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Relief of refractory angina with continuous intravenous infusion of nitroglycerin.

Seventy-five patients with chest pain due to prolonged myocardial ischemia (group I, n=45) or acute myocardial infaction (group II, n=30) were treated with continuous intravenous infusion of nitroglycerin. pain relief was achieved immediately or after titration in 40 of 45 group I patients and 22 of 30 group II patients. Of the 29 group I patients who received narcotic analgesics for pain relief prior to the nitroglycerin infusion, 20 experienced a decrease in narcotics required for pain relief while intravenously receiving nitroglycerin. Twenty-four of 28 group I patients and 14 of 19 group II patients who had angina refractory to multiple doses of sublingual nitroglycerin received relief with intravenous administration of nitroglycerin. This data suggests that intravenous administration of nitroglycerin is useful, adjunctive therapy for chest pain even when refractory to multiple doses of sublingual nitroglycerin.

Clinical outcomes after stereotactic radiosurgery for idiopathic trigeminal neuralgia.

OBJECT: Stereotactic radiosurgery is an increasingly used and the least invasive surgical option for patients with trigeminal neuralgia. In this study, the authors investigate the clinical outcomes in patients treated with this procedure. METHODS: Independently acquired data from 220 patients with idiopathic trigeminal neuralgia who underwent gamma knife radiosurgery were reviewed. The median age was 70 years (range 26-92 years). Most patients had typical features of trigeminal neuralgia, although 16 (7.3%) described additional atypical features. One hundred thirty-five patients (61.4%) had previously undergone surgery and 80 (36.4%) had some degree of sensory disturbance related to the earlier surgery. Patients were followed for a maximum of 6.5 years (median 2 years). Complete or partial relief was achieved in 85.6% of patients at 1 year. Complete pain relief was achieved in 64.9% of patients at 6 months, 70.3% at 1 year, and 75.4% at 33 months. Patients with an atypical pain component had a lower rate of pain relief (p = 0.025). Because of recurrences, only 55.8% of patients had complete or partial pain relief at 5 years. The absence of preoperative sensory disturbance (p = 0.02) or previous surgery (p = 0.01) correlated with an increased proportion of patients who experienced complete or partial pain relief over time. Thirty patients (13.6%) reported pain recurrence 2 to 58 months after initial relief (median 15.4 months). Only 17 patients (10.2% at 2 years) developed new or increased subjective facial paresthesia or numbness, including one who developed deafferentation pain. CONCLUSIONS: Radiosurgery for idiopathic trigeminal neuralgia was safe and effective, and it provided benefit to a patient population with a high frequency of prior surgical intervention.

Motor cortex stimulation for central and peripheral deafferentation pain. Report of eight cases.

The authors tested a modified motor cortex stimulation protocol for treatment of central and peripheral types of deafferentation pain. Four patients with thalamic pain and four with peripheral deafferentation pain were studied. Preoperative pharmacological tests of pain relief were performed using phentolamine, lidocaine, ketamine, thiopental, and placebo. In five patients we placed a 20- or 40-electrode grid in the subdural space to determine the best stimulation point for pain relief for a few weeks before definitive placement of a four-electrode array. In three patients, the four-electrode array was implanted in the interhemispheric fissure as a one-stage procedure to treat lower-extremity pain. In two patients with pain extending from the extremity to the trunk or hip, dual devices were implanted to drive two electrodes. Six of eight patients experienced pain reduction (two each with excellent, good, and fair relief) from motor cortex stimulation. No correlation was apparent between pharmacological test results and the effectiveness of motor cortex stimulation. Patients with peripheral deafferentation pain, including two with phantom-limb pain and two with brachial plexus injury, attained pain relief from motor cortex stimulation, with excellent results in two cases. Testing performed with a subdural multiple-electrode grid was helpful in locating the best stimulation point for pain relief. Motor cortex stimulation may be effective for treating peripheral as well as central deafferentation pain.

Acupuncture and subtypes of chronic pain: assessment of long-term results.

