Linear Visual Analogue Scale Research Articles

New Breast Pain Chart for Objective Record of Mastalgia.

Mastalgia is the commonest affliction of mammary gland among ladies of the reproductive age group. Since etiopathogenesis and therapy are different for cyclical and noncyclical pain, it is imperative to ascertain the exact type correctly. This is usually done in the breast clinics by advising the patient to fill a pain diary over a period of 2months over two menstrual cycles. The Cardiff pain chart records the severity of pain in the form of a triangle for mild to moderate pain and a square for severe pain. Moreover, Cardiff pain chart does not allow a patient to record the severity of pain on days of menses, as she has to put the letter "P" in the box. These problems have been resolved in the new breast pain chart. In the new pain chart, the lady records pain severity in the form of visual linear analogue scale score on every day of menstrual cycle. She enters her menstrual experience on a separate part of chart, which allows us to visualize the full month's pain severity in an uncluttered way.

Spine Surgery under Spinal Anaesthesia

Introduction Spine surgery like discectomy, decompression and lumbar fusions are most commonly performed under general anesthesia, which can be associated with several perioperative morbidities including prone positioning morbidities (for example ocular complications especially in patients with single precious eye), nausea, vomiting, lung atelectasis, pulmonary aspiration, prolonged post-anesthesia recovery and special complications for high risk patients as those with chest problems and or liver problems. It may be possible to reduce general anesthesia complications rate if the procedure is performed under spinal anesthesia. This may also remarkably reduce postoperative pain. Material and Methods To investigate the safety and efficacy of spinal anesthesia in elective lumbar spine surgeries. A prospective study evaluating the relative morbidities associated with Spinal anesthesia for lumbar and lower dorsal spine surgery. 174 patients scheduled for spine surgery. 172 patients scheduled for lumbar surgery(revision posterior spinal fusion 11 patients, removal of instrumentation 5 patients, vertebroplasty 25 patients, 15 patients for soft TLIF, 23 patients for Posterolateral fusion, 26 for TLIF, 37 for decompression and 30 patients for discectomies). Two patients scheduled for dorsal 10–11–12 decompression and posterolateral fusion. The clinical outcome was determined by the presence of postoperative pain, the absence of anesthesia-related complications, and the overall postoperative recovery.patients satisfaction was evaluated by asking questions about their experience. 174 patients agreed to receive spinal anesthesia for the procedure. Recorded data for all patients included: age; total surgical time; occurrence of nausea, vomiting, atelectasis, or cardiopulmonary complication; ability to arise out of bed on the day of surgery; and the total number of inpatient hospital days. Postoperative pain and satisfaction were assessed Formularbeginn. Results There were a total of 174 patients, with a mean age range from (16–75 years). The patients undergoing spine surgery with spinal anesthesia.operative time range from (45–300 minutes) The spinal anesthesia were different with respect to the expected surgical time, pain assessed with a linear visual analogue scale, hospital stay, or the likelihood of arising out of bed on the day of surgery. There were no major cardiopulmonary complications. Patients with spinal anesthesia had no nausea and vomiting.spinal anaesia produce hypotension and decrease blood loss. These patients were able to help us at positioning at the beginning of surgery. Intraoperative talks or interactions was possible. Blood loss range(50cc-1200cc) We need to inject extra dose during surgery in 7 cases and only one 3 level revision lumbar case last for 5 hours we need to convert after 3 hours to general anesthesia. Postoperative patient can eat immediately. Delayed assessment of the full neural recovery is the only drawback. Conclusions Lumbar spine anesthesia as an alternative to general anesthesia in spine surgery has shown less blood loss, better surgical field better postoperative pain control, less postoperative nausea and vomiting and less positioning complications.

Effect of intrathecal clonidine versus fentanyl on bupivacaine spinal block in transurethral resection of prostate surgeries.

