Pain Medicine Use Research Articles

A comparative study of postoperative chronic pain after tension free inguinal hernia repair using absorbable versus non-absorbable sutures for mesh fixation

Background: Inguinal hernias are very commonly encountered by surgeons throughout the world. Chronic groin pain may be caused by nerve injury either during dissection or retraction, or nerve entrapment due to post-operative fibrosis, or mesh related fibrosis, or lastly sutures used to fix the mesh. The mesh can be secured by non-absorbable sutures or absorbable sutures. Material and methods: This is a prospective, descriptive, single centre and randomized study was conducted in the Department of General Surgery, N.C Medical College and Hospital over a period of 1 year. All patients of 21-80 years old, who were admitted for elective inguinal hernia repair, were included for the study. Patients with bilateral, recurrent, irreducible or incarcerated hernia and patients with co morbid conditions that might interfere with pain assessment (e.g. impaired cognitive function, limited mobility, daily use of pain medicine); and patients who had undergone surgery in the groin area were excluded from the study. Results: Out of 180 patients 90 were having right inguinal hernia, 56 patients with left inguinal hernia and 34 patients were having bilateral inguinal hernia. we analyzed post- operative pain using VAS score on alternate basis till 10th post-operative day. In Group A, mesh fixation was done by non-absorbable suture material polypropylene (n=90) and Group B, mesh fixation was done by monofilament absorbable suture material poliglecaprone (n=90). On post-operative day 1 the mean VAS score in group A was 6.12±1.03, while that in group B was 5.01±0.93, on day 10, the mean VAS score in group A was 2.41±0.56, while that in group B was 1.62±0.46, with a p value of 0.039 which is statistically significant. Overall, Group B experienced less pain compared to group A. Mean VAS score at 1st month in group A was 1.93±0.62 and in group B was 1.52±0.34 and at 2nd month it was 1.31±0.54 in group A and 1.03±0.26 in group B. Conclusion: Patients with absorbable suture for mesh fixation has less groin pain as compared to nonabsorbable suture in hernia repair during 6 months follow up period.

PREVALENCE OF OVER THE COUNTER PAIN MEDICATION USE AMONG HIGH SCHOOL VOLLEYBALL PLAYERS

Background:Volleyball’s popularity among middle and high school girls continues to rise with many athletes playing the sport year-round. While up to 40% of high school basketball players consume analgesics frequently to manage sport related pain, there is limited evidence regarding the prevalence of over the counter (OTC) pain medicine use among high school volleyball players.Hypothesis/Purpose:Identify the prevalence of OTC pain medicine use in high school volleyball players and assess its association with prior injury and sports specialization level.Methods:Female volleyball players from 78 high schools were recruited to enroll in this prospective cohort study during the fall 2018 volleyball season. Baseline data were collected on demographic and volleyball characteristics including volume and type of volleyball participation, sport-related injuries over the previous twelve months, and level of sport specialization. The frequency of OTC pain medication use for pain management not related to menstrual cramps over the previous seven days was also collected. Participants were asked to describe their OTC pain medicine use during practice, matches, or conditioning and the location of pain they were treating.Results:In total, 2,073 female athletes (Age: 15.6 ± 1.1, BMI: 22.4 ± 3.5, Grade: 9-12) enrolled in the study. Sixty-nine percent (n=1425) reported no OTC pain medication use over the past seven days, 16.0% (n=332) reported seldom (one day/week) OTC medication use, 12.6% (n=261) reported sometimes (2-3 days/week) using OTC medications, and 2.7% (n=55) reported frequent (4-5 days/week) OTC medication use. In the same time period, 24.8% (n=513) used OTC medications during practice, 16.0% (n=331) during matches, and 21.4% (n=443) during conditioning. Across practice, matches, and conditioning OTC medications were most frequently used to control headaches (7-13%) and knee pain (4-6%). Highly specialized volleyball players were more likely to frequently use OTC medications (4.5%) compared to low (1.97%) and moderately specialized (2.5%) athletes (p=0.001). Of those reporting no OTC medications use, 16.7% (n=238) had an injury in the last year compared 36.4% (n=20) of athletes who frequently used OTC medications also reporting an injury in the last year (p<0.001).Conclusion:Almost one third of female high school volleyball athletes reported using OTC pain medications in the past week. Those with a history of injury and highly specialized athletes were more likely to use OTC medications. Coaches, athletic trainers, and healthcare providers should be aware of trends in the use of OTC medications among volleyball athletes as its popularity continues to rise.