OBJECTIVE: To determine patients' opinions of pain relief for a longer time after one treatment period of acupuncture for chronic pain. PATIENTS AND SETTING: Two hundred and eleven patients had acupuncture treatment for chronic pain at the Pain Clinic of Malmo University Hospital during 1983-5. Their mean duration of pain was 10.4 years prior to treatment. INTERVENTION: The patients were treated with needle acupuncture with a combination of local and distal points every 1-2 weeks. Both manual and electrical stimulation was utilized. The mean number of treatments was 7.8. DESIGN: In 1988, all patient documents were screened, and the pain conditions were classified as nociceptive, neurogenic, or psychogenic. Of the 211 treated patients, initial results could be evaluated from the clinic records in 202 cases. Eighty-five of these patients (42.1%) experienced pain relief immediately after the treatment period. These patients were sent a 1-page questionnaire by mail in 1988. OUTCOME MEASURES: pain relief over defined time periods (yes/no); do more work at home or at workplace (yes/no); analgesic consumption. RESULTS: Only 35 patients (17.3% of all patients) still experienced pain relief 6 months after treatment. Among those with nociceptive pain, 70 of 142 (49%) had experienced initial pain relief, while those with neurogenic or psychogenic pain experienced relief in only 11 of 34 and four of 26 of the cases, respectively. pain relief for > 6 months was experienced by 33 of 142 of the cases with nociceptive pain, but by only two of 34 of those with neurogenic pain, and by none of those with psychogenic pain. CONCLUSION: Only patients with nociceptive pain can be expected to get pain relief for > 6 months after one treatment period of acupuncture, and of these only a small proportion will be helped.

Vinblastin iontophoresis in treating intractable pain.

A group of 36 patients were tested for the effects of percutaneous iontophoretic application of Vinblastin inj., a microtubular transport inhibitor (Gideon Richter, Hungary) in the treatment of chronic intractable pain. The group is divided into two subgroups: (1) 16 patients with persistent root pain following one or more operations for lumbar intervertebral disk herniation. (2) 20 patients with persistent pain in the area of the radicular skin zones or in the skin innervation areas of peripheral nerves. Vinblastin was injected in the place of maximal pain, 0.01% concentration in the total amount of 5 mg of active substance. The active electrode was the anode. There were at least 15 procedures per patient. The therapeutic effect was evaluated from the patients' subjective reports on pain relief in per cent, from the intensity of actual pain and from the interference of pain intensity with daily activities. Considering all the criteria, an improvement was achieved in 29 cases, i.e. 81%. The beneficial effect of the therapy was observed from the 8th to 10th application. In the first group of patients, 69% showed a clinically significant relief of the algetic symptoms. In the other group, the therapeutic effect was 90% of cases. A significant difference between both these groups was found to be in the degree of pain relief after the end of therapy. In the first group the average pain relief was 22.2%, in the other one 47.7%. This difference is statistically highly significant. Except for one case, the beneficial effect was always recorded in the place of administration (under the anode). Apart from local skin irritation in 2 patients and spot burns under the electrode in 2, no other side adverse effects were seen in the course of therapy, after its termination or at the checks made after some time interval (maximum 3 years).

Pain and pain relief experienced by hospice patients with cancer.

The purpose of this descriptive study was to explore the pain intensity and pain relief experienced by hospice patients with cancer and the variables that might be associated with that pain. The sample consisted of 118 consenting patients and their primary caregivers receiving hospice care in their homes. Methods involved a secondary analysis of data from a study of quality of life. The Hospice Quality of Life Index (HQLI), used in the study, assesses multidimensional aspects of quality of life including pain relief. Each item is assessed on a 1 (worst) to 10 (best) scale. To eliminate pain-free patients from the analysis, an additional item asks how severe pain is when it is at its worst. Both patients and caregivers were asked to evaluate the patient's quality of life on admission and after 3 weeks of hospice care. Relationships were sought among items on the HQLI and between pain and demographic characteristics. Results revealed that most patients experience pain (82%) but that caregivers were not able to accurately estimate that pain. pain relief, even after 3 weeks of hospice care, was less than optimal, with many patients (42%) reporting pain relief at a level of 5 or less. A significant difference in pain at its worst was found by type of cancer. Although there were differences by gender, these were not significant. Pain was found to be weakly related to enjoyable activity, sleeping, fatigue, physical care, hope, and anger. Results support the idea that pain is important to overall quality of life, but despite its importance, pain in hospice patients with cancer still is not well managed.

