Is outcome for low risk obstetric patients influenced by parity and intervention?

Maternal and perinatal morbidity were examined to assess the influence of parity and intervention procedures among 1032 women considered low risk at commencement of labour. A diagnosis of fetal distress, failure to progress during labour, maternal problems after delivery and consultation with or transfer of the neonate to a paediatrician occurred more frequently amongst nulliparous women (p less than 0.001). Failure to progress in labour was found to be influenced by parity (primigravida), maternal age (less than 20 years) and also by the use of epidural anaesthetic for pain relief (p less than 0.001). Prevalence of abnormal delivery was found to be influenced by parity (primigravida), failure to progress in labour and diagnosis of fetal distress. The use of epidural anaesthesia for pain relief was also found to increase the rate of abnormal delivery (p less than 0.001). Statistically significant differences occurred between the groups of patients, with patients of private specialists having the highest rates for induction (34%), use of epidural for pain relief (40%) and abnormal delivery (46%).

Neutron therapy (dT, 14 MeV) for recurrence of rectal cancer: interim analysis from Munster.

For rectal recurrent cancer and macroscopic residual disease after surgery neutron radiotherapy has been suggested to be superior to photon radiotherapy. At the d,T generator in Munster (14 MeV) 20 patients have been treated with a combined photon-/neutron-radiotherapy: two patients with residual disease after surgery: among the 18 patients with rectal recurrence 15 for pain relief; all for tumor control. Tumor resection had been carried out in five recurrent tumors. Six patients presented with distant metastases. 30 to 40 Gy photons for tumor region and potential microscopic spread with 2 Gy per fraction and 5 to 10 Gy neutrons for macroscopic tumor volume with 0.7 to 1.6 Gy per fraction were applied using multiple fields (three to five). The mean follow-up period is nine months. pain relief was achieved in eleven of 15 patients (73%), the onset of pain was fast, the probability for a pain-free period is 46% for nine months and for survival 56% for twelve months. Side-effects were slight to moderate beside a severe subcutaneous fibrosis in two patients. The superiority of neutrons to photons in rectal recurrent cancer remains questionable and is to be proven in a prospective trial comparing different schedules for frequency, onset and duration of pain relief, tumor control, survival and side-effects.

Repeat radiosurgery for refractory trigeminal neuralgia.

OBJECTIVE: Stereotactic radiosurgery has become an important and minimally invasive alternative for patients with refractory trigeminal neuralgia. When a second procedure is necessary, the outcomes are unknown. The degree of pain relief and morbidity after repeat radiosurgery were studied. METHODS: Thirty-one patients underwent a second gamma knife radiosurgery procedure because of unsatisfactory or unsustained relief of pain after the first procedure. Twenty-seven patients were assessable at median follow-up periods of 42.7 and 20.4 months after the first and second procedures, respectively. Most patients had undergone multiple previous operations of other types (microvascular decompression, radiofrequency rhizotomy, glycerol rhizotomy, balloon compression). The median target doses of the first and second radiosurgeries were 75 and 64 Gy, respectively. All patients were evaluated by a physician who did not participate in patient treatment. RESULTS: After the first radiosurgical procedure, 13 patients had an excellent response initially (complete relief without any medication), 3 had a good response (complete relief with some medication), 7 had a fair response (>50% relief), and 4 had a poor response (<50% pain relief or treatment failure). Repeat radiosurgery was performed in patients with recurrent or residual pain. After the second radiosurgical procedure, 5 patients had an excellent response, 8 had a good response, 10 had a fair response, and 4 had a poor response. Thirteen patients (48%) achieved complete pain relief (with or without medication). Two patients (7.4%) experienced new sensory symptoms after the first radiosurgical procedure, and three (12.7%, actuarial) experienced new sensory symptoms after the second procedure. CONCLUSION: Repeat radiosurgery provided a similar rate of pain relief as the first procedure, despite a modest dose reduction. The risk of new sensory symptoms was increased, but no other morbidity was identified. For patients who experience recurrent pain and choose to undergo a second procedure, our current procedure is to deliver a maximum dose of 50 to 60 Gy to a trigeminal target anterior to the root entry zone near the entrance of the nerve beneath the petrous dura.

