Elastómeros en bloqueos periféricos. Nuestra experiencia / Peripheral blockade with elastomeric pumps. Our experience

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Radiculalgia transitoria tras administración de parche hemático epidural en la cefalea por hipotensión intracraneal espontánea, conducta a seguir / Management of transient radicular pain after receiving an epidural blood patch for headaches due to spontaneous intracranial hypotension

La cefalea por hipotensión intracraneal espontánea es una entidad poco frecuente y en la mayoría de los casos se resuelve de forma rápida y espontánea, siendo el tratamiento inicial sintomático. Sin embargo, en ocasiones la clínica puede llegar a ser muy incapacitante, requiriendo para su diagnóstico y tratamiento la realización de un parche hemático epidural. Describimos el caso de una mujer de 49 años sin antecedente previo de punción dural o epidural, que ingresa en el Servicio de Neurología por cefalea frontal bilateral de 9 días de evolución asociada a náuseas, vómitos y diplopía, diagnosticándose de cefalea por hipotensión intracraneal espontánea. Ante la persistencia de la clínica a pesar del tratamiento médico, se realiza un parche hemático epidural en la Clínica del Dolor de nuestro hospital. La paciente presenta a las 24 h una notable mejoría de la cefalea y diplopía, pero relata lumbalgia y radiculalgia izquierda, que mejora con tratamiento convencional y se recupera ad integrum. La radiculalgia transitoria posprocedimiento, tal como describimos en nuestra paciente, es una incidencia a tener en cuenta y clínicamente aceptable en el contexto del tratamiento con parche hemático epidural de la cefalea hipotensiva (AU)

Spontaneous intracranial hypotension headache is an uncommon disease that resolves spontaneously in most of the cases and in a short period of time. The initial treatment should be symptomatic. In some patients the symptomatology is extremely disabling, and in these cases both the diagnosis and treatment may be performed by an epidural blood patch. A 49-year-old Caucasian woman, with no previous record of epidural or intrathecal puncture, consulted in the Emergency Department complaining of a 9-day history of frontal headache and diplopia, along with nausea and vomiting. The patient was diagnosed with spontaneous intracranial hypotension headache. Considering the symptomatology and the uncontrolled pain, the Pain Unit of our hospital performed an epidural blood patch. In the first 24 h the patient reported a remarkable relief of both headache and diplopia but developed a left lumbar radiculopathy that was treated successfully with supportive measures. Transient lumbar radiculopathy is a common and acceptable event secondary to the use of epidural blood patch as a treatment for spontaneous intracranial hypotension headache (AU)

[Management of transient radicular pain after receiving an epidural blood patch for headaches due to spontaneous intracranial hypotension]. / Radiculalgia transitoria tras administración de parche hemático epidural en la cefalea por hipotensión intracraneal espontánea, conducta a seguir.

Spontaneous intracranial hypotension headache is an uncommon disease that resolves spontaneously in most of the cases and in a short period of time. The initial treatment should be symptomatic. In some patients the symptomatology is extremely disabling, and in these cases both the diagnosis and treatment may be performed by an epidural blood patch. A 49-year-old Caucasian woman, with no previous record of epidural or intrathecal puncture, consulted in the Emergency Department complaining of a 9-day history of frontal headache and diplopia, along with nausea and vomiting. The patient was diagnosed with spontaneous intracranial hypotension headache. Considering the symptomatology and the uncontrolled pain, the Pain Unit of our hospital performed an epidural blood patch. In the first 24h the patient reported a remarkable relief of both headache and diplopia but developed a left lumbar radiculopathy that was treated successfully with supportive measures. Transient lumbar radiculopathy is a common and acceptable event secondary to the use of epidural blood patch as a treatment for spontaneous intracranial hypotension headache.

[Opioids for chronic noncancer pain: recommendations based on clinical practice guidelines]. / Uso de opioides en el tratamiento del dolor crónico no oncológico. Recomendaciones basadas en las guías de práctica clínica.