Intra-aortic balloon pumping in coronary artery disease.

Cardiogenic shock and severe left ventricular failure after acute myocardial infarction, refractory angina pectoris at rest either of new onset or superimposed on stable angina pectoris, or occurring in the post infarct (less than 2 weeks) period, and the suspicion of a slowly evolving infarction are the main indications for intra-aortic balloon pumping at the Thoraxcenter. 76 patients were treated with intra-aortic balloon pumping for cardiogenic shock after acute myocardial infarction and left ventricular failure, 42/76 (55%) could be weaned, 9 (12%) died within 3 months, 33 (43%) survived over 3 months, to date 29 are alive. 42 patients with refractory angina at rest were treated with intra-aortic balloon pumping. pain relief was prompt in 41 (98%), who subsequently underwent coronary artery bypass grafting. Total myocardial infarction rate was 11% (5/42), total mortality rate was 7%. Perioperative myocardial infarction rate was 8% (4/42) and perioperative mortality was 7% (3/42). pain relief was prompt in 14/17 patients (82%) with post infarct refractory angina. In 3 patients pain persisted despite intra-aortic balloon pumping, all sustained a myocardial infarction, 1 died, 2 other patients were excluded for surgery. 12 patients underwent coronary artery bypass grafting, none died, none developed acute myocardial infarction, 3 have mild stable angina. In 8 patients a slowly evolving myocardial infarction was suspected. pain relief was prompt in 7/8 (88%) after institution of intra-aortic balloon pumping. Intra-aortic balloon pumping improves prognosis in cardiogenic shock after myocardial infarction, and abolishes refractory ischemic pain.

Percutaneous vertebroplasty for osteoporotic compression fractures: quantitative prospective evaluation of long-term outcomes.

PURPOSE: Osteoporotic vertebral compression fractures may cause debilitating pain that lasts for weeks or months, and which is often neither quickly nor completely relieved by conventional conservative therapy. Previous retrospective studies have suggested significant and nearly immediate pain relief, as well as rapid and sustained functional recovery, after percutaneous polymethylmethacrylate vertebroplasty (PPV). This prospective, quantitative study with long-term follow-up was designed to evaluate the safety and efficacy of PPV as a new treatment for patients with osteoporotic vertebral body compression fractures of the lumbar and thoracic spine. MATERIALS AND METHODS: PPV was performed in 30 patients with 54 symptomatic osteoporotic vertebral compression fractures who had a less-than-satisfactory response to conventional therapy. All procedures were performed by a single operator with significant experience in performing PPV. The Musculoskeletal Outcomes Data Evaluation and Management Scale (MODEMS) spinal intervention questionnaire, which includes the SF-36, was administered to all patients before intervention and exactly 2 weeks after the final PPV procedure. Pain and disability, treatment expectations and satisfaction, mental function, and quality of life were evaluated by four specialized modules, and responses to questionnaires preceding treatment were compared to those obtained at follow-up. Results of a long-term follow-up questionnaire were collected 15-18 months after the final vertebroplasty treatment. RESULTS: Our population consisted of three men and 27 women, with a mean age of 79 years. Fifty-four PPV procedures were performed for compression fractures in these 30 patients. Significant postprocedural improvement in all four MODEMS modules was demonstrated at 2 weeks (treatment score, P <.0001; pain and disability, P <.0001; physical function, P =.0004; and mental function, P =.0009). A small epidural leak of polymethylmethacrylate in one patient was asymptomatic and did not require intervention. At long-term follow-up (15-18 mo), 22 of 23 patients responding remained satisfied with the outcome of therapy and believed that the procedure had provided durable pain relief. Verbal pain scores documented significantly diminished back pain at 2 weeks (P <.0001) and again at long-term follow-up when compared to baseline (P <.0001). CONCLUSIONS: PPV is a safe and efficacious procedure for the relief of pain and disability after osteoporotic vertebral compression fractures. Patient satisfaction is high and persists when compared to preprocedural expectations; durable pain relief is provided.