Effect of near-infrared rays on female menstrual pain in Korea.

Most Korean women who experience menstrual pain have reported taking pain medicine and making use of complementary alternative therapies. However, because some interventions may cause side effects, more effective pain-relieving measures need to be identified. This study using a non-equivalent group design, evaluated the effects of near-infrared rays on dysmenorrhea among Korean women. The experimental group wore a near-infrared ray abdominal belt for the duration of one menstrual cycle until the end of the menstrual period, while the control group used hot packs. The level of menstrual pain, menstrual pain duration, and pain medicine use were measured. The menstrual pain, average menstrual pain duration, and use of analgesics were reduced in the near-infrared rays group. The results of this study indicate that the near-infrared ray LED belt was effective in reducing menstrual pain, menstrual pain duration compared to the use of analgesics in Korean women with dysmenorrhea. Therefore, near-infrared rays may be used to relieve menstrual pain and improve the quality of life of women with dysmenorrhea in Korea.

A synopsis of current practices in minimally invasive surgery for adult spinal deformity

&lt;p&gt;To provide a comprehensive summary of the status, indications and developments in the use of minimally invasive surgery in the field of adult spinal deformity. This study was performed by expert review of literature which has been published and is indexed on PubMed. The most appropriate and recent articles were selected to obtain a consolidation of information and knowledge on use and benefits of minimally invasive surgery in adult spinal deformity. Various MIS techniques have been developed to perform the complex ASD surgeries. These include the transforaminal lateral interbody fusion (TLIF), percutaneous segmental fixation as well as the lateral body interbody fusion (LLIF). It is important for a surgeon to obtain a holistic view of current literature and recommended guidelines on the procedures available for ASD surgeries. Overall, minimally invasive spine surgery has resulted in less use of pain medicine, less blood loss, lower infection rates, less requirement for intensive care, less hospitalization, reduction in physiologic stress, reduction in complication rates, reduction in muscle atrophy and preservation of normal motion with fusion rates being as high as 80-95%. More articles consolidating the vast literature on minimally invasive spine surgery need to be published to allow a surgeon to effectively weight the benefits and drawbacks of it. More research needs to be performed to compare the efficacy of sub-types of minimally invasive spine surgery.&lt;/p&gt;

Methylprednisolone Does Not Reduce Persistent Pain after Cardiac Surgery.

Persistent incisional pain is common after cardiac surgery and is believed to be in part related to inflammation and poorly controlled acute pain. Methylprednisolone is a corticosteroid with substantial antiinflammatory and analgesic properties and is thus likely to ameliorate persistent surgical pain. Therefore, the authors tested the primary hypothesis that patients randomized to methylprednisolone have less persistent incisional pain than those given placebo. One thousand forty-three patients having cardiopulmonary bypass for cardiac surgery via a median sternotomy were included in this substudy of Steroids in Cardiac Surgery (SIRS) trial. Patients were randomized to 500 mg intraoperative methylprednisolone or placebo. Incisional pain was assessed at 30 days and 6 months after surgery, and the potential risk factors were also evaluated. Methylprednisolone administration did not reduce pain at 30 days or persistent incisional pain at 6 months, which occurred in 78 of 520 patients (15.7%) in the methylprednisolone group and in 88 of 523 patients (17.8%) in the placebo group. The odds ratio for methylprednisolone was 0.93 (95% CI, 0.79 to 1.09, P = 0.37). Furthermore, there was no difference in worst pain and average pain in the last 24 h, pain interference with daily life, or use of pain medicine at 6 months. Younger age, female sex, and surgical infections were associated with the development of persistent incisional pain. Intraoperative methylprednisolone administration does not reduce persistent incisional pain at 6 months in patients recovering from cardiac surgery.