Aims:Our study aimed at comparing the onset, degree and recovery time of sensory and motor block, the hemodynamic effects and postoperative pain relief using intrathecal bupivacaine alone, bupivacaine along with fentanyl and clonidine.Materials and Methods:A total of 90 patients, undergoing transurethral resection of prostate (TURP) surgeries under spinal anesthesia were studied. Patients were randomly divided in a double-blind manner into three groups of 30 patients each. Group A (control) patients given subarachnoid block with 0.5% hyperbaric bupivacaine with 0.5 ml of normal saline. Group B patients were given subarachnoid block with 0.5% hyperbaric bupivacaine along with fentanyl 25 μg. Group C patients were given subarachnoid block with 0.5% hyperbaric bupivacaine 10 mg along with clonidine 30 μg and 0.3 ml of normal saline. After administering the subarachnoid block, vitals were recorded before and after surgery. Level of sensory block, the duration of motor block (DOMB), duration of sensory blockade (DOSB), the quality of postoperative analgesia using linear visual analog scale (VAS), and side effects were evaluated.Results:The time required to attain a maximum height of the block was significantly more in Group B as compared to Groups A and C, which was statistically significant. However, there was no statistically significant difference between Groups A and C. The mean DOSB in Groups A, B, and C were 90.83 ± 9.48 min, 135.33 ± 12.59 min, and 155.17 ± 17.49 min, respectively. The mean DOMB in Groups A, B, and C were 83.83 ± 6.52 min, 115.50 ± 14.70 min and 120.67 ± 11.50, respectively. Time of the first request of analgesia in Groups A, B and C in postoperative period were 132.50 ± 21.53 min, 296.00 ± 50.07 min, and 311.83 ± 65.34 min. patients had. VAS was significantly of higher value in Group A than Groups B and C.Conclusions:Intrathecal clonidine in a combination of bupivacaine for TURP provides more satisfactory anesthesia and analgesia and has less side effects.

Postoperative analgesia after laparoscopic cholecystectomy by preemptive use of intravenous paracetamol or ketorolac: A comparative study

Background: Laparoscopic cholecystectomy is associated with postoperative pain due operative ports site and residual intraperitoneal gas CO 2 . Preemptive analgesia is one of the promising strategies of postoperative pain relief. The present study is undertaken to compare the efficacy of preemptive intravenous paracetamol versus ketorolac for post operative analgesia after laparoscopic cholecystectomy. Method: Ninety adult consented patients 18-58 yr of age, of either sex, of ASA grade I/II were randomized into two equal groups of 45 patients each. Patients of group I received infusion of paracetamol 1 g and group II received infusion of ketorolac 30 mg, 30 minutes before the induction of general anaesthesia. Postoperative pain was evaluated by standard 10 cm linear visual analogue scale at different time intervals. When VAS was more than 3 rescue analgesic 50 mg tramadol intravenously stat was given. Intraoperative hemodynamic and any side effects were also recorded for statistical analysis. Results: Demographic profile and hemodynamic parameters i.e intraoperative heart rate and mean arterial blood pressure were comparable in both the groups. Post operative VAS scores were persistently higher in paracetamol group with statistically significant difference (P value < 0.05). All 45 patients in paracetamol group and 8 patients in ketorolac group required rescue analgesic within 6 hrs of study time. Total tramadol consumption was much higher (2250 mg) in paracetamol group as compared to 400 mg in ketorolac group. Conclusion: Preemptive use of ketorolac exerted superior postoperative analgesia after laparoscopic cholecystectomy in comparison to paracetamol without any significant side effect.

Effectiveness of local anesthetic on postoperative pain in different levels of laparoscopic gynecological surgery.

