Susan Shott

Intraspinal morphine for chronic pain : A retrospective, multicenter study

Intraspinal opioids are frequently used in the treatment of cancer and noncancer pain, but few studies have evaluated the efficacy of this technique. This multicenter, retrospective study surveyed physicians in the United States regarding their standard practices when using intraspinal opioids delivered via an implanted drug administration device. Thirty-five physicians (50.0%) responded, providing 429 usable patient forms (52.4%), which sought information about screening, outcomes, dosing, and adverse effects. Patients with malignant (32.7%) and noncancer (67.3%) pain had been treated for an average of 14.6 +/- 0.57 months (range, 8-94 months) at the time of form completion. For all patients, the mean percent relief was 61.0% +/- 1.35%. Patients with somatic pain tended to have greater relief, as measured by a global rating of pain relief, than did patients with other types of pain (Mann-Whitney test, P = 0.0003). After titration during the first 3 months, intrathecal morphine doses increased only twofold from 6.84 +/- 0.65 mg/day at 3 months to 13.19 +/- 1.76 mg/day at 24 months. Compared to those with noncancer pain, malignant pain patients had a higher average initial dose. The average dose used by cancer patients escalated quickly and then stabilized, whereas the average doses used by noncancer pain patients exhibited a more gradual, linear increase in dose. Long-term adverse drug effects were uncommon, but system malfunction, usually catheter related, occurred in 21.6% of patients. Prospective, randomized, controlled clinical studies of long-term efficacy and adverse effects are warranted.

Repair of Full Thickness Rotator Cuff Tears: Gender, Age, and Other Factors Affecting Outcome

Seventy-two full thickness rotator cuff tears (72 patients) were treated with an open rotator cuff repair between 1986 and 1993. The average postoperative followup was 54 months (range, 24-102 months; standard deviation, 22 months). Fifty-three (74%) patients had no pain, 16 (22%) patients had slight pain without restriction of activities, and three (4%) patients had moderate pain with activity compromise. Women with an associated biceps tendon rupture tended to have worse results. Women had a negative, statistically significant relationship between age and shoulder scoring scales, but age at the time of surgery was not related to any outcome variables for men. A rotator cuff tear greater than or equal to 5 cm2 as determined at the time of surgery was associated with a poorer outcome. The average University of California at Los Angeles score was 32 points (range, 7-35 points; standard deviation, 5 points). The average Constant-Murley score was 78 of 100 points (range, 12-95 points; standard deviation, 15 points). A yes response was given for an average of 10 of 12 questions on the Simple Shoulder Test (range, 0-12 questions; standard deviation, 3 questions). More than 4 years after open rotator cuff repair, patients had a 94% patient satisfaction rate with lasting relief of pain and improved function.

Normalization of joint moments during gait: a comparison of two techniques

Joint moments are commonly used to characterize gait. Factors like height and weight influence these moments. This study determined which of two commonly used normalization methods, body mass or body weight times height, most reduced the effects of height and weight on peak hip, knee, and ankle external moments during walking. The effectiveness of each normalization method in reducing gender differences was then tested. Gait data from 158 normal subjects were analyzed using unnormalized values, body mass normalized values, and body weight times height normalized values. Without normalization, height or weight accounted for 7-82% of the variance in all 10 peak components of the moments. With normalization, height and weight accounted for at most 6% of the variance with the exception of the hip adduction moment normalized by body weight times height and the ankle dorsiflexion moment normalized by body mass. For the hip adduction moment normalized by body weight times height, height still accounted for 13% of the variance (p<0.001) and for the ankle dorsiflexion moment normalized by body mass, 22% of the variance (p<0.001). After normalization, significant differences between males and females remained for only two out of 10 moments with the body weight times height method compared to six out of 10 moments with the body mass method. When compared to the unnormalized data, both normalization methods were highly effective in reducing height and weight differences. Even for the two cases where one normalization method was less effective than the other (hip adduction-body weight times height; ankle dorsiflexion-body mass) the normalization process reduced the variance ascribed to height or weight by 48% and 63%, respectively, as compared to the unnormalized data.

Barriers to Cancer Pain Relief: Fear of Tolerance and Addiction

The purposes of this study were to (a) test the feasibility of the Cancer Total Quality Pain Management (TQPM) Patient Assessment Tool in a population of oncology inpatient and outpatients; and (b) identify factors associated with poor pain relief. The Cancer TQPM Tool was adapted from the American Pain Societys Quality Assurance Standards on Acute Pain and Cancer Pain and was tested in a convenience sample of 200 patients. The majority of patients reported that the TQPM Tool was easy to understand and to use, providing evidence for the feasibility of the tool. Factors associated with higher pain intensity included the inpatient setting, the presence of metastatic disease, hesitancy in bothering the nurse, and concerns regarding tolerance and addiction. Although there was a strong relationship between concern about addiction and concern about tolerance, fear of tolerance appeared to have a greater effect on pain intensity scores than did fear of addiction. The findings from this study suggest that the Cancer TQPM Patient Assessment Tool can be used effectively in both inpatients and outpatients to determine outcomes and the quality of cancer pain management, as well identify factors associated with poor pain control. Clinical implications include more effective education of patients and caregivers, including equivalent emphasis on tolerance and addiction.

