Comparison of preoperative pain and medication use in emergency patients presenting with irreversible pulpitis or teeth with necrotic pulps.

OBJECTIVE: This retrospective study compared differences in preoperative pain and medication use in patients with moderate to severe pain who sought emergency endodontic care for teeth with irreversible pulpitis and for symptomatic teeth with necrotic pulps. STUDY DESIGN: A total of 323 patients seeking emergency endodontic treatment completed questionnaires regarding their biographical information, pain, pain history, and medications. Teeth were tested for vitality, mobility, percussion, and palpation pain. Lymphadenopathy was also evaluated. RESULTS: Patients with irreversible pulpitis waited significantly (P <.05) longer before seeking emergency care (9 days vs 4 days) than patients with symptomatic teeth with necrotic pulps. No differences (P >.05) were found between the groups in terms of analgesic or antibiotic use and pain relief from preoperative narcotic medications. Nonnarcotic analgesics were reported to significantly reduce pain more often in patients with symptomatic teeth with necrotic pulps. There were sex differences in the group of patients with irreversible pulpitis: More women than men were taking analgesic medications and, in the group having symptomatic teeth with necrotic pulps, more men than women reported pain relief from their analgesic medications. CONCLUSION: Patients with irreversible pulpitis wait longer to seek emergency treatment. A majority (81%-83%) of emergency patients with moderate to severe pain will have taken some type of medication(s) to help control their pain, and more women than men with irreversible pulpitis will take an analgesic. By taking their preoperative medication(s), this group of patients will get relief 62% to 65% of the time; furthermore, more men than women with symptomatic teeth with necrotic pulps will experience pain relief.

Clinical and physiologic evaluation of stellate ganglion blockade for complex regional pain syndrome type I.

OBJECTIVE: The efficacy of peripheral sympathetic interruption after stellate ganglion blockade was assessed by a sympathetic function test. Results were compared with clinical signs such as temperature changes, pain reduction, and the development of Horner syndrome to evaluate the correlation with clinical investigations. DESIGN: Stellate ganglion blockade with local anesthetics was carried out via an anterior paratracheal approach in 33 patients suffering from complex regional pain syndrome type I. Patients were examined before and after the procedure. For assessment of sympathetic nervous function, the vasoconstrictor response to sympathetic stimuli was assessed using laser Doppler flowmetry. Clinical parameters like surface temperature changes (thermography), pain relief (visual analogue scale), and Horner syndrome were monitored. RESULTS: Twenty-three (70%) of 33 patients developed an increase in temperature difference between the treated hand and the contralateral hand of more than 1.5 degreesC after the procedure, which is a clinical sign of sympathicolysis. In 48% (n = 11) of these patients, the sympathetic function test showed an undisturbed sympathetic nervous function. In 10 patients, no significant increase in temperature difference was observed. Although these patients presented with a normal sympathetic vasoconstrictor response, 4 felt pain relief of more than 50%, suggesting a placebo effect. Only 7 patients with pain relief revealed both clinical sympathicolysis and extinguished sympathetic nervous function and qualified for sympathetically maintained pain. CONCLUSIONS: Clinical investigation is not reliable in the assessment of stellate ganglion blockade. Proof of sympathetically maintained pain based on pain relief after stellate ganglion blockade is not conclusive.

Why is the pain relief of dying patients often unsuccessful? The relatives' perspectives.

