Outcome assessment following limited wrist fusion: objective wrist scoring versus patient satisfaction.

Eighteen nonrheumatoid patients were reviewed an average of 4.4 years following limited wrist fusion to evaluate whether patient satisfaction or objective wrist scoring more closely correlated with functional outcome. Range of motion, grip strength, pain relief, radiographs, and patient satisfaction were assessed by examination and interview, and each wrist was scored based on a clinical scoring system described by Cooney. Twelve patients (67%) were very satisfied with their results, and six (33%) were dissatisfied. Thirteen (72%) experienced good pain relief, 12 of whom denied functional restrictions. Six patients (33%) reported suboptimal wrist function, and four indicated they had inadequate pain relief. Despite high levels of satisfaction in 12 patients, the objective wrist scores were only fair and poor. These low wrist scores unreliably reflected functional outcome. Patient self-assessment of wrist performance, however, was uniformly predictive. pain relief was more critical to patient satisfaction than residual range of motion. Therefore, compared to objective wrist scoring, consideration of patient satisfaction may allow more accurate prediction and assessment of functional outcome following limited wrist fusion. Satisfactory postoperative function appears to be more dependent on pain relief than residual motion.

Bilateral thoracoscopic splanchnicectomy in patients with chronic pancreatitis.

BACKGROUND: Intractable pain, the most prominent feature of chronic pancreatitis, causes the patient great disability, and its treatment poses a difficult problem for gastroenterologist and surgeon alike. The main goal of treatment is to provide sufficient and lasting pain relief without the use of opiates. Conservative management, including stopping alcohol consumption, dietary measures, pancreatic enzyme suppletion and analgesics, is discussed. When these measures fail, surgery is often unavoidable. Indications, effect on pain relief, morbidity and mortality of drainage and resection procedures are described. Bilateral thoracoscopic splanchnicectomy, a newly developed operation to alleviate pain irrespective of the type of anatomic abnormality, is outlined in more detail. Early encouraging results of pain relief in patients with chronic pancreatitis after thoracoscopic splanchnicectomy are presented.

pain relief in Thailand.

Pain is a complex problem, for both those who are enduring it and those trying to relieve it. Most people in the developed world have access to adequate treatment and management of pain, the availability of trained and educated doctors and nurses, feasible opioid prescribing policies, as well as ready access to appropriate medication. Often, this is not the case in developing countries such as Thailand. This paper is based on recent experience in the southeast of Thailand providing pain relief for persons with HIV and AIDS in Rayong Province at the Camillian Social Centre. The severity and frequency of pain endured by this group of individuals presented a daily challenge. Problems encountered in providing pain relief for these patients and some potential solutions are described. There is a lack of literature on pain relief in Thailand.

Pain management in a rheumatology department: a satisfaction survey.

OBJECTIVES: To evaluate the quality of pain management in a teaching hospital rheumatology department. METHODS: We conducted a satisfaction survey among all the patients admitted to the conventional rheumatology department of our teaching hospital over a 1-month period (88 patients with a mean length of stay of 5 d). The patients were asked to complete a questionnaire on the day of discharge. The professional staff was not informed of the survey. RESULTS: The mean pain severity score at admission (visual analog scale, VAS) was 7.76 +/- 1.76 and the mean score decrease with treatment was 7.27 +/- 2.81. Expected pain relief and actual pain relief were correlated (R = 0.39; P = 0.001). Nearly all the patients (96.1%) reported have been encouraged to communicate about their pain. Information on the treatment was given to 89.3% of the patients; no significant differences in pain severity or pain relief were found between the patients who did and did not receive this information. The patients were satisfied with their management by the physicians (VAS: 8.83 +/- 2.07) and nurses (VAS: 8.68 +/- 1.72). CONCLUSION: Satisfaction with pain management (a subjective criterion) was good in our patients. However, no validated tools for measuring satisfaction are available, and measurements should be repeated to look for improvements over time. Limitations to these results include the placebo effect, the influence of memory, and the effects of the behavior of hospitalized patients. A repeat survey is needed.

Long-term pain relief produced by intrathecal morphine infusion in 53 patients.

