Pain Management

*Prepared by Kathy Kessel, Library Service \~ VAMC Northport, NY*

# 

## APRIL 2004

This bibliography on PAIN MANAGEMENT was prepared by Kathy Kessel,
Library Service, VAMC, Northport, NY as part of a VA Library Network
(VALNET) effort to identify useful published information relating to
trends in health care. This bibliography will be updated monthly. Please
check with your Library Service if you are interested in this resource
or would like to identify other materials specific to your information
needs. All bibliographies can be accessed from the VALNET web site at:
<http://vaww.vhacoweb1.cio.med.va.gov/VALNET/Bibliographies.asp>

Bibliographies prepared for this project are:

> **Chemical/Biological Terrorism**\
> Prepared by Halyna Korhun, Library Service, VAMC, Albany, NY
>
> **Customer Focused Health Care And Delivery**\
> Prepared by Sandra Brayson, Library Service, VAMC, Portland, OR
>
> **End Of Life Care**\
> Prepared by June Roullard, Library Service, VAMC, Togus, ME
>
> **Hepatitis C**\
> Prepared by Barry Powell, Library Service, VAMC, Memphis TN
>
> **High Performance Development Model (HPDM)**\
> Prepared by Joyce Zarrinnahad, Central Office Library, Washington, DC
>
> **Patient Education**\
> Prepared by Liz Burns, Library, VAMC, Kansas City, MO
>
> **Patient Safety\
> **Prepared by Farkhanda Sheikh, Library Service, VAMC, Perry Point, MD
>
> **Personal Digital Assistant (PDAs)\
> **Prepared by Caryl Kazen, VACO Library Service, Washington, DC
>
> **Post-Traumatic Stress Disorder\
> **Prepared by Caryl Kazen, VACO Library Service, Washington, DC
>
> **Severe Acute Respiratory Syndrome (SARS)**
>
> **Smallpox\
> **Prepared by June Roullard, Library Service, VAMC, Togus, ME
>
> **Veterans Health Care**\
> Prepared by Susan Harker, VAMC, Library Service, Miami, FL
>
> **Women\'s Health**\
> Prepared by Karen March, Library Service, VAMC, Fayetteville, NC

Aaron, S. D., et al. \"Topical tetracaine prior to arterial puncture: a
randomized, placebo-controlled clinical trial.\" *Respiratory Medicine.*
97, no. 11(2003): 1195-9 UI 14635973.

The objective of this randomized, double-blind, placebo-controlled
clinical trial was to determine whether a topical anesthetic agent
(tetracaine) provides effective local analgesia prior to radial arterial
puncture. Tetracaine or placebo gel was applied 45 min prior to arterial
puncture to patients who were referred for elective arterial blood gas.
The primary outcome was the patient\'s perception of pain associated
with the procedure as measured by a visual analog scale. Fifty patients
were randomized into the study, 24 received tetracaine and 26 placebo.
Mean pain score on the visual analog scale was 26.2 +/- 32.6 for the
tetracaine-treated patients and 23.8 +/- 27.4 for the placebo-treated
patients (P = 0.78). Mean time from the first skin puncture to
successful procurement of 1 ml of arterial blood was 70 +/- 103s in the
tetracaine group and 49 +/- 48s in the placebo group (P = 0.40).
Difficulty of arterial puncture as assessed by the respiratory therapist
performing the test was identical for the two groups (P = 0.86). We
conclude that tetracaine gel did not decrease patient\'s perception of
pain associated with arterial puncture, nor did its use facilitate the
ABG procedure.

Alford, J. W., R. Tashjian, and R. M. Terek. \"Pigmented villonodular
synovitis of the knee presenting as sciatica.\" *The Journal of Knee
Surgery.* 16, no. 3(2003): 182-4 UI 12943290.

Andersen, T., et al. \"Pain 5 years after instrumented and
non-instrumented posterolateral lumbar spinal fusion.\" *European Spine
Journal.* 12, no. 4(2003): 393-9 UI 12756629.

Pain drawings have been used in spine surgery for diagnostic use and
psychological evaluation of fusion candidates; they have rarely been
used to evaluate pain status after spinal fusion. This study is a 5-year
follow-up on a randomised clinical trial assigning patients to
posterolateral spinal fusion with or without pedicle screw
instrumentation. Patients were mailed a pain drawing and questionnaires
including questions regarding work, social status, smoking status, the
Dallas Pain Questionnaire (DPQ), and the Low Back Pain Rating Scale
(LBPRS). Pain drawings were scored using a visual inspection method and
a surface-based point scoring and evaluated for the presence of donor
site pain. Pain drawings from 109 patients (87% of the initially
included patients), 56 men and 53 women, mean age at follow-up 51 years,
were analysed. Fifty-three patients had undergone an instrumented fusion
and 56 a non-instrumented fusion. Some presence of low back pain was
marked by 79% and leg pain by 69%. Sixty-two percent of the pain
drawings were classified as \"organic\" and 38% as \"non-organic\".
There was no difference between the instrumented and the uninstrumented
group. DPQ and LBPRS scores were higher in the non-organic group (
P=0.007). Using the point scoring, no difference between the
instrumented and the uninstrumented group was seen. The results of the
point scoring were found to correlate with the DPQ and LBPRS scores (
P=0.001). Working patients (39%) had significantly better scores than
the rest. Ten percent of the patients had donor site pain. Twenty
percent of spinal fusion patients are totally pain free at 5-year
follow-up. Ten percent still experience donor site pain. In general,
instrumentation does not affect the amount and localisation of pain 5
years after lumbar spinal fusion surgery. The pain drawing seems to be a
valuable tool when following spinal fusion patients, but its use as
prognostic marker in connection with fusion surgery needs further
investigation.

Anonymous. \"Heart care methods put ED in top 5%, can help others.\" *Ed
Management.* 15, no. 11(2003): 126-7 UI 14655615.

Anonymous. \"Molecule of the month: ranolazine.\" *Drug News &
Perspectives.* 16, no. 6(2003): 391 UI 12973449.

Anonymous. \"Pain reliever gets buff.\" *Consumer Reports.* 68, no.
12(2003): 57 UI 14680012.

Arain, S. R., et al. \"The efficacy of dexmedetomidine versus morphine
for postoperative analgesia after major inpatient surgery.\" *Anesthesia
& Analgesia.* 98, no. 1(2004): 153-8, table of contents UI 14693611.

Thirty-four patients scheduled for elective inpatient surgery were
randomized equally to receive either dexmedetomidine (initial loading
dose of 1- microg/kg over 10 min followed by 0.4 microg. kg(-1). h(-1)
for 4 h) or morphine sulfate (0.08 mg/kg) 30 min before the end of
surgery. We determined heart rate (HR), mean arterial blood pressure
(MAP), respiratory rate (RR), sedation and analgesia (visual analog
scale), and use of additional morphine in the postanesthesia care unit
(PACU) and up to 24 h after surgery. Groups were similar for patient
demographics, ASA physical status, surgical procedure, baseline
hemodynamics, and intraoperative use of drugs and fluids.
Dexmedetomidine-treated patients had slower HR in the PACU (by an
average of 16 bpm), whereas MAP, RR, and level of sedation were similar
between groups. During Phase I recovery, dexmedetomidine-treated
patients required significantly less morphine to achieve equivalent
analgesia (PACU dexmedetomidine group, 4.5 +/- 6.8 mg; morphine group,
9.2 +/- 5.2 mg). Sixty minutes into recovery only 6 of 17
dexmedetomidine patients required morphine in contrast to 15 of 17 in
the morphine group. The administration of dexmedetomidine before the
completion of major inpatient surgical procedures significantly reduced,
by 66%, the early postoperative need for morphine and was associated
with a slower HR in the PACU. IMPLICATIONS: The use of dexmedetomidine
for postoperative analgesia resulted in significantly less additional
pain medication (morphine) and slower heart rates than a control group
receiving only morphine. These outcomes may prove advantageous for
patients who might be placed at higher risk by tachycardia or large
doses of morphine.

Axelsson, K., et al. \"Patient-controlled regional analgesia (PCRA) with
ropivacaine after arthroscopic subacromial decompression.\" *Acta
Anaesthesiologica Scandinavica.* 47, no. 8(2003): 993-1000 UI 12904192.

BACKGROUND: The aim of the study was to evaluate postoperative analgesia
and safety of wound instillation of ropivacaine either by a single dose
or a patient-controlled regional anaesthesia (PCRA) technique. METHODS:
In 40 patients undergoing arthroscopic subacromial decompression the
surgeon placed a catheter into the subacromial space at the end of the
operation. In Phase I (10 patients), ropivacaine 250 mg was injected
twice within 1 h. In Phase II, 30 patients were randomised into three
groups: group prilocaine-ropivacaine (PR) = 20 ml of 1%
prilocaine-epinephrine injected preoperatively into the subacromial
bursa + 20 ml of 0.5% ropivacaine infused in the catheter
postoperatively; group saline-ropivacaine (SR) = saline-epinephrine (20
ml) preoperatively + 0.5% ropivacaine as in group PR; group
saline-saline (SS) = saline-epinephrine (20 ml) preoperatively + saline
postoperatively. The PCRA pump was filled with local anaesthetic or
saline to allow boluses of 10-ml each, maximum one bolus/h, via the
catheter. Pain relief, side-effects and venous plasma concentration of
ropivacaine were evaluated during a 24-h-test period. RESULTS: The free
plasma concentration of ropivacaine was 0.12 + 0.041 mg l-1 in Phase I.
No adverse effects were seen. In Phase II pain at rest and on movement
was lower in group PR than in group SS during the first 30 min
postoperatively (P \< 0.05). Group PR had the lowest morphine
consumption (P \< 0.05). Five to seven boluses were administered via the
PCRA-pump, and 20 min after administration of the study solution, pain
was lower in groups PR and SR compared with group SS (P \< 0.001).
CONCLUSIONS: Preoperative intrabursal prilocaine with epinephrine +
postoperative subacromial administration of ropivacaine by
PCRA-technique provided the most effective analgesia with no major
side-effects. The free plasma concentrations of ropivacaine were far
below toxic concentrations.

Balazs, E. A. \"Analgesic effect of elastoviscous hyaluronan solutions
and the treatment of arthritic pain.\" *Cells Tissues Organs.* 174, no.
1-2(2003): 49-62 UI 12784041.

Elastoviscous hyaluronan solutions have an analgesic effect when
injected intra-articularly in animal and human joints. This was first
discovered using animal behavioral models and later confirmed in
neurophysiological studies in cat and rat joints. These studies on both
normal and experimentally produced arthritis in joints confirmed that
only elastoviscous solutions of hyaluronan or certain of its derivatives
(hylans) have a desensitizing effect on nociceptive sensory receptors.
Recently, this desensitizing effect of elastoviscous hyaluronan
solutions was also demonstrated on intact or on isolated patches of
oocyte cell membranes. Viscosupplementation, the exchange of
pathological synovial fluid in arthritic joints with pure elastoviscous
solutions of hyaluronan or hylans, is a widely accepted therapeutic
modality used to provide long-lasting analgesia in human knee joints.
The clinical studies performed on human and animal temporomandibular
joints since the mid-1970s are reviewed. These trials used three
distinctly different preparations made from hyaluronan of different
average molecular weight, polydispersity and, consequently, different
elastoviscous properties. These differences are demonstrated and the
consequences on the potential efficacy of the preparations are
discussed. Copyright 2003 S. Karger AG, Basel \[References: 60\]

Ballantyne, J. C. \"Does epidural analgesia improve surgical outcome?\"
*British Journal of Anaesthesia.* 92, no. 1(2004): 4-6 UI 14665544.

Benzer, W., S. Hofer, and N. B. Oldridge. \"Health-related quality of
life in patients with coronary artery disease after different treatments
for angina in routine clinical practice.\" *Herz.* 28, no. 5(2003):
421-8 UI 12928741.

BACKGROUND AND AIM: The assessment of health-related quality of life
(HRQL) increasingly is an important outcome in the management and care
of patients with angina. The aim of this study was to describe the
baseline HRQL in patients with coronary artery disease (CAD) and angina
and to report the impact of the three established therapeutic
strategies, continued medical treatment (CMT), percutaneous coronary
intervention (PCI) or coronary artery bypass grafting (CABG) on HRQLover
a 12-month follow-up period. PATIENTS AND METHODS: The change in
specific HRQL scores and angina severity was evaluated in a routine
clinical practice setting in 158 patients with CAD and angina treated
either with CMT, PCI, or CABG. The measure used in this study to assess
HRQL was the MacNew Heart Disease HROL Questionnaire (MacNew). It was
administered before coronary angiography and 12 months after treatment
stratification. Angina pectoris was assessed with the modified Canadian
Cardiovascular Society\'s classification. RESULTS: The MacNew
discriminated between treatment groups with lowest (poorest HROL)
baseline global, physical,and social HRQL scores seen in patients with
subsequent CABG. There were significantly greater improvements in global
and emotional HRQL scores after both PCI and CABG than after CMT. In all
three treatment groups, improved HRQLscores were associated with
improved angina grade. CONCLUSION: The present study has shown clearly
that evaluating HRQL as an outcome before and after different treatments
for angina is feasible and useful in routine clinical practice.
Measurement of HRQL discriminated between treatment groups at baseline
and was responsive demonstrating improvement with each treatment
alternative but most notably with CABG. The improved HROL was consistent
with changes in angina severity. The MacNew may be useful when comparing
outcomes across different treatments among patients with CAD and angina.

Bertolotto, M., et al. \"Resistive index in patients with renal colic:
differences after medical treatment with indomethacin and ketorolac.\"
*Radiologia Medica.* 106, no. 4(2003): 370-5 UI 14612828.

PURPOSE: To investigate whether colour Doppler US can demonstrate
haemodynamic differences in patients with renal colic after
pharmacological treatment with indomethacin and ketorolac. MATERIALS AND
METHODS: We studied 180 consecutive patients with unilateral acute renal
colic with colour Doppler US; 90 were treated with indomethacin, 90 with
ketorolac. Furthermore, 37 consecutive patients without obstruction (17
treated with indomethacin and 20 with ketorolac) were also examined and
considered normal controls. RESULTS: In the patients with renal colic
the average resistive index (RI) was significantly greater on the side
of the colic after administration of either indomethacin or ketorolac
(p\<0.001). The average RI in the obstructed kidneys was significantly
higher in the patients treated with ketorolac than with indomethacin
(p\<0.005). No statistically significant differences were shown between
the average RIs of the non obstructed kidneys of the patients with renal
colic and between the kidneys of the control patients treated with
either indomethacin or ketorolac. DISCUSSION AND CONCLUSIONS: Doppler
evaluation of patients with renal colic requires careful interpretation
after the administration of nonsteroidal anti-inflammatory drugs
(NSAIDs), since values of renal RI depend on the drug that has been used
to relieve symptoms.

Bewyer, D. C., and K. J. Bewyer. \"Rationale for treatment of hip
abductor pain syndrome.\" *Iowa Orthopaedic Journal.* 23(2003): 57-60 UI
14575251.

Patients with lower back or buttock pain that radiates into the
posterior or lateral leg are often referred to physical therapy with a
diagnosis of sciatica. Often the physical exam does not reveal
neurologic findings indicative of radiculopathy. Instead, there is hip
abductor muscle pain and weakness. This syndrome involves muscle
imbalances that result in overuse strain of the gluteus medius and
gluteus minimus muscles, myofascial trigger points, and trochanteric
bursitis. This paper describes hip abductor pain syndrome and provides a
rationale for the diagnosis and treatment. \[References: 23\]

Bhagat, K., and H. M. Chinyanga. \"Trends in cancer pain management.\"
*Central African Journal of Medicine.* 46, no. 2(2000): 46-54 UI
14674210.

BACKGROUND: Pain is a prevalent symptom in cancer patients, affecting up
to 50% of patients undergoing active cancer treatment and up to 90% of
those with advanced disease. Although adequate relief can be achieved in
the majority of cancer patients, pain is often treated inadequately in
traditional settings and sometimes even under the management of more
specialised units. In this review the authors use their experience and
that of others to review the evaluation and diagnosis of pain syndromes
and the principles of management. This is in keeping with increasing
recognition by bodies such as the World Health Organisation and other
governmental agencies who have recognised the importance of pain
management as part of routine cancer care. Conducting a comprehensive
assessment, competently providing analgesic drugs, and communicating
with the patient and family allow effective management of pain in the
cancer patient. \[References: 37\]

Bianconi, M., et al. \"The pharmacokinetics and efficacy of ropivacaine
continuous wound instillation after spine fusion surgery.\" *Anesthesia
& Analgesia.* 98, no. 1(2004): 166-72, table of contents UI 14693613.

Because local anesthetic continuous wound instillation has not been
evaluated after spine fusion surgery, we designed this study to
determine whether this technique could enhance analgesia and improve
patient outcome after posterior lumbar arthrodesis. Thirty-eight
patients undergoing spine stabilization were randomly divided into two
groups. The M group received a postoperative baseline IV infusion of
morphine plus ketorolac for 24 h, and the R group received IV saline. In
both groups, a multihole 16-gauge catheter was placed subcutaneously; in
the R group, the wound was infiltrated with a solution of ropivacaine
0.5% 200 mg/40 mL, and infusion of ropivacaine 0.2% 5 mL/h was
maintained for 55 h. In the M group, saline infusion was given at the
same rate. Pain scores were taken at rest and on passive mobilization by
nurses blinded to patient analgesic treatment. The total plasma
ropivacaine concentration was evaluated. Pain scores and rescue
medication requirements (diclofenac and tramadol) were significantly
less in the R group than in the M group. Postoperative blood loss was
less and the length of hospital stay was shorter in the R group. The
ropivacaine peak total plasma concentration occurred at 24 h during
infusion and was within safe limits; no toxic local anesthetic side
effects were observed. These results suggest that wound infiltration and
continuous instillation of ropivacaine 0.2% is effective for pain
management after spine stabilization surgery. IMPLICATIONS:
Postoperative pain after lumbar arthrodesis is related to soft tissue
and muscle dissection and to manipulations and removal at the operation
site. By blocking noxious stimuli from the surgical area, infiltration
and wound perfusion with ropivacaine were more effective in controlling
pain than systemic analgesia.

Bianconi, M., et al. \"Pharmacokinetics and efficacy of ropivacaine
continuous wound instillation after joint replacement surgery.\"
*British Journal of Anaesthesia.* 91, no. 6(2003): 830-5 UI 14633754.

BACKGROUND: As continuous wound instillation with local anaesthetic has
not been evaluated after hip/knee arthroplasties, our study was designed
to determine whether this technique could enhance analgesia and improve
patient outcome after joint replacement surgery. METHODS: Thirty-seven
patients undergoing elective hip/knee arthroplasties under spinal block
were randomly assigned to two analgesia groups. Group M received
continuous i.v. infusion of morphine plus ketorolac for 24 h. Then, a
multi-hole 16 G catheter was placed subcutaneously and infusion of
saline was maintained for 55 h. Group R received i.v. saline. Thereafter
the wound was infiltrated with a solution of ropivacaine 0.5% 40 ml,
then a multi-hole 16 G catheter was placed subcutaneously and an
infusion of ropivacaine 0.2% 5 ml h(-1) was maintained for 55 h. Visual
analogue scale scores were assessed at rest and on passive mobilization
by nurses blinded to analgesic treatment. Total plasma ropivacaine
concentration was measured. RESULTS: Group R showed a significant
reduction in postoperative pain at rest and on mobilization, while
rescue medication requirements were greater in Group M. Total
ropivacaine plasma concentration remained below toxic concentrations and
no adverse effects occurred. Length of hospital stay was shorter in
Group R. CONCLUSION: Infiltration and wound instillation with
ropivacaine 0.2% is more effective in controlling postoperative pain
than systemic analgesia after major joint replacement surgery.

Bilgin, M., Y. Akcali, and F. Oguzkaya. \"Extrapleural regional versus
systemic analgesia for relieving postthoracotomy pain: a clinical study
of bupivacaine compared with metamizol.\" *Journal of Thoracic &
Cardiovascular Surgery.* 126, no. 5(2003): 1580-3 UI 14666036.

BACKGROUND: The effects of a local anesthetic delivered through a
catheter inserted in the extrapleural region by a surgeon and an
analgesic agent given systemically on pain after thoracotomy were
assessed. METHODS: The patients in group I (n = 25) had a catheter
inserted between the parietal pleura and the endothoracic fascia by a
surgeon, and 0.5% bupivacaine was given through this catheter. Another
25 patients (group II) had metamizol given intravenously. Respiratory
function tests, arterial blood gases, range of shoulder motion, and
postoperative pain were evaluated for each group. Bupivacaine and
metamizol were given just before finishing the thoracotomy and then
repeated every 4 hours for 3 days. RESULTS: There was no statistical
difference in arterial blood gases between the groups (P \>.05). There
were statistically significant differences in the respiratory function
tests, range of shoulder motion, and visual analogue scale (P \<.05)
between the groups. Group I had fewer complications than group II. There
was no mortality in either group. CONCLUSIONS: Bupivacaine given through
a catheter to the extrapleural region before finishing thoracotomy is
substantially beneficial for the prevention of postoperative pain and
reduction of postoperative complications.

Boden, W. E. \"Practical approach to incorporating new studies and
guidelines for antiplatelet therapy in the management of patients with
non-ST-segment elevation acute coronary syndrome.\" *American Journal of
Cardiology.* 93, no. 1(2004): 69-72 UI 14697469.

Bolin, D. J. \"Transdermal approaches to pain in sports injury
management.\" *Current Sports Medicine Reports.* 2, no. 6(2003): 303-9
UI 14583158.

There is much lore about training room treatments for common overuse and
traumatic musculoskeletal injuries. This review looks at the evidence
behind many of the common transdermal treatments that are purported to
reduce pain and inflammation and improve function. These include
cryotherapy, laser treatments, electrical stimulation, ultrasound and
phonophoresis, extracorporeal shock wave therapy, and iontophoresis. In
addition, there are numerous over the counter sports creams and
prescribed topical treatments that are routinely used. With the pressure
to treat athletes safely and efficiently, sports practitioners must rely
on well-proven evidence to build the most effective treatment plans.
\[References: 52\]

Bouter, L. M., et al. \"Cochrane back review group.\" *Spine.* 28, no.
12(2003): 1215-8 UI 12811262.

Bruera, E., et al. \"Methadone versus morphine as a first-line strong
opioid for cancer pain: a randomized, double-blind study.\" *Journal of
Clinical Oncology.* 22, no. 1(2004): 185-92 UI 14701781.

PURPOSE: To compare the effectiveness and side effects of methadone and
morphine as first-line treatment with opioids for cancer pain. PATIENTS
AND METHODS: Patients in international palliative care clinics with pain
requiring initiation of strong opioids were randomly assigned to receive
methadone (7.5 mg orally every 12 hours and 5 mg every 4 hours as
needed) or morphine (15 mg sustained release every 12 hours and 5 mg
every 4 hours as needed). The study duration was 4 weeks. RESULTS: A
total of 103 patients were randomly assigned to treatment (49 in the
methadone group and 54 in the morphine group). The groups had similar
baseline scores for pain, sedation, nausea, confusion, and constipation.
Patients receiving methadone had more opioid-related drop-outs (11 of
49; 22%) than those receiving morphine (three of 54; 6%; P =.019). The
opioid escalation index at days 14 and 28 was similar between the two
groups. More than three fourths of patients in each group reported a 20%
or more reduction in pain intensity by day 8. The proportion of patients
with a 20% or more improvement in pain at 4 weeks in the methadone group
was 0.49 (95% CI, 0.34 to 0.64) and was similar in the morphine group
(0.56; 95% CI, 0.41 to 0.70). The rates of patient-reported global
benefit were nearly identical to the pain response rates and did not
differ between the treatment groups. CONCLUSION: Methadone did not
produce superior analgesic efficiency or overall tolerability at 4 weeks
compared with morphine as a first-line strong opioid for the treatment
of cancer pain.

Buggy, D. J., et al. \"Lack of analgesic efficacy of oral
delta-9-tetrahydrocannabinol in postoperative pain.\" *Pain.* 106, no.
1-2(2003): 169-72 UI 14581124.

We have evaluated the efficacy of delta-9-tetrahydrocannabinol
(delta-9-THC), the main psychoactive constituent of cannabis, in
postoperative pain. In a randomized double-blind, placebo-controlled,
single-dose trial, we investigated 40 women undergoing elective
abdominal hysterectomy. Randomization took place when postoperative
patient-controlled analgesia was discontinued on the second
postoperative day. When patients requested further analgesia, they
received a single, identical capsule of either oral delta-9-THC 5 mg
(n=20) or placebo (n=20) in a double-blind fashion. The primary outcome
measure was summed pain intensity difference (SPID) at 6 h after
administration of study medication derived from visual analogue pain
scores on movement and at rest. Secondary outcome measures were time to
rescue medication and adverse effects of study medication. Mean (SD) VAS
pain scores before medication in the placebo and delta-9-THC groups were
6.3(2.6) and 6.4(1.3)cm on movement, and 3.2(1.9) and 3.3(0.9) on rest,
respectively. There were no significant differences in mean (95%
confidence interval of the difference) SPID at 6 h between the groups
\[placebo 7.9, delta-9-THC 4.3(-1.8 to 9.0)cm h on movement; placebo
8.8, delta-9-THC 4.9(-0.2 to 8.1)cm h at rest\] and time to rescue
analgesia \[placebo 217, delta-9-THC 163(-22 to 130)min\]. Increased
awareness of surroundings was reported more frequently in patients
receiving delta-9-THC (40 vs 5%, P=0.04). There were no other
significant differences with respect to adverse events. This study
demonstrates no evidence of an analgesic effect of orally administered
delta-9-THC 5 mg in postoperative pain in humans.

Bullington, J., et al. \"Meaning out of chaos: a way to understand
chronic pain.\" *Scandinavian Journal of Caring Sciences.* 17, no.
4(2003): 325-31 UI 14629634.

