Prediction of vertebral failure loads from spinal and femoral dual-energy X-ray absorptiometry, and calcaneal ultrasound: an in situ analysis with intact soft tissues

The anatomic and physiological bases for nociception are present even in very preterm neonates. Neonates show the same behavioral, endocrine, and metabolic responses to noxious stimuli as older subjects. Preterm infants appear to be more sensitive to painful stimuli and have heightened responses to successive stimuli. Infants receiving intensive care are subjected to frequent stressful procedures and also chronic noxious influences related to the environment of care. Inflammatory conditions such as necrotizing enterocolitis may also cause pain. Untreated pain in babies is associated with increased major morbidity and mortality. Nonpharmacological interventions, including environmental modification and comforting during procedures reduce stress. Intravenous opiates are the mainstay of pharmacological analgesia. A pure sedative agent can provide physiological stability in settings in which there are less acutely painful stimuli or when there are adverse effects from, or tolerance to, opiates. Local anesthesia of skin and mucous membranes is helpful for invasive procedures. Antipyretic analgesics such as acetaminophen have a role in inflammatory pain.     

Evaluation of prescription opioids using operant-based pain measures in rats.

Opioids are the most effective compounds available for the relief of pain, yet there are a number of side effects that are of great concern to clinicians. For example, opioids are powerful reinforcers, and the treatment of pain using opioids could lead to the development of addiction. In addition, there is an increasing body of literature demonstrating that the repeated administration of opioids could lead to a phenomenon called opioid-induced hyperalgesia (i.e., increased sensitivity to painful stimulation). Studies examining these potential adverse effects are necessary in the development of novel analgesics. Furthermore, most studies of pain sensitivity and pain relief use reflex-based procedures to identify analgesics; however, it is argued here that operant-based procedures provide measures that are more analogous to the human condition (i.e., the mechanisms of pain are similar to those in humans) and should be useful in the assessment of novel analgesics. A series of studies examining the effects of opioids and the influence of variables such as age are discussed to demonstrate the utility of this approach. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Regional anesthetic procedures in pediatric anesthesia

Regional anaesthetic procedures are not popular in paediatric anaesthesia in many institutions. However, regional anaesthesia is gaining ground, especially in a "new" concept of balanced paediatric anaesthesia. The decisive argument for the use of regional anaesthesia is the prolongation of pain relief further into the postoperative phase. The minimal haemodynamic and respiratory side effects during epidural and spinal anaesthesia, the reduced narcotic requirement and the potential early mobilisation all speak in favour of practical application of these techniques. Specially adapted needles and catheters have reduced the technical limitations. The use of nerve stimulators has optimize the accuracy of needle and catheter positioning. The use of a nerve stimulator is therefore highly recommended for peripheral nerve blocks in children. On the other hand, the use of regional anaesthesia in children has potential disadvantages, which should be considered. Special knowledge and continuous training are required. Many techniques are time consuming and personnel intensive, at least temporarily, and the combination of general and regional anesthesia exposes the child to the potential risk inherent in both procedures. The aim of this paper is to discuss procedures which have gained favour in paediatric regional anaesthesia during the past few years. These include caudal, epidural and spinal anaesthesia, especially for infants with high narcotic risk, as well as fascia iliaca compartment blocks for lower extremity analgesia and penile blocks. Many peripheral nerve blocks require special experience and therefore are not discussed here, but they are used routinely by specialists in all age groups. Good anatomic and pharmacologic knowledge should be a prerequisite for all physicians who use regional anaesthetic procedures. Continuous training and critical analysis are needed for good results. Only then can such methods be introduced into routine paediatric anaesthetic practice.     

Challenges in the transfer of contingency management techniques: Comment on Silverman et al. (2001).

