The role of laparoscopy in the management of pelvic pain in women of reproductive age

OBJECTIVE: To review the diagnostic and therapeutic roles of laparoscopy in women of reproductive age with acute and chronic pelvic pain. DATA IDENTIFICATION: Studies relating to the use of laparoscopy in women with acute and chronic pelvic pain were identified through the literature and MEDLINE searches. CONCLUSION(S): Laparoscopy has an important place in the management of conditions that cause acute pelvic pain in women of reproductive age, including ectopic pregnancy, pelvic inflammatory disease, tubo-ovarian abscess, and adnexal torsion. The procedure frequently facilitates the diagnosis and provides the necessary access for surgical treatment. Prompt diagnosis and effective management prevent complications and help preserve fertility. The role of laparoscopy in women with chronic pelvic pain is more controversial and limited, but abnormal laparoscopic findings are detected in approximately 60% of those who have undergone a multidisciplinary investigation and received a tentative clinical diagnosis. The access provided by laparoscopy permits the effective surgical treatment of many of the conditions encountered, including endometriosis, pelvic adhesions, ovarian lesions, and symptomatic uterine retroversion.     

Sedation of adult critically ill ventilated patients in intensive care units: a national survey

Pain management presents exciting opportunities for nurse anesthetists. Today there are thousands of pain clinics and pain services dedicated to the diagnosis and treatment of chronic and acute pain. By becoming familiar with the principles involved in the management of chronic and acute pain, the different treatment modalities available, and the organization of pain clinics and pain services, nurse anesthetists will be able to take advantage of the opportunities they provide.     

The social communication model of pain.

Everybody is an expert on pain, by virtue of biological preparedness and personal experience. Unfortunately, this expertise fails large numbers of people, and we must improve our understanding through theoretical and research advances. A vast research-based literature on the nature and management of pain is now available, and there have been dramatic advances in our understanding and management of pain. Nevertheless, there continue to be major problems in the management of severe acute pain and chronic pain. It is argued that a formulation of pain that explicitly focuses upon social factors would more readily address human needs than models that focus upon biophysical and/or psychological factors alone (intrapersonal processes). Although ancient protective biological systems provide for escape and avoidance of pain, evolution of human capacities for cognitive processing and social adaptation necessitate a model of pain incorporating these capabilities (interpersonal processes). The more inclusive and comprehensive social communication model of pain is described and illustrated. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Acute liver failure induced by alcohol and paracetamol in an HCV-infected haemophiliac

Paracetamol (acetaminophen) is frequently used by haemophiliacs in the management of acute or chronic pain, primarily due to its lack of adverse effects when taken at therapeutic doses. We describe acute hepatic and renal toxicity of paracetamol in a 36-year-old patient with haemophilia B, chronic hepatitis C and chronic alcohol abuse. Moderate doses of paracetamol (6 g/d for 4 d), taken with therapeutic intent, resulted in life-threatening organ dysfunction which gradually recovered with full supportive care.     

Do patients receive adequate pain control after discharge from the ED?

Studies on the effectiveness of pain management have uniformly concluded that health care providers underestimate or undertreat pain. In the emergency department (ED) in which this study was conducted, physicians receive formal didactic and bedside teaching on pain recognition and management in order to heighten the awareness of patients' need for pain control. The purpose of this study was to determine if this outpatient pain management of patients with acute, painful conditions is better than that reported in the medical literature. In this prospective study, 110 adult patients who had an acute, painful diagnosis were telephoned 48 hours after discharge from the ED and asked if they felt their pain at home was well controlled. Patient satisfaction with pain control was higher (91%) than that reported in the medical literature. Also, pain medication was provided more frequently by this study's ED (95%). Education on pain awareness and treatment is a way to improve pain management.     

Acute and chronic pain in adults and children with cancer.

Reviews current research and clinical practice concerning pain experienced by cancer patients. Etiological subtypes of pain (disease related vs treatment related) are discussed, and an overview of assessment methodology for acute and chronic pain is presented. Also discussed are psychological interventions for pain in adult and pediatric cancer patients, including hypnosis, cognitive-behavioral therapy, biofeedback, relaxation, and operant conditioning. A review of the literature indicates a need for basic research, for controlled outcome studies of psychological interventions, and for education of health care professionals in the mechanisms and management of pain. Difficulties in conducting applied behavioral research in oncology units are noted, and the value of multidisciplinary collaboration is emphasized. (51 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Elevation of intracranial pressure following transjugular intrahepatic portosystemic stent-shunt for variceal haemorrhage

Increased intracranial pressure and cerebral oedema in patients with chronic liver disease is rare and is more typical of acute liver failure. Transjugular intrahepatic portosystemic stent-shunt is being increasingly used in the management of uncontrolled variceal haemorrhage in patients with cirrhosis. In our institution, a total of 160 patients has undergone transjugular intrahepatic porto-systemic stent-shunt for variceal haemorrhage; 56 of these procedures were emergencies for uncontrolled variceal haemorrhage. Four of these 56 patients developed features of acute liver failure, with marked deterioration in liver function tests and elevated intracranial pressure. This unusual but important complication of transjugular intrahepatic portosystemic stent-shunt has not been reported in the literature previously, and may have important consequences both for clinical practice and in the provision of further clues to understanding the pathogenesis of increased intracranial pressure in patients with liver diseases.     

