BMJ 2001 Oct 6;323(7316):791-4
[Medline record in process]
PMID: 11588085, UI: 21471884
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Br J Anaesth 2001 Feb;86(2):272-4
Department of Anaesthesia, University of Toronto, Toronto Western Hospital, Ontario, Canada.
Due to the growing importance of quality assurance and cost containment in healthcare, eliciting patients' preferences for post-operative outcomes may be a more economical and reliable method of assessing quality. Three hundred and fifty-five day surgery patients completed a pre-operative written questionnaire to identify patients' preferences for avoiding 10 particular post-operative symptoms: pain, nausea, vomiting, disorientation, shivering, sore throat, drowsiness, gagging on the tracheal tube, thirst and a normal outcome. The two scoring methods used to evaluate preferences were priority ranking and relative value scores. The effects of age, gender, previous health status, type of surgery and previous experience of anaesthesia on patients' preferences were also examined. Avoiding post-operative pain, gagging on the tracheal tube and nausea and vomiting are major priorities for day-case patients. Anaesthetists should take patients' preferences into consideration when developing guidelines and planning anaesthetic care.
PMID: 11573673, UI: 21457576
Clin J Pain 2001 Sep;17(3):264-75
WHOQOL Centre for the Study of Quality of Life, Department of Psychology, University of Bath, UK. s.m.skevington@bath.ac.uk
OBJECTIVE: The study aimed to validate a new, multidimensional, multilingual instrument (the WHOQOL-100) for assessing QOL in chronic pain patients. METHODS: Chronic pain patients (N = 106) who agreed to participate in an established pain management program (PMP) were assessed for quality of life (QOL) before and one month after the intervention. The WHOQOL-100 is a generic profile containing 25 facets of QOL organized in 6 domains. It was administered concurrently with the MOS Short Form-36, the Beck Depression Inventory, and measures of pain intensity, duration, disruption and distress. RESULTS: The patients were outpatients and inpatients with a mean age of 44 years and mean pain duration of 8 years. The sample included 70 (66%) women. After the PMP, QOL had significantly improved generally. and in the physical, psychological and independence domains, as well as in 10 facets of QOL including pain and discomfort. Good QOL is consistently associated with low levels of pain severity and pain distress and little pain disruption. Overall internal consistency reliability was good and for most facets and domains but marginal for the pain facet. When compared with the SF-36. the WHOQOL-100 shows good concurrent validity, greater comprehensiveness and very good responsiveness to clinical change. DISCUSSION: The WHOQOL-100 indicates significant improvements to QOL for those entering a PMP and is validated for the clinical assessment of chronic pain patients and for use in multi-national clinical trials, clinical governance and audit.
PMID: 11587119, UI: 21470751
Clin J Pain 2001 Sep;17(3):256-63
Rehabilitation Sciences Research Group, Faculty of Social and Health Sciences and Education, University of Ulster at Jordanstown, County Antrim, Northern Ireland, UK. dh.hurley@ulst.ac.uk
OBJECTIVES: The aim of this study was to investigate potential associations between the Acute Low Back Pain Screening Questionnaire (ALBPSQ), a biopsychosocial screening instrument for identifying patients at risk of chronicity, and relevant variables at 1-year follow-up in a cohort of patients with low back pain. STUDY DESIGN: A 1-year prospective study was conducted in which patients who had previously received treatment in the Northern Ireland National Health Service (n = 118) were requested to complete a follow-up questionnaire package of pain and functional disability measures and a patient-centered questionnaire of seven variables considered relevant from the patient's perspective. PATIENTS: Ninety patients (76% response rate) returned the completed questionnaire package. RESULTS: The ALBPSQ total score and cutoff score of 112 were significantly positively associated with the pain and functional disability questionnaire scores at follow-up but did not significantly discriminate for difference scores on these measures. Although six of the seven patient-centered variables were significantly associated with the screening questionnaire total score, the cutoff score was strongly predictive of only one variable (work loss) and failed to demonstrate high levels of sensitivity for other variables (i.e., medication use, additional treatment, poor exercise participation). CONCLUSIONS: The findings of this study demonstrate that scores on the ALBPSQ were positively correlated with patients' levels of pain and functional disability at 1-year follow-up and correctly classified all patients reporting some degree of work loss but had minimal predictive strength for the other patient-centered variables evaluated.