The aim of this study was to assess the effects of preemptive and preclosure analgesia on postoperative pain intensity in patients undergoing different levels of laparoscopic surgery. Two hundred and twenty-six patients who underwent laparoscopic gynecological surgery were enrolled in this quasi-randomized, prospective, placebo controlled study. The operations were classified as level 1 or level 2 according to the extent of the surgery. Lidocaine 1% was administered at the port sites before making the incision in the preincisional study group. In preincisional control group, same amount of saline was infiltrated in same manner. Lidocaine 1% was infiltrated at the port site immediately after removing the trocars in preclosure study group. In preclosure control group, the same amount of saline was infiltrated in the same manner. Postoperative pain intensity was evaluated by linear visual analogue scale. It was found that preclosure lidocaine infiltration was more effective on postoperative pain intensity than its placebo group in level 1 and level 2 surgery groups at 1 and 2h postoperatively. The administration of preincisional lidocaine improved postoperative pain scores significantly more than its placebo group in level 1 laparoscopic surgery group at 1 and 2h postoperatively and in level 2 laparoscopic surgery group at 1h postoperatively. Lidocaine infiltration at port sites had beneficial effects on pain intensity in the early postoperative period after laparoscopic gynecological surgery. However, the results of present study showed that the analgesic effect mechanism of local anesthetic was unrelated to the preemptive analgesia hypothesis.

COMPARATIVE EVALUATION OF CURRENT METHODS OF ANESTHESIA IN PERFORMANCE OF TRANSRECTAL PROSTATE BIOPSY

Prostate biopsy guided by transrectal ultrasonography (TRUS) is largely used in prostate cancer diagnostics. This procedure is usually quite painful and fear of pain could scare patients from this important research. The aim of the study was to compare methods of anesthesia for prostate biopsy. The patients were divided into 4 groups (40 patients in each group). TRUS-guided periprostatic anesthesia with 1% solution of lidocaine (10 ml) was carried out in the first group. An intrarectal introduction of 5 g EMLA cream (lidocaine 2,5% and prilocaine 2,5%) was applied in the second group. The intrarectal introduction of 10% lidocaine spray (3 doses) was used in the third group. Placebo as ultrasonic gel was utilized for the fourth group. The authors used the 100-score linear visual analog scale (LVS 1-100) and 5-score numeric visual scale (NVS-4). Minimal scores of pain were obtained in patients using TRUS-guided periprostatic anesthesia with 1% solution of lidocaine (10 ml). This type of anesthesia didn't lead to increase of the number of complications.

Efficacy of 0.1% triamcinolone with nanoliposomal carrier formulation in orabase for oral lichen planus patients: A clinical trial

IntroductionLichen planus (LP) is a chronic mucocutaneous disease, with different clinical subtypes. The erythematous-ulcerative type is accompanied by pain and burning sensation. Topical or systemic corticosteroid therapy is among the common treatments. No evidence is available supporting the superiority of any specific type or dose of treatment. Nano-drugs have recently been used for the management of oral lesions. This study sought to compare the anti-inflammatory effects of 0.1% triamcinolone acetonide in Orabase® with and without nanoliposomal carriers on oral lichen planus (OLP). MethodsThis randomized clinical trial was performed on 60 patients with erythematous-ulcerative OLP. Formulations of 0.1% triamcinolone acetonide with and without nanoliposomal carriers in Orabase were used 3 times a day for a month in case and control groups, respectively. Pain intensity by linear Visual Analog Scale [0–10] and cross sectional area of the lesions by a grid paper (mm2) were measured before and one, two and four weeks after treatment. Data were analyzed using t-test, chi-square, Fisher’s Exact, Mann–Whitney and Wilcoxon Singed-Rank tests. ResultsThe pain intensity and size of oral lesions decreased statistically by each drug formulation (P≤0.001). Also there were significant differences between the two formulations after two and four weeks of treatment (P<0.05). ConclusionBased on the results, the efficacy 0.1% triamcinolone acetonide with nanoliposomal carrier formulations was more effective than 0.1% triamcinolone acetonide without nanoliposomal for OLP.

