Reirradiation with local-field radiotherapy for painful bone metastases.

PURPOSE: The purpose of this study was to evaluate retrospectively the effectiveness, prognostic factors, and sequelae of the first course of local-field reirradiation for painful bone metastases. PATIENTS AND METHODS: From 1994 to 2000, a total of 30 patients were reirradiated for painful bone metastases. The most commonly used initial treatment regimen was 30 Gy/10 Fr/2 wk. An additional dose in the range from 10 Gy/5 Fr to 26 Gy/13 Fr was reirradiated. RESULTS: Fifteen patients (50%) showed some type of pain relief after reirradiation. Patients with initial CR were more likely to respond than those with previous PR (100% vs. 41%). The median duration of pain relief was five months. The duration of response was longer in initial CR than initial PR. The median survival time of responders after retreatment was 11 months. No patient developed radiation myelopathy. Prognostic factors for pain relief were duration from initial treatment, performance status (PS), and status of bone metastases. CONCLUSION: Reirradiation for patients with a long duration from initial treatment (> or = 4 months), good PS (ECOG: 1-2), or solitary bone metastases was effective for pain relief. The appropriate indications, optimal dose, fractions, and technique for reirradiation to painful bone metastases should be further explored in randomized study.

Postoperative pain relief by epidural morphine.

Postoperative pain relief was studied in 280 patients undergoing various kinds of surgery, e.g., thoracic, upper and lower abdominal, perineal, obstetric, and orthopedic. Morphine, 2 or 4 mg, was given after surgery through an indwelling epidural catheter. Excellent analgesia was noted in 87% of patients; only 3.5% of patients were dissatisfied. A single injection gave complete pain relief for the entire postoperative period in 30% of cases; in the remaining patients the mean duration of analgesia was 10.7 hours (SD +/- 4.3). Plasma morphine concentrations recorded after 2-mg doses suggest a regional spinal action as the basis for the long duration of analgesia, although the initial effect after 4-mg doses might well include systemic responses due to rapid vascular uptake of morphine from the epidural space. Peak expiratory flow (PEF) measurements and arterial blood gas analyses showed no significant early postoperative respiratory depression. Absence of sedation, orthostatic hypotension, respiratory depression, and motor paralysis facilitated early ambulation with less risk for postoperative respiratory complications. It is concluded that 2-mg doses of epidural morphine give good analgesia of long duration despite low plasma levels. After upper abdominal and thoracic surgery higher doses (4 mg) may be necessary in healthy patients. Elderly and frail patients appear to be sensitive to epidural morphine and doses in excess of 2 mg should be avoided regardless of the type of surgery. With this dose schedule we have not encountered delayed respiratory depression.

Interpleural analgesia for postoperative pain relief in renal surgery patients.

The feasibility of interpleural analgesia for postoperative pain relief after renal surgery using anterior intercostal incision was studied in 16 adult patients. 20 ml bupivacaine plain 5 mg/ml in ten patients, and the same dose of bupivacaine with epinephrine 5 micrograms/ml in six patients, was injected through epidural catheter into the pleural space of the operated side, maximally three times per 24 hours. As additional pain medication, oxycodone i.m. was given if needed. In ten control patients, oxycodone was the only pain medication. Postoperative pain relief in patients who received interpleural bupivacaine plain was excellent in four, moderate in four and poor in two cases. For supplemental pain relief the patients were given 2.1 +/- 1.1 (SEM) injections of oxycodone during the three days. Control patients received, respectively. 11.6 +/- 0.7 injections of oxycodone, and they considered the pain relief excellent in six and moderate in four cases. Median duration of interpleural analgesia was in bupivacaine plain cases 6 h (range 2-14 h) and in bupivacaine with epinephrine 7 h (range 4-15 h). The mean peak serum concentration of bupivacaine plain was 1868 +/- 168 ng/ml, and that of bupivacaine with epinephrine 1312 +/- 273 ng/ml. No complications were seen. The results suggest that interpleural analgesia obtained by 20 ml bupivacaine 5 mg/ml three times a day gives most patients good pain relief.

Factort of vaso-occlusive pain in children with sickle cell disease.

