Single-dose oral Naproxen ( Naprosyn ) for acute postoperative pain: a quantitative systematic review.

BACKGROUND: Naproxen ( Naprosyn ) and Naproxen ( Naprosyn ) sodium are non-steroidal anti-inflammatory drugs used in a variety of painful conditions, including the treatment of postoperative pain. This review aims to assess the efficacy, safety and duration of action of a single oral dose of Naproxen ( Naprosyn )/Naproxen ( Naprosyn ) sodium for moderate to severe acute postoperative pain in adults, compared with placebo. METHODS: The Cochrane Library (issue 4 2002), EMBASE, PubMed, MEDLINE and an in-house database were searched for randomised, double blind, placebo controlled trials of a single dose of orally administered Naproxen ( Naprosyn ) or Naproxen ( Naprosyn ) sodium in adults with acute postoperative pain. pain relief or pain intensity data were extracted and converted into dichotomous information to give the number of patients with at least 50% pain relief over 4 to 6 hours. Relative benefit and number-needed-to-treat were then calculated. The percentage of patients with any adverse event, number-needed-to-harm, and time to remedication were also calculated. RESULTS: Ten trials with 996 patients in met the inclusion criteria. Six trials compared Naproxen ( Naprosyn ) sodium 550 mg (252 patients) with placebo (248 patients); the NNT for at least 50% pain relief over six hours was 2.6 (95% confidence interval 2.2 to 3.2). There was no significant difference between the number of patients experiencing any adverse event on treatment compared with placebo. Weighted mean time to remedication was 7.6 hours for Naproxen ( Naprosyn ) sodium 550 mg (206 patients) and 2.6 hours for placebo (205 patients). Four other trials used lower doses. CONCLUSION: A single oral dose of Naproxen ( Naprosyn ) sodium 550 mg is an effective analgesic in the treatment of acute postoperative pain. A low incidence of adverse events was found, although these were not reported consistently.

Maternal satisfaction with childbirth and intrapartum analgesia in nulliparous labour.

OBJECTIVE: To assess maternal satisfaction with childbirth and intrapartum pain relief in nulliparous women labouring at term. METHODS: Prospective randomised clinical trial comparing epidural and non-epidural analgesic techniques on term labour outcomes in nulliparous women. Within 24 h of delivery the women were surveyed regarding their opinions about the birthing experience and the allocated analgesic regimen. A postal survey was conducted 6 months postpartum to assess opinions about intrapartum analgesia in a subsequent pregnancy. RESULTS: A total of 992 women were randomised to receive continuous midwifery support (CMS) or epidural (EPI) analgesia on presentation for delivery. There was a high crossover rate from CMS to EPI (61.2%) and a lesser non-compliance rate in the EPI group (27.8%). The early post-partum recollections revealed a high satisfaction with epidural analgesia and lower satisfaction with alternative pain relief measures. Ten percent of women in the CMS group reported negative feelings about their allocated pain relief compared with 1% in the EPI group (P < 0.001), and 10% of all women reported negative feelings about their overall childbirth experience. At the 6-month postpartum survey factors associated with the planned use of epidural analgesia in a subsequent pregnancy were induction of labour (odds ratio (OR) 2.4, 95% confidence interval (CI) 1.2, 4.7) and prior utilisation of epidural analgesia (OR 28.1, 95% CI 14.5, 54.7). CONCLUSIONS: Maternal satisfaction with intrapartum analgesia was significantly higher with epidural analgesia than non-epidural analgesic techniques. Overall satisfaction scores for labour and delivery were high regardless of analgesic approach, reflecting the multiple issues other than pain relief that are involved in the childbirth experience.

Operative management of neuromatous knee pain: patient selection and outcome.

