Difference In Pain Relief Research Articles

Stimulating Catheters in Continuous Popliteal Block

In Response: We thank Dr. Navas for his observations (1) on our recent manuscript (2). Results of our prospective, randomized, blinded trial suggested that stimulating catheters can provide some minor advantages over nonstimulating catheters in continuous posterior popliteal sciatic nerve block. We agree with Dr. Navas that although the observed reduction in onset time was statistically significant, its clinical relevance is questionable. However, the use of a stimulating catheter reduced the amount of local anesthetic and rescue pain medication required to produce the same quality of postoperative analgesia as is provided with a nonstimulating catheter. In our investigation the sciatic nerve was reached 10 cm proximal to the popliteal crease before the 2 main branches of the sciatic nerve divide. One explanation for the shorter onset time was that the final position of the catheter tip was closer to the nerve when direct stimulation through the catheter was used to identify correct positioning. In this study we placed the catheter at the stimulation of either the tibialis or common peronealis nerve. Even though Taboada et al. (3) demonstrated better performance when the tibial twitch was used instead of the common peroneal twitch, we were not able to find differences in results by stratifying for the twitch used for catheter placement. However, our study was not designed to answer this question. The shorter onset time observed in the common peroneal distribution, as compared with the tibial distribution, may have been attributable to the different size of the two nerves. This agrees with findings reported by Taboada et al. (3). The quality of pain relief was measured at fixed intervals. Both groups had adequate pain relief, and we did not observe differences in pain relief. However, patients with nonstimulating catheters achieved adequate pain relief by consuming more local anesthetic and more rescue tramadol. This could be evidence that the final position of the catheter tip was closer to the nerve with the stimulating than nonstimulating catheters. This hypothesis is supported by findings of Salinas et al. (4), who showed in volunteers that the minimum stimulating current through the catheter resulting in a proper muscular twitch was lower when the catheter was placed with a stimulation-guided technique than that observed after placing the catheter with a “conventional” blind technique. The femoral block was placed for tourniquet pain and was not relevant postoperatively because the block dissipated quickly. Pain after surgery was related to the sciatic nerve distribution and not the saphenous one. Finally, we agree with Dr. Navas that keeping the catheter in place is one of the major problems in failure rate of continuous peripheral nerve blocks. We did not observe differences between stimulating and nonstimulating catheters with respect to this technical problem. Andrea Casati, MD University of Parma Department of Anesthesiology and Pain Therapy Ospedale Maggiore di Parma Parma, Italy [email protected] Francois Singelyn Catholic University of Lovanio St-Luc Hospital Brussels, Belgium Zbignew Koscielniak-Nielsen, MD Copenhagen University Hospital Copenhagen, Denmark Cuido Fanelli, MD Ospendale Maggiore di Parma Parma, Italy

Treatment of Imported Fire Ant Stings With Mitigator Sting and Bite Treatment—A Randomized Control Study

To evaluate the efficacy of the commercially available product Mitigator Sting and Bite Treatment in reducing the pain after imported fire ant stings. Twenty-four volunteer subjects were exposed to imported fire ant stings on both fore-arms. The subjects received Mitigator paste on 1 arm and calamine lotion on the opposite arm, in a blinded manner, from 90 seconds to 10 minutes after exposure. Subjects recorded pain on a 100-mm visual analog scale 60 seconds, 20 minutes, and 3 days after exposure. A 2-tailed paired t test was used to compare the difference in reduction of pain over time between the Mitigator-treated arms and the calamine-treated arms. At 60 seconds, the mean visual analog scale pain score was 23.9 mm for the Mitigator group and 24.5 mm for the calamine group. At 20 minutes, the mean score was 7.6 mm (delta = 16.3) for the Mitigator group and 12.7 mm (delta = 11.8) for the calamine group. At 3 days, the mean score was 2.4 mm (delta = 21.5) for the Mitigator group and 2.9 mm (delta = 21.6) for the calamine group. There was no significant difference between groups for change in visual analog scale pain score at 60 seconds, 20 minutes (P = .256), or 3 days (P = .64). There was no significant difference in pain relief between calamine and Mitigator for imported fire ant stings.

WITHDRAWN: Non-aspirin, non-steroidal anti-inflammatory drugs for treating osteoarthritis of the knee.

Reason for withdrawal from publication Review has been withdrawn until an update can be undertaken to reflect the current evidence. To view the published versions of this article, please click the 'Other versions' tab.

