 4 ml and a lockout time of 20 min; patients in group PCA received continuous infusion of nicomorphine 0.5 mg h-1 and a bolus dose of 2 or 3 mg with a lockout time of 20 min. Control of pain was significantly better from 12 to 48 h after operation (except at 42 h) in group PCIA. Nausea and pruritus occurred significantly more frequently in group PCA. Patient satisfaction was greater in group PCIA. We conclude that the use of 0.2% ropivacaine using PCIA was an efficient way of managing pain after major shoulder surgery and compared favourably with PCA nicomorphine in terms of pain relief, side effects and patient satisfaction.",1999.0,0,0
1901,9926181,Peroperative treatment with i.v. ketoprofen reduces pain and vomiting in children after strabismus surgery.,H Kokki; E Homan; K Tuovinen; S Purhonen,"Strabismus surgery is associated with both pain and vomiting. Ketoprofen is widely used in adults to treat acute pain, but there are only few reports of its use in children. This randomised, double-blind, placebo-controlled, parallel group study was designed to investigate the analgesic effect of i.v. ketoprofen and its effect on the incidence of vomiting in children after day-case strabismus surgery. Fifty-nine ASA 1 children, aged 1-12 years, entered the study. After premedication with diazepam and glycopyrronium, anaesthesia was induced with fentanyl and propofol and maintained with isoflurane. After induction the children in the ketoprofen group received 1 mg kg-1 ketoprofen followed by an infusion of 1 mg kg-1 ketoprofen over 2 h. In the placebo group, children received 0.9% saline. The postoperative pain was assessed by the Maunuksela pain score (0 = no pain, 10 = worst possible pain). All children received fentanyl as a rescue analgesic if the Maunuksela score was > or = 3. In the ketoprofen group the number of fentanyl doses was smaller compared to the placebo group (median 1, quartiles (0-2) vs. 2 (1-3), P = 0.047). The children in the ketoprofen group had less pain at 30 min (P = 0.02) and the worst pain observed in the post anaesthesia care unit was lower (3 (0-6) vs. 5 (3-8), P = 0.035). The incidence of vomiting was less in the ketoprofen group compared to the placebo group (17% vs. 41%, P = 0.036). No serious adverse reactions occurred. We concluded that ketoprofen administered i.v. during the operation produced analgesia and reduced opioid consumption and the incidence of vomiting in children after strabismus surgery.",1999.0,0,0
1902,9926184,"The effects of tramadol on postoperative nausea, vomiting and headache after ENT surgery. A placebo-controlled comparison with equipotent doses of nalbuphine and pethidine.",A A van den Berg; E Halliday; E K Lule; M S Baloch,"Opioids given as adjuncts to balanced inhalational anaesthesia augment postoperative nausea and vomiting (PONV). Tramadol, equipotent to pethidine, does not depress respiration, but can cause an increase in blood pressure and headache via its monoaminergic actions. Nalbuphine, ten times as potent as pethidine, has a ceiling respiratory depressant and ceiling analgesic effect at > 0.3 mg.kg-1. We compared the effects of equipotent doses of tramadol and nalbuphine (3.0 and 0.3 mg.kg-1, respectively) given as analgesic with induction of anaesthesia on emesis during recovery from anaesthesia and on PONV and headache until 24 h after ENT surgery, using saline (0.2 ml.kg-1) and an equipotent dose of pethidine (1.5 mg.kg-1) as controls. The study population (N = 281) comprised 4 comparable subgroups (N = 69 to 71 each). Anaesthetic medications were standardised. Emesis during recovery from anaesthesia and nausea, vomiting, retching, headache and administrations of antiemetic and analgesics until 24 h after surgery were recorded. Emesis and antiemetic requirements during recovery from anaesthesia were similar and infrequent in each group, as were the incidences of nausea alone (3 to 5%), vomiting alone (17 to 31%), and nausea with vomiting (10 to 22%) during the first 24 h after surgery. However, any complaint of PONV was least frequent in the saline and pethidine groups (32% and 37%, respectively) and most frequent in the tramadol and nalbuphine groups (49% and 52%, respectively; P < 0.05 versus saline, both comparisons; P = NS versus pethidine, both comparisons). The times to onset and severity of PONV were similar in each group, but patients given nalbuphine most frequently (P < 0.025) needed rescue antiemetic to treat PONV. Headache occurred with similar frequency in each group. It is concluded that tramadol, nalbuphine and pethidine have similar emetic effect in the doses and manner used, and that tramadol does not increase the incidence of post-operative headache when used as peroperative analgesic.",1999.0,0,0