Stereotactic radiosurgery for idiopathic trigeminal neuralgia.

OBJECT: Each year a greater number of patients with trigeminal neuralgia (TN) undergo radiosurgery, including a large number of patients who are candidates for microvascular decompression (MVD). METHODS: The case characteristics and outcomes of 117 consecutive patients who underwent radiosurgery were retrieved from a prospectively maintained database. The mean patient age was 67.8 years; and the majority (58%) of patients had undergone surgery previously. The dependent variable for all analyses of facial pain was complete pain relief without medication (excellent outcome). Median follow-up duration was 26 months (range 1-48 months). The actuarial rate of achieving and maintaining an excellent outcome was 57% and 55% at 1 and 3 years, respectively, after radiosurgery. A greater percentage of patients who had not previously undergone surgery achieved and maintained excellent outcomes (67% at 1 and 3 years) than that of patients who had undergone prior surgery (51% and 47% at 1 and 3 years, respectively; relative risk [RR] = 1.77, 95% confidence interval [CI] 1.01-3.13, p = 0.04). New persistent trigeminal dysfunction was noted in 43 patients (37%). Tolerable numbness or paresthesias occurred in 29 patients (25%), whereas bothersome dysesthesias developed in 14 patients (12%). Only a radiation dose of 90 Gy correlated with new trigeminal deficits or dysesthesias (RR = 3.10, 95% CI 1.64-5.81, p < 0.001). Excellent outcomes in patients with new trigeminal dysfunction were achieved and maintained at rates of 76% and 74% at 1 and 3 years, respectively, after radiosurgery, compared with respective rates of 46% and 42% in patients who did not experience postradiosurgery trigeminal dysfunction (RR = 4.53, 95% CI 2.03-9.95, p < 0.01). CONCLUSIONS: Radiosurgical treatment provides complete pain relief for the majority of patients with idiopathic TN. There is a strong correlation between the development of new facial sensory loss and achievement and maintenance of pain relief after this procedure. Because the long-term results of radiosurgery still remain unknown, MVD should continue to be the primary operation for medically fit patients with TN.

Perceptions of pain and pain relief in labour: the gulf between experience and observation.

In a national sample of 10,702 women delivered in one week in 1990 data on their perceptions of pain and the effectiveness of pain relief methods were compared with those of the professionals attending them. Professionals' conceptions of pain relief tended to be restricted to pharmacological methods. Overall, the level of agreement about effectiveness of pain relief was quite low, with medical staff commonly believing they were providing adequate pain relief while the women reported it as unsatisfactory. This was particularly the case for pethidine, while 'Entonox' was rated more highly by women than staff. Professionals were significantly more likely to agree with one another about effectiveness than to agree with the women, and were less likely to have responded where the women judged their pain relief as poor.

Use of the World Health Organization guidelines on cancer pain relief before referral to a specialized pain service

In 1986 the World Health Organization (WHO) released guidelines for cancer pain relief. Since then, several controlled studies on effectiveness and practicability of these guidelines have been published. Various authors described inadequate use of these guidelines.We analysed, whether the pain medication of 160 cancer patients referred to the anesthesiological pain clinic at the university hospital of Vienna corresponded to the WHO guidelines or not. Adequacy of pain treatment was assessed using the pain management index (PMI). Multiple criteria were chosen to assess the conformity of the treatment with the guidelines. Furthermore we studied the effect of a strict use of the WHO guidelines in these patients.The average pain intensity of the referred patients was 75 mm (VAS). Negative PMI scores, indicating inadequate pain therapy, were fount in 39 % of cases. A violation of the rules was found in 38% of the therapy schedules. Pain medication was then modified by switching to fixed time intervals, escalation of the steps of the WHO ladder, increasing the dosage or treating neuropathic pain with adjuvant drugs. Two weeks later the average pain score of the patients was reduced to 27 mm (VAS). At that time 72% of the patients quoted an adequate reduction of pain.Inadequate knowledge or disregard of the WHO guidelines for cancer pain relief are common and result in unnecessary and prolonged suffering in these patients.