The management of intractable knee pain secondary to neuromata continues to be optimized. Forty-three patients with intractable knee pain were studied prospectively. Consideration for this procedure requires pain of at least a 1-year duration, failure of conservative management, pain localization at a Tinel's point, and at least a 5-point reduction of pain on a visual analog scale after nerve blockade with 1% lidocaine. Thirty patients met the criteria for the procedure and 25 patients underwent the procedure. Mean patient age was 50.3 years and mean duration of pain was 6.6 years. Pain etiology included total knee replacement in 10 patients and trauma in 15 patients. Mean number of prior operations on the knee was 5.1. Sixty-two nerves were excised in the 25 patients, including the infrapatellar branch of the saphenous nerve (N = 24), the tibiofibular branch of the peroneal nerve (N = 5), the medial retinacular nerve (N = 12), the lateral retinacular nerve (N = 8), the medial cutaneous nerve (N = 6), the anterior cutaneous nerve (N = 3), and the lateral femoral cutaneous nerve (N = 4). Complete pain relief was obtained in 11 patients (44%). Partial pain relief was reported in 10 patients (40%). No pain relief was reported in 4 patients (16%). Follow-up ranged from 1 to 4 years. Selective denervation for neuromatous knee pain is beneficial in select patients. Patient satisfaction was 84% (21 of 25 patients) after the procedure. No patient was made worse.

Radiation therapy in bone metastases from lung cancer

The record of 73 patients with 153 sites of bone metastases from a lung cancer treated by radiation have been reviewed to evaluate the effectiveness of pain relief. Radiation therapy for bone metastases was found to be very effective. Sufficient symptomatic improvement was achieved in 94% of all patients, while 63% obtained almost complete pain relief that was sustained until death. Onset of a symptomatic response to radiotherapy was within less than 20 Gy in total dose in more than 80% of all patients. There were no significant differences in the frequency of pain relief among the various histological types of primary lung tumors.

Results of treatment of recurrent dorsoradial wrist neuromas.

Dorsoradial wrist neuromas diagnosed and treated by traditional techniques remain the most difficult for which to achieve satisfactory pain relief. Between 1981 and 1985, 52 patients with dorsoradial wrist neuromas were treated by neuroma resection and implantation of the nerves innervating the neuroma into the brachioradialis muscle. Critical to this treatment schema was preoperative use of nerve blocks to diagnose overlapping patterns of the cutaneous nerves in this region. Of patients for whom this technique was the first surgical treatment of their neuroma (primary group), 100% achieved good to excellent pain relief. Among patients in whom the neuroma had been operated on once previously (first recurrence group), 88% achieved good to excellent pain relief with the technique described in this article. Of patients treated who had had 3 or more previous "neuroma" operations (multiple recurrence group), this technique resulted in excellent pain relief in 56%. Factors contributing to a poorer result in the multiple recurrence group included duration of pain longer than 24 months and the patient's unemployment. The diagnostic and surgical approach detailed in this article has yielded clinical results that recommend this approach not only as the primary treatment of choice but also as the treatment to help patients with pain from recurrent dorsoradial neuromas. The apparent susceptibility of the superficial branch of the radial nerve (SBRN) to form painful neuromas has been well documented. Once established, the neuroma appears particularly resistant to treatment. Based on experimental and cadaveric studies, we have formulated a treatment plan for patients with dorsoradial wrist neuromas.(ABSTRACT TRUNCATED AT 250 WORDS)

Radiotherapy for symptomatic osseous metastases: special reference to the analysis of patients achieved complete pain relief

