Epidural morphine by the caudal route for postoperative pain relief.

In order to detect the ability of epidural morphine, administered by the caudal route, to produce pain relief and in order to compare pain relief by this method with intramuscular injections of opiates, 90 patients scheduled for surgery below the umbilical level were studied. Four milligrams of preservative-free morphine in 10 ml normal saline was compared with intramuscular injections of opiates, using a visual analogue scale. The average pain score was significantly lower in the epidural group during the first 12 postoperative hours. In the epidural group, 38% required additional intramuscular injections during the first 12 h, whereas 86% of the patients in the intramuscular group received opiate injections. No patients developed respiratory depression. Side effects were more common in the intramuscular group than in the epidural group. It is concluded that epidural morphine by the caudal route is a better choice than intramuscular injections in controlling postoperative pain below the umbilical level.

Topical radiotherapy in the management of skeletal metastases

Local radiotherapy plays an important role in the palliative management of bone metastases. Different concepts of dose fractionation are in use. A judgement of the efficacy of these concepts should be based on their different palliative treatment endopoints. The efficacy of radiotherapy using published data can be analysed with respect to pain relief and re-establishment of bone integrity as treatment endopoints. Trials stratifying radiooncological techniques according to an optimization of quality of life are missing. Nevertheless, the rationale for individual treatment in daily work is based on systemic tumor extent, life expectancy, the kind of symptoms and the location of the metastasis in question. In patients with reduced live expectancy a remarkably high chance of pain relief (70%) could be achieved with single doses of 8 Gy. The latency period until pain relief is shorter with higher single doses. In case of recurrence of pain reirradiation with a single dose results in an equally high response rate. Patients with a solitary metastasis, patients with longer live expectancy and patients with pathological fractures should be treated with 'curative' doses, aimed to cause maximum tumor cell killing. Impaired bone stability in patients who are not suitable for surgical intervention requires orthetic supply. Apart from the effect of pain relief, remineralization is the important treatment goal for these patients. Conventional radiotherapy with doses of 40-50 Gy resulted in remineralization in 60-80% of the patients 4-8 weeks after irradiation. Remineralization could not be acceierated by short course fractionation courses.

Lamotrigine in the treatment of chronic refractory neuropathic pain.

Many patients suffer from chronic, intractable neuropathic pain. Despite similar diagnoses and presumed pathophysiologies, symptoms and response to treatment can differ. Monotherapy is only occasionally successful. In this prospective survey, 20 patients with chronic, neuropathic pain not responding to interventional therapy received lamotrigine, sometimes as monotherapy and sometimes combined with oral morphine. The latter occurred in patients who lost pain relief from morphine after time. Ten patients did not respond to the drug; 4 were temporary responders and 6 patients obtained sustained pain relief. It is interesting that 5 patients regained opioid responsiveness and that the drug combination produced excellent pain relief for more than 5 months. We hypothesize an additive effect between morphine and lamotrigine.

pain relief during delivery by transcutaneous electrical nerve stimulation.

The degree of pain alleviation achieved by transcutaneous electrical nerve stimulation (TNS) during delivery has been evaluated. The usual technique of TNS was modified to suit the requirements of pain relief during delivery. Two pairs of electrodes were taped on the parturient's back at levels TH10--L1 and S2--S4. These segments correspond to the pathway of pain afferents into the spinal cord during the first and second stages, respectively. Stimulation was delivered by a two-channel generator producing biphasic pulses which were variable in frequency and amplitude. A low-intensity stimulation was given continuously and a high-intensity stimulation could be initiated by the parturient herself whenever pain increased. Stimulation was provided via the thoracic electrodes throughout the delivery, whereas sacral stimulation was added from the later part of the first stage. No complications with respect to mother or child have occurred. One hundred and forty-seven women have been treated, 65 (44%) of whom considered the pain relief by TNS to be good to very good, 65 (44%) experienced moderate effect, while 17 (12%) women considered that TNS was without effect. In view of the relatively good results and since no complications have occurred, we consider the method recommendable as a primary pain relieving measure to which conventional methods can be added according to need.

Postoperative pain relief by demand analgesia.