PURPOSE: A descriptive, longitudinal design was used to evaluate the pain management strategies used in children with sickle cell disease who were experiencing pain during a vaso-occlusive episode. METHODS: A list of the medications (name, amount, mode of delivery, and frequency) prescribed and administered for pain management for each participant was recorded on the Medication Quantification Scale Worksheet, starting from day 1 of hospitalization to the day of discharge. Children were asked once each evening to provide three separate ratings of how much the pain medication helped them during the day, evening, and night using a 0-to-10 rating scale. RESULTS: Using patient-controlled analgesia (PCA), children self-administered only 35% of the analgesic medications that were prescribed and reported little pain relief. No significant relationships were found between changes in pain relief scores and the amount of analgesics administered. CONCLUSIONS: Clinicians need to monitor the amount of analgesics delivered in relationship to pain relief and assist children to titrate PCA administration of analgesics to achieve optimal pain control, or to advocate for changes in the PCA regimen when children cannot assume control of pain management.

Effective pain relief with continuous intrapleural bupivacaine after thoracotomy in infants and children.

The effect of continuous intrapleural bupivacaine on pain relief after lateral thoracotomy was studied in nine infants (< or = 15 kg body weight) and 11 children (> 15 kg body weight). An intrapleural catheter was inserted under direct vision during surgery. After extubation, the patients were transferred to the ICU where vital signs and pain scores were monitored. An intrapleural infusion of bupivacaine 0.25% with adrenaline was given at a loading dose of 0.625 mg.kg-1 body weight followed by a continuous infusion with a starting rate of 1.25 mg.kg-1.h-1. Haemodynamic and respiratory parameters did not differ significantly from control values throughout the study period in either group. The mean infusion rate could be reduced stepwise in both groups to 0.75 +/- 0.32 mg.kg-1.h-1 and 0.73 +/- 0.38 mg.kg-1.h-1 respectively. The pain score indicated a rapid onset of analgesia in both groups and remained low during the study period. The degree of analgesia amongst other factors was position dependent. The lack of any recognizable side effects or complications related to this method has been most encouraging. Only one child required a supplementary dose of an opioid. We conclude that continuous intrapleural access has proved to be a safe and suitable route for pain relief in infants and children following thoracotomy.

Neonatal circumcision and pain relief: current training practices.

OBJECTIVE: We conducted a national survey of pediatric, family practice, and obstetrics and gynecology residency program directors to determine the curriculum content and predominant practices in US training programs with regard to neonatal circumcision and anesthesia/analgesia for the procedure. METHODS: Residency directors of accredited programs were surveyed in two mailings of a forced response and short answer survey (response rate: 680/914, 74%; pediatrics 83%; family practice 72%; obstetrics 71%). RESULTS: Pediatric residents were less likely than family practice [odds ratio (OR), 0.04; 95% confidence interval (CI), 0.02-0.08] or obstetrical (OR, 0.14; 95% CI, 0.08-0.23) residents to be taught circumcision. Training and local custom were rated as important determinants of medical responsibility for neonatal circumcision. Pediatric residents training in programs in which community pediatricians perform circumcisions were more likely to learn circumcision (OR, 39.0; 95% CI, 14.3-110.6) as were obstetric residents (OR, 79.0; 95% CI, 22.4-306.4) training in programs in which community obstetricians perform circumcision. In programs that teach circumcision, pediatric (84%; OR, 3.4; 95% CI, 1.7-7.1) and family practice (80%; OR, 2.7; 95% CI, 1.7-4.2) programs were more likely than obstetric programs (60%) to teach analgesia/anesthesia techniques to relieve procedural pain. Overall, 26% of programs that taught circumcision failed to provide instruction in anesthesia/analgesia for the procedure. Significant regional variations in training in circumcision and analgesia/anesthesia techniques were noted within and across medical specialties. CONCLUSIONS: Residency training standards are not consistent for pediatric, family practice, and obstetrical residents with regard to neonatal circumcision or instruction in analgesia/anesthesia for the procedure. Training with regard to pain relief is clearly inadequate for what remains a common surgical procedure in the United States. Given the overwhelming evidence that neonatal circumcision is painful and the existence of safe and effective anesthesia/analgesia methods, residency training in neonatal circumcision should include instruction in pain relief techniques.

Why do patients feel positive about patient-controlled analgesia?

