Corticosteroid injections for trochanteric bursitis: is fluoroscopy necessary? A pilot study.

BACKGROUND: Numerous studies have demonstrated that therapeutic injections carried out to treat a variety of different pain conditions should ideally be performed under radiological guidance because of the propensity for blinded injections to be inaccurate. Although trochanteric bursa injections are commonly performed to treat hip pain, they have never been described using fluoroscopy. METHODS: The authors reviewed recorded data on 40 patients who underwent trochanteric bursa injections for hip pain with or without low back pain. The initial needle placement was done blindly, with all subsequent attempts done using fluoroscopic guidance. After bone contact, imaging was used to determine if the needle was positioned on the lateral edge of the greater trochanter (GT). Once this occurred, 1 ml of radiopaque contrast was injected to assess bursa spread. RESULTS: The GT was contacted in 78% of cases and a bursagram obtained in 45% of patients on the first needle placement. In 23% of patients a bursagram was obtained on the second attempt and in another 23% on the third attempt. Four patients (10%) required four or more needle placements before a bursagram was appreciated. Attending physicians obtained a bursagram on the first attempt 53% of the time vs 46% for fellows and 36% for residents (P=0.64). Older patients were more likely to require multiple injections than younger patients. CONCLUSIONS: Radiological confirmation of bursal spread is necessary to ensure that the injectate reaches the area of pathology during trochanteric bursa injections.

Ethical dilemmas in pain management.

The purpose of this study was to survey the membership of the American Pain Society and the American Academy of Pain Medicine to determine their beliefs about ethical dilemmas in pain management practice. Respondents rated ethical dilemmas for their importance as well as their own competence in dealing with these ethical issues. The survey also included an open-ended question that asked respondents to describe clinical situations in which they had encountered ethical dilemmas. A total of 1,105 surveys were analyzed, with physicians (N = 612), nurses (N = 189), and psychologists (N = 166) representing the professions with the greatest response. Management of pain at the end of life, general undertreatment of pain, and undertreatment of pain in the elderly were the most frequently encountered dilemmas. Qualitative data were analyzed to identify ethical issues in the case examples provided by the respondents. Major themes included inappropriate pain management, barriers to care, interactions and conflicts with others, regulatory/legal issues, euthanasia, assisted suicide, and research issues. We conclude that ethical dilemmas are common in pain management practice and that resolution of these dilemmas requires commitment by individual professionals as well as health systems.

Satisfaction with epidural and intravenous patient-controlled analgesia.

OBJECTIVE: Postoperative intravenous (i.v.) versus epidural morphine patient-controlled analgesia (PCA) were compared regarding maintenance of initial PCA route, pain levels, side effects, and levels of satisfaction. Additionally, the role of preoperative attitudinal expectations in predicting postoperative levels of satisfaction with pain management as well as maintenance of initial PCA route was evaluated. DESIGN: After either abdominal or thoracic surgery, 70 eligible patients were randomized to receive morphine either through an epidural route (n = 37) or an intravenous PCA pump (n = 33). SETTING: A large tertiary university teaching hospital in a major northeastern city. OUTCOME MEASURES: Patients completed visual analogue rating scales 1 week before surgery regarding attitudes such as expectations of satisfaction with pain management after surgery and expectations of medication efficacy postsurgically. Postoperatively, beginning the day after surgery, patients were asked to complete visual analogue rating scales every 12 hours until they were discharged, for a maximum of 3 postoperative days. The scales evaluated included pain, ability to think, and satisfaction with pain control. RESULTS: There were no significant between-group differences on the postoperative visual analogue scales. Although the overall rate of changing the initial PCA route to which the patients were randomized was identical for both groups (30%), those patients who had thoracic surgery changed their route of PCA administration significantly less when their initial PCA route was epidural (20%) than when their initial PCA route was i.v. (46%) (P <.05). Patients who were satisfied with pain control postoperatively were more likely to have been started on i.v. PCA (P =.001), have lower preoperative expectations of postoperative satisfaction with pain (P <.001), and have higher preoperative expectations of medication effects on postoperative pain (P <.001). Additionally, older patients (P =.007) and patients with lower preoperative expectations of postoperative satisfaction with pain (P =.003) were more likely to adhere to their initial treatment protocol. CONCLUSIONS: Both techniques, i.v. and epidural PCA, result in high levels of satisfaction. Satisfaction with PCA can be accurately predicted in nearly three of four patients based on initial PCA route and preoperative attitudes. Additionally, maintaining the initial treatment plan can be accurately predicted based on age and preoperative attitudes. Patient expectations about pain relief should be addressed preoperatively, particularly with younger patients, for optimal results.