In order to determine relatives' opinions of the pain relief of dying patients a postal questionnaire was sent to close relatives (n = 371) of aged patients (mean age 80.1 years) who had died one to two years earlier. In the relatives' opinions, 57% of the patients (n = 211) had suffered from moderate to severe pain and in 22% (n = 46) of these the pain relief was unsuccessful. Inadequate pain relief was associated with a feeling of helplessness in the patients (odds ratio 2.6), insufficient self-determination of analgesic use (9.4), unsatisfactory care of daily needs such as nutrition (8.3), and insufficient care of concomitant symptoms such as dry mouth (6.2). The pain relief was also evaluated as having been unsuccessful when the relatives received limited information about the forthcoming death (5.7), when it was difficult to discuss with the clinical staff (5.7), and when the relatives were not supported by, for example, comforting and heartening (7.9) or encouraging to participate in the care (7.2). In the multivariate analysis, the self-determination of the patients about their pain medication (5.7), difficulties of the relatives to discuss issues with the nursing staff (3.7) and poor atmosphere of the treatment environment (2.8) emerged as the most significant associates of unsuccessful pain relief. The results show that dissatisfaction with the pain management is associated with low appreciation of the treatment of other discomforts and complaints. Successful pain management therefore requires a holistic approach to the wider spectrum of problems in dying patients.

Analgesia in cancer: beliefs and an update

Cancer pain relief is not yet adequate, but there are resources for this. Professional's misconception and the tabu about that pain in cancer is inevitable have been contributing to this problem. Important nurses' knowledge lacuna about pain relief in cancer was found by this study. The WHO program about pain relief in cancer is presented too.

Microvascular decompression for trigeminal neuralgia in patients with multiple sclerosis.

AIMS: To assess whether microvascular decompression (MVD) is a safe and efficacious treatment for patients with trigeminal neuralgia (TGN) and multiple sclerosis (MS). METHODS: Case records were reviewed of all patients with TGN and MS who underwent posterior fossa exploration with a view to MVD between 1993 and 2001. In all patients, magnetic resonance tomoangiography (MRTA) demonstrated vascular compression. RESULTS: Nine patients were included in the study. Seven patients underwent MVD alone; in 2 patients a partial sensory rhizotomy of the trigeminal nerve was added to the decompression. All patients had excellent initial pain relief. Recurrence of neuralgia was noted in 5 patients after MVD and in 1 of the 2 patients after partial sensory rhizotomy. Long-term pain relief was obtained in 1 patient who underwent a redo MVD after postoperative MRTA scans demonstrated recurrent vascular compression of the root entry zone (REZ). Thus only 4 out of 9 patients maintained pain relief. In addition, 3 patients experienced transient worsening of their MS. CONCLUSIONS: Although MVD provides good initial pain relief, the recurrence rate is much higher than that obtained in 'idiopathic' TGN. Although all procedures for the treatment of TGN are worse than those for idiopathic TGN, it is concluded that because of the high recurrence rate together with the morbidity associated with the procedure MVD should not be offered to patients with TGN and MS. Copyright 2003 S. Karger AG, Basel

Cost analysis of a mucoadhesive foam versus conventional treatment for postepisiotomy patients.

The cost of treating postepisiotomy pain and edema with foam containing 1% hydrocortisone acetate and 1% pramoxine hydrochloride and a spray with 20% benzocaine was compared in 200 postpartum patients. Treatment with foam was demonstrated to be more effective than benzocaine spray with greater pain relief and reduction of edema as shown by lower patient need of supplemental pain-relief measures. Treatment with foam was also determined to be less expensive than benzocaine spray when the cost of the supplemental pain-relief measures for benzocaine-treated patients were assessed. Methods used to determine actual hospital costs are presented, and supplemental pain relief treatments are discussed. Use of this type of cost analysis may be useful to the P & T Committee when determining actual cost-effectiveness of different treatment modalities.

Segmental epidural analgesia for labor and delivery.

A study to evaluate segmental epidural analgesia in labor is described. Bupivacaine (0.25 per cent) was used during the first stage of labor and for the second stage, either 3 per cent - Chloroprocaine delivered through the catheter (Group I) or 1 per cent Lidocaine as a perineal infiltrate (Group II) was used. There were 124 full term patients of whom, 36 were nulliparous and 88 were multiparous. The effects of segmental epidural analgesia on maternal blood pressure, pain relief, preservation of lower limb motor power, duration and progress of labor, and fetal outcome were evaluated. pain relief during the first stage of labor was satisfactory in 114 (92 per cent) of the patients. There were no significant changes in maternal blood pressure, motor power in lower limbs, efficiency of uterine contractions and internal rotation of the presenting part when analgesia was effective. The use of 2-Chloroprocaine for second stage pain relief required low forceps delivery in 84 (91 per cent) patients, as compared to 14 (44 per cent) patients that had 1 per cent Lidocaine local infiltration. Fetal outcome, was excellent in all cases in that the one minute Apgar score was never lower than 7.

