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Severe Pain (severe + pain)
Kinds of Severe Pain Selected AbstractsCONTROLLED-RELEASE OXYCODONE RELIEVES MODERATE TO SEVERE PAIN IN A 3-MONTH STUDY OF PERSISTENT MODERATE TO SEVERE BACK PAINPAIN MEDICINE, Issue 2 2002Article first published online: 4 JUL 200 Patricia Richards, MD, PhD; Pinggao Zhang, PhD; Michael Friedman, PhD; Rahul Dhanda, PhD. (Purdue Pharma L.P.) Introduction: Opioids are frequently prescribed for management of persistent low back pain, however, efficacy has not been well documented, and concerns are that opioids may impair physical functioning. Objective: To compare controlled-release oxycodone (CRO) with placebo in controlling pain and to observe the effect of CRO on quality of life and functionality. Methods: A double-blind, randomized, placebo-controlled, parallel-group study of 3 months duration was conducted in 110 subjects (49 males, 61 females), mean age 48 years (19,80 years). Subjects had a 3- to 12-month history of moderate to severe persistent low back pain and were previously unresponsive to therapeutic doses of NSAIDs, and/or low dose combination opioid analgesics. At baseline 4% of subjects were on opioids, 39% on NSAIDs, and 57% both NSAIDs and opioids. Subjects were treated with 10 mg CRO tablet or 10 mg oral placebo q12h, titrated to stable pain control. Existing treatment regimens of acetaminophen, NSAIDs, or oral steroids were allowed to continue. The Brief Pain Inventory (BPI), the Roland Morris Functionality Questionnaire, and the MOS 36-Item Short-Form Health Survey (SF-36) were the measures of pain intensity, functionality, and quality of life. Treatments were compared using repeated measures ANCOVA with baseline value as covariate. Results: CRO treatment was significantly superior to placebo on the BPI average pain intensity and average percent pain relief scores overall (4.6 vs 5.4, P = .03, and 47.2 vs 36.3, P = .05, respectively). Fewer CRO subjects discontinued because of inadequate pain control (P < .001). No significant differences between treatments were observed in either Roland Morris or SF-36 scores. Common adverse events for CRO were nausea, constipation, somnolence, headache, and pruritus, consistent with opioid use. Conclusions: Three-month treatment with CRO provides significant pain relief for subjects with persistent moderate to severe back pain, without significantly impairing functionality and quality of life. The support of Purdue Pharma L.P. for this research project is gratefully acknowledged. [source] Titration with Oxymorphone Extended Release to Achieve Effective Long-Term Pain Relief and Improve Tolerability in Opioid-Naive Patients with Moderate to Severe PainPAIN MEDICINE, Issue 7 2008Richard Rauck MD ABSTRACT Objective., Assess the effectiveness and tolerability of a program of gradual dose titration with oxymorphone extended release (ER) for treatment of moderate to severe chronic pain in opioid-naive patients. Design., Open-label, nonrandomized 6-month study with a titration/stabilization period of ,1 month followed by a 5-month maintenance period. Setting., Multidisciplinary pain centers in the United States. Patients., Adult opioid-naive patients with moderate to severe chronic pain. Interventions., Patients were gradually titrated from a 5-mg dose of oxymorphone ER (taken every 12 hours) to a stabilized dose that provided effective pain relief and was well tolerated. Outcome Measures., Brief Pain Inventory Short Form questions 5 and 9, patient and physician global assessments of pain relief, adverse events (AEs), and discontinuations. Results., The majority (94/126; 75%) of patients were stabilized on a dose of oxymorphone ER that provided effective pain relief with tolerable AEs. Most (81/94; 86%) required <24 days to reach a stable dose. Sixteen percent of patients in the titration period and 17% of patients in the maintenance period discontinued because of AEs possibly or probably related to oxymorphone ER. Patients completing the entire 5-month maintenance period experienced effective pain relief with significant (>50%) reductions of pain interference with quality-of-life measures. There was minimal dose escalation over the 5 months and low use of rescue medication. Conclusions., Oxymorphone ER provided effective pain relief from moderate to severe chronic pain in opioid-naive patients. Gradual titration was well tolerated, with a low rate of discontinuations caused by AEs. [source] Opioids and the Management of Chronic Severe Pain in the Elderly: Consensus Statement of an International Expert Panel with Focus on the Six Clinically Most Often Used World Health Organization step III Opioids (Buprenorphine, Fentanyl, Hydromorphone, Methadone, Morphine, Oxycodone)PAIN PRACTICE, Issue 4 2008Joseph Pergolizzi MD ,,Abstract Summary of consensus: 1.,The use of opioids in cancer pain:, The criteria for selecting analgesics for pain treatment in the elderly include, but are not limited to, overall efficacy, overall side-effect profile, onset of action, drug interactions, abuse potential, and practical issues, such as cost and availability of the drug, as well as the severity and type of pain (nociceptive, acute/chronic, etc.). At any given time, the order of choice in the decision-making process can change. This consensus is based on evidence-based literature (extended data are not included and chronic, extended-release opioids are not covered). There are various driving factors relating to prescribing medication, including availability of the compound and cost, which may, at times, be the main driving factor. The transdermal formulation of buprenorphine is available in most European countries, particularly those with high opioid usage, with the exception of France; however, the availability of the sublingual formulation of buprenorphine in Europe is limited, as it is marketed in only a few countries, including Germany and Belgium. The opioid patch is experimental at present in U.S.A. and the sublingual formulation has dispensing restrictions, therefore, its use is limited. It is evident that the population pyramid is upturned. Globally, there is going to be an older population that needs to be cared for in the future. This older population has expectations in life, in that a retiree is no longer an individual who decreases their lifestyle activities. The "baby-boomers" in their 60s and 70s are "baby zoomers"; they want to have a functional active lifestyle. They are willing to make trade-offs regarding treatment choices and understand that they may experience pain, providing that can have increased quality of life and functionality. Therefore, comorbidities,including cancer and noncancer pain, osteoarthritis, rheumatoid arthritis, and postherpetic neuralgia,and patient functional status need to be taken carefully into account when addressing pain in the elderly. World Health Organization step III opioids are the mainstay of pain treatment for cancer patients and morphine has been the most commonly used for decades. In general, high level evidence data (Ib or IIb) exist, although many studies have included only few patients. Based on these studies, all opioids are considered effective in cancer pain management (although parts of cancer pain are not or only partially opioid sensitive), but no well-designed specific studies in the elderly cancer patient are available. Of the 2 opioids that are available in transdermal formulation,fentanyl and buprenorphine,fentanyl is the most investigated, but based on the published data both seem to be effective, with low toxicity and good tolerability profiles, especially at low doses. 