Survival after massive ecstasy overdose

This study was designed to evaluate the potential advantages of combined epidural and light general anesthesia over the commonly employed general anesthesia during open heart surgery. Twenty-four patients undergoing mitral valve replacement were thus studied. General anesthesia was maintained with an isoflurane-nitrous oxide-oxygen was mixture and morphine sulfate (0.4 mg/kg i.v. initially) followed by postoperative pain control with morphine in 12 patients (group GA). The remaining 12 patients (group EAA) received continuous epidural bupivacaine (0.125%)-morphine (50 micrograms/ml) supplemented with the same gas mixture as group GA. Epidural infusion was continued until the third postoperative day. Changes in the serum cortisol and beta-endorphin levels together with postoperative pain relief defined as good (scale 0-2), fair (3-4), or poor (5-10) were observed serially. Lower cortisol levels were observed in group EAA than in group GA (P < 0.05) just before skin closure, on the second and the third postoperative day. The beta-endorphin levels were substantially lower in group EAA than in group GA throughout the observation. The pain scores were good in 2 patients (17%), fair in 6 (50%), and poor in 4 (33%) for group GA, and good in 8 (67%), fair in 3 (25%), and poor in 1 (8%) for group EAA. We thus conclude that a combined epidural and light general anesthesia is considered to attenuate the stress response and thereby provides a better quality of postoperative pain control.     

Operative management of Haglund's deformity in the nonathlete: a retrospective study

Haglund's deformity, or "pump bump," is a common cause of posterior heel pain. Management of the condition usually consists of nonoperative therapy. This study presents a retrospective study of 65 cases (53 patients), with symptomatic Haglund's deformity in nonathletes (13 male and 40 female), who presented during a 4-year period (1989-1994). Sixty-five percent (39 heels) of these patients failed to respond to nonoperative therapy for an average of 62 weeks, (range, 4-260 weeks). This group of patients went on to operative treatment. Surgical management consisted of excision of the posterior calcaneal tuberosity through a medial longitudinal incision with debridement, reattachment of the Achilles tendon using bone anchors, and 4 weeks of postoperative immobilization. Thirty-nine patients (74%) were contacted for follow-up. The average follow-up period for these patients was 155 weeks, (range, 92-335 weeks). There were 50% excellent results, 47% good results, 3% fair results (1 patient), and no poor results. The Maryland Foot Score for operated heels was an average of 67/100 preoperative and an average of 92/100 postoperative. On unoperated heels the score was an average of 81/100 at first evaluation and an average of 86/100 at final evaluation. Complications included one recurrence of painful prominence, one wound infection, and one incisional neuroma. The outcome of these cases demonstrated that in those patients who fail nonoperative treatment, surgical treatment of Haglund's deformity produces a predictably good surgical result when performed using the technique described.     

Wheat bran- but not oat bran-enriched diets increase the mucosal height of the cecum and colon of newly weaned and aged rats

BACKGROUND: The quality of pain relief during the first 48 hours following ambulatory surgery has been poorly documented. This questionnaire study was performed to evaluate the nature and severity of pain after the patient leaves the hospital. METHODS: 1100 patients in the age group 5-88 years who underwent ambulatory surgery during a period of 6 months were asked to complete a questionnaire 48 h after the end of the operation. In the case of children, parents were asked to complete a similar questionnaire. The questions were related to pain experienced during the first 48 h after surgery and to the nature and severity of postoperative complications. RESULTS: A total of 1035 out of the 1100 patients returned the questionnaire, 94.1%. Overall the majority (65%) of patients had only mild pain at home; however, patients undergoing certain types of surgery had moderate-to-severe pain: inguinal hernia surgery (62% patients), orthopaedic surgery (41%), hand surgery (37%) and varicose vein surgery (36%). In these patients the severity of pain did not decrease during the 2-day study period. About 10% patients had more severe pain than they had anticipated, and 20% had difficulty in sleeping at night due to severe pain. Despite this, over 95% of patients were satisfied with management of postoperative pain. Nausea (20%), tiredness (20%) and vomiting (8%) were the commonest complications reported during the first 48 h. A significant association was found between the administration of a general anaesthetic and the incidence of nausea postoperatively. A large number of patients were alone at home after the operation (28.4%); some (3.8%) had no access to a relative or friend in case of need. CONCLUSION: Our results show that about 35% of day-surgery patients experience moderate-to-severe pain at home in spite of analgesic medication. About 20% of patients had sleep problems due to severe pain. However, only 5% of patients were dissatisfied. Better analgesic techniques are necessary for patients undergoing certain types of surgery. Patient information and follow-up routines need to be improved.     