Effects of intermittent hemodialysis on buprenorphine and norbuprenorphine plasma concentrations in chronic pain patients treated with transdermal buprenorphine

The present study was designed to study the impact of intermittent hemodialysis on the disposition of the partial agonist buprenorphine and its metabolite norbuprenorphine during therapy with transdermal buprenorphine in chronic pain patients with end-stage kidney disease. Ten patients (mean age 63 years) who had received transdermal buprenorphine for at least 1 week, were asked to provide blood samples immediately before and after hemodialysis. Blood samples were analysed for buprenorphine and its metabolite norbuprenorphine. The median buprenorphine plasma concentrations were found to be 0.16 ng/ml before and 0.23 ng/ml after hemodialysis. A significant correlation between plasma levels and administered doses was observed (Spearman R = 0.74; P < 0.05). In three patients norbuprenorphine plasma levels were detected. No differences in pain relief before and after hemodialysis were observed. This investigation shows no elevated buprenorphine and norbuprenorphine plasma levels in patients with renal insufficiency receiving transdermal buprenorphine up to 70 μg/h. Furthermore, hemodialysis did not affect buprenorphine plasma levels, leading to stable analgesic effects during the therapy.

A Cochrane Systematic Review Finds No Evidence to Support the Use of Antibiotics for Pain Relief in Irreversible Pulpitis

The Cochrane Systematic Review promotes evidence-based outcomes studies. The review summarized here was conducted in an attempt to achieve reliable evidence concerning the effectiveness, or otherwise, of prescribing antibiotics for patients having irreversible pulpitis. A competent search strategy was developed and used across several databases including MEDLINE to identify randomized controlled trials for inclusion. Assessment of methodological quality was based on criteria defined by The Cochrane Collaboration. Clinical outcome, expressed in terms of pain relief, was examined. There was a relative dearth of research providing a high level of evidence. Only one methodologically sound trial was found that compared pain relief with systemic antibiotic/analgesic treatment against a placebo/analgesic combination during the acute preoperative phase of irreversible pulpitis. Although the selected study used a relatively small, low-powered sample, it did provide some evidence that there is no significant difference in pain relief for patients with untreated irreversible pulpitis who received antibiotics versus those who did not. These findings increase the rationale to investigate the teaching of safe and effective antibiotic prescribing in endodontics and to advance the development of appropriate evidence-based clinical guidelines.

Shock Wave Therapy for Chronic Achilles Tendon Pain

Shock wave therapy has been used for treatment of several soft tissue disorders that are characterized by chronic pain. We sought to determine if shock wave therapy reduces chronic Achilles tendon pain. Forty-nine patients were enrolled in a double-blind randomized placebo-controlled trial. Each patient was treated once a month for 3 months. The primary outcome measure was a reduction in Achilles tendon pain during walking. At the end of the trial, we found no difference in pain relief between the shock wave therapy group and the control group. There were two patients (62 years and 65 years) with tendon ruptures in the treatment group, suggesting caution when treating older patients. These results provide no support for the use of shock wave therapy for treatment of patients with chronic Achilles tendon pain. However, the confidence intervals include the potential for a clinically relevant treatment effect. Therapeutic study, Level I (systematic review of Level I RCTs-and study results were homogenous). See the Guidelines for Authors for a complete description of levels of evidence.

Surgical interruption of pelvic nerve pathways for primary and secondary dysmenorrhoea.