HIV multidisciplinary teams work: Support services improve access to and retention in HIV primary care

The multidisciplinary team model of HIV care evolved out of necessity due to the diverse characteristics and needs of people living with HIV disease. Though it is now accepted as the international standard of care, it represents a significant departure from methods of care for other infectious diseases, and debate continues regarding the effectiveness of its interventions. The debate has been largely uninformed by data; for example, little is known about the relationship between ancillary support services and primary care outcomes. We hypothesized that support services increase access to and retention in HIV primary care in an inner city public hospital clinic. We conducted a retrospective analysis of clinical data sets on 2,647 patients at the CORE Center, Chicago from 1997-1998 to investigate the relationship between four support services--case management (CM), transportation (TRANS), mental health (MH) and chemical dependency (CD)--and access to and retention in HIV primary care. We found that patients who received each of these services were significantly more likely to receive any care, regular care and had more visits than patients with no service, and retention increased by 15-18%. Female gender, younger age, self-pay status and IDU predicted less regular care. Need for all services was substantial and significantly greater in women. Outcomes improved to the greatest extent among patients who needed and received each service. We conclude that support services significantly increased access to and retention in HIV primary care. Our findings validate the multidisciplinary team model of HIV care, and suggest that health services that are tailored to the express needs of patients lead to better care and improved health outcomes. Further testing of changes in health care delivery to meet the rapidly changing needs of people living with HIV disease and respond to the constantly changing practice of HIV medicine is urgently needed to maintain and extend the advances in HIV care outcomes of the past decade.

Outcome after rectovaginal fascia reattachment for rectocele repair

OBJECTIVE This study was undertaken to determine the effects of rectovaginal fascia reattachment on symptoms and vaginal topography. STUDY DESIGN Standardized preoperative and postoperative assessments of vaginal topography (the Pelvic Organ Prolapse staging system of the International Continence Society, American Urogynecologic Society, and Society of Gynecologic Surgeons) and 5 symptoms commonly attributed to rectocele were used to evaluate 66 women who underwent rectovaginal fascia reattachment for rectocele repair. All patients had abnormal fluoroscopic results with objective rectocele formation. RESULTS Seventy percent (n = 46) of the women were objectively assessed at 1 year. Preoperative symptoms included the following: protrusion, 85% (n = 39); difficult defecation, 52% (n = 24); constipation, 46% (n = 21); dyspareunia, 26% (n = 12); and manual evacuation, 24% (n = 11). Posterior vaginal topography was considered abnormal in all patients with a mean Ap point (a point located in the midline of the posterior vaginal wall 3 cm proximal to the hymen) value of -0.5 cm (range, -2 to 3 cm). Postoperative symptom resolution was as follows: protrusion, 90% (35/39; P <.0005); difficult defecation, 54% (14/24; P <.0005); constipation, 43% (9/21; P =.02); dyspareunia, 92% (11/12; P =.01); and manual evacuation, 36% (4/11; P =.125). Vaginal topography at 1 year was improved, with a mean Ap point value of -2 cm (range, -3 to 2 cm). CONCLUSION This technique of rectocele repair improves vaginal topography and alleviates 3 symptoms commonly attributed to rectoceles. It is relatively ineffective for relief of manual evacuation, and constipation is variably decreased.

Vaginal Mesh for Prolapse A Randomized Controlled Trial

OBJECTIVE: To present 3-month outcomes of a double-blind, multicenter randomized controlled trial comparing traditional vaginal prolapse surgery without mesh with vaginal surgery with mesh. METHODS: Women with pelvic organ prolapse quantification prolapse stages 2–4 were randomized to vaginal colpopexy repair with mesh or traditional vaginal colpopexy without mesh. The primary outcome measure was objective treatment success (pelvic organ prolapse quantification stage 1 or lower) at 3 months. Secondary outcome measures included quality-of-life variables and complication rates. RESULTS: Sixty-five women were recruited from January 2007 to August 2009, when the study was halted due to predetermined stopping criteria for vaginal mesh erosion at a median follow-up of 9.7 months (range, 2.4–26.7 months). Thirty-two women underwent mesh colpopexy (24 anterior mesh, eight total mesh), and 33 women had vaginal colpopexies without mesh (primarily uterosacral ligament suspension) and concurrent colporrhaphy. There were no statistically significant baseline differences between the mesh and no-mesh groups with respect to demographics, menopausal status, and race. Analysis of the mesh and no-mesh women found no difference with respect to overall recurrence (mesh: 19 [59.4%] compared with no mesh: 24 [70.4%], P=.28). There were five (15.6%) vaginal mesh erosions. Two cystotomies and one blood transfusion occurred in the mesh group only. Subjective cure of bulge symptoms was noted in 93.3% of mesh patients and 100% of no-mesh patients. Furthermore, subjective quality-of-life measurements did not differ between the two groups at baseline or 3 months postoperatively. CONCLUSION: At 3 months, there is a high vaginal mesh erosion rate (15.6%) with no difference in overall objective and subjective cure rates. This study questions the value of additive synthetic polypropylene mesh for vaginal prolapse repairs. CLINICAL TRIAL REGISTRATION: Clinicaltrials.gov, www.clinicaltrials.gov, NCT00475540. LEVEL OF EVIDENCE: I