Surgical fasciectomy of the trapezius muscle combined with neurolysis of the Spinal accessory nerve; results and long-term follow-up in 30 consecutive cases of refractory chronic whiplash syndrome

BackgroundChronic problems from whiplash trauma generally include headache, pain and neck stiffness that may prove refractory to conservative treatment modalities. As has previously been reported, such afflicted patients may experience significant temporary relief with injections of local anesthetic to painful trigger points in muscles of the shoulder and neck, or lasting symptomatic improvement through surgical excision of myofascial trigger points. In a subset of patients who present with chronic whiplash syndrome, the clinical findings suggest an affliction of the spinal accessory nerve (CN XI, SAN) by entrapment under the fascia of the trapezius muscle. The present study was undertaken to assess the effectiveness of SAN neurolysis in chronic whiplash syndrome.MethodsA standardized questionnaire and a linear visual-analogue scale graded 0-10 was used to assess disability related to five symptoms (pain, headache, insomnia, weakness, and stiffness) before, and one year after surgery in a series of thirty consecutive patients.ResultsThe preoperative duration of symptoms ranged from seven months to 13 years. The following changes in disability scores were documented one year after surgery: Overall pain decreased from 9.5 +/- 0.9 to 3.2 +/- 2.6 (p < 0.001); headaches from 8.2 +/- 2.9 to 2.3 +/- 2.8 (p < 0.001); insomnia from 7.5 +/- 2.4 to 3.8 +/- 2.8 (p < 0.001); weakness from 7.6 +/- 2.6 to 3.6 +/- 2.8 (p < 0.001); and stiffness from 7.0 +/- 3.2 to 2.6 +/- 2.7 (p < 0.001).ConclusionsEntrapment of the spinal accessory nerve and/or chronic compartment syndrome of the trapezius muscle may cause chronic debilitating pain after whiplash trauma, without radiological or electrodiagnostic evidence of injury. In such cases, surgical treatment may provide lasting relief.

Adhesive capsulitis: Prospective observational multi-center study on the Niel-Asher technique (NAT)

ObjectiveTo evaluate “The Niel-Asher Technique (NAT)” for adhesive capsulitis. MethodProspective observational multi-center study. Subjects154 patients (113 from Israel, 25 from the UK and 16 from the US) with pain, stiffness and globally restricted gleno-humeral mobility shoulder for more than three months. Outcome measuresChange in active range of motion (AROM) Flexion and Abduction of the gleno-humeral joint measured by a goniometer; changes in pain as evaluated by the patients on a linear Visual Analogue Scale (VAS). Analysis was based on the intention-to-treat principle. ResultsMultivariate repeated measures analysis of covariance indicated that there was a significant improvement in AROM abduction and flexion across time, with no interaction between time and phase of illness (acute/stiff/resolving). The improvement in range of motion was significantly more pronounced in patients from Israel compared to the UK and US. Similarly, among patients from Israel, large and statistically significant reduction in the VAS pain score between baseline and post-treatment assessments was observed. ConclusionsAll patients demonstrated a significant improvement in AROM for both flexion and abduction. The data supports the notion that NAT is autonomously reproducible. NAT demonstrated significant improvement in AROM for both flexion and abduction with a consistent average of twelve degrees improvement per treatment session. The mean number of treatments was 7. NAT expedites both pain reduction and increased mobility for adhesive capsulitis over and above the natural history.

Comparison of 2 Methods of Incision Closure in Patients With Adolescent Idiopathic Scoliosis Undergoing Posterior Spinal Fusion Surgery

