Methylmethacrylate as an adjunct in internal fixation of pathological fractures. Experience with three hundred and seventy-five cases.

In 323 patients with 375 pathological fractures or impending fractures, local tumor resection and internal fixation supplemented by intramedullary methylmethacrylate proved highly successful. One hundred and thirty-nine patients had metastases from breast carcinoma; 142, metastases from other tumors; and forty-two, myeloma or lymphoma. The mean survival for the 210 patients who had undergone operation two years or more before final evaluation was 15.4 months. Ninety-four per cent of the patients who were ambulatory before fracture regained the ability to walk. Eighty-five per cent had excellent or good pain relief and in only five was pain relief rated poor. There were four failures of fixation and six functionally poor results. Twenty patients died within four weeks of operation, but the remaining patients benefited from the procedure in terms of pain relief, improved mobility, and ease of nursing care.

Surgical management of chronic pancreatitis: long-term results in 141 patients.

The management of pancreatic pain is a controversial subject and the treatment recommended varies from one extreme to the other. Some authorities advise simply waiting for chronic pancreatitis to 'burn out', while others practise removal of the entire gland. In this paper we present 141 patients who underwent surgery for chronic pancreatitis at the Mayo Clinic. The main indication for operation was pancreatic pain and the choice of operation was based on anatomical abnormalities in the gland. The long-term results of the policy are reviewed (mean follow-up 8.5 years). Length of history, aetiology of disease, pancreatic dysfunction and pathology, time after operation and continued alcohol abuse were computer analysed for a statistically significant influence on pain relief, ability to work, pancreatic function and survival. There was one operative death (mortality rate 0.7 per cent). Continued drinking was not shown to affect postoperative pain relief but 10-year survival was significantly less in alcoholics than in those with non-alcoholic pancreatitis (P less than 0.02). Dilated ducts and duct calculi were associated with good results for pain relief although this association did not achieve statistical significance. Parenchymal calcification and time after operation did not influence the results of surgery. When the operation failed to relieve pain, spontaneous remission occurred in a few cases only. Seventy-seven per cent of patients had lasting relief of pain and operations selected on the basis of gross pathology were equally effective in relieving pain. Longitudinal pancreaticojejunostomy in those with dilated ducts and a Whipple operation for disease of the pancreatic head gave good results.(ABSTRACT TRUNCATED AT 250 WORDS)

Cannabis use for chronic non-cancer pain: results of a prospective survey.

There has been a surge in interest in medicinal cannabis in Canada. We conducted a questionnaire survey to determine the current prevalence of medicinal cannabis use among patients with chronic non-cancer pain, to estimate the dose size and frequency of cannabis use, and to describe the main symptoms for which relief was being sought. Over a 6-week period in mid-2001, 209 chronic non-cancer pain patients were recruited in an anonymous cross-sectional survey. Seventy-two (35%) subjects reported ever having used cannabis. Thirty-two (15%) subjects reported having used cannabis for pain relief (pain users), and 20 (10%) subjects were currently using cannabis for pain relief. Thirty-eight subjects denied using cannabis for pain relief (recreational users). Compared to never users, pain users were significantly younger (P=0.001) and were more likely to be tobacco users (P=0.0001). The largest group of patients using cannabis had pain caused by trauma and/or surgery (51%), and the site of pain was predominantly neck/upper body and myofascial (68% and 65%, respectively). The median duration of pain was similar in both pain users and recreational users (8 vs. 7 years; P=0.7). There was a wide range of amounts and frequency of cannabis use. Of the 32 subjects who used cannabis for pain, 17 (53%) used four puffs or less at each dosing interval, eight (25%) smoked a whole cannabis cigarette (joint) and four (12%) smoked more than one joint. Seven (22%) of these subjects used cannabis more than once daily, five (16%) used it daily, eight (25%) used it weekly and nine (28%) used it rarely. Pain, sleep and mood were most frequently reported as improving with cannabis use, and 'high' and dry mouth were the most commonly reported side effects. We conclude that cannabis use is prevalent among the chronic non-cancer pain population, for a wide range of symptoms, with considerable variability in the amounts used. Discussions between patients and health care providers concerning cannabis use may facilitate education and follow up, and would allow side effects and potential interactions with other medications to be monitored. Clinical trials of cannabis for chronic non-cancer pain are warranted.

Assessing and treating pain in the newborn

OBJECTIVES: To update information about available neonatal pain assessment and pain relief methods.METHOD: Medical literature review of the past 10 years, including textbooks, general reviews, systematic reviews, prospective, randomized controlled studies, retrospective works and case studies. Literature was reviewed based on the author clinical and scientific experience regarding pain evaluation and treatment.RESULTS: Lack of verbal expression of pain is one of the major impediments to adequate pain relief in the neonatal period. Nowadays, several valid pain assessment tools are available, including the analysis of the neonate facial features and multidimensional tools, as NIPS, CRIES, and PIPP. Non-pharmacological pain relief can be achieved by non-nutritive suction and suction of dextrose water. Neonatal analgesia, in general, includes de the use of paracetamol, opioids and local anesthetics. Opioids remain the main resource for acute pain treatment in the neonatal intensive care unit. Sedatives are important agents to decrease patient activity and restlessness, but they do not relieve pain.CONCLUSION: Based on medical, ethical, and humanitarian grounds, neonatal pain should be considered and treated.