This article critiques K. Silverman, D. Svikis, E. Robles, M. L. Stitzer, and G. E. Bigelow's (see record 2001-14365-002) study of a contingency management intervention for reinforcing development of job-related skills in substance abusing women. The strengths of Silverman et al.'s study include studying a patient population of major public health concern, expanding contingency management techniques to a vocational training setting, reinforcing gradual approximations, implementing the intervention for a long duration, and carefully designing and executing the experimental procedures. However, many of these strengths may also be interpreted as weaknesses if the ultimate goal is to apply contingency management techniques in self-sustaining, community-based settings. The need to evaluate long-term cost-effectiveness of these procedures is described, and the difficulties in transferring contingency management techniques to real-world settings is discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A comparison of the nasal mask and the nasopharyngeal airway in paediatric chair dental anaesthesia

This study compared the quality of anaesthesia and surgical access afforded by two techniques for the administration of anaesthesia during paediatric chair dental procedures. A total of 50 ASA 1 paediatric day case patients were randomly assigned to receive anaesthesia through either the traditional Goldman nasal mask or through a nasopharyngeal airway. Patients in the nasal mask group were judged to have significantly worse airway patency (p = 0.0001) and significantly more episodes of airway obstruction (14 vs. 4; p = 0.0032) than those in the nasopharyngeal airway group. Anaesthetic, surgical and oxygen saturation data did not differ significantly between the two groups. Operating conditions were universally graded as excellent in the nasopharyngeal airway group, while those in the nasal mask group were graded as excellent/good in only 79% of cases (p < 0.0001). These results suggest that better quality anaesthesia and operating conditions can be achieved by using a nasopharyngeal airway rather than the traditional nasal mask for the administration of anaesthesia to paediatric chair dental patients.     

Management of postoperative pain in surgical units

In order to improve the management of postoperative pain many publications insist on progressive changes in care organization. The following list outlines steps to be taken for implementation of these changes: 1) an initial analysis of management of post-operative pain allows awareness of reforms to be proposed; 2) participation of health teams in special training in order to use evaluation tools and collect data (use of analgesics, adverse effects); 3) establishing policies and procedures: recovery room, guidelines for analgesic use and adverse effects; 4) notifying patient about the various procedures to be used in postoperative period--discussion with the patient during the preoperative interview; 5) current use of standard patient-controlled analgesia (PCA) and locoregional analgesia; 6) use of combined techniques in order to achieve a balanced analgesia; 7) implementing a quality assurance programme which should include analgesic effectiveness, patient satisfaction and prevention of complications; and 8) planning of an Acute Pain Service based on a clinical nurse co-ordinator which offers highly effective forms of postsurgical analgesia.     

Estimation of the relationship between the noninvasively detected activity of single motor units and their characteristic pathological changes by modelling

Postoperative management of the patellofemoral patient requires the clinician to implement a program which reestablishes functional activities of daily living. This paper will discuss the postoperative management of the patellofemoral patient. Effective rehabilitation techniques are needed to progress the patient. Surgical procedures, such as a lateral retinacular release, proximal realignment, and distal realignments, are frequently utilized techniques; however, long-term clinical outcome studies are lacking. The postoperative protocols discussed utilize an evaluation-based treatment approach model. The model defines evaluation techniques, leading the clinician to a specific rehabilitation pathway. The crucial element of postoperative management focuses on a treatment and exercise approach similar to the nonoperative management. Inappropriate or overly aggressive exercises may lead to possible neurologic dysfunction or delayed muscle function. The clinician must recognize that patients may exhibit articular cartilage damage, and, thus, rehabilitation programs must be designed to minimize the potential risks of progressing this lesion.     

Wound care pain management

Undertreatment of all types of acute and chronic pain is common, both in the United States and around the world. Moreover, a literature review of pressure ulcer pain and its management suggests that this area of pain medicine is truly in its infancy. This article includes a discussion of current literature, anatomy and physiology of pain related to pressure and ischemic ulcers and assessment methods. It also describes treatment modalities, including conservative measures, medication management and invasive procedures. Special emphasis is placed on the use of opioid analgesics in the management of severe acute and chronic wound pain.     