A prospective, randomized, and controlled clinical trial. To compare surgical zipper with subcuticular Monocryl sutures in terms of incision closure time, cosmetic results, and the complication rate in patients with adolescent idiopathic scoliosis (AIS) undergoing posterior spinal fusion (PSF) surgery. In previous literatures, the application of surgical zipper to incision closure has been reported to be associated with a favorable outcome. However, in the PSF surgery of patients with AIS, the use of surgical zipper has not been described. Ninety female patients with AIS undergoing PSF were assigned randomly to 2 incision closure groups either using surgical zipper or using the 4-0 absorbable subcuticular suture. The incision outcome was evaluated with the Hollander Incision Evaluation Score at 7 days, 2 weeks, 6 months, and 1 year after surgery, respectively. Besides, a visual analogue scale was allocated to each patient to rate the cosmetic result of the incision. The 2 groups were compared to determine the differences in terms of incision closure time, the complication rate, and cosmetic results. The incision closure using surgical zipper consumed significantly less time than that using subcuticular suture (45.3 vs. 540.5 s, P < 0.001). As for the cosmetic results, no significant differences of Hollander Incision Evaluation Score scores between the 2 suturing groups were found. Besides, patients' satisfaction with cosmetic outcome on a linear visual analogue scale also revealed similar results between the 2 groups. As for postoperative complications, we found 1 case of mild blister due to allergy to the tape of the dressings and 2 cases of incisional pain in the Monocryl suture group. The application of surgical zipper in PSF surgery is a safe and effective method. The ease and the speed of application make surgical zipper an attractive option for incision closure in patients with AIS undergoing PSF. 4.

Is periprostatic nerve block a gold standard in case of transrectal ultrasound-guided prostate biopsy?

Introduction:Controversy exists over the pain during prostate biopsy. Periprostatic nerve block (PNB) is a gold standard anesthetic technique during transrectal ultrasound (TRUS)-guided prostate biopsy. Recent studies showed that PNB alone is insufficient as analgesic. We compared the efficacy of tramadol and intraprostatic nerve block (INB) in addition to PNB.Materials and Methods:We conducted a prospective double blinded placebo controlled study at our institute in 150 consecutive patients. Patients were randomized into three groups. Group A received PNB with INB with 1% lignocaine. Group B received oral tramadol with PNB. Group C patients were administered PNB only with 1% lignocaine. Patients were asked to grade the pain level using 11 point linear visual analog scale (VAS) at the time of ultrasound probe insertion, at time of anesthesia, during biopsy, and 30 min after biopsy.Results:The study groups were comparable in demographic profile, prostate-specific antigen (PSA) levels, and prostate size. Group A recorded the minimum mean pain score of 2.66 during prostate biopsy which was significantly lower than group 3 (P < 0.001). Group B recorded significantly lower pain score at time of probe insertion and at anesthetic needle insertion than other two groups.Conclusions:PNB provides better pain control in TRUS-guided prostate biopsy but still there is need of additional analgesic in the form of tramadol or INB. Tramadol has advantage of oral intake and analgesic effect at time of probe insertion and at nerve block. Both tramadol and INB may be used in combination along with PNB.

The Comparison of Periprostatic Nerve Blockage with the Combination of Perianally and Intrarectally Lidocaine Gel and Intrarectally Indomethacin Suppository in the Control of Pain Related to Transrectal Ultrasound Guided Prostate Biopsy Procedure

Aims : In this study, we aimed to evaluate the effectiveness of the use of periprostatic nerve blockage with the combination of perianally and intrarectally lidocaine gel and intrarectally indomethacin suppository in the control of pain related to the TRUS-Bx procedure. Materials and Methods : The data of 88 patients who underwent TRUS-Bx were retrospectively evaluated. The sample were divided in two groups according to the type of topical anesthesia previous to TRUS-Bx. In group 1 (n=42), while the combination of perianally and intrarectally lidocaine gel with intrarectally indomethacin suppository were applied to provide local anesthesia, a periprostatic nerve blockage by using 10 ml of %1 lidocaine solution were also performed in addition to this combination in group 2 (n=46). Ten point linear visual analog scale (VAS) was used to evaluate the pain. While VAS-1 score evaluated the pain that occured during TRUS probe placement and/or manipulations, VAS-2 score analysed the pain that occurred during the performation of needle biopsy. Results : The mean ages, PSA values, and prostate volumes were similar between two groups (P= 0.437, P= 0.187, P= 0.194; respectively). The analysis of the pain related to TRUS probe placement and manipulation showed that VAS-1 score was found 2.72 ± 0.7 and 2.68 ± 08, respectively. The comparison of VAS-1 scores revealed that there was no statistically significant difference between two groups. Nevertheless, VAS-2 score, which evaluated the pain during the needle biopsy, was determined 5.36 ± 1.08 in group 1 and 2.13 ± 0.76 in group 2. It was found that VAS-2 score was significantly lower in group 2 (P= 0.001). Conclusion : Our study revealed that periprostatic nerve blockage provided additional improvement in the control of pain related to only the step of needle biopsy in TRUS-Bx procedure.

