Diagnostic approaches to common oral symptoms

In routine dental practice patients seek oral care for various reasons. Some of these reasons are pain, swelling and ulcers. This chapter will deal with various aspects involved in evaluating the above listed symptoms AU)

Two methods of pain assessment in children with sickle cell disease. Agreement of patients, doctors and nurses - Poster abstract

OBJECTIVE: To determine whether pain severity scores (visual analogue scale (VAS) from 0-10) and/or grades (none, mild, moderate or severe) for bone pain in children with sickle cell disease, agreed when performed by patients, doctors and nurses, and to determine whether the pain scores and/or grade assigned predicted the use of narcotics or a return visit for the same pain episode. DESIGN AND METHODS: All children aged 5-18 years known to have homozgous SS disease who attended the Sickle Cell Clinic at the University Hospital of the West Indies, and were admitted to the day care center with painful crisis, from 25/04/1999 to 01/06/1999 were invited to participate. Informed consent was obtained. All patients/guardians consented, leading to observation of 30 episodes in 22 children (four children had 2 episodes, two children had 3 episodes). On admission and discharge, pain severity ws confidentially and independently assigned a VAS score and grade by patient, doctor and nurse. Medicatons used for pain were recorded. Patients with return visits within 7 days were noted. Scores/grades by each individual at admission and discharge were compared to the other 2 scores/grades yielding kappa values. The distribution of scores across grades was determined. VAS scores and grades at patient admission and discharge were compared across patient groups defined by subsequent return visit to clinic, using the Mann-Whitney two-sample statistic. RESULTS: Comparison of VAS scores between rates yielded kappas ranging from 0.40 to 0.69, demonstrating fair to substantial agreement, wheras with grades, kappas ranged from 0.52 to 0.90, demonstrating moderate to near perfect agreement. The minimum score associated with norcotic use was 5. The scores/grades at the initial visit did not predict those who would have return visits (po0.4). CONCLUSIONS: The visual analogue scale and grading system can successfully be used in this clinical setting. In this pilot study, doctors and nurses correlated well with patients in scoring the pain. There is a minimum threshold of a score of 5 below which narcotics are not prescribed. Return visits are determined by factors other than the score at initial visit. Further work using this type of tool is to be encouraged.(AU)

Pain control after major surgery

OBJECTIVE: To assess the adequacy and efficacy of postoperative pain management. DESIGN: A prospective clinical study. SETTING: The Georgetown and New Amsterdam Public Hospitals, Guyana. SUBJECTS: Two hundred consecutive patients undergoing major abdominal surgery. MAIN OUTCOME MEASURES: Presence or absence of significant postoperative pain during the first 24 hours. RESULTS: All the patients experienced pain postoperatively. Sixty one percent of patients considered their pain severe, 30 percent rated it moderate and only 9 percent mild. Reasons for this deficiency of care are partly attributable to the patients themselves and also the health care staff. CONCLUSIONS: Postopertive pain is poorly managed in our general hospitals. (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)

Cognitive therapy for the management of sickle cell disease pain: an evaluation of a community based intervention

Sickle cell disease [SCD] is the most prevalent haemoglobinopathy in Northern Europe [WHO, 1985]. It primarily affects the Caribbean and African population as well as small numbers of people from Mediterranean and India [NAHAT,19991]. SCD's most common symptoms is the vaso-occlusive cricis or "painful cricis". Painful crises are the principal cause of morbidity among patients with SCD and account for the second greatest number of hospital admissions with an average of seven days. Whilst numbers vary, most patient experience at least one severe episode per year requiring hospital admission for control. This inevitably causes severe disruption to educational and social aspects of patients' lives, which in turn, has consequences for achievement capabilities and psycho-social adjustment[Thomas and Westerdale,1996]. Nevertheless, traditionally the focus of treatment for SDC pain has been upon its physical aspects.This has been at the expense of consideration of the psycho-social and socio-cultural factors involved and may account for some of the difficulties fraught within the current treatment for SCD pain. [AU]

Pulsating magnetic therapy (PMT) attentuates hyperalgesia in rat model on neuropathic pain - abstract

The aim of this study was to investigate if Pulsating Magnetic Therapy (PMT) could modify the pain response in the peripheral neuropathy produced by sciatic nerve ligation in the rat. Male Sprague-Dawley rats were anaesthetized and the right sciatic nerve loosely ligated in the mid-thigh. A second group were sham operated. Starting on the fifth post-operative day, half of each group of animals were subjected to one hour of PMT for five consecutive days. The pain response was measured on both sides, using radiant heat method on post-operative days five, seven and nine. The animals with the ligated sciatic nerve developed the typical neuropathic syndrome on the operated limb. Following PMT, the pain-induced withdrawal response was significantly decreased in the nerve-ligated limbs compared with the sham operated group on days five and seven after surgery. On day 9, no differences in pain-induced withdrawal response were noted. No statistically significant differences in withdrawal response of the unaffected hind paw was noted in any of the animals. It was concluded that PMT reduces hyperalgesia induced by sciatic nerve ligation in rats and that PMT does not produce direct analgesic effect in acute pain (AU)

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)

New frontiers in chronic pain management - abstract

Chronic pain, unlike acute pain, represents a failure of modern medical science. In 1956, John Bonica proposed the concept of the multidisciplinary pain clinic and since then the issues of chronic pain have become popular and have assumed increasing importance in medical care. Those issues have included social, economic, medical and political aspects of chronic pain. This abstract deals with the recent advances relating to the medical issues of chronic pain. The following issues would be considered: 1. Classification of chronic pain; 2. Clinical features of chronic pain; 3. Psychological features of chronic pain; 4. Sympathetic blocks and pain implications; 5. Thermography and its diagnostic applications for pain management; 6. Cancer pain management; 7. Tachykinins and substance; 8. Somatostatin; 9. Opiate receptors:endorphins and enkephalins; 10. Epidural blood patch and chronic headaches; 11. Magnetotherapy; 12. Laser therapy and chronic pain. The above-mentioned recent advances in chronic pain have served or may serve to improve the quality of chronic pain management. These advances serve as the catalyst to explore new frontiers in chronic pain management (AU)

A study of the incidence and importance of post suxamethonium pains following anaesthesia - abstract

A two part questionnaire was filled out for Barbadian patients undergoing anaesthesia at the Queen Elizabeth Hospital. Members of the Department of Anaesthesia filled out part I on clinical details, anaesthetic technique, surgical procedure and types of fasciculation. A trained interviewer who was unaware of the aims of the project completed part II with the patient within 10 days of the operation. Questions were directed to the time of ambulation, degree of exercise, and the amount of pain or stiffness. The results show a low incidence of post suxamethonium pains (4.46 percent). Pain and or stiffness is most likely to occur after suxamethonium in patients undergoing major operations, performing mild exercise in the postoperative period, in the 21-30 year age group and in females. Ambulation appears to be a factor in the production of pain. The dose of suxamethonium given on a body weight basis is unimportant in the production of pain and no protection is apparent in the use of thiopentone during induction, or of halothane, omnopon, valium or pethidine as supplements to anaesthesia. Severe fasciculations were not particularly common and did not necessarily produce post suxamethonium pains (AU)