Pain is a multidimensional phenomenon lying at the intersection between
biology and culture. The modern understanding of pain takes into account
emotional, psychological, socio-political and existential aspects of
pain as well as physiological, anatomical factors. Our aim in this study
was to deepen the understanding of psychosocial, existential aspects of
pain and to discuss how clinicians can better understand and treat
patients with chronic pain. A focus group was formed consisting of a
researcher and a group of clinicians (n = 3) with various backgrounds
working at a specialized pain clinic. The group met once a month during
a 6-month period. Questions concerning the life-world of the pain
patient as well as inquiries into the conditions for \'the good clinical
encounter\' were investigated. The results of this study consist of a
systematization of the data (focus group meetings) collected and
analysed in a collaborative effort between the researcher and group
participants. The findings are presented in terms of themes. The main
metaphor used to describe the path from the seeking of medical help to
successful rehabilitation was order out of chaos. Ordering chaos was a
process moving from diagnosis through a phase of heightened
self-awareness towards responsibility-taking on the part of the patient.
Related themes presented, illustrated and discussed in the paper concern
problems of linkage, the role of flexibility and creativity in the
healing process and the kind of clinical encounter conducive for the
journey from chaos to the creation of new meaning.

Butrick, C. W. \"Interstitial cystitis and chronic pelvic pain: new
insights in neuropathology, diagnosis, and treatment.\" *Clinical
Obstetrics & Gynecology.* 46, no. 4(2003): 811-23 UI 14595223.

Cascinu, S., et al. \"Pain and its treatment in hospitalized patients
with metastatic cancer.\" *Supportive Care in Cancer.* 11, no. 9(2003):
587-92 UI 12905055.

GOALS: The aim of this prospective study was to assess the quality of
pain management hospitalized cancer patients. PATIENTS AND METHODS: In a
quantitative and qualitative evaluation from six oncology centers in
Italy, all consecutive cancer patients complaining of pain and
hospitalized during the same 2 weeks were requested to fill in a McGill
pain questionnaire (MPQ), a present pain intensity scale (PPI), and a
hospital anxiety and depression acale (HADS), and to answer a
questionnaire focused (QF) on the quality of medical and nursing care.
The healthcare provider\'s antalgic prescriptions were assessed by an
index of pain management (IPM). MAIN RESULTS: Of 120 patients with pain
admitted to oncology divisions (65 men and 52 women; mean age 57 years,
range 21-79 years), 117 completed the questionnaires. The quantitative
evaluation (PPI) showed a significant pain reduction between admission
and discharge pain levels-from 2.65 to 1.50 ( p\<0.001). While a
significant reduction of anxiety (HADS) was also found-from 10.24 to
9.11 ( p\<0.001)-depression did not improve (9.83 and 9.72). The most
relevant information from qualitative evaluation (QF) was: in 37.6% of
patients, pain level was higher overnight; 47% waited for spontaneous
decrease of pain intensity before asking for nurse or physician
intervention; 69% asked for nurse help when pain level was really high.
The health care response to patients\' pain was not completely
satisfactory, since analgesic prescription was adequate in 56.52% but
inadequate in 43.47%. CONCLUSIONS: Pain control in hospitalized cancer
patients is not completely satisfactory. The physician\'s attitude is to
underestimate and undertreat pain, while nurses are not adequately
trained for timely intervention despite published guidelines for pain
management. The findings of this study support the concern of inadequate
knowledge and inappropriate attitudes regarding pain management, even in
cancer patients hospitalized in medical oncology divisions.

Chaitman, B. R., et al. \"Effects of ranolazine with atenolol,
amlodipine, or diltiazem on exercise tolerance and angina frequency in
patients with severe chronic angina: a randomized controlled trial.\[see
comment\].\" *Jama.* 291, no. 3(2004): 309-16 UI 14734593.

CONTEXT: Many patients with chronic angina experience anginal episodes
despite revascularization and antianginal medications. In a previous
trial, antianginal monotherapy with ranolazine, a drug believed to
partially inhibit fatty acid oxidation, increased treadmill exercise
performance; however, its long-term efficacy and safety have not been
studied in combination with beta-blockers or calcium antagonists in a
large patient population with severe chronic angina. OBJECTIVES: To
determine whether, at trough levels, ranolazine improves the total
exercise time of patients who have symptoms of chronic angina and who
experience angina and ischemia at low workloads despite taking standard
doses of atenolol, amlodipine, or diltiazem and to determine times to
angina onset and to electrocardiographic evidence of myocardial
ischemia, effect on angina attacks and nitroglycerin use, and effect on
long-term survival in an open-label observational study extension.
DESIGN, SETTING, AND PATIENTS: A randomized, 3-group parallel,
double-blind, placebo-controlled trial of 823 eligible adults with
symptomatic chronic angina who were randomly assigned to receive placebo
or 1 of 2 doses of ranolazine. Patients treated at the 118 participating
ambulatory outpatient settings in several countries were enrolled in the
Combination Assessment of Ranolazine In Stable Angina (CARISA) trial
from July 1999 to August 2001 and followed up through October 31, 2002.
INTERVENTION: Patients received twice-daily placebo or 750 mg or 1000 mg
of ranolazine. Treadmill exercise 12 hours (trough) and 4 hours (peak)
after dosing was assessed after 2, 6 (trough only), and 12 weeks of
treatment. MAIN OUTCOME MEASURES: Change in exercise duration, time to
onset of angina, time to onset of ischemia, nitroglycerin use, and
number of angina attacks. RESULTS: Trough exercise duration increased by
115.6 seconds from baseline in both ranolazine groups (pooled) vs 91.7
seconds in the placebo group (P =.01). The times to angina and to
electrocardiographic ischemia also increased in the ranolazine groups,
at peak more than at trough. The increases did not depend on changes in
blood pressure, heart rate, or background antianginal therapy and
persisted throughout 12 weeks. Ranolazine reduced angina attacks and
nitroglycerin use by about 1 per week vs placebo (P\<.02). Survival of
750 patients taking ranolazine during the CARISA trial or its associated
long-term open-label study was 98.4% in the first year and 95.9% in the
second year. CONCLUSION: Twice-daily doses of ranolazine increased
exercise capacity and provided additional antianginal relief to
symptomatic patients with severe chronic angina taking standard doses of
atenolol, amlodipine, or diltiazem, without evident adverse, long-term
survival consequences over 1 to 2 years of therapy.

Chandler, A., F. Kinnaird, and M. Wood. \"Developing and implementing a
pain management benchmark.\" *Nursing Times.* 99, no. 39(2003): 46-7 UI
14562663.

For most patients, pain is an inevitable part of the cancer journey.
Pain may be acute or chronic, it may be related to the disease process
or to treatments such as surgery, radiotherapy or chemotherapy. For
80-90 per cent of patients with cancer, effective pain relief could be
attained using the analgesic guidelines outlined by the World Health
Organization (1996). However, in routine practice this is not achieved
(Portenoy and Lesage, 1999), which highlights the need to review and
improve practice continuously.

Chung, J. W., and J. C. Lui. \"Postoperative pain management: study of
patients\' level of pain and satisfaction with health care providers\'
responsiveness to their reports of pain.\" *Nursing & Health Sciences.*
5, no. 1(2003): 13-21 UI 12603717.

The present prospective survey was conducted in a 1200-bed hospital to
examine postoperative patients\' current pain intensity, most intense
pain experienced, satisfaction with postoperative pain management, and
differences regarding pain and satisfaction levels. All adult patients
admitted to a hospital in Hong Kong for surgery, except those receiving
local anesthesia, were eligible to enter this study. The patient outcome
questionnaire developed by the American Pain Society was used to solicit
data about patients\' pain and satisfaction with pain relief. The
subjects were 294 postoperative patients. Approximately 85% complained
about varying degrees of pain during the 24 h prior to the assessment of
their pain. When interviewed, most patients complained of mild to
moderate pain (median = 2 on a 10-point scale), while the median for
\'worst pain intensity\' was 5. Approximately 80% of the subjects
indicated that both the nurses and physicians reminded them to report
pain when it occurred. Only 143 (48.6%) agreed that the nurses and
physicians sufficiently emphasized the importance of pain relief. Those
who received acute pain services, provided by anesthetists, reported
lower levels of current pain intensity. Over 65% of the subjects were
satisfied with all levels of health care providers, regarding their
postoperative pain management.

Cohen, M. R. \"Patient controlled analgesia. Pushing for safe pain
relief.\" *Nursing.* 33, no. 11(2003): 10 UI 14653251.

Conroy, B. P., et al. \"Interscalene block for elective shoulder
surgery.\" *Orthopedics.* 26, no. 5(2003): 501-3 UI 12755214.

This study assessed patient experiences with interscalene block
anesthesia for elective shoulder surgery. Routine use of interscalene
anesthesia was introduced at our institution in 1997. All patients who
underwent interscalene anesthesia during the first 3 years of our
experience with this regional anesthetic technique were asked to respond
to an anesthesia-related questionnaire. Overall patient satisfaction
with interscalene anesthesia was 87%, and success rate in achieving a
complete motor and sensory block was 79%. The duration of pain relief
postoperatively was 10.5 hours for patients with a successful block.
Patients consistently reported that having an interscalene block was
less painful than anticipated; 90% said they would have interscalene
anesthesia again for shoulder surgery. This study demonstrates that
interscalene anesthesia for elective shoulder surgery is safe and well
accepted in this patient population.

Cook, P., J. Stevens, and C. Gaudron. \"Comparing the effects of femoral
nerve block versus femoral and sciatic nerve block on pain and opiate
consumption after total knee arthroplasty.\" *Journal of Arthroplasty.*
18, no. 5(2003): 583-6 UI 12934209.

The goal of this study was to compare femoral and femoral plus sciatic
nerve blocks in the postoperative pain management of patients undergoing
total knee arthroplasty (TKA). A total of 97 patients participated in a
convenience sample, comparative study. Patients who received femoral
nerve block only (n = 30) reported statistically higher pain scores (P
\<.05) and showed 61% higher opiate consumption than those who received
femoral and sciatic nerve blocks (n = 67) in the first 24 hours after
surgery. The results suggest that the combined femoral and sciatic nerve
block provides superior pain management in the early postoperative
period after TKA.

Crane, R. A., P. C. Wilson, and G. Behrens. \"Pain control in hospice
home care: management guidelines.\" *American Journal of Hospice &
Palliative Care.* 7, no. 6(1990): 39-42 UI 14686472.

Cremeans-Smith, J. K., et al. \"Spouses\' and physicians\' perceptions
of pain severity in older women with osteoarthritis: dyadic agreement
and patients\' well-being.\" *Pain.* 106, no. 1-2(2003): 27-34 UI
14581107.

This study examined agreement between patients and two role partners
(spouses and physicians) on patients\' pain severity and the
relationships between dyadic agreement and patients\' well-being. We
hypothesized that compared to disagreement between patients and role
partners, dyadic agreement would be related to better psychological
well-being (more disease-specific self-efficacy and positive affect, and
less depression). Participants were 114 older women with osteoarthritis,
their caregiving husbands, and their rheumatologists. Among
patient-spouse dyads, agreement was associated with better well-being,
especially when compared to spouses\' underestimation of patients\'
pain. Contrary to predictions, patient-physician agreement was not
related to better patient well-being. Agreement between patients and
physicians was associated with less (rather than more) self-efficacy and
positive affect when compared to physicians\' underestimation of
patients\' pain.

Cunliffe, J. \"Reflections on pain management: a case study.\"
*International Journal of Palliative Nursing.* 9, no. 10(2003): 449-53
UI 14593283.

This article discusses issues relating to pain management at the end of
life. Through reflections on a case study of a single patient many
aspects of pain management are highlighted. These include difficulties
in assessing pain, the need to respect patient autonomy, out-of-hours
concerns and the possible role of integrated care pathways. The need to
be aware of the potential value of non-pharmaceutical approaches is also
discussed.

Dahl, J. L. \"The myths and realities of pain control with opioids.\"
*Wmj.* 102, no. 5(2003): 19 UI 14621926.

D\'Arcy, Y. \"Using tunneled epidural catheters to treat cancer pain.\"
*Nursing.* 33, no. 9(2003): 17 UI 14562821.

Dawkins, S. \"Patient-controlled analgesia after coronary artery bypass
grafting.\" *Nursing Times.* 99, no. 47(2003): 30-1 UI 14689672.

Patient-controlled analgesia is a method of pain control that allows the
patient to self-administer opioid medication as and when it is needed.
Pain is a personal experience and one pain-relieving intervention may
not be effective for all patients. This article reviews the literature
on patient-controlled analgesia, particularly with reference to patients
after coronary artery bypass grafting. Pain policies and education
programmes need to be proactive in addressing staff and patient gaps in
knowledge and misconceptions about pain assessment and management.
Nurses need to appreciate the nature and importance of research in
promoting a more critical approach to patient care and the development
of quality nursing practice. \[References: 19\]

Debreceni, G., et al. \"Continuous epidural or intercostal analgesia
following thoracotomy: a prospective randomized double-blind clinical
trial.\" *Acta Anaesthesiologica Scandinavica.* 47, no. 9(2003): 1091-5
UI 12969101.

BACKGROUND: Pain following thoracotomy is frequently associated with
clinically important abnormalities of pulmonary function. The aim of the
current study was to compare the efficacy of continuous thoracic
epidural analgesia (EDA) to continuous intercostal (IC) block for
postoperative pain and pulmonary function in a prospective, randomized,
double-blinded clinical trial. METHODS: Fifty patients undergoing lung
lobectomy for malignancies were randomized into two groups (25/group).
Respiratory function (forced vital capacity, forced expiratory volume
per 1 s/forced vital capacity, maximum midexpiratory flow rate, peak
expiratory flow rate) were evaluated preoperatively, within 4 h after
the operation and on the first postoperative day. Visual analog scale
(VAS: 0-10) scores were evaluated four-hourly for 20 h. RESULTS: The VAS
scores were significantly lower in the EDA versus IC group at the 4th,
8th, and 12th h of observation (mean +/- SD) 5.5 +/- 2.9 vs. 7.3 +/- 2.2
P = 0.04; 4.1 +/- 2.1 vs. 5.1 +/- 2.9 P = 0.02; 3.6 +/- 1.9 vs. 5.2 +/-
2.4 P = 0.01, respectively. Respiratory function parameters deteriorated
significantly in both groups (P \< 0.001) with no significant difference
between the groups. Only one major adverse effect was detected: one
patient suffered from rib osteomyelitis after intercostal cannulation
and healed following surgical repair. CONCLUSIONS: The results of the
present study show that following thoracotomy in the early postoperative
period continuous EDA is a better pain relieving method than continuous
IC block, as indicated by the VAS scores.

Dell, H. \"New compound fires up pain research.\" *Drug Discovery
Today.* 8, no. 23(2003): 1053 UI 14693457.

Dernedde, M., et al. \"Comparison of different concentrations of
levobupivacaine for post-operative epidural analgesia.\" *Acta
Anaesthesiologica Scandinavica.* 47, no. 7(2003): 884-90 UI 12859311.

BACKGROUND: The relative effects of the mass, volume and concentration
of local anaesthetic solution used for epidural anaesthesia and
analgesia are still under debate. Clinical studies have shown
discrepancies, probably because of limited consideration of total dose.
METHODS: This prospective, randomized and blinded study evaluated the
spread, the quality of post-operative analgesia and the incidence of
side-effects of continuous thoracic epidural levobupivacaine 15 mg/h in
three different concentrations: 1.5 mg/ml, 10 ml/h (n = 26), 5 mg/ml, 3
ml/h (n = 33) or 7.5 mg/ml, 2 ml/h (n = 31). The following variables
were registered within 48 h: sensory block, pain scores, rescue morphine
consumption, motor blockade, haemodynamics, sedation, nausea and
vomiting, and patient satisfaction. RESULTS: The three groups were
similar with regard to demographics, quality of analgesia, morphine
consumption, and satisfaction rate. The upper level of sensory block was
two segments higher in the 1.5 mg/ml group. Motor blockade in the lower
limbs was low in the three groups. Haemodynamic profile was more stable
in the higher concentration groups compared with the 1.5 mg/ml patient
group (P \< 0.001). Nausea was more frequent in the 1.5 mg/ml group (P =
0.02). CONCLUSION: The same dose of levobupivacaine provides an equal
quality of analgesia in low or high volume continuous thoracic epidural
infusion with reduced haemodynamic instability and nausea in the low
volume/high concentration groups.

Derrode, N., et al. \"Influence of peroperative opioid on postoperative
pain after major abdominal surgery: sufentanil TCI versus remifentanil
TCI. A randomized, controlled study.\" *British Journal of Anaesthesia.*
91, no. 6(2003): 842-9 UI 14633756.

BACKGROUND: Sufentanil and remifentanil are characterized by two
different pharmacokinetic profiles. The aim of this study was to compare
the effects of sufentanil and remifentanil administered using
target-controlled infusion (TCI) on recovery and postoperative analgesia
after major abdominal surgery. METHODS: Thirty adult patients scheduled
for open colorectal surgery were included in a prospective, randomized
study. Sufentanil TCI (sufentanil group) or remifentanil TCI
(remifentanil group) was administered during surgery. In the
remifentanil group, 30 min before the anticipated end of surgery,
morphine 0.15 mg x kg(-1) was administered i.v. In the sufentanil group,
an effect-site concentration of 0.25 ng x ml(-1) was targeted at
extubation. In both groups, postoperative pain was controlled by
titration of i.v. morphine and then patient-controlled analgesia with
morphine. RESULTS: The extubation time was similar in the two groups
(mean (SD) 13 (6) and 14 (6) min in the sufentanil and remifentanil
groups respectively). Visual analogue scale scores were significantly
greater during the first 2 h after tracheal extubation in the
remifentanil group than in the sufentanil group. The time to first
analgesic request in the postanaesthesia care unit was significantly
longer in the sufentanil group than in the remifentanil group (55 (64)
(range 2-240) vs 11 (7) (1-29) min; P\<0.001). The cumulative morphine
dose for titration was significantly greater in the remifentanil group
(P\<0.01). The cumulative morphine dose used during titration and
patient-controlled analgesia was significantly greater in the
remifentanil group 4, 12 and 24 h after extubation (P\<0.05).
CONCLUSION: TCI sufentanil (0.25 ng ml(-1) effect-site concentration at
extubation) is more effective than the intraoperative combination of
remifentanil TCI infusion with morphine bolus (0.15 mg x kg(-1)) for
postoperative pain relief after major abdominal surgery and does not
compromise extubation and recovery.

Diener, H. C. \"Important advances in headache.\" *Lancet. Neurology.*
3, no. 1(2004): 12 UI 14693101.

Dowling, R., et al. \"Improved pain control after cardiac surgery:
results of a randomized, double-blind, clinical trial.\[see \].\"
*Journal of Thoracic & Cardiovascular Surgery.* 126, no. 5(2003): 1271-8
UI 14665996.

OBJECTIVE: We sought to determine whether a continuous regional infusion
of a local anesthetic delivered to the operative site would result in
decreased levels of postoperative pain and narcotic requirements for
patients who undergo a standard median sternotomy for cardiac surgery.
METHODS: A double-blind, randomized, controlled trial was conducted at a
single center. Patients who were undergoing elective coronary artery
bypass graft surgery alone or combined with laser transmyocardial
revascularization received bilateral intercostal nerve blocks with
either ropivacaine or saline. At wound closure, 2 catheters with
multiple side openings were inserted percutaneously and placed directly
over the sternum. The same agent (ropivacaine vs saline) was then
administered as a continuous regional infusion for 48 hours through an
elastomeric pump. Requirements for postoperative systemic narcotic
analgesics and pain assessment scores were recorded for 72 hours after
the operation. Secondary outcome measures were hospital length of stay
and pulmonary function test results. Pain scores and narcotic use on the
second postoperative day were also compared to avoid the confounding
influence of anesthesia administered at the time of the operation.
RESULTS: The total amount of narcotic analgesia required by the
ropivacaine group was significantly less than that of the control group
(47.3 vs 78.7 mg, respectively; P =.038). The ropivacaine group required
less narcotics on postoperative day 2 as well (15.5 vs 29.4 mg, P
=.025). The mean overall pain scores for the ropivacaine group were
significantly less than the mean overall scores for the normal saline
group (1.6 vs 2.6, respectively; P =.005). Patients receiving
ropivacaine had a mean length of stay of 5.2 days compared with 8.2 days
for patients in the normal saline group (P =.001). Excluding the data
from outliers (length of stay = 39 days), the normal saline group mean
length of stay was 6.3 days (P \<.01). There was no difference in
assessment of pulmonary function. CONCLUSION: Continuous delivery of
local anesthetics significantly improved postoperative pain control
while decreasing the amount of narcotic analgesia required in patients
who underwent standard median sternotomy. There was also a significant
decrease in hospital length of stay, which is likely to result in
significant cost reductions.

Du Manoir, B., et al. \"Randomized prospective study of the analgesic
effect of nefopam after orthopaedic surgery.\" *British Journal of
Anaesthesia.* 91, no. 6(2003): 836-41 UI 14633755.

BACKGROUND: Balanced postoperative analgesia combines non-narcotic drugs
and opioids. We organized a large study to evaluate nefopam analgesia
and tolerance in combination with morphine for patient-controlled
analgesia (PCA) after orthopaedic surgery. METHODS: Two hundred and one
patients scheduled to undergo hip arthroplasty were included in this
multicentre (n=24), double-blind, randomized study comparing nefopam (20
mg every 4 h for 24 h) with placebo, the first dose being infused
peroperatively. The primary outcome measure was the cumulative morphine
dose received postoperatively by PCA over 24 h. Secondary outcome
measures were the amount of morphine received as a loading dose in the
postanaesthesia care unit (PACU) and during the 24-h observation period,
and pain assessments using a visual analogue scale (VAS) and a verbal
pain scale (VPS), patient\'s satisfaction with analgesia and treatment
tolerance. RESULTS: The two groups were comparable with respect to their
characteristics and preoperative pain assessment. PCA-administered
morphine over 24 h was significantly less for the nefopam group than the
control group (21.2 (15.3) and 27.3 (19.2) mg respectively; P=0.02).
This morphine-sparing effect was greater (35.1%) for patients with
severe preoperative pain (VAS\>30/100). For the entire study period
(loading dose and PCA), morphine use was less for the nefopam group
(34.5 (19.6) vs 42.7 (23.6) mg; P=0.01). Pain VAS at PACU arrival and
during the whole PACU period was significantly lower for the nefopam
than for the placebo group (P=0.002 and 0.04 respectively). Patient
satisfaction was similar for the nefopam and placebo groups. CONCLUSION:
In combination with PCA morphine, nefopam gives significant
morphine-sparing with lower immediate postoperative pain scores without
major side-effects. This analgesic effect seems to be particularly
notable for patients with intense preoperative pain.

Dworkin, R. H., et al. \"Pregabalin for the treatment of postherpetic
neuralgia: a randomized, placebo-controlled trial.\[see comment\].\"
*Neurology.* 60, no. 8(2003): 1274-83 UI 12707429.

OBJECTIVE: To evaluate the efficacy and safety of pregabalin in the
treatment of postherpetic neuralgia (PHN). METHODS: The authors
conducted a multicenter, parallel-group, double-blind,
placebo-controlled, 8-week, randomized clinical trial in PHN, defined as
pain for 3 or more months following herpes zoster rash healing. Patients
(n = 173) were randomized to treatment with pregabalin or placebo.
Patients randomized to pregabalin received either 600 mg/day (creatinine
clearance \> 60 mL/min) or 300 mg/day (creatinine clearance 30 to 60
mL/min). The primary efficacy measure was the mean of the last seven
daily pain ratings. Secondary endpoints included additional pain
ratings, sleep interference, quality of life, mood, and patient and
clinician ratings of global improvement. RESULTS: Pregabalin-treated
patients had greater decreases in pain than patients treated with
placebo (endpoint mean scores 3.60 vs 5.29, p = 0.0001). Pain was
significantly reduced in the pregabalin-treated patients after the first
full day of treatment and throughout the study, and significant
improvement on the McGill Pain Questionnaire total, sensory, and
affective pain scores was also found. The proportions of patients with
\>or=30% and \>or=50% decreases in mean pain scores were greater in the
pregabalin than in the placebo group (63% vs 25% and 50% vs 20%, p =
0.001). Sleep also improved in patients treated with pregabalin compared
to placebo (p = 0.0001). Both patients and clinicians were more likely
to report global improvement with pregabalin than placebo (p = 0.001).
Given the maximal dosage studied, pregabalin had acceptable tolerability
compared to placebo despite a greater incidence of side effects, which
were generally mild to moderate in intensity. CONCLUSIONS: Treatment of
PHN with pregabalin is safe, efficacious in relieving pain and sleep
interference, and associated with greater global improvement than
treatment with placebo.

Eefting, F., et al. \"Randomized comparison between stenting and
off-pump bypass surgery in patients referred for angioplasty.\"
*Circulation.* 108, no. 23(2003): 2870-6 UI 14656913.

BACKGROUND: Stenting improves cardiac outcome in comparison with balloon
angioplasty. Compared with conventional surgery, off-pump bypass surgery
on the beating heart without cardiopulmonary bypass may reduce
morbidity, hospital stay, and costs. The purpose, therefore, was to
compare cardiac outcome, quality of life, and cost-effectiveness 1 year
after stenting and after off-pump surgery. METHODS AND RESULTS: Patients
referred for angioplasty (n=280) were randomly assigned to stenting
(n=138) or off-pump bypass surgery. At 1 year, survival free from
stroke, myocardial infarction, and repeat revascularization was 85.5%
after stenting and 91.5% after off-pump surgery (relative risk, 0.93;
95% CI, 0.86 to 1.02). Freedom from angina was 78.3% after stenting and
87.0% after off-pump surgery (P=0.06). Quality-adjusted lifetime was
0.82 year after stenting and 0.79 year after off-pump surgery (P=0.09).
Hospital stay after the initial procedure was 1.43 and 5.77 days,
respectively (P\<0.01). Stenting reduced overall costs by 2933 dollars
(26.2%) per patient (8276 dollars versus 11 209 dollars; P\<0.01).
Stenting was more cost-effective in 95% of the bootstrap estimates.
CONCLUSIONS: At 1 year, stenting was more cost-effective than off-pump
surgery while maintaining comparable cardiac outcome and quality of
life. Stenting rather than off-pump surgery, therefore, can be
recommended as a first-choice revascularization strategy in selected
patients.

Ehrmann, E. H., H. H. Messer, and G. G. Adams. \"The relationship of
intracanal medicaments to postoperative pain in endodontics.\"
*International Endodontic Journal.* 36, no. 12(2003): 868-75 UI
14641427.

