Intrathecal ziconotide and baclofen provide pain relief in seven patients with neuropathic pain and spasticity: case reports.

Seven cases of combination of intrathecal (IT) ziconotide and baclofen therapy in patients with refractory neuropathic pain and spasticity were reviewed. Five of the seven adult patients were receiving IT baclofen treatment when ziconotide was initiated. All five patients had experienced at least one previous failed IT treatment regimen. Pain intensity scores improved by a mean of 50.3% with the use of ziconotide-baclofen therapy. Mean time to onset of pain relief was 15 weeks, at a mean ziconotide dose of 3.7 microg/day. Within this group of patients, adverse events were observed in one patient, but they were not considered to be ziconotide related and subsequently resolved. The remaining two patients were receiving ziconotide treatment when baclofen was initiated. Pain intensity scores improved by 75% and 30%, respectively. Pain relief was evident at two weeks and one week, with corresponding ziconotide doses of 2.4 microg/day and 14.4 microg/day, respectively. One patient in this group reported adverse events, but all resolved during continued treatment with the study drugs. Treatment regimens varied between patients in these case series; each regimen used a different titration strategy and different concentrations of ziconotide and baclofen. Combination IT ziconotide and baclofen therapy may be a treatment option for patients with neuropathic pain and spasticity. Future studies are warranted to determine the optimal dosing and titration schedules for ziconotide-baclofen usage.

Cancer pain: progress since the WHO guidelines.

In has been 15 years since the WHO Guidelines for the management of cancer pain were developed. This article reviews the guideline development and its effectiveness. Current trends in cancer care utilizing aggressive chemotherapeutic and surgical protocols lead to many patients living longer with advanced cancer and an attendant increase in pain. Future trends in cancer pain care are outlined.

The double-catheter technique for intrathecal medication trial: a brief technical note and report of five cases.

A method for intrathecal (IT) trials using a double-catheter technique is described. This technique involves placement of an IT and epidural catheter simultaneously. The rationale for this technique is the ability to treat a postdural puncture headache promptly should one develop during the trial.

Grip form and graphomotor control in preschool children.

OBJECTIVE: The purpose of this study was to examine the utility of the grip scale presented by Schneck and Henderson, the effect of grip form on drawing accuracy, and the effect of implement diameter on grip form and drawing accuracy. METHOD: Sixty boys and girls who were 3, 4, and 5 years of age performed 20 trials of a precision drawing task, 4 trials each with five implements of varying diameters (4.7, 7.9, 11.1, 14.3, and 17.5 mm). RESULTS: First, all 1,200 grips could be coded according to Schneck and Henderson's 10-grip whole-configuration assessment system, but the interrater reliability was lower than expected (.67 proportion of perfect agreement). Second, using Schneck's five-level scoring system, the level of grip significantly affected drawing accuracy, with the highest grip level used most often with the highest accuracy scores and the lowest observed grip level used most often with the lowest accuracy scores. Third, increasing implement diameter led to significantly lower level grips but did not significantly affect accuracy. CONCLUSIONS: Therapists are recommended to use Schneck and Henderson's 10-grip scale only for documenting the persons' grips and changes in their grips, but if comparisons between individual persons are desired, then Schneck's five-level scale, which affords greater generalizability, should be used. Further, children with graphomotor performance deficits are not likely to benefit from grip manipulations because such strategies were shown to make better only performance that is already good.

Skipping and hopping of undergraduates: recollections of when and why.

The purpose of this study was to compare the reasons why young adults skip and hop and when they last skipped and hopped. Retrospective data collected from 664 undergraduate students showed that the most common explanation for skipping was related to affect (54%), but the most common explanations for hopping were more functional. No significant differences appeared in the time frames of the participants' last remembered bout of skipping or hopping, although significantly more failed to remember the last time they hopped than the last time they skipped.

Preemptive intrathecal ketamine injection produces a long-lasting decrease in neuropathic pain behaviors in a rat model.

BACKGROUND AND OBJECTIVES: Ketamine is an N-Methyl-D-Aspartate (NMDA) receptor antagonist, which has been found to effectively treat somatic and neuropathic pain. This study examines the effect (on neuropathic pain) of preemptive ketamine using different routes of administration (intrathecal versus intraperitoneal). METHODS: The Institutional Animal Care and Use Committee approved the study. Thirty male Sprague-Dawley rats (250-275 g) were divided into three treatment groups [intrathecal saline/intraperitoneal saline or Control (CTL), intrathecal ketamine/intraperitoneal saline (ITK), and intrathecal saline/intraperitoneal ketamine (IPK)] prior to undergoing surgery to induce neuropathic pain by tight ligation of the left L5 and L6 spinal nerves. All drugs were given 15 minutes before nerve ligation. The ITK group received intrathecal ketamine (0.5% solution, 1 mg/kg), the IPK group received intraperitoneal ketamine (0.5% solution, 1 mg/kg), saline was given in equal volume (approximately 0.05 mL). Mechanical allodynia, cold allodynia, and ongoing pain behaviors indicative of neuropathic pain were assessed on postoperative days 1, 3, 7, and 14 using validated methods. RESULTS: Compared with the CTL group, the ITK group showed a state of decreased mechanical allodynia, cold allodynia, and ongoing pain as revealed by the von Frey hair, acetone, and cold plate testing, respectively. Further, this decrease was sustained for at least 2 weeks. The IPK group showed intermediate results between the CTL and ITK. CONCLUSIONS: Neuropathic pain behaviors were significantly reduced for at least 2 weeks after intrathecal ketamine was preemptively administered to animals undergoing surgery to induce neuropathic pain. The mechanism of action is thought to be prevention of spinal cord sensitization.