The present report details the characteristics of the analgesic effects of morphine administered chronically by infusion pumps implanted in 53 patients suffering from terminal metastatic disease. The median postimplant survival time in these patients was 4 months. Patients (mean age 58 years) were characterized according to the duration of pain before pump implantation (mean 16 months), prior consumption of systemic opioids (mean one to six daily analgesic equivalents of morphine), and their response to a trial intrathecal dose of morphine (1 to 2 mg). The median infusion dose at 2 weeks was 3.8 mg/day. The analgesic index, calculated as (quality of pain relief x duration of pain relief in hours)/morphine dose in mg, that was observed after the trial dose of morphine was determined for each patient. A close correlation was observed between the acute (2-week) infusion dose necessary to produce pain relief and the analgesic index such that the infusion dose = -8.0 x log (analgesic index) + 17.1. By 16 weeks, the mean spinal morphine dose for the group had increased by a factor of about 2.5; however, significant variation in the dose incrementation was documented. The maximum increase was observed in patients with a low analgesic index, and this rapid incrementation was usually correlated with an unsatisfactory overall outcome. Evidence that long-term infusion continues to yield analgesia was evidenced in six cases where there was an unanticipated loss of drug infusion and a corresponding increase in parenteral narcotic consumption. These data indicate the long-term efficacy and safety of spinal opioid infusion in patients with terminal cancer, and emphasize the advantage of assessing the sensitivity of the patient to spinal opioids by a standardized trial injection prior to pump placement as a prognostic indication of outcome.

A clinical survey of controlled-release morphine sulphate for cancer pain relief in a Japanese hospice.

Seventy-six cancer patients were studied on the use of controlled-release morphine sulphate (MS Contin) for cancer pain relief in the hospice of Yodogama Christian Hospital in Japan. The mean initial and maximum dosages were 81.4 mg and 178.6 mg respectively. While 46 patients (61%) did not need an increase in the initial dosage, 26 patients (34%) needed an increase ranging between 8 and 125%. Four patients (5%) required an increment of more than 500% of the initial dosage, because of apparent nerve involvement. This clinical survey showed that the total effectiveness was 92% and that 90% of the patients could experience control of pain with a daily dosage of 240 mg or less of MS Contin. Side effects observed were as follows: drowsiness 21%, nausea 11%, vomiting 8%, constipation 8%, confusion 7%, hallucination 3%. In conclusion, MS Contin offers effective cancer pain relief with minimal side effects in the majority of patients.

Fear during labor.

BACKGROUND: The aims of the present study were to compare primiparous and multiparous women's experiences of fear of delivery during an early stage of active labor (cervix dilatation 3-5 centimeters) and to study whether fear of delivery, measured during the early stage of active labor, was a predictor of the amount of pain relief received during the remaining part of labor (cervix dilatation 5 cm - partus), of the duration of the remaining part of labor, and of the occurrence of instrumental vaginal delivery and emergency cesarean section. METHOD: Thirty-five primiparous and 39 multiparous women answered the Delivery Fear Scale (DFS) once during the early stage of labor and before they had received any pain relief. RESULTS: Primiparous women reported higher levels of fear than multiparous women did. Fear during the first phase of labor predicted only the total amount of pain relief received during labor. CONCLUSION: The clinical implications of the study are that the delivery staff should consider women's fear during labor and pay attention especially to primiparous women's increased risk of higher levels of fear during an early stage of active labor, as compared with multiparous women's. The challenge for staff of a delivery ward is to support the woman in labor in a way that decreases fear, which in turn might reduce the woman's need of pain relief.

Fetal oxygen saturation during epidural and paracervical analgesia.