Comparative Study on Cryosurgery with Carbamazepine and Alcohol injection in Trigeminal Neuralgia

Objectives: To assess the efficacy of Cryosurgery for the treatment of Trigeminal neuralgia and to compare this procedure with Carbamazepine and alcohol block. Materials and method-A prospective study with 75 cases of Trigeminal neuralgia was carried out in the Department of Oral and Maxillofacial Surgery, Bangabandhu Sheikh Mujib Medical University from January 2006 to December 2007. Out of 75 cases 25 treated with Carbamazepine only, starting dose 100 mg b.d. with incremental dose up to 800 mg, 25 received alcohol block with maintenance dose of Carbamazepine 200 mg b.d. over the study period and 25 received Cryosurgery with initial maintenance dose of Carbamazepine 100 mg b.d. then tappered on 1st follow up visits and withdrawn on the 2nd follow up visits. Visual linear analogue scale (VAS) was used to measure pain intensity in different groups. Results: Out of different treatment modalities on follow up onwards pain control was better in Cryosurgery than Carbamazepine and alcohol block. Conclusion: This study reveals that the efficacy of Cryosurgery is better than Carbamazepine and alcohol block to eliminate the pain intensity in Trigeminal neuralgia. DOI: http://dx.doi.org/10.3329/bjms.v11i3.11721 Bangladesh Journal of Medical Science Vol. 11 No. 03 July’12

Role of 0.4% glyceryl trinitrate ointment after haemorrhoidectomy: results of a prospective randomised study

Conventional haemorrhoidectomy (CH) is well known to cause significant post-operative pain and delayed return to daily activities. Both surgical wounds and sphincterial apparatus spasms are likely responsible for the pain. In this study, we evaluated the role of glyceryl trinitrate ointment (GTN) in reducing post-operative pain, ameliorating wound healing and recovery after CH. Between 01/08 and 12/11, 203 patients with symptomatic haemorrhoids were enrolled in the study and received (103 patients) or not (100 patients) 0.4 % GTN ointment for 6 weeks after surgery. Pain was assessed using a 10-cm linear visual analogue scale (VAS). Data on post-operative pain, wound secretion and bleeding, return to normal activities and complications were recorded. Data were analysed using Fisher's exact and Mann-Whitney tests. GTN-treated group experienced significantly less pain during the first week after surgery (p < 0.0001). This difference was more evident starting from post-operative day 4 (p < 0.0001). A significant higher percentage of untreated patients experienced severe pain (mean VAS score > 7) (10 % vs 31 %). There were significant differences in terms of secretion time (p = 0.0052) and bleeding time (p = 0.02) in favor of GTN. In addition, the duration of itching was less in the GTN group (p = 0.0145). Patients treated with GTN were able to an early return to daily activities compared to untreated (p < 0.0001). Fifteen GTN-treated patients (14.6 %) discontinued the application because of local discomfort and headache. GTN ointment enhances significantly post-operative recovery, reducing pain in terms of duration and intensity. This effect might be secondary to a faster wound healing expressed by reduced secretion, bleeding and itching time.