2.,The use of opioids in noncancer-related pain:, Evidence is growing that opioids are efficacious in noncancer pain (treatment data mostly level Ib or IIb), but need individual dose titration and consideration of the respective tolerability profiles. Again no specific studies in the elderly have been performed, but it can be concluded that opioids have shown efficacy in noncancer pain, which is often due to diseases typical for an elderly population. When it is not clear which drugs and which regimes are superior in terms of maintaining analgesic efficacy, the appropriate drug should be chosen based on safety and tolerability considerations. Evidence-based medicine, which has been incorporated into best clinical practice guidelines, should serve as a foundation for the decision-making processes in patient care; however, in practice, the art of medicine is realized when we individualize care to the patient. This strikes a balance between the evidence-based medicine and anecdotal experience. Factual recommendations and expert opinion both have a value when applying guidelines in clinical practice. 3.,The use of opioids in neuropathic pain:, The role of opioids in neuropathic pain has been under debate in the past but is nowadays more and more accepted; however, higher opioid doses are often needed for neuropathic pain than for nociceptive pain. Most of the treatment data are level II or III, and suggest that incorporation of opioids earlier on might be beneficial. Buprenorphine shows a distinct benefit in improving neuropathic pain symptoms, which is considered a result of its specific pharmacological profile. 4.,The use of opioids in elderly patients with impaired hepatic and renal function:, Functional impairment of excretory organs is common in the elderly, especially with respect to renal function. For all opioids except buprenorphine, half-life of the active drug and metabolites is increased in the elderly and in patients with renal dysfunction. It is, therefore, recommended that,except for buprenorphine,doses be reduced, a longer time interval be used between doses, and creatinine clearance be monitored. Thus, buprenorphine appears to be the top-line choice for opioid treatment in the elderly. 5.,Opioids and respiratory depression:, Respiratory depression is a significant threat for opioid-treated patients with underlying pulmonary condition or receiving concomitant central nervous system (CNS) drugs associated with hypoventilation. Not all opioids show equal effects on respiratory depression: buprenorphine is the only opioid demonstrating a ceiling for respiratory depression when used without other CNS depressants. The different features of opioids regarding respiratory effects should be considered when treating patients at risk for respiratory problems, therefore careful dosing must be maintained. 6.,Opioids and immunosuppression:, Age is related to a gradual decline in the immune system: immunosenescence, which is associated with increased morbidity and mortality from infectious diseases, autoimmune diseases, and cancer, and decreased efficacy of immunotherapy, such as vaccination. The clinical relevance of the immunosuppressant effects of opioids in the elderly is not fully understood, and pain itself may also cause immunosuppression. Providing adequate analgesia can be achieved without significant adverse events, opioids with minimal immunosuppressive characteristics should be used in the elderly. The immunosuppressive effects of most opioids are poorly described and this is one of the problems in assessing true effect of the opioid spectrum, but there is some indication that higher doses of opioids correlate with increased immunosuppressant effects. Taking into consideration all the very limited available evidence from preclinical and clinical work, buprenorphine can be recommended, while morphine and fentanyl cannot. 7.,Safety and tolerability profile of opioids:, The adverse event profile varies greatly between opioids. As the consequences of adverse events in the elderly can be serious, agents should be used that have a good tolerability profile (especially regarding CNS and gastrointestinal effects) and that are as safe as possible in overdose especially regarding effects on respiration. Slow dose titration helps to reduce the incidence of typical initial adverse events such as nausea and vomiting. Sustained release preparations, including transdermal formulations, increase patient compliance.,, [source] High intrathecal bupivacaine for severe pain in the head and neckACTA ANAESTHESIOLOGICA SCANDINAVICA, Issue 7 2009C. LUNDBORG Background: Severe pain in the head and neck is associated with a lowered quality of life and conventional pain therapy often does not provide adequate relief. The aims of this study were to investigate the efficacy, pain relief, benefits and adverse effects of intracisternal or high cervical (IHC) administration of bupivacaine in patients with severe pain in the head, neck and face regions. Methods: Between 1990 and 2005, 40 patients (age 27,84 years) were treated with continuous IHC infusions of bupivacaine for various non-cancer (n=15) or cancer-related (n=25) refractory pain conditions (duration 1 month,18 years) in the head, neck, mouth and shoulder regions. Results: Visual analogue scale scores and opioid requirements decreased markedly after the start of the treatment and remained lowered throughout the study. No tachyphylaxis for bupivacaine was observed. Major side effects were few and most often transient. Most patients showed unchanged or improved mobility. There was no mortality, neurological damage or other severe events attributable to procedures in the study protocol. Conclusion: For patients with severe and refractory pain in areas innervated by cranial and upper cervical nerves, cervical high spinal analgesia can provide safe and effective analgesia. [source] Soldiers With Musculoskeletal InjuriesJOURNAL OF NURSING SCHOLARSHIP, Issue 3 2008Bonnie M. Jennings Purpose: To describe Soldiers' (e.g., U.S. Army personnel) perspectives of the effect of musculoskeletal injuries. Design: Data were collected in the summer of 2003 using a prospective survey design. The survey was mailed to active duty Soldiers on modified work plans because of musculoskeletal injuries. These Soldiers were assigned to one Army installation in the US. Methods: Responses to the survey questions were analyzed using descriptive statistics. The numerous handwritten comments were evaluated qualitatively. Findings: Injuries most often involved the back and knees (18% each). At least 47% of the injuries were work related. Injuries interfered with Soldiers' abilities to perform military tasks such as road marching (80%) and organized physical training (69%). Although many respondents indicated they were not experiencing pain, at least some Soldiers reported mild pain for each of 19 anatomic locations. Severe pain was reported most often for the lower back (21%). In their