Thursday, September 11, 2008

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Saturday, June 14, 2008

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Neonatal circumcision and pain relief: current training practices.

OBJECTIVE: We conducted a national survey of pediatric, family practice, and obstetrics and gynecology residency program directors to determine the curriculum content and predominant practices in US training programs with regard to neonatal circumcision and anesthesia/analgesia for the procedure. METHODS: Residency directors of accredited programs were surveyed in two mailings of a forced response and short answer survey (response rate: 680/914, 74%; pediatrics 83%; family practice 72%; obstetrics 71%). RESULTS: Pediatric residents were less likely than family practice [odds ratio (OR), 0.04; 95% confidence interval (CI), 0.02-0.08] or obstetrical (OR, 0.14; 95% CI, 0.08-0.23) residents to be taught circumcision. Training and local custom were rated as important determinants of medical responsibility for neonatal circumcision. Pediatric residents training in programs in which community pediatricians perform circumcisions were more likely to learn circumcision (OR, 39.0; 95% CI, 14.3-110.6) as were obstetric residents (OR, 79.0; 95% CI, 22.4-306.4) training in programs in which community obstetricians perform circumcision. In programs that teach circumcision, pediatric (84%; OR, 3.4; 95% CI, 1.7-7.1) and family practice (80%; OR, 2.7; 95% CI, 1.7-4.2) programs were more likely than obstetric programs (60%) to teach analgesia/anesthesia techniques to relieve procedural pain. Overall, 26% of programs that taught circumcision failed to provide instruction in anesthesia/analgesia for the procedure. Significant regional variations in training in circumcision and analgesia/anesthesia techniques were noted within and across medical specialties. CONCLUSIONS: Residency training standards are not consistent for pediatric, family practice, and obstetrical residents with regard to neonatal circumcision or instruction in analgesia/anesthesia for the procedure. Training with regard to pain relief is clearly inadequate for what remains a common surgical procedure in the United States. Given the overwhelming evidence that neonatal circumcision is painful and the existence of safe and effective anesthesia/analgesia methods, residency training in neonatal circumcision should include instruction in pain relief techniques.

Qualitative assessment of pain relief and functional improvement after coronary bypass surgery. A questionnaire survey among 527 patients

INTRODUCTION: We wanted to assess postoperative pain relief and functional improvement in all CABG patients (546) from Gentofte County Hospital (GCH) in 1997, so as to elicit better information on what to expect after CABG. MATERIAL AND METHODS: A descriptive cross-sectional survey, was carried out in 1999. All surviving patients (527) were sent a questionnaire with 17 questions in five categories: The course of the operation, pain level, medicine consumption postoperatively, working situation, and educational level. The inclusion criterion was CABG in GCH in 1997. RESULTS: One hundred and five women and 441 men (mean age 74 and 67 years) were entered. Response rate: 98%. Mortality rate: 0.9% in 30 days and 3.5% in two years. Sixty-four percent were satisfied with the course of the operation. In two years 33% were rehospitalised and 6% had a new CABG/PTCA. Other frequent diagnoses for readmission were AMI, arrhythmia, and angina. Considerable wound discomfort was reported by 21% (chest) and 13% (leg/arm). Marked pain relief and functional improvement was achieved postoperatively (95%). Postoperative angina was not associated with limitation in daily activities. Postoperative medicine consumption: 52% antihypertensives and 20% anti-angina medicine. The return-to-work rate, for those working before the operation was 75% in about two months, with a slight preponderance in those employed in the private sector. DISCUSSION: The study shows a high survival rate in two years after CABG. Considerable pain relief and functional improvement was achieved, and only a very small group derived no benefit from the operation. A large amount of patients had wound discomfort, which leaves an unsolved problem.

Naloxone does not affect pain relief induced by electrical stimulation in man.

We wished to determine if pain relief that resulted from transcutaneous (TNS) or spinal cord electrical stimulation in patients with chronic pain was due to activation of an endogenous opiate-related pain control system. Naloxone (0.4-10 mg) or saline was injected in double-blind fashion intravenously into opiate-naive subjects with chronic pain who achieved 30% or greater pain relief with spinal cord stimulation (4 patients) or TNS (9 patients). Subjects rated their pain during stimulation and 2, 5, 10 and 15 min after the injection. Two days or more later the procedure was repeated using the alternate agent (naloxone or saline). Naloxone did not decrease the pain relief induced by stimulation, and therefore the effects of stimulation are probably not mediated by the endogenous opiates.

