Palliative radiotherapy of appendicular osteosarcoma in 95 dogs.

Ninety-five dogs with either a presumptive (n = 24) or biopsy confirmed diagnosis (n = 71) of osteosarcoma received palliative radiotherapy using 60Co photons. Parallel opposed beams were used with each dog receiving either 10 Gy on days 0, 7 and 21 (n = 58) or 8 Gy on days 0 and 7 (n = 37). The 8 Gy fractionation scheme was given with the intent of retreating upon relapse from pain relief. Only 9 of 37 (24%) dogs in the 8 Gy group returned for retreatment. Forty-seven of the 95 dogs (49%) received concurrent or sequential chemotherapy. Seventy of the 95 dogs (74%) experienced pain relief following treatment. In dogs experiencing pain relief the median duration of response was 73 days. Numerous clinical variables were evaluated as predictors of response. The only variable significantly related to achieving a response was the use of chemotherapy. The following variables were significantly related to the duration of response: extent of bone lysis, chemotherapy use, length of bone involved and tumor site (humerus). In a multivariate analysis (n = 73 dogs), after adjusting for chemotherapy use, extent of bone involvement (p = 0.01) and tumor site (p = 0.02) retained statistical significance, while degree of bone lysis did not (p = 0.11). No difference in response incidence or duration was found between 3 fractions of 10 Gy vs. 2 fractions of 8 Gy. Administration of a low initial dose with the intent of retreatment was not a successful strategy.

A preliminary list to identify attitudes toward different conditions for discussing possible termination or refusal of medical treatment except for pain relief.

Effective communication about decisions concerning termination or refusal of medical treatment except for pain relief necessitates clarifying the attitudes of those in the decision-making process. Effective communication increases the likelihood that a patient's advance directives are implemented and decreases the likelihood of litigation. Psychotherapists, counselors, chaplains, etc. can be facilitators of effective communication. This study generated a list for use in discussion by asking persons who cared for individuals with terminal illnesses, critical injuries or elderly people what conditions seemed appropriate for termination or refusal of medical treatment except for pain relief. The 182 out of 204 individuals who contributed conditions showed clear agreement on terminal illnesses, brain disorders, dependence on machines for life, and other irreversible deterioration or severe loss of quality of life, lack of suitable treatment, patient's wish, and concern about the effect of the patient's condition on others. Some specified further qualifications, such as at what point during a terminal illness termination or refusal was appropriate. The list with notes could be appended to a Living Will or a Durable Power of Attorney for Health Care. The notes should be updated periodically. Through use and research, the list also can be refined further.

The impact of clinical, morphological, psychosocial and work-related factors on the outcome of lumbar discectomy.

In a prospective controlled trial on 46 patients undergoing lumbar discectomy, three classes of variables (medical data including MRI-identified morphological abnormalities, general psychological factors and psychosocial aspects of work) were analyzed with regard to their predictive value for the outcome of lumbar disc surgery at 2 year follow-up. Multiple regression analyses were used to identify the best predictor variables of four different outcome measures (i.e. pain relief, reduction of disability in daily activities, return to work and surgical outcome). MRI-identified nerve root compromise and social support from the spouse were independent predictors of pain relief 2 years after surgery (R2 = 0.40, P < 0.01). Return to work 2 years after surgery was best predicted by depression and occupational mental stress (R2 = 0.36, P < 0.001). MRI-identified extent of herniation and depression were significant predictors of a good surgical outcome after lumbar discectomy (R2 = 0.61, P < 0.001). This study has demonstrated that the outcome of discectomy is critically dependent on which outcome variables are selected and that different sorts of predictor variables have a distinct influence on the various outcome variables. Obvious morphological alterations (i.e. disc extrusions, nerve root compromise) proved to be significant predictors of postoperative pain relief and improvement of disability in daily activities justifying a surgical treatment approach in these cases. The most important finding of this study was that return to work was not influenced by any clinical findings or MR-identified morphological alterations, but solely by psychological factors (i.e. depression) and psychological aspects of work (i.e. occupational mental stress).