Sleep-promoting effects of melatonin: at what dose, in whom, under what conditions, and by what mechanisms?

Hydrocodone is a semisynthetic opioid with analgesic and antitussive properties qualitatively similar to other opioid agonists. Ibuprofen is a nonsteroidal antiinflammatory agent with analgesic and antipyretic activity and is an effective, primarily peripheral-acting antiinflammatory analgesic. The objective of this clinical trial was to determine the additive analgesic effect of the combination of 15 mg hydrocodone bitartrate with 400 mg ibuprofen, relative to 400 mg ibuprofen alone and placebo, in the treatment of postoperative pain. The single-dose analgesic efficacy of the combination of hydrocodone bitartrate with ibuprofen was compared with ibuprofen alone and placebo in 120 patients with moderate or severe postoperative pain after abdominal surgery. Analgesia was measured during the 6-hour period after dosing based on onset of relief, hourly and summary variables, and duration of effect. A significantly greater proportion of patients treated with the hydrocodone/ibuprofen combination reported onset of relief compared with ibuprofen or placebo; however, the distribution functions for time to onset of relief did not differ among treatments. Hydrocodone with ibuprofen and ibuprofen alone were significantly more effective than placebo for all measures of analgesia. The combination of hydrocodone with ibuprofen was significantly superior to ibuprofen for all hourly analgesic evaluations, weighted sum of pain intensity differences (SPID), total pain relief (TOTPAR), and global rating of study medication. No patients in the hydrocodone with ibuprofen group required analgesic remedication during the 6-hour study period, compared with 25% and 82% in the ibuprofen and placebo groups, respectively. The analgesic superiority of 15 mg hydrocodone bitartrate combined with 400 mg ibuprofen compared with 400 mg ibuprofen alone was demonstrated across many efficacy variables.     

Evaluation of the effectiveness of NSAIDs in the prevention of postoperative pain. Comparison between pre- and postoperative administration of sodium naproxen in orthopedic surgery

The aim of the study was to assess the efficacy of the preoperative sodium Naproxen administration to reduce analgesic requirements in the postoperative period. 75 patients (ASA I-II), 50 male and 25 female, aged between 25 and 70 years and weighed between 50 and 90 kg, undergoing lumbar laminectomy were subjected to the same anesthetic technique. Patients were allocated randomly to one of three groups. Group I received intravenous sodium naproxen (550 mg) immediately after induction of anesthesia. Group II received intravenous sodium Naproxen (550 mg) at the end of surgery. Group III received intravenous normal saline immediately after induction of anesthesia. Postoperative every patient was given by request intramuscular Buprenorphine (0.3 mg) for pain relief (at 6 h intervals). Buprenorphine requirements in the group I were significantly lower than in either of the other groups (p < 0.01 and p < 0.0001 respectively), while significant differences were not observed between group II and III. Moreover the 54% of patients in the group I did not require analgesic drugs in the postoperative period in opposition to the 20% of pts. in the group II and the 12% of pts. in the group III (p < 0.05 and p < 0.01 respectively). We conclude that NSAIDs when given before tissue damage may prevent nociceptor sensitisation and probably reduce hyperexcitability of the spinal cord. Preoperative administration of NSAIDs provides better protection against peripheral nerve sensitisation than postoperative administration.     

