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Kinds of Patients. Selected AbstractsTranscatheter versus Surgical Closure of Secundum Atrial Septal Defect in Adults: Impact of Age at Intervention.CONGENITAL HEART DISEASE, Issue 3 2007A Concurrent Matched Comparative Study Abstract Objectives., To compare the short- and mid-term outcomes of surgical (SUR) vs. transcatheter closure of secundum atrial septal defect (ASD) using Amplatzer septal occluder (ASO) in adults with a very similar spectrum of the disease; and to identify predictors for the primary end point. Design., Single-center, concurrent comparative study. Surgically treated patients were randomly matched (2:1) by age, sex, date of procedure, ASD size, and hemodynamic profile. Setting., Tertiary referral center. Patients., One hundred sixty-two concurrent patients with ASD submitted to ASO (n = 54) or SUR closure (n = 108) according with their preferences. Main Outcome Measures., Primary end point was a composite index of major events including failure of the procedure, important bleeding, critical arrhythmias, serious infections, embolism, or any major cardiovascular intervention-related complication. Predictors of these major events were investigated. Results., Atrial septal defects were successfully closed in all patients, and there was no mortality. The primary event rate was 13.2% in ASO vs. 25.0% in SUR (P = .001). Multivariate analysis showed that higher rate of events was significantly associated with age >40 years; systemic/pulmonary output ratio <2.1; and systolic pulmonary arterial pressure >50 mm Hg; while in the ASO group the event rate was only associated with the ASD size (>15 cm2/m2; relative risk = 1.75, 95% confidence interval 1.01,8.8). There were no differences in the event-free survival curves in adults with ages <40 years. Conclusions., The efficacy for closure ASD was similar in both groups. The higher morbidity observed in SUR group was observed only in the patients submitted to the procedure with age >40 years. The length of hospital stay was shorter in the ASO group. Surgical closure is a safe and effective treatment, especially in young adults. There is certainly nothing wrong with continuing to do surgery in countries where the resources are limited. [source] The Influence of Congenital Heart Disease on Psychological Conditions in Adolescents and Adults after Corrective SurgeryCONGENITAL HEART DISEASE, Issue 6 2006Kambiz Norozi MD ABSTRACT Objective., The present study was designed to examine psychological characteristics of adolescents and adults with operated congenital heart disease (ACHD). Particularly it was to be examined whether cardiological parameters may be associated with subjectively perceived impairments and measures of psychological distress. Patients., A total of 361 men (209) and women (152) between 14 and 45 years underwent medical checkups and an interview on psychological and sociological issues. Setting., The medical part consisted of a complete cardiological examination including the classification of residual symptoms according to the New York Heart Association (NYHA), and spiroergometry. The Brief Symptom Inventory was used for depicting current psychological and somatic symptoms. These were assessed on 9 subscales: somatization, obsession-compulsion, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism. Results., The analyses revealed statistically significant associations between the degree of NYHA class and psychological symptoms. These findings could not be reproduced for physical fitness as measured by peak oxygen consumption. No gender differences emerged. Conclusions., Our results suggest that psychological measures of ACHD are not directly dependent on their physical fitness or on the severity of residual symptoms. Instead, patients' subjective appraisal of their disease severity and the conviction to what degree one can depend on the operated heart may be important determinants of psychological states. [source] Verapamil-sensitive Ventricular Tachycardia in an InfantCONGENITAL HEART DISEASE, Issue 3 2006Christopher Snyder MD ABSTRACT Patients., We report on a 6-month-old patient with a right bundle, superior axis tachycardia at 197 beats per minute. The tachycardia was unresponsive to adenosine, propranolol, flecainide, or amiodarone, or synchronized cardioversion. Overdrive atrial pacing terminated the tachycardia and since initiating verapamil, no recurrences of his tachycardia have occurred. Conclusions., If an infant presents with a right bundle, superior axis ventricular tachycardia unresponsive to multiple antiarrhythmic medications and synchronized cardioversion, but responsive to overdrive atrial pacing, one must consider verapamil-sensitive ventricular tachycardia and initiate appropriate therapy. [source] Factors associated with development of stroke long-term after myocardial infarction: experiences from the LoWASA trialJOURNAL OF INTERNAL MEDICINE, Issue 2 2005J. HERLITZ Abstract. Objective., To describe factors associated with the development of stroke during long-term follow-up after acute myocardial infarction (AMI) in the LoWASA trial. Patients., Patients who had been hospitalized for AMI were randomized within 42 days to receive either warfarin 1.25 mg plus aspirin 75 mg daily or aspirin 75 mg alone. Design., The study was performed according to the probe design, that is open treatment and blinded end-point evaluation. Setting., The study was performed in 31 hospitals in Sweden. The mean follow-up time was 5.0 years with a range of 1.7,6.7 years. Results., In all, 3300 patients were randomized in the trial, of which 194 (5.9%) developed stroke (4.2% nonhaemorrhagic, 0.5% haemorrhagic and 1.3% uncertain. The following factors appeared as independent predictors for an increased risk of stroke: age, hazard ratio and 95% confidence interval (1.07; 1.05,1.08), a history of diabetes mellitus (2.4; 1.8,3.4), a history of stroke (2.3; 1.5,3.5), a history of hypertension (2.0; 1.5,2.7) and a history of smoking (1.5;1.1,2.0). Most of these factors were also predictors of a nonhaemorrhagic stroke whereas no predictor of haemorrhagic stroke was found. Conclusion., Risk indicators for stroke long-term after AMI were increasing age, a history of either diabetes mellitus, stroke, hypertension or smoking. [source] The incidence and survival of acute de novo leukaemias in Estonia and in a well-defined region of western Sweden during 1982,1996: a survey of patients aged ,65 yearsJOURNAL