Contemporary diagnostic and management techniques for extraesophageal reflux disease.

PURPOSE OF REVIEW: To review recent advances in the diagnosis and treatment of extraesophageal reflux. RECENT FINDINGS: For most patients, the diagnosis of extraesophageal reflux relies on history and laryngoscopic exam. The reliability and reproducibility of reporting these measures may be improved with validated symptom questionnaires and standardized scoring of physical exam findings. Though dual probe pH monitoring has been the gold standard for diagnosis, it does not measure non-acid reflux events. Intraluminal impedance monitoring has the capability of measuring all esophageal reflux events (liquid, solid, gas) and may be useful in the diagnosis of non-acid reflux.Proton pump inhibitors have replaced histamine receptor antagonists as the mainstay of treatment for extraesophageal reflux. Histamine receptor antagonists are used predominantly for nocturnal acid breakthrough, or step-down therapy. Promotility and cytoprotective agents are used less commonly. Baclofen is currently being evaluated for its ability to decrease the incidence of transient lower esophageal sphincter relaxations and reduce post-prandial acid and non-acid reflux events. For individuals refractory to medical therapy, laparoscopic fundoplication techniques have proven efficacy in relieving some symptoms; the long-term benefit is not yet known. There is yet no established data on the effects of endoluminal therapies on extraesophageal reflux symptoms. SUMMARY: The diagnosis of extraesophageal reflux for most patients relies on history and laryngoscopic exam. The diagnosis can be further verified by dual probe pH and impedance monitoring. Proton pump inhibitors are the mainstay of treatment. Laparoscopic fundoplication is proven to relieve symptoms, but there is yet no data on the effects of endoluminal therapies on extraesophageal reflux symptoms.

Implementation of RCGP guidelines for acute low back pain: a cluster randomised controlled trial.

BACKGROUND: The Royal College of General Practitioners (RCGP) has produced guidelines for the management of acute low back pain in primary care. AIM: To investigate the impact on patient management of an educational strategy to promote these guidelines among general practitioners (GPs). DESIGN OF STUDY: Group randomised controlled trial, using the health centre as the unit of randomisation. SETTING: Primary care teams in north-west England. METHOD: Twenty-four health centres were randomly allocated to an intervention or control arm. Practices in the intervention arm were offered outreach visits to promote national guidelines on acute low back pain, as well as access to fast-track physiotherapy and to a triage service for patients with persistent symptoms. RESULTS: Twenty-four centres were randomised. Two thousand, one hundred and eighty-seven eligible patients presented with acute low back pain during the study period: 1049 in the intervention group and 1138 in the control group. There were no significant differences between study groups in the proportion of patients who were referred for X-ray, issued with a sickness certificate, prescribed opioids or muscle relaxants, or who were referred to secondary care, but significantly more patients in the intervention group were referred to physiotherapy or the back pain unit (difference in proportion = 12.2%, 95% confidence interval [CI] = 2.8% to 21.6%). CONCLUSION: The management of patients presenting with low back pain to primary care was mostly unchanged by an outreach educational strategy to promote greater adherence to RCGP guidelines among GPs. An increase in referral to physiotherapy or educational programmes followed the provision of a triage service.

Postoperative hyperthermia of unknown origin treated with dantrolene sodium.
Inada H, Jinno S, Kohase H, Fukayama H, Umino M.
Section of Anesthesiology and Clinical Physiology, Department of Oral Restitution, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan. inada.anph@tmd.ac.jp
An 11-year-old girl was scheduled for alveolar cleft bone grafting with an iliac bone under general anesthesia. Anesthesia was performed with 70% nitrous oxide, 30% oxygen, and propofol. On the first and second postoperative day, persistent hyperthermia was observed. Because the administration of diclofenac sodium had not been effective for the hyperthermia, dantrolene sodium was given. Her body temperature gradually dropped and returned to normal level on the fifth postoperative day. The hyperthermia in the present case might have been caused by a rapidly elevated muscle metabolism in response to pain and stress after the propofol anesthesia. The oral administration of dantrolene sodium successfully lowered the patient's high body temperature.


The use of muscle relaxant / relaxants medications in acute low back pain.

