Pain
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Angina pectoris that is refractory to optimal medication and revascularization is becoming an increasingly common clinical problem. Recently the US Food and Drug Administration (FDA) approved transmyocardial laser revascularization (TMLR) for use in this group of patients and a large numbers of patients have already undergone this therapy. Unfortunately TMLR has is associated with an unacceptably high perioperative mortality (Cooley DA, Frazier OH, Kadipasaoglu KA, Lindenmeir MH, Pehlivanoglu S, KoIff JW, Wilansky S, Moore WH. ⋯ Am J Med Sci 1966;252:289-295). Here we describe a patient with end stage coronary artery disease and chronic refractory angina whose has been successfully treated with repeated unilateral left SGBs following multiple bypass operations, angioplasty procedures and laser therapy. This case report details his progress over a 34 month follow-up period.
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Little is known about the epidemiology of pain in children. We studied the prevalence of pain in Dutch children aged from 0 to 18 years in the open population, and the relationship with age, gender and pain parameters. A random sample of 1300 children aged 0-3 years was taken from the register of population in Rotterdam, The Netherlands. ⋯ The intensity of pain was higher in the case of chronic pain (P<0. 001) and multiple pains (P<0.001), and for chronic pain the intensity was higher for girls (P<0.001). These findings indicate that chronic pain is a common complaint in childhood and adolescence. In particular, the high prevalence of severe chronic pain and multiple pain in girls aged 12 years and over calls for follow-up investigations documenting the various bio-psycho-social factors related to this pain.
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Clinical Trial
Human chromaffin cell graft into the CSF for cancer pain management: a prospective phase II clinical study.
A number of pre-clinical studies have demonstrated the value of adrenal medullary allografts in the management of chronic pain. The present longitudinal survey studied 15 patients transplanted for intractable cancer pain after failure of systemic opioids due to the persistence of undesirable side-effects. Before inclusion, all the patients had their pain controlled by daily intrathecal (I-Th) morphine administration. ⋯ In most cases, we noted a relationship between analgesic responses and CSF met-enkephalin levels. The results of this phase II open study demonstrate the feasibility and the safety of this approach using chromaffin cell grafts for long-term relief of intractable cancer pain. However, while analgesic efficacy was indicated by the reduction or stabilization in complementary opioid intake, these observations will need to be confirmed in a controlled trial in a larger series of patients.
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The effectiveness of systemic lidocaine in relieving acute and chronic pain has been recognized for over 35 years. In particular, systemic lidocaine has been utilized both as a diagnostic and therapeutic tool for intractable neuropathic pain during the last decade. The introduction of oral lidocaine congeners such as mexiletine has significantly extended the usage of lidocaine therapy in chronic pain settings. ⋯ However, there remain inconsistencies in the scientific basis underlying the clinical application of lidocaine therapy. Recent demonstration of changes in tetrodotoxin (TTX)-sensitive and TTX-resistant sodium channels following nerve injury and their link to certain neuropathic pain symptoms may lead to the development of subtype-specific sodium channel blockers. The thoughtful use of lidocaine therapy and the potential application of subtype-specific sodium channel blockers could provide better management of distinctive neuropathic pain symptoms.
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Case Reports
Spinal cord stimulation: a possible therapeutic alternative for chronic mesenteric ischaemia.
A 78-year-old male patient had chronic, unrelieved abdominal pain due to mesenteric ischaemia. Unsuccessful pharmacological approaches included oral morphine plus coadjuvants as well as a sympathetic celiac plexus block which gave pain relief that lasted for 72 h. In order to obtain long-lasting relief, a trial epidural stimulating electrode was implanted after obtaining informed consent and Ethical Committee approval. ⋯ Thereafter, a spinal cord stimulator was implanted. At the time of writing, 11 months after implantation, the degree of analgesia is complete. We believe that spinal cord stimulation may represent an alternative approach in controlling pain due to mesenteric ischaemia.