1903,9926187,Patient-controlled analgesia with oxycodone in the treatment of postcraniotomy pain.,P Tanskanen; J Kyttä; T Randell,"Moderate to severe pain occurs after craniotomy in 60% of patients. We evaluated the feasibility and safety of patient-controlled analgesia (PCA) with oxycodone in neurosurgical patients, and compared the efficacy of paracetamol with ketoprofen. In the study there were 45 patients, who received either paracetamol 1000 mg or ketoprofen 100 mg three times a day. Oxycodone-boluses 0.03 mg/kg were given by PCA-device maximally three times an hour, lock-out time 10 min. The amount of oxycodone used, pain scores and side-effects were recorded. The ketoprofen group required less oxycodone than the paracetamol group (medians 37.1 mg vs 19.6 mg, P < 0.05). The VAS scores were comparable between the groups at the beginning of the study, during the first postoperative evening and the next morning, but the paracetamol group had a higher score at the conclusion of the study (P < 0.05). The patients in both groups were equally satisfied with the pain relief. There were no differences in side-effects between the groups. PCA with oxycodone is a suitable method for pain control after craniotomy. No progressive hypoventilation, desaturation or excessive sedation were encountered. Ketoprofen appeared to be more effective than paracetamol.",1999.0,0,0
1904,9926189,"Intra-articular buprenorphine after knee arthroscopy. A randomised, prospective, double-blind study.",G Varrassi; F Marinangeli; A Ciccozzi; G Iovinelli; G Facchetti; A Ciccone,"Demonstration of peripheral opioid receptors in inflamed synovia supports the concept of peripheral opioid analgesia. The aim of this study was to evaluate the analgesic effect of intra-articular administration of buprenorphine after knee arthroscopy. In a double-blind randomised trial, 48 patients were assigned to four groups: group A patients received buprenorphine 100 micrograms i.a. and NaCl 0.9% i.m., group B patients received bupivacaine 0.25% 50 mg i.a. and NaCl 0.9% i.m., group C patients received NaCl 0.9% i.a. and buprenorphine 100 micrograms i.m., and group D patients received NaCl 0.9% i.a. and NaCl 0.9% i.m. Intensity of postoperative pain was evaluated by VAS at recovery (T0) and 1, 3, 6, 12, 24 h after operation (T1, T2, T3, T4, T5), at rest and during passive 10 degrees knee flexion. Total analgesic requirements and side effects related to study drugs were recorded. The VAS scores were significantly higher in groups C and D than in group A and B patients. The differences were significant at T0, T1, T2 and T3. At T1, group C and D patients had greater analgesic requirement than groups A and B. No patients developed side effects. Intra-articular buprenorphine and i.a. bupivacaine, both produced equally good postoperative pain control and allowed a significant reduction of analgesic requirement after knee arthroscopy.",1999.0,0,0
1905,9928687,Efficacy of ketorolac tromethamine versus meperidine in the ED treatment of acute renal colic.,G L Larkin; W F Peacock; S M Pearl; G A Blair; F D'Amico,"To compare the efficacy of intramuscular ketorolac and meperidine in the emergency department (ED) treatment of renal colic, a prospective, controlled, randomized, double-blind trial was conducted in an academic ED with 76,000 annual visits. Participants were volunteer ED patients with a diagnosis of ureterolithiasis confirmed by intravenous pyelogram. Subjects were randomized 1:1 to receive a single intramuscular injection of either 60 mg ketorolac or 100 to 150 mg meperidine, based on weight. Of the 70 patients completing the trial, 33 received ketorolac and 37 received meperidine. Demographic characteristics and baseline pain scores of both groups were comparable (P = NS, Mann Whitney U). Ketorolac was significantly (P < .05) more effective than meperidine in reducing renal colic at 40, 60, and 90 minutes as measured on a 10-cm visual analogue scale. Similar proportions of patients in each group were given rescue analgesia and admitted. Of patients who were discharged home without rescue, those treated with ketorolac left the ED significantly earlier than those treated with meperidine (3.46 v 4.33 h, P < .05). These results show that intramuscular ketorolac as a single agent for renal colic is more effective than meperidine and promotes earlier discharge of renal colic patients from the ED.",2001.0,0,0
