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Obstetric, pelvic, visceral and vascular pain

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VISCERAL CHEST PAIN - ROLE OF ESOPHAGEAL MANOMETRY

Mats BorJesson. Martin Pilhall, Clas Mannheimern, Peter Rolnyona, Multidisciplnary Pain Center, nnClmical Physiology section, Gastroenterology section, Dept of Medicine, Sahlgrenska Univ Hospital/Ostra, S-416 85 Goteborg, Sweden

Aim of the Study. Visceral chest pain remains a large problem in today's health care Esophageal manometry has been used for studies ofesophageal peristalsis, and today is used for investigation of chest pain of unknown origin The aim of this study was to investigate the results ofesophageal manometry and acid exposure measurement in patients with unknown chest pain, compared to patients with other symptoms of referral

Methods 597 consecutive esophageal manometnes 1993-98, and the accompanying 24-hour pH-measurements were investigated retrospectively The symptoms ofremittal were recorded

Results 203 patients (=34%) had chest pain only, 41 (=7%) had reflux dyspepsia and chest pain, 234 (=39%) had reflux dyspepsia only, and the remaining 119 patients (=20%) had other symptoms of referral (i e dysphagia, nausea) The chest pain patients were older (59 vs 49 years, p<0 0001), had higher peristaltic amplitudes (mean 118 mmHg vs 95 mmHg, p=0.02), higher prevalence of esophageal dysmotility (i e. nutcracker 14 3% vs 4 5%, p<0 0001) and shorter acid exposure time ( p=0.005)

Conclusions 1/3 of patients were referred for esophageal manometry because of chest pain The chest pain patients were older, had a shorter reflux time, and higher esophageal peristaltic contractions They also showed significantly more esophageal dysmotility in the form of nutcracker esophagus Esophageal manometry is a well established method for investigation of chest pain of unknown origin

ARRESTING OF VISCERAL PAIN BY COMBINATION OF FENTANIL AND TRAMAL

Vyacheslav Rakitin*, Sergey Pavlov*, Rehabilitation Centre, Inst for Advanced Medical Studies, Novokuznetsk, 654055, Russia

Aim of Investigation. To search for effective method ofanalgesia in patients with acute myocardial mfarction (AMI) at preadmission stage.

Methods Pain syndrome i e its severity, character, generalization, motor reaction were assessed Assessment of analgesic action in regard to its intensity and duration, effect on hemodynamics and external respiration, sedative effect, adverse reaction occurrence was performed We assessed hemodynamics measuring heart rate, arterial pressure, ECG readings in 12 main and 7 additional positions as well Besides, stress-hormones (cortisol and insulin) were tested to assess adaptive capabilities. Emergency cardiac care was provided for 107 pts aged 42-80 yrs of both genders with non-complicated AMI mainly macrofocal with antenolateral localization characterized by violent or extremely violent pain Neurolep-tanalgesia as a combination ofFentanil and Dropendol was used for analgesia in Group 1 that involved 52 pts, in 55 pts of Group II pain was arrested with combination ofFentanil and Tramal Unlike Dropendol Tramal is a long-term drug exerting a potent analgesic effect as a result of its opiodergic action

Results. In both groups high analgesic action, equal reaction of humoral system on the therapy and insufficient change of hemodynamics were observed. In Group 121% demonstrated suppression of respiration, recurrence of pain as well as other adverse reactions Only 4% complained ofatnal discomfort that was eliminated with additional sedative therapy High rate of negative reactions is obviously attributed by the age

Conclusions Combination of Fentanil-Tramal is the most effective analgesic in patients with AMI at preadmission stage and particularly in aged patients

RESPONSE OF DIFFERENT COMPONENTS OF PAIN FROM CHRONIC PANCREATITIS TO ANALGESICS

Clive H Wilder-Smith Nociception Research Group, Univ of Beme, CH-3011 Beme, Switzerland

Aim of Investigation To examine the response of different components of pain from chronic pancreatitis to morphine and tramadol

