Reduction of carboplatin induced emesis by ondansetron.

Ondansetron is a selective 5-HT3 antagonist with significant antiemetic properties in patients receiving cytotoxic chemotherapy. Patients who had suffered severe vomiting on carboplatin alone (23 patients with ovarian carcinoma) or in combination (two patients with testicular cancer) despite intensive antiemetic regimens were treated with ondansetron, given as 8 mg immediately prior to carboplatin followed by 8 mg orally, 8 hourly for 5 days. Twenty-five patients received 58 courses of ondansetron. In the first 24 h after the first course of chemotherapy with ondansetron, 17 patients (68%) experienced no vomiting, five patients (20%) had almost complete control and the other three patients had partial control. During the subsequent 4 days slightly lesser control was achieved. Nausea was similarly controlled in most patients. Twenty-two patients stated a preference for ondansetron with future chemotherapy. Fourteen patients received additional chemotherapy with ondansetron and in only three patients did the efficacy of therapy lessen. Toxicity was mild and transient with headache and constipation predominant. No extrapyramidal reaction was seen. Sedation was absent. Ondansetron is highly effective in refractory vomiting associated with carboplatin chemotherapy. It may be particularly beneficial when an extrapyramidal reaction has occurred on previous antiemetics and when sedation is unacceptable.

Double-blind evaluation of piroxicam and naproxen following missed dosage in patients with inflammatory arthritis.

We conducted two separate double-blind withdrawal studies in parallel; one involved 20 patients taking piroxicam 20 mg daily, and the other involved 20 patients taking naproxen 750 mg daily. After 48 hour withdrawal of active medication, the naproxen group showed significant deterioration in eight of the 14 parameters measured and the piroxicam group in one of the 14 parameters measured. The deterioration in the naproxen group was significantly greater than that in the piroxicam group in five of the 14 parameters measured. These findings are consistent with the long half-life of piroxicam and suggest that non-compliance leading to omission of piroxicam for two days is of less clinical importance than omission of naproxen for two days.

Pain-mood relationships in patients with rheumatoid arthritis.

Pain-mood relationships were investigated in 23 patients with long-standing rheumatoid arthritis over a two-week period. Patients completed form B of the Eysenck personality inventory on entry to the study and visual analogue scales for pain, anxiety and sadness daily throughout the study period. Two pain-mood relationships were identified: a synchronous relationship in which pain and mood scores were positively correlated and an asynchronous relationship in which pain and mood scores were uncorrelated. Furthermore, in all patients reporting high pain and showing synchronous relationships, the pain and mood scores were similar in magnitude, while in all patients reporting high pain and showing asynchronous relationships, the pain and mood scores were dissimilar in magnitude. The latter patients remained calm and happy despite severe pain. All patients reporting low pain showed synchronous and close relationships between pain and mood. Extraversion, neuroticism, age, duration and severity of disease were unrelated to pain severity and the pain-mood relationships recorded. The asynchronous pain-mood relationship was attributed to a coping response to severe pain. Patient education combined with physical, psychological and pharmacological treatments might induce such a response in patients unable to cope with chronic pain.

The visual analogue scale: its use in pain measurement.

Use of pain rating scales, especially the visual analogue scale (VAS), has increased dramatically in the last decade. Consideration of the VAS in terms of its physical structure and the patient's behaviour when confronted with the scale, casts doubt on its validity. It is non-linear and prone to bias which limits its use as a serial measure of pain severity. Measuring pain intensity alone imposes further limitations. The McGill Pain Questionnaire measuring several dimensions of pain appears to be a better alternative.

Problems associated with pain measurement in arthritis: comparison of the visual analogue and verbal rating scales.

Thirty-seven arthritis patients participating in a drug withdrawal trial, simultaneously completed a 20-point visual analogue scale and 7-point verbal rating scale for pain severity while on active medication and 48 hours following its withdrawal. The relationship between the two scales could be better approximated by a curve than a straight line, and further interpretation suggested that the relationship might be sigmoidal. This indicates that only the middle of the scales are linearly related with a lack of agreement occurring towards the upper and lower ends. Although the visual analogue scale proved superior to the verbal rating scale in its ability to detect changes in pain, until more is known about factors which influence subjective magnitude estimation, this conclusion must remain tentative. The implications of the findings to pain measurement are discussed.

The analgesic effects of transcutaneous electrical nerve stimulation and placebo in chronic pain patients. A double-blind non-crossover comparison.

