Chronic pancreatitis: results of a protocol of management.

Thirty-five patients with chronic pancreatitis of varying cause have been treated according to a protocol first introduced in 1979. At the end of a mean follow up time of 2.1 years, only 54% of patients were found to have derived benefit defined by pain relief and improved quality of life. Patients with alcoholic pancreatitis did particularly poorly, and alcoholics who continued to drink almost never benefited. Patients with dilated pancreatic ducts were more likely to do well than those with small ducts, and pancreaticojejunostomy had a satisfactory record of pain relief. Patients with biliary pancreatitis generally did well with cholecystectomy and clearance of the common bile duct. The 40-80% pancreatectomy had a poor record for pain relief, and produced diabetes in the majority of patients in whom it was used. Nothing will reverse the established pathology of chronic pancreatitis, which remains an unsatisfactory condition to treat.

Variation in the placebo effect in randomised controlled trials of analgesics: all is as blind as it seems.

The objective was to investigate the relationship between pain relief scores produced by placebo and by active interventions in randomised controlled trials (RCTs). Individual patient categorical pain relief scores from 5 placebo-controlled single-dose parallel-group RCTs in acute postoperative pain were used to calculate the percentage of the maximum possible pain relief score (%maxTOTPAR) for the different treatments. One hundred and thirty of the 525 patients in the 5 trials had a placebo. Individual patients' scores with placebo varied from 0 to 100% of the maximum possible pain relief. The proportion who obtained more than 50% of the maximum possible pain relief with placebo varied from 7% to 37% across the trials; with the active drugs the variation was from 5 to 63%. Mean placebo scores were related to the mean score for the active treatments in each study; the higher the mean active score, the higher the mean placebo score. This relationship disappeared when median values were used. Medical folklore has it that the amount of relief obtained with placebo is one-third of the maximum possible (and does not vary), and that one-third of patients respond to placebo. The results show that the amount of relief obtained with placebo varies considerably between patients, that 38% of patients obtained more than 10% of the maximum possible relief, and 16% obtained greater than 50%. In double-blind, randomised parallel-group studies of high quality placebo scores should not vary. Despite these conditions being met the placebo scores did vary. The previous explanation, of a relationship between the mean placebo scores and the mean scores for the active treatments was not supported.

Contradictory correlations between derived scales.

In a clinical trial one scale of pain relief is scored backwards relative to another (high on one corresponding to low on the other), with a consequent large negative correlation. But two derived scales of total pain, obtained by multiplying average pain relief on each scale by duration of pain (common to both pain relief measurements) gave an almost zero correlation. This apparent contradiction is explained by the inverse relationship between the pain relief scales and the large differences in duration of pain experienced by the patients.

Determinants of patient satisfaction with migraine therapy.

Determinants of patient satisfaction with migraine treatment are not well understood. The objective of this study was to evaluate which treatment outcomes influence patient satisfaction with treatment. Analyses were performed on data from 1506 migraineurs from two clinical trials of rizatriptan for treatment of migraine. Satisfaction with treatment was assessed 2 h after initial treatment and prior to use of rescue therapy. Over 90% of patients who were pain-free at 2 h were at least somewhat satisfied with treatment compared with <10% of patients with moderate or severe pain. Only 60-70% of patients with mild pain at 2 h experienced some level of satisfaction with treatment. For patients with mild pain at 2 h, results showed subjects who reported severe pain at baseline, absence of associated symptoms at 2 h and pain relief within the first 90 min had at least a 76% probability of being at least somewhat satisfied. This probability decreased with the presence of associated symptoms, slower pain relief and moderate baseline pain intensity. Fast, complete pain relief is one important factor in determining short-term patient satisfaction with treatment.

The Oncology Nursing Society: commitment and activities promoting cancer pain relief.

The primary mission of the ONS is promoting excellence in oncology nursing. In its efforts to accomplish this mission, the undertreatment of cancer pain has emerged as a significant issue for clinicians, educators, researchers, and administrators involved in the care of people with cancer. In an effort to promote cancer pain relief, the ONS contributes human, administrative, and financial resources from its existing organizational structure, personnel, and volunteers in the variety of ways described above. The structure of the ONS enables it to support the goal of cancer pain relief from the broadest of policy-making activities nationally to the provision of care by a nurse to a patient and family. The ONS Position Paper on Cancer Pain, other position papers and statements, adopted resolutions, and the strategic planning process will continue to guide the ONS's commitment and contributions to promoting cancer pain relief.

Long-term outcome of spinal cord stimulation and hardware complications.

Spinal cord stimulation (SCS) is a treatment modality for medically intractable chronic pain. This study reports an 11-year experience with SCS assessing long-term pain relief and specifically evaluating complications and revisions. It took the form of a retrospective review of medical/surgical records with a postal questionnaire. The subjects were 102 patients with medically intractable chronic pain who underwent SCS implantation between 1989 and 2000. There were 64 revision operations carried out on 35 patients. These comprised electrode replacement/repositioning (29), generator replacement (23), cable failure (3) and implant removal (5). Five (4.9%) implants became infected and 2 required removal. Clinician-reported pain relief was substantial in 69 (68%) patients. This study adds to the weight of evidence that patients undergoing SCS derive significant benefits in terms of pain relief. However, revision rates remain high due to technical and biological factors. Copyright 2003 S. Karger AG, Basel

Epidural opioids for postoperative pain relief following hepatectomy.