Role of laparoscopy in the staging of gastrointestinal cancer

Accurate staging plays a primary role in determining the appropriate treatment of gastrointestinal malignancies. Recently, laparoscopy has emerged as a staging modality that is more sensitive and specific in staging most gastrointestinal cancers than preoperative imaging modalities. The addition of laparoscopic ultrasonographic techniques has achieved even greater staging accuracy. Consequently, patients with disease that is amenable to resection are better identified, and others with locally advanced disease are spared unnecessary laparotomies. Since laparoscopic techniques may be associated with low morbidity and a rapid recovery, palliative procedures are being developed for patients with advanced gastrointestinal malignancies. This reviews summarizes the current status of laparoscopic staging of gastrointestinal malignancies and compares this technique to preoperative imaging modalities. Also discussed are promising staging technologies and therapeutic procedures that may soon play an important role in the management of gastrointestinal cancer patients.     

Pathogenesis of porcine Actinobacillus pleuropneumonia: Part I. Effects of surface components of Actinobacillus pleuropneumoniae in vitro and in vivo

The aim of this study was to evaluate the quality of pain management in prehospital emergency care and to get more information about the administration of analgesics in prehospital patients. METHODS: Patients with painful diseases or injuries who had been brought to Munich hospital's were included in the study. Immediately after having reached the hospitals' emergency department, they were evaluated using a 101-point visual analogue scale for the severity of pain at four predefined periods. Information about the patient, the diagnosis, and the analgesic treatment used by the emergency teams were drawn from the patient's chart. RESULTS: A total of 462 patients were included in the study. The mean pain score on arrival of the emergency team was 64 points; 36.5% of the patients were treated with analgesics. In 28.1% the emergency team tried to reduce pain through external measures (i.e., setting of fractures). In 35.3% there was no therapeutic intervention. In cases in which analgesic therapy was initiated, a definite reduction in pain was achieved during emergency care. Visual analogue scores decreased from 70 points at the beginning to 29 points at arrival to the hospital's emergency department. Analgesics were most frequently used for patients with cardiopulmonary diseases (47.2%), followed by patients with traumatic accidents (35.5%) and patients with acute abdominal pain (25.2%). Of the analgesics, opioids were given most frequently (87.0%). Nonopioid analgesic agents were used in 32.1%. The results of our investigation demonstrate that in many cases the administration of analgesics is not individualized to the patients needs. CONCLUSION: During the prehospital period of emergency care many patients suffer from severe pain. The development of patient-oriented concepts concerning pain management could contribute to improvement of pain therapy in prehospital emergency medicine.     

Postoperative opioid analgesia: time for a reconsideration?

Postoperative pain relief has improved in recent years with the development of new analgesics, additional routes of administration and the appearance of the hypothesis of preemptive as well as balanced analgesia (Kehlet H; Postoperative pain relief-what is the issue? Br J Anaesth 1994;72:375-8). Many initial improvements simply involved the administration of opioid analgesics in new ways, such as continuous or on demand intravenous (i.v.) or epidural infusion. These methods allow lower total opioid dosages, provide a more stable concentration of opioid at the receptor and correspondingly better analgesic effects, and also fewer unwanted side effects. Although opioids have played a prominent role in postoperative analgesia for centuries and are still often administered as a matter of routine, their frequent minor side effects and the increasing availability of suitable alternatives may limit their future use in some situations. Thus, the recent emphasis on ambulatory surgery and accelerated surgical stay programs, both with a focus on early recovery of organ function and provision of functional analgesia [i.e., pain relief that allows normal function (Kehlet H: Postoperative pain relief-what is the issue? Br J Anaesth 1994;72:375-8)] provide an opportunity for a reappraisal of opioid use in these settings. For this debate, controlled clinical studies on the opioid-sparing effect of different analgesic techniques are mentioned, and preferably studies with multiple dosing of analgesics and/or a reasonably large patient sample size. These data do not allow a proper meta-analysis to be performed because of the large variability in surgical procedures, dosing regimens, assessment criteria, among others.     

Kuzbanian controls proteolytic processing of Notch and mediates lateral inhibition during Drosophila and vertebrate neurogenesis

Intraoperative haemorrhage or major bleeding may still cause serious problem in present-day neurosurgery, especially with reference to major vascular procedures despite the improving surgical techniques and methods of performing bloodless procedures. This is why certain neurosurgical procedures are not attempted without prior preparation of a major amount of blood. Jehovah's Witnesses refuse their consent to be subjected to blood transfusion of their own or foreign blood despite their full awareness of a potential danger to their lives. This paper describes three patients subjected to the major vascular intracranial procedures (two cases of clipping intracranial aneurysms, and one case of removal of arteriovenous intracranial angioma in anaemic patient), and one case of endovascular neuroradiosurgical procedure in intracranial aneurysm. This last method is presented as alternative procedure to decrease complications that are related to bloodless interventions suggest certain management methods which may decrease the surgical risk. One of those methods erythropoietin in treatment of postoperative anaemia and in preparing anaemic patients to vascular intracranial procedures.     