PMID: 11587118, UI: 21470750
Clin J Pain 2001 Sep;17(3):249-55
Department of Psychiatry, The University of Chicago, Illinois, USA. lance.mccracken@rnhrd-tr.swest.nhs.uk
OBJECTIVE: Most conceptualizations of chronic pain acknowledge the importance of culture and social circumstances. Cultural and social influences may differ for persons of different racial or ethnic groups, and this circumstance may lead them to experience and adjust differently to pain. The current study compared adjustment to chronic pain by blacks and whites seeking treatment for chronic pain. SUBJECTS AND MEASURES: Fifty-seven black and 207 white patients completed measures of anxiety, depression, disability, pain, and physical symptoms during their initial visit to a university pain clinic. RESULTS: Comparisons showed that the groups did not differ with regard to age, sex, education, chronicity of pain, pain location, work status, previous surgeries, medical diagnosis, medication, wage replacement, or involvement in litigation. However, the black group reported higher pain severity, more avoidance of activity, more fearful thinking, more physical symptoms, and greater physical and psychosocial disability. The groups remained significantly different with regard to avoidance, fearful thinking, and physical symptoms after pain severity was statistically controlled for; however, they did not remain different on disability. CONCLUSIONS: These results show that blacks and whites with chronic pain experience pain differently. Several factors may underlie these differences, including family situation, health care experiences, or other unmeasured behavioral, environmental, or social influences. Other investigators should attempt to replicate these findings and more closely examine variables that may explain them.
PMID: 11587117, UI: 21470749
Clin J Pain 2001 Sep;17(3):245-8
Division of Behavioural Medicine, Guy's King's & St. Thomas' School of Medicine, Biomedical Sciences and Dentistry, Guy's Hospital, London, United Kingdom.
OBJECTIVE: This was a preliminary investigation of patients' beliefs about cannabinoids and the associations between those beliefs, beliefs about medication, and personal and pain variables with regard to patients' willingness to try cannabinoids as analgesics. DESIGN: A self-completion questionnaire was used. SETTING: The investigation took place in an outpatient pain clinic. PATIENTS: Sixty-seven patients with chronic pain were involved. OUTCOME MEASURES: The outcome measures were patients' stated willingness to use cannabinoids and the extent of their agreement or disagreement with statements concerning cannabinoids and medicines in general. RESULTS: Fifty-two percent of patients were doubtful about taking cannabinoids: unwillingness was strongly associated with specific concerns about side effects, addiction, tolerance, and losing control but not with general beliefs about medication or personal or medical variables other than age. CONCLUSIONS: The concerns of patients with chronic pain about taking cannabinoids as analgesics may reduce their utility and efficacy; accurate information is required to counter this effect.
PMID: 11587116, UI: 21470748
Clin J Pain 2001 Sep;17(3):236-8
Department of Anesthesiology and Intensive Care, Lund University Hospital, Sweden.
CASE REPORT: A 73-year-old woman with bilateral severe pain in her legs and feet was admitted to the hospital. The pain had started spontaneously without any known trauma a year earlier and had progressively worsened to the point that she was unable to walk. The patient complained of pain, discoloration, and sweating of the lower extremities. Physical examination revealed swollen, cold, wet, and blue extremities, with both allodynia and hyperalgesia, fulfilling criteria for a diagnosis of complex regional pain syndrome (CRPS) type 1. Laboratory findings demonstrated a hemoglobin level of 180 g/L(-1) and a hematocrit of 47%, leading to a diagnosis of polycythemia vera (PCV). Her condition slowly improved after repeated venesection, mild analgesics, and amitriptyline. CONCLUSIONS: Polycythemia vera has not been described previously as a contributing factor in CRPS. In the present case, the diagnosis of PCV was important, because its treatment also improved the CRPS.
PMID: 11587114, UI: 21470746
Clin J Pain 2001 Sep;17(3):229-35
Department of Psychology, University of Washington, Seattle, USA.
