Breakthrough pain characteristics and syndromes in patients with cancer pain. An international survey.

Breakthrough pain (BKP) is a transitory flare of pain that occurs on a background of relatively well controlled baseline pain. Previous surveys have found that BKP is highly prevalent among patients with cancer pain and predicts more severe pain, pain-related distress and functional impairment, and relatively poor quality of life. An international group of investigators assembled by a task force of the International Association for the Study of Pain (IASP) evaluated the prevalence and characteristics of BKP as part of a prospective, cross-sectional survey of cancer pain. Fifty-eight clinicians in 24 countries evaluated a total of 1095 patients with cancer pain using patient-rated items from the Brief Pain Inventory (BPI) and observer-rated measures. The observer-rated information included demographic and tumor-related data, the occurrence of BKP, and responses on checklists of pain syndromes and pathophysiologies. The clinicians reported BKP in 64.8% of patients. Physicians from English-speaking countries were significantly more likely to report BKP than other physicians. BKP was associated with higher pain scores and functional interference on the BPI. Multivariate analysis showed an independent association of BKP with the presence of more than one pain, a vertebral pain syndrome, pain due to plexopathy, and English-speaking country. These data confirm the high prevalence of BKP, its association with more severe pain and functional impairment, and its relationship to specific cancer pain syndromes. Further studies are needed to characterize subtypes of BKP. The uneven distribution of BKP reporting across pain specialists from different countries suggests that more standardized methods for diagnosing BKP are needed.

Physicians' recognition of the symptoms experienced by HIV patients: how reliable?

To assess how well physicians recognize common symptoms in HIV patients and identify factors associated with symptom recognition, a multicenter cross-sectional survey was performed in a random sample of 118 hospitalized and 172 ambulatory HIV patients, and their attending physicians. Patients' reports of 16 different symptoms were compared to physicians' reports of whether each symptom was present and/or specific treatments prescribed. Overall, fatigue, anxiety, skin problems, fever, and weight loss were more often recognized by physicians than other symptoms. Agreement between patients and physicians was poor to moderate, with Kappa statistics ranging from 0.17 (dry mouth) to 0.58 (fever). Recognition was independently more likely for ambulatory patients (adjusted odds ratio 1.69, P < 0.001) and for patients seen as sicker (adjusted odds ratio 1.88, P < 0.001). Appropriate symptom management requires improved symptom recognition. More systematic clinical examinations, including attentive patient interview, are needed.

Evolution of the French public's knowledge and attitudes regarding postoperative pain, cancer pain, and their treatments: two national surveys over a six-year period.

UNLABELLED: Pain management has become a notable feature of public health policy and mass media communication in France over the past few years. To assess the evolution of the knowledge and attitudes of the French population with respect to pain management and morphine use, telephone surveys using similar questionnaires were conducted in 1990 (n = 1001) and 1996 (n = 1006). The proportion of respondents who would take pain management adequacy into consideration when selecting a surgical facility increased from 52% to 81% (P < 0.001), as did the proportion who associated morphine with pain treatment (from 44% to 80%; P < 0.001) or who would not be afraid of becoming addicted to morphine after it had been prescribed for pain relief (from 26% to 69%; P < 0.001). However, the proportion of respondents who agreed that morphine can be prescribed to patients with pain increased only slightly. In 1996, 58% of the respondents believed that their knowledge had improved over the past 5 yr and associated this improvement first with television, followed by written press articles and by interaction with physicians. Increased awareness of pain management possibilities among the public may generate increased demand on health professionals to provide adequate and precise information addressing each patient's needs. IMPLICATIONS: The results of two representative surveys conducted over a 6-yr interval show significant improvements of knowledge and attitudes regarding pain and its management in the French general population. However, these results point to the need for additional specific information that should be provided through patient-physician interactions.

Paraganglioma of the cauda equina: MR findings. One case.

Paraganglioma of the filum terminale is a rare tumor but well described in the neurosurgery and pathology literature. Few MRI reports are mentioned. Paraganglioma, often misdiagnosed with ependymoma or schwannoma on MRI images, must be kept in mind, when a highly vascular lesion with serpentine vessels is observed.

Underestimation and undertreatment of pain in HIV disease: multicentre study.

