Acceptable Pain Research Articles

Depth of cutaneous analgesia after application of a eutectic mixture of the local anesthetics lidocaine and prilocaine (EMLA cream)

Background: EMLA cream, a eutectic mixture of lidocaine and prilocaine, is a topical anesthetic, frequently used to avoid pain during venipuncture and superficial surgery. However, the depth of analgesia needs further exploration. Objective: Our purpose was to investigate the depth of cutaneous analgesia after application of EMLA cream. Methods: In a single-blind crossover study, EMLA cream was applied under occlusion to the left thighs of 16 subjects. Eleven had application times of 60 and 120 minutes. Five subjects had application times of 3 to 4 hours. Approximately 10 minutes after removal of the EMLA cream, a skin biopsy punch (diameter 4 mm) was inserted to a depth of 1 mm into the skin and the subject rated the pain intensity on a visual analogue scale. If there was no pain or if pain was assessed as acceptable, a new biopsy punch was inserted at a new site to the depth of 2 mm. In this manner, the insertion depth was gradually increased in steps of 1 mm down to a maximum of 6 mm. No skin specimens were removed. Results: After 60 and 120 minutes of EMLA application the mean insertion depths with acceptable pain were 2.9 and 4.5 mm (P < .01), respectively. After 3 to 4 hours of application, 6-mm deep insertions were made with acceptable pain in all 5 subjects. Conclusion: Skin biopsy punch insertions in steps of 1 mm appear adequate for assessing the depth of cutaneous analgesia. Biopsy punch insertions with acceptable pain can be made to depths of 1 to 2 mm after 60 minutes, to 2 to 3 mm after 120 minutes, and to 6 mm after 3 to 4 hours of EMLA cream application. (J Am Acad Dermatol 2000;42:584-8.)

Metastatic Bone Pain

Patients with cancer and bone metastases are vulnerable to severe pain, especially when changing their body position, and many such persons die with unrelieved pain. One step in obtaining acceptable pain control is communicating one's pain to health care providers. This descriptive study aimed to depict possible gender differences in the meaning of pain in the context of pain self-report and self-management decision making for 10 men and 10 women with cancer and bone metastasis. No clear gender differences were found in the narrative data obtained during semistructured interviews. Both men and women equated pain with cancer recurrence. Pain interfered with work, social activities, and relationships. Most participants preferred not to tell others, even health care providers, about their pain. More than one half of the 20 participants did not take pain medications on schedules recommended by physicians. The study findings provide oncology nurses with direction for education related to pain management for persons with metastatic bone pain and their family members. Further research with a larger sample is needed to clarify how to overcome barriers to better pain management in this population.

Analgesic Efficacy and Bioavailability of Ketorolac in Postoperative Pain: A Probability Analysis

Background The analgesic efficacy and bioavailability of 30 mg intramuscular ketorolac was studied in 24 patients with severe or very severe postoperative pain. Methods Pain and pain relief were determined by a five-point verbal rating scale and data were submitted to a probability analysis. Ketorolac plasma levels were determined by high-performance liquid chromatography. Results Two patients chose not to finish the study; 22 patients completed the study achieving at least good pain relief. Of these 22 patients, 13 reached complete pain relief. Ketorolac was rapidly absorbed. Notwithstanding, pain relief increased gradually, showing considerable delay with regard to plasma concentrations. Analysis of the probability-time curves revealed that 25% of the patients obtained moderate pain relief at 7 min after ketorolac administration, 50% at 11 min, 75% at 29 min, and 95% at 60 min. Good pain relief was achieved in 25, 50, and 75% of the patients at 1.1, 1.8, and 2.7 h, respectively. Complete pain relief was achieved in 25% and 50% of the patients at 2.6 h and 3.7 h, respectively. The probability of exhibiting an acceptable pain relief in responsive patients for more than 5 h was 0.97. No serious side effects were detected. Conclusions Results show that 30 mg intramuscular ketorolac is an adequate treatment for postoperative pain in the Mexican population. Therefore, the use of higher doses is not justified. Due to gradual installation of analgesia, administration of additional analgesic medication before 1 h is not recommended.