OF INTERNAL MEDICINE, Issue 1 2004E. Luik Abstract. Objectives., To compare the incidence and survival of acute de novo leukaemias with particular reference to political/socio-economic and environmental factors in two neighbouring countries over the three 5-year periods (1982,1996). Patients., The present report covers only patients diagnosed when aged ,65 years. Setting., A well-defined area of Sweden, the so-called Western Swedish Health Care Region and Estonia. Population-wise, the western Swedish Region and Estonia are very similar; area-wise they are also well comparable. Results., The number of acute de novo leukaemias was quite dissimilar in the two countries (Estonia, n = 137, Sweden, n = 354). The age standardized incidence rates regarding the total number of acute de novo leukaemias was 5.31 per 100 000 inhabitants/year for Estonia and 7.99 for Sweden, this difference being statistically significant. However, the difference was merely attributable to incidence rates as regards acute myeloblastic leukaemias (AML); on the contrary, differences as regards acute lymphoblastic leukaemias (ALL) and non-classifiable, undifferentiated or biphenotypic acute leukaemias (uAL) were negligible. The relative survival for the total material of patients was significantly higher for Swedish when compared with Estonian patients (P < 0.001). Thus, the relative survival for the total material of patients aged ,65 years in Estonia at 1 year was 8.5% and at 3 years 3.5% respectively. The corresponding figures for the Swedish patients were considerably higher, 22.7 and 7.7% respectively. This difference, however, applied only for patients with AML (P < 0.001), whereas the results for patients with ALL and uAL were equally dismal. Conclusion., The results clearly reflect how political and socio-economic factors may influence the survival of acute leukemia patients in two neighbouring countries. [source] Longitudinal Treatment Outcomes for Geriatric Patients with Chronic Non-Cancer Pain at an Interdisciplinary Pain Rehabilitation ProgramPAIN MEDICINE, Issue 9 2010Kathleen M. Darchuk PhD Abstract Objective., This study examined depression, pain catastrophizing, psychosocial functioning, and physical and emotional health attributes for geriatric patients admitted to an interdisciplinary pain rehabilitation center compared with middle and younger age groups. Design., Quasi-experimental time series. Setting., Interdisciplinary pain rehabilitation center at a tertiary referral medical center. Patients., In total, 411 patients with chronic non-cancer pain completed the pain rehabilitation program from October 2004 to April 2006. Patients were divided into three groups based on age: older (ages 60+; n = 78); middle-age (ages 40,59; n = 230) and younger (ages 18,39; n = 141). Intervention., A 3-week outpatient interdisciplinary pain rehabilitation program based on a cognitive-behavioral model that incorporates opioid withdrawal. Outcome Measures., The Multidimensional Pain Inventory (MPI), Short Form-36 Health Status Questionnaire (SF-36), Pain Catastrophizing Scale (PCS), and Center for Epidemiological Studies-Depression Scale (CES-D) were administered at admission, discharge, and 6 months following treatment. The frequency of patients using opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), and benzodiazepines at each assessment point were compared. Results., Older patients reported reduced depression, catastrophizing, pain severity, and pain interference (P < 0.001) at discharge and 6 months follow-up. Older patients also reported increased perceived control, and physical and social functioning at discharge and follow-up (P < 0.001). Improvement in older patients was comparable in magnitude to that of middle-age patients on all variables, whereas younger patients exhibited greater improvement on four variables. Significant reductions in analgesic use were observed in all groups. Conclusion., Interdisciplinary pain rehabilitation incorporating opioid withdrawal can improve long-term psychological, social and physical functioning for geriatric chronic pain patients. [source] Negligible Analgesic Tolerance Seen with Extended Release Oxymorphone: A Post Hoc Analysis of Open-Label Longitudinal DataPAIN MEDICINE, Issue 8 2010R. Norman Harden MD Abstract Objective., To examine the development of analgesic tolerance in patients on oxymorphone extended-release (OxymER). Design.,Post hoc analysis of data from a previously conducted prospective 1 year multi-center open-label extension study in which patients were able to titrate as needed. Patients., Sample of 153 hip and knee osteoarthritis (OA) subjects on OxymER. Primary analyses were limited to study completers (n = 62) due to the large amount of missing data for the noncompleters (n = 91). Outcome Measures., Main outcome measures included OxymER doses (pill counts) and pain intensity ratings using a visual analog scale at monthly visits. Results., There were significant dose increases from weeks 1 to 2 and 2 to 6 (P < 0.05). Doses stabilized around week 6, suggesting the completion of what we defined as "titration." Both doses and pain ratings were stable when this titration phase was excluded from the analysis (P = 0.751; P = 0.056, respectively). Only 28% of the patients had any dose changes following this titration. While there was a significantly greater dose at week 52 compared with week 10 (P = 0.010), the increase in dose became insignificant after excluding four subjects who required two dose increases (P = 0.103). Conclusions., The results showed that most of the titration/dose stabilization changes occurred within the first 10 weeks. A minority (28%) of subjects required dosage increases after this (defined) titration period. Pain reports stabilized statistically after 2 weeks. The findings of this post hoc analysis suggest a lack of opioid tolerance in the majority (72%) of these OA patients who completed this study following a defined titration period on OxymER. Summary., This post hoc analysis of oxymorphone ER consumption in osteoarthritis pain vs pain report showed that most dose changes occurred during an initial "titration period" as defined. Following this titration few subjects increased dose and analgesia remained stable. These findings suggest a lack of longitudinal opioid tolerance in the majority of those OA subjects who completed the trial. [source] Chronic Pain after Spinal Cord Injury: Results of a Long-Term StudyPAIN MEDICINE, Issue 7 2010Ehsan