Dysmenorrhoea is the occurrence of painful menstrual cramps of uterine origin and is a very common gynaecological complaint with negative effect on a sufferer's quality of life. Medical therapy for dysmenorrhoea includes oral contraceptive pills (OCP) and nonsteroidal anti-inflammatory drugs (NSAIDs) which both act by suppressing prostaglandin levels. While these treatments are very successful there is still a 20 to 25% failure rate and surgery has been an option for such cases. Uterine nerve ablation (UNA) and presacral neurectomy (PSN) are two surgical treatments that have become increasingly utilised in recent years due to advances in laparoscopic procedures. These procedures both interrupt the majority of the cervical sensory pain nerve fibres. Observational studies have supported the use of these procedures for primary dysmenorrhoea. However, both operations only partially interrupt the cervical sensory nerve fibres in the pelvic area and, therefore, this type of surgery may not always benefit women with dysmenorrhoea. To assess the effectiveness of surgical interruption of pelvic nerve pathways as treatment for primary and secondary dysmenorrhoea, and to determine the most effective surgical treatment. We searched the Cochrane Menstrual Disorders and Subfertility Group Trials Register (searched 9 June 2004), CENTRAL (The Cochrane Library Issue 2, 2004), MEDLINE (1966 to Nov 2003), EMBASE (1980 to Nov 2003), and CINAHL (1982 to Oct 2003). Attempts were also made to identify trials from the metaRegister of Controlled Trials and the citation lists of review articles and included trials. In most cases the first or corresponding author of each included trial was contacted for additional information. The inclusion criteria were randomised comparisons of surgical techniques of interruption of the pelvic nerve pathways (using both open and laparoscopic procedures) for the treatment of primary and secondary dysmenorrhoea. The main outcome measures were pain relief and adverse effects. Eleven randomised controlled trials (RCTs) were identified that initially appeared to fulfil the inclusion criteria for this review. Two trials were subsequently excluded (Garcia Leon 2003; Sutton 1991). Of the remaining nine trials, eight were included in the meta-analysis. The results of one trial were included in the text of the review for discussion because the data were not available in a form that allowed them to be combined in the meta-analysis. Five trials investigated laparoscopic uterine nerve ablation (LUNA), two trials laparoscopic presacral neurectomy (LPSN) and two open presacral neurectomy (PSN). For the treatment of primary dysmenorrhoea there was some evidence of the effectiveness of laparoscopic uterine nerve ablation (LUNA) when compared to a control or no treatment. The comparison between LUNA and laparoscopic presacral neurectomy (LPSN) for primary dysmenorrhoea showed no significant difference in pain relief in the short term; however, long-term LPSN was shown to be significantly more effective than LUNA. For the treatment of secondary dysmenorrhoea six identified RCTs addressed endometriosis and one included women with uterine myomas. The treatment of LUNA combined with surgical treatment of endometrial implants versus surgical treatment of endometriosis alone showed that the addition of LUNA did not aid pain relief. For PSN combined with endometriosis treatment versus endometriosis treatment alone there was an overall difference in pain relief although the data suggests this may be specific to laparoscopy and for midline abdominal pain only. Adverse events were significantly more common for presacral neurectomy; however, the majority were complications such as constipation, which may spontaneously improve. There is insufficient evidence to recommend the use of nerve interruption in the management of dysmenorrhoea, regardless of cause. Future methodologically sound and sufficiently powered RCTs should be undertaken.

Antibiotics do not reduce toothache caused by irreversible pulpitis

Cochrane Oral Health Group Trials Register and the Pain, Palliative Care and Supportive Care Group Trials Register, the Cochrane Central Register of Controlled Trials, Medline and Embase. Randomised controlled trials (RCT) were included that involved patients over the age of 18 years who had presented with a single tooth with a clinical diagnosis of irreversible pulpitis. Abstracts of studies were independently assessed by two reviewers. The primary outcome was patient-reported pain (intensity/duration) and pain relief measured on a categorical scale in the preoperative phase of irreversible pulpitis. Secondary outcomes were type, dose and frequency of medication required for pain relief. Only one trial was included so pooling of data from studies was not possible and a descriptive summary is presented. One trial of 40 participants was included. There was a close parallel distribution of the pain ratings in both the intervention and placebo groups over the 7-day study period. The between-group differences in sum pain intensity differences for the penicillin group were 6.0+/-10.5, and for placebo 6.0+/-9.5 (P=0.776; differences assessed by Mann-Whitney-Wilcoxon test considered to be statistically significant at P=0.05). The sum pain percussion intensity differences for the penicillin group were 3.5+/-7.5 and placebo 2.0+/-7.0 (P=0.290). There was no significant difference in the mean total number of ibuprofen tablets (P=0.839) and acetaminophen tablets (P=0.325) taken for pain relief in either group over the study period. The administration of penicillin over placebo did not appear to significantly reduce the quantity of analgesic medication taken (P=0.05) for irreversible pulpitis. This review based on one methodologically sound but low-powered small sample trial, provides some evidence that there is no significant difference in pain relief between individuals who had untreated irreversible pulpitis who did or did not take antibiotics in addition to analgesics.