Methods In a randomised and double-blind study 25 patients in severe pain from chronic pancreatitis were treated with oral tramadol or morphine Doses were individually titrated during 5 days of hospitalisation Pain intensity and pain relief VAS scores were noted for all 41 different pain locations and components qid Pain was classified as neuropathic (stabbing, shooting, burning, paroxysmal, burning) or nociceptive (dull, aching, movement-associated, pressure, throbbing) The VAS scores of the two pain components and the responses to morphine and tramadol were compared over time by ANOVA/MANOVA

Results Box-Whiskers (median point, mterquartiles box, range whiskers) of pain intensity before (pre) & on dosing days 1-5

1 here were no significant dmerences in pain intensity or pain reiier scores at any time between the 2 pain components or the morphine and tramadol groups The doses of tramadol (mean 840 mg (range 80-1920)) and morphine (238mg (20-1125)) required did not correlate with the presence of either pain component

Conclusions Severe neuropathic and nociceptive pain from chronic pancreatitis responded similarly well to individually titrated doses of oral morphine and tramadol

Acknowledgment Partial sponsorship Gruenenthal, Switzerland

AN INSTRUMENT TO ASSESS PAIN AND PAIN MANAGEMENT DURING LABOR AND DELIVERY

Thomas Elliott. Mary Godfrey*, Colleen Renier*, Jeanette Palcher*, St Mary's/Duluth Clinic Health System, 400 E 3rd St, Duluth, MN 55805, USA

Aim of Investigation To create an instrument to assess pain and the quality of pain management during obstetncal labor and delivery

Methods Instrument development was accomplished by these steps 1. Define purpose, 2 Formulate conceptual framework, 3. Determine specific objectives, 4 Review literature, 5 Study other instruments including the APS Patient Survey questions. 6. Involve expert consultants, 7. Conduct focus groups, 8. Pilot test instrument, 9. Revise instrument, and 10. Conduct content validation

Results: No instruments were found that could meet our purpose and objectives Most APS Patient Survey questions were not appropriate for obstetncal patients Through consensus of expert practitioners and focus groups of patients an instrument was designed Following pilot testing and content validation a final version evolved The final instrument was tested in 100 postnatal women within 24 hours of delivery

Conclusions An instrument to assess pain and the quality of pain management during obstetncal labor and delivery has been designed and tested in a cohort of women [N = 100]. The methods used may be helpful to other investigators for instrument design and validation. A description of the patients' pain experience and pain management during labor and delivery will be presented. This instrument may be useful to other investigators studying pain and pain management in obstetncal populations

Acknowledgments Supported by SMDC Health System, Division of Education and Research

ABDOMINAL WALL NERVE BLOCKADE FOR POSTOPERATIVE ANALGESIA AFTER CAESAREAN SECTION

Golnar M. Fathy. Essam S. Abdella, Hosam T. Salem* and Alaaeldin A. Youssef*. Depts ofAnaesthesiology and Obstetncs & Gynaecology, Faculty of Medicine, Assmt Univ, Assiut. Egypt

Aim of Investigation To investigate the value of bilateral abdominal wall nerve blockade (T10-L1) using local anaesthetic at the end of surgery in relieving the postoperative pain and allowing early ambulance and breastfeedmg

Methods. Postoperative analgesia using bilateral abdominal wall nerve blockade (T10-L1) was performed in 25 patients (block group) immediately after caesarean section under general anaesthesia This was done by injection of a cocktail of05 % bupivacaine without adrenaline and xylocaine 2%, 25 mL in each side Step 1, 10 mL of solution is infiltrated to block the iliomguinal nerve, step 2, 5 mL of solution is given to block T10. At step 3, 10 mL is infiltrated to block Tl 1 and T12 A control group (25 patients), the postoperative analgesia was done by mependine

Results: Postoperative analgesia was more effective in the block group for a duration ranging from 1-15 hours (mean 7 884 28 SD). The meanSD requirement for narcotics were 500 00 mg and 112 0^21.79 mg of mependine in the block and control groups, respectively

Conclusion Patients with abdominal field block were awake, alert and comfortable dunng the immediate postoperative penod. They were painfree sufficiently able to put their babies to the breast earlier and more frequently than the control group