Surgical treatment of recalcitrant plantar fasciitis

Twenty-six patients (35 feet) underwent partial plantar fasciectomy with neurolysis of the nerve to the abductor digiti quinti muscle. Nonsurgical treatment for plantar fasciitis had been unsuccessful in these patients. Patients were followed after surgery for an average of 37.5 months. Six patients were male and 20 patients were female; the average age was 49 years. All patients had failed to respond to nonsurgical treatment for an average of 21.5 months. In addition to routine history and physical examination patients were evaluated before and after surgery with a subjective foot rating system, and a detailed questionnaire was used to assess post-operative functional outcome. Thirty-two patients (92%) had a satisfactory functional outcome, and three patients (8%) had an unsatisfactory result (21 excellent, 11 good, 3 fair, 0 poor). The Maryland Foot Score increased from a preoperative average of 74.8/100 points to a postoperative average of 90.6/100 points. Four patients (11%) had postoperative complications, including superficial wound infection (two patients), deep venous thrombosis (one patient), and superficial phlebitis (one patient), all of which resolved uneventfully with treatment. Ten patients (28.6%) reported some degree of heel pain after surgery. All 10 patients denied limitation in activity related to postoperative pain. The average period before return to daily activity and restricted work duty was 5.6 weeks and to full work duty without restriction was 8.7 weeks. Although the length of time for partial or complete resolution of symptoms is variable, a successful treatment outcome can be expected in most patients who are treated for recalcitrant plantar fasciitis.     

Long-term effects of continuous intrathecal opioid treatment in chronic pain of nonmalignant etiology

In the present retrospective investigation, the long-term effects of continuous intrathecal opioid therapy via implantable infusion pump systems were examined in 120 patients with chronic, nonmalignant pain syndromes. The follow-up period was 6 months to 5.7 years (mean 3.4 years +/- 1.3 standard error of the mean). Deafferentation pain and neuropathic pain showed the best long-term results, with 68% and 62% pain reduction (visual analog scale), respectively. The mean morphine dosage initially administered was 2.7 mg/day (range 0.3-12 mg/day); after an average of 3.4 years, it was 4.7 mg/day (range 0.3-12 mg/day). In a long-term observation of 28 patients who received intrathecal morphine for longer than 4 years. 18 patients (64.3%) had a constant dosage history and 10 patients (35.7%) showed an increase in morphine dosage to more than 6 mg/day 1 year after dosage determination. In seven cases, a tolerance developed: in four patients the tolerance was controlled by means of "drug holidays"; but in three patients it was necessary to remove the pump systems. Explantation of the pump system occurred in 22 additional cases for other reasons. Throughout the follow-up period, 74.2% of the patients profited from the intrathecal opiate therapy: the average pain reduction after 6 months was 67.4% and, as of the last follow-up examination, it was 58.1%. Ninety-two percent of the patients were satisfied with the therapy and 81% reported an improvement in their quality of life. The authors' 6-year experience with administration of intrathecal opioid medications for nonmalignant pain should encourage the use of this method in carefully selected patients.     

Chronic precentral stimulation in trigeminal neuropathic pain

The results of Deep Brain Stimulation in deafferentation pain syndromes, in particular in thalamic pain, indicate that excellent long-term pain relief can hardly ever be achieved. We report 7 cases using Motor-Cortex-Stimulation for treating severe trigeminal neuropathic pain syndromes, i.e., dysaesthesia, anaesthesia dolorosa and postherpetic neuralgia. The first implantation of the stimulation device for precentral cerebral stimulation was performed in June 1993, the last in September 1995. In all but one case the impulse-generator was implanted after a successful period of test stimulation. Successful means a pain reduction of more than 50% as assessed with a Visual Analogue Scale. Excluding one case, in whom a prolonged focal seizure resulting in a postictal speech arrest occurred during test stimulation, there have been no operative complications and the postoperative course was uneventful. In all the other patients the pain inhibition appeared below the threshold for producing motor effects. Initially these patients reported a good to excellent pain relief. In three of 6 patients a good to excellent pain control was maintained for a follow-up period of 5 months to 2 years. In the remaining three patients the positive effect decreased over several months.     

Epidural morphine plus ketamine for upper abdominal surgery: improved analgesia from preincisional versus postincisional administration

Increased postoperative pain may be caused by central nervous system plasticity, which may be related to actions of N-methyl-D-aspartic acid (NMDA) receptors on neurons in the dorsal horn of the spinal cord. Opioids act mainly on presynaptic receptors and reduce neurotransmitter release, while ketamine antagonizes NMDA receptors and prevents wind-up and long-term potentiation. Thus, we postulated that central nervous system sensitization would be prevented more effectively by the preoperative use of these two drugs simultaneously, and the effect of preemptive analgesia would be demonstrated. Ketamine, 60 mg, and morphine, 2 mg, were injected epidurally through an indwelling catheter that was inserted at the T7-8 interspace in 60 ASA physical status class 1-2 patients. The drugs were injected before induction of anesthesia (Group 1; n = 30) or immediately after removal of a surgical specimen (Group 2; n = 30). An additional 2 mg of morphine was injected when the patients complained of resting pain. The analgesic effect was assessed by the time from first analgesic injection to second dose and the number of patients who needed supplemental injections. Complications were also noted. The duration of analgesia was longer (P < 0.01) in Group 1 (31.1 +/- 16.0 h) than in Group 2 (21.1 +/- 12.0 h), and the proportion of patients who needed supplemental injections was decreased (P < 0.05) in Group 1 (56.7%) compared with Group 2 (90.0%). The incidence of adverse effects was not different between the two groups. In conclusion, preoperative administration of morphine and ketamine is more effective in reducing postoperative pain than it is when given during the operation.     