Postoperative pain relief is only apparently an easy task. A brief survey of literature investigating the discomfort experienced in the postoperative phase is all but encouraging. One can identify four basic problems in obtaining adequate results by delivery of analgesic drugs: a) the biological variability among individual patients, b) the unpredictable uptake of the drug administered intramuscularly, c) the time lag involved between request by the patient and the subsequent administration of a single dose and d) the lack of knowledge about the nature of the discomfort and its remedies. An alternative strategy introducing "On-Demand" analgesia administering prescribed doses at the right moment is presented and analysed a) as an operant conditioning process implementing a particular reinforcement schedule (behavioural sciences), as well as b) a negative feedback control loop that entrust the central judgement to the patient (system theory). Both approaches give insight into the results: the technique copes with biological variability; anticipating pain induced by fear disappears; the feedback strategy works well and patients adapt to a wide range in prescriptions; intermittent administration makes more efficient use of the analgesic; an optimal result is demonstrated in studies comparing on-demand analgesia with the normal IM-regime and epidural analgesia; continuity in pain relief can be obtained in routine clinical practice.

Pancreatoduodenectomy for chronic pancreatitis: anatomic selection criteria and subsequent long-term outcome analysis.

OBJECTIVE: The authors sought to provide a framework through outcome analysis to evaluate operations directed toward the intractable abdominal pain of severe chronic pancreatitis centered in the pancreatic head. Pancreatoduodenectomy (PD) was used as an example. SUMMARY BACKGROUND DATA: Head resection for severe chronic pancreatitis is the treatment of choice for a ductal system in the head obliterated by severe disease when associated with intractable abdominal pain. To evaluate the effectiveness of promising head resection substitutes for PD, a framework is necessary to provide a reference standard (i.e., an outcome analysis) of PD. METHODS: Inclusion criteria were severe chronic pancreatitis centered in the pancreatic head, intractable abdominal pain, and a main pancreatic duct obstruction or stricture resulting in absent drainage into the duodenum from the uncinate process and adjacent pancreatic head areas or the entire gland. Since 1986, 57 consecutive cases with these criteria underwent PD (47 head only and 10 total pancreatectomy). Clinical and anatomic predictor variables were derived from the history, imaging studies, and pathologic examination. These variables then were tested for association with the following outcome events gathered during annual follow-up: pain relief, onset of diabetes, body weight maintenance, and peptic ulceration. RESULTS: Operative mortality was zero. In 57 patients with a mean follow-up of 42 months, the 5-year outcome event for survival was 93% and the onset of diabetes was 32%. All new cases of diabetes occurred more than 1 year after resection. In 43 cases > or =1 year postoperative with a mean follow-up of 55 months, all patients indicated significant pain relief and 76% were pain free. pain relief was more common in patients with diabetes or in those patients with a pancreatic duct disruption. Death was more common in patients with diabetes. Weight maintenance was more common if preoperatively severe ductal changes were not present. Total pancreatectomy was associated with peptic ulceration. CONCLUSIONS: Using selection criteria, the outcome analysis standardized anatomic and clinical variables as to how they were associated with the outcome events (calibrated the effects of the operation with each variable). In these selected patients, PD is safe and significantly relieves pain. Sequelae are from diabetes, provided total pancreatectomy is avoided.

Use of the World Health Organization guidelines on cancer pain relief before referral to a specialized pain service

In 1986 the World Health Organization (WHO) released guidelines for cancer pain relief. Since then, several controlled studies on effectiveness and practicability of these guidelines have been published. Various authors described inadequate use of these guidelines.We analysed, whether the pain medication of 160 cancer patients referred to the anesthesiological pain clinic at the university hospital of Vienna corresponded to the WHO guidelines or not. Adequacy of pain treatment was assessed using the pain management index (PMI). Multiple criteria were chosen to assess the conformity of the treatment with the guidelines. Furthermore we studied the effect of a strict use of the WHO guidelines in these patients.The average pain intensity of the referred patients was 75 mm (VAS). Negative PMI scores, indicating inadequate pain therapy, were fount in 39 % of cases. A violation of the rules was found in 38% of the therapy schedules. Pain medication was then modified by switching to fixed time intervals, escalation of the steps of the WHO ladder, increasing the dosage or treating neuropathic pain with adjuvant drugs. Two weeks later the average pain score of the patients was reduced to 27 mm (VAS). At that time 72% of the patients quoted an adequate reduction of pain.Inadequate knowledge or disregard of the WHO guidelines for cancer pain relief are common and result in unnecessary and prolonged suffering in these patients.