INTRAVENOUS PCA WITH PIRITRAMIDE OR MEPERIDINE IN OBSTETRIC ANALGESIA

N. Gnessinger. H. Binder, D. Risack, W Koppert, H. Schmitt, R. Sitti, Depts of Anesthesiology and Gynecology, Univ Eriangen, Krankenhausstr. 12, 91054 Eriangen, Germany

Aim of Investigation: This study evaluates the efficacy and side effects of intravenous PCA with the u. - opioid agonist pintramide in the treatment of labor pain compared to PCA with mependine and intramuscular administration of mependine

Methods After approval by the Institutional Ethics Committee and informed consent 90 nulliparous women with a cervical dilatation of 3-4 cm were randomly divided into three groups: PCA with mependine (mep), PCA with pintramide (pir) or intramuscular injection of mependine (1 mg/kg KG). PCA loading-dose: 50 mg mep or 7,5 mg pir, bolus: 5 mg mep or 1 mg pir, lock-out time. 10 mm, total dose limit 200 mg mep or 37,5 mg pir Monitonng included pain scores, sedation score, side effects, neonatal APGAR score, heart rate and SaO;

Results Total consumption was mep i m. 80,5 +/- 25 mg, mep PCA- 92,4 +/- 35,5 mg and pir PCA- 19,8 +/- 7,3 mg. PCA patients reached significantly lower pain scores up to a cervical dilatation of 8 cm. There were no significant differences between mep- and pir- PCA in relation to analgesia and side effects. The pir- PCA group showed significantly prolonged durations of birth and an 1 increased frequency ofcesarean sections APGAR scores below 7 ] at 5 mm were observed in 6 neonates in the pir group compared to , two in either of the mep groups 82%ofthepartunentsmthemep-PCA group were satisfied with their pain treatment, 68 % in the pir-PCA group and no one in the mep i.m group.

Conclusions. Intravenous PCA with strong opioids results in a more effective analgesia than intramuscular administration and improves patients' satisfaction. The high quality analgesia ofepi-dural techniques cannot be achieved. Pintramide should not be used for obstetnc analgesia

PAIN IN THE SECOND STAGE OF LABOUR

L Jauncey. Dept of Nursing and Midwifery, Univ of Stirling, Scotland, FK9 4LA (Spon- Niven)

Aim of Investigation: Little is known about the nature of the pain of second stage labour, since no large studies have been earned out using concurrent, rather than retrospective, pain assessments. As the first part of a major study of second stage labour, the views of midwives who attend UK women in labour were sought in order to determine its defining charactenstics, which could include pain

Method A representative sample of sixty midwives working in Scotland were administered a questionnaire on their definition of second stage labour, how it was distinguished from transition and from first stage, and the behavioural signs which signified the par-turant's readiness to deliver

Results Midwives rarely reported that pain was a defining characteristic of second stage labour Instead they focused on obstetric signs such as the changing strength of contractions or on behavioural cues such as irritability and restlessness When pain was highlighted, midwives differed about whether it typically increased or decreased during second stage.

Conclusions Midwives attend all births in the UK and deliver 90% of babies (all normal vaginal deliveries) Despite this extensive experience, their knowledge of second stage pain appears minimal This may be because their attention is focused on the other important aspects of delivery.

LABOR PAIN AND MATERNAL SATISFACTION WITH CHILDBIRTH: NATURAL VS. EPIDURAL ANALGESIA

Suresh Kannan. Sanjay Datta, Robert N Jamison, (SPON Edward Michna) Dept of Anesthesia, Bngham and Women's Hospital, Harvard Medical School, Boston, MA, USA

Aim of Investigation: To assess the difference in maternal satisfaction with pain and childbirth ofpartunents who have natural childbirth vs those who plan for natural childbirth and end up having epidural analgesia for labor and delivery

Methods 100 women admitted for labor and delivery who planned to have natural childbirth were surveyed Of these, fifty percent were selected because they requested epidural analgesia midway through their labor All participants were asked to complete a packet of self-report questionnaires at the time of admission and a self-report questionnaire on the day after labor A questionnaire was also filled out by a staff member involved in the study to document information about the labor process

