(214) Rofecoxib Provides Superior Relief of Pain in Osteoarthritis (OA) Compared to Celecoxib.

We performed a randomized, double-blind, clinical trial to evaluate pain relief efficacy of rofecoxib and celecoxib at highest indicated once daily doses in osteoarthritis. 1082 patients meeting entry criteria for OA, responsive to NSAIDs, were randomized 3:3:1 to treatment with rofecoxib 25 mg QD (n = 471), celecoxib 200 mg QD (n = 460) or placebo (n = 151). Efficacy was assessed over the first 6 days of therapy and at weeks 2, 4 and 6 by WOMAC questionnaire and patient global assessment of response to therapy (PGART). Demographics were well balanced. Significantly more patients on placebo discontinued prematurely compared to both active groups (p < 0.001) mainly due to lack of pain relief efficacy. Rofecoxib provided statistically superior relief of night pain (p = 0.023), morning stiffness (p = 0.002), rest pain (p = 0.023), and walking pain (p = 0.005) compared to celecoxib. Rofecoxib was significantly superior to celecoxib on all WOMAC subscales including pain (p = 0.008), stiffness (p = 0.001) and physical function (p = 0.01). Rofecoxib was superior to celecoxib in % of patients with good or excellent PGART over 6 weeks (p = 0.014) and provided quicker onset of pain relief as assessed by time to first report of good or excellent response (p < 0.001). Both active groups were superior to placebo on efficacy endpoints. Incidence of clinical AEs, drug related AEs, serious AEs, and discontinuations due to AEs was similar between active groups. In this study, once daily doses of rofecoxib provided superior relief of pain and other related symptoms in OA compared to celecoxib and placebo. All treatments were generally well tolerated.

Bilateral chronic proximal plantar fasciopathy: treatment with electrohydraulic orthotripsy.

BACKGROUND: Patients presenting for treatment of chronic plantar fasciopathy often have bilateral involvement. When various nonoperative treatments fail, subsequent intervention may be problematic, especially since bilateral surgery (bilateral fascial release) may not be realistic because of variable, frequently restrictive postoperative weightbearing limitations. METHODS: Twenty-three patients (46 heels) were treated with electrohydraulic high-energy orthotripsy to the plantar entheses of both feet while under the same anesthesia (conscious sedation). Following orthotripsy, all patients immediately were fully weightbearing and resumed normal activities of daily living and work, usually within 24 hours. Progressive return to athletic activities was allowed. Patients were assessed by three outcome parameters: (1) pain measured objectively by a dolorimeter combined with the patient's subjective evaluation of the level of pain; (2) pain after 5 minutes of walking upon arising; and (3) pain with daily activities. All pain measurements were done by the visual analog scale. RESULTS: Patients initially experienced varied pain relief responses. This included earlier pain relief in one heel compared to the other, as well as better pain relief in one heel than the other at the 6- and 12-week evaluations, but with much less variance at the 1-year evaluation. By 3 months following orthotripsy, 28 heels (61%) had good or excellent results. These results were maintained or improved at 1 year. In 18 heels (39%), the outcome was fair or poor. Nineteen heels received a second orthotripsy application; one patient requested a second orthotripsy treatment of only one heel, while nine patients requested a second treatment of both heels. The outcome showed further improvement following the second application of orthotripsy. At 1 year after one or two orthotripsy applications, 19 patients (38 heels) were satisfied with the results in both heels (83%), while four patients (eight heels) still had an unsatisfactory outcome (17%). CONCLUSION: Electrohydraulic high-energy orthotripsy is a reasonable nonincisional method for treating patients with bilateral chronic proximal plantar fasciopathy under a single anesthetic without the prolonged nonweightbearing status often recommended for patients following unilateral open or endoscopic fascial release.

Clinical outcomes after stereotactic radiosurgery for idiopathic trigeminal neuralgia.

OBJECT: Stereotactic radiosurgery is an increasingly used and the least invasive surgical option for patients with trigeminal neuralgia. In this study, the authors investigate the clinical outcomes in patients treated with this procedure. METHODS: Independently acquired data from 220 patients with idiopathic trigeminal neuralgia who underwent gamma knife radiosurgery were reviewed. The median age was 70 years (range 26-92 years). Most patients had typical features of trigeminal neuralgia, although 16 (7.3%) described additional atypical features. One hundred thirty-five patients (61.4%) had previously undergone surgery and 80 (36.4%) had some degree of sensory disturbance related to the earlier surgery. Patients were followed for a maximum of 6.5 years (median 2 years). Complete or partial relief was achieved in 85.6% of patients at 1 year. Complete pain relief was achieved in 64.9% of patients at 6 months, 70.3% at 1 year, and 75.4% at 33 months. Patients with an atypical pain component had a lower rate of pain relief (p = 0.025). Because of recurrences, only 55.8% of patients had complete or partial pain relief at 5 years. The absence of preoperative sensory disturbance (p = 0.02) or previous surgery (p = 0.01) correlated with an increased proportion of patients who experienced complete or partial pain relief over time. Thirty patients (13.6%) reported pain recurrence 2 to 58 months after initial relief (median 15.4 months). Only 17 patients (10.2% at 2 years) developed new or increased subjective facial paresthesia or numbness, including one who developed deafferentation pain. CONCLUSIONS: Radiosurgery for idiopathic trigeminal neuralgia was safe and effective, and it provided benefit to a patient population with a high frequency of prior surgical intervention.