Topically applied anaesthetics for treating perineal pain after childbirth

Perineal trauma is a major problem affecting millions of women around the world each year. The degree of perineal pain and discomfort associated with perineal trauma is often underestimated. Pain often interferes with basic daily activities for the woman such as walking, sitting and passing urine and also negatively impacts on motherhood experiences. To assess the effects of topically applied anaesthetics for relief of perineal pain following childbirth whilst in hospital and following discharge. We searched the Cochrane Pregnancy and Childbirth Group Trials Register (February 2004), CINAHL (1982 to December 2002) and MIDIRS (last searched February 2003). We checked reference lists of trials and review articles. Randomised controlled trials comparing topically applied anaesthetic with no treatment, placebo or alternative treatment. Two authors independently assessed trial eligibility and quality and double-entered the data. We contacted study authors for additional information. Eight trials made up of 976 women were included in the review. Five of these trials measured pain experienced up to 24 hours after birth but different methods to assess pain were used in each of the studies. All five trials showed no difference in pain relief when the topical anaesthetic was compared with placebo. One of these studies looked at topical anaesthetics compared with indomethacin vaginal suppositories but there was no significant difference in mean pain scores. All trials reported only short-term follow up (up to four days). Two trials looked at additional analgesia taken for perineal pain, with one trial finding that less additional analgesia was required with epifoam use in comparison with placebo (relative risk (RR) 0.58, 95% confidence interval (CI) 0.40 to 0.84, one trial, 97 women). However, lignocaine/lidocaine showed no difference with regard to additional analgesia use. Adverse effects were not formally measured in the studies; however, some studies commented that there were no side-effects severe enough to discontinue treatment. One study found that the women in the treatment group were more satisfied than the placebo group (RR 0.09, 95% CI 0.01 to 0.65, one trial, 103 women). Evidence for the effectiveness of topically applied local anaesthetics for treating perineal pain is not compelling. There has been no evaluation for the long-term effects of topically applied local anaesthetics.

Two replicate randomized, double-blind, placebo-controlled trials of the time to onset of pain relief in the acute treatment of migraine with a fast-disintegrating/rapid-release formulation of sumatriptan tablets

Background: The gastric stasis that commonly accompanieBackground:722 migraine headache may impair absorption of conventional oral tablets in the stomach. A fast-disintegrating/rapid-release formulation of sumatriptan has been developed to enhance tablet disintegration and drug dispersion and potentially improve absorption. Objective: Two studies were conducted comparing the time to onset of relief from moderate or severe migraine pain with the fast-disintegrating/rapid-release formulation of sumatriptan tablets 50 and 100 mg and placebo. Methods: These were 2 identically designed randomized, double-blind, parallel-group studies. Sumatriptan 50 or 100 mg or placebo was taken on an outpatient basis to treat a single moderate or severe migraine attack. Using a personal digital assistant, patients recorded the time of dosing and the time at which pain severity reached none or mild (ie, pain relief) or none (ie, pain free) in real time so that the time to onset of relief could be measured as a continuous variable. Onset of relief was defined as the earliest time point at which a statistically significant difference in pain relief compared with placebo was achieved and maintained through 2 hours after dosing. Before dosing and at pre-determined time points after dosing, patients also provided an assessment of migraine pain as none, mild, moderate, or severe. At a clinic visit within 1 week after treatment of the migraine attack, patients were queried about adverse events. For each adverse event, investigators recorded whether study medication was considered the cause. Data analyses were undertaken for each study individually and, in post hoc analyses of the primary and key secondary end points, on pooled data from both studies. Results: The 2 studies comprised 2696 patients: 902 received sumatriptan 50 mg, 902 received sumatriptan 100 mg, and 892 received placebo. Patients' mean age ranged from 40.2 to 40.8 years across treatment groups, and most patients were female (83%–87%) and white (92%–93%). In the analysis of pooled data, sumatriptan tablets provided significantly more effective pain relief compared with placebo as early as 20 minutes after dosing with the 100-mg dose and as early as 30 minutes after dosing with the 50-mg dose ( P ≤ 0.05). Similar results were observed for the individual studies: in study 1, sumatriptan tablets were significantly more effective than placebo at 25 minutes with the 100-mg dose and at 50 minutes with the 50-mg dose; in study 2, sumatriptan tablets were significantly more effective than placebo at 17 minutes for the 100-mg dose and at 30 minutes for the 50-mg dose ( P ≤ 0.05). In the pooled data, the cumulative percentages of patients with pain relief by 2 hours after dosing were 72% for the 100-mg dose and 67% for the 50-mg dose, compared with 42% for placebo ( P ≤ 0.001, both sumatriptan doses vs placebo). The cumulative percentages of patients with a pain-free response by 2 hours were 47% for the 100-mg dose, 40% for the 50-mg dose, and 15% for placebo ( P ≤ 0.001, both sumatriptan doses vs placebo). In the individual studies, significantly more patients receiving either sumatriptan dose were migraine free 2 hours after dosing and had sustained pain relief and a sustained pain-free response over 24 hours compared with placebo ( P ≤ 0.001, both sumatriptan doses vs placebo). The only drug-related adverse events reported in >2% of patients in any treatment group in either study were nausea (both studies: 3% sumatriptan 100 mg, 2% sumatriptan 50 mg, 1% placebo) and paresthesia (study 1: <1% sumatriptan 100 mg, <1% sumatriptan 50 mg, 0% placebo; study 2: 3% sumatriptan 100 mg, 1% sumatriptan 50 mg, <1% placebo). Conclusions: In these studies, sumatriptan tabletConclusions:722 in a fast-disintegrating/rapid-release formulation were effective for the acute treatment of moderate to severe migraine pain, were generally well tolerated, and achieved an onset of pain relief as early as 20 minutes for 100 mg and as early as 30 minutes for 50 mg.