AIM: To investigate the relationship of postoperative pain to three
different medicaments placed in the root canal after a complete
biomechanical debridement of the root canal system in patients
presenting for emergency relief of pain. METHODOLOGY: Two hundred and
twenty-three teeth belonging to 221 patients presenting as emergencies
to the Royal Dental Hospital of Melbourne were included in the study.
Inclusion was limited to patients with a diagnosis of pulp necrosis and
acute apical periodontitis. All teeth underwent conventional root canal
treatment, which involved the instrumentation to the apices of each
canal at the first visit. Canals were instrumented using a stepback
technique and hand-files along with irrigants using Milton\'s (1% sodium
hypochlorite) solution followed by 15% EDTAC. The canals were dried and
one of the following three medicaments was inserted into the canal in
random sequence: Group 1: Ledermix paste (Lederle Pharmaceuticals,
Division of Cyanamid, Wolfratshausen, Germany); Group 2: calcium
hydroxide paste (Calcipulpe, Septodont, France); and Group 3: no
dressing. Before dismissal, the preoperative pain experienced on the
previous night was recorded using a visual analogue pain scale. Patients
were then instructed to record the degree of pain experienced 4 h after
treatment and daily for a further 4 days. RESULTS: The mean score pain
for all three groups was between 42 and 48 prior to treatment being
commenced. After 4 days, the pain score for Group 2 was 10, for Group 3
was 7 and for Group 1 was 4. Mean preoperative pain level was 44.4 (of a
maximum 100) for all groups, and declined by 50% (to 22.1) after 24 h.
Patients in Group 1 (Ledermix) experienced significantly less (P = 0.04)
postoperative pain than those in the other two groups. There was no
significant difference between Group 2 (calcium hydroxide) and Group 3
(no dressing). CONCLUSION: Under the conditions of this study, painful
teeth with acute apical periodontitis that had been dressed with
Ledermix paste gave rise to less pain than that experienced by patients
who had a dressing of calcium hydroxide or no dressing at all. Ledermix
is an effective intracanal medicament for the control of postoperative
pain associated with acute apical periodontitis, with a rapid onset of
pain reduction.

Enck, R. E. \"Complications in pain management.\" *American Journal of
Hospice & Palliative Care.* 7, no. 6(1990): 3-5 UI 14686463.

Fava, M. \"The role of the serotonergic and noradrenergic
neurotransmitter systems in the treatment of psychological and physical
symptoms of depression.\" *Journal of Clinical Psychiatry.* 64, no.
Suppl 13(2003): 26-9 UI 14552653.

Major depressive disorder is a medical condition that includes
abnormalities of affect and mood, cognition, and physical functioning.
In particular, as many as 76% of patients suffering from depression are
found to report somatic symptoms, including various types of pain such
as headaches, stomach pain, back pain, and vague, poorly localized pain.
Although the pathophysiology of depression is still unknown, there is
significant evidence for abnormalities of the norepinephrine (NE) and
serotonin (5-HT) neurotransmitter systems in depressive disorders.
Interestingly, both 5-HT and NE also appear to exert analgesic effects
via descending pain pathways and therefore play a modulating role in
pain. There are many effective antidepressant treatments available.
However, residual symptoms are relatively common, among both partial
responders and responders without remission. A recent study from our
group has shown that responders who have not achieved remission have
significantly more somatic symptoms than remitters following 8 weeks of
treatment with fluoxetine. These data may suggest that antidepressants
that are particularly effective in the treatment of pain and painful
physical symptoms may yield higher remission rates in major depressive
disorder. \[References: 34\]

Faymonville, M. E., et al. \"Increased cerebral functional connectivity
underlying the antinociceptive effects of hypnosis.\" *Cognitive Brain
Research.* 17, no. 2(2003): 255-62 UI 12880897.

The neural mechanisms underlying the antinociceptive effects of hypnosis
are not well understood. Using positron emission tomography (PET), we
recently showed that the activity in the anterior cingulate cortex
(midcingulate area 24a\') covaries with the hypnosis-induced reduction
of affective and sensory responses to noxious thermal stimulation
\[Faymonville et al., Anesthesiology 92 (2000) 1257-1267\]. In the
present study, we assessed changes in cerebral functional connectivity
related to the hypnotic state, compared to simple distraction and the
resting state. Nineteen highly hypnotizable right-handed volunteers were
studied using H2(15)O-PET. The experimental conditions were hot noxious
or warm non-noxious stimulation of the right hand during resting state,
mental imagery and hypnotic state. Using a psychophysiological
interaction analysis, we identified brain areas that would respond to
noxious stimulations under the modulatory action of the midcingulate
cortex in, and only in, the hypnotic state. Hypnosis, compared to the
resting state, reduced pain perception by 50%. Pain perception during
rest and mental imagery was not significantly different. Analysis of PET
data showed that the hypnotic state, compared to normal alertness (i.e.,
rest and mental imagery), significantly enhanced the functional
modulation between midcingulate cortex and a large neural network
encompassing bilateral insula, pregenual anterior cingulate cortex,
pre-supplementary motor area, right prefrontal cortex and striatum,
thalamus and brainstem. These findings point to a critical role for the
midcingulate cortex in the modulation of a large cortical and
subcortical network underlying its influence on sensory, affective,
cognitive and behavioral aspects of nociception, in the specific context
of hypnosis.

Ferreira de Albuquerque, R., Jr., et al. \"Temporomandibular disorder or
Eagle\'s syndrome? A clinical report.\" *Journal of Prosthetic
Dentistry.* 90, no. 4(2003): 317-20 UI 14564284.

This clinical report describes the diagnosis and treatment of a patient
under emotional stress with orofacial pain, headaches, and the feeling
of a foreign body in the throat. An elongated styloid process at the
beginning of the oral pharynx was diagnosed. Although these symptoms
could be aspects of Eagle\'s syndrome, deflective occlusal
interferences, tender muscles of mastication, and a clicking
temporomandibular joint led to an evaluation for temporomandibular
disorder related to malocclusion. An occlusal splint was used to confirm
the diagnosis and to alleviate symptoms. Occlusal adjustments were
subsequently performed. In a 10-year follow-up, the patient had no
complaints.

Fillingim, R. B. \"Hyperalgesia versus response bias in fibromyalgia.\"
*Pain.* 105, no. 3(2003): 385-6 UI 14527698.

Forster, J. G., et al. \"Epinephrine added to a lumbar epidural infusion
of a small-dose ropivacaine-fentanyl mixture after arterial bypass
surgery of the lower extremities.\" *Acta Anaesthesiologica
Scandinavica.* 47, no. 9(2003): 1106-13 UI 12969104.

BACKGROUND: The addition of epinephrine (2 micro g.ml-1) to a thoracic
epidural infusion of an opioid-local anesthetic mixture improves
analgesia. Here, we studied whether epinephrine could improve analgesia
also at lumbar level, when added to an epidural infusion of a low-dose
ropivacaine-fentanyl mixture after arterial bypass surgery of the legs.
METHODS: Patients in group RFE (n = 21) received a postoperative
epidural infusion containing ropivacaine (1 mg.ml-1), fentanyl (2 micro
g.ml-1), and epinephrine (2 micro g.ml-1). Patients in group RF (n = 25)
received a similar infusion without epinephrine. The infusion speed was
1 ml.10 kg-1. h-1. The infusion was scheduled for 48 h. RESULTS:
Epinephrine did not reduce the need for rescue pain medication. Visual
analog scale scores (VAS) for pain at rest were low and similar in the
groups. Pain intensity was stronger during leg movement \[mean VAS
1.5-2.6 (range 0-9)\], but it was not affected by the coadministration
of epinephrine. The groups did not differ concerning frequency and
severity of side-effects. Epinephrine did not reduce fentanyl plasma
concentrations. Ropivacaine concentrations were slightly lower in group
RFE only in the samples 6 h from the start of the infusion, but not
anymore on the first and second postoperative day. CONCLUSION: In the
dosage used here, epinephrine did not improve epidural lumbar analgesia.
Different distances from the epidural application site to the
alpha2-adrenergic receptors of the spinal cord, and differing
epinephrine dose requirements may explain why epinephrine as an additive
improves epidural analgesia at thoracic, but not at lumbar level.

Frerick, H., et al. \"Topical treatment of chronic low back pain with a
capsicum plaster.\" *Pain.* 106, no. 1-2(2003): 59-64 UI 14581111.

The efficacy and tolerance of a capsicum plaster in non-specific low
back pain was investigated in a double-blind, randomised,
placebo-controlled multicentre parallel group study. A total of 320
patients were randomly assigned to two groups of n=160 subjects treated
by the active or the placebo plaster. The main outcome measures used
were a compound pain subscore of the Arhus low back rating scale
(continuous variable), and a response criterion of a reduction in pain
subscore=30% from baseline to final assessment (secondary,
non-continuous variable). In addition, the partial pain scores,
disability and mobility restriction subscores, the total score of the
Arhus low back rating scale, the global evaluation of efficacy by
investigator and patient, adverse events, a patient questionnaire on use
of the plaster, and an evaluation of tolerance by investigator and
patient were obtained. After 3 weeks treatment with capsicum and placebo
plaster respectively, the compound pain subscore was reduced by 42%
(capsicum) and 31% (placebo) from values on entry. Responder rate was
67% versus 49% (p=0.002). The investigators rated efficacy as
\"excellent\" or \"good\" by 74% and 36%; the patient\'s efficacy rating
\"symptomfree\" or \"improved\" reached 82% and 50%. Adverse local drug
reactions were found in 12 patients (7.5%) on capsicum and 5 (3.1%) on
placebo. No systemic side-effects were observed. The superiority of the
treatment of chronic non-specific low back pain with capsicum plaster
compared to placebo was clinically relevant and highly statistically
significant. The capsicum plaster offers a genuine alternative in the
treatment of non-specific low back pain.

Garrido, I. P., et al. \"Comparison of ischemia-modified albumin levels
in patients undergoing percutaneous coronary intervention for unstable
angina pectoris with versus without coronary collaterals.\" *American
Journal of Cardiology.* 93, no. 1(2004): 88-90 UI 14697474.

This study compared ischemia-modified albumin levels, a marker of
ischemia in patients undergoing percutaneous coronary intervention.
Ischemia-modified albumin levels were significantly lower in patients
with collateral circulation compared with those without collateral
circulation.

Gerard, S., B. H. Smith, and J. A. Simpson. \"A randomized controlled
trial of spiritual healing in restricted neck movement.\[see
comment\].\" *Journal of Alternative & Complementary Medicine.* 9, no.
4(2003): 467-77 UI 14499022.

OBJECTIVE: To investigate the clinical effectiveness of visiting a
spiritual healer in restricted neck movement. DESIGN: Pragmatic
randomized controlled trial. SETTING/LOCATION: Spiritual-healing clinic
in Aberdeen, Scotland. SUBJECTS: Sixty-eight (68) volunteers over the
age of 18 years with restricted neck movement not currently receiving
spiritual healing. INTERVENTION: Three weekly sessions of spiritual
healing treatment lasting approximately 30 minutes each. Control group
received normal care (no spiritual healing). OUTCOME MEASURES: Range of
neck movement in three directions. Visual analog scales of pain and
overall well-being, Short Form 36 (SF-36) Health Survey general health
questionnaire, Hospital Anxiety and Depression Scale, and Chronic Pain
Grade were also measured. RESULTS: After treatment, the change from
baseline in rotation and flexion-extension was significantly greater in
the treatment group compared to the control group (mean standard
deviation \[SD\]: 26.3 degrees (21.0 degrees) versus 2.1 degrees (15.1
degrees), p \< 0.001 and 20.7 degrees (23.0 degrees) versus -0.03
degrees (15.2 degrees), p \< 0.001, respectively). Subjects from the
treatment group were also observed to have reduced their pain severity
scores after 3 weeks of treatment compared to those of the control group
(median change from baseline \[range\], -2.25 \[-8, 2\] versus 0 (-6,
4), p = 0.03). For SF-36, the treatment group had significantly improved
their scores more than the control group for physical function and
energy and vitality. There was a shift in the treatment group toward
milder chronic pain grades but this was not significant. There were no
significant differences between treatment and control groups in the
other outcome measures. CONCLUSION: This study tentatively supports the
effectiveness of visiting a spiritual healer in restricted neck
movement. However, larger studies over longer periods, with placebo
interventions, are required for corroboration and to gauge the scale of
treatment effect.

Gerlach, K., et al. \"Postoperative analgesia after preincisional
administration of remifentanil.\" *Minerva Anestesiologica.* 69, no.
6(2003): 563-9, 569-73 UI 14564253.

AIM: The aim of this study was to assess postoperative analgesia after
preincisional and postincisional administration of remifentanil.
METHODS: Randomized trial, 24 hours. Setting: University hospital,
hospitalized care. Patients: 48 adult patients scheduled for lumbar
vertebral surgery. Interventions: in group R5, patients received an
infusion of 0.2 microg kg(-1) min(-1) remifentanil over 5 minutes,
followed by a break of 15 minutes before anesthesia was started.
Anesthesia was induced by infusion of 0.25 microg kg(-1) min(-1)
remifentanil and a bolus of 1.5 microg kg(-1) propofol, followed by a
continuous infusion of 2 to 3 microg kg(-1) h-1 propofol and 0.25 microg
kg(-1) min(-1) remifentanil until end of anesthesia. In group R20,
patients received 0.05 microg kg(-1) min(-1) remifentanil over 20
minutes before the induction of anesthesia. In group RL, anesthesia was
induced and maintained with propofol. After surgery began, a
remifentanil infusion of 0.5 microg kg(-1) min(-1) was given for 50
minutes, then reduced to 0.25 microg kg(-1) min(-1). The total
remifentanil doses were similar in the 3 groups. Measures: patients used
patient-controlled analgesia (piritramide) for postoperative pain
management. They recorded pain on a numeric rating scale every half
hour. Statistics: Kruskal-Wallis test, pairwise Mann-Withney U-test,
orthogonal polynomials (pain scores). RESULTS: Patients given
postincisional remifentanil (RL) had the slowest decrease in
postoperative pain scores (p\<0.01) and the highest cumulative
piritramide consumption (p\<0.08). CONCLUSION: The preincisional
administration of remifentanil followed by a continuous infusion of 0.25
microg kg(-1) min(-1) appears to reduce pain scores and piritramid
consumption when compared with a postincisional regimen.

Gibler, W. B., A. L. Blomkalns, and S. P. Collins. \"Evaluation of chest
pain and heart failure in the emergency department: impact of
multimarker strategies and B-type natriuretic peptide.\" *Reviews in
Cardiovascular Medicine.* 4, no. Suppl 4(2003): S47-55 UI 14564228.

In the emergency setting, acute chest pain and shortness of breath
represent common patient presentations. Cardiac biomarkers including
myoglobin, creatine kinase (CK)-MB, troponin, and b-type natriuretic
peptide provide diagnostic and prognostic information for patients with
chest pain and shortness of breath. This article reviews the use of
cardiac biomarkers in the emergency department to evaluate acute
coronary syndrome and congestive heart failure. \[References: 46\]

Gimbel, J. S., P. Richards, and R. K. Portenoy. \"Controlled-release
oxycodone for pain in diabetic neuropathy: a randomized controlled
trial.\[see comment\].\" *Neurology.* 60, no. 6(2003): 927-34 UI
12654955.

BACKGROUND AND OBJECTIVE: Opioid treatment has played a limited role in
the management of diabetic neuropathy, in part because of concerns about
the responsiveness of neuropathic pain to opioid treatment. This
controlled study evaluated the efficacy and safety of controlled-release
(CR) oxycodone in subjects with moderate to severe pain due to diabetic
neuropathy. METHODS: This multicenter, randomized, double-blind,
placebo-controlled, parallel-group study included 159 subjects with
moderate to severe pain due to diabetic neuropathy. Treatment began with
either one 10-mg tablet of CR oxycodone (n = 82) or identical placebo (n
= 77) every 12 hours. Doses could be increased every 3 days to a maximum
of 6 tablets (60 mg CR oxycodone) every 12 hours. Treatment lasted up to
6 weeks. The primary efficacy variable was overall average daily pain
intensity during study days 28 to 42. RESULTS: At an average (SD) dose
of 37 (21) mg per day (range 10 to 99 mg/d), CR oxycodone provided more
analgesia than placebo (p= 0.002) in the intent-to-treat cohort. From
days 28 to 42, overall average daily pain intensity (least squares mean
+/-SE), rated in subject diaries on a numeric scale of 0 (no pain) to 10
(pain as bad as you can imagine), was 4.1 +/- 0.3 in subjects given CR
oxycodone and 5.3 +/- 0.3 in placebo-treated subjects. Overall, 80 (96%)
of 82 subjects given CR oxycodone and 52 (68%) of 77 subjects who
received placebo reported adverse events. The most common adverse events
in the CR oxycodone group were opioid related. CONCLUSIONS: In this
6-week trial, CR oxycodone was effective for the treatment of moderate
to severe pain due to diabetic neuropathy. Adverse events were typical
of opioid-related side effects.

Goodman, D., P. B. Hiniker, and J. M. Paley. \"How to improve home care
pain management processes.\" *Home Healthcare Nurse.* 21, no. 5(2003):
325-34 UI 12792414.

This article describes the process and tools one agency used when their
ORYX indicator, \"managing a patient\'s pain,\" was consistently below
the national benchmark. The process can be used for addressing Adverse
Events through the OBQI Process as well.

Goodman, M. B. \"Sensation is painless.\" *Trends in Neurosciences.* 26,
no. 12(2003): 643-5 UI 14624845.

Emily Dickinson declared: \'After great pain, a formal feeling comes\'.
This formal feeling begins when sensory neurons are activated by noxious
stimuli, such as stepping on a tack. Recently, Seymour Benzer\'s group
identified sensory neurons in Drosophila larvae that mediate aversive
responses to noxious heat and mechanical stimuli. Thresholds for
behavioral and nerve responses are elevated by mutations in the painless
gene, which encodes a TRP ion channel protein. Painless thus joins an
elite group of TRPs implicated in sensory transduction in insects,
nematodes, mammals and fish. \[References: 19\]

Goolsby, M. J. \"Diagnosis and treatment of heel pain.\" *Journal of the
American Academy of Nurse Practitioners.* 15, no. 11(2003): 485-6 UI
14685984.

The American College of Foot and Ankle Surgeons (ACFAC) clinical
practice guideline (CPG) summarizes the literature on the assessment and
diagnosis of heel pain. The framework classifies heel pain depending on
whether the cause is mechanical, neurological, arthritic, traumatic, or
from another origin. Treatment strategies are included for the most
common form of heel pain that are caused by mechanical problems.

Graven-Nielsen, T., and L. Arendt-Nielsen. \"Induction and assessment of
muscle pain, referred pain, and muscular hyperalgesia.\" *Current Pain &
Headache Reports.* 7, no. 6(2003): 443-51 UI 14604503.

Muscle pain can be induced and assessed experimentally by a variety of
methods. Ischemic and exercise-induced muscle pain are typical
endogenous pain models; external stimulation with mechanical,
electrical, and chemical modalities constitute the exogenous models.
These models are a good basis to study the muscle sensitivity, muscle
pain responses under normal and pathophysiologic conditions, and drug
efficacy on specific muscle pain mechanisms. When evaluating muscle pain
in clinical or experimental settings, it is important to assess
parameters related to the pain intensity, pain quality, referred and
local distribution, and the deep tissue sensitivity in local and
referred areas. The experimental test paradigm must include different
stimulation modalities (multimodal) to obtain sufficiently advanced and
differentiated information about the human nociceptive system under
normal and pathophysiologic conditions because the different stimuli
activate different receptors, pathways, and mechanisms. This may be a
useful approach in future mechanism-based classification and treatment
of muscle pain. Similarly, the multimodal approach is important in
clinical studies to provide evidence for which specific muscle pain
modalities and mechanisms are affected and how they are modulated by
pharmacologic approaches. \[References: 72\]

Griner, P. \"Pain and symptom control in patients with advanced
cancer.\" *American Journal of Hospice & Palliative Care.* 7, no.
6(1990): 8-9 UI 14686465.

Groves, K. E. \"An introduction to the Micrel Micropump MP Daily
portable syringe driver.\" *International Journal of Palliative
Nursing.* 9, no. 11(2003): 468-73 UI 14676723.

In this article the author describes the Micrel Micropump MP Daily (MP
Daily) portable syringe driver. This follows the author\'s experience of
a 4-month pilot of the device by an inpatient palliative care unit.
Portable syringe drivers are commonly used to deliver continuous
subcutaneous infusions in palliative care situations. Those in current
use are not without problems and serious adverse events have
occasionally been reported, mainly resulting from confusion between
models. The MP Daily syringe driver addresses some of these issues while
remaining small, lightweight and inexpensive, with a long battery life
and fitting into the pocket of a shirt of pyjama jacket. Improvements
over current models include an on/off button, the absence of facilities
to set a zero rate or change the rate once the syringe driver is
running, and the absence of a boost button. In addition, there are
improved alarms, a message display system and a configuration menu.
Although confusion remains a problem, and the ideal has not yet been
reached, the MP Daily goes some considerable way towards reducing risks
and opportunities for human error. \[References: 21\]

Gunter, J. \"Chronic pelvic pain: an integrated approach to diagnosis
and treatment.\" *Obstetrical & Gynecological Survey.* 58, no. 9(2003):
615-23 UI 12972837.

Chronic pelvic pain affects upward of 15% of women and is a frustrating
condition for both patients and physicians. Chronic pelvic pain is not a
disease, but a syndrome that results from a complex interaction between
neurologic, musculoskeletal, and endocrine systems that is further
influenced by behavioral and psychologic factors. Traditional approaches
to this disorder have been surgical, although long-term success rates
have been disappointing. Placebo response to surgery is common, and many
conditions that contribute to the pain cannot be identified or treated
with a surgical approach. Many patients will require a combination of
both pharmacologic and nonpharmacologic treatments in addition to
various types of invasive procedures. It is now recognized that many
disorders contribute to the chronic pelvic pain symptom complex; thus,
an integrated multidisciplinary approach to diagnosis and treatment is
essential to achieve the greatest success. TARGET AUDIENCE:
Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES:
After completion of this article, the reader will be able to describe
the pathophysiology of chronic pelvic pain, to outline the evaluation of
a patient with chronic pelvic pain, and to explain the treatment options
for patients with chronic pelvic pain. \[References: 87\]

Hall, F. \"Use of exercise in the management of non-malignant chronic
pain.\" *Professional Nurse.* 18, no. 7(2003): 412-4 UI 12674052.

Many studies have shown that, when incorporated into a chronic pain
management programme, exercise can be very beneficial for people with
chronic non-malignant pain. The pain programme will use cognitive
behavioural strategies with the aims of improving fitness, counteracting
unhelpful beliefs and improving stress levels.

Halperin, R., et al. \"Long-term follow-up (5-20 years) after uterine
ventrosuspension for chronic pelvic pain and deep dyspareunia.\"
*Gynecologic & Obstetric Investigation.* 55, no. 4(2003): 216-9 UI
12904695.

OBJECTIVE: To examine the long-term outcome of patients undergoing
uterine ventrosuspension for chronic pelvic pain and deep dyspareunia.
METHODS: Eighty-two patients, presenting with retroverted uterus, pelvic
pain and deep dyspareunia, underwent uterine ventrosuspension by
laparotomy or laparoscopy during the period from 1981 to 1996. Only
patients (56) with no pelvic pathologic condition, as identified
intraoperatively, participated in the study. At the beginning of the
year 2002, 41 out of 56 patients (73.2%) were attained by telephonic
questionnaire, and they were asked to refer to the uterine
ventrosuspension procedure. RESULTS: Patients\' average age was 32.3
years, and the mean duration of preoperative symptoms was 3 years. The
mean follow-up period was 12 (range 5-20) years. The initial improvement
in preoperative symptoms was observed in 70.7% of patients, whereas the
final improvement was observed in 46.3% of patients, with no significant
difference comparing the approach of laparotomy versus laparoscopy.
Hysterectomy after uterine suspension was performed in 12.1% of patients
(4.3% after laparotomy and 22.2% after laparoscopy). Twenty-three
patients (56.1%) would recommend this operative procedure to others.
CONCLUSION: The long-term outcome of patients undergoing uterine
ventrosuspesnion approximates to 50% success rate, with no significant
difference comparing the approach of laparotomy versus laparoscopy.
Copyright 2003 S. Karger AG, Basel

Henriksson, K. G. \"Hypersensitivity in muscle pain syndromes.\"
*Current Pain & Headache Reports.* 7, no. 6(2003): 426-32 UI 14604501.

The aim of this review is to present research that has a bearing on the
pathogenesis of hypersensitivity in muscle pain syndromes. Allodynia and
hyperalgesia in these syndromes can be segmental or generalized and
temporary or permanent. Hypersensitivity in muscle pain conditions in
the clinic is best diagnosed by determining the pressure pain threshold.
In a disorder such as fibromyalgia, decreased pain thresholds also are
found at sites where there is no tenderness. Pathogenetic mechanisms for
allodynia and hyperalgesia can be identified at several levels of the
nociceptive system, from the nociceptors in the muscle to the cortex.
Central sensitization of nociceptive neurons in the dorsal horn and a
disturbed balance between inhibitory and facilitatory impulses in the
descending tracts from the brain stem to the dorsal horn are the main
mechanisms for pain hypersensitivity. Changes in function, biochemical
make-up, and synaptic connections in the nociceptive neurons in the
dorsal horn are considered to be caused by neuronal plasticity.
\[References: 59\]

Hermsen, M. A., and H. A. ten Have. \"Moral problems in palliative care
practice: a qualitative study.\" *Medicine, Health Care & Philosophy.*
6, no. 3(2003): 263-72 UI 14620463.

Clarifying and analysing moral problems arising in the practice of
palliative care was the objective of participatory observations in five
palliative care settings. The results of these observations will be
described in this contribution. The moral problems palliative caregivers
have to deal with in their daily routines will be explained by
comparison with the findings of a previously performed literature study.
The specific differences in the manifestation of moral problems in the
different palliative care settings will be highlighted as well.
\[References: 25\]

Howard, F. M. \"The role of laparoscopy in the chronic pelvic pain
patient.\" *Clinical Obstetrics & Gynecology.* 46, no. 4(2003): 749-66
UI 14595216.

Hugel, H., J. E. Ellershaw, and A. Dickman. \"Clonazepam as an adjuvant
analgesic in patients with cancer-related neuropathic pain.\" *Journal
of Pain & Symptom Management.* 26, no. 6(2003): 1073-4 UI 14654258.