Three different techniques for administering analgesia during transrectal ultrasound-guided prostate biopsy: a comparative study

The efficacy of three different analgesic techniques during transrectal ultrasound (TRUS) guided prostate biopsy, including (i) periprostatic blockage (PPB), (ii) intrarectal gel instillation, and (iii) sedoanalgesia were compared. During a period of five months, 100 consecutive men were enrolled in this study. A 10-point linear visual analogue scale (VAS) was used to assess the pain scores during (VAS 1), immediately after (VAS 2) and one hour after (VAS 3) the needle biopsy procedure. The relationship between the level of pain, prostate volume, age and PSA was determined. There were no statistically significant differences between the four groups in terms of mean age and PSA values. The pain scores were significantly lower in sedoanalgesia and PPB groups (p = 0.0001). There was no statistically significant difference between the groups in terms of complications. In this study, it was shown that patient comfort is better and it is possible to get decreased pain scores with PPB or sedoanalgesia. However, PPB is a preferable method in TRUS-guided prostate biopsy since it is much more practical in outpatient clinics.

Patient experiences during waiting time for dental treatment

Objectives. The aim of this study was to evaluate patient experiences of inconvenience and treatment need while waiting for dental treatment. Materials and methods. A systematic sample of 210 patients with varying lengths of waiting time was drawn from the waiting list for non-emergency treatment in the City of Turku. A questionnaire covering socio-demographic background was mailed to the patients. The level of inconvenience caused by waiting was assessed by a linear visual analogue scale (0–100). Results. A total of 112 subjects (60%) completed and returned the questionnaire and 109 (58%) gave permission to collect data from their patient records. The average inconvenience score was 42.9, with those who had waited for 3 months or less reporting less inconvenience than those that had waited for 4 months or more. There was not a straightforward linear correlation between length of waiting time and level of inconvenience experienced. Experiences of inconvenience were independent of socio-demographic background. The patient-reported maximum acceptable waiting time for non-urgent dental treatment was 45.8 days. Fewer than half (42.0%) of the subjects had received treatment while waiting for comprehensive care; women (51.7%) significantly (p < 0.05) more often than men (31.5%). Fillings and unspecified emergency treatments were the most commonly needed treatment. Conclusions. Waiting for dental treatment appears to be well-tolerated, as long as the waiting time remains reasonable. Treatment providers seem to have few means with which to rank dental patients into several queues with different urgencies.

Stability and Tolerability of High Concentrations of Intrathecal Bupivacaine and Opioid Mixtures in Chronic Noncancer Pain: An Open-Label Pilot Study

To evaluate the stability and tolerability of high concentrations of bupivacaine-opioid solutions when used by intrathecal infusion. Prospective, open label, pilot cohort study. Outpatients at a University medical center. Twelve patients with inadequate pain control already receiving intrathecal opioids and low dose bupivacaine. Increasing concentrations and doses of bupivacaine between 1 and 5% were prescribed to be added to a stable daily opioid dose. Drug infusate sampling and analysis using high performance liquid chromatography. Physical examination, assessment of pain and function between (0-60 days) using a linear visual analog scale, and the Oswestry Disability Index. Final daily doses of bupivacaine were 4-21.4 mg delivered at measured concentrations of 0.4-3.7%. Two patients experienced reversible motor weakness at 6 mg of bupivacaine/day. The in vitro and in vivo sampling of concentrations up to 3.7% of bupivacaine demonstrated that the stability for bupivacaine with morphine (1.2-3%) or hydromorphone (0.4-1%) was >96% of the manufactured concentration. There were no clinically significant changes in the visual analog pain scale or the Oswestry Disability Index. This in vivo study demonstrates excellent stability of high concentrations of intrathecal bupivacaine and opioid mixtures. No nonreversible neurological complications were identified in patients receiving daily doses of bupivacaine up to 21.4 mg. Tolerability was variable because of motor weakness. Given that all intrathecal local anesthetics may be neurotoxic, caution must be exercised if high concentrations and daily doses are to be delivered over prolonged periods.

