Diet and pain (2)

There is a strong association between diet and the development of chronic diseases namely, cardiovascular diseases, Type 2 diabetes, hypertension, some cancers and Alzheimer's disease. Studies have found that a diet low in fat and high in fibre not only helps to reduce the risk of chronic diseases but is also essential in reducing inflammation. Inflammation is in fact, a critical aspect in the development of the above-mentioned conditions which are characterised by low-grade inflammation. The pain associated with these conditions may not be immediate as the effects of these conditions accumulate over many years before being detected.

Diet and pain (1)

Most, if not all human beings have some point in time experienced even the slightest bit of pain which occurs as a result of a minor injury, mentrual pain or the pain which accompanies a sickness/disease; it is known fact that pain is a fairly common occurence and an inevitable part of life.

Hospital admissions for acute painful crisis in Trinidad and Tobago. Are the British Committee for Standards in Haematology (BCSH) guidelines applicable?

We observed consecutive hospital admissions for acute painful crisis (APC) among adults with Sickle Cell Disease (SCD) over a 6-month period in Trinidad and Tobago. Episodes (111) of APC resulted in 82 admissions of 59 patients. The most common site for pain was the trunk. Patients ranged in age from 17 to 53 years (median: 25). Median length of hospital stay was 4 days. Total dose of Pethidine given per admission ranged from 100 to 1650 mg (median: 525). The mean dose of morphine was 70 mg. Six (7%) of patients were readmitted within 10 days of discharge. Twenty-five (30%) of patients had chest pain at presentation of whom 10 (12%) had consolidation on chest X-ray, defining the acute chest syndrome (ACS). There was one death caused by biliary sepsis. The study revealed seemingly low opiate usage for in-hospital treatment of APC with acceptable rates of readmission. The BCSH 2003 guidelines seemed applicable apart for the choice and route of fluid for rehydration and opiate analgesia.

Management of cancer pain

Cancer remains a major worldwide health problem with an estimated nine million new cases occurring annually. The incidence is progressively increasing, especially in the Caribbean and Latin America. About one-half of all cancer patients and over 70-80% of those with advanced cancer experience moderate to severe pain. Several surveys have clearly shown that about 80-90% of patients can have their pain easily controlled with simple available resources. Yet sadly, pain is often under-estimated and under-treated, resulting in unnecessary suffering and a compromised quality of life. There are many obstacles to adequate cancer-pain relief (AU)

Significance of fever in Jamaican patients with homozygous sickle cell disease

OBJECTIVE: To investigate the cause and outcome of high fever in Jamaican children with homozygous sickle cell disease. DESIGN: Retrospective review of febrile episodes in a three year period (1 September 1993 to 31 August 1996). SETTING: Sickle Cell Clinic, an outpatient clinic in Kingston run by the Medical Research Council Laboratories (Jamaica). PATIENTS: Patients with homozygous sickle cell disease under 17 years of age presenting with an anxillary temperature o 39.0§c (102.4§F). MAIN OUTCOME MEASURES: Diagnosis, death. RESULTS: There were 165 event in 144 patients (66 (45.8 percent) boys) with a median age of 6.1 years. Bacteraemia was found in 10 (6.1 percent) events (three Streptococcus pneumoniae, two Haemophilus influenzae type b, two Salmonella sp, one Escherichia coli, one Enterobactor sp, and one Acinetobacter sp), and urinary tract infections in four (2.4 percent). All cultures of cerebrospinal fluid were sterile. Acute chest syndrome occured in 36 (21.8 percent) events. A painful crisis was associated with 45 (27.3 percent) events and was the only pathology identified in 20 events (12.1 percent). Hospital admission was necessary in 66 cases including all those with bacteraemia and 31 with acute chest syndrome. There were two deaths: a 5 year old boy with septic shock associated with H influenzae septicaemia, and a 3 year old boy with the acute chest syndrome. CONCLUSIONS: Painful crisis and acute chest syndrome were the most common complications associated with high fever, but other important associated features included bacteraemia and urinary tract infection. Enteric Gram negative organisms accounted for 50 percent of positive blood cultures. (AU)

