Procedure-related pain among adult patients with hematologic malignancies.

BACKGROUND: Cancer patients undergo numerous invasive diagnostic procedures. However, there are only sparse data on the characteristics and determinants for procedure-related pain among adult cancer patients. METHODS: In this prospective study, we evaluated the characteristics and determinants of procedure-related pain in 235 consecutive hematologic patients (M/F:126/109; median age 62 years, range 20-89 years) undergoing a bone marrow aspiration/biopsy (BMA) under local anesthesia. Questionnaires were used to assess patients before-, 10 min and 1-7 days post BMA. Using logistic regression models, we calculated odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS: 165/235 (70%) patients reported pain during BMA; 92 (56%), 53 (32%) and 5 (3%) of these indicated moderate [visual analogue scale (VAS)>or=30 mm], severe (VAS>54 mm) and worst possible pain (VAS=100 mm), respectively. On multivariate analyses, pre-existing pain (OR=2.60 95% CI 1.26-5.36), anxiety about the diagnostic outcome of BMA (OR=3.17 95% CI 1.54-6.52), anxiety about needle-insertion (OR=2.49 95% CI 1.22-5.10) and low employment status (sick-leave/unemployed) (OR=3.14 95% CI 1.31-7.55) were independently associated with an increased risk of pain during BMA. At follow-up 10 min after BMA, 40/235 (17%) patients reported pain. At 1, 3, 6 and 7 days post BMA, pain was present in 137 (64%), 90 (42%), 43 (20%) and 25 (12%) patients, respectively. CONCLUSIONS: We found that 3/4 of hematologic patients who underwent BMA reported procedural pain; one third of these patients indicated severe pain. Pre-existing pain, anxiety about the diagnostic outcome of BMA or needle-insertion, and low employment status were independent risk factors.

Systemic adenosine infusion reduces the area of tactile allodynia in neuropathic pain following peripheral nerve injury: a multi-centre, placebo-controlled study.

Systemic adenosine has been shown in earlier case reports and a small placebo-controlled study to reduce pathological sensory dysfunction such as tactile allodynia in neuropathic pain. To evaluate this further, the effects of systemic adenosine infusion (50 microg/kg/min for 60 min) on tactile sensory dysfunction and pain was evaluated in 26 patients suffering peripheral neuropathic pain characterized by dynamic tactile allodynia. A randomized, cross-over, double-blind, placebo-controlled technique was used in this multi-centre study. Psychophysical methods were used to evaluate sensory dysfunction and spontaneous pain. The area of dynamic tactile allodynia was significantly reduced by adenosine compared with placebo (p=0.043), but spontaneous pain and tactile pain threshold were not significantly improved compared with the effects of placebo treatment. As a secondary outcome, a higher incidence of positive subjective effects on the clinical pain condition, in a few cases with long duration (several months), following adenosine treatment was found when the global effect of respective treatment was assessed (p=0.028). The results demonstrate involvement of adenosine receptor-sensitive pain mechanisms in some aspects of the sensory dysfunction often found in neuropathic pain.

The safety and efficacy of intrathecal adenosine in patients with chronic neuropathic pain.

UNLABELLED: Adenosine and adenosine analogs decrease pain-like behavior in animal models of both acute nociceptive and neuropathic pain via adenosine receptor activation at spinal and/or supraspinal levels. This open study is the first in a series of intrathecal (IT) adenosine administration studied for the evaluation of efficacy and side effects in 14 patients. All had chronic neuropathic pain with tactile hyperalgesia and/or allodynia primarily of traumatic origin. The effects of IT adenosine (500 microg [n = 9] or 1000 microg [n = 5]) were evaluated. Approximate areas of tactile pain were mapped. Spontaneous and evoked pain (visual analog scale score 0-100) and tactile pain thresholds were assessed before and 60 min after injection. The injection caused transient pain (<60 min) in the lumbar region in five patients. There were no other side effects. Spontaneous and evoked pain was reduced (median score from 65 to 24 [P<0.01] and from 71 to 12 [P<0.01], respectively) in parallel with increased tactile pain thresholds in allodynic areas. Areas of tactile hyperalgesia/allodynia were reduced (median reduction 90%; P<0.001). Twelve patients experienced pain relief (median 24 h). We conclude that IT adenosine transiently causes lumbar pain in a subgroup of patients and may reduce various aspects of chronic neuropathic pain. IMPLICATIONS: This is the first series of patients with chronic neuropathic pain in which tolerability to spinal adenosine administration has been evaluated. A subset of patients reported transient low back pain as the only side effect. Spontaneous and evoked pain intensity decreased in most patients, an effect lasting for a median of 24 h.