Current Indications of Neurolytic Blocks in Cancer Pain

The concept of palliative care for cancer pain treatment is being accepted throughout several countries. As a consequence, invasive procedures available to provide acceptable pain relief in cancer patients have been rediscussed in terms of less invasiveness, lower technology, and more care. Very few neurolytic blocks survive in the common clinical practice, among them the neurolytic celiac plexus block and the percutaneous cervical cordotomy are considered the most effective. The former has recently been reconsidered [1•] after years of debate in the literature; the later is a specific neurosurgical procedure that may provide regional anesthesia by destroying specific pathways with heat. In this article we’ll try to define which role both procedures may currently have in the management of cancer pain.

This Month in ANESTHESIOLOGY

This Month in ANESTHESIOLOGY

Continuous Intracisternal and High Cervical Intrathecal Bupivacaine Analgesia in Refractory Head and Neck Pain

Background : The upper cervical component of the spinomesencephalic tract and cranial nerves V, VII (nervus intermedius), IX, and X are involved in mechanisms of acute and chronic pain from head and neck structures. To date there is no reliable method for relief of refractory pain (i.e., pain that cannot be relieved by conventional pharmacologic therapies) from these structures. Therefore, we explored continuous intracisternal infusion of bupivacaine for the treatment of refractory pain of the head and neck. Methods : Intracisternal catheters were inserted in 13 adults with refractory nonmalignant (n = 4) and malignant (n = 9) pain from the head, face, mouth, neck, and upper extremities ; 0.5% plain bupivacaine was infused continuously at rates of 1-7 (median 1.5) mg/h with optional bolus doses of 0.5-2.0 mg 4-2 times/h. The efficacy was assessed from pain relief (daily VAS max , VAS min , and VAS mean scores 0-10), daily doses of intracisternal bupivacaine and total opioid (expressed as mg parenteral morphine-eq), amount of nocturnal sleep, and rates of adverse effects. Results :The 13 patients were treated for 3-182 days (median 37, total 712 days), 3 patients being treated at home for 10-112 days (median 88, total 210 days). In one patient, the efficacy of the treatment could not be estimated because of advanced senility. Eleven of the remaining 12 patients obtained acceptable pain relief with daily doses of intracisternal bupivacaine ranging from 20 to 118 mg (median 37 mg) : VAS mean scores decreased from 7 to 2, mean pain relief increased from 30% to 80%, total opioid daily dose decreased from 53 to 36 mg parenteral morphine-eq, and nocturnal sleep increased from 2 to >6 h (all figures are median values). Speech, eating, walking, and natural functions were generally not affected. Side effects such as tiredness and malaise, somnolence and sleep, feeling of coldness in the neck and skull base, transient post-spinal puncture headache, paresthesias, hoarseness, dysphagia, transient paresis of the upper/lower extremities, episodic miosis and conjunctival hyperemia, and transient orthostatic arterial hypotension were each observed in one or two patients. No patient presented clinical evidence of phrenic nerve paralysis. There was no nausea or vomiting. No persistent neurologic deficit or death could be attributed to the intracisternal pain treatment. Conclusions : Continuous intracisternal infusion of bupivacaine may be a useful method in exceptional, well selected patients with refractory pain from the head and neck structures. Further studies are necessary to establish the indications and the safety of the method.

Diagnostic and operative microlaparoscopy: a preliminary multicentre report.

