Care-related pain in hospitalized patients: severity and patient perception of management.

BACKGROUND: Hospitalized patients commonly undergo painful procedures, but little is known about care-related pain (CRP) in the overall population of inpatients. We conducted a cross-sectional 1-day survey to assess the prevalence and characteristics of CRP and its management in all units of a university hospital in Paris and determined the factors linked to severe CRP. METHODS: All patients who were able to communicate and were hospitalized for at least 24 h but not in a day-care or neonatal unit were included. RESULTS: From 938 patients who completed the questionnaire, 554 patients reported pain within the previous 24 h, for a 59% prevalence of pain, and 540 (58%) had experienced CRP in the previous 15 days (51% males; mean [SD] age 54 [18] years). Of 907 procedures, 330 (37%) resulted in severe pain. The most-often reported painful procedures were vascular punctures and patient mobilization. Severe CRP was associated with long hospitalization; non-vascular invasive punctures, catheterization, mobilization or radiological examination; or pain during the previous 24 h due to surgery or treatment. Only half of the patients declared that they had received information regarding the painful procedure. Treatment for pain was proposed and delivered in less than one quarter of cases. CONCLUSIONS: Our results of a survey of pain management in hospitalized patients relate to a wide variety of medical conditions and procedures. Health-care workers should be more systematic in managing CRP, and attention should be paid to patients at greatest risk of severe CRP.

Efficacy and safety of oral ketamine for the relief of intractable chronic pain: A retrospective 5-year study of 51 patients.

BACKGROUND: This work summarizes the efficiency, failures and adverse effects of oral administration of ketamine at home for intractable pain. METHODS: This 5-year retrospective study involved testing ketamine by intravenous in-hospital administration, then a conversion to an oral route, or oral treatment directly administered at home. The daily intravenous dose was increased by steps of 0.5 mg/kg to attain an effective daily dose of 1.5-3.0 mg/kg. Pain was evaluated on a numeric scale from 0 to 10, and evidence of adverse effects was collected every day. The effective daily dose was delivered orally (three to four intakes). If effective, ketamine was continued for 3 months. Short infusions or direct oral treatment began with a 0.5-mg/kg dose, then the daily ketamine dose was increased in 15- to 20-mg increments. RESULTS: Among 55 cases (51 patients, neuropathic pain 60%), the mean effective oral dose was 2 mg/kg. Ketamine was effective in 24 patients (44%, mean pain reduction 67 ± 17%), partially effective in 20% (mean pain reduction 30 ± 11%), with a mean opioid sparing of 63 ± 32%, and failure in 22%. Half of the patients experienced adverse effects, but only eight had to stop treatment. For patients with opioid therapy, failure of ketamine was less frequent (7% vs. 36%; p < 0.02), with fewer adverse effects (33% vs. 68%; p < 0.01). CONCLUSIONS: Pain was reduced or abolished in two-thirds of patients under ketamine therapy; ketamine was effective for patients taking opioids and resulted in few adverse effects.

Determinants of patient satisfaction regarding pain care.

BACKGROUND: The management of pain in hospitalized patients remains a major public hospital priority. It has been the object of three French national programs since 1999. The purpose of this study was to reassess pain prevalence, pain intensity and patient perception of its management ten years after the first national program and to determine the factors related to the patient satisfaction with efforts to decrease pain intensity. METHODS: A 1-day cross-sectional survey in a university hospital. RESULTS: Pain prevalence was 59%. Pain intensity varied according to the medical department with lower intensity in surgery and obstetrics than medicine departments. Eighty-one percent of patients were satisfied with their pain management. Patient satisfaction was higher when doctors and nurses were heavily involved in the process of pain relief (OR=6.6; 95% CI 3.8, 11.4), and when their pain had decreased (OR=2.9; 1.7, 5.0). The magnitude of decrease in pain were higher when the medical team was involved (OR=1.9; 95% IC 1.1, 3.3) and pain intensity was measured (OR=1.6; 1.0, 2.4). Perceptions of doctor and nurse involvement in the patient's care was higher when pain intensity was measured (OR=6.0; 3.4, 10.5), an immediate treatment offered (OR=3.5; 2.0, 6.2), encouragement to ask for an analgesic was provided (OR=2.0; 1.1, 3.5) and for patients with acute pain (OR=2.2; 1.0, 4.7). CONCLUSIONS: This study identifies the factors related to patient satisfaction with pain management and the magnitude of the decrease in pain which should allow further efforts to improve the management of pain and reduce its intensity in hospital inpatients.

Anatomical and radiological evidence for the iliolumbar vein as an inferior lumbar venous system.

The purpose of this work was to study an inferior lumbar venous system, which turned out to be the vertical component of the iliolumbar vein as defined in early works by Bourgery and Jacob, though there is a terminological ambiguity between the iliolumbar vein and the ascending lumbar vein in the literature. However, the iliolumbar vein is most commonly defined as a vein draining the fourth and fifth lumbar vertebral segments. Cadaver studies, including one injection-corrosion, and in vivo venograms were analyzed by visual inspection and measurements. Whether the injection was made via the axillary or the saphenous veins, the inferior lumbar vein was always filled, demonstrating that it is part of the vertebral venous system. An interruption or a plexiform shape of the venous system at the level of the third lumbar vertebra, and an increase in caliber as this vein runs downwards, allowed differentiating the inferior lumbar vein from the ascending lumbar vein. The inferior lumbar vein and the superior iliac vein drained into the iliac veins, either external or internal iliac vein, but typically into the common iliac vein, separately or with a single common trunk. This common trunk was observed in 92% of the dissected cases on the right side and in 46% on the left, whereas it was seen in 50% of the radiological studies on the right side and 52% on the left. Consequently, the inferior lumbar vein was the main component of the iliolumbar vein, and as such should be differentiated from the ascending lumbar vein.