[Poor leadership behind poor pain relief. Medical audit of cancer-related pain treatment]. / Dåligt ledarskap bakom dålig smärtvård. Medicinsk revision av cancersmärtvård.

A clinical audit of the treatment of cancer-related pain, ordered by Stockholm County Council and the Karolinska Institute, was performed at two Stockholm hospitals. Of 153 consecutive cancer patients interviewed while attending the preoperative out-patient clinic of the Dept. of Anaesthesiology at Karolinska Hospital, 93 (61%) reported pain varying in intensity from 2.4 to 6.6 on a 10-point visual analogue scale. The pain was cancer-related in 20 patients, treatment-related in 28 patients, and associated with disease in 40 patients (e.g., post-herpetic neuralgia, urethritis, decubital ulcer or constipation). Nine patients had undetected neuropathic pain components, and 18 patients reported both significant pain intensity and dissatisfaction with the treatment. The auditors found these patients to have persistent pain problems despite the availability of time and opportunity to resolve them. The audit included interviews with staff at three hospital departments, who filled in questionnaires, and scrutiny of the medical records of about 120 cancer patients, 5-10 records from each department being selected to illustrate the management of pain problems. Findings from the staff questionnaires and interviews were compared with the picture of pain management elicited from the patients' records. The hospital departments were all found to be characterised by similar problems: lack of pain analysis or diagnosis, failure to detect neuropathic pain components, and underdosing of opioid analgesics irrespective of pain intensity. The auditors' conclusions included a need of pain education, particularly for doctors as fewer doctors than nurses had attended pain courses.

[Pain analysis is vital in rheumatic diseases. Pain often causes much worry to patients]. / Smärtanalys vital vid reumatiska sjukdomar. Smärtan oftast patientens största bekymmer.

The article consists of a synthesis of a rheumatic pain symposium held at the annual meeting of the Swedish Medical Association in 1996. Various aspects of pain in rheumatic diseases were discussed, such as physiological, neurohumoral and neurogenic mechanisms, sensory stimulation treatment, differentiation of mechanical and inflammatory pain, quality enhancement by improved co-operation between primary and tertiary care facilities, pharmacological treatment with (centrally and peripherally acting) opioids, selective cyclo-oxygenase inhibitors, and NMDA (N-methyl-D-aspartate) receptor antagonists. For patients with rheumatic disorders exacerbated by pain problems, as for other patients, a pain diagnosis is of fundamental importance. This can be achieved by analysis of the social, psychological, physiological and medical factors contributing to the cause and degree of pain and to pain behaviour, and of the extent to which the pain may be nociceptive (i.e., inflammatory, mechanical, or ischaemic in origin), neurogenic or idiopathic. Pain analysis should be followed by individualised treatment focused on the patient's most crucial problems, thus enhancing the prospect of optimal treatment outcome.

[Pain analysis is vital in rheumatic diseases. The pain is often the patient's worst problem]. / Smärtanalys vital vid reumatiska sjukdomar. Smärtan oftast patientens största bekymmer.