A total of 223 patients with 498 symptomatic osseous metastases treated by radiotherapy between July 1985 and June 1991 were retrospectively analyzed. Most sites, 409 (82%), were irradiated by conventional fractionation, while the remaining 89 sites were irradiated by dose-increment fractionation, low-dose short schedules or hyperfractionation. The total dose ranged from 5.4 to 74 Gy (mean, 41.4 Gy). Daily pain assessment was done by patients themselves on an 11-point scale, i.e., 10: pretreatment pain, 0: disappearance of pain following radiotherapy. In addition, improvement in performance status (PS) and the duration of complete pain relief were assessed. The following results were obtained. 1) pain relief: Of 498 evaluated sites, complete pain relief and partial pain relief were achieved in 403 sites (81%) and 64 sites (13%), respectively. No significant difference was seen in the incidence of complete pain relief between weight-bearing bone and non-weight-bearing bone. Patients with PS 1, 2 or 3 were significantly superior to those with PS 4 in terms of complete pain relief (P < 0.05-0.001). The complete response rate increased in accordance with the dose delivered, i.e., 49% at 20 Gy, 70% at 30 Gy and 77% at 40 Gy, in all of the 498 sites irradiated; 60%, 86% and 95% of 403 sites, respectively, achieved complete pain relief. Regarding the fractionation regimens, dose-increment fractionation was superior to both conventional fractionation and low-dose short schedules in terms of complete pain relief rate. 2) Improvement of PS: Of 223 evaluated patients, PS was improved 1 to 3 steps in 162 (73%) at the completion of radiotherapy. The improvement rates of patients with PS 2 or 3 were significantly better than those with PS 4 (P < 0.025, 0.001). 3) Duration of complete pain relief: Of 288 appraisable sites, the recurrence of pain was recognized in 23 (9%) at intervals of 3 to 21 months (median, 5 months). On the other hand, the duration of pain relief was 16 to 79 months (median, 32 months) in 26 sites of survivors, and 1 to 28 months (median, 5 months) in 239 sites of decreased patients. The mean total dose was 48.5 Gy (TDF: 82) to 62 sites with a duration of pain relief of more than 13 months. 4) Re-irradiation to the same site: Of 14 sites retreated after initial complete response with a total dose of 30 to 50 Gy (mean, 48 Gy), 11 (79%) were in weight-bearing bone and 9 (64%) responded completely. 5) Patients with unsatisfactory pain relief (pain score > or = 6): Of 31 sites, 27 (94%) were in patients with PS 4, and 19 (61%) received a total dose below 30 Gy. 6) The 11-point scale for patient self-assessment of pain relief following radiotherapy was thought to be useful and easy to adopt in general clinics.

"Why haven't you taken any pain killers?" A patient focused study of the walking wounded in an urban emergency department.

OBJECTIVES: (1) To assess the proportion of patients of triage category 3-5 presenting to the minor side of an urban emergency department who present without taking prior pain relief, and (2) to describe the reasons why they do not take pain relief for their presenting complaint METHOD: By patient interview of a convenience sample of 60 adult patients in the setting of an urban emergency department. RESULTS: Fifteen of 60 patients had taken analgesia and 45 of 60 (75%) had not. Sixteen reasons were volunteered to the interviewer. Most patients offered one reason only 39 of 45 (87%). The three commonest single reasons cited for not taking pain relief were "don't like taking tablets" 10 (22%), "run out of tablets" 10 (22%), five (11%) said their "pain not bad enough". Six (13%) patients cited two reasons for not taking pain relief. Only three (6%) patients indicated that they "did not think about pain relief". Six (13%) of patients had inappropriate perceptions of how pain killers may interfere with their care. CONCLUSION: Most patients presenting with painful conditions to the minor side of an urban emergency department had not taken pain relief. The study highlights there are many different reasons for this and staff should not presume that it was because the patient "did not think about it". Ongoing education of staff and patients is needed.

Survey of postoperative pain in University Hospital Kuala Lumpur.

One hundred and eighty-three patients undergoing surgery were interviewed twenty-four hours following surgery to assess the quality of pain relief they received in the immediate postoperative period. Interviews were conducted using a standard questionnaire for all patients. They were asked to (1) rate the quality of pain relief they obtained on a Visual Pain Analogue Scale (VPAS-0 being no pain and 10 being the worst imaginable pain); (2) state whether they were happy and satisfied with the pain relief they received; (3) if dissatisfied, they were asked to give their reasons. 37.7% (69 patients) had moderate to severe pain--pain score greater than 6 on the VPAS. Most of these patients had undergone abdominal or major orthopaedic surgery. 32.7% (60 patients) were unhappy with their postoperative pain control. The main reasons for complaint from the patients were that analgesic injections were either not given promptly or were not given at all. The survey also highlighted the inadequate under-administration of narcotic injections in the postoperative period despite orders being written up. It showed there is an urgent need for setting up an Acute Pain Service for better postoperative pain control. An anaesthesiology based Acute Pain Service was started in October 1992.