Switching opioids to transdermal fentanyl in a clinical setting

INTRODUCTION: The use of transdermal fentanyl is gaining in importance in the management of cancer pain. We describe the reasons for switching opioid medication to transdermal fentanyl in a pain management unit. METHODS: Case records of patients treated with transdermal fentanyl in our pain clinic were evaluated retrospectively. Conversion ratios were calculated from the opioid dosage before and after conversion. Pain intensities were assessed on a numeric rating scale (NRS 0: no pain, 10: worst pain imaginable). RESULTS: From October 1995 to December 1997 101 patients received transdermal fentanyl. Thirty-six patients had been treated with transdermal fentanyl before admission to our pain clinic, and relevant information was missing for one patient, so 64 patients were evaluated. Opioid therapy was switched to transdermal fentanyl during in-patient treatment for 53 patients and during out-patient treatment for 11 patients. Before conversion patients were treated with slow-release morphine (48%), immediate-release morphine (17%), buprenorphine (11%), tramadol (11%), levomethadone (5%), tilidine/naloxone (5%) and piritramid (3%). Reasons for opioid rotation were inadequate pain relief ( 33%), the patients' wish to reduce oral medication (20%), gastrointestinal side effects such as nausea (31%), vomiting (13%) and constipation (19%), dysphagia (27%) or others. Reduction of side effects was reported by 10 of 19 patients. In 12 of 21 patients, in whom the medication was switched because of inadequate pain relief, a reduction in pain intensity was reported. DISCUSSION: Conversion to transdermal therapy may readjust the balance between opioid analgesia and side effects. The opioid switch resulted in more pain relief or fewer side effects in half of the patients. A proposed equianalgesic conversion ratio between 70:1 and 100:1 from oral slow-release morphine to transdermal fentanyl can be confirmed by our data. Conversion rates from other opioids to transdermal fentanyl are suggested.

Why do patients feel positive about patient-controlled analgesia?

We studied 200 patients to identify the aspects of their experience of patient-controlled analgesia (PCA) that made them feel 'extremely positive' about this technique. After PCA had been withdrawn, patients completed a questionnaire which included the following topics: pre-operative information, pain relief, the degree of control that PCA afforded the patient, side-effects and safety. Multiple regression analysis identified three factors of their experience which were associated uniquely with feeling 'extremely positive' about PCA: having better pain relief, not worrying about 'giving oneself too much drug' and not experiencing feeling 'peculiar in the head'. Control over pain relief, although highly correlated with feeling 'extremely positive' about PCA, was unimportant when these variables were controlled. Because of the well-recognised difficulties in measuring satisfaction with analgesic regimens, we suggest that a satisfaction score based on these variables would be a significant advance on existing methods.

Patient-controlled analgesia with piritramid for the treatment of postoperative pain.

Patient-controlled analgesia (PCA, intravenous self-application of narcotics) was studied during the early postoperative period. Subjects were 40 ASA I-III patients recovering from elective major and minor surgery (20 each having undergone abdominal or orthopedic operations). Whenever the patients required pain relief, piritramid demand doses of 2.0 mg were given via the hand-button of a microprocessor-controlled injection pump (On-Demand Analgesia Computer, ODAC). Hourly maximum dose was set to 15 mg with a pump refractory time of 1 minute between valid demands. A continuous low-dose piritramid infusion (0.24 mg/h) was additionally administered in order to prevent catheter obstruction. Duration of the PCA period was 19.7 +/- 6.5 hours (mean +/- SD). During this time, 17.1 +/- 13.8 demands per patient were recorded resulting in mean individual piritramid consumptions of 30.4 +/- 28.1 micrograms/kg/h. Self-administration was characterized by considerable intra- and interindividual variability. Following abdominal surgery, slightly more piritramid was needed compared with orthopedic patients, although less pain relief was achieved in the former group. The same proved to be true for a comparison between the sexes, males requiring significantly more piritramide for less pain relief than females (p = 0.05). Over-all efficacy and patient acceptance proved to be excellent. Effectiveness of PCA was judged superior by about 73% of patients when compared with previously experienced conventional postoperative analgesia. Side effects (sweating, nausea, emesis) occurred in about 20% but were usually of minor intensity. No serious circulatory or respiratory problems were observed during the PCA period. Patient-controlled analgesia is discussed as a promising concept for the treatment of acute pain and for clinical pain research.