We studied 200 patients to identify the aspects of their experience of patient-controlled analgesia (PCA) that made them feel 'extremely positive' about this technique. After PCA had been withdrawn, patients completed a questionnaire which included the following topics: pre-operative information, pain relief, the degree of control that PCA afforded the patient, side-effects and safety. Multiple regression analysis identified three factors of their experience which were associated uniquely with feeling 'extremely positive' about PCA: having better pain relief, not worrying about 'giving oneself too much drug' and not experiencing feeling 'peculiar in the head'. Control over pain relief, although highly correlated with feeling 'extremely positive' about PCA, was unimportant when these variables were controlled. Because of the well-recognised difficulties in measuring satisfaction with analgesic regimens, we suggest that a satisfaction score based on these variables would be a significant advance on existing methods.

The evaluation of the effectiveness of half-body irradiation as palliative treatment in patients with multiple bone metastases

The results of simplified method of hemibody irradiation of 23 patients with multiple painful bone metastases are presented. In all cases without proven bone metastases in skull and distal part of limbs, these parts of the body were excluded from irradiated field. The study comprised 25 cases of hemibody irradiation. The degree of pain relief and performance status improvement was assessed one and two months after treatment, depending on clinical and histopathological diagnosis and type of bone metastases. The best symptomatic results were obtained in the cases of multiple myelomas (100% of pain relief), prostate cancers (the average degree of 78%) and lung cancers (88%). Considering histopathological diagnosis, the best answer was found in multiple myeloma and squamous cell cancer (88%). Taking into account type of metastases the best result was obtained in the cases of osteolytic metastases (65%). No difference between upper and lower hemibody irradiation was found. The statistically significant correlation between pain relief, performance status improvement and decrease of analgetics use was found. The obtained results suggest that presented simplified form of hemibody irradiation is an effective symptomatic treatment modality in the cases with multiple painful bone metastases, giving an increase of life quality without significant radiation morbidity.

Family reports of cancer pain, pain relief, and prescription access.

PURPOSE: The authors 1) describe family caregiver reports of degree of pain, pain relief, and prescription access in persons with advanced cancer during the last 4 weeks of life and 2) test for differences according to geographic location and care setting. DESCRIPTION OF STUDY: A randomized, stratified sample of 375 caregivers was produced from a list of all state residents who died of cancer in 1994. Written informed consent was received from 170 family caregivers (46%) who were then interviewed by telephone. Caregiver responses regarding pain intensity, pain relief, prescription access, and care setting were analyzed. RESULTS: Eighty-six percent (n = 147) of caregivers reported that pain was a problem, and 61% (n = 103) recalled a great deal to quite a bit of pain compared with 25% (n = 44) who recalled some or little pain. The mean degree of pain was 2.23 (SD +/- 1.32) on a scale of 1 (a great deal) to 5 (no pain). Of 140 caregivers reporting pain relief data, 46% (n = 64) reported that interventions either stopped the pain or that pain became much better, whereas 54% (n = 76) reported that interventions made the pain a little better, had no effect, or made it worse. The overall mean of pain relief was 2.62 (SD +/-.87) on a scale of 1 (usually stopped the pain) to 5 (made it worse). Greater degrees of pain were associated with reports of less pain relief (r = -19; P =.02). No differences in pain or pain relief were found across county type or patient care setting. Caregivers in the institution-only group (n = 18) recalled lower degrees of pain and the home-only group (n = 61) reported the most pain relief. Many in this latter group were served by hospice and home health nurses, and only 4% of the entire sample were served by physicians alone. Notably, 12% (n = 21) of the sample reported problems filling prescriptions. Of these, half had difficulty obtaining medicine because it was "not available." A total of 48 problems with prescription access were found that were distributed evenly across county types and patient care settings. CLINICAL IMPLICATIONS: Findings suggest that caregiver reports about the degree of pain or the effectiveness of pain interventions do not vary by residence or care setting at the end of life. pain relief is moderate at best. Health professionals in all patient care settings should routinely address the issue of obtaining and paying for prescriptions, and local cancer pain task forces should be formed to advocate for better pain relief. An additional solution is to equip families with problem-solving skills specific to cancer pain.

Combined fluphenazine and lidocaine for pain relief in head and neck cancers.

A successful method of treating intractable neoplastic pain in 12 cases is discussed. A completely new method was tried combining long-acting phenothiazine and lidocaine to achieve long-lasting pain relief. This combination gave pain relief which lasted for weeks. A possible explanation of the mechanism is offered.