Relationship between stressful life events and pain in young adults age 20-34

Pain (including headache, neckache, backache, chest pain, abdominal pain or pain in the limbs) that is not managed properly in young adults results in decreased productivity and poor work attendance. Multiple diagnostic and therapeutic interventions can cost the health care system excessively and can lead to iatrogenic disease. Negative reactions in caregivers can ensue and overall, individuals can be left with a sense of hopelessness for recovery. Mental and physical health are inextricably linked. Neglect of the psychosocial components in the sea-i-rch for the etiology and management of physical pain at the primary level may be reducing the opportunity for speedy recovery. This study was done to determine the relationship between recent and remote stressful life events and the development of pain. A case-control study was conducted among adults age 20-34 years attending one private, one government and one university clinic in Kingstom, Jamaica. 46 cases with pain and 70 controls who were pain-free were chosen. The findings suggest no relation between the actual number of life events and pain but there is a clear association between the preception of a negative impact of a series of life changes on the development of physical pain. The findings also show that of overriding significance in the development of pain is the perceived lack of social support available to the patient. A significant relationship was also found between the perception of a tumultuous childhood and pain although no relationship was found between specific remote childhood stressors and pain. This study highlights the need for greater attention to the integration of mental health and primary care beginning with the training of health workers and education at policy level, service delivery level and of the public (AU)

Day-care management of sickle cell painful crisis in Jamaica: a model applicable elsewhere?

In the U.K. and the U.S.A., painful crises account for 80-90 percent of sickle-related hospital admissions, with average durations of 5-11 d. In Jamaica, many severe painful crises are managed in a day-care centre. Patients (n = 1160) with homozygous sickle cell (SS) disease aged 18 years and over were registered with the clinic during a 1-year study period. Of these, 216 patients with 476 painful crises attended the day-care facility for a total of 688 d. Most patients (119 or 55.1 percent) had single crises and for most crises (338 or 71 percent), patients attended for only 1 d, when they were given bed rest, assurance, rehydration and analgesia. Patients with complicated painful crises were usually referred for admission after initial pain relief and the rest were monitored during the day. In the evening they were given the option of hospital admission or allowed home with oral analgesia. Hospital admission for complicated painful crises or inadequate pain relief occurred in 42 (8.8 percent) crises and home management in 434 (91.2 percent) crises. Of 186 patients initially selecting home management, 20 percent returned for further day-care and five (2.7 percent) died during subsequent admission for that painful crisis, one without other known complications, two with acute chest syndrome (one associated with Salmonella septicaemia), another with Salmonella septicaemia, and one with dengue haemorrhagic fever. With suitable oral analgesia, adequate education and support, the majority of severe painful crises in SS disease in Jamaica have been managed on an outpatient basis. This model of patient care may merit assessment in other communities where painful crises are a common clinical problem.(Au)

Relationship between stressful life events and pain in young adults age 20-34

Pain (including headache, neckache, backache, chest pain, abdominal pain or pain in the limbs) that is not managed properly in young adults results in decreased productivity and poor work attendance. Multiple diagnostic and therapeutic interventions can cost the health care system excessively and can lead to iatrogenic disease. Negative reactions in caregivers can ensue and overall, individuals can be left with a sense of hopelessness for recovery. Mental and physicaal health are inextricably linked. Neglect of the psychosocial components in the sea-i-rch for the etiology and management of physical pain at the primary level may be reducing the opportunity for speedy recovery. This study was done to determine the relationship between recent and remote stressful life events and the development of pain. A case-control study was conducted among adults age 20-34 years attending one private, one government and one university clinic in Kingston, Jamaica. 46 cases with pain and 70 controls who were pain-free were chosen. The findings suggest no relation between the actual number of life events and pain but there is a clear association between the perception of a negative impact of a series of life changes on the development of physical pain. The findings also show that of overriding significance in the development of pain is the perceived lack of social support available to the patient. A significant relationship was also found between the perception of a tumultuous childhood and pain although no relationship was found between specific remote childhood stressors and pain. This study highlights the need for greater attention to the integration of mental health and primary care beginning with the training of health workers and education at policy level, service delivery level and of the public.(Au)