Somatic sympathetic vasomotor changes documented by medical thermographic imaging during acupuncture analgesia.

Acupuncture is widely used for pain relief in many musculoskeletal disorders, and evidence suggests that modulation of the sympathetic nervous system responses which play an integral part in somatic pain, is an important mechanism of acupuncture action. This prospective study of 20 patients with neck and arm pain measured finger temperature, controlled by somatic sympathetic vasomotor activity before and after needle acupuncture. Responses were correlated with visual analogue scale (VAS) of pain severity. An association was found between pain relief and reduced sympathetic vasomotor activity. In 10 patients with significant reduction in visual analogue scale (VAS) pain (p less than .05), the mean change in temperature (delta t degrees C) was 0.55 (SD +/- 0.86) with significant difference in pre to post treatment temperatures (p less than .01). In 10 patients without significant pain relief on VAS scoring (p greater than .05), the mean t degrees C was 0.20 (SD +0.72) without significant difference in pre to post treatment temperatures (p greater than .05). The relevance of somatic sympathetic influences on musculoskeletal pain and modulation of sympathetic activity by acupuncture will be discussed.

Intraventricular morphine administration for control of chronic cancer pain.

Twenty cancer patients with severe chronic pain have been treated with intraventricular morphine sulfate. Adequate pain relief until death was achieved in 10 patients; 1 patient has been treated for 9 months and is still being treated. In 2 patients, the effects of the morphine sulfate on their unilateral pelvic pain wore off after 4 and 6 months because of tumor progression. At that time, they underwent chordotomy procedures elsewhere. The treatment was discontinued in 4 patients for reasons other than inadequate pain relief, such as medical complications or resolution of pain. In 3 patients, the procedure was abandoned when emotional and psychological factors interfered with pain control. Dose requirements of intraventricular morphine sulfate varied greatly, depending on the total daily dose of systemic narcotic intake at the onset of the study. Intraventricular morphine sulfate is a feasible and reliable method to achieve pain relief in selected cancer patients with severe chronic pain when the maximum tolerated dose of systemic narcotic analgesics has become insufficient to control their pain.

Non-oncologic chronic pain relief with opioids

Opioids for non cancer pain control are controversial. The evaluation of the pain relief, changes in quality of life and complications due to long term infusion of opioids in the lumbar subarachnoid space in 11 patients with non cancer pain were the goals of this study. Patients were previously treated with drugs and surgical procedures, without significant pain relief. Patients were asked to compare pain characteristics and daily life activities before and after this treatment. The long term spinal opioids through implantable pumps for non-oncologic pain produced pain relief but did not improve the quality of life in the majority of the cases.

Postoperative analgesia using epidural methadone. Administration by the lumbar route for thoracic pain relief.

The effectiveness of methadone given postoperatively by the lumbar epidural route to patients following upper abdominal or thoracic surgery was assessed. Intermittent injections of methadone diluted in large volumes of normal saline were given during the first 48 hours after surgery. pain relief was assessed by both the patient and an observer using a visual linear analogue scoring system. Methadone 4-5 mg in 18-20 ml normal provided good postoperative pain relief for 6-8 hours.

Influence of calcium channel blockers and beta-blockers on pain relief with iontophoresis

We studied usefulness of iontophoresis on pain relief using several Ca channel blockers, propranolol and guanethidine. Subjects were 18 healthy adult volunteers. We used 4% lidocaine with/without several drugs (2 mg of nicardipine, verapamil, diltiazem, propranolol and 10mg of guanethidine), and evaluated the pain relief effect with Nakahama's algesimeter. In all groups except for propranolol group, the pain recognition time was elongated significantly in comparison with control. In making comparison between each Ca channel blocker, we did not observe any significant differences, but, in propranolol group, elongation of pain threshold time was observed in some subjects. During these processes, systemic blood pressure and heart rate showed no remarkable changes. Our results suggest that it is possible to achieve more prolonged analgesic effect by the Ca channel blockers.

Postoperative pain therapy: a survey of patients' expectations and their experiences.

For 2 months elective surgical patients (n = 259) were asked preoperatively about their expectations of pain and pain relief. At both 24 and 72 h after their surgery they were asked about their pain and pain control. The analgesics they received were monitored for the first 72 h. The survey revealed that patients do not have the necessary knowledge about pain relief to contribute effectively in their own pain management. Analgesics administered intermittently were generally effective when given, however, the dosing interval was too long for the agents used resulting in frequent reports of poor pain relief. We conclude that patients need better education on postoperative pain control therapy. Medical staff could prescribe, and nursing staff administer, analgesics more effectively.