Treatment of pain of diffuse metastatic cancer by stereotactic chemical hypophysectomy: long term results and observations on mechanism of action.

Stereotactic instillation of absolute alcohol into the sella turcica for pituitary destruction was carried out in 29 patients divided into two groups. Seventeen with prostatic carcinoma underwent a total of 19 injections with 94% good to excellent results that persisted throughout the remainder of the patient's life-span. The longest survival was 9 months. Brief relapses did occur, but spontaneous remissions were the rule. A second group of mixed cancers contained 12 patients who received a total of 13 injections. Eleven patients had good to excellent results that persisted in all but 1 patient. The longest survival was 7 months. Hormonal levels and prolactin stimulation tests failed to show any correlation between hormonal changes and pain relief. Naloxone reversal of analgesia did not occur. There was no loss of cognitive function shown on psychological testing. Pathological studies showed destruction of the pituitary gland, which was subtotal in some patients despite good pain relief. All examinations showed that the pituitary stalk was destroyed. Patients who survived longer also showed degeneration of the supraoptic and paraventricular nuclei of the hypothalamus and the median eminence. All but 1 patient with pain relief exhibited a lack of antidiuretic hormone (ADH) production. Interpretation of the data indicates that ADH or its associated neurophysins act as central pain transmitters. The production of these transmitters is decreased or abolished by chemical hypophysectomy through the destruction of hypothalamic nuclei.

Postsurgical pain relief: patients' status and nurses' medication choices.

This study consisted of two interrelated parts. In the first part, the adequacy of pain relief in hospitalized post-surgical patients was assessed and described and in the second part ways in which nurses on the same units chose analgesic medications were examined and analyzed. Pain was considered a subjective experience. Patients were interviewed, and their charts reviewed on the third postoperative day. The sample included 109 patients in 5 central Illinois hospitals. After all patient interviews were completed, 121 nurses on the same units responded to a questionnaire which included clinical vignettes. Results of the patient interviews indicated that 75.2% of these patients were in moderate or marked pain distress and that a general question did not adequately assess pain. Chart review indicated that these patients were actually receiving less narcotic analgesics than they could receive. Nurses were overly concerned about the possibility of addiction; choices of analgesic medications seemed irrational; and knowledge of the drugs was inadequate. Moreover, these nurses indicated that complete pain relief after surgery was not their major goal. In 2 sets of identical vignettes where the only difference was the sex of the patient, nurses selected less medication for pain for female patients (P < 0.001 and P < 0.025 respectively). Factors that nurses consider in administering and choosing postoperative analgesia are described.

Buprenorphine-soaked absorbable gelatin sponge: an alternative method for postlaminectomy pain relief.

There have been several reports of instillation of buprenorphine in the intact epidural space in an attempt to control postoperative pain, but none in which an absorbable gelatin sponge soaked with buprenorphine is placed directly in the epidural space. In the present study, carried out on 30 patients (study group) undergoing noncervical laminectomies, 0.3 mg buprenorphine diluted to 5 mL with normal saline soaked into an absorbable gelatin sponge was placed in the epidural space under direct vision. In 30 other patients (control group) undergoing laminectomies, absorbable gelatin sponge soaked with 5 mL normal saline was placed in the epidural space. Pulse rate, mean arterial pressure, respiratory rate, pain score by visual analog scale, duration of analgesia, and adverse effects, if any, were noted preoperatively and postoperatively at 1, 2, 3, 4, 5, 6, 12, 18, and 24 hours. The presence of any neurologic symptoms was also assessed at these time intervals as well as on the seventh postoperative day. The authors observed that changes in pulse rate, mean arterial pressure, and respiratory rate were not statistically significant between the control and the study groups. The pain relief score, duration of pain relief (14.8 +/- 0.77 hours in the study group vs. 0.66 +/- 0.15 hours in the control group), and sedation were significantly better in the study group. No patient demonstrated any respiratory depression (respiratory rate <12/min), bradycardia, pruritus, or neurologic pressure symptoms, although the incidence of nausea was higher in the study group.

Clinical effects of epidural block during labour. A prospective study.

