Carol A. Warfield

Acute pain management : programs in U.S. hospitals and experiences and attitudes among U.S. adults

Background : The objective of the survey was to assess the status of acute pain management in U.S. hospitals and attitudes of adults in the U.S. toward postoperative pain management, information that has not been previously available. Methods : Two telephone questionnaire surveys were conducted. U.S. hospital participants, including 100 teaching hospitals (acute care hospitals with a residency program and/or university affiliation), 100 nonteaching (community) hospitals with fewer than 200 beds, and 100 nonteaching (community) hospitals with 200 beds or more were interviewed regarding current and future pain management programs and related topics. Adult participants in 500 U.S. households were interviewed on attitudes and experiences with postoperative pain and its management. Results : Forty-two percent of the hospitals have acute pain management programs, and an additional 13% have plans to establish an acute pain management program. Seventy-seven percent of adults believe that it is necessary to experience some pain after surgery. Fifty-seven percent of those who had surgery cited concern about pain after surgery as their primary fear experienced before surgery. Seventy-seven percent of adults reported pain after surgery, with 80% of these experiencing moderate to extreme pain. Conclusions : Despite a growing trend in pain management, increased professional and public awareness including the establishment of pain management programs and public and patient education is needed to reduce the incidence and severity of postoperative pain.

Facet joint degeneration as a cause of low back pain.

Recognizing that not all patients with low back pain have lumbar disc disease, the authors began to inject facet joints in June 1982 and have experience now with 21 patients, each injected under fluoroscopic control with a mixture of local anesthetic and steroid. One technical problem occurred when large osteophytes blocked access to the facet joints. Otherwise, there were no complications and minimal morbidity. Most patients (15 of 20; 75%) had an initial response, but a much smaller number (six of 18 followed more than three months; 33%) had a lasting response. Repeat injections, when done, always led to temporary improvement but rarely to lasting relief (one of five; 20%). Three factors characterized the patients: a negative screening examination for other causes of back pain or sciatica; back pain with tenderness localized over one or more facet joints; and radiologic changes of degenerative joint disease within the facet joints. Facet joint disease may be a significant cause of low back pain. The above three criteria are useful in clinical identification of patients with this problem. Facet joint injections play an important role in the diagnosis and treatment of low back pain.

Risk assessment of hemorrhagic complications associated with nonsteroidal antiinflammatory medications in ambulatory pain clinic patients undergoing epidural steroid injection.

We prospectively studied 1035 individuals undergoing 1214 epidural steroid injections to determine the risk of hemorrhagic complications. A history of bruising or bleeding was present in 176 (15%) patients. A platelet count was assessed in 77 patients before the epidural steroid injection; none was less than 100 × 109/L. Nonsteroidal antiinflammatory drugs (NSAIDs) were reported by 383 (32%) patients, including 34 patients on multiple medications. Aspirin was the most common NSAID and was noted by 158 patients, including 104 patients on 325 mg or less per day. There were no spinal hematomas (major hemorrhagic complications). Blood was noted during needle or catheter placement in 63 (5.2%) patients (minor hemorrhagic complications). NSAIDs did not increase the frequency of minor hemorrhagic complications. However, increased age, needle gauge, needle approach, needle insertion at multiple interspaces, number of needle passes, volume of injectant, and accidental dural puncture were all significant risk factors for minor hemorrhagic complications. There were 42 patients with new neurologic symptoms or worsening of preexisting complaints that persisted more than 24 h after injection; median duration of the symptoms was 3 days (range, 1–20 days). Our results confirm those of previous studies performed in obstetric and surgical populations that document the safety of neuraxial techniques in patients receiving NSAIDs. We conclude that epidural steroid injection is safe in patients receiving aspirin-like antiplatelet medications. Minor worsening of neurologic function may occur after epidural steroid injection and must be differentiated from etiologies requiring intervention.

Utilization patterns of tricyclic antidepressants in a multidisciplinary pain clinic: a survey.

OBJECTIVES Tricyclic antidepressants (TCA) have been shown to provide analgesia for a variety of neuropathic and headache pain syndromes regardless of the presence of depression. There is a high incidence of depression in patients with chronic pain, thereby making tricyclic antidepressants particularly suitable for chronic pain patients. We wanted to study patterns of use of tricyclic antidepressants in our Pain Management Center (Beth Israel Hospital, Boston, MA, U.S.A.) primarily to answer four questions: (1) What percentage of all patients were treated with tricyclic antidepressants? (2) How many patients were treated with each antidepressant, and what was the dose range used for individual antidepressants? (3) Were tricyclic antidepressants beneficial for chronic pain, and was that response dependent on a particular dose? (4) Did patients receive an adequate TCA trial, and what factors led to the discontinuation of a TCA trial? METHODS A total of 1,145 pain clinic patient charts were reviewed in alphabetical sequence. A total of 282 patients were identified as being treated with tricyclic antidepressants. Data were obtained from these 282 charts regarding the patients age, diagnosis, tricyclic antidepressant use and dose, other pain treatments, response to treatment, and side effects. The existing diagnosis of depression was documented if possible. Tricyclic antidepressant doses were defined as low doses when the equivalent of 50 mg or less of amitriptyline was used, and as full doses when the equivalent of at least 150 mg of amitriptyline was used. Response to treatment was noted as mild, moderate, or marked improvement. Patients reporting mild improvement were considered nonresponders. RESULTS Of 1,145 patients, 282 were treated with tricyclic antidepressants. A total of 205 (73%) of the patients were treated with low doses and only 34 (12%) with full doses. The remaining 43 (15%) received intermediate doses. Amitriptyline was the most commonly used drug (58%). Amitriptyline and doxepin appeared to be more effective than other tricyclic antidepressants. The rate of response to our treatment among the 31 patients with a coexisting diagnosis of depression was similar to the patients without documented depression. In patients with tricyclic antidepressants as the only treatment, there was only a trend toward greater response with full dose. In terms of side effects causing dose limitation or discontinuation of the drug, clomipramine, amitriptyline, and doxepin appeared to be worse than imipramine, desipramine, and nortriptyline. CONCLUSION Tricyclic antidepressants were used in 25% of patients referred to a multidisciplinary pain center and were commonly used in low to intermediate doses, even in situations in which there were neither side effects nor optimal clinical response.