Hutchings, C. B., et al. \"Patients with chest pain calling 9-1-1 or
self-transporting to reach definitive care: which mode is quicker?\"
*American Heart Journal.* 147, no. 1(2004): 35-41 UI 14691416.

OBJECTIVE: We examined differences in transport times for patients with
chest pain who used private transportation compared with patients who
used emergency medical services (EMS) to reach definitive medical care.
METHODS: This was a retrospective cohort study with data used from the
Rapid Early Action for Coronary Treatment (REACT) trial conducted in 20
US cities. Elapsed time to care was examined through the use of (1)
decision to seek care to initial care (emergency department \[ED\]
arrival versus EMS arrival on scene \[n=1209\]); (2) decision to ED
arrival (for both groups \[n=2388\]); (3) time to thrombolytic therapy
once admitted to the ED (for both groups \[n=309\]); and (4) decision to
seek care to thrombolytic therapy (n=276). Elapsed travel times were
ranked within Zip Codes and submitted to a nested analysis of variance
model to determine if elapsed times were different between modes of
transport. RESULTS: Private transportation (35 minutes) resulted in
faster ED arrival than using EMS (39 minutes, P =.0014). However, if one
considers EMS treatment to be initial care, calling 9-1-1 (6 minutes)
resulted in much quicker care than patients using private transportation
to the ED (32 minutes, P \<.001). Transport by EMS resulted in a shorter
elapsed time to thrombolytic administration compared with patients using
private transportation when considering ED \"door-to-needle\" time (32
vs 49 minutes, respectively \[P \<.001\]) or time from decision to seek
care until administration of thrombolytic therapy (75 vs 92 minutes,
respectively, \[P =.042\]). CONCLUSIONS: Although private transportation
results in a faster trip to the ED, quicker care is obtained with the
use of EMS.

Iizuka, T., et al. \"Response to sumatriptan in headache of MELAS
syndrome.\" *Neurology.* 61, no. 4(2003): 577-8 UI 12939448.

Janicki, T. I. \"Chronic pelvic pain as a form of complex regional pain
syndrome.\" *Clinical Obstetrics & Gynecology.* 46, no. 4(2003): 797-803
UI 14595221.

Jasmin, L., et al. \"Is noradrenaline a significant factor in the
analgesic effect of antidepressants?\" *Pain.* 106, no. 1-2(2003): 3-8
UI 14581104.

Jensen, J., et al. \"Direct activation of the ventral striatum in
anticipation of aversive stimuli.\" *Neuron.* 40, no. 6(2003): 1251-7 UI
14687557.

The brain \"reward\" system, centered on the limbic ventral striatum,
plays a critical role in the response to pleasure and pain. The ventral
striatum is activated in animal and human studies during anticipation of
appetitive/pleasurable events, but its role in aversive/painful events
is less clear. Here we present data from three human fMRI studies based
on aversive conditioning using unpleasant cutaneous electrical
stimulation and show that the ventral striatum is reliably activated.
This activation is observed during anticipation and is not a consequence
of relief after the aversive event. Further, the ventral striatum is
activated in anticipation regardless of whether there is an opportunity
to avoid the aversive stimulus or not. Our data suggest that the ventral
striatum, a crucial element of the brain \"reward\" system, is directly
activated in anticipation of aversive stimuli.

Jensen, M. P., W. R. Nielson, and R. D. Kerns. \"Toward the development
of a motivational model of pain self-management.\" *Journal of Pain.* 4,
no. 9(2003): 477-92 UI 14636816.

Adaptive management of chronic pain depends to a large degree on how
patients choose to cope with pain and its impact. Consequently, patient
motivation is an important factor in determining how well patients learn
to manage pain. However, the role of patient motivation in altering
coping behavior and maintaining those changes is seldom discussed, and
theoretically based research on motivation for pain treatment is
lacking. This article reviews theories that have a direct application to
understanding motivational issues in pain coping and presents a
preliminary motivational model of pain self-management. The implications
of this model for enhancing engagement in and adherence to chronic pain
treatment programs are then discussed. The article ends with a call for
research to better understand motivation as it applies to chronic pain
self-management. In particular, there is a need to determine whether
(and which) motivation enhancement interventions increase active
participation in self-management treatment programs for chronic pain.
\[References: 100\]

Jovey, R. D., et al. \"Use of opioid analgesics for the treatment of
chronic noncancer pain\--a consensus statement and guidelines from the
Canadian Pain Society, 2002.\" *Pain Research & Management.* 8, no.
Suppl A(2003): 3A-28A UI 14685304.

Jung, J., et al. \"Defibrillation efficacy and pain perception of two
biphasic waveforms for internal cardioversion of atrial fibrillation.\"
*Journal of Cardiovascular Electrophysiology.* 14, no. 8(2003): 837-40
UI 12890046.

Efficacy and Pain Perception of Two Biphasic Waveforms. INTRODUCTION: We
evaluated the influence of the peak voltage of waveforms used for
internal cardioversion of atrial fibrillation on defibrillation efficacy
and pain perception. A low peak voltage biphasic waveform generated by a
500-microF capacitor with 40% tilt was compared to a standard biphasic
waveform generated by a 60-microF capacitor with 80% tilt. METHODS AND
RESULTS: In 19 patients with paroxysmal atrial fibrillation (79% male,
age 55 +/- 11 years, 21% with heart disease), the atrial defibrillation
threshold (ADFT) was determined during deep sedation with midazolam for
both waveforms in a randomized fashion using a step-up protocol.
Internal cardioversion with a single lead (shock vector: coronary sinus
to right atrium) was successful in 18 (95%) of 19 patients. ADFT energy
and peak voltage were significantly lower for the low-voltage waveform
(2.1 +/- 2.4 J vs 3.5 +/- 3.9 J, P \< 0.01; 100 +/- 53 V vs 290 +/- 149
V, P \< 0.01). Sedation then was reversed with flumazenil after ADFT
testing. Two shocks at the ADFT (or a 3-J shock if ADFT \>3 J) were
administered to the patient using each waveform in random order. Pain
perception was assessed using both a visual scale and a numerical score.
ADFTs were above the pain threshold in 17 (94%) of 18 patients, even
though the ADFT with the 500-microF waveform was \<100 V in 63% of the
patients. Pain perception was comparable for both waveforms (numerical
score: 6.5 +/- 2.4 vs 6.3 +/- 2.6; visual scale: 5.4 +/- 2.6 vs 5.2 +/-
3.1; P = NS, 500-microF vs 60-microF). The second shock was perceived as
more painful in 88% of the patients, independent of the waveform used.
CONCLUSION: Despite a 66% lower peak voltage and a 40% lower energy, the
40% tilt, 500-microF capacitor biphasic waveform did not change the pain
perceived by the patient during delivery of internal cardioversion
shocks. Pain perception for internal cardioversion probably is not
influenced by peak voltage alone and increases with the number of
applied shocks.

Kaplan, S. A., M. A. Volpe, and A. E. Te. \"A prospective, 1-year trial
using saw palmetto versus finasteride in the treatment of category III
prostatitis/chronic pelvic pain syndrome.\" *Journal of Urology.* 171,
no. 1(2004): 284-8 UI 14665895.

PURPOSE: This study was designed to assess the safety and efficacy of
saw palmetto or finasteride in men with category III prostatitis/chronic
pelvic pain syndrome (CP/CPPS). MATERIALS AND METHODS: A prospective,
randomized, open label, 1-year study was designed to assess the safety
and efficacy of saw palmetto and finasteride in the treatment of men
diagnosed with CP/CPPS. Patients were randomized to finasteride (5 mg
once daily) or saw palmetto (325 mg daily) for 1 year. Patients were
evaluated using the National Institutes of Health Chronic Prostatitis
Symptom Index, individual domains (pain, urinary symptoms, quality of
life and mean pain score) and the American Urological Association
Symptom Score at baseline, 3, 6 and 12 months. RESULTS: A total of 64
consecutive men 24 to 58 years old (mean age 43.2) with a diagnosis of
CP/CPPS were equally randomized to the 2 treatment arms. All 64 men had
previously received antibiotics (duration of 3 to 93 weeks), 52 (82%)
had been on alpha-blockade. There were 61, 57 and 56 patients evaluable
at 3, 6 and 12 months, respectively. At 1 year mean total National
Institutes of Health Chronic Prostatitis Symptom Index score decreased
from 23.9 to 18.1 in the finasteride group (p \<0.003), and from 24.7 to
24.6 in the saw palmetto arm (p = 0.41). In the finasteride arm the
quality of life and pain domains were significantly improved at 1 year;
however, urination was not. Adverse events included headache (3 cases)
in the saw palmetto group and decreased libido (2 cases) in the
finasteride group. At the end of the trial 13 of 32 (41%) and 21 of 32
(66%) opted to continue saw palmetto and finasteride, respectively.
CONCLUSIONS: CP/CPPS treated with saw palmetto had no appreciable
long-term improvement. In contrast, patients treated with finasteride
had significant and durable improvement in all various parameters except
voiding. Further studies are warranted to ascertain the mechanism and
reproducibility of these effects in a placebo controlled trial.

Katsarava, Z., et al. \"Abnormal habituation of \'nociceptive\' blink
reflex in migraine\--evidence for increased excitability of trigeminal
nociception.\" *Cephalalgia.* 23, no. 8(2003): 814-9 UI 14510928.

We studied the habituation of the \'nociceptive\' blink reflex (nBR) in
15 healthy subjects and 17 migraine patients interictally as well as
during unilateral migraine headache within six hours of onset and after
treatment. In healthy volunteers the mean regression coefficient (MRC)
was - 3.9 following right sided and - 4.9 left sided stimulation. This
equals an amplitude loss of 19.5% (5 x -3.9) and 24.5% (5 x -4.9),
respectively, across five consecutive sweeps. An augmentation of nBR
responses was found in migraine patients interictally: MRC = 3.3
following stimulation of the headache side (HA) and MRC = 4.0 of the
non-headache side (non-HA). The differences were statistically
significant (anova: d.f. = 1, F = 25.8, P \< 0.001). During the migraine
attack MRCs were negative both before (-5.0, HA and - 4.0, non-HA) and
after treatment (-2.6, HA and - 1.9 non-HA) and significantly differed
from those outside the migraine attack (anova: d.f. = 2, F = 12.4, P \<
0.001). The demonstrated lack of habituation of the nBR responses
indicates an abnormal trigeminal nociceptive processing in migraine
patients outside the migraine attack.

Kelemen, K., Q. Q. Yu, and L. Howard. \"Small intestinal angiosarcoma
leading to perforation and acute abdomen: a case report and review of
the literature.\" *Archives of Pathology & Laboratory Medicine.* 128,
no. 1(2004): 95-8 UI 14692839.

A 76-year-old man presented to the emergency room with abdominal pain
and fatigue. The patient had a history of gastrointestinal bleeding. An
abdominal computed tomographic scan showed collections of free air in
the abdomen with obstruction of the distal small intestine and multiple
masses in the liver. Laparotomy revealed a widespread malignant neoplasm
in the abdomen, with multiple tumor nodules in the ileal wall,
mesentery, and liver. The ileal wall was perforated within the area of
one of the tumors. Pathologic examination of the lesion showed a
neoplasm composed of solid sheets of spindle and undifferentiated cells,
forming interlacing delicate vascular channels with atypical endothelial
cells. The tumor cells were positive for the endothelial marker CD31,
whereas reactivity for a broad panel of epithelial and other endothelial
markers was negative. This case demonstrates that although angiosarcomas
of the gastrointestinal tract are rare, they should be considered in
cases of intestinal perforation or severe bleeding, especially in the
elderly. A broad panel of immunochemical markers might be necessary to
establish the pathologic diagnosis. \[References: 15\]

Kern, U., et al. \"Botulinum toxin type A influences stump pain after
limb amputations.\" *Journal of Pain & Symptom Management.* 26, no.
6(2003): 1069-70 UI 14654254.

Kharasch, E. D. \"Perioperative COX-2 inhibitors: knowledge and
challenges.\" *Anesthesia & Analgesia.* 98, no. 1(2004): 1-3 UI
14693572.

Kim, J. S. \"Central post-stroke pain or paresthesia in
lenticulocapsular hemorrhages.\" *Neurology.* 61, no. 5(2003): 679-82 UI
12963762.

Twenty patients were studied who developed central poststroke pain or
paresthesia after lenticulocapsular hemorrhage. Pain or paresthesia
occurred 0 to 24 months after the onset, more prominently in the leg
than other body parts. The symptoms were described as numb, cold,
burning, aching, swollen, and squeezing in various combinations. The
mean score of the visual numerical scale was 5.6. The lesions involved
the dorsal part of the posterior limb of the internal capsule, probably
damaging the thalamocortical sensory pathway.

Kumar, S., and R. J. Hall. \"Drug treatment of stable angina pectoris in
the elderly: defining the place of calcium channel antagonists.\" *Drugs
& Aging.* 20, no. 11(2003): 805-15 UI 12964887.

Chronic stable angina pectoris (CSAP) resulting from coronary artery
disease (CAD) is common in elderly patients, and significantly reduces
their quality of life. Myocardial revascularisation procedures in this
age group entail significant risks, largely related to comorbidities
rather than advanced age itself. Coronary artery anatomy is more likely
to be technically unsuitable for revascularisation and angina more
resistant to drug treatment. Therefore, elderly patients often take
combinations of antianginal drugs. Calcium channel antagonists (CCAs)
are effective antianginal drugs first introduced for clinical use in the
late 1970\'s. They reduce myocardial ischaemia by both causing
vasodilatation of coronary resistance vessels and reducing cardiac
workload (negative inotropic effect). However, adverse effects related
to abrupt arterial vasodilatation limited the tolerability of these
short acting \'first generation\' drugs (nifedipine, verapamil and
diltiazem). Furthermore, short acting nifedipine may occasionally
increase both the frequency of angina pectoris and mortality in patients
with CAD. Since then, long acting formulations of first generation
agents and new chemical entities (second and third generation drugs)
have been developed. These are well tolerated and effective at
attenuating both myocardial ischaemia and the frequency and severity of
angina pectoris in most patients with stable CAD. Current guidelines on
the drug treatment of CSAP propose that beta-adrenoceptor antagonists
(beta-blockers) should be used as first line medication primarily for
their prognostic benefits, and that CCAs need only be introduced if
beta-blockers are not tolerated, contraindicated or ineffective. Despite
this, there is a wealth of evidence from clinical trials that
demonstrate equal antianginal efficacy for CCAs and beta-blockers. The
presence of chronic heart failure and prior myocardial infarction are
clear indications for the use of beta-blockers in preference to CCAs for
the treatment of CSAP. However, in patients with both CSAP and
hypertension, second and third generation CCAs may offer prognostic
benefits of similar magnitude to those provided by beta-blockers.
Therefore, antianginal drug therapy must be tailored to the individual
needs and comorbidities of each elderly patient. \[References: 91\]

Kurella, M., W. M. Bennett, and G. M. Chertow. \"Analgesia in patients
with ESRD: a review of available evidence.\[see comment\].\" *American
Journal of Kidney Diseases.* 42, no. 2(2003): 217-28 UI 12900801.

Moderate to severe pain frequently accompanies chronic diseases in
general and end-stage renal disease (ESRD) in particular. Several
analgesic agents and associated metabolites show altered
pharmacokinetics in the presence of reduced glomerular filtration rate.
Drug-related side effects may exacerbate symptoms frequently observed in
persons with chronic kidney disease (CKD; eg, fatigue, nausea, vomiting,
and constipation) or those often attributed to hemodialysis therapy (eg,
orthostatic hypotension and impaired cognition). Persons with advanced
CKD and ESRD are at increased risk for adverse effects of analgesic
agents because of enhanced drug sensitivity, comorbid conditions, and
concurrent medication use. Dose adjustment and avoidance of certain
analgesics may be required in patients with advanced CKD and ESRD. We
review the available evidence on pharmacokinetics and adverse drug
effects of various analgesic agents commonly used in patients with
advanced CKD and ESRD. Determining an optimal approach to the control of
pain in patients with advanced CKD and ESRD will require additional
research. \[References: 96\]

Kvarnstrom, A., et al. \"The effectiveness of intravenous ketamine and
lidocaine on peripheral neuropathic pain.\" *Acta Anaesthesiologica
Scandinavica.* 47, no. 7(2003): 868-77 UI 12859309.

BACKGROUND: Neuropathic pain is often severe and resistant to
pharmacological treatment. The aims of the present study were to assess
the analgesic effect of ketamine and lidocaine and to investigate if
measurement of different variables of sensibility could be used to
identify responders. We also wanted to study if treatment resulted in
changes of sensibility. METHODS: Twelve patients with long-lasting
peripheral neuropathic pain of traumatic origin were included. The
effects of ketamine hydrochloride (Ketalar, Parke Davis) 0.4 mg/kg and
lidocaine hydrochloride (Xylocain, Astra) 2.5 mg/kg were investigated.
Saline was used as placebo. The intensity of continuous pain was
measured by a visual analogue scale (VAS). Warm and cold perception as
well as heat and cold pain thresholds were assessed. Sensibility to
touch was also tested. Systemic plasma concentrations of lidocaine and
ketamine were assessed. RESULTS: The mean reduction in VAS-scores was
55%, 34% and 22% for ketamine, lidocaine and placebo, respectively. A
significant difference was registered between ketamine and placebo (P =
0.009). Response to treatment (50% reduction in VAS-score during
infusion) was recorded in 7/12 in the ketamine, 4/12 in the lidocaine
and 2/12 in the placebo group. Quantitative sensory testing (QST) of
thermal sensitivity and sensory tests for mechanical stimuli could not
separate responders from non-responders and neither were the results
from these assessments changed by the infusion of the drugs. Lidocaine
and particularly ketamine were associated with frequent side-effects,
the most common being somnolence and dizziness. CONCLUSION: Ketamine
showed a significant analgesic effect. The clinical usefulness is,
however, limited by disturbing side-effects.

Lau, H., and N. G. Patil. \"Selective non-stapling of mesh during
unilateral endoscopic total extraperitoneal inguinal hernioplasty: a
case-control study.\" *Archives of Surgery.* 138, no. 12(2003): 1352-5
UI 14662538.

HYPOTHESIS: Selective non-stapling of the mesh during unilateral
endoscopic total extraperitoneal inguinal hernioplasty (TEP) may reduce
postoperative pain and morbidity rate. DESIGN: Case-control study.
SETTING: Division of general surgery at a university-affiliated teaching
hospital. PATIENTS: Two hundred patients who underwent TEP.
INTERVENTION: Endoscopic total extraperitoneal inguinal hernioplasty
with and without stapling the mesh. The mesh was stapled when the
diameter of the hernial defect was greater than 4 cm or there was an
inadequate overlap of the defect by the mesh. MAIN OUTCOME MEASURES:
Postoperative pain score and morbidity rate were compared between
patients who had stapling and selective non-stapling of the mesh during
TEP. RESULTS: Demographic features, hernia types, and mean operative
times of the 2 groups were comparable. Postoperative pain scores upon
coughing from the day of operation to postoperative day 6 were lower in
patients who had not had the mesh stapled, but the difference was not
statistically significant. Comparisons of the mean length of hospital
stay, postoperative morbidity, and time taken to resume normal
activities showed no significant difference between the 2 groups. With a
mean follow-up of 1 year, no neuralgia or recurrence was noted in either
group during follow-up. CONCLUSIONS: Selective non-stapling of the mesh
did not confer short-term benefits, such as reduced postoperative pain
and morbidity, compared with those who had routine stapling of the mesh
during TEP. For patients with a hernial defect measuring less than 4 cm,
TEP can be performed without stapling the mesh. The selective
non-stapling strategy also helps to reduce the cost of the operation and
the potential for nerve entrapment.

Lauretti, G. R., G. M. Oliveira, and N. L. Pereira. \"Comparison of
sustained-release morphine with sustained-release oxycodone in advanced
cancer patients.\" *British Journal of Cancer.* 89, no. 11(2003):
2027-30 UI 14647133.

The antinociceptive effect of morphine and oxycodone is mediated
preferentially at micro and kappa receptors, respectively. The aim of
this study was to evaluate the analgesic profile of the combination of
morphine and oxycodone in cancer pain, compared to the standard
administration of morphine alone. Controlled-release formulations of
oxycodone (CRO) and morphine (CRM) were compared in 26 patients. The
study started with an open-label, randomised titration phase to achieve
stable pain control for 7 days, followed by a double-blind, randomised
crossover phase in two periods, 14 days each. At any point, patients
were allowed to use oral immediate-release morphine (IRM) as needed, in
order to keep visual analogue scale \< or =4. Pain, satisfaction,
adverse effects and number of daily rescue morphine tablets were
assessed. A total of 22 patients were evaluated. The weekly upload
consumption ratio in morphine/oxycodone was 1 : 1.8 (1.80, 1.83, 1.76,
1.84). The weekly IRM consumption was higher in patients having CRM
compared to patients having CRO (ratio morphine/oxycodone: 1.6, 1.6,
1.6, 1.7) (P\<0.05). Patients receiving oxycodone complained of less
nausea and vomiting. The rescue morphine analgesic consumption was 38%
higher in patients receiving only morphine, compared to patients
receiving both morphine and oxycodone. The results suggest that the
combination of morphine/oxycodone (opioids with differential
preferential sites of action) can be a useful alternative to morphine
alone, resulting in a better analgesia profile and less emesis.

Lee, M. S., et al. \"Effects of Qi-therapy on blood pressure, pain and
psychological symptoms in the elderly: a randomized controlled pilot
trial.\" *Complementary Therapies in Medicine.* 11, no. 3(2003): 159-64
UI 14659379.

Recently, we reported that Qi-therapy may be beneficial in reducing
negative psychological symptoms and increasing melatonin levels,
neutrophil function and natural killer cell cytotoxicity in young
subjects. However, there is little scientific evidence of its efficacy
in elderly subjects. Therefore, this study was designed to investigate
the effects of Qi-therapy on anxiety, depression, fatigue, pain and
blood pressure in elderly subjects. Ninety-four elderly subjects were
randomly assigned to either Qi-therapy (n=47) or mimic therapy (n=47)
groups. Both groups received a 10-min intervention period once using
similar procedures. The Qi-therapy group exhibited greater reduction in
anxiety, depression, fatigue, pain level and blood pressure compared to
the placebo group; the difference in anxiety was significant (P=0.014).
These results suggest that even a brief application of Qi-therapy may
exert a positive psychological and physiological effect. However,
further research is necessary in order to fully understand the long-term
impact of Qi-therapy on psychological health and the cardiovascular
system.

Lee-Elliott, C. E., D. Dundas, and U. Patel. \"Randomized trial of
lidocaine vs lidocaine/bupivacaine periprostatic injection on
longitudinal pain scores after prostate biopsy.\" *Journal of Urology.*
171, no. 1(2004): 247-50 UI 14665886.

PURPOSE: Periprostatic lidocaine reduces immediate post-prostate biopsy
pain but still many men will not consent to re-biopsy. We performed a
randomized study to assess whether adding long acting local anesthesia
to a short acting agent would further reduce pain. MATERIALS AND
METHODS: A total of 300 men undergoing transrectal ultrasound guided
prostate biopsy were sequentially randomized to receive either short
acting local lidocaine (lid) or short and long acting lidocaine and
bupivacaine (lid/bup). A 7-day questionnaire was used to study daily
pain (10-point visual analog score), bleeding (hematuria, PR bleeding,
hematospermia), visits to the family doctor and analgesic use, and
whether they would agree to future re-biopsy. RESULTS: Of the 256
questionnaires returned 250 were suitable for analysis. Cross-sectional
comparison showed no intergroup differences in mean pain scores
immediately after biopsy (2.24, 95% CI 1.94-2.5 vs 2.61, 95% CI 2.3-2.9,
p = 0.88 in lid and lid/bup groups, respectively). There was a
significant rebound in visual analog scale at 1 hour in the lid group
but not in the lid/bup group (+ 0.9 vs + 0.09, p = 0.0006). Longitudinal
analysis showed the global pain experience after lid/bup was better
compared to lidocaine alone, with significantly less pain every
subsequent day (p = 0.0006 to 0.002). No difference was seen in
morbidity, analgesia usage or number refusing future re-biopsy (9.6% vs
9.8%). CONCLUSIONS: Long and short acting local anesthetics together
significantly attenuate the 1-hour rebound increase in pain scores seen
after short acting anesthesia alone. Improved pain scores were sustained
during the subsequent week and we advocate routine combination use for
transrectal ultrasound guided prostate biopsy.

Leo, R. J. \"A word of caution about the implied role for duloxetine in
pain management.\" *Journal of Clinical Psychiatry.* 64, no. 10(2003):
1270 UI 14658982.

Maimone-Baronello, M., F. Piccoli, and V. La Bella. \"Great auricular
neuralgia: a case report.\" *Headache.* 43, no. 9(2003): 1005-6 UI
14511279.

Malmstrom, K., et al. \"Analgesic efficacy of etoricoxib in primary
dysmenorrhea: results of a randomized, controlled trial.\" *Gynecologic
& Obstetric Investigation.* 56, no. 2(2003): 65-9 UI 12900528.

OBJECTIVE: To determine the efficacy of etoricoxib in the treatment of
primary dysmenorrhea. METHODS: Seventy-three women were randomly
assigned to receive single oral doses of etoricoxib 120 mg, placebo, or
naproxen sodium 550 mg at the onset of moderate to severe pain
associated with menses. During 3 consecutive menstrual cycles in this
double-blind, 3-period, crossover study, pain intensity and pain relief
were assessed over the 24-hour period following dosing, and global
ratings of therapy were made at 8 and 24 h after dosing. Tolerability
was assessed by spontaneous reports of adverse experiences. RESULTS:
Etoricoxib 120 mg provided analgesic efficacy superior to placebo for
the primary endpoint, total pain relief over 8 h (TOPAR8, p\<0.001), and
for all secondary endpoints (p\<0.050). The analgesic effect of
etoricoxib 120 mg over the first 8 h was similar to that of naproxen
sodium 550 mg. All treatments were well tolerated. CONCLUSIONS:
Etoricoxib 120 mg provided rapid and sustained analgesia that was
superior to placebo and similar to that of naproxen sodium 550 mg.
Copyright 2003 S. Karger AG, Basel

Manias, E. \"Medication trends and documentation of pain management
following surgery.\" *Nursing & Health Sciences.* 5, no. 1(2003): 85-94
UI 12603725.