written comments, Soldiers expressed a sense of frustration with their injuries, the healthcare system and providers, and their unit leaders. Conclusions: Healthcare personnel are challenged to better manage Soldiers with musculoskeletal injuries and expedite their return to full duty. Unit leaders are challenged to create work environments that focus on injury prevention and allow injured Soldiers time to heal. Clinical Relevance: The Soldiers in this study were often engaged in physically challenging work or sports activities when injured. Because people outside the Army engage in similar activities (e.g., construction workers, endurance athletes), the findings from this study might be applicable to nonmilitary communities. Additionally, with the number of Reserve and National Guard Soldiers currently on active duty, civilian nurses might be caring for Soldiers with musculoskeletal injuries. [source] Women's narratives on experiences of work ability and functioning in fibromyalgiaMUSCULOSKELETAL CARE, Issue 1 2010Merja Sallinen MSc Abstract Background:,Fibromyalgia is a significant health problem for women of working age. However, little is known about the long-term effects of fibromyalgia in everyday life or on work ability. Methods:,A narrative interview study was conducted to explore the experiences of work ability and functioning of patients with a long history of fibromyalgia. Twenty women, aged 34,65 years, were purposively chosen for the interviews, to reach a wide range of patients with different social and professional backgrounds. Results:,Four types of experience concerning work ability were identified in the narratives: confusion, coping with fluctuating symptoms, being ,in between' and being over the edge of exhaustion. Severe pain and fatigue symptoms, combined with a demanding life situation and ageing, seemed to lead to substantial decrease in work ability and functioning over the long term. In the narratives, vocational rehabilitation or adjustments to work tasks were rarely seen or were started too late to be effective. Conclusions:,Exploring the life stories of women with fibromyalgia can reveal the perceived causes and consequences of fibromyalgia related to work ability or disability, which can be utilized in developing client-centred rehabilitation approaches and effective interventions to support work ability and avoid premature retirement in fibromyalgia patients. Copyright © 2009 John Wiley & Sons, Ltd. [source] Efficacy and tolerability of diclofenac potassium sachets in acute postoperative dental pain: a placebo-controlled, randomised, comparative study vs. diclofenac potassium tabletsINTERNATIONAL JOURNAL OF CLINICAL PRACTICE, Issue 3 2006C. M. Hofele Summary This double-blind, randomised, parallel-group trial compared the analgesic efficacy of single 50 mg doses of diclofenac potassium sachets and tablets with placebo in 184 patients with moderate/severe pain after third molar extraction. The primary efficacy variable was the average pain reduction from baseline during the first 2-h postdose, using a visual analogue scale (VAS). During the first 2-h postdose, sachets and tablets significantly reduced pain (p < 0.05) vs. placebo with an incremental benefit seen for sachets over tablets (p < 0.05). Onset of analgesic effect (VAS) was at 30 min for sachets and 45 min for tablets. Pain reduction vs. placebo (VAS) was maintained for 8 h for sachets and tablets (p < 0.05). VAS-findings were confirmed by pain relief and intensity verbal scale assessments. Fewer patients remedicated vs. placebo. No safety issues were identified. This study demonstrates that both diclofenac potassium sachets and tablets offer patients suffering from acute pain conditions an effective treatment with incremental analgesic benefits seen for sachets. [source] OVERCOMING BARRIERS TO PAIN RELIEF IN THE CARIBBEANDEVELOPING WORLD BIOETHICS, Issue 3 2009CHERYL MACPHERSON ABSTRACT This paper examines pain and pain relief in the Caribbean, where pain is widely perceived as an unavoidable part of life, and where unnecessary suffering results from untreated and under treated pain. Barriers to pain relief in the Caribbean include patient and family attitudes, inadequate knowledge among health professionals and unduly restrictive regulations on the medical use of opioids. Similar barriers exist all over the world. This paper urges medical, nursing and public health professionals, and educators to examine attitudes towards pain and pain relief and to work towards making effective pain relief and palliation more accessible. It recommends that i) health professionals and officials be better educated about pain, palliation and opioids, ii) regulatory restrictions be updated in light of clinical and scientific evidence, iii) opioid procurement policies be adjusted to facilitate increased medical use, iv) medical charts and records be modified to routinely elicit and document patients levels of pain, and v) educational campaigns be developed to inform the public that moderate and severe pain can be safely relieved at the end of life and other stages of life. The professional, respectful, and beneficent response to patients in pain is to provide rapid and aggressive pain relief or to urgently consult a pain or palliative specialist. When a health system hinders such efforts the ethical response is to identify, facilitate and advocate for overcoming barriers to improvement. [source] Intranasal fentanyl in 1,3-year-olds: A prospective study of the effectiveness of intranasal fentanyl as acute analgesiaEMERGENCY MEDICINE AUSTRALASIA, Issue 5 2009Joanne Cole Abstract The primary objective of the present study was to determine the effectiveness of intranasal fentanyl analgesia in children aged 1,3 years with acute moderate to severe pain presenting to the ED. We also aimed to gather information on the safety and acceptability of intranasal fentanyl in this age group. Two paediatric ED enrolled children aged 1,3 years, with acute moderate or severe pain. Intranasal fentanyl was administered (1.5 µg/kg) via a mucosal atomiser device using a 50 µg/mL solution of fentanyl. Physiological parameters (heart rate, respiratory rate, oxygen saturations and level of consciousness) were measured at regular intervals. Objective pain assessment was completed using the Faces, Legs, Arms, Cry, Consolability (FLACC) score. Forty-six children presenting with acute moderate to severe pain were included. The median FLACC score before intranasal fentanyl administration was 8 (interquartile range [IQR] 5,10), decreasing to 2 (IQR 0,4) 10 min post fentanyl (P < 0.0001) and 0 (IQR 0,2) 30 min post fentanyl (P < 0.0001). A clinically significant decrease in FLACC scores was seen in 93% of children 10 min post fentanyl administration and 98% of children 30 min post fentanyl. Intranasal fentanyl delivery using a mucosal atomiser was well tolerated by all children. There were no adverse drug reactions or adverse events detected. Intranasal fentanyl is an effective, safe and well-tolerated mode of analgesia for children aged 1,3 years with moderate to severe pain. [source] Use of web-based data collection to evaluate analgesic administration and the decision for surgery in horses with colicEQUINE VETERINARY JOURNAL, Issue 4 2005N. A. WHITE Summary Reasons for performing