OBJECTIVE: The need for major opioids in the treatment of chronic pain unrelated to cancer is increasing. We therefore appraised available clinical practice guidelines in order to identify recommendations for good practice in the use of these drugs. MATERIAL AND METHODS: By searching the main guideline repositories as well as resources provided by medical associations, we identified clinical practice guidelines on the use of major opioids published up to 2007. Fourteen of the 28 guidelines we found met the inclusion criteria. To appraise the guidelines we applied the criteria for scientific evidence of the AGREE collaboration (Appraisal of Guidelines Research and Evaluation). The AGREE instrument consists of 23 items organized in 6 areas for appraisal. RESULTS: Of the 14 guidelines appraised, 5 were judged to be of high quality. In each of the 5 selected guidelines, the relation between a recommendation and the evidence it was based on was stated explicitly; all 5 had overall quality scores over 60%. The recommendations drawn from these guidelines deal with 3 sequential moments in the use of opioids: start of treatment, maintenance therapy, and withdrawal of the drug. CONCLUSION: The use of opioids to treat chronic noncancer pain is controversial in terms of effectiveness, safety, and the possibility of addiction or abuse. The opioid should be indicated for the pain and prescribed with caution; each case should be assessed individually. Following the recommendations drawn from these guidelines will be important for achieving control of both pain and the accompanying symptoms. The use of major opioids to relieve chronic pain unrelated to cancer, and therefore to improve the quality of life of patients who experience this type of pain, is a legitimate treatment approach.

Uso de opioides en el tratamiento del dolor crónico no oncológico. Recomendaciones basadas en las guías de práctica clínica / Opioids for chronic noncancer pain: recommendations based on clinical practice guidelines

Objetivo: Debido a la necesidad creciente del uso de opioides mayores en el tratamiento del dolor crónico no oncológico (DCNO), se evalúan las guías de práctica clínica (GPC) existentes y se sugieren unas recomendaciones prácticas específicas de buen uso de estos fármacos. Material y método: La búsqueda de las GPC publicadas hasta el año 2007 relacionadas con el uso de opioides mayores en el tratamiento del DCNO se realizó en los principales centros de recogida y almacenamiento de GPC y en las sociedades científicas. Catorce de los veintiocho documentos encontrados cumplían criterios de inclusión y fueron incluídas en el estudio. Para la evaluación de su validez con criterios de evidencia científica se utilizó el instrumento Agree que consiste en 23 apartados distribuidos en 6 áreas. Resultados: De las catorce GPC evaluadas 5 fueron seleccionadas por su alta calidad metodológica. En todas ellas había una relación entre cada recomendación y la evidencia en la cual estaban basadas y todas tenían una puntuación superior al 60%. Las recomendaciones sugeridas se agrupan en 3 apartados referente al uso secuencial del uso de opioide: Inicio del tratamiento, durante el mantenimiento y criterios y retirada del mismo. Conclusión: El uso de opioides en el tratamiento de pacientes con DCNO es tema controvertido debido a lo que concierne a su eficacia, seguridad y posibilidad de adicción y/o abuso. Tiene que ser indicado y prescrito con precaución y siempre valorando a cada paciente de forma individual. El seguimiento de las recomendaciones expuestas es importante tanto para un buen control del dolor como de los síntomas acompañantes. El uso de opioides mayores para el alivio del DCNO y por tanto, para mejorar la vida de los pacientes que lo padecen, es una alternativa totalmente legítima(AU)

Objective: The need for major opioids in the treatment of chronic pain unrelated to cancer is increasing. We therefore appraised available clinical practice guidelines in order to identify recommendations for good practice in the use of these drugs. Material and methods: By searching the main guideline repositories as well as resources provided by medical associations, we identified clinical practice guidelines on the use of major opioids published up to 2007. Fourteen of the 28 guidelines we found met the inclusion criteria. To appraise the guidelines we applied the criteria for scientific evidence of the AGREE collaboration (Appraisal of Guidelines Research and Evaluation). The AGREE instrument consists of 23 items organized in 6 areas for appraisal. Results: Of the 14 guidelines appraised, 5 were judged to be of high quality. In each of the 5 selected guidelines, the relation between a recommendation and the evidence it was based on was stated explicitly; all 5 had overall quality scores over 60%. The recommendations drawn from these guidelines deal with 3 sequential moments in the use of opioids: start of treatment, maintenance therapy, and withdrawal of the drug. Conclusion: The use of opioids to treat chronic noncancer pain is controversial in terms of effectiveness, safety, and the possibility of addiction or abuse. The opioid should be indicated for the pain and prescribed with caution; each case should be assessed individually. Following the recommendations drawn from these guidelines will be important for achieving control of both pain and the accompanying symptoms. The use of major opioids to relieve chronic pain unrelated to cancer, and therefore to improve the quality of life of patients who experience this type of pain, is a legitimate treatment approach(AU)