Bilateral CT-guided percutaneous cordotomy for cancer pain relief.

AIM: CT-guided percutaneous cordotomy is a useful procedure for treating unilateral cancer pain, however, bilateral cordotomy can be required on some occasions. We evaluated the effectiveness and complications of bilateral cordotomy. MATERIALS AND METHODS: Two hundred and thirty-four patients who suffered from unilateral cancer pain underwent CT-guided percutaneous cordotomy. The procedure was repeated in 22 patients, and nine patients had bilateral cordotomy. Effectiveness and complications were recorded after each procedure. RESULTS: Of nine patents (three women and six men) having bilateral percutaneous cordotomy in our study, four patients had mirror pain after the first procedure. In the remaining five patients the contralateral pain was due to new pain sites. The pain scores before and after the first procedure were 9.3 (range 7-10) and 1.2 (range 0-3), respectively. After the first procedure complete or satisfactory pain relief was achieved in all patients. The duration between the two procedures ranged from 7-243 days (mean 59.8 days). The pain scores before and after the second procedure were 8.4 (range 5-10) and 1.6 (range 0-4), respectively. After the second procedure complete or satisfactory pain relief was reported in all patients. There were no complications in four patients. One patient developed transient motor deficit after the first procedure. Other complications (nausea/vomiting, headache, ipsilateral neck pain, postcordotomy dysesthesia) were mild and transient. CONCLUSION: CT-guided percutaneous cordotomy is a useful procedure for the treatment of severe unilateral cancer pain syndromes. The procedure can be repeated on the other side at least 1 week later. These results show that the success on the second side appears to be similar to the first side with low complication rate for both procedures.

Personality traits in the mechanisms of interferential therapy for osteoarthritic knee pain.

The role of hypochondriacal, depressive, and hysterical personality traits in response to interferential therapy (IFT) was studied in 50 patients with chronic knee osteoarthrosis. Personality traits were assessed through the Minnesota Multiphasic Personality Inventory. Each patient received ten sessions of IFT during two weeks. pain relief was assessed subjectively (with a numerical pain-relief scale) at the end of treatment and one week later in a single-blind method. Patients who experienced pain relief of 50% or more were considered responders (n = 22). Those who experienced pain relief of 25% or less were considered nonresponders (n = 24). No statistically significant difference was found between the two groups on any of the personality traits studied. These personality traits apparently have no effect on the response of osteoarthritic knee pain to IFT.

pain relief in infants after major surgery: a descriptive study.

Twenty subjects (nurses or parents) were interviewed concerning postoperative pain and pain relief in infants. Details of postoperative analgesics given were obtained from hospital records of 32 infants, aged 0 to 12 months, who had undergone major surgery, and routines for postoperative pain relief in infants were investigated at four Swedish hospitals where major surgery is performed on infants. Although both nurses and parents were found to be able to recognize postoperative pain reactions in infants, attitudes to pain relief were not uniform. In principle, postoperative pain relief is given "as required," although both dosage and intervals between doses are arbitrary.

Analgesic effects of epidurally administered fentanyl for postoperative pain relief--comparison with buprenorphine

We did a retrospective study on 177 patients after upper and lower abdominal surgery, and compared the efficacy of epidural administration of fentanyl and that of buprenorphine for postoperative pain relief. In fentanyl (F) group, 73 patients received fentanyl 0.1 mg with saline 8 ml epidurally after operation, followed by a constant rate infusion of 0.025 for 18-24 hrs. In buprenorphine (B) group, 104 patients, received buprenorphine 0.2 mg with saline 9 ml epidurally. After upper abdominal surgery, 33 patients (76.7%) in F group and 27 patients (52.9%) in B group obtained satisfactory analgesia (P < 0.05). The difference of the degree of analgesia after lower abdominal surgery was not significantly different in both groups. Respiratory depression occurred in 19 patients in B group and 5 patients in F group (P < 0.05). It is concluded that epidural fentanyl delivered by continuous infusion offers a significant advantage compared with epidural buprenorphine for postoperative pain relief following upper abdominal surgery.