Microlaparoscopes have been evaluated for minimally invasive laparoscopy using minimal anaesthesia or analgesia since our preliminary report on microlaparoscopy in 1993. This international multicentre report of safety and efficacy of diagnostic and operative microlaparoscopy was completed to evaluate the role of microlaparoscopy in a wide spectrum of gynaecological indications, diagnoses of pelvic and tubal disease, tubal occlusion and assisted reproduction. A total of 408 patients from seven centres around the world were included in this report. Of the 164 patients who underwent microlaparoscopy under local analgesia only three patients (1.8%) converted to i.v. sedation because of pain intolerance. All 71 patients who underwent microlaparoscopy under i.v. sedation as planned tolerated the procedure with acceptable pain level perception. Only one abdominal wall minor bleeding and one uterine wall minor bleeding were recorded in the remaining 173 patients who underwent microlaparoscopy under general anaesthesia. Visualization of the pelvic organs was sufficient in all 408 cases for diagnosis and treatment of selected pelvic pathology. We concluded, based on this sizeable microlaparoscopy series, that this outpatient procedure can replace large diameter laparoscopy for diagnosis and treatment of various pelvic conditions. Microlaparoscopy can safely replace large diameter laparoscopy in motivated patients who require minor operative procedures such as tubal occlusion, minor adhesiolysis, tubal gamete or embryo transfers and fulguration of endometriotic implants. This series demonstrated that operative microlaparoscopy can be carried out under general anaesthesia, reducing to nil the potential damage of a large diameter tracer. Future improvements in i.v. sedation in combination with i.p. local anaesthesia will potentially eliminate the need for general anaesthesia in some of the patients undergoing minor operative microlaparoscopy.

Dose response relationship and multiple dose efficacy and toxicity of samarium-153-EDTMP in metastatic cancer to bone

Introduction: The optimal dose of samarium-153-EDTMP ( 153Sm-EDTMP) for effective palliation of painful metastases to bone is under investigation. It is not known whether increased doses of 153Sm EDTMP will lead to better and longer pain and tumour control and survival. Multiple dose efficacy and toxicity is of importance as most Patients will require prolonged support for pain. Methods: Twenty-eight (28) patients were treated with 0.75 mCi/kg, 35 patients with 1.5 mCi/kg and 19 patients with 3 mCi/kg in three sequential Phase I–II trials. Multiple doses were given to patients on the 0.75 mCi/kg and 1.5 mCi/kg dose levels. Results: At all dose levels adequate pain control was achieved in 78–95% of patients. The duration of pain control was 40–56 days with the best results in the 1.5 mCi/kg group (56 days). There is no evidence that increasing dose leads to better and longer pain control, tumour response and survival, but toxicity is increased. Multiple doses can be given with acceptable toxicity and pain control, however, only 38% of patients will qualify for multiple treatments. Conclusion: 153Sm-EDTMP provides adequate and safe palliation but multiple doses can only be given in 38% of patients. There is not a clear dose-response relationship. The length of pain control is satisfactory but not ideal and hospitalisation for 4 days every 6–8 weeks is a disadvantage. Further research is required to combine 153Sm-EDTMP with cytostatics and to administer it on an out patient basis.

Single-patient data meta-analysis of 3453 postoperative patients: oral tramadol versus placebo, codeine and combination analgesics

The analgesic effectiveness and safety of oral tramadol were compared with standard analgesics using a meta-analysis of individual patient data from randomised controlled trials in patients with moderate or severe pain after surgery or dental extraction. Calculation of %maxTOTPAR from individual patient data, and the use of >50%maxTOTPAR defined clinically acceptable pain relief. Number-needed-to-treat (NNT) for one patient to have >50%maxTOTPAR compared with placebo was used to examine the effectiveness of different single oral doses of tramadol and comparator drugs. Eighteen randomised, double-blind, parallel-group single-dose trials with 3453 patients using categorical pain relief scales allowed the calculation of %maxTOTPAR. The use of >50%maxTOTPAR was a sensitive measure to discriminate between analgesics. Tramadol and comparator drugs gave significantly more analgesia than placebo. In postsurgical pain tramadol 50, 100 and 150 mg had NNTs for >50%maxTOTPAR of 7.1 (95% confidence intervals 4.6–18), 4.8 (3.4–8.2) and 2.4 (2.0–3.1), comparable with aspirin 650 mg plus codeine 60 mg (NNT 3.6 (2.5–6.3)) and acetaminophen 650 mg plus propoxyphene 100 mg (NNT 4.0 (3.0–5.7)). With the same dose of drug postsurgical patients had more pain relief than those having dental surgery. Tramadol showed a dose-response for analgesia in both postsurgical and dental pain patients. With the same dose of drug postsurgical pain patients had fewer adverse events than those having dental surgery. Adverse events (headache, nausea, vomiting, dizziness, somnolence) with tramadol 50 mg and 100 mg had a similar incidence to comparator drugs. There was a dose response with tramadol, tending towards higher incidences at higher doses. Single-patient meta-analysis using more than half pain relief provides a sensitive description of the analgesic properties of a drug, and NNT calculations allow comparisons to be made with standard analgesics. Absolute ranking of analgesic performance should be done separately for postsurgical and dental pain.