STUDY DESIGN: Prospective cohort study. OBJECTIVES: To determine the characteristics of patients who take muscle relaxants / relaxant for back pain after seeking care and to determine the relationship of muscle relaxant / relaxants use with recovery from the episode of low back pain. SUMMARY OF BACKGROUND DATA: Low back pain is a common condition with a generally favorable short-term prognosis. Physicians in the acute setting commonly prescribe muscle relaxants. The indications for use and outcomes are not clear. METHODS: We performed a secondary data analysis of a cohort of 1633 patients who sought care from a variety of practitioners (primary care, physician of chiropractic, orthopedic surgeon, Health Maintenance Organization) for low back pain. Patients were enrolled in the physician's office and interviewed at baseline, 2, 4, 8, 12, and 24 weeks. Pain, functional status, medication use, health care utilization, and satisfaction with care were assessed. RESULTS: muscle relaxants / relaxant were used by 49% of patients; among those who sought care from doctors, 64% used muscle relaxants. muscle relaxant / relaxants users were more impaired at baseline. Over time, among patients with greater functional status impairment (Roland disability score > 12) at baseline, muscle relaxant / relaxants users had somewhat slower recovery from the episode of back pain. This finding persisted after controlling for baseline functional status, age, worker's compensation status, and use of nonsteroidal inflammatory agents. CONCLUSIONS: Use of muscle relaxants / relaxant was very common among patients with acute low back pain. muscle relaxant / relaxants use was not associated with more rapid functional recovery.

Benzodiazepine prescribing behaviour and attitudes: a survey among general practitioners practicing in northern Thailand.
Srisurapanont M, Garner P, Critchley J, Wongpakaran N.
BACKGROUND: Over-prescribing of benzodiazepines appears common in many countries, a better understanding of prescribing practices and attitudes may help develop strategies to reduce prescribing. This study aimed to evaluate benzodiazepine prescribing behaviour and attitudes in general practitioners practising in Chiang Mai and Lampoon, Thailand. METHODS: Questionnaire survey of general practitioners in community hospitals, to estimate: i) use of benzodiazepines for anxiety/insomnia, panic disorder, depression, essential hypertension, and uncomplicated low back pain and ii) views on the optimal duration of benzodiazepine use. RESULTS: Fifty-five of 100 general practitioners returned the completed questionnaires. They reported use of benzodiazepines for anxiety/insomnia (n=51, 93%), panic disorder (n=43, 78%), depression (n=26, 43%), essential hypertension (n=15, 27 %) and uncomplicated low back pain (n=10, 18%). Twenty-eight general practitioners would prescribe benzodiazepines for non-psychiatric conditions, 17 for use as muscle relaxants. Seventy-five per cent, 62% and 29% of the general practitioners agreed or totally agreed with the use of benzodiazepines for insomnia, anxiety and depression, respectively. Practitioners agreed that prescribing should be less than one week (80%); or from 1 week to 1 month (47%); or 1 to 4 months (16%); 4 to 6 months (5%) or more than 6 months (2%). Twenty-five general practitioners (45%) accepted that they used benzodiazepines excessively in the past year. CONCLUSION: A considerable proportion of general practitioners in Chiang Mai and Lampoon, Thailand inappropriately use benzodiazepines for physical illnesses, especially essential hypertension and uncomplicated low back pain. However, almost half of them thought that they overused benzodiazepines. General practitioner's lack of time, knowledge and skills should be taken into account in improving prescribing behaviour and attitudes.

Drug therapy of back pain

The importance of analgesic drugs in the treatment of low back pain is a matter of intense debate. Based on the current literature, a multidisciplinary approach combining drug treatment with physical and psychotherapy has proven to be the most successful treatment of back pain. This perspective is challenged by various anesthesiologists who claim that early use of opioids in back pain therapy is the concept of choice. The results of recent studies regarding this matter are controversial. This chapter reviews the historical background of analgetic drugs and provides an overview of the current diagnostic and therapeutic options in the treatment of back pain. Recommendations are given based on the results of current randomized controlled studies.

Diazepam augments gender differences in cutaneous LD flux response to local cooling.
Melik Z, Cankar K.
Institute of Physiology, School of Medicine, Zaloska 4, 1000 Ljubljana, Slovenia. ziva.melik@mf.uni-lj.si
Cutaneous vasoconstriction in response to local cooling is normally greater in females than in males. Cold induces amplification of alpha2-adrenoceptor affinity for norepinephrine and increases reflex sympathetic thermoregulatory output. Benzodiazepines are drugs with very well-known binding to the central and peripheral benzodiazepine receptors. Besides these effects they decrease sympathetic output and as it was shown in the last decade they act synergistically with alpha-adrenoceptors. In the present study we tested the hypothesis that the benzodiazepine diazepam interacts with an alpha-adrenoceptor mechanism at the level of microcirculation. We measured laser-Doppler blood flux changes provoked by local cooling before and after oral application of a low dose of diazepam (5 mg) in 9 healthy males and in 11 healthy females with regular menstrual cycles. The results of our experiments show that in females there is a significant reduction (ANOVA, p < 0.05) in laser-Doppler flux during the first four minutes of cooling after taking of diazepam. In males, there is no significant difference in the responses to cold before and after an application of diazepam. Our results suggest that diazepam, in addition to its well-known effect on BZ receptors may also interact with alpha2C-adrenoceptors in the vessel wall during local cooling.