The purpose of the present study was to examine prescribing and
administering activities for sedative and analgesic medication in
postoperative patients, and to describe nurses\' documentation practices
for pain management in nursing notes. A prospective audit was undertaken
of medication order charts and nursing notes of 100 patients on the
operation day and over the first four days following surgery. Almost all
patients received some form of infusion, while the use of \'as
required\' analgesics varied from one-third to over two-thirds of
patients during the postoperative period. Few patients were prescribed
fixed-order analgesics or sedative medications. An audit of nursing
entries found that nurses had documented inadequately in four major
areas: pain assessment, use of non-pharmacological interventions, use of
pharmacological interventions, and outcome of interventions. The
findings contribute to improving our understanding of nurses\' pain
management and identify the need to use clinical judgement that is
individualized to patients\' needs.

Mann, E. \"Chronic pain and opioids: dispelling myths and exploring the
facts.\" *Professional Nurse.* 18, no. 7(2003): 408-11 UI 12674051.

Opioid use for chronic non-malignant pain remains controversial and is
surrounded by myths and misconceptions. As new research emphasises the
importance of early effective pain management, comprehensive,
well-researched guidelines may help the care of patients with chronic
non-malignant pain.

Mannion, S., and T. O\'Brien. \"Ketamine in the management of chronic
pancreatic pain.\" *Journal of Pain & Symptom Management.* 26, no.
6(2003): 1071-2 UI 14654257.

Marchand, S., et al. \"Analgesic and placebo effects of thalamic
stimulation.\" *Pain.* 105, no. 3(2003): 481-8 UI 14527708.

Numerous clinical studies have reported successful relief of chronic
pain with sensory thalamic stimulation. However, even with the extensive
use of sensory thalamic stimulation as a clinical tool in the relief of
chronic pain, the results are still inconsistent. This discrepancy could
probably be explained by the fact that the majority of these studies are
case reports or retrospective analyses, which have often used imprecise
pain measurements that do not allow a rigorous statistical evaluation of
pain relief. None of these studies measured the effect of stimulation on
clinical pain for longer than a few hours per day, which is an important
aspect considering that clinical pain can vary over time. Moreover,
placebo controls are seldom included. In the current study, we measured
patients\' pain perception at home over a 2-week period, both during
days of normal stimulation of the sensory thalamus and during days
without stimulation. Patients also came to the laboratory to assess the
effects of thalamic and placebo stimulation on clinical pain,
experimental heat pain, innocuous air puff and visual stimulation. A
potential relation between the perceived paresthesia and analgesic
efficacy during thalamic and placebo stimulation was also explored. We
found that thalamic stimulation significantly affected clinical and
experimental pain perception, but that an important placebo component
also exists. On the other hand, neither thalamic nor placebo stimulation
affected air puff and visual ratings, suggesting that the effect applies
specifically to pain and hence is not caused by a general change in
attention. The level of paresthesia elicited during the placebo
manipulation was also directly correlated with the degree of placebo
pain relief. These results suggest that thalamic stimulation produces a
small but significant reduction in pain perception, but that a
significant placebo effect also exists.

Marcus, D. A. \"Gender differences in chronic pain in a
treatment-seeking population.\" *Journal of Gender-Specific Medicine.*
6, no. 4(2003): 19-24 UI 14714446.

OBJECTIVE: To compare pain characteristics, disability, and comorbid
psychological distress between genders in a treatment-seeking sample of
patients with chronic pain. METHODS: Consecutive patients with chronic
pain were evaluated and assigned a pain diagnosis. Gender differences
were compared on responses to questions about pain symptoms, associated
disability, and psychological distress. RESULTS: The pain sample (N =
716) was predominately female (63%). Pain locations, diagnoses, and
trigger factors were similar in male and female patients. Male patients
reported a greater mean pain severity (7.16 males vs 6.82 females; P =
0.05), greater pain constancy (41.2% vs 26.7%; P \< 0.001), and more
days per week with pain (6.37 vs 5.87; P \< 0.001). In addition, males
reported higher levels of disability, with reduced activity more than 3
days per week in 70.2% of males and 56.0% of females, and complete
disability more than 3 days per week in 55.9% of males and 37.3% of
females (P \< 0.001). Quality of life measures were additionally reduced
for both physical and psychological categories in men versus women (P =
0.05 to \< 0.01). CONCLUSIONS: There are important gender differences in
treatment-seeking patients with chronic pain. Males report higher levels
of pain and disability, with reduced physical and psychological quality
of life, as compared to females. These differences in treatment-seeking
patients may reflect gender differences in treatment-seeking behavior.

Marcus, J., G. Elkins, and F. Mott. \"The integration of hypnosis into a
model of palliative care.\" *Integrative Cancer Therapies.* 2, no.
4(2003): 365-70 UI 14713329.

There exists a need for a broad and inclusive model of integration of
mind-body interventions for palliative care. Symptoms relating to
psychological distress and existential concerns are even more prevalent
than pain and other physical symptoms among those with life-limiting
conditions. The hypnotic model\'s purpose is to improve the patient\'s
total psychological, social, and spiritual well-being. A 4-stage model
of interventions is offered to assist the clinician in developing and
implementing appropriate hypnotherapeutic treatment for noncurative
patients. The focus of the hypnotherapy is to ameliorate the effects of
pain and dyspnea to restore a level of psychological and physical
wellbeing. Within this model of therapy for patients with active,
progressive, far-advanced disease and a short life expectancy, the goals
of the hypnotic intervention are to provide relief from pain and
shortness of breath. Other focuses include assisting the patient with
the psychological adjustment to their noncurative and ultimately final
state.

Mata, M., J. Glorioso, and D. J. Fink. \"Development of HSV-mediated
gene transfer for the treatment of chronic pain.\" *Experimental
Neurology.* 184, no. Suppl 1(2003): S25-9 UI 14597322.

Chronic pain is often difficult to treat effectively. We have exploited
the high affinity of herpes simplex virus (HSV) for peripheral sensory
neurons to create HSV-based vectors for the treatment of chronic pain.
We have demonstrated that an HSV-based vector expressing proenkephalin
reduces pain-related responses in rodent models of inflammatory pain,
neuropathic pain, and pain resulting from cancer in bone. A human trial
has been proposed.

McAloon, C., P. C. O\'Connor, and M. Boyer. \"Patient\'s perception of
pain on admission and discharge from the emergency department.\" *New
Jersey Nurse.* 33, no. 8(2003): 7 UI 14692389.

Patients presenting to the emergency department have a common complaint
of pain. Whether admitted to the hospital or discharged to home,
patients are leaving the emergency department in a higher level of pain
than would be considered tolerable or comfortable. Pain can be a major
impediment to an adequate quality of life. Unrelieved or chronic pain
causes anxiety, depression, sleep disturbances, decreased self-esteem
and self-worth, inactivity, altered family dynamics, financial stress
and an increase in the number of health-care visits. The purpose of this
study was to evaluate patients\' perception and report of pain in the ED
from the time of arrival to the time of discharge. The sample consisted
of 63 females and 62 males from an ED of an urban hospital in Trenton,
New Jersey. The mean age for the males was 40 years, and the mean age
for the females was 41 years. The pain level of the participants was
measured by the use of a visual analogue scale at the time of arrival
and at the time of discharge from the ED. A paired t-test for related
samples revealed that the VAS scores decreased from 5.90 to 3.38 (p =
.000).

McCleane, G. \"Pharmacological management of neuropathic pain.\" *CNS
Drugs.* 17, no. 14(2003): 1031-43 UI 14594443.

In health, the nervous system exists in a balance between inhibitory and
excitatory influences. This balance may be upset if neural tissue is
damaged or irritated and may give rise to neuropathic pain. Such
neuropathic pain does not respond consistently to opioid analgesics or
NSAIDs and it may therefore be necessary to utilise other therapeutic
agents with known activity on either the excitatory or inhibitory
components of the pain pathway. These other agents are traditionally
considered with reference to their original uses; we still refer to
tricyclic antidepressants (TCAs) and anticonvulsant drugs when a
consideration of their modes of action may allow more rational use. For
example, carbamazepine is related to the TCAs by virtue of its chemical
structure and proposed mode of action and yet is still classified as an
anticonvulsant drug.With respect to the opioids, increasing evidence
points to an analgesic effect in neuropathic pain, although concerns
regarding tolerance and dependence still prevent more widespread use.
The anticonvulsants comprise a group of compounds possessing
anticonvulsant and analgesic properties, but each possesses differing
modes of action and so several members of the class should be tried
before a conclusion is reached that they, as a whole, are ineffective.
TCAs may also have a role in the treatment of neuropathic pain. As with
all drugs, if their use is not associated with pain relief in a defined
period of time, their use should be terminated. Topical TCAs may also
have a role where the area of neuropathic pain is small. Other options,
such as SSRIs, membrane stabilisers, capsaicin, baclofen and clonidine
may have potential in treating neuropathic pain.The available evidence
regarding the efficacy of currently available agents for the treatment
of neuropathic pain is sparse. With the knowledge of achieving
analgesia, according to the modes of actions of various agents it is
hoped that the treatment of this difficult condition may be more logical
and successful. \[References: 133\]

McCleane, G., B. Koch, and C. Rauschkolb. \"Does SPM 927 have an
analgesic effect in human neuropathic pain? An open label study.\"
*Neuroscience Letters.* 352, no. 2(2003): 117-20 UI 14625037.

The aim of the study is to establish if the putative anticonvulsant SPM
927 has an analgesic effect in human neuropathic pain and to assess its
tolerability. This is an open label study of 25 adult human subjects
with resistant neuropathic pain. Subjects were treated with SPM 927 in a
dose-escalating scheme to 600 mg daily, if tolerated. Treatment was
continued for 4 weeks then withdrawn without tapering. Pain scores were
recorded using a 11-point Likert score and a categorical pain-rating
scale. Laboratory parameters and, electrocardiographs (ECGs) were
collected; side effects were noted. Of the 25 enrolled subjects, 12
completed the study according to the protocol. The remaining subjects
dropped out due to adverse events (n=12) or withdrawn consent. Mean
daily pain scores (Likert score) fell by 0.83 (95% CI -1.77, +0.11) at
the end of maintenance and rose by 0.58 (95% CI -0.23, +1.40) after
withdrawal of SPM 927. Similar changes were seen in the categorical
pain-rating scores. There were decreases in the mean scores for shooting
pain, paraesthesia, and allodynia, but much less change in the numbness
and burning-pain scores. The most common side effects were nausea,
dizziness, leukocytosis, and increased ALT. No consistent changes in ECG
recordings or haemodynamic variables were observed. SPM 927 may have an
analgesic effect in human neuropathic pain and was reasonably well
tolerated in this study. These data support the continued clinical
development of SPM 927 for neuropathic pain.

McGuigan, C., et al. \"Case report: recurrent temporalis muscle swelling
and headache.\" *Neurology.* 60, no. 4(2003): 724-5 UI 12601126.

Meier, T., et al. \"Efficacy of lidocaine patch 5% in the treatment of
focal peripheral neuropathic pain syndromes: a randomized, double-blind,
placebo-controlled study.\" *Pain.* 106, no. 1-2(2003): 151-8 UI
14581122.

Peripheral neuropathic pain syndromes (PNPS) are difficult to treat
because commonly used analgesics are often ineffective when, for
example, touch-evoked allodynia, hyperalgesia, and pain paroxysms are
present. To investigate whether lidocaine patch 5% treatment is also
effective in postherpetic neuropathy (PHN) and in other PNPS, 40
patients with various forms and localizations of PNPS completed a
prospective, randomized, placebo-controlled, two-way, cross-over study
in three medical hospitals. Patients suffering from pain in a localized
skin area with intensity above 40 mm visual analog scale (VAS) and a
stable consumption of pain medication were included in this study. The
study was divided into four phases: 3-day run-in phase, treatment phase
1, wash-out period, and treatment phase 2, each lasting 1 week. At the
discretion of the patients, up to four patches (covering a maximum of
560 cm2) were applied onto the maximally painful area for 12 consecutive
hours daily, always either by day or at night. Throughout the four
phases, ongoing pain, allodynia, quality of neuropathic symptoms,
quality of sleep, and adverse events were assessed. When, after the
wash-out period, the pain intensity scores did not return to the
pre-treatment values (+/-20%), these patients were excluded from the
study. The present study revealed that, as an add-on therapy, the
lidocaine patch 5% was clearly effective in reducing ongoing pain
(P=0.017) and allodynia (P=0.023) during the first 8 h after application
and that the patches also worked well over a period of 7 days (P=0.018)
in diverse focal PNPS. Calculation of the numbers needed to treat (NNT)
to obtain one patient with more than 50% relief of ongoing pain revealed
that the NNT of 4.4 in the present study compared reasonably well with
other studies of PHN, such as topically applied capsaicin (NNT:
5.3-infinity) or systemic treatment with gabapentin (NNT: 3.2-5.0).

Meissner, W., et al. \"Acupuncture decreases somatosensory evoked
potential amplitudes to noxious stimuli in anesthetized volunteers.\"
*Anesthesia & Analgesia.* 98, no. 1(2004): 141-7, table of contents UI
14693608.

The effect of acupuncture on pain perception is controversial. Because
late amplitudes of somatosensory evoked potentials (SEPs) to noxious
stimuli are thought to correlate with the subjective experience of pain
intensity, we designed this study to detect changes of these SEPs before
and after acupuncture in a double-blinded fashion. Sixteen volunteers
were anesthetized by propofol and exposed to painful electric stimuli to
the right forefinger. Then, blinded to the research team, the
acupuncture group (n = 8) was treated with electric needle acupuncture
over 15 min at analgesic points of the leg, whereas the sham group (n =
8) received no treatment. Thereafter, nociceptive stimulation was
repeated. SEPs were recorded during each noxious stimulation from the
vertex Cz, and latencies and amplitudes of the N150 and P260 components
were analyzed by analysis of variance. P260 amplitudes decreased from
4.40 +/- 2.76 microV (mean +/- SD) before treatment to 1.67 +/- 1.21
microV after treatment (P \< 0.05), whereas amplitudes of the sham group
remained unchanged (2.64 +/- 0.94 microV before versus 2.54 +/- 1.54
microV after treatment). In conclusion, this double-blinded study
demonstrated that electric needle acupuncture, as compared with sham
treatment, significantly decreased the magnitudes of late SEP amplitudes
with electrical noxious stimulation in anesthetized subjects, suggesting
a specific analgesic effect of acupuncture. IMPLICATIONS: This
double-blinded study demonstrates that electric needle acupuncture, as
compared with sham treatment, significantly decreases the magnitudes of
late somatosensory evoked potential amplitudes with electrical noxious
stimulation in anesthetized subjects, suggesting a specific analgesic
effect of acupuncture.

Meng, C. F., et al. \"Acupuncture for chronic low back pain in older
patients: a randomized, controlled trial.\" *Rheumatology.* 42, no.
12(2003): 1508-17 UI 12890859.

OBJECTIVE: To determine if acupuncture is an effective, safe adjunctive
treatment to standard therapy for chronic low back pain (LBP) in older
patients. METHODS: The inclusion criteria for subjects were: (i) LBP \>
or =12 weeks and (ii) age \> or =60 yr; the exclusion criteria were (i)
spinal tumour, infection or fracture and (ii) associated neurological
symptoms. The subjects were randomized to two groups. The control group
of subjects continued their usual care as directed by their physicians,
i.e. NSAIDs, muscle relaxants, paracetamol and back exercises. Subjects
in the acupuncture group in addition received biweekly acupuncture with
electrical stimulation for 5 weeks. Outcome was measured by the modified
Roland Disability Questionnaire (RDQ) at weeks 0, 2, 6 and 9. The
primary outcome measure was change in RDQ score between weeks 0 and 6.
RESULTS: Fifty-five patients were enrolled, with eight drop-outs.
Twenty-four subjects were randomized to the acupuncture group and 23
were randomized to the control group. Acupuncture subjects had a
significant decrease in RDQ score of 4.1 +/- 3.9 at week 6, compared
with a mean decrease of 0.7 +/- 2.8 in the control group (P = 0.001).
This effect was maintained for up to 4 weeks after treatment at week 9,
with a decrease in RDQ of 3.5 +/- 4.4 from baseline, compared with 0.43
+/- 2.7 in the control group (P = 0.007). The mean global transition
score was higher in the acupuncture group, 3.7 +/- 1.2, indicating
greater improvement, compared with the score in the control group, 2.5
+/- 0.9 (P \< 0.001). Fewer acupuncture subjects had medication-related
side-effects compared with the control group. CONCLUSIONS: Acupuncture
is an effective, safe adjunctive treatment for chronic LBP in older
patients.

Mense, S. \"The pathogenesis of muscle pain.\" *Current Pain & Headache
Reports.* 7, no. 6(2003): 419-25 UI 14604500.

Nociceptive nerve endings in muscles and other tissues are equipped with
a multitude of receptor molecules for endogenous pain-producing and
sensitizing agents. Particularly interesting molecules are the
purinergic receptors, which can be activated by adenosine triphosphate
(ATP), and the vanilloid receptor, which is sensitive to protons (low
pH). The purinergic receptors are activated by tissue damage because
cell necrosis is associated with the release of ATP. A low pH is present
in many pathologic conditions such as ischemia and inflammation. At the
spinal and medullar level, painful muscle lesions induce marked
neuroplastic changes that result in hyperexcitability and hyperactivity
of nociceptive neurons. This central sensitization is the basis for the
spontaneous pain and hyperalgesia of patients. The transition from acute
to chronic muscle pain is complete when the initially functional changes
are transformed into structural ones. Patients with morphologic
alterations in their nociceptive system are difficult to treat because
the changes need time to normalize. \[References: 47\]

Mercadante, S., et al. \"Celiac plexus block for pancreatic cancer pain:
factors influencing pain, symptoms and quality of life.\" *Journal of
Pain & Symptom Management.* 26, no. 6(2003): 1140-7 UI 14654266.

Neurolytic celiac plexus block (NCPB) is claimed to be an effective
method of pain control for pancreatic cancer pain. However, the factors
that may influence long-term analgesia, adverse effects, and quality of
life after performing NCPB have never been determined. In a prospective
multicenter study, 22 patients who underwent NCPB were followed until
death. Numerous parameters other than pain and symptom intensity were
evaluated, including age, gender, initial site of cancer, sites of pain,
possible peritoneal involvement, technique, and oncologic interventions.
Indices were calculated to determine the opioid consumption ratio (EAS)
and the trend of opioid escalation (OEI). NCPB was effective in reducing
opioid consumption and gastrointestinal adverse effects for at least 4
weeks. In the last four weeks prior to death, there was the typical
trend of increasing symptom intensity common to the terminal cancer
population. None of the factors studied influenced the analgesic
effectiveness of NPCB. NPCB, performed by skilled clinicians, regardless
of the technique chosen, is a safe and useful means that should be
considered as an adjuvant to common analgesic regimens at any stage, as
it may allow the reduction of the visceral component of pancreatic pain
that may prevail in certain phases of the illness. The analgesic and
symptomatic effect of NCPB is presumably advantageous for about four
weeks. A possible factor interfering with long-term outcome includes the
capacity of cancer to involve the celiac axis, which can distort the
anatomy and prevent neurolytic spread, or modify the pain mechanisms.
Outcomes are strongly based on individual variation.

Messin, R., et al. \"A pilot double-blind randomized placebo-controlled
study of molsidomine 16 mg once-a-day in patients suffering from stable
angina pectoris: correlation between efficacy and over time plasma
concentrations.\" *European Journal of Clinical Pharmacology.* 59, no.
3(2003): 227-32 UI 12734607.

OBJECTIVES: A new once-a-day (o.a.d.) formulation of molsidomine (16 mg)
was evaluated in patients with stable angina pectoris. The aims were to
characterize its pharmacokinetics after a single dose, to demonstrate
its clinical efficacy and safety versus placebo and to investigate
correlations between pharmacokinetics and pharmacodynamics. METHODS:
Forty-two patients were recruited in a double-blind, crossover,
randomized placebo-controlled trial. The pharmacokinetics of molsidomine
and SIN-1, its active metabolite, were determined at specific time
points (3, 6, 10, 14, 18, 22 and 24 h) after the administration of a
single dose of molsidomine 16 mg o.a.d. in all patients distributed into
seven groups. Twenty-eight of these 42 patients showed a positive
baseline cycloergometric exercise test response during the run-in
placebo period and were used to compare the efficacy of molsidomine to
placebo. Relationships between plasma concentration in molsidomine or
SIN-1 and ischemic threshold were assessed in 16 of the 28 patients with
a positive exercise test at baseline. Indeed, the censored variable
ischemia-limited tolerance to exercise could not be evaluated in those
patients who did not show exercise-induced ischemia anymore under
molsidomine 16 mg o.a.d. Pharmacokinetic-pharmacodynamic relationships
were evaluated using regression models and correlation coefficients.
RESULTS: The highest average concentration in molsidomine and SIN-1
occurred after 6 h, then a plateau of 15-20 ng/ml molsidomine and
0.8-3.0 ng/ml SIN-1 was maintained for at least 8 h and the mean
residual molsidomine concentration 24 h post-drug intake was around 8
ng/ml, still in the effective range of 5-10 ng/ml. A significant
increase in total workload (+52 W min, P=0.009), total exercise time
(+32 s, P=0.003) and time to angina (+25 s, P=0.016) was measured with
molsidomine 16 mg o.a.d. relative to placebo. Using linear regression,
significant correlation coefficients were determined between molsidomine
plasma concentrations (but not SIN-1) and exercise test improvements
(r=0.827, P\<0.001 for the total workload; r=0.772, P\<0.001 for the
total exercise time; and r=0.566, P=0.028 for the time to 1 mm
ST-segment depression). CONCLUSION: The pharmacokinetics of molsidomine
16 mg in patients with stable angina pectoris is compatible with a
o.a.d. dosage regimen. This o.a.d. formulation is effective and
well-tolerated, providing a 24-h therapeutic control of myocardial
ischemia. A positive and significant linear relationship between
molsidomine plasma concentration and the increase in exercise tolerance
was observed.

Milingos, S., et al. \"Laparoscopic management of patients with
endometriosis and chronic pelvic pain.\" *Annals of the New York Academy
of Sciences.* 997(2003): 269-73 UI 14644834.

Endometriosis has been traditionally included among the most important
causes of chronic pelvic pain (CPP) in women of reproductive age. The
main clinical manifestations of endometriosis are dysmenorrhea,
dyspareunia, and chronic nonmenstrual pain. Despite the high prevalence
of endometriosis in women suffering from CPP, controversy still exists
regarding the true association between the stage and extent of this
peculiar disease and the severity of pain. Over the last decade,
advances in endoscopic technology have enabled gynecologic surgeons to
recognize many atypical appearances of the endometriotic implants not
known to exist before, thus allowing their complete excision or
destruction. Laparoscopic surgery may offer considerable relief in
patients with endometriosis and CPP. Although cases with advanced
endometriosis seem to benefit the most, we also support surgical
treatment in patients with early endometriosis diagnosed using
laparoscopy, as many will experience improvement in their symptoms.
\[References: 27\]

Milling, L. S., M. R. Levine, and S. A. Meunier. \"Hypnotic enhancement
of cognitive-behavioral interventions for pain: an analogue treatment
study.\" *Health Psychology.* 22, no. 4(2003): 406-13 UI 12940397.

Recent meta-analyses have shown that adding hypnosis enhances the
effectiveness of cognitive-behavioral psychotherapy. This hypnotic
enhancement effect was evaluated in the analogue treatment of pain.
Individuals scoring in the high (n = 135) and low (n = 150) ranges of
hypnotic suggestibility were randomly assigned to 1 of 6 conditions:
Stress Inoculation Training, the same treatment provided hypnotically,
nonhypnotic analgesia suggestions, hypnotic analgesia suggestions, a
hypnotic induction treatment, or a control condition. The 5 analogue
treatments reduced experimental pain more than the control condition,
but were not different from one another. Under circumstances optimized
to detect an enhancement effect, neither Stress Inoculation Training nor
analgesia suggestions produced more relief when delivered in a hypnotic
context than identical treatments provided nonhypnotically.

Miyake, H., et al. \"Presacral extramedullary hematopoiesis.\"
*Surgery.* 135, no. 1(2004): 112-3 UI 14694310.

Montanini, S., and R. Siliotti. \"Analgesic therapy services and levels
of essential care.\" *Minerva Anestesiologica.* 69, no. 6(2003): 479-80,
480-1 UI 14564247.

Motl, R. W., B. D. Knowles, and P. J. O\'Connor. \"Examination of pain
ratings associated with elicitation of the maximal H-wave and maximal
M-wave in the soleus and flexor carpi radialis muscles.\" *International
Journal of Neuroscience.* 113, no. 11(2003): 1477-86 UI 14585748.

The present study involved an examination of pain ratings associated
with elicitation of the maximal H-wave and maximal M-wave in the soleus
and flexor carpi radialis (FCR) muscles. Sixteen male students provided
pain intensity ratings associated specifically with elicitation of the
maximal H-wave and maximal M-wave in the soleus and FCR muscles before
and after a 1 h period of seated rest on two trials separated by 1 wk.
There were no significant interactions or main effects of Muscle Group,
Time, or Trials for the pain ratings associated with the maximal H-wave
and maximal M-wave in the soleus and FCR muscles. Pain ratings and
current were higher for the maximal M-wave than the maximal H-wave in
both the soleus and FCR muscles. We concluded that pain ratings
associated with the maximal H-wave and maximal M-wave do not differ
between the soleus and the FCR muscles, and that pain ratings are higher
for the maximal M-wave than the maximal H-wave.

Naylor, W. \"Pain in fungating wounds: another perspective.\" *Ostomy
Wound Management.* 49, no. 11(2003): 9-12 UI 14652409.

Nikanne, E., et al. \"Ketoprofen for postoperative pain after
uvulopalatopharyngoplasty and tonsillectomy: two-week follow-up study.\"
*Otolaryngology - Head & Neck Surgery.* 129, no. 5(2003): 577-81 UI
14595282.