Modirian MD Abstract Objective., Chronic pain after spinal cord injury (SCI) is a common and considerable complication and may continue for a long time. Design., During a 2-year survey, 13.9 ± 3.0 years after injury, a total of 1,295 war-related spinal cord injury survivors were thoroughly examined by physical and rehabilitation specialists and all relevant data, consisting of type and site of pain as well as exacerbating or palliative factors, were recorded. Patients., The mean age of the survivors was 35.9 ± 7.2; 98.5% were male and 1.5% were female. The level of injury was cervical in 9.3%, thoracic in 67%, and lumbosacral in 23.7%, with 8.1% tetraplegic and 89.1% paraplegic. About 89.8% had complete spinal cord injuries and 10.2% had incomplete spinal cord injuries, based on sensory and motor testing. Results., Spinal cord related pain was reported in 64.9% of the subjects; 8.8% reported a history of pain but had no complaint at the time of examination, and 26.3% had never suffered from any pain. Patients suffering from lumbar spinal cord injury reported the highest percent of pain perception, with pain detected in 83.5% of these patients. Common sites of reported pain were the distal lower extremities (46.5%), proximal lower extremities (40.9%), pelvic girdle (24.5%), and upper limbs (5.7%). Conclusion., Spinal cord injury-related pain interferes with daily activities of patients and significantly influences their quality of life. [source] Pain in Long-Term Breast Cancer Survivors: Frequency, Severity, and ImpactPAIN MEDICINE, Issue 7 2010Mark P. Jensen PhD Abstract Objective., To better understand the severity and impact of pain in women who are breast cancer survivors. Design., Cross-sectional survey. Setting., Cancer wellness clinic. Patients., Two hundred fifty-three women with a history of early-stage breast cancer who had completed therapy and were without evidence of disease. Interventions., None. Outcome Measures., A survey that included questions about cancer history, pain, sleep problems, and physical and psychological functioning. Results., About half of the participants (117 or 46%) reported some pain, although most rated its intensity as mild. Both average and worst pain ratings showed significant associations with physical functioning (rs, ,0.48 and ,0.43, respectively), severity of sleep problems (rs, 0.31 and 0.30), and psychological functioning (rs, ,0.27 and ,0.24). Age (with younger participants slightly more likely to report pain) and history of antiestrogen therapy showed nonsignificant trends to predict the presence of pain. Conclusions., The study findings provide new and important knowledge regarding the severity and impact of pain in female breast cancer survivors. The results indicate that clinicians should assess pain regularly in breast cancer survivors and treat this pain when indicated. The findings also support the need for research to determine whether improved pain management would result in improved quality of life for women with a history of breast cancer. [source] The Role of Central Hypersensitivity in the Determination of Intradiscal Mechanical Hyperalgesia in Discogenic PainPAIN MEDICINE, Issue 5 2010Juerg Schliessbach PhD Abstract Objective., The primary aim of the present study was to investigate whether there is a relationship between central hypersensitivity (assessed by pressure pain thresholds of uninjured tissues) and intradiscal pain threshold during discography. The secondary aim was to test the hypothesis that peripheral noxious stimulation dynamically modulates central hypersensitivity. Patients., Twenty-four patients with positive provocation discography were tested for central hypersensitivity by pressure algometry before and after the intervention with assessments of pressure pain detection and tolerance thresholds. Intradiscal pain threshold was assessed by measuring intradiscal pressure at the moment of pain provocation during discography. Correlation analyses between intradiscal pain threshold and pressure algometry were made. For the secondary aim, pressure algometry data before and after discography were compared. Results., Significant correlation with intradiscal pain threshold was found for pressure pain detection threshold at the toe (regression coefficient: 0.03, P = 0.05) and pressure pain tolerance thresholds at the nonpainful point at the back (0.02, P = 0.024). Tolerance threshold at the toe was a significant predictor for intradiscal pain threshold only in multiple linear regression (0.036, P = 0.027). Detection as well as tolerance thresholds significantly decreased after discography at the painful and the nonpainful point at the back, but not at the toe. Conclusions., Central hypersensitivity may influence intradiscal pain threshold, but with a modest quantitative impact. The diagnostic value of provocation discography is therefore not substantially impaired. Regional, but not generalized central hypersensitivity is dynamically modulated by ongoing peripheral nociceptive input. [source] Immediate Benefits of a Brief 10-Minute Exercise Protocol in a Chronic Pain Population: A Pilot StudyPAIN MEDICINE, Issue 4 2010Amy Burleson Sullivan PsyD Abstract Objective., Determining the acute effects of a brief, 10-minute exercise protocol on pain, mood, and perceived exertion. Patients., Twenty-eight subjects who were admitted to the Cleveland Clinic Chronic Pain Rehabilitation Program (CPRP), and who were capable of completing an experimenter-designed and controlled treadmill protocol were included in this pilot study. Methods., A within-group repeated measure analysis was used to compare 28 subjects admitted to the Cleveland Clinic CPRP. Measures of heart rate were obtained using the Nellcor Oximax, pulse oximeter; measures of mood and pain were obtained using a 0,10 Likert scale, and perceived exertion measured with a visual analog scale. Each measure was taken pre- and post-10-minute exercise protocol. Results., The brief exercise protocol was associated with self-report of immediate antidepressant and anxiolytic effects. Additionally, after the 3-week CPRP, self-reports in perceived exertion decreased. Brief exercise was not found to have an acute analgesic effect. Conclusion., This preliminary research revealed a temporal association of improvement in self-rated anxiety and depression, following a brief exercise protocol, and over the course of 3 weeks leads to decreased perceived exertion. Therefore suggesting that brief exercise is a