Objective and subjective response in stage D2 prostate cancer patients with cancer pain

Fourty-eight patients with stage D2 prostate cancer, initially treated with endocrine therapy at the University of Tokyo between 1981 and 1990, were followed up and analysed. For the assessment of a subjective response, pain score, narcotic score, and performance stages (PS) were used. Of the fourty-eight patients, twenty-one suffered from cancer pain due to bone metastases. These patients showed significantly (p < 0.01) more lesions of bone metastases and higher PS, compared with patients without cancer pain. The progression free survival of these patients was significantly (p < 0.01) lower than that of patients without cancer pain, although the actuarial survival was not significant. In twenty-one patients with cancer pain, the objective and subjective response rates to endocrine therapy were 75% and 86%, respectively. The duration of pain relief was 1.25-54 (median 19) months. Those rates to anti-cancer chemotherapy in refractory patients (8 patients) previously treated with endocrine therapy were both 25% and those to additional administration of flutamide (FUL) or diethylstilbestrol (DES) in refractory patients (6 patients) were 33% and 100%, respectively. Although the duration of pain relief was 0.78-8 (median 2) months, the additional administration of DES or FLU led to pain relief and improved quality of life (QOL) in all 6 patients. Endocrine therapy such as LH-RH agonist and non-steroidal pure anti-androgen, which has no severe side effects, would be of great usefulness in stage D2 prostatic cancer patients with pain on the basis of efficacy and safety.(ABSTRACT TRUNCATED AT 250 WORDS)

Deriving dichotomous outcome measures from continuous data in randomised controlled trials of analgesics.

Reports of RCTs of analgesics frequently describe results of studies in the form of mean derived indices, rather than using discontinuous events--such as number or proportion of patients with 50% pain relief. Because mean data inadequately describe information with a non-normal distribution, combining mean data in systematic reviews may compromise the results. Showing that dichotomous data can reliably be derived from mean data, at least in acute pain models, indicates that more meaningful overviews or meta-analysis may be possible. This study investigated the relationship between continuous and dichotomous analgesic measures in a set of individual patient data, and then used that relationship to derive dichotomous from continuous information in randomised controlled trials (RCTs) of analgesics. Individual patient information from 13 RCTs of parallel-group and crossover design in acute postoperative pain was used to calculate the percentage of the maximum possible pain relief score (%maxTOTPAR) and the proportion of patients with greater than 50% pain relief (> 50%maxTOTPAR) for the different treatments. The relationship between the measures was investigated in 45 actual treatments and 10,000 treatments simulated using the underlying actual distribution; 1283 patients had 45 separate treatments. Mean %maxTOTPAR correlated with the proportion of patients with > 50%maxTOTPAR (r2 = 0.90). The relationship calculated from all the 45 treatments predicted to within three patients the number of patients with more than 50% pain relief in 42 of 45 treatments, and 98.8% of 10,000 simulated treatments. For seven effective treatments, actual numbers-needed-to-treat (NNT) to achieve > 50%maxTOTPAR compared with placebo were very similar to those derived from calculated data.

Percutaneous stereotactic radiofrequency thermal rhizotomy for the treatment of trigeminal neuralgia.