Perilunate dislocation and fracture dislocation: A critical analysis of the volar-dorsal approach

A combined volar-dorsal approach was used to treat 11 perilunate dislocations and fracture dislocations between 1989 and 1994. The mean average age of the patients was 38 years, and the mean average time between injury and surgery was 13 hours. Outcome was assessed after an average of 30 months. Results were based on measurements of grip strength, range of motion, radiographs, and patient satisfaction. Patient satisfaction was high in 9 of 11 patients. Seven had satisfactory pain relief, and 5 had returned to their previous occupation without limitation. The wrist flexion-extension arc and grip strength averaged 71% and 77%, respectively, compared to the opposite side. Follow-up radiographs demonstrated complete union of all 8 wrist fractures. For all 11 patients, the carpal height ratio averaged 0.50. Neither scapholunate dissociation nor significant dorsal intercalated segmental instability existed, but 1 wrist developed scapholunate advanced collapse arthritis. Although perilunate instability patterns of injury create significant derangement in carpal anatomy and are among the most challenging of traumatic wrist injuries to correct, our results show that a combined volar-dorsal approach can be used safely and effectively to restore normal intercarpal relationships and provide fixation for accompanying fractures. For the majority of patients, the outcome after this procedure is characterized by acceptable pain relief as well as functional motion and grip strength.

Comparison of continuous infusion of fentanyl to bolus dosing in neonates after surgery

Objective: Concern about respiratory depression may lead to underuse of postoperative narcotic analgesia in neonates. The authors compared continuous infusion of fentanyl with bolus dosing in infants after surgery to determine whether continuous infusion is associated with less respiratory depression. Study Design: In the first phase of the study, 16 patients were randomly assigned to receive fentanyl by continuous infusion (C) or bolus dosing every 2 hours (B) in a double-blinded trial. Respiratory events were recorded. An observational pain score and saliva for cortisol concentration were obtained 2, 8, and 24 hours after beginning treatment to compare efficacy of pain control. In the second phase, 20 additional patients received fentanyl by continuous infusion in an unblinded fashion, with the same data collection, to more accurately determine the incidence of respiratory events. Results: In phase 1, apnea occurred in eight of nine B patients (89%) compared with one of seven C patients (14%; P < .009), prompting termination of the randomized trial. The incidence of apnea or significant respiratory depression in the next 20 patients (phase 2) who received fentanyl by continuous infusion was 25% (5 of 20; P < .01 v B). Episodes of apnea in B patients required significantly more intervention than episodes in C patients ( P < .01). However, in phase 2, more patients remained intubated and ventilated than in phase 1. Pain scores and salivary cortisol concentrations decreased over the 24-hour study period and were similar in B and C patients during both phases of the study. Conclusion: Continuous infusion of fentanyl at the doses studied is associated with pain control similar to that with bolus dosing at regular intervals. Although episodes of respiratory depression were less severe and less frequent for C patients, there may be an increased need for ventilator support with continuous infusion of fentanyl to achieve acceptable pain control. Providing adequate pain control to neonates in the immediate postoperative period remains a challenge.

Continuous intracisternal and high cervical intrathecal bupivacaine analgesia in refractory head and neck pain.