safe, nonpharmacologic strategy for immediately improving mood, and has further implications for mortality risk. [source] Leech Therapy for Symptomatic Relief of Cancer PainPAIN MEDICINE, Issue 3 2010Mehmet Emin Kalender MD Abstract Objective., Most patients with advanced stage cancer report moderate to severe pain. The leech (Hirudo medicinalis) is commonly used in traditional medicine for relief of localized pain. Design., We report a case of severe pain related to advanced stage cancer successfully treated by self-applied leeches. Setting and Patients., A 62-year-old male patient with synchronous renal cell carcinoma and leiomyosarcoma was admitted with severe pain in the lumbar region. The pain was refractory to radiotherapy, and systemic and epidural analgesic infusion. Results., Two months the patient came to the clinic in good condition free of pain. The patient reported outpatient self-treatment with seven leeches to the lumbar region in the interim that resulted in complete healing of pain. Conclusions., This is the first report indicating possible activity of leeches in cancer pain. [source] Assessment of Celiac Plexus Block and Neurolysis Outcomes and Technique in the Management of Refractory Visceral Cancer PainPAIN MEDICINE, Issue 1 2010Michael A. Erdek MD ABSTRACT Objective., To assess demographic and clinical factors associated with celiac plexus neurolysis outcomes. Design., Retrospective clinical data analysis. Setting., A tertiary care, academic medical center. Patients., Forty-four patients with terminal visceral (mostly pancreatic) cancer who failed conservative measures. Interventions., Fifty celiac plexus alcohol neurolytic procedures done for pain control after a positive diagnostic block. Outcome Measures., A successful treatment was predefined as >50% pain relief sustained for ,1 month. The following variables were analyzed for their association with treatment outcome: age, gender, duration of pain, origin of tumor, opioid dose, type of radiological guidance used, single- vs double-needle approach, type of block (e.g., antero- vs retrocrural), immediate vs delayed neurolysis, volume of local anesthetic employed for both diagnostic and neurolytic blocks, and use of sedation. Results., Those variables correlated with a positive outcome included lower opioid dose and the absence of sedation. Strong trends for a positive association with outcome were found for the use of computed tomography (vs fluoroscopy), and using <20 mL of local anesthetic for the diagnostic block. Conclusions., Celiac plexus neurolysis may provide intermediate pain relief to a significant percentage of cancer sufferers. Both careful selection of candidates based on clinical variables, and technical factors aimed at enhancing the specificity of blocks may lead to improved outcomes. [source] Postdural Puncture Headache in Complex Regional Pain Syndrome: A Retrospective Observational StudyPAIN MEDICINE, Issue 8 2009Alexander G. Munts MD ABSTRACT Objective., To describe the unusual course of postdural puncture headache (PDPH) after pump implantation for intrathecal baclofen (ITB) administration in patients with complex regional pain syndrome (CRPS)-related dystonia. Design., Case series based on data collected from 1996 to 2005. Setting., Movement disorders clinic, university hospital. Patients., A total of 54 patients with CRPS-related dystonia who were treated with ITB. Results., A high incidence (76%) and prolonged course (median 18 days, range 2 days to 36 months) of PDPH was found. Radionuclide studies performed in two patients with long-lasting symptoms (12,16 months) did not reveal cerebrospinal fluid (CSF) leakage. In patients without signs of CSF leakage (N = 38), epidural blood patches administered in 24 patients were effective in 54%, while ketamine infusions administered in six patients were effective in 67%. Conclusions., Our observations may suggest that other mechanisms besides intracranial hypotension play a role in the initiation and maintenance of PDPH in CRPS and stimulate new directions of research on this topic. [source] Pain Symptom Profiles in Persons with Spinal Cord InjuryPAIN MEDICINE, Issue 7 2009Yenisel Cruz-Almeida MSPH ABSTRACT Objective., Persistent pain is a common consequence of spinal cord injury. A patient-specific assessment that combines both the identification of pain symptoms and psychosocial factors is needed for a tailored treatment approach. The aim of the study was to define pain symptom profiles and to determine their relationship with psychosocial factors in persons with spinal cord injury. Design., Face-to-face interview and examination. Setting., VA Medical Center and Miami Project to Cure Paralysis, Miami, Florida. Patients., Persons with spinal cord injury (135 men and 21 women) provided detailed descriptions of 330 neuropathic pains. Outcome Measures., The American Spinal Injury Impairment Scale, pain history and measures of pain interference, life satisfaction, locus of control, social support and depression. Results., The exploratory factor analyses and regression analyses revealed three distinct symptom profiles: 1) aching, throbbing pain, aggravated by cold weather and constipation predicted by a combination of chance locus of control and lower levels of life satisfaction; 2) stabbing, penetrating, and constant pain of high intensity predicted by a combination of pain interference, localized pain, powerful others locus of control and depressed mood; and 3) burning, electric, and stinging pain aggravated by touch and muscle spasms predicted by pain interference. Conclusions., Although these results need to be replicated in other spinal cord injury samples, our findings suggest that pain symptom profiles may be a useful way to further characterize pain in a comprehensive assessment strategy. [source] Intravenous Magnesium for Complex Regional Pain Syndrome Type 1 (CRPS 1) Patients: A Pilot StudyPAIN MEDICINE, Issue 5 2009Susan Collins MSc ABSTRACT Objectives., To explore the feasibility of intravenous magnesium administration as a potential candidate intervention for a large size trial in Complex Regional Pain Syndrome Type 1 (CRPS 1). Design., Randomized clinical trial. Setting., Outpatient pain clinic. Patients., Ten CRPS 1 patients. Interventions., Eight patients received 70 mg/kg magnesium sulphate infusions in 4 hours for 5 days. For blinding purposes, 2 patients received equal amount NaCl 0.9% solutions (data not analyzed or presented). Interventions were accompanied