BACKGROUND: Trigeminal neuralgia (TN) is the most common cephalic neuralgia in people over the age of fifty, with a mean incidence of 4 per 100,000. Percutaneous stereotactic differential radiofrequency thermal rhizotomy (RTR) is a well-recognized surgical treatment for TN. The purpose of this study was to evaluate a management algorithm for TN and to evaluate the effectiveness of RTR for TN after failure of pharmacologic management. METHODS: Two hundred and fifty-eight (258) patients underwent RTR from 1992-1996 and were prospectively evaluated. These patients were characterized by age, sex, side of the face and division(s) involved. Patients were evaluated for pain relief, recurrence requiring or not requiring re-operation, and the type and rate of complications. They were followed by serial clinical evaluation and telephone interview. Patients were grouped according to results: (A) Successful Result--excellent or good pain relief; (B) Unsuccessful Result--fair, poor or no pain relief. The RTR group was compared to historical controls. Follow-up ranged from 12-80 months (mean = 38 months). RESULTS: At early follow-up (defined as median postoperative period up to 6 months), pain relief that was excellent or good (successful results) occurred in 224/258 (87%). At long-term follow-up (> 6 months) recurrence of tic pain required re-operation in 31 patients (12%). In 37 patients (14%), recurrence of tic pain did not require re-operation. Dysesthesia developed in 20 patients (8%); corneal analgesia developed in 8 patients (3%). "Anesthesia dolorosa" developed in 5 patients (2%) and was medically managed. At the conclusion of the long-term follow-up period, 214/258 patients (83%) had excellent to good pain relief (successful result). There were no mortalities, no significant morbidity and a low rate of minor complications. CONCLUSION: With the use of this specific diagnostic and management algorithm, patients with TN can be successfully managed with RTR.

Development of a cancer pain prognostic scale.

The purpose of this study was to develop a Cancer Pain Prognostic Scale (CPPS) which could predict the likelihood of pain relief within 2 weeks for cancer patients with moderate to severe pain. Seventy-four (74) consecutive patients who presented with cancer-related pain were managed in accordance with the guidelines for pain management developed by the United States Agency for Health Care Policy and Research (AHCPR). Patients were followed weekly using the Brief Pain Inventory (BPI), and medications were recorded weekly for 3 weeks. Baseline scores from the Functional Assessment of Cancer Therapy (FACT-G), Mental Health Inventory (MHI), Karnofsky Performance Status (KPS), and Memorial Symptom Assessment Scale Short Form (MSAS-SF) at initial interview served as explanatory variables in a logistic regression model. pain relief > or = 80% at the end of weeks 1 and 2 were used as outcomes in this model. From this analysis, we developed a predictive formula, the CPPS, which includes the worst pain severity, FACT-G emotional well being, daily opioid dose, and pain characteristics. The rule yields a numerical score that ranges from 0-17. Higher scores correspond to a higher probability of good pain relief. The CPPS has the potential to rapidly identify patients with poor pain prognosis. It can be used as a research tool to characterize pain in cancer patients.

External fixator of the cervical spine--a new diagnostic tool

Soft tissue injuries of the neck may cause severe long-standing pain. The clinical findings are sparse and the identification of the painful segments with conventional diagnostic tools is often impossible. Temporary segmental external fixation for a soft tissue injury of the cervical spine was performed as a diagnostic procedure in 24 patients. The instrumentation was applied according to the established techniques of the insertion of facet screws in the cervical spine. The segments to be instrumented were evaluated by clinical and radiological findings, such as local pain and increased mobility in the functional X-rays. However, none of these findings were convincing enough to proceed directly to fusion for pain relief. Evaluation of external fixation consisted of alternatively fixing different instrumented segments and having the patients rate their pain on a visual analogue pain scale. External fixation of the suspected segments resulted in marked pain relief, which was recorded subjectively by the visual analogue pain scale in 68% of the patients. The pain relief (8.2 points preoperatively--2.6 points postoperatively on average) could be permanently established by successful fusion of these segments in 17 patients. Four of the patients indicated no relief of pain at the follow-up (12.9 months postoperatively). No fusion was performed in 3 patients in whom the diagnostic procedure with external fixation allowed no conclusion about the painful segment. As it is an invasive procedure, external fixation of the cervical spine should be reserved for cases, in which conventional methods have failed to established a clear diagnosis of segmental instability and conservative therapy could not relieve the symptoms.(ABSTRACT TRUNCATED AT 250 WORDS)

Long term effects of oral sustained release morphine on neuropsychological performance in patients with chronic non-cancer pain.