OBJECTIVE: To measure the prevalence, severity, and impact of pain on quality of life for HIV patients; to identify factors associated with undertreatment of pain. DESIGN: Multicentre cross sectional survey. SETTINGS: 34 HIV treatment facilities, including inpatient hospital wards, day hospitals, and ambulatory care clinics, in 13 cities throughout France. SUBJECTS: 315 HIV patients at different stages of the disease. PATIENTS: recorded presence and severity of pain and rated quality of life. Doctors: reported disease status, estimate of pain severity, and analgesic treatment ordered. RESULTS: From 30% (17/56) of outpatients to 62% (73/118) of inpatients reported pain due to HIV disease. Pain severity significantly decreased patients' quality of life. Doctors underestimated pain severity in 52% (70/135) of HIV patients reporting pain. Underestimation of pain severity was more likely for patients who reported moderate (odds ratio 24) or severe pain (165) and less likely for patients whose pain source was identified or who were perceived as more depressed. Of the patients reporting moderate or severe pain, 57% (61/107) did not receive any analgesic treatment; only 22% (23/107) received at least weak opioids. Likelihood of analgesic prescription increased when doctors estimated pain to be more severe and regarded patients as sicker. CONCLUSIONS: Pain is a common and debilitating symptom of HIV disease which is gravely underestimated and undertreated.

[Use of opiates for chronic pain]. / L'utilisation des opiacés pour les douleurs chroniques.

World Health Organization (WHO) has recommended since 1986 simple methods to control pain due to cancer. The use of analgesic medications, appropriate to the severity of pain reported by the patient, is the key point of WHO guidelines. It has been shown that the use of analgesic medication and particularly of morphine to control severe pain is insufficient for a majority of patients worldwide. This communication presents the main results of French national studies among representative samples of cancer patients and physicians (primary care physicians and medical oncologists) faced with cancer pain. These studies confirm that cancer pain is inadequately treated for 51% of patients and identify among French physicians attitudinal barriers to the proper use of morphine. Results are discussed with regard to the national policy against pain now in progress in France.

Oncologists and primary care physicians' attitudes toward pain control and morphine prescribing in France.

BACKGROUND: Two representative samples of primary care physicians (N = 600) and medical oncologists (N = 300) in France were surveyed about their attitudes toward and knowledge about cancer pain management. METHODS: The survey was conducted by telephone with a questionnaire based on a model developed by the University of Wisconsin-Madison Pain Research Group. It was designed to assess physicians' estimates of the prevalence of pain among patients with cancer, their practice in prescribing analgesics, their training in cancer pain management, and the quality of care received by cancer patients in their own practice and in France. RESULTS: Barriers to adequate cancer pain management are prevalent and consistently more common among primary care physicians than among medical oncologists. Although 85% of primary care physicians and 93% of medical oncologists express satisfaction with their own ability to manage cancer pain, 76% of primary care physicians and 50% of medical oncologists report being reluctant to prescribe morphine for cancer pain. Both groups cite fear of side effects as their main reason to hesitate to prescribe morphine. Concerns about the risk of tolerance (odds ratio [OR], 1.15-2.52), perceptions that other effective drugs are available (OR, 1.11-2.41), perceptions that morphine has a poor image in public opinion (OR, 0.96-2.07), and the constraints of prescription forms (OR, 1.12-2.26) contribute significantly to physicians' infrequent prescription of morphine, as are being female (OR, 1.01-2.03) and being an older oncologist (OR, 1.09-2.51). CONCLUSIONS: This study (1) confirms the existence among French physicians of attitudinal barriers and knowledge deficits previously reported in other countries that can impede cancer pain management, (2) identifies new barriers to the proper prescription of morphine for cancer pain control, and (3) reveals discrepancies in physicians' attitudes and knowledge about pain control which suggest a need for the systematic evaluation of cancer patients' care.

Multicentre study of cancer pain and its treatment in France.