Effects and pharmacokinetics of high dose metoprolol on chest pain in patients with suspected or definite acute myocardial infarction.

OBJECTIVE: Pain intensity and the plasma concentrations of metoprolol and its major metabolite alpha-hydroxymetoprolol as well as noradrenaline (NA), adrenaline (A) and neuropeptide Y (NPY) were determined in patients with pain due to definite or suspected acute myocardial infarction (AMI) after graded metoprolol infusion. Pain intensity and metoprolol kinetics were assessed over 8 h. METHODS: Twenty-seven patients of either sex, aged 48-84 years with ongoing chest pain upon arrival to the Coronary Care Unit (CCU) were subdivided into two groups: (1) patients with ECG signs of threatening transmural myocardial damage (n = 15); and (2) patients without such ECG signs (n = 12). Pain intensity was assessed by a numerical rating scale (NRS) and venous blood was obtained for determination of plasma catecholamine and NPY concentrations. A continuous infusion of metoprolol (3 mg.min-1 i.v) was started and serial blood samples for plasma catecholamines, NPY as well as metoprolol and its major metabolite alpha-hydroxymetoprolol were obtained from the contralateral arm. RESULTS: Initial pain intensity was 5.9 (arbitrary units) and 5.4 in the groups with and without signs of transmural myocardial damage, respectively. One third of the patients with ST changes reported full pain relief (NRS = 0) within 70 min after starting metoprolol infusion (accumulated dose, 15-180 mg). Among the patients without ST changes upon arrival, full pain relief was obtained in 70% (accumulated dose, 30-120 mg). There was a dose-dependent relation between accumulated metoprolol dose and pain relief. The diagnosis of acute myocardial infarction (AMI) was confirmed in all 15 patients with ECG signs on arrival of transmural myocardial damage. The mean metoprolol dose in this group was 91(12) mg. The mean metoprolol dose in the 12 patients without ST changes was 64(8) mg. In all, seven of these patients developed definite AMI. The terminal half-life of unchanged metoprolol ranged from 2.5 to 8.5 h in group 1 and from 2.2 to 5.2 h in group 2. In group 1, metoprolol half-life was 4.5 h and total plasma clearance (CL) 54.1 1.h-1. In group 2, the metoprolol half-life was 3.7 h and total plasma clearance 75.4 1.h-1. There was a significant difference in clearance between the groups. After the intravenous metoprolol infusion, alpha-hydroxymetoprolol concentrations increased gradually. In groups 1 and 2, maximal concentrations in plasma (Cmax) were 143 and 135 nmol.1(-1) for alpha-hydroxymetoprolol and 2830 and 1653 nmol.1(-1) for metoprolol, respectively. Plasma NA or NPY did not differ between the groups. In contrast, plasma A was significantly higher during the initial 90 min of observation in patients with ECG signs of transmural myocardial damage. CONCLUSION: High-dose intravenous metoprolol was well tolerated in patients with suspected AMI. There was a more rapid and almost complete pain relief in patients without signs of transmural ischaemia compared with the patients with ECG signs of transmural AMI at arrival. In the later group of patients, plasma clearance of metoprolol was significantly reduced.

Comparisons of pain relief mechanisms between needling to the muscle, static magnetic field, external qigong and needling to the acupuncture point.