Oncological outcome and patient satisfaction with skin-sparing mastectomy and immediate breast reconstruction: a prospective observational study

BackgroundThe management of early breast cancer (BC) with skin-sparing mastectomy (SSM) and immediate breast reconstruction (IBR) is not based on level-1 evidence. In this study, the oncological outcome, post-operative morbidity and patients' satisfaction with SSM and IBR using the latissimus dorsi (LD) myocutaneous flap and/or breast prosthesis is evaluated.Methods137 SSMs with IBR (10 bilateral) were undertaken in 127 consecutive women, using the LD flap plus implant (n = 85), LD flap alone (n = 1) or implant alone (n = 51), for early BC (n = 130) or prophylaxis (n = 7). Nipple reconstruction was performed in 69 patients, using the trefoil local flap technique (n = 61), nipple sharing (n = 6), skin graft (n = 1) and Monocryl mesh (n = 1). Thirty patients underwent contra-lateral procedures to enhance symmetry, including 19 augmentations and 11 mastopexy/reduction mammoplasties. A linear visual analogue scale was used to assess patient satisfaction with surgical outcome, ranging from 0 (not satisfied) to 10 (most satisfied).ResultsAfter a median follow-up of 36 months (range = 6-101 months) there were no local recurrences. Overall breast cancer specific survival was 99.2%, 8 patients developed distant disease and 1 died of metastatic BC. There were no cases of partial or total LD flap loss. Morbidities included infection, requiring implant removal in 2 patients and 1 patient developed marginal ischaemia of the skin envelope. Chemotherapy was delayed in 1 patient due to infection. Significant capsule formation, requiring capsulotomy, was observed in 85% of patients who had either post-mastectomy radiotherapy (PMR) or prior radiotherapy (RT) compared with 13% for those who had not received RT. The outcome questionnaire was completed by 82 (64.6%) of 127 patients with a median satisfaction score of 9 (range = 5-10).ConclusionSSM with IBR is associated with low morbidity, high levels of patient satisfaction and is oncologically safe for T(is), T1 and T2 tumours without extensive skin involvement.

Factors influencing time course of pain after depot oil intramuscular injection of testosterone undecanoate

Pain following depot intramuscular (IM) injection of oil vehicle-based drugs has been little studied. This study aimed to determine prospectively the prevalence, determinants, severity and functional consequences of pain during the week after IM injection of 1 000 mg testosterone undecanoate (TU) in a 4-mL castor oil vehicle. Androgen-deficient men receiving regular T replacement therapy at an academic andrology clinic were recruited to report pain scores using a coloured visual linear analogue scale at seven times over the first day and daily for a week after a deep IM gluteal injection. The time course and covariables influencing pain scores were analysed by mixed model analysis of variance (ANOVA). Following 168 injections in 125 men, pain was reported by 80% of men, peaking immediately after injection, reaching only moderate severity, lasting 1-2 days and returning to baseline by day 4. The pain required little analgesic use and produced minimal interference in daily activities. The time course of pain scores was reproducible in the 43 men who underwent two consecutive injections. Pain was more severe in men who had an earlier painful injection, but less severe in older and more obese men. There were negligible differences in post-injection pain experience between experienced nurses administering injections. Deep IM gluteal injection of depot TU in 4-mL castor oil is well tolerated and post-injection pain is influenced by earlier painful injection experience, as well as age and obesity.

Early Complications After High Tibial Osteotomy –A Comparison of Two Techniques

This prospective cohort study compared opening wedge high tibial osteotomy with use of the Puddu plate and the Vitoss synthetic cancellous bone versus closing wedge high tibial osteotomy with use of the AO/ASIF L-plate, focusing on complications (nonunions, infections, loss of correction, reoperations) and patient satisfaction (visual linear analog scale). During a 10-month period, we performed high tibial osteotomy for 40 patients experiencing medial knee osteoarthritis and a varus deformity. The average follow-up was 11 months. The complication rate in patients treated with the opening wedge technique was significantly higher regarding tibial nonunion, loss of correction, and material failure. Patients in the closing wedge group were more satisfied with the postoperative result. This study found that the Puddu plate, despite 6 weeks of non-weight bearing facilitating the osseous consolidation with Vitoss cement, was not able to maintain the correction during the time required for bone healing.