The Use of Humor in Patients With Recurrent Ovarian Cancer

Humor has been shown to decrease the use of pain medicine, improve mood, and decrease stress. However, the timing and setting for using humor can be perceived differently depending on the patient and the context. Our objective was to better understand how patients with recurrent ovarian cancer experience humor to gain insight into the feasibility of using humor as a therapeutic adjunct. We conducted structured patient interviews with women being treated for recurrent ovarian cancer. The phenomenological method of Colaizzi was used to gain an in-depth understanding of how women with recurrent ovarian cancer use and view humor in relation to their diagnosis. Most patients used humor to cope with cancer and felt that humor alleviated their anxiety. The use of humor by physicians and nurses was perceived as appropriate and positive. A previous relationship with a physician was often felt necessary before the use of humor. Humor was often perceived not only in traditional jokes but was also found in humorous anecdotes from the caregiver's life outside of medicine. This study revealed that humor is an often used coping mechanism for women with recurrent ovarian cancer and subjectively helps alleviate anxiety. The use of humor by physicians was found to be universally perceived as appropriate and positive. The waiting area seems to be a place where humorous experiences would be welcomed. These findings provide additional insight into the role that humor plays in the lives of patients with recurrent ovarian cancer.

Baseline Characteristics Associated with Vitamin D Deficiency in Sickle Cell Disease and the Effect of Vitamin D Replacement

Abstract 2139 Background:African Americans have lower vitamin D levels than the general population, which is thought to be due to decreased utilization of ultraviolet rays to convert vitamin D into an active form. Sickle cell patients have even lower vitamin D levels than African American controls. Preliminary studies at Tulane University correlated low vitamin D levels with markers of hemolysis (decreased hemoglobin (Hgb), increased reticulocyte count and lactate dehydrogenase (LDH)). Our main question was whether vitamin D deficiency in sickle cell patients is due to lack of outdoor activity or diet, or increased vitamin D metabolism during bone marrow turnover secondary to hemolysis. Design and Methods:80 adult sickle cell patients received pain, dietary, and outdoor activity level surveys. Vitamin D 25-hydroxy (25(OH)D), hemolytic lab markers (Hgb, Hct, LDH, total bilirubin, and reticulocyte count) were obtained. Results:Baseline Assessment: Vitamin D levels were available on 70 patients: 24.3% were normal or mildly deficient (≥20 ng/mL), 30% moderately deficient (10-<20 ng/mL), and 45.7% severely deficient (<10 ng/mL). We could not verify a correlation between LDH and 25(OH)D levels, but there was a trend towards increased total bilirubin in patients severely deficient in vitamin D (p = 0.06). Severely anemic patients (Hgb 5-<7 gm/dL) had significantly lower average 25(OH)D levels (p = 0.02). When comparing patients with moderately and severely deficient 25(OH)D levels to patients with no or mild deficiency, there was a significantly increased use of healthcare facilities (see Table 1). Though there was no significant difference in intake of fish, cheese, or eggs, there was a significant decrease in milk intake (see Table 1). There was no significant difference in days spent in bed or time spent outdoors (see Table 1).Table 1Healthcare utilization, milk intake, and time spent outdoors compared to patients with vitamin D hydroxy levels ≥ 20 ng/mLAverage days in hospital and ER over 6 months (p value)Average milk intake (p value)Average time spent outside on a daily basis (p value)Control (25(OH)D levels ≥ 20 ng/mL, n=17)3.1several times/week1-3 days/monthModerately Deficient (25(OH)D levels 10-<20 ng/mL, n=21)11.4 (0.01)several times/month (0.06)1-3 days/month (0.44)Severely Deficient (25(OH)D levels <10 ng/mL, n=32)9.8 (0.01)several times/month (0.02)1-3 days/month (0.11)Subjectively, patients did not report increased frequency of mild to moderate pain, vasocclusive crises, or use of pain medications in the moderately and severely vitamin D deficient groups but they did report higher rates of hospitalization due to sickle cell crises (p = 0.03, 0.005 respectively).Effects of Vitamin D replacement: 56 patients took vitamin D replacement. After replacement, there was no difference in frequency of pain and pain medicine use, or days in the hospital and ER. However, pain levels appeared to be less intense (see Table 2). There was a trend towards fewer days spent in the hospital and ER (p = 0.089) in the 6 months following vitamin D replacement and there were significantly fewer Sickle Cell Day Hospital visits (p = 0.037).Table 2Healthcare facility use and pain levels after vitamin D replacementAverage mild to moderate pain frequencyAverage vasocclusive crises frequencyAverage mild to moderate pain level ratingAverage vasocclusive crisis pain level ratingAverage pain medicine intake frequencypre vitamin D supplementation2-3 times/monthonce a month5.57.8once a weekpost vitamin D supplementation2-3 times/monthonce a month5.07.1once a weekp-value0.20.150.030.020.35 Conclusions:Though we could not correlate vitamin D deficiency with LDH as a marker of hemolysis, lower Hgb levels seemed to be predictive of more severe vitamin D deficiency. Patients with more severe vitamin D deficiency did not report to have increased pain frequency or pain medication use, but had more ER visits and hospitalizations. When vitamin D was replaced, it did not decrease pain frequency, but it did decrease severity. We conclude that vitamin D replacement could lessen pain in sickle cell patients and thus utilization. Disclosures:Kruse-Jarres:Bayer: Consultancy; Grifols: Consultancy; Talecris: Consultancy; Inspiration: Consultancy; NovoNordisk: Consultancy; Baxter: Consultancy.

