Relief of refractory angina with continuous intravenous infusion of nitroglycerin.

Seventy-five patients with chest pain due to prolonged myocardial ischemia (group I, n=45) or acute myocardial infaction (group II, n=30) were treated with continuous intravenous infusion of nitroglycerin. pain relief was achieved immediately or after titration in 40 of 45 group I patients and 22 of 30 group II patients. Of the 29 group I patients who received narcotic analgesics for pain relief prior to the nitroglycerin infusion, 20 experienced a decrease in narcotics required for pain relief while intravenously receiving nitroglycerin. Twenty-four of 28 group I patients and 14 of 19 group II patients who had angina refractory to multiple doses of sublingual nitroglycerin received relief with intravenous administration of nitroglycerin. This data suggests that intravenous administration of nitroglycerin is useful, adjunctive therapy for chest pain even when refractory to multiple doses of sublingual nitroglycerin.

Single-dose rofecoxib for acute postoperative pain in adults: a quantitative systematic review.

BACKGROUND: Rofecoxib is a cyclo-oxygenase 2 selective inhibitor. This systematic review of rofecoxib in acute pain examined studies in adults of analgesic efficacy over six hours, the amount and quality of the evidence on extended duration of analgesia, and the quality and quantity of evidence on adverse events. METHODS: Cochrane Library (issue 4, 2001), Biological Abstracts (March 2002), MEDLINE (March 2002) and PubMed (March 2002) were searched using rofecoxib as a free text term. The area under the pain relief versus time curve was dichotomized using validated equations to derive the proportion of patients on rofecoxib 50 mg or placebo with at least 50% pain relief over six hours. This was used to calculate the number needed to treat for at least 50% pain relief over six hours for rofecoxib compared with placebo. Information on duration of analgesia and adverse events was also collected. RESULTS: Five included trials investigated 1,118 patients, of whom 211 received placebo and 464 received rofecoxib 50 mg. The NNT for rofecoxib 50 mg was 2.3 (95% confidence interval 2.0 to 2.6). The weighted mean remedication time was 1.9 hours for placebo (126 patients), 7.4 hours for Ibuprofen ( Motrin ) 400 mg (97 patients) and 13.6 hours for rofecoxib 50 mg (322 patients). CONCLUSION: Rofecoxib at 2-4 times the standard daily dose for chronic pain is an effective single dose oral analgesic in acute pain. Limitations in trial reporting constrain conclusions about longer duration of analgesia and adverse event profile.

Deriving dichotomous outcome measures from continuous data in randomised controlled trials of analgesics.

Reports of RCTs of analgesics frequently describe results of studies in the form of mean derived indices, rather than using discontinuous events--such as number or proportion of patients with 50% pain relief. Because mean data inadequately describe information with a non-normal distribution, combining mean data in systematic reviews may compromise the results. Showing that dichotomous data can reliably be derived from mean data, at least in acute pain models, indicates that more meaningful overviews or meta-analysis may be possible. This study investigated the relationship between continuous and dichotomous analgesic measures in a set of individual patient data, and then used that relationship to derive dichotomous from continuous information in randomised controlled trials (RCTs) of analgesics. Individual patient information from 13 RCTs of parallel-group and crossover design in acute postoperative pain was used to calculate the percentage of the maximum possible pain relief score (%maxTOTPAR) and the proportion of patients with greater than 50% pain relief (> 50%maxTOTPAR) for the different treatments. The relationship between the measures was investigated in 45 actual treatments and 10,000 treatments simulated using the underlying actual distribution; 1283 patients had 45 separate treatments. Mean %maxTOTPAR correlated with the proportion of patients with > 50%maxTOTPAR (r2 = 0.90). The relationship calculated from all the 45 treatments predicted to within three patients the number of patients with more than 50% pain relief in 42 of 45 treatments, and 98.8% of 10,000 simulated treatments. For seven effective treatments, actual numbers-needed-to-treat (NNT) to achieve > 50%maxTOTPAR compared with placebo were very similar to those derived from calculated data.

Thermoradiotherapy for local control of chest wall invasion in patients with advanced non-small cell lung cancer.