1906,9928771,Assessment and treatment of neuropathic cancer pain following WHO guidelines.,S Grond; L Radbruch; T Meuser; R Sabatowski; G Loick; K A Lehmann,"Neuropathic pain syndromes are one of the major problems of cancer pain treatment. The present study surveys 593 cancer patients treated by a pain service following the WHO guidelines for relief of cancer pain. Of these, 380 presented with nociceptive, 32 with neuropathic and 181 with mixed (nociceptive and neuropathic) pain. In patients with nociceptive, mixed and neuropathic pain, the average duration of evaluated pain treatment was 51, 53 and 38 days, respectively. Non-opioid or opioid analgesics were given to 99%, 96% and 79%, antidepressants to 8%, 25% and 19%, anticonvulsants to 2%, 22% and 38% and corticosteroids to 26%, 35% and 22% of patients, respectively. Systemic analgesia was supported by palliative antineoplastic treatment (48%, 56% and 38% of patients), nerve blocks (3%, 6% and 6%), psychotherapy (3%, 7% and 3%), physiotherapy (6%, 12% and 13%) and transcutaneous electric nerve stimulation (1%, 6% and 6%). Analgesic treatment resulted in a significant pain relief in all groups of patients, as the mean pain intensity (NRS) decreased from 66 (nociceptive), 65 (mixed) and 70 (neuropathic) on admission to 26, 30 and 28 after 3 days and 18, 17 and 21 at the end of survey. The total outcome of pain treatment was not predicted by the designation to nociceptive, mixed or neuropathic pain. In conclusion, neuropathic cancer pain is not intractable and can be relieved in the majority of patients by treatment following the WHO guidelines.",1999.0,0,0
1907,9928780,Peripherally administered sufentanil inhibits pain perception after postpartum tubal ligation.,M Rorarius; P Suominen; G Baer; P Pajunen; R Tuimala; P Laippala,"The clinical effectiveness of locally administered opioids is still under discussion; in particular, the potency of morphine in settings other than intra-articular arthroscopy has been questioned. We developed another pain model, postpartum resection of the fallopian tubes for sterilisation, in which each patient serves as her own control when one side is infiltrated with the active drug (in this study sufentanil 5 mg) and the contralateral side with normal saline. In the control group both sides are infiltrated with plain saline. After 30 min from the end of anaesthesia onwards, 26 out of 30 patients observed significant pain relief on the side of the sufentanil infiltration, which in 11 patients lasted until the end of the observation period 24 h postoperatively; no difference was observed in the control group. In our pain model with a high assay sensitivity, the infiltration of one side with the lipophilic test drug, sufentanil, caused local analgesia in primarily non-inflamed tissue. The use of each patient as her own control excluded inter-subject bias.",1999.0,0,0
1908,9929793,Analgesia for trauma and burns.,R Hedderich; T J Ness,"This article has described the physiologic impact of trauma- and burn-related pain as well as the effect of a clinician's choice of analgesic method, using the specific example of regional analgesia for pain caused by chest trauma. It has been observed that trauma exerts a holistic influence upon the organism, marshalling reflexes, multi-system physiologic stress responses, and psychologic responses--some adaptive and others maladaptive. There is reason to consider that timely analgesia can intervene in this dynamic process and interdict the establishment of a debilitated state. A key finding of these studies is that a report of pain relief may not be the best outcome measure since the choice of analgesic method(s) has a significant impact on the secondary effects of pain. Although extrapolated from studies of perioperative pain, findings do suggest that there may be a critical period of time during which the secondary effects of a painful stimulus may be attenuated or reversed. How long this period of reversibility exists has not been determined, so planning for the level and goals of analgesia intervention should occur early on. Analgesia should be viewed not only as a humanitarian gesture, but also a therapeutic maneuver with the goal being the early restoration of function and the mitigation of a chronic debilitated state. There is scattered evidence that regional analgesic techniques using local anesthetics have some advantages over other analgesic modalities, particularly in the trauma patient with pulmonary compromise; however, as with other medical interventions, one should develop a strategic plan of application which includes consideration of potential complications and side effects, in addition to the potential therapeutic effects. The traumatized body, as well as the attending physician, must deal with inflammation, the neurohumoral reaction, musculoskeletal reflex responses, and numerous other reactions designed to stabilize an acutely destabilized systemic entity. Multimodal