Major controversies in chronic pain

Pain medicine is a relatively new speciality in clinical medicine. While it is widely accepted and recognized, there are some areas of controversy which makes this speciality interesting and open to diverse kinds of research opportunities and clinical innovations. In this presentation, several controversial areas have been selected for discussion because of their scientific merit, clinical applicability, and evolving status in the physician's armamentarium. EPIDURAL STEROIDS FOR LOW PAIN: Epidural steroid injections remain one of many modalities for managing chronic low back pain. The frequency, dose, kind of steroids used and management of complications are still open to discussion. Meta-analysis of the applicability of epidural steroids for low back pain leaves a lot to be desired. More importantly, the criteria for epidural steroid injection have not yet been clearly delineated. REFLEX SYMPATHETIC DYSTROPHY (RSD) AND NEUROPATHIC PAIN: Most clinicians propose that RSD has become a "legal phenomenon" rather than a medical one. This observation indicates the adversarial focus that the injured patient possesses as far as his recovery and rehabilitation are concerned. The different diagnosis techniques and the corresponding diverse therapeutic modalities available for treating RSD are still controversial. CANCER PAIN MANAGEMENT: Cancer pain management is very important in the overall management of the cancer patient, especially when dying and death appear inevitable. A proposed fourth step of the World Health Organization three-step ladder for pain management and its implication will be discussed. MORPHINE AS ANTI-ANALGESIC AGENT: Review of the pharmacological activity of morphine metabolities will be undertaken. A re-evaluation of morphine-3-glucuronide and its analgesic activity may help to explain some interesting physiological phenomena observed during morphine administration. PAIN EDUCATION AND PAIN CERTIFICATION: In the United States of America the education of medical and nursing students regarding pain therapy has been largely ignored. The situation is unfortunate since most young health care professionals have to deal with chronic pain problems as soon as they commence their practices. As pain medicine develops, it is important to have adequate credentialing.(AU)

Trial of three methods of introperative bupivacaine analgesia for pain after paediatric groin surgery

To evaluate the relative effectiveness of three techniques of regional anaesthesia in the provision of postoperative analgesia in children. Methods: Random assignment of 183 children scheduled for groin surgery to one of three groups. Bupivacaine 0.5 percent plain (2 mg.kgˉ) was injected by the surgeon after skin incision. Group A received wound infiltration. Group B had regional nerve blockade. Group C had a combination of both methods. Post-operatively, pain was assessed using the CHEOPS behavioral scale at half-hourly intervals until discharge home. Satisfactory pain control was arbitrarily defined as CHEOPS score of ≤ six. Potential differences among the groups were sought using graphical presentation of mean pain scores, the frequencies of pain scores, and the incidence of postoperative vomiting and oral analgesic consumption. Results: Fifteen patients had to be excluded from analysis. This left 61 patients in Group A, 55 in Group B and 52 in Group C. There were no demographic differences among the groups. No differences were demonstrated among the groups either in CHEOPS pain scores at any observation point (P = >0.8), or in the incidence of vomiting or need for postoperative analgesia. (P = 0.52 and P = 0.41 respectively). Overall, 80 percent of the observations made (1135/1425) met our definition of satisfactory pain control. A post hoc calculation of the power of the study confirmed sufficient power to detect a 5 percent difference among groups. Conclusion: All three methods achieved analgesia with 80 percent of the pain scores meeting our definition of satisfactory pain control. None of the techniques enjoyed any apparent advantage (AU)

The painful crises of sickle cell disease - is Jamaican experience relevant?