Pain relief, Health-Related Quality of Life (HRQoL) and disability in Chronic Low Back Pain (CLBP) patients: Results of an observational study

The aim of this study was to assess the impact of pain relief on HRQoL and disability in CLBP patients treated with the fentanyl transdermal system. Data come from an observational study conducted at 17 clinical centers in the U.S. Eligible patients (N=131) had a CLBP diagnosis for at least 3 months and were receiving short-acting opioids when transdermal fentanyl was added. Patients completed the Treatment Outcomes in Pain Survey (TOPS), the SF-36 Health Survey, the Oswestry Disability Index (ODI) and a 10-point numerical rating scale (NRS) of pain severity at baseline and after at least 9 weeks of transdermal fentanyl treatment. Patients were categorized into 5 groups according to NRS changes from baseline to endpoint: worse (increase in NRS), same (no change in NRS), “small” pain relief (NRS improved 1–2 points), “moderate” pain relief (NRS improved 3–4 points), and “large” pain relief (NRS improved 5–8 points). Multivariate analysis of variance (MANOVA) was used to test the significance of differences in mean score changes on the TOPS, SF-36 and ODI across the 5 pain relief groups. Overall, mean score changes differed significantly across patients stratified by differences in pain relief on the TOPS (MANOVA F=4.0, p<0.001), SF-36 (MANOVA F=2.3, p<0.001) and ODI (ANOVA F=10.5, p<0.001). Patients who experienced greater pain relief showed substantially larger HRQoL improvement and decreased disability than patients who experienced little or no pain relief. Even patients who experienced “small” pain relief showed a clinically meaningful reduction in disability (ODI improvement of 7.6 points) and statistically significant improvement in several HRQoL domains. We conclude that pain relief provided by treatment with transdermal fentanyl significantly reduces the HRQoL burden and disability reported by CLBP patients. The aim of this study was to assess the impact of pain relief on HRQoL and disability in CLBP patients treated with the fentanyl transdermal system. Data come from an observational study conducted at 17 clinical centers in the U.S. Eligible patients (N=131) had a CLBP diagnosis for at least 3 months and were receiving short-acting opioids when transdermal fentanyl was added. Patients completed the Treatment Outcomes in Pain Survey (TOPS), the SF-36 Health Survey, the Oswestry Disability Index (ODI) and a 10-point numerical rating scale (NRS) of pain severity at baseline and after at least 9 weeks of transdermal fentanyl treatment. Patients were categorized into 5 groups according to NRS changes from baseline to endpoint: worse (increase in NRS), same (no change in NRS), “small” pain relief (NRS improved 1–2 points), “moderate” pain relief (NRS improved 3–4 points), and “large” pain relief (NRS improved 5–8 points). Multivariate analysis of variance (MANOVA) was used to test the significance of differences in mean score changes on the TOPS, SF-36 and ODI across the 5 pain relief groups. Overall, mean score changes differed significantly across patients stratified by differences in pain relief on the TOPS (MANOVA F=4.0, p<0.001), SF-36 (MANOVA F=2.3, p<0.001) and ODI (ANOVA F=10.5, p<0.001). Patients who experienced greater pain relief showed substantially larger HRQoL improvement and decreased disability than patients who experienced little or no pain relief. Even patients who experienced “small” pain relief showed a clinically meaningful reduction in disability (ODI improvement of 7.6 points) and statistically significant improvement in several HRQoL domains. We conclude that pain relief provided by treatment with transdermal fentanyl significantly reduces the HRQoL burden and disability reported by CLBP patients.