Protocolo de intervención en el trastorno de hiperactividad en una unidad de salud mental infanto-juvenil / Protocol of intervention in the attention hiperactivity deficit disorder in an infant-juvenile unit of mental health

El trastorno por déficit de atención/hiperactividad(TDAH) constituye una derivación frecuente en lasUnidades públicas de Salud Mental Infanto-Juvenil. Sinembargo, en muchas ocasiones esta derivación no esadecuada, magnificándose el número de casos incluidosbajo este epígrafe.El diagnóstico de TDAH debe hacerse atendiendo aunos criterios estrictos y siguiendo una metodologíaespecífica. La realización de evaluaciones eficaces seráclave a la hora de implementar tratamientos más efectivosa nivel cognitivo, emocional, comportamental, deaprendizaje social y escolar, generalizándose los resultadosa los dos contextos más habituales del niño: familiay escuela.Desde la Unidad de Salud Mental Infanto-Juvenil delInstituto Psiquiátrico José Germain, hemos detectado lanecesidad de establecer un protocolo de intervenciónmultiprofesional para nuestra zona que optimice la evaluacióne intervención en los casos de TDAH, presentándoseen este trabajo sus principales directrices

The Attention Hiperactivity Deficit Disorder (TDAH) constitutes a frequent derivation in the public Units ofInfant-Juvenile Mental Health. However, in many occasionsthis derivation is not accepted, being magnified thenumber of cases included under this epigraph.The diagnosis of TDAH should be made assisting tosome strict criteria and following a specific methodology.The realization of effective evaluations will be crucialto implement more effective treatments in theselevels: cognitive, emotional, comportamental, socialand school learning; being generalized the results to thetwo more habitual contexts of the children: family andschool.From the Infant-Juvenile Unit of Mental Health ofthe Psychiatric Institute José Germain, we have detectedthe necessity to establish a protocol of intervention withseveral proffesionals for our area that optimizes theevaluation and intervention in the TDAH cases, showingup in this work their main guidelines (AU)

Calcitonin for metastatic bone pain.

BACKGROUND: Pain is the most frequent symptom experienced by cancer patients, its intensity dependent on the site of the tumour. Tumours that compromise bone or nervous structures due to the bone destruction process are the most painful. There are several treatments to deal with pain (and other symptoms) caused by bone metastases. The hormone, calcitonin, has the potential to relieve pain, and also retain bone density, thus reducing the risk of fractures. This review is an update of a previously published review in The Cochrane Library (Issue 3, 2003) on this topic. OBJECTIVES: To assess the effectiveness of calcitonin in controlling metastatic bone pain and reducing bone complications (hypercalcemia, fractures and nerve compression) in patients with bone metastases. SEARCH STRATEGY: Electronic searches were performed in MEDLINE (1966 to 2005), EMBASE (1974 to 2005), the Cochrane Central Register of Controlled Trials (Issue 2, 2005), specialised registers of the Cochrane Cancer Network and of the Cochrane Pain, Palliative and Supportive Care Group. Registers of clinical trials in progress were also searched. SELECTION CRITERIA: Studies were included if they were randomised, double-blind clinical trials of patients with metastatic bone pain, treated with calcitonin, where the major outcome measure was pain, assessed at four weeks or longer. DATA COLLECTION AND ANALYSIS: Study selection and data extraction were performed by two independent review authors. Only two studies (90 patients) were eligible for inclusion in the review and therefore meta-analysis of the data was not possible. Intention-to-treat analysis was performed by imputing all missing values as adverse outcomes. MAIN RESULTS: Of the two small studies included in the review, one study showed a non-significant effect of calcitonin in the number of patients with total pain reduction (RR 2.50; CI 95%, 0.55 to 11.41). The second study provided no evidence that calcitonin reduced analgesia consumption (RR 1.05; CI 95%, 0.90 to 1.21) in patients with painful bone metastases. There was no evidence that calcitonin was effective in controlling complications due to bone metastases; for improving quality of life; or patients' survival. Although not statistically significant, a greater number of adverse effects were observed in the groups given calcitonin in the two included studies (RR 3.35, CI 95%, 0.72 to 15.66). AUTHORS' CONCLUSIONS: The limited evidence currently available does not support the use of calcitonin to control pain from bone metastases. Since the last version of this review, none of the new relevant studies have provided additional information on this treatment, in contrast to other therapeutic approaches that should be considered.