Long-term outcome of spinal cord stimulation and hardware complications.

Spinal cord stimulation (SCS) is a treatment modality for medically intractable chronic pain. This study reports an 11-year experience with SCS assessing long-term pain relief and specifically evaluating complications and revisions. It took the form of a retrospective review of medical/surgical records with a postal questionnaire. The subjects were 102 patients with medically intractable chronic pain who underwent SCS implantation between 1989 and 2000. There were 64 revision operations carried out on 35 patients. These comprised electrode replacement/repositioning (29), generator replacement (23), cable failure (3) and implant removal (5). Five (4.9%) implants became infected and 2 required removal. Clinician-reported pain relief was substantial in 69 (68%) patients. This study adds to the weight of evidence that patients undergoing SCS derive significant benefits in terms of pain relief. However, revision rates remain high due to technical and biological factors. Copyright 2003 S. Karger AG, Basel

Hospitalized children's descriptions of their experiences with postsurgical pain relieving methods.

The purpose of this study was to describe children's (aged 8-12 yr) experiences with postsurgical pain relieving methods, and their suggestions to nurses and parents concerning the implementation of pain relief measures in the hospital. The data were collected by interviewing children (N = 52) who were inpatients on a pediatric surgical ward in the university hospital of Finland. Content analysis was used to analyze the data. The children rated the intensity of pain on a visual analogue scale. The results indicated that all of the children used at least one self-initiated pain relieving method (e.g. distraction, resting/sleeping), in addition to receiving assistance in pain relief from nurses (e.g. giving pain killers, helping with daily activities) and parents (e.g. distraction, presence). The children also provided suggestions, especially as it relates to nurses (e.g. creating a more comfortable environment), regarding the implementation of effective surgical pain relief. However, some cognitive-behavioral and physical methods were identified that should be implemented more frequently in clinical practice. Furthermore, most children reported their worst pain to be severe or moderate, which indicates that pain management in hospitalized children should be more aggressive. Copyright 2002 Elsevier Science Ltd.

Degenerative conditions of the lumbar spine treated with intervertebral titanium cages and posterior instrumentation for circumferential fusion.

Thirty-five consecutive patients were evaluated at an average follow-up time of 20 months after circumferential lumbar spinal fusion. All patients had degenerative conditions of the lumbar spine and same-day anterior spinal fusion by using titanium cages packed with autograft bone and posterior instrumentation combined with a posterolateral autogenous bone graft. The purpose of this study was to determine whether anterior titanium cage placement and posterior instrumentation with autologous bone graft was a safe and efficacious procedure in patients with degenerative disease of the lumbar spine. Fusion rates, complications, pain relief, medication use, and work status were specifically analyzed. Although previous reports documented the use of this technique for trauma and tumor cases, few studies assessed clinical and radiographic results in patients with degenerative conditions of the lumbar spine. Plain radiographs were used to determine spinal fusion at each spinal level. All patients were administered preoperative and postoperative questionnaires regarding three specific clinical-outcome parameters. These consisted of pain level, medication use, and work status. Intraoperative and postoperative complications were also documented. Radiographic results showed that 61 (97%) of 63 lumbar levels undergoing an arthrodesis procedure fused either anteriorly, posteriorly, or both. Of the 35 patients in this series, 33 (94%) fused at all levels, and two did not. Substantial pain relief was reported in 46% of all patients. Thirteen (37%) patients had one or more surgical complications. Circumferential spinal fusion in patients with degenerative etiologies yields excellent radiographic fusion rates and good pain relief. The procedure is technically demanding and is associated with a high rate of complications.

Localization of specific joint causing hindfoot pain: value of injecting local anesthetics into individual joints during arthrography.