Responsiveness of the EQ-5D health-related quality-of-life instrument in assessing low back pain.

OBJECTIVE: To compare the responsiveness of the EuroQol five-dimensional questionnaire (EQ-5D) generic quality-of-life instrument with that of specific instruments-the Brief Pain Inventory (BPI) and the Oswestry Disability Index (ODI)-in assessing low back pain. METHODS: Data were obtained from a group of patients receiving epidural steroid injections. We assessed responsiveness by using correlation, by estimating standardized response means, by receiver operating characteristic curve analysis, and by comparing the minimum clinically important differences peculiar to each of the instruments. RESULTS: ODI, BPI, and EQ-5D index scores, and changes in scores, were found to be correlated. Estimated standardized response means and receiver operating characteristic curve analysis suggested lower responsiveness for the EQ-5D index score. Clinically significant categories of mild, moderate, and severe BPI pain intensity translated into progressively and significantly lower mean EQ-5D index scores. An increase or a decrease in severity level reported on any of the five EQ-5D dimensions was associated with significant changes (with appropriate signs) in the condition-specific scores. No change in severity in any EQ-5D dimension was associated with no change in the specific scores. Significant changes in the EQ-5D index scores were associated with clinically important changes in the ODI and BPI scores. Correlation between index scores and responses on EQ-5D's visual analogue scale was only moderate. CONCLUSIONS: The EQ-5D index is less responsive than instruments specific to pain measurement, although it is capable of indicating clinically important changes. The lower responsiveness arises from EQ-5D's more limited gradation of severity and its multidimensionality.

Ultrasound-guided spinal accessory nerve blockade in the diagnosis and management of trapezius muscle-related myofascial pain.

We report the first description of ultrasound-guided spinal accessory nerve blockade using single-shot and subsequently continuous infusion (via a perineural catheter) local anaesthetic techniques, for the diagnosis and treatment of myofascial pain affecting the trapezius muscle. A 38-year-old man presented with a two-year history of incapacitating left suprascapular pain after a fall onto his outstretched hand. The history and clinical examination was suggestive of myofascial pain affecting the trapezius muscle. This had been unresponsive to pharmacological therapy, physiotherapy or suprascapular nerve blockade. Following identification of the spinal accessory nerve in the posterior triangle of the neck, we performed ultrasound-guided nerve blocks, first using a single injection of local anaesthetic and subsequently using a continuous infusion via a perineural catheter, to block the nerve and temporarily relieve the patient's pain. We have demonstrated that the spinal accessory nerve is identifiable in the posterior triangle of the neck and can be blocked successfully using ultrasound guidance. This technique can aid the diagnosis and treatment of myofascial pain originating from the trapezius muscle.

A pilot study of the dose-response of caudal methylprednisolone with levobupivacaine in chronic lower back pain.

The question as to what constitutes the ideal epidural steroid injection remains unresolved. We performed a prospective, randomised, double-blind, AB/BA 2 × 2 crossover study of caudal 40 vs 80 mg methylprednisolone acetate (in 20 ml levobupivacaine 0.125%) in outpatients with chronic low back pain. Data from 33 participants were analysed. The Oswestry Disability Index improved in both dose groups over time following injection. However, a statistically significant improvement was only observed in the 40 mg methylprednisolone acetate group (40 mg: p < 0.001; 80 mg: p = 0.33). There was no statistically significant difference between the dose groups in change in the Oswestry Disability Index with respect to time. Methylprednisolone acetate 40 mg appears to be as effective as 80 mg in improving disability associated with chronic low back pain, and should be considered in preference to the 80 mg dose for outpatients with chronic low back pain attending for repeat caudal steroid injection.

Demyelinating disease of Schilder type in three young South African children: dramatic response to corticosteroids.

Three young children with the Schilder variant of multiple sclerosis were seen within a 3-year period at our hospital. The diagnosis was made on the basis of the typical (but not pathognomonic) clinical and magnetic resonance imaging (MRI) findings after eliminating other demyelinating and post-infectious disorders of the central nervous system. All three patients were treated with prednisone (2 mg/kg/day), which resulted in complete recovery in one patient and mild and moderate residual hemiparesis in the two other patients, respectively. Corticosteroid therapy was continued until the patients' neurologic condition normalized or no further clinical improvement occurred. No relapses were seen after discontinuation of corticosteroid treatment. Computed tomographic (CT) scan and MRI findings after completion of corticosteroid therapy were equally dramatic and corresponded with the clinical improvement. A strongly positive tuberculin skin test and a positive history of contact with adult tuberculosis in two of our patients raise the possibility of a connection between tuberculosis and Schilder's disease.