Réplica a “¿Hasta cuándo debemos soportar el dolor agudo en nuestros hospitales? / Reply. How much longer must we put up with acute pain in our hospitals?

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An implantable drug delivery system (IDDS) for refractory cancer pain provides sustained pain control, less drug-related toxicity, and possibly better survival compared with comprehensive medical management (CMM).

BACKGROUND: The randomized clinical trial of implantable drug delivery systems (IDDS) plus comprehensive medical management (CMM) versus CMM alone showed better clinical success at 4 weeks for IDDS patients. This 'as treated' analysis assessed if improvements in pain control, drug toxicity and survival were maintained over time. PATIENTS AND METHODS: We compared those who received IDDS with those who did not receive IDDS (non-IDDS). All patients had Visual Analogue Scores (VAS) for pain > or =5/10 on at least 200 mg morphine or equivalent daily. RESULTS: At 4 weeks, 46 of 52 (88.5%) IDDS patients achieved clinical success compared with 65 of 91 (71.4%; P=0.02) non-IDDS patients, and more often achieved > or =20% reduction in both pain VAS and toxicity [35 of 52 (67.3%) versus 33 of 91 patients (36.3%); P=0.0003]. By 12 weeks, 47 of 57 (82.5%) IDDS patients had clinical success compared with 35 of 45 (77.8%; P=0.55) non-IDDS patients, and more often had a > or =20% reduction in both pain VAS and toxicity [33 of 57 (57.9%) versus 15 of 45 patients (33.3%); P=0.01]. At 12 weeks the IDDS VAS pain scores decreased from 7.81 to 3.89 (47% reduction) compared with 7.21 to 4.53 for non-IDDS patients (42% reduction; P=0.23). The 12 week drug toxicity scores for IDDS patients decreased from 6.68 to 2.30 (66% reduction), and for non-IDDS patients from 6.73 to 4.13 (37% reduction; P=0.01). All individual drug toxicities improved with IDDS at both 4 and 12 weeks. At 6 months, only 32% of the group randomized to CMM and who did not cross over to IDDS were alive, compared with 52%-59% for patients in those groups who received IDDS. CONCLUSIONS: IDDS improved clinical success, reduced pain scores, relieved most toxicity of pain control drugs, and was associated with increased survival for the duration of this 6 month trial.

[Pain in the hospital: from prevalence to quality standards]. / El dolor en el hospital: de los estándares de prevalencia a los de calidad.

OBJECTIVES: Pain diminishes the quality of life of patients and a high prevalence of pain calls into question the quality of health care being delivered. The present study analyzes the prevalence of pain in one hospital, by departments and by therapeutic approach used. PATIENTS AND METHODS: This cross-sectional study was carried out in a representative sample of 309 patients admitted to a tertiary care hospital. Information was gathered by patient interviews and by reviewing hospital records for personal characteristics, clinical situation, pain characteristics and analgesic treatment. RESULTS: The prevalence of pain was 54.7% overall. The prevalence of pain eligible for treatment (intensity >2 on a visual analog scale) was 43.5%. The prevalence of pain that was moderate to intense (>3) was 34.7%. No analgesia was prescribed for 18.7% of the patients eligible, and analgesia was effective for 47.3%. Analgesia was provided on demand (63.2%) in most clinic protocols, usually with nonsteroidal antiinflammatory drugs, acetaminophen, opioids and special techniques, administered in combination to half the patients. The prevalence and intensity of pain and the prescription protocols varied from one hospital department to another. Analgesic treatment was adequate for 67.1% of the patients. CONCLUSIONS: The results suggest that the prevalence of pain in the hospital is high and that it is possible to improve quality of clinical approach, in agreement with studies that have been appearing since the 1980s. The persistence of the problem of pain in health care centers requires action on all levels of the health care system.

[Descriptive analysis of chronic pain clinics operating in Spain in 2001]. / Análisis descriptivo en el año 2001 de las Unidades de Tratamiento del Dolor Crónico en España.