OBJECTIVE: To describe the treatment of cancer pain in France and to evaluate the predictive factors for inadequate management. DESIGN: Multicentre, representative cross sectional survey. SETTING: 20 treatment centres, including cancer centres, university hospitals, state hospitals, private clinics, and one homecare setting (in which patients are supported at home). SUBJECTS: 605 patients with cancer. MAIN MEASURES: Patients rated prevalence and severity of pain and functional impairment related to pain. Doctors reported patients' cancer characteristic, performance status, pain severity, and analgesic drugs ordered. RESULTS: 57% (340/601) of patients with cancer reported pain due to their disease, and, of those with pain, 69% (224/325) rated their worst pain at a level that impaired their ability to function. 30% (84/279) were reported as receiving no drugs for their pain. Of the 270 patients in pain for whom information on treatment was available 51% (137/270) were not receiving adequate pain relief, according to an index based on the World Health Organisation's guidelines. French doctors were found to underestimate the severity of their patients' pain. Younger patients, patients without metastatic disease, patients with a better performance status, and patients who rated their pain as more severe than their doctors did were at greater risk for undertreatment of their pain. CONCLUSIONS: In the light of the high prevalence and the severity of pain among patients with cancer, the assessment and treatment of cancer pain in France remain inadequate, emphasising the need for changes in patient care.

[Postoperative analgesia in France. A study of the prescribing doctor's approach]. / L'analgésie postopératoire en France. Etude sur l'attitude des médecins prescripteurs.

Every year nearly 4 million surgical procedures are carried out in France: about two thirds of the patients will suffer moderate to severe postoperative pain. Beside the obvious philosophical reasons, purely medical arguments also favour good quality postoperative pain relief. In this country, unlike the situation prevailing in many other countries, anaesthetists are in charge of postoperative pain relief. The survey reported here was carried out by questioning the usual prescribers and it reports their attitudes and practices. The results would show a rather good situation: anaesthetists seem to have an interest in the subject, and the approach looks very satisfactory but these points remain to be proved in practice. There is considerable interest in some drugs, but others are in disgrace for unclear reasons. New methods of administration are not very familiar. We may conclude from this study that a greater awareness of the problem is desirable, that general and specific scientific information should be made available, that clearly defined treatment plans should be established and evaluated regularly, and that financial resources must be envisaged.

Temperature monitoring during epidural anesthesia for cesarean delivery.

Tympanic, rectal, and axillary temperatures were measured and compared in 12 ASA Physical Status I and II parturients during epidural anesthesia for cesarean delivery. Measurements were performed before (T0) and at 15 (T1), 30 (T2), 45 (T3), and 60 (T4) minutes after epidural anesthesia. At birth, rectal neonatal and maternal temperatures were measured. Before anesthesia, maternal tympanic and rectal temperatures were statistically not different but higher than axillary temperature (difference, 0.5 degrees C). During anesthesia, all three maternal temperatures decreased. There was no difference for the first 45 minutes between rectal and tympanic membrane temperatures and no difference between tympanic and axillary temperatures after 30 minutes. The difference between rectal and tympanic temperatures became significant at T4. During the same period, the difference between axillary and tympanic temperatures became nonsignificant at T3 and T4. At birth, both maternal and newborn rectal temperatures were similar at 36.0 +/- 0.2 degrees C. The relative hypothermia observed in the newborns at birth after regional anesthesia was well correlated with the decrease in maternal temperature. A decrease in tympanic temperature of 1.4 degrees C developed during the course of epidural anesthesia for cesarean delivery. This decrease was underestimated by the measurement of rectal and axillary temperatures.

Relationship between the sterol content of yeast cells and their fermentation activity in grape must.

In grape must of high sugar concentration, yeast growth, the viability rate of "resting" yeast cells, and fermentation activity were stimulated under certain conditions of aeration and temperature. This stimulation might be interpreted as being a result of the yeast cell sterol content. The addition of certain sterols to the fermenting medium was able to increase this sterol content. According to aeration conditions of the medium, which determined the sterol content of yeasts, the sterols added in the medium acted as (i) growth factors, (ii) fermentation inhibitors, and (iii) survival factors for the yeast.

Evidence for the existence of "survival factors" as an explanation for some peculiarities of yeast growth, especially in grape must of high sugar concentration.

The retardation and arrest of fermentation, observed before the complete sugar consumption of high-sugar grape must, come from an inhibition of the yeast metabolism during its decline phase and are variable with the strain. The addition of nutritional growth factors stimulates the initial growth of the yeast but is ineffective in the decline phase. Some substances, known previously as yeast anaerobic growth factors (sterols, oleanolic acid, oxytocin), in some conditions (initially aerated grape must and aerobically cultivated yeast) act by increasing the viability of the resting cells and prolonging their fermentation activity. These substances have been named "survival factors."