Topical Capsaicin in the Management of HIV-Associated Peripheral Neuropathy

Distal symmetrical peripheral neuropathy (DSPN) is a particularly distressing pain syndrome associated with human immunodeficiency virus (HIV) disease. Capsaicin has been found to be effective in relieving pain associated with other neuropathic pain syndromes, and is mentioned as a possible topical adjuvant analgesic for the relief of DSPN. This multicenter, controlled, randomized, double-masked clinical trial studied patients with HIV-associated DSPN and compared measures of pain intensity, pain relief, sensory perception, quality of life, mood, and function for patients who received topical capsaicin to the corresponding measures for patients who received the vehicle only. Twenty-six subjects were enrolled in the study. At the end of 1 week, subjects receiving capsaicin tended to report higher current pain scores than did subjects receiving the vehicle (Mann-Whitney test; P = 0.042). The dropout rate was higher for the capsaicin group (67%) than for the vehicle group (18%) (chi 2 test of association; P = 0.014). There were no other statistically significant differences between the capsaicin and vehicle groups with respect to current pain, worst pain, pain relief, sensory perception, quality of life, mood, or function at study entry or at any time during the 4-week trial. These results suggest capsaicin is ineffective in relieving pain associated with HIV-associated DSPN.

Transvaginal electrical stimulation for female urinary incontinence

OBJECTIVE Our purpose was to determine the objective and subjective efficacy of transvaginal electrical stimulation for treatment of common forms of urinary incontinence in women. STUDY DESIGN A prospective, double-blind, randomized clinical trial included 121 women with either urinary incontinence caused by detrusor instability or genuine stress incontinence, or both (mixed incontinence). Participants used the assigned device for 8 weeks. Identical preintervention and postintervention assessment included multichannel urodynamic testing, quality-of-life scale, and urinary diaries. RESULTS A total of 121 women completed this study at four North American urogynecology centers. Detrusor instability was cured (stable on provocative cystometry) in 49% of women with detrusor instability who used an active electrical device (p = 0.0004, McNemars test), whereas there was no statistically significant change in the percentage with detrusor instability in the sham device group. There was no statistically significant difference between the preintervention and postintervention rates of genuine stress incontinence for either the active device group or the sham device group. CONCLUSION This form of transvaginal electrical stimulation may be effective for treatment of detrusor overactivity, with or without genuine stress incontinence.

Increased Frequency of Acute Local Reaction to Intra-Articular Hylan GF-20 (Synvisc) in Patients Receiving More Than One Course of Treatment

Background: Intra-articular knee injections with hylan GF-20 (Synvisc) have been shown to provide temporary relief of osteoarthritic symptoms. Several studies have suggested that repeated courses of treatment with this product may be administered without an increase in the likelihood of an adverse reaction. The present study was performed to test the hypothesis that the likelihood of a painful reaction to hylan GF-20 does not increase in patients who receive more than one course of treatment.Methods: The records of all patients who had received more than one course of treatment with hylan GF-20 were compared with a group of patients who had received only one course of treatment during the same fifteen-month period at a single center. The single-course group was prospectively enrolled and followed, as part of an ongoing randomized trial. The two groups were compared with respect to several demographic and clinical parameters as well as with respect to the frequency of painful acute local reactions following injections of hylan GF-20.Results: Local reactions to hylan GF-20 occurred significantly more often in patients who had received more than one course of treatment than they did in patients who had received only a single course of treatment; the reactions occurred in four (21%) of nineteen patients in the former group and in one (2%) of the forty-two patients in the latter (p = 0.029). All of the reactions were severe enough to cause the patient to seek unscheduled care. Following corticosteroid injection, the reactions abated without apparent sequelae. With the numbers available, no significant differences were detected between the multiple-course and single-course groups in terms of age, gender, body-mass index, or severity or bilaterality of the disease.Conclusions: The present study suggests that it may be reasonable to counsel patients who have been treated with a course of hylan GF-20 and who desire an additional course that the likelihood of a painful acute local reaction to the medication appears to be increased. Additional study of the frequency of acute local reactions following repeated courses of hylan GF-20 and investigation of the mechanisms of those reactions are warranted.