The analgesic effects of high frequency transcutaneous electrical nerve stimulation (TNS), "acupuncture-like" TNS and placebo TNS were evaluated in 33 patients with rheumatoid arthritis and chronic hand pain using a randomized, double-blind, non-crossover design. An oscilloscope was employed to monitor the stimulator output in the TNS treatment groups and to provide strong suggestion and a focus of attention in the placebo treatment group. The two forms of TNS were applied at the highest intensity that could be tolerated by patients. Assessments of resting pain, joint tenderness, grip strength and grip pain were made before and after treatment. The pain and joint tenderness measurements showed high frequency TNS, "acupuncture-like" TNS and placebo TNS to be equally effective in producing analgesia of similar degree and trend over time. The grip strength measurements showed no significant change. The results obtained with placebo are probably due to the suggestion and attention effects of the visual stimulus. The implications of these results in respect to pain control pathways are discussed. Although TNS given at high intensity was shown to be no better than placebo applied with strong suggestion, this does not preclude its use as a method of pain control in rheumatoid arthritis.

Acupuncture in the treatment of chronic cervical pain. A pilot study.

Thirteen patients with neck pain of at least two years' duration participated in the study. Patients were randomly assigned to either an acupuncture group or a placebo TNS (transcutaneous nerve stimulation) group. Initial pain scores revealed no significant difference between the groups with respect to pain severity. Patients were treated twice weekly for four weeks, at the end of which pain relief was measured using a simple descriptive scale. Even though an attempt was made to maximize the effect of placebo TNS using strong verbal suggestion, acupuncture still proved superior to placebo in the relief of cervical pain (p less than 0.01). The implications of these findings are discussed.

Transcutaneous electrical nerve stimulation in rheumatoid arthritis.

The therapeutic effect of once weekly transcutaneous electrical nerve stimulation in patients with rheumatoid arthritis was compared with placebo in a randomised, double-blind, non-crossover study lasting three weeks. Thirty-two patients with classic or definite rheumatoid arthritis and wrist involvement were evaluated. Transcutaneous electrical nerve stimulation was better than the placebo in relieving pain at rest and while gripping. In addition, grip strength, measured as power and work done, immediately improved following transcutaneous electrical nerve stimulation but returned almost to initial values between assessments. No significant improvement was shown for the placebo group.

Placebo therapy in rheumatoid arthritis.

Few studies have attempted to describe the effect of placebo therapy on chronic pain. In this study pain was assessed daily, for 25 days, in 23 patients with rheumatoid arthritis. Patients received placebo during the last 9 days of the study. Pain scores during the first 16 days acted as a baseline from which each patient's response to placebo could be determined. Patients completed Form B of the Eysenck Personality Inventory on entry into the study, a pre-treatment expectation rating scale and a post-treatment assessment scale. Five patients were excluded from analysis because of trends in their baseline pain scores. Of the remaining patients, nine responded positively to placebo and five responded negatively. Four patients reported no significant change in pain and were found to be more introverted than both the negative (p less than 0.05) and positive placebo responders. Consequently, the degree of extraversion might prove a useful predictor of therapeutic response. No significant relationship was found between the patients expectation of therapy and the observed response which suggests that therapeutic outcome is not pre-determined. However, the patients assessment of therapeutic effect was closely related to the observed response (p less than 0.05). Neuroticism was greater in patients with side-effects than those without (p less than 0.05) and might be utilized as a means of detecting those patients most likely to complain of unrelated symptoms while on a new therapy. The different placebo responses observed draws attention to the difficulties in making therapeutic judgements in clinical practice and of assessing efficacy in drug trials.

A simple pressure dolorimeter for the quantification of joint tenderness in inflammatory arthritis.

A simple pressure dolorimeter for the detection and quantification of joint tenderness is described and evaluated. The pressure dolorimeter was more sensitive than a modified Ritchie Index in measuring degree of joint tenderness and as sensitive in detecting tender joints. The interobserver error of the pressure dolorimeter was low, and in a drug withdrawal study, the pressure dolorimeter was able to detect change in joint tenderness whereas the conventional Ritchie Index was not. These results suggest that the pressure dolorimeter is a simple, reliable and sensitive instrument for measuring joint tenderness in patients with inflammatory joint disease. It is also inexpensive and readily available.

The activities of daily living index in rheumatoid arthritis: an observer variation study.

The Northwick Park activities of daily living (ADL) index was used to assess functional disability in rheumatoid arthritis patients. Assessments were carried out by two pairs of observers and inter-observer variation was studied. No significant differences were found between observers for the total independence score and the total time taken to complete individual tasks. A significant difference was found between observers in Pair A with regard to the total assessment time, as one member from this pair took consistently longer to complete the assessment than the other. Although this trend was also apparent in Pair B, this was not significant. The modified ADL index is recommended for routine assessment in the general treatment and rehabilitation of patients with rheumatoid arthritis.