by standardized physical therapy. Outcome Measures., Pain was assessed using an 11-point Box scale (three times daily for a week) and the McGill Pain Questionnaire. Skin sensitivity was measured with the Semmes Weinstein Monofilaments, (other) impairments with the Impairment Level Sumscore. In addition, functional limitations (Radboud Skills Questionnaire, questionnaire rising and sitting down) and quality of life (Short Form-36 [SF-36], EuroQol) were evaluated. Assessments were performed at baseline, 1, 3, 6, and 12 weeks after intervention. Results., Mild systemic side effects were experienced and the infusions were locally well tolerated. Pain was significantly reduced at all follow up compared with baseline (T1: P = 0.01, T3: P = 0.04, T6: P = 0.02, T12: P = 0.02). McGill sensory subscale improved significantly at T1 (number of words chosen: P = 0.03 and pain rating index: P = 0.03). Impairment level (P = 0.03) and quality of life (EuroQol P = 0.04, SF-36 physical P = 0.01) were significantly improved at T12. No improvement was found for skin sensitivity and functional limitations. Conclusion., Intravenous magnesium significantly improved pain, impairment and quality of life and was well tolerated. The results of this pilot study are encouraging and suggest that magnesium IV as a treatment in CRPS 1 should be further explored in a large size formal trial design. [source] Impact of Chronic Musculoskeletal Pathology on Older Adults: A Study of Differences between Knee OA and Low Back PainPAIN MEDICINE, Issue 4 2009Natalia E. Morone MD ABSTRACT Objectives., The study aimed to compare the psychological and physical characteristics of older adults with knee osteoarthritis (OA) vs those of adults with chronic low back pain (CLBP) and to identify psychological and physical predictors of function as measured by gait speed. Design., Secondary data analysis. Method and Patients., Eighty-eight older adults with advanced knee OA and 200 with CLBP who had participated in separate randomized controlled trials were selected for this study. Measures., Inclusion criteria for both trials included age ,65 and pain of at least moderate intensity that occurred daily or almost every day for at least the previous 3 months. Psychological constructs (catastrophizing, fear avoidance, self-efficacy, depression, affective distress) and physical measures (comorbid medical conditions, pain duration, pain severity, pain related interference, self-rated health) were obtained. Results., Subjects with CLBP had slower gait (0.88 m/s vs 0.96 m/s, P = 0.002) and more comorbid conditions than subjects with knee pain (mean 3.36 vs 1.97, P < 0.001). All the psychological measures were significantly worse in the CLBP group except the Multidimensional Pain Inventory,Affective Distress score. Self-efficacy, pain severity, and medical comorbidity burden were associated with slower gait regardless of the location of the pain. Conclusions., Older adults with chronic pain may have distinct psychological and physical profiles that differentially impact gait speed. These findings suggest that not all pain conditions are the same in their psychological and physical characteristics and may need to be taken into consideration when developing treatment plans. [source] Are Spirituality and Religiosity Resources for Patients with Chronic Pain Conditions?PAIN MEDICINE, Issue 2 2009Arndt Büssing Prof Dr ABSTRACT Objective., We studied whether or not spirituality/religiosity is a relevant resource for patients with chronic pain conditions, and to analyze interrelations between spirituality/religiosity (SpREUK Questionnaire; SpREUK is an acronym of the German translation of "Spiritual and Religious Attitudes in Dealing with Illness"), adaptive coping styles that refer to the concept of locus of disease control (AKU Questionnaire; AKU is an acronym of the German translation of "Adaptive Coping with Disease"), life satisfaction, and appraisal dimensions. Patients., In a multicenter cross-sectional study, 580 patients with chronic pain conditions were enrolled. Results., We found that the patients relied on both external powerful sources of disease control and on internal powers and virtues, while Trust in Higher Source (intrinsic religiosity) or Illness as Chance (reappraisal) were valued moderately; Search for Meaningful Support/Access (spiritual quest orientation) was of minor relevance. Stepwise regression analyses revealed that the internal sources of disease control, such as Conscious and Healthy Way of Living and Positive Attitudes, were (apart from the religious denomination) the strongest predictors of patients' reliance on spirituality/religiosity. Both behavioral styles were rated significantly lower in patients who regarded themselves as neither religious nor spiritual. Positive disease interpretations such as Challenge and Value were clearly associated with a spiritual quest orientation and intrinsic religiosity. Conclusion., The associations between spirituality/religiosity, positive appraisals. and internal adaptive coping strategies indicate that the utilization of spirituality/religiosity goes far beyond fatalistic acceptance, but can be regarded as an active coping process. The findings support the need for further research concerning the contributions of spiritual coping in adjustment to chronic pain. [source] The Effect of Preemptive Analgesia in Postoperative Pain Relief,A Prospective Double-Blind Randomized StudyPAIN MEDICINE, Issue 1 2009Seetharaman Hariharan MD ABSTRACT Objective., To analyze the effect of infiltration of local anesthetics on postoperative pain relief. Design., Prospective randomized double-blind trial. Setting., University Teaching Hospital in Barbados, West Indies. Patients., Patients undergoing total abdominal hysterectomy. Interventions., Patients were randomly allocated into one of four groups according to the wound infiltration: 1) preoperative and postoperative 0.9% saline; 2) preoperative saline and postoperative local anesthetic mixture (10 mL 2% lidocaine added to 10 mL 0.5% bupivacaine); 3) preoperative local anesthetic mixture and postoperative saline; and 4) preoperative and postoperative local anesthetic mixture. Both patients and investigators were blinded to the group allocation. All patients received pre-incision tenoxicam and morphine, standardized anesthesia, and postoperative morphine by patient-controlled analgesia. Outcome measures., The amount of morphine used and the intensity of pain as measured