Bone marrow necrosis, is the most common cause of the painful crises in the sickle cell disease, is a recurrent cause of morbidity. In Jamaica, these events increase in incidence in late teenage, are most common in young adults and decrease progressively in frequency and severity after the age of 30 years. Precipitating events include cold exposure, exertion, infections, and stress but skin cooling is the commonest factor in Jamaica. Risk factors include pregnancy, especially the last trimester and immediate post partum period and a high haemoglobin level. The MRC Laboratories [Jamaica] undertakes the management of over 5000 patients islandwide and treats 4-12 painful crises daily. Crises admitted to the day care centre are deemed of sufficient severity to require narcotic analgesia and patients are given rehydration and their response to analgesia monitored during the day. After assessment at 4pm. they are given the option of hospital admission or discharge home with similar analgesia in oral form. Over 90 percent elect to return home. It is estimated that the South East London Health Authority spent 1.9 million pounds on the inpatient management of the painful crises last year, four times the entire budget of the MRC Laboratories [Jamaica] which supervises the outpatient clinical care and research programmes among a much larger population. It is proposed that the Jamaican model of outpatient care for the painful crises may provide a more acceptable and less socially disruptive therapeutic approach and would free resources which could be used to improve other aspects of patient care in sickle cell disease. Its applicability should be explored in the United Kingdom.[AU]

Outpatient management of the painful crisis in homozygous SS disease: trends and outcomes - abstract

The painful crisis of sickle cell disease is a major cause of recurrent morbidity normally managed by hospital admission. The MRC Laboratories Sickle Cell Unit has been exploring possiblities of outpatient management and the experience in a day care centre over a one-year period (1/4/95 - 31/3/96) is reviewed. During this period 597 painful crises of sufficient severity to require narcotic analgesia among 292 patients with homozygous sickle cell (SS) disease received treatment. Attendances within a 7-day period were arbitrarily considered the same crisis and those separated by more than 7 days as separate crises. There were 146 (50 percent) males and ages ranged from 3.3 - 50.1 years. Single painful crises occurred in 169 patients, 2 crises in 54, 3 - 5 crises in 66, 6 - 9 crises in 9, and more than 9 crises in 4 patients. A cyclical model was found to fit both the monthly attendances and meteorological temperature data for the same period. Fever exceeded 39§C in 11 patients (3 acute chest syndrome, 1 Haemophilus influenza septicaemia, 1 infected leg ulcer; 6 had sterile blood cultures and no apparent cause other than painful crisis). By 3pm patients were given the option of admission or discharge. 25 patients (8.9 percent) with 30 crises were admitted to hospital and 267 patients (91.4 percent) with 567 crises were discharged with oral analgesia. It is proposed that outpatient management of painful crises is feasible, selected by the great majority of patients, and can markly reduce demands on inpatient services. (AU)

Extracorporeal shock wave lithotripsy without anaesthesia: a preliminary report of initial experience in Jamaica

Extracorporeal shock wave lithtripsy (ESWL) is the method of choice of treating most renal and ureteric stones. The electrohydraulic generated shock wave litholriptors, however, tend to produce pain at the shock wave entry site on the skin, and these treatments are usually administered under general anaesthsea. With the acquisition of an electrohydraulic ESWI machine (Econolith - 2000) by the UWI in August 1995, this method of treating stones is now available in Jamaica. Between September and November 1995 data was prospectively collected on all patients treated by ESWL. There were 20 patients in all undergoing 22 treatment sessions with 2 repeats. There were 11 females and 9 males with ages ranging from 24 to 73 years. A total of 20 renal stones and 2 ureteric were treated. Thirteen patients received Tenoxicam 40 mg IM 20 minutes before the procedure as the only form of analgesia. Of the thirteen patients, only one patient described the procedures as severely painful. Four patients described it as moderately painful and the remaining eight patients described the procedure as producing only mild pain or discomfort. There were no complications apart from bruising of the skin at the shock wave entry site of eight patients. There was fluoroscopic evidence of fragmentation of all stones during treatment. Patients receiving Tenoxicam 40 mg IM we able to be discharge a from hospital immediately after the treatment. In conclusion, from our preliminary experience thus far, electrohydraulic ESWL can be safely and humanely administered with good effect using 40 mg of Tenoxicam administered intra muscularly, thus obviating the need for general or regional anaesthesia with its attendant morbidity and mortality (AU)