The article consists of a synthesis of a rheumatic pain symposium held at the annual meeting of the Swedish Medical Association in 1996. Various aspects of pain in rheumatic diseases were discussed, such as physiological, neurohumoral and neurogenic mechanisms, sensory stimulation treatment, differentiation of mechanical and inflammatory pain, quality enhancement by improved cooperation between primary and tertiary care facilities, pharmacological treatment with (centrally and peripherally acting) opioids, selective cyclo-oxygenase inhibitors, and NMDA (N-methyl-D-aspartate) receptor antagonists. The aim of the symposium, with its focus on the manifest pain problem, was to improve our knowledge and skill in the understanding and treatment of this large patient category. For patients with rheumatic disorders exacerbated by pain problems, as for other patients, a pain diagnosis is of fundamental importance. This can be achieved by analysis of the social, psychological, physiological and medical factors contributing to the cause and degree of pain and to pain behaviour, and of the extent to which the pain may be nociceptive (i.e., inflammatory, mechanical, or ischaemic in origin), neurogenic or idiopathic. Pain analysis should be followed by individualised treatment focused on the patient's most crucial problems, thus enhancing the prospect of optimal treatment outcome.

The use of central regional anesthesia techniques in Sweden: results of a nation-wide survey. Swedish Association of Anesthesia and Intensive care.

BACKGROUND: Epidural and subarachnoid anesthesia are well established central regional techniques for surgical anesthesia. Two additional techniques, combined spinal epidural (CSE) block and continuous spinal anesthesia (CSA), have recently become popular. However, data on nation-wide use of central regional blocks are not available. METHOD: With the aims to survey the use of central regional techniques, to evaluate the risk of complications to central regional blocks and to document the use of continuous epidural techniques for postoperative pain management in Sweden during 1993, a questionnaire was mailed to all 105 Swedish anesthesiology departments. RESULTS: Questionnaires were returned by 62 departments, representing all categories of Swedish hospitals. Central regional blocks were used for surgical anesthesia in 20-40% of reported surgical procedures. Subarachnoid anesthesia was the main technique for orthopedic surgery on the lower limb, elective cesarean section and transurethral resection of the prostate. Epidural block was used for orthopedic and vascular surgery. CSE block was used by 42 departments and CSA by 21 departments. Postoperative epidural analgesia was used by 59 departments, most commonly with continuous infusion of local anesthestics and/or epidural bolusdoses of morphine. Nineteen neurological sequelae were reported after epidural (n = 7) and subarachnoid (n = 12) blocks. Routines for registration of complications varied greatly. CONCLUSIONS: Subarachnoid block was preferred for shorter surgical procedures (< 60 min), whereas epidural and CSE blocks were chosen when severe postoperative pain could be anticipated, as continuous epidural analgesia was well established for postoperative pain management. Improved routines for registration of complications to central regional blocks are needed.

Is acupuncture an alternative in idiopathic pain disorder?

This study investigated the pain-relieving effect of an intensive type of periosteal acupuncture stimulation in patients with idiopathic pain disorder. Twelve patients, 2 males and 10 females, with a mean age of 54, were included in the study. The average duration of their pain was 12.6 years. Each treatment consisted of brief but painful manual stimulation of 3 to 4 periosteal sites. Over a 3-8-month period each patient had between 4-11 treatments, an average of 7. Analgesic drugs that patients were on prior to the study were continued but no other physical or psychological treatment for their pain was applied. Ten patients had either no responses to treatment or only transient responses which were not maintained until the following treatment. Two patients benefitted from treatment, having long periods of substantial pain reduction. All responses were assessed on pain scales maintained daily before and during the entire period of treatments. For the majority (83%) of patients in this study, with an idiopathic pain disorder, periosteal acupuncture stimulation was not a treatment alternative.

Systemic mexiletine relieves chronic allodynialike symptoms in rats with ischemic spinal cord injury.

We have recently reported a chronic allodynialike symptom in rats after ischemic spinal cord injury. This pain-related behavior is resistant to a number of pharmacologic treatments, including morphine, clonidine, carbamazepine, baclofen, and muscimol. In the present report, we present evidence indicating that systemic mexiletine, a local anesthetic and antiarrhythmic agent, effectively relieves the allodynia-like symptoms at doses of 15 and 30 mg/kg in these rats without inducing major side effects. It is suggested that systemically applied mexiletine may be useful in treating central pain in patients with spinal cord injury.