Adjunctive thalidomide therapy of childhood tuberculous meningitis: possible anti-inflammatory role.

The objective of this study was to determine the safety and tolerability of the immunomodulatory agent thalidomide as adjunct therapy in children with tuberculous meningitis. Children with stage 2 tuberculous meningitis received oral thalidomide for 28 days in a dose-escalating study, in addition to standard four-drug antituberculosis therapy, corticosteroids, and specific treatment of complications such as raised intracranial pressure. Clinical and laboratory evaluations were carried out. Fifteen patients (median age, 34 months) were enrolled. Thalidomide was administered via nasogastric tube in a dosage of 6 mg/kg/day, 12 mg/kg/day, or 24 mg/kg/day. The only adverse events possibly related to the study drug were transient skin rashes in two patients. Levels of tumor necrosis factor-alpha in the cerebrospinal fluid decreased markedly during thalidomide therapy. Clinical outcome and neurologic imaging showed greater improvement than that experienced with historical controls. Thalidomide appeared safe and well tolerated in children with stage 2 tuberculous meningitis and could have important anti-inflammatory effects. These promising results have led us to embark on a randomized, double-blind, placebo-controlled trial of the efficacy of thalidomide in tuberculous meningitis.

Stüve-Wiedemann syndrome in children surviving infancy: clinical and radiological features.

We report three children from two inbred Arab families with Stüve-Wiedemann syndrome who have survived the first year of life (ages are 6 years, 2.8 years and 2 years). All exhibited a characteristic phenotype resembling that described by Chen et al.[(2001). Am J Med Genet 101:240-245]. In all three children the skeletal abnormalities progressed to severe bowing of the long bones with prominent joints and severe spinal deformity. Neurological symptoms were present in all of them. These included temperature instability with excessive sweating, reduced pain sensation with repeated injury to the tongue and limbs, absent corneal reflexes and a smooth tongue. Mentality was normal in all of them. Radiological changes included under tubulation of the diaphyses, rarefaction and striation of metaphyses, destruction of the femoral heads and spinal deformity. We confirm that survival in this syndrome is possible and that the prognosis improves after the first year of life. This should be taken into consideration when counselling parents of affected children. This report further supports the existence of a characteristic phenotype in Stüve-Wiedemann syndrome survivors which include, in addition to the skeletal abnormalities and distinctive radiological features, neurological symptoms reminiscent of dysautonomia.

Chronic pain after spinal cord injury: a survey of practice in spinal injury units in the USA.

OBJECTIVE: To determine the current practice regarding assessment and management of patients with chronic pain after spinal cord injury (SCI) in the United States of America (USA). METHODS: A postal questionnaire sent to the medical directors of 12 spinal injury units in the USA. RESULTS: A response was received from eight of the 12 units. Chronic pain was considered a significant problem amongst patients with SCI. There was inconsistency of opinion regarding prevalence estimates, investigation and management of chronic pain after SCI; but classification systems for pain were remarkably similar amongst units. Most felt that there was a need for further information, although only one unit said it was presently conducting research into the subject. CONCLUSION: Our survey has demonstrated the uncertainty that exists amongst USA specialists dealing with pain after SCI, and strengthens the case for more research into the subject with a view to developing guidelines for care.

'End-of-life' decision making within intensive care--objective, consistent, defensible?

OBJECTIVE: To determine the objectivity, consistency and professional unanimity in the initiation, continuation and withdrawal of life-prolonging procedures in intensive care--to determine methods, time-scale for withdrawal and communication with both staff and relatives--to explore any professional unease about legality, morality or professional defensibility. DESIGN: A structured questionnaire directed at clinical nurse managers for intensive care. SETTING: All intensive care units in the Yorkshire region. RESULTS: The survey reported a lack of consistency and objectivity in decision making in this area, with accompanying unease amongst staff. CONCLUSIONS: There is a need to work towards more consistent care, both before and during admission, for the protection of the individual patient and to allow rational assessment of intensive care need. Comprehensive audit should lead to objective defensible decisions and facilitate informed choice. More open debate and better communication should minimise this issue as a source of stress amongst staff in intensive care.

Pharmacokinetics of a syrup formulation of amoxycillin-potassium clavulanate in children.

