Assessment of satisfaction with treatment for chronic pain.

The purpose of this study was to develop an instrument to assess satisfaction with treatment of chronic pain, evaluate the reliability and validity of this instrument, and then examine predictors and consequences of satisfaction. The Pain Service Satisfaction Test (PSST) is the result of this effort. Fifty adult patients receiving services for chronic pain in a university pain clinic completed the PSST as part of a survey mailed to their homes. Findings supporting the validity of the PSST included significant positive correlations with a general measure of treatment satisfaction, patient ratings of global treatment satisfaction and effects of treatment, and physician ratings of patient satisfaction with treatment. Regression analyses of predictors of satisfaction highlighted significant contributions of confidence and trust in the provider, pain reduction, and waiting in the clinic. These predictors together accounted for 60% of satisfaction with treatment. Treatment satisfaction was negatively correlated with depression, reported number of physicians consulted, and number of physician visits for pain in the past 12 months; and there was a trend toward a negative correlation with disability. Results of the present study support the importance of satisfaction with treatment as a predictor and possible determinant of later health, function, and service utilization.

The enlistment medical examination--reasons for failure.

During 1984 a short summary of all recruits who failed their recruitment medical examination at Leven was kept. An overall failure rate of 19% was discovered and no recruit examined in 1984 from Army Careers Information Office, Leven, was dismissed from service on medical grounds. It seems quite likely, therefore, that the Regulations covering medical fitness are adequate. Indeed, the Regulations may sometimes exclude fit men from Army service.

The use of AH8165 for Caesarian section.

The use of AH8165, a new non-depolarising relaxant, for Caesarian section is reported. The rapidity of action and the absence of significant placental transfer of the drug were confirmed. AH8165 has a definite place in obstetric anaesthesia.

Pressure-heart rate relationship in intact and after stepwise elimination of three major baroreflex loops in dogs.

Systemic arterial blood pressure (BP)-heart rate (HR) relationship (the pressor test) is often used as an index of baroreflex. We evaluated this index by simultaneously comparing BP-HR, right carotid sinus pressure (CSP)-nerve action potentials (NAP), and NAP-HR relationship in dogs anesthetized with pentobarbital. BP was increased or decreased stepwise by intravenous (IV) infusions of phenylephrine or sodium nitroprusside, respectively. In nine dogs BP-HR and CSP-NAP relationships were measured and NAP-HR relationship was constructed before and after sequential and stepwise sectioning of the left aortic depressor nerve (LADN), the right aortic depressor nerve (RADN), and blockade of the left carotid sinus nerve (BLK) with 1% lidocaine. We found that HR was a negative sigmoidal function of BP in intact dogs. Linear slope of this relationship was significantly reduced after sectioning of LADN and RADN, but returned toward baseline after BLK. NAP was a positive sigmoidal function of CSP in intact dogs. Linear slope of this relationship was significantly depressed after sectioning of LADN and RADN. However, after BLK, the slope surpassed control, suggesting the existence of a central communication between the two carotid sinuses. HR was a negative function of NAP in intact dogs. However, as the other baroreflex feedback loops were eliminated, the slope of the NAP-HR relationship approached zero indicating that a closed integrated parallel feedback system is required for reflex regulation of HR. Our findings suggest that under normal conditions the pressor test is a valid index for baroreceptor function, but its use may not be warranted in chronic pathological states, such as atherosclerosis and hypertension. However, in contrast to the present acute experimental model, chronic pathological processes may not develop in sequence, and baroreceptor function on the affected site may not be completely eliminated from the baroreceptor loop such as performed in this study.

Intravenous ketamine for postoperative analgesia.

Thirty-six consecutive patients who had undergone major surgery were carefully studied for 6 hours postoperatively in an attempt to evaluate the relative analgesic and respiratory-depressant effect of morphine, ketamine, and placebo administered by continuous intravenous infusion. Side-effects, vital signs and respiratory measurements were recorded hourly by a consultant physician. With regard to the dosage and method of administration, ketamine was shown to be less effective than morphine for the first 3 hours postoperatively, but equally effective subsequently, whereas the patients who received ketamine showed a greater progressive tendency for their respiratory parameters to improve with time. Recommendations regarding the postoperative control of pain are made, and the need for further study is noted.