study: There is no current veterinary information with regard to data entry on a website. We therefore completed a prospective study on use of analgesics in relation to the need for abdominal surgery using a web-based survey instrument. Objectives: To establish an internet-based data entry system that could be used to record prospective data on horses with colic. Hypothesis: Failure of horses to respond to the initial administration of an analgesic is an indicator of the need for abdominal surgery. Methods: A survey was developed to determine if the response to administration of an analgesic during a veterinarian's first examination of a horse with colic was related to the need for surgery. Veterinarians were contacted via AAEP and ECN listservs requesting submission of cases using a log-in system at a data entry website. The survey was completed by submission of a data entry page. Results: Twenty-seven veterinarians submitted details of 119 cases of colic, 28 of which required surgery. The need for surgery was significantly associated with moderate or severe pain observed during the first examination compared to mild or no pain, and with constant pain or return of pain after administration of one or more analgesics and the need to administer a second analgesic treatment. Abnormal findings on rectal examination were not associated with the need for surgery, whereas total absence or decrease of intestinal sounds was significantly related to the odds that surgery was needed. The web-based data collection was successful in collecting all data points on the survey for each case. Conclusions: This study reinforced veterinarians' use of response to therapy as a way to determine the need for abdominal surgery. Potential relevance: When a specific diagnosis has not been made, lack of response or resumption of colic after analgesic administration should be considered as an indicator of the need for surgery. Web-based collection of data allows veterinary practitioners to participate in clinical research by providing prospective data. [source] Gemcitabine induced digital ischaemia and necrosisEUROPEAN JOURNAL OF CANCER CARE, Issue 3 2010A. HOLSTEIN md HOLSTEIN A., BÄTGE R. & EGBERTS E.-H. (2010) European Journal of Cancer Care19, 408,409 Gemcitabine induced digital ischaemia and necrosis A 70-year-old woman presented with a 7-day history of severe pain, paresthesia, oedema, acrocyanosis and punctate haemorrhagic lesions on her fingertips. The complaints began 2 days after the second cycle of a first-line chemotherapy consisting of cisplatin or carboplatin, and gemcitabine due to advanced urothelial carcinoma. At the fingertips of both hands, haemorrhagic and partly ulcerative lesions were found; these were attributed to vascular toxicity of gemcitabine. Therapeutically sympathicolysis by bilateral blockade of the brachial plexus was performed, accompanied by intravenous administration of the prostacyclin analog iloprost, fractionated heparin subcutaneously and oral therapy with corticosteroids and aspirin. Digital amputation could be avoided. Acral ischemia is a rare but probably underreported adverse effect of gemcitabine therapy and a potential source of misdiagnosis. [source] Parents and Practitioners Are Poor Judges of Young Children's Pain SeverityACADEMIC EMERGENCY MEDICINE, Issue 6 2002Adam J. Singer MD Objective: Visual analog pain scales are reliable measures in older children and adults; however, pain studies that include young children often rely on parental or practitioner assessments for measuring pain severity. The authors correlated patient, parental, and practitioner pain assessments for young children with acute pain. Methods: This was a prospective, descriptive study of a convenience sample of 63 emergency department patients aged 4-7 years, with acute pain resulting from acute illness or painful invasive procedures. A trained research assistant administered a structured pain survey containing demographic and historical features to all parents/guardians. Children assessed their pain severity using a validated ordinal scale that uses five different faces with varying degrees of frowning (severe pain) or smiling (no pain). Each face was converted to a numeric value from 0 (no pain) to 4 (severe pain). Parents and practitioners independently assessed their child's pain using a validated 100-mm visual analog scale (VAS) marked "most pain" at the high end. Pairwise correlations between child, parent, and practitioner pain assessments were performed using Spearman's or Pearson's test as appropriate. The association between categorical data was assessed using ,2 tests. Results: Sixty-three children ranging in age from 4 to 7 were included. Mean age (±SD) was 5.7 (±1.1); 42% were female. Fifty-seven successfully completed the face scale. The distribution of the children's scores was 0-17%, 1-9%, 2-30%, 3-14%, and 4-30%. Mean parental and practitioner scores (±SD) on the VAS were 61 (±26) mm and 37 (±26) mm, respectively (maximal = 100 mm). Correlation between child and parent scores was 0.47 (p < 0.001). Correlation between child and practitioner scores was 0.08 (p = 0.54). Correlation between parent and practitioner scores was 0.04 (p = 0.001). Conclusions: There is poor agreement between pain ratings by children, parents, and practitioners. It is unclear which assessment best approximates the true degree of pain the child is experiencing. [source] Early Intervention With Almotriptan Improves Sustained Pain-free Response in Acute MigraineHEADACHE, Issue 10 2003Ninan T. Mathew MD Objective.,To determine whether treatment of migraine with almotriptan, when pain intensity is mild, improves 1- and 2-hour pain-free and sustained pain-free rates compared with treatment when pain intensity is moderate or severe. Methods.,This was a post hoc analysis derived from an open-label, multicenter, long-term study of the safety, tolerability, and efficacy of almotriptan 12.5 mg. Patients who met International Headache Society criteria for migraine with or without aura were eligible. Patients were instructed to take a single dose of almotriptan 12.5 mg at the onset of a migraine attack. Rescue medication could be taken if migraine pain had not disappeared at 2 hours. A second dose of almotriptan 12.5 mg could be taken if head pain recurred within 24 hours of the initial dose. Patients reported the intensity of pain at baseline and at 1 and 2 hours postmedication using a 4-point scale: no pain, mild, moderate, or severe pain. They also reported recurrence of pain (return of moderate or severe pain within 2 to 24 hours of taking the study medication) and use of rescue medication. Rescue medication consisted of supplemental analgesics taken for pain relief at 2 to 24 hours postdose. Ergotamines and other 5-HT1B/1D agonists were excluded as rescue medications. Based on these patient-reported end points, sustained pain-free rates, defined as pain-free at 2 hours with no recurrence from 2 to 24 hours and no use of rescue medication, were calculated. Results.,A higher proportion of migraine attacks of mild intensity were pain-free at 1 hour (35.3%) compared with attacks of moderate or severe intensity (7.5%) (P < .001). Two-hour pain-free rates also were significantly higher with mild intensity pain (76.9%) compared to moderate or severe intensity (43.9%) (P < .001). In addition, recurrence rates and use of rescue medication were reduced when attacks were treated during mild pain. Recurrence was 12.9% for mild pain versus 25.0% for moderate or severe pain (P < .001), and use of rescue medication was 9.4% for mild pain versus 17.2% for moderate or severe pain (P < .001). Sustained pain-free rates were nearly twice as high when attacks were treated during mild intensity pain (66.6%) compared with attacks treated during moderate or severe pain (36.6%) (P < .001). Conclusion.,Treatment with almotriptan 12.5 mg during migraine attacks of mild pain intensity improves 1- and 2-hour pain-free and sustained pain-free responses. [source] Clinical Benefits of Early Triptan Therapy for MigraineHEADACHE, Issue 2002Julio Pascual MD Although triptans have been proven effective for acute treatment of migraine, reserving them for moderate or severe pain may produce suboptimal pain relief and higher rates of recurrence. Recent evidence indicates that early intervention at the onset of pain improves outcomes. Post hoc analysis of a long-term, open-label European study of almotriptan 12.5 mg found that the percentage of attacks rendered pain-free at 2 hours was significantly greater when patients treated mild pain (84%) than when the intervention occurred during moderate or severe pain (53%). A similar pattern emerged with respect to the consistency of pain relief, with a significant advantage for early intervention (88% versus 56%, respectively). A difference in favor of early intervention was also seen with respect to recurrence, need for rescue medication, and adverse events. The recurrence rate was significantly lower in patients treating mild pain (28%) than in those delaying treatment until the pain became moderate or severe (33%), which suggests that achieving pain freedom results in less recurrence. These results were generally replicated in post hoc analysis of a subgroup of patients from a randomized, placebo-controlled trial (the Spectrum Study) of oral sumatriptan 50 mg in migraineurs. This analysis demonstrated that with early intervention, pain was less likely to intensify, fewer attacks required redosing, more attacks remained pain-free 24 hours postdose, and normal function returned more quickly. In sum, early intervention with triptans can improve outcomes, avoiding much of the pain and disability associated with treating moderate or severe attacks. [source] The efficacy of pain control following nonsurgical root canal treatment using ibuprofen or a combination of ibuprofen and acetaminophen in a randomized, double-blind, placebo-controlled studyINTERNATIONAL ENDODONTIC JOURNAL, Issue 8 2004K. A. Menhinick Abstract Aim, To compare ibuprofen, to an ibuprofen/acetaminophen combination in managing postoperative pain following root canal treatment. It is hypothesized that the drug combination will provide more postoperative pain relief than the placebo or ibuprofen alone. Methodology, Patients presenting at the Texas A&M Baylor College of Dentistry's graduate endodontic clinic, experiencing moderate to severe pain, were considered potential candidates. Fifty-seven patients were included based on established criteria. Following administration of local anaesthesia, a pulpectomy was performed. The patients were administered a single dose of either: (i) placebo; (ii) 600 mg ibuprofen; or (iii) 600 mg ibuprofen and 1000 mg of acetaminophen. Patients recorded pain intensity following treatment on a visual analogue scale and a baseline four-point category pain scale as well as pain relief every hour for the first 4 h then every 2 h thereafter for a total of 8 h. A general linear model (GLM) analysis was used to analyse the outcome. Results, Based upon the GLM analysis, there was a significant difference between the ibuprofen and the combination drug group, and between placebo and combination drug groups. There was no significant difference between the placebo and the ibuprofen. Conclusion, The results demonstrate that the combination of ibuprofen with acetaminophen may be more effective than ibuprofen alone for the management of postoperative endodontic pain. [source] Symptomatic treatment of osteoarthritis: paracetamol or NSAIDs?INTERNATIONAL JOURNAL OF CLINICAL PRACTICE, Issue 2004Karel PAVELKA MD SUMMARY The clinical management of osteoarthritis (OA) is today symptomatic, its main goals being relief of pain and improvement of function. Therapy should be multimodal and composed of non-pharmacological, pharmacological and, if necessary, surgical procedures. Paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs) are evidence-based drugs for the symptomatic relief of OA. Newly published comparative studies have shown that NSAIDs are more effective than paracetamol , in contrast to studies from the early 1990s. Some studies have documented that more severe pain and the presence of inflammation can predict better response from NSAIDs than from paracetamol; on the other hand other studies have not confirmed this. Patient preference studies have shown that patients favour NSAIDs, but up to 40% consider paracetamol at least as effective as NSAIDs. With regard to efficacy, safety and cost, the majority of new guidelines recommend paracetamol as a first-choice analgesic for patients with OA of the knee or hip, and the use of NSAIDs only in cases of inadequate effect of paracetamol and especially in the presence of inflammation. There is much evidence that OA is a phasic disease and it may be that NSAIDs are useful during identifiable periods of inflammatory activity and can be avoided at other times. The concept of the short-term use of NSAIDs during flares and the use of a simple analgesic in the long term seems to be the best variant for the majority of patients with optimal benefit/risk and cost-effectiveness. [source] Nicolau Syndrome: three cases and reviewINTERNATIONAL JOURNAL OF DERMATOLOGY, Issue 11 2006Kelli Luton MD Nicolau Syndrome, also known as livedo-like dermatitis (LLD) or embolia cutis medicamentosa (ECM), is an infrequent complication following intramuscular and intra-articular injection of various drugs. This rare entity is characterized by severe pain and erythematous-ecchymotic reticular lesions at the injection site, which in many cases lead to necrotic ulcers and scarring. We report three cases of Nicolau Syndrome following injection of diclofenac, penicillin G, and cyanocobalamin. [source] Necrotizing fasciitis: delay in diagnosis results in loss of limbINTERNATIONAL JOURNAL OF DERMATOLOGY, Issue 10 2006Rajat Varma MD A 58-year-old man presented to the Emergency Room with a 1-day history of severe pain in the left lower extremity preceded by several days of redness and swelling. He denied any history of trauma. He also denied any systemic symptoms including fever and chills. His past medical history was significant for diabetes, hypertension, deep vein thrombosis, and Evans' syndrome, an autoimmune hemolytic anemia and thrombocytopenia, for which he was taking oral prednisone. Physical examination revealed a warm, tender, weeping, edematous, discolored left lower extremity. From the medial aspect of the ankle up to the calf, there was an indurated, dusky, violaceous plaque with focal areas of ulceration (Fig. 1). Figure 1. Grossly edematous lower extremity