Effect of ethanol ingestion on renal regulation of water and electrolytes

Ablative functional neurosurgery can be useful in some selected patients for the treatment of harmful spasticity in the lower limbs. Microsurgical drezotomy was introduced in 1972, on the basis of anatomical studies of the human dorsal root entry zone (DREZ) showing a topographical segregation of the afferent fibers according to their size and thus functional destinations. It consists of a 3 mm deep microsurgical lesion directed at a 45 degree angle in the postero-lateral sulcus, penetrating the DREZ in its ventro-lateral aspect, at the level of all the rootlets considered as involved in spasticity (and pain). It destroys mainly the lateral (nociceptive) and central (myotatic) afferent fibers as well as the facilitatory medial part of the Lissauer tract, whilst sparing most of the medial (lemniscal) fibers and the inhibitor lateral part of the Lissauer tract. We report a series of 121 bedridden patients suffering from harmful spasticity in one (15) or both (106) lower limbs and treated with microsurgical drezotomy. Surgery was decided on because of abnormal postures in flexion in two-thirds of the patients and in hyperextension in one-third, additional pain in 75 of them, and hyperactive bladder in 38 cases. The post-operative results were evaluated after a mean follow-up time of 5 years and 6 months. Both spasticity and spasms were significantly decreased or suppressed respectively in 78% and 88% of the patients. When present, pain was relieved without abolition of sensation in 82%. These benefits resulted in either disappearance or marked reduction of the abnormal postures and articular limitation in 90% of the patients. When present preoperatively, urinary leakage disappeared in 85% of the cases. Mild to severe complications occurred in 32 patients and precipitated or were responsible for death in 6 cases (5%). This is explained by the fact that most of the patients, especially those affected by multiple sclerosis, were in very precarious general and neurological conditions. Microsurgical drezotomy has however enabled a large majority of these severely disabled patients to sit and lie comfortably, and allowed them to reach a significantly improved quality of life.     

Efficacy and kinetics of carprofen, administered preoperatively or postoperatively, for the prevention of pain in dogs undergoing ovariohysterectomy

OBJECTIVE: To determine what effect the timing of carprofen administration has on the severity of postoperative pain in dogs undergoing ovariohysterectomy and to investigate the pharmacokinetics of carprofen under these conditions. STUDY DESIGN: A prospective, randomized, double-blind, clinical trial. ANIMALS: Sixty-two adult bitches weighing between 10 and 25 kgs, undergoing elective ovariohysterectomy. METHODS: Examinations were performed for 20 hours postoperatively using subjective visual assessment scoring systems (DIVAS) and objective mechanical nociceptive threshold measurements. Forty dogs were assigned to one of three groups: (1) preoperative carprofen; (2) postoperative carprofen; and (3) no analgesics (saline injections). The dose of carprofen was 4.0 mg/kg subcutaneously. In another 22 bitches, the pharmacokinetics of carprofen given preoperatively or postoperatively at the same dose were examined. RESULTS: The dogs given carprofen preoperatively had lower pain scores than the other groups, significantly so at 2 hours postextubation (P < .01 and P < .05, Kruskal-Wallis and post hoc Dunn's). Mechanical pain thresholds measured at the distal tibia showed the development of hyperalgesia at 12 and 20 hours postextubation; this was prevented by both the preoperative (P < .05 at 12 and 20 hours, Kruskal-Wallis) and postoperative (P < .05 at 20 hours, Kruskal-Wallis) administration of carprofen. Mechanical pain threshold testing at the wound showed a significant analgesic effect of carprofen. Plasma concentrations of carprofen were not directly related to analgesia; maximum plasma concentration, the area under the curve to the last data point, and area under the first moment curve up to the last data point were all significantly higher in the dogs given carprofen postoperatively (P < .05, Mann-Whitney). CONCLUSION: Preoperative administration of carprofen has a greater analgesic effect than postoperative administration in the early postoperative period in dogs undergoing ovariohysterectomy. Plasma levels of carprofen are not related to the degree of analgesia achieved. CLINICAL RELEVANCE: Carprofen provides effective analgesia after canine ovariohysterectomy. The timing of analgesic administration is important to optimize the control of postoperative pain.     