Clinical effects of epidural block during labour. A prospective study.

The aim of this study was to evaluate the clinical effects of epidural block for pain relief during labour in an obstetric unit which manages mainly high-risk pregnancies. In the majority of the 62 patients studied only 5 ml of a 0,5% solution of bupivacaine was sufficient for effective pain relief. In 75% of patients total pain relief was obtained. Complications of the procedure were hypotension in 32% of patients and bladder atony needing catheterization in 19%. The mean fall in blood pressure was greater in patients with pre-existing hypertension. The incidence of instrumental delivery was 40%, inadequate bearing-down effort being the indication in 54% of these cases. An abnormal fetal heart rate pattern on cardiotocography developed in 13 of 58 fetuses who were monitored internally, while in 3 cases an abnormal pattern because even more abnormal (in one-third of these cases this followed hypotension in the mother). The only statistically significant change in fetal heart rate patterns on cardiotocography was a decrease in the beat-to-beat variability. Epidural block is a very effective form of pain relief during labour but has potentially serious effects, especially in high-risk pregnancies. Precautions to minimize the risk of complications include the administration of intravenous fluid before the procedure and careful monitoring of the patient and her unborn baby. A cardiotocographic monitor is essential for the latter purpose.

MRI-guided frameless stereotactic percutaneous cordotomy.

BACKGROUND: Use of intraoperative myelography as a radiologic guidance for percutaneous cervical cordotomy (PCC) has been superseded by more modern imaging. The only significant advancement in cordotomy techniques over the last 30 years has been CT-guided PCC. The goal of this study was to demonstrate the feasibility of an MRI-guided frameless technique in high cervical cordotomy. METHODS: We describe 6 patients with intractable pain treated using a frameless, MRI-guided, stereotactic, PCC technique in combination with standard physiological localization procedures. Results were compared with those from 32 patients who underwent PCC in the last 5 years using physiological localizing techniques only. RESULTS: Six patients (100%) who underwent the frameless technique had excellent pain relief postoperatively. Patients in the non-stereotactic group, on average, required a higher number of lesions (2.5 vs. 1.2, p < 0.005), and 7 (22%) of these patients had unsatisfactory pain relief following PCC (p = 0.21). Five patients in the non-stereotactic group had weakness postoperatively and 1 had changes in bladder function. Postoperative weakness occurred in 1 patient undergoing the frameless technique. At an average of 6 months of follow-up (range 5-11), excellent pain relief was achieved in 83% (5/6) of MRI frameless PCC patients and 55% (16/29) of standard PCC patients (p = 0.20). CONCLUSIONS: Intraoperative frameless stereotaxy provides surgeons with accurate information that helps to guide the operative approach and precisely tailor the trajectory and depth of the electrode, potentially increasing the safety and efficacy of the operation. Copyright 2003 S. Karger AG, Basel

Paracetamol, tiaramide and placebo for pain relief after orthopedic surgery.

Eighty patients took part in this double-blind, single-dose group-comparative study, comparing the analgesic efficacy of tiaramide hydrochloride 100 mg and 200 mg, paracetamol 1000 mg, and placebo for pain after orthopedic operations. The four treatment groups were similar on entry to the trial. pain relief was assessed up to 6 h after treatment, using a visual analogue pain scale and a pain score, both giving similar results. Statistically significant pain relief (mean pain intensity differences and sum of pain intensity differences) was seen in the group receiving paracetamol compared to those receiving placebo or tiaramide from 1 h to 6 h after drug ingestion. There was no significant difference between placebo and tiaramide 100 or 200 mg. No adverse reactions were reported.