by visual analog pain scale were recorded at 1, 2, 3, 4, 8, 12, 24, and 48 hours postoperatively. Results., Eighty patients were studied with 20 in each group. Total dose of morphine used by patients who received preoperative and postoperative local anesthetic infiltration was lesser compared to other groups, although there was no statistically significant difference. Similarly, there was no difference in the intensity of pain between any groups. Conclusions., Local anesthetic infiltration before and/or after abdominal hysterectomy does not reduce the intensity of postoperative pain and analgesic requirements. [source] Role of Biphosphonates and Lymphatic Drainage Type Leduc in the Complex Regional Pain Syndrome (Shoulder,Hand Syndrome)PAIN MEDICINE, Issue 1 2009Andrea Santamato MD ABSTRACT Background., Complex regional pain syndrome (CRPS) is a clinical entity that has been termed in numerous ways in the last years. Clinically, CRPS describes an array of painful conditions that are characterized by a continuing (spontaneous and/or evoked) regional pain that is seemingly disproportionate in time or degree to the usual course of any known trauma or other lesion. The pain is regional and usually has a distal predominance of abnormal sensory, motor, sudomotor, vasomotor, and/or trophic findings. Design., Case report. Setting., University Medical Center. Patients., In this report, we described the case of a 68-year-old hemiplegic female affected by cerebrovascular accident that presented a clinical case of CRPS shoulder,hand syndrome (CRPS-SHS) at the right hand after a hemorrhagic stroke. Interventions., This report evaluated the effects of biphosphonates and lymphatic drainage type Leduc in CRPS-SHS. Outcome Measures., The pain level of the patients was measured with the visual analog scale. A scoring system for the clinical severity of CRPS-SHS, laboratory tests, and X-ray films were also performed. Results., We reported in this patient a great improvement of pain and edema of the right hand, with a significant reduction of bone demineralization. Conclusions., This combined treatment may be a viable alternative for this syndrome; however, further investigation is needed to determine its reproducibility in large case series. [source] A Prospective Controlled Study in the Prevalence of Posttraumatic Headache Following Mild Traumatic Brain InjuryPAIN MEDICINE, Issue 8 2008S. Faux FAFRM (RACP) FFPMANZCA ABSTRACT Objective., To establish the prevalence of post traumatic headache, persisting at 3 months following minor traumatic brain injury. Design., A prospective controlled study of patients admitted with a diagnosis of mild traumatic brain injury and matched orthopedic controls over 12 months during 2004. Setting., A level two inner city Emergency Department in Sydney, Australia. Patients., One hundred eligible sequential admissions with mild traumatic brain injury as defined by American Congress of Rehabilitation Medicine, 1993, and 100 matched minor injury controls with nondeceleration injuries. Interventions., Subjects were part of a study on prediction of postconcussive syndrome and had neuropsychological tests, balance test and pain recordings taken at the time of injury, at 1 month and at 3 months post injury. Outcome Measures., Main measures were the reporting of headache "worse than prior to the injury" and concordant with the definition of Posttraumatic Headache according to International Headache Society Classification of Headache Disorders 2003. Results., 15.34% of those with minor head injury continued to complain of perisistant posttraumatic headache at 3 months compared to 2.2% of the minor injury controls. Conclusions., To the authors' knowledge this is the first controlled prospective study in the prevalence of posttraumatic headache following mild traumatic brain injury. [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] Defining Patient-Centered, Multidimensional Success Criteria for Treatment of Chronic Spine PainPAIN MEDICINE, Issue 7 2008Jennifer L. Brown PhD ABSTRACT Objective., This study aimed to define patient-determined success criteria for treatment of chronic spine pain across four domains: pain, fatigue, emotional distress, and interference with daily activities. Patients., Seventy chronic spine pain patients were recruited from university-affiliated pain clinics. Design., The study design was longitudinal, with pretreatment and post-treatment assessments. Post-treatment assessment occurred approximately 2 months after treatment initiation. Outcome Measures., Participants completed the Patient-Centered Outcomes Questionnaire and Follow-Up Patient-Centered Outcomes Questionnaire. Results., At pretreatment, patient requirements for success were a 58% reduction in pain, 61% reduction in fatigue, 64% reduction in distress, and 66% reduction in interference. These criteria, derived using a direct-scaling approach, are more stringent than criteria developed using other methods. However, patients adjusted their success criteria over time by becoming less stringent, and they used these less stringent criteria to make global judgments of treatment success. Using a scale comparison approach, success criteria for pain were a raw change of 17.5 points (0,100 numerical rating scale) and percent change of 25%. Other criteria were 7.5 (11%) for fatigue, 5.0 (13%) for distress, and 9.5 (12%) for interference. Conclusions., Future research should validate these success criteria, particularly for the less studied domains of fatigue, distress, and interference, and investigate how these criteria evolve over the course of different treatments. [source] Facial Pain: A Possible Therapy with Stellate Ganglion BlockPAIN MEDICINE, Issue 7 2008Ilaria Salvaggio MD ABSTRACT Objective., The goal of the present study is to verify the efficacy of stellate ganglion block (SGB) in the treatment of facial pain that can be found in different pathological syndromes, and also to examine whether the efficacy is dependent upon when this therapy is administered. Patients., Fifty patients (divided into two randomized groups) with facial pain caused by traumas, iatrogenic issues, herpes zoster, or neurological pathologies participated in this study. Design and Interventions., The first group (N = 25) was treated with SGB produced by 10 administrations of 10 mg of levobupivacaine given every other day, followed by one administration per month for 6 months thereafter. The second group was treated with the drugs tramadol 