Primary and secondary control among children undergoing medical procedures: Adjustment as a function of coping style.

The literature suggests that optimal adjustment to relatively uncontrollable stressors may require adjusting oneself to the stressors rather than trying to alter them. This possibility was explored for low-controllability stressors (e.g., painful medical procedures) associated with leukemia. Children's reports of coping strategies and goals were classified as primary control coping (attempts to alter objective conditions), secondary control coping (attempts to adjust oneself to objective conditions), or relinquished control (no attempt to cope). Secondary control coping was positively associated with (1) general behavioral adjustment assessed by the Child Behavior Checklist and (2) illness specific adjustment assessed by children's own distress ratings and by behavioral observations during painful procedures. All significant group differences showed better adjustment among secondary control children than among the primary or relinquished groups. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Vesico ureteric reflux and urinary tract infections in children

BACKGROUND: UTIs in children are a common problem in general practice. The difficult aspects lie in the management of recurrent UTIs and the further investigation and treatment of vesico ureteric reflux. OBJECTIVE: To give some insight into the difficulties of the clinical diagnosis and further management of UTIs in children of different ages. DISCUSSION: This is a controversial area of management in paediatric practice. This article gives an insight into my personal approach to these problems, which form a large part of my clinical practice. My perspective is that of paediatric urologist working in a tertiary teaching hospital. Other people working in this field may take a very different approach.     

Breast cancer and benign breast disease patients evaluated in relation to oxidative stress

The 'WHO Analgesic Ladder' is a well validated approach for the selection of appropriate analgesic therapy for cancer pain as well as pain in AIDS. The mainstay of analgesic intervention for cancer and AIDS pain of moderate to severe intensity continues to be the appropriate use of opioid analgesics. There is, however, a growing appreciation for the role of adjuvant analgesics, such as antidepressants and other psychotropic medications, at each step of the WHO Analgesic Ladder, particularly in the treatment of neuropathic pain. Knowledge of the indications and usefulness of psychotropic analgesic drugs in cancer and AIDS pain populations will be most important to clinicians practicing in psycho-oncology/AIDS settings, particularly since these drugs are useful not only in the treatment of psychiatric complications of cancer and AIDS, but also as adjuvant analgesic agents in the management of pain. This paper reviews the literature on the use of antidepressants, psychostimulants, neuroleptics, anticonvulsants and other psychotropic analgesics in the management of cancer and AIDS pain. Mechanisms of analgesia, drug selection, and recommendations for clinical usage are discussed. The appropriate and timely use of psychotropic adjuvant analgesic drugs represents an opportunity for active psychiatric contribution to the multidisciplinary management of cancer and AIDS pain.     

Anaesthetic considerations for children undergoing stereotactic radiosurgery

An anaesthetic case report of children undergoing stereotactic radiosurgery is presented, with a review of the inherent unique anaesthetic challenges. Twelve stereotactic radiosurgery procedures performed at The Prince of Wales Hospital, Sydney, were retrospectively reviewed. Despite differences in approach by individual anaesthetists to managing these children, an overall safe sequence may be evolved. The use of stereotactic radiosurgery for paediatric neuropathology is reviewed. The potential anaesthetic problems related to the paediatric patient and the peculiarities of the procedure are discussed and related to our series.     

Diabetes mellitus increases the severity of anemia in non-dialyzed patients with renal failure

Therapeutic means for patients with disseminated painful bone metastases in breast cancer are strongly limited. There is a big need of an effective and well tolerated therapy. The aim of this study was to evaluate the efficacy of rhenium-186 HEDP for pain palliation in patients with bone metastases in breast cancer. 17 patients with painful bone metastases taking analgesics received one or more injections of 1295 MB9 rhenium-186 HEDP. In 59% of the patients the therapy resulted in a significant reduction of pain. The duration of pain relief partially hold on up to nine weeks. The main side effects of therapy were a short decrease of platelets and leucocytes and an increase of pain for 1-2 days. As conclusion we found out that therapy with rhenium-186 HEDP can be used complementarily to analgesic therapy and radiation in patients with painful disseminated bone metastases in breast cancer.     