Does transumbilical single incision laparoscopic adjustable gastric banding result in decreased pain medicine use? A case-matched study

Background We report on our initial experience of laparoscopic adjustable gastric banding performed through a single transumbilical incision of approximately 2.5 cm. All single incision bands were placed using the Covidien SILS Port™ and the Allergan Lap-Band ®. The purpose of the present study was to report on the analgesic use after single-incision laparoscopic surgery (SILS) adjustable gastric banding versus that after conventional laparoscopic gastric banding at a community hospital. Methods A retrospective review of postoperative pain medication use and the time to return to work was conducted of 24 consecutive SILS adjustable gastric banding procedures compared with 24 traditional 5-incision laparoscopic adjustable gastric banding procedures. Results The patients in both groups were evenly matched for age, body mass index, and co-morbidities. All patients were discharged home on postoperative day 1. No complications developed. The mean patient-controlled analgesia morphine use during hospitalization for the SILS group was 33 ± 19.22 mg versus 49 ± 23.78 mg in the traditional group ( P <.05). The mean period of postoperative pain medication use for the SILS group was 2 days versus 5 days for the traditional group ( P <.05). However, the mean period to return to work was 9.5 days for the SILS group versus 11 days for the traditional group ( P = NS). Conclusion Transumbilical single-incision laparoscopic adjustable gastric banding with mechanical port fixation resulted in significantly decreased postoperative pain medication use compared with traditional laparoscopic gastric banding with suture fixation of the band port. Also, the patients tended to return to work earlier after SILS gastric banding.

Consumer Medication Guides

EDITOR'S ABSTRACTThe United States Food and Drug Administration (FDA) publishes consumer guides to encourage safe and appropriate use of both nonprescription and prescription drugs by patients. Clinicians should know what information their patients receive, especially from credible sources such as the FDA. These consumer guides are available on the FDA consumer Web site: http://www.fda.gov/ForConsumers. The current consumer guides on Safe Use of Pain Medicine and on Nonsteroidal Antiinflammatory Drugs are presented.

Academy of Breastfeeding Medicine Founder's Lecture 2009: Maternity Care Re-Evaluated

Abstract In the 1990s a rising tide of medical, surgical, and instrumental interventions served to make childbirth almost treated like a disease. This report supports a different approach to childbirth. A case and discussions of induction are presented. A national survey of 1,573 pregnant women throughout the United States was collected. Although most U.S. childbearing women are low risk, childbirth is "procedure intensive." Women reported significant interventions such as regional analgesia (76%), ruptured membranes (65%), forceful pushing (75%), and cesarean sections (32%). The U.S. rate of cesarean sections in 2005 was the fourth highest among 25 countries. The epidural has many negative features. When used in labor it extends the length of time from 5 to 7 h, causes a raised temperature greater than 100.4 degrees C in 15-30% of infants and mothers, and produces a very sleepy baby at birth, irritable and with increased crying for 3 weeks. The three hormones that relieve pain are turned off by the epidural or a cesarean section. Maternal and infant mortality was doubled as a result of cesarean section. After cesarean sections, subsequent pregnancies have types of abnormal attachments of the placenta to the uterus. British physicians recommend normal birth, defined as labor that starts on its own and uses no analgesia, no inductions, no interventions, no epidurals, and no cesarean sections. The doula's presence decreases labor length, significantly decreases cesarean sections, means less use of pain medicine, and gives greater breastfeeding rates.