100 mg/day and gabapentin 1800 mg/day orally for 6 months; during the 7th month they were given SGB therapy using the same methodology as that described for the first group. Results., Before treatment, the mean visual analog scale (VAS) pain score for the first group was 8.89; after the 10th block treatment it was just 0.2, and it remained at that reduced level for the 6th and 12th months. Before treatment, the mean VAS pain score for the second group was 8.83; after the 20th day on medication it was reduced to 4.1, after 6 months it was 5.7 and after 12 months it was 4.9. Conclusions., Our results indicate that patients must be treated with SGB therapy precociously to receive its full benefits. [source] Sleep-Disordered Breathing and Chronic Opioid TherapyPAIN MEDICINE, Issue 4 2008Lynn R. Webster MD ABSTRACT Objective., To assess the relation between medications prescribed for chronic pain and sleep apnea. Design., An observational study of chronic pain patients on opioid therapy who received overnight polysomnographies. Generalized linear models determined whether a dose relation exists between methadone, nonmethadone opioids, and benzodiazepines and the indices measuring sleep apnea. Setting., A private clinic specializing in the treatment of chronic pain. Patients., Polysomnography was sought for all consecutive (392) patients on around-the-clock opioid therapy for at least 6 months with a stable dose for at least 4 weeks. Of these, 147 polysomnographies were completed (189 patients declined, 56 were directed to other sleep laboratories by insurance companies, and data were incomplete for seven patients). Available data were analyzed on 140 patients. Outcome Measures., The apnea,hypopnea index to assess overall severity of sleep apnea and the central apnea index to assess central sleep apnea. Results., The apnea,hypopnea index was abnormal (,5 per hour) in 75% of patients (39% had obstructive sleep apnea, 4% had sleep apnea of indeterminate type, 24% had central sleep apnea, and 8% had both central and obstructive sleep apnea); 25% had no sleep apnea. We found a direct relation between the apnea,hypopnea index and the daily dosage of methadone (P = 0.002) but not to other around-the-clock opioids. We found a direct relation between the central apnea index and the daily dosage of methadone (P = 0.008) and also with benzodiazepines (P = 0.004). Conclusions., Sleep-disordered breathing was common in chronic pain patients on opioids. The dose,response relation of sleep apnea to methadone and benzodiazepines calls for increased vigilance. [source] Can the Neuropathic Pain Scale Discriminate Between Non-neuropathic and Neuropathic Pain?PAIN MEDICINE, Issue 2 2008David A. Fishbain MD, FAPA ABSTRACT Objectives., 1) To determine if the neuropathic pain scale (NPS) can be used to classify chronic pain patients (CPPs) as having primarily neuropathic vs non-neuropathic pain, and furthermore; 2) to determine what, if any, cut-off score can be used to reliably make this determination. Design., A total of 305 CPPs consecutive admissions to The Rosomoff Pain Center were administered the NPS and were assigned a diagnosis according to the physical examination and all available test results. CPPs with a diagnosis of chronic radiculopathy and spondylolysis/degenerative arthritis were segregated into two groups for the purposes of having a group representative of neuropathic pain (chronic radiculopathy) and non-neuropathic pain (spondylolysis/degenerative arthritis). Applying neuropathic pain criteria to each "of these two groups": a neuropathic pain "subtype" was identified within the chronic radiculopathy group; and, a non-neuropathic pain "subtype" was identified within the spondylolysis/degenerative arthritis group. This step was performed in order to assure that the CPPs selected for further analysis were truly representative of neuropathic and non-neuropathic pain. Discriminant function analysis was then employed to determine if NPS scoring could differentiate between these two "subtypes." Results from the discriminant function analysis model were utilized to derive an NPS cut-off score above which CPPs would be classified as having neuropathic pain. For the diagnoses of myofascial pain syndromes, spinal stenosis, epidural fibrosis, fibromyalgia, complex regional pain syndromes 1 and 2, and failed back surgery syndrome, a predicted NPS score was calculated and compared with the cut-off score. Setting., Multidisciplinary pain facility. Patients., Chronic pain patients. Results., The NPS appeared to be able to separate CPPs into neuropathic pain vs non-neuropathic pain subtypes. The derived cut-off score from the model was 5.53. Myofascial pain syndrome and spinal stenosis had predictive scores lower than this cut-off score at 3.81 and 4.26, respectively. Epidural fibrosis, fibromyalgia, complex regional pain syndromes 1 and 2, and failed back surgery syndrome had predictive scores higher than the cut-off score at 6.15, 6.35, 6.87, 9.34, and 7.19, respectively. Conclusions., The NPS appears to be able to discriminate between neuropathic and non-neuropathic pain. A debate is currently raging as to whether diagnoses, such as fibromyalgia and complex regional pain syndrome 1, can be classified as neuropathic. Our NPS cut-off score results suggest that these diagnoses may have a neuropathic pain component. The reliability and validity of our NPS method will need to be tested further in other neuropathic pain models, such as diabetic peripheral neuropathic pain. [source] Open-Label Exploration of an Intravenous Nalbuphine and Naloxone Mixture as an Analgesic Agent Following Gynecologic SurgeryPAIN MEDICINE, Issue 6 2007Assaf T. Gordon MD ABSTRACT Objective., The purpose of this series was to explore a 12.5:1 fixed-dose ratio of an intravenous nalbuphine and naloxone mixture (NNM) for use in patients following gynecologic surgery. Design and Patients., Open-label, nonrandomized case series. The first series was a dose-ranging investigation for 12 patients following elective total abdominal hysterectomy or myomectomy. In this series, fentanyl was used for intraoperative analgesia, and patients were assigned to a lower NNM (2.5 mg/0.2 mg) or to a higher NNM (5 mg/0.4 mg) dose group. The second series evaluated the fixed dose of 5 mg nalbuphine/0.4 mg naloxone for four patients undergoing ambulatory gynecologic procedures. In the second series, no opioid agents were administered intraoperatively to eliminate the possibility of