The aim of this study was to evaluate the clinical effects of epidural block for pain relief during labour in an obstetric unit which manages mainly high-risk pregnancies. In the majority of the 62 patients studied only 5 ml of a 0,5% solution of bupivacaine was sufficient for effective pain relief. In 75% of patients total pain relief was obtained. Complications of the procedure were hypotension in 32% of patients and bladder atony needing catheterization in 19%. The mean fall in blood pressure was greater in patients with pre-existing hypertension. The incidence of instrumental delivery was 40%, inadequate bearing-down effort being the indication in 54% of these cases. An abnormal fetal heart rate pattern on cardiotocography developed in 13 of 58 fetuses who were monitored internally, while in 3 cases an abnormal pattern because even more abnormal (in one-third of these cases this followed hypotension in the mother). The only statistically significant change in fetal heart rate patterns on cardiotocography was a decrease in the beat-to-beat variability. Epidural block is a very effective form of pain relief during labour but has potentially serious effects, especially in high-risk pregnancies. Precautions to minimize the risk of complications include the administration of intravenous fluid before the procedure and careful monitoring of the patient and her unborn baby. A cardiotocographic monitor is essential for the latter purpose.

Treatment of renal colic by desmopressin intranasal spray and diclofenac sodium.

The vasopressin analogue, 1-desamino-8-arginine vasopressin (desmopressin), is a potent antidiuretic without the pressor effects of vasopressin. A total of 18 patients with acute renal colic due to stone disease received 40 microgramsf1p4mopressin intranasal spray with encouraging results. There was a significant decrease in the colic pain intensity from an initial mean visual analogue score of 67 +/- 17 mm. to 39 +/- 36 mm. within 30 minutes (p < 0.001). Eight patients (44.4%) had complete pain relief within 30 minutes of administering intranasal desmopressin spray. Nine of 10 patients who required intramuscular diclofenac sodium achieved complete pain relief within another 30 minutes. In other words, when intranasal desmopressin spray was administered before diclofenac sodium, 94.4% of the patients achieved complete pain relief and were discharged home. The mechanism of analgesic action of desmopressin in renal colic is uncertain. At the peripheral level, desmopressin may alleviate the acute renal colic through its potent antidiuretic effect or by relaxing the renal pelvic and ureteral smooth muscles. The central analgesic effect of desmopressin by stimulating the release of the hypothalamic beta-endorphin is proposed. We conclude that intranasal desmopressin spray can be used successfully in the treatment of renal colic. It may also replace prostaglandin synthetase inhibitors in treating renal colic with the advantage of avoiding the potential side effects. Further studies are needed to investigate whether the combination of desmopressin with analgesics or spasmolytic drugs offers competitive results compared with those achieved by prostaglandin synthetase inhibitors in the treatment of renal colic.

Intraventricular morphine administration for control of chronic cancer pain.

Twenty cancer patients with severe chronic pain have been treated with intraventricular morphine sulfate. Adequate pain relief until death was achieved in 10 patients; 1 patient has been treated for 9 months and is still being treated. In 2 patients, the effects of the morphine sulfate on their unilateral pelvic pain wore off after 4 and 6 months because of tumor progression. At that time, they underwent chordotomy procedures elsewhere. The treatment was discontinued in 4 patients for reasons other than inadequate pain relief, such as medical complications or resolution of pain. In 3 patients, the procedure was abandoned when emotional and psychological factors interfered with pain control. Dose requirements of intraventricular morphine sulfate varied greatly, depending on the total daily dose of systemic narcotic intake at the onset of the study. Intraventricular morphine sulfate is a feasible and reliable method to achieve pain relief in selected cancer patients with severe chronic pain when the maximum tolerated dose of systemic narcotic analgesics has become insufficient to control their pain.

The need for pain relief in uncomplicated deliveries in an alternative birth center compared to an obstetric delivery ward.

The need for pain relief during uncomplicated labour and delivery was studied in 125 women attending an Alternative Birth Center (ABC) and 170 women attending an obstetrical ward. The ABC was staffed only with midwives and assistant nurses who took care of all deliveries. In case of complications the doctor on duty at the obstetrical ward could come in a few minutes and the patient was transferred to the obstetrical ward. At the ABC the delivery room was next to the sleeping rooms and the living room and the woman in labour could have a chat with the women, who had given birth. At the obstetrical ward this was not possible. The delivery rooms were on one floor, and after giving birth the woman was moved to another floor. Women at the ABC were older and had a higher social status than women at the obstetrical ward. Twenty four of the 170 women had initially planned to give birth at the ABC but gave birth at the obstetrical ward due to accommodation restrictions at the ABC. Women refused by the ABC resembled women giving birth at the ABC but their need for pain relief was identical with the other women giving birth at the obstetrical ward. pain relief with pethidine was 4 times more frequent among women giving birth at the obstetrical ward (18%) than at the ABC (4.8%). Pethidine was predominantly administered to young women and primiparas at the obstetrical ward and to women with prolonged labour at both birthplaces.