Results No differences were found on demographic variables between groups Women who decided to have an epidural reported significantly longer duration of labor, and much more than expected labor pain (p<0 01) despite experiencing less pain following epidural placement. Women who had natural childbirth perceived their partner to be more supportive than those who have epidural analgesia (p<0.001) Although pain was significantly less, those who planned for natural childbirth and elected to have an epidural during labor perceived their labor to be less satisfying than those who succeeded with natural childbirth (p<0 05)

Conclusion The results of this study suggest that there were differences in satisfaction among those who had natural childbirth and those who did not Further studies are needed to evaluate the relationship of pain and duration of labor with a women's ability to succeed with natural childbirth

EFFECTS OF INTRATHECAL MORPHINE ON POST-OPERATIVE ANALGESIA AND OXYGEN SATURATION AFTER CESAREAN SECTION

Ritsuko Masuda. Tetsuo Inoue*, Kazuyuki Imanaga, Akira Ogura, Dept of Anaesthesia, Chiba-Hokusoh Hosp , Nippon Medical School, 1715 Kamagan, Iniba, Chiba, 270-1694, Japan

Aim of Investigation Postoperative analgesic and respiratory effects were assessed after Cesarean section under spinal anesthesia with morphine

Methods Twenty-five partunents (34 55.8w gestation) undergoing Cesarean section gave informed consent to participate in the study Spinal anesthesia was performed at L3/4 interspace using local anesthetic and 0.2mg of morphine Visual analogue scale (VAS), Oxygen saturation (SpO;) in room air. Heart rate (HR) and respiratory rate (RR) were estimated periodically during 48h after the spinal injection Continuous records of SpO; and HR were performed and analyzed by NOVA Card system Oxygen supply was prepared when desaturation (SpO; < 90 %) was found. Side effects such as nausea, pruntis and unnaly retention were also evaluated

Results All the postoperative VAS values were less than 2 during the first 24h and were maintained at less than in the next 24h period There was no patient required oxygen supply Desaturations (SpO; < 90 %, > 1 mm) were not recorded, however transient SpO; falls (92-90, <lmin) were found in 3 patients Throughout the study period, SpO; was maintained above 96% in 12 patients (48%) In the remaining 52% of the patients, the lowest SpO; was found from midnight till dawn during sleep. Low respiratory rate (<12breath mm '), bradycardia (< 50bpm) and urinary retention (>24h) were not observed Five patients (20%) developed pruntis

Conclusions The efficacy of mtrathecal morphine ofO 2mg for post Cesarean section pain was almost satisfactory more than 24h without severe SpO; depression Circadian rhythm might affect the changes of SpO; to some extent

EPIDURAL BUPIVACAINE VERSUS COMBINED SPINAL-EPIDURAL BUPIVACAINE AND FENTANYL FOR CONTROL OF LABOR PAIN IN PRIMIGRAVIDA

Laila H. Mohammed. Obey M El-H, Shaker and Diaa Abdel Aal*, Anesthesiology Dept Faculty of Medicine Assiut Univ, Assiut. Egypt

Aim of Investigation. To investigate the effects of addition of Fentanyl to the standard epidural analgesia in pnmigravida

Methods. 60 full term consenting pnmigravidas without gross medical or obstetric problems were included, classified into three groups received epidural Bupivacame, epidural Bupivacaine plus fentanyl and epidural Bupivacaine plus mtrathecal fentanyl respectively Monitoring was made for maximum possible pain relief scores also maternal and fetal wellbemg using COROMETERICS 415B.

Results Pain Relief Score (PRS) was Excellent in 45% of partunents of group III compared to 15%, 25% in groups II and I Highest sensory level was obtained in group III then in group II and least level in group I. Onset of action was earliest in group III then other groups but longest duration of block was obtained in group II than III and the least time of block was in group I Cervical dilatation was more rapid m group III then group I and II There was no difference in frequency, intensity, duration ofutenne contraction or duration of labor or even the mode of delivery in all groups Neonatal assessment showed that all babies were bom in good condition with Apgar score more than 7 also there were no differences in fetal heart rate or blood gas levels in all groups

Conclusion. This study concluded that the combined spinal- epidural technique provided better labor pain control than the standard epidural analgesia Addition of fentanyl extradurally or mtrathe-cally to the local anesthetics improved the efficacy of analgesia and the overall maternal satisfaction was greater in group III than in groups I and II Reduced incidence of side effects, total dose of drugs used