Regional anesthesia techniques for pain control in the intensive care unit.

The judicious use of regional anesthesia in the intensive care unit should improve patient comfort. Techniques covered include intercostal nerve blocks, interpleural blocks, paravertebral blocks, brachial plexus blocks, and femoral nerve blocks. Rational patient selection for each technique mentioned is also discussed.

Changes in basketball shooting patterns as a function of distance.

The effect of distance on the accuracy and movement form in basketball shooting was examined using a dynamic systems approach. Five male and five female young adults (M = 26 yr.) with no basketball experience beyond regular physical education shot a basketball 20 times at each of eight distances from 5 to 40 ft. (Natural condition). Also, they pretended to shoot the ball 5 times at each of the eight distances, for a total of 200 shots each (Pretend condition). In the Natural condition, shooting accuracy significantly decreased as shooting distance increased. Across both conditions and across four body components (feet position, hand position, trunk rotation, and jump height), the participants shifted from one movement pattern to another 86.3% of the time as shooting distance increased. The distances at which the transitions occurred were significantly shorter in the Natural than the Pretend condition for the feet and hand components but not the trunk and jump-height components. These results indicated that shooting a basketball at increasing distances can be portrayed as a dynamic system characterized by abrupt changes in at least four body components at critical distances.

Sevoflurane or halothane anesthesia: can we tell the difference?

UNLABELLED: This study was performed to evaluate the ability of anesthesiologists to differentiate between sevoflurane, a newer, more expensive anesthetic, and halothane. A total of 113 assessments were made by 36 anesthesiologists on 58 children, aged 6 mo to 6 yr, scheduled for bilateral myringotomy and tube placement. All patients received midazolam (0.5 mg/kg per os) approximately 30 min before the induction of anesthesia. Sevoflurane or halothane was randomly selected for anesthetic induction and maintenance. The anesthesiologists, who were unaware of the anesthetic being used, were asked to identify the anesthetic based on clinical signs and to assess the quality of induction, speed of induction, and speed of emergence using a visual analog scale (VAS; minimum score = 0, maximum score = 100). The anesthesiologists correctly identified the anesthetic only 56.6% of the time. This was not significantly different from the 50% that would result from random guessing (P = 0.08). Further, there were no significant differences in VAS scores between the two groups. This study suggests that in premedicated pediatric patients undergoing brief surgical procedures, anesthesiologists cannot correctly differentiate between sevoflurane and halothane. The lack of significant differences in VAS scores suggests that the speed of induction, the speed of emergence, and the quality of induction are similar under these clinical conditions. Any purported benefits of sevoflurane seem to be of minor consequence under the circumstances studied. IMPLICATIONS: When the anesthetic halothane or sevoflurane is administered in a blind, randomized fashion, anesthesiologists could not reliably identify which drug was being used to anesthetize children for a brief surgical procedure. These results suggest that the differences between the two drugs in clinical practice are small and may not justify the additional cost of sevoflurane.

The independence of horizontal and vertical dimensions in handwriting with and without vision.

The purpose of this study was to investigate the relationship between horizontal and vertical components of handwriting production when subjects were instructed to vary the size of these components separately or together. The effect of vision on these instructed size transformations also was examined. Eight female adults participated in the experiment. The basic task was to write the words 'poppy' and 'wood' cursively five times, the first time in their normal size and then with four size transformations. These transformations--one-fourth, one-half, double, and four-times their normal size--were made under three different sets of instructions (width only, height only, both) and in two visual conditions (normal, blindfolded), for a total of six sets of five repetitions. The individual slopes (changes in actual values across the transformation values) for width and height under instructions to change both parameters were almost identical to the width and height slopes under instructions to change only the single parameter, supporting the notion of the independence of the horizontal and vertical components. Further, an analysis of these individual slopes indicated that the size transformations were significantly greater (p less than 0.05) (and closer to the instructed values) with vision than without vision.

The effect of age on relative timing variability and transfer.

The purpose of this study was to investigate potential qualitative differences in relative timing across age both within and across speed conditions. Forty right-handed males performed 48 trials of a five-component coincident-timing task at one speed and then 16 more at a different speed. The independent variables were age (5-7, 8-10, 11-13 years, and adult), speed (slow and fast), and block order (training and transfer). The results indicated that within-speed relative timing consistency improved with increasing age for movement-time and pause-time components, while across-speed transfer improved with age only for pause time. movement velocity emerged as a more stable timing parameter than movement time across speeds for all groups. The last movement-time component correlated highly with the total response times, suggesting that coincident-timing accuracy was controlled to a large degree by a final, fine-tuning correction. These results imply that developmental deficits in relative timing increase the attention demands of a given task, thereby reducing a child's capacity to concurrently control his movements and monitor events in the environment.