The upper cervical component of the spinomesencephalic tract and cranial nerves V, VII (nervus intermedius), IX, and X are involved in mechanisms of acute and chronic pain from head and neck structures. To date there is no reliable method for relief of refractory pain (i.e., pain that cannot be relieved by conventional pharmacologic therapies) from these structures. Therefore, we explored continuous intracisternal infusion of bupivacaine for the treatment of refractory pain of the head and neck. Intracisternal catheters were inserted in 13 adults with refractory nonmalignant (n = 4) and malignant (n = 9) pain from the head, face, mouth, neck, and upper extremities; 0.5% plain bupivacaine was infused continuously at rates of 1-7 (median 1.5) mg/h with optional bolus doses of 0.5-2.0 mg 4-2 times/h. The efficacy was assessed from pain relief (daily VAS(max), VAS(min), and VAS(mean) scores 0-10), daily doses of intracisternal bupivacaine and total opioid (expressed as mg parenteral morphine-eq), amount of nocturnal sleep, and rates of adverse effects. The 13 patients were treated for 3-182 days (median 37, total 712 days), 3 patients being treated at home for 10-112 days (median 88, total 210 days). In one patient, the efficacy of the treatment could not be estimated because of advanced senility. Eleven of the remaining 12 patients obtained acceptable pain relief with daily doses of intracisternal bupivacaine ranging from 20 to 118 mg (median 37 mg): VAS(mean) scores decreased from 7 to 2, mean pain relief increased for 30% to 80%, total opioid daily dose decreased from 53 to 36 mg parenteral morphine-eq, and nocturnal sleep increased from 2 to >6h (all figures are median values). Speech, eating, walking, and natural functions were generally not affected. Side effects such as tiredness and malaise, somnolence and sleep, feeling of coldness in the neck and skull base, transient post-spinal puncture headache, paresthesias, hoarseness, dysphagia, transient paresis of the upper/lower extremities, episodic miosis and conjunctival hyperemia, and transient orthostatic arterial hypotension were each observed in one or two patients. No patient presented clinical evidence of phrenic nerve paralysis. There was no nausea or vomiting. No persistent neurologic deficit or death could be attributed to the intracisternal pain treatment. Continuous intracisternal infusion of bupivacaine may be a useful method in exceptional, well selected patients with refractory pain from the head and neck structures. Further studies are necessary to establish the indications and the safety of the method.

Pain assessment and the use of morphine.

AimThe aim of this article is to augment and update the nurse's knowledge of pain assessment and management in children, and to highlight the central role of the nurse in achieving effective and acceptable pain management for the children in his/her care.

Long-term intrathecal morphine and bupivacaine in patients with refractory cancer pain. Results from a morphine:bupivacaine dose regimen of 0.5:4.75 mg/ml.

There are no clinical data regarding the ratios and concentrations in which morphine and bupivacaine should be combined, when given intrathecally, to improve analgesia while decreasing adverse effects. This study was undertaken to test the clinical efficacy of a constant infusion of 0.5 mg/ml morphine plus 4.75 mg/ml bupivacaine (morphine: bupivacaine approximately 1:10), given through open intrathecal catheters. In 53 patients, the clinical efficacy was estimated from: pain relief (visual analog scale scores 0-10); daily dosages (intrathecal and total opioid and intrathecal bupivacaine); scores (0-5) of nonopioid analgesic and sedative consumption, gait and daily activity, and amount of sleep; and rates of adverse effects. During the intrathecal period (7-334, median 29 days), all 53 patients obtained acceptable pain relief (visual analog scale scores 0-2 vs. 6-10 in the pre-intrathecal stage). The total opioid daily consumption decreased (median 10 vs. 120 mg), the sleep was about two times longer, the nonopioid analgesic and sedative consumption about two times lower, and the gait ability pattern was unchanged. The daily dose of intrathecal morphine (median 6 mg) and the daily intrathecal volumes (median 10 ml) were low, whereas the daily dose of intrathecal bupivacaine was relatively high (median 50 mg). Side effects potentially related to intrathecal morphine (seizures, cerebral, and spinal clonus) were not recorded. Side effects attributable to intrathecal bupivacaine (in patients not having these complications before the intrathecal treatment) occurred in the forms of late urinary retention (9 of 27), paresthesias (11 of 27), paresis/gait impairment (9 of 27), and occasional episodes of orthostatic arterial hypotension (1 of 53 patients). A constant intrathecal infusion with a morphine:bupivacaine ratio of approximately 1:10 and concentrations of morphine of 0.5 mg/ml and bupivacaine of 4.75 mg/ml may significantly improve the relief of refractory cancer pain with a certain risk of adverse effects (which should be balanced against pain by the patient) from the relatively high intrathecal bupivacaine doses and concentration.