Prescription analgesic and antidepressant utilization and cost among elderly Medicaid beneficiaries before and after nursing home admission.

OBJECTIVES: The objectives of this study were to describe changes in prescription analgesic and antidepressant medications and to track the costs associated with these medication changes when elderly Medicaid beneficiaries move from the community to a nursing home setting. DESIGN: Retrospective analysis of Medicaid long-term care and drugs claims data for fiscal year 2000 from three different states. SETTING: Long-term care facilities in three different states. PARTICIPANTS: We studied 1321 elderly Medicaid beneficiaries newly admitted to a nursing home during the study period. MEASUREMENTS: Pain medications were grouped into four different categories and all antidepressants were grouped into one category. For each medication category, we obtained the number of unique patients for whom it was prescribed, the number of days it was prescribed, and the amount paid by Medicaid. We then calculated the percentage of subjects prescribed and the amount paid per day for each medication class before and after nursing home admission. RESULTS: Except for skeletal muscle relaxants, 21% to 39% of beneficiaries already had claims linked to each medication class while still living in the community. After nursing home admission, the percentage of beneficiaries exposed to each medication class increased by 2% to 33%. Cost per day of therapy increased by 10% to 83%. There was significant variation among the states in utilization and cost per day of therapy. CONCLUSIONS: We draw three major conclusions: (1) community-dwelling elderly Medicaid beneficiaries in this study use more prescription analgesics and antidepressants than community-dwelling elders in prior studies; (2) there is a significant increase in medication utilization and cost on nursing home admission; and (3) significant variability in medication use and cost exists among the three states examined. Further investigation to elucidate the reasons for these differences could assist legislators in formulating sound public policy to contain Medicaid expenditures without sacrificing patient care.

Anesthetic management of three patients with myotonic dystrophy in a family

Case-1: A 24-year-old woman was admitted because of pressing hydramnion. She was treated by ritodrine hydrochlorides leading to rhabdomyolysis, and she was diagnosed as myotonic dystrophy. She underwent cesarean section because of urgent premature birth. The surgery was performed with spinal anesthesia using tetracaine. Case-2: A 1-year-old boy, the son of Case 1, underwent orchiopexy. He showed respiratory distress at birth and needed respiratory support for 140 days. The surgery was performed under general anesthesia combined with caudal anesthesia. Anesthesia was induced with nitrous oxide-oxygen-sevoflurane. He was intubated without muscle relaxants. Since he recovered consciousness soon after the surgery, he was extubated and returned to the ward. Case-3: A 30-year-old woman, the sister of Case 1, underwent tonsillectomy. At the age of 27 she underwent salpingectomy under general anesthesia with nitrous oxide-oxygen-halothane, after which she was diagnosed as myotonic dystrophy. She was anesthetized with propofol and fentanyl. Because severity of the myotonic dystrophy varies among the patients, the strategy for anesthesia should be planned on each patient. Generally speaking, regional anesthesia including spinal and epidural anesthesia is preferable.

Treatment of fibromyalgia with Cyclobenzaprine, Flexeril: A meta-analysis.

OBJECTIVE: To systematically review the effectiveness of Cyclobenzaprine, Flexeril in the treatment of fibromyalgia. METHODS: Articles describing randomized, placebo-controlled trials of Cyclobenzaprine, Flexeril in people with fibromyalgia were obtained from Medline, EMBase, Psyclit, the Cochrane Library, and Federal Research in Progress Database. Unpublished literature and bibliographies were also reviewed. Outcomes, including global improvement, treatment effects on pain, fatigue, sleep, and tender points over time, were abstracted. RESULTS: Five randomized, placebo-controlled trials were identified. The odds ratio for global improvement with therapy was 3.0 (95% confidence interval [95% CI] 1.6-5.6) with a pooled risk difference of 0.21 (95% CI 0.09-0.34), which calculates to 4.8 (95% CI 3.0-11) individuals needing treatment for 1 patient to experience symptom improvement. Pain improved early on, but there was no improvement in fatigue or tender points at any time. CONCLUSION: Cyclobenzaprine, Flexeril-treated patients were 3 times as likely to report overall improvement and to report moderate reductions in individual symptoms, particularly sleep.