OBJECTIVE: In our previous study, we reported that both
uvulopalatopharyngoplasty (UPPP) and tonsillectomy are associated with
unacceptable intense pain during the first 24 hours after surgery. To
investigate the pain progression at home, we followed the same 53
patients for 14 days after surgery. Twenty-two patients underwent
tonsillectomy and 31 patients underwent UPPP. STUDY DESIGN: A
prospective, longitudinal, parallel-group study was conducted. METHODS:
Beginning on the first postoperative day, the patients were allowed to
use 50 mg ketoprofen capsules at a dosage of 5 mg/kg/24 hr. The patients
evaluated their own pain four times a day for the first 5 days. Two
weeks after the surgery during a follow-up visit patients reported the
present pain; and a total consumption of analgesics, and all adverse
events for 14 days. RESULTS: Patients in both study groups had
significant pain, especially in the morning, for the first week after
surgery. In half of the patients, severe pain interfered with eating and
sleeping, and in one third of the patients, the pain lasted 2 weeks or
longer. The need for ketoprofen was significantly higher after UPPP than
that after tonsillectomy (P = 0.001). One patient after tonsillectomy
and 3 patients after UPPP needed electrocautery to stop secondary
bleeding. CONCLUSIONS: Both UPPP and tonsillectomy are associated with
intense postoperative pain. Standard ketoprofen capsules are too
short-acting to ensure undisturbed sleep.

North, R. A. \"The P2X3 subunit: a molecular target in pain
therapeutics.\" *Current Opinion in Investigational Drugs.* 4, no.
7(2003): 833-40 UI 14619405.

P2X receptors are hetero-oligomeric proteins that function as membrane
ion channels and are gated by extracellular ATP. The P2X3 subunit is a
constituent of the channels on a subset of sensory neurons involved in
pain signaling, where ATP released by damaged and inflamed tissue can
initiate action potentials. The tissue distribution of this subunit,
along with experiments using antagonists, antisense oligonucleotides and
gene knockouts, suggests that it may be a useful target for the
development of pain therapeutics. This has been substantiated by the
development by Abbott of a small molecule that selectively blocks P2X3
subunit-containing P2X receptors, and which is effective in a range of
animal models of neuropathic and chronic inflammatory pain.
\[References: 89\]

Offenbacher, M., et al. \"Validation of a German version of the
\'Disabilities of Arm, Shoulder and Hand\' questionnaire (DASH-G).\"
*Zeitschrift fur Rheumatologie.* 62, no. 2(2003): 168-77 UI 12721705.

OBJECTIVE: In 1994 the American Academy of Orthopedic Surgeons\' outcome
research committee developed and validated a functional outcome
questionnaire for disabilities of the upper extremity (DASH). The
objective of our study was to translate the DASH into German and to
evaluate its reliability and validity for German-speaking patients with
shoulder pain. METHODS: Translation-backtranslation of the DASH was
performed according to published guidelines. Psychometric properties and
validity were assessed in 49 consecutive patients with shoulder pain
originating from within the shoulder girdle. Age, duration of symptoms
and current pain were obtained. Test-retest reliability was assessed in
a subset of 18 patients who filled in the questionnaire 10 days later.
Internal consistency was evaluated with Cronbach\'s alpha coefficient.
Test-retest reliability was assessed using Spearman correlations and the
Bland and Altman plot. To study the validity, we examined the
correlation of the DASH with other measures of function of the upper
extremity including the HAQ subscales relating to the upper extremity
and pain measures (e.g. numerical rating scale, SF-36 pain scale). We
also examined our hypothesis that the DASH is moderately correlated with
measures of range-of-motion (e.g., forward flexion and abduction).
RESULT: Translation-backtranslation revealed no major difficulties. The
mean age of the patients was 59 years, mean duration of symptoms 60
months and current pain score 5.6 (NRS). Test-retest reliability was
0.90 for the total DASH. The internal consistency was 0.96. Strong
correlations (p\<0.01) were found between the DASH and the mean among
the five subscales of the HAQ representing upper extremity function
(0.88) and pain as measured with the SF-36 bodily pain scale (-0.79). As
hypothesized, the DASH was also moderately correlated with measures of
range-of-motion (e.g. forward flexion rho=-0.49; abduction rho=-0.57).
CONCLUSION: Our data confirm that the German version of the DASH retains
the characteristics of the American original and is a reliable and valid
instrument to measure functional disability in German speaking patients
with shoulder pain.

Okmen, E., et al. \"Effects of enoxaparin and nadroparin on major
cardiac events in high-risk unstable angina treated with a glycoprotein
IIb/IIIa inhibitor.\" *Japanese Heart Journal.* 44, no. 6(2003): 899-906
UI 14711185.

Clinical trials have reported the beneficial effects of platelet
glycoprotein (GP) IIb/IIIa receptor antagonists and low-molecular-weight
heparins (LMWH) on major cardiac events (MACE) in patients presenting
with unstable angina or non-ST elevation myocardial infarction. A number
of studies have documented the significant superiority of
low-molecular-weight heparins, especially enoxaparin, over
unfractionated heparin in the treatment of acute coronary syndromes. The
purpose of this study was to compare the effects of two different LMWHs,
enoxaparin and nadroparin, accompanied by platelet GP IIb/IIIa
inhibition on MACE in high-risk unstable angina. The study was designed
as an open-label and observational study. Sixty-eight patients
presenting with unstable angina associated with high-risk criteria were
randomly assigned to treatment with enoxaparin plus tirofiban (36
patients, mean age 57 +/- 11) or nadroparin plus tirofiban (32 patients,
mean age: 58 +/- 8). In-hospital MACE including acute myocardial
infarction (AMI), recurrent refractory angina, death, stroke, and urgent
revascularization were compared between the study groups. Patient
characteristics and durations of LMWH and tirofiban treatments were not
different between the study groups. Coronary artery risk factors, except
family history (which was observed more frequently in the enoxaparin
group, P = 0.02), were also similar. MACE between the enoxaparin and
nadroparin groups including AMI (5.5%, 6%), recurrent refractory angina
(19%, 12%), death (0%, 3%), stroke (was not observed in either group),
urgent revascularization (14%, 12%) and total MACE (19%, 15%) were not
different. Enoxaparin and nadroparin, accompanied by GP IIb/IIIa
inhibitor therapy, have similar effects on the development of major
cardiac events in patients presenting with unstable angina and high-risk
characteristics.

O\'Neal, M. G., T. Beste, and D. P. Shackelford. \"Utility of preemptive
local analgesia in vaginal hysterectomy.\" *American Journal of
Obstetrics & Gynecology.* 189, no. 6(2003): 1539-41; discussion 1541-2
UI 14710057.

OBJECTIVE: Our purpose was to determine whether preemptive
administration of long-acting local anesthetics before vaginal
hysterectomy will improve postoperative pain. STUDY DESIGN: A blinded,
randomized, trial of paracervical injection of 0.5% bupivacaine with
epinephrine or normal saline solution placebo with epinephrine was
conducted. Verbal analog pain scores were collected at 1, 2, 3, 4, 6,
and 24 hours after surgery. Morphine use in the postanesthesia care unit
and by patient-controlled morphine analgesia was recorded. RESULTS:
Twenty patients were enrolled. Nine were randomized to bupivacaine.
There was no difference between groups regarding age, length of surgery,
blood loss, or length of stay. Pain scores were lower in the bupivacaine
group by analysis of variance (P=.03). Total morphine and
patient-controlled analgesia morphine was significantly less in patients
receiving bupivacaine (P=.01 and.04). CONCLUSION: Paracervical block
with a 0.5% bupivacaine with 1:200,000 epinephrine before vaginal
hysterectomy is associated with lower pain scores and a reduction in
morphine requirements after surgery.

Pappagallo, M. \"Newer antiepileptic drugs: possible uses in the
treatment of neuropathic pain and migraine.\" *Clinical Therapeutics.*
25, no. 10(2003): 2506-38 UI 14667954.

BACKGROUND: Both neuropathic pain and migraine are now being treated
with a variety of newer antiepileptic drugs (AEDs). The proven efficacy
of gabapentin in postherpetic neuralgia (PHN) and painful diabetic
neuropathy (PDN), and of divalproex sodium in the prevention of migraine
has led to increased clinical investigation of the newer AEDs for these
conditions. While basic and clinical research are expanding the
knowledge base concerning the fundamental mechanisms of neuropathic pain
and migraine, growing recognition of the similarities in the
pathophysiology of epilepsy, migraine, and various chronic pain
disorders has further heightened interest in exploring the newer AEDs in
the treatment of these conditions.OBJECTIVE: The goals of this article
were to review the empiric basis and scientific rationale for the use of
AEDs in the treatment of neuropathic pain and migraine; summarize
available clinical research on the use of 5 newer AEDs (gabapentin,
lamotrigine, oxcarbazepine, topiramate, and zonisamide) in these
conditions; and provide a summary comparison of the dosing,
tolerability, and drug-interaction potential of these agents.METHODS:
Relevant English-language articles were identified through searches of
MEDLINE (1990-March 2003), American Academy of Neurology abstracts
(1999-2003), and American Epilepsy Society abstracts (2000-2002). The
search terms were antiepileptic medication or drug, migraine headache,
neuropathic pain, pathophysiology, treatment, mechanism of action,
gabapentin, lamotrigine, oxcarbazepine, topiramate, and
zonisamide.CONCLUSIONS: The newer AEDs possess the potential advantages
of better tolerability and fewer drug-drug interactions compared with
standard treatments such as tricyclic antidepressants or established
AEDs. However, with the exception of data supporting the efficacy of
gabapentin in PHS and PDN, there is currently insufficient evidence to
determine whether the newer AEDs have equal or superior efficacy
relative to proven pharmacotherapies. \[References: 144\]

Parsanezhad, M. E., et al. \"Comparative, double-blind, randomized,
placebo-controlled trial of intraperitoneal of bupivacaine and lidocaine
for pain control after diagnostic laparoscopy.\" *Journal of the
American Association of Gynecologic Laparoscopists.* 10, no. 3(2003):
311-5 UI 14567803.

STUDY OBJECTIVE: To compare the effect of intraperitoneal bupivacaine
and lidocaine on reducing pain after diagnostic laparoscopy. DESIGN:
Randomized, double-blind, placebo-controlled study (Canadian Task Force
classification I). SETTING: University teaching hospital. PATIENTS: One
hundred thirty-four women with unexplained infertility. INTERVENTION:
Diagnostic laparoscopy with intraperitoneal administration of
bupivacaine or lidocaine. MEASUREMENTS AND MAIN RESULTS: Patients were
randomized into one of four groups. In group A, at the end of
laparoscopy 0.125% bupivacaine 30 ml was instilled into the pelvic
cavity and the same dose was instilled over the diaphragmatic vault.
Groups B and C received the same volume of 5% lidocaine and normal
saline, respectively. Group D received no intraperitoneal agent. The
verbal pain scale questionnaire was used to assess postoperative pain.
Pain scores 2 and 24 hours postoperatively were significantly lower for
group A than for groups B and C (p = 0.0001). Scores in group B were
also significantly lower than those in groups C and D (p = 0.0001).
Women in group A required less additional analgesia than those in the
other groups. CONCLUSION: Compared with lidocaine and placebo,
intraperitoneal bupivacaine significantly decreased postoperative pain,
and this effect was long lasting.

Pasero, C. \"Epidural analgesia for postoperative pain, part 2.\" *AJN,
American Journal of Nursing.* 103, no. 11(2003): 43-5 UI 14625423.

Pasero, C., and M. McCaffery. \"Controlled-release oxycodone.\" *AJN,
American Journal of Nursing.* 104, no. 1(2004): 30-2 UI 14707810.

Patt, R. B. \"Non-pharmacologic measures for controlling oncologic
pain.\" *American Journal of Hospice & Palliative Care.* 7, no. 6(1990):
30-7 UI 14686471.

Pepine, C. J., et al. \"Effects of angiotensin-converting enzyme
inhibition on transient ischemia: the Quinapril Anti-Ischemia and
Symptoms of Angina Reduction (QUASAR) trial.\[see comment\].\" *Journal
of the American College of Cardiology.* 42, no. 12(2003): 2049-59 UI
14680725.

OBJECTIVES: We sought to determine whether angiotensin-converting enzyme
inhibition (ACE-I) (i.e., quinapril) prevents transient ischemia
(exertional and spontaneous) in patients with coronary artery disease
(CAD). BACKGROUND: It is known that ACE-I reduces the risk of death,
myocardial infarction (MI), and other CAD-related outcomes in high-risk
patients. Numerous studies have confirmed that ACE-I improves coronary
flow and endothelial function. Whether ACE-I also decreases transient
ischemia is unclear, because no studies have been adequately designed or
sufficiently powered to evaluate this issue. METHODS: Using a
randomized, double-blinded, placebo-controlled, multicenter design, we
enrolled 336 CAD patients with stable angina. None had uncontrolled
hypertension, left ventricular (LV) dysfunction, or recent MI, and all
developed electrocardiographic (ECG) evidence of ischemia during
exercise. They were randomly assigned to one of two groups: 40 mg/day
quinapril (n = 177) or placebo (n = 159) for 8 weeks. Patients then
entered an additional eight-week treatment phase to examine the full
dose range. Those assigned to 40 mg quinapril continued that dose and
those assigned to placebo were titrated to 80 mg/day. Treadmill testing,
the Seattle Angina Questionnaire, and ambulatory ECG monitoring were
used to assess responses at baseline and at 8 and 16 weeks. RESULTS: The
groups did not differ significantly at entry or in terms of indexes
assessing myocardial ischemia at 8 or 16 weeks of treatment. In this
low-risk population, ACE-I was not associated with serious adverse
events. CONCLUSIONS: Our findings suggest short-term ACE-I in CAD
patients without hypertension, LV dysfunction, or acute MI is not
associated with significant effects on transient ischemia.

Perry, C. P. \"Peripheral neuropathies and pelvic pain: diagnosis and
management.\" *Clinical Obstetrics & Gynecology.* 46, no. 4(2003):
789-96 UI 14595220.

Petzke, F., et al. \"Increased pain sensitivity in fibromyalgia: effects
of stimulus type and mode of presentation.\" *Pain.* 105, no. 3(2003):
403-13 UI 14527701.

Fibromyalgia (FM) is defined in part by sensitivity to blunt pressure.
Pressure pain sensitivity in FM is evaluated typically by the use of
\'ascending\' testing methods such as tender point counts or
dolorimetry, which can be influenced by response bias of both the
subject and examiner. Methods that present stimuli in a random,
unpredictable fashion might minimize the influence of these factors. In
this study, we compared the results of ascending and random assessments
of both pressure and thermal pain sensitivities in 43 FM patients and 28
age- and gender-matched controls. Even though FM is defined on the basis
of pressure sensitivity, this group was also more sensitive to heat
stimuli, presented in either ascending or random paradigms. In both the
patient and control groups, the pain ratings to painful sensations
evoked by both thermal and pressure stimuli were significantly greater
in the random, compared with the ascending method. The number of
subjects classified as \'expectant\' because they rated pain higher in
ascending than random paradigms was similar for FM and control groups.
Both patients and controls exhibited a similar degree of sensitization
to pressure and thermal stimuli. The increased sensitivity to both
pressure and thermal stimuli for threshold and suprathreshold stimuli in
FM patients is consistent with central augmentation of pain processing.

Pickering, T. G. \"Effects of stress and behavioral interventions in
hypertension. Pain and blood pressure.\" *Journal of Clinical
Hypertension.* 5, no. 5(2003): 359-61 UI 14564139.

Piotrowski, M. M., et al. \"Massage as adjuvant therapy in the
management of acute postoperative pain: a preliminary study in men.\"
*Journal of the American College of Surgeons.* 197, no. 6(2003): 1037-46
UI 14644293.

BACKGROUND: Opioid analgesia alone may not fully relieve all aspects of
acute postoperative pain. Complementary medicine techniques used as
adjuvant therapies have the potential to improve pain management and
palliate postoperative distress. STUDY DESIGN: This prospective
randomized clinical trial compared pain relief after major operations in
202 patients who received one of three nursing interventions: massage,
focused attention, or routine care. Interventions were performed twice
daily starting 24 hours after the operation through postoperative day 7.
Perceived pain was measured each morning. RESULTS: The rate of decline
in the unpleasantness of postoperative pain was accelerated by massage
(p = 0.05). Massage also accelerated the rate of decline in the
intensity of postoperative pain but this effect was not statistically
significant. Use of opioid analgesics was not altered significantly by
the interventions. CONCLUSIONS: Massage may be a useful adjuvant therapy
for the management of acute postoperative pain. Its greatest effect
appears to be on the affective component (ie, unpleasantness) of the
pain.

Portenoy, R. \"Drug therapy for cancer pain.\" *American Journal of
Hospice & Palliative Care.* 7, no. 6(1990): 10-9 UI 14686466.

Post-White, J., et al. \"Therapeutic massage and healing touch improve
symptoms in cancer.\" *Integrative Cancer Therapies.* 2, no. 4(2003):
332-44 UI 14713325.

Complementary therapies are increasingly used to reduce side effects of
cancer treatment, without evidence for their effectiveness. In a
randomized, prospective, 2-period, crossover intervention study, the
authors tested the effects of therapeutic massage (MT) and healing touch
(HT), in comparison to presence alone or standard care, in inducing
relaxation and reducing symptoms in 230 subjects. MT and HT lowered
blood pressure, respiratory rate (RR), and heart rate (HR). MT lowered
anxiety and HT lowered fatigue, and both lowered total mood disturbance.
Pain ratings were lower after MT and HT, with 4-week nonsteroidal
antiinflammatory drug use less during MT. There were no effects on
nausea. Presence reduced RR and HR but did not differ from standard care
on any measure of pain, nausea, mood states, anxiety, or fatigue. MT and
HT are more effective than presence alone or standard care in reducing
pain, mood disturbance, and fatigue in patients receiving cancer
chemotherapy.

Prasad, S. S., et al. \"MRI measurements of the cervical spine and their
correlation to Pavlov\'s ratio.\" *Spine.* 28, no. 12(2003): 1263-8 UI
12811269.

STUDY DESIGN: Pavlov\'s ratio from plain radiographs in patients with
neck pain but no radicular symptoms was compared with the areas of the
cervical spinal cord and cerebrospinal fluid column on magnetic
resonance scans. SUMMARY OF BACKGROUND DATA: The area of the cervical
canal or cord obviously depends on both the sagittal and transverse
diameters. Although the pathology in stenosis of the cervical spine is
mainly in the sagittal plane, narrowing only in the sagittal diameter
may not indicate significant reduction in the area of the canal. The
transverse area of the cord has been shown to correlate well with the
pathologic changes of the cord in cervical myelopathy. We correlated
Pavlov\'s ratio on the plain radiographs to the area of the
cerebrospinal fluid column and the area of the cord on the magnetic
resonance scan. METHODS: We examined the lateral radiographs and axial
and sagittal T2-weighted magnetic resonance scans in the neutral
position of the cervical spine (C4-C7) of 87 patients with 332 levels
with neck pain but no radicular symptoms and normal magnetic resonance
scans. On the magnetic resonance images, the sagittal diameters of the
cerebrospinal fluid column and the cord were measured at the midvertebra
level on T2 sagittal images from C4 to C7. From the T2 axial images, the
area of the cord and the area of the cerebrospinal fluid column were
measured at the same levels. RESULTS: The correlation between Pavlov\'s
ratio and the area of cerebrospinal fluid column was moderate, with the
highest value of 0.31 at C5. The sagittal diameter of the cerebrospinal
fluid column showed variable correlation with the area of the
cerebrospinal fluid column. The highest correlation was 0.68 between the
sagittal diameter and the area of the cerebrospinal fluid column at C7.
The correlation between Pavlov\'s ratio and the area of the cord is
around zero, with the highest correlation of 0.21 at C4. The sagittal
diameter of the cord showed a moderate correlation with the area of the
cord. CONCLUSION: This study shows a poor correlation between Pavlov\'s
ratio and the space available for the cord. Therefore, this ratio cannot
be solely relied upon to predict the area changes in that plane of the
cervical spinal canal.

Rashiq, S., et al. \"The effect of opioid analgesia on exercise test
performance in chronic low back pain.\" *Pain.* 106, no. 1-2(2003):
119-25 UI 14581118.

The effect of opioid analgesia on tests of muscular function in chronic
low back pain (CLBP) is unknown. Twenty-eight subjects with CLBP of at
least moderate intensity performed the Sorensen isokinetic exercise test
once after receiving 1 microg/kg fentanyl intravenously and once after
placebo in a randomized-order double-blind crossover design. Naloxone 3
microg/kg was administered after the fentanyl phase. Fentanyl reduced
mean+/-SD pain from 4.0+/-2.1 to 3.1+/-2.2 on a 0-10 verbal rating scale
(P\<0.05). Mean+/-SD Sorensen test performance was 77+/-49 s in the
fentanyl arm and 60+/-42 s in the placebo arm. This represents an
increased performance with fentanyl of 28% (P\<0.001). We conclude that
in addition to relieving pain in CLBP, the administration of 1 microg/kg
fentanyl is associated with an improvement in lumbar exercise test
performance. We presume that the pain relief resulted in increased test
performance. Our result is at odds with those of randomized trials which
have failed to demonstrate increased function following the treatment of
pain with opioid analgesics. This highlights the complexity of the
interaction between pain, analgesia and changes in function.

Riggs, A. \"Controlling pain in the elderly: careful treatment can
prevent suffering, improve quality of life.\" *Journal of the Arkansas
Medical Society.* 100, no. 6(2003): 192-3 UI 14661400.

Ringler, R., et al. \"BOLD effects in different areas of the cerebral
cortex during painful mechanical stimulation.\" *Pain.* 105, no.
3(2003): 445-53 UI 14527705.

The contribution of four cortical areas (S1, S2, insular cortex and
gyrus cinguli) to pain processing was assessed by functional magnetic
resonance imaging (fMRI). Phasic (mechanical impact) and tonic stimuli
(squeezing) were applied to the back of a finger, both at two different
strengths. Stimuli were adjusted to inflict weak and strong pain
sensations. It had been shown before that stronger noxious mechanical
stimuli induce a weaker input from myelinated mechanoreceptors, but a
more vigorous input from nociceptive primary afferents, and vice versa.
Sizes of activation clusters and percent increase of the blood
oxygenation level dependent (BOLD) signal during activation were
compared in the areas of interest. Phasic stimulus patterns were more
closely reflected in the time course of the MR signal in S1, S2 and the
cingulate than tonic patterns, since the tonic stimuli tended to induce
slow MR signal increase also during the resting periods which is in
parallel to the persisting character of the tonic pain sensations. In S1
only the contralateral side was activated in most cases, and the more
painful stimuli did not induce greater BOLD responses compared to the
less painful stimuli in this area. Paradoxically, more painful stimuli
produced smaller activation clusters in S1, both in tonic and phasic
stimulus trials. In contralateral S2 more painful phasic stimuli induced
significantly stronger BOLD responses than the weaker stimuli. The
responses to tonic stimuli did not differentiate painfulness and were
significantly smaller than the phasic. Activation clusters in this area
were also smaller for tonic stimuli. In the gyrus cinguli more painful
phasic stimuli induced stronger BOLD responses, but no difference was
seen between tonic stimulation of different strength. Though the insular
cortex was often bilaterally activated, no significant differences
between stimulus quality or intensity were found. Our results provide
evidence for a contribution of the S2 projection area and of the
cingulate cortex to the processing of the intensity dimension of phasic
mechanical pain. Such evidence was not found for the S1 area, which
probably receives dominant input from non-nociceptive mechanoreceptors.

Roberts, R. O., et al. \"Low agreement between previous physician
diagnosed prostatitis and national institutes of health chronic
prostatitis symptom index pain measures.\" *Journal of Urology.* 171,
no. 1(2004): 279-83 UI 14665894.

PURPOSE: We evaluate the agreement between self-reported physician
diagnosed prostatitis and pain questions from the National Institutes of
Health Chronic Prostatitis Symptom Index (CPSI). MATERIALS AND METHODS:
A randomly selected cohort of white men 47 to 90 years old from Olmsted
County, Minnesota completed a study questionnaire on a history of
physician diagnosed prostatitis in the preceding 2 years, including the
CPSI questions. The medical records were also reviewed for physician
diagnosis of chronic prostatitis during the preceding 10 years. RESULTS:
Of 1,543 men 27 (1.7%) reported a physician diagnosis of prostatitis in
the preceding 2 years. There were strong associations between
self-reported prostatitis and pain at the tip of the penis (OR 6.3, 95%
CI 1.4, 28.5), ejaculatory (5.9, CI 1.3, 26.6) and testicular (3.6, 1.2,
10.8) pain. The chance corrected agreement between self-reported
prostatitis and pain symptoms was low at 0.01 (pubic pain) to 0.07 (pain
at the tip of the penis, ejaculatory pain and testicular pain).
Agreement in positive responses was also low at 3.7% (perineal pain) to
8% (pain at the tip of the penis, ejaculatory pain and testicular pain).
The predictive value of the modified total CPSI score for prostatitis
was 0.67, which was better than chance (0.5). Associations based on
medical record ascertainment of prostatitis during followup were weak,
and the area under the curve was 0.57, which was no better than chance.
CONCLUSIONS: These findings demonstrate low agreement between CPSI-like
pain measures and self-reported physician diagnosed prostatitis. The
stronger associations between pain symptoms and self-reported diagnosed
prostatitis, and the moderate predictive ability of the modified total
CPSI score measures for self-reported prostatitis compared to medical
record ascertainment demonstrate the sensitivity of the CPSI to
prevalent symptoms. Thus, the tool may be best used to evaluate the
severity of current symptoms rather than to assess the presence or
absence of prostatitis.

Robertson, P. A., A. S. Don, and M. V. Miller. \"Painful lumbosacral
melorheostosis treated by fusion.\" *Spine.* 28, no. 12(2003): E234-8 UI
12811287.

STUDY DESIGN: A case report of low back pain associated with a diagnosis
of melorheostosis of the lumbosacral spine. OBJECTIVE: To describe a
rare presentation of melorheostosis and subsequent successful surgical
treatment. SUMMARY OF BACKGROUND DATA: Melorheostosis is a rare
condition and spinal pain has not been described in association with the
condition. METHODS: A patient with disabling low back pain and suspected
melorheostosis of the lumbosacral spine responded favorably to
diagnostic facet joint blocks. Treatment was lumbosacral fusion and
biopsy of the abnormal bone. The densely sclerotic bone presented
technical difficulties requiring modification of surgical technique.
RESULTS: Dramatic pain and disability reduction occurred following
lumbosacral fusion. Histologic examination was consistent with
melorheostosis. CONCLUSION: Melorheostosis rarely causes severe low back
pain that can respond favorably to fusion surgery.