High Transdermal Fentanyl Requirements in a Patient with Chronic Cancer Pain

To report a case of high transdermal fentanyl dosage requirements in a patient with chronic cancer pain. Clinical studies, review articles, and relevant laboratory information. A 42-year-old woman with cervical cancer was admitted for control of her pain. Her outpatient analgesic regimen was a continuous intravenous infusion of morphine sulfate (MS) via an ambulatory infusion device. Upon admission, supplemental doses of intravenous MS were administered in an effort to eliminate the pain. Transdermal fentanyl therapy was initiated on hospital day 1 at 100 micrograms/h and the MS continuous intravenous infusion dosage was increased. Over the next four days, the patient experienced episodes of inadequate pain control and the transdermal fentanyl dosage was increased in increments of 100 micrograms/h. On hospital day 4 the MS continuous infusion was converted to patient-controlled analgesia (PCA). The patient reported acceptable pain control with a regimen of transdermal fentanyl 500 micrograms/h and MS via PCA and she was discharged home on hospital day 7. This patient's high transdermal fentanyl dosage requirement was related to disease progression. She experienced an acute pain episode that may have been effectively managed by increasing the dosage of her continuous intravenous MS infusion.

Patient‐controlled analgesia with and without background infusion. Analgesia assessed using the demand: delivery ratio

Sixty adult patients following general surgical operation were treated with patient-controlled analgesia using morphine. Patients were allocated into three groups to receive: no background infusion, a 1 mg.h-1 or a 2 mg.h-1 background infusion. The other controls on the patient-controlled analgesia machine were set to allow a maximum dose of morphine of 6 mg.h-1 to each group. Analgesia was assessed after 4 and 24 h using a 100 mm horizontal visual analogue scale. The number of analgesic requests made by the patient and the number of those requests which resulted in successful deliveries was recorded. Patients who received a regimen including a background infusion had improved pain relief, particularly in the first 4 h of treatment (p < 0.05). Patients who received a background infusion of 2 mg.h-1 had an increased incidence of nausea (p < 0.05). A background infusion of 1 mg.h-1, with a 1 mg bolus dose and a 12 min lockout interval provided acceptable pain relief without excessive nausea. In all three groups the ratio of analgesic requests to successful deliveries correlated with the degree of pain reported by visual analogue score (p = 0.0001).

Description of a mechanistic approach to pain management in advanced cancer. Preliminary report

A mechanistic approach to advanced cancer pain management is proposed, based on the clinically perceived anatomical and pathophysiological mechanisms of pain generation. It is an extension of the World Health Organisation (WHO) analgesic ladder in which severity of pain is the principal determinant of analgesic choice. The mechanistic categories are: superficial somatic, deep somatic, visceral and neurogenic (mixed or pure i.e., nociceptive component present or absent). Allocation of pain to the different categories is based on clinical history, physical findings and investigations to establish the site and extent of active primary or metastatic tumour deposits, and evidence of previous response to medication. Drug choice sequence is determined by the dominant pain mechanism judged to be present and not the severity of the pain. In order to describe this approach, mechanisms of pain, disease distribution and drug treatment have been analysed in the first 20 consecutive patients who consented to enter a longitudinal pain description and evaluation study on admission to an inpatient hospice unit. Despite a high exclusion rate from research standard monitoring due to severity of illness and related factors, the majority of eligible patients approached to enter the study did so, and the pain scoring was well tolerated. The implications of this for future research and clinical practice are discussed. In 6 patients only 1 pain mechanism was identified (visceral 4, deep somatic 2). Two mechanisms were present in 8 patients and 3 mechanisms in 6 patients. The deep somatic mechanism was identified in 15 patients, visceral mechanism in 13, neurogenic in 10 and superficial somatic in 2. The most common combination of mechanisms was neurogenic/visceral/deep somatic (5 patients) and neurogenic/deep somatic (4 patients). No patient had neurogenic pain alone or superficial pain alone. To achieve optimal analgesia, a mean of 2.8 drug classes per patient was required (range: 1–5). All 20 patients required an opioid, and in 2 patients with visceral pain only, morphine was the initial and sole analgesic used. None of the 15 patients with deep somatic pain achieved acceptable pain relief with an anti-inflammatory drug alone at conventional dose levels. It is concluded that the approach is feasible, and prospective assessment and validation of the response of these proposed mechanism categories to specific drug classes is now underway. Assessment of the anti-inflammatory responsive component of nociceptive cancer pain has emerged as a priority for further investigation.