OBJECTIVE: The current study explored whether immersive virtual reality continues to reduce pain (via distraction) with repeated use. SETTING: The study was conducted in a burn care unit at a regional trauma center. PATIENTS: Seven patients aged 9-32 years (mean age of 21.9 years; average of 23.7% total body surface area burned [range, 3-60%]) performed range-of-motion exercises of their injured extremity under an occupational therapist's direction on at least 3 separate days each. INTERVENTION: For each physical therapy session, each patient spent equal amounts of time in virtual reality and in the control condition (no distraction). The mean duration of physical therapy in virtual reality was 3.5, 4.9, and 6.4 minutes for the first, second, and third session, respectively. Condition order was randomized and counter-balanced. OUTCOME MEASURES: For each of the three physical therapy sessions, five visual analog pain scores for each treatment condition served as the dependent variables. RESULTS: Pain ratings were statistically lower when patients were in virtual reality, and the magnitude of pain reduction did not diminish with repeated use of virtual reality. The results of this study may be examined in more detail at www.vrpain.com. CONCLUSIONS: Although the small sample size limits generalizability. results provide converging preliminary evidence that virtual reality can function as a strong nonpharmacological pain reduction technique for burn patients during physical therapy. Results suggest that virtual reality does not diminish in analgesic effectiveness with three (and possibly more) uses. Virtual reality may also have analgesic potential for other painful procedures or pain populations. Practical implications are discussed.
PMID: 11587113, UI: 21470745
Clin J Pain 2001 Sep;17(3):206-14
California Pain Medicine Centers and Reflex Sympathetic Dystrophy Institute, University of California School of Medicine, Los Angeles 90095, USA. paindoc@UCLA.edu
BACKGROUND: Advances in neurobiology serve as the basis for current and evolving implantable pain modalities, consisting of neurostimulation and neuraxial drug administration systems. Appropriate treatment of pain begins with an accurate diagnosis based on thorough physical and behavioral evaluations. MEASURES: The medical evaluation includes a review of the patient's medical history, diagnostic studies, physical examination, complete diagnostic workup, and screening trial of the proposed implantable therapy. The behavioral evaluation includes a review of the patient's history and medical records, clinical interview, mental status examination, psychological testing, and determination of suitability for implantation. CONCLUSIONS: Patients with chronic pain are subject to neurophysiological, emotional, and behavioral influences that govern their perception of pain and of pain relief. Therefore, treatment of chronic pain is multidisciplinary, drawing on cognitive and behavioral psychological therapies, functional rehabilitation, orthopedic and neurologic surgery, medications, nerve blockade, neuroaugmentative procedures, and sometimes neurodestructive procedures. Appropriate selection of patients helps ensure that implantable therapies are used for those who are most likely to benefit.
PMID: 11587110, UI: 21470742
Clin J Pain 2001 Sep;17(3):200-5
The WellBeing Group and University of Texas Southwestern Medical Center, Plano 75093, USA.
OBJECTIVE: The objective of this article is to provide a brief overview of the major psychosocial risk factors impacting recovery from spine surgery. RESULTS: Numerous personality, cognitive, behavioral and historical factors affecting surgical recovery are reviewed. Among the most significant issues that have been found to have an adverse influence on outcome are Minnesota Multiphasic Personality Inventory scale elevations associated with pain sensitivity, depression, anger and anxiety. Maladaptive pain coping strategies, litigation, workers' compensation and reinforcement of pain behavior by the spouse also have been found to reduce spine surgery results. A number of other factors are reviewed, including pre-existing psychological problems, sexual and physical abuse, marital distress and substance abuse. CONCLUSIONS: Presurgical psychological screening should be included in the medical diagnostic process of spine surgery candidates, especially when the major goal is pain reduction, or when the surgeon recognizes the existence of psychosocial risk factors. Suggestions for future directions in the development of presurgical psychological screening procedures are also given.
PMID: 11587109, UI: 21470741
Clin J Pain 2001 Sep;17(3):192-9
Department of Psychiatry, The University of Texas Southwestern Medical Center at Dallas, 75390-9044, USA. gatchel@utsouthwestern.edu
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.