The pharmacokinetics of a syrup formulation consisting of four parts of amoxycillin and one part of potassium clavulanate (Augmentin) were studied in 11 paediatric patients, 3 to 14 years of age. Single oral doses of 25 mg of Augmentin per kg body weight (20 mg of amoxycillin per kg plus 5 mg of potassium clavulanate per kg, i.e. 1 mg of the syrup per kg) were administered on an empty stomach, and were well accepted and tolerated. Mean peak plasma concentrations 60-90 min after dosing were 7.2 mg/l for amoxycillin and 2.0 mg/l for clavulanic acid. Mean terminal phase plasma half-lives were 1.4 and 1.0 h, respectively. It is concluded that 25-mg/kg doses of this syrup formulation of Augmentin administered three times daily should be adequate therapy for various childhood bacterial infections.

Tuberculous granulomas in childhood tuberculous meningitis: radiological features and course.

The clinical course and serial cranial computerized tomographic (CT) findings of 202 children with tuberculous meningitis (TBM) admitted to Tygerberg Hospital between 1985 and 1994 were reviewed with regard to the incidence, CT appearance and clinical course of associated intracranial tuberculous granulomas. Thirty-four patients (16.85 per cent) had associated intracranial granulomas. Thirty-eight individual lesions were analysed and classified as meningeal, parenchymal or ependymal according to their central nervous system (CNS) location. Twenty-five patients had round to irregular, brain iso-, hypo- or hyperdense meningeal granulomas with variable degrees of enhancement and peri-lesional hypodensities. Four patients had diffusely enhancing, brain isodense, enplaque-like ependymal granulomas associated with the ventricular ependymal lining. Four patients with miliary tuberculosis and TBM showed multiple small diffusely enhancing, brain iso- or hyperdense parenchymal lesions and associated hypodensities on initial CT. Although granulomas in the meningeal and ependymal group had the propensity to paradoxically enlarge or appear on standard four-drug antituberculosis therapy, the majority resolved uneventfully. Rapid resolution of small parenchymal granulomas associated with miliary tuberculosis occurred in all cases. Most granulomas in this series were co-incidental, asymptomatic CT findings. In rare cases, the development or enlargement of a strategically located granuloma may result in complications.

Possible role of adjunctive thalidomide therapy in the resolution of a massive intracranial tuberculous abscess.

We present the case of a young child who developed a massive tuberculous abscess of the posterior fossa while being treated for pulmonary tuberculosis. Clinical improvement after surgical excision of the abscess was followed by recurrence of symptoms of acutely raised intracranial pressure on standard antituberculosis and corticosteroid therapy. Magnetic resonance (MR) imaging of the brain showed that a multiloculated abscess had developed anterior to the excision site of the original abscess. The recurring abscess was partly excised and drained but could not be removed completely because of its proximity to the brain stem. Thalidomide, a potent inhibitor of tumour necrosis factor alpha (TNF-alpha), was added to the treatment regimen and resulted in marked clinical improvement with resolution of the abscess within 4 months. The remaining CT lesion had the appearance of a small granuloma. Both the clinical and the radiological response was maintained after 1 year of antituberculosis treatment.

Chronic pain after SCI. A patient survey.

STUDY DESIGN: A survey of chronic pain experience after spinal cord injury. OBJECTIVE: To investigate the prevalence, severity and impact of chronic pain amongst spinal cord injury (SCI) patients in our region, and assess the need for additional resources to address the problem. METHODS: A postal questionnaire was sent to 216 spinal cord injury patients (10% of the Yorkshire regional spinal injury database). SETTING: Yorkshire region, UK. RESULTS: A response was received from 67% of the patients. Seventy-nine per cent of patients said they presently suffered with pain, with 39% describing it as severe. Comparison of pain and non-pain groups using chi-squared analysis showed that complete injury was significantly more likely than incomplete injury to result in chronic pain (P<0.05), and increased severity of pain (P<0.05). 43% of patients with pain said they required further treatment for it. Chronic pain had a significant impact on daily activities and was a major factor in causing unemployment (18%) and depression (39%). CONCLUSION: The study confirms that pain is a major problem in SCI patients which is not currently being adequately addressed. A multidisciplinary approach to management and prospective studies of treatments are required in order to reduce the prevalence and severity of pain in these patients. Spinal Cord (2000) 38, 611 - 614.

Chronic pain after spinal cord injury: a survey of practice in UK spinal injury units.