mu-opioid reversal by naloxone postoperatively. Outcome Measures., Pain control was assessed using a Verbal Pain Scale (0,10). Vital signs, side effects, and adverse events were recorded to determine drug safety. Results., In the first series, there were no adverse events; however, each patient required rescue medication (either morphine or fentanyl). In the second series, two of the four patients reported a reduction in pain following drug administration and did not require any further analgesic agents in the 3-hour postoperative period. One patient had an asymptomatic lowering of heart rate after receiving the drug. Conclusion., Additional research of the unique combination therapy of nalbuphine and naloxone is warranted to further determine its potential clinical efficacy and safety. [source] Necessary and Discretionary Activities in Knee Osteoarthritis: Do They Mediate the Pain,Depression Relationship?PAIN MEDICINE, Issue 5 2007Patricia A. Parmelee PhD ABSTRACT Objective., This study examined direct vs indirect associations of pain and physical function with depression in 369 older adults with osteoarthritis (OA) of the knee. A key focus was the distinction of functional disability in necessary tasks (basic and instrumental activities of daily living) from discretionary, leisure activities. Design., A naturalistic longitudinal study examined effects of demographic variables, indicators of arthritis status, general health, pain, and several measures of functional disability upon depressive symptoms at baseline and 1 year later. Setting and Patients., Participants with diagnosed knee OA were recruited from rheumatological and general geriatric outpatient clinics, as well as public service announcements. Outcome Measure., Depressive symptoms, measured with the Center for Epidemiologic Studies Depression scale. Results., At baseline, the relationships of depression with functional disability and activity limitation were wholly mediated by pain. In contrast, activity participation was independently linked with depression, even controlling health and demographic variables. A 1-year follow-up revealed that depressive symptoms increased with increasing health problems, and with reduction in activity participation over time. Having and retaining favorite pastimes were also associated with reduced depressive symptomatology at baseline and follow-up, respectively. Conclusions., These data highlight the disease-specific nature of paths among depression, pain, and disability, and the importance of considering discretionary as well as necessary activities in evaluating effects of pain upon quality of life. [source] The Incidence of Spontaneous Epidural Abscess in Olmsted County from 1990 Through 2000: A Rare Cause of Spinal PainPAIN MEDICINE, Issue 4 2007Anne E. Ptaszynski MD ABSTRACT Objective., The primary objective of this study is to determine the population-based incidence of spontaneous epidural abscess. The secondary objective is to characterize the clinical course of patients with this rare infectious disease. Design., The records-linkage system of the Rochester Epidemiology Project was used to identify incident cases of spontaneous epidural abscess in residents of Olmsted County, Minnesota, USA, from 1990 through 2000. Setting., Tertiary referral medical center. Patients., All patients were residents of Olmsted County and had spontaneous epidural abscesses that were radiographically or surgically confirmed. Results., Eight patients, including six women, were identified and the mean age was 56 years (range, 40,80). The incidence of epidural abscess was 0.88 cases per 100,000 person-years (95% confidence interval, 0.27,1.48). The median time from symptom onset to diagnosis was 18 days (interquartile range, 4,30 days). Six patients presented with spinal pain and one presented with focal neurological deficits. Risk factors were identified in all patients, including concomitant infections, diabetes mellitus, immunosuppression, and intravenous substance abuse. Staphylococcus aureus was cultured in six patients and streptococcal species were cultured in two patients. Three patients were treated surgically and five received medical treatment. One patient treated surgically and one patient treated medically had residual neurological deficits. One patient, who was immunosuppressed and received medical treatment died of pneumonia. Conclusions., This is the first published report of the population-based incidence of spontaneous epidural abscess. These findings could serve as a reference point for further epidemiological research related to this uncommon infection. [source] Chronic Pain and Violent Ideation: Testing a Model of Patient ViolencePAIN MEDICINE, Issue 3 2007Daniel Bruns PsyD ABSTRACT Objective., Physicians are at risk of patient-perpetrated violence. The objective of this study was to test a clinical model of patient violence, which had been developed previously by Fishbain and colleagues. The developers of this model believed that it would be associated with increased risk of violence in pain patients. Design., Hypotheses generated by the model were tested using manova and chi-square procedures. Setting., A total of 527 subjects for this study were patients obtained from 90 medical facilities in 30 U.S. states. Patients., All subjects were patients being treated for injury and nonmalignant pain. All of the subjects were adults, ranging in age from 18 to 65 years, and were able to read at the sixth-grade level. The demographics of the sample approximated U.S. Census data for race, education, age, and gender. Results., The results included findings that violent ideation was associated with higher levels of physical difficulties, including pain (P = 0.01), problems with functioning (P = 0.0003), and somatic complaints (P = 0.0001). Significant psychosocial variables included hostility (P < 0.0001), dependency (P < 0.0001), substance abuse (P < 0.0001), litigation (P < 0.001), and a lack of trust in the physician (P < 0.001). Conclusions., Using the Battery for Health Improvement 2 as a measure, the findings of this study consistently supported the Fishbain Model of violence risk, and also reinforced the need for psychological assessment and management when working with chronic pain patients. Suggestions for intervention were also offered, but further research will be necessary to see whether these interventions are effective in decreasing patient violence. [source] | |||||||||||||||||||||||||||||||||||||||||||