Problems related to dorsal root entry zone lesions.

Several clinical problems related to the dorsal root entry zone lesions (DREZLs) in 15 patients with chronic pain are presented and discussed in terms of ratings of pain relief following surgery, development of sensory or motor weakness and postmortem histologies. Subjective pain relief exceeding 70% was achieved at around 2 weeks after the operations in most patients (13/15), and then decreased in some to 30 from 70% in the follow-up observations. Our new "objective" pain relief score was tested in these patients. A significant positive correlation between subjective pain relief and our objective pain relief scale was found, but some discrepancies between them were also found during the follow-up. Sensory loss, motor weakness, paraesthesia and a new pain were found as complications in 12, 7, 4 and 6 patients, respectively. Postmortem histological findings of the spinal cord in two patients with systemic lupus erythematosus and uterine cancer, who received bilateral DREZLs twice and bilateral DREZLs plus commissural myelotomy, respectively, indicate that care should be taken to avoid extension of the coagulation beyond the dorsal horn.

Spinal cord stimulation--a long-term evaluation in patients with chronic pain.

Spinal cord stimulation (SCS) is an established treatment modality for chronic pain, angina pectoris, and peripheral vascular disease. This study evaluates experience with SCS over a 13-year period with emphasis on surgical complications, revisions and pain relief. It took the form of a retrospective study of medical/surgical records coupled with a postal/telephone questionnaire. The subjects consisted of seventy patients, aged from 21 to 76 years (mean 47; median 46), with severe, chronic pain refractory to conventional treatment, who underwent SCS implantation between 1984 and 1997. It investigated surgical revisions, complications and pain relief. There were 72 surgical revisions comprising electrode replacement/repositioning (32), generator replacement (22), cable failure (6) and implant removal (12). Half the devices were revised within 3 years (95% confidence interval: 2-5 years) of implantation. Six (8.6%) implants became infected. Sixty per cent of patients reported substantial relief of pain. This study shows that the majority of patients undergoing SCS derive significant benefit in terms of pain relief, but commonly require surgical revisions due to both technical and biological factors. These devices require systematic evaluation to determine optimal usage, clinical effectiveness and cost-benefit analysis.

The efficiency and tolerance of half-body irradiation (HBI) in patients with multiple metastases. The Krakow experience.

AIM: To present our experience regarding the efficiency and tolerance of half-body irradiation in patients with multiple cancer metastases. PATIENTS AND METHODS: Between January 1986 and December 1997, 102 patients with multiple cancer metastases received half-body irradiation (HBI) at the Center of Oncology--Maria Sklodowska-Curie Memorial Institute in Krakow. Most of the patients (93/102) had bone metastases (Table 1). The HBI was performed with 9 MV photon beam from linear accelerator. In 88 patients only one region (upper, mid or lower) was treated, and 14 patients received upper and lower HBI (13 patients), or upper and mid HBI (one patient) (Table 2). The mean doses were: 6 Gy in upper HBI, 8 Gy in mid HBI, and 9 Gy in lower HBI (Table 3). RESULTS: The positive palliative effect (complete or partial pain relief) was observed in 77 (75.5%) patients (Table 4). Complete pain relief was higher in patients with prostate cancer, and in patients who received mid or lower HBI. During follow-up 47 (46.1%) patients developed pain progression after treatment (Table 5). The probability of survival without pain progression was higher in patients who developed complete pain relief (86.7% at 6 months, 69.3% at 12 and 24 months) than in patients with partial response (52.9% at 6 months, 32.8% at 12 months, and 5.5% at 24 months) (Figure 1). In most of the patients (74/102, 72.5%) the tolerance was good. CONCLUSIONS: HBI is an efficient method for palliation in patients with multiple painful metastases.