A Randomized Prospective Placebo-Controlled Study of Intravenous Magnesium Sulphate vs. Metoclopramide in the Management of Acute Migraine Attacks in the Emergency Department

The objective of this randomized, placebo-controlled, double-blind study was to determine the effectiveness of intravenous magnesium sulphate and intravenous metoclopramide in the treatment of acute migraine attacks in the Emergency Department when compared with placebo. Adult patients who presented to the Emergency Department with a headache that met International Headache Society (IHS) criteria for acute migraine were infused with either 10 mg of intravenous metoclopramide, 2 g of intravenous magnesium sulphate or normal saline over 10 min. At 0, 15, and 30 min, patients were asked to rate their pain on a standard visual analogue scale. At 30 min, patients were asked in a standard manner about the need for rescue medication. Adverse affects were also recorded. Patients were followed up by telephone within 24 h for any recurrence after discharge. The primary endpoint of the study was the difference in pain relief between the groups at 30 min. Of the 120 patients who met IHS criteria, seven were excluded from the study due to insufficient data. The number of patients, gender, age and initial visual analogue scale (VAS) scores were comparable between groups. Each group experienced more than a 25-mm improvement in VAS score at 30 min. However, there was no significant difference detected in the mean changes in VAS scores for pain. The rescue medication requirement was higher in the placebo group. The recurrence rate in 24 h was similar between the groups. Although patients receiving placebo required rescue medication more than the others, metoclopramide and magnesium have an analgesic effect similar to placebo in migraine attacks.

Treatment of suspected symptomatic cholelithiasis with glycopyrrolate: A prospective, randomized clinical trial

Glycopyrrolate is advocated for the treatment of acute pain from suspected symptomatic cholelithiasis. However, there is no clinical evidence to substantiate its use. This study is designed to evaluate the efficacy of glycopyrrolate in relieving acute abdominal pain of suspected biliary tract origin. Between July 2002 and April 2003, a convenience sample of patients presenting to the emergency department with upper abdominal pain of suspected biliary tract origin was randomized to receive either intravenous glycopyrrolate or placebo (normal saline solution). Pain level was assessed at baseline using a visual analog scale, with a repeat assessment 20 minutes after intervention. Patients and clinicians were blinded to the study drug. Because of difficulty with patient enrollment, the trial was terminated before achievement of the initial goal of 54 patients. On analysis of the 38 patients completing the study protocol, glycopyrrolate and placebo groups had similar demographic and baseline characteristics. There was no significant difference in pain relief between patients receiving glycopyrrolate and those receiving placebo (median decrease in visual analog pain scale pain 3 mm [95% confidence interval -2 to 17 mm] versus 8 mm [95% confidence interval -2 to 20 mm], respectively). Although limited by small size and convenience sampling, these results fail to demonstrate any improvement in pain of suspected biliary tract origin with the administration of glycopyrrolate. Further study is needed to determine whether intravenous glycopyrrolate has any significant analgesic effect for patients with this condition.

The effects of alfentanil or remifentanil pretreatment on propofol injection pain

Study objective To compare the efficacy of alfentanil, remifentanil, and saline in minimizing the propofol injection pain. Design Randomized, double-blind study. Setting University hospital. Patients 175 ASA physical status I and II, adult female patients undergoing minor gynecological procedures with general anesthesia. Interventions Unpremedicated patients were randomly allocated to one of four groups. Patients received 2 mL (1 mg) of alfentanil (n = 43), 2 mL of remifentanil 0.01 mg (n = 43), 2 mL of remifentanil 0.02 mg (n = 45), or 2 mL of saline (n = 44) 30 seconds prior to administration 5 mL of propofol 1%. Measurements Patients were asked whether they had pain due to propofol injection. Their pain scores were evaluated with a Visual Analogue Scale. In the Postanesthesia Care Unit, frequency of postoperative nausea, vomiting, hypotension, and flushing were all determined. Main result The remifentanil and alfentanil groups showed significantly less frequency and severity of pain than the saline group ( p < 0.05). When the alfentanil group was compared with the remifentanil groups, significant differences in pain relief associated with injection of propofol ( p < 0.001) were noted. Remifentanil 0.02 mg relieved pain associated with injection of propofol more effectively than remifentanil 0.01 mg ( p < 0.001). Conclusions The remifentanil and alfentanil groups showed significantly less frequency and severity of pain than did the saline group. Remifentanil was effective in preventing propofol injection pain, and should be used at a dose of at least 0.02 mg for this purpose. Remifentanil may be an alternative drug for prevention of propofol injection pain.