Sickle cell anemia day hospital: an approach for the management of uncomplicated painful crises.

Painful crisis episodes are poorly treated in sickle cell anemia, both in timeliness and appropriateness of care. Delayed treatment in Emergency Departments, unrelieved pain, frequent admissions, and prolonged hospitalizations are common. We established a Day Hospital (DH) to determine if an alternative care delivery system could improve pain relief and reduce unnecessary hospital admissions for patients with uncomplicated painful crises. Trained DH staff delivered prompt titration for pain relief based on each patient's analgesic history and qualitative and quantitative assessments. Response to therapy and comorbidities commanded disposition. During the first 5 years of DH operation there were 2554 visits; 60% of the patients had severe pain. During an average visit of 4.5 hours, 84% of the patients were titrated to relief; 90% had pain relief within 2 to 4 hours. Overall, 81% of the patients were discharged home (70% initially and 90% to 94% in the last 3 years). During the first 5 years of the DH, there were 2612 emergency department (ED) visits that averaged 13 hours each. The combined ED and DH admissions during this time represented a 40% decrease in the baseline ED admission rate of 92%, (1 year pre-DH). Patients with uncomplicated painful crisis were admitted 5 times less often from the DH (8.3%) than from the ED (42.7%). The length of stay (LOS) for inpatients followed by the DH staff decreased by 1.5 days, while the LOS for patients followed by non-DH staff remained unchanged. Reduction of admissions and LOS represented a savings of approximately $1.7 million. We conclude that a dedicated facility provides the kingpin for effective and rapid painful crisis management, reduces hospitalizations, and facilitates integration of the approach into other areas of care. (Blood. 2000;95:1130-1136)

A survey of pain relief clinics in the South Western Region.

All the district general hospitals in the South Western Health Region have a pain relief service in existence or planned for the immediate future. Almost all are recognized by the allocation of anaesthetic consultant sessions. In most cases, this allocation is less than the time required for pain relief. All the consultants concerned work in single disciplinary clinics and accept both in-patient and out-patient referrals. They provide an advisory and therapeutic service to patients in the care of other clinicians and give tuition, mainly to junior anaesthetists. Most also undertake domiciliary assessment and treatment. In most clinics the pain relief Service is hampered by inadequate facilities. The minimum facilities for a basic efficient service are here reviewed.

Antidiuretic hormone levels and the effect of indomethacin on ureteral colic.

We treated 25 patients with ureteral colic and urographically verified stones with 50 mg. indomethacin intravenously. Pain was relieved completely in 17 patients, while in 8 incomplete or no pain relief was achieved after the infusion of indomethacin. Patients completely relieved of pain had significantly higher levels of antidiuretic hormone in plasma before the infusion of indomethacin (18.2 plus or minus 3.4 pg./ml.) than patients with incomplete or no pain relief (7.2 plus or minus 1.3 pg./ml.) (p less than 0.01). These findings indicate that the volume status and/or the level of antidiuretic hormone may be of critical importance for pain relief after infusion of indomethacin in patients with ureteral colic.

The analgesic effect of transcutaneous electrical nerve stimulation (TNS) in patients with rheumatoid arthritis. A comparative study of different pulse patterns.

Transcutaneous electrical nerve stimulation (TNS) was used on 20 patients with severe wrist pain due to rheumatoid arthritis. Three different stimulation frequencies were used: high 70 Hz stimulation (70 TNS), low frequency 3 Hz stimulation (3 TNS) and brief trains of stimuli with an internal frequency of 70 Hz and with a repetition rate of 3 Hz (3-70 TNS). The analgesic effect was evaluated on the patient's own estimate of pain relief and by means of a loading test in which the length of time the patient could hold a weight before and after TNS was used. The loading test and the patients' own estimate of pain relief corresponded well. After 70 TNS, 18 patients could double their loading time. The corresponding figure for 3-70 TNS was 16 patients and for 3 TNS 5 patients. The average duration of pain relief after cessation of stimulation was 18 h for 70 TNS and 15 h for 3-70 TNS, while those who responded to 3 TNS experienced pain relief for only 4 h on average.

Epidural morphine analgesia after cesarean delivery.