Ethics and pain: why and for whom?

This paper gives a historical overview to the development of this special issue of Pain Medicine. A brief synopsis of the articles of this issue is offered followed by a review of characteristics of pain, pain patients, and the system we practice in, that can lead to ethical dilemmas. These issues include the inherent difficulty of "curing" chronic pain, the psychopathology of chronic pain patients, end-of-life issues, the patient-physician relationship, the use of unproven methods, the vulnerability of pain patients, the increasing economic pressures of pain clinics, litigation, and the workers' compensation system.

The psychological assessment of patients with chronic pain.

This article reviews the objectives of psychological evaluations, as well as the standard pain center evaluation protocol that uses a pain questionnaire, a structured clinical interview, and pain assessment measures that include pain intensity rating scales and the McGill Pain Questionnaire. The most frequently used measures of psychological status, such as the Beck Depression Inventory and the Minnesota Multiphasic Personality Inventory (MMPI), are reviewed. Psychological predictors of invasive procedures and of disability are also outlined. The importance of listening to the patient in a multidisciplinary setting is emphasized.

Intraoperative therapeutic suggestions in day-case surgery: are there benefits for postoperative outcome?

To determine if improved postoperative recovery in surgical inpatients receiving intraoperative therapeutic suggestions are applicable in an outpatient population, 70 consenting, unpremedicated adults undergoing elective outpatient hernia repair under general anaesthesia were allocated randomly to either a therapeutic tape (TT) or a comparison tape (CT) group. A standardized general anaesthetic technique was used with propofol, fentanyl or alfentanil, isoflurane and nitrous oxide in oxygen. Pain, and nausea and vomiting were assessed after operation at 30, 60 and 90 min and at 2, 6 and 24 h. The presence of other side effects, such as headache and muscular discomfort, in addition to recall of tape contents, were also evaluated after operation. Absorption ability was measured before operation. The groups were similar in patient characteristics, preoperative, surgical and anaesthetic characteristics, and level of absorption. There were no differences in pain ratings or need for analgesics administered at any time after operation. Nausea/vomiting was experienced significantly fewer times by patients in group TT compared with group CT over the first 90 min (group CT 15%, group TT 4%; P < 0.02), but not over the last three assessment times (group CT 10%, group TT 14%; P < 0.25). The therapeutic tape group experienced fewer side effects over the entire postoperative assessment period (P = 0.03), in particular less headaches (P = 0.03) and less muscular discomfort (P < 0.02). Use of intraoperative therapeutic suggestions could present mildly significant postoperative benefits in outpatients.

Pain knowledge and attitudes of healthcare providers: practice characteristic differences.

OBJECTIVE: To evaluate the knowledge and attitudes of different healthcare professionals regarding pain issues such as addiction, the assessment of pain, scheduling, use of analgesics, and pediatric pain. Additionally, to determine whether differences exist based on hospital setting, years of service, clinical practice area, and country of origin. DESIGN: A total of 686 nurses, physicians, pharmacists, and medical/nursing students from three hospitals completed a 17-item survey evaluating knowledge and beliefs about pain. SETTING: The three hospital settings were a large city hospital, a private community hospital, and a state medical school-based hospital. RESULTS: The overall percentage "correct" score was only 56%. Physicians scored significantly higher, and pharmacists scored significantly lower than other groups. Nurses scored significantly less concordantly than physicians on 11 of the 17 items. Those identifying anesthesiology as their clinical practice area scored significantly higher than all other areas, whereas those practicing within medicine demonstrated significantly more "correct" scores than those in surgery. City hospital respondents scored significantly lower than professionals practicing in the other two hospitals; non-U.S. country of origin professionals scored significantly lower than U.S. country of origin healthcare professionals. There were no significant differences based on postgraduate years of practice. CONCLUSIONS: Significant knowledge deficits regarding currently accepted principles of pain management practice as well as beliefs that could interfere with optimal care, mandate a need for educational interventions. Significant differences by profession, clinical practice area, and hospital setting reflect populations to be targeted for interventions. Unwarranted fear of addiction is a misunderstood and important concept that needs to be addressed.