INTRATHECAL MORPHINE, FENTANYL AND BUPIVACAINE FOR LABOR PAIN

A SaadatNiaki*. M Amani, Imam Hossem Medical Center, Beheshti Medical Univ, Madam St, Tehran 16179, Iran

Aim of Investigation To investigate the relationship between pain relief scores produced by combination of mtrathecal Morphine, fentanyl and Morphine, Fentanyl Plus Bupivacaine (0 25%) in randomised controlled trials (RCTs)

Methods Ethical approval and informed consent were obtained 60 ASA1 Vanous Gravida (1-3) with uncomplicated pregnancies in active labor were studied Patients were allocated randomly into one of the 2 Groups, group study (s) received Morphine sulfate 0 2 mg (1ml) Fentaly 25 mic (1ml) and 0 25% bupivacame (0 5ml) plus Dextrose 20% (0 5ml) Group control (c) received same drugs without 0 25% Bupivacaine The pain level of contraction was noted on a ten point visual Analog pain score (VAPs) Vital signs (Mother, fetus), side effects were evaluated Statistical analysis, T-Test and analysis of vanance significant level P < 0 05

Results There were no significant differences between both groups with respects to patient demographics (Age, Weight, panty, graduation) In first and second stage of labor 100% of patients in (s) had Excellent Analgesia (E A ) (VAS 0-1) On the other hand 100% of(c) had good Analgesia (G A ) (VAS 2-3) In third stage of labor 83 3% of patients in (S) had (E A) and 16 7% had (G A) At the same time 70% of(C) had (G A) and 30% of patients had Moderate Analgesia (M A) (VAS 4-5)

Conclusion Both the two methods are operable and reliable providing adequate analgesia with predictable side effects But, relief of pain in (S) group was better than (C) group Specially, during the passage of fetus to the vaginal canal

Acknowledgment Supported by research council of Beheshti Medical Sciences Univ of Iran

EPIDURAL FENTANYL COMPARED TO INTRATHECAL FENTANYL IN EARLY LABOR

Shen Kou Tsai. Li Kuei Chen, Wei Zen Sun, Martin S Mok, (SPON M Lippmann) Dept of Anesthesiology, National Taiwan Univ Hospital, College of Medicine, Taipel, Taiwan, ROC

Aim of Investigation Combined spinal-epidural (CSE) analgesia with mtrathecal (IT) opioid is a popular mode of pain control in early labor However, pruntus following IT fentanyl is reported to occur in 60-100% oflabonng partunents Therefore this study was undertaken to evaluate the efficacy and pruntus in laboring partun-ents receiving epidural fentanyl in early labor Methods: With approval of the Hospital's Human Research Committee, 120 full term nulliparous with spontaneous or induced labor (cervical dilatation<5 cm) were studied The patients were randomized to receive mtrathecal fentanyl 20 mcg (ITF, N=60) or epidural fentanyl 50 mcg (diluted in 10 ml N/S) (EPF, N=60) Standard epidural analgesia with 0 05% bupivacaine and 0 0002% fentanyl 10-15ml/hr infusion was performed when cervix dilated more than 5 cm. BP, HF, RR and 0; saturation were monitored Pain relief was assessed using a 10cm VAS scale. Statistical analysis included Chi-square and ANOVA were used to analyze the mean of differences, p<0 05 was considered significant

Results Demographics were similar between the groups EPF in early labor provided a longer duration of satisfactory analgesia (5 hrs) compared to that of ITF (2 hrs) and had a lower incidence of pruntus (10%vs 70%)

Conclusion: EPF had a decreased incidence and seventy of pruntus compared to ITF and provided a long duration of analgesia in early labor.

RANDOMISED PLACEBO CONTROLLED TRIAL OF LOFEXIDINE HYDROCHLORIDE FOR CHRONIC PELVIC PAIN IN WOMEN

William Stones. Lucy Bradbury*, Denise Andersen*, Dept of Obstetncs and Gynaecology, Univ of Southampton, Pnncess Anne Hospital, Southampton SO 16 5YA, UK, and Britannia Pharmaceuticals Limited, 41-51 Bnghton Rd, Redhill, RH1 6YS, UK

Aim of Investigation: To assess the efficacy of the orally active Ct;-adrenoceptor agonist lofexidine hydrochlonde for relief of chronic pelvic pain in women.