The effectiveness and safety of 5 mg of epidurally administered morphine for postoperative analgesia was determined in 276 healthy women undergoing cesarean delivery. Overall pain relief, time to administration of additional analgesic medications, and adverse side effects were evaluated. Epidural injection of 5 mg of morphine provided good to excellent pain relief lasting 24 to 36 hours for 83% of patients. Also, review of hospital records for a subset of 34 patients revealed that requirements for additional systemic analgesics were markedly less when postoperative pain relief was provided by epidural administration of morphine than by conventional analgesia therapy. Pruritus, nausea, and vomiting occurred frequently, but were easily treated. Although late respiratory depression did not occur in this group, the authors continue to observe patients closely and monitor respiratory rates for 24 hours.

Attitudes of patients to obstetric analgesia at the University College Hospital, Ibadan, Nigeria.

pain relief, for different reasons, is controversial worldwide. We designed this study to assess the level of awareness of antenatal patients to analgesia in labour and to evaluate the effect of age, parity and educational status on the awareness and acceptability of pain relief in labour. A structured questionnaire was administered to 1,000 antenatal patients between 1 June 2000 and 31 May 2001. Spearman's correlation coefficient was applied to estimate the correlation between the ranked dependent variable (awareness and acceptability) and age, parity and educational status (independent variables). Awareness of pain relief methods was seen in only 27.1%. The most common method known was the use of systemic opioids (80%); only 10% were aware of epidural analgesia and about 14% knew of inhalational analgesia. Acceptance of methods was, however, 57.6%. The most common reason for non-acceptance was that 'The pain of labour is natural' in 76.5%, 12% feared complications to the baby and 25% gave other reasons. Age, parity and educational status did not affect awareness. Educational status had positive correlation (rho = 0.13, P < 0.05) with acceptance while age had a negative correlation (rho = -0.124, P<0.05). Awareness of obstetric analgesia is still relatively low in this environment; however, a high proportion of patients would accept analgesia in labour if offered.

Deltoid muscle flap for massive rotator cuff tears: 41 cases with a mean 7-year (minimum 5 year) follow-up

PURPOSE OF THE STUDY: The aim of this study was to assess outcome after deltoid muscle flap repair of massive rotator cuff tears. We examined functional and radiological results at least five years after surgery. MATERIAL AND METHODS: We reviewed 41 shoulders operated by three senior surgeons (MC, DK, HT). None of the patients were lost to follow-up. The global Constant score was used for pre- and postoperative functional assessment. Three groups were distinguished by preoperative active flexion (group I<90 degrees, group II 90 degrees -120 degrees, group III > 120 degrees ). AP, double oblique (3 rotation views to measure the subacromial space), and Lamy lateral radiographs were obtained in all patients. Shoulder anatomy was evaluated at last follow-up in eight patients: magnetic resonance imaging (MRI) because of persistent pain in one patient and ultrasonography performed by one radiologist (NC) in seven patients. RESULTS: The study population included 26 men and 15 women, mean age at surgery 59 years (42-78, 8). Mean follow-up was 7 years (5-8.5, 0.9). In the coronal plane, there were no distal tears, the stump was in an intermediate position in 7 cases (17%) and retracted to the glenoid in 34 (83%). In the sagittal plane, the supraspinatus exhibited a full thickness tear in all cases. The tear extended anteriorly or posteriorly in all cases. Thirty-eight patients (92%) were satisfied at last follow-up; their global Constant score had improved from 37 to 62 points. Mean anterior flexion improved from 113 degrees to 148 degrees and flexion force from 1.3 kg to 2.9 kg. When preoperative flexion was less than 90 degrees (11 cases), mean gain was + 89 degrees. Inversely, 7 of the 18 patients with flexion > 120 degrees lost a mean 40 degrees at last follow-up. Twenty-seven patient were reviewed at 12 and 89 months: pain relief and force were maintained. The subacromial space, measured in 88% of the cases, was 7.3 mm preoperatively and 5.5 mm at last follow-up. The subacromial space narrowed in 20 patients (56%); none of the patients exhibited an improvement. The flap was explored by ultrasonography in seven patients and by MRI in one: the flap was continuous in 50% and measured more than 4 mm in thickness. Reviews at 12 then 89 months demonstrated good maintenance of pain relief and progression of active flexion and force. DISCUSSION AND CONCLUSION: This long-term study confirms the usefulness of the deltoid flap for the treatment of full thickness massive tears of the rotator cuff. The flap provides persistent pain relief and good function and force. This technique should be discussed for young patients in good physical condition when preoperative imaging demonstrates and irreparable alteration of the tendinomuscular structures (supraspinatus retraction, fatty degeneration, severe amyotrophy). The technique is particularly useful when preoperative flexion is less than 90 degrees. Although the population size is too small for statistical analysis, indications for deltoid flap repair should probably be limited to tears involving at most two tendons and sparing the subscapularis.