Allen H. Lebovits

Patient noncompliance with self‐administered chemotherapy

The contribution of patient factors to nonadherence with self‐administered cancer chemotherapy along with its prevalence was studied. Fifty‐one patients with breast cancer enrolled in protocols that included the orally administered medications Cytoxan (cyclophosphamide) and/or prednisone were interviewed and assessed at five points in time over a 6‐month period. Two summary measures of patient nonadherence derived by self‐report were developed: (1) dosage, the overall percentage of drug missed during 26 weeks of treatment; and (2) behavioral, the percentage of behavioral events or prescribing occasions on which a criterion level of drug was missed. Twenty‐two patients (43%) met criteria for noncompliance according to both behavioral and dosage definitions. Univariate analyses showed more nonadherence in the clinic and private community settings than in the academic setting. Stepwise multiple logistic regression analyses assessed the contribution of patient demographic, psychologic, and physical symptom factors on patient noncompliance. In the regression analyses patient noncompliance was associated with (1) treatment location, more nonadherence in the private community‐based treatment sector than in the academic setting; and (2) income, more nonadherence among those having lower incomes. In assessing total dose requirements in clinical research trials, rates of patient nonadherence need to be considered, and treatment location controlled.

Pain management of pancreatic carcinoma: a review

&NA; This paper reviews the most commonly used pain management interventions with patients who have carcinoma of the pancreas. Prior research has focused on the use of celiac plexus block. Other methods such as pain medication as well as chemical and surgical splanchnicectomy are also reviewed. Results of this review point to very successful pain relief rates with celiac plexus block and the urgent need for vigorous evaluation studies of pain management techniques in patients with pancreatic carcinoma.

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

ObjectiveWe 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. DesignOne 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. ResultsSixty-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. ConclusionsAlthough 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.

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 nonintrusive approach to the problem of identification of the premenstrual syndromes, with particular focus on the issue of compliance with 2 months of daily prospective record keeping. 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 record keeping. 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 responsibilites 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.

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.

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.

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.

Ketorolac Versus Fentanyl for Postoperative Pain Management in Outpatients

ObjectiveThe 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. DesignA double-blind randomized trial. SettingAn ambulatory surgery unit in a university-affiliated hospital. PatientsSixty-nine patients undergoing elective laparoscopy, inguinal hernia repair, or knee arthroscopy were enrolled. InterventionPatients were randomly assigned to receive intravenous ketorolac 30 mg (n = 38) or fentanyl 50 fig (n = 31) for moderate to severe postoperative pain. Outcome MeasuresPain, 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. ResultsPain 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. ConclusionsKetorolac appears not to 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.

Chronic pain and Crohn's disease: treatment difficulties

Formal observation of the interactions between chronic pain patients and their treating physicians has been infrequently reported. Four chronic pain patients with Crohns disease are reviewed during their course of treatment with the Mount Sinai Pain Management Service. Clinically and behaviorally descriptive findings, supplemented by markedly elevated Minnesota Multiphasic Personality Inventory (MMPl) profiles, indicate a noncompliant, manipulative, and acting-out mode of interaction between the patients and their doctors. Results are discussed in light of prior research and treatment implications for the pain specialist. Identification of and sensitivity to such potentially dysfunctional doctor–patient relationships are important in the evaluation and treatment of chronic pain itself.

Chronic pain patients and mental health services

CHRONIC PAIN PATIENTS AND MEt