analgesia, with the balanced use of systemic and regional medications, has given the best short- and long-term results in studies of postthoracotomy pain. The use of a similar combined plan for posttraumatic analgesia seems logical; however, many questions remain as yet unanswered. In particular, what are the optimal combinations of techniques/medications to employ to maximize analgesia and minimize secondary effects of trauma? Can an aggressive multimodal approach intervene effectively in the development of chronic pain states, and if so, for how long? What are the long-term benefits to be derived from making a significant impact on the stress response? Last, but not least, can analgesic interventions be shown to be cost-effective according to current societal pressures to reduce the cost of health care? These and other questions are not easy to answer. Trauma strikes, in a variable fashion, patients of all ages, with all forms of comorbidity, and is treated by a technology that continues to evolve. Previous research related to the effects of analgesic treatments has been hampered by the limitations that arise when isolated groups embark on vast projects with limited numbers of patients available. It is time for investigators at multiple centers to embark on coordinated efforts to address long-term questions related to trauma and the therapeutic efficacy of analgesia.",1999.0,0,0
1909,9931520,Advantages of fentanyl over morphine in analgesia for ventilated newborn infants after birth: A randomized trial.,E Saarenmaa; P Huttunen; J Leppäluoto; O Meretoja; V Fellman,"To compare the efficacy and adverse effects of fentanyl or morphine analgesia during the first 2 days of life in newborn infants who underwent mechanical ventilation. In a randomized double-blind trial, 163 infants were allocated to receive a continuous infusion of fentanyl (10.5 microg/kg over a 1-hour period followed by 1.5 microg/kg/hr) or morphine (140 microg/kg over a 1-hour period followed by 20 microg/kg/hr) for at least 24 hours. The severity of pain was assessed with physiological parameters, a behavioral pain scale, and stress hormone concentrations before and 2 and 24 hours after the start of treatment. The analgesic effect was similar in both groups, as judged by the pain scale. Plasma adrenaline and noradrenaline concentrations decreased significantly from 0 to 24 hours in both groups. Median adrenaline decrease was 0.5 nmol/L (interquartile range [IQR] 1.1;0.0) in the fentanyl and 0.7 nmol/L (IQR 1.3;0.1) in the morphine group, noradrenaline 2.1 nmol/L (IQR 9.0;0.2), and 3.0 nmol/L (IQR 7. 5;0.3), respectively. beta-endorphin decreased significantly only in the fentanyl group ( 14 pmol/L (IQR 28; 7), P <.05). Decreased gastrointestinal motility was less frequent in the fentanyl group (23% vs 47%, P <.01). With at least as effective analgesia as with morphine, fentanyl had fewer side effects. Fentanyl may be superior to morphine for short-term postnatal analgesia in newborn infants.",1999.0,0,0
1910,9932756,"Patient-controlled sedation and analgesia, using propofol and alfentanil, during colonoscopy: a prospective randomized controlled trial.",C Roseveare; C Seavell; P Patel; J Criswell; J Kimble; C Jones; H Shepherd,"Patient-controlled sedation (PCS) enables titration of dosage to an individual's requirements and is potentially useful in colonoscopy. The aim was to compare the value of patient-controlled sedation, using propofol and alfentanil, with that of intravenous diazemuls and pethidine during colonoscopy. Following randomization, 66 patients undergoing colonoscopy received either an intravenous bolus of pethidine (50 mg) and diazemuls (10-20 mg) prior to colonoscopy or were connected to an infusion pump containing propofol (10 mg/ml) and alfentanil (25 microg/ml). Patients self-administered 0.5 ml boluses as often as they required. Pain and sedation score were recorded by a nurse specialist and on a patient questionnaire. An anaesthetist was present throughout the procedure. PCS provided lighter sedation (median sedation score, 3 versus 4; P=0.0001), less analgesia (median pain score, 1 versus 0; P=0.004), a smaller maximum fall in systolic blood pressure (23 mmHg versus 33 mmHg; P=0.02) and a faster recovery time (median 10 min versus 40 min; P=0.0001), irrespective of the dose administered, compared with a diazemuls-pethidine combination. The duration of the procedure was unaffected. All patients were satisfied with their level of sedation. Patient-controlled sedation is an effective alternative to premedication with narcotic/benzodiazepine combinations during colonoscopy.",1999.0,0,0