The Effect of Transcutaneous Electrical Nerve Stimulation on Pain after Thoracotomy

The effect of postoperative transcutaneous electrical nerve stimulation (TENS) was evaluated in 24 patients in two randomly selected groups who underwent thoracotomy. The patients in one group received TENS through periincisional electrodes, and the remaining patients were treated with sham stimulator setups. The stimulators remained in place for 48 hours after operation. Subjective pain scores, duration of stay in the recovery room, tolerance to chest physical therapy, complaints of nausea, time to end of mechanical ventilation, and narcotic requirements were evaluated. Patients in the TENS group had significantly lower pain scores during the first 24 hours postoperatively (p = 0.014), shorter recovery room stays (p = 0.013), and better tolerance of chest physical therapy on both day 1 (p = 0.018) and day 2 (p = 0.006). No respiratory complications occurred in either group.

Topiramate relieves refractory intercostal neuralgia

Chronic pain is a well-known and troublesome complication following thoracotomy. Approximately 50% of patients experience some type of chronic post-thoracotomy pain syndrome (PTPS) even 2 years after thoracic surgery.1 Persistent pain after thoracotomy may indicate either a possible recurrence or progression of malignancy. However, a few patients have intense, sharp, shooting and burning pain, consistent with neuropathic pain located in the distribution of an intercostal nerve (intercostal neuralgia). This is not related to the malignancy, and can be due to nerve entrapment, neuroma formation, or persistent nerve irritation. Various centrally acting pharmacologic therapies are used to treat neuropathic pain, including antidepressants and anticonvulsants, in addition to opioid and nonopioid analgesics. Anticonvulsants that are reported to decrease neuropathic pain include phenytoin, carbamazepine, sodium valproate, and gabapentin.2-4 However, many patients either do not receive optimal pain relief or are unable to continue with these medications because of adverse effects. Topiramate …

Obturator neuropathy after forceps delivery

&NA; A 31‐year‐old woman developed a disabling obturator neuropathy as a result of a difficult delivery. This was successfully diagnosed and treated by obturator nerve blocks with anesthetic and steroid at the obturator foramen. (Obstet Gynecol 64:47S, 1984)

Academic Women Faculty: Are They Finding the Mentoring They Need?

BACKGROUND Although women comprise an increasing proportion of US medical school faculty, they are underrepresented at higher ranks. Lack of effective mentoring may contribute to this disparity. We examined the role of academic rank, research focus, parenting, and part-time work on mentoring importance, needs, and gaps. METHODS In 2009, women faculty members of Harvard Medical School and Harvard School of Dental Medicine were invited by e-mail to participate in a 28-item structured questionnaire. Descriptive statistics and adjusted logistic regressions were used to identify relevant themes. RESULTS Of the 1179 women faculty who responded, 54% had a mentor, and 72% without a mentor desired mentoring. The most important mentor characteristic identified was availability. Respondents endorsed most mentoring areas as important (range 51%-99%); 52% of respondents identified mentoring gaps (area important and unmet) in developing and achieving career goals and negotiation skills. Interest in mentorship for skills needed for advancement (research and lecturing skills and getting national recognition) was significantly associated with lower rank. Assistant professors were most likely to identify mentoring related to writing and publishing articles, whereas associate professors identified program development/strategic planning as important. Faculty who are parents identified gaps in finding collaborators and balancing work and family life. CONCLUSIONS This survey identified a desire for both comprehensive and targeted mentoring to address gaps that varied by faculty rank, research focus, parenting, and work time status. Strategies to enhance mentoring should address career stages and include a structured framework for assessing mentoring gaps.

Facial flushing and/or generalized erythema after epidural steroid injection

E pidural steroid injections have become one of the most frequently used conservative options in the management of acute and chronic back pain (1). As the indications for epidural steroid injections increase so do the reports of adverse responses associated with this procedure. We describe a series of 12 patients each of whom developed facial flushing and/or generalized erythema after receiving an epidural steroid injection for lumbar or cervical radiculopathy.

Epidural steroid injection as a treatment for cervical radiculitis

Sixteen patients with clinical evidence of cervical root inflammation and negative computerized tomography and/or myelogram findings were treated with injections of Depo-Medrol into the cervical epidural space. All patients had pain of at least 3-month duration and had failed trials of conservative therapy. Of the 16 patients, 12 had subjective improvement in their pain. Six of the 12 patients who had preinjection neurologic changes had improvement in their objective neurologic findings. Epidural steroid injection seems to have a role in the treatment of cervical radiculities.