The efficacy and complications of laparoscopic presacral neurectomy in pelvic pain.

OBJECTIVE: To evaluate the efficacy and complications of laparoscopic presacral neurectomy in pelvic pain. METHODS: We reviewed records of 655 patients receiving laparoscopic conservative surgery and laparoscopic presacral neurectomy for diagnoses including adenomyosis with dysmenorrhea (n = 55), moderate and severe endometriosis with dysmenorrhea (n = 127), minimal and mild endometriosis with dysmenorrhea (n = 208), primary dysmenorrhea (n = 99), and chronic pelvic pain with or without pathologic disease (n = 166). pain relief was evaluated at least 12 months postoperatively. RESULTS: pain relief was evaluated in 527 patients. Significant pain relief (no pain or mild pain requiring no medication) was found in 22 (52%) of 42 women with adenomyosis, in 75 (73%) of 103 with moderate to severe endometriosis with dysmenorrhea, in 123 (75%) of 164 with minimal to mild endometriosis with dysmenorrhea, in 64 (77%) of 83 with primary dysmenorrhea, and in 84 (62%) of 135 with chronic pelvic pain. There were four major complications (0.6%) that required further surgery, including injury of the right internal iliac artery (n = 1) and chylous ascites (n = 3). Three cases (0.5%) had laceration of the middle sacral vein controlled during laparoscopy. In addition, 485 (74%) of the 655 patients complained of constipation after laparoscopic presacral neurectomy, which was relieved easily by medication. CONCLUSION: Presacral neurectomy can be performed safely and efficiently by laparoscopy and is a valuable alternative treatment for pelvic pain.

The mysterious persistence of hypnotic analgesia.

Hypnotic treatment of pain has a long history and, among hypnotic phenomena, pain relief is a relatively commonplace focus for intervention, yet we lack a conceptual explanation for this treatment. Hilgard's neodissociation theory accounts for the phenomenon of acute hypnotic analgesia, but not of persistent pain relief. Perhaps the enduring effect of hypnotic treatment can be explained at either of two levels: a neurophysiological model or a learning model. This explanation leads to the further question: How does hypnotic treatment of recurring pain achieve enduring relief? Clinical experience suggests a two-component model. First, the clinician communicates specific ideas that strengthen the patient's ability to derive therapeutic support and to develop a sense of openness to the unexplored possibilities for pain relief within the security of nurturing therapeutic relationship. Second, the clinician employs posthypnotic suggestions that capitalize on the patient's particular pain experiences, which simultaneously ameliorate the pain experience, and which, in small, repetitive increments, tend to maintain persistent pain relief over increasing periods of time.

Changes in voluntary muscle strength, somatosensory transmission and skin temperature concomitant with pain relief during autotraction in patients with lumbar and sacral root lesions.

Earlier clinical observations of rapid changes of certain neurological dysfunctions after autotraction treatment of patients with lumbar and sacral root affections have been evaluated by objective registration methods. Isokinetic recordings of maximal voluntary strength showed that in 6 out of 8 patients, weakness of the foot dorsal flexor muscles could be more or less completely restored after one session of autotraction resulting in pain relief. In a group of patients with clinical signs of impaired sensibility, the low or abolished SEP responses to nerve stimulation on the affected side were restituted in 4 out of 5 cases during autotraction. The asymmetric leg skin temperatures in 10 patients with sciatic pain levelled off in the 6 cases obtaining pain relief by the traction. The results suggest a causal relationship between pain relief and restitution of certain neurological deficits.

Analgesia in cancer: beliefs and an update

Cancer pain relief is not yet adequate, but there are resources for this. Professional's misconception and the tabu about that pain in cancer is inevitable have been contributing to this problem. Important nurses' knowledge lacuna about pain relief in cancer was found by this study. The WHO program about pain relief in cancer is presented too.