Adult Outcomes Following Amputation or Lengthening for Fibular Deficiency

Fibular deficiency results in a small, unstable foot and ankle as well as a limb-length discrepancy. The purpose of this study was to assess outcomes in adults who, as children, had had amputation or limb-lengthening, commonly used treatments for fibular deficiency. Retrospective review of existing data collected since 1950 at six pediatric orthopaedic centers identified 248 patients with fibular deficiency who were twenty-one years of age or older at the time of the review. Excluding patients with other anomalies and other treatments (with the excluded group including six who had had lengthening and then amputation), we identified ninety-eight patients who had had amputation or limb-lengthening for the treatment of isolated unilateral fibular deficiency. Sixty-two patients (with thirty-six amputations and twenty-six lengthening procedures) completed several questionnaires, including one asking general demographic questions, the Beck Depression Inventory-II, the Quality of Life Questionnaire, and the American Academy of Orthopaedic Surgeons Lower Limb Questionnaire including the Short Form-36. A group of twenty-eight control subjects completed the Beck Depression Inventory-II and the Quality of Life Questionnaire. There were forty men and twenty-two women. The average age at the time of the interview was thirty-three years. There were more amputations in those with fewer rays and less fibular preservation. Lengthening resulted in more surgical procedures (6.3 compared with 2.4 in patients treated with amputation) and more days in the hospital (184 compared with sixty-three) (both p<0.0001). However, when we compared treatment outcomes we did not find differences between groups with regard to education, employment, income, public assistance or disability payments, pain or use of pain medicine, sports participation, activity restriction, comfort wearing shorts, dislike of limb appearance, or satisfaction with treatment. No patient who had been treated for fibular deficiency reported signs of depression. The only significant difference between treatment groups shown by the Quality of Life Questionnaire was in the scores on the Job Satisfiers content scale, with the amputees scoring better than the patients treated with lengthening (p=0.015). The American Academy of Orthopaedic Surgeons Lower Limb Module did not demonstrate differences in health-related quality of life or physical function. The patients who were treated with lengthening had started out with more residual foot rays and more fibular preservation than the amputees. They also required more surgical intervention than did those with an amputation. While patients with an amputation spent less of their childhood undergoing treatment, they were found to have a better outcome in terms of only one of seventeen quality-of-life parameters. Both groups of patients who had had treatment of fibular deficiency were functioning at high levels, with an average to above-average quality of life compared with that of the normal adult population.

A Guide to Safe Use of Pain Medicine for Consumers

Editor's Note: The following bulletin was published by the Food and Drug Administration (FDA) and posted on its Consumer Health Information Web site at http://www.fda.gov/consumer/updates/painmeds022309.html on February 23, 2009. We present it here because it is important for clinicians to know what their patients are being told by other authoritative sources.

Transdermal Nicotine Patch for Postoperative Pain Management: A Pilot Dose-Ranging Study

Nicotine has been shown to be antinociceptive in the postoperative period in animal studies. Human studies with nasal nicotine sprays have had mixed results, possibly due to variability in pharmacokinetics and potential patient variables such as exposure to nicotine in tobacco smokers. In this pilot study, we examined the analgesic effect of a transdermal nicotine patch applied before surgery in nonsmokers. We conducted a randomized, double-blind, prospective placebo-controlled trial of 40 subjects, undergoing general surgery that required postoperative patient-controlled analgesia and an overnight hospital admission. Immediately before surgery, a transdermal nicotine patch containing 0, 5, 10, or 15 mg was applied. The primary outcome variable was pain report using a numerical rating scale (NRS) in the first hour after surgery and over the next 5 days. Secondary outcomes were pain medication use, hemodynamic values, nausea, and sedation. Patients treated with nicotine reported lower pain scores when compared with those treated with placebo during the first hour after surgery (P = 0.003, average NRS decrease = 1.4, 95% CI = 0.3-2.6) and for 5 days after surgery (P = 0.03, average NRS decrease = 1.0, 95% CI = 0.1-1.9). There was no increased benefit of nicotine with doses larger than 5 mg. There was a trend suggesting decreased pain medicine use, increased nausea, decreased tachycardia, and slightly decreased systolic blood pressure in the nicotine groups, but these values did not reach significance. Transdermal nicotine, 5-15 mg, reduced postoperative pain scores but failed to decrease the need for opioid analgesics or opioid-related side effects after general surgical procedures.