with well-demarcated, dusky, violaceous plaque with focal ulceration Laboratory data revealed a white blood cell count of 6.7 × 103/mm3[normal range, (4.5,10.8) × 103/mm3], hemoglobin of 11.5 g/dL (13.5,17.5 g/dL), and platelets of 119 × 103/mm3[(140,440) × 103/mm3]. Serum electrolytes were within normal limits. An ultrasound was negative for a deep vein thrombosis. After the initial evaluation, the Emergency Room physician consulted the orthopedic and dermatology services. Orthopedics did not detect compartment syndrome and did not pursue surgical intervention. Dermatology recommended a biopsy and urgent vascular surgery consultation to rule out embolic or thrombotic phenomena. Despite these recommendations, the patient was diagnosed with "cellulitis" and admitted to the medicine ward for intravenous nafcillin. Over the next 36 h, the "cellulitis" had advanced proximally to his inguinal region. His mental status also declined, and he showed signs of septic shock, including hypotension, tachycardia, and tachypnea. Vascular surgery was immediately consulted, and the patient underwent emergency surgical debridement. The diagnosis of necrotizing fasciitis was then made. Tissue pathology revealed full-thickness necrosis through the epidermis with subepidermal splitting. Dermal edema was also present with a diffuse neutrophilic infiltrate (Fig. 2). This infiltrate extended through the fat into the subcutaneous tissue and fascia. Tissue cultures sent at the time of surgery grew Escherichia coli. Initial blood cultures also came back positive for E. coli. Anaerobic cultures remained negative. Figure 2. Necrotic epidermis with subepidermal splitting. Marked dermal edema with mixed infiltrate and prominent neutrophils. Hematoxylin and eosin: original magnification, ×20 After surviving multiple additional debridements, the patient eventually required an above-the-knee amputation due to severe necrosis. [source] Autohemicastration in a man without schizophreniaINTERNATIONAL JOURNAL OF UROLOGY, Issue 5 2001Akiko Murota-Kawano Abstract A 52-year-old unmarried bag craftsman was admitted to East Tokyo Metropolitan Hospital because of a large scrotal hematoma. He had accidentally hit his right testis against the edge of a desk early the previous morning. He had resected his right testis with scissors to release from severe pain 30 min after the accident. He had sutured the scrotal incision with two stitches of string by himself. At the emergency operation 36 h after the self-mutilation, we removed a hematoma weighing 283 g and ligated the cut end of the right spermatic cord after adequate debridement. He was diagnosed by a psychiatrist as having slightly low intelligence without psychotic disorder or drug abuse. [source] Childrens'and Adolescents'Use of Diaries for Sickle Cell PainJOURNAL FOR SPECIALISTS IN PEDIATRIC NURSING, Issue 4 2001Virginia Egbert Maikler ISSUES AND PURPOSE. To evaluate the characteristics of vaso-occlusive episodes, home management of pain and its impact on the daily activities, and a diary as a method of data collection. DESIGN AND METHODS. Forty-six adolescents and 75 children were asked to complete daily diaries during the intervention period of a larger study. RESULTS. Mild pain was recorded 95% of the time; moderate pain, 3%; and severe pain, 1%. The pattern and location of pain varied greatly. Adolescents used more interventions than did children. When pain intensity was mild, 80% of the children/adolescents maintained school, social, and home activities, but decreased play/sport activities. When pain intensity was high, they decreased their participation in all activities. PRACTICE IMPLICATIONS. Sickle cell pain episodes are unpredictable and highly variable. Diaries can enhance children's and adolescents'documentation and communication about their pain experiences. [source] Item selection and content validity of the Critical-Care Pain Observation Tool for non-verbal adultsJOURNAL OF ADVANCED NURSING, Issue 1 2009Céline Gélinas Abstract Title.,Item selection and content validity of the Critical-Care Pain Observation Tool for non-verbal adults. Aim., This paper is a report of the item selection process and evaluation of the content validity of the Critical-Care Pain Observation Tool for non-verbal critically ill adults. Background., Critically ill patients experience moderate to severe pain in the intensive care unit. While critical care clinicians strive to obtain the patient's self-report of pain, many factors compromise the patient's ability to communicate verbally. Pain assessment methods often need to match the communication capabilities of the patient. In non-verbal patients, observable behavioural and physiological indicators become important indices for pain assessment. Method., A mixed method study design was used for the development of the Critical-Care Pain Observation Tool in 2002,2003. More specifically, a four-step process was undertaken: (1) literature review, (2) review of 52 patients' medical files, (3) focus groups with 48 critical care nurses, and interviews with 12 physicians, and (4) evaluation of content validity with 17 clinicians using a self-administered questionnaire. Results., Item selection was derived from different sources of information which were convergent and complementary in their content. An initial version of the Critical-Care Pain Observation Tool was developed including both behavioural and physiological indicators. Because physiological indicators received more criticism than support, only the four behaviours with content validity indices >0·80 were included in the Critical-Care Pain Observation Tool: facial expression, body movements, muscle tension and compliance with the ventilator. Conclusion., Item selection and expert opinions are relevant aspects of tool development. While further evaluation is planned, the Critical-Care Pain Observation Tool appears as a useful instrument to assess pain in critically ill patients. [source] A Novel Interdisciplinary Analgesic Program Reduces Pain and Improves Function in Older Adults After Orthopedic SurgeryJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 1 2009R. Sean Morrison MD OBJECTIVES: To examine the effect of a multicomponent intervention on pain and function after orthopedic surgery. DESIGN: Controlled prospective propensity score,matched clinical trial. SETTING: New York City acute rehabilitation hospital. PARTICIPANTS: Two hundred forty-nine patients admitted to rehabilitation after hip fracture repair (n=51) or hip (n=64) or knee (n=134) arthroplasty. INTERVENTION: Pain assessment at rest and with physical therapy (PT) by staff using numeric rating scales (1 to 5). Physician protocols for standing analgesia and preemptive analgesia before PT were implemented on the intervention unit. Control unit patients received usual care. MEASUREMENTS: Pain, analgesic prescribing, gait speed, transfer time, and percentage of PT sessions completed during admission. Pain and difficulty walking at 6, 12, 18, and 24 weeks after discharge. RESULTS: In multivariable analyses intervention patients were significantly more likely than controls to report no or mild pain at rest (66% vs 49%, P=.004) and with PT (52% vs 38%, P=.02) on average for the first 7 days of rehabilitation, had faster 8-foot-walk times on Days 4 (9.3 