Methods Premenopausal women with an intact uterus were eligible for entry into the study if they had chronic pain ofutenne or ovanan ongin for at least six months, laparoscopy had excluded specific pathology, and they were using effective contraception Subjects were randomised using a sealed envelope system to receive lofexidine hydrochlonde or placebo for eight weeks The protocol included weekly dose increments for the first three weeks depending on symptomatic response from an initial dose of 200 micrograms twice daily to a maximum of 600 micrograms twice daily. The pnmary end point was a 50% or greater reduction in the visual analogue scale (VAS) for pain.

Results. 19 women were randomised to the lofexidine treatment arm and 20 to placebo. 9 in the lofexidine group and 14 in the placebo group completed 8 weeks of treatment Drowsmess, dry mouth and dizziness were more common in the lofexidine group but headache was more common in the placebo group Intention-to-treat analysis, where subjects who discontinued were considered treatment failures, showed improvement in 4/19 of those randomised to lofexidine, and 8/20 of those randomised to placebo

Conclusions: There is current research interest in an adrenoceptor mediated antinociception However, this pilot study has not demonstrated therapeutic efficacy of lofexidine in pelvic pain. Evaluation of lofexidine in chronic pain conditions more clearly associated with central sensitisation may be appropnate

PELVIC PAIN IN WOMEN WHO USED DIFFERENT TYPES OF IRANIAN AND FOREIGN l.U.C.D.

Simin Taavoni*. MS of midwifery education, (tutor of Iran Medical Sciences Univ), Tehran, Iran

Aim of InvestigationTo measure and compare the percentage of pain in women after use of Iranian (Cooper 7, Tcu200, ml) and foreign (LoopB,C,D, Cooper7, Tcu200, T380A, ml 375) I U Ds

Methods: This is a field study of 1620 women (347 with Iranian I.U.Ds and 1273 with foreign I.U.Ds) who have been using the mentioned methods for birth control, in the family planning clinics of Iran Medical Sciences Univ in 1994 were chosen (Poisson statistical selection used) The tool used was a checklist made of 3main parts To analyze the information, the descriptive statistics and life table were used.

Results The highest percentage of pain in Iranian I.U Ds was seen 7-12 month after use (28 57%) and in foreign types 0-3 months after use (40 91%). The severe pain was seen after 24 months use of foreign cooper7 and T200 (0 0045) and after 3 months use of foreign T380A (0 0020) The totally percentage after 0-3 months Iranian and foreign I U Ds used was 0.0007, after 4-6 months was 0 0016, after 19-24 months was 0 0033 and this rate unchanged up 11.5 years

Conclusion. The person who inserted the foreign I U Ds which caused severe pain were students and midwives having one year course Severe pain which result in discontinuation ofIUDs was not seen in Iranian types (Cooper7, T200 and ml) and foreign types of loop B,C and D It seems it is better to have a longitudinal study about foreign loops

A PAIN CONTROL COURSE FOR WOMEN WITH VVS

Moniek M. ter Kuile. Philomeen Th.M Weijenborg*, (SPON Fnts A M Winter), Dept ofGynecology, Leiden Univ Medical Centre, PO Box 9600, 2300 RC Leiden, The Netherlands

Vulvar vestibulitis syndrome (VVS) is thought to be the most frequent cause ofdyspareunia in women and is one of the major subtypes ofvulvodynia VVS is a chronic, persistent clinical syndrome characterized by severe pain on vestibular touch or attempted vaginal entry, exquisite tenderness to a cotton-swab palpation of the vestibular area, and physical findings confined to vestibular erythema

At our Dept a pain control course was developed for women with VVS It is a group program (6-8 women) of twelve, two-weekly sessions of two hours The program informs the women about a wide range ofsomatical and psychological aspects of their pain problem and provides a program of home exercises. The program is based on the principles of cognitive-behavioral therapy for chronic pain and sexual problems.