A critical appraisal of the pain associated with iatrogenic adult spinal deformity, and treatment by spinal cord stimulation. A case report and review of the literature.

Objective. Over the past two decades, with the increasing use of spinal instrumentation to treat deformity, surgical restoration has become more frequent. A complication of surgical reconstruction for adult scoliosis, the iatrogenic flat back syndrome, has been described. Results of surgical realignment have been disappointing in terms of pain relief. The objective of this study is to examine a case of so-called flat back deformity and describe treatment via spinal cord stimulation. Materials and Methods. This is a case report of an individual who presented a spine center with the flat back deformity and pain. Results. Following exclusion of reversible compressive pathology, a 46 year-old male with the iatrogenic flat back deformity and lumbosacral and thigh pain was treated with implantation of a thoracic spinal cord stimulator. Significant pain relief was obtained without resorting to additional major reconstructive surgery. Conclusions. Literature on the pain associated with flat back deformity is incomplete regarding description and characterization of pain. Given the unpredictability of spinal osteotomy to address this pain, a possible alternative treatment strategy is presented. This involves the use of selective pharmaceutical therapy and spinal cord stimulation. Based on the response of this patient to spinal cord stimulation, it is a possible that a component of this persistent pain is neuropathic, despite the fact that preoperative imaging studies failed to disclose a significant compressive lesion.

Bradykinin-mediated hypotension after infusion of plasma-protein fraction.

In patients who required volume expansion during extracorporeal circulation, the plasma bradykinin concentration was monitored simultaneously with the mean arterial pressure during infusion of either albumin solution or PPF. The PKA content of the PPF and the albumin solution was 29 and 3 U/L, respectively, measured spectrophotometrically. In six patients receiving 250 ml of PPF, the mean arterial pressure decreased 22% to 54% within 1.5 min after infusion, whereas the plasma bradykinin concentration, measured by radioimmunoassay, increased significantly (p less than 0.0005) during the first minute. In six patients receiving 250 ml of 4% albumin solution, no blood pressure changes were found, and the plasma bradykinin concentration rose only slightly. In vitro, linear correlation (r = 0.94, p less than 0.0005) was observed between the level of PKA of 26 different lots of PPF and the concentrations of bradykinin that were generated in Hageman factor-deficient plasma after incubation with PPF. It is concluded that the hypotensive reactions observed after PPF infusion during extracorporeal circulation are caused by the PKA-induced bradykinin generation.

Different effects of thiopental in severe hypoxia, total ischemia, and low-flow ischemia in rat heart muscle.

The effect of thiopental (100 mg X 1(-1] during total ischemia, low-flow ischemia, and severe hypoxia with maintained flow was investigated in the isolated perfused rat heart. During total ischemia the rate of decline of tissue creatine phosphate and adenosine triphosphate was no different in thiopental-treated and untreated hearts. The development of ultrastructural damage during total ischemia, the release of creatine kinase on reperfusion, and the exacerbation of ultrastructural damage after reperfusion were unaffected by thiopental. When thiopental was added to the perfusate during hypoxia and during low-flow ischemia at a normal pH(7.4), creatine kinase release during reoxygenation and during reperfusion was significantly less (P less than 0.005 and P less than 0.05, respectively) than in the untreated groups. After low-flow ischemia at a low pH (6.5), creatine kinase release was no different in thiopental-treated and untreated hearts. Thus, thiopental afforded protection of the myocardium in hypoxia and low-flow ischemia at pH 7.4 but not in total ischemia and low-flow ischemia at pH 6.5. The data are consistent with the hypothesis that during total ischemia and low-flow ischemia at pH 6.5, acidosis favors the entry of thiopental into the cell, causing inhibition of mitochondrial function and reduction of ATP production. During hypoxic perfusion and low-flow ischemia at pH 7.4, when the decrease in pH is less, the cardiodepressant effect of thiopental may offset any deleterious effect of the drug on intracellular organelles such as mitochondria.