seconds vs 13.2 seconds, P=.02) and 7 (6.9 vs 9.2 seconds, P=.02), received more analgesia (23.6 vs 15.6 mg of morphine sulfate equivalents per day, P<.001), were more likely to receive standing orders for analgesia (98% vs 48%, P<.001), and had significantly shorter lengths of stay (10.1 vs 11.3 days, P=.005). At 6 months, intervention patients were less likely than controls to report moderate to severe pain with walking (4% vs 15%, P=.02) and that pain did not interfere with walking (7% vs 18%, P=.004) and were less likely to be taking analgesics (35% vs 51%, P=.03). CONCLUSION: The intervention improved postoperative pain, reduced chronic pain, and improved function. [source] Musculoskeletal Pain and Risk for Falls in Older Disabled Women Living in the CommunityJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 4 2002Suzanne G. Leveille PhD OBJECTIVES: To determine whether musculoskeletal pain increased risk for falls in older women with disabilities. DESIGN: Prospective population-based cohort study. SETTING: The city and county of the eastern area of Baltimore. PARTICIPANTS: One thousand two women aged 65 and older, participants in the Women's Health and Aging Study, representing the one-third of older women who were living at home with disabilities, followed semiannually for 3 years beginning in 1991. MEASUREMENTS: Pain was categorized into four groups according to severity and location. Widespread pain was defined as pain in the upper and lower extremities and in the axial skeletal region, with moderate to severe pain in at least one region (, 4 on a 10-point numeric rating scale, 10 = excruciating pain). Moderate to severe lower extremity pain that did not meet criteria for widespread pain was the next category. The reference category was no pain or mild pain in one site. The additional category of "other pain" was pain that did not fit into the other three groups. The occurrence of falls and fall-related injuries were assessed at each interview. RESULTS: Of the 940 women who participated in at least one follow-up examination, 39% fell in first year; of the survivors, 36% fell in Year 2, and 39% in Year 3. After adjusting for several major risk factors for falls, women with widespread pain had an increased likelihood of falling during follow-up (adjusted odds ratio (AOR) = 1.66, 95% confidence interval (CI) = 1.25,2.21) compared with those with no or mild pain in only one musculoskeletal site. Women who had other musculoskeletal pain but not widespread pain or lower extremity pain also had an increased risk of falls (AOR = 1.36, 95% CI = 1.02,1.82). Among women with musculoskeletal pain, risk for falls was lower in those who used daily analgesic medication. Risk for recurrent falls and self-reported fractures due to falls was also elevated in women with musculoskeletal pain, most consistently in women with widespread pain. CONCLUSIONS: Musculoskeletal pain, particularly widespread pain, is a substantial risk factor for falls in older women with disabilities. These findings add an important dimension to our understanding of the multifactorial processes leading to falls in older persons. J Am Geriatr Soc 50:671,678, 2002. [source] A comparison of pain and health-related quality of life between two groups of cancer patients with differing average levels of painJOURNAL OF CLINICAL NURSING, Issue 5 2003Barbro Boström MNSc Summary ,,A study was performed to describe and compare pain and Health-Related Quality of Life (HRQOL) in two groups of cancer patients in palliative care as well as to describe the correlation between pain and HRQOL. ,,Forty-seven patients with mild average pain [Visual Analogue Scale (VAS) , 3] and 28 patients with moderate to severe average pain (VAS > 3) were included. Medical Outcomes Study Short Form (SF-36) was used to evaluate HRQOL, pain intensity levels were measured with the VAS on Pain-O-Meter. ,,Compared to patients with mild pain, patients with moderate to severe pain had statistically significant, higher pain intensity for the items ,pain at time of interview', ,worst pain in the past 24 hours' and ,pain interrupting sleep.' They also had the lowest scores of the SF-36 dimensions: physical functioning, role-physical, and bodily pain. Patients with moderate to severe pain had statistically significant, fewer months of survival. There were statistically significant positive correlations between pain items and negative correlation between pain and SF-36 dimensions. ,,The conclusion is that pain has a negative impact on HRQOL, especially on physical health and that pain increases towards the final stages of life. Even if patients have to endure symptoms such as fatigue and anxiety during their short survival time, dealing with pain is an unnecessary burden, which can be prevented. [source] Refusing analgesics: using continuous improvement to improve pain management on a surgical wardJOURNAL OF CLINICAL NURSING, Issue 6 2002Eloise C. J. Carr BSc, PGCEA Summary , ,Despite advances in pain control many patients experience moderate to severe pain whilst in hospital. Contributory factors include inadequate assessment and documentation of pain, as well as patient and professional misconceptions. , ,A 28-bedded surgical ward in a District General Hospital in the South of England was the setting for the project. A small preliminary audit of pain on this ward indicated that some patients experienced postoperative pain, which was not effectively controlled. A ,continuous improvement' framework was used to increase understanding of the problem and identify an aim for the project, which was to reduce the number of patients refusing analgesics when offered by nurses. , ,An audit to ascertain how many patients refused analgesia revealed that, of 133 patients offered, 93 (70%) refused. Using the ,Model for Improvement' (Langley et al., 1996) a number of changes were introduced, including a patient information sheet, regular documented pain assessment and an innovative staff education programme. To evaluate if the changes in practice had been successful, further audit data were collected from 167 patients. Sixty-three (44%) accepted analgesics, indicating a significant decrease in the number refusing (P = 0.005). , ,This small project demonstrated that continuous improvement methodology can improve the management of pain and quality of care for patients. Such an approach brings practitioner and patient into meaningful understanding and offers solutions which are realistic, achievable and sustainable over time. Despite finite resources and increased pressure on staff it is possible to motivate people when they feel they have ownership and change is meaningful. , ,Continuous improvement methods offer an exciting, feasible, patient-centred approach to improving care. [source] High intrathecal bupivacaine for severe pain in the head and neckACTA ANAESTHESIOLOGICA SCANDINAVICA, Issue 7 2009C. LUNDBORG Background: Severe pain in the head and neck is associated with a lowered quality of life and conventional pain therapy often does not provide adequate relief. The aims of this study were to investigate the efficacy, pain relief, benefits and adverse effects of intracisternal or high cervical (IHC) administration of bupivacaine in patients with severe pain in the head, neck and face regions. Methods: Between 