Ketorolac versus fentanyl for postoperative pain management in outpatients.

OBJECTIVE: The purpose of this study was to compare the efficacy and safety of i.v. ketorolac and fentanyl for moderate to severe postoperative pain in patients undergoing elective surgery in an ambulatory surgery unit. DESIGN: A double-blind randomized trial. SETTING: An ambulatory surgery unit in a university-affiliated hospital. PATIENTS: Sixty-nine patients undergoing elective laparoscopy, inguinal hernia repair, or knee arthroscopy were enrolled. INTERVENTION: Patients were randomly assigned to receive intravenous ketorolac 30 mg (n = 38) or fentanyl 50 micrograms (n = 31) for moderate to severe postoperative pain. OUTCOME MEASURES: Pain, assessed using a 100-mm visual analog scale and a 5-point verbal pain scale; adverse effects, as well as vital signs were recorded every 15 min for 150 min or until discharge from the postanesthesia care unit, 6 and 24 h after discharge. RESULTS: Pain reduction on both visual analog and verbal scales was significantly greater with fentanyl than ketorolac at 15 min. In addition, the proportion of patients requiring remedication at the 15-min time point was significantly greater in the ketorolac group. However, there were no significant differences between fentanyl and ketorolac between 30 and 150 min after surgery. Notably, pain reduction was significantly greater with ketorolac on the verbal scale at the 6 h measurement. CONCLUSIONS: Ketorolac appears not be as effective as fentanyl in treating early postoperative pain. Although fentanyl still appears to be the drug of choice in the early postoperative period, the parenteral use of ketorolac was more effective during the later postoperative period in providing longer lasting analgesia.

Pain in hospitalized patients with AIDS: analgesic and psychotropic medications.

OBJECTIVE: We undertook this study to evaluate the use of analgesic and psychotropic medication in acquired immunodeficiency syndrome (AIDS) patients with pain and to determine whether our previous findings of a high prevalence of pain in patients with AIDS who were hospitalized could be replicated. Additional factors related to pain were evaluated, such as death during hospital stay, i.v. drug abuse, and length of hospital stay. DESIGN: One hundred thirty-nine medical charts randomly selected from 1 year of hospital admissions of patients with AIDS were reviewed in a systematic manner for pain, prescription of analgesic and psychotropic medication, patient demographics, and disease characteristics. RESULTS: Sixty-one percent of the charts reviewed had at least one note of nonprocedural pain. Sixty-eight percent of pain patients were prescribed a nonnarcotic (most commonly acetaminophen), and 44% a narcotic. Sixty-two percent of pain patients were prescribed a psychotropic medication. Patients with pain were significantly more likely to receive an analgesic as well as psychotropic medication, particularly a sedative-hypnotic, than patients without pain. Having pain was not significantly related to other factors such as i.v. drug abuse except for length of hospital stay. Most of the previous study findings were replicated with the notable exception of the rate of prescription of psychotropics as well as acetaminophen, which increased substantially in this study. CONCLUSIONS: Although pain is a prevalent problem in hospitalized AIDS patients, narcotics as well as antidepressants appear to be underutilized. It is suggested that medical education regarding pain management in AIDS patients is an important first step in a more aggressive approach.

The selection of a residency program: prospective anesthesiologists compared to others.