The aim of this study is to evaluate the effect of this group program as measured by different standanzed questionnaires at posttreat-ment and follow-up in companson with pretreatment levels Up until now nearly 50 women with VVS completed the program The results indicate that this group program can help women with VVS leam to cope with the problem and can reduce pain in different sexual pain situations. In this presentation the program will be descnbed in more detail and the results will be presented

TREATMENT OF PAIN AND DISTROPHIC LESIONS (DLS) IN CHRONIC PERIPHERAL VASCULAR DISEASES (CPVDS)

Koval. Pablo R. Saiach, Julio* Private Outpatient Pain Clinic Billmghurst 1506, (1425) Capital Federal, Argentina

Aim of Investigation: To demonstrate that CPVD pain can have a different etiology other than ischemic and that relief of lower extremities (LEs) CPVD pain is associated with ulcer healing and delimitation ofnecrotic areas To demonstrate also that with pain relief, amputation can be avoided

Methods. We studied a group of 44 (22 m, 22 f) painful diabetic (21), artenopathic (17) and venous insufficiency (6) patients (PTs) without response to conventional medical treatments or by-pass surgery (9 LEs), followed dunng 2-26 months (m = 7 months). 21 of them with surgeon indication of amputation because of pain or necrosis. Once pain etiologic diagnosis was made (ischemic, neu-rophatic, myofascial and/or inflammatory-infectious) the treatment of the pain itself was started accordingly For ischemic pain IV or IM hdocaine (LIDO), sympathetic blockade with .25% LIDO or thigh infiltration technique with 25% LIDO For neurophatic pain IV or IM LIDO, valproic acid, amitryptiline, tramadol or a combination of these drugs For inflammatory-infectious pain NSAID + antibiotics For myofascial pain trigger point injection Pain in 15 PTs had only one cause, in 22 PTs had two causes and in 7 PTs had three causes Local treatment of DLs was not aggressive Pain relief was measured by an 0-10 VAS scale, walking distance, and sleeping hours, DLs were monitored by photographic images.

Results: Pain relief: excellent in 29 PTs (66%), good in 9 PTs (20%), fair in 1 PT (2%), no relief in 5 PTs (11%) DLs: 32 LEs (27 PTs) Healed 24 LEs (75%) (21 PTs), quit treatment 5 LEs (15%) (3 PTs), amputation of 3 LEs (3 PTs) LEs rescued from amputation 18/21 12 diabetic, 6 artenophatic LEs amputated 2 diabetic, 1 artenophatic

Conclusions. Pain in CPVDs is not synonymous with ischemic pain Pain relief in CPVD PTs allows rehabilitation walking exercises Pain relief is associated with healing of DLs LIDO resulted useful in treating pain in CPVDs In CPVD PTs, amputation can be avoided with the treatment described above

IS IN ROMANIA RIGHT HYPOCHONDRIAL PAIN IN RELATION WITH ALIMENTARY ABUSES DURING THE WINTER HOLIDAYS?

Monica Marton Popovici*. Diana Pop Petre*, Tereza Muresan Craciun*, TG Mures, Medical Clinic NR.II, Univ of Medicine and Pharmacy TG.Mures, Romania

Aim of Investigation We have investigated the relationship between alimentary abuses well known during the winter holidays, in Romania and its reflection through right hypochondria! pain.

Methods. It was made a retrospective study on observation papers of Medical Clinic NR II from TG Mures, including 5 years back period and a number of 247 patients with acute or chronic abdominal pain

Results: Different diagnosis of right hypochondnal pain includes gall bladder infections (31,59%) acute and chronic chole-cystitis (17,82%), gallstones (13,77%), chronic persistent hepatitis (20,65%), chronic peptic ulcer (20,65%), cirrhosis (10,53%), chol-angitis (3,65%), chronic pancreatitis (0,8%), acute abdomen (0,8%) and different kind ofneoplasia (11,23%) The therapy used for most of the patients 242 wasjust symptomatic treatment for releasing pain, in 4 cases we need surgical assistance and 1 patient died