Rogers, R. M., Jr. \"Pelvic denervation surgery: what the evidence and
anatomy teach us.\" *Clinical Obstetrics & Gynecology.* 46, no. 4(2003):
767-72 UI 14595217.

Roig, S., et al. \"Spontaneous coronary artery dissection causing acute
coronary syndrome: an early diagnosis implies a good prognosis.\"
*American Journal of Emergency Medicine.* 21, no. 7(2003): 549-51 UI
14655234.

Spontaneous coronary artery dissection is an unusual cause of acute
coronary syndrome. We describe a series of cases that with an early
diagnosis and aggressive treatment, which includes percutaneous
angioplasty with stent implantation and cardiac surgery, had a good
outcome. The objective was to study the demographic characteristics,
clinical settings, treatments, and inhospital course of patients with
spontaneous coronary artery dissection. We studied a retrospective case
series in 3 coronary care units in third-level university hospitals. The
spontaneous coronary artery dissection diagnosis was made by coronary
angiography. Seven cases of spontaneous coronary artery dissections were
recorded. They were 5 women and 2 men. The age range was 28 to 64 years.
Two of them took oral contraceptives and one case occurred in the
postpartum period. An acute anterior wall myocardial infarction was the
most frequent clinical presentation, occurring in 4 of the 7 cases. In
fact, the left anterior descending artery was involved in 6 cases. An
urgent coronary angiogram was performed in all cases. Definitive
treatment included percutaneous angioplasty and stent implantation in 3
cases, coronary artery bypass surgery in 2 case, and cardiac
transplantation in another case. One patient was treated medically. None
of the patients died in the hospital. Spontaneous coronary artery
dissection remains an unusual cause of acute coronary syndrome. It
should be included in the differential diagnosis of acute myocardial
infarction, especially when it affects young, healthy females. An early
clinical suspicion and diagnosis with urgent coronary angiography and
aggressive treatment that includes percutaneous angioplasty with stent
implantation and cardiac surgery could improve the prognosis of these
patients.

Rollins, G. \"COX-2 inhibitors reduce knee replacement surgery
problems.\" *Report on Medical Guidelines & Outcomes Research.* 14, no.
24(2003): 1, 5-6 UI 14677563.

Rollnik, J. D., et al. \"Repetitive magnetic stimulation for the
treatment of chronic pain conditions.\" *Supplements to Clinical
Neurophysiology.* 56(2003): 390-3 UI 14677415.

Salo, D., et al. \"Can patients accurately read a visual analog pain
scale?\" *American Journal of Emergency Medicine.* 21, no. 7(2003):
515-9 UI 14655227.

The objective of this study was too determine if patients can accurately
read a visual analog scale (VAS) for pain. A 100-mm visual analog pain
scale designed for patient use was printed on the top page of carbonless
copy paper with a perfectly aligned hatched scale on the second (bottom)
page. Patients over the age of 18 in acute pain were enrolled in this
prospective, descriptive study. Patients were asked demographic
questions and to indicate their pain severity with a single mark through
the 100-mm scale. Once scored, patients were asked to read the number
from the hatched bottom scale. Two physician-raters, blinded to
patients\' and each other\'s readings, then scored the VAS. Analysis of
physician interrater reliability and correlation of patient and
physician readings was performed. One hundred forty-five patients were
enrolled. Seventy-nine patients (54.5%) read the VAS exactly as
physician-readers. One hundred thirty-eight (95.2%) read their VAS
within +/-2 mm of physician readings. Ninety-five percent of patients
are able to read a VAS within +/-2 mm of physician readings. The data
suggests this instrument could be used by discharged patients in
longitudinal pain studies or with help in management of chronic pain.

Schnoll, S. H., and M. F. Weaver. \"Addiction and pain.\" *American
Journal on Addictions.* 12, no. Suppl 2(2003): S27-35 UI 12857661.

The use of opioid medications for analgesia is associated with concerns
about adverse side effects and the potential for development of physical
dependence, tolerance, or addiction. Pain often is undertreated, which
may provoke drug-seeking behavior by patients. Physicians must assess
requests for more pain medication as stemming from either undertreatment
of pain, development of physical tolerance, or addiction. Important
tools for addiction screening include the use of questionnaires, patient
interviews, and lab tests. In this study, the physiological and
behavioral consequences of chronic pain and its treatment with opioids,
along with guidelines for prescribing opioid pain medication, are
presented. \[References: 26\]

Schulte, H., et al. \"Pharmacological modulation of experimental phasic
and tonic muscle pain by morphine, alfentanil and ketamine in healthy
volunteers.\" *Acta Anaesthesiologica Scandinavica.* 47, no. 8(2003):
1020-30 UI 12904196.

BACKGROUND: Muscle pain is a major clinical problem but the underlying
mechanisms and its pharmacological modulation need further
investigation. This study on 15 volunteers evaluates if two experimental
muscle pain models are sensitive to micro -receptor agonists and to an
N-methyl-D-aspartate (NMDA)-receptor antagonist. METHODS: In the left
tibialis anterior, intramuscular electrical (IMES) pain thresholds were
determined for single (SPTmuscle) and five (RPTmuscle) repeated stimuli.
Also pain to suprathreshold stimulation at 150% of RPTmuscle, 10 s, was
assessed on a visual analog scale (VAS) as AUCimes (area under the VAS
curve). In the right TA muscle, pain intensity on infusion of 0.5 ml of
hypertonic saline, 5% (AUCsaline) and pain distribution indicated as
local and referred were evaluated. Pain variables were assessed before,
during and after intravenous infusions of morphine (10 microg x kg-1
min-1, 10 min), alfentanil (target-controlled infusion, plasma
concentration; 60 ng ml-1, 60 min) and ketamine (10 microg x kg-1 min-1,
60 min). All data were normalized to baseline pain values (before drug
infusions were initiated) and compared with placebo (midazolam, 2 microg
x kg-1 min-1, 10 min). RESULTS: SPTmuscle increased (log mean values +/-
SD, mA) with morphine (0.11 +/- 0.17, P \< 0.05), alfentanil (0.28 +/-
0.24, P \< 0.001) and ketamine (0.19 +/- 0.18, P \< 0.01) as compared
with placebo (-0.03 +/- 0.12). Alfentanil and ketamine also increased
RPTmuscle (0.25 +/- 0.21, P \< 0.01 and 0.21 +/- 0.19, P \< 0.05,
respectively) as compared with placebo (0.00 +/- 0.17). Pain to IMES
(AUCimes) was reduced (median values \[25th-75th percentiles\], cm x s)
by alfentanil and ketamine (-19.7 \[-14.6 - -29.6\] and-12.8 \[-8.3 -
-27.8\], P \< 0.05, respectively) vs. placebo (-0.8 \[1.6 - -12.3\]).
Similar drug effects were seen when pain to infusion of hypertonic
saline (AUCsaline) was assessed (alfentanil:-388 \[-99 - -677\] and
ketamine:-326 \[-227 - -573\], P \< 0.05 compared with placebo: 150
\[449\--240\]). Ketamine also reduced the size of the local pain area
(-58.4 \[-21.2 - -176.1\], \< 0.05) as compared with placebo (-0.4
\[70.6 - -13.4\]). The frequency of referred pain was also lower when
ketamine was given (3/13, P \< 0.05) vs. placebo (9/14). CONCLUSION: The
study demonstrates that experimental muscle pain induced in humans by
electrical stimulation and infusion of hypertonic saline is sensitive to
pharmacological modulation similar to preclinical animal tests and
clinical trials. The data suggest that these models can be valuable
tools in analgesic drug development.

Sharp, H. T. \"Myofascial pain syndrome of the abdominal wall for the
busy clinician.\" *Clinical Obstetrics & Gynecology.* 46, no. 4(2003):
783-8 UI 14595219.

Shaw, R. W. \"Evaluation of the role of laser treatment for the
treatment of pain in endometriosis.\" *Annals of the New York Academy of
Sciences.* 997(2003): 240-6 UI 14644831.

There have been few appropriately conducted trials to evaluate the
effectiveness of laser destruction of endometriosis in relieving pain
symptoms, yet the techniques are increasingly being used. Laser
destruction has been shown to be more effective than the placebo effect
of laparoscopy alone in one trial, at least at 6-month follow-up.
Longer-term studies suggest increasing recurrence of symptoms with time
\[23% at 12 months in one study, and 44% by a mean of 19.7 months (5-60)
follow-up\]. These recurrence rates are similar to those seen following
6 months medical treatment. It is unknown whether laparoscopic
uterosacral nerve ablation (LUNA) in addition to destruction of lesions
will produce better results, and appropriate trials are needed in
several areas to determine the role of laser therapy. \[References: 8\]

Shechter, M., et al. \"External counterpulsation therapy improves
endothelial function in patients with refractory angina pectoris.\[see
comment\].\" *Journal of the American College of Cardiology.* 42, no.
12(2003): 2090-5 UI 14680732.

OBJECTIVES: The goal of this study was to investigate the influence of
short-term external counterpulsation (ECP) therapy on flow-mediated
dilation (FMD) in patients with coronary artery disease (CAD).
BACKGROUND: In patients with CAD, the vascular endothelium is usually
impaired and modification or reversal of endothelial dysfunction may
significantly enhance treatment. Although ECP therapy reduces angina and
improves exercise tolerance in patients with CAD, its short-term effects
on FMD in patients with refractory angina pectoris have not yet been
described. METHODS: We prospectively assessed endothelial function in 20
consecutive CAD patients (15 males), mean age 68 +/- 11 years, with
refractory angina pectoris (Canadian Cardiovascular Society \[CCS\]
angina class III to IV), unsuitable for coronary revascularization,
before and after ECP, and compared them with 20 age- and gender-matched
controls. Endothelium-dependent brachial artery FMD and
endothelium-independent nitroglycerin (NTG)-mediated vasodilation were
assessed before and after ECP therapy, using high-resolution ultrasound.
RESULTS: External counterpulsation therapy resulted in significant
improvement in post-intervention FMD (8.2 +/- 2.1%, p = 0.01), compared
with controls (3.1 +/- 2.2%, p = 0.78). There was no significant effect
of treatment on NTG-induced vasodilation between ECP and controls (10.7
+/- 2.8% vs. 10.2 +/- 2.4%, p = 0.85). External counterpulsation
significantly improved anginal symptoms assessed by reduction in mean
sublingual daily nitrate consumption, compared with controls (4.2 +/-
2.7 nitrate tablets vs. 0.4 +/- 0.5 nitrate tablets, p \<0.001 and 4.5
+/- 2.3 nitrate tablets vs. 4.4 +/- 2.6 nitrate tablets, p = 0.87,
respectively) and in mean CCS angina class compared with controls (3.5
+/- 0.5 vs. 1.9 +/- 0.3, p \<0.0001 and 3.3 +/- 0.6 vs. 3.5 +/- 0.5, p =
0.89, respectively). CONCLUSIONS: External counterpulsation
significantly improved vascular endothelial function in CAD patients
with refractory angina pectoris, thereby suggesting that improved
anginal symptoms may be the result of such a mechanism.

Simpson, D. M., et al. \"Lamotrigine for HIV-associated painful sensory
neuropathies: a placebo-controlled trial.\" *Neurology.* 60, no.
9(2003): 1508-14 UI 12743240.

OBJECTIVE: To evaluate the efficacy and tolerability of lamotrigine
(LTG) for the treatment of pain in HIV-associated sensory neuropathies.
METHODS: In a randomized, double-blind study, patients with
HIV-associated distal sensory polyneuropathy (DSP) received LTG or
placebo during a 7-week dose escalation phase followed by a 4-week
maintenance phase. Randomization was stratified according to whether or
not patients were currently using neurotoxic antiretroviral therapy
(ART). RESULTS: The number of patients randomized was 92 (62 LTG, 30
placebo) in the stratum receiving neurotoxic ART and 135 (88 LTG, 47
placebo) in the stratum not receiving neurotoxic ART. Mean change from
baseline in Gracely Pain Scale score for average pain was not different
between LTG and placebo at the end of the maintenance phase in either
stratum, but the slope of the change in Gracely Pain Scale score for
average pain reflected greater improvement with LTG than with placebo in
the stratum receiving neurotoxic ART (p = 0.004), as did the mean change
from baseline scores on the Visual Analogue Scale for Pain Intensity and
the McGill Pain Assessment Scale and patient and clinician ratings of
global impression of change in pain (p \</= 0.02). The incidence of
adverse events, including rash, was similar between LTG and placebo.
CONCLUSIONS: Lamotrigine was well-tolerated and effective for
HIV-associated neuropathic pain in patients receiving neurotoxic
antiretroviral therapy. Additional research is warranted to understand
the differing response among patients receiving neurotoxic
antiretroviral therapy compared with those not receiving neurotoxic
antiretroviral therapy.

Sinatra, R. S., et al. \"Preoperative rofecoxib oral suspension as an
analgesic adjunct after lower abdominal surgery: the effects on
effort-dependent pain and pulmonary function.\" *Anesthesia &
Analgesia.* 98, no. 1(2004): 135-40, table of contents UI 14693607.

Rofecoxib is a selective cyclooxygenase-2 inhibitor that reduces pain
and inflammation without inhibiting platelet function. We examined its
effects on effort-dependent pain, postoperative morphine requirements,
and pulmonary function in 48 patients recovering from open abdominal
surgery. Spirometric measurement of forced expiratory volume(1) and
vital capacity (FVC) were assessed preoperatively. One hour before the
induction of a standardized general anesthetic, patients were given
either placebo oral suspension (Group A), or rofecoxib oral suspension
(25 mg \[Group B\] or 50 mg \[Group C\]) in a double-blinded manner.
Postoperative pain control was provided with IV morphine in the
postanesthesia care unit and IV-patient-controlled analgesia morphine on
the patient care unit. Morphine dose, pain intensity at rest, and pain
after respiratory effort (postoperative spirometry) were assessed at 12
and 24 h after study drug administration. The patient-controlled
analgesia morphine dose at 24 h was reduced 44% in Group B (30.3 +/-
17.5 mg) and 59% in Group C (22.1 +/- 16.5 mg) versus Group A (53.7 +/-
31.1 mg); P \< 0.01 (A versus B). At 12 h, pain scores at rest and after
spirometry were lower in Groups B and C than in A (P \< 0.05). At 24 h,
resting pain scores were lowest in Group C (P \< 0.05). Twelve-hour FVC
was best preserved in Group C (P \< 0.03). There were no inter-group
differences in adverse effects or perioperative blood loss. Rofecoxib
oral suspension provided a morphine-sparing effect, as well as
improvements in pain control and 12-h FVC in patients recovering from
open abdominal surgery. IMPLICATIONS: Rofecoxib belongs to class of
analgesics known as cyclooxygenase-2 inhibitors that reduce pain and
inflammation with less risk of bleeding than standard nonsteroidal
antiinflammatory drugs. We found that patients treated with rofecoxib 25
or 50 mg before open abdominal surgery required less IV morphine during
the first day of recovery. Despite reductions in morphine requirements,
rofecoxib-treated patients reported lower pain intensity scores at rest
and after a vigorous cough. In the 50-mg group, improvements in pain
control correlated with greater preservation of baseline cough
effectiveness (vital capacity) at 12 h. These findings may offer
clinical advantages in patients with preexisting pulmonary disease.

Sindrup, S. H., et al. \"Venlafaxine versus imipramine in painful
polyneuropathy: a randomized, controlled trial.\" *Neurology.* 60, no.
8(2003): 1284-9 UI 12707430.

BACKGROUND: Tricyclic antidepressants (TCA) are often used in the
treatment of painful polyneuropathy. Venlafaxine is a serotonin and weak
noradrenaline reuptake inhibitor antidepressant with a different profile
of other pharmacologic actions from those of TCA. OBJECTIVE: To test if
venlafaxine would relieve painful polyneuropathy and compare its
possible efficacy with that of the TCA imipramine. METHODS: The study
design was randomized, double blind, and placebo controlled, with a
three-way crossover. Forty patients were assigned to one of the
treatment sequences, and 29 completed all three study periods. The daily
doses were venlafaxine 225 mg and imipramine 150 mg. During the three
treatment periods, each of 4 weeks\' duration, patients rated pain
paroxysms, constant pain, and touch- and pressure-evoked pain by use of
0- to 10-point numeric rating scales. RESULTS: The sum of the individual
pain scores during treatment week 4 was lower on venlafaxine (80% of
baseline score; p = 0.006) and imipramine (77%; p = 0.001) than on
placebo (100%) and did not show any statistical difference between
venlafaxine and imipramine (p = 0.44). The individual pain scores for
pain paroxysms, constant pain, and pressure-evoked pain showed a similar
pattern, whereas touch-evoked pain was uncommon and was not altered by
any of the drugs. Numbers needed to treat to obtain one patient with
moderate or better pain relief were 5.2 for venlafaxine and 2.7 for
imipramine. CONCLUSION: Venlafaxine relieves pain in polyneuropathy and
may be as effective as imipramine.

Sjoling, M., et al. \"The impact of preoperative information on state
anxiety, postoperative pain and satisfaction with pain management.\"
*Patient Education & Counseling.* 51, no. 2(2003): 169-76 UI 14572947.

The primary objective of this study was to test whether specific
information given prior to surgery can help patients obtain better pain
relief after total knee arthroplasty (TKA). Secondary objectives were to
study the impact of preoperative information on state and trait anxiety,
satisfaction with pain management and satisfaction with nursing care.
The study was an intervention study with two groups of equal size
(n=30). The intervention group was given specific information while the
control group received routine information. Pain assessments were made
preoperatively and every 3h for the first three postoperative days,
using the visual analogue scale (VAS). The results of this study suggest
that information does influence the experience of pain after surgery and
related psychological factors. The postoperative pain declined more
rapidly for patients in the treatment group, the degree of preoperative
state anxiety was lower and they were more satisfied with the
postoperative pain management.

Small, E. J., et al. \"Combined analysis of two multicenter, randomized,
placebo-controlled studies of pamidronate disodium for the palliation of
bone pain in men with metastatic prostate cancer.\[see comment\].\"
*Journal of Clinical Oncology.* 21, no. 23(2003): 4277-84 UI 14581438.

PURPOSE: Bone metastases occur in approximately 80% of patients with
advanced prostate cancer. Pain is common in these patients. The purpose
of this study was to evaluate the effect of an intravenous
bisphosphonate, pamidronate disodium, on pain control in metastatic
prostate cancer patients. PATIENTS AND METHODS: Two multicenter,
double-blind, randomized, placebo-controlled trials were conducted in
patients with bone pain due to metastatic prostate cancer, with disease
progression after first-line hormonal therapy. Intravenous pamidronate
disodium (90 mg) or placebo was administered every 3 weeks for 27 weeks.
Efficacy was measured via self-reported pain score (Brief Pain
Inventory), analgesic use, the proportion of patients with a
skeletal-related event (SRE; defined as pathologic fracture, radiation
or surgery to bone, spinal cord compression, or hypercalcemia), and a
pilot quantitative measurement of mobility. Laboratory evaluations
included serum prostate-specific antigen, interleukin-6, bone alkaline
phosphatase, and urinary bone resorption markers. RESULTS: Results of
the two trials were pooled. There were no sustained significant
differences between the pamidronate and placebo groups in self-reported
pain measurements, analgesic use, proportion of patients with an SRE, or
mobility at week 9 or 27. Urinary bone resorption markers were
suppressed in the pamidronate group compared with placebo. CONCLUSION:
Pamidronate disodium failed to demonstrate a significant overall
treatment benefit compared with placebo in palliation of bone pain or
reduction of SREs. Evaluation of more potent bisphosphonates in patients
with prostate cancer is warranted.

Somers, M. P., et al. \"Additional electrocardiographic leads in the ED
chest pain patient: right ventricular and posterior leads.\" *American
Journal of Emergency Medicine.* 21, no. 7(2003): 563-73 UI 14655239.

In the evaluation of the patient with chest pain, the 12-lead electro
cardiogram is a less-than-(ECG) perfect indicator of acute myocardial
infarction (AMI), particularly when used early in the course of the
acute ischemic event; this relative insensitivity for AMI results from
many different issues, including a less-than-optimal imaging of certain
areas of the heart. It has been suggested that the sensitivity of the
12-lead ECG can be improved if 3 additional body surface leads are used
in selected individuals. Acute posterior (PMI) and right ventricular
myocardial infarctions are likely to be underdiagnosed, because the
standard lead placement of the 12-lead ECG does not allow these areas to
be assessed directly. Additional leads frequently used include leads
V(8) and V(9), which image the posterior wall of the left ventricle, and
lead V(4R), which reflects the status of the right ventricle. The
standard ECG coupled with these additional leads constitutes the 15-lead
ECG, the most frequently used additional lead ECG in clinical practice.
The use of the additional leads might not only confirm the presence of
AMI, but also provide a more accurate reflection of the true extent of
myocardial damage.

Staats, P. S., et al. \"Intrathecal ziconotide in the treatment of
refractory pain in patients with cancer or AIDS: a randomized controlled
trial.\" *Jama.* 291, no. 1(2004): 63-70 UI 14709577.

CONTEXT: Ziconotide (formerly SNX-111) selectively blocks N-type
voltage-sensitive calcium channels and may be effective in patients with
pain that is refractory to opioid therapy or those with intolerable
opioid-related adverse effects. OBJECTIVE: To assess the safety and
efficacy of intrathecal ziconotide in patients with pain that is
refractory to conventional treatment. DESIGN, SETTING, AND PATIENTS:
Double-blind, placebo-controlled, randomized trial conducted from March
12, 1996, to July 11, 1998, at 32 study centers in the United States,
Australia, and the Netherlands. Patients were 111 individuals ages 24 to
85 years with cancer or AIDS and a mean Visual Analog Scale of Pain
Intensity (VASPI) score of 50 mm or greater. Patients were randomly
assigned in a 2:1 ratio to receive ziconotide or placebo treatment.
INTERVENTIONS: Intrathecal ziconotide was titrated over 5 to 6 days,
followed by a 5-day maintenance phase for responders and crossover of
nonresponders to the opposite treatment group. MAIN OUTCOME MEASURE:
Mean percentage change in VASPI score from baseline to the end of the
initial titration period. RESULTS: Of the evaluable population, 67
(98.5%) of 68 patients receiving ziconotide and 38 (95%) of 40 patients
receiving placebo were taking opioids at baseline (median morphine
equivalent dosage of 300 mg/d for the ziconotide group and 600 mg/d for
the placebo group; P =.63, based on mean values), and 36 had used
intrathecal morphine. Mean (SD) VASPI scores were 73.6 (1.8) mm in the
ziconotide group and 77.9 (2.3) mm in the placebo group (P =.18). Mean
VASPI scores improved 53.1% (95% confidence interval \[CI\],
44.0%-62.2%) in the ziconotide group and 18.1% (95% CI, 4.8%-31.4%) in
the placebo group (P\<.001), with no loss of efficacy of ziconotide in
the maintenance phase. Pain relief was moderate to complete in 52.9% of
patients in the ziconotide group compared with 17.5% in the placebo
group (P\<.001). Five patients receiving ziconotide achieved complete
pain relief, and 50.0% of patients receiving ziconotide responded to
therapy compared with 17.5% of those receiving placebo (P =.001).
CONCLUSION: Intrathecal ziconotide provided clinically and statistically
significant analgesia in patients with pain from cancer or AIDS.

Stacey, B. R., and R. L. Glanzman. \"Use of gabapentin for postherpetic
neuralgia: results of two randomized, placebo-controlled studies.\"
*Clinical Therapeutics.* 25, no. 10(2003): 2597-608 UI 14667960.

BACKGROUND: Postherpetic neuralgia (PHN), which affects up to 70% of
elderly persons with herpes zoster, can have debilitating effects,
including physical and social disability and significant psychological
distress. A variety of agents have been used, either singly or in
combination, to control PHN, including topical and oral analgesics,
antidepressants, and antiepileptic drugs (AEDs). However, PHN often
proves refractory to these therapies. OBJECTIVE: This article reviews
available data on the use of the newer AED gabapentin for the control of
PHN. METHODS: A MEDLINE search was undertaken to identify all
randomized, placebo-controlled trials on the use of gabapentin in PHN.
The search terms were gabapentin and postherpetic neuralgia. RESULTS:
The literature search identified 2 published studies of the efficacy of
gabapentin in a total of 563 patients with PHN that had persisted for at
least 3 months after the healing of herpes zoster rash. The studies
employed multiple outcome measures, including visual analog and Likert
scales for pain intensity, and quality-of-life and functional measures
that included the Medical Outcomes Study 36-item Short Form Health
Survey (SF-36) and the Profile of Mood States. At maximum target dosages
of 1800 to 3600 mg/d, gabapentin produced significant reductions in mean
daily pain scores compared with placebo on both visual analog(P \<
0.001) and Likert scales (P \< 0.01). Improvements were also seen on the
SF-36 subscales for physical functioning, bodily pain, vitality, and
mental health(P \< 0.01). CONCLUSION: Gabapentin may provide benefits in
terms of alleviation of pain and overall quality of life in patients
with chronic PHN. \[References: 27\]

Stephens, J., et al. \"The burden of acute postoperative pain and the
potential role of the COX-2-specific inhibitors.\" *Rheumatology.* 42,
no. Suppl 3(2003): iii40-52 UI 14585917.

Pain has been recognized as a problem of global proportions, and
postoperative pain is one of the most common types of pain.
Postoperative pain is acute and, although it is preventable and/or
treatable, it is often undertreated. Lack of appropriate analgesic
management has significant impact on clinical and economic outcomes.
Negative clinical outcomes of inadequately managed acute postoperative
pain include extended hospitalization, compromised prognosis, higher
morbidity and mortality, and the development of a chronic pain state as
a result of neuronal plasticity. Although estimating the economic burden
of postoperative pain is difficult, this burden is considerable and
results from direct costs due to excess health-care resource use, as
well as indirect costs due to reduced patient functionality and
productivity. These latter factors also have a significant adverse
impact on patients\' quality of life and may be associated with the
development of depression and anxiety. Thus, improved clinical outcomes
are dependent not only on the availability of effective drugs but also
on their appropriate utilization. A multimodal approach incorporating
different drugs and techniques is effective in reducing postoperative
pain but is limited by the currently available therapies. The efficacy
of opioids is well established, but there are concerns about dependency,
respiratory depression and side-effects, which patients often find
intolerable. Non-steroidal anti-inflammatory drugs (NSAIDs) are
effective as adjunctive medication in a multimodal regimen but are
associated with side-effects, such as platelet dysfunction and renal and
gastrointestinal toxicity, that have special clinical significance in
patients undergoing surgical procedures. Cyclooxygenase-2-specific
inhibitors such as celecoxib, rofecoxib and valdecoxib, were developed
to provide the efficacy of non-specific NSAIDs while limiting associated
toxicity. These agents have demonstrated analgesic efficacy and an
opioid-sparing effect in a variety of surgical procedures, suggesting
their value as an alternative to non-specific NSAIDs. Further studies
are needed to determine the impact of these drugs on clinical and
economic outcomes when used in a programme of postsurgical pain
management. \[References: 137\]

Stephenson, N., J. A. Dalton, and J. Carlson. \"The effect of foot
reflexology on pain in patients with metastatic cancer.\" *Applied
Nursing Research.* 16, no. 4(2003): 284-6 UI 14608562.