Morphine is increasingly used in patients with chronic non-cancer pain, but a major concern associated with chronic use relates to possible cognitive side-effects. The aim of this long-term prospective study was to evaluate the cognitive impact of oral sustained release morphine in patients with non-cancer pain. A battery of neuropsychological tests to explore attention, psychomotor speed and memory was administered. The effects of morphine on pain, quality of life, mood, subjective memory impairment and side-effects were also investigated. Evaluations were performed at baseline in patients free from opioids and then after 3, 6 and 12 months. Twenty-eight patients were included: 18 received oral sustained morphine (range 40-140 mg/day), ten patients stopped morphine prematurely because of side-effects or insufficient pain relief and were followed as a control group. There was no impairment of any neuropsychological variable over time in the morphine treated patients in comparison with the control group. Two measures of information processing speed - the Stroop interference score and the digit symbol test were improved at 6 and 12 months and there were significant correlations with the pain relief and improvement of mood. Self-reported memory impairment improved notably in responders to morphine. Morphine induced persisting effects on pain, and to a lesser extent on quality of life and mood. The visual analog scale score for side-effects increased at 12 months and essentially consisted of gastrointestinal disorders. This study demonstrates that 12 months treatment with oral morphine does not disrupt cognitive functioning in patients with chronic non-cancer pain and instead results in moderate improvement of some aspects of cognitive functioning, as a consequence of the pain relief and concomitant improvement of well-being and mood.

Evaluation of outcomes in patients following surgical treatment of chronic exertional compartment syndrome in the leg.

OBJECTIVE: To evaluate outcomes in patients who had a fasciotomy performed on their leg(s) for chronic exertional compartment syndrome (CECS). DESIGN: A retrospective descriptive cohort study. SETTING: Tertiary care sport medicine referral practice. PATIENTS: A consecutive series of 62 patients surgically treated for CECS from January 1991 to December 1997. MAIN OUTCOME MEASURES: A questionnaire was designed and developed to assess pain (using a 100 mm visual analogue scale), level of improvement, level of maximum activity, satisfaction level, and the occurrence of reoperations. RESULTS: Fifty patients had anterior/lateral compartment involvement, 8 patients had deep posterior compartment involvement, and 4 patients had anterior/lateral/deep posterior compartment involvement. The demographics of the 39 respondents and 23 nonrespondents were similar. The mean percent pain relief of respondents was 68% (95% CI [confidence interval] = 54% to 82%). There was no relationship between percent pain relief and the documented immediate post exercise compartment pressures. A clinically significant improvement was reported by 26 of 32 (81%) anterior/lateral compartment patients and 3 of 6 (50%) patients with deep posterior compartment involvement. Patient level of activity after fasciotomy was classified as equal to or higher than before the operation with a lesser degree of pain by 28 of 36 (78%) patients, while 8 of 36 (22%) patients reported lower activity levels than before the operation. Of the patients reporting lower activity, seven were due to exercise related pain in the post operative leg(s) and one was due to lifestyle changes. Thirty of 38 patients (79%) were satisfied with the outcome of the operation. Four of 62 patients (6%) failed the initial surgical procedure and required revision surgery for exercise-induced pain. In addition, one of these individuals also had a sympathectomy and another had a neurolysis performed at the time of revision surgery. Three of the 62 (5%) patients had subsequent operations for exercise-induced pain on different compartments than the initial surgical procedure. One individual had an unsuccessful operative repair of a posttraumatic neuroma. Postoperative complications were reported by 5 of 39 (13%) patients in the additional comments section of the questionnaire. CONCLUSIONS: The majority of patients surgically treated for CECS experience a high level of pain relief and are satisfied with the results of their operation. The level of pain relief experienced by patients is not related to the magnitude of the immediate post exercise compartment pressures. Despite the possibility that some patients have less favorable outcomes, experience complications, or need subsequent operations, fasciotomy is recommended for patients with CECS as there is no other treatment for this condition.

Pain management in a rheumatology department: a satisfaction survey.