Comparison of microdebrider subcapsular tonsillectomy to harmonic scalpel and electrocautery total tonsillectomy

Objective The aim of this study was to compare microdebrider subcapsular tonsillectomy (MST) with total tonsillectomies either by harmonic scalpel (TTH) or electrocautery (TTE) in children with obstructive sleep-disordered breathing from tonsillar hypertrophy. Design Retrospective review of prospectively collected data. Setting Tertiary academic hospital. Patients Eighty consecutive children with obstructive sleep-disordered breathing from tonsillar hypertrophy who underwent MST between January and April of 2003 were compared with a smaller historical cohort of 25 patients who underwent TTEs and TTHs from January to December of 2001. Main outcome measures Primary: days to no narcotic pain medicine use and days to solid food intake; secondary: estimated blood loss, surgical time, and postoperative complications. Results Fifty-four patients who underwent MSTs and 25 patients who underwent total tonsillectomies met study criteria for a total of 79 patients. The cohorts showed no significant demographic differences between groups. The MST group had a significantly shorter duration of pain medicine use (3.7 ± 0.5 days) than the TTE (7.0 ± 0.6 days) or TTH groups (6.8 ± 0.7 days; P < .001). The MST group (3.5 ± 0.6 days) and the TTH group (3.6 ± 0.8 days) achieved solid food intake faster than the TTE group (5.4 ± 0.7 days; P = 0.004). There was a significantly higher estimated blood loss with the MST group (38.8 ± 6.1 mL) than the TTH group (19 mL ± 8.2) and the TTE group (15.1 ± 7.4 mL; P < .001). TTH (27.3 ± 3.1 minutes) took longer than MST (20.3 ± 2.3 minutes) and TTE (21.9 ± 2.8 minutes; P = .018). Conclusion Microdebrider subcapsular tonsillectomy is valuable in treatment of children with tonsillar hypertrophy because of the decreased pain medicine use and more rapid return to solid food.

Vinorelbine, doxorubicin, and prednisone in androgen‐independent prostate cancer

Ultimately, patients with metastatic prostate cancer progress on androgen ablation therapy. The investigation of new chemotherapeutic regimens for the treatment of androgen-independent prostate cancer (AIPC) is essential. The authors conducted a Phase II trial with vinorelbine, doxorubicin, and daily prednisone (NAP) to investigate the antitumor activity and palliative response of this regimen in patients with AIPC. Forty-six patients entered this Phase II combination chemotherapy trial. Patients were treated with both vinorelbine and doxorubicin at doses of 20 mg/m2 on Days 1, 8, and 15 every 28 days and prednisone 5 mg twice daily. Endpoints included prostate-specific antigen (PSA) response and palliation, as measured by the Functional Assessment of Cancer Therapy-Prostate (FACT-P) instrument, the Brief Pain Inventory Scale, and a narcotic analgesic log. The median follow-up for all 46 patients was 13.4 months. Fifty-two percent of patients had impaired performance status at baseline. One responding patient remained on NAP and was progression-free at 11.5 months. Thirty-nine patients progressed, 3 patients died prior to response assessment, and 3 patients refused therapy. The median overall survival was 57 weeks (95% confidence interval [95% CI], 36-76 weeks), and the median time to disease progression was 17 weeks (range, 11-24 weeks). The PSA response among the 36 patients who completed 3 cycles of NAP was 42% (95% CI, 26-59%). There was a statistically significant improvement in quality of life measured both by the FACT-General instrument (P = .03) and the FACT-P instrument (P = .0006) over the 3 months compared with baseline measurements. Pain medicine use also improved: The median morphine equivalents among patients who were taking pain medications at the time of study enrollment showed a substantial decline after 1 cycle of treatment that was maintained. Pain (as assessed by the Brief Pain Inventory) improved compared with baseline pain at the 2nd-month assessment (worst pain, P = .08; least pain, P = .02; and average pain, P = .003). Overall, the regimen was tolerated well. The most common side effects were mild fatigue and gastrointestinal complaints (all of which were Grade 1 or 2 [according to Version 2.0 of the Expanded Common Toxicity Criteria]). Seventeen patients (37%) experienced Grade 3 or 4 neutropenia. Five patients (11%) developed a cardiac ejection fraction of <50% during treatment and had doxorubicin discontinued. No patients developed clinical congestive heart failure. The NAP combination produced substantive palliation and a moderate response rate in men with AIPC.