PMID: 11587108, UI: 21470740
Eur J Anaesthesiol 2001 Nov;18(11):763-5
Department of Neurology, University of Heidelberg, GermanyDepartment of Neuroradiology, University of Heidelberg, Germany.
We present a case of hypoxic brain damage that occurred after intramuscular injection of diclofenac due to a severe anaphylactic reaction. A 38-year-old nurse treated herself for acute lower back pain with 100 mg diclofenac intramuscularly. Five minutes later, she collapsed and developed coma and respiratory arrest. After cardiopulmonary resuscitation she was transferred to hospital. On admission she was comatose and received controlled ventilation of the lungs. Magnetic resonance imaging and computerized tomography showed signs of hypoxic brain injury and the patient died from central cardiopulmonary failure 7 days later. Intramuscular treatment with non-steroidal anti-inflammatory drugs such as diclofenac has rare but potentially severe side-effects. Therefore, intramuscular injections are inappropriate and should be replaced with oral or rectal treatment, which has similar absorption profiles.
PMID: 11580784, UI: 21464618
Eur J Pharmacol 2001 Aug 24;426(1-2):39-44
Departamento de Farmacobiologia, Centro de Investigacion y de Estudios Avanzados del Instituto Politecnico Nacional, Mexico, D.F., Mexico.
The involvement of nitric oxide (NO), cyclic GMP and ATP-sensitive K(+) channels in the antinociceptive effect of ketorolac was assessed using the formalin test in the rat. Local administration of ketorolac in a formalin-injured paw produced a dose-dependent antinociceptive effect due to a local action, as drug administration in the contralateral paw was ineffective. Pretreatment of the injured paw with N(G)-L-nitro-arginine methyl ester (L-NAME, an NO synthesis inhibitor), 1H-(1,2,4)-oxadiazolo(4,2-a)quinoxalin-1-one (ODQ, a soluble guanylyl cyclase inhibitor) or glibenclamide (an ATP-sensitive K(+) channel blocker) prevented ketorolac-induced antinociception. However, pretreatment with saline or N(G)-D-nitro-arginine methyl ester (D-NAME) did not block antinociception. Local administration of S-nitroso-N-acetylpenicillamine (SNAP, an NO donor) was inactive by itself, but increased the effect of ketorolac. The present results suggest that the antinociceptive effect of ketorolac involves activation of the NO-cyclic GMP pathway, followed by an opening of ATP-sensitive K(+) channels at the peripheral level.
PMID: 11525769, UI: 21417256
JAMA 2001 Oct 3;286(13):1578
Department of Surgery, University of California-San Francisco.
[Record supplied by publisher]
PMID: 11585479
Lancet 2001 Sep 22;358(9286):1015
Publication Types:
PMID: 11586989, UI: 21470195
N Engl J Med 2001 Sep 27;345(13):935-40
Department of Anesthesiology, Washington University, St Louis, MO 63110, USA.
BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.
PMID: 11575284, UI: 21442321
Support Care Cancer 2001 Sep;9(6):428-34
Kangasala Health Centre, Finland. hhinkka@sci.fi
The aim of this prospective study was to assess the quality of cancer pain control during the last week of life in two different types of units for terminal cancer patients in Finland: on health centre wards (N=20) and in a hospice (N=30). Pain scores (VAS), defined daily doses (DDD), routes of administration and costs of pain medication were analysed for each patient. On the 7th-last day before death and during the very last day of life (24 h), respectively, the following results were seen: proportions of patients using strong opioids 64% and 84%, mean equivalent parenteral morphine doses of strong opioids 42 mg and 57 mg, mean pain scores (VAS 0-10) 3.11 and 3.05, mean daily cost of pain medication 2.22 and 2.90 euros. Pain control was thus found to be good with low costs. On the 7th day before death strong opioids were used for a greater proportion of patients on the health centre wards. Differences were also seen in the routes of administration used for strong opioids. Weak opioids were used more in the hospice and NSAIDs, more on the health centre wards. However, no differences were found either in the mean doses of strong opioids or in the quality or the costs of pain control between the health centre wards and the hospice.
PMID: 11585269, UI: 21469016
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