BACKGROUND: We tested the feasibility of hyperthermia combined with concurrent radiotherapy (thermoradiotherapy) for pain relief and local control of non-small cell lung cancer (NSCLC) invading to the chest wall. METHODS: Thirteen patients with advanced NSCLC (eight stage IIIB and five stage IV) and severe pain caused by chest wall invasion of tumor were treated with thermoradiotherapy. During the conventional fractionated radiotherapy period, 8-MHz radiofrequency capacitive hyperthermia was administered once or twice per week for a total of three to nine treatment sessions. pain relief, objective tumor response, thermometry, and toxicity were evaluated. RESULTS: Twelve of the 13 patients (92%) experienced satisfactory pain relief, and objective tumor shrinkage was observed in 11 of the 13 patients (85%), including complete regression in two. The thermometry parameters of minimum and maximum intratumor temperatures, mean of all intratumor temperatures, and rate of the time during which intratumor temperature was 41 degrees C or higher were 37.6 +/- 0.8 degrees C, 42.4 +/- 0.7 degrees C, 40.3 +/- 0.3 degrees C, and 80.1 +/- 8.6%, respectively. Adverse reactions included local transient skin pain in three patients, but no major toxicity was observed. CONCLUSION: Concurrent thermoradiotherapy for chest wall invasion by advanced NSCLC was feasible, with tolerable toxicity, and it may be effective for pain relief and local tumor control. Further studies comparing thermoradiotherapy and radiotherapy alone for such patient populations are warranted.

Intraventricular morphine produces pain relief, hypothermia, hyperglycaemia and increased prolactin and growth hormone levels in patients with cancer pain.

The effects of analgesic, thermoregulatory and endocrine functions of administering morphine sulphate (0.3 mg) into the lateral cerebral ventricle via an Ommaya catheter were assessed in eight patients with cancer pain. Satisfactory control of intractable pain was obtained in these patients, without any change in other sensory modalities. The delay in the onset of pain relief and the duration of analgesia ranged, respectively, from 20 to 40 min and from 12 to 16 h after drug injection. In addition, intraventricular administration of morphine caused a reduction in rectal temperature in these patients at an ambient temperature of 24 degrees C. The hypothermia in response to the injection of morphine was due to cutaneous vasodilation and sweating. There was no change in metabolism or in respiratory evaporative heat loss after morphine injection. Further, 10 to 20 min after intraventricular administration of morphine, the blood levels of prolactin, growth hormone and glucose were elevated in these patients. The changes in temperature and endocrine levels lasted for 1-3 h. In addition to the pain relief, these side-effects of morphine treatment were short-lasting and disappeared as the morphine treatment continued. The results indicate that activation of opiate receptors in the brain produced pain relief, hypothermia (due to cutaneous vasodilation and sweating), and increased blood levels of prolactin, growth hormone and glucose in patients with cancer pain.

Cervical radiculopathy: open study on percutaneous periradicular foraminal steroid infiltration performed under CT control in 30 patients.

BACKGROUND AND PURPOSE: Cervical radiculopathy is a common entity that can become unremitting, seriously disrupting the patient's work and social activities. The purpose of our study was to evaluate the feasibility, tolerance, and efficacy of transforaminal periganglionic steroid infiltration under CT control. METHODS: Thirty patients with cervical radiculopathy, despite at least 1 month of appropriate medical treatment, underwent percutaneous periradicular foraminal steroid infiltration under CT control. Sixteen patients had foraminal degenerative stenosis, and 14 patients had disk herniation. The intensity of radicular pain was scored on an analogic visual scale (AVS). pain relief was classified as excellent when the pain had diminished by 75% or more; good, by 50%-74%; fair by 25%-49%; or poor, by less than 25%. The patients were followed up at 2 weeks and at 6 months. RESULTS: No local complications occurred after the procedure. The mean AVS pain scores were 6.5 points before the procedure and 3.3 points 2 weeks after, with significant pain relief (P <.001). pain relief was excellent in 11 patients (37%) and good in seven patients (23%). There was no rebound of pain at the 6-month follow-up. The duration of symptoms before infiltration and the intensity and cause of radiculalgia were not predictive of radicular pain relief. CONCLUSION: Intraforaminal cervical infiltration produced substantial sustained pain relief, whatever the cause of the radiculalgia. The CT approach ensures the safety of vital structures and allows the precise injection of a steroid specifically targeted to the ganglia.

Autologous islet transplantation to prevent diabetes after pancreatic resection.