Inhibitors of tyrosine kinase

BACKGROUND AND OBJECTIVES: Neurolytic superior hypogastric plexus block has been shown to be safe and effective in selected cancer patients. A large cohort of patients was studied to evaluate the continued efficacy and safety of this block in cancer patients with advanced disease. METHODS: A total of 227 pelvic pain patients with gynecological, colorectal, or genitourinary cancer who experienced poor pain control due to either progression of disease or to untoward side effects were enrolled in this study during a 3-year period. All pain patients receiving oral opioids were eligible to participate. A bilateral percutaneous neurolytic superior hypogastric plexus block with 10% phenol was performed 1 day after a successful diagnostic block with 0.25% bupivacaine. RESULTS: All patients reported a visual analog scale (VAS) pain score of 7-10/10 before the block. A positive response to a diagnostic block was obtained in 159 patients (79%). Overall, 115 patients of the 159 patients who responded to a diagnostic block (72%, 95% confidence interval of 65-79%) had satisfactory pain relief (VAS < 4/10), 99 (62%) after one block, and 16 (10%) after a second block. The remaining 44 patients (28%) had moderate pain control (VAS 4-7/10) after two blocks and received oral pharmacological therapy and epidural analgesic therapy with good results. Both groups experienced significant reductions in oral opioid therapy after the neurolytic blocks. No additional blocks were required by patients who had a good response during a follow-up period of 3 months. No complications related to the block were detected. CONCLUSIONS: Neurolytic superior hypogastric plexus block provided both effective pain relief and a significant reduction in opioid usage (43%) in 72% of the patients who received a neurolytic block. Overall, this represents 51% of the patients enrolled in the study. Poor results should be expected in patients with extensive retroperitoneal disease overlying the plexus because of inadequate spread of the neurolytic agent.     

Respiration and circulation after total hip replacement surgery. A comparison between parenteral analgesics and continuous lumbar epidural block

The cardiopulmonary effects of two different types of postoperative analgesic regimes were compared in 31 cardiorespiratorily healthy patients subjected to total hip replacement surgery. The investigation was performed preoperatively on the morning of the day of surgery and during the first 3 days postoperatively. All patients received continuous lumbar epidural analgesia preoperatively, during surgery and up to the end of the first measurement period, which started 2.5 h after surgery. Ten patients were subseuqently given pentazocine (Fortalgesic) intramuscularly on demand for pain relief throughout the investigation, while 14 patients received 0.4% plain lidocaine (Xylocain), and seven patients 0.4% lidocaine with adrenaline (1/400,000) as a continuous lumbar epidural drip for analgesia thorughout the investigation. It was confirmed that the operative procedure itself did not significantly influence the postoperative arterial oxygenation, while the type of postoperative analgesic regimen was of considerable importance in this respect. Thus, patients given pentazocine showed a significant increase in pulmonary venous admixture, due both to an increase in true shunt and to an increase in ventilation/perfusion disturbances. This pattern of poor pulmonary function still persisted on the third postoperatively. In patients given an epidural block no significant changes in pulmonary venous admixture were noted postoperatively, and thus there was no reduction in PaO2. All patients, irrespective of the type of analgesic regimen used, had a significantly increased cardiac index and oxygen uptake postoperatively, although patients given an epidural block showed a greater increase in cardiac index, and thus a tendency towards a more hyperkinetic circulation than those given pentazocine.     