OBJECTIVE: To determine current practice regarding assessment and management of patients with chronic pain after spinal cord injury (SCI) in the UK. METHODS: A postal questionnaire sent to the medical directors of the 12 spinal injury units in the UK. RESULTS: A response was received from nine of the 12 units. Chronic pain was felt to be a significant problem amongst patients with SCI, with inconsistent opinion between respondents regarding prevalence, aetiology and classification of chronic pain after spinal cord injury. Only one unit had established protocols for the investigation and management of pain, and most units felt that guidelines would be useful. Most felt that there was a need for further information on the subject. CONCLUSION: Our survey has demonstrated the uncertainty that exists amongst specialists dealing with pain after SCI, and emphasised the need for more research into the problem.

Low and conventional dose cyclopenthiazide on glucose and lipid metabolism in mild hypertension.

In a double-blind, placebo controlled, randomised parallel study we investigated the antihypertensive activity and metabolic adverse effects of three doses of cyclopenthiazide in 53 patients with mild hypertension. After a 4 week placebo washout period, patients with diastolic blood pressures between 90-110 mm Hg were randomly assigned to receive 50 micrograms, 125 micrograms and 500 micrograms of cyclopenthiazide or matching placebo, over an 8 week active treatment period. Blood pressure was recorded at 2 weekly intervals during the trial. Venous samples were taken for evaluation of drug effect on indices of carbohydrate and lipid metabolism just prior to, and on completion of, the active treatment period. Systolic and diastolic blood pressure decreased significantly (P less than 0.05) with the 125 micrograms and 500 micrograms doses of cyclopenthiazide. No change was apparent in any index of glucose and lipid metabolism over time. Low and conventional doses of cyclopenthiazide lower blood pressure without alteration to the metabolic profile in the short term.

Patient-controlled analgesia and urinary retention following lower limb joint replacement: prospective audit and logistic regression analysis.

We studied a number of factors that may be associated with urinary retention, in particular the method of postoperative analgesia delivery, in 47 men and 69 women undergoing lower limb joint replacements. The following factors were studied: age, gender, height, weight, previous history of urinary retention, presence of symptoms suggestive of urinary tract obstruction, type of anaesthetic (general anaesthetic or spinal anaesthetic), type of postoperative analgesia (intramuscular or patient-controlled analgesia with morphine) and the total dose of morphine given. Urinary retention developed in 18.1% of patients. Stepwise logistic regression analysis was used to identify independent explanators of an increased probability of developing urinary retention. Three factors emerged - male gender, increasing age and the use of patient-controlled analgesia.

Effect in man of aspirin, standard indomethacin, and sustained release indomethacin preparations on gastric bleeding.

1. We have compared acute gastric bleeding caused by a new slow release preparation of indomethacin (indomethacin Continus) with that caused by aspirin and other indomethacin preparations. 2. In a randomized crossover study, blood loss into timed gastric aspirates was determined in 20 healthy volunteers after receiving, over 96 h, either placebo, aspirin (600 mg four times daily; 17 doses) indomethacin BP (50 mg three times daily; 13 doses), Indocid-R (75 mg twice daily; 9 doses) or indomethacin Continus (75 mg twice daily; 9 doses). A venous blood sample was also taken during each treatment period for subsequent determination of alpha 1-glycoprotein, and for drug assay. 3. Gastric bleeding on placebo was 1.4 (0.7-2.8) microliters 10 min-1 (mean, 95% confidence interval). Both aspirin and the indomethacin preparations caused significantly more bleeding (P less than 0.05). Rates of bleeding after aspirin, indomethacin BP, Indocid-R, and indomethacin Continus were respectively 22.0 (10.7-47.2) microliters 10 min-1, 4.4 (2.2-9.1) microliters 10 min-1, 10.8 (5.3-22.3) microliters 10 min-1, and 5.1 (3.0-10.6) microliters 10 min-1. 4. Rates of bleeding after indomethacin BP and indomethacin Continus, but not Indocid-R, were significantly less than after aspirin (P less than 0.01). 5. Salicylate or indomethacin was detectable in the plasma of all subjects after the active treatment periods, except for one instance involving a subject allocated indomethacin BP. Indomethacin levels were significantly higher 2 h after Indocid-R than with indomethacin BP or indomethacin Continus. 6. alpha 1-acid glycoprotein levels were not significantly affected by prior treatment with aspirin or indomethacin.