Mobilization of arachidonate and docosahexaenoate by stimulation of the 5-HT2A receptor in rat C6 glioma cells

Distraction has been found to be effective for the attenuation of experimental and acute clinical pain but its efficacy for chronic pain management remains unclear. There are even some suggestions that distraction may be a counterproductive strategy for chronic pain sufferers. In this study we found that a word shadowing distraction task increased the ability of a group of 12 female and eight male chronic low back pain (CLBP) sufferers to carry out a brief (maximum 300 s) step-up exercise that temporarily increased their pain (P < 0.05). This 15% increase in exercise time was not accompanied by an increase in reported pain after the exercise. Interestingly, the same distraction task did not increase the cold pressor (CP) tolerance time for the CLBP group but produced a 26% increase in tolerance time for a pain-free control group consisting of nine females and nine males (P < 0.05). Also, performance on the distraction task during the CP was worse for the CLBP group than the controls (P < 0.05). Although these findings should be interpreted cautiously because of the parameters of the experiment, they do suggest that distraction is a potentially useful technique to assist chronic pain sufferers.     

Fractures of the lateral process of the talus: two case reports and a comprehensive literature review

Fractures of the lateral process of the talus are frequently overlooked and should be considered in the differential diagnosis of patients with acute and chronic ankle pain. Early diagnosis is emphasized in all series reviewed in the literature to prevent long-term complications. Thorough radiographic evaluation is necessary to determine the need for operative vs. nonoperative management. Small nondisplaced fractures are treated with cast immobilization, whereas large or displaced fractures usually require open reduction and internal fixation. Comminution of fragments may necessitate surgical excision. To achieve the best possible results, a timely diagnosis is required, and it is our belief that early treatment has better overall results.     

Chronic mandibular dislocation: the role of non-surgical and surgical treatment

Although the management of acute dislocations of the temporomandibular joint (TMJ) has not changed significantly in recent years, chronic dislocations continue to be treated by a variety of methods. Long-standing cases are the most difficult and frustrating to manage. This paper reports on four cases demonstrating the signs and symptoms associated with some forms of chronic. TMJ dislocations, and the difficulties encountered in the management of some of these conditions. An algorithm based on a critical review of the literature is proposed for the management of both acute and chronic TMJ conditions, and recommendations are made on how to eliminate or reduce their recurrence.     

Development of a pediatric burn pain and anxiety management program

To facilitate effective management of pain and anxiety, and to permit more objective assessment of changes in this management, a pain and anxiety guideline was developed and has been followed uniformly for 3 years. The guideline describes four patient care categories: (1) ventilated acute, (2) nonventilated acute, (3) chronic acute, and (4) reconstructive. A small and consistent formulary was emphasized. A specific guideline for background, procedural, and transition pain and anxiety management was developed for each patient care category. All pain and anxiety medications given to all acutely burned children admitted to the Institute for 12 consecutive months were recorded, and daily pain and anxiety discomfort scores were noted using a 5-level action-based bedside scoring system. Doses of individual pain and anxiety medications were calculated as mg per kg per patient-day in each category, and all doses were found to be within guideline specifications. The efficacy of the guideline was judged by four discomfort scores: (1) background pain, (2) procedural pain, (3) background anxiety, and (4) procedural anxiety, and were adequate in all patient categories. There were no complications related to overmedication experienced during the interval. Our objective was to develop a guideline for pain and anxiety management that: (1) was safe and effective over a broad range of ages and injury acuities seen in the unit, (2) was explicit in its recommendations, (3) had a limited formulary to optimize staff familiarity with agents used, and (4) took advantage of the presence of a bedside nurse to continuously evaluate efficacy and intervene when needed through dose-ranging. Although many drugs are appropriate, our choices were based on institutional familiarity and simplicity. This process of developing a clear and consistent guideline can be duplicated in any unit.     

Current principles of multidisciplinary treatment of pain in orthopedic clinics

Differentiated strategy of treating patients with acute and chronic pain is developed. Preemptive analgesia is a priority trend in the treatment of acute postoperative pain. The most prevalent method of postoperative analgesia is prolonged opioid epidural analgesia carried out in intensive care wards and other wards by an acute pain management team. For treating patients with chronic painful syndromes, protocols of initial clinical and diagnostic evaluation are developed, permitting the choice of individual treatment strategy. Differentiated complex drug therapy planned with consideration for individual course of the painful syndrome is the basis of treating patients with phantom pain syndrome. Algorithms of differentiated therapy of radicular and spondylogenic pain are designed. Stage-by-stage analysis of treatment efficacy is carried out using modern electrophysiological methods. Realization of the proposed organization principles improved the efficacy of postoperative analgesia to 88.2%, prevented the development of postoperative painful syndrome in 35.6% cases, decreased the incidence of phantom pain syndrome after amputation of the limb from 63.3 to 31.6% and increased the efficacy of this syndrome treatment to 70.1%, and increased the efficacy of treating vertebrogenic painful syndromes to 82.3%.     