Current guidelines for the drug treatment of ankylosing spondylitis

Ankylosing spondylitis (AS) is a systemic inflammatory rheumatic disease involving spinal and sacroiliac joints. This condition is responsible for back pain, stiffness and discomfort. Several drugs are currently available in the management of AS, and may be divided into 3 groups. The first includes nonsteroidal anti-inflammatory drugs (NSAIDs), which are the main drug group used in AS because they reduce pain and stiffness in most patients. Several NSAIDs are available but phenylbutazone is considered the NSAID of choice in AS. However, other NSAIDs give similar beneficial results and the medication of preference in specific to each patient. All NSAIDs share common gastrointestinal toxicity, and they should be administered during periods of flare-up of the disease. The second drug group that has been used in the treatment of patients with AS comprises analgesics, muscle relaxants and low dose corticosteroids. They can be considered as adjuvant therapy. These drugs are helpful when NSAIDs are poorly tolerated or ineffective. Second-line treatments or disease modifying antirheumatic drugs (DMARDs) are included in the third group. These drugs are required in cases of longstanding severe or refractory AS. Sulfasalazine has proven to be effective in such cases, leading to improvement in clinical and laboratory indices of disease activity. Beneficial results are mainly evident in patients with AS who have peripheral disease involvement. Other medications (such as methotrexate or gold salts, for instance) require properly designed controlled studies to evaluate their effectiveness in the treatment of this disorder, while immunosuppressive agents have little to offer in the management of patients with AS and require further studies. Some specific clinical features are observed in AS: enthesopathy may be treated with local injection of corticosteroids; sacroiliac joint pain may be managed by corticosteroid injection performed under fluoroscopic control or guided by computed tomography. The management of patients with AS includes some other procedures such as patient education, rest, a programme of physical exercise and physiotherapy. In parallel with pharmacotherapy, these procedures are of great importance in reducing stiffness and spinal ankylosis, and thus improve the patient's quality of life.     

APN: evaluation behavioral scale of acute pain in newborn infants

AIM: This study was designed to validate a behavioral acute pain rating scale for term and preterm neonates (APN). METHODS: From January through June 1996, neonates requiring a heel lance or a venous puncture for blood sampling at the intensive care unit and the nursery of Poissy Hospital were recruited into the study. After a pilot study, a pain rating scale was developed. The scale score pain ranged from 0 to 10 and it evaluated three items: facial expression, limb movements, and vocal expression with ratings per item ranging from 0 to 4, 0 to 3 and 0 to 3, respectively. Two observers evaluated independently each infant during a painful procedure (puncture for a blood sample) and during a dummy procedure (rubbing the thigh softly). RESULTS: Forty-two neonates born between 25 and 41 weeks gestational age were included in the study. Medians (quartiles) of gestational age, birth weight, and corrected postmenstrual age at time of investigation were 34 (29-39) weeks, 1,850 (1,055-3,093) g, and 35.5 (31-39) weeks, respectively. Ten infants were intubated. The scale showed to be sensitive because all possible scores were obtained; during painful procedures scores ranged from 1 to 10, with 95% of scores > or = 3 while during dummy procedures they ranged from 0 to 5, with 88% of scores < or = 2. The medians (95% confidence interval) of scores were for painful procedures 5 (5 to 7) and for dummy procedures 1 (0 to 1). This indicates a good specificity of the scale. High intercorrelation of items (internal consistency) was confirmed by a Cronbach's coefficient alpha of 0.88. Inter-rater agreement was high since the Krippendorff R test was 91.2. CONCLUSION: This behavioral acute pain rating scale for newborns demonstrated a good specificity and sensitivity, internal consistency and inter-rater reliability. This scale could be used to test the analgesic effects of different therapies during painful procedures.