BACKGROUND: Extensive pancreatic resection for small-duct chronic pancreatitis is often required for pain relief, but the risk of diabetes is a major deterrent. OBJECTIVE: Incidence of pain relief, prevention of diabetes, and identification of factors predictive of success were the goals in this series of 48 patients who underwent pancreatectomy and islet autotransplantation for chronic pancreatitis. PATIENTS AND METHODS: Of the 48 patients, 43 underwent total or near-total (> 95%) pancreatectomy and 5 underwent partial pancreatectomy. The resected pancreas was dispersed by either old (n = 26) or new (n = 22) methods of collagenase digestion. Islets were injected into the portal vein of 46 of the 48 patients and under the kidney capsule in the remaining 2. Postoperative morbidity, mortality, pain relief, and need for exogenous insulin were determined, and actuarial probability of postoperative insulin independence was calculated based on several variables. RESULTS: One perioperative death occurred. Surgical complications occurred in 12 of the 48 patients (25%): of these, 3 had a total (n = 27); 8, a near-total (n = 16); and 1, a partial pancreatectomy (p = 0.02). Most of the 48 patients had a transient increase in portal venous pressure after islet infusion, but no serious sequelae developed. More than 80% of patients experienced significant pain relief after pancreatectomy. Of the 39 patients who underwent total or near-total pancreatectomy, 20 (51%) were initially insulin independent. Between 2 and 10 years after transplantation, 34% were insulin independent, with no grafts failing after 2 years. The main predictor of insulin independence was the number of islets transplanted (of 14 patients who received > 300,000 islets, 74% were insulin independent at > 2 years after transplantation). In turn, the number of islets recovered correlated with the degree of fibrosis (r = -0.52, p = 0.006) and the dispersion method (p = 0.005). CONCLUSION: Pancreatectomy can relieve intractable pain caused by chronic pancreatitis. Islet autotransplantation is safe and can prevent long-term diabetes in more than 33% of patients and should be an adjunct to any pancreatic resection. A given patient's probability of success can be predicted by the morphologic features of the pancreas.

Intercostal nerve block, interpleural analgesia, thoracic epidural block or systemic opioid application for pain relief after thoracotomy?

The purpose of this study was to investigate the effect of different pain-relief methods (regional and systemic) following thoracotomies on the cardiovascular system, pulmonary gas exchange, various endocrine parameters and subjective perception. A further aspect was to evaluate the benefits of interpleural analgesia as a new regional technique against already established regional techniques, such as intercostal nerve block and thoracic epidural block. All postoperative pain methods led to a significant time-dependent reduction of the adrenaline concentrations in plasma while the noradrenaline concentrations did not change significantly. There were no statistical differences in catecholamine concentrations among the different study groups, although the mean concentrations of adrenaline in patients having a thoracic epidural block for pain relief were lower in comparison to the findings in other groups. The plasma concentrations of the "stress metabolites", such as glucose, free fatty acids and lactate, as well as the haemodynamic (mean arterial pressure, heart rate) and pulmonary parameters (blood gas analyses), showed no significant differences among groups. In contrast to the other pain-relieving methods, interpleural analgesia did not lead to sufficient pain relief in that 7 out of 10 patients needed supplementary systemic opioid therapy. Therefore, interpleural analgesia for pain relief following thoracotomies cannot be recommended.

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.

Motor cortex stimulation for central and peripheral deafferentation pain. Report of eight cases.

The authors tested a modified motor cortex stimulation protocol for treatment of central and peripheral types of deafferentation pain. Four patients with thalamic pain and four with peripheral deafferentation pain were studied. Preoperative pharmacological tests of pain relief were performed using phentolamine, lidocaine, ketamine, thiopental, and placebo. In five patients we placed a 20- or 40-electrode grid in the subdural space to determine the best stimulation point for pain relief for a few weeks before definitive placement of a four-electrode array. In three patients, the four-electrode array was implanted in the interhemispheric fissure as a one-stage procedure to treat lower-extremity pain. In two patients with pain extending from the extremity to the trunk or hip, dual devices were implanted to drive two electrodes. Six of eight patients experienced pain reduction (two each with excellent, good, and fair relief) from motor cortex stimulation. No correlation was apparent between pharmacological test results and the effectiveness of motor cortex stimulation. Patients with peripheral deafferentation pain, including two with phantom-limb pain and two with brachial plexus injury, attained pain relief from motor cortex stimulation, with excellent results in two cases. Testing performed with a subdural multiple-electrode grid was helpful in locating the best stimulation point for pain relief. Motor cortex stimulation may be effective for treating peripheral as well as central deafferentation pain.