1990 and 2005, 40 patients (age 27,84 years) were treated with continuous IHC infusions of bupivacaine for various non-cancer (n=15) or cancer-related (n=25) refractory pain conditions (duration 1 month,18 years) in the head, neck, mouth and shoulder regions. Results: Visual analogue scale scores and opioid requirements decreased markedly after the start of the treatment and remained lowered throughout the study. No tachyphylaxis for bupivacaine was observed. Major side effects were few and most often transient. Most patients showed unchanged or improved mobility. There was no mortality, neurological damage or other severe events attributable to procedures in the study protocol. Conclusion: For patients with severe and refractory pain in areas innervated by cranial and upper cervical nerves, cervical high spinal analgesia can provide safe and effective analgesia. [source] Febrile Ulceronecrotic Mucha-habermann Disease: a Rare, Severe VariantJOURNAL OF CUTANEOUS PATHOLOGY, Issue 1 2006Michele M. Thompson A 56 year old Hispanic man presented with extensive ulcerative skin lesions, involving his lower trunk, groin and upper legs, severe pain and a temperature of 38.7 degrees Celsius. He was admitted to the Medical Intensive Care Unit for empiric intravenous antibiotics. Several biopsies were performed. In the following days his condition worsened and ulcerative lesions involved nearly all of his skin. Previous biopsies were consistent with pityriasis lichenoides et varioliformis acuta (PLEVA), however, neither this, nor others in the histological differential diagnosis, fit his severe and worsening clinical picture. Histology revealed vacuolar alteration with dyskeratotic keratinocytes and a superficial perivascular mixed infiltrate of lymphocytes and eosinophils. There was confluent parakeratosis containing neutrophils, and a diminished granular layer with pallor in the upper portion of the spinous layer. Immunofluorescence studies were negative. These findings were consistent with PLEVA. A clinical diagnosis of febrile ulceronecrotic Mucha-Habermann disease was made. Febrile ulceronecrotic Mucha-Habermann disease is a rare and severe variant of PLEVA characterised by high fever and papulonecrotic skin lesions. Twenty-five cases have been previously reported. We present the clinical and histological findings in this unusual clinical presentation. [source] Do health care professionals underestimate severe pain more often than mild pain?JOURNAL OF EVALUATION IN CLINICAL PRACTICE, Issue 5 2005Statistical pitfalls using a data simulation model Abstract Rationale, When comparing patients' pain ratings with the health care professional's conception of pain assessed by Visual Analogue Scales (VAS) ratings, statistical problems arise. Method and Result, In this data simulation study we have shown that the tendency for health care professionals to underestimate severe pain compared with mild pain is probably not attributed to difficulties in judging severe pain more often than mild but the result of professionals having a different and often narrower distribution of their ratings compared with patients. [source] Evaluation of hernia repair operation in Child,Turcotte,Pugh class C cirrhosis and refractory ascitesJOURNAL OF GASTROENTEROLOGY AND HEPATOLOGY, Issue 3 2007Joo Kyung Park Abstract Background and Aim:, Abdominal wall hernia is a common feature of decompensated liver cirrhosis and frequently causes life-threatening complications or severe pain. However, there have been no data reported on postoperative mortality, hepatic functional deterioration and recurrence rate according to Child,Turcotte,Pugh (CTP) class and to the presence of refractory ascites. Methods:, The study population comprised 53 liver cirrhosis patients who underwent hernia repair operation. Comparisons were made of 30-day mortality among the different CTP classes, and between those with or without refractory ascites. Liver function was also analyzed just before the operation, in the immediate postoperative period, and in the remote postoperative period. Results:, Seventeen patients were in CTP class A, 27 patients in class B, and 9 patients in class C. The median follow-up duration was 24 months. There was single 30-day postoperative mortality in class C, and no CTP class deterioration after 30 days of operation. There was no mortality or recurrences in 17 patients with medically refractory ascites. The difference in 30-day mortality according to CTP class and the presence of refractory ascites did not show statistical significance (P = 0.17 and 0.97, respectively). Conclusion:, Hernia operation could be done safely in CTP class A and B with low rate of recurrences, and there was no definitive increase in the operative risk in class C. In addition, refractory ascites did not increase operative risk and recurrence rate. Therefore, surgical repair might be recommended even in patients with refractory ascites and poor hepatic function to prevent life-threatening complications or severe pain. [source] Predictors of health-care consultation for recurrent abdominal pain among urban schoolchildren in MalaysiaJOURNAL OF GASTROENTEROLOGY AND HEPATOLOGY, Issue 2 2001Christopher Chiong Meng Boey Abstract Aim: To look at the predictors of health-care consultation for recurrent abdominal pain among urban schoolchildren in Malaysia. Methods: Recurrent abdominal pain was defined as ,at least three episodes of abdominal pain, severe enough to affect a child's activities over a period longer than 3 months. A health-care consulter was defined as a child who had been brought to see a doctor regarding recurrent abdominal pain at least once in the past year. Children aged between 9 and 15 years were randomly chosen from schools in the city of Petaling Jaya, given questionnaires to fill in and interviewed to determine whether they fulfilled the above criteria for having symptoms of recurrent abdominal pain and for being a consulter. Bivariate analysis and multiple logistic regression analysis were performed on the data obtained. Results: One hundred and forty-three (9.61%) children fulfilled the criteria for recurrent abdominal pain out of a total of 1488 schoolchildren interviewed. There were 65 (45.5%) consulters and 78 (54.5%) non-consulters. Among the consulters, the male to female ratio was 1:1.4, while among the non-consulters, the ratio was 1:1.1. On bivariate analysis, the Chinese had a significantly lower likelihood to consult a doctor (P = 0.02), while the other two races did not show any increase in consultation (Malays, P = 0.08; Indians, P = 0.21). Among those with severe pain, there was a significantly higher prevalence of consulters (P < 0.01). Furthermore, those whose sleep was interrupted by abdominal pain were more likely to consult (P < 0.01). Children who had consulted a doctor were more likely to be missing school because of abdominal pain (P < 0.01). Following multiple logistic regression analysis, ethnicity was no longer a significant predictor. Conclusions: Approximately 45.5% of schoolchildren with recurrent abdominal pain in an urban setting were brought to see a doctor. Predictors of recent health-care consultation were school absence, pain severity and interruption of sleep caused by abdominal pain. [source] | ||||||||||||||||||||||||||||||||||||||||