The journal of pain : official journal of the American Pain Society
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Herpes zoster causes substantial morbidity, especially among older adults. Although the acute cutaneous manifestations can be painful and troublesome, the most important consequence of herpes zoster (shingles) is the chronic pain syndrome known as postherpetic neuralgia (PHN). Previous studies have suggested that declining varicella-zoster virus (VZV)-specific cell-mediated immune (CMI) responses account for the increased frequency of herpes zoster seen in older adults. This led to the idea that immunization designed to boost VZV-specific CMI responses might reduce the risk of herpes zoster. This hypothesis was tested in a large, randomized, placebo-controlled clinical trial called the Shingles Prevention Study (SPS). Compared with the placebo group, herpes zoster vaccine recipients had a 61.1% reduction in zoster "burden of illness" (an index incorporating incidence and severity of herpes zoster); a 66.5% reduction in the incidence of postherpetic neuralgia; and a 51.3% reduction in the incidence of herpes zoster. The incidence of serious adverse events was not different between the overall vaccine and placebo populations. The most frequently encountered adverse event among vaccine recipients was local reactogenicity, with self-limited and generally mild tenderness, warmth, or erythema occurring at the injection site in about one-half of vaccine recipients. The zoster vaccine was approved by the US Food and Drug Administration in 2006 and is indicated for prevention of herpes zoster in immunocompetent persons aged 60 years and older. ⋯ The herpes zoster vaccine provides physicians with an effective means for reducing a patient's risk for developing shingles and its attendant complications. No significant safety concerns regarding the vaccine have been identified. Indications for use of the attenuated-virus vaccine in special subpopulations continue to evolve.
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Randomized Controlled Trial Comparative Study
Lumiracoxib 400 mg compared with celecoxib 400 mg and placebo for treating pain following dental surgery: a randomized, controlled trial.
This randomized, double-blinded, double-dummy, parallel-group, single-center study compared a single dose of the novel selective COX-2 inhibitor lumiracoxib (400 mg), with celecoxib (400 mg) or placebo in dental pain. Patients > or =17 years with moderate-to-severe dental pain were recruited after surgical extraction of 2 or more partially or fully bony impacted molars. Pain intensity was measured using the categorical scale and the primary efficacy variable was the summed pain intensity difference over 8 hours after dosing (SPID-8). Patient disposition and demographics were comparable between lumiracoxib 400 mg (n = 156), celecoxib 400 mg (n = 156), and placebo (n = 52) groups. Lumiracoxib was statistically superior (P < .001) to both celecoxib and placebo in reducing pain intensity (SPID-8; least-squares means: 8.31, lumiracoxib; 4.26, celecoxib; -1.87, placebo). Significantly more patients treated with lumiracoxib (58.9%) considered treatment to be good or excellent compared with celecoxib and placebo (42.3% and 5.7%, respectively; P = .001). Lumiracoxib was superior to celecoxib and placebo for all other secondary efficacy variables. All treatments were well-tolerated. In conclusion, 400 mg lumiracoxib was well-tolerated and provided significantly superior analgesia to 400 mg celecoxib or placebo in patients with moderate-to-severe pain after dental surgery. ⋯ In a randomized, double-blinded, double-dummy, parallel-group, single-center study, a single dose of the novel selective COX-2 inhibitor lumiracoxib (400 mg) was well-tolerated and provided significantly superior analgesia to 400 mg celecoxib or placebo in patients with moderate-to-severe dental pain after surgical extraction of impacted molars.
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Like other types of neuropathic pain, postherpetic neuralgia (PHN) can be resistant to many types of pharmacologic and interventional therapies. Although many analgesic agents have been used for the treatment of other types of neuropathic pain, tricyclic antidepressants, antiepileptic drugs, opioids, and lidocaine patch appear to demonstrate relative analgesic efficacy for the treatment of pain from PHN. There are fewer studies on the use of interventional options for the treatment of pain from PHN. The majority of interventional therapies show equivocal analgesic efficacy although some data indicate that intrathecal methylprednisolone may be effective. Further randomized, controlled trials will be needed to confirm the analgesic efficacy of analgesic and interventional therapies to determine their role in the overall treatment of patients with PHN. ⋯ This article reviews the analgesic options for the treatment of PHN and suggests that tricyclic antidepressants, membrane stabilizers, opioids, and lidocaine patch may demonstrate analgesic efficacy in this group of patients. These data may potentially help clinicians who attempt to provide analgesia in patients with PHN.
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Randomized Controlled Trial
Effects of a selective cyclooxygenase-2 inhibitor on postoperative inflammatory reaction and pain after total knee replacement.
The goal of this study was to evaluate the systemic and peripheral effects of preoperative administration of cyclooxygenase-2 inhibitor on pain and inflammation occurring with total knee replacement (TKR). Patients undergoing elective TKR were prospectively and randomly given oral rofecoxib (25 mg) or placebo (control group) 1 hour before surgery. All patients received an epidural combined with isoflurane anesthesia during the operation and patient-controlled epidural analgesia postoperatively. The outcome measures included pain scores during rest and movement of knee joints and cumulative morphine consumption. Femoral blood and knee joint drainage fluids were examined for leucocyte numbers and concentrations of cytokines (including IL-6, IL-8, IL-10, and TNF-alpha). Periarticular circumferential increments at 48 hours served as an indication of inflammatory edema. Pain scores during rest and knee joint movement on postoperative days 1 and 2 were better in those given rofecoxib than in control subjects, and cumulative morphine consumption for the first 24 hours was significantly reduced. Both groups had higher concentrations of IL-6 and IL-8 in knee drainage fluid compared with serum levels. Rofecoxib significantly decreased regional IL-6 and TNF-alpha level after surgery. Moreover, the incidence of febris and degree of local edema were lower in the rofecoxib group (P < .05), and peripheral IL-6 level significantly correlated with pain score at 48 hours. Preoperative administration of rofecoxib increases patient satisfaction with analgesia, reduces opioid requirement, and decreases both systemic and local anti-inflammation after TKR. ⋯ This randomized, double-blinded trial shows that preoperative administration of rofecoxib can greatly ameliorate the pain occurring with total knee joint replacement surgery and its accompanying reduction of general and local inflammatory reactions.
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Review
A review of objective pain measures for use with critical care adult patients unable to self-report.
Critically ill patients experience significant levels of pain and discomfort from multiple intrinsic and extrinsic sources while in the intensive care unit (ICU). The use of objective pain measures in nonverbal patients is an essential alternative approach for pain assessment when self-reports are unavailable. This paper provides a critical review of the psychometric properties of 6 objective pain measures that were developed to assess pain in nonverbal adult patients in the ICU. The strengths and weaknesses of these objective measures are evaluated, as well as their applicability for use with this patient population. Although 2 of the 6 objective pain measures showed good evidence of validity and reliability, none has undergone vigorous validation or has been accepted as a standardized measure. Findings from the available studies of objective pain measures provide useful information to direct future research to develop and validate clinically useful pain measures for use with critically ill patients unable to self-report. ⋯ This review provides clinicians with a summary of the psychometric properties of 6 objective pain measures and discusses their applicability for use to assess pain in critically ill adult patients unable to self-report.