Standardization of epidural preparations for postoperative analgesia.
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Analgesia, Epidural↗
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Results for “Referred Pain”
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Differential effect of compression-ischaemia block on warm sensation and heat-induced pain.
The effect of compression-ischaemia nerve block on psychophysical thresholds for warm sensation and heat-induced pain was studied on 19 normal human volunteers. Although those two sensory submodalities should be predicted to block simultaneously, based on the fact that both are served by unmyelinated primary afferents, it was actually found that warm sensation was much more vulnerable to compression-ischaemia than heat-induced pain. This is interpreted as resulting from different summation requirements for each of the two sensory modalities; sensation of warmth depends on spatial summation to a larger extent than heat-induced pain. Such differential vulnerability is in line with recent clinical studies reporting deterioration of warm sensation associated with preservation of heat pain in peripheral nerve disorders caused by diabetes, ageing and other neuropathic processes.
Afferent Pathways↗
Trigeminal chemosensitivity: Differences in relation to the time of the day.
Day-night differences of trigeminal chemosensitivity were investigated in 18 healthy volunteers employing both pain-related cortical potentials and pain ratings in response to stimulation of the nasal mucosa with CO2. Day-night differences were found with N 1 P2 amplitudes, P2 latencies and pain ratings. It is concluded that the time of the day must not be ignored when human chemosensitivity is investigated at suprathreshold levels.
Adult↗
Hyperventilation-echocardiography test for the diagnosis of myocardial ischaemia at rest.
The purpose of this study was to assess the feasibility, safety, specificity and sensitivity of the hyperventilation test performed under echocardiographic monitoring for the provocation of vasospastic ischaemia. Hyperventilation (approximately 30 cycles.min-1 for 5 min) was performed in 104 hospitalized patients, referred for pain typical of angina at rest, under 2-D echocardiographic and 12-lead electrocardiographic monitoring. All the tests were completed and no significant side effect was observed. In-hospital documentation of spontaneous myocardial ischaemia and/or ergonovine-induced ischaemia was achieved in 38 patients (group I). A positive hyperventilation-echocardiography test (occurrence of new transient asynergies or worsening of basal ones) was obtained in 32/38 patients. Among the group I patients, only 23 had diagnostic ST-T changes and only 16 experienced chest pain during the hyperventilation-echo test. Of the 66 patients without evidence of myocardial ischaemia at rest (negative ECG monitoring during hospitalization and/or negative ergonovine maleate-echo test)--Group II, none showed echocardiographic changes, seven presented ST-T changes and six complained of typical chest pain during the test. Thus, in relation to in-hospital documentation of myocardial ischaemia at rest, both spontaneous and/or ergonovine-induced episodes, the hyperventilation-echo test showed a specificity of 100%, a sensitivity of 84%, a positive predictive value of 100% and a negative predictive value of 92%. In conclusion, hyperventilation performed under echocardiographic monitoring is feasible and safe; it can be proposed as a screening test to unmask vasospastic myocardial ischaemia in patients with angina at rest, in whom documentation of spontaneous episodes is not available.
Adult↗
Musculoskeletal problems in the tomato growing industry: 'tomato trainer's shoulder'?
Tomato training entails highly repetitive shoulder muscle contractions, static contractions and work at shoulder level, factors linked in other working groups with neck and shoulder complaints. The frequency of musculoskeletal complaints was compared using the Nordic Questionnaire in 56 tomato trainers and 52 other matched glasshouse workers whose job did not include these work task factors. A higher 12- month (odds ratio (OR) = 5.9; [95% confidence interval (CI) = 2.4-16.7] and 7- day (OR = 3.6, CI = 1.2-11.1) period prevalence of shoulder complaint was recorded in trainers than in pickers and deleafers. Other upper limb and upper trunk complaints were also more common in tomato trainers, highlighting an area of ergonomic concern.
Adult↗
Evaluation of endometriosis in uterosacral ligaments by transrectal ultrasonography.
Uterosacral ligaments are one of the common targets of pelvic endometriosis, which is usually clinically rather than surgically diagnosed. This study was performed to determine if uterosacral ligaments infiltrated by endometriosis could be detected by transrectal ultrasonography. Uterosacral ligaments in non-endometriosis subjects (n = 64) were observed as low echoic homogeneous arcs in both sides of the uterine cervix. Patients who had endometriosis (n = 29) on the ligaments showed thick and irregularly-shaped uterosacral ligaments by the transrectal ultrasound examination. The results also suggested that the thickness of uterosacral ligaments was associated with the clinical symptoms. Transrectal ultrasonography may provide quantitative information to manage patients with infiltrating endometriosis.