pain relief mechanisms of needling to the pain-producing muscle, application of a static magnetic field or external qigong, and needling to the acupuncture point were investigated in an experimentally designed pain producing muscle of animals. Single isometric twitch height in situ was reduced gradually by 10 Hz tetanic stimulation for one hour of the gastrocnemius muscle of guinea pigs. This reduction of twitch height was recovered by injection of 0.3-1 ml saline to the artery of this muscle, or of injection of a vasodilator, isoproterenol dissolved in 0.1 ml saline. Hence, reduction of twitch height could be induced by reduction of circulation in the muscle and recovery of it could be induced be recovery of circulation. Since it is easily considered that a pain substance might be accumulated in a muscle under reduced circulation, and such an accumulated substance might be eliminated by recovery of circulation, the reduction of twitch height after tetanic stimulation could be estimated as the pain-producing muscle and recovery of twitch, as the pain relieving muscle. 1) Needling to the pain muscle, 2) application of a static magnetic field or external qigong to the muscle, and 3) needling to the acupuncture point recovered the reduced twitch height due to tetanic stimulation. Atropine abolished this effect induced by the above 1, 2 and 3 procedures. Hence, the cholinergic vasodilator nerve might be involved in the induction of this effect. A sciatic nerve cut did not influence the effect of 1), but abolished the effect of 3). Denervation and capsaicin abolished the effect of 1). Substance P and a calcitonin gene- related peptide (CGRP) recovered the reduced twitch height, and atropine blocked the effect of CGRP, but did not block that of substance P. The effect of 2) was equivalent to that of anticholinesterase. A rostral lesion of the contralateral anterior hypothalamus did not abolish the effect of 3, but a caudal lesion of this region did. Electrical stimulation of this region produced an effect similar to that of 3). From these results, it was concluded that muscle pain relief by these procedures might be induced by recovery of circulation due to the enhanced release of acetylcholine as a result of activation of the cholinergic vasodilator nerve endings innervated to the muscle artery. However, manners of activation of the cholinergic nerve was different in effects of 1), 2) and 3). 1) might be induced by axon reflex of the CGRP nerve, 2) might be induced by inhibition of cholinesterase and 3) might be induced by a somato-autonomic reflex. The reflex center of this might be in the anterior hypothalamus.

Are single fractions of radiotherapy suitable for plantar fasciitis?

The use of radiotherapy for plantar fasciitis has never been reported in Australasia and is scarcely found in the English language medical literature, but it is commonly used in Europe, especially in Germany. In Europe, treatment courses consisting of multiple small fractions have been associated with high levels of pain relief. In the present report, the use of single fractions or radiotherapy was evaluated by reviewing seven consecutive patients referred for treatment and by applying objective and subjective criteria for pain relief. One patient died of unrelated causes soon after treatment and one declined to receive radiotherapy. Four patients each received a single dose of 8 Gy resulting in complete pain relief. One patient was treated with 8 Gy and 12 weeks later was retreated achieving partial pain relief. A follow-up interview was conducted after a mean of 15.6 months, ranging from 1.5 to 30 months. No acute or late effects occurred; however, the possibility that delayed effects may yet occur, particularly carcinogenesis, cannot be excluded. Radiotherapy for this common condition should be investigated further as it might be safer and more effective than other methods currently in use.

pain relief by high-dose medroxyprogesterone acetate in advanced prostatic cancer

The effect of high-dose medroxyprogesterone acetate was studied in 7 patients with advanced prostatic cancer. Results in 7 patients were no change (NC) in 5 (71%) and progressive disease (PD) in 2 patients (29%). However, pain relief was obtained in 6 of the 7 patients (86%). As side effects, 2 patients (29%) showed moon-face and 2 patients weight gain (29%). These results indicate that treatment of high-dose medroxyprogesterone acetate is useful for pain relief in patients with advanced prostatic cancer.

Predictors of outcome in surgically managed patients with typical and atypical trigeminal neuralgia: comparison of results following microvascular decompression.