Postoperative pain relief with epidural morphine or buprenorphine and intramuscular morphine was investigated in 67 patients undergoing hepatectomy. When the patient first complained of pain after surgery, 1 or 2mg of epidural morphine, or 0.06 mg of epidural buprenorphine given either at T 10-11 or L 3-4, or 0.1 mg/kg of morphine intramuscularly was administered. Lumbar epidural morphine 2mg, as well as thoracic epidural morphine 2mg, produced excellent and long-lasting pain relief. Nine of 12 patients receiving thoracic epidural buprenorphine 0.06 mg were completely pain-free. Thoracic epidural morphine 1 mg and lumbar epidural buprenorphine 0.06 mg produced incomplete analgesia. Analgesic duration of intramuscular morphine tended to be shorter than that of 2 mg of epidural morphine. PaCO2 increased significantly following thoracic epidural morphine 2 mg, although PaCO2 did not change after lumbar epidural morphine 2 mg. No patient had serious side effects. The lumbar epidural administration of 2 mg morphine may be recommended for postoperative analgesia following hepatectomy.

Spinal cord stimulation in diabetic lower limb critical ischaemia: transcutaneous oxygen measurement as predictor for treatment success.

OBJECTIVES: to evaluate whether transcutaneous oxygen tension (TcpO(2)) measurements could be used as a specific prognostic parameter in selecting diabetic patients for permanent device implantation. METHODS: sixty consecutive diabetic patients (28 with autonomic neuropathy), classified as Fontaine stage III or IV, underwent spinal cord stimulation (SCS) for ischaemic pain, after failed conservative or surgical treatment. Pedal TcpO(2)on the dorsum of the foot and ankle-pressure Doppler measurements were performed before, and 2 and 4 weeks after implantation. RESULTS: limb salvage and good pain relief were achieved in 35 patients, while in 12 partial pain relief and limb salvage for at least 6 months were obtained. In 13 patients the method failed and the ischaemic limbs were amputated. Only 3 of the 28 patients with neuropathy had any long-term benefit. Limb salvage was achieved in those patients with a significant increase in TcpO(2)within 2 weeks of stimulation. The stage of the neuropathy was inversely related to the success of SCS therapy. The ankle-brachial pressure index (ABPI) did not change after stimulation. CONCLUSIONS: diabetic patients with significant increase of TcpO(2)and pain relief during a 2-week test period may be successfully treated by long-term SCS unless they have advanced autonomic neuropathy. Copyright 2000 Harcourt Publishers Ltd.

Trigeminal sensory evoked potential in retrogasserian glycerol injection for trigeminal neuralgia

Since Dr. Hakanson reported retrogasserian glycerol injection method for treatment of idiopathic trigeminal neuralgia, its effectiveness for pain relief has been documented in a few reports. However, effects of glycerol in nervous tissue and mechanism of pain relief of the trigeminal neuralgia have not been elucidated yet. So we attempted to make clear what changes happen in trigeminal sensory evoked potential (TEP) of the patients with trigeminal neuralgia after retrogasserian glycerol injection. For this purpose we had to obtain normal TEP from 12 normal subjects in the beginning. The TEP by upper lip stimulation and recorded at contralateral C5 or C6 (TEP.V2) was consisted of 4 positive and 2 negative potentials in the analysis time of 40 msec which were named P3, N10, P14, P20, N30 and P40. The TEP.V3 that was obtained by lower lip stimulation was consisted of 3 positive and 3 negative potentials that were named N3, P10, N14, P20, N30 and P40. Most remarkable change of the TEP.V2 after glycerol injection in the pain relief group of patients with trigeminal neuralgia involving second division was amplitude attenuation of N10. There was no significant prolongation of peak latencies of P3, N10 and P20. It was remarkable that this amplitude decrease (about 38% of the pre-injection value) was recognized only in the pain relief group. On the contrary the mean amplitude of no relief group decreased only to 86% of the pre-injection value.(ABSTRACT TRUNCATED AT 250 WORDS)

Percutaneous vertebroplasty--a new method for alleviation of back pain

Percutaneous vertebroplasty (PV) is an interventional radiological procedure for the treatment of pain in patients with vertebral compressions caused by osteoporosis, metastases or hemangioma. The method was introduced by Professors P Galibert and H Deramond at the University Hospital of Amiens, France in 1984. It consists of percutaneous injection of bone cement (polymethylmethacrylate) into the vertebral body under fluoroscopy guidance. PV has proved to be effective and safe. Permanent complete or partial pain relief is obtained within hours or days in more than 90% of cases. The complication rate is low, less than 3% for patients with osteoporosis and up to 10% in patients with metastases. We report on the first 17 patients (11 with osteoporosis, 3 with metastases and 3 with hemangiomas) treated in Sweden at the Department of Interventional Neuroradiology, Sahlgrenska Hospital, Goteborg University. We obtained complete pain relief in 71% and partial pain relief in 17% of cases. The majority of the patients improved in mobility and quality of life. We had no clinical complications.