The Bologna Eubiosia Project: Hospital-at-Home Care for Advanced Cancer Patients

Since 1985 the Associazione Nazionale per lo Studio e la Cura dei Tumori Solidi (ANT), an Italian nonprofit anticancer organization, has provided a hospital-at-home care program for advanced and very advanced cancer patients. This program is part of the Eubiosia Project which also includes a number of complementary services. Teams of doctors, nurses, and psychologists work round-the-clock in the region and on hospital wards, assisted by diagnostic and therapeutic facilities applicable at home and by a round-the-clock on-call service seven days a week. The patients who were treated between December 1985 and December 1991 numbered 5603, of whom 2130 received treatment in 1991 alone, with 702 patients on line at the end of the period. The mean duration of home care for the first 2803 deceased patients was 62 days, and the percentage of deaths at home was 70%. We analyzed control of the main symptoms and the residual survival in three groups of patients--stomach, lung, and breast cancer sufferers--and found that acceptable pain control was achieved in 95% of cases. From the retrospective analysis of our data it can be seen that the eligibility criteria for entry to home care should not only depend upon performance status and the presence of symptoms, but should also take into account the factors that are inherent to the natural history of any kind of tumor as well as the social, domestic, and psychological characteristics of the patients.

A LONG-TERM SURVIVING CASE OF ADVANCED BREAST CANCER WITH LYMPHANGITIS TYPE LUNG METASTASIS

A 35-year-old woman was admitted to this hospital because of a mass in the left breast in April 1981. She had had a fever, cough and dyspnea which were relatively controlled by antibiotics prescribed by a previous doctor. Slight cough and dyspnea, however, were yet observed and lymphangitis carcinomatosa of the lung was suspected by a chest X-ray film. The diagnosis of breast cancer with lung metastasis was confirmed by an aspiration biopsy cytology of the breast mass and open lung biopsy. Simple mastectomy with external axillary dissection was performed. The combined chemoendocrine therapy using cyclophosphamide, adriamycin, tegafurl and antiestrogens was added postoperatively. She has been well without any symptoms such as respiratory distress during these 10 years, except an acceptable pain due to multiple bone metastasis. This is a rare case of long-term survival bearing a lymphagitis type lung metastasis from not only breast cancer but also any other malignancies.

Comparison of intermittent bolus with continuous infusion of epidural morphine in the treatment of severe cancer pain

Twenty-eight patients with severe pain due to cancer, who could no longer obtain acceptable pain relief from optimised doses of oral opioids, were entered into a study which compared pain relief, satisfaction with pain therapy and estimates of neuropsychological functioning during treatment with spinally administered (i.e., epidural and intrathecal) morphine as either repeated bolus doses or as a continuous infusion. These measures of efficacy and side effects were repeated every 2 weeks until either the patient died (82% of patients), withdrew from the study or were no longer able to complete the tests due to deterioration of their condition. The mean (range) duration of treatment was 169 (6–537) days for those patients receiving continuous infusion and 140 (28–378) days for those patients receiving repeated bolus doses. There was no significant difference in visual analogue pain scores, pain relief scores and satisfaction scores between the bolus and infusion groups. Furthermore, low pain scores and high pain relief scores indicated that both treatment modalities provided effective pain control. Similarly, there was no significant difference between the two groups in the various tests used to assess depression or neuropsychological function (i.e., memory, vigilance, attention and processing). There was a significantly greater degree of dose escalation in patients receiving continuous infusion compared to patients receiving repeated bolus doses. For 6 patients in the infusion group the catheter was sited in the intrathecal space, as the dose requirements by the epidural route exceeded the delivery capacity of the pump. For 4 patients in the bolus group the catherer was similarly sited, due to pain on injection and leakage/blockage. The epidural administration of morphine as either a continuous infusion or intermittent bolus doses provided an equivalent extent of pain relief and no consistent difference in tests designed to assess depression and neuropsychological function.