1911,9932882,A prospective study of long-term intrathecal morphine in the management of chronic nonmalignant pain.,V C Anderson; K J Burchiel,"To examine in a prospective manner the long-term safety and efficacy of chronic intrathecal morphine in patients with severe, nonmalignant pain refractory to less invasive modalities. Forty patients with severe, chronic nonmalignant pain poorly managed by systemic medications were identified as candidates for intraspinal trial of morphine. Thirty participants reported successful pain relief during trial and were implanted with an intraspinal delivery system. Standardized measures of pain and functional status were assessed before treatment was begun and at defined intervals during the subsequent 24 months. Intrathecal opioid use and pharmacological and device-related complications were also monitored. The participants had a mean age of 58 +/- 13 years and a mean pain duration of 8 +/- 9 years. Fifty-three percent of the study participants were women. Pain type was characterized as mixed neuropathic-nociceptive (15 of 30 patients, 50%), peripheral neuropathic (10 of 30 patients, 33%), deafferentation (4 of 30 patients, 13%), or nociceptive (1 of 30 patients, 3%). Forty-seven percent of the patients were diagnosed with failed back surgery syndrome. Significant improvement over baseline levels of visual analog scale pain was measured at each follow-up examination after implant. Overall, 50% (11 of 22 patients) of the population reported at least a 25% reduction in visual analog scale pain after 24 months of treatment. In addition, the McGill Pain Questionnaire, visual analog scale measures of functional improvement and pain coping, and several subscales of the Chronic Illness Problem Inventory showed improvement throughout the follow-up period. Pharmacological side effects were managed medically by morphine dose reduction, addition of bupivacaine, or replacement of morphine with hydromorphone. Device-related complications requiring repeat operations were experienced by 20% of the patients. Continuous intrathecal morphine can be a safe, effective therapy for the management of severe, nonmalignant pain among a carefully selected patient population and can result in long-term improvement in several areas of daily function.",1999.0,0,0
1912,9933696,Thoracic epidural anesthesia for pain relief and postoperation recovery with modified radical mastectomy.,C C Yeh; J C Yu; C T Wu; S T Ho; T M Chang; C S Wong,"The purpose of this study was to investigate whether thoracic epidural anesthesia (TEA) provides better postoperative pain relief and recovery than general anesthesia (GA) for modified radical mastectomy (MRM) surgery. Sixty-four patients rated as American Society of Anesthesiologists (ASA) 1 to 3 who underwent MRM surgery were included in the study. In TEA group patients, 2% lidocaine (15-20 ml) was administered via the epidural route as primary anesthesia, in conjunction with midazolam (5-10 mg) and fentanyl (<250 microg) for amnesia. The GA patients were maintained with isoflurane and 50% nitrous oxide in oxygen. After operation the patients were given pethidine (1 mg/kg IM) as required for pain relief. The time to first pethidine requirement, total pethidine consumption, worst pain score, bed rest time, satisfaction score, and anesthesia-related side effects were recorded for 2 days after surgery. The results show that TEA provided a more prolonged analgesic effect than GA after operation. A longer time to first pethidine requirement (19.2 +/- 1.5 vs. 7.6 +/- 2.5 hours) (p < 0. 001) and decreased pethidine consumption (17.2 +/- 7.0 vs. 76.3 +/- 17.4 mg) (p < 0.001) were observed in the TEA group than in the GA group, respectively. A worse visual analog scale (VAS) pain score was observed in the GA group (5.7 +/- 0.6) than in TEA patients (4.3 +/- 0.4) (p < 0.01). The average bed rest time was significantly shorter in the TEA group (16.9 +/- 0.9 hours) (p < 0.01) than in the GA group (27.1 +/- 4.1 hours). Overall satisfaction scores were significantly higher in the TEA group (4.4 +/- 0.1) (p < 0.01) than in the GA group (3.5 +/- 0.2). Side effects were observed at a higher frequency in the GA group (16/32) (p < 0.0001) than in the TEA group (3/32). The frequency of pethidine injection for pain relief was significantly lower in the TEA group (8/32) (p < 0.0001) than in the GA group (24/32). The total hospital cost (NT 64,392 +/- 3,523 vs. NT 53,806 +/- 2,817) (p = 0.0342) and anesthesia cost (NT 7,968 +/- 246 vs. NT 5,268 +/- 262) (p < 0.0001) are also significantly lower in the TEA group than the GA group. In conclusion, TEA provided better postoperative pain relief and recovery and lower cost than GA for MRM surgery.",1999.0,0,0