The painful crisis of homozygous sickle cell disease: clinical features

The details of onset, perceived precipitating factors, associated symptoms, and pain distribution in the painful crisis of homozygous sickle cell (SS) disease have been prospectively recorded in 183 painful crises in 118 patients admitted to a day-care centre in Kingston, Jamaica. Painful crises developed most frequently between 3 p.m. and midnight, most commonly affected patients aged 15-29 years, affected the sexes equally, and were not obviously influenced by menstrual cycle. Of the perceived precipitating factors, skin cooling occurred in 34 percent, emotional stress in 10 percent, physical exertion in 7 percent, and pregnancy in 5 percent of women of child-bearing age. Cold as a precipitant was not less common in patients with more subcutaneous fat. Pain affected the lumbar spine in 49 percent, abdomen in 32 percent, femoral shaft in 30 percent, and knees in 21 percent. There was a highly significant excess of bilateral involvement in limb and rib pain. Recurrent painful crises occurred in 40 patients but showed no evidence of involving similar sites on successive occasions. Abdominal painful crises were associated with abdominal distention in 18 ( 31 percent) and with referred rib pain in a further 15 (26 percent) of crises. Fever was common even in apparently uncomplicated painful crises, suggesting that fever is characteristic of the painful crisis itself after and not necessarily indicative of infection. Following investigation and treatment in a day-care centre, over 90 percent of patients returned home (AU)

Pain relief in practice

Conventional approaches to dealing with pain often focus exclusively on drug treatment, but pain treatment should be considered in a wider context. Much pain would be avoided and medical costs reduced if simple preventive measures were widely taught and practised

Ethnic differences in the experience of pain

Investigations of ethnic differences in pain experience have been largely confined to the hospital or laboratory. Such studies are limited by the potentially confounding effects of the expectation of pain in the former and of little or no pain in the latter. The present investigation overcomes some of these methodological problems by studying ethnic differences in pain experience following ear piercing. Afro-West Indian, Anglo-Saxon and Asian subjects (n=84) completed a pain questionnaire and two rating scales after ear-piercing. Half the subjects were told the study was about pain and half that it was concerned with sensation. There were highly significant ethnic differences in pain ratings. The pain condition produced higher ratings than the sensation condition but there were no significant sex differences. The results are discussed in the context of subjects' ratings of their parents' attitudes to minor injury and their own ability to cope with pain. It is argued that investigation of the bases of ethnic differences in pain experience is important in order to develop maximally efficient pain control regimes for all sections of the population. (AU)

Endoscopic and gastric acid studies in homozygous sickle cell disease and upper abdominal pain

Upper endoscopic and gastric acid output studies were done in 51 patients with homozygous sickle cell (SS) disease and recurrent epigastric pain. Twenty (39 percent) had abnormalities in the upper gastrointestinal tract including 18 (35 percent) with peptic ulcers. Mean bassal and maximum acid output were similar in patients with and without duodenal ulcer (DU). Because DU in SS disease does not appear to be associated with high acid outputs observed in other populations, it may reflect reduced mucosal resistance, possibly resulting from ischaemia. This hypothesis was supported by the significantly lower fetal haemoglobin level among SS-DU patients. (Summary)