Postoperative pain relief by preanesthetic administration of buprenorphine suppository in elective mastectomy

Seventy female patients scheduled for elective mastectomy were divided into three groups: Buprenorphine suppository (BPS) 0.4 mg group (n = 29); BPS 0.2 mg (n = 23) group; and control (scopolia extract and tannic acid suppository) group (n = 18). Suppositories were administered rectally to patients of each group one hour before induction of anesthesia. Plasma buprenorphine concentrations, sedation scores at entering the operating room, postoperative pain scores and side effects were evaluated. There were no significant differences in sedation effects of suppository among the three groups. Although there were significant differences in pain scores except at the time when patients left the operating room between BPS 0.2 mg group and the control group, postoperative pain relief in BPS 0.2 mg group was judged not enough. However, postoperative pain relief was more satisfactory in the BPS 0.4 mg group. Plasma concentrations of the BPS 0.4 mg group were higher than those of the BPS 0.2 mg group. Although nausea and vomiting were observed in 5 patients (17.2%) of the BPS 0.4 mg group and 4 patients (17.4%) of the BPS 0.2 mg group, respiratory depression and changes in blood pressure and heart rate were not observed in all groups. In conclusion, preanesthetic administration of the BPS 0.4 mg seemed to be useful for postoperative pain relief after elective mastectomy.

Thoracoscopic thoracic splanchnicectomy for chronic pancreatitis with intractable abdominal pain.

The therapeutic advantages of a thoracoscopic thoracic splanchnicectomy (TTS) to relieve the pain of chronic pancreatitis patients was evaluated. The TTS procedure (four bilateral and five unilateral TTS), was performed on nine patients from April 1993 to October 1995. Based on radiographic images, the pancreatic duct of seven cases were diagnosed as being "nondilated" (<3 mm), whereas two cases were "dilated" (> or = 3 mm). A 5-mm thoracoscope was introduced through the fifth intercostal space on the anterior axillary line, and an additional two cannulas were introduced under direct thoracoscopic vision. The sympathetic chain, at a level from Th 5 to 9, was then resected and electrocoagulated. We performed a unilateral TTS corresponding to the symptomatic side; however, if pain relief was insufficient, an additional sympathectomy was done on the other side. The early postoperative course was uneventful, and immediate pain-relief was normally possible after TTS except for three patients who demonstrated minor intercostal neuralgia at the site of the trocars inserted for TTS. Six of nine patients were able to return to their preoperative work of lifestyle at a maximum follow-up of 24 months (the median and mean durations were 15.0 and 13.7 months, respectively). In addition, no postoperative deterioration of either the endocrine or exocrine function of the pancreas was observed. In conclusion, TTS proved to be a safe and reliable procedure for the pain relief of the chronic pancreatitis.

Non-prosthetic management of grade IV osteochondral lesions of the glenohumeral joint.

Osteochondral lesions of the glenohumeral joint in early stages and in younger patients are an important problem and present a challenge during clinical decision making. Although prosthetic arthroplasty remains the gold standard for treatment in later stages of the disease, alternatives are desirable in the early stages and in young patients. The purposes of this study are to evaluate the results of arthroscopic debridement and capsular release in patients with grade IV osteochondral lesions of the glenohumeral joint and to determine the factors associated with their success. Sixty-one patients with grade IV osteochondral lesions of the glenohumeral articular surfaces were treated with arthroscopic debridement, with or without arthroscopic capsular release. Standardized data collection was performed at the initial office visit and at the time of final follow-up. Overall outcome was analyzed with regard to patients' self-assessment of pain, function, improvement, satisfaction, and duration of pain relief. Forty-five of the patients had a minimum follow-up of 2 years. Time-to-event analysis was used to evaluate the duration of pain relief. The mean patient satisfaction score (0 = not satisfied; 10 = completely satisfied) improved from 0.67 preoperatively to 6.28 at final follow-up (P <.0001), with 87% of patients indicating that they would have the surgery again. Although workers' compensation patients obtained inferior results, significant improvement in pain and function was obtained in 88% of all patients (P <.0001). Most patients noted the onset of pain relief within 5 weeks of surgery and obtained a duration of pain relief of 28 months or greater (P <.05). The addition of concomitant procedures, such as acromioplasty, distal clavicle resection, labral debridement, or labral repair, did not have a negative impact on the functional results after arthroscopic debridement and capsular release. In well-selected patients with grade IV osteochondral lesions of the glenohumeral joint, significant improvements in pain relief and function follow arthroscopic debridement of the glenohumeral joint. Arthroscopic capsular release can be added in patients with a loss of passive arcs of shoulder motion. Osteochondral lesions greater than 2 cm(2) appear to be associated with return of pain and failure of this procedure.