Improvement of health care for headache patients with a regional pain management network

AbstractA pain management network with pain specialists and general practitioners was established in Cologne to examine and improve the structures of outpatient headache management. The project was divided into an analysis of pain management (P1; one year) and a second phase (P2; two years) with interventions like consultations and education. Eighty physicians working in general practice participated. Patients' and physicians' data on pain and treatment were documented three times (T1, T2, T3) within 12 weeks. Differences in pain relief and quality of life were compared between P1 and P2.Most of the outcome parameters were improved in T2. These changes were more evident in P2. In P2, physicians increasingly used headache diaries and recommended psychotherapy. Triptans were prescribed more frequently for migraine and antidepressants for tension-type headache. The network provided an improvement in outpatient health care of headache patients.

Feasibility Study Comparing Oral Paracetamol and Oral Non-Steroidal Anti-Inflammatory Drugs for Treating Pain after Musculoskeletal Injury: a Randomised, Double Blind, Controlled Trial

Objectives To investigate the efficacy and safety of oral paracetamol compared with oral non-steroidal anti-inflammatory drugs (NSAIDs) or combination therapy in relieving pain after limb injury in an emergency department. Design Double blind, randomised, controlled study. Setting Emergency department of a university hospital in the New Territories of Hong Kong. Subjects 50 adult patients with painful isolated limb injuries. Main outcome measures Primary outcome measures were pain relief at rest and with limb movement, and adverse events. Results There was no statistical difference in the mean reduction in pain score between oral paracetamol and oral NSAIDs in the first two hours of treatment or over three days. Patients' pain reduced significantly over three days but it was unclear whether this was due to natural healing rather than analgesic medication. There was no significant difference in pain relief between paracetamol and NSAIDs over three days treatment. All combinations appeared to be safe with no major adverse effects reported in the study. Conclusion Oral paracetamol may be as effective and as safe as moderate dose of NSAIDs in the management of musculoskeletal pain. A larger study is required to confirm this hypothesis.

Spinal cord stimulation in complex regional pain syndrome: cervical and lumbar devices are comparably effective

Spinal cord stimulation (SCS) has been used since 1967 for the treatment of patients with chronic pain. However, long-term effects of this treatment have not been reported. The present study investigated the long-term effects of cervical and lumbar SCS in patients with complex regional pain syndrome type I. Thirty-six patients with a definitive implant were included in this study. A pain diary was obtained from all patients before treatment and 6 months and 1 and 2 years after implantation. All patients were asked to complete a seven-point Global Perceived Effect (GPE) scale and the Euroqol-5D (EQ-5D) at each post-implant assessment point. The pain intensity was reduced at 6 months, 1 and 2 years after implantation (P<0.05). However, the repeated measures ANOVA showed a statistically significant, linear increase in the visual analogue scale score (P=0.03). According to the GPE, at least 42% of the cervical SCS patients and 47% of the lumbar SCS patients reported at least 'much improvement'. The health status of the patients, as measured on the EQ-5D, was improved after treatment (P<0.05). This improvement was noted both from the social and from the patients' perspective. Complications and adverse effects occurred in 64% of the patients and consisted mainly of technical defects. There were no differences between cervical and lumbar groups with regard to outcome measures. SCS reduced the pain intensity and improves health status in the majority of the CRPS I patients in this study. There was no difference in pain relief and complications between cervical and lumbar SCS.