Treatment of lumbar facet joint syndrome by CT-guided infiltration of the intervertebral joints

INTRODUCTION: Lumbar facet joint syndrome is a common condition, involving about 79% of patients suffering from low back pain. Denervation by scalpel or electrofrequency is a well-known method of treating it. An alternative method for longer lasting pain relief is CT-guided intraarticular infiltration of facet joints with local anaesthetics and cortisone. METHODS: In 62 patients with facet syndrome a total of 205 joints were infiltrated, CT monitoring being used in all cases. Each facet joint was infiltrated with 0.3 ml bupivacaine and 0.8 ml methylprednisolone. The patients were divided into three groups. Group 1 consisted of 24 persons who had undergone lumbar disc surgery, group 2 of 23 patients with spondylarthrosis of the facet joints, and group 3 of 15 patients who had undergone lumbar disc surgery but had additional spondylarthrosis. Very good results were defined as pain relief for longer than 4 weeks, good results as pain relief for up to 4 weeks and poor results as brief pain relief or none at all. In 27 patients facet infiltration was performed for the purpose of diagnosis. RESULTS: Results were significantly in group 2 than in group 1 (Fisher's exact test P < 0.012). In group 3 results were better than in group 1, but worse than in group 2. These differences were not statistical by significant (Table 3). Seven patients in the diagnostic group had no pain relief, and facet syndrome was excluded. CONCLUSIONS: CT-guided facet joint infiltration is a good method for treatment and diagnosis of lumbar facet joint syndrome. It can be repeated and has no severe side effects. The best results were seen in patients with spondylarthrosis of the facet joints. After lumbar disc surgery the pain relief was shorter, though it also yielded good results. For patients with unspecific low back pain, facet joint injections are a very good diagnostic method, allowing definite exclusion of lumbar facet syndrome.

Validation of World Health Organization Guidelines for cancer pain relief: a 10-year prospective study.

This paper reports on the experience gained using World Health Organization Guidelines for cancer pain relief over a 10-year period in an anaesthesiology-based pain service associated with a palliative care programme. The course of treatment of 2118 patients was assessed prospectively over a period of 140,478 treatment days. Non-opioid analgesics (WHO step I) were used on 11%, weak opioids (WHO step II) on 31% and strong opioids (WHO step III) on 49% of treatment days. Administration was via the enteral route on 82% and parenterally on 9% of treatment days. On the remaining days, either spinally applied opioids (2%) or other treatments (6%) were utilised. Fifty-six percent of the patients were treated with morphine. Morphine dose escalation was observed in about one-half of the patients being cared for until death, whereas the other half had stable or decreasing doses over the course of treatment. Co-analgesics were administered on 37% of days, most often antidepressants (15%), anticonvulsants (13%) and corticosteroids (13%). Adjuvants to treat symptoms other than pain were prescribed on 79% of days, most commonly laxatives (42%), histamine-2-receptor antagonists (39%) and antiemetics (35%). In addition, palliative antineoplastic treatment was performed in 42%, nerve blocks in 8%, physiotherapy in 5%, psychotherapy in 3% and TENS in 3% of patients. A highly significant pain reduction was achieved within the 1st week of treatment (P < 0.001). Over the whole treatment period, good pain relief was reported in 76%, satisfactory efficacy in 12% and inadequate efficacy in 12% of patients. In the final days of life, 84% rated their pain as moderate or less, while 10% were unable to give a rating. Analgesics remained constantly effective in all 3 steps of the WHO ladder. Other clinical symptoms were likewise significantly reduced at 1 week after initial assessment, with the exception of neuropsychiatric symptoms. During the course of treatment, the latter were the major symptoms on 23% of days, followed by nausea (23%), constipation (23%) and anorexia (20%). Our results emphasise once again the marked efficacy and low rate of complications associated with oral and parenteral analgesic therapy as the mainstay of pain treatment in the palliative care of patients with advanced cancer. Wide dissemination of WHO guidelines among doctors and healthcare workers is thus necessary to effect a clear improvement in the treatment of the many patients suffering from cancer pain in the clinical and home setting.