[Enterobacter cloacae spondylodiscitis through misuse of high-dose intravenous buprenorphine]. / Spondylodiscite à Enterobacter cloacae par mésusage intraveineux de la buprénorphine haut dosage.

INTRODUCTION: We report a case of Enterobacter cloacae spondylodiscitis related to risk practices in intravenous drug addicts (IVDA). OBSERVATION: The patient, a former heroin addict, was receiving long-term, high-dose buprenorphine maintenance treatment. He had been misusing the treatment, injecting it daily for several months. The clinical course included several uncommon features that are usually found in IVDA patients: subacute infection, apyrexia, and minimal inflammatory syndrome. This infection also led to the discovery of his HIV infection. DISCUSSION: Any dorsolumbar pain in IVDA patients, including those receiving regular drug maintenance treatment and especially those with HIV infection, should suggest spondylodiscitis, because of these patients' enhanced sensitivity to infection and the frequent bacteremia caused by persistent or transitory relapse involving injection (exchange of material, reuse of needles, syringes, cotton swabs, and risk of contamination through the hands or saliva).

Therapeutic efficacy in experimental polyarthritis of viral-driven enkephalin overproduction in sensory neurons.

Rheumatoid arthritis is characterized by erosive inflammation of the joints, new bone proliferation, and ankylosis, leading to severely reduced locomotion and intense chronic pain. In a model of this disease, adjuvant-induced polyarthritis in the rat, neurons involved in pain transmission and control undergo plastic changes, especially at the spinal level. These changes affect notably neurons that contain opioids, such as enkephalins deriving from preproenkephalin A (PA) precursor protein. Using recombinant herpes simplex virus containing rat PA cDNA, we enhanced enkephalin synthesis in sensory neurons of polyarthritic rats. This treatment markedly improved locomotion and reduced hyperalgesia. Furthermore, the progression of bone destruction slowed down, which is the most difficult target to reach in the treatment of patients suffering from arthritis. These data demonstrate the therapeutic efficacy of enkephalin overproduction in a model of systemic inflammatory and painful chronic disorder.

Laterally elevated wedged insoles in the treatment of medial knee osteoarthritis: a prospective randomized controlled study.

OBJECTIVE: To compare the clinical effects of laterally wedged insoles and neutrally wedged insoles (used as control) in patients with medial femoro-tibial knee osteoarthritis (OA). DESIGN: 6-month prospective randomized controlled study. PATIENTS: outpatients with painful medial femoro-tibial knee OA. OUTCOME MEASURES: patient's overall assessment of disease activity (5 grade scale), WOMAC index subscales and concomitant treatments. STATISTICAL ANALYSIS: Performed as an intention-to-treat analysis. Main criterion: improvement in the patient's assessment of activity (defined as a reduction of 1 grade or more at month 6 compared to baseline, and no intraarticular injection or lavage during the study). Secondary criteria for assessment: (a) improvement in the patient's assessment of activity at months 1 and 3 compared to baseline, (b) improvement in the WOMAC subscales at months 1, 3 and 6, compared to baseline (defined as an improvement of at least 30%, and no intraarticular injection or lavage during the study) and (c) concomitant therapies (analgesics and NSAIDs). RESULTS: The baseline characteristics of the 156 recruited patients (41 males, 115 females, mean age 64.8 years) were not different in the two treatment groups. At months 1, 3 and 6 the percentages of patients with improvement in assessment of disease activity, in WOMAC pain, joint stiffness, and physical functioning subscales were similar in the two groups. The number of days with NSAIDs intake during the previous 3 months was decreased at month 6 compared with baseline in the group furnished with laterally wedged insoles (14.1 days+/-28 vs 9.9 days+/-27, P=0.04, Wilcoxon paired test), while it remained unchanged in the other group (15.5 days+/-24 vs 15+/-28, P=0.56). Compliance and tolerance were satisfactory. Compliance was different between the two groups at month 6, with a greater frequency of patients who wore insoles permanently in the laterally wedged insole group than in the other group (87.8% vs 74.3%;P=0.032). CONCLUSION: This study failed to demonstrate a relevant short-term symptomatic effect of laterally-wedged insoles in medial femoro-tibial OA. However, the decrease in NSAIDs consumption together with better compliance in the treated group are in favor of a beneficial effect of laterally-wedged insoles in medial femoro-tibial OA.

Neuronal monoamine reuptake inhibitors enhance in vitro susceptibility to chloroquine in resistant Plasmodium falciparum.

Chloroquine resistance in Plasmodium falciparum was reversed in vitro by the neuronal monoamine reuptake inhibitors and antidepressants desipramine, sertraline, fluoxetine, and norfluoxetine but not by carbamazepine, an antiseizure and mood-stabilizing tricyclic drug resembling desipramine which only weakly inhibits neuronal monoamine reuptake. These findings have important clinical implications for drug combination therapy.