A comparison of treatment outcomes with Gamma Knife radiosurgery versus Glycerol Rhizotomy in the management of trigeminal neuralgia

Purpose/Objective: To compare treatment outcomes of Gamma Knife radiosurgery versus Glycerol Rhizotomy in the management of trigeminal neuralgia. Materials/Methods: At the Jefferson Hospital for Neuroscience, patients with medical refractory trigeminal neuralgia are treated with Glycerol Rhizotomy (GR) or Gamma Knife radiosurgery (GK). Since 1994, 79 patients have undergone GR, and from 1996 through December 2002, 109 patients have been treated with GK radiosurgery. Each GK patient received a dose between 70 and 90 Gy with a 4 mm collimator prescribed to the 100% isodose line. Surgical patients underwent glycerol needle injection into Meckel’s cave under fluoroscopic guidance and intravenous sedation. A retrospective review utilizing chart reviews and self-administered or telephone-administered questionnaires was used to evaluate level of pain control, time to pain recurrence, treatment related side effects, and overall patient satisfaction with GK and GR. A modified Barrow Neurologic Index (BNI) score was utilized to score pain (I: no pain, and no meds; II: occasional pain not requiring meds; IIIa: No pain and pain medication used; IIIb: some pain, adequately controlled with medication; IV: Some pain, not adequately controlled with medication; V: severe pain without relief). The complication of facial numbness was also measured with a BNI score (I: no facial numbness; II: some facial numbness/not bothersome, III: some facial numbness/somewhat bothersome, and IV: facial numbness/very bothersome). Results: Thirty GR patients, and 31 GK patients were evaluated. Median follow-up for the GR group was 33.5 months and 29 months in the GK group. Thirteen GR patients and 15 GK patients had prior surgical interventions. Two surgical patients had prior Gamma Knife radiosurgery, and 12 GK patients had prior GR. All 61 patients had BNI scores of IV (some pain/not controlled with meds) or V (severe pain/no relief) prior to receiving surgical or radiosurgical treatment. The average number of years with trigeminal pain prior to intervention was 6.9 and 9.6 years in the GR and GK groups, respectively. GR patients were twice as likely to report pain relief at 1.7 weeks than GK patients. The mean time to pain relief was 1.7 and 5.1 weeks in the GR and GK groups, respectively. The BNI scores in the GR group at the time of last follow up are as follows: I in 10 patients (33%), II in 0, IIIa in 10 (33%), IIIb in 1 (3%) and IV in 9 (30%) and for the GK group a BNI score of I in 9 (29%), II in 3 (10%), IIIa in 8 (26%) and IIIb in 7 (23%) and IV in 4 (13%). Using the BNI definition of pain relief (scores I, II, IIIa and IIIb), 70% of GR patients and 87% of GK patients achieved pain relief (p=0.0328, log-rank comparison). At the time of questionnaire, 56% of GR and 59% of GK patients reported no use or less use of pain medicine than prior to treatment. Facial numbness was the most commonly reported treatment related side effect in both groups. New onset of facial numbness was reported in 53% of GR patients, and in 32% of the GK patients. Ten GR patients reported bothersome facial numbness (III in 6, IV in 4 pts.), and 1 GK patient reported facial numbness (III in 1, IV in 0 pts.) (p= 0.0026, Chi square). Seventy-three percent of GR patients, and 81% of GK patients were mostly or very satisfied with their treatment and 90% of patients in both groups would recommend their received treatment to others. Conclusions: Gamma Knife radiosurgery is a safe and non-invasive treatment for trigeminal neuralgia. Despite a longer interval to pain relief, GK patients achieved more lasting pain relief and less treatment related complications of facial numbness than GR patients.

Morbidity after temporomandibular joint arthrography is lower than after removal of lower third molars

The morbidity after temporomandibular joint arthrography was studied as the amount of pain, use of pain medicine, and disturbed sleep and was compared with the morbidity after removal of lower third molars. The morbidity was substantially higher after surgery than after arthrography. It was concluded that the morbidity after arthrography can be kept at a low level and that it should not restrict the indications for this examination.