Thirty-six oncology inpatients participated in this third pilot study
investigating the effects of foot reflexology in which equianalgesic
dosing was calculated. Foot reflexology was found to have a positive
immediate effect for patients with metastatic cancer who report pain,
although there was no statistically significant effect at 3 hours after
intervention or at 24 hours after intervention. Further study is
suggested for foot reflexology delivered by family in the homes for
management of cancer pain.

Stute, P., et al. \"Analysis and treatment of different types of
neuropathic cancer pain.\" *Journal of Pain & Symptom Management.* 26,
no. 6(2003): 1123-31 UI 14654264.

Neuropathic pain is a major problem in the treatment of cancer pain. We
performed a retrospective analysis of 213 cancer patients with
neuropathic pain treated by a pain service following the World Health
Organization guidelines for relief of cancer pain. Of these, 79%
presented with nerve compression pain, 16% with nerve injury pain, and
5% with sympathetically-maintained pain. Whereas nerve compression and
nerve injury pain were caused most frequently by cancer growth,
sympathetically-maintained pain was caused most frequently by cancer
treatment. There were no significant differences in the use of
analgesics, the mean pain intensity, or the efficacy of analgesic
treatment among the three groups. Nerve injury pain and
sympathetically-maintained pain were treated more frequently with
adjuvant analgesics, especially antidepressants and anticonvulsants. The
variety of different neuropathic pain syndromes should be separated in
future studies of the efficacy of different treatment approaches.

Sueda, S., et al. \"Did the widespread use of long-acting calcium
antagonists decrease the occurrence of variant angina?\" *Chest.* 124,
no. 6(2003): 2074-8 UI 14665482.

BACKGROUND: We have not often encountered variant angina (VA) since the
use of long-acting calcium antagonists (L-CAs) became widespread.
OBJECTIVES: This study examined the frequency of VA retrospectively.
METHODS: and results: We diagnosed angiographically confirmed coronary
spastic angina (CSA) in 349 consecutive patients using selective spasm
provocation tests from January 1991 to December 2002. During this
period, 3,148 diagnostic cardiac catheterizations and 1,515 selective
spasm provocation tests were performed. Seventy-four of these 349
patients (21.2%) had VA. Coronary spasms were defined as transient
luminal narrowings of \> 99%, and VA was defined as an ST elevation
during spontaneous attacks or noninvasive stress tests. We classified
the 12 years of the study into four periods of 3 years each. No tendency
to decrease for the ratio of the number of patients with CSA and the
number of selective spasm provocation tests was observed among the four
time periods (18%, 24%, 32%, and 23%, respectively). However, the number
of patients with VA (28, 33, 9, and 4) and the VA/CSA ratio (32%, 28%,
14%, and 5%, respectively) in the four group significantly decreased.
The frequency of administration of calcium antagonists (CAs) before
hospital admission (49% vs 33%, respectively; p \< 0.05) was
significantly higher in the last time period (from 2000 to 2002) than in
the first period (from 1991 to 1993). L-CAs were administered in \> 90%
of CSA patients who had been medicated with CAs before hospital
admission in the last period (from 2000 to 2002), while L-CAs were
administered in only 20% in the former period (from 1991 to 1993). The
administration of statins and angiotensin-converting enzyme
inhibitors/angiotensin receptor blockers before hospital admission
gradually increased according to the period passed, but not
significantly. CONCLUSION: The frequency of VA has decreased in Japan,
possibly due to the widespread use of therapy with L-CAs.

Sugden, S., C. Dunbar, and K. A. Ka. \"Is there a need for an
interactive teaching tool on pain management in cancer?\" *International
Journal of Palliative Nursing.* 9, no. 11(2003): 485-8 UI 14676725.

Svorkdal, N., C. American College of, and A. American Heart. \"Pro:
anesthesiologists\' role in treating refractory angina: spinal cord
stimulators, thoracic epidurals, therapeutic angiogenesis, and other
emerging options.\" *Journal of Cardiothoracic & Vascular Anesthesia.*
17, no. 4(2003): 536-45 UI 12968247.

Titler, M. G., et al. \"Acute pain treatment for older adults
hospitalized with hip fracture: current nursing practices and perceived
barriers.\" *Applied Nursing Research.* 16, no. 4(2003): 211-27 UI
14608555.

This article examines acute pain management practices for patients 65
years of age and older who were hospitalized during 1999 for hip
fracture. Data were collected from the medical records of patients (N =
709) admitted to 12 hospitals in the Midwest and from questionnaires on
pain practices completed by nurses (N = 172) caring for these patients.
The major variables examined were (1). pharmacological and
nonpharmacological treatments for acute pain in hospitalized elders,
(2). nurses\' perceived stage of adoption for avoiding meperidine use
and for administering analgesics around-the-clock, and (3). nurses\'
perceived barriers to optimal treatment of acute pain in elders.
Acetaminophen was the most frequently administered analgesic, but
administered doses were far less than the maximum daily recommended
dose. More than one third (39%) of the nurses reported that they always
avoided the use of meperidine, and over half reporting avoiding its use
sometimes. However, the majority of patients (56.8%) received at least
one dose of meperidine, even though evidence suggests that other
analgesic agents are more appropriate for treatment of acute pain in
elders. Only 27% of patients received patient-controlled analgesia, and
only 22.3% of patients received around-the-clock administration during
the first 24 hours after admission of analgesics that had been ordered
on a prn basis. The majority of nurses were aware that around-the-clock
administration of analgesics was preferable, but only 33.7% were
persuaded (believed) that this method should be used. Intramuscular
injection was used for 52.2% of patients, even though this route is not
recommended for older adults. The most frequently used
nonpharmacological intervention was repositioning, followed by use of
pressure relief devices and cold application. Nurses reported difficulty
contacting physicians and difficulty communicating with them about type
and/or dose of analgesics as the greatest barriers to pain management.
Findings from this multi-site study show that active and focused
\"translation\" interventions are needed to promote adoption of
evidence-based acute pain management practices by health care providers.

Tobinick, E. L. \"Targeted etanercept for treatment-refractory pain due
to bone metastasis: two case reports.\" *Clinical Therapeutics.* 25, no.
8(2003): 2279-88 UI 14512134.

BACKGROUND: Parallel bodies of research suggest both a central role for
osteoclasts in tumor-induced destruction of bone and the ability of
biologic tumor necrosis factor-alpha (TNF-alpha) antagonists to
attenuate the osteoclast-mediated bone destruction that accompanies a
variety of nonmalignant disorders. Additional studies have implicated
TNF-alpha in the promotion of osteoclast-mediated malignant osteolysis
and the pathogenesis of neuropathic pain. TNF-alpha antagonists have the
potential to interfere in both processes. OBJECTIVE: This article
reviews the cases of 2 patients with treatment-refractory pain due to
cancer metastases to bone who were given targeted injections of the
biologic anti-TNF agent etanercept based on its potential to interfere
directly with both malignant activation of osteoclasts and neuropathic
pain. METHODS: One patient had a diagnosis of non-small cell lung cancer
and the other had a diagnosis of breast cancer. Both presented with
treatment-refractory pain due to bone metastases. The 2 patients
received etanercept 25 mg by targeted SC injection in anatomic proximity
to the site of spinal metastasis for relief of their
treatment-refractory pain. RESULTS: Both patients experienced rapid,
substantial, and sustained relief of chronic refractory pain at the
treatment site after targeted administration of etanercept. Symptomatic
improvement was correlated with objective measures of improvement,
including weight gain in 1 patient and decreased uptake of radioactive
tracer at the targeted site on positron emission tomography in the
other. CONCLUSIONS: Etanercept delivered by targeted SC injection may be
of clinical benefit in selected patients with treatment-refractory pain
caused by bone metastases. Clinical trials are needed to define the
potential benefit of biologic TNF-alpha antagonists in the treatment and
prevention of malignant osteolysis.

Tornkvist, L., A. Gardulf, and L. E. Strender. \"Effects of
\'pain-advisers\': district nurses\' opinions regarding their own
knowledge, management and documentation of patients in chronic pain.\"
*Scandinavian Journal of Caring Sciences.* 17, no. 4(2003): 332-8 UI
14629635.

This study investigated whether district nurses\' opinions changed after
the education and introduction of district nurses as \'pain-advisers\'
at primary health care centres (PHCCs) regarding working conditions and
satisfaction with pain control management at their PHCCs, their own
knowledge of pain control and satisfaction with their own pain control
management, pain assessment and nursing documentation of patients with
chronic pain conditions. A study area (SA) with five PHCCs and a control
area (CA) with seven PHCCs were selected. In the SA, 28 and in the CA,
25 district nurses answered a questionnaire both before and after the
introduction of the \'pain-advisers\' into the SA. The district nurses
in both areas in 1996 and 1998 considered many aspects of pain
management to be unsatisfactory. According to the district nurses in the
SA, several statistically significant improvements were achieved after
the introduction of the \'pain-advisers\'; more district nurses reported
that pain policies or other written information were now available at
their PHCCs, that they were more satisfied with present overall routines
at their PHCCs, that a better pain control was applied at their PHCCs
regarding patients with leg ulcers, that they themselves to a greater
extent performed individual pain assessments of the patients and that
they more often used pain visual analogue scales to assess the
patients\' pain and to evaluate the results of the pain treatment. They
also reported an increased satisfaction with their own nursing
documentation. Although much remains to be done, it must be acknowledged
that the \'pain-advisers\', with relatively small resources, managed to
make significant improvements.

Trim, J., F. Fordyce, and S. Dua. \"Using clinical governance to
standardise an epidural service.\" *Nursing Standard.* 18, no. 9(2003):
43-5 UI 14649193.

Continual epidural infusions are an accepted intervention for the
management of postoperative pain (McQuay and Moore 1998). Benchmarking
nationally through an unpublished audit of Pain Society members
identified variation in the concentrations prescribed and delivery
systems used. These differences were reflected in local practice. As a
result of the local disparity in the management and provision of
epidural infusions, the acute pain service at Southampton University
Hospitals NHS Trust worked in conjunction with the pharmacy department
to standardise the service provided to patients and staff. This process
was complicated by the difficulty in obtaining anaesthetist consensus
for a standard solution that was commercially available and funding for
the dedicated delivery system.

Tynecka-Turowska, M., et al. \"The use of instrumental examinations in
the diagnosis of headaches.\" *Neurological Sciences.* 24, no. 4(2003):
305-7 UI 14658058.

Headaches are the most common complaint reported by patients to their
physician. They can be divided into spontaneous and symptomatic. The
findings of the history and examination may suggest the need for
diagnostic testing. The ancillary investigation and management of
headache is discussed.

Valle, R. F., and J. J. Sciarra. \"Endometriosis: treatment
strategies.\" *Annals of the New York Academy of Sciences.* 997(2003):
229-39 UI 14644830.

Endometriosis is often a perplexing medical condition for both the
physician and the patient. Accordingly, development of treatment
strategies based on the needs of the individual patient is highly
desirable. Although endometriosis has been part of the clinical practice
for almost a century, many questions remain relating to the relationship
between endometriosis and infertility as well as endometriosis and
pelvic pain. Endometriosis is a disease of reproductive-age women, and
it is now well recognized that a genetic susceptibility appears
probable. The prevalence in the general population has never been
clearly established. Factors to consider in management include the age
and reproductive desires of the patient, the stage of the disease, and,
most importantly, the symptoms. Therapeutic options include no
treatment, medical therapy, surgery, or combination therapy. Oral
contraceptives, androgenic agents, progestins, and gonadotropin
releasing hormone (GnRH) analogs have all been used successfully,
although at the present time, the latter preparations are the most
popular medical therapy for endometriosis. Leuprolide acetate, goserelin
acetate, and nafarelin acetate are all effective agents. Surgical
therapy is appropriate, especially for advanced stages of the disease.
Laparoscopy is an effective surgical approach with the goal of excision
of visible endometriosis in a hemostatic fashion. Since endometriosis is
a chronic condition, it is not uncommon for recurrences to occur. While
endometriosis remains an enigmatic disease, the introduction of new
pharmacologic agents, such as GnRH analogs and newer endoscopic methods
of surgical treatment, have facilitated and improved the overall
management of this disease. \[References: 26\]

Van As, C., L. J. Mulder, and E. L. Spierings. \"Painful swelling of the
abdomen.\" *Neurology.* 61, no. 1(2003): 138 UI 12847178.

van Seventer, R., et al. \"Comparison of TTS-fentanyl with
sustained-release oral morphine in the treatment of patients not using
opioids for mild-to-moderate pain.\" *Current Medical Research &
Opinion.* 19, no. 6(2003): 457-69 UI 14594516.

OBJECTIVE: This randomised, multicentre, direct open comparative trial
evaluated the efficacy, treatment convenience, tolerability and safety
aspects of transdermal therapeutic system (TTS)-fentanyl and
sustained-release oral morphine (SRM) in both opioid-naive patients with
moderate-to-severe cancer-related pain and in patients who had already
been using opioids for mild-to-moderate pain. The two treatment groups
were run in parallel. Special attention was paid to constipation,
nausea/vomiting, drowsiness and respiratory depression. PATIENTS AND
METHODS: The 131 enrolled patients started the 4-week treatment at low
doses of opioid (25 microg/h TTS-fentanyl for 3 days or 30 mg SRM every
12 h) and were individually titrated. Tolerability, efficacy and safety
were assessed throughout the study period. Frequency of constipation was
the primary study variable and accordingly the study was powered for
this. Both patients and investigators made a global treatment
evaluation. RESULTS: TTS-fentanyl and SRM were shown to be equally
effective. Pain control and sleep quality improved with both treatments.
None of the patients developed respiratory depression. Statistically
significantly more patients in the SRM treatment group discontinued the
trial prematurely (59% vs 27%; p \< 0.001), particularly due to adverse
events (36% vs 4%; p \< 0.001). Fewer patients in the TTS-fentanyl than
in the SRM treatment group reported constipation during the trial. This
finding was statistically significant after 1 week of treatment (27% vs
57%; p = 0.003). The favourable tolerability profile of TTS-fentanyl was
also reflected in both the patient and the investigator global
evaluation of the treatment. Patient assessment favoured TTS-fentanyl
treatment in terms of a significantly lower rate of troublesome
side-effects (\'quite a bit\' to \'very much\' troublesome side-effects
in 14% vs 36% of patients; p = 0.003) and less interruption of daily
activities (absence of any interruption of daily activities in 88% vs
63% of patients; p = 0.012). Investigators scored TTS-fentanyl as
significantly better with respect to \'side-effects\' (p = 0.039) and
\'overall impression\' (p = 0.013). Sub-analyses of opioid-naive users
gave similar results. CONCLUSION: These data indicate that TTS-fentanyl,
when used as an opioid of first choice in the treatment of
cancer-related pain, is as effective as, but better tolerated than, SRM,
including in opioid-naive patients.

van Tulder, M., et al. \"Updated method guidelines for systematic
reviews in the cochrane collaboration back review group.\" *Spine.* 28,
no. 12(2003): 1290-9 UI 12811274.

STUDY DESIGN: Descriptive method guidelines. OBJECTIVES: To help
reviewers design, conduct, and report reviews of trials in the field of
back and neck pain. SUMMARY OF BACKGROUND DATA: In 1997, the Cochrane
Collaboration Back Review Group published method guidelines for
systematic reviews. Since its publication, new methodologic evidence
emerged and more experience was acquired in conducting reviews. METHODS:
All reviews and protocols of the Back Review Group were assessed for
compliance with the 1997 method guidelines. Also, the most recent
version of the Cochrane Handbook (4.1) was checked for new
recommendations. In addition, some important topics that were not
addressed in the 1997 method guidelines were included (e.g., methods for
qualitative analysis, reporting of conclusions, and discussion of
clinical relevance of the results). In May 2002, preliminary results
were presented and discussed in a workshop. In two rounds, a list of all
possible recommendations and the final draft were circulated for
comments among the editors of the Back Review Group. RESULTS: The
recommendations are divided in five categories: literature search,
inclusion criteria, methodologic quality assessment, data extraction,
and data analysis. Each recommendation is classified in minimum criteria
and further guidance. Additional recommendations are included regarding
assessment of clinical relevance, and reporting of results and
conclusions. CONCLUSIONS: Systematic reviews need to be conducted as
carefully as the trials they report and, to achieve full impact,
systematic reviews need to meet high methodologic standards.

Waddell, D. D., C. A. Cefalu, and D. C. Bricker. \"An open-label study
of a second course of hylan G-F 20 for the treatment of pain associated
with knee osteoarthritis.\" *Current Medical Research & Opinion.* 19,
no. 6(2003): 499-507 UI 14594522.

OBJECTIVE: To evaluate the efficacy and tolerability of a second course
of hylan G-F 20 for the treatment of osteoarthritic knee pain in
patients who experienced a clinical benefit with an initial course of
therapy. RESEARCH DESIGN AND METHODS: In this prospective, open-label
study, men or women (\>/=40 years of age) with knee osteoarthritis (OA)
received three weekly injections of hylan G-F 20. Consecutive patients
who requested a second course of hylan G-F 20 therapy due to OA knee
pain subsequent to pain relief with a first course of therapy were
enrolled between October 26, 2000 and January 18, 2001. MAIN OUTCOME
MEASURES: Pain while walking on a flat surface (Western Ontario and
McMaster\'s Universities Osteoarthritis Index, WOMAC, question A1),
WOMAC domain C (physical functioning), full WOMAC, and patient and
investigator overall visual analog scales (VAS). Efficacy variables were
measured at baseline and at weeks 1, 2, 4, 8, 12 and 26. An analgesic
washout was required before all efficacy evaluations. RESULTS: Patients
receiving at least one injection of hylan G-F 20 (n = 71) were
predominantly Caucasian (84.5%) and female (64.8%), with a mean age of
65.5 years and mean weight of 200.1 pounds. The mean time between the
first and second courses of hylan G-F 20 was 19.6 months (median 17.6
months). With hylan G-F 20, pain while walking on a flat surface was
significantly lower (p \< 0.001) than baseline at all time points up to
week 26 (mean +/- SEM: -1.40 +/- 0.10 at week 26). Actual scores
decreased from 2.4 +/- 0.10 at baseline to 0.97 +/- 0.11 at week 26.
Scores for the WOMAC domain C, full WOMAC and patient and investigator
overall VAS also significantly improved (p \< 0.001) at all time points.
A second course of hylan G-F 20 was generally well-tolerated, based on
the low incidence of local adverse events (AEs) - only one patient
(1.4%) experienced a severe event, the types of AEs, and the fact that
no patients discontinued the study due to these AEs. The types of
related AEs observed were not qualitatively different from those listed
in the current product information and published literature. CONCLUSION:
A second course of hylan G-F 20 therapy is an appropriate therapy for
the treatment of OA knee pain in patients who had a previous favorable
clinical response. For continued relief of osteoarthritis knee pain,
this study supports repeat use of hylan G-F 20 in these patients.

Weerakkody, N. S., et al. \"Effects of local pressure and vibration on
muscle pain from eccentric exercise and hypertonic saline.\" *Pain.*
105, no. 3(2003): 425-35 UI 14527703.

In human subjects the triceps surae of one leg was exercised
eccentrically by asking subjects to walk backwards on an inclined
treadmill. Before the exercise controlled local pressure, applied to the
muscle with an electromagnet, produced mild soreness, which was reduced
when the pressure was combined with vibration. When delayed-onset muscle
soreness (DOMS) had set in, 24-48 h after the exercise, vibration
increased pain from local pressure. Vibrating at different frequencies
suggested 80 Hz as the optimal frequency. During 2-h testing
post-exercise, evidence of a change in character of the effects of
vibration was first detected at 6 h. It persisted up to 72 h
post-exercise. When muscle pain was generated in an unexercised triceps
by injection of hypertonic (5%) saline, controlled local pressure
applied to the sore area increased pain levels by 32% while pressure
plus vibration reduced this to 11%. In a subject with DOMS, local
pressure again increased pain from saline by 32% but combining it with
vibration increased pain further by an additional 20%. The effect of
vibration on DOMS could be abolished with a large nerve fibre block
applied to the sciatic nerve. It is concluded that the vibration effects
are the result of stimulation of large-diameter mechanoreceptive
afferents in the muscle which, it is speculated, play a role in
generating DOMS.

Weisse, C. S., P. C. Sorum, and R. E. Dominguez. \"The influence of
gender and race on physicians\' pain management decisions.\" *Journal of
Pain.* 4, no. 9(2003): 505-10 UI 14636818.

This study set out to examine whether gender or race influences
physicians\' pain management decisions in a national sample of 712 (414
men, 272 women) practicing physicians. Medical vignettes were used to
vary patient gender and race experimentally while holding symptom
presentation constant. Treatment decisions were assessed by calculating
maximum permitted doses of narcotic analgesic (hydrocodone) prescribed
for initial pain treatment and for follow-up care. No overall
differences by patient gender or race were found in decisions to treat
or in maximum permitted doses. However, for persistent back pain, female
physicians prescribed lower doses of hydrocodone, especially to male
patients. For renal colic, lower doses were prescribed to black versus
white patients when the patient was female, whereas the reverse was true
when patients were male. These findings challenge a fairly extensive
literature suggesting that physicians treat women and minorities less
aggressively for their pain, and results offer further evidence that
pain treatment decisions are influenced physician gender.

Wilson, G. R., and G. M. Reisfield. \"Morphine hyperalgesia: a case
report.\" *American Journal of Hospice & Palliative Care.* 20, no.
6(2003): 459-61 UI 14649563.

We report a case of a patient with metastatic testicular cancer and
intractable pain refractory to massive doses of oral, intravenous, and
intrathecal (IT) opioids supported by analgesic adjuvants. During our
efforts to control his pain, the patient exhibited opioid-induced
hyperalgesia, an uncommon but important phenomenon seen with high-dose
opioid therapy. With appropriate opioid adjustment\--in this case
reduction of intrathecal morphine dosage by a factor of 100\--the
condition rapidly resolved and the patient became pain-free and remained
so until his death six weeks later. The keys to identifying this
uncommon, but treatable, opioid side effect are recognizing it as a
possibility when aggressive efforts to control pain with high doses of
opioids, especially when administered neuraxially, are met with
increasing pain.

Yeung, C. K., M. C. Leung, and D. H. Chow. \"The use of
electro-acupuncture in conjunction with exercise for the treatment of
chronic low-back pain.\" *Journal of Alternative & Complementary
Medicine.* 9, no. 4(2003): 479-90 UI 14499023.

OBJECTIVES: To determine the effect of a series of electro-acupuncture
(EA) treatment in conjunction with exercise on the pain, disability, and
functional improvement scores of patients with chronic low-back pain
(LBP). DESIGN: A blinded prospective randomized controlled study.
Subjects and interventions: A total of 52 patients were randomly
allocated to an exercise group (n = 26) or an exercise plus EA group (n
= 26) and treated for 12 sessions. OUTCOME MEASURES: Numerical Rating
Scale (NRS), Aberdeen LBP scale, lumbar spinal active range of movement
(AROM), and the isokinetic strength were assessed by a blinded observer.
Repeated measures analysis of variance (R-ANOVA) with factors of group
and time was used to compare the outcomes between the two groups at
baseline (before treatment), immediately after treatment, 1-month
follow-up, and 3-month follow-up. The level of significance was set at p
= 0.05. RESULTS: Significantly better scores in the NRS and Aberdeen LBP
scale were found in the exercise plus EA group immediately after
treatment and at 1-month follow-up. Higher scores were also seen at
3-month follow-up. No significant differences were observed in spinal
AROM and isokinetic trunk concentric strength between the two groups at
any stage of follow-up. CONCLUSIONS: This study provides additional data
on the potential role of EA in the treatment of LBP, and indicates that
the combination of EA and back exercise might be an effective option in
the treatment of pain and disability associated with chronic LBP.

Zelman, D. C., et al. \"Development of a metric for a day of manageable
pain control: derivation of pain severity cut-points for low back pain
and osteoarthritis.\" *Pain.* 106, no. 1-2(2003): 35-42 UI 14581108.

The objective of this study was to adapt the concept of \'episode-free
day\', a metric for measuring symptom relief in daily units, to the
clinical outcome literature for persistent pain. The episode-free day
metric is widely used in other medical literature, but no analogous
measure exists in pain literature. Prior focus groups with this
population suggested that a \'Day of Manageable Pain Control\' was an
appropriate name for the metric. In the present study, in order to
derive a statistical criterion for \'Manageable Day\', we used Serlin et
al.\'s (Pain 61 (1995) 277) cut-point derivation method to derive a
single cut-point on a 0-10 scale of average pain that divided groups
with significant persistent pain optimally on pain-related functional
interference. Participants were 194 patients with moderate-severe low
back pain (n=96) or osteoarthritis (n=98). For both patient samples,
\'5\' was the cut-point that optimally distinguished groups on
pain-related interference. \'5-8\' and \'5-7\' were double cut-point
solutions that optimally divided LBP and OA samples into three
categories (e.g. lowest, medium and highest average pain), respectively.
Derived cut-points were confirmed using a variety of measures of
functional disability. Together with research that showed that average
pain ratings of approximately 5 and below permit increased function and
quality of life in patients with moderate to severe low back pain and
osteoarthritis, our findings provide support for the use of 0-5 on a
0-10 numeric average pain severity scale as one possible criterion for a
Manageable Day.

Zissin, R. \"CT diagnosis of an acute epiploic appendagitis in a
redundant sigmoid colon clinically suspected as acute appendicitis.\"
*Israel Medical Association Journal: Imaj.* 5, no. 11(2003): 835-6 UI
14650118.