Attitudes to pain and pain relief in adult surgical patients.

pain relief after surgery is frequently inadequate. In the last few years much research has been devoted to improving the situation. Unfortunately, very little work has been undertaken to explore the patients' contribution to pain management. The beliefs and attitudes held by patients when they enter the hospital environment may be responsible in some instances for their not achieving optimal pain relief from the available techniques. We have studied some of these attitudes with a survey of 180 adult patients admitted for elective surgery. We found that most patients still expect pain following surgery. However, they are not afraid to ask for analgesics when in pain and do not attribute pain to their own wrong doing. There are, however, some patients who appear to have 'deviant' pain beliefs that could hinder their appropriate use of analgesics. Sadly, it is impossible to identify these patients according to age, gender, socio-economic group or previous experience of pain or surgery.

Paracetamol, tiaramide and placebo for pain relief after orthopedic surgery.

Eighty patients took part in this double-blind, single-dose group-comparative study, comparing the analgesic efficacy of tiaramide hydrochloride 100 mg and 200 mg, paracetamol 1000 mg, and placebo for pain after orthopedic operations. The four treatment groups were similar on entry to the trial. pain relief was assessed up to 6 h after treatment, using a visual analogue pain scale and a pain score, both giving similar results. Statistically significant pain relief (mean pain intensity differences and sum of pain intensity differences) was seen in the group receiving paracetamol compared to those receiving placebo or tiaramide from 1 h to 6 h after drug ingestion. There was no significant difference between placebo and tiaramide 100 or 200 mg. No adverse reactions were reported.

The use of surgical sympathectomy in the treatment of chronic renal pain.

OBJECTIVE: To assess the efficacy of renal sympathetic denervation in the treatment of chronic renal pain. PATIENTS AND METHODS: In a 10-year period, 21 patients suffering from chronic renal pain underwent 27 renal denervation operations, six of which were bilateral. The cause of pain was the loin pain haematuria syndrome in 18 patients. RESULTS: Four operations resulted in complete pain relief to date (median follow-up 53.5 months). pain relief after the other 23 operations in 18 patients lasted a median of 6 months. Assuming that recurrent pain was due to neuronal regeneration, nine of the 18 patients with recurrent pain underwent a total of 10 re-explorations of the renal pedicle, stripping it of all nerve fibres and areolar tissue. Three of these re-explorations produced complete pain relief to date (median follow-up 40 months). The median pain-free interval of the other seven re-explorations in six patients was 19 months. CONCLUSION: Renal denervation cures severe intractable pain in about 25% of patients. Recurrence of pain could be prevented in more patients if there was a way of preventing re-innervation.

Radiation therapy for painful bone metastases; aiming at optimal treatment schedules

PURPOSE: To evaluate the pain relief obtained by radiation therapy for painful bone metastases, with a special regard to general condition. MATERIALS AND METHODS: Between June 1998 and May 2000, 54 patients with 86 painful bone metastases were treated with radiation therapy whose effects could be evaluated for a minimum period of 6 months or until death. Treatment schedules were 3 Gy/fraction/day (30-36 Gy/10-12 fractions) in usual cases (61 lesions), 4-8 Gy/fraction/day (8-20 Gy/1-5 fractions) in patients with a poor general condition (9 lesions), and 2 Gy/fraction/day (40-50 Gy/20-25 fractions) in lesions with a large radiation field (16 lesions). RESULTS: Complete pain relief without medication (CR) was achieved in 40 lesions (47%). Significant predictors for CR were primary site (p = 0.0003), performance status (p = 0.0060), pain score (p = 0.0190), narcotic score (p < 0.0001), and prognosis (p < 0.0001), but no difference was found in CR among treatment schedules. No evidence of severe radiation-induced complication was seen. CONCLUSION: General condition (performance status and prognosis) has an influence on pain relief. Compared with the daily 2 Gy protocol, the daily 3 Gy protocol has the advantage of shorter treatment time. The treatment schedule should be assessed in patients with a large radiation field and/or poor general condition. Especially for the patients with poor general condition, combined pain medication should be considered.