OBJECTIVES: To describe the characteristics and care approaches to care of chronic pain clinics operating in Spain in 2001. DESIGN: Cross-sectional mail survey of pain clinics in Spain. SETTING: Chronic pain clinics in Spain. STATISTICAL ANALYSIS: Descriptive statistics of pain clinics responding to the questionnaire. RESULTS: Fifty-six of the 79 pain clinics (70.8%) responded; 57.1% were in public facilities, 55.4% were affiliated with medical schools, and 53.6% were interdisciplinary units. Both acute and chronic pain were treated by 72.4% of the respondents. Anesthesiology departments supervised 89.3% of the clinics. Only 57.1% had staff permanently assigned to the pain clinic. A mean 2194 (SD 2041) visits by patients were received annually. The most commonly applied treatments were drugs, blocks, spinal techniques, and transcutaneous electrical nerve stimulation. Implantable systems were more frequently used in chronic pain clinics than in mixed pain clinics, and in university-affiliated clinics than in non-teaching facilities (P=0.03 in both comparisons). A psychological approach was used more often in interdisciplinary clinics than in units operated by staff from a single specialty (P<0.01). CONCLUSIONS: Chronic pain clinics were not evenly distributed throughout Spain. The number of patients treated at pain clinics was high. The various characteristics of pain clinics--such as funding source, interdisciplinarity, university affiliation, and specialization in chronic pain--a were factors that affected the use of certain treatments.

El dolor en el hospital: de los estándares de prevalencia a los de calidad / Pain in the hospital: from prevalence to quality standards

OBJETIVOS: El dolor compromete la calidad de vida de los pacientes y su elevada prevalencia pone en entredicho la calidad asistencial. Este trabajo analiza la prevalencia del dolor en un hospital, en función de los bloques de servicios y del abordaje terapéutico realizado. PACIENTES Y MÉTODOS: Estudio transversal en una muestra representativa de 309 pacientes ingresados en un hospital de tercer nivel. Mediante entrevista con el paciente y revisión de su historia clínica se recogió información de su filiación, situación clínica, dolor, características del mismo y tratamiento antiálgico. RESULTADOS: La prevalencia global del dolor fue del 54,7%; del 43,5% considerando sólo el dolor candidato a tratamiento (intensidad >2 en la escala visual analógica) y del 34,7% considerando el dolor moderado-intenso (>3). Un 18,7% de los pacientes tributarios de analgesia no tenían prescripción y la efectividad analgésica se con-siguió en el 47,3%. La mayoría de pautas fueron a demanda (63,2%), principalmente con AINE, paracetamol, opioides y técnicas especiales, administrándose de forma combinada en la mitad de los pacientes. Los bloques hospitalarios mostraron variaciones en la prevalencia e intensidad del dolor y en los patrones de prescripción. En el 67,1% de los pacientes el tratamiento analgésico fue adecuado. CONCLUSIONES: Los resultados sugieren una prevalencia elevada de dolor en el hospital y la posibilidad de mejorar la calidad de su abordaje clínico, en concordancia con los estudios publicados desde los años 80. La persistencia de este problema en los centros asistenciales exigiría una mayor actuación de todos los niveles del sistema sanitario

OBJETIVES: Pain diminishes the quality of life of patients and a high prevalence of pain calls into question the quality of health care being delivered. The present study analyzes the prevalence of pain in one hospital, by departments and by therapeutic approach used. PATIENTS AND METHODS: This cross-sectional study was carried out in a representative sample of 309 patients admitted to a tertiary care hospital. Information was gathered by patient interviews and by reviewing hospital records for personal characteristics, clinical situation, pain characteristics and analgesic treatment. RESULTS: The prevalence of pain was 54.7%overall. The prevalence of pain eligible for treatment (intensity >2 on a visual analog scale) was 43.5%. The prevalence of pain that was moderate to intense (>3) was 34.7%. No analgesia was prescribed for 18.7% of the patients eligible, and analgesia was effective for 47.3%. Analgesia was provided on demand (63.2%) in most clinic protocols, usually with nonsteroidal antiinflammatory drugs, aceta-minophen, opioids and special techniques, administered in combination to half the patients. The prevalence and intensity of pain and the prescription protocols varied from one hospital department to another. Analgesic treatment was adequate for 67.1% of the patients. CONCLUSIONS: The results suggest that the prevalence of pain in the hospital is high and that it is possible to improve quality of clinical approach, in agreement with studies that have been appearing since the 1980s. The persistence of the problem of pain in health care centers requires action on all levels of the health care system

