European journal of pain : EJP
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The development and refinement of an acute pain service based on the increased availability of clinical evidence would be expected to improve the quality of postoperative pain control. This report reviews the application of postoperative patient-controlled analgesia (PCA) using intravenous morphine in a single institution between 2002 and 2005. More than 5000 patients were evaluated and the results were compared with a similar study performed 10 years ago. ⋯ We conclude that, in our institution over the last decade, PCA has become more popular for postoperative pain management but with no attendant improvement in pain relief or reduction in side effects. Using PCA alone may result in poorer quality postoperative analgesia. Our findings add to the growing body of evidence that postoperative pain management has not substantially improved despite increased adoption of acute pain services.
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Randomized Controlled Trial
Perioperative ketamine does not prevent chronic pain after thoracotomy.
Thoracotomy is often responsible for chronic pain, possibly of neuropathic origin. To confirm preclinical studies, the preventive effects of perioperative ketamine were tested in a randomized, double-blind, placebo-controlled clinical trial on persistent neuropathic pain after thoracotomy. Eighty-six patients scheduled for thoracotomy under standardised general anaesthesia were randomised to receive either ketamine (1 mg kg(-1) at the induction, 1 mg kg(-1) h(-1) during surgery, then 1 mg kg(-1) during 24 h; n=42) or normal saline (n=44). ⋯ Ketamine improved immediate postoperative pain, but the groups were similar in terms of neuropathic pain and intake of analgesics, 6 weeks (NPSI score: ketamine: 1.25 [0-4.125]; placebo: 1 [0-4]) and 4 months after surgery. Thus, ketamine given in 24-h infusion failed to prevent chronic neuropathic pain after thoracotomy. Other perioperative preventive long-lasting treatments or techniques could be tested in this context.
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Randomized Controlled Trial
Cannabinoid-induced effects on the nociceptive system: a neurophysiological study in patients with secondary progressive multiple sclerosis.
Although clinical studies show that cannabinoids improve central pain in patients with multiple sclerosis (MS) neurophysiological studies are lacking to investigate whether they also suppress these patients' electrophysiological responses to noxious stimulation. The flexion reflex (FR) in humans is a widely used technique for assessing the pain threshold and for studying spinal and supraspinal pain pathways and the neurotransmitter system involved in pain control. In a randomized, double-blind, placebo-controlled, cross-over study we investigated cannabinoid-induced changes in RIII reflex variables (threshold, latency and area) in a group of 18 patients with secondary progressive MS. ⋯ The visual analogue scale score for pain also decreased, though not significantly. Conversely, the H/M ratio measured before patients received cannabinoids remained unchanged after therapy. In conclusion, the cannabinoid-induced changes in the RIII reflex threshold and area in patients with MS provide objective neurophysiological evidence that cannabinoids modulate the nociceptive system in patients with MS.
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A within-patient change in pain score after treatment is statistically 'reliable' when it exceeds the smallest detectable difference (SDD). The aims of the present study were (i) to determine SDD for scoring pain behavior on a 0-5 point adjectival scale, and (ii) to explore the relationship between SDD, clinically important difference (CID) and effect size (ES) following treatment of known efficacy, and to compare these parameters of pain behavior with those of VAS-scores of pain intensity [van Grootel RJ, van der Bilt A, van der Glas HW. Long-term reliable change of pain scores in individual myogenous TMD patients. ⋯ Interpretation of changes in health-related quality of life. The remarkable universality of half a standard deviation. Med Care 2003;41:582-92]) suggests that for myogenous TMD (chronic pain not caused by somatic disease and with a large chance on recovery following treatment), there are higher expectations of what constitutes important change.