Factors predicting orofacial pain patient satisfaction with improvement.

AIMS: To determine psychosocial predictors of patients' ratings of satisfaction with improvement and subjective pain relief. This study also examined the underlying components of patient satisfaction with improvement, as assessed at follow-up. METHODS: The sample consisted of 107 chronic orofacial pain patients evaluated at a university-based orofacial pain clinic and referred for treatment with individualized treatment plans. Pain and psychosocial functioning were assessed with standard, reliable, validated self-report instruments administered at the initial evaluation. Follow-up data were collected via a telephone-administered structured interview 8 months after the initial evaluation. Regression methodology was used to determine prediction models for satisfaction with improvement and subjective pain relief. Patient ratings of the quality of the caregiver communication were used as a control variable in all analyses. RESULTS: Quality of caregiver communication predicted approximately 10 to 14% of the variance in outcomes in all models. Greater initial use of cognitive coping strategies and reduced depression predicted higher ratings of satisfaction with improvement and increased pain relief. When concurrent relationships among variables at the follow-up were examined, greater subjective pain relief since the evaluation, lower current pain, and higher ratings of overall mood were significant predictors of patient satisfaction with improvement. CONCLUSION: This study is one of the first to report that the use of certain cognitive coping strategies is associated with positive outcome for patients suffering from orofacial pain. These findings underscore the importance of individual differences on behavioral and psychosocial parameters in the prediction of patients' subjective evaluation of treatment outcome.

The efficiency and tolerance of half-body irradiation (HBI) in patients with multiple metastases. The Krakow experience.

AIM: To present our experience regarding the efficiency and tolerance of half-body irradiation in patients with multiple cancer metastases. PATIENTS AND METHODS: Between January 1986 and December 1997, 102 patients with multiple cancer metastases received half-body irradiation (HBI) at the Center of Oncology--Maria Sklodowska-Curie Memorial Institute in Krakow. Most of the patients (93/102) had bone metastases (Table 1). The HBI was performed with 9 MV photon beam from linear accelerator. In 88 patients only one region (upper, mid or lower) was treated, and 14 patients received upper and lower HBI (13 patients), or upper and mid HBI (one patient) (Table 2). The mean doses were: 6 Gy in upper HBI, 8 Gy in mid HBI, and 9 Gy in lower HBI (Table 3). RESULTS: The positive palliative effect (complete or partial pain relief) was observed in 77 (75.5%) patients (Table 4). Complete pain relief was higher in patients with prostate cancer, and in patients who received mid or lower HBI. During follow-up 47 (46.1%) patients developed pain progression after treatment (Table 5). The probability of survival without pain progression was higher in patients who developed complete pain relief (86.7% at 6 months, 69.3% at 12 and 24 months) than in patients with partial response (52.9% at 6 months, 32.8% at 12 months, and 5.5% at 24 months) (Figure 1). In most of the patients (74/102, 72.5%) the tolerance was good. CONCLUSIONS: HBI is an efficient method for palliation in patients with multiple painful metastases.

pain relief with morphine, intrathecally or peridurally?

We investigated pain relief following 1-2 mg morphine intrathecally applied in 7 patients with cancer pains and in 5 patients with multiple rib fractures (group 1). For postoperative pain relief (group 2) we applied 1-2 mg morphine intrathecally in 26 patients immediately before the induction of the anaesthesia. In 30 patients we applied 4 mg morphine epidurally in 10-20 ml saline solution for postoperative pain relief (group 3). In the first group the duration of the pain relief was 25,2 hours, in the second group 31 hours and in the third group 15,7 hours. In the second group a respiratory depression occurred in 3 cases and was successfully treated with naloxon. In the third group a bladder disorder occurred in two cases. Because of the risk of respiratory depression following intrathecally applied morphine, we recommend the epidural way of application.