Análisis descriptivo en el año 2001 de las Unidades de Tratamiento del Dolor Crónico en España / Descriptive analysis of chronic pain clinics operating in Spain in 2001

OBJETIVO: Descripción de las características y actividad asistencial de las Unidades de Dolor Crónico (UDC)de España durante el año 2001.DISEÑO: Estudio transversal basado en una encuesta por correo realizada a las UDC españolas. UNIDAD DE ESTUDIO: UDC españolas. ANÁLISIS: Análisis descriptivo de las UDC que cumplimentaron la encuesta. RESULTADOS: De 79 UDC encuestadas, respondieron56 (70,8%), de las cuales el 57,1% eran públicas, el55,4% desarrollaban actividad docente y el 53,6% eran multidisciplinares. El 72,4% de UDC eran mixtas. El89,3% eran dependientes del Servicio de Anestesiología. Sólo un 57,1% de UCD disponían de personal con dedicación exclusiva. La media del número de visitas anual por UDC fue de 2.194 (±2.041). Los recursos terapéuticos más utilizados fueron los fármacos, los bloqueos, las técnicas espinales y las técnicas de estimulación transcutáneas (TENS). Los sistemas implantables también fueron más frecuentes en las unidades de dolor crónico que en las de dolor mixto así como, también fue más frecuente en las universitarias que en las no universitarias (p= 0,03y p= 0,03 respectivamente). El abordaje psicológico se utilizó más en las multidisciplinares que en las unidisciplinarias (p<0,01). CONCLUSIONES: La distribución geográfica de las UDC en España no fue homogénea. La actividad asistencial de dichas UDC fue importante. Diversas características de las UDC como fuente de financiación, multidisciplinariedad, práctica de docencia universitaria y especialización en sólo dolor crónico, condicionaron la utilización de algunos tratamientos para el dolor

OBJECTIVES: To describe the characteristics and care approaches to care of chronic pain clinics operating in Spain in 2001.DESIGN: Cross-sectional mail survey of pain clinics in Spain. SETTING: Chronic pain clinics in Spain. STATISTICAL ANALYSIS: Descriptive statistics of pain clinics responding to the questionnaire. RESULTS: Fifty-six of the 79 pain clinics (70.8%) responded; 57.1% were in public facilities, 55.4% were affiliated with medical schools, and 53.6% were interdisciplinary units. Both acute and chronic pain were treated by 72.4%of the respondents. Anesthesiology departments supervised89.3% of the clinics. Only 57.1% had staff permanently assigned to the pain clinic. A mean 2194 (SD 2041) visits by patients were received annually. The most commonly applied treatments were drugs, blocks, spinal techniques, and transcutaneous electrical nerve stimulation. Implantable systems were more frequently used in chronic pain clinics than in mixed pain clinics, and in university-affiliated clinics than in non-teaching facilities (P=0.03 in both comparisons).A psychological approach was used more often in interdisciplinary clinics than in units operated by staff from a single specialty (P<0.01).CONCLUSIONS: Chronic pain clinics were not evenly distributed throughout Spain. The number of patients treated at pain clinics was high. The various characteristics of pain clinics—such as funding source, interdisciplinarity, university affiliation, and specialization in chronic pain—a were factors that affected the use of certain treatments

Radioisotopes for metastatic bone pain.