OBJECTIVES: To evaluate the quality of pain management in a teaching hospital rheumatology department. METHODS: We conducted a satisfaction survey among all the patients admitted to the conventional rheumatology department of our teaching hospital over a 1-month period (88 patients with a mean length of stay of 5 d). The patients were asked to complete a questionnaire on the day of discharge. The professional staff was not informed of the survey. RESULTS: The mean pain severity score at admission (visual analog scale, VAS) was 7.76 +/- 1.76 and the mean score decrease with treatment was 7.27 +/- 2.81. Expected pain relief and actual pain relief were correlated (R = 0.39; P = 0.001). Nearly all the patients (96.1%) reported have been encouraged to communicate about their pain. Information on the treatment was given to 89.3% of the patients; no significant differences in pain severity or pain relief were found between the patients who did and did not receive this information. The patients were satisfied with their management by the physicians (VAS: 8.83 +/- 2.07) and nurses (VAS: 8.68 +/- 1.72). CONCLUSION: Satisfaction with pain management (a subjective criterion) was good in our patients. However, no validated tools for measuring satisfaction are available, and measurements should be repeated to look for improvements over time. Limitations to these results include the placebo effect, the influence of memory, and the effects of the behavior of hospitalized patients. A repeat survey is needed.

Treatment of pancreatic pain with interpleural bupivacaine: an open trial.

This study comprised 12 patients admitted for interpleural catheter treatment of chronic pancreatic pain. After the insertion of a left-sided interpleural catheter, 20 ml of bupivacaine 0.5% plain was given, followed by top-ups of 10-20 ml bupivacaine 0.5% as needed. Catheters were left in situ for 12-30 h. Immediate pain relief was achieved in all patients. Five patients had only a single blockade offering pain relief for a median of 33 days. One patient suffering from pancreatic carcinoma remained pain-free until death 45 days later. Seven patients returned for a second blockade after a median of 10 days. After this second blockade long-lasting pain relief was achieved in three patients for 70, 105 and 145 days. Two patients experienced pain relief lasting 11-14 days, while in two patients only a short-lived effect was observed, 3-8 days. Unimportant pneumothorax occurred in one patient. No cardiovascular or respiratory side-effects were recorded. We consider interpleural blockade an alternative worth further investigations in the future in the treatment of patients suffering from chronic pancreatic pain.

Postobstructive chronic pancreatitis: results with distal resection.

HYPOTHESIS: For most patients with chronic obstructive pancreatitis, distal pancreatectomy confers pain relief. DESIGN: Retrospective case series. Follow-up was complete in 80% of study subjects (mean follow-up, 6.7 years). SETTING: Tertiary care center. PATIENTS: Among 484 patients with chronic pancreatitis undergoing operation from 1976 to 1997, 40 with postobstructive chronic pancreatitis were identified. Criteria for selection included an isolated, dominant major pancreatic duct stricture or cutoff, changes of chronic pancreatitis in the distal pancreas, and ostensibly normal parenchyma without calcification in the proximal gland. The patients were reviewed with regard to operative procedure, postoperative course, and outcome. MAIN OUTCOME MEASURES: Outcome measures included degree of pain relief, morbidity and mortality of operation, survival, rates of endocrine and exocrine insufficiency, and ability to return to work and/or normal activities. RESULTS: All but 1 of the 40 patients had abdominal pain, and 20 (50%) had recurrent episodes of acute pancreatitis. Suspicion of malignancy was a concern in 16 patients (40%). Thirty-eight patients underwent distal pancreatectomy; 1 had a central resection and another a Roux-en-Y cystojejunostomy. There was no operative mortality, but significant morbidity occurred in 15%. Among 31 patients with preoperative pain in whom long-term follow-up was available, complete or significant pain relief was achieved in 25 (81%); 74% returned to normal social function, but about half had some element of pancreatic insufficiency. CONCLUSIONS: Distal pancreatectomy is a safe procedure and achieves pain relief and good quality of life in a large percentage of patients (80%) with presumed postobstructive chronic pancreatitis. However, some of these patients with chronic pancreatitis involving the entire gland have disease masquerading as postobstructive chronic pancreatitis secondary to an ostensibly isolated dominant pancreatic ductal stricture.