BACKGROUND: We wanted to assess changes in fetal oxygenation during maternal epidural or paracervical analgesia in labor. METHODS: A prospective, open and non-randomized study. Twenty healthy parturients were enrolled before they asked for pain relief. Informed consent was obtained. Fetal and maternal oxygen saturations were measured before and up to 1 h after the initiation of analgesia. Fetal oximetry was performed with the Nellcor N-400 oximeter+FS-14B fetal oxygen sensor (Nellcor Puritan Bennett, Pleasanton, California, USA). Maternal oximetry was done with Datex Satlite portable monitor (Datex, Finland). Visual analog scale was used for assessing pain relief. Two-way analysis of variance and students t-test were used for statistical analyses. RESULTS: Fetal oxygenation initially improved in both groups. The saturation then returned to baseline in both groups. In the epidural group, the values remained at baseline or slightly below, while in the paracervical group the saturation remained a little higher than baseline (p=0.009). No change was seen in maternal oxygenation or heart rate. No change in fetal heart rate was found either. Epidural block was superior to paracervical block with respect to pain relief (p=0.002). CONCLUSIONS: There was a small but significant difference in fetal oxygenation between epidural and paracervical groups during the observation period. The magnitude of the difference is hardly clinically significant. A larger, randomized study is needed to elucidate the mechanisms behind this finding.

Patient attitudes regarding pca and associated costs.

PURPOSE: To determine patients' knowledge and attitudes towards patient-controlled analgesia (PCA) costs through the use of our acute pain service quality assurance (QA) programme. METHODS: Quality Assurance questionnaires were distributed to all patients receiving PCA opioids for > 12 hr. Patients were asked to note the presence of side effects (nausea/vomiting, pruritus, urinary retention), to indicate their satisfaction with regard to their pain relief, follow-up assessments, treatment of side effects, and to recall the previous method of pain relief and their satisfaction with it. Patients were also asked to estimate the total cost of PCA (0-$50, $50-100, $100-200, > $200), and what amount if any they would be willing to pay (0-$50, $50-100, $100-200, > $200). Results obtained over a recent four month period were reviewed. RESULTS: One hundred and thirty-three questionnaires were distributed and 103 (77%) were returned. The percentage of patients rating their satisfaction as very good or excellent was 86% for pain relief, 96% for follow-up, 71% for side effect treatment, but only 43% for their previous surgical pain relief (P < 0.001). The distribution of cost estimates was 10% $50-100, 37% $100-200 and 53% > $200 with 60% willing to pay a portion of this cost. Those willing to pay were more likely to have had very good or excellent pain relief (94% vs 71%, P < 0.05) and treatment of side effects (71% vs 48%, P < 0.05) than those not willing to pay. CONCLUSIONS: Patients continue to be highly satisfied with PCA therapy and are aware of the costs involved. A majority of patients were willing to pay to obtain this service if necessary. Patients who had poorer pain relief and less efficacious treatment of their side effects were less willing to pay.

Gamma Knife radiosurgery for treatment of trigeminal neuralgia: idiopathic and tumor related.

Sixty patients with trigeminal neuralgia who did not have a response to pharmacologic treatment (including 22 who had no response to conventional surgical treatment) underwent stereotactic radiosurgical treatment with the Leksell Gamma Knife. A radiosurgical maximum dose of 70 Gy was delivered to the trigeminal nerve root adjacent to the pons via a 4-mm collimator helmet in 51 patients who presented with trigeminal neuralgia unrelated to tumors. In these patients, the root was localized by stereotactic MRI. Follow-up assessment of pain relief was accomplished by a third party not involved in the patients' clinical care. Within a latency period of 1 day to 4 months following the treatment, 38 of 51 patients (74.5%) were completely free of pain and eventually all medications were tapered off. An additional seven patients (13.7%) experienced reductions in pain from 50 to 90% and utilized little or no medications. Patients who had no prior surgical intervention fared much better than those who had previous surgery to relieve their facial pains. At last follow-up, a mean of 16.3 months (range 6-36 months) after treatment, 41 patients (80.4%) remained pain-free or had marked pain reduction. There were four patients with recurrent pain. All 26 patients with classical symptoms of trigeminal neuralgia with no atypical features who had no prior surgery, had complete or nearly complete pain relief, and none of these patients had recurrent pain. Nine patients with trigeminal neuralgia due to tumors received standard radiosurgical treatment directed at their tumors, and eight of nine (88.8%) had pain relief. Of the total of 60 patients treated for trigeminal neuralgia, 49 (81.7%) experienced complete or nearly complete relief of pain at last follow-up. Only one patient with pre-existing facial sensory loss due to a tumor had a mild increase in facial numbness. No other patient experienced either loss of facial sensation or any other complication. Gamma Knife radiosurgery appears to be a minimally invasive, safe, and effective therapy of trigeminal neuralgia.