The changing focus of chronic temporomandibular disorders: management within a hospital-based, multidisciplinary pain centre

Despite evidence to the contrary, many dentists still cling to outdated beliefs and practices regarding the aetiology and management of chronic temporomandibular disorders (TMDs). Chronic pain disorders require a multidisciplinary approach with a strong focus on psychological factors. Treatment failures and relapse are likely if such factors are not considered. Most chronic temporomandibular pain problems are extracapsular and of myofascial origin. Mechanistic or invasive treatments in such cases may be inappropriate and can cause harm. Conservative measures used for other types of chronic muscular pain are generally recommended. All health practitioners who deal with acute and chronic pain should be aware of recent major advances in the understanding of pain mechanisms. Along with psychosocial considerations, these must be emphasised in undergraduate and continuing education programmes.     

AgNOR mark epithelial foci in malignant transformation in hamster cheek pouch carcinogenesis

Research demonstrates that many nurses lack knowledge about pain assessment, the differences between acute and chronic pain, and the use of pain rating scales. In this article, the authors describe an instrument for evaluating chronic pain, the purpose of which is to assess systematically the various dimensions of chronic pain and its impact on quality of life. This assessment can establish a baseline for developing clients' treatment plans and can be used to evaluate the effectiveness of treatment plans. Using this tool can provide an accurate multidimensional assessment of clients' chronic pain experiences. The article also discusses recommendations for other applications of the tool.     

Hypnosis treatment of clinical pain: understanding why hypnosis is useful

Clinical and experimental research literature indicates hypnosis is very useful for severe and persistent pain, yet reviews suggest hypnosis is not widely used. To encourage more widespread clinical application, the author reviews recent controlled clinical studies in which hypnosis compares favorably with other interventions; links advances in understanding endogenous pain modulation to a neurophysiologic view of hypnosis and hypnoanalgesia; relates the neurophysiology of hypnoanalgesia to management of chronic pain; challenges the view that hypnotic pain control is only for the highly hypnotizable patient; and raises issues about how people learn to control pain with hypnosis. Training in hypnotic analgesia may usefully enhance nervous system inhibitory processes that attenuate pain.     

Opioids in treatment of chronic noncancer pain

Opioids have been accepted as appropriate analgesic treatment for pain associated with cancer. However, controversy exists about their use for chronic noncancer pain. Reasons for reluctance are concerned about efficacy and potential adverse effects such as respiratory depression, addiction, physical dependence or intolerance. Many physicians worry about liability and legal restrictions. Nevertheless, pain management of chronic severe pain with opioids can be the only help when alternative methods are too risky of fail to be effective. This article briefly reviews the published literature on this topic and discusses some practical guidelines for the use of opioids in the treatment of non-cancer pain.     

Certain features of carbohydrate metabolism in phosphomycin-resistant avirulent forms of group A streptococci

A model of acute spinal and phantom pain syndromes caused by the formation of an abnormally increased excitation generator (AIEG) in the system of dorsal horns of the spine was used to study the effects of sodium valproate when used chronically in the phantom pain syndrome, when given in a single dose in the acute pain syndrome and when applied to the spine with disinhibitors inducing the pain syndrome. It was shown that during chronic administration sodium valproate produced a stress-preventive action, but failed to affect pain sensation and to prevent the development of the pain syndrome. When used in the acute pain syndrome, sodium valproate had a marked analgesic effect, and when applied to the spine it substantially reduced the manifestations of the pain syndrome. The action of sodium valproate on the AIEG can be accounted for by the higher GABA level that results in the hyperpolarization of neurons which are a part of AIEG. When the latter is formed and operates in acute and chronic pain syndromes there are differences in the functional activity of the neurochemical structures responsible for the realization of pain reaction components. This is suggested by varying effects of sodium valproate on pain sensation during acute and chronic experiments.     

Chronic aortic dissection presenting as a prolonged febrile disease and arterial embolization

Aortic dissection most often is an acute event dominated by excruciating pain and other symptoms which suggest the diagnosis. Our report and a review of the medical literature demonstrate that chronic aortic dissection may, rarely, present as a prolonged febrile illness, with night sweats, weight loss, pleural effusion, and little or no pain. These symptoms may be associated with a markedly elevated erythrocyte sedimentation rate (ESR), anemia of chronic disease, and hyperglobulinemia. Awareness of this unusual presentation, a high index of suspicion, and confirmation by an appropriate imagine technique (CT or MRI of the chest or transesophageal echocardiography have a very high sensitivity) will result in earlier diagnosis and better patient outcome.     

Formal measurement of pain by nurses

How often have we heard nurses complain because doctors have not prescribed adequate pain relief for patients? Nurses, however, are just as guilty as doctors of not managing patients with acute and chronic pain adequately. Concern that nurses in her district were not using, or were using inappropriately, pain assessment tools prompted the author to undertake a small survey of current practice. The results confirmed her suspicions, but subsequent continuing education programmes on pain management seem to be helping to raise nurses' awareness of their responsibilities in this crucial area of care.