Postoperative epidural infusion of morphine and bupivacaine is safe on surgical wards. Organisation of the treatment, effects and side-effects in 2000 consecutive patients

BACKGROUND: There was an obvious need to improve the quality and safety of our postoperative pain treatment and to introduce an improved routine service on surgical wards. METHODS: It was decided to use postoperative epidural infusion of morphine 0.04 mg/ml and bupivacaine 2.5 mg/ml (0.25%) 4-8 ml/h as pain relief after major surgery. An education programme was run emphasising the benefits, side-effects and the importance of regular monitoring of pain intensity, vital functions (respiratory rate, blood pressure, heart rate), motor function of the legs and the need for additional drugs in order to detect side-effects as well as lack of adequate analgesic effect. A detailed observation sheet was used collecting information every 2 h throughout the epidural treatment period in order to secure monitoring and adjustment of the treatment. Close contact was maintained with the wards. RESULTS: We present a detailed analysis of our first 2000 postoperative patients, mainly after orthopaedic (46.1%), gastrointestinal (32.0%), urologic (8.7%) and vascular (8.5%) surgery. Duration of the treatment was less than 24 h in 41.4% and more than 48 h in 29.7%. Pain relief was adequate in most patients, best after vascular surgery in the lower extremities (mean VAS 0.15/10.0 (95% confidence interval 0.09-0.23)) and less after gastrointestinal (mean VAS 0.49/10 (0.43-0.54)) and thoracic surgery (mean VAS 0.59/10 (0.38-0.81)). The infusion was stopped due to respiratory depression in 3 patients (0.15%). Four (0.2%) had systolic blood pressure < 80 mmHg and had to be treated with vasopressors. A total of 56 (2.8%) patients were considered to be problem patients due to excessive sedation (0.4%), hypotension (0.7%), respiratory depression (1.6%) or lower extremity paralysis (0.05%). All patients had urinary catheter until 6 h after termination of the epidural treatment. One patient had the epidural catheter accidentally placed subarachnoidally and experienced severe respiratory depression. No permanent sequelae were recorded in the postoperative patients, but 2 traumatised patients developed epidural abscesses after 3 weeks of treatment, which resulted in lower extremity paralysis. Late response to the warning signs might have contributed to the irreversible paraplegia. CONCLUSION: Our experience with this postoperative epidural analgesia regime is favourable. It has been easy to administer and monitor. Pain relief was excellent, side-effects were few and picked up by the established routines followed by the ward staff except in the 2 trauma patients who developed epidural abscesses. The staff on the surgical wards were motivated for this kind of work. Education and strict surveillance routines are mandatory in order to secure prompt action when warning signs develops (e.g. lower limb paralysis).     

Dynamic external fixation for distal radius fractures

Thirty adult patients with closed comminuted and mostly intraarticular fractures of the distal radius were treated by closed reduction and immobilization with a dynamic external wrist fixator during a 2-year period. In 13 patients with severely comminuted and unstable fractures, additional Kirschner wires were used. After 10 to 14 days of rigid fixation in neutral position, the motion element was unlocked to allow up to 30 degrees flexion. Six weeks later, the fixator was removed. The patients then were observed for an average of 24 weeks. An excellent functional outcome was seen in 6 patients (20%), a good outcome in 20 patients (67%), and a fair outcome in 4 patients (13%). Anatomically, 15 patients (50%) had an excellent result, 14 (47%) a good outcome, and 1 (3%) a fair outcome. Only minimal loss of reduction averaging 1 degree palmar tilt was seen during mobilization. There were 2 major complications: 1 deep Kirschner wire tract infection and 1 index metacarpal fracture. Minor complications such as sensory disturbances and pin tenderness were present but recovered completely after removal of the fixator. This study provides promising data and offers an alternative method in the treatment of distal radius fractures with severe comminution. In cases with postreductive unstable fragments, additional Kirschner wires should be used to allow early mobilization of the wrist.     

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.     

Strontium-89 for palliation of pain from bone metastases in patients with prostate and breast cancer