A study was undertaken to investigate factors important to senior medical students, particularly prospective anesthesiology residents, in selecting a residency program. A previously published questionnaire was used to determine whether previous findings could be replicated. One hundred ninety-seven senior medical students rated the importance of 22 items in their selection of a residency program. Factors were ranked nearly identically as in the previous study. Factors rated as most important were "diversity of training experience" as well as "house officer satisfaction," whereas items about treating patients with the acquired immunodeficiency syndrome were rated as least important. There were gender differences that showed women assigned more importance to having a manageable case load, call schedules, and geographic location. Prospective anesthesiology residents perceived "prestige" of the program, and the department as significantly more important than did prospective nonanesthesiology residents. The replication of results with regard to the overall ranking of factors demonstrates the reliability of the results. Resident selection committees need to focus on the issue of quality of training, the impression made by the interviewers, and include satisfied residents as part of the interview process.

Early anesthesia evaluation of the ambulatory surgical patient: does it really help?

STUDY OBJECTIVE: To evaluate whether early evaluation by the anesthesiologist is more beneficial for the ambulatory surgical patient than a day-of-surgery visit. DESIGN: A randomized study evaluating patients with different surgical procedures. SETTING: Ambulatory surgical outpatients at a university-affiliated integrated ambulatory surgical unit. PATIENTS: Sixty-three ASA physical status I and II women scheduled to undergo elective dilatation and curettage or gynecologic laser surgery. INTERVENTIONS: Approximately half of the patients received an early (1 to 7 days preoperative) anesthesia evaluation, and half received a day-of-surgery evaluation. All patients underwent the surgical procedures with a standardized general anesthetic. MEASUREMENTS AND MAIN RESULTS: The effect of an early versus a day-of-surgery anesthesia visit was evaluated with regard to patient anxiety levels; patient satisfaction with the surgical and anesthetic experience; operating room, recovery room, and ambulatory surgery unit time; anesthetic and analgesic requirements; and frequency of postoperative problems within 72 hours at home. There were no differences between the groups in demographic characteristics, anesthesia or analgesic requirements, degree of satisfaction with the ambulatory surgical experience, time spent in recovery room, or frequency of problems on postoperative follow-up. We were unable to demonstrate any differences between those patients seen early versus those seen on the day of surgery in anxiety levels preoperatively and postoperatively. CONCLUSIONS: Healthy ASA physical status I and II ambulatory surgical patients do not benefit from reducing preoperative anxiety by visiting the anesthesiologist prior to the day of surgery.

Correlates of a residential pesticide contamination in a self-selected sample.

We evaluated the behavioral, health perception, and physical health correlates of a residential pesticide misapplication on 54 individuals and identified factors differentially related to various levels of distress. Study participants were mainly concerned with health issues and exhibited somatic symptoms. Behavioral actions designed to obtain information regarding exposure levels and to reduce exposure were adopted. We found that factors such as a higher contamination level, involvement in a lawsuit, and belonging to a consumer action group, were strongly related to higher levels of psychological distress and, to a lesser extent, to behaviors, somatic symptoms, and health perceptions.

Cost offset from a psychiatric consultation-liaison intervention with elderly hip fracture patients.

OBJECTIVE: The authors hypothesized that psychiatric liaison screening of elderly patients with hip fractures would shorten the average length of hospital stay and increase the proportion of patients who returned home after discharge. METHOD: The study was performed at Mount Sinai Medical Center in New York and Northwestern Memorial Hospital in Chicago. The subjects were 452 patients 65 years or older who were consecutively admitted for surgical repair of fractured hips. During a baseline year the patients received traditional referral for psychiatric consultation. During the experimental year all the patients at Mount Sinai and the patients on one Northwestern Unit were screened for psychiatric consultation. RESULTS: The patients who received psychiatric liaison screening had a higher consultation rate than those who received traditional consultation. The rates of DSM-III disorders in the experimental year were 56% at Mount Sinai and 60% at Northwestern. The mean length of stay was reduced from 20.7 to 18.5 days at Mount Sinai and from 15.5 to 13.8 days at Northwestern, resulting in reductions in hospital costs ($647/day) of $166,926 and $97,361, respectively. Fees generated from Medicare service delivery could have paid for the $20,000 psychiatric intervention cost at each site. There was no difference, however, between the two years in the discharge placement of patients. CONCLUSIONS: Admission psychiatric liaison screening of elderly patients with hip fractures results in early detection of psychiatric morbidity, better psychiatric care, earlier discharge, and substantial cost savings to the hospital.