Postoperative pain relief by preanesthetic administration of buprenorphine suppository in elective mastectomy

Seventy female patients scheduled for elective mastectomy were divided into three groups: Buprenorphine suppository (BPS) 0.4 mg group (n = 29); BPS 0.2 mg (n = 23) group; and control (scopolia extract and tannic acid suppository) group (n = 18). Suppositories were administered rectally to patients of each group one hour before induction of anesthesia. Plasma buprenorphine concentrations, sedation scores at entering the operating room, postoperative pain scores and side effects were evaluated. There were no significant differences in sedation effects of suppository among the three groups. Although there were significant differences in pain scores except at the time when patients left the operating room between BPS 0.2 mg group and the control group, postoperative pain relief in BPS 0.2 mg group was judged not enough. However, postoperative pain relief was more satisfactory in the BPS 0.4 mg group. Plasma concentrations of the BPS 0.4 mg group were higher than those of the BPS 0.2 mg group. Although nausea and vomiting were observed in 5 patients (17.2%) of the BPS 0.4 mg group and 4 patients (17.4%) of the BPS 0.2 mg group, respiratory depression and changes in blood pressure and heart rate were not observed in all groups. In conclusion, preanesthetic administration of the BPS 0.4 mg seemed to be useful for postoperative pain relief after elective mastectomy.

Percutaneous lumbar sympathetic plexus catheter placement for short- and long-term pain relief: CT technique and results.

PURPOSE: The purpose of this work was to evaluate the use of percutaneously placed lumbar sympathetic plexus catheter placement under CT guidance in patients with complex regional pain syndrome (CRPS) or nonspecified neuropathic pain (NP) of the lower extremity. METHOD: Sixteen lumbar sympathetic plexus catheter placements were performed in seven patients with CRPS and seven patients with NP. A 19 gauge epidural catheter was placed anterior to the psoas muscle at the L2-3 level. Twenty-five to 840 mg of bupivacaine hydrochloride per day was administered for a 1 to 8 day duration. RESULTS: In CRPS patients, there was complete short-term pain relief in one patient, considerable in four, mild in one, and none in one. There was total long-term pain relief in one patient and considerable long-term pain relief in three. In three patients, there was enduring pain relief at last follow-up. In NP patients, the procedure yielded considerable short-term pain relief in four, mild in two, and none in one. There was no enduring long-term in any of these patients. A retroperitoneal abscess developed in one patient and resolved on intravenous antibiotics without sequelae. CONCLUSION: Percutaneous lumbar sympathetic plexus catheter placement is easily performed, achieves short-term pain relief in the majority of patients, and may prove effective in long-term pain relief of CRPS patients.

Interpleural administration of bupivacaine for postoperative analgesia after thoracotomy in patients with patent ductus arteriosus.

Interpleural analgesia for postoperative pain with bupivacaine 0.25%, 0.375% and 0.5% at dosage of 1.5 mg/kg was evaluated in three randomized groups (A, B and C) of 22 children having triple ligation for patent ductus arteriosus (PDA). Complete pain relief was obtained within 30 min irrespective of the concentration of bupivacaine. The duration of pain relief significantly varied with the concentrations of the drug used, respectively 5.02 +/- 0.4 h, 6.88 +/- 0.7 h and 8.24 +/- 1.08 h (mean +/- SD) for 0.25%, 0.375% and 0.5% bupivacaine (p less than 0.05). No side effects were observed and no other supplemented narcotics were given. We concluded that 0.5% bupivacaine at the dose of 1.5 mg/kg was effective in postoperative pain relief after thoracotomy in patients undergoing PDA ligation surgery.

Pancreatoduodenectomy for chronic pancreatitis: anatomic selection criteria and subsequent long-term outcome analysis.