1913,9952116,Intrathecal morphine delivered via subcutaneous pump for intractable pain in pancreatic cancer.,H S Gilmer-Hill; J E Boggan; K A Smith; C F Frey; F C Wagner; L J Hein,"Pain secondary to unresectable pancreatic cancer is frequently severe and extremely difficult to control with traditional methods of analgesia. This retrospective study reports the analgesic effects of intrathecal morphine sulfate by implanted infusion pumps in nine patients with unresectable adenocarcinoma of the pancreas. Nine patients were implanted over a 2-year period. Preoperative morphine i.v. equivalents were a mean of 81.51 mg/day, with a range of 20-140 mg/day. Patients were hospitalized for a trial dose of 1-2 mg of intrathecal Duramorph, 1 mg/ml, via lumbar puncture to assess whether adequate pain relief could be achieved and whether there would be drug-related side effects. All patients who received a trial dose experienced excellent pain relief, and subsequently underwent implantation of a lumbar subarachnoid catheter and infusion pump during the same hospitalization. The mean number of days from diagnosis to pump implant was 119, with a range of 3-587 days. The mean maximum daily dose was 21.28 mg, with a range of 3-73.10 mg. No patient experienced respiratory depression or excess sedation which prevented achievement of pain control. Minor supplemental narcotic use was documented in three of the nine patients. Assessment of pain control was made by the level of activity and the analog pain scale, with 0 being no pain and 10 being the worst pain imaginable. All of the patients experienced good to excellent relief of pain. The mean duration of intrathecal morphine sulfate use until death was 137.3 days, with a range of 52-354 days. This series of nine patients indicates that long-term administration of intrathecal morphine via implanted infusion pump in patients with pancreatic cancer is both efficacious and safe. All patients and their families reported an improved quality of life with an increased level of activity.",2001.0,0,0
1914,9972621,[The opinion of pediatricians on childhood pain].,I Riaño Galán; B Mayoral González; G Solís Sánchez; G Orejas Rodríguez-Arango; S Málaga Guerrero,"The objective of this study was to evaluate the current sensibility and knowledge of pediatricians regarding the issue of pediatric pain assessment and management. In October 1996 we conducted a mail survey of all 686 members of the Asturias, Cantabria and Castilla y León Pediatric Society. Physicians were asked to complete and return a confidential 95-item questionnaire. One hundred fifty-seven (23%) of eligible physicians responded. Ninety percent of the respondents agreed they had insufficient training in pain management. Sixty-nine percent though their knowledge to deal with acute pain was adequate. Only 12% admitted to having enough background to treat chronic pain. Sixty-five percent of the respondents admitted to know no method at all for pain evaluation, while 82% had never applied any in their clinical practice. About half the respondents (42%) did not know any guidelines for the management of pediatric pain, although 75% considered they would be very useful. A high percentage of pediatricians answered that analgesia was required before performing certain diagnostic or therapeutic procedures (lumbar puncture, venous canalization, arterial puncture and others), but differences in relation to age, sex and clinical setting of the physicians were detected in these responses. The most used drug for the treatment of moderate acute pain is acetaminophen (88%), for severe acute pain metamizol (58%) and for severe chronic pain acetaminophen-codeine (37%). Only 48% admitted to having used opioids. Pediatricians in this society seem to be too confident about the topic of acute pain management in their patients, even though they report a lack of training which could influence the quality of the care they are offering to their patients. Opioid use is very low. Training in childhood pain management is needed.",1999.0,0,0
1915,9988910,Cancer and chronic pain.,C Hassed,"The effective management of cancer pain is one of the greatest challenges for GPs. Pain management can be best achieved with a knowledge of the fundamentals of cancer pain and its assessment. A systematic and holistic approach to its treatment needs to be individualised for each patient, taking into account the relevant physical, psychological and spiritual factors. GPs are part of a team including oncologists, palliative care specialists, nursing services, paramedical staff, counsellors and clergy and so should know about and make use of the ever-improving support services which are available to ensure that insoluble pain problems are a rare occurrence.",1999.0,0,0