Predictors of physician nonadherence to chemotherapy regimens.

Physician nonadherence to cancer treatment regimens may diminish treatment efficacy and compromise clinical research. The influence of clinical, demographic, and psychosocial patient characteristics on physician adherence to breast cancer chemotherapy was investigated, as was the role of the clinician's attitudes concerning the chemotherapy. One hundred seven women recently diagnosed with breast cancer were followed for 26 weeks of treatment. Fifty-six (52%) of the patients experienced unjustified modification for at least one chemotherapeutic agent. Stepwise multiple regression revealed independent contributions of increased patient age, treatment setting (clinic versus academic or community private practice), and stage of disease to physician nonadherence. Regimen complexity, delay in seeking treatment, and presence of psychiatric disorder did not contribute, in general, to unjustified regimen modifications. Patient psychological and psychiatric factors, however, did influence prescribing behavior for vincristine. Physician awareness of factors contributing to unnecessary treatment modifications may reduce the frequency of such behaviors.

Reflex sympathetic dystrophy and posttraumatic stress disorder. Multidisciplinary evaluation and treatment.

Reflex sympathetic dystrophy (RSD) may co-occur with posttraumatic stress disorder (PTSD). A case study is reported of a challenging adolescent patient who presented to a chronic pain service with RSD and PTSD. A multidisciplinary approach utilizing nerve-block therapy with adjunctive pharmacologic treatment, physical rehabilitation, and behavioral/cognitive psychological therapy was employed to produce a significant reduction in pain as well as a more physically and psychologically functional adolescent. The diagnosis and treatment of each disease is essential for the successful resolution of symptoms.

Sphenopalatine ganglion block: clinical use in the pain management clinic.

Clinical experience with the sphenopalatine ganglion (SPG) block combined with a review of prior studies led to conducting a retrospective evaluation of four patients with chronic pain treated with the SPG block. The review of case reports suggests the usefulness of SPG blocks in the pain management clinic.

Issues in the identification of premenstrual syndromes.

Lack of information about the natural history of the premenstrual syndromes may make efforts regarding classification and treatment misguided. Thus, we report a naturalistic and noninstrusive approach to the problem of identification of the premenstrual syndromes, with particular focus on the issue of compliance with 2 months of daily prospective recordkeeping. Seventy-nine patients presenting for treatment of severe premenstrual symptoms were evaluated with a structured interview, psychological tests, and 2 months of daily prospective ratings of their symptoms. Weekly group follow-up meetings were held to foster compliance with recordkeeping. The typical woman seeking treatment for premenstrual symptoms in this study was middle-aged, highly educated, highly functioning, living in an urban setting, either married with children and family responsibilities or single and living alone, and supporting herself by a high-level job. She was anxious and depressed with multiple medical and gynecological problems. Despite a highly stressful life, she functioned at a very high level, but had consulted mental health professionals in the past. In general, she did not want medication. Consistent with other reports, only 20% of women seeking treatment for premenstrual symptoms had a premenstrual syndrome prospectively confirmed on the basis of 2 months of daily ratings. However, 81% of those with a prospectively confirmed premenstrual syndrome stated that after the 2-month evaluation period their symptoms no longer interfered with their functioning.

The asbestos worker who smokes: adding insult to injury.

Evaluates whether asbestos workers who smoke cigarettes, thereby increasing their cancer risk synergistically, differ from asbestos workers who choose not to smoke. Demographic, personality, psychologic, and cognitive differences were examined. Engaging in this highly detrimental health behavior was related exclusively to cognitive factors. Although current smokers were cognitively aware of their added health risk, in comparison to past and "never" smokers, they minimized the salience of awareness by fatalistically attributing their health to chance factors such as luck and by minimizing the dangers of smoking, the benefits of smoking cessation, and their own increased vulnerability to life-threatening illnesses. Results are explained in light of the apparent denial of risk. The need for physician intervention is strongly advocated.