Operative Treatment of Calcific Tendinitis of the Shoulder

Purpose: We evaluated the results of surgical treatments for calcific tendinitis of the shoulder according to operative methods. Materials and Methods: Retrospective review was done on 32 patients surgically treated for calcific tendinitis from January 1996 through December 2002. Mean age of two groups, open (16 cases) and arthroscopic (16 cases), was 43 years and 46 years, respectively, and mean follow-up after the operation, 9 months and 11 months, respectively. The results of the operation were clinically and radiologically evaluated. The Constant-Murley score was used for the shoulder function. Results: There was no significant difference in pain relief, improvement of range of motion and maintenance of abduction power between the two groups. In both groups, range of rotation was markedly limited and more than 30% of the patients in each group suffered postoperative pain for more than 12 weeks. Preoperatively, the Constant-Murley score was 33 and 32, respectively and at the final follow-up, 80 and 78, respectively. Conclusion: Open and arthroscopic surgery for calcific tendinitis of the shoulder were successful and there was no significant difference in the overall results between the two groups.

The GI Cocktail is no more effective than plain liquid antacid: a randomized, double blind clinical trial

The “GI Cocktail” is a mixture of medications often given in the Emergency Department (ED) for dyspepsia symptoms. Several combinations are used, but the most effective has not yet been determined. This study compared three combinations commonly given for dyspepsia. The study was a prospective, randomized, double-blinded trial comparing antacid (group 1); antacid + Donnatal® (group 2); antacid + Donnatal® + viscous lidocaine (group 3) for acute treatment of dyspepsia in the ED. Patients were randomly assigned to receive one of the three medication combinations. Patients rated their discomfort on a Visual Analog Scale (VAS) immediately before receiving the medication and 30 min later. Change in VAS was the primary study endpoint. A 13-mm difference in VAS was considered clinically significant. VAS change in the three groups was compared using multivariable regression, controlling for pretreatment VAS, study drug, previous antacid use, and gastrointestinal (GI) history. One hundred twenty patients were enrolled between July and December 2000. One hundred thirteen subjects (113) completed the protocol: Group 1 (N = 38); Group 2 (N = 37); Group 3 (N = 38). There was no statistically significant difference between the groups in terms of age, gender, GI history, previous antacid use, or initial degree of pain. Group 1 had a 25 ± 27 mm mean (± SD), decrease in pain; Group 2, 23 ± 22 mm decrease; and Group 3, 24 ± 26 mm decrease. There was no statistically significant difference in pain relief between the three groups on univariate analysis or multivariable regression. In conclusion, the addition of Donnatal® or Donnatal® + lidocaine to an antacid did not relieve dyspepsia better than plain antacid. The “GI Cocktail” concoction may not be necessary.

Radiofrequency Lesioning Using Two Different Time Modalities for the Treatment of Lumbar Discogenic Pain: A Randomized Trial

A prospective randomized trial. To evaluate the efficacy of percutaneous intradiscal radiofrequency thermocoagulation by modifying the duration of heating, using two different time methods, for relieving pain and improving functional disability. Lumbar discogenic pain is the major problem in lumbar degenerative disc disease that percutaneous intradiscal radiofrequency thermocoagulation has been suggested for as a nonsurgical invasive treatment technique for lumbar discogenic pain. In a previous controlled study, this method was found to be ineffective with 8 weeks of follow-up. Sixty patients with chronic low back pain were selected for provocative discography to diagnose the discogenic pain and to locate the discs to be treated. From this group, 39 patients were randomly selected and divided into two groups. In the first group, treatment was performed for 120 seconds, and in the second group for 360 seconds, both at 80C. Patients were assessed with a visual analogue scale for pain relief and functional improvement. Evaluations were performed before, immediately after treatment, at 1 and 2 weeks, and at 1, 3, and 6 months after the procedure. A total of 39 patients with positive provocative discographies were found to eligible for the study. There were no statistical differences in pain relief and functional improvement between two groups (P > 0.05). The immediate, 1-week and 2-week, and 1-month visual analogue scale (VAS) scores were decreased significantly in both groups when comparing them with the pretreatment scores (P < 0.05). However, the final values after 6 months were similar to those measured at the beginning of the study (P > 0.05). Percutaneous intradiscal radiofrequency thermocoagulation has been suggested and performed to relieve discogenic pain. In the previous controlled study, no effective pain relief has been obtained. In this study, the authors increased the duration of radiofrequency thermocoagulation to improve the effectiveness of this method. Yet, the authors have not found any significant differences between the application of lesioning at two different times in percutaneous intradiscal radiofrequency thermocoagulation.