Intraventricular morphine for control of pain in terminal cancer patients.

Satisfactory control of intractable pain has been achieved in 17 terminal cancer patients by injecting small doses of morphine into the lateral cerebral ventricle via an Ommaya reservoir. Pain relief together with a favorable behavioral response was obtained without interference with other sensory modalities, noticeable physical changes, or side effects annoying or severe enough for the patient to discontinue therapy. Eleven patients developed tolerance, but this phenomenon does not require withdrawal of treatment. Chronic intraventricular morphine administration can be safely performed on an outpatient basis, and results in control of midline, bilateral, and diffuse pain associated with orofacial and disseminated cancer. However, this experience is preliminary and further clinical trials are needed to determine the place of this method of therapy in the management of chronic pain.

[Regional blockage for arterial blood pressure control during placement of head holder in neurosurgery]. / Bloqueo regional para el control de la tensión arterial durante la colocación del craneostato en neurocirugía.

OBJECTIVE: To achieve a hemodynamic stability in neurosurgery during placement of the craniostate, we compared the effects of blocking frontal and occipital nerves with supplementary doses of fentanyl with the effects observed after subcutaneous infiltration of craniostate fixation points. MATERIAL AND METHODS: We studied 34 patients with intracranial masses programmed for craniotomy who were randomly allocated into three groups. Group I received fentanyl 3-5 micrograms/kg, 5 minutes before implantation of craniostate; Group II was treated with subcutaneous infiltration of mepivacaine 2% at craniostate fixation points; and Group III underwent blockade of frontal and occipital nerves. Mean arterial blood pressure was measured at baseline, immediately before craniostate placement, and during the maximal rise induced after placement of the craniostate. RESULTS: Mean arterial blood after craniostate placement was significantly higher in Group I than in Group II (p < 0.01), and higher than in Group III (p < 0.05). CONCLUSIONS: Blockade of frontal and occipital nerves is a useful method for maintaining hemodynamic stability during craniostate placement in neurosurgical patients.

[Sensitivity, specificity, and predictive values of fine-needle biopsy in thyroid cancer]. / Sensibilidad, especificidad y valores predictivos de la biopsia con aguja fina en cáncer de tiroides.

One-hundred and eleven patients were studied with the objective of exploring the diagnostic usefulness of the fine needle aspiration (FNA) biopsy in cases with cancer of the thyroid gland. The mean age of the total sample was 42.4 years, with 89 percent females. A thyroid gland FNA was done in all cases as well as a surgical intervention for the establishment of a definitive diagnosis (i.e., gold standard). The cytologic diagnosis was done by the same expert pathologist in all cases. The diagnostic accuracy was obtained using a 2 x 2 table. Sensitivity was found to be 72 percent and specificity 91 percent, with 85.5 percent of diagnostic accuracy. Taking into account a 30 percent prevalence in our sample, predictive values were found to be 81 percent for positive and 87 percent for negative. It is concluded that FNA is better than the gold standard in the following points: it is easy to do, it has lower risk, and it has lower discomfort and financial cost. FNA showed a better utility to identify the absence of cancer. This is a procedure which is recommended for use in hospitals similar to the General Hospital of Mexico S.S. as part of the presurgical diagnosis in cases with clinical suspicion of thyroid gland malignancy.

Drug-drug interactions of non-steroidal anti-inflammatory drugs with other drugs in patients with rheumatic diseases.

OBJECTIVE: To determine the prevalence of and identify drug-drug interactions (DDI) between non-steroidal anti-inflammatory drugs (NSAID) and other drugs in a prescription database of patients with rheumatic iseases. MATERIAL AND METHODS: This is a cross-sectional study of a drug prescription database saving information on 35,000 individuals who benefited from a pre-paid medical system serving bank employees and their relatives. The analysis included one year period (from January to December 1998). NSAID-DDI were listed and classified into 3 levels (1: minor; 2: moderate, and 3: high health risk or death risk) according to DRUGDEX(r) as well as MEDLINE and EMBASE search. RESULTS: We analyzed 3,207 NSAID prescriptions (1.7±1.6 per patient) to 1,855 rheumatic patients (adults: 76.7%; geriatric: 20.2%, and pediatric: 3.0%; soft tissue rheumatism: 52%; osteoarthritis: 19%, and rheumatoid arthritis: 10%). There were 648 (20.20%) NSAID-DDI prescriptions: 594 (91.66%) corresponded to level 1; 46 (7.09%) to level 2, and 8 (1.23%) to level 3. In addition, 96 (2.99%) prescriptions included NSAID duplications. Interestingly, we found no NSAID-DDI with anticoagulants, anticonvulsants, and oral hypoglycemiants were found. CONCLUSIONS: The prevalence of NSAID-DDI prescriptions to 1,855 rheumatic patients was 20.20% in one year. NSAID-DDI was mostly (91.66%) level 1, and rarely (1.23%) level 3. NSAID duplications were found in 2.99%. These results provides information on the frequency of prescriptions with DDI, which might potentially produce harmful effects and data, which may help in the development of studies searching for the clinical relevance of NSAID-DDI.

Intrathecal therapy: rationale, technique, clinical results.

In 35 patients a subcutaneously implanted injection port/reservoir was used to provide intrathecal morphine to relieve pain due to cancer. The reservoir offers an alternative to rather expensive devices. It can be used for repeated injections or for infusion. It is easy to locate and facilitates ambulatory treatment. The injections were carried out by members of the patient's family after they had been taught how to do it. Initially, doses of 0.25-0.5 mg of morphine resulted in pain relief for 14 to 24 hours. After 5 weeks of treatment morphine requirements increased to 0.75-2 mg. Side-effects were minimal, and three delayed CSF fistula, two of them confirmed by isotope tracking with Tc99m, closed spontaneously.

Intraventricular morphine for intractable cancer pain: rationale, methods, clinical results.

The experience with the administration of intraventricular morphine for the control of malignant pain in 197 patients is analyzed. Small doses of morphine injected via a ventricular reservoir provided satisfactory control of otherwise intractable pain in terminal cancer-patients. Complete analgesia together with a favourable behavioral response was obtained without noticeable neurological changes or side-effects annoying or severe enough for the patients to discontinue therapy. Tolerance was much less marked than with parenteral opiates. Chronic intraventricular therapy can be safely performed on an outpatient basis by injecting the opiate once or twice a day. The method may be improved by using refillable continuous-infusion devices and new drugs, able to retain the analgesic effects of morphine while eliminating the unwanted ones.

Effects of lumbar sympathetic block on kidney function in cirrhotic patients with hepatorenal syndrome.

We studied the effects of unilateral lumbar sympathetic block on kidney function in eight patients with cirrhosis and hepatorenal syndrome. In five patients with basal glomerular filtration rate (GFR) below 25 ml/min, sympathetic block induced a significant increase in GFR, osmolal clearance, urinary sodium excretion, fractional excretion of filtered sodium (FENa) and effective renal plasma flow (ERPF) and a decrease in plasma renin activity. In the three patients with basal GFR greater than 25 ml/min, sympathetic block produced no significant change in renal function. We conclude that sympathetic block might improve renal function in cirrhotics with hepatorenal syndrome, particularly those with more impaired GFR.