We have used strontium-89 chloride (89Sr) for the palliative treatment of metastatic bone pain. Seventy-six patients (50 males with prostate carcinoma and 26 females with breast cancer) were treated with 148 MBq of 89Sr. Sixteen patients were retreated, receiving two or three doses; the total number of injected doses was consequently 95. The Karnofsky performance status was assessed and pain and analgesia were scored on scales of 9 and 5 points, respectively. The efficacy of 89Sr was evaluated at 3 months of treatment. Three levels of response were considered: good - when there was an increase in the Karnofsky status and a decrease in the pain score (equal to or higher than 4) or analgesic score (equal to or higher than 1); partial - when there was an increase in the Karnofsky status and a decrease in the pain score (2 or 3 points) without significant changes in the analgesic score; no response - if no variation or deterioration in these parameters was observed. In prostate cancer patients, the response was good in 64% of cases and partial in 25%, and there was no response in the remaining 11%. In breast cancer patients, the response was good in 62% of cases and partial in 31%, and there was no response in the remaining 8%. Duration of the response ranged from 3 to 12 months (mean 6 months). In the patients who were retreated the effectiveness was as good as after the first dose of 89Sr. A decrease in the initial leucocyte and platelet counts was observed after the 1st month of treatment, with a gradual partial to complete recovery within 6 months. It is concluded that 89Sr is an effective agent in palliative therapy for metastatic bone pain in patients with prostate or breast carcinoma. If required, retreatment can be administered safely and with the same efficacy as is achieved by the first dose.     

Identification and characterization of a novel DNA marker associated with epidemic Burkholderia cepacia strains recovered from patients with cystic fibrosis

Postoperative pain is a common reason for the delayed discharge and unanticipated hospital admission of out-patients. In this study, we examined the pattern of pain in ambulatory surgical patients and determined those factors that predict postoperative pain. Ten thousand eight consecutive ambulatory surgical patients were prospectively studied. Preoperative patient characteristics, intraoperative variables, and pain in the postanesthesia care unit (PACU) and the ambulatory surgical unit (ASU) and 24 h postoperatively were documented. The incidence of severe pain was 5.3% in the PACU, 1.7% in the ASU, and 5.3% 24 h postoperatively. In the PACU, younger male adults (36 +/- 13 vs 47 +/- 22 yr), ASA physical status I patients, and patients with a higher body mass index (26 +/- 5 vs 25 +/- 5 kg) had a higher incidence of severe pain. In the group with severe pain, the duration of anesthesia, the duration of stay in the PACU and the ASU, and the time to discharge was longer than in the group without severe pain. In the PACU, orthopedic patients had the highest incidence of pain (16.1%), followed by urologic (13.4%), general surgery (11.5%), and plastic surgery (10.0%) patients. In patients who had general anesthesia, the intraoperative dose of fentanyl was significantly smaller in the group with severe pain than in the group without severe pain when body mass index and duration of anesthesia were taken into consideration. Body mass index, duration of anesthesia, and certain types of surgery were significant predictors of severe pain in the PACU. This knowledge will allow us to identify those patients at risk of severe postoperative pain and manage them prophylactically. Implications: The pattern of pain was examined in 10,008 consecutive ambulatory surgical patients. The incidence of severe pain was 5.3% in the postanesthesia care unit, 1.7% in the ambulatory surgical unit, and 5.3% 24 h postoperatively. Body mass, duration of anesthesia, and certain types of surgery were significant predictors of pain in the postanesthesia care unit. These data will allow us to better predict those patients who need intense prophylactic analgesic therapy.     

Suprascapular nerve block for postoperative pain relief in arthroscopic shoulder surgery: a new modality?

Arthroscopic shoulder surgery has a 45% incidence of severe postoperative pain. Opiates and interscalene nerve blocks have a high incidence of side effects, and intraarticular local anesthetic has been shown to be ineffective when used for postoperative pain relief. The suprascapular nerve supplies 70% of the sensory nerve supply to the shoulder joint, and local anesthetic block of this nerve is effective in certain shoulder pain disorders. To determine the efficacy of a suprascapular nerve block, subcutaneous saline was compared with a suprascapular nerve block using 10mL of 0.5% bupivacaine with 1:200,000 epinephrine before general anesthesia was induced. In the immediate postoperative period, a 51% reduction in demand and a 31% reduction in consumption of morphine delivered by a patient-controlled analgesic system was demonstrated. There was more than fivefold reduction in the incidence of nausea, as well as reduced visual analog and verbal pain scores for patients who received a suprascapular nerve block. The duration of hospital stay was reduced by 24% in the suprascapular nerve block group. A 24-h phone call interview revealed a 40% reduction in analgesic consumption and a reduction in verbal pain scores at rest and on abduction. There were no complications from the suprascapular nerve block. This study demonstrates that a suprascapular nerve block for pain relief in arthroscopic shoulder surgery is an effective and safe modality of postoperative pain relief.