OBJECTIVE: The authors sought to provide a framework through outcome analysis to evaluate operations directed toward the intractable abdominal pain of severe chronic pancreatitis centered in the pancreatic head. Pancreatoduodenectomy (PD) was used as an example. SUMMARY BACKGROUND DATA: Head resection for severe chronic pancreatitis is the treatment of choice for a ductal system in the head obliterated by severe disease when associated with intractable abdominal pain. To evaluate the effectiveness of promising head resection substitutes for PD, a framework is necessary to provide a reference standard (i.e., an outcome analysis) of PD. METHODS: Inclusion criteria were severe chronic pancreatitis centered in the pancreatic head, intractable abdominal pain, and a main pancreatic duct obstruction or stricture resulting in absent drainage into the duodenum from the uncinate process and adjacent pancreatic head areas or the entire gland. Since 1986, 57 consecutive cases with these criteria underwent PD (47 head only and 10 total pancreatectomy). Clinical and anatomic predictor variables were derived from the history, imaging studies, and pathologic examination. These variables then were tested for association with the following outcome events gathered during annual follow-up: pain relief, onset of diabetes, body weight maintenance, and peptic ulceration. RESULTS: Operative mortality was zero. In 57 patients with a mean follow-up of 42 months, the 5-year outcome event for survival was 93% and the onset of diabetes was 32%. All new cases of diabetes occurred more than 1 year after resection. In 43 cases > or =1 year postoperative with a mean follow-up of 55 months, all patients indicated significant pain relief and 76% were pain free. pain relief was more common in patients with diabetes or in those patients with a pancreatic duct disruption. Death was more common in patients with diabetes. Weight maintenance was more common if preoperatively severe ductal changes were not present. Total pancreatectomy was associated with peptic ulceration. CONCLUSIONS: Using selection criteria, the outcome analysis standardized anatomic and clinical variables as to how they were associated with the outcome events (calibrated the effects of the operation with each variable). In these selected patients, PD is safe and significantly relieves pain. Sequelae are from diabetes, provided total pancreatectomy is avoided.

Lumbar facet joint synovial cyst: percutaneous treatment with steroid injections and distention--clinical and imaging follow-up in 12 patients.

PURPOSE: To determine the imaging characteristics of lumbar facet joint synovial cysts after percutaneous treatment with steroid injections and distention of the cyst and to correlate these findings with the clinical outcome. MATERIALS AND METHODS: Clinical outcome and imaging findings were retrospectively studied in 12 patients (four men, eight women) aged 45-79 years (mean, 60 years) with a symptomatic lumbar facet joint synovial cyst treated with percutaneous steroid injections. At varying times after the procedure, patients were contacted for clinical follow-up, and repeat imaging was performed to verify the status of the cyst. RESULTS: Excellent pain relief was achieved in nine (75%) of 12 patients. At follow-up imaging, the cyst completely regressed in six (67%) of these nine patients, partially regressed in two (22%) patients, and was unchanged in one (11%) patient. One (8%) of the 12 patients had transient pain relief, with recurrence of symptoms at short intervals after each of three injections. No pain relief was achieved in two (17%) of 12 patients. CONCLUSION: Image-guided percutaneous steroid injections are often effective in the treatment of lumbar facet joint synovial cysts and may result in complete regression of the cyst.

Why is the pain relief of dying patients often unsuccessful? The relatives' perspectives.

In order to determine relatives' opinions of the pain relief of dying patients a postal questionnaire was sent to close relatives (n = 371) of aged patients (mean age 80.1 years) who had died one to two years earlier. In the relatives' opinions, 57% of the patients (n = 211) had suffered from moderate to severe pain and in 22% (n = 46) of these the pain relief was unsuccessful. Inadequate pain relief was associated with a feeling of helplessness in the patients (odds ratio 2.6), insufficient self-determination of analgesic use (9.4), unsatisfactory care of daily needs such as nutrition (8.3), and insufficient care of concomitant symptoms such as dry mouth (6.2). The pain relief was also evaluated as having been unsuccessful when the relatives received limited information about the forthcoming death (5.7), when it was difficult to discuss with the clinical staff (5.7), and when the relatives were not supported by, for example, comforting and heartening (7.9) or encouraging to participate in the care (7.2). In the multivariate analysis, the self-determination of the patients about their pain medication (5.7), difficulties of the relatives to discuss issues with the nursing staff (3.7) and poor atmosphere of the treatment environment (2.8) emerged as the most significant associates of unsuccessful pain relief. The results show that dissatisfaction with the pain management is associated with low appreciation of the treatment of other discomforts and complaints. Successful pain management therefore requires a holistic approach to the wider spectrum of problems in dying patients.