BACKGROUND: Bone metastases manifest through pain, which can arise even before the injury is radiologically detected. Pain occurs as a result of bone destruction and, as more destruction ensues, more pain can be experienced. Radiculopathies, plexopathies and shrinkage of spinal nerves due to tumour growth and fractures are very frequent in these patients. Relief of pain from bone metastasis can be achieved by treating the cancer itself; radiotherapy; conventional analgesics; and specific drugs that work on the bone tumour-induced alteration: biphosphonates, calcitonin or radioactive agents. OBJECTIVES: To determine the efficacy of radioisotopes to control metastatic pain in patients with bone metastases and complications due to bone metastases (hypercalcaemia, bone fracture and spinal cord compression) as well as its efficacy in terms of patient survival and adverse effects. SEARCH STRATEGY: Randomised and controlled clinical trials related to this review were retrieved electronically using MEDLINE (1966-2003), EMBASE (1974-2003) and Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 1 2003). general strategies to identify RCTs were combined with specific commands to identify trials of radioisotopes and metastatic bone pain. SELECTION CRITERIA: The inclusion criteria were: randomised trials of patients with metastatic bone pain that compared treatment with radioisotopes and placebo, and where the major outcome was either pain or complications of bone metastases (eg, hypercalcaemia, bone fracture, spinal cord compression) assessed at least four weeks after treatment. DATA COLLECTION AND ANALYSIS: The quality of included studies was assessed using the Jadad scale and the Oxford Pain Validity Score. Two independent reviewers extracted the data and completed a standard form designed for that purpose. An intention-to-treat analysis was performed, and global estimates of effect were calculated using a random effects model. MAIN RESULTS: Four trials (325 patients) provided data that suggest a small effect of radioisotopes on pain control both at short and medium term (one to six months). No evidence was available to assess long-term effects (12 months). Only one study provided data on analgesia use and concluded that patients given either radioisotopes or placebo showed similar levels of analgesic use when compared to baseline use. Leukocytopenia and thrombocytopenia are secondary effects associated with the administration of radioisotopes. The incidence of leukocytopenia is significantly greater in patients treated with radioisotopes (RR=4.56, 95% CI (1.22,17.08)). There were also a greater number of thrombocytopenia events in the treatment group, without reaching statistical significance. REVIEWER'S CONCLUSIONS: The efficacy of radioisotopes has been assessed in clinical trials with small sample sizes and short-term evaluations of the outcomes. There is some evidence indicating that radioisotopes may give complete reduction in pain over one to six months with no increase in analgesic use, but adverse effects, specifically leukocytopenia and thrombocytopenia, have also been experienced.

Actitudes terapéuticas ante la meralgia parestésica / Approaches to treating meralgia paresthetica

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Calcitonin for metastatic bone pain.

BACKGROUND: Pain is the most frequent symptom experienced by cancer patients, its intensity dependent on the site of the tumour. Tumours that compromise bone or nervous structures due to the bone destruction process are the most painful. There are several treatments to deal with pain (and other symptoms) caused by bone metastasis. The hormone, calcitonin, has the potential to relieve pain, and also retain bone density, thus reducing the risk of fractures. OBJECTIVES: To assess the effectiveness of calcitonin in controlling metastatic bone pain and reducing bone complications (hypercalcemia, fractures and nervous compression) in patients with bone metastases. SEARCH STRATEGY: Electronic searches were performed in MEDLINE (1966-2001), EMBASE (1974-2001), the Cochrane Central Register of Controlled Trials (Issue 2, 2001), specialised registers of the Cochrane Cancer Network and of the Cochrane Pain, Palliative and Supportive Care Group. Registers of clinical trials in progress were also searched. SELECTION CRITERIA: Studies were included if they were randomised, double-blind clinical trials of patients with metastatic bone pain, treated with calcitonin, where the major outcome measure was pain, assessed at four weeks or longer. DATA COLLECTION AND ANALYSIS: Study selection and data extraction were performed by two independent reviewers. Only two studies (90 patients) were eligible for inclusion in the review and therefore meta-analysis of the data was not possible. Intention-to-treat analysis was performed by imputing all missing values as adverse outcomes. MAIN RESULTS: Of the two small studies included in the review, one study showed a non-significant effect of calcitonin in the number of patients with total pain reduction (RR 2.50; CI 95%, 0.55 to 11.41). The second study provided no evidence that calcitonin reduced analgesia consumption (RR 1.05; CI 95%, 0.90 to 1.21) in patients with painful bone metastases. There was no evidence that calcitonin was effective in controlling complications due to bone metastases; for improving quality of life; or patients' survival. Although not statistically significant, a greater number of adverse effects were observed in the groups given calcitonin in the two included studies (RR 3.35, CI 95%, 0.72 to 15.66). REVIEWER'S CONCLUSIONS: The limited evidence currently available for systematic review does not support the use of calcitonin to control pain from bone metastases. Until new studies provide additional information on this treatment, other therapeutic approaches should be considered.