Conclusions Patient with right hypochondnal pain who need hospital assistance during the winter holidays had cholecistic infections, hepatic and duodenal affections Frequency ofnght hypochondnal pain after month shows that in December-January is 62,35% and dunng the summer July-August isjust 21,34% That means alimentary abuses dunng the winter holiday are directly responsible of abdominal pain For releasing pain were enough symptomatic drugs like spasmolitics, nonopioid analgesics and weak opioids

NON-VISCERAL CHRONIC PELVIC PAIN: AN INTEGRATIVE APPROACH

A Ungaretti Jr , T. Y. Lm. M. J Tcixeira, H J Pai, H F G Barboza, E. F Stocchero, G. T L. Constantmo, B A C F Sousa Pain Clinic, University of San Paulo Medical School, Rua Conselheiro Brotero 1539, cj 12, Cep 01232-010, Sao Paulo, Brazil.

Aim of Investigation. Non-visceral chronic pelvic pain (CPP) is a noncychc long duration pain in the low abdominal and pelvic regions, without specific recognized visceral disease The present study aimed the presentation of the clinical aspects and the results of a multidisciplmary treatment of 100 patients presenting CPP

Methods: Gynaecologic. urologic, proctologic, physiatnc neuro-logic, psychologic, electrophysiologic and image evaluations were made in all of the patients Analgesics, psychotropics, physical medicine, dry needling and/or infiltration oftngger points with local anaesthetics were performed for treatment of pain Psychoter-apy, relaxation, and/or hypnosis, were prescnbed, when necessary

Results. Seventy (70%) were female, aged from 23 to 71 years (mean = 44 7 years) The mean duration of pain was 74 3 months Organic or functional visceral abnormalities were diagnosed in 5% of the cases Myofascial pain syndrome (MPS) of the pelvic floor and gluteus muscles was diagnosed in 54% of the patients and pe-npheral neuropathy (PN) in 30% In 11% of the patients, MPS was associated to PN The multidisciplmary treatment resulted in significant improvement of pain in 42.3% of the cases. The average of VAS decreased from 7 7, at the beginning of the treatment, to 4 5, after the treatment The mean follow-up was 15 3 months.

Conclusion The PNs and specially the MPSs are one of the sources of pain in patients with non-visceral CPP The appropnate diagnosis and treatment are very important for the mtegrative pain therapy of this chronic condition

CLINICAL AND SOCIAL ASPECTS OF TREATMENT OF PAIN IN PATIENTS WITH LEG ISCHEMIA

Georgy Zoloyev*. Natalia Kryukova*, Sergey Uchitel*, Alexander Zoloyev*, Dept of Vascular Surgery and Rehabilitation, Rehabilitation Centre, Novokuznetsk Branch of Kemerovo Univ, Novokuznetsk, 654055, Russian Federation, CIS Aim of Investigation To assess efficiency ofvanous methods of treatment of pain in patients with cntical leg ischemia and its social outcomes

Methods We observed 107 patients with cntical leg ischemia (Fontame III-IV stage, ankle pressure < 50Hgmm) Pendural anesthesia or opiates i.e Morphine, Promedol injections were administered to anesthetize All patients underwent surgical treatment In 74 patients vanous artenal reconstructions were performed In 33 patients amputation was done

Results Twenty-nine patients underwent pendural blocking dunng 2-12 days (average 6,7 days) In all cases anesthesia occurred to be adequate But it appeared to be feasible only at the preoperation and early postoperation stages In remaining patients opiates were injected both before and following the operation. For all that, anesthesia efficiency differed essentially In 81 patients surgical treatment enabled complete arresting of pain In 26 patients including 11 amputees pain was not eliminated that resulted in the administration of opiates for further 15-60 days. Classical signs of abstinence were not revealed but some patients complained sleep disturbance, erethism etc Psychological dependence manifested itself in fear that pain would start after opiate withdrawal

Conclusions Pendural blocking is an effective anesthetic method but its use is time-limited Long term application of opiates in postoperative penod cause physical and psychological drug dependence but its signs differ considerably from the signs of opiate dependence occurred in addicts that should be taken into account m treatment of patients with long-standing pain related to cntical leg ischemia

9th WORLD CONGRESS ON PAIN, 1999, Vienna, Austria, p. 309 - 313

   

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