OBJECT: Microvascular decompression (MVD) has become one of the primary treatments for typical trigeminal neuralgia (TN). Not all patients with facial pain, however, suffer from the typical form of this disease; many patients who present for surgical intervention actually have atypical TN. The authors compare the results of MVD performed for typical and atypical TN at their institution. METHODS: The results of 2675 MVDs in 2264 patients were reviewed using information obtained from the department database. The authors examined immediate postoperative relief in 2003 patients with typical and 672 with atypical TN, and long-term follow-up results in patients for whom more than 5 years of follow-up data were available (969 with typical and 219 with atypical TN). Outcomes were divided into three categories: excellent, pain relief without medication; good, mild or intermittent pain controlled with low-dose medication; and poor, no or poor pain relief with large amounts of medication. The results for typical and atypical TN were compared and patient history and pain characteristics were evaluated for possible predictive factors. CONCLUSIONS: In this study, MVD for typical TN resulted in complete postoperative pain relief in 80% of patients, compared with 47% with complete relief in those with atypical TN. Significant pain relief was achieved after 97% of MVDs in patients with typical TN and after 87% of these procedures for atypical TN. When patients were followed for more than 5 years, the long-term pain relief after MVD for those with typical TN was excellent in 73% and good in an additional 7%, for an overall significant pain relief in 80% of patients. In contrast, following MVD for atypical TN, the long-term results were excellent in only 35% of cases and good in an additional 16%, for overall significant pain relief in only 51%. Memorable onset and trigger points were predictive of better postoperative pain relief in both atypical and typical TN. Preoperative sensory loss was a negative predictor for good long-term results following MVD for atypical TN.

Analgesic efficacy and pharmacokinetic evaluation of meperidine and hydroxyzine, alone and in combination.

As part of a study to evaluate the analgesic efficacy of meperidine and hydroxyzine, alone and in combination, a double-blind complete crossover study of meperidine (50 mg IM), hydroxyzine (100 mg IM), meperidine (50 mg IM) plus hydroxyzine (100 mg IM), and saline placebo was conducted. Thirty patients with chronic moderate to severe pain due to metastatic cancer were evaluated as to pain relief following administration of all four study medications. All of the treatment groups showed statistically significant analgesic activity as compared to placebo. Hydroxyzine provided sustained pain relief to six hours, whereas meperidine produced analgesia up to two hours. The combination produced additive analgesia only during the first 2 hr. The pharmacokinetics of meperidine and hydroxyzine were compared to observed analgesia. Significant correlation between serum drug levels of meperidine and hydroxyzine and pain relief resulted and the serum levels of meperidine and hydroxyzine necessary for analgesia were calculated to be 0.10-0.15 mg/ml and 60-70 ng/ml; respectively. The observed analgesia of the meperidine/hydroxyzine combination was correlated with the analgesia of the individual agents and the limited additive analgesia observed with the addition of meperidine to hydroxyzine does not justify the added toxicity of the narcotic.

Postoperative intramuscular dextromethorphan injection provides postoperative pain relief and decreases opioid requirement after hemorrhoidectomy.

BACKGROUND: Previous studies have shown that dextromethorphan (DM) produces an analgesic/antihyperalgesic effect. This study was designed to examine whether postoperative DM intramuscular (i.m.) injection could reduce post-hemorrhoidectomy pain. METHODS: At the end of the surgery, patients in the study group (n = 30) were given an intramuscular injection of 40 mg DM and 20 mg chlorpheniramine (CPM) while in the study group (n = 30), the patients were given intramuscular 20 mg CPM only. Pethidine (1 mg/kg, i.m.) was prescribed for postoperative pain relief if required. The time to first pethidine injection, total pethidine consumption, worst pain score, and pethidine-related side effects were recorded for 48 h postoperatively. RESULTS: The time from the end of operation to the first pethidine injection was 5.4 +/- 1.6 h and 17.8 +/- 3.7 h (P = 0.006) in the control group and the study group, respectively. Total pethidine consumption was 139.5 +/- 11.5 mg and 77.5 +/- 12.2 mg (P < 0.001) in the control group and the study group, respectively. The worst VAS score was 7.5 +/- 0.2 and 7.1 +/- 0.2 (P = 0.09) in the control and the study groups, respectively. The number of patients who required pethidine injection was 29 and 21 (P < 0.005) in the control and the study groups, respectively. The number of patients who suffered pethidine-related side effects was 7 and 1 (P < 0.025) in the control and the study groups, respectively. CONCLUSIONS: We found that intramuscular DM given at the end of operation could provide good postoperative pain relief and decrease the pethidine requirement after hemorrhoidectomy.