Adult↗
Symptomatic enlarged iliopsoas bursae in the presence of a normal plain hip radiograph.
The clinical and radiological features of seven cases of enlarged iliopsoas bursae are presented, all of which had normal plain hip radiographs. Two cases had rheumatoid arthritis, one had septic arthritis diagnosed by synovial biopsy and the remaining four cases occurred as isolated findings, in the absence of any recognized hip pathology. A communication with the hip joint was demonstrated in one case associated with septic arthritis. All patients presented with symptoms of hip pain and limitation of movement. Two patients had a groin mass, one of which produced localized pressure symptoms and retroperitoneal extension. All patients had an arthrogram or bursogram performed. In the two cases where a mass was palpable, ultrasound and computed tomography were performed. We conclude that, in the presence of persistent hip pain or reduced range of movement, an enlarged iliopsoas bursa should be considered as a potential diagnosis, even in cases where the plain hip radiograph is normal.
Adult↗
Unreasonably low bispectral index values in a volunteer with genetically determined low-voltage electroencephalographic signal.
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Anesthesia, General↗
A new human experimental pain model: the heat/capsaicin sensitization model.
The heat/capsaicin sensitization model is a new human experimental pain model that synergistically combines non-invasive physical and chemical methods of nociceptor stimulation to produce stable and long-lasting hyperalgesia with a low potential for skin injury. In 10 healthy volunteers the forearm was stimulated with a 45 degrees C thermode for 5 min to produce an area of secondary hyperalgesia. Applying capsaicin cream for 30 min further expanded the area of secondary hyperalgesia. Periodically heating the treated skin with a previously non-painful temperature of 40 degrees C re-kindled the sensitization enough to maintain stable areas of secondary hyperalgesia for 4h. The evoked pain was moderate and well tolerated. The heat/capsaicin sensitization model should be well suited for studying pain mechanisms and testing new analgesics.
Adult↗
Clinical trial of a cervical traction modality with electromyographic biofeedback.
A new design of cervical traction modality with closed loop traction weight control based on electromyographic (EMG) biofeedback was developed. It consists of the development of a high signal-to-noise ratio EMG scanner, on-line self-adjusted traction weight controller, computer interface hardware, and closed loop biofeedback control software. Six healthy, young adults received conventional cervical traction to establish basic information of cervical EMG activities. Twenty-four patients with cervical radiculopathy were randomly divided into two groups for clinical assessment by conventional and new EMG biofeedback traction modality. The average electromyographic activity in healthy subjects ranged from 2.41 to 3.49 microV, whereas EMG activity in patients with neck pain ranged from 4.75 to 6.97 microV. There was a significant decrease of EMG activity during the whole traction phase, especially at pull phase in healthy subjects, but it was not as significant in patients with cervical radiculopathy. There was no significant change of myoelectric activity in the paraspinal muscles at vertebral levels C1-2, C3-4, and C5-6. Comparison of the average EMG activity of the paraspinal C-5 muscle in different phases of cervical traction showed a more significant decrease of EMG activity during the pull phase of traction as well as after traction in the high muscle tension group (with EMG activity above 5 microV), especially with the biofeedback traction modality. The raised traction force from start to optimum was shortened from 4 to 2 wk to achieve the same effective outcome by biofeedback as conventional traction modality.
Adult↗
The relation between cervical discographic pain responses and radiographic images.
OBJECTIVE: The purpose of this study was to investigate the relation between cervical discographic pain responses and radiographic images. DESIGN: Records were reviewed for a series of patients who had undergone cervical discography. SETTING: All patients were being treated at a spine specialty clinic. PATIENTS: A total of 269 discs were studied in 161 discographic procedures in patients with neck, shoulder, or arm pain. All patients underwent other diagnostic procedures before discography, including magnetic resonance imaging, computed tomography (CT), and CT/myelography. INTERVENTIONS: During the injection of contrast in each disc evaluated, the patient was asked if any pain was felt, and if so, was it similar or dissimilar to the pain typically experienced. OUTCOME MEASURES: Results were determined by analyzing the pain responses during disc injection with respect to imaged pathology seen on the axial CT discographic image of the disc. Results were further analyzed based on patient age. RESULTS: There was a significant relation between the radiographic image of the disc and the results of clinical pain provocation (p < 0.01; chi2). Among the 35 discs appearing as normal, clinical pain was provoked in only 14.3%. Among the 234 discs appearing as abnormal, clinical pain was provoked in 77.8%. The mean age of the patients with painless radiographically abnormal discs was significantly greater than that of the patients in the other subgroups of the study population. CONCLUSIONS: There was good agreement between the radiographic appearance of the disc and the pain provocation results. Discs that were painless but disrupted were found among older patients. Among such patients, discography may be particularly helpful in differentiating clinically significant abnormalities from those associated with aging.
Adult↗
The Bennett lesion of the shoulder.
In this article we review the imaging features and significance of the Bennett lesion of the shoulder. Standard radiographic, computed arthrotomographic, and MR findings in three baseball pitchers diagnosed with Bennett lesions of the shoulder are discussed. A crescent-shaped region of mineralization at the posteroinferior aspect of the glenoid rim, consistent with a Bennett lesion, arises at the insertion of the posterior joint capsule. The diagnosis of this lesion, typically in baseball pitchers, should raise suspicion for associated labral and rotator cuff abnormalities.
Adult↗
The circadian rhythm of biliary colic.
We evaluated 50 consecutive patients with symptomatic gallstones for the clinical features of biliary pain with particular reference to the timing of their painful episodes. Thirty-eight of the 50 patients were able to provide the time of onset of biliary pain in the 24-h cycle. The time of onset of biliary pain displays significant circadian periodicity (p = 0.0032), with its peak at 00:25 h. Forty-five patients had more than 1 episode of pain. Of these 84% had either all or over half of their attacks of biliary pain at the same clock time. Twenty-two patients with renal colic (a close parallel to biliary pain) and 31 patients with episodic abdominal pain from miscellaneous causes showed no circadian or other periodicity in the time of onset of pain. In only 1 of these patients did the abdominal pain recur consistently at the same clock time. "Typical" biliary pain has its onset at night and tends to recur at the same clock time. It is steady and relatively mild, lasting 1-5 h, it is felt in the right upper quadrant or the epigastrium, may radiate to a variety of sites, is associated with some additional symptoms, and is not usually related to meals. The chronobiological and other features of biliary pain reported here should be useful in the diagnostic evaluation of abdominal pain.
Adolescent↗
Relationship between dental pain perception and 24 hour ambulatory blood pressure: a study on 181 subjects.
OBJECTIVE: To investigate dental pain perception in a large group of essential hypertensive subjects. METHODS: A total of 130 hypertensive patients together with 51 normotensive subjects were submitted to tooth-electrical stimulation to determine the dental pain threshold (occurrence of pulp sensation) and tolerance (time when the subject asked for the test to be stopped). Blood pressure was measured at rest, before pain perception evaluation, and during a 24 h period by ambulatory monitoring. RESULTS: The normotensive and hypertensive subjects differed with regard to pain threshold (P = 0.002) and tolerance (P = 0.01). Pain perception variables were significantly correlated with both resting blood pressure and 24 h, diurnal and nocturnal arterial pressures, the correlation between pain threshold and 24 h systolic blood pressure being the most significant (r = 0.31, P < 0.0001). By contrast, parameters indicating 24 h blood pressure variability (percentage of nocturnal blood pressure reduction and 24 h blood pressure variation coefficients) were not associated with pain perception. Moreover, among the hypertensives only, a significant relationship was observed between pain sensitivity and both baseline and 24 h pressures. No association was found when pain perception and blood pressure were correlated in the normotensive group. CONCLUSIONS: The correlation between both baseline and 24 h blood pressure and pain perception has been confirmed in a large group study of normotensive and hypertensive subjects. Moreover, even among the hypertensive range of blood pressure, the higher the blood pressure is, the lower the sensitivity to pain is. These findings strengthen the hypothesis of a role of the degree of blood pressure elevation in modulating pain sensitivity.
Adult↗
Third cervical nerve root and ganglion compression: clinical syndrome, surgical anatomy, and pathological findings.
OBJECTIVE: The aim of this study is to determine whether C3 nerve root and ganglion compression occurs and, if so, to provide a preliminary description of the associated clinical syndrome and surgical pathological findings. METHODS: The normal anatomy of the C2-C3 foramen was studied bilaterally in five fresh cadaver dissections and on 10 normal vertebral angiograms. Six patients were selected whose C3 dermatome sensory deficits resolved after C2-C3 facetectomy for C3 nerve root and ganglion decompression. RESULTS: Patients with C3 nerve root and ganglion compression presented with radiating pain, dysesthesias, and numbness referred to the C3 pain dermatome: the scalp area behind and over the ear, the pinna, and the angle of the mandible. At physical examination, the presence of analgesia/dense hypalgesia in the C3 pain dermatome established the diagnosis. Imaging studies were suggestive but inconclusive. Surgical pathological findings showed the C3 nerve root and medial portion of the ganglion flattened by C2-C3 facet and uncovertebral joint spurs and the lateral part of the ganglion stretched and flattened by C2-C3 arthrosis and the C2-C3 vertebral loop. Decompression was obtained by a complete facetectomy. Complications required four operations: recurrence, contralateral C3 root decompression, bilateral C2 nerve root decompression, and C2-C3 fusion. CONCLUSION: C3 nerve root and ganglion compression, although uncommon, does occur. It presents with radiating pain, dysesthesias, numbness, and a C3 dermatome sensory deficit. The associated clinical syndrome resolves after facetectomy and C3 root and ganglion decompression.
Adult↗
Clinical practice guidelines. Particular reference to the management of pain in the lumbosacral spine.
Clinical practice guidelines and protocols are a seductive way of trying to improve the standard of clinical practice. If these are to be most effective, they must evaluate rigorously the evidence supporting a particular management strategy and make appropriate recommendations based on this information. This process needs to be objective, should engage and obtain endorsement from the disciplines that are involved in providing the care, and be accompanied by appropriate implementation strategies. Subsequently, the impact of these strategies should be measured. Existing guidelines for the management of lumbosacral pain largely conform to criteria for guidelines development. It can therefore be expected that they will benefit practitioners and the community.
Costs and Cost Analysis↗
Anterior knee pain: a review.
OBJECTIVE: To establish whether there is consensus in the areas of definition, classification, assessment, diagnostic tests, and management of anterior knee pain. DATA SOURCES: A Medicine search for the years 1988-1995 was performed using the terms patellofemoral joint, knee joint and pain, injury and rehabilitation, and anterior knee pain. In addition, references from selected papers were examined. STUDY SELECTION: A total of 77 references specifically related to anterior knee pain were reviewed in the areas of definition, classification, assessment, diagnostic tests, and management. Although a small number of these papers were analytic in their study design, most of the papers reviewed were descriptive. DATA EXTRACTION: Definitive statements on anterior knee pain in the areas noted herein were extracted and summarized. Similar statements were then grouped as indicative of general consensus. Independent and divergent statements were also summarized for each area of anterior knee pain. DATA SYNTHESIS: Most of the literature related to anterior knee pain is subjective in nature and demonstrates limited consensus among experts. There is no generally accepted definition or classification of anterior knee pain. There was some agreement on the assessment, use of diagnostic tests, and management of anterior knee pain, but there are no definitive or objective management outcome criteria. CONCLUSIONS: The scientific literature on anterior knee pain is sparse. This review supports a need for the development of consensus guidelines for anterior knee pain. A consensus approach to anterior knee pain could result in the more efficient use of high-yield diagnostic tests, the use of more effective and standardized protocols for assessment and treatment, increased patient satisfaction, and recommendations on fitness counseling and early prevention.
Diagnostic Tests, Routine↗
Behavioral alterations and vascular dementia.
BACKGROUND: Vascular dementia is one of the most frequent forms of dementia, where behavioral and cognitive symptoms coexist. Negative signs, such as apathy, abulia, opposition, and agnosia, are badly tolerated and dramatically experienced by caregivers, even worse than the other signs of cognitive decline. REVIEW SUMMARY: We have studied 120 subjects affected by subcortical vascular dementia (group A) and 120 subjects suffering from multiinfarct dementia (group B) for 24 months. The main outcomes of the study were the global performance, the global behavioral symptoms, the caregiver stress, the depression status, and the insight in their clinical situation. CONCLUSIONS: Group A manifested a reduction of depression, agitation and suicidal ideation during follow-up, with a constant tendency to refer somatic pain, to exhibit anxiety, and an evident increase in apathy, cognitive abulia, social withdrawal, and loss of insight. On the contrary, group B showed a constant tendency to manifest depression, somatic pain, anxiety, agitation, cognitive abulia, social withdrawal, and suicide ideations; they manifested a decrease of apathy and an increase in delusions, hallucinations, craving for food, and loss of insight and awareness. Their behavioral alterations were stronger than those exhibited by group A, and that was reflected by an increment of caregivers' burden score. Even from a behavioral perspective, multiinfarct dementia is not the same as subcortical vascular dementia. This opinion must be taken into account to find more suitable and tailored therapy to specific pathologies and not to a single, generic entity.
Activities of Daily Living↗