Decrease In Analgesic Consumption Research Articles

Analgesic use may not decrease in the first postoperative year in patients underwent total knee arthroplasty due to advanced osteoarthritis

BackgroundTotal knee arthroplasty (TKA) is expected to relieve pain and reduce the use of analgesics in patients with advanced knee osteoarthritis. However, in some cases, there is no relief in the pain of the patients and the use of analgesics continues. The aim of this study was to compare analgesic consumption one year before and after TKA in the same patient group and to evaluate whether there is a decrease in analgesic consumption after TKA. MethodThe cumulative amounts of analgesia used by the patients in the one-year periods before and after the operation were checked from the automated patient records system and the national systems showing drug prescriptions. The dosages of all the analgesics used in the one-year periods before and after the operation were calculated and converted to oral morphine equivalents (OME). The demographic data of the patients, cumulative OME and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores were used in the assessment. ResultsIt was observed that there was a statistically significant improvement in Womac scores after the treatment compared to the pre-treatment. Although the mean amount of analgesics decreased compared to pre-treatment, it was not statistically significant. Also, age and preoperative analgesic use were found to be the two most important factors in relation to total postoperative analgesic consumption. ConclusionThe results of this study indicate that there may not be a substantial reduction in the use of analgesic by patients within the first year after TKA. Furthermore, the age and preoperative analgesic use were identified as the two primary factors influencing postoperative analgesic consumption. Level of evidenceRetrospective Cohort Study.

Comparison of analgesic efficacy of ultrasound-guided erector spinae block with port site infiltration following laparoscopic cholecystectomy

ABSTRACT Background One of the foremost common medical reasons for delayed discharge following ambulatory surgery is pain. Erector spinae plane block (ESPB) is a comparatively new technique utilized for intra‑ and post‑operative analgesia. We aimed to compare the analgesic efficacy of ESPB with port site infiltration in laparoscopic cholecystectomy (LC) patients. Methods Forty-four patients 18–60 years old with body mass index (BMI) of 18–35 kg/m2 who were scheduled for laparoscopic cholecystectomy were randomized into two groups (22 patients each) either to obtain an ultrasound‑guided Bilateral ESPB (group A) or port‑site infiltration of local anesthetic (group B) after anesthesia induction. The primary outcome was the total postoperative nalbuphine consumption in the first 24 h. Results The overall amount of rescue analgesia was significantly lower in group A (8.27 ± 1.12 mg for nalbuphine as first-line rescue analgesic and 10 patients needed ketorolac as second line rescue analgesic) than in group B (15.92 ± 2.11 mg for nalbuphine as first-line rescue analgesic and 22 patients needed ketorolac as second-line rescue analgesic) during the first 24 h postoperatively. The time to first analgesic request showed statistically significant difference between the two groups with longer time in group A (p value < 0.001). The numerical rate score at rest and when coughing was significantly lower in group A than group B. Conclusion Erector spinae plane block was superior to port site infiltration regarding decrease in analgesic consumption and prolongation in time of postoperative rescue analgesia in patients undergoing laparoscopic cholecystectomy.

English

BACKGROUND Post caesarean section pain requires effective analgesia. Effective analgesia is integral to improvement of quality and patient care among lower segment caesarean section (LSCS) patients. Magnesium, an N-methyl-D-aspartate receptor antagonist along with calcium-channel blocker, has previously been investigated for its analgesic properties. But there is scanty previous literature available for intramuscular magnesium sulphate in the analgesic role in post caesarean mothers. The purpose of this study was to evaluate the effect of existing MgSO4 regimens (among severe pregnancy induced hypertension patients, excluding eclampsia) during early 1st 24 hours’ postoperative analgesic requirements in caesarean section patients comparing to only analgesic group. METHODS It is a retrospective observational study, conducted from January 2019 to June 2020. Patients were randomly selected, normal patients as control = 50 who got post-operative inj. diclofenac 75 mg IM twice a day and rescue analgesia inj. diclofenac 75 mg IM. Test sample comprised of 50 randomly selected severe pregnancy induced hypertension (PIH) patients who got prophylactic inj. magnesium sulphate by Pritchard regimen for 24 hrs. post delivery with 4 gm 20 % inj. magnesium sulphate intravenous with 10 gm 50 % intramuscular in both buttocks as loading dose followed by 5 gm 50 % inj. magnesium sulphate intramuscular 4th hourly for 24 hrs. along with inj. diclofenac 75 mg IM twice a day. Visual analogue scale for pain was noted among both the groups, and were compared for the effect of analgesics in the study groups. RESULTS There was a decrease in analgesic consumption and immediate post-operative pain in the group receiving MgSO4 with analgesic (inj. diclofenac 75 mg), in comparison to control group of inj. diclofenac 75 mg. (P &lt; 0.0001). CONCLUSIONS There was a decrease in analgesic consumption in the group receiving MgSO4 plus analgesic, in comparison to control group (analgesic group). Pain severity assessment 2, 6, 12 and 24 hours post operatively showed that there was a statistically significant decrease in pain scores between the study and the control groups (P &lt; 0.0001). It established the role of magnesium sulphate as an adjuvant analgesic along with diclofenac or other traditionally used pain medications among the post caesarean mothers in early post-operative period. KEYWORDS Analgesia, Pregnancy, Post-Operative Analgesia, Magnesium Sulphate, Lower Segment Caesarean Section (LSCS), Pain Relief, Obstetrics

V11-11 ROBOTIC AUGMENTATION CYSTOPLASTY FOR CONTRACTED BLADDER SECONDARY TO CYSTITIS: A 1-YEAR OUTCOME ASSESSMENT

You have accessJournal of UrologyTransplant, Misc GU Cancers & Bladder Reconstruction (non-cancer) (V11)1 Apr 2020V11-11 ROBOTIC AUGMENTATION CYSTOPLASTY FOR CONTRACTED BLADDER SECONDARY TO CYSTITIS: A 1-YEAR OUTCOME ASSESSMENT Chi Hang Yee*, Peter Ka Fun Chiu, Yun Sang Chan, Jeremy Yuen Chun Teoh, Mandy Ho Man Tam, Hon Ming Wong, Chi Kwok Chan, See Ming Hou, and Chi Fai Ng Chi Hang Yee*Chi Hang Yee* More articles by this author , Peter Ka Fun ChiuPeter Ka Fun Chiu More articles by this author , Yun Sang ChanYun Sang Chan More articles by this author , Jeremy Yuen Chun TeohJeremy Yuen Chun Teoh More articles by this author , Mandy Ho Man TamMandy Ho Man Tam More articles by this author , Hon Ming WongHon Ming Wong More articles by this author , Chi Kwok ChanChi Kwok Chan More articles by this author , See Ming HouSee Ming Hou More articles by this author , and Chi Fai NgChi Fai Ng More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000945.011AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Ketamine abuse can result in a small contracted bladder via a pathological inflammatory and fibrotic process. We reported the 1-year outcome of robotic augmentation cystoplasty in patients diagnosed of ketamine cystitis. METHODS: This is a prospective series of patients with ketamine cystitis who underwent robotic augmentation cystoplasty in our institution. During the surgery, 30-35cm ileal segment was isolated for augmentation in a clamp cystoplasty manner. Assessment included basic demographic data, functional bladder capacity (FBC), pelvic pain and urgency/frequency (PUF) symptom scale, EQ-VAS and analgesic consumption. Pre-operative and 1-year follow-up data were compared. RESULTS: Between October 2014 and July 2018, 11 patients underwent the procedure. Mean operative time was 283.8 ±98.9 minutes. Pre-operative mean FBC was 58.1 ± 36.6, 1-year post-operative FBC was 309.3 ± 231.5ml (p=0.001). Improvement in PUF total score (mean score 27.0 ± 4.1 vs 15.6 ± 6.1, p=0.003) and decrease in analgesic consumption (number of patients 6 vs 1, p=0.037) were observed after operation. One patient had Clavien-Dindo grade 1 complication and one patient had Clavien-Dindo grade 3 complication. CONCLUSIONS: Robotic augmentation cystoplasty provides a minimally invasive surgical option to significantly improve the bladder capacity in patients with a contracted bladder. Pain relief can also be achieved in severe cystitis patient after robotic augmentation ileocystoplasty. Source of Funding: Nil © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e1017-e1018 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Chi Hang Yee* More articles by this author Peter Ka Fun Chiu More articles by this author Yun Sang Chan More articles by this author Jeremy Yuen Chun Teoh More articles by this author Mandy Ho Man Tam More articles by this author Hon Ming Wong More articles by this author Chi Kwok Chan More articles by this author See Ming Hou More articles by this author Chi Fai Ng More articles by this author Expand All Advertisement PDF downloadLoading ...

The analgesic efficacy of paravertebral block for percutaneous nephrolithotomy: A meta-analysis of randomized controlled studies.

Introduction:The analgesic efficacy of paravertebral block for percutaneous nephrolithotomy remains controversial. We conduct a systematic review and meta-analysis to explore the analgesic efficacy of paravertebral block for patients with percutaneous nephrolithotomy.Methods:We have searched PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases, and randomized controlled trials (RCTs) assessing analgesic efficacy of paravertebral block for percutaneous nephrolithotomy are included in this meta-analysis.Results:Five RCTs are included in the meta-analysis. Overall, compared with control group after percutaneous nephrolithotomy, paravertebral block is associated with the decrease in analgesic consumption (standard mean difference (Std. MD) = −1.55; 95% confidence interval (CI) = −2.18 to −0.92; P < .00001) and additional analgesics (risk ratio (RR) = 0.17; 95% CI = 0.07 to 0.44; P = .0003), prolonged time to first analgesic requirement (Std. MD = 1.51; 95% CI = 0.26 to 2.76; P = .02). There is no statistical difference of adverse events including nausea or vomiting (RR = 0.51; 95% CI = 0.11 to 2.35; P = .38), or itching (RR = 0.69; 95% CI = 0.26 to 1.81; P = .45) between 2 groups.Conclusions:Paravertebral block is effective for pain control after percutaneous nephrolithotomy.

Impact of Medical Care on Symptomatic Drug Consumption and Quality of Life in Headache: A One-Year Population Study.

Background: Chronic headache is one of the most common pain conditions, often leading to symptomatic drug overuse. The aim of this study was to provide data on symptomatic drug consumption in an Italian outpatient population and to describe how the clinical picture of headache may change after headache experts take charge of the care of affected individuals.Methods: A total of 199 adults complaining of chronic headache were recruited through 32 pharmacies in the Pavia health district. Participants underwent four evaluations: a baseline assessment (T0) and three follow-up evaluations performed by a neurologist at 3, 6, and 12 months (T3, T6, and T12, respectively). On each occasion, they underwent a complete neurological assessment and received therapeutic adjustments to achieve better management of their headache.Results: On the basis of a preliminary telephone interview, the prevalence rates of chronic headache and medication overuse headache (MOH) were 16 and 12%, respectively. At 12 months of follow-up, we observed a significant decrease in the frequency of attacks (T0: 9 ± 9/month vs. T12: 2 ± 2/month; p < 0.001), in the number of days/month with headache (T0: 11 ± 9 vs. T12: 4 ± 4; p < 0.001) and in single attack duration (T0: 34 ± 30 h vs. T12: 10 ± 19 h; p < 0.001). Careful headache management resulted in a significant decrease in analgesic consumption (T0: 12 ± 16 vs. T12: 4 ± 6 doses/month; p = 0.014) and a significant increase in quality of life, measured using the Migraine Disability Assessment Scale (MIDAS) and Headache Under-Response to Treatment (HURT) scales (p < 0.001).Conclusions: Headache management by a specialist is more effective than self-treatment, resulting in an overall benefit for headache patients.

Opioid Sparing Anaesthesia for Living-Donor Renal Transplantation-A Case Report

Introduction: Opioids have been the mainstay for perioperative analgesia. Non-opioid drugs with analgesic properties improve intraoperative multimodal analgesia and lead to a decrease in analgesic consumption, reduction in pain scores, postoperative rescue analgesia and in postoperative nausea and vomiting. We report a case of a patient with Alport Syndrome and End Stage Renal Disease (ESRD) proposed for elective Living-Donor Renal Transplantation, with reported allergies/intolerance to opioids. Case report: 30-year-old male patient, American Society of Anesthesiologists physical status IV, medical history of Alport Syndrome, ESRD treated with peritoneal dialysis, allergy to tramadol and morphine intolerance. A general intravenous anaesthesia and TAP block was performed. Remifentanil and propofol were used until loss of consciousness. Propofol infusion was then started for effect-site concentration. Maintenance of anaesthesia was achieved with remifentanil infusion to target effect-site, dexmedetomidine infusion and a bolus of ketamine. An ultrasound guided TAP block was performed, using ropivacaine. Analgesia was complemented with paracetamol. Surgical procedure lasted 2 h during which patient was stable, with no record of any adverse events. Emergence of anaesthesia was smooth and painless, and there were no analgesic needs during the time-spent in the recovery unit. Postoperative analgesia plan was PCA pump of morphine with ketamine, and paracetamol every 6 h. During the first 48 h, acute pain team reported no PCA pump requirements, no important discomfort and no complications. Patient improved uneventfully, with a total length of hospital stay of 8 days. Discussion and learning points: Patients proposed for renal transplantation surgery, with ESRD, present significant challenges for the anaesthesiologist and alternatives to use of opioids could be an option. An opioid sparing technique using regional anaesthesia combined with several drugs with analgesic properties was performed and good analgesic control was accomplished, with no adverse effects, providing a good and fast recovery after a renal transplantation.

Safety and efficacy of combination therapy with low-dose gemcitabine, paclitaxel, and sorafenib in patients with cisplatin-resistant urothelial cancer.

418 Background: Various chemotherapeutic regimens have been examined. However, there is no effective regimen, and some studies have been stopped because of severe adverse events. Therefore, maintenance of quality of life is also important. This study examine the anti-cancer effects, changes in the quality of life (QoL), and safety of combined therapy of low dose gemcitabine, paclitaxel, and sorafenib in these patients. Methods: Twenty patients were treated with gemcitabine (700 mg/m2 on day 1), paclitaxel (70 mg/m2 on day 1), and sorafenib (400 mg/day on days 8–22). QoL and pain relief were evaluated using the short-form survey (SF)-36 and the visual analogue scale (VAS). Data on QoL and pain were collected on the day before the first cycle was started and 8 weeks after starting the therapy. A total of 124 cycles were administered and the median (IQR) number of treatment cycles per patient was 5 (3–8) cycles. Results: Among 20 patients, 12 and 8 patients were received as 2nd- and 3rd-line therapy, respectively. In 2nd-line therapy, median / interquartile range of VAS scores after therapy (2 / 2–3) significantly decreased (p = 0.012) compared to their pretreatment levels (3 / 2–5). Likewise, a significant decrease was also found in 3rd-line therapy (5/ 4–6 to 3/ 2–3, p = 0.028). Similar findings were confirmed by the bodily pain score from the SF-36 survey. A decrease in analgesic consumption was seen in three patients (17.6%), and 2 patients (11.8%) was improved the pain without increasing the dose. Complete responses, partial responses, and stable disease were found in 0 (0.0%), 1 (5.0%), and 13 patients (65%), respectively. The period of overall survival after starting of this therapy was 7 (5–11) months. Three patients (15.0%) stopped therapy because of grade 3 fatigue and hand-foot reactions. Conclusions: Combined therapy of low dose gemcitabine, paclitaxel, and sorafenib was well tolerated. QoL was maintained and improvements in their pain levels were found after treatment. We suggest that this treatment regimen is worthy of consideration as 2nd- and 3rd-line therapy for patients with CDDP-resistant UC. Clinical trial information: 000010957.

The effect of magnesium sulphate on postoperative analgesia requirements in gynecological surgeries.

Objective:Recent studies have shown the positive effect of magnesium sulphate (MgSO4) on pain reduction and postoperative analgesic requirements in patients undergoing surgery. We assessed the effect of MgSO4 on intra-operative and postoperative analgesic requirements in patients undergoing lower abdominal gynecological laparotomy.Materials and Methods:This randomized clinical trial was conducted on 30 female patients at Rasool-e-Akram (referral and academic) hospital in Tehran from August 2012 to March 2013. The patients who were candidates for gynecologic surgeries (hysterectomy and/or myomectomy) were randomized into study (n=15) and control (n=15) groups. Same anesthetic technique was used in all patients. Besides induction of the anesthesia in the study group, we administered MgSO4 50 mg/kg/hr intravenously (IV) for analgesic purposes as a bolus dose and then 8 mg/kg IV as maintenance dose. Control group received the same anesthetic agents and the same amount of isotonic saline instead of MgSO4. Analgesic consumption was measured in both groups postoperatively within 24 hours. The visual analog scale (VAS) was used for the evaluation of postoperative pain in both groups.Results:There was a decrease in analgesic consumption and pain in the group receiving MgSO4, in comparison to control group. Pain severity assessment, 24 hours post operatively showed similar results in both groups. There was a statistically significant difference in prescribed dose of pethidine between study and control groups (p=<0.0001).Conclusion:Intra-operative MgSO4 is effective in postoperative pain control following lower abdominal laparotomy. Further studies with larger sample sizes and longer follow-up should be performed to obtain more information about safety and to determine whether doses of MgSO4 can provide postoperative analgesic benefits.

Effect of Balneotherapy in chronic low back pain treatment

The balneotherapy is a therapy that uses the mineral springs for the treatment of numerous diseases, and the physical properties of these waters may have a role in the mechanism of action of mineral water. Over the past decades, a re-assessment of the use of mineral water for the treatment of several diseases has taken place around the world. Chronic low back pain is a major public health problem in industrialized countries, it affects 80% of people and, in 85% of cases, the inaugural episode is followed by recorrencies. Its incidence and prevalence increases with age and is considered chronic when it persists for more than 7-12 weeks.The impoverished existing evidence contrasts with the popularity of these treatments and with the expenses incurred by insurers and health systems of some European countries (eg. Germany).The authors proposed reviewing the literature to clarify the present evidence regarding the effect of this therapeutic modality in the treatment of chronic low back pain. The meta-analysis of 2 randomized clinical trials concluded there was a significant reduction in pain intensity, measured on a 100mm visual analogue scale (VAS), in treated patients relative to controls. Individually, one of these studies also showed a decrease in analgesic consumption (p <0.01) and the other one showed an increase in functionality measured by the modified Schober test (p <0.001). One randomized study evaluated the VAS, lumbar mobility, and the Oswestry, EuroQoL-5D and Short Form-36 indices, with a significant improvement in all tests in the treatment group relative to the controls. The improvement observed in the first three lasted 10 weeks. It was also observed a significant decrease in the consumption of NSAIDs and analgesics in the treatment group, but the difference between groups was not statistically significant. Another randomized study showed an improvement in VAS (p <0,01), decrease in the paravertebral muscle spasms and sensitivity (p <0.01), as well as increased mobility (p <0.01) in patients treated for a period 3 months. In contrast, the improvement observed in the control group was only temporary and only in the VAS (p <0.01). In a nonrandomized study were evaluated pain intensity, Oswestry index, quality of life, use of NSAIDs/analgesics, and the subjective perception of disease for patients and observers. All parameters were significantly improved, and the effects lasted at least months. The mean age of the patients ranged from 39-44 to 64 years. The data collected showed significant improvements in pain, functionality, quality of life and consumption of NSAID/analgesic drugs in patients with chronic low back pain undergoing thermal therapy. As a major limitation, there were no double-blinded studies, since the physical and chemical properties of the mineral springs differ significantly from those found in tap water. We conclude that balneotherapy is an effective modality in the treatment of chronic low back pain in patients of middle age, being necessary more studies to validate thermal waters for individual springs, and pharmacoeconomic studies that evaluate the balneotherapy as a complementary modality in the management of low back pain is chronic.

The analgesic effect of electrostimulation (WoundEL®) in the treatment of leg ulcers

This study aims to demonstrate the analgesic efficacy of electrostimulation (ES), a recognised treatment for leg ulcers. Patients treated by ES for leg ulcers between 2011 and 2013 were included in the study. The pain score obtained with the numerical rating scale (NRS) was reported before the start of the ES (D0), after 3 days (D3) and 1 week following treatment initialisation. The analgesic treatments (AT) were reported at each assessment. Seventy-three patients were included (mean age 75·19 years): 31 venous leg ulcers, 21 mixed venous leg ulcers, 2 arterial ulcers, 17 hypertensive ischaemic ulcers, 1 Hydrea(®)-induced ulcer and an amputation stump ulcer. The NRS at D0 was on average 5·3 (median = 6) while it was 2·2 at D7 (median = 2), that is P < 0·001. The results were also significant between D0 and D3 (P < 0·001). A decrease in the number of AT used was observed between D0 (2·0 AT per patient on average) and D7 (1·7 AT on average) (P < 0·001). We also observed a decrease in the consumption of grade 3 analgesics on D0 and D7 (P = 0·03). This study demonstrates the rapid analgesic efficacy of ES in leg ulcers, with a clear impact on the NRS score and especially on the decrease in analgesic consumption.

Percutaneous ultrasonography and computed tomography guided pancreatic cryoablation: Feasibility and safety assessment

ObjectiveTo assess the safety and feasibility of percutaneous cryoablation on pancreatic cancer via ultrasonography (US) and computed tomography (CT) guidance. Materials and methodsThis retrospective review was approved by the institutional review board and of informed consent. Thirty-two patients (18 men and 14 women; median age 62; age range, 30–77years) with pancreatic cancer (stage II/III/IV, 3/11/18) treated with percutaneous US and CT guided cryoablations between February 2009 and February 2010 were eligible for this review. Thirteen tumors in pancreatic head and 19 in pancreatic body and/or tail measuring 2–11cm (mean, 5.2cm±8 [standard deviation]) were ablated with 49 procedures in total. Feasibility was analyzed by enhanced CT 1–3months post procedure and safety was assessed by clinical signs, symptoms and laboratory results. ResultsNeither procedural death nor serious complications occurred. Fifteen tumors (46.9%) smaller than 5cm were successfully ablated by one session of cryoablation. Twenty-seven patients experienced a ⩾50% reduction in pain score, 22 experienced a 50% decrease in analgesic consumption and 16 experienced a ⩾20 increase in Karnofsky Performance Status (KPS) Score. Partial response (PR) and stable disease (SD) turned up in 9 and 21 patients, respectively, lesions in whom were identified controlled by none enhancement on enhanced CT. Mean and median survival was 15.9 and 12.6months, respectively. The 6-, 12- and 24-month survival rates were 82.8%, 54.7% and 27.3%, respectively. ConclusionUS and CT guided percutaneous cryoablation is a safe and promising local treatment for pancreatic cancer.

Low-dose gemcitabine and paclitaxel combination therapy as second- or third-line treatment in patients with advanced urothelial cancer: Pain relief and tolerability.

310 Background: Pain is the most devastating symptom of advanced urothelial cancer (UC). In addition, analgesics often decrease quality of life. So, pain relief and reduction of dosage are important goals for patients with such advanced UC. Cisplatin (CDDP)-containing chemotherapy is most effective regimen in patients with metastatic or recurrent UC. On the other hand, there is no established regimen for advanced UC after CDDP-containing chemotherapy. We performed low-dose combined therapy of gemcitabine (GEM) and paclitaxel (PTX), named GP therapy, as second- or third-line treatment for these patients. Methods: Thirty-three patients with metastatic and/or recurrent urothelial cancer (upper urinary tract = 13 and bladder =20 patients) previously treated with CDDP-containing chemotherapy were treated with GP therapy (GEM = 70 mg/m2 and PTX = 700 mg/m2 on day 1 and 8, repeated every 28 days). Survival was calculated from judgment of tumor progression. Pain was measured on a visual analog scale of 0–10. Positive effects for pain relief were defined as a decrease in analgesic consumption or a decrease in pain grade according to the visual analog scale, without increasing the dose of analgesics. Regulation of analgesics was performed by independent team that did not know this study. Pain relief and survival were compared with other chemotherapy (control; GEM alone = 9 and PTX-based chemotherapy except for GP therapy = 14). Results: At the start of this treatment, 31 patients had abdominal or back pain due to UC. In addition, 3 patients also had bone pain of metastatic tumors. In GP therapy, 28 patients (84.8%) were judged as positive in pain and only 1 patient needed to increase analgesics. On the other hand, control group showed 13 of 23 patients (56.5%) were stable and 7 (30.4%) were judged as positive in pain. Kaplan-Meier survival curves showed overall survival periods in patients with GP therapy were better compared to control group (p=0.023). All patients were received in the outpatient setting because severe side effect was not occurred. Conclusions: Low-dose GP therapy is feasible and well-tolerated as second/third-line chemotherapy in patients with advanced UC.

Control of Pain After Surgical Debridement of Burn Wounds

Dear Editor, We read with interest your article on the use of gabapentin pain control after burn debridement (1). Gabapentin has a well-established role in the management of neuropathic pain, and has been investigated in the past decade regarding its ability to potentiate the effect of morphine on postoperative pain, or decrease the amount of pain experienced by patients after surgery. This study represents one of the only randomized, placebo-controlled, double-blind studies to look at gabapentin in burn patients. The authors found that 1200mg of gabapentin 2 hours prior to operative debridement of burn wounds led to a significant decrease in pain in the immediate 24-hour postoperative period, as measured by the visual analog score and by patient-requested morphine consumption. While the results are important and consistent with the growing body of literature, there remain methodological questions that are not addressed (2-4). First, while the authors state that total burn surface area in all patients were comparable (average of 13% ± 25 in the placebo group versus 19% ± 29 in the gabapentin group), there are several additional characteristics that can significantly affect pain, both pre-and post-operatively. Burn severity, type of burn (flame, chemical) and location on the body are not addressed here. In addition, the extent of debridement must also be considered, with regard to both surface area and depth. Conditions such as infection or other complicating medical conditions are also not mentioned in the article, which can be common in burn patients, and which can significantly affect patient outcome. Secondly, neuropathic pain induced by burns can lead to chronic and debilitating pain; this should be evaluated, depending on the feasibility of follow-up. The authors state that “Fassoulaki et al. (5) were unable to demonstrate a decrease in analgesic consumption and VAS scores at rest or after movement during the first 24h after the operation” due to “differences in the types of surgeries performed.” In fact, however, Fassoulaki et al. (5) were able to find that gabapentin reduced requirement for analgesics and led to decreased pain with movement within the first week post-operatively; the caveat was that this difference did not persist long-term (at 10 days or 3 months). Because chronic pain control can be such an important aspect of clinical outcomes in burn patients, this is critical to consider when thinking about impact on changes in management. In summary, this study provides important support for the use of gabapentin in postoperative pain, and represents one of the only studies to address its use in burn patients. However, several questions regarding the clinical condition of patients (burn severity, type of burn, location of burn, extent of debridement, and presence of infection) must be considered; long-term sequelae with regard to chronic pain must also be addressed. All of these variables must be taken into account before the true impact of gabapentin in these patients can be determined.

The value of intermittent cervical traction in recent cervical radiculopathy

Objective Our objective is to assess the effect of mechanical and manual intermittent cervical traction on pain, use of analgesics and disability during the recent cervical radiculopathy (CR). Methods We made a prospective randomized study including patients sent for rehabilitation between April 2005 and October 2006. Thirty-nine patients were divided into three groups of 13 patients each. A group (A) treated by conventional rehabilitation with manual traction, a group (B) treated with conventional rehabilitation with intermittent mechanical traction and a third group (C) treated with conventional rehabilitation alone. We evaluated cervical pain, radicular pain, disability and the use of analgesics at baseline, at the end and at 1, 3 and 6 months after treatment. Results At the end of treatment improving of cervical pain, radicular pain and disability is significantly better in groups A and B compared to group C. The decrease in consumption of analgesics is comparable in the three groups. At 6 months improving of cervical and radicular pain and disability is still significant compared to baseline in both groups A and B. The gain in consumption of analgesics is significant in the three groups: A, B and C. Conclusion Manual or mechanical cervical traction appears to be a major contribution in the rehabilitation of CR particularly if it is included in a multimodal approach of rehabilitation.

La kétamine dans la douleur aiguë : de la pharmacologie à la clinique

Ketamine is a well-known general anesthetic in use for a long time. The role of NMDA receptor in the processing of nociceptive input has led to renewed clinical interest in N-methyl-D-aspartate (NMDA) receptor antagonists such as ketamine. Animal studies on ketamine and opioid tolerance have shown promising results. Recent data in animal experiments as in clinical trials have clearly reported that pain modulation is related to an equilibrium between antinociceptive and pronociceptive systems. Therefore, the apparent pain level could not only be a consequence of a nociceptive input increase but could also result from a pain sensitization process. We evaluate the clinical literature and discuss the efficacy of low-dose ketamine in the management of acute pain when administered alone or in conjunction with other analgesic agents as morphine. Low-dose of ketamine is a peroperative intravenous bolus (0.1 to 0.5 mg/kg) followed by a constant infusion rate (1 to 2 mcg/kg per min) for 24 to 72 hours. Those ketamine doses improved postoperative pain management by reducing hyperalgesia due to both surgical trauma and high peroperative opioid doses. This antihyperalgesic action of ketamine also limited the postoperative morphine tolerance leading to a decrease in analgesic consumption and an increase in the analgesia quality. Adverse effects were not increased with small dose ketamine. The evidence suggests that low-dose ketamine is a safe and useful in postoperative pain management when used as an adjunct to local anesthetics, opioids, or other analgesic agents.

Kétamine à faibles doses : antihyperalgésique, non analgésique

Recent data in animal experiments as in clinical trials have clearly reported that pain modulation is related to an equilibrium between antinociceptive and pronociceptive systems. Therefore, the apparent pain level could not only be a consequence of a nociceptive input increase but could also result from a pain sensitization process. Glutamate, via NMDA receptors, plays a major role in the development of such a neuronal plasticity in the central nervous system, leading to a pain hypersensitivity that could facilitate chronic pain development. By an action on NMDA receptors opioids also induce, in a dose dependent manner, an enhancement of this postoperative hypersensitivity. “Antihyperalgesic” doses of ketamine, an NMDA receptor antagonist, were able to decrease this central sensitization not only in painful animal but also in human volunteers exposed to different pain models, or in the postoperative period. Many studies have reported that ketamine effects are elicited when this drug is administered the following manner: peroperative bolus (0.1 to 0.5 mg/kg), followed by a constant infusion rate (1 to 2 μg/kg per min) during the peroperative period and for 48 to 72 hours after anaesthesia. Those ketamine doses improved postoperative pain management by reducing hyperalgesia due to both surgical trauma and high peroperative opioid doses. This antihyperalgesic action of ketamine also limited the postoperative morphine tolerance leading to a decrease in analgesic consumption and an increase in the analgesia quality.

Pamidronate improves the quality of life and induces clinical remission of bone metastases in patients with thyroid cancer

Skeletal metastases from thyroid cancer are poorly responsive to medical or radioiodine treatment. Bone destruction in skeletal metastases results from osteoclast-induced bone resorption. Therefore, a new approach in the therapy of bone metastases consists in using aminobisphosphonates, such as pamidronate, which are potent inhibitors of osteoclastic activity. In the present study, 10 thyroid cancer patients with painful osteolytic bone metastases were administered pamidronate (90 mg, as a 2 hour intravenous infusion) monthly for 12 consecutive cycles. Bone pain, quality of life, performance status, analgesic consumption and disease staging were evaluated before and during the trial. The patients who had been administered pamidronate showed a significant decrease in bone pain (P = 0.0052). Performance status improved nearly significantly (P = 0.051), while the quality of life showed a remarkable amelioration. However, no significant decrease in analgesic consumption was recorded. Partial radiographic response of bone lesions was observed in 2/10 patients. The side effects of pamidronate were mild and transient. In conclusion, monthly infusion of pamidronate is a well-tolerated treatment that induces significant relief from bone pain and improves the quality of life of thyroid cancer patients with symptomatic and osteolytic bone metastases. © 2001 Cancer Research Campaign http://www.bjcancer.com

Bilateral thoracoscopic splanchnicectomy: effects on pancreatic pain and function.

To evaluate prospectively the effect of bilateral thoracoscopic splanchnicectomy on pancreatic pain and function. Severe pain is often the dominant symptom in pancreatic disease, despite a wide variety of methods used for symptom relief. Refinement of thoracoscopic technique has led to the introduction of thoracoscopic splanchnicectomy in the treatment of pancreatic pain. Forty-four patients, 23 with pancreatic cancer and 21 with chronic pancreatitis, were included in the study and underwent bilateral thoracoscopic splanchnicectomy. Effects on pain (visual analogue scale) and pancreatic function (standard secretin test, basal serum glucose, plasma insulin, and C-peptide) were measured. Four patients (9%) required thoracotomy because of bleeding. There were no procedure-related deaths. The mean duration of follow-up was 3 months for cancer and 43 months for pancreatitis. Pain relief was evident in the first postoperative week and was sustained during follow-up, the average pain score being reduced by 50%. All patients showed a decrease in consumption of analgesics. Neither endocrine nor exocrine function was adversely affected by the procedure. Bilateral